WORK STUDY OF NURSES WITH REFERENCE TO SAFE INJECTION PRACTICES IN A DELUXE ROOM UNIT OF CORPORATE HOSPITAL IN HYDERABAD
Author(s): F. Ikbal, A.K. Jaiswal
Vol. 18, No. 1 (2006-01 - 2006-12)
F. Ikbal(1), A.K. Jaiswal(2)
Key Words: Work-study, Safe Injection Practices, Deluxe Room Unit, Corporate Hospital
ABSTRACT
Work study helps to find out how a particular work is
done and the scope of improvement. It is an important
tool to improve the efficiency and effectiveness. Across
the globe there is an acute shortage of nurses. Drug
administration through injection is one of the major
activities of nurses during their duty time. Unsafe injection
practices have caused death and other complications.
This study is aimed at understanding the existing injection
practices and improving so that it saves times as well it
is made safe.
INTRODUCTION
With the widening role of health care organizations, the
work method and procedural part are consuming large
manpower right from skilled to unskilled for providing of
better patient care1,2. On the other hand, the output of
the health care organizations cannot be measured directly
and quantitatively. As human resources are vital
resources, it is necessary to measure the work/service
provided by individual and group3. The best method,
which can be applied for this purpose, is the Time and
Motion study techniques.
On the other side in India, where unnecessary injections
are common, the average number of healthcare injections
per person is estimated to be 3.7 per year (this includes
all healthcare injections, including those given to
diabetics for administering insulin)4-6.
WORK-STUDY
It is a generic term for those techniques, particularly
method study and work measurement which are
used in the examination of human work in all its contexts,
and which leads systematically to the investigation of
all the facts which affects the efficiency and economy of
the situation being reviewed, in order to effect
improvement.7
Method study and work measurement are closely
linked, method study is concerned with the reduction
of the work content of operation, while work
measurement is concerned with the investigation and
reduction of the ineffective time and the subsequent
establishment of time standard for the operation on the
basis of work content as established by method study.
OBJECTIVE OF THE STUDY
- To undertake method study of injection practices
by nurses.
- To undertake work measurement of injection
practices by nurses.
- To develop standard work-study for nurses with
reference to safe injection practices.
DISCUSSION AND FINDINGS
Work-study method
Basic work-study procedure.
There are eight basic steps, some of which are common
to both method study (MS) and work measurement
(WM)
- Select (MS and WM)
- Record (MS and WM)
- Examine (MS and WM)
- Develop (MS)
- Measure (WM)
- Define (WM)
- Install (MS)
- Maintain (MS)
For mentioned work-study of nurses with respect to safe injection practices, unit of deluxe room has been selected
Step 1: Select
In this step identified topic is selected i.e.
Work-study of nurses with respect to safe injection
practices.
Step 2: Record
The current activities involved in injection practices
have been recorded.
The fact has been recorded in form of flow chart as
follows:
S. No.
Activity
1
Nurse Checking case
2
Nurse Reaching to patients bed
3
Checking availability of medicine
4
Prescription given to attenders (attendants)
5
Nurse come back to nursing station
6
Attender’s delay in getting medicine
7
Nurse Reaching to patients bed
8
Collecting medicine
9
Nurse come back to nursing station
10
Checking medicine
11
Opening vial
12
Opening disposable syringe
13
Dissolving injection
14
Loading syringe
15
Reaching to patient bed
16
Positioning patient and cleaning injection site
17
Injection administered
18
Nurse come back to nursing station
19
Disposal of syringe
20
Remarks given by nurse in case sheet
PROCESS FLOW CHART
The study can be carried out by preparing process
chart, which is a chart to record a process in a
compact manner, as a means of understanding and
improving it.
The process chart explains systematically the series of
actions done during the work process and also gives the
information graphically.
The process chart is prepared based on certain number
of symbols i.e. Operation. Transportation, Inspection,
Delay and Storage. Sometimes few /activities may be
combined also.
