1. Quality of Nursing Service in B. P. Koirala Institute of Health Sciences, Nepal
R.S. Mehta, Asst. Professor
Medical-Surgical Nursing Department
Email: ramsharanmehta7@yahoo.com
B.P. Koirala Institute of Health Sciences, Nepal
Abstract:
Quality nursing service means offering a range of nursing service as per the hierarchical
needs of the clients in various settings. The success should be appropriate, safe, effective,
and economical and should satisfy clients in all dimensions of health. Nursing with other
health workers all over the world are facing difficult challenges. The public's expectation
of them continues to rise. Nurses are asked to provide higher quality health services with
fewer resources and different constraints. At the same time, the knowledge and skills-
base needed to perform effectively in their chosen fields of endeavor continues to grow
and change rapidly. Health care personnel will continue in the workforce for many years,
while the information that they acquired during their education may rapidly become
obsolete.
Health care institutions and their managers are also confronted with these realities. The
challenge is to continue to maintain or improve the quality of the care and the
comprehensiveness of health service converges, while introducing changes in care
delivery system. Finally governments at local, regional and national levels are attempting
to obtain greater value for the money they spend on health care. Faced with growing
expectations of quality they are being asked to be more accountable for the results of
their health care expenditures. Thus, they also have an important role to play in ensuring
and improving the quality of health services provided in both the public and private
sectors.1
The main objectives of this study were to assess the quality of nursing service provided
by ward in-charges and nurses. It was hospital based descriptive exploratory study
conducted in all the 28 wards of BPKIHS using five sets of Performa (tool) to evaluate
their leadership qualities, functional capabilities, nursing care status, environmental
sanitation of the unit and the documentation of clients. The data was collected in May and
June 2006 by trained nurses, nurses working in the unit by participative observation
methods. It was found that in average the ward in-charges were middle range performers
(69.2%), performance level of ward in-charges are average (48.28%), nursing care status
is satisfactory (72.32 %), cleanliness level is also satisfactory ( 65.9 %), and the level of
documentation is above average ( 73.23 %).
The findings of the study clearly illustrate the need of continuous in-service education on
managerial aspects of nurses so that quality of nursing service can be improved.
Key Words: Quality, Nursing, Service

2. Introduction:
Knowledge, like muscles, must be nourished constantly and used frequently to
retain function. Learning like motion, is more easily maintained if it's momentum
has not been interrupted.
Quality of care simply means that what is done for the patient is necessary, and that what
is necessary is done. Coordination of care is displayed when the different parts of the
care on different days by different caregivers, and care from various departments are
harmonized into the whole patient care
Leadership qualities: The quality of technical care consists in the application of
medical science and technology in a way that maximizes its benefits to health without
correspondingly increasing its risk. The degree of quality is, therefore, the extent to
which the care provided is expected to achieve the most favorable balance or risks and
benefits. Proper performances of interventions are known to be safe, affordable to the
society and produce an impact on mortality, morbidity, disability and malnutrition.
The dimensions of quality are: Technical competence effectiveness (correct manner),
efficiency (maximum benefit to client, use of available resources, cost affective,
continuity service delivery, interpersonal relations (respect, confidentiality, courtesy,
responsiveness and equality), safety (maximum risk of injury; infection and side effect),
and Amenities.
Some of the important quality assurance mechanism, which is considered, for providing
health care in our country is: Licensure, credentialing (granting authorization to provide
specific patient care and treatment), Accreditation, standards, indicators, continuous
education, procedure and infection control.
Functional capabilities: In recent years, acquired a new philosophy of health, which
may be stated as: Health is human fundamental rights, an essence of productive life, and
not the result of ever increasing expenditure of medical care. Health is intersectorial, and
integral part of development, health is counter to the concept of quality of life, involves
individuals, states and international responsibility. Health and it's maintenance is a major
social investment and health is world-wide social goal.
