WARD MANAGEMENT


WARD MANAGEMENT

At the end of this presentation the participants will be able to:

  • State the meaning and objective of ward management
  • Highlight the attributes of a ward manager
  • Outline golden rule for effective ward management.
  • Apply the principles of administration in ward management in various health care settings.
  • Discuss the elements of ward management.

Introduction:

Management is all about judicious utilization of limited resources, and as potential head of health institutions, there is need to understand how to do this to get desired results at a minimum cost. The continuation of the overall plan and activity of nursing department in hospital provides needed the creation of different units and wards and providing manager to be in control because nursing being a vital aspect of health care needs to properly organize its activity. Nurses that work in these wards are in frequent contact with the patients and hence their roles in restoring health and confidence of the patients are of utmost importance. The ability to optimally manage human and material resources especially the nursing staff result in the quality of nursing care and is a reflection on the image of the hospitals. This therefore places demand for ward managers to be in control.

MANAGEMENT

Management is the process that coordinates the effort of people to accomplish goals and objectives by using available resources efficiently and effectively to achieve a desired objective. Grovernor Plowman sees management as a technique by means of which the purpose and objectives of a particular human group are determined, clarified and effectuated.

Brech, (2005) defines management as a process of entailing responsibility for the effective and economical planning and regulation of the operations of an enterprise in the fulfillment of a given process or task.

American institute of management sees management as being used to designate either a group of functions or the personnel who carry them out, to describe either an organization’s official hierarchy or activities of men who compose it, to provide antonym to either labour or ownership.

All people who oversee the functions of other people, who work in subordinate position, are managers. The manager is expected to get people to put in their best. To do this, the manager has to understand people, their emotional, physical and intellectual needs. She should appreciate that each member of the group has his own personal needs, aspirations and that these are influenced by such factors as the ethnic, social, political, economic and technological environment in the place of work.

Not all people can manage effectively or aspire to management positions. Whenever people, work together, there is a general need for the coordination of efforts in order to attain expected result in reasonable time.

FUNCTIONS OF A MANAGER

PLANNING:

 According to Kozier, Erb, and Burke, (2011), planning is an ongoing process that involves assessing situation, establishing objectives based on assessment of a situation or future trends and developing a plan of action that identifies priorities, delineates who is responsible, determines deadlines and describes how the intended outcome is to be achieved and evaluated.

Okoronkwo (2005) stated that planning involves deciding what to do, when, where, how to do it and by whom and with what resources. Planning specifically is concerned with three fundamental questions:

·         Where are we now?

·         Where do we want to go?

·         How are we going to get there?

It involves decision making. The ward manager therefore is a decision maker who carries out plans. The planning function consists of determining the objectives, policies, procedures, methods, rules, budgets and other plans needed to achieve the  objectives of the ward, the most important being  the wholistic care of patients leading to recovery or to a peaceful death. Planning is a mental work that involves thinking before acting. It enables the ward manager to be in charge of nursing care in their units, determine ways to support nursing staff in preventing harm to patients and generally oversee the operations of the ward.

ORGANIZING:

The organizing function determines how the work is to be accomplished. The manager must define and assign job allocations. This establishes relationships between tasks to be performed, and individuals to perform them. Organizing, according to Okoronkwo (2005) involves determining responsibilities, communicating expectations and establishing the chain of command for authority and communication. A main reason for organizing is to have each member know what activities she is to perform. Organizing also involves the establishment of hierarchical structure. The best way to clarify organizational structure is to draw an organizational chart which is a schematic or pictorial representation of what happens in an organization. While organizing the manager must delegate some authority to subordinates so that they can carry out their duties for which they are responsible.

STAFFING:

Okoronkwo (2005) stated that staffing is the finding, selecting, appointing and placing of people to work as defined. It aims at ensuring that the personnel placed in a particular job are suitable in terms of awareness of the role appropriate for performance of the assigned tasks. The nurse manager should place people in the job according to their potentials and capabilities. The objective is to put the right person in the right job and at the right time. Staffing also involves training of employees, promoting them, appraising their performance and giving them opportunities for further development. In addition, staffing includes a wise and appropriate system of compensation. It is also the duty of the ward manager to ensure that there is enough staff to cover ward three shift daily. This she can achieve by vetting the duty rosters, annual leave rosters, noting staff on casual or sick leave.