Operation: An operation represents the real work that
is carried out, mainly the time spent on treatment to
patient directly.
Transportation: The staff moves certain object or moving
one place to another place, except when the movement
is not part of the operation and inspection.
Inspection: Inspection means a person examining the
work accuracy or checking the materials required or
checking and comparing with a standard as quantity or
quality.
Delay: There may be some gap between activities or
before performing the next action some delay due to
various reasons.
Storage: Storage occurs when the activity is stopped
and it is not performed.
Symbols for activities
PROCESS FLOW CHART FOR ABOVE MAINTAINED ACTIVITIES
(For larger image, click here)
Total 450 events were observed as far as syringe/needle
use and disposal was concerned at deluxe room ward of
premier hospital, which is of 15 beds.
The following was observed:
- Patient’s attender was being sent for getting medicine
from centralized pharmacy.
- Out of 450 injections
- Intraveinous 320
- Intramuscular 90
- Subcutaneous 40
- Most of injections administered were antibiotics.
- Dissolving of medicine was not proper.Tips of finger
were touching vial cap.
- Nurse were carrying injection with bare hands up to
patients room.
- None of the nurses wore gloves.
- For intramuscular injections, gluteal region was not
cleaned properly.
- Intramuscular injections were not administered at
given site.
- Injection abscess was the commonest complication.
- Recapping of needle after administration of injection
done – 436 times.
- Discarding syringe without removing needle – 423
times.
- The providers batched all the syringes along with
needles.
- After finishing of work, these syringes were destroyed
one by one leading to increased chances of needle
stick injuries
- Many activities of repeated handing of sharps occur
while giving injections. These are like breaking the
ampoule, removing of needle after tip burning,
handing needle cutter and recapping of needle.
Step 3 Examine
In the entire process of injection administration, nurse
has done following activities.
- Inspection: Nurse has done 3 activities of inspection.
- Operation: Nurse had done 10 activities of operation.
- Transportation: Nurse has moved 6 times.
- Delay: Attenders delayed in getting medicine.
- Storage: No activity.
Step 4 Develop
It was found that most of the time had been spent on
transportation as well as in getting the medicine from
the store. New method was developed as below.
S. No.
Activity
1
Nurse checking case sheet
2
Opening disposable syringe
3
Checking vial
4
Opening vial
5
Dissolving injection
6
Loading syringe
7
Nurse reaching to patients bed
8
Positioning and cleaning site
9
Injection administered
10
Nurse reaching to nursing station
11
Disposal of syringe
12
Remarks given by nurse in case sheet
Step 5 Measures
In this step time taken for existing work has been
recorded.
Existing method of injection administration
S. No.
Activity
Time
1
Nurse Checking case sheets
2 min
2
Nurses Reaching to patient’s bed
1 min
3
Checking availability of medicine
1 min
4
Prescription given to attenders
1 min
5
Nurse come back to nursing station
1 min
6
Attenders delay in getting medicine
1 min
7
Nurse Reaching to patients bed
10 min
8
Collecting medicine
30 sec
9
Nurse come back to nursing station
1 min
10
Checking medicine
1 min
11
Opening vial
30 sec
12
Opening disposable syringe
30 sec
13
Dissolving injection
1 min
14
Loading syringe
30 sec
15
Reaching to patient bed
1 min
16
Positioning patient and cleaning injection site
1 min
17
Injection Administered
2 min
18
Nurse come back to nursing station
1 min
19
Disposal of syringe
1 min
20
Remarks given by nurse in case sheet
30 sec
Total time taken by qualified nurse to administer one
injection is 28 minutes and 30 seconds.
Step 6 Define
New method of injection administration
S. No.
Activity
Time
1
Nurse checking case sheet
2 min
2
Opening disposable syringe
30 sec
3
Checking vial
30 sec
4
Opening vial
30 sec
5
Dissolving injection
1 min
6
Loading syringe
30 sec.
