Management strategies in managing nursing Practice: Leadership styles

Management strategies in managing nursing Practice: Leadership styles of nursing administration

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This is a broad nursing-administration topic. It can be organized into:

Management strategies in nursing practice
Leadership styles in nursing administration
Leadership functions such as delegation, staffing, communication, motivation, and conflict resolution
Quality improvement, patient safety, and change management
Practical examples for ward or unit management

At a high level, nursing management focuses on planning, organizing, staffing, directing, coordinating, controlling, and evaluating care. Leadership determines how the nurse manager influences staff: for example, democratic leadership supports participation, while situational leadership adapts to staff competence and the urgency of care.

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This is a broad nursing-administration topic. It can be organized into:

Management strategies in nursing practice
Leadership styles in nursing administration
Leadership functions such as delegation, staffing, communication, motivation, and conflict resolution
Quality improvement, patient safety, and change management
Practical examples for ward or unit management

Please choose one for detailed notes:

Management strategies in nursing practice
Leadership styles in nursing administration
Both, in exam-note format
Practical ward-management examples

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"Lower Respiratory Tract Infections"[MeSH Terms] AND nursing

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WHO lower respiratory tract infection clinical management adults pneumonia nursing care guidance

Nursing Care Plan: Lower Respiratory Tract Infection (LRTI)

Suitable for a patient with acute bronchitis, bronchiolitis, or pneumonia. Adapt it to the diagnosis, age, severity, local protocol, and prescriber’s orders.

Assessment

Subjective findings

Cough, with or without sputum
Shortness of breath, chest discomfort, fatigue
Fever, chills, poor appetite
Difficulty sleeping due to cough or breathlessness

Objective findings

Fever, tachypnea, tachycardia
Low SpO₂ or cyanosis
Crackles, wheeze, diminished breath sounds
Productive cough with purulent sputum
Use of accessory muscles, nasal flaring, inability to speak full sentences
Abnormal chest imaging or laboratory findings, if ordered

1. Nursing Diagnosis: Ineffective Airway Clearance

Related to: increased tracheobronchial secretions, inflammation, fatigue, and weak cough.
Evidenced by: productive cough, abnormal breath sounds, retained secretions, dyspnea, or ineffective coughing.

Goals / expected outcomes

Patient will demonstrate an effective cough.
Airway will remain clear, with reduced secretions and improved breath sounds.
Patient will maintain adequate oxygenation as ordered.

Nursing interventions and rationale

Interventions	Rationale
Assess respiratory rate, depth, pattern, sputum amount/color, cough effectiveness, and lung sounds regularly.	Detects deterioration, retained secretions, and response to treatment.
Position in high-Fowler’s or semi-Fowler’s position, unless contraindicated.	Improves chest expansion and facilitates breathing.
Encourage coughing and deep-breathing exercises. Teach splinting of the chest if pain is present.	Mobilizes secretions and promotes alveolar ventilation.
Encourage fluids if not contraindicated by cardiac or renal disease.	Helps thin respiratory secretions.
Provide humidified oxygen or humidification as prescribed.	May reduce airway dryness and help mobilize secretions.
Encourage early ambulation and regular position changes.	Prevents secretion pooling and improves ventilation.
Perform chest physiotherapy, suctioning, or nebulization only as indicated and prescribed.	Assists secretion removal when the patient cannot clear the airway independently.
Administer prescribed bronchodilators, mucolytics, and antibiotics or antivirals; observe response and adverse effects.	Treats bronchospasm, assists secretion clearance, and addresses the underlying infection when indicated.

Evaluation

Cough is effective.
Sputum is expectorated more easily.
Breath sounds improve and respiratory distress decreases.

2. Nursing Diagnosis: Impaired Gas Exchange

Related to: inflammation, alveolar fluid or exudate, ventilation-perfusion imbalance, or airway obstruction.
Evidenced by: low SpO₂, dyspnea, cyanosis, restlessness, confusion, tachypnea, or abnormal arterial blood gases if measured.

Goals / expected outcomes

Patient will maintain SpO₂ within the prescribed target range.
Patient will show reduced dyspnea and work of breathing.
Patient will remain alert, without signs of hypoxia.