Nursing care status: Factors like overflow of patients, imbalanced nurse patient ratio,
ineffective work distribution, inadequate facilities for in-service education training,
inadequate supply of equipment and facilities, first contact care provider, unknown about
diagnosis, advances in disease pathogens, new trends of disease, twenty four hour station
duty etc. effects the health of nursing personnel14. Therefore, it's necessary to evaluate
whether these factors are helping or hindering nursing care in the institute or not.
With the ongoing emphasis on resource management, cost control, efficiency in patient
care, quality improvement, and accountability, we are required to provide quality patient
care and documentation at the same time. Nurses are expected to fulfill major and
sometimes conflicting responsibilities with reduced staffing. When we cannot fulfill both

3. the responsibilities, we try to satisfy ourselves by fulfilling the one with the higher
priority.
Documentation: Documentation must be accurate, clear, concise, complete, and
timely. Speed is of the essence when working in healthcare, but accuracy and
completeness are imperative when documenting. Do not let the patient’s health
be compromised by worrying about the speed; make sure it gets done right the
first time. Documentation must have meaning today, tomorrow, and in the
unforeseen future. One of the difficulties with documentation is that we never
know when what we document will be needed. You want to make sure the right
information gets documented and that documentation is done correctly. Nursing
documentation is important and not just for legal purposes. The results and
benefits of nursing documentation are greater than the sum of the tasks
themselves. It isn’t an easy task, but it is necessary and it is a way of giving high-
quality patient care. The lack of proper documentation can negatively impact
patient care and can ultimately cause other problems.7
Transitions in health care have sparked public and professional concern regarding the
status of inpatient hospital nursing and its effect on the quality of care in hospitals,
prompting the Institutes inquiry into this issue. It has been well documented that the work
environment affects nurse satisfaction and turnover; which in turn influences the
organizational lost of replacing nurses. Theoretically, the environment in which care is
delivered affects patient, nursing and institutional outcome. Nursing can be though of as
an organization's surveillance system, in those nurses is present around the clock. In
addition, nurses functioning in such an environment can apply resources as appropriate
for best meeting patient needs and for communicating problems to the physician in a
timely manner. Theoretically, these environmental factors are responsible for better
patient, nurse and organizational outcomes.
Objectives:
The Objectives of the study was to find out the leadership characteristics ranking of the
ward in-charges, evaluate performance level of ward in-charges on various managerial
activities, investigate the nursing care status in the wards, assess the environmental
sanitation status maintained in the ward and evaluation of nursing documentation
standard maintained in their respective wards.
Methodology:

4. It was hospital based descriptive exploratory study design conducted in all the 28
Wards/Units (Medical-I, II, III, Surgical- I,II,III, Orthopedic, Eye, ENT, Paying,
ICU/CCU, Dialysis, OT (Day Care, Routine, Emergency, Gynae), Emergency,
Antenatal/Labor, Postnatal, Gynae, Pediatric-I,II, NICU/PICU/MICU/Nursery, CSSD,
Tropical, Derma, Psychiatric, Dressing/Injection room) of BPKIHS, where Nurses
provide Nursing care to the clients. The In-charges, Nurses, documentation maintained in
the ward and Observation of real situation was the source of data collection. The main
areas of study were: leadership characteristics ranking of the ward in-charges, level of
ward in-charges on various managerial activities, the nursing care status in the wards, the
environmental sanitation status maintained in the ward and nursing documentation
standard maintained in their respective wards. Using total enumerative sampling
technique all the wards/units of BPKIHS was selected for study purpose.
To collect the data, Leadership Characteristics ranking Performa developed by ICN was
used and the Performance level Performa, Nursing care status evaluation Performa,
Environmental sanitation evaluation Perform and Nursing documentation
(Recording/Reporting) evaluation Performa developed by the investigators was used.
Method of data collection: 2-3 nurses working in the same unit were selected randomly
from respective wards are trained and involved in data collection under the guidance of
investigators. The collected data was entered in SPSS-10.5 software package and
analyzed. The details of the findings are depicted in tables and graphs in the results.
