You are on page 1of 25

PATIENT CARE

ISSUES,
MANAGEMENT ISSUES
&
EMPLOYMENT ISSUES

SUBMITTED BY:
Neenu Jacob
M.Sc(N)

PATIENT CARE ISSUES,


MANAGEMENT ISSUES AND
EMPLOYMENT ISSUES
INTRODUCTION:
Nursing is defined as providing care to the healthy or sick individuals
for preventive, promotive, curative and rehabilitative needs. The Consumers
are patients with complex needs. With increased awareness of health care,
health care facilities and consumer protection Act, patients/clients are
getting awareness about their rights. Nurses also have now the expanded
role, with the result the legal responsibility is increased. Hence, it is
important for nursing personnel working in hospital, community and
educational field to develop understanding of Legal and Ethical issues of
Nursing. Issues need deliberations and common consensus. They need to be
reviewed periodically. Issues which seem not feasible, and ideal, may become
practice with the change of time. Some of these issues threaten nurses who
do not keep up with the changing development. These issues are base for
the future trends in care.
MEANING OF LEGAL ISSUES
It is a standard or rules of conduct established and inforced by the
government. These are intended to protect the public

A. PATIENT CARE ISSUES


Nursing covers a wide range of disciplines and health-care issues that are
always changing and at the forefront of what guides this career path. Issues
such as health-care reform, nursing shortages, low salaries and ethics are
some of the issues being faced. With nursing being an integral part of

hospitals, nursing homes, home health agencies and colleges, the discipline
has to keep current of changing policies and be prepared to address
whatever may arise.
Nursing Shortage
The nursing shortage is a major issue facing the biggest licensed profession
in the health-care system. This shortage will affect health care more each
day, as it appears not much is being done to stop it. Many emergency rooms
have longer wait times due to less nursing staff, and hospital floors are
feeling the effects as well. This is affecting patient care because the number
of patients to one nurse is increasing, therefore decreasing the quality of
care. This shortage is being felt in hospitals, nursing homes and homehealth agencies. Nursing has been lobbying for patients by seeking
legislation to help with the nursing shortage and with funding for nursing
schools.
Health-Care Reform
Nurses have always been involved with health-care reform as advocates for
patients. The American Nursing Association (ANA) has been working to have
the voice of nurses heard. Nurses are in support of a public plan, so
Americans who are underinsured or uninsured will have access to
affordable, quality health insurance. The ANA has taken the stand that
health care is not a privilege but a right. It is lobbying for a reduction in cost
and an end to high out-of-pocket costs for services, as well as ending
discrimination pertaining to pre-existing conditions
DUTY TO REPORT OR SEEK MEDICAL CARE FOR A PATIENT:

A nurse who is caring for a patient has a legal duty to ensure that the
patient receives safe and competent care.
This duty requires that the nurse maintain an appropriate standard of
care and

also obtain an appropriate care from other professionals

when that is necessary.


If the outcome is unfavourable, the nurse can be found to have
breached a duty to the patient.
In a recent study, the failure to rescue individuals experiencing life
threatening complications was linked to a lower number of RNs.
Additionally, the nurse has a responsibility to critically examine the
medical orders that are written for a patient.

CONFIDENTIALITY AND RIGHT TO PRIVACY:


Confidentiality and the right to privacy with respect to ones personal
life are basic concerns in our society.
The federally legislated Health information and protection Act (HIPPA)
is demanding major efforts of all health care providers regard to
protecting patient privacy.
Only information that the patient specifically release may be shared
with others.
A nurse who gives out information without authorization from the
patient or from the legally responsible guardian can be held liable and
that results harm.
So the nurse should be cautious about what information share
verbally and with whom.
INFORMED CONSENT:
Every person has the right to either agree or to refuse health care
treatment.
Because of this right, doctors need consent from patients before they
can treat them.

