Chapter VI

Control systems most used in nursing administration

As mentioned in the previous chapter, control as an element of administration

consists of the establishment of systems that allow monitoring or tracking the activities
of the organization, as well as measuring current and past results, in relation to those
expected, with the purpose of knowing if what was expected has been obtained, in order
to correct, improve and formulate new plans if necessary.

Now, these systems according to Balderas María are supervision and evaluation.
Both systems are the most used in nursing administration and are the ones that will be
described below according to the author Balderas María in her book on nursing services
administration.

Nursing Supervision and Evaluation

Supervision

In nursing, supervision is: a democratic direction that guides the efforts and
actions of the supervisory staff to achieve organizational objectives, through the
development of the potential of the supervisee, in order to provide quality nursing care,
promote staff development supervised, maintain discipline and interest in work, optimize
human and material resources, create an environment favorable to productivity and
ensure the achievement of institutional objectives.

Now, supervision is the primary function of bosses, deputy bosses, supervisors and
service managers. In nursing, supervision is carried out according to administrative
levels; Thus, for example, managerial level supervision is carried out by the head nurse,
intermediate level supervision is carried out by the deputy head of nurses and supervisors
and, finally, operational level supervision corresponds to those in charge of the service.

From this point of view, it would be important to highlight some functions of the
intermediate level nursing supervisor.

Duties of the Intermediate Nursing Supervisor

These are:
 1. Establish a situational supervision diagnosis.
2. Prepare supervision plan.
3. Analyze and assess the quantity and category of nursing personnel required in the
assigned work area.
4. Collaborate with the head of service in the assignment and distribution of
personnel.
5. Take part in the planning and execution of in-service teaching programs.
6. Determine the ideal work system for the services.
7. Participate in personnel integration techniques.
8. Solve problems that are reported to you or that you detect; If they are out of
reach, transfer them to the corresponding hierarchical level.
9. Prepare the distribution of shifts, schedules, vacations, breaks, and other
calendars of the nursing staff.
10. Calculate personnel needs according to categories.
11. Maintain discipline and interest in work.
12. Promote cooperative efforts in the health team.
13. Select personnel to apply incentives and sanctions aimed at nursing staff.
14. Establish means to serve ascending, descending, horizontal and general
communication systems.
15. Prepare reports and receive them.
16. Take decisions.
17. Receive and delegate functions.
18. Conduct staff interviews when necessary.
19. Apply surveys to know the skills of the staff.
20. Evaluate personnel, directly or indirectly, in your area.
21. Provide incidental or planned teaching.
22. Participate in job descriptions and corresponding analysis.

23. Take part in clinical sessions, promoting staff participation.

24. Manage and develop forms of supervision and evaluation of personnel.
25. Supervise the care provided by the nursing service to the patient.
26. Plan with the medical staff and other health team professionals the actions
corresponding to patient care.
27. Provide an environment favorable to productivity.
28. Ensure that the patient has an environment of trust, well-being and hygiene.
 29. Promote creativity and innovation, in order to improve nursing care.
30. Participate in teaching and guiding family members.
31. Monitor the conservation and proper use of the installed capacity of the service.
32. Guide staff on the handling of special equipment, when required.
33. Evaluate the equipment and material needs of the services.
34. Collaborate in the development of technical-administrative instruments of the
department.
35. Contribute to the development and updating of forms managed by department
personnel.
36. Monitor the adequate and timely provision of material and equipment in the
services.
37. Preparation of reports.

It should be noted that supervision will always be carried out by highly qualified
personnel. A supervision program will indicate exactly the methods and means that will
be used for supervision and will never exceed a period of six months.

That said, in the next section we will emphasize the description of the distribution
of time for supervision, the barriers in supervision and the methods and means of
supervision for a better understanding of this control system.

Time distribution for supervision

The way in which time is distributed to carry out high-level supervision term, will
allow or not its success.

According to research studies carried out by supervisory personnel, parameters

have been established to distribute time when supervising. These parameters are:

Supervision area Estimated time

Supervision of staff 45% of the day
Supervision of care provided 20% of the day
mentioned
Supervision of the ability 20% of the day
installed

Teaching actions 5% of the day

 Investigation 5% of the day
Personal activities 5% of the day
TOTAL 100%

Barriers to supervision

Supervision in nursing, like any interpersonal process, faces barriers that limit, or
simply prevent, the achievement of objectives. Some of the most common are:

• Do not schedule supervision.

