Final Report or Observations, Activities, and Recommendations Concerning

Transcription

1 tit.. MAR Mifi'JUW Fina Report or Observations, Activities, and Recommendations Concerning The Nurs:tng Service Seou Nationa University Hospita and The Schoo or Nursing Seou Nationa University Seou, Korea D. Joan [Viiams, B.S., M.N.A. Adviser in Nursing Administration Under The University of Minnesota - nternationa Cooperation Administration Contract Assisting Seou Nationa University and the Repubic of Korea.. S December 1959

2 {\/1 (1 St-. ("' _,>(,f'... j { i Foreward The first adviser in Nursing to Seou Nationa University, Miss Margery S. Low, served from March 1957 unti December 1958 with particuar interest and emphasis directed to nursing education. Miss Low aso made significant contributions in nursing administration. The second Minnesota adviser to Seou Nationa University in the fied of nursing has been Miss D. Joan Wiiams, the writer of this report. Though Miss,Wiiams' primary area or attention was nursing administration, she aso provided vauabe continuing advice and assistance to the Schoo or Nursing reative to curricuum and course deveopment and instructiona methods. Miss Wiiams' educationa background incudes a Bacheor of Science degree in Nursing, Master degree in Nursing Administration, both granted by the University of Minnesota, and a Postgraduate Certificate in Operating Room Nursing from Yae University. She has had broad experience in nursing administration and education both in coegiate and private hospitas. Because of her devoted interest and industry in nursing and her abiity to work effectivey with peope, her accompishments have been great. The recognition of the nurse as a member of the medica team and emphasis of "patient centered" care have been furthered by her work at Seou Nationa University. N. L. Gaut, Jr., M. D. Adviser in Medicine Seou Nationa University ' \ \ j

3 Acknowedgements.. As near the competion of my year as nursing adviser to Seou Nationa University, find mysef thinking back to the first few weeks of my visit here. find that words are inadequate to express my sincere appreciation to a of the fine peope who have made my visit here so peasant. My ow;n persona growth in understanding peope and their contributions to this word has benefited beyond description. Specific thanks are due to the peope with whom have been working cosey: Miss New, Soon Han, Director of Nurses; Mrs. Lee, Kwi Hyang, Director of the Schoo of Nursing; Miss Lee, Song Hi; Miss Kang, Yoon Hi, and Miss Yang, Un Sook, hospita nursing supervisors; Dean Myung, Choo Wan; Dr. Kim, Dong k and Mr. Kim, Young Ki. The Minnesota advisory starr has, of course, been the "guiding ight" for many of my activities. Dr. A. E. Schneider, Dr. George Schimert, Dr. E. B. Brown, Dr. N. L. Gaut and Dr. Edon Bergund have been most patient, understanding and hepfu. The "home front 11 support was aso greaty appreciated. Miss Margery Low, my predecessor, continued to hep me throughout the year. Miss Katherine J. Densford and Miss Edna Fritz have continued their support of the program. Unofficiay, Miss Ruth Weise of the University of Minnesota Schoo or Nursing facuty has made vauabe contributions to my work and to the Korean participants in Minneapois. My sincere thanks and appreciation to a or you. [ f

4 ntroduction Athough the history and description of Seou Nationa University Hospita has been presented in detai by Mr. Genn Mitche, hospita administration adviser (1957-5S), a few comments are necessary here to carify the status of the nursing department in the tota organization. Seou Nationa University Hospita is a 450 bed hospita which incudes a cinica services for the care of Korean peope. t is an od buiding, constanty under reconstruction and rehabiitation panned as part of the Minnesota Project; it is a spacious and sprawing buiding spread over an acre of and. Service faciities such as the aundry, the kitchen, the morgue, and the pharmacy are in separate buidings, athough some are connected by corridors. Administrativey, the hospita is attached to the Coe~ of Medicine, Seou Nationa University. Therefore the medica staff is responsibe to the Dean of the Coe~ for teaching and research activities and to the Hospita Superintendent for the care of patients. The administrative staff of the hospita is ony tokeny responsibe to the Dean of the Coe~, but in actuaity report directy to University Headquarters and the Ministry of Education in the Korean gpvernment. The organizationa pan of the hospita is as foows: f'ervice j r1 ):>epartment~ Penera AffairSi -~ ub sectio _1_-ub section inance ~n. Affair~ - 3 -

5 . Organization of Nursing Department The nursing department is directy responsibe to the superintendent of the hospita. The interna organization of the nursing department seems to be we defined and generay functions in the approved ines. See Organizationa Chart on foowing page. The nursing administrative staff (nursing office) has seven officia positions. They incude 1. The Director of Nurses. 2. The surgica supervisor, now caed assistant director. 3. The medica supervisor, now on eave as a participant to the University of Minnesota. 4. The out-patient department supervisor. 5. The evening supervisor. 6. The night supervisor. 7. House mother. A except the Director are grade 4 government officias and the Director hods a grade 3 appointment. The medica and surgica supervisor are required to spend a considerabe amount of time in nursing administration duties. When the medica supervisor was seected to go to the University of 1tnnesota as a nurse participant, some reorganization was necessary. Since the project provides that the participant's saary sha be continued, it was not possibe to hire a repacement (no budget). The possibiity of the temporary promotion of one of the head nurses was discussed, but it was decided to reassign duties throughout the supervisory staff instead. Therefore, the out-patient department supervisor was asked to assume the cinica supervision of imited seected areas, and the remaining areas were divided ~tween the director and the surgica supervisor. Because this reduced the amount of actua supervision avaiabe, the head nurses were given the responsibiity of increased supervision. The tite of the Surgica Supervisor was miseading, and thus was changed to Assistant Director to indicate that administrative probems of a cinica areas woud be processed through this person... There is much to be desired in this present organization, of course. With the return of the medica supervisor, additiona changes wi be necessary. The cinica supervisors shoud not be required to work in the nursing administrative office. They shoud have offices on the cinica services and their time shoud be devoted to supervisory activities. This then woud necessitate the creation of at east one, and preferaby two positions for the nursing administrative office. One person coud be designated as assistant director, nursing service and one coud be designated assistant director, inservice education. At present, a services are oosey assigned to either the medica or surgica supervisor. Again this requires spreading supervisory services - 4 -