Consent may be expressed in words or implied by the patients


actions.
For certain procedures consent form is required as the part of the
consent process.
Consent should be documented on the chart.
Obtain consent for the treatment is the responsibility of the medical
provider. (eg : physician, dentist, nurse practitioner )
Information should be shared with client include a description of
procedures, any alternatives for treatment, the risk involved in the
procedures and the problem results.
A person can only give valid consent if they are competent or have
capacity. Capacity means the person is able to understand the
information that is necessary to make a decision about the proposed
treatment.
If someone is not capable of giving consent, they need a substitute
decision maker to act on their behalf.
ADVANCE DIRECTIVES:
Advance directives are legal documents and are described in
legislation as patient wishes.
They completed in advance of the situation in which they might be
needed.
In the emergency situation where the patient is incapable and there is
no substitute decision maker available then the health care provider
obligated to follow those wishes.
There are various types of advance directives.
LIVING WILL:
A living will provides information on preference regarding end of-life
issues such as care to provide and whether or not to provide various
resuscitation measures.
Eg: most commonly they declare that if I am terminally ill and not
expect to recover , then I want this care and do not want this care given

The living will request no resuscitation or limited resuscitation efforts to be


undertaken physician must write orders limiting resuscitation in the
records.

DURABLE POWER OF ATORNEY FOR THE HEALTH CARE:


It is a document that legally designates a substitutionary decision-maker
should be the person be incapacitated. This document may be combined
with living will contains advance directives.

FRAUD:
Fraud is deliberate deception for the purpose of personal gain and is
usually prosecuted as a crime.
One example would be trying to obtain a better position by giving
incorrect information about the patient to a physician.
This may be prosecuted as a crime, because the nurse placing the
patient in a danger.
Courts tend to be more harsh in decisions regarding fraud than in
cases involving simple malpractices, because fraud represent a
deliberate attempt to mislead others for your own gain and could
result in harm to those assigned to your care.
ASSAULT AND BATTERY:
Assault is saying or doing to make person genuinely afraid.
Battery is touching a person when that individual has not
consented to the action .
Assault and battery are crimes under the law.
Both are most commonly treated as criminal cases when they
involve suspected abuse of a patient.
FALSE IMPRISONMENT:

Making a person stay in a place against his wishes is false


imprisonment.
the person may be forced to stay either by physical or verbal
means.
Example: if you do not stay in your bed, ill sedate you.
The patient has the right to leave the health care institution
regardless of the medical advice .
Health care providers are obligated to document the behaviour of
concern, problem solve alternative actions, and then try those
alternative actions before resorting to any type of restraint.
Documentation of the entire process is essential.
Nurses who determine the need for restraints must obtain a
physicians order as soon as possible.
MEDICATION ERRORS:
Medication errors are most common cause of adverse outcomes for
hospitalized patients.
The incidence of medication errors ranges from 4% to 17% of all
people being admitted to a hospital.
Errors had different sources, including inappropriate medication
for the condition being treated, incorrect dosage or frequency of
administration of medication and wrong route of administration.
Some errors result from drugs with similar name, look alike
medication containers and also hand writing problems may
contribute to lack of clarity.

B.

MANAGEMENT ISSUES

Nurses working in doctors' offices and hospitals have a difficult job


caring for patients and meeting the needs of both coworkers and superiors
within the institution. Nurse Managers who work in the medical professional
also have a complex and challenging role. It is a considerable challenge to

meet the needs of the organization, the needs of patients, and the needs of
the nurse employees

MEETING THE NEEDS OF THE CO-WORKERS AND SUPERIORS:


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

TURN OVER:
Turn over means the rate at which the employees leave a company and
are replaced by other peoples or staffs.
Maintaining adequate staffing levels is a major issue in nursing
management.
Representatives working in nurse management and leadership are
often faced with the responsibility of controlling attrition rates.
Turnover in the nursing industry can be more difficult to control.
Nurses faced with long work hours for relatively little pay have few
motivations to remain in one position and often seek employment
opportunities at competing hospitals and neighboring clinics.
Since recruiting and training new nurses takes time and money, the
nursing leaders are charged with consistently working to keep
turnover levels low and to maintain current staff levels in an effort to
provide a minimum of quality patient care.
FUNDING:

Funding concerns are relevant to all areas of nursing leadership and


management.
Lack of funding is an issue for many nurse managers who seek to
provide sufficient compensation to existing nurses as well as to recruit
new nursing professionals for hire.
An underfunded institution cannot attract and provide for the right
professionals.
Funding inadequacies can also become a harm to the level of training
provided to medical staff, in addition to the needs for medical
equipment and supplies.
When the medical institution's quality of staff and training standards
must be lowered because of budgetary concerns, the overall level of
patient care is unavoidably reduced.
WORK LOAD:
Individual nurse manager workload and overall medical workload are
issues in leadership.
The medical profession is one that never sleeps and has an almost
constant need for qualified professionals both in hiring and
scheduling.
Not only do nurse professionals work long hours and many days per
week, but nurse managers and leaders are also faced with an everincreasing workload.
Dealing with patient concerns, providing training and support to
nurses, and acting as a liaison between doctors, nurses and medical
administration members can be taxing and stressful.
Many nurses are unwilling to enter into the nurse management field
because of the added stress and responsibility.
ISSUES REGARDING MALPRACTICE IN NURSING MANAGEMENT

*Issues of delegation and supervision

The failure to delegate and supervise within acceptable standards of


professional practice.
*Issues related to staffing

Inadequate accreditation standards- adequate number of staff


members in a time of advancing patient activity and limited resources.

Inadequate staffing, i.e. short staffing.

Floating staff from unit to unit.


ETHICS

Nurses are held to a high standard of ethics when it comes to patients,


co-workers and themselves. They provide care, promote human rights
and values, and help meet the needs of the less fortunate and
vulnerable. A major ethical goal is to also keep patients' information
confidential, and this includes not discussing patients in public
places. Another ethical issue is protecting patients from negligent coworkers who may endanger them. The individual nurse must not
endanger the patient and has to be accountable to the standards of
the field.
EFFECT
Effects of reform, shortages, ethics and salaries are issues that keep
nurses constantly thinking, growing and changing. Nursing
instructors make far less money than nurses in the clinical setting.
They also make less than other educators in different fields. In order
for nursing to succeed, there needs to be qualified candidates
educated, but with these low salaries nurses are not flocking to this
career path. Without these types of nurses being adequately filled
then qualified candidates will not have the opportunity to be taught.

These salaries need to be increased, and colleges and universities


need to see the value in these instructors.

ISSUES IN NURSING CURRICULUM DEVELOPMENT

Where are we now?


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

Walker describes five types of validation

Academic validation

Professional validation

Economic validation

Institutional validation

Performance validation

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


program.
Where we want to go?
This deals with the thinking and aspiration for future. Faculty must think
whether the educational program what is designed will help to meet the
expectations of individuals, families and communities in accordance far with
the developed countries or not.
What we want to achieve?
Nurse educators must be able to analyze and think critically that we are
preparing the students with the adequate skills to perform their expected
roles in all the three domains of professional tasks such as practical,
communication and intellectual skills according to the institutional goals
and educational objectives. The three types of skills to be achieved:Domain of attitudes (communication skills)
For example, feelings, values and interpersonal relationships
Domain of practical skills (imitation control and automatism)
Domain of intellectual skills(knowledge and recall of facts)
For example, Interpretation of data and problem solving.
How can we achieve?
The faculty must think the ways by which the curriculum can be developed
to which is relevant to meet the needs of the country.