Results & Discussions:
Very few literatures were available on this study in world. No study was available in
Nepalese context.
Leadership Characteristics: It was found that the mean score obtained was
55.37(69.2%) out of 80 full score. The range score was 41-66, and SD =7.422. It was
found that most of the ward in-charges were of middle ranking that is (69.2%), which
require a lot of effort to make them competent. The details about the leadership
characteristics are depicted in table – I
Performance level: It was found that the mean score obtained was 37(48.28%) out of
total 75 full score. The performance level of ward in-charges on various managerial
activities is below average. This clearly illustrates the poor quality of nursing
management in ward and needs continuous nursing education on management. The
details about the leadership characteristics are depicted in table – II
Nursing Care Status of ward: It was found that the mean score obtained was
47(72.32%) out of total 65 full score. The nursing care status in BPKIHS is satisfactory
i.e. mean percentage score was 47(72.32%), out of 65. which clearly illustrate that the
nursing care level in BPKIHS is not compromised. The details about the leadership
characteristics are depicted in table – III

5. Environment Sanitation of ward: It was found that the mean score obtained was
19.77(65.9%) out of total 30 full score. The environmental sanitation (cleanliness) of the
ward was above average standard i.e. mean score 19.77(65.9%), out of total score 30,
which gives clearly picture of better environmental sanitation. The details about the
leadership characteristics are depicted in table – III
Nursing Documentation Status of the Ward: It was found that the mean score obtained
was 91.53(73.23 %) out of total 125 full score. The nursing documentation status was
satisfactory i.e. mean score was 91.53 (73.23%) out of total score of 125, which clearly
illustrate the improved documentation status at BPKIHS. The details about the leadership
characteristics are depicted in table – IV
In general we can conclude that the personal leadership characteristics and performance
of ward in-charges are average and need to improve. In spite of inadequate leadership
characteristics the quality of nursing service and nursing documentation status is
satisfactory and above average.
Conclusions:
Based upon the findings it was concluded that the nursing leaders (especially ward In-
charges) needs improvement in leadership quality by continuous nursing education,
where as the quality of nursing service and documentation needs improvement in some
parameters.
Acknowledgement:
We heartily express thanks to all the nursing staffs, for helping us in data collection and
all the ward In-charges of 28 wards for their kind cooperation and support for providing
the information.
References:
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3. Boccoli E, Lavazza L, Tomaiuolo M, Brandi A, Melani AS, Trianni G. The
content and structure of nursing documentation in Careggi Hospital, Florence,
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6. 7. Nursing documentation must make sense, must have meaning, and must
communicate.
8. Effect of Poor Documentation. Journal of the Academy of Hospital
Administration, Volume 16 No. 2 July-December 2004
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IOM, 1993.
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2007;Katahmandu, Nepal.