6 ...., "" ~VENNG AND tght SUPERVSoruJ- ~URSNG ~ TLDENT:i [OSPT AL SUPERNTENDENif. ~CTOR OF NL'RSE - -@fj) NURSES nterna medicine Neuro and chest surgery Genera surgery (incudes orthopedics) Obstetrics and gynecoogy Pediatrics (incudes ENT, Dermatoogy) Dentistry and E.ye Operating room Tubercuosis soation Psychiatry J STAFF NURSiji ~~~~~ ~--i~u~:~~e ~R$CTJ QPD suftj finical SUPV,st--J--~URGCAL SUPV bJhPED. SUPVJ Tbc OR OB-GYN soation CSR PEDS Medicine PAR Psychiatry SURG.

7 -... very thin. t is conceivabe, therefore, that one more supervisory position woud provide much needed supen'ision. t is visuaized then that four supervisors woud cover the areas of out-patient department, medicine, surgery, and obstetrics. n subdivision a areas coud be covered in this manner: (Organizationa Chart on Page 5). Out-patient Department A cinics 2. Medica Supervisor nterna medicine soation Tubercuosis Psychiatry 3. Surgica Supervisor Genera surgery Chest and neuro-surgery Operating room Post anesthesia room Centra Suppy room 4. Obstetrica 3upervisor Obstetrics and gynecoogy Pediatrics (incuding present additiona services) Athough the work oad here seems unequa, further sub-division seems unwise and, in fact, impossibe in the near future, without the appointment of supervisors for each of the speciaties. The new supervisor woud assume the task of supervising the nursing service of the obstetrica and pediatric departments where there is a great dea of work to be done. There are a tota of 73 officia nursing positions in the hospita. As just described, 7 of these are utiized in nursing administrative positions. The remainder are distributed as foows: Head Nurses (in-patient) 11 Staff nurses (in-patient) 43 Staff nurses (out-patient) 12 f During recent years, the student nurse enroment was high and in addition the schoo was required to educate nurses for the armed forces. n the past 2 years this has been discontinued and the numbers of students has decreased from approximatey 160 to the present number of 55. This obviousy affected the nursing department and additiona nursing personne was mandatory. HoSpita administration agreed to charge each patient a sma amount per diem and this money woud be used to hire "aid nurses". - 6-

8 There are now 55 such positions and these peope are utiized on every service. Nine of them are men who are assigned to the services where there is consider abe patient transportation to be done and to the mae psychiatric ward. n 1959, the government decreed an increase in saary for a government empoyees. The budget was aready estabished, however, so this necessitated a reduction in the number of professiona personne. Since the number remaining was inadequate to provide even minimum coverage (one nurse per shift per station) another appea was made to hospita administration for additiona "temporary" positions. At this time the casses were graduating from the nursing schoos in the area and nurses were searching for positions. The fina resut was the provision for 20 "temporary" positions at a token saary of Hw 5,000 per month ($5.00 on the oca' market) and room and board. This, then, provided a grand tota of 73 officia nursing positions, 55 aid nurses, and 20 temporary nursing positions for the nursing department. Athough this number provides minimum service at the present time with the present work pattern, additiona positions wi be necessary when a hospita wards are rehabiitated and open and when nurses are required to provide the majority of the nursing care. At present the famiy sti gives the majority of the physica care to the patient, and though do not recommend this be competey aboished, do beieve that many improvements coud be evoved it the number of reatives were decreased. This wi be discussed in more detai under Ward Management. Personne Poicies Personne poicies for government empoyees are in print but are fexibe with the demands of the situation and the decisions of the administration. A nurses are required to ive in the dormitory, except grade 4 and above who may, upon specia request, ive at home. This means that few nurses continue to work after marriage, athough some woud do so. As ong as the suppy of nurses meets the current demand, this is no probem and it most certainy is convenient to have the nursing staff avaijabe at a moment's notice. However, a few of the ong-tenure head nurses have reached a grade 4 position. This poicy, then, refects an unfair priviege for nurses hoding the same job tite with different grades. t is recommended, therefore, that officia grades be estabished for specific eves of nursing personne: Grade 3- director, Grade 4 supervisory staff, Grade 5 genera staff nurses. f it were possibe to provide a senior and junior grade eve under grade 4, this woud permit a sighty higher saary for supervisors over head nurses. The present saaries are deporaby ow compared to western standards, but are reativey midde-cass in the economy of the nation. The saary range for nursing empoyees is as foows: Grade 3: Hw 60,000-65,000 + room and board Grade 4: Hw 35,000-50,000 " Grade 5: Hw 30,000-35,000 " Temporary Nurse: Hw 5,000 + room and board Aid Nurse: Hw 5,000-15,000-7-