Nursing interventions and rationale

Interventions	Rationale
Monitor SpO₂ continuously or at scheduled intervals according to severity.	Identifies hypoxemia early.
Assess for increasing respiratory distress: severe dyspnea, accessory-muscle use, altered mental status, cyanosis, or exhaustion.	These can indicate impending respiratory failure.
Administer oxygen exactly as prescribed and titrate only according to protocol or order.	Corrects hypoxemia while avoiding inappropriate oxygen administration in susceptible patients.
Maintain upright positioning and reposition at least regularly as tolerated.	Enhances lung expansion and ventilation distribution.
Cluster nursing care and allow rest periods.	Reduces oxygen demand and fatigue.
Collaborate for ABG testing, chest imaging, escalation of oxygen device, or respiratory therapy review if condition worsens.	Supports prompt diagnosis and treatment escalation.

Evaluation

SpO₂ is within target.
Respiratory rate and effort improve.
Patient is less restless and can speak more comfortably.

3. Nursing Diagnosis: Hyperthermia

Related to: infectious process.
Evidenced by: elevated temperature, chills, sweating, and tachycardia.

Goals / expected outcomes

Temperature will return toward the normal range.
Patient will verbalize improved comfort and maintain adequate hydration.

Interventions

Monitor temperature, pulse, hydration status, and level of consciousness.
Encourage oral fluids if safe and not restricted.
Provide light clothing, comfortable room temperature, and tepid measures if appropriate.
Administer prescribed antipyretics and antimicrobial medicines.
Obtain sputum or blood specimens before first antimicrobial dose if ordered, without delaying urgent treatment.
Monitor for sepsis indicators: hypotension, confusion, oliguria, persistent tachycardia, rising respiratory rate, or worsening oxygenation.

Evaluation

Temperature reduces.
Patient is hydrated and more comfortable.
No signs of clinical deterioration or sepsis occur.

4. Nursing Diagnosis: Activity Intolerance

Related to: imbalance between oxygen supply and demand, fatigue, fever, and dyspnea.

Goals / expected outcomes

Patient will perform essential activities with minimal dyspnea.
Patient will identify pacing and energy-conservation methods.

Interventions

Assess response to activity: dyspnea, pulse, respiratory rate, SpO₂, and fatigue.
Assist with personal hygiene and mobility during acute illness.
Schedule care to provide rest between activities.
Progress activity gradually as symptoms and oxygenation improve.
Teach energy conservation: slow pace, sitting for care when possible, and stopping if dizzy or severely breathless.

Evaluation

Patient completes activities with stable vital signs and less fatigue.

5. Nursing Diagnosis: Deficient Knowledge

Related to: lack of information about illness, medications, home care, and prevention.

Goals / expected outcomes

Patient or caregiver will explain the treatment plan and warning signs requiring medical review.
Patient will demonstrate correct medication and infection-prevention practices.

Health teaching

Take prescribed medicines exactly as directed. Do not share or save antibiotics.
Drink adequate fluids unless restricted.
Perform deep breathing, coughing exercises, and prescribed inhaler or nebulizer technique.
Avoid smoking, vaping, and exposure to smoke.
Use hand hygiene, cover coughs/sneezes, and avoid close contact with high-risk people while acutely ill.
Keep recommended influenza, COVID-19, and pneumococcal vaccines up to date when eligible.
Attend follow-up, especially if symptoms persist, recur, or a chest X-ray review was advised.

Seek urgent medical review immediately if there is:

Severe or rapidly worsening breathlessness
SpO₂ below the patient’s prescribed target, cyanosis, or inability to speak full sentences
New confusion, drowsiness, fainting, or severe weakness
Chest pain, coughing blood, persistent high fever, or signs of dehydration
Very low urine output, hypotension, or concern for sepsis

Acute LRTI commonly presents with cough, fever, tachypnea, and respiratory distress, as described in Tintinalli’s Emergency Medicine. The WHO’s severe pneumonia criteria include pneumonia symptoms plus respiratory rate over 30/min, severe respiratory distress, or room-air SpO₂ below 90% in adults.

Recent evidence syntheses confirm that LRTIs remain a major global cause of illness and death, but they do not replace patient-specific assessment or local antibiotic guidance: GBD 2021 systematic analysis (PMID 38636536) and 2025 global review (PMID 40733510).

Leadership styles of nursing administration

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nursing leadership styles administration authoritative guidance

Leadership Styles in Nursing Administration

Leadership style is the manner in which a nurse administrator influences, guides, motivates, communicates with, and manages nursing staff to achieve safe and effective patient care. A good nurse leader chooses the style according to the staff’s experience, the clinical situation, workload, and urgency.

