Textbook on Ward management in Nursing Practice I Clement
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SECTION 1
Introduction

Introduction to Ward ManagementCHAPTER 1

 
INTRODUCTION
Ward management is the responsibility of the head nurse and her nursing team. The ward management includes: Management of client care, management of the personnel, management of supplies and equipments and management of environment. The head nurse is in-charge of a small individual nursing unit. She is responsible to the director of the nursing service either directly or through a supervisor. Head nurse holds one of the important positions in the hospital. She is administrative officer who receives her authority in direct line from the director of the hospital through the director of nursing service. In democratic institutions she has an opportunity to participate in the formulation of hospital policy which affects her work. Head nurse in a hospital in which student nurses are educated is responsible to the director of the school of nursing for providing on her ward a suitable educational field. The head nurse may or may not have responsibility for formal ward teaching.2
 
FACTORS INFLUENCING WARD MANAGEMENT
Ward management is one of the prerequisites for good nursing care. There are many factors involved in good ward management, which the nurse manager/supervisor needs to understand thoroughly for good management of the ward as follows.
  1. Knowledge of the ward means that knowledge of all the duties and activities to be performed in ward.
  2. Planning the schedule of the ward refers to a planned program for each day's work to save time and use available time in a useful way for nursing the clients.
  3. Starting the work on time: Proper arrangements are made so that all nurses do their job in right time as assigned promptly.
  4. Preventing interruptions: Good management requires avoidance of interruption whenever possible, e.g. changing assignments are anticipated.
  5. Establishment of ward routines: These provide a plan for delegation of duties and getting the work done in an efficient way. Policy manuals of the institution help to establish ward routines which include handling orders, writing and giving reports, checking medicine cards, summarizing charts, handling telephone calls, checking and ordering, supplies, keeping cupboards stocked distributing linen, collecting specimens, there is more time left for individualized nursing, supervision and teaching.
  6. Use of democratic method in establishing ward policy: When ward objectives are to be determined and policies to be established or changed, better co-operation are achieved if participation of the entire staff is encouraged.
  7. Orientation of new personnel: Well developed orientation program helps good ward management. When new staff has entered the hospital, they must be oriented to hospital as well as the ward, which helps new nurses develop desirable understanding and attitudes.
  • 8A. Orientation of hospital will include the type of hospital, organization of hospital, aim of nursing service, relationship of hospital with medical/nursing schools or colleges, doctors, different departments in relation to nursing services, health services for nurses, meal hours, plans for periodical conferences and staff development.3
  • 8B. Orientation of ward/unit will include the introduction of new nurses to ward personnel. Services represented on the ward (medical, surgical, gynecology, etc), methods of assignment working schedule of the day (patients time of awakening, taking JPR, meal timings, etc.) resting hours, visiting hours, etc. duties of non-professional workers, methods of obtaining daily assignments (Handling orders, charting, etc.), ward tour/rounds. Location of equipment. Location of existing and emergency equipments, and other sources of information such as procedures routines, and ward policy book, etc. and also introduction of required special experiences.
  1. Maintenance of suitable environment: Elements which help maintain suitable environment in the ward include prevention of noise, good ventilation, cleanliness of ward, well functioning equipments, good housekeeping, etc. Because, noise hampers relaxation and rest; improper ventilation is harmful to health. A sanitary, safe, restful environment is necessary to the patient's welfare and comfort as well as that of all members of the ward personnel. Cleanliness and order improve morale and tend to make workers careful and neat in their habits. Maintenance of building and equipment in good repair is economical as well as safe and efficient.