7
Nurse reaching to patients bed
1 min
8
Positioning and cleaning site
1 min
9
Injection administered
2 min
10
Nurse reaching to nursing station
1 min
11
Disposal of syringe
1 min
12
Remarks given by nurse in case sheet
30 sec
Total time taken by a qualified nurse to administer
injection to patient is 11 minutes and 30 second.
PROCESS FLOW CHART FOR NEW METHOD:
(For larger image, click here)
Total time taken to administered injection by a qualified nurse is 11 minutes and 30 seconds
Inspection 2 activities has taken time of 2 minutes 30 seconds.
Operation 8 activities has taken time of 7 minutes.
Transportation 2 activities has taken 2 minutes.
Step 7 Install
Above new method for injection administration has been
installed successfully with following changes.
- Inspection changes
- Process (operational) changes
- Transportation changes
- Infrastructure changes
1. Inspection changes:
- Careful checking of case sheet has been done
to find out whether patient is allergic to any drug
and conforming that antibiotic sensitivity test
has been done.
- Injection site was checked carefully.
2. Process (operational) changes:
- Stocks of frequently used antibiotics were kept
at nursing station so delay in getting medicine
has been cut off.
- Injections were carried in a tray to patient bed.
- Injection site was cleaned was cleaned with
appropriate antiseptic material.
- Injections administered as defined.
- After giving injection, recapping of needle was
not done, and syringe kept in tray without
recapping needle, so that needle stick can be
injuries prevented.
- Use of needle destroyer (electric type) for burning
the tip of the needle as soon as nurse reaches
to nursing station.
3. Transportation changes:
- Transportation has been reduced as stock of
medicine has been kept at nursing station,
Nurse is now reaching to patient with prescribed
injection.
4. Infrastructure changes:
- Needle destroyer (electric type) has been
provided in all places.
OBSERVATIONS:
- Total time for administration of injection has been
reduced by 17 minutes.
- Transportation has been done twice only.
- No needle stick injuries were noted for period of 20
days after implementation of new method.
- No case of intragluteal abscess has been reported.
- No case of drug-induced allergy has been noted.
Step 8 Maintain
Above new method of safe injection administration has
been maintained by supervising the process frequently
by nursing superintendent.
Work-study of nurses with reference to safe injection
practices does away with unnecessary processes and
thus helps in reduction of steps involved. Once
implemented it results in increased efficiency of process
with all over requirement of nursing staff. It also helps in
improving the quality care and increased patient
satisfaction.
As human sources are vital sources, it is necessary to
measure the work/service provided by individual and
group. The best method, which can be applied for this
purpose, is the Time and Motion study techniques.
But work-study takes time and needs strong staff
commitment so as to achieve hospital operations
successfully.
REFERENCE
- Bamisaiye A, Abodunde M B, Ransome-Kuti O. A
Simple Work-Sampling System for use in Hospitals
and Health Centers in the Developing World, Journal
of tropical pediatrics, Vol 30, (6) 299-303
- Torrie J. The development of work-study in the
hospital field, Occupational medicine, Vol 13, (1)
122- 124
- Cleone W. Application of work-study to the design
of factory surgery, Occupational medicine, Vol 15,
(1) 59.64
- Kermode M, Holmes W, Biangtang, Mathew S
Giffard S, Safer injections, fewer injections: Injection
safety in rural North India. Tropical medicine and
international health, Vol 10, (5) 2005 May, 423-432.
- Mariappan T. ‘Ensuring better output in hospitals’
Express Healthcare Management, 16 – 30th April
2003.
- Rao SKM. Need for safe injection practices & safe
mgmt of sharp waste disposal, Express Healthcare
Management, 16-30, June 2004.
- Hall A J. First do no harm, Tropical Medicine and
International health, February 2000; 5(2):79.