9 Nurses work six days a week athough government poicy states 5 days. Because of the 11 nature of their work and the needs of the country" they are asked to work six days. Head nurses are automaticay off duty on Sunday and the other personne rotate according to a set staffing pattern. Weekend staffing is dangerousy ow, but the work oad is so markedy reduced that it seems satisfactory to retain the present pattern. For personne satisfaction, however, woud incude the head nurses in the rotation pan so that staff nurses coud be off duty on Sunday at more frequent intervas. Vacation time is granted ony upon written request of the empoyee and approva by the hospita administrator. During this reconstruction period of the country, a Koreans are dedicated to their work and many of them have never taken a vacation. n actuaity, the government poicies provide for 20 days vacation and 20 days sick eave each year. Though records are kept, these imitations are not enforced. f an empoyee is absent over 40 days, hie saary continues up to 6 months. The next 6 months he is carried at hafsaary and finay asked to resign. This whoe area is invoved in the ack of insurance programs and the Korean's genera phiosophy of concern for his feow-man. Personne satisfaction and performance requirements woud be greaty enhanced by specific, enforced personne poicies however, and it is recommended that personne poicies for a hospita empoyees, within the scope of government poicies, be prepared and enforced. These were so prepared by the nursing department for the nursing department and submitted to hospita administration. They'were rejected since comparabe poicies were not avaiabe for other departments. Empoyment and termination of personne is aso determined by hospita administration. Few written references are received or sent to other hospitas regarding an empoyee's previous empoyment. This area needs great expansion to insure hiring as good a nurse as possibe. Athough records can be easiy fasified, the Director shoud have the satisfaction of knowing that she tried to obtain adequate records. Athough the Director of Nurses interviews and recommends appicants for empoyment to the administrator, the fina choice rests with the President of the University. t is recommended that the Director be permitted to make the choice of appicants and the approva of the administrator be granted on the basis of the empoyee's quaifications. Termination of empoyment is extremey difficut except by resignation. Th:5.s makes discipine of empoyees practicay impossibe since they have no fear of job insecurity. The mechanics for termination of an empoyee incude review by a specia committee in the hospita, recorrmendation for termination to University officias, to the Ministry of Education and finay to the President. The kindy nature of the Koreans make them reticent to put this machinery into action. ndeed, it is difficut to get initia evidence unti the probem is virtuay out of hand. t is recommended, then, that an evauation system be estabished throughout the hospita with the "discipinary board" meeting at specific intervas. A probem empoyees coud then be presented at this meeting and the appropriate action instituted. This woud remove the stigma of persona criticism which is so abhorrent to the Korean nature. The mechanics are there, they shoud be used. nefficient workers and irresponsibe empoyees woud be graduay dismissed and the J

10 empoyee morae and performance woud be increased for they woud know that good performance woud be expected of every one. Performance records become an important part of the evauation system of any personne program. Systematic, periodic evauations shoud be done on every empoyee in the nursing department. This procedure can be divided among the supervisory personne so that the burden is not too great for any one person. For exampe, head nurses shoud evauate the work of staff nurses and aid nurses on their respective stations; supervisors shoud evauate the work of the head nurses; the Director shoud evauate the work of the supervisors and the Administrator shoud evauate the Director. The evauations are useess, of course, if they are not used constructivey. Each empoyee, therefore, shoud be conferenced by his supervisor nnd informed about his work. With this system operating, it woud soon become easy to discipine and to compiment empoyees. The heath program for the nursing staff (in fact, for a hospita empoyees) shoud be studied. Annua physica exams shoud be compete examinations. Because of the high tubercuosis rate in Korea, a nurses shoud have chest x-rays every 6 months. Perhaps the fina point in personne poicies that woud stress woud be pacement of personne. There are ~~ny divided opinions regarding the vaue of the nurse who can work in any department versus the nurse who becomes speciaized in a speciaty area. Obviousy there are advantages to both. n the interest of improved patient care and satisfied personne, however, nurses shoud be permitted to work in the cinica area of their choice whenever possibe. Rotation of staff for orientation purposes coud be pe::.nr.tted for three to six months, but thereafter the nurse shoud be assi~ed to a cinica area and remain there unti it is necessary in the intereet of better patient care to transfer her, - 9-