Leadership style	Main features	Advantages	Limitations	Best used in
Autocratic / authoritarian	Leader makes decisions independently and gives clear instructions.	Fast decisions; clear direction; useful when staff are inexperienced.	May reduce staff participation, confidence, and satisfaction if used routinely.	Emergencies, resuscitation, disasters, unsafe practice, severe staff shortage.
Democratic / participative	Staff participate in planning, problem-solving, and decision-making.	Improves teamwork, motivation, communication, and acceptance of decisions.	Decision-making can be slow.	Ward meetings, policy development, quality-improvement projects, care planning.
Laissez-faire / permissive	Leader gives staff substantial freedom to make decisions and manage work.	Encourages autonomy and creativity in skilled teams.	Poor coordination, role confusion, and missed standards may occur when oversight is inadequate.	Teams of highly competent, responsible, self-directed nurses.
Transformational	Leader creates a shared vision, inspires staff, supports growth, and encourages positive change.	Improves morale, professional development, innovation, retention, and quality of care.	Needs time, communication skill, and staff engagement.	Change management, mentorship, introducing new care models, improving unit culture.
Transactional	Leader focuses on task completion, rules, performance standards, rewards, and corrective action.	Promotes accountability, efficiency, and consistency.	Can become task-focused and may not encourage creativity.	Routine work, audit compliance, documentation standards, infection-control procedures.
Situational	Leader changes style based on the task, urgency, and competence of staff.	Flexible and practical; meets individual staff needs.	Requires good assessment and judgment by the nurse administrator.	Daily ward management, supervising students, handling new staff, emergencies.
Servant leadership	Leader prioritizes staff needs, listens, supports development, and removes barriers to care.	Builds trust, teamwork, staff wellbeing, and a supportive culture.	May be perceived as weak if boundaries and accountability are unclear.	Staff development, mentoring, supportive work environments.
Bureaucratic	Leader follows hospital policies, hierarchy, rules, and standard procedures closely.	Ensures safety, legal compliance, and uniform practice.	Can be rigid and slow to adapt.	Medication administration, infection prevention, documentation, high-risk procedures.
Charismatic	Leader influences others through confidence, enthusiasm, and strong communication.	Can energize staff and mobilize action during change.	Team may become overly dependent on the leader.	Inspiring a team during major change or crisis.

Most appropriate style in nursing administration

There is no single best style for every setting. Situational and transformational leadership are generally the most useful in modern nursing administration:

Use autocratic leadership during an emergency, such as cardiac arrest, mass casualty, or rapid clinical deterioration.
Use democratic leadership for staff meetings, duty-roster concerns, unit policies, and quality-improvement work.
Use transformational leadership to improve morale, introduce evidence-based practice, and mentor staff.
Use transactional or bureaucratic leadership when compliance with protocols, documentation, medication safety, or infection-control procedures is needed.
Use laissez-faire leadership only when staff are experienced, accountable, and able to work independently.

Qualities of an effective nurse administrator

An effective nursing leader should demonstrate:

Clear communication
Clinical competence and sound judgment
Fairness and accountability
Ability to delegate appropriately
Conflict-resolution skills
Motivation and staff recognition
Ethical decision-making
Team building and collaboration
Ability to manage change
Commitment to patient safety and quality care

Short conclusion

Nursing administration requires flexible leadership. A nurse manager should not rely on one fixed approach. The leadership style must be selected according to patient acuity, staff competence, organizational policies, and the need for participation or rapid action. The American Nurses Association overview similarly describes autocratic, democratic, laissez-faire, transformational, transactional, servant, and situational approaches, each suited to different practice contexts.

Recent reviews suggest that leadership style influences staff satisfaction and healthcare outcomes, with relational and supportive approaches often associated with better workforce outcomes. See the 2024 systematic review (PMID 38986429) and the 2025 evidence-based leadership review (PMID 39707727).

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Leadership Styles in Nursing Administration

Leadership in nursing administration is the process of influencing nursing personnel to provide safe, efficient, and patient-centered care. A nurse administrator uses different leadership styles depending on the clinical situation, staff competence, and organizational goals.

1. Autocratic leadership

The nurse leader makes decisions independently and gives direct instructions to staff. Staff participation is limited.

This style is useful during emergencies, such as cardiac arrest, disaster situations, severe staff shortage, or when immediate action is required. It provides quick decision-making and clear direction. However, routine use can lower staff morale, reduce creativity, and make nurses dependent on the leader.

