Standard Operating Procedures in Nursing Practice

Grooming of Nursing students

General Guidelines

  1. Maintain personal hygiene and cleanliness.
  2. Wear clean, ironed uniforms and shoes.
  3. Keep hair clean, styled neatly, and away from face.
  4. Avoid excessive jewelry, perfumes, and colognes.
  5. Keep nails clean and trimmed.

Uniform Requirements

  1. Wear approved nursing uniforms.

  2. Ensure uniforms fit properly and are clean.

  3. Wear closed-toe shoes with non-slip soles

     

Hair and Makeup

  1. Keep hair tied back if longer than shoulder-length.

  2. Avoid bold or bright hair colors.

  3. Keep makeup subtle and natural-looking.

Nail Care

  1. Keep fingernails trimmed and clean.

  2. Avoid artificial nails or nail polish.

     

Jewelry and Accessories

  1. Wear minimal jewelry (e.g., wedding band, watch).

  2. Avoid dangling earrings or necklaces.

Body Art and Tattoos

  1. Cover visible tattoos.

  2. Avoid visible body piercings.

  3. Mehandi is not permitted

General Pre- clinical instructions/SOP’s

For students

  1. All students must carry necessary clinical articles/equipment (e.g., stethoscope, penlight, pocket articles).
  2. Students must follow the hospital or clinical area policies/protocols.
  3. Mobile phones are strictly prohibited in the clinical area
  4. Discipline and professional etiquettes should be maintained during clinical postings
  5. Students must communicate in English with the health care team and in local language with the patients.
  6. Students must be oriented to the learning objectives and must be oriented to the clinical area.

For Nursing Faculty/Clinical Instructor/Preceptor

  1. Nursing faculty must use the skills learning lab effectively for demonstrating clinical skills to the students.
  2. Ensuring that all students have the necessary learning materials (e.g., supplies, models, checklists, etc.) during the skills learning.
  3. Every procedure must be taught by the faculty with the objectives, steps and checklist.
  4. Nursing faculty must simulate the clinical setting as much as possible in the skill learning lab.
  5. The nursing faculty must demonstrate skill from beginning to end, without skipping any steps followed by summarization. 
  6. Allow students to practice the skill in small groups not more than 10 students, taking turns with various roles (practicing, observing, giving feedback, simulating role of patient, etc)

General Clinical area SOP’s

For students

  1. Arrive 15 minutes before to the clinical area.
  2. On arrival the students must sign in the attendance register maintained in the hospital by the nursing superintendent.
  3. The students shall make use of a planner or daily diary to stay organized, which will be signed by the nursing faculty on a daily basis.
  4. Confidentiality and professionalism must be maintained while interacting with patients.
  5. Students must notify the concerned authority if case of any absence
  6. 100% clinical attendance must be maintained by the students.
  7. Patient’s document such as reports, case sheet, etc must not be misused or damaged.
  8. Clinical rounds along with the nursing fraternity/ doctors must be attended.

For Nursing Faculty/Clinical Instructor/Preceptor

  1. 1: 10 student and faculty ratio must be maintained.
  2. All faculty must maintain their attendance through biometric before and after the clinical postings
  3. Any leave or absence must be intimated to the higher authorities through proper channel.
  4. The clinical practice areas must meet the requirements of the curriculum.
  5. Anecdotes of the students must be maintained in the clinical area
  6. The nursing faculty must determine by reviewing the clinical volume and provide students with sufficient practice to meet clinical objectives.
  7. The nursing faculty must ensure that the clinical practice area also has scope for student teaching
  8. The clinical rotation plans must be developed in a way to distribute students across clinical practice areas evenly.
  9. Clinical rounds and clinical teaching must be carried out.
  10. Clinical skills must be demonstrated to the students
  11. Provision must be made to learn the clinical skills from the nursing officers, nursing superintendents as well.
  12. The faculty and students must maintain a safe and supportive patient environment during procedures.
  13. The nursing faculty/ tutors/clinical instructor must have the necessary teaching materials and evaluation tool to effectively guide and evaluate the students in clinical practice.
  14. Document students performance and progress in assessment and care of the women.
  15. Clinical competencies of the students must be assessed by appropriate clinical check lists.
  16. Ensure the students complete all the clinical requirements before the completion of the clinical posting.
  17. Monitor student daily objectives and provide constructive feedback

General Clinical area SOP’s

  1. Day to day post clinical conference must be held 
  2. Feed back of the student’s performance must be provided
  3. Performs student evaluations in a timely manner
  4. Conduct DOP (Direct Observation of Procedural Skills) the OSCE ( Objective Structured Clinical Examination) to assess students’ clinical skills and competence
  5. The nursing faculty must develop and implement structured practical examinations for the students.
  6. Identify areas for improvement
Pediatric Department SOP’s

General Clinical area SOP’s

  1. Review the paediatric-specific policies and procedures and give all the necessary materials before posting the students.
  2. The clinical areas must meet the requirements of the curriculum.
  3. Familiarize student with paediatric medication dosages and calculations.
  4. Student should know how to assess growth and development stages.
  5. Review paediatric assessment techniques.
  6. Attend pre-clinical briefings and orientations.

Clinical Site Arrival

  1. Arrive 15 minutes before scheduled shift.
  2. Report to designated meeting area or charge nurse.
  3. Introduce yourself to staff, patients, and families.

Paediatric Patient Care

  1. Assess paediatric patients using age-specific developmental stages.
  2. Use paediatric-specific vital sign parameters.
  3. Administer medications using paediatric dosing calculations.
  4. Use paediatric-sized equipment (e.g., blood pressure cuffs).
  5. Provide family-centered care.

Communication

  1. Use child-friendly language and communication techniques.
  2. Engage parents/guardians in care decisions.
  3. Clarify unclear instructions or orders.
  4. Report concerns or issues promptly.
  5. Participate in family-centered rounds.

Safety Protocols

  1. Ensure childproofing measures (e.g., secure furniture).
  2. Use safety equipment (e.g., infant scales).
  3. Maintain paediatric patient safety during transfers.
  4. Follow hospital emergency codes (e.g., code pink).
  5. Report incidents or near-misses.

Paediatric-Specific Procedures

  1. Vital sign assessment (e.g., pulse oximetry).
  2. Paediatric medication administration.
  3. Use of paediatric-specific equipment (e.g., nebulizers).
  4. Child and infant restraint techniques.
  5. Newborn assessment and care.

Documentation

  1. Complete accurate and timely documentation.
  2. Use approved paediatric documentation formats.
  3. Record paediatric-specific data (e.g., growth charts).

Family-Centered Care

  1. Involve parents/guardians in care decisions.
  2. Provide emotional support to families.
  3. Educate families on paediatric care.
  4. Respect cultural and spiritual diversity.
  5. Encourage breastfeeding support.

Infection Control

  1. Follow proper hand hygiene.
  2. Use PPE (e.g., gloves, masks).
  3. Clean and disinfect equipment.
  4. Report exposures or spills.

Emergency Preparedness

  1. Know paediatric emergency procedures (e.g., child CPR).
  2. Participate in drills and training.
  3. Respond to emergency codes.
  4. Stay calm and follow instructions.

Evaluation and Feedback

  1. Receive and act on feedback.
  2. Evaluate own performance.
  3. Complete self-assessment tools.
  4. Attend debriefing sessions.

Additional Considerations

  1. Confidentiality and HIPAA.
  2. Child abuse and neglect recognition.
  3. Pediatric pain management.
  4. Cultural sensitivity and awareness.
  5. Collaboration with interdisciplinary teams
Midwifery Nursing SOP’s

The clinical practice areas must have the facilities available for

  • Antenatal care
  • Labor/assessment of patients presenting with signs of labor 
  • Delivery and the management of delivery complications     
  • Newborn care and management of newborn problems     
  • Postpartum care   
  • Management of obstetric emergencies    
  •  Family planning    
  •  General gynecologic care
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Types of facilities where the students can be expected to work including

  • A hospital or First Referral Unit (FRU) 
  • 24/7 Primary Health Center or CHC 
  • Sub-center or MCH clinics

The students must follow the Pre-Clinical SOPs such as

  • Hand hygiene and personal protective equipment (PPE)
  • Patient assessment and vital signs
  • Documentation and record-keeping
  • Infection control and biohazard management

With regard to the antenatal Antenatal SOPs, the students must

  • Initial assessment and risk identification
  • Fetal monitoring and well-being assessment
  • Pregnancy-induced hypertension management
  • Gestational diabetes management

While taking care of intrapartum cases, the students must involve in

  • Labor assessment and progress monitoring
  • Pain management and analgesia administration
  • Fetal heart rate monitoring
  • Instrumental delivery (forceps/ventouse)

Postpartum cases must be assessed and managed by the students for

  • Post-delivery assessment and care
  • Bleeding management and hemorrhage control
  • Pain management and analgesia administration
  • Breastfeeding support and lactation management

The clinical skills the students must demonstrate when taking care newborns are

  • Initial newborn assessment
  • Vital signs and temperature regulation
  • Cord care and vaccination administration
  • Neonatal resuscitation

Other SOPs related to Midwifery skills are

  • Medication administration and management

  • Patient education and discharge planning

  • Emergency response (postpartum hemorrhage, eclampsia, etc.)

  • Documentation and reporting

     

Midwifery-Specific SOPs must be completed as per the syllabus are

  • Conducting normal vaginal deliveries
  • Managing prolonged labor and obstructed labor
  • Performing episiotomy and suturing
  • Conducting postpartum examinations

Students must complete all the case studies, care presentations, case book and log book as prescribed in the curriculum.

Medical Surgical Nursing SOP’s

Pre-Clinical SOPs to be followed by the students

  • Hand hygiene and personal protective equipment (PPE)
  • Patient assessment and vital signs
  • Documentation and record-keeping
  • Infection control and biohazard management
  • Medication administration and management

Assessment for the various systems must be carried out by the students such as

  • Head-to-toe assessment
  • Cardiovascular assessment
  • Respiratory assessment
  • Neurological assessment
  • Musculoskeletal assessment

Patient Assignment

  • Assign patients to students based on acuity and learning needs.
  • Ensure students understand patient diagnoses, treatments, and plans.
  • Review patient charts and documentation requirements.

Clinical Rounds

  • Conduct daily clinical rounds with students to observe and provide feedback.
  • Focus on assessment, planning, implementation, and evaluation.
  • Encourage critical thinking and prioritization.

Medication Administration

  • Supervise students during medication administration.
  • Ensure understanding of medication names, doses, and potential side effects.
  • Monitor student compliance with medication administration policies.

Wound Care and Dressing Changes

  • Demonstrate and teach wound care and dressing change techniques.
  • Ensure students understand wound assessment and documentation.
  • Supervise students during wound care procedures.

Vital Sign Assessment

  • Teach and demonstrate vital sign assessment techniques.
  • Ensure students understand normal and abnormal vital sign ranges.
  • Monitor student accuracy in documenting vital signs.
Community Health Nursing SOP’s

Health Assessments: SOP for conducting community health assessments (surveys, screenings, and home visits), including tools and techniques used.

Pre-Assessment Planning

Define Assessment Goals

  • Identify the specific health areas to be assessed (e.g., maternal health, communicable diseases, nutrition).
  • Outline the demographic groups or regions to be targeted (e.g., households, schools, vulnerable populations).

Community Engagement

  • Coordination with Local Health Authorities: Inform local health officials (DHO, PHC staff) about the assessment and seek necessary approvals.
  • Community Mobilization: Collaborate with community leaders, local health workers (ASHA/ANMs), and stakeholders to ensure community participation and trust.
  • Safety and Cultural Sensitivity: Understand local cultural norms and prepare culturally appropriate materials and approaches for the assessment.

Preparation of Tools and Equipment

  • Survey Forms: Develop or use standardized forms/questionnaires covering demographic information, health history, lifestyle factors, disease prevalence, etc.
  • Screening Tools: Blood pressure monitors, glucometers, haemoglobin meters, weighing scales, growth monitoring charts, thermometers, etc.
  • Health Education Materials: Prepare educational pamphlets, posters, or flipcharts to raise awareness during interactions.
  • PPE (Personal Protective Equipment): Ensure all team members have gloves, masks, and hand sanitizers for infection control during home visits.

Health Education: Guidelines for delivering health education programs on topics like sanitation, nutrition, immunization, family planning, etc.

Nursing Care: Procedures for providing nursing care in the community, including maternal care, child health, chronic disease management, and referrals.

First Aid and Emergency Response: Guidelines for administering basic first aid and managing common emergencies in community settings.

Screening Process

Vital Signs and Basic Health Check

  • Measure blood pressure, heart rate, respiratory rate, and body temperature.
  • For maternal and child health, measure weight, height/length, and mid-upper arm circumference (MUAC) in children.
  • Screen for common conditions (anemia, malnutrition, diabetes) using appropriate tools (hemoglobin meter, glucometer, weighing scale).

Disease Screening

  • Screen for communicable diseases (e.g., tuberculosis, malaria, dengue) by taking appropriate medical history and using rapid diagnostic kits where available.
  • Screen for non-communicable diseases (e.g., hypertension, diabetes) by taking blood pressure and blood sugar levels.

Health Counseling

  • Provide immediate health education based on screening results.
  • Refer high-risk individuals to nearby health centers for further evaluation and treatment.

Home Visit Protocol

a) Pre-Visit Preparation

  • Community Mapping: Use available community health records or local health workers to identify homes with vulnerable individuals (e.g., pregnant women, elderly, infants).
  • Team Composition: Assign teams of students or nursing staff for specific households, ensuring gender balance and language proficiency, if needed.

b) Conducting the Home Visit

  1. Introduction and Consent
  • Introduce yourself to the household and explain the purpose of the visit.
  • Obtain consent from the head of the household or the individual being assessed.

2. Environmental Assessment

  • Observe the living conditions, sanitation facilities, water supply, waste disposal practices, and food storage methods.

3. Health Assessment

  • Collect health data from household members, including immunization status, pregnancy history, and chronic diseases.
  • Perform physical assessments (e.g., check for signs of malnutrition, dehydration, Anemia).

4. Health Education

  • Provide health education on topics like hygiene, nutrition, family planning, disease prevention, and environmental sanitation.
  • Distribute educational pamphlets or other materials as needed.

c) Referrals and Follow-Up

  • Identify individuals requiring further health services and provide referral slips to local health centres.
  • Follow up on previously identified health conditions during repeat visits.
Psychiatric Nursing SOP’s

Communication

  • Student will learn how to maintain firm and polite communication at the same time
  • Understand the various IPR techniques and use them
  • Understand the importance of maintaining a healthy communication with the client

Well structured statements

  • The student should use well structured statements while talking to the client. 
  • No form of verbal abuse or abusive gestures should be demonstrated in front of the patient
  • The body language of the student should be decent and polite.
  • Patient must be greeted and addressed by their names while conversing.

Non verbal expressions

  • Students must be cautious in showing any form of non verbal expression in front of the patient
  • Patient should not be touched or leaned upon while talking
  • No whispering or facial expressions to be given in front of the patients

IPR Techniques

  • Proper IPR Techniques must be used while communicating. 
  • Patient must be acknowledged and recognized 
  • Appropriate usage of silence and active listening must be done by the students.

Privacy

  • Students should strictly prohibit from discussing openly about the condition of the patient.
  • Patient name and details should not be used for any reference apart from therapeutic purposes.
  • Any form of personal exchange of information like phone numbers e mails/ address should not be encouraged.

Confidentiality

  1. Students should strictly prohibit from discussing openly about the condition of the patient.
  2. Patient name and details should not be used for any reference apart from therapeutic purposes.
  3. Any form of personal exchange of information like phone numbers e mails/ address should not be encouraged.
  4. Students should be assertive in refusing to give or take any personal details while communicating with the patient.
  5. The documents containing personal details should not be disclosed to any other individual not related to the patient

Patient Rights

Outcome: Ensure patients receiving psychiatric care understand and receive their rights and responsibilities.

  1. Patient Rights: Patient must receive respectful care regardless of age, gender, culture, or diagnosis.
  2. Right to  Confidentiality and privacy.
  3. Right to Informed consent for treatment, ECT.
  4. Right to Refuse treatment or participation in research.
  5. Right to Access medical records provided that will not cause harm to self or others.
  6. Right to receive e mails, telephone calls from friends, relatives
  7. Right to Receive information on diagnosis, treatment, and prognosis in a language they understand.
  8. Right to Complain or appeal without fear of retribution.
  9. Right to refuse tonsuring.