FACULTY OF HEALTH SCIENCES

DEPARTMENT OF NURSING: JANUARY 2013 CLASS

NURSING ADMINISTRATION
Course Code NRSG 355
Clinical Placement Report Nakuru County and Referral Hospital

Report compiled by:

LUCY GATHONI BSN-1-2562-1/2013

GRACE WAFULA BSN-1-1981-1/2013
MAUREEN MULUNDA BSN-1-1656-1/2013
MARGARET KUYA BSN-1-2156-1/2013

INTRODUCTION
Nakuru county Referral Hospital is a level 5 Referral hospital located in Nakuru, off Nakuru
Nairobi highway along the show ground. It is a referral hospital of the county with 580 bed
capacity. It is a high catchment area serving Kenyas largest and most highly populated region
with a wide variety of study cases and elective options.
The hospital has over 20 wards and various clinics attached. It provides all major services
including antenatal care, anti-retroviral therapy, basic emergency obstetric care, comprehensive
emergency obstetric care, curative inpatient services, curative outpatient services, family
planning, HIV counseling and testing, immunization, integrated management of childhood
illnesses, prevention of mother to child transmission of HIV, radiology services, tuberculosis
diagnosis, laboratory and treatment and youth friendly services.
Vision:
To be a public hospital of excellence in the country
Mission statement:
To provide an integrated high quality affordable curative, preventive and rehabilitative care
Core Values:Integrity
Excellence
Compassion
Continuous improvement
Teamwork

We reported to the hospital administration on 23rd of November 2015 at 7:30am and were
received well by the Nursing officer in charge of the hospital. We then received the hospital
report given by the covering nurses and later assigned to different units under each unit in charge
for example medical ward, surgical ward, reproductive department and supplies department. We
also went to the procurement department where we were taught about procurement process.
On subsequent days of our placement we reported at 7:30am, received the hospital report from
the nurses covering then each of us was assigned different managerial duties in different wards
which included checking of proper documentation of cardex and nursing care plans,
completeness of emergency trays, availability of staff on duty and any complaints from the staff
and the general state of the ward. We gave feed back to the respective ward and unit in-charges
and urged them to utilize the nursing tools for better patient management.
Each day one of us remained in the supplies and non-pharmaceuticals department to assist in
issuing and control of supplies.

NURSING SERVICES
The nursing department is headed by a Chief Nurse who is the manager of the nursing services
at the hospital. The chief nurse is appointed by the county health management team based on
qualification, experience and the capability to provide management services.
The chief nurse is responsible for effective management of nursing services and nursing staff at
the hospital and is assisted by departmental/sectional heads as indicated in the organogram
below.

Organization chart for Nursing Services- Nakuru county Referral County Hospital

Nursing Services Manager

Deputy Nursing
Services Manager

Nursing
Manager Surgical Unit

Nursing
Manager Out
Patient
Department

Outpatient/Casua
lty/Special
Clinics

Ward Incharges/
Male and Female

Nurse
practitioners

Nurse
Practitioiners

Support Staff

Support Staff

Nursing
Manager
Reproductive
Health

Nursing
Manager
Medical Unit

Ward Incharges:
NBU,Maternity,
Post
Natal
,Gynae

Ward Incharges:
Male/Female

Nurse
practitioners

Nurse
Practitioners

Support Staff

Support taff

The organogram shows the chain of command from the top management to the lower cadre of
staff. It:

Facilitates easy flow of information from the lower level to top level and top level to lower level.
depicts the interrelationship within the units of nursing

The hospital has different cadres of nursing staff that contributes to the effective health service
delivery at the hospital as indicated in the establishment below:

Nursing Staff Deployment Status

Department
Administration
Surgical Wards
New born unit
Pediatric ward
Maternity unit
Psychiatric Ward
Medical Wards
Critical care unit
Theatre
Special Clinics
Maternal Child Health Clinic
Casualty
Isolation ward
Total Number

No. of Nurses
7
27
14
21
43
13
26
13
11
12
22
13
7
229

No. of Patient
0
73
27
41
94
47
55
2
-

The Nurse Manager

The Nurse Manager is tasked with the responsibility of managing nursing services and therefore
performs her responsibilities in line with the management theories and functions to ensure that
the services meet the required standards and thresholds.
Management theories applied in Nakuru county referral Hospital from our observation and
experience includes:

Classical Theory
-

This theory emphasizes on systematic information collection, analysis and identification

of causes and effects followed by effective organization of management structure.