11 Nursing Administration The nursing service has the responsibiity of summoning and coordinating itsef and its other departmenta coeagues for the care of the patient. t is administration that appies the resources that are avaiabe to the purpose which is aready estabished. Nursing servi~e administration is the system of activities directed toward the nursing care of patients. This is a simpe statement, but the principes, practices and poicies invoved in carrying out this definition are compicated and intricate and frequenty misunderstood. f the nursing department is responsibe for coordinating the care of the patient, it must be abe to operate as a department with the prestige and authority commensurate with the position. t must aso be capabe of assuming the authority given to it. For a matters deaing soey with the department of nursing, the director shoud have the authority to operate autonomousy. For a matters which invove other departments, she automicay woud operate through hospita administrative channes. For exampe, the rotation of nurses from one station to another shoud be the decision of the director of nurses. However, estabishing a pick up and deivery service shoud be discussed and decided by a department heads. Staffing of each nursing unit is the responsibiity of the director of nurses. She reviews the work oad of each department, the positions avaiabe and assigps the personne in the best way possibe. The number of positions at present is barey adequate. As the patient census increases, the number of reat:t -..res is decreased, and the number of student nurses is decreased, more posit:~ o:r. s are going to be necessary. The director of nurses shoud be abe to ju.stif:r these positions on the basis of work oad and the required hours of nu"sin? c::re per patient per day. Tbe quaity of the nursing staff is aso the responsibiity of the director of nurses. Obviousy, she cannot personay be responsibe for individua actions, so she must depend on various procedures to assist in maintajning the quaity of the staff. f a usua precautions have been exercised in the empoyment of personne, it is then necessary to keep the staff constanty informed of new poicies and procedures as we as the atest deveopments in medica and nursing care. An active, up-to-date in-service education program must be carried out. There are many opportunities for inservice education avaiabe at Seou Nationa University Hospita. When doctors are asked to give casses fer nurses, these casses shoud be coordinated with nursing care casses. New equipment arrives reguary. Organized demonstration casses shoud be hed to keep a the staff informed. n addition to reguary schedued in-service education casses, the quaity of nursing care shoud be evauated. This subject has been discussed under ''Personne Poicies" but it is so important that fee it needs repeating. t is virtuay non-exist~nt for the empoyed nursing staff at the present time. To improve the quaity of nursing care, the supervisory staff, incuding the head nurses must estabish a periodic evauation system and record these evauations so that a copy may be paced in each empoyee's - 10-

12 personne fie. One of the most important areas of nursing service is that of reporting. There are many forms of reports and records used at Seou Nationa University Hospita. This whoe area needs considerabe study, for many of these records are merey checking systems. For exampe: report from the aundry, report on syringe breakage. Certainy reports are necessary but they shoud be meaningfu instead of a mere coection of facts. A critica survey shoud be made of a reports received in the nursing office, and those reports which are merey dupicates or checking systems shoud be eiminated or simpified. One very time-consuming activity in the nursing office is the administration of the aid nurse program. A monies coected from patients for aid nurses (both specia nurses and reguar starr) are turned over to the Director of Nurses. She is responsibe, then, for paying the aid nurses each month, and keeping a records pertaining to the "aid nurse fund." n addition to the aid nurse payro, this fund is used to purchase some sma items for the nursing department such as pencis, matches, fy-swatters, etc. Another such "fund" is the incubator fund. Since obstetrica patients are free patients, the hospita is unabe to provide the soap, powder, mik, baby cothes, etc., necessary for the care of the new born. A specia charge was estabished for the baby paced in the isoette or incubator. This money was turned over to the nursing office to purchase the above suppies. t is recommended that a coections for hospita service be handed by the cashier's department. Requisitions for hospita suppies shoud be handed through reguar hospita purchasing channes and not by sending an aid nurse out to the oca market. The head nurses meet with the supervisory staff each Wednesday morning. This meeting is used to inform the head nurses about new poicies and procedures and to isten to their probems. A representative from the interne staff hns recenty been asked to attend these meetings to discuss some of the probems which require the assistance and cooperation of the doctors. Once a month the supervisors, head nurses and chief residents meet with the administrator of the hospita. At this meeting, the nurses hesitate to voice their probems so itte vaue is derived from the meeting. t has been stated that each head nurse and resident of the respective departments hesitate to admit any difficuties within "their" department. t seems to me this is just perpetuating the system of separate departments without the benefit of the advantages to be gained from standards estabished for the whoe hospita. Evening and night supervision of the nursing department needs to be studied and improved. These supervisors are responsibe for the tota operation of the hospita after 5 p.m. athough there is an administrative officor on ca after 5 p.m. Much of their time is spent in administrative duties w.ith itte time to make adequate visits to the nursj_ng stations. Th3 r8ports given to and by the supervisors are often sketchy. r

13 A reguar routine of dutiee for the evening and night supervisor shoud be estabished. They shoud be responsibe for the supervision and evauation of a nursing personne during their hours on duty. A function~ ings of the department shoud operate through the supervisor. For exampe, if emergency surgery is required, the supervisor shoud be notified to ca the nurses on "ca" duty. She shoud be notified of a new admissions, dis charges, deaths, and any unusua occurrence anywhere in the hospita The supervisory staff shoud be encouraged to meet together for the purpose of increasing their own technica knowedge. Severa of the girs read Engish we enough to benefit from review of Engish anguage nursing journas and to present this information to the rest of the staff. There is itte opportunity to pan for the future in the present work day of the nursing starr. Each person is kept busy with such a myriad of detais pertaining to the present that they have itte desire to think or pan for the future. Hours of observation of the daiy traffic in and out of the nursing office revea nursing responsibe for so many non-nursing activities that it is amazing that these nurses are abe to keep their main purpose in mind at a. These non-nursing activities (such as expaining to a famiy the various charges on his hospita bi, or teing a famiy iving on hospita property that he must move) must be referred to the proper administrative officer where it shoud be handed without further question. The fina point sha make in nursing administration is the rea need for recognition of the nursing department as an integra working unit of the hospita organization. This wi be referred to in a areas of this report. f nursing is to make progress, nurses must be respected for the contributions they can make; their ideas must be considered and discussed; they must have authority to operate within the department of nursing. Some wrong decisions are to be expected, but nurses wi not earn to administer efficienty and we unti they have adequate opportunity to do so. They need the strong support of hospita administration, medica starr and other department heads. The recognition given during the past years, due primariy to the presence of a foreign advisor, is not heathy. They must be reco 1ized for their own vaue. n tum, nurses must accept this responsibiity and recognition and strive to improve their own status