INFLUENCING:  

To Influence means issuing orders to accomplish the job and to help maintain harmonious coexistence of the members of the organization working together. The influencing function of a manager includes directing, leading, guiding, teaching, coaching and supervising subordinates. Therefore influencing is the process around which all performances revolve.  This process has many dimensions such as employee needs, morale, job satisfaction, productivity leadership and communication. Through the influencing function, the supervisor seeks to create a conducive environment to employee satisfaction at the same time achieve the objectives of the institution.

CONTROLLING:

This is the managerial function that ensures that plans made are followed and objectives achieved. In other words to control means to determine whether the plans are being carried out, is progress made towards objectives and whether other actions must be taken to correct deviations and shortcomings. This relates to the importance of planning as the primary function of the manager. A manager would not be able to check whether work was proceeding properly if there were no standard and criteria as a checklist. Controlling also include replanning or taking corrective action if objectives are not met.

WHAT IS WARD MANAGEMENT?

The ward is the patient’s home where the patient spends his period of hospitalization. Ward management according to Kozier, Erb and burk (2011) is a process whereby the ward manager through people and with people makes use of ward resources to achieve ward objective. The main goal of ward management includes optimal utilization of ward resources to produce maximum output in patient care, provide personal training and advancement of patient care services.

Objectives of Ward Management:

v  To foster team spirit in the ward that will provide highest quality healthcare services.

v  To provide a clean, well ventilated environment, free from infection, accidents and hazards for patients.

v  To provide facilities that meets the needs of patient and their attendants.

v  To optimally utilize ward resources for maximum output. 

v  To encourage personnel training,job satisfaction and advancement for patient care.

Who is a ward manager?

Managers are people who are primarily responsible for the achievement of organizational goals.   A ward manager is a person trained in the scientific basics of nursing, who have met certain prescribed standards of education and clinical competence, required to provide services that are essential in the promotion, maintenance, and restoration of health and well-being of patients. The nurse, being the hub of all activities in a hospital, centered on the patient, a W M is a nurse responsible for the management of a hospital ward.


The ward manager, according to Sue Pembrey (1980) remains the key nurse in negotiating the care of the patient because she is the only person in the nursing structure who actually and symbolically maintains continuity of care to the patient. She is also the only nurse who has direct managerial responsibilities for both patients and ward staff. It is this combination that makes the role unique and so important in nursing. Ward manager is usually looked upon as a confident adviser. She must visit patients regularly and take this opportunity to provide guidance to nurses.


The Royal Council of Nursing (RCN) holds the position that a ward manager is central to ward standards. The interface between health care management and clinical delivery combines managerial responsibility for care delivery, the ward setting, those who deliver care and those who receive the care. Robert Francis (2013) noted that ward manager’s role as leader of a unit, caring for patients is universally recognized as absolutely critical. However, not all nurses want to undertake this, or are capable of undertaking this challenging but rewarding role, and it is not always easy to identify suitable candidates.

Attributes of a ward manager

The ward manager should possess attributes of a good leader, able to influence her staff to work willingly towards the achievement of the ward objectives.

Vision/Mission andWisdom: should have ability to see and think about the future with imagination of an important task/assignment ahead. With wisdom, she is focused, not sitting to wait for events to occur before thinking of how to handle challenges. Wisdom is the ability to apply knowledge and experience to any given situation. It gives insight and the ability to recognize a problem before it becomes an emergency.

Hard working:  Elevation of a nurse practitioner to a ward manger often emanate from hard working, because success comes from hard-work. A hard worker does not believe in short cuts. She strives to maintain the highest standards to achieve excellence in nursing care of her patients.

Discipline:A ward manager must be disciplined because success is not possible without discipline. According to Houston and Marquis (2011), self discipline is the willingness to perform the acts that are beneficial to us even though we do not want to perform them because they may be unpleasant. She cannot be a truant, yet expects the subordinate to be angel.

Good listening with good communication skill: A good ward manager should have good listening/communication skill.She should always give a listening ear to the subordinates and patients under his care. Effective communication enhances understanding and cooperation. These make them feel important and respected.

Others include:  humility, tactful and diplomatic,courageous and confident.