(1) F. Ikbal is Assistant Professor, Deptt. of Hospital Management, Deccen School of Management , Hyderabad
(2) A.K. Jaiswal is Hospital Administrator, GBH American Hospital, Udaipur
F. Ikbal(1), A.K. Jaiswal(2)
Key Words: Work-study, Safe Injection Practices, Deluxe Room Unit, Corporate Hospital
ABSTRACT
Work study helps to find out how a particular work is done and the scope of improvement. It is an important tool to improve the efficiency and effectiveness. Across the globe there is an acute shortage of nurses. Drug administration through injection is one of the major activities of nurses during their duty time. Unsafe injection practices have caused death and other complications. This study is aimed at understanding the existing injection practices and improving so that it saves times as well it is made safe.
INTRODUCTION
With the widening role of health care organizations, the work method and procedural part are consuming large manpower right from skilled to unskilled for providing of better patient care1,2. On the other hand, the output of the health care organizations cannot be measured directly and quantitatively. As human resources are vital resources, it is necessary to measure the work/service provided by individual and group3. The best method, which can be applied for this purpose, is the Time and Motion study techniques.
On the other side in India, where unnecessary injections are common, the average number of healthcare injections per person is estimated to be 3.7 per year (this includes all healthcare injections, including those given to diabetics for administering insulin)4-6.
WORK-STUDY
It is a generic term for those techniques, particularly method study and work measurement which are used in the examination of human work in all its contexts, and which leads systematically to the investigation of all the facts which affects the efficiency and economy of the situation being reviewed, in order to effect improvement.7
Method study and work measurement are closely linked, method study is concerned with the reduction of the work content of operation, while work measurement is concerned with the investigation and reduction of the ineffective time and the subsequent establishment of time standard for the operation on the basis of work content as established by method study.
OBJECTIVE OF THE STUDY
- To undertake method study of injection practices by nurses.
- To undertake work measurement of injection practices by nurses.
- To develop standard work-study for nurses with reference to safe injection practices.
DISCUSSION AND FINDINGS
Work-study method
Basic work-study procedure. There are eight basic steps, some of which are common to both method study (MS) and work measurement (WM)
- Select (MS and WM)
- Record (MS and WM)
- Examine (MS and WM)
- Develop (MS)
- Measure (WM)
- Define (WM)
- Install (MS)
- Maintain (MS)
For mentioned work-study of nurses with respect to safe injection practices, unit of deluxe room has been selected
Step 1: Select
In this step identified topic is selected i.e. Work-study of nurses with respect to safe injection practices.
Step 2: Record
The current activities involved in injection practices have been recorded.
The fact has been recorded in form of flow chart as follows:
| S. No. | Activity |
|---|---|
| 1 | Nurse Checking case |
| 2 | Nurse Reaching to patients bed |
| 3 | Checking availability of medicine |
| 4 | Prescription given to attenders (attendants) |
| 5 | Nurse come back to nursing station |
| 6 | Attender’s delay in getting medicine |
| 7 | Nurse Reaching to patients bed |
| 8 | Collecting medicine |
| 9 | Nurse come back to nursing station |
| 10 | Checking medicine |
| 11 | Opening vial |
| 12 | Opening disposable syringe |
| 13 | Dissolving injection |
| 14 | Loading syringe |
| 15 | Reaching to patient bed |
| 16 | Positioning patient and cleaning injection site |
| 17 | Injection administered |
| 18 | Nurse come back to nursing station |
| 19 | Disposal of syringe |
| 20 | Remarks given by nurse in case sheet |
PROCESS FLOW CHART
The study can be carried out by preparing process chart, which is a chart to record a process in a compact manner, as a means of understanding and improving it.
The process chart explains systematically the series of actions done during the work process and also gives the information graphically.
The process chart is prepared based on certain number of symbols i.e. Operation. Transportation, Inspection,
Delay and Storage. Sometimes few /activities may be combined also.
Operation: An operation represents the real work that is carried out, mainly the time spent on treatment to patient directly.
Transportation: The staff moves certain object or moving one place to another place, except when the movement is not part of the operation and inspection.
Inspection: Inspection means a person examining the work accuracy or checking the materials required or checking and comparing with a standard as quantity or quality.
Delay: There may be some gap between activities or before performing the next action some delay due to various reasons.