  2. Providing supplies and equipment in a hospital: There should be provision for proper supplies and equipment for efficient work supplies are expendable items or those articles which are used up and must be recorded periodically such as soap, and detergents, paper towels, stationery, food, sterile goods, etc. Equipments include more permanent articles and may be classified as fixed or movable. Fixed equipment is not a part of the structure of the building but is attached to its walls or floor such as sterilizers and sinks. Movable equipments include furniture, instruments, syringes, dishes, etc.
    For good management, all materials (supplies and equipment) should be adequate free from repair, accessible, and conveniently located and should maintain the standard, in the materials, according to their use, maintain good exchange system, inventory and requisition (proper polices and performs are used for material management). It is always better to have 4controls. Apply department in every hospital for providing efficient nursing service.
  3. Clear cut, specific orders for medical therapy and nursing: Good ward management needs a clear cut doctor's orders and nursing orders, which are very essential to safeguard the patient welfare. They help prevent errors and thus they protect the doctor, the nurse and the hospital. It is always better that orders be written and signed by the doctor. There are some standing orders that also should be written in the policy book of the hospital, and then only the nurses are able to carry out the standing orders. Nursing orders, given by the nurse supervisor, should be specific and easily communicated to the concerns nurses to carry out and the same which avoid confusion and other odd events.
  4. Record keeping, maintaining accurate records is essential for good management: They might be patient clinical records, administrative records, all have legal and scientific value, so that recording competence should be maintained. Records will include administrative records. Doctor's orders, nursing orders, nurse's notes, record of treatment, etc. While using records proper instruction to be followed by proper use of clinical records. In addition proper maintenance of records of equipments losses and replacements, records of personnel performance are also a part of good management.
  5. Reporting: Reports are of prime importance both to good ward management and to a well-functioning hospital. Many reports are oral and are concerned mainly with the immediate functioning of the ward such as reports between nurses and reports to doctors and supervisors. Reports are written as they may be needed for legal purposes, when they are to serve as a source of reference, or to be used by several people.
    Written reports include day, evening and night reports and those relating to accidents and unusual condition which may reflect the quality of care the patient has received, Reports to other departments in the hospital and to agencies outside the institution are usually written. A report to be of the greatest use and to save time and duplication of efforts must be prompt, complete, accurate and objective. Reports which have legal 5significance, especially those describing accidents and mistakes, are written by the individuals involved and should include all identifying information, which in any way may have contributed to the situation.
  6. Maintenance of high morale among all members of the staff.
  7. Establishment of good relationship: Establishing good working relationship within the ward and with other associates is an essential factor in good work management. In the hospital where every individual and every department exists for its contribution to the patient and his well-being, there are interdependencies and interrelationships which must be understood and respected. When good relationship exists, people are enthusiastic about their work. They feel themselves to be a part of the institution. A warm, friendly atmosphere prevails; the hospital. The attitude of nurses and other employees is reflected to the patients.
  8. Delegating responsibility: Whenever an individual is responsible to another person, delegation of duties is essential. In a hospital ward the bedside care o the patients is delegated to the staff and student nurses, housekeeping duties are assigned to other personnel. The delegation of responsibility will be made in accordance with the ability of individuals within the frame of policy of the hospital.
  9. Assigning duties and responsibility: Well-planned assignments of duties and responsibilities have following objectives.
    1. To provide the patient with the best possible nursing care.
    2. To plan assignment which are interesting and stimulating to professional growth?
    3. To provide a well rounded educational experience for student nurses.
    4. To achieve good ward management.
To achieve good ward management, seven principles should be kept in mind when planning assignments which include:
 