Golden rules for a good ward management

  1. Early arrival to duty: The ward manager should form the habit of arriving early to duty. This will give the chance to read through reports and handover sheets, settle down mind/body and organize tasks before the hustle and bustle of the shift ahead. 
  2. Make a note: Writing down activities for the day will allow you to clearly see what tasks you need to accomplish. If it is just for personal use only, it could be in any form one fancy, whether it’s a tick box on handover notes, the important thing is make a to-do list in the notebook or a grid of patient names with associated tasks to perform.
  3. Time planning: Estimate how long it will take to accomplish a task. Add time estimates next to each task/personnel so that you can see at a glance how much time you’re likely to spend on each. This will prevent spending too much time on one task/personnel and neglecting another. 
  4. Prioritize task. Since there are list of tasks for the day, it’s a good idea to prioritize them. Select the needs/tasks to be done first, the tasks that are urgent, and ones that need to be undertaken before the others. What would happen if a task wasn’t carried out immediately? Give each task on the list a number according to how urgent it is number1 being the most urgent and 10 being the least.
  5. Follow schedule: Ignore tasks that are not on the list, to maximize best use of time. Avoiding activities such as watching television, taking long chats, sending mails or getting involved in long conversations with colleagues, will allow more tasks to be included to a shift and make work less stressful.
  6. First thing first/Learn to say “No” with compassion. The manager cannot be everywhere at the same time, some things will have to wait. Quick assessment of situations will suggest which case should be attended to first. Attend to life threatening situations first. Say something like ‘I’m sorry I have to deal with this right now, but I will be back to help you in a few minutes.’ This is because other’s (colleagues/patient’s) priorities may be different to yours, so try not to assume they would understand.
  7. Take a break. The stress of the ward may make you feel like you can’t take a break, but using a few minutes to recollect your thoughts and actions can help you relax and focus on what needs to be done. All works and no play make jack a doll boy. 
  8. Be flexible. Working on a ward can be unpredictable and your expectations can change very quickly, so learn to be flexible and respond to what’s going on around you. It may be useful to regularly reassess and refresh your to-do list as shift continues. 
  9. Encourage yourself. . Appreciate yourself for the achievements made so far. With practice, you will get better at time management. Berating yourself for things that you didn’t manage to do during your shift is not helpful. There will always be something that you wanted to do but didn’t have time.

Elements of Ward Managements:

The components of ward management include;

  • Patient care.
  • Personnel management.
  • Ward Sanitation and Provision of Therapeutic environment
  • Supply and equipment.
  • Interpretation of policies and procedures.

A). Patient care:

The ward manager is concerned with the security, comfort and well being of every patient in the ward. It is the duty of the ward manager to utilize administrative and professional skill, to coordinate the following activities in her ward, to provide timely and effective nursing care including nutrition, proper handing and taking over of shifts, utilization of nursing process approach in proper assessment of patients need, planning and implementing care. She is responsible for 24hours of nursing care of patient in the hospital. She offers a helping hand to physicians in carrying out procedures, assisting and preparing equipment for diagnostic tests and therapeutic measures.  Giving medication and monitoring of patients for any reaction and making necessary actions to combat them.

 She keeps patients clinical report which is the most important records in the hospitals. All the papers needed for documentation of nursing care plans must be provided. She is concerned with patient and relatives about maintaining, improving health and continuing treatment after discharge. Above all, it is the responsibility of ward manager to organize a ward round activity.  Most important records in the hospitals

Ward round: Ward round is a tool of supervision, evaluation and teaching centered on patients in the ward. It plays a crucial role in reviewing and planning a patient’s care. It is an opportunity to inform and involve patients, and for joint learning for health. Doctors and nurses are two essential figures at ward round.  It is in no way, necessary for ward manager to feel inferior to a doctor when he comes to do ward rounds. Her function is that of coordinating the teams which functions for the benefit of patients.

Preparations for Round:

  • Ward should be clean and tidy.
  • There should not be too many visitors/relatives in the ward.
  • Patient charts should be up to date and all relevant information regarding patient should be available.
  • Have all patients in bed before round.
  • Diagnostic trays should be ready for use.
  • Rounds should not be conducted during lunch time/visiting hours.

Conducting Round:

  • Ensure that  you and your nurses joins ward rounds
  • Ensure that a nurse stays on patient’s side to help in patient’s examination.
  • Remember and report nurses observations to doctor.
  • Record orders/get them written by doctors. 

Principles for best practice during ward round:

This recommendation was jointly produced by the Royal College of physician and Royal college of Nursing, (2015) as principles for best practice conducting medical ward rounds.