Storage: Storage occurs when the activity is stopped and it is not performed.
Symbols for activities
PROCESS FLOW CHART FOR ABOVE MAINTAINED ACTIVITIES
(For larger image, click here)
Total 450 events were observed as far as syringe/needle use and disposal was concerned at deluxe room ward of premier hospital, which is of 15 beds.
The following was observed:
- Patient’s attender was being sent for getting medicine from centralized pharmacy.
- Out of 450 injections
- Intraveinous 320
- Intramuscular 90
- Subcutaneous 40
- Most of injections administered were antibiotics.
- Dissolving of medicine was not proper.Tips of finger were touching vial cap.
- Nurse were carrying injection with bare hands up to patients room.
- None of the nurses wore gloves.
- For intramuscular injections, gluteal region was not cleaned properly.
- Intramuscular injections were not administered at given site.
- Injection abscess was the commonest complication.
- Recapping of needle after administration of injection done – 436 times.
- Discarding syringe without removing needle – 423 times.
- The providers batched all the syringes along with needles.
- After finishing of work, these syringes were destroyed one by one leading to increased chances of needle stick injuries
- Many activities of repeated handing of sharps occur while giving injections. These are like breaking the ampoule, removing of needle after tip burning, handing needle cutter and recapping of needle.
Step 3 Examine
In the entire process of injection administration, nurse has done following activities.
- Inspection: Nurse has done 3 activities of inspection.
- Operation: Nurse had done 10 activities of operation.
- Transportation: Nurse has moved 6 times.
- Delay: Attenders delayed in getting medicine.
- Storage: No activity.
Step 4 Develop
It was found that most of the time had been spent on transportation as well as in getting the medicine from the store. New method was developed as below.
| S. No. | Activity |
|---|---|
| 1 | Nurse checking case sheet |
| 2 | Opening disposable syringe |
| 3 | Checking vial |
| 4 | Opening vial |
| 5 | Dissolving injection |
| 6 | Loading syringe |
| 7 | Nurse reaching to patients bed |
| 8 | Positioning and cleaning site |
| 9 | Injection administered |
| 10 | Nurse reaching to nursing station |
| 11 | Disposal of syringe |
| 12 | Remarks given by nurse in case sheet |
Step 5 Measures
In this step time taken for existing work has been recorded.
Existing method of injection administration
| S. No. | Activity | Time |
|---|---|---|
| 1 | Nurse Checking case sheets | 2 min |
| 2 | Nurses Reaching to patient’s bed | 1 min |
| 3 | Checking availability of medicine | 1 min |
| 4 | Prescription given to attenders | 1 min |
| 5 | Nurse come back to nursing station | 1 min |
| 6 | Attenders delay in getting medicine | 1 min |
| 7 | Nurse Reaching to patients bed | 10 min |
| 8 | Collecting medicine | 30 sec |
| 9 | Nurse come back to nursing station | 1 min |
| 10 | Checking medicine | 1 min |
| 11 | Opening vial | 30 sec |
| 12 | Opening disposable syringe | 30 sec |
| 13 | Dissolving injection | 1 min |
| 14 | Loading syringe | 30 sec |
| 15 | Reaching to patient bed | 1 min |
| 16 | Positioning patient and cleaning injection site | 1 min |
| 17 | Injection Administered | 2 min |
| 18 | Nurse come back to nursing station | 1 min |
| 19 | Disposal of syringe | 1 min |
| 20 | Remarks given by nurse in case sheet | 30 sec |
Total time taken by qualified nurse to administer one injection is 28 minutes and 30 seconds.