• Negative attitudes of those supervisees.
• Negative supervisor attitudes.
• Abuse of power and authority when supervising.
• Incorrectly distributing supervision time.
• Unqualified supervisory personnel.
• Lack of knowledge of the area to be supervised.
• Deficient managerial support to the supervisor.
• Large number of personnel to supervise.
• Inappropriate assignments to the supervisee.
• Frequent absences of supervisory and supervised personnel.
• Communication barriers.
• Personnel conflicts.
• Unfounded criticism of supervised personnel.
• Non-acceptance of supervision.
• Age of the supervisor and supervisees.
• Indiscipline of those supervisees.
• Low employee morale.
• Shoestring budget.
• Resistance to changes by the supervisor and those supervisees.
• Unpunctuality of employees.
• Autocratic leadership of the supervisor.
 Methods and means of supervision

First of all, it is important to remember that supervision is democratic management

of personnel development, and that its main interest is the supervisee. From this, it can
be done in two ways:

1. Direct supervision, through observation, tour, interviews and teaching

2. Indirect supervision, through usual nursing records, statistics, personnel
files, technical-administrative instruments, reports and care plans.

A. Methods

Observation

Observation is the action of applying the senses of perception carefully, according

to certain purposes. Since it must be done objectively, it is equivalent to obtaining data,
facts and phenomena.

Observation pursues the purpose of obtaining information about the effectiveness

of the care provided, specifying the problem areas.

The values of the supervisory staff will be present in the observation, so ability and
honesty are important in making judgments. Although observation is done continuously,
it should not be confused with surveillance; On the contrary, what is reported about what
is observed will serve to guide, stimulate, help or restrict, in such a way that a feeling of
confidence is fostered in the worker.

Not only the staff will be observed, but also the patient, the environment and the
re course materials used in nursing care.

The annotation of outstanding facts will be examined with critical judgment, in

order to specify the quality of the care provided and, consequently, improve nursing care.

Supervision tour

The tour is one of the most useful forms of direct supervision. It must be pla need
and with well-defined purposes. Through observation, problem situations will surely
have been identified for which solutions will be established during the tours.
 Approaching patients and family members allows us to detect nursing care needs
that have not been resolved. This approach during the tour constitutes an excellent
opportunity to guide and collaborate with the supervised personnel. At the same time, it
promotes a feeling of security in the patient and family, by demonstrating concern for
their comfort, well-being, hygiene and timely care.

Getting closer to the staff strengthens positive interpersonal relationships by

allowing them to express their concerns, problems, complaints and suggestions, among
others. Remember that it is important to know how to listen, which means being
interested in people.

The time for the daily tour must be distributed according to an action plan and a
schedule of activities. During it, situations are frequently faced that require an immediate
solution: try not to delay making decisions, as this would aggravate the problem. If there
is a climate of group cooperation, the same personnel will collaborate in making
decisions. For this, it is essential to have exercised positive leadership.

It is important to write down the observed events considered as outstanding in the

daily journey, in order to explain and predict, as far as possible, the fortuitous events that
may occur, and to be prepared for decision making.

Interviews

The interview should always have a defined objective and be planned in such a
way as to provide the expected results. It is a product of needs identified when
supervising. It is planned based on a limited number of questions, with a structure that
allows an interaction in which tension can be released, problems solved, analyzed,
suggested, guided, shown solidarity, among others. It is important to create an
environment of mutual respect and trust. The interviewee must feel that his cooperation
is important, and that he has not been used for the supervisor's particular purposes, which
must be strictly true.

The essential purpose of interviews is to improve staff productivity, so their results

should always propose some solution.

Interviews must be carried out in a place that ensures the privacy of the participant.
 Teaching

Teaching to produce significant changes at work is a way to super aim and, at the
same time, to ensure a positive result.

Supervision by itself is not teaching, but it must apply educational actions. cative
in their work.

The intellectual structures and the thought process itself pass through the
experience of the subject in relation to the surrounding objects. The learning (knowledge,
skills, abilities and attitudes) necessary for a professional task are acquired in the
theoretical-practical confrontation.

When teaching it is important to promote meaningful learning. The supervisor

should not limit herself to informing how to do it, but rather induce the staff to obtain the
necessary experiences that allow them to learn how to put it into practice.

Learning will allow you to solve problems on your own, investigate situations to
create innovations by cultivating intellectual abilities. Relatively autonomous action in
terms of interests, attitudes and values must be attempted by the supervisor, as a product
of teaching.