Ø  Structuring ward rounds: The preparation, schedule and post round review with allocation of task.

Ø  Patient’s participation: preparing patients in advance and promoting shared decision-making and self management.

Ø  Protection of vulnerable patients: ward manager should ensure their needs are articulated and addressed.

Ø  Ensure nurses involvement: sharing information about patient and being informed of all patients care.

Ø  Use of safety checklist: this will reduce omissions and variations in practice.

Ø  Discharge planning: set a date for patients discharge and give detailed plan on how to manage their care outside hospital.   

B) Personnel management:

 In personnel management everyone” is important. Personnel are shown in clear and easy-to-understand terms how important, valuable and essential their contribution is to the ward work. Personnel should be informed extensively about current developments at the work place at all times.

Ward manager should use her professional and administrative roles to discharge her duties effectively. She is in charge of her ward representing and answerable to the head of nursing services. She is charged with the responsibility of controlling and supervision of activities of all personnel contributing to patient’s care - nursing, medical and domestic staff. Roles in personnel management include Schedule of duty, motivation,teaching, orientation and Conflict resolution.

Schedule of duty: (Roster and Duty Allocation)

She prepare monthly, weekly and daily duty roster for nurses and assistants for effective coverage of the ward. On assumption of duty, she should analyze nursing needs of patient’s, draws up a duty allocation plan that will aid holistic nursing care. Duty allocation should be patient centered. A nurse should be assigned to holistically nurse a patient as demanded in nursing process. Encourage staff to improve skill through continuing education. Use incentive within her powers to motivate staff to do more work satisfactorily and she can use corrective or disciplinary measures for defaulters.

Motivation:

Motivation is the inner force in a staff ,in form need, right, privilege/desire that pushes one to generate more energy that can be used to do more/harder task for greater productivity. The ward manager should learn to appreciate performance of her staff. She should not remain an authority that boss the subordinate all the time. Appreciation in form of recognition, encouragementand praise is not just being nice but can strengthen team work. The fact that recognition and praise themselves have an influence is often overseen, but are often conspicuous when absent. It also encourages personnel to give their feedback on a regular basis. Always encourage interest and guarantee equipment that helps to ease work.

Teaching andOrientation: Give teaching and guidance (incidental or planned) to juniors - staff and students and newly employee. Provide Proper orientation to the ward staff, on guidelines, ward routines, policies and procedures. This helps to gain cooperation and makes personnel management easier. Arrange training programmes of nursing staff, students and others. Ensure adequate monitoring and evaluation of ward functions and see to staff welfare.

Conflict resolution: Maintain good relationships among all categories of staff and with patients and their relatives. A ward manager should be able to utilize strategies in resolving conflict among her staff. Investigation of complaints of cases should be paramount instead of being judgmental. Discipline nursing and domestic staff if need be.


C). Ward sanitation and provision of therapeutic environment:

The primary role of the hospital is to provide curative care to the sick through provision of a shelter in the hospital, under direct supervision by the ward manager. It requires a systematically organized ‘In patient care’ facility. This is very important because while providing curative care, there should be provision to look into the patients physical, emotional and psychological needs. 

The ward manager should ensure adequate environmental cleanliness and therapeutic environment is provided for patient care. She should ensure that concerned domestic staff keeps the ward; its annexes and environments clean and tidy. Linen, ward equipment-up-keep and repairs are maintained. The patient must feel at home having a clean, peaceful atmosphere, and adequate provision for self-entertainment. Therapeutic environment entails a whole lot of activities that will control the ward environment and make it safe and less harmful for patients such as:

  • Temperature regulation.
  • Proper light.
  • Elimination of unpleasant odours.
  • Safe water supply.
  • Safe disposal of waste (dry and wet)
  • Dust control
  • Ward Free from insects and pest.
  • Protection from injury (mechanical, thermal, chemical).
  • Protection from radiation.
  • Provide adequate privacy.
  • Control of visitors.
  • Prevention of cross infection in the ward (Nosocomial).

D). Supply and equipment.

This entails all the physical equipments/instruments needed in the ward for the performance of the daily ward duties. The ward manager should always assess and determine the needs of her wards and put up requisition for supply and actually ensure they are supplied and maintains inventory. Prompt and adequate supplies facilitate the work of the staff and ultimately increase productivity.