Step 6 Define
New method of injection administration
| S. No. | Activity | Time |
|---|---|---|
| 1 | Nurse checking case sheet | 2 min |
| 2 | Opening disposable syringe | 30 sec |
| 3 | Checking vial | 30 sec |
| 4 | Opening vial | 30 sec |
| 5 | Dissolving injection | 1 min |
| 6 | Loading syringe | 30 sec. |
| 7 | Nurse reaching to patients bed | 1 min |
| 8 | Positioning and cleaning site | 1 min |
| 9 | Injection administered | 2 min |
| 10 | Nurse reaching to nursing station | 1 min |
| 11 | Disposal of syringe | 1 min |
| 12 | Remarks given by nurse in case sheet | 30 sec |
Total time taken by a qualified nurse to administer injection to patient is 11 minutes and 30 second.
PROCESS FLOW CHART FOR NEW METHOD:
(For larger image, click here)
Total time taken to administered injection by a qualified nurse is 11 minutes and 30 seconds
Inspection 2 activities has taken time of 2 minutes 30 seconds.
Operation 8 activities has taken time of 7 minutes.
Transportation 2 activities has taken 2 minutes.
Step 7 Install
Above new method for injection administration has been installed successfully with following changes.
- Inspection changes
- Process (operational) changes
- Transportation changes
- Infrastructure changes
1. Inspection changes:
- Careful checking of case sheet has been done to find out whether patient is allergic to any drug and conforming that antibiotic sensitivity test has been done.
- Injection site was checked carefully.
2. Process (operational) changes:
- Stocks of frequently used antibiotics were kept at nursing station so delay in getting medicine has been cut off.
- Injections were carried in a tray to patient bed.
- Injection site was cleaned was cleaned with appropriate antiseptic material.
- Injections administered as defined.
- After giving injection, recapping of needle was not done, and syringe kept in tray without recapping needle, so that needle stick can be injuries prevented.
- Use of needle destroyer (electric type) for burning the tip of the needle as soon as nurse reaches to nursing station.
3. Transportation changes:
- Transportation has been reduced as stock of medicine has been kept at nursing station, Nurse is now reaching to patient with prescribed injection.
4. Infrastructure changes:
- Needle destroyer (electric type) has been provided in all places.
OBSERVATIONS:
- Total time for administration of injection has been reduced by 17 minutes.
- Transportation has been done twice only.
- No needle stick injuries were noted for period of 20 days after implementation of new method.
- No case of intragluteal abscess has been reported.
- No case of drug-induced allergy has been noted.
Step 8 Maintain
Above new method of safe injection administration has been maintained by supervising the process frequently by nursing superintendent.
Work-study of nurses with reference to safe injection practices does away with unnecessary processes and thus helps in reduction of steps involved. Once implemented it results in increased efficiency of process with all over requirement of nursing staff. It also helps in improving the quality care and increased patient satisfaction.
As human sources are vital sources, it is necessary to measure the work/service provided by individual and group. The best method, which can be applied for this purpose, is the Time and Motion study techniques. But work-study takes time and needs strong staff commitment so as to achieve hospital operations successfully.
REFERENCE
- Bamisaiye A, Abodunde M B, Ransome-Kuti O. A Simple Work-Sampling System for use in Hospitals and Health Centers in the Developing World, Journal of tropical pediatrics, Vol 30, (6) 299-303
- Torrie J. The development of work-study in the hospital field, Occupational medicine, Vol 13, (1) 122- 124
- Cleone W. Application of work-study to the design of factory surgery, Occupational medicine, Vol 15, (1) 59.64
- Kermode M, Holmes W, Biangtang, Mathew S Giffard S, Safer injections, fewer injections: Injection safety in rural North India. Tropical medicine and international health, Vol 10, (5) 2005 May, 423-432.
- Mariappan T. ‘Ensuring better output in hospitals’ Express Healthcare Management, 16 – 30th April 2003.
- Rao SKM. Need for safe injection practices & safe mgmt of sharp waste disposal, Express Healthcare Management, 16-30, June 2004.
- Hall A J. First do no harm, Tropical Medicine and International health, February 2000; 5(2):79.
(1) F. Ikbal is Assistant Professor, Deptt. of Hospital Management, Deccen School of Management , Hyderabad
(2) A.K. Jaiswal is Hospital Administrator, GBH American Hospital, Udaipur