Focuses on effectiveness and efficiency of service provision

Application of Henri Fayols functions and principles of management Planning,

Organizing, Coordinating and Controlling.

Hierarchical arrangement of offices, where one level of job is subject to control by the
next higher level ( Chain Of command) is evident at the institution

Appointment of authority made on grounds of technical competence.

Rules, decisions and cautions are formulated and recorded in writing.

Behavioral approach Theories (Human Relations or psychological theories)

-

Abraham Maslow- the nurse manager recognizes hierarchy of human needs and always
strives to ensure that the staffs are motivated and encouraged to perform.

Systems theory
-

The organization is viewed as a system of interrelated parts (departments) that has a set of
activities which enables inputs to be converted into outputs.

The hospital operates as an open system whereby there is interaction with the external
environment and social systems.

The staff and employees of the hospital are able to communicate with each other (Team
Work) and contribute to the achievement of institutional goals and objective.

ROLE OF A NURSE AS A MANAGER

-

A nurse is a member of the Hospital Management Team (HMT) that is responsible for the

overall management of health services in the hospital.

The nurse manager plans and does budgeting for the nursing department i.e. human

resources and other resource management.

Participates in mentorship of nursing staff and students.
Management of the nursing staff i.e. deployment, development, supervision and
motivation.

Advises the Chief Executive officer on all matters pertaining nursing services at the

County referral hospital.

Compiles nursing reports and data on monthly basis and submits them to the County

Nursing Officer.
Implements health policies and guidelines.
Acts as a link with the county on nursing issues and seeks guidance on nursing matters

from the county Team.

Collaborates with other multi-disciplinary team members to ensure continuity of health

services.
Develops, disseminates, and supervises implementation of nursing policies and

guidelines at the hospital level.

Links with other departments within and outside the hospital for example Annex hospital.
MANAGERIAL FUNCTIONS

1. Planning
The Nurse Manager with assistance from the departmental heads plans and develops specific
goals and objectives for the respective nursing units every quarter. They assess, implement and
evaluate the nursing care provided in the hospital to ensure that they meet the set standards.
Assessment:
-

Before service provision is done at the ward or department levels the nurses are
encouraged to assess their patients needs and come up with priority care options using
nursing care process.

All nurses in the hospital have been trained on the nursing care process tool and are able
to utilize the skill in preparing nursing care plans for patients.

All care provided in the wards are documented in form of cardex and patients notes in
file which are then used for decision making

Comprehensive data is collected from the patients through history taking and physical
examination and are documented in respective files.

Reports are done from the departments every day and submitted to the nurse manager as
daily bed returns and daily hospital reports.

Setting goals and objectives

The nurse managers in the wards and departments are tasked with setting goals and objectives
for the service delivery in their respective units. These are aimed at quality service provision to
the clients and are also used for performance appraisals at the end of the financial year.
The objectives cover the service provision and other needs for the department e.g. materials and
supplies.
Implementation
-

All plans are implemented by the nurse providers and managers in the wards and
departments

Evaluation
-

Evaluation of planned activities is carried out periodically by the nurse practitioners and
managers.

Daily evaluations are made on the care plans developed at the ward.

Handing over reports and shift handing over is done at the end of the day

Nursing rounds are conducted daily to evaluate patient care for example through
checking for completeness of the emergency tray, nursing care plans for individual
patients and cardex and observation charts.

2. Organizing
The nurse manager is responsible for organizing the nursing services at the hospital in order to
ensure a smooth and coordinated service delivery.
-

Nursing department has developed an organogram at the top management and at the
department level. The organogram depicts the chain of command and how the department
is managed.