 These includes surgical and non surgical e.g. syringes and needles, cotton wool, lotions, detergents, linens, instruments for various procedures such as dressings, tables, chairs, beds etc.

E). Interpretation of policies and procedures.       

 It is the duty of the ward manager to interpret standing policies and procedures of the hospital and ward to the staff. Policies and procedures are standing plans which helps in decision making. They will help the subordinates, to take decisions and the ward administration will continue to flow even in the absence of the manager. The policies and procedures should be made very clear, written in simple, clear language, avoiding the use of ambiguous words e.g. examination in progress, visiting hours 4pm – 6pm.

TOOLS FOR EFFECTIVE WARD MANAGEMENT

1. Organizational philosophy:

This simply means the beliefs of an organization. For any organization to succeed, it must have a sound set of beliefs on which its policies and actions are based. The ward manager should develop her philosophy from the beliefs of the nursing service in assisting the patient with meeting his activities of daily living when he is located along the health-illness continuum. It is this set of beliefs that will determine actions that will lead to the achievements of ward objectives.

2. Organizational chart This is also called an organogram. It is used to show organizational structure. The chart shows the positions of every staff in the department (ward), and to whom each person is responsible to. It helps in delegation of duties and in communication.

3. Supervision: is a management tool that aims at overseeing, observing and assessing performance of workers in all their activities to ensure adequacy of standard to monitor the extent the desired objective have been achieved. It is a process of helping the subordinate to improve on her performance to ensure that one delivers the best possible care to the client.

The supervisory role of a ward manager should apply to every shift and staff so that they can:

Ø  Fulfill their ward leadership responsibilities

Ø  Guide clinical cares rendered to patients

Ø  Ensure monitoring, evaluation and maintenance of nursing care standards

Ø  Teach and give orientation to clinical practice and procedures

Ø  Be a good role model to professional practice and behaviors

Ø  Oversee the up keep of ward environment.

Ø  Assume high visibility as the nurse leader of the ward

Ø  Oversee the maintenance of proper records and registers

4. Delegation- is a management process that permits the transfer of duty/ responsibility and authority from an executive to a subordinate for which shall be accounted for.

 Ward manager should develop good human relations in her ward through effective delegation. She should gain co-operation from subordinates and supervisors. Delegation should include administrative roles and responsibilities for patient care. She should evaluate the skill of the personnel before assigning duties and responsibility to a subordinate.

5. Nursing Audit –is an administrative tool for assessment of the quality of nursing care.It is a systematic method of assessment and evaluation of nursing cares rendered, to see to which extent the desired objective was achieved. It involves the review of clients’ records for the Structure, process and outcomes through which the outcomes were achieved. Structure deals on therapeutic environment required for nursing care delivering. Process – deals with the manner and willingness of delivery of nursing care.  Outcome deals with measurable results of care giving to clients’ e.g. healing time of wound by first intention.

The ward manager should be able to audit nursing cares rendered in her ward to check mate how close/far she is to the set standard.  Auditing can be done retrospectively after patient’s discharged or concurrent while the client is still receiving care in the hospital. Benefits include; improves the quality of patients care, helps the nurses to improve on their deficiencies and reduce the incidence and severity of medico-legal complications.


6. Formulation of policy and procedure: formulation of policies and procedures is one of the most important functions of management. Policies according to Huston and Marquis (2011) are general statements that channel the thinking of all staff charged with decision making.  Policies and procedures are formulated based on the organization. In this contest, it is hospital and ward. It is a guide that clearly spells out responsibilities and states actions for a particular circumstance. Policies and procedure ensure uniformity in decision making and should be in written order e.g. nursing care. Procedures are derived from policies but they are much more specific than policies and are guides to actions. They spell out the steps that should be followed in order to carry out a policy e.g. the procedure book in the wards.

7. Budget - According to Harold and Heinz (2005), budgeting is the formulation of plans for a given future period in numerical terms, either in financial terms or nonfinancial terms. Budgeting involves estimating cost that will cover of manpower, physical materials and services. It is the duty of the ward manager to identify those needs that are necessary for patient care for the smooth running of the ward.

IMPORTANCE OF A GOOD WARD MANAGER

Ward manager are without doubt the professional gate keepers of the ward environment. The ward will function more smoothly; work start early, manages resources within budget. A good ward manager is able to represent and defend her ward in times of need and problems. She is a goal getter for her people. WM grows in strength, prestige, position and recognition. She stands the chances for recommendation for a higher post both within and outside environment.