7. Table: - I
Leadership Characteristics ranking of the ward In-charges
N=27
Obtained Score Mean Obtained
Full Score= 5 (100%) score
Leadership
SN
Characteristics Mean
Mean
1 2 3 4 5 Percentage
Score
Score (%)
1 Vision 0 7.4 29.6 59.3 3.7 3.59 71.8
2 External Awareness 0 7.4 37 55.6 0 3.48 39.6
3 Customer Orientation 0 0 48.1 48.1 3.7 3.55 71
4 Political Skill 0 11.1 55.6 33.3 0 3.22 64.4
5 Motivation 0 11.1 29.6 48.1 11.1 3.59 71.8
6 Confidence and Trust 0 3.7 51.9 44.4 0 3.40 68
7 Influence and
3.7 14.8 44.4 37.0 0 3.18 63.6
Negotiation
8 Creative and Strategic
0 11.1 48.1 37.0 3.7 3.33 66.6
thinking
9 Interpersonal 0 11.1 11.1 74.1 3.7 3.70 74
10 Team Building 0 7.4 25.9 55.6 11.1 3.70 74
11 Oral Communication 0 7.4 22.2 51.9 18.5 3.81 76.2
12 Written Communication 0 11.1 40.7 40.7 7.4 3.44 68.6
13 Self Direction 0 19.5 42.7 25.9 11.8 3.70 74
14 Decisiveness 0 11.1 33.3 51.9 3.7 3.48 69.6
15 Problem Solving 0 7.4 40.7 48.1 3.7 3.48 69.6
16 Review and Change 0 3.7 59.3 37.0 0 3.33 66.6
Total Score Obtained 55.37 69.2
( full score=80) Mean=55.37 Range=41-66 SD=7.4222

8. Table: - II
Performance Level of Ward In-charges on Various Managerial Activities
N=23
Obtained Score Obtained Mean
Full Score= 3 (100%) Percentage score
SN Performance Characteristics
Always Often Rarely Mean Percentage
(3) (2) (1) Score Score (%)
1 Believe that team nursing will
work
87 8.7 4.3 1.173 39
2 Work a good example to others 43.5 52.2 4.3 1.608 53
3 Try to learn as much as possible
about every part of my job
52.2 43.5 4.3 1.521 51
4 Enthusiastic about work 43.5 47.8 8.6 1.521 54
5 Able to control my temper 65.2 17.4 17.4 1.521 51
6 Admit it when am wrong 47.8 52.2 0 1.521 51
7 Try to understand the other
person’s viewpoint
69.6 21.7 8.6 1.260 42
8 Think before speak 60.9 34.8 4.3 1.434 48
9 Feel that each team member is
important in caring for the patient
72.7 18.2 9.1 1.363 45
10 Able to plan ahead 74 13.0 13 1.391 46
11 Systematic about doing own
work
52.2 43.5 4.3 1.521 51
12 Show my confidence in team? 65.2 30.4 4.3 1.391 46
13 Consider both the worker and the
patient when I plan the 68.2 27.3 4.5 1.363 45
assignments
14 Give complete report to every
team members
65.2 26.1 8.7 1.434 48
15 Ask more often than command 56.5 39.1 4.3 1.478 49
16 My team voluntarily seek advice 78.3 21.7 0 1.217 41
17 Check to determine that all
assignments have been 59.1 31.8 9.1 1.500 50
completed properly
18 Try to be objective in evaluating
the work of others
77.8 47.8 4.3 1.565 52
19 Try to find out all the facts before
I draw conclusions
65.2 30.4 4.3 1.391 46
20 Offer praise often 65.2 30.4 4.3 1.260 42
21 Inform my team members of their
program
87 4.3 8.7 1.217 41
22 Try to help each member of
team improve
65.2 21.1 8.7 1.434 48
23 Encourage discussion during the
team conference
69.6 30.4 0 1.304 43
24 Keep the nursing care plans up
to date
28.6 47.6 23.8 1.809 60
25 Use nursing care plans 21.7 43.5 21.7 1.95 65
Total Score Obtained ( full score=75) 37 48.28

9. Table: - III
Nursing Care Status and Environmental Sanitation Maintained in he Ward
N= 28
Obtained Score Obtained Mean