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

EMPLOYMENT ISSUES

UNEMPLOYMENT:
India as a nation is faced with massive problem of unemployment.
Unemployment can be defined as a state of worklessness for a man fit
and willing to work.
It is a condition of involuntary and not voluntary idleness.
India Unemployment rate 10.7%
Some features of unemployment have been identified as follows:
-The incidence of unemployment is much higher in urban areas than in
rural areas.
-Unemployment rates for women are higher than those for men.
-The incidence of unemployment among the educated is much higher
than the overall unemployment.
-There is greater unemployment in agricultural sector than in industrial
and other major sectors

MINIMUM WAGE:
A minimum wage is the lowest hourly, daily or monthly wage that
employers may legally pay to employees or workers.
It generally applies to unskilled or semi-skilled laborers working in
service industries or manufacturing plants.
AGE DISCRIMINATION:
Older workers are more likely to have been with a company for a
longer period of time.
They are therefore likely to be in a senior position, or at the very
least have had many years to receive raises in the salary.
This increases the damage for past and future lost wages and
benefits.
Employee law suit against employers are increasing yearly because
the age discrimination occurs frequently.
WORK- LIFE BALANCE:

Balancing life and work is major issue for many managers.


If you are spending most of your time working, though your home life
will take a challenge.

Consequences of poor work-life balance:

IFL
SETS
WE
AF
S
L
O

N A L O IF
T EU I EE
WDX

N OC A T S
C TI R S
M I A DD E M
E
I TP I T
F ER T
R XI I O E I
NC
A DT
N A
AO O
N VN
L N O
E V
D
O

TG

I R ET G U
E E
H C

S
HE

P E N N E
S
DT
DE S
D
S
E
E

A
T
D S
I

WORK-PLACE VIOLENCE
Workplace violence can be any act of physical violence, harassment, or
other threatening, disruptive behavior that occurs at the work site.
Workplace violence can affect or involve employees, visitors,
contractors, and other non-Federal employees.
A number of different actions in the work environment can cause
workplace violence.
Work place violence can be inflicted by an abusive employee, a
manager, supervisor, co-worker, customer, family member, or even a
stranger.
Whatever the cause or whoever the perpetrator, workplace violence is
not to be accepted or tolerated.

The best prevention comes from identifying any problems early and
dealing with them.
It is best prevented by pre employment screening, employee
identification badges and guard services.
SEXUAL HARASSMENT
Sexual harassment is a form of illegal employment discrimination in
many countries, and is a form of abuse (sexual and psychological).
Sexual harassment, is intimidation or coercion of a sexual nature, or
the unwelcome or inappropriate promise of rewards in exchange for
sexual favors.
Intimidation is intentional behaviour "which would cause a person of
ordinary sensibilities" fear of injury or harm.
Coercion is the practice of forcing another party to behave in an
involuntary manner (whether through action or inaction) by use of
threats, intimidation or some other form of pressure or force.
Coercion may involve the actual infliction of physical pain/injury or
psychological harm in order to enhance the credibility of a threat
Torture is one of the most extreme examples of coercion i.e. severe
pain is inflicted until the victim provides the desired information.
It includes a range of behavior from seemingly mild transgressions to
actual sexual abuse or sexual assault.
For many businesses, preventing sexual harassment have become key
goals of legal decision-making
ISSUES RELATED TO NURSING SHORTAGE
The nursing shortage is another international event. Why is there a
nursing shortage? There are many opinions regarding that question. I
have been a nurse long enough to recognize that nursing shortages

wax and wane. This shortage is more noticeable, however and it is


lasting longer. The nurse shortage itself is a contributing factor
because the shortage creates staffing problems, mandatory overtime,
and constant calls for additional shift work. National nursing
organizations are making strong efforts at stopping the shortage by
mandating better nurse- to-patient ratios, eliminating mandatory
overtime, and increasing salaries and benefits for nurses.