It is evident that teaching within supervisory action requires the application cation
of teaching principles and techniques, therefore the supervisor has the responsibility
responsibility to know the theories of the teaching-learning process.

The transmission of knowledge can be incidental or planned, but it will always

take into account man as a biopsychosocial being; It always occurs in specific situations
that generate a product.

B. Monitoring means

Usual nursing records

The nurse handles various forms of paperwork, so many that they may be
considered excessive. Currently, the question is how to avoid managing an excessive
number of them, which undoubtedly takes time away from direct patient care.

Reviewing records is important in indirect supervision. Among the different forms

that the nurse manages are:

1. Nurse sheet.
2. Nursing care plans.
3. Muja of clinical records and treatments.
4. 24-hour fluid balance sheet.
5. Daily patient census.
6. Intensive care sheet.
7. Medication request.
8. Vouchers to the equipment center.
9. Newborn identification cards.
10. Daily work report at the supply center.
11. Nursing staff rotation and distribution plan.
12. Nursing staff vacation rotation plan.

13. Nursing staff break rotation plan.

14. Various reports.

Nurse sheet. It is one of the most important instruments to indirectly monitor the
effectiveness of care: staff notes show their experiences, knowledge and qualities. It is
also possible to detect staff failures and needs that must be resolved. The notes on the
nurse's sheet constitute a summary of the care provided to the patient and their response
to the care received.

Nursing care plans . The nursing care plan is another useful instrument for
carrying out indirect supervision. It indicates the degree of knowledge, experience and
capacity of the staff to detect needs and health problems in the patient and, at the same
time, schedule actions for their solution. Due to its importance for nursing care, it will be
discussed in a separate chapter.

Clinical records and treatments sheet . This sheet is a monitoring instrument,

which allows evaluating the progress in the patient's recovery. It also allows us to know
the compliance of the staff in nursing care focused on the biological aspect of the patient.

24-hour fluid balance sheet. As in the previous case, the responsibility and skill of
the nursing staff is noted in the execution of this very important activity in the treatment
of the patient.
 It is possible to detect problems in measuring liquids, filling out forms, and others
that require immediate attention from the supervisor.

Daily patient census. The census allows the supervisor to know the movement of
patients and, therefore, the distribution of personnel and the appropriate work system for
the services. The statistical data obtained regarding the average and daily number of
patients also indicate the workload of the nursing staff.

Intensive care sheet. Each institution has its own forms, but in general they cover
complex special care; By evaluating them, the quality of care is known.

Medication request. With various formats, it helps us calculate the daily

allowance, consumption and its use.

Vouchers to the equipment center. It is important that the supervisor reviews the
vouchers made by the personnel of the different services, in order to know the cost of
equipment and material resources, which will allow her to foresee the timely provision of
material and equipment.

Newborn identification cards. The supervisor will verify the data on the cards
against those recorded on the identification bracelets, an important action to foresee
errors and avoid them in a timely manner.

The expulsion nurse frequently writes down some observations on the cards.
vations related to birth, which allow the supervisor to evaluate the quality of nursing
care.

Daily report of work in the equipment and sterilization center.

This report will allow the nurse supervisor to calculate staff productivity and at the
same time know the shifts with the highest workload, information that will be useful to
distribute and assign the necessary staff.

The establishment of a minimum and maximum of productivity will be determined

according to the data in the report. The indicators for personnel calculation are also
susceptible to modification according to the reports.

Nursing staff rotation and distribution plan . Like any plan, the nursing staff
rotation and distribution plan must contain justification, objectives, organization,
activities (indicators, calculation, distribution and descriptive letter) and evaluation. It is
generally carried out by the head nurse, together with the supervisory and deputy head
staff: it is advisable to keep this plan updated.

As a supervisory instrument, this plan provides an overview of human resources

and their distribution. When distributing personnel, it is worth considering assigning the
right person to the position. The supervisory function will be aimed at promoting better
distribution and staffing in services.

Nursing staff vacation rotation plan. Like the previous one, this one contains the
aspects of a plan and is prepared by the head nurse, deputy head and supervisory staff: it
is essential to calculate and distribute substitute personnel.

When determining vacation periods, it is important that the plan contemplates a

margin of flexibility for unforeseen cases, takes into account, as far as possible, the
preferences of the staff, and observes the legal aspects of worker rights.