14 nterdepartmenta Reationships t is recogp.ized that the nursing department is the argest department of a hospita; it is the one department that has constant direct contact with the patient; it covers a wide variety of activities and is therefore an expensive department to operate. t hods a vita position for it coordinates ~ a of the work done by a departments for the patient. This poses a rea probem when individua departments do not appear to recognize this fact and are interested ony in the work done by that department. This invoves cooperation at a eves and woud resut in improved efficiency in a departments. Pharmacy The procedure for obtaining medications at present is time consuming and cumbersome. The usua procedure is as foows. On afternoon rounds a doctor writes medication orders for the foowing day. The prescription must aso be written at this time. The nurse then copies the prescriptions into a "drug book". The prescriptions are then picked up the foowing morning between 8 and 9 a.m. and deivered to the pharmacy. The drugs are returned to the station between 11:30 a.m. and 1 p.m. Obviousy, there is considerabe deay in giving of medications. n addition, the packages are marked ony with the patient's name and the dosage. Nurses then compare the packages with the 11 drug book" and write the name of the drug on the package. This is not ony dangerous; it is utiizing nursing hours for pharmacy work. Recenty a arge number of drugs has been issued to the nursing stations as 11 stock 11 medications to avoid deay when "stat" medications are ordered or new orders are written in the morning. This is actuay an unsatisfactory answer to the probem since the drugs are used but prescriptions are not competed for the drugs and therefore they are not repaced. n addition, a daiy check must be made of the drugs to determine what drugs have been used and then the search begins for the patient who received the drugs. Another probem is met when the patient is permitted to purchase medications on the open market. Athough th:.s is against hospita poicy, some doctors encourage it, and many others accept it when patients say they wi obtain their own drugs. Athough beieve that patients have the right and priviege of knowing what treatment they are receiving, do not beieve they shoud be tod what drugs to purchase on the market. Specific recommendations are many in the area of medications: 1. Orders shoud be considered continuous unti discontinued. A 3-4 day suppy shoud be dispensed at one time. 2. Prescriptions shoud be deivered to the pharmacy by 7:30 a.m. n the hours before the out-patient department opens, the hospita prescriptions coud be fied and returned to the wards by 9:30 a.m. 3. Each drug must be identified by the name of the drug, the strength of the

15 drug in the package and the name of the patient Nurses must obtain prescriptions from the physicians tor every drug used. Hospita poicy regarding purchase of drugs by patients shoud be foowed. Doctors shoud not permit patients to purchase these drugs. When this is done, these drugs shoud be removed from the patient's room to the nursing station so that accurate records may be kept The use of the "drug book" on the nursing station shoud be eiminated. This is merey a "check" to be sure that the pharmacy fis a prescriptions and it shoud not be necessary. 7. More frequent, efficient pick-up and deivery service shoud be instituted. This shoud be studied for a areas of the hospita. Dietary Department The dietary service for patients in the past has been sketchy and virtuay no specia diets were avaiabe. The hospita charges separatey for food and about 50% of the patients eect to provide their own food. This makes operation of the kitchen expensive and with inadequate budget, the hospita was unabe to provide satisfactory, appetizing meas. This year a graduate of the Coege of Home Economics, Seou Nationa University was empoyed as hospita dietitian and the service and food has noticeaby improved. Faciities for deivery of the food, however, do not provide rapid service and as a resut, food is often cod. After the food carts are deivered to the wards, a nurse and nurse aid have the responsibiity of deivering the trays to the patients. f the patient does not wish to eat at this time, the tray is saved and heated ater on by either famiy or the nursing staff. Trays are gathered up by the nursing starr and paced in the ward kitchens where they are coected by the kitchen starr at a ater time. The seection of diets incude iquid, genera, diabetic, sat-free, and post partum. No consutation regarding diets is done with the dietition. Perhaps the biggest probem for the nursing department in this area centers around the 50% of the patients who prefer to have their food provided by their famiies. A ward kitchen is provided on each ward for famiies to use whie preparing the meas. This is a probem mainy from the standpoint of ceaniress. Charcoa briquets are used as a source of heat in sma cay "hwaro" or meta stoves. Dust, ashes, garbage, and running water are constant deterrants to the most industrious of head nurses in her attempts to keep the... ward cean. n addition. the haway sinks are used for washing dishes and the patient's rooms are stacked with cooking utensis, dishes and foods of a kinds. ' t is difficut to make recommendations in this area that wi answer a probems without osing some advantagee for the patient. The foowing poicies are suggested: -14-