ISSUES IN NURSE MIGRATION

Nurse migration has attracted a great deal of political as well as media


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

THE RIGHT TO WORK AND THE RIGHT TO PRACTICE


Professionally active nurses are important players in an increasingly
competitive and global labor market. Unable to meet domestic need
and demand, many industrialized countries are looking abroad for a
solution to their workforce shortages; the magnitude of current
international recruitment is unprecedented (ICN, 2005). For nurses to
practice their profession internationally, they need to meet both
professional standards and migration criteria. The right to practice,

e.g., to hold a license or registration, a professional criteria, and the


right to work, e.g. to hold a work permit, a migration criteria, are
sometimes linked. Yet they often require a different set of procedures
with a distinct set of competent authorities.
In the interest of public safety, nurses' qualifications must be screened
in a systematic way to ensure they meet the minimum professional
standards of the country where they are to deliver care. This may be
in the form of a paper screen, for example automatic recognition of
qualifications received from a given country or school; tests, such as
the NCLEX licensing exam; supervised clinical practice, as seen in an
adaptation period; and/or successful completion of an orientation
course/program
Language is a crucial vehicle for the vital communication needed both
between the patient and care provider, and also between members of
the health team. It is not surprising that in many countries, a nurse's
right to practice is limited if the foreign-educated nurse's language
skills do not support safe care practices. Passing specific language
tests are required in certain countries. In others, the employer is held
responsible

for

ascertaining

the

language

competence

of

the

employees/health professionals. Clearly, history has demonstrated a


tendency for migrant flows to be the strongest between source and
destination countries that share a common language (Kingma, 2006).
For example, nurses wishing to migrate from Morocco will tend to go
to France while nurses from Ghana will be attracted by the United
Kingdom. As the pools of nurses willing to migrate change, and as
language

competency

becomes

professional

advancement

requirement, language barriers may prove to be less of a constraint,


and we may see Chinese nurses working in Ireland and Korean nurses
going to the US

Foreign nurses also need to meet national security and immigration


criteria in-order-to enter the country and to stay on a permanent or
temporary basis, with or without access to employment.. For example
a tightening of border restrictions after terrorism attacks or the
opening of borders with new economic agreements, such as the
expansion of the European Union, will continue to influence nurse
migration patterns.

EXPLOITATION AND DISCRIMINATION


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

ESSENTIAL TERMS AND CONDITIONS IN AN EMPLOYMENT


CONTRACT
An employment relationship has traditionally been governed by the
terms and conditions of the employment contract. Previously, the
employer retained sole control in respect of the terms and conditions
of employment to be incorporated into the employment contract.
However, over the years there has been an increase in the implied
terms and conditions which are also read into the contract.
Additionally, then there are the statutory terms and conditions which
also apply. A badly drafted employment contract which does not
correctly express the intentions of the employer on such matters as
working hours, prolonged illness, bonus payments, usage of office

computer facilities, transfers, retirement age, confidentiality, conflict of


interest, disciplinary action and imposition of punishment, etc or the
omission to mention some of these items in an employment contract
can give rise to serious consequences for employers. This talk will
focus on what are considered as essential terms and conditions which
employers must incorporate into an employment contract and the
consequences of failure to do so.
UNSATISFACTORY WORK PERFORMANCE AND TERMINATION OF
EMPLOYMENT
The Courts have time and again reiterated that employees enjoy security of
tenure of employment. The maxim "easy to hire difficult to fire" is a truism
even in the case of probationers. No employer having hired a person at
considerable cost and having exposed the person to training, formal or
otherwise, will want to terminate the person. However, when an employee
has an attitude problem or whose work performance is not up to the
expectations he cannot be terminated by the employer simply by invoking
the termination clause in the employment contract. The employer has to
follow certain rules and procedures and only at the end of it can he
terminate the services of a non-performing employee. Even then, there are
no iron clad assurances that the termination will not be challenged by the
employee at the Industrial Court. How does an employer ensure that he
minimizes the risk of being challenged in Court over a termination of
employment due to unsatisfactory work performance? This talk will attempt
to take you out of the labyrinth.