It is highly advisable to intersperse vacation periods, so that a very long period

does not elapse between them, since the staff's performance will decrease if it is not done
this way. If the legal period is 10 x 3 (3 periods of 10 days per year) it implies that each
period will occur every four months.

Nursing staff break rotation plan. The importance of this plan lies in the fact that
through this instrument the distribution of personnel per day is organized, the necessary
personnel for sixth and seventh day substitutes are foreseen, and the number of personnel
needed is determined with certainty. daily in the services.

Various reports. It is common to find patterns of formats for reporting, which is

considered inconvenient, since it automates the information and produces errors, in
addition to leading to a loss in the richness of details, creativity and innovations of the
worker.

Better results are obtained if the worker is taught how to prepare their reports, the
aspects they should include and how to synthesize the information in statistical tables.

Assessment
 The Evaluation of nursing human resources is understood as a system through
which it is possible to diagnose and propose solutions to the problems of nursing
services, with the purpose of measuring and comparing the progress of care plans,
determining the effectiveness of actions of the personnel, verify the results of the
supervision programs, detect the areas that require reinforcement for the development of
personnel, ensure the correct use of material resources, foresee the constant existence of
material resources in good condition, avoid waste and specify the problems that limit
patient care. Evaluation steps

However, it is important that evaluation as a systematic process is carried out in

stages, permanently and also taking care to use the results to obtain progress. The cost
and time spent in the evaluation will be sterile if the results are archived.

When evaluating, it is important to take into account: the objectives, needs,

resources, scope and measurement instruments, according to the following stages or
steps:

1. Investigate by aspects.
2. Quantify with qualitative-quantitative parameters.
3. Specify results compared to what was planned.
4. Establish solutions to problems or determine new goals.
5. Communicate the results of the evaluation to those involved.
6. Evaluate the evaluation instruments.

Some ways to evaluate nursing staff are:

a) Profiles.
b) Skills inventories.
c) Graphics.
d) Patient survey concentrates and formats. However, the eve luation of
medical care considers many other factors. To you nuation, examples of
three instruments used for evaluation are shown. luation in nursing.

I) Guide to evaluating medical care.

II) Guide to evaluate the nursing department:

1. Department organization

• Philosophy
• Goals
• Policies
• Organization system and organizational charts
• Flowcharts
• Manuals
• Definition of functions
• Communication system
• Work systems
• Administrative technical instruments

2. Human Resources

• Personnel calculation
• Absenteeism calculation
• Shortcomings
• Issues
• Stock
• Introduction and staff development
• Ladder system
• Bacteriological control and detectionof cases
• Work risks

3. Material resources

Endowment
Maintenance

• Conservation
• Utilization
• Calculation
• Control systems
 Administrative diagnosis

Results of plans and programs

Like the previous guide, the guide to evaluate the nursing department should be
more complete.

Nursing roles in different areas and levels of care

Before approaching the description of nursing roles in the different areas and
levels of care, it is advisable to review some basic concepts that help to better understand
the topic. First of all, what is meant by role?

The Encarta encyclopedia defines it as:

The pattern of behavior of people in social situations. He also points out that it can
be understood as the role that the person plays in the social drama...

Thus, this gives us to understand that the professional role of nurses is related to
the context where the work is carried out. In this sense, the roles or roles that nurses can
carry out are: the care role, the teaching role, the administrative role and the research
role.

The care role refers to humanized, systematic, high-quality care to promote health,
protect from diseases and participate in the required therapy, through the application of
general or specific nursing techniques and procedures.

The teaching role corresponds to the transmission of knowledge in the professional

training of nursing human resources, in health education, in training and in continuing
education, based on needs, risk factors and teaching-service integration.

The administrative role encompasses specific actions based on the theory and
methodology of administration applied to the nursing service, to improve care for the
individual, family and community.

The research role involves the application of knowledge through the application of
corresponding theories and methodologies, based on diagnoses of various aspects of
health that lead to the development of projects to improve care within nursing.
 Now, the traditional conception that has considered nursing as an auxiliary
profession to medicine changed, imposing a redefinition of the roles of the profession
and an expansion of its activities and work areas at different levels of care. For this
reason, it is impossible to give a sufficiently broad textual framework of all the areas
where the profession is practiced, to completely cover the expectations of understanding
about nursing roles, so we will only refer to some areas immersed in the different levels
of care to describe the roles that the nursing profession plays.