FACTORS INFLUENCING WARD MANAGEMENT

Ward Management is one of the pre requisites for good nursing care. There are many factors involved in good ward management, which the manager needs to understand thoroughly for the effective management. If the ward manager, fails to be aware, understand and plan for the under listed factors, definitely her ward will be in shambles e.g.

}  Poorly designed hospital wards which lack adequate features will not promote suitable habitable and working environment.

}  Interruptions in the ward from establishing ward routines e.g. power outage, inconsistent supplies of equipments.

}  Failure of orientation of new personnel.

}  Poor communication skill.

}  Poor working relationship

}  Poor delegation and supervision.

CONCLUSION

Ward management is a process of utilizing human and material resources by a ward manager to achieve a desired objective. The ward manager remains the key nurse in negotiating the care of the patient because she is the only person in the nursing structure who actually and symbolically maintains continuity of care to the patient. She is responsible for ensuring high quality, safe and effective nursing care through assessment, planning/intervention and evaluation of evidence –based care, carried out in line with best practices.


REFRENCES

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             of Executive co Coaching. Journal of Nurse Managers.

Anene, P.N. Managerial functions of a nurse: implication for effective ward management. Nurse’s Hallmark. Anambra MCPDP, Nigeria.

Harold, k. & Heinz, W. (2005).Management: A global perspective. Singapore: McGraw-Hill Book Co.

Hood , L .(2013). Conceptual Bases of Professional Nursing. Philadelphia:Lippincolt Williams & Wilkins.

Huston , C.J. & Marquis, B.L. (2011).Retention and productivity strategies for nurse managers. Philadelphia: J.B. Lippincott.

Huston ,C.J. & Marquis, B.L. (2011) Leadership roles and management functions in Nursing. Philadelphia: J.B. Lippincott.

Kozier, B., Erb, G., A. J. & Burke, K. (2011). Fundamentals of Nursing. New jersey:     Prentice Hall.

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Question

1. Most important records in the hospitals

a.       Patients clinical report

b.      Treatment admission an discharge record

c.       Ward equipment record

d.      All of the above

2. The following is responsible for 24hours of nursing care of patient in the hospital.

a)      student nurse

b)      staff nurse

c)      ward manager

d)     head of nursing service

3. Well planned nurses’ duty schedule in a shift is called------------------

a)      time schedule

b)      duty roster

c)      shift

d)     duty allocation

4. Organized accommodation for care of the sick and injured in hospital is

a)      hospital care delivery

b)      blood bank

c)      ward

d)     clinic

5. Mention 2 components of ward management

    a) ---------------------------------------------------------------------------------------

   b)  ---------------------------------------------------------------------------------------

6. List 2 factors that can affect ward management

  a) ----------------------------------------------------------------------------------------

  b) ---------------------------------------------------------------------------------------

7. -------------------------------------is a management tool that permits the transfer of duty, responsibility and authority from an executive to a subordinate for which shall be accounted for.

 a) Supervision

  b) Coordination

(c ) monitoring

(d) delegation

8. --------------------------------- and ------------------------------ are two essential figures at ward round.

9. ------------------------------is the formulation of plans for a given future period in numerical terms, either in financial terms or nonfinancial terms aimed at estimating cost that will cover of manpower, physical materials and services.

a) Accounting

b) Budgeting

( c) Financing

(d) Monthly requisitions

10. -----------------------------------------------------entails a whole lot of activities that will control the ward environment and make it safe and less harmful for patients.

(a) Ward sanitation

(b­­­­­­­) Therapeutic environment

( c) Adequate waste management

(d) Control of visitors


ANSWERS

1. (a) Patients clinical report

2. (c ) ward manager

3. (d) duty allocation

4. ( c) ward

5.   - Patient care,    - Personnel management.

 -Ward Sanitation and Provision of Therapeutic environment

      -Supply and equipment,    -Interpretation of policies and procedures.

Any 2 above answers the question

6. Poor working relationship, poor working environment, poor delegation and supervision.    Failure of orientation to new personnel,  Poor communication skill. Any 2 answers the question.

7.   Delegation

8.   Doctors and Nurses

9.   (b)  budgeting

10.  (b) therapeutic environment





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