16 i j 1. Adequate, nourishing, attractive food prepared by the hospita kitchen. t shoud automaticay be provided as a part of hospita care. 2. A cooking in the hospita wards must be eiminated in the interest of good pubic heath principes. 3. The dietitian shoud be asked for consutation regarding individua patient's diets. More patient teaching shoud be done in this area 4. Patient's trays shoud be identified in the kitchen to faciitate deivery on the wards. 5. Kitchen personne shoud be utiized to deiver and to pick up mea trays to the patient. 6. A imited quantity of food shoud be avaiabe after hours for ate admissions, ate deiveries etc. This coud be dispensed by the night supervisor to the stations where it coud be heated and served by aid nurses. 7. The nursing staff shoud be more aware of the patient's diets, record accuratey on the charts and work more cosey with the dietitian in providing specia diets when ordered by the physician. Housekeeping Department The genera housekeeping for the hospita is administered by the genera affairs section of hospita administration. A nobe attempt is made by the workers to keep the hospita foors swept and mopped, the windows washed periodicay and other genera housekeeping procedures performed. nadequate suppies and equipment, such as soap, mops and buckets make this an amost insurmountabe task. Housekeeping is considered such a menia task that these empoyees are practicay on the bet tom Of the "cass ist'. As a resut they are often soveny in their appearance and few have pride in their work. Nurses order these empoyees around with itte concern for their work oad or work organization. They are often asked to assist with transporting patients (hand-carrying stretchers) because they are the ony men avaiabe. Recommendations in this area incude: 1. A hospita-wide campaign for ceaniness shoud be carried out and enforced continuousy. 2. A housekeeping supervisor shoud be empoyed Routines for hospita housekeeping shoud be prepared and foowed. 4. Famiies shoud be enisted to assist with the hospita ceaniness campaign. 5. The nursing staff shoud set exampes for the housekeeping staff and other hospita staff by keeping cean treatment rooms, utiity rooms and - 15-

17 using every opportunity fot teaching patients, famiies and others. Laundry At present nursing administration is responsibe for the personne in the aundry. Patient inen is issued to each station weeky based on the current census. Routine change of inen is done weeky. Additiona suppies are avaiabe for intermediate changes when necessary~ A patient is charged with sheets and piow cases when he is admitted and these are coected when he is discharged. There has been considerabe oss of inen, however and a sstisfactory checking system has not been deveoped. Patients must suppy their own bankets and this provides an exceent camoufage for hospita inens if adequate cheeks have not been made. There have been so many improvements during the past year that it is truy most encouraging. Patient pajamas are now avaiabe for a patients, and sheets and piow-cases are avaiabe at more frequent intervas. More towes and wash coths are necessary. These sma items, as we as others such as masks, surgery caps, etc., are washed by the aid nurses on each ward since there is danger of osing them in the hospita aundry. Soap is issued weeky to the aundry on the basis of work to be done. This is authorized by the Director of Nurses. A daiy report is made to the Director of Nurses isting the numbers of each artice washed each day. This varies with the weather, the water avaiabe and the amount of inen to be washed. However, there is a constant backog of used inen waiting to be washed. Recommendations 1. The aundry department shoud be responsibe to the genera affairs section rather than to the nursing department. 2. Laundry inventory sh0ud be handed by aundry personne rather than nursing personne. 3. Laundry of sma items shoud be done by the aundry at a specific time each day to prevent oss of these items. 4. Adequate drying space shoud be provided so that a constant work oad coud be carried by the aundry. 5. Laundry trucks now in the store room shoud be put into use immediatey for transporting used inen within the hospita corridors. Large bundes are now "head carried" or "back carried." 6. Towes and wash coths shoud be purchased so that more nursing care.. coud be given to patients

18 Laboratory One of the usua hospita commodities that has been difficut and expensive to procure in Korea has been test tubes. t has been necessary to prepare used medication vias for the coection of bood sampes. This preparation is done by the aboratory and issued on an exchange basis to the nursing stations. nternes draw the bood specimens each morning and they are coected by a aboratory aid on routine rounds about 10:30 a.m. Two recommendations evove from the present work pattern 1. Laboratory specimens shoud be coected by 8 a.m. each morning. 2. A used medication vias shoud be turned over daiy to the aboratory so that a stations coud receive bottes without the necessity of exchange. Summary The main objective of hospita operation is the best possibe care for the patient. This invoves every department and every empoyee in those departments. t aso requires great cooperation between departments so that a work done for the patient can be coordinated. Because the nursing department is the one most cosey associated with the patient, they must have cordia, cooperative working reationships with a departments. This then, requires consideration by a departments for the work of the nursing department and their cooperation in estabishing coordinated routines