S Full Score= 5 (100%) Percentage score
Item/Particular
N
Mean Percentage
A. Nursing care status: 1 2 3 4 5
Score Score (%)
1 Nursing care provided to the
0 14.8 44.4 29.6 11.1 3.37 67.4
patient
2 Maintaining nursing care
0 11.5 30.8 46.2 11.5 3.57 71.4
record and report
3 Carry out doctors order 3.7 3.7 22.2 40.7 29.6 3.88 77.6
4 Health education to the
11.1 25.9 37 18.5 7.4 2.85 57
patient
5 Discharge teaching provided
3.1 11.5 42.3 34.6 7.7 3.30 66
to patient
6 Nurse patient relation 0 18.5 18.5 59.3 3.7 3.48 69.6
7 Team spirit within nursing 0 0 32.1 57.1 10.7 3.78 75.6
8 Team spirit with other health
0 0 25.0 60.7 14.1 3.785 75.6
personnel
9 Co-ordination of activities 0 14.3 14.3 57.1 14.3 3.71 74.2
10 Environmental sanitation or
0 15.4 26.9 26.9 30.8 3.73 74.6
cleanliness of ward
11 Maintenance of emergency
4 0 32 40 24 3.80 76
drugs trolley
12 Admission and Discharge
0 0 8 56 36 4.28 85.6
Register maintained
B. Environmental Sanitation / 72.32
Total= 47
Cleanliness
a Toilet 0 3.7 55.6 37 3.7 3.40 68
b store room 0 16 36 40 8 3.40 68
c Nurses station 4 20 40 36 0 3.08 61.6
d Kitchen 4.2 4.2 45.8 41.7 4.2 3.37 67.4
e slice room 0 20 52 28 0 3.08 61.6
f ward with Siling 3.7 3.7 37 55.6 0 3.44 68.8
(Total full score=95 ) Mean Total Score Obtained
19.77 65.9

10. Table: - IV
Evaluation of Documentation (Recording/Reporting) Maintained in the Ward
N=26
Obtained Score Obtained score
Details of Full Score= 5 (100%) Full Score= 5 (100%)
SN
Documentation Mean Percentage
1 2 3 4 5
Score Score (%)
1 Vital Signs: (TPR, BP,
0 0 21.7 60.9 17.4 3.95 79
HT. Wt.)
2 Drug Cardex 0 0 13.6 63.6 22.7 4.09 81.8
3 Inventories: store 0 0 32 40 28 3.96 79.2
4 Intake/output 0 13.6 18.2 59.1 9.1 3.63 72.6
5 Nursing care records 0 20.8 20.8 44.8 12.5 3.50 70
6 Incidental records 0 4.3 34.8 47.8 13.0 3.69 73.8
7 Daily expenditure
0 3.8 23.1 50 23.1 3.92 78.4
records
8 Round: doctors 5.3 5.3 26.3 36.8 26.3 3.73 74.6
9 Log book 37.5 0 25.0 37.5 0 2.62 52.4
10 Student's record:
performance, teaching
procedure checklist 0 0 42.9 42.9 14.3 2.71 74.2
attendance, assignment
evaluation formats
11 Duty roster 0 12 0 48 40 4.16 83.2
12 Office records: inter
0 4 24 60 12 3.478 69.56
office correspondence
13 Leave records 0 8 24 40 28 3.88 77.6
14 Census 4.5 13.6 18.2 36.4 27.3 3.68 73.6
15 Infection: Nosocomial 12.5 12.5 44.8 16.7 12.5 3.04 60.8
16 Consent: Informed *&
0 0 20.8 54.2 25.0 4.04 80.8
high risk
17 Pre operative checklist 0 5.6 11.1 44.4 38.9 4.16 83.2
18 Medico-legal records 0 13 13 47.8 26.1 3.86 77.2
19 Admission discharge
deaths, cases 0 4.5 9.1 59.1 27.3 4.09 81.1
absconded
20 OT scrub/circulating
0 0 0 60 40 4.40 88
nurse record
21 Nursing care plan 16.7 16.7 50 16.7 0 2.66 53.2
22 Nursing assessment
22.2 16.7 22.2 33.3 5.6 2.83 56.6
records
23 Special records pupil
GCS LOC MSE reflexes
21.4 21.4 7.1 35.7 14.3 3.00 60
Edema chest sound
heart sound
24 Performance record
(AER) staff students’ 0 17.4 17.4 65.2 0 3.47 69.4
helpers
25 Bills admission discharge
investigations OT special 4.3 4.3 13 43.5 34.8 4.00 80
charge
Total Score Obtained ( full score=125) 91.53 73.23