MISCONDUCT AND IMPOSITION OF PUNISHMENT

It has long been held that the employer has the inherent right to
discipline his workers. Should misconduct be committed, the employer
after a proper inquiry has been instituted can impose a suitable
punishment, including dismissal if the offence committed was of a
serious nature. The decision on the type of punishment to be imposed
is under all circumstances a subjective one. The Courts will interfere
if, among others, the action taken by the management was perverse,
baseless or unnecessarily harsh or was not just or fair. There have
been occasions where employers have imposed the punishment of
dismissal for misconduct which they have assessed as serious but
these cases have been reviewed by the Industrial Court and the
decision of the employer substituted. Given that imposition of
punishment is a subjective matter, what factors or criteria should an
employer apply in determining appropriate punishment for
misconduct committed in employment. This talk, among others, will
examine some of the issues to be taken into account
RENEWAL OF NURSING REGISTRATION
So that registration office is updated with nurses in practice. Of
course re- registration may qualify its periodicity and qualifications of
nurses e.g. clinical experience, attendance at continuing education
etc.

DIPLOMA VS DEGREE IN NURSING FOR REGISTRATION TO PRACTICE


NURSING

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

SPECIALIZATION IN CLINICAL AREA

It

could

be

either

through

clinical

experience

or

education.

Specialization in cure and specialized care required for patients


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

NURSING CARE STANDARDS

Standards must be laid down and followed so that clients understand


the quality of care expected from the nurses

SUMMARY AND CONCLUSION


Overall, legal and ethical issues are occurs in every fields. Some
issues recur frequently in nursing practice. It is wise for the nurse to
understand these particular issues as they related to individual
practice. The nurse and other health care team members have the
rights and responsibilities to prevent and overcome the issues which
occurs in their field.

ASSIGNMENT:
Write an assignment on strategies to overcome the employment issues.

THEORY APPLICATION:
GENERAL SYSTEM THEORY.

INPUT

OUTPUT
Students gained
knowledge
regarding
patient care
issues,
management
issues,
employment
issues &
medico-legal
issues

Students
having
inadequate
knowledge
regarding
patient care
issues,
management
issues,
employment
issues &
medico-legal
FEED BACK
issues.
THROUGH PUT

Teaching about
the patient care
BIBLIOGRAPHY
issues,
management
Book reference:
issues,
th
1. Ann Mariner-Tomey
employment (1992) 4 edition Nursing management
Mosby
publishers.
issues
& medicolegal issues using
2. Jacqualine
powerM.Katz
point & Elener Green Managing quality, A guide to systemwide performance
management in health care mosby publishers
presentation
3.,E.R.Tattersall Nursing management in practice ;Thomson east kill bride,
Scotland
4. Basavanthappa BT, (2008) Text book of Nursing administration, 2 nd
edition, Jaypee brothers: Newdelhi
5. M. Rokeach, The Nature of Human Values, New York, The Free
Press,1973.
6.H.M. Trice and J.M. Beyer, The Culture of work Organisations, Englewoods
Cliffs, NJ, Prentice Hall, 1993.

7.J.P. Kotler and J.L. Herkett, Corporate Culture and Performance, NewYork,
The Free Press, 1992.
8.E.H. Schin, Organisational Culture and Leadership, 2nd ed., San
Francisco,Jossey-Bass, 1992
9.Sakharskar BM, (2006) Text book of Hospital administration and
planning , 1st edition, Jaypee brothers: Newdelhi.
10.Syed Amin Tabish, (2003) Text book of planning, organisation, and
management, 2nd edition, Jaypee brothers: Newdelhi.
11.Janice Rider Ellis (2004), Nursing in todays world, 8th ed; Lippincott
Williams Wilkins, page no: 289-302
12.Francis .C.M (2004) Medical ethics, 2nd ed: Jaypee brothers
publications. Page no: 28-30
14.Sally h.rankin (1983), patient education :issues ,principles and
guidelines, 1st ed; J.b Lippincott company, page no:100-101

Journal reference:
1. Peterson R (2006). A patient care team approach to multicultural
patient care issues, 10:3, page no:75-90
2. sahshee broota(2000) Employment - Issues and trends, 45:23
Page no: 68-90
Net reference:
*www.google.com
*www.scribd.com