19 V Ward Managemeht t has often been said by nursing administrators that the most important singe individua in the nursing department is the head nurse of the individua nursing unit. f each unit is functioning smoothy, patients receive good care, doctors receive good service and the personne on that unit are happy in their work. Obviousy these are "big shoes to fi." The customs of the country which has decreed that women are servants for men, the menia status of nursing in the past, and the ack of education in administration for nurses has made it difficut for nurses to assume the roe of a head nurse in charge of he~ station. Unti recent years, doctors were in charge of the nursing units and there are sti remnants of the probems which evoved from the change-over. For exampe, if a doctor wishes to go a~inst hospita poicy, the nurses cannot object, and to protect themseves, wi not report the offender to the proper channes. The emphasis from doctor-centered care to patient-centered care is sowy deveoping. This wi ony be accompished when nurses are forced to provide the majority of the nursing care for patients. Modern concepts of medica and nursing care are more and more providing for the emotiona security of the patient. One of the most important eements in the security of the Korean patient is his famiy. The nursing staff in Korea shoud recognize the vaue of the famiy in teaching good heath habits and utiize a opportunities that are avaiabe. One member of the famiy shoud be permitted to stay with the patient, but it is difficut for the nurses to barge into the famiy circe (often incuding mother, rather, grandparents and severa chidren) to offer nursing services which are often rejected by either the patient or the members of the famiy. n addition, there have been inadequate suppies for use in nursing care. Up unti this year there has been a minimum amount of inen and utensis, and the hot water for bathing must sti be hand-carried from the kitchen or heated in buckets in the ward kitchens. t is no sma wonder that if the patient says 11 No", the nurse wi not encourage him. n spite of the handicaps, there has been progress in this area in the past year. Work assignments are made primariy on a functiona basis. Unfortunatey, in many areas it is aso based on a so-caed "cass" system. For instance, some aurses fee they shoud not have to do such things as assist a patient with a bed pan. This is deegated to the aid nurses. Students have compained that a they are assigned to do is take the temperatures and change the beds. This whoe area depends upon the changing attitude of the nursing staff and their acceptance of the concept of patient-centered care.. There are severa toos that can aid in promoting these attitudes. One is the daiy work assignment prepared by the head nurse. This shoud be prepared through the assignment of specific patients, rather than by the functiona methods. t must be done daiy with consideration for the experience of students, the care needed by the patients, and the tota work to be done. -1.$-

20 .., ' ;,, Another too is the patient Kardex, a simpe record of each patient on the ward showing medications, treatments, specia probems and other facts which wi enhance the care of the patient. t shoud be referred to frequenty, used as the basis of reporting from shift to shift, and changed as often as necessary. The tendency at present is to use it ony as another record of medications and treatments, and is actuay just an additiona chore, rather than an aid to information Ward teaching and bedside teaching are probaby the most reaistic means of increasing knowedge in both medica and nursing care techniques. This area is sady negected on the wards at Seou Nationa University Hospita. Nurses ask few questions of the medica staff regarding the care of patients but rather seem content to foow orders without knowing why. This whoe area coud be easiy deveoped. Nurses shoud recognize that they wi be compimented rather than criticized if they exercise inteectua curiosity regarding the care of patients. The deveopment of poicy and procedure books has been sow but steady. The use of ~hese books is dependent upon the head nurse. Once the poicy is estabished, it must be foowed. f a new procedure is deveoped, a nurses must be informed, demonstrations hed and the practice of the procedure instituted. Supervision of nursing staff and nursing students is an accepted duty of the head nurse. This invoves observation of a personne at work, correction or praise when indicated and periodic written evauations. The schoo of nursing provides an evauation form to be used for the students. A simiar evauation instrument shoud be deveoped for the nursing staff and shoud be used by the head nurses at reguar intervas. Supervisory and patient rounds are probaby the most important means by which the head nurse keeps informed about the care and condition of patients and the work of empoyees. They shoud be made at east daiy and more frequenty if necessary. This time can be utiized for many things - patient teaching, student teaching, pubic information, and even checking on housekeeping and maintainance repairs necessary for a we functioning unit. Recommendations for the improvement of ward management, therefore, incude: 1. The head nurse must assume the position of ward manager, enforcing a estabished hospita poicies and procedures, regardess of pressure from medica staff or patients. 2. A nurses must be encouraged to recognize the need for patient-centered care, the patient-teaching responsibiities inherent there-in, and the necessity of oyaty to the hospita and the nursing profession by practicing good nursing care. 3. The newy estabished nurses "ca system 11 shoud be expained to a patients and put into use. The reduction in the number of reatives shoud assist in the use of the ca system

21 4. Work assignments for the nursing staff shoud be on the basis of patient care, rather than on a functiona basis of work to be done. 5. Reguar ward casses, teaching rounds and bedside cinics shoud be # panned and conducted on each unit. 6. Supervisory rounds and evauation records shoud be done at reguar intervas. 7. Nurses must recognize that their position in the society wi b$ enhanced and improved ony through their own actions. They must prove their own capabiities by increasing their knowedge, accepting and practicing changes in poicies and procedures, and deveoping a persona integrity that wi aways be above question. The above recommendations can be considered for a nursing units. There are aways a few specific statements which appy to the speciaty departments. For Exampe : Pediatrics 1. The head nurse shoud have the authority to assign patients to specific rooms on basis of diagnosis, age group, etc. 2. The pay room shoud be used more extensivey. The department coud aso be easiy made attractive for chidren and this shoud be considered in the seection of paint when the remodeing is competed. 3. Nurses interested in pediatric nursing shoud be encouraged to deveop this interest and shoud be permitted to remain on the pediatrics station. Obstetrics 1. Aseptic technic in the deivery room area shoud be rigidy enforced. 2. Nursery technic shoud be individuaized for each baby and a modified aseptic technic enforced to minimize cross-infections. 3. Routine nursing care such as bathing is equay important, if not more so, for the post partum patient. This shoud be carried out routiney as a teaching procedure for the new mother. Operating Room 1. The traffic of unauthorized persons in the operating room must be reduced. nfection hazards (the wearing of street cothing in the operating rooms, indi.scrimate scheduing of contaminated cases, etc.) and exposion hazards (wearing of wooen or nyon cothing, smoking, etc.) must be removed by the enforcement of strict reguations. 2. ThGre is a great waste of nursing service in the operating room due to the

22 ate starting time of surgica procedures. Obviousy, there are t~o soutions: a) nurses shoud not report for duty unti a ater hour, or b) the surgeons shoud begin operating at an earier hour. 3. The operating room head nurse must cooperate with the nursing office by reeasing nursing staff when the schedue so permits. 4. Aseptic technic must be improved~ Uniforms worn in the operating room shoud not be permitted without cover gown outside of the surgica suite. soation 1. soation technic to prevent cross contamination must be estabished. A hospita personne, incuding aboratory technicians, maids, etc., must gown (and mask where indicated) before entering a patient's room. 2. Visitors to the isoation department shoud be eiminated. 3. A diagnostic admission room shoud be estabished. 4. Termina ceaning shoud be estabished. W~ny of these recommendations cannot be carried out without the cooperation of the madica staff, the administration of the hospita and a other hospita departments. Adequate suppies and equipment must be provided to permit the procedures to be carried out, and then the poicies and procedures must be foowed by every person invoved

23 V Nursing Education The background of the deveopment of the Department of Nursing, Coege of Medicine has been we described in the report.of Miss Margery Low, nursing adviser This section, then, wi be a progress report of the past year. The Department of Nursing was officiay estabished, through the approva of President Rhee on January 13, n the document which estabished the department, no provision was ~ade for facuty positions for the new department. This means, then, that the facuty of the Coege of Medicine are aso the facuty of the Department of Nursing and a authority rests with this facuty. With the strong support of the Dean of the Coege of Medicine, one of the new facuty positions aotted to the Coege by the Ministry of Education was reserved for the position of Director of the Department of Nursing. n November, 1959, Mrs. Lee Kwi Hyang, former Principa of the Technica High Schoo for Nurses, was eected by the facuty to the position of Director of the Department of Nursing. The question of future facuty members is an imminent one. As the Technica High Schoo phases out in , these facuty positions shoud be transferred to the Department of Nursing. The present facuty members have been working hard to improve the eve of teaching and to increase their own knowedge in educationa methods. Athough some of them do not possess the quaifications required for university facuty, some provision shoud be made to retain them as part of the teaching staff. t was recommended by Miss Low that facuty members be permitted to enro as students through reguar University channes to take one or two educationa casses each semester for credit. This has not been possibe, and the recommendation is again repeated. This woud permit the present facuty to work towards obtaining the necessary quaifications for appointment to the university facuty... n the next two years there wi be a tota of eeven nurses who wi have been participants at the University of Minnesota Schoo of Nursing. Six of these, incuding Mrs. Lee, are members of the schoo facuty and must be appointed as facuty members of the Department of Nursing. Due to the distinct separation of the hospita and the schoo, nurses in the hospita do not assume any responsibiity for the teaching of students. Cooperation woud be greaty improved and teaching greaty enhanced if some forma recognition was provided for quaified nurses in the hospita. t seems that the return of the hospita nurse participants from Minnesota woud provide an idea opening for consideration of this proposa. Supervisors and head nurses with specia preparation in cinica areas shoud be appointed as cinica instructors for the Department of Nursing and shoud be given specific responsibiity for teaching. Much of the teaching is currenty done by members of the medica staff

24 .. i Many of the doctors are interested in the improvement of nursing service and nursing education, but they need assistance in understanding the current phiosophies of nursing education and the changes occurring as a resut of the growth of the profession. t is recommended that reguar facuty meetings be conducted where curricuum, methods of teachings and correated experience for students coud be discussed and pans made for improving course content. t is the responsibiity of the nursing members of the facuty to inform the medica staff just what course content wi meet the objectives of the course and the tota curricuum. n the curricuum for the coegiate program, casses in each area of cinica experience wi be taught concurrenty with the experience. This wi require the medica staff to teach severa times a year instead of once as in the past. The facuty meetings suggested above woud aso provide the means to expain the vaues of this curricuum pan to an aready busy medica staff. The proposed curricuum and cinica rotation pan is attached to this report. Course outines for each course must be reviewed and revised in the interest of upgrading the course to a coegiate eve. Consideration shoud be given to increase the amount of student participation in cass work. Because of the ack of text books in the Korean anguage, most of the student's reference materia is notes obtained from ectures and conferences. The coege students shoud be abe to use the Engish text books more readiy and assignments shoud be given which wi require independent work on the part of the student. With the opening of the nursing education buiding in February, 1959, the cassroom faciities are ampe. The nursing arts aboratory is beautifuy equipped. t is recommended that teaching equipment that is used infrequenty in this aboratory be turned over to the hospita for use in nursing care. t can be borrowed from the hospita when the actua cass is to be hed. Athough the document providing the counterpart for the furniture for the schoo buiding has been signed, the money has not yet been reeased by the Ministry of Reconstructioni A efforts to obtain this money shoud ~e intensified, or the budget of the Department of Nursing shoud incude a yeary aowance to provide for,gradua acquisition of furniture. n addition, the budget shoud make aowance for maintainance of the buidings. Some provision must be made fer keeping the buiding cean and in good repair. Ground breaking ceremonies for the construction of the new dormitory directy behind the schoo buiding were hed in December, Expected competion wi be in the fa of 1960, and it is hoped that this winter wi be the ast spent in the present grossy inadequate iving quarters. The future of nursing education at Seou Nationa University appears bright. Cooperation, understanding and assistance is needed from a areas of the heath fied. With continued hard work by the 'nursing facuty and * Reeased ate in December