Thus, within this context, the topic will be developed starting with the levels of
health care based on what was written by José Manuel Abad in his book Study of Health
Care Levels in Venezuela.

First level of health care

According to José Manuel Abad, this level, based on criteria of location of

services, magnitude and vulnerability of the population's health problems, with the
available technology, can be defined as:

The initial assistance instrument of the Health Administration, which, due to its
lower complexity, facilitates access and participation of the population who demand or
not demand health services, which is offered in a timely, outpatient manner and without
distinction of age, sex or reasons for consultations, obtaining the maximum health
product with little investment of resources.

Consequently, all nursing activities according to the different roles they play are
framed in outpatient care and active participation in the community. With this clarified,
let's start with the nursing roles at this level:

Healthcare role

The goal of the nurse in this role is to achieve the highest possible level of health
for the individual, family or community through the provision of care and health
promotion. So the nurse, in her daily practice, performs the following functions:

1. Community study to identify health needs.

2. Assessment of family and environmental health.
3. Censuses and home visits.
4. Promotion of social organization for health.
5. Pregnancy detection and control.
6. Control of the child's health.
7. Somatometry.
8. Immunizations.
9. Participation in priority programs, such as tuberculosis, diarrhea and
leprosy, among others.
10. Environmental sanitation (treatment of excreta, water and garbage, housing
hygiene, promotion of sanitary works and food management).
11. Management and control of equipment necessary for field work.
12. Channeling the patient to existing health services in the community.
13. Caring for the individual's health in a personalized, comprehensive and
continuous manner, respecting their values, customs and beliefs.
14. Participate in the preparation, analysis and discussion of the health situation
of its population, detecting vulnerable groups, risk factors and
implementing actions aimed at their reduction and/or elimination.
15. Carry out actions that provide solutions to health problems, identified in the
Health Situation Analysis.
16. Participate in epidemiological surveillance programs.

17. Carry out actions included in health programs that provide solutions to the
problems of your community.
18. Carry out and control the Nursing Care process, as a scientific method of
the profession.
19. Record in the comprehensive medical history all available information
about the problems identified in individuals, the family and the community.
20. Assess the information collected to carry out nursing actions.
21. Evaluate the responses of the individual, family or community to treatment
and nursing care, recording them in the comprehensive medical history.
22. Carry out health promotion and promotion activities for individuals,
families and the community.
23. Carry out disease prevention and protection activities for individuals,
families and the community.
24. Carry out healing and palliative care activities for the individual.
25. Carry out rehabilitation and social reintegration activities for individuals
 and families.
26. Execute nursing techniques and procedures within the scope of your
competence.
27. Carry out actions aimed at maintaining health surveillance and control of
infectious diseases in the population.
28. Carry out actions aimed at controlling the environment and achieving a
healthy environment.
29. Plan and execute nursing actions in emergency and disaster situations.
30. Promote intersectoral and multidisciplinary collaboration in the
management of health care for the population.

In general terms, these are all the activities of the nurse in their care role in the
community, but to be more specific we will touch on some areas:

Immunization area: here the activities carried out by the nurse in her care role are
the preparation of the equipment (cellars), the administration of vaccines, the handling
and conservation of vaccines in accordance with the guidelines established to guarantee
the cold chain, the review of the vaccine cards, the management and filling out of the
daily vaccination record, the maintenance of the refrigerators and cellars according to the
guidelines of the immunization expansion program, among others.

Comprehensive adult care area: this service carries out activities such as:
vaccination, extraction of samples for the detection and monitoring of communicable
diseases (syphilis), measurement of vital signs, filling out the comprehensive medical
history (DSP - 01) for follow-up. and control of chronic diseases, if the patient has any,
participation in the preparation of the health certificate, referral of the user to specialized
consultations, participation in the medical physical examination, completion of the
nursing care process, etc.

Adult emergency area: here the activities correspond to the administration of oral,
intravenous, intramuscular and subcutaneous medications, administration of vaccines
(toxoid and anti-rabies), administration of solutions, intravenous catheterization,
measurement and recording of vital signs, oxygen therapy , dressings and application of
bandages, sterilization of material and equipment, handling and filling out the anti-rabies
form, daily vaccination record, notebook of administered medications, notebook for
monitoring vital signs and anti-rabies treatment notebook, performing the capillary blood
glucose test and performing electrocardiograms.

Supervised treatment area: in this service the care activities carried out are filling
out TB forms and records, collecting sputum samples, administering and monitoring
compliance with medications for TB treatment, and administering the vaccine. PPD.

Administrative role

The objective of the nurse in this role includes the administration of services
through a set of activities that try to guarantee the coordination of the efforts of the
people who provide nursing care to the individual, family and community. In daily
practice, the nurse in her administrative role performs functions such as:

1. Participate in the development of plans and programs of the nursing

department.
2. State administrative rules and techniques in nursing procedures.
3. Formulate nursing department policies.
4. Participate in the definition of roles and responsibilities of the nursing staff.
5. Organize nursing care.
6. Plan and schedule nursing care.
7. Organize and control the nursing reporting and records system.
8. Direct and make decisions.
9. Collaborate in the development of nursing staff.
10. Delegate functions and assign activities.
11. Participate in the evaluation of health services.
12. Supervise and evaluate nursing actions.
13. Keep control of the material and equipment necessary for care.
14. Promote multidisciplinary meetings to improve care.
15. Analyze service problems and present solutions.
16. Calculate the personnel needed in the services.
17. Plan and control nursing care.
18. Advise on health planning at the institutional, service, municipal, provincial
and national levels.
19. Advise on nursing matters at institutional, service, municipal, provincial
and national levels.
20. Direct the nursing team in community care units.
 21. Design, implement and participate in quality evaluation programs for
nursing activity and establish standards for its measurement.
22. Establish nursing care, education and research policies.
23. Ensure the organization of the nursing staff's workstation.
24. Execute and control compliance with ethical and bioethical principles.
25. Develop administrative activities depending on the composition of the
Nursing Work Team.
26. Participate and direct nursing service meetings that are scheduled according
to the Nursing Work Team pyramid.
27. Participate in administrative and scientific nursing techniques.
28. Monitor nursing performance area to maintain and improve services.

To be more specific with the nursing administrative role, we will highlight two
important areas such as:

The department of the head of nursing: where he plays the administrative role
through activities such as adaptation and direction of the application of policies,
standards, projects, programs and health plans, direction of the diagnosis of the current
health situation of the community assigned, planning, programming and direction
required by the assigned community, in what corresponds to the fulfillment ment of its
objectives of health promotion, prevention, care and rehabilitation, establishment of the
patient referral and counter-referral system, to achieve comprehensive health care in its
area of influence, active participation in epidemiological surveillance tasks and in the
teaching-care programming. Active participation in institutional self-assessment to
measure the impact of health actions, as well as to identify and apply the necessary
corrective measures.

The nursing coordination department: in which the administration role is carried

out through activities such as calculating the necessary personnel in the services,
planning and controlling nursing care, analyzing service problems and presenting
solutions, maintaining control of the material and equipment necessary for care, establish
care policies, education and research in nursing

Teaching role

The objective of nursing in this role is related to the incorporation and transmission
of the knowledge and skills of the profession, whether it is continued training of team
members or educational programs aimed at the user or individual, family and
community. In this sense, the nurse in her teaching role performs activities such as:

1. Design, plan and participate in continuing education programs for nursing

staff and other health professionals.
2. Advise on educational planning at the municipal, provincial, national and
international level.
3. Perform managerial and teaching functions in national and international
university and non-university courses and schools.
4. Integrate the courts for granting and ratifying teaching status.
5. Perform methodological functions in national and international teaching
institutions.
6. Coordinate courses, stays, internships, diplomas and master's degrees, both
national and international.
7. Provide incidental teaching in the workplace.
8. Participates in teaching individuals and groups.
9. Collaborate in teaching nursing students and other professionals, in clinical
health or care practices.
10. Collaborate in in-service teaching programs.
11. Provides health guidance and education.
12. Provides teaching in special treatments.

In reference to some areas that demonstrate the nursing teaching role at this level
are:

The adult hygiene area: where it promotes healthy habits in general, through
educational sessions related to the importance of good nutrition, exercising, vaccination
and the prevention of sexually transmitted infections.

The area of immunization: in which the importance of vaccination is promoted,

(What are they? What are they for? And what effects do they have?

The area of breastfeeding: where its importance and the effects it has on the
baby's health at an organic and psychological level are raised.

The supervised treatment area: in which educational sessions related to the

prevention of tuberculosis, signs and symptoms of the disease, tests to be performed to
detect the disease, etc. are given.

The prenatal control area: where the pregnant woman is instructed on the care
they should take during pregnancy (nutrition, vitamin consumption, control of their
tension and weight, etc.). In addition, women of childbearing age are guided on family
planning.

Likewise, there is an educational room to hold workshops, educational sessions

and inductive sessions for nursing students and professionals. Here, seminars are given
on topics related to the field of nursing, updates on the different health programs that are
carried out in the different areas or services, and inductive sessions for all substitutes
who are entering the institution.

Research role

The objective of the nurse who plays this role has to do with carrying out research
projects and disseminating the methods used through publications in nursing or health
journals, communications or presentations at conferences, etc. The nurse within this role
as such develops activities such as:

1. Application of scientific research methods with the purpose of improving

nursing care, innovating techniques; procedures and even concepts and
actions.
2. Participate in studies or research carried out in the services.
3. Conducts research studies related to different areas of nursing.
4. Participate in research and epidemiological control studies.
5. Conducts and participates in research in nursing and other areas with the
aim of contributing to professional development and improving the health
of the population.
6. Disseminates and applies research results to contribute to improving health
care, nursing care, and professional development.

7. Coordinates, controls and participates in the execution of clinical trials in

research centers.
8. Integrate scientific advice.
 Second level of care

The second level of care, based on demographic criteria of age and sex, as well as
the specific health problem of the population; can be defined as; the instrument of health
administration, with greater structural and functional complexity than the first level of
care, where health problems are treated according to age, sex and the reason for
consultation in the health services of the outpatient clinics or hospitals of the system.

In this way, the second level of care can be described as the site or place of a
health organization where the population is assisted on an individualistic basis, that is,
based on their age, sex and the specific problem they suffer from.

Therefore, the second level of care is conceptualized as:

"The Instrument of Health Administration" which indicates that it constitutes a

procedure for the administration of health services, to guarantee the care of the
population who could not find the solution to their problem at the First Level, and
maintains continuity of the health care during the course of the process within the
system. In this way, the second level serves as support to the first, from whom it
receives, the entire population or clientele through referrals of special cases.

Second Level care can be outpatient or hospital; It is ambulatory when it is carried

out through the outpatient production units or activities that do not require the patient's
stay within the Institution, such as the outpatient consultations of Internal Medicine,
General Surgery, Pediatrics, Gynecology-obstetrics, Ophthalmology,
Otorhinolaryngology, Cardiology, Pneumonology and Psychiatry. It is hospital-based,
when the general hospital is the only health institution in the community, to provide care
through outpatient consultations of basic specialties, perform diagnostic and/or
therapeutic procedures that are few complex and that warrant hospitalization of the
patient in the services. general medicine, surgery, pediatrics and gynecology – obstetrics.

Now, as this is a level where there is both outpatient and hospital care, we dare to
point out that the care, administrative, teaching and research roles are very similar to
those of the first and third levels of care; Therefore, we will not develop these roles and
will take as reference those of the levels already mentioned.
 Third level of care

The third level of care, based on the criteria of organic location of the injury or
damage, can be defined as; The Instrument of health administration of maximum
structural and functional complexity, where health problems are addressed specifically
according to the organ, apparatus or system affected, requiring special diagnostic and
therapeutic procedures and in-hospital or eventually outpatient.

Care is generally provided through hospitalization or temporary confinement of the

patient to undergo diagnostic or therapeutic procedures specific to the level.

It should be noted that the nursing role at this level is the same as at the first level
of care, differing in that care is aimed at restoring the health of the population within the
health center and not extramurally.

Likewise, we can note that it is impossible to cover all the activities carried out by
nurses in their different roles in the areas of a tertiary care center, so we will only give
some examples. In this case we will take the area of internal medicine for this purpose.

Internal medicine area

Healthcare role

In the daily practice of the nurse in the internal medicine area, in her care role, she
performs functions such as:

* Provide nursing care in accordance with a well-founded diagnosis mentioned in

the health problems of patients.

* Collaborate in diagnostic and treatment exams. Carry out specific protection

actions for susceptible groups.

Fourth level of care

This level is where high technologies are included for a group of certain diseases
(cancer). This level proposes an example of hospital structuring for an institution whose
mission is to care for the highest level of complexity of pathologies, such as transplants
and treatments and interventions, which require the participation of several specialties
and supra-specialists simultaneously to solve each case. particular.
 Its care is hospital-based and it develops activities for a single system
(cardiovascular, neurological, orthopedics, trauma, etc.) it is called a “reference
hospital.”