Clear job descriptions and specifications have been taken into consideration by the
nursing department and each staff knows their responsibilities and mandates.

All communication are made in an organized system e.g. when there is an issue at the
ward level the nurse in-charge is responsible for solving it and only refers the cases to the
Nurse manger in extreme circumstances.

Vertical communication in the organization is encouraged and is done within the

departments or staff to staff.

The nurse manager assigns responsibilities to specific staff through appointments and
delegation of responsibilities.

Duty allocation is made using centralized schedules completed by the Nurse Manager and
this acts as a master plan for the nursing personnel in the hospital. The schedule provides
an overall picture of staffing situation and is used in eliminating bias amongst the staff.

A decentralized schedule is also made at the ward level to effectively manage the nurse
practitioners at that level.

3. Human Resources management (Staffing)

Staffing involves the filling and keeping filled the positions in the organization structure, done by
identifying workforce requirements , recruiting, selecting, placing ,promoting, planning the
career, compensating and training the job holders to accomplish their tasks effectively and
efficiently.
Recruitment: Selection of staff is done at the county level whereby after advertisement,
applicants are selected based on the qualifications and job description, then shortlisted,
interviewed and successful candidates are taken for orientation and deployed to different wards.
Conflict resolution: Conflicts are handled and solved according to the magnitude and manner of
presentation by the aggrieved parties. Conflict can cause the misdirection of efforts against
workmates instead of working towards achievement of organizational goals. The organization
resolves conflicts among staff by using the following principles;
Communicating to self and others that conflict is a necessary process.
Determining similarities and differences in facts, goal, methods and values.
Assessing the degree of conflict- ask questions about quality of decisions.

 Assess each situation and match the best approach regardless of which is your
favorite.
Assisting others in assessing conflict and seeing how best they can approach.

The manager also overcomes organizational conflict through; Improving team spirit,
enhancing effective communication, regular job rotations and employee counseling
services.
Performance appraisal: Nurses working at the hospital are assessed and appraised based on set
targets that are made at the beginning of the financial year, the targets contributes to the overall
performance of the County Health Management Team and the performance targets are used as a
measure of promotion for staff.

4. Controlling
Controlling is a function that is concerned with measuring and correcting performance of
employees to ensure that the planned objectives are achieved. It involves the regulation of
activities so that some targeted elements of performance remains within acceptable limits. It
measures performance against goals and plans, shows where negative deviation exists and
actions taken to correct them. The Nurse Manager is responsible for maintaining the quality of
standards within the hospital and has put in place a Quality Assurance team (QAT) to oversee
that this is done.
The QAT is authorized by the CEO to investigate any activity within its terms of reference. It is
authorized to seek any information it requires from any member of staff and all members of staff
are directed to co-operate with any request made by the committee.
FINANCIAL MANAGEMENT.
The hospital contributes significantly to the local economy by providing employment
opportunity for skilled and non- skilled labour.The hospital sources of revenue for day to day
running cost are made of patients fees which are the biggest source of revenue, other sources

include externally funded programmes and donated services and the county. It is the hospital
polices to continue upholding procurement policies that focus on prudent management. The
hospital continues to publish its accounts and reports with accepted accounting principles.
There is a departmental monthly inventory and a general hospital inventory done twice a
year. This is entered in the hospital database for evaluation and reference.
During resource allocation the hospital prioritizes patient care and payments for supportive
staff.

What measures has the institution put in place for cost containment?
Cost containment is the process of maintaining organizational cost within a specified budget
restraining expenditures to meet organizational goals. The measures that the institution has put in
place for cost containment are:

Review of operational controls and assessment of cost containment measures. This is

done yearly to check whether what was budgeted for, has been used well.

The institution, through different departments, purchases only what was budgeted within
that financial year.

Cost sharing whereby the institution collects money from patients according to the care
given in every department .For instance nursing care, consultant fee, investigations.

The institution receives aids from donors who may supply them with equipment,
materials and maintenance of the hospital.

NURSING OBJECTIVES
1. MATERIAL MANAGEMENT