2. Democratic leadership

The nurse leader involves staff in planning, decision-making, and problem-solving. The final responsibility remains with the nurse administrator.

This style promotes teamwork, job satisfaction, communication, and commitment to decisions. It is suitable for ward meetings, planning duty schedules, developing nursing policies, and quality-improvement activities. Its limitation is that reaching a decision can take more time.

3. Laissez-faire leadership

The leader gives experienced staff considerable freedom to make decisions and carry out their work, with minimal direct supervision.

It can promote independence and confidence among skilled, responsible nurses. However, if staff lack experience or direction, it may lead to poor coordination, unclear responsibilities, and reduced patient-care standards. Therefore, it is most suitable for competent, self-motivated teams.

4. Transformational leadership

A transformational nurse leader motivates and inspires staff toward a shared vision. The leader encourages learning, professional development, innovation, and positive change.

This style is useful when improving patient safety, introducing new policies, adopting evidence-based practice, mentoring nurses, or improving morale. It helps build a positive work environment and supports staff retention.

5. Transactional leadership

Transactional leadership focuses on rules, task completion, performance standards, rewards, and corrective action when standards are not met.

It is useful for maintaining discipline, completing documentation, following medication protocols, infection-prevention measures, and meeting audit requirements. Its weakness is that it may emphasize tasks and compliance more than staff development or creativity.

6. Situational leadership

Situational leadership means the nurse administrator changes the leadership approach according to the situation and the staff member’s competence, confidence, and experience.

For example, a new nurse may need close supervision and direct instruction, while an experienced nurse may need only support and delegation. This is one of the most practical leadership approaches in nursing administration because patient-care situations and staff needs vary daily.

7. Servant leadership

A servant leader focuses on supporting staff, listening to their concerns, developing their skills, and removing barriers to good patient care.

This approach builds trust, respect, teamwork, and staff wellbeing. It is helpful in mentoring, staff development, and creating a supportive nursing work environment. The nurse administrator must still maintain professional boundaries and accountability.

8. Bureaucratic leadership

A bureaucratic leader works strictly according to hospital rules, policies, hierarchy, and standard operating procedures.

This leadership style is important in areas requiring strict safety and legal compliance, including medication administration, documentation, infection prevention, blood transfusion, and high-risk procedures. It may be less flexible when rapid change is required.

Conclusion

No leadership style is best in every situation. An effective nursing administrator uses:

Autocratic style for emergencies
Democratic style for group decisions and quality improvement
Transformational style for motivation and change
Transactional and bureaucratic styles for rules, standards, and accountability
Situational style to match leadership with staff ability and clinical needs

References

American Nurses Association. Leadership in Nursing. American Nurses Association. Available from: ANA leadership guidance.
Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing: Theory and Application. 10th ed. Philadelphia: Wolters Kluwer; 2021.
Yoder-Wise PS. Leading and Managing in Nursing. 8th ed. St. Louis: Elsevier; 2023.
Cummings GG, Tate K, Lee S, et al. Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies. 2018;85:19-60. Available from: PubMed record.
Wu Y, Awang SR, Ahmad T. A systematic review of leadership styles in healthcare sector: Insights and future directions. Geriatric Nursing. 2024. Available from: PubMed record.

Different types of channels and communication

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Communication in Nursing Administration

Communication is the exchange of information, ideas, feelings, instructions, and feedback between people. In nursing administration, effective communication is necessary for coordination of care, delegation, patient safety, staff motivation, documentation, and teamwork.

Elements of communication

A communication process includes:

Sender: person who gives the message, such as a nurse manager.
Message: information or instruction being communicated.
Channel: medium through which the message is sent.
Receiver: person for whom the message is intended.
Feedback: response that confirms whether the message was understood.
Noise or barriers: factors that interfere with the message, such as workload, language differences, poor hearing, unclear instructions, or interruptions.

Types of Communication

1. Verbal communication

Verbal communication uses spoken words. It includes conversation, telephone calls, ward rounds, handovers, meetings, teaching, and staff briefings.

Example: The nurse in charge verbally informs the staff nurse about a change in a patient’s condition.

It is fast and allows immediate clarification and feedback. However, important verbal orders and handover information should be documented according to policy.

2. Written communication

Written communication uses written words or symbols. It includes nursing notes, care plans, reports, medication records, duty rosters, policies, notices, emails, and incident reports.

Example: A nurse documents the patient’s vital signs, nursing interventions, and response to treatment in the nursing record.

Written communication provides a legal record, supports continuity of care, and reduces misunderstanding. It must be accurate, clear, timely, objective, confidential, and complete.

3. Non-verbal communication

Non-verbal communication occurs without spoken words. It includes facial expression, eye contact, posture, gestures, touch, tone of voice, silence, physical distance, and appearance.

Example: A nurse’s calm tone, attentive posture, and eye contact can reassure an anxious patient.

Non-verbal behavior should match spoken communication. If a nurse says “I am listening” but appears rushed or avoids eye contact, the patient may feel ignored.

4. Electronic or digital communication

Electronic communication includes telephone calls, emails, electronic health records, secure messaging systems, video meetings, telehealth, and hospital information systems.

Example: The nurse manager sends the monthly duty roster through the approved hospital email system.

It is rapid and useful for coordination. Nurses must protect patient privacy and use only authorized, secure systems for clinical information.

5. Formal communication

Formal communication follows the official organizational structure and established rules. It is used for professional and official purposes.

Examples include:

Written policies and procedures
Official notices and circulars
Shift handover reports
Staff meetings
Performance appraisals
Incident reports
Reports sent through the nursing hierarchy

Formal communication provides accountability, clarity, and an official record.

6. Informal communication

Informal communication occurs naturally among staff outside official channels. It may take place during breaks, casual conversations, or social interaction.

It can help build relationships and spread information quickly. However, it can also lead to rumors, misinformation, and conflict. A nurse administrator should encourage respectful informal communication but clarify important information through formal channels.

Channels of Communication

A communication channel is the route through which information moves in an organization.

1. Downward communication

Downward communication flows from a higher level of authority to a lower level.

Examples:

Nursing superintendent to nurse manager
Nurse manager to staff nurse
Charge nurse to nursing students

It is used to give instructions, policies, assignments, feedback, goals, and performance expectations.

Example: The nurse manager explains a new infection-prevention policy to ward staff.

2. Upward communication

Upward communication flows from lower-level staff to higher-level management.

Examples:

Staff nurse reporting a shortage of supplies to the nurse manager
Nurse manager reporting staffing problems to the nursing superintendent
Staff giving feedback on a new policy

It helps administrators understand staff concerns, patient-care problems, and unit needs.

3. Horizontal or lateral communication

Horizontal communication occurs between persons at the same level of authority.

Examples:

Communication between two staff nurses
Communication between nurse managers of different wards
Communication between nurses and other professionals, such as physiotherapists, pharmacists, or laboratory staff

It promotes coordination, teamwork, and continuity of patient care.

4. Diagonal communication

Diagonal communication occurs between people from different departments and different levels of authority.

Example: A staff nurse directly communicates with the infection-control nurse, pharmacist, or laboratory supervisor to resolve a patient-care issue.

It can speed up problem-solving but should remain consistent with institutional policy and professional roles.

Communication Networks in Nursing Administration

Chain network

Information moves through the formal hierarchy, from one level to the next.

Example: Nursing superintendent → nurse manager → charge nurse → staff nurse.

It maintains authority and discipline but can be slow and messages may become distorted.

Wheel network

One central person, usually the nurse manager, communicates directly with all group members.

It allows quick decision-making and clear control. However, it can make staff overly dependent on the leader.

Circle network

Each person communicates mainly with the persons immediately next to them.

It allows shared participation but may be slower when urgent decisions are needed.

All-channel or star network

All members can communicate freely with each other.

This promotes teamwork, problem-solving, staff participation, and interdisciplinary collaboration. It is useful in team nursing and quality-improvement activities, but needs coordination to prevent confusion.

Barriers to Effective Communication

Common barriers include:

Use of unclear language or medical jargon
Language and cultural differences
Noise, interruptions, and heavy workload
Lack of privacy
Poor listening
Assumptions and prejudice
Emotional stress, fear, anger, or anxiety
Incomplete documentation
Unclear chain of command
Failure to confirm that a message was understood

Measures to improve communication

Use simple, clear, and respectful language.
Listen actively and allow questions.
Use feedback and repeat-back methods for important instructions.
Document accurately and promptly.
Maintain confidentiality.
Use structured handover tools, such as SBAR: Situation, Background, Assessment, Recommendation.
Communicate changes in patient condition promptly.
Confirm critical information with the responsible person.
Encourage upward communication so staff can report concerns without fear.

Clear, frequent, two-way communication supports safe transitions and teamwork in clinical care. This is also emphasized in Sabiston Textbook of Surgery, which describes the importance of clear communication between healthcare teams during care transitions. A recent systematic review of nurse leaders’ communication competence also identifies interpersonal communication as a core competence for nurse administrators.

References

Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing: Theory and Application. 10th ed. Wolters Kluwer; 2021.
Yoder-Wise PS. Leading and Managing in Nursing. 8th ed. Elsevier; 2023.
Kämäräinen P, Mikkola L, Nurmeksela A. Nurse leaders' interpersonal communication competence: A mixed-method systematic review. Journal of Advanced Nursing. 2024. Available through PubMed.

Different healthcare delivery system of bhutan JDWNRH and district hospital

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Bhutan health system

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Healthcare Delivery System in Bhutan

Bhutan provides free public healthcare to its citizens. The system is mainly based on Primary Health Care (PHC) and a referral structure that delivers services from the community level to specialist hospitals. Modern allopathic medicine and Bhutanese traditional medicine, called Sowa Rigpa, are both part of the national health system.

The Ministry of Health plans, manages, and monitors health services across the country.

Levels of healthcare delivery

1. Community and outreach level

This is the first contact point for people living in villages and remote areas. Services are delivered through:

Village health workers
Outreach clinics
Mobile health teams
School health services
Home visits
Health education and preventive programmes

The focus is on health promotion, immunization, nutrition, antenatal and postnatal care, family planning, sanitation, early identification of illness, and referral when needed.

2. Basic Health Unit (BHU) and Primary Health Centre level

Basic Health Units are the main primary-care facilities, especially in rural areas. They provide preventive, promotive, basic curative, and rehabilitative services.

Services commonly include:

Outpatient treatment for common illnesses
Maternal and child health care
Antenatal care, postnatal care, and family planning
Immunization
Basic laboratory tests
Treatment of minor injuries and common infections
Health education
Referral of complicated patients to a district hospital

The Ministry of Health reports a nationwide network of hospitals, BHUs, and outreach clinics, reflecting Bhutan’s effort to make care available even in geographically remote areas. See the Ministry of Health overview.

3. District hospitals

A district hospital is the secondary-level health facility for a dzongkhag or district. It receives referrals from BHUs, primary health centres, and outreach clinics.

District hospitals provide a wider range of services than BHUs, such as:

Outpatient and inpatient care
Emergency services
Basic medical and surgical services
Maternal and newborn care, including delivery services
Paediatric care
Management of communicable and non-communicable diseases
Diagnostic services, including laboratory and basic imaging where available
Pharmacy services
Minor operations and stabilization of emergency patients
Referral of complicated cases to regional or national referral hospitals
Traditional medicine units in many districts

Role of nurses in district hospitals: Nurses assess and triage patients, provide bedside care, administer medications, assist with procedures and deliveries, maintain records, educate patients and families, coordinate referrals, and monitor patients before transfer to higher centers.

4. Regional referral hospitals

Bhutan has regional referral services to manage patients whose needs exceed the capacity of district hospitals. Regional referral hospitals provide specialist consultation, more advanced investigations, specialist surgery, and care for severe or complicated cases.

The main referral hospitals are located in:

Thimphu: National Referral Hospital
Mongar: Eastern Regional Referral Hospital
Sarpang/Gelephu: Central Regional Referral Hospital

According to a WHO Bhutan primary-health-care case study, the two regional referral hospitals and the National Referral Hospital provide tertiary-level care. The system aims to link preventive, curative, and rehabilitative care across all levels. Read the WHO Bhutan PHC case study.

Jigme Dorji Wangchuck National Referral Hospital (JDWNRH)

Jigme Dorji Wangchuck National Referral Hospital, Thimphu, is the apex hospital of Bhutan’s public healthcare system. It is commonly called JDWNRH.

JDWNRH functions as a national tertiary referral hospital. It receives complicated cases from district hospitals and regional referral hospitals. Patients may also be referred for services that are unavailable in lower-level facilities.

Major functions of JDWNRH

Provides specialized and super-specialized medical care
Receives referrals for complex and critically ill patients
Provides emergency and intensive care services
Offers specialist medical, surgical, paediatric, obstetric, and gynaecological services
Provides advanced diagnostic investigations and laboratory services
Manages patients requiring specialized treatment, complex surgery, rehabilitation, or long-term care
Serves as a teaching and clinical-training center for doctors, nurses, and other health professionals
Supports national programmes, policy implementation, clinical standards, and referral coordination
Coordinates transfer of patients requiring treatment outside Bhutan when highly specialized care is unavailable nationally

For nursing administration, JDWNRH requires strong coordination among departments, effective triage, patient flow management, specialized nursing care, infection prevention, documentation, staff supervision, and safe referral and discharge planning.

Referral system

The usual referral pathway is:

Community / Outreach Clinic → BHU or Primary Health Centre → District Hospital → Regional Referral Hospital → JDWNRH

A patient is referred upward when the required care, equipment, medicines, specialist, investigation, or intensive monitoring is unavailable at the lower facility.

For example:

A child with mild fever may be treated at a BHU.
A patient with severe pneumonia may be admitted to a district hospital.
A patient requiring specialist surgery or intensive care may be referred to a regional hospital or JDWNRH.

After improvement, the patient may be referred back to the district hospital or BHU for follow-up care. This is called a counter-referral.

Although this referral structure is intended to ensure proper use of resources, some people bypass primary or district facilities and go directly to referral hospitals. This can contribute to overcrowding and longer waiting times at higher-level hospitals, as discussed in a Bhutan healthcare access study.

Difference between JDWNRH and a District Hospital

JDWNRH is the national, tertiary-level hospital. It manages highly complicated cases, offers specialist services, trains health professionals, and receives referrals from across Bhutan.

A district hospital is a secondary-level hospital. It provides general inpatient, outpatient, emergency, maternity, medical, surgical, and diagnostic services for people in its local dzongkhag. It stabilizes and refers patients who require specialist or advanced care.

Conclusion

Bhutan’s healthcare delivery system is designed around primary health care, free access, and a stepwise referral pathway. BHUs and outreach clinics provide care near communities; district hospitals provide broader secondary care; regional referral hospitals provide specialist care; and JDWNRH provides national tertiary and highly specialized services.

D Reference

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site:moh.gov.bt Bhutan Annual Health Bulletin referral hospital JDWNRH district hospital healthcare delivery system PDF

References

Royal Government of Bhutan, Ministry of Health. Overview: Health Services in Bhutan. The Ministry describes Bhutan’s primary-health-care network, including hospitals, Basic Health Units (BHUs), and outreach clinics. Available from: Ministry of Health overview.
World Health Organization. Bhutan: A Primary Health Care Case Study in the Context of the COVID-19 Pandemic. WHO Regional Office for South-East Asia; 2022. Describes Bhutan’s primary-care approach, the two regional referral hospitals, and JDWNRH as the National Referral Hospital. Available from: WHO Bhutan PHC case study.
Tshering D, et al. Health inequities in Bhutan’s free healthcare system: a health policy dialogue summary. Health Policy and Planning. 2025. Discusses the three-tier health system, referral hospitals in Thimphu, Mongar, and Sarpang, and challenges such as bypassing district-level services. Available from: full article.
Ministry of Health, Royal Government of Bhutan. Publications. Includes national health policies, health-sector plans, and reports related to Bhutan’s health services. Available from: MOH publications.
Royal Audit Authority, Bhutan. Audit Report on the Health Sector: 9th Five-Year Plan Review. Describes the health-service network of regional hospitals, district hospitals, BHUs, outreach clinics, and overseas referral services. Available from: health-sector report.

Time management strategies

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Time Management Strategies in Nursing

Time management is the planned and effective use of time to complete nursing duties safely, meet patient needs, reduce stress, and improve productivity.

1. Plan the shift

At the beginning of each shift, receive a complete handover and review:

Patient diagnosis and current condition
Vital signs and abnormal findings
Medication times
Investigations and procedures
Doctors’ rounds
Nursing priorities and care plans

Make a written or electronic “to-do” list for the shift.

2. Prioritize patient care

Perform the most urgent and important tasks first. Use the ABCDE approach:

A: Airway
B: Breathing
C: Circulation
D: Disability, such as altered consciousness
E: Exposure and full assessment

A patient with airway obstruction, severe breathing difficulty, active bleeding, chest pain, shock, or sudden unconsciousness must be attended to before routine tasks such as bed making or documentation.

3. Use the urgent-important principle

Classify activities into four groups:

Urgent and important: Attend immediately. Example: low oxygen saturation or hypoglycemia.
Important but not urgent: Plan and complete. Example: patient teaching and discharge planning.
Urgent but less important: Delegate if appropriate. Example: obtaining routine supplies.
Neither urgent nor important: Avoid or postpone. Example: unnecessary phone use or repeated nonessential interruptions.

4. Set realistic goals

Set clear, achievable goals for the shift. Break large work into smaller activities.

For example:

Give morning medications on time.
Complete assessments before ward rounds.
Reposition dependent patients every two hours or according to the care plan.
Prepare discharge teaching before the patient leaves.

Avoid trying to complete too many tasks at once.

5. Organize work and cluster care

Combine several nursing activities during one patient visit, where clinically appropriate.

For example, during one bedside visit, the nurse may:

Assess pain and vital signs
Administer prescribed medicines
Assist with hygiene or repositioning
Check IV fluids
Provide brief health teaching
Ensure the call bell and needed items are within reach

This reduces unnecessary trips, saves time, and promotes patient comfort. Do not cluster care if it delays time-critical treatment or disturbs a patient who needs rest.

6. Delegate safely

Delegation means assigning an appropriate task to another qualified team member while retaining responsibility for overall nursing care.

Tasks that may be delegated according to local policy and staff competence include:

Bed making
Assisting with hygiene
Measuring vital signs
Transporting stable patients
Collecting supplies
Assisting with feeding, mobility, or positioning

Before delegating, ensure the task is appropriate, the person is competent, instructions are clear, and supervision or follow-up occurs. The registered nurse remains accountable for assessment, nursing judgment, evaluation, and tasks outside the delegate’s scope of practice. The ANA delegation guidance emphasizes that safe delegation depends on the patient’s condition, team member competence, and applicable law and policy.

7. Communicate effectively

Use concise, clear communication with the healthcare team. For critical communication, use SBAR:

S: Situation
B: Background
A: Assessment
R: Recommendation

Give complete handover, report changes early, document promptly, and clarify unclear prescriptions. Good communication prevents duplication, delays, and errors.

8. Avoid interruptions and manage distractions

Prepare equipment before starting procedures. Keep essential supplies organized. Complete one task before moving to another when possible.

When interrupted, reassess priorities before returning to the original task. Interruptions during medication administration are especially risky. Use a quiet area or “do not disturb” practice where available.

9. Manage documentation promptly

Document assessments, interventions, medications, observations, and patient responses as soon as possible after care. Late documentation can lead to omissions, incorrect information, and loss of continuity of care.

Use approved abbreviations only and record facts objectively.

10. Use time-saving tools

Useful tools include:

Shift planner or patient worksheet
Care-plan checklist
Medication schedule
Electronic reminders
Calendar and duty roster
Standardized handover sheet
Supply checklist

Review and update the plan when patient conditions or unit workload change.

11. Learn to say no appropriately

Avoid accepting nonessential tasks when urgent patient-care duties need attention. Politely explain the priority and negotiate another time or seek assistance. This does not mean refusing necessary teamwork, but protecting patient safety and preventing overload.

12. Take short breaks and maintain wellbeing

Fatigue reduces concentration and increases the risk of error. Take scheduled breaks when patient care allows, drink water, eat adequately, and seek support if workload becomes unsafe.

13. Evaluate the shift

At the end of the shift, review:

Were all priority tasks completed?
Were medications and treatments given on time?
Were important changes reported and documented?
What caused delays?
What can be improved during the next shift?

This improves future planning and professional practice.

Conclusion

Effective time management in nursing means planning, prioritizing, organizing, delegating, communicating, documenting, and evaluating. The first priority is always patient safety. A nurse should remain flexible because patient conditions can change suddenly.

References

Marquis BL, Huston CJ. Leadership Roles and Management Functions in Nursing: Theory and Application. 10th ed. Wolters Kluwer; 2021.
Yoder-Wise PS. Leading and Managing in Nursing. 8th ed. Elsevier; 2023.
American Nurses Association. Time Management Tips for Nurses. Available from: ANA time-management guidance.
American Nurses Association. Delegation in Nursing: Building a Stronger Team. Available from: ANA delegation guidance.
Darach N, Kim MS, Wisesrith W. Data analytics and administrative decision-making in nursing management: A systematic review. Journal of Nursing Management. 2025. Available from: PubMed record.

Understanding staffing patterns and schedules

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