FUNCTIONS OF WARD SISTER
The ward sister is responsible to the nursing superintendent/Matron for the management of the wards and supervisions of the nursing and domestic staff.6
zoom view
Fig. 1.1: Functions of ward sister
She would be assisted in carrying out the following duties by staff nurse clinical and domestic staff as the case may be. The main aim of the ward sister should be to foster team spirit in her area of work (Fig. 1.1).
  1. TEACHING OF NURSING STUDENTS
    1. Planned and incidental teaching.
    2. Supervision of student's work.
    3. Consultation and cooperation with sister tutor in arranging demonstration.
    4. Discussion with students to promote good attitudes, complete ‘record of practical work’ and in valuation to confidential reports.
  2. WARD STAFF
    1. Assignment of work and arrangement of duties by taking rott-calls of nursing and domestic staff.
    2. Co-ordination and facilitating work of other staff, e.g. occupational therapist, social worker, dietician, voluntary worker.
    3. In-service training.
    4. Orientation of new staff.
    5. Maintaining good relationships among all categories of staff and with patients and their relatives.
    6. Discipline of nursing and domestic staff. Reporting on absence of staff.
    7. Confidential reports.
  3. WARD MANAGEMENT
    1. Cleanliness of ward, its annexes and environments.7
    2. Linen and ward equipment-up-keep and repairs.
    3. Custody of dangerous drugs. Records of their administration.
    4. Indents for drugs, surgical supplies, stores, diets.
    5. Maintenance of stock registers, inventories.
    6. Interpretations of hospital policies and regulations and their implementation.
    7. Investigation of complaints.
    8. Issue of stores, etc.
  4. GENERAL
    1. Rounds with medical staff and Nursing Superintendent/Matron.
    2. Taking round special visitors.
    3. Participation in staff education and staff meetings.
    4. Participation in professional activities.
    5. Any other duty as may be specified from time to time.
  5. NURSING CARE OF PATIENT
    1. Admissions and discharges: Management of patient admissions: Greet new patient, introduce self and others. Orientation of patients to services of the unit policies, rules, regulation, visiting hours, food timings, etc.
    2. Management of patient discharge: Give all instructions for follow-up care; inform family, hand over belongings.
    3. Doctor's rounds: Activities to be performed before rounds:
      1. To keep ready all investigations.
      2. To complete patient charts organized, in order and ready.
      3. To keep unit ready.
      4. All equipment in order.
      5. All the patients are in bed.
        Activities during Doctor's rounds
        1. Assist with the examinations
        2. Take notes on significant comments
        3. Report symptoms, reactions, etc.
        Activities after rounds:
        1. See that the patients are comfortable.
        2. Carry out the changes ordered, e.g. investigations, new medication, stat orders, etc.
    4. Drug administration: Check for drug stocks, narcotics and drugs nearing expiry date and take necessary action.8
    5. Operation theatre administration (OT): Check OT list, patient and family is informed, preoperative preparation, patient consent and chart is complete, etc.
    6. Interdepartmental coordination: Establish good interpersonal relationship with other health service departments in the hospital and ensure effective coordination to improve patient care. For example: Dietary, laundry, laboratory, X-ray, blood bank, general services, biomedical engineering department, etc.
    7. Reporting: (A) Make daily written report of problems of patient care and unit management to the supervisor or the director of nursing service (Nursing officer) at the end of the shift. (B) Maintain incident reports of any untoward happenings.
Nursing care of patients in general:
  1. Admission and discharge of patient.
  2. Efficient nursing care personal comfort and toiled of patient, administration of drugs and treatment, observation and recording.
  3. Patient's diet.
  4. Assistance, to medical staff in examination of patients and treatment.
  5. Rounds with medical staff.
  6. Assistance at or supervision of clinical investigations, pre-operative and postoperative care.
  7. Maintenance of patient records.
  8. Care of patient's personal effects in accordance with hospital rules.
  9. Following of prescribed rules regarding accident or death of a patient.
  10. Giving and receiving reports.
  11. Information to relatives and friends.
  12. Intimation to Nursing Superintendent/Matron of any special emergency in the ward.
 
ORGANIZATION PRINCIPLES IN WARD MANAGEMENT
Basic principles of this so-called authoritarian organization are listed by Barr. Burton and Brueckner and are here adapted to hospital organization.9
  1. Authority is centralized in the individual, the director of the hospital.
  2. Responsibility may be delegated along established lines. The director of the hospital delegates to the director of the nursing service the responsibility for seeing that the patients in the hospital are well-nursed. The standards of good nursing are determined by the director of nursing service and her staff members.
  3. Clear and unambiguous delegation of authority must accompany the delegation of responsibility. The director of nursing service, since she is responsible for the quality of nursing care, must have the authority to employ and discharge nurses and other nursing service personnel.
  4. Lines through which this delegated authority will flow must be clearly and ambiguously defined. No individual should receive suggestions covering the same item from more than one person.
  5. Duties and activities must be assigned down through the line of authority.
  6. The performance of duties assigned to any level will be checked by the next higher level through the system.
  7. Facility for cooperation and coordination must be provided through group meetings, conferences, common planning, written instructions, reports and the like.
  8. There must be flexibility of operation. Sometimes conditions within the institution make it advisable to vary relationships from the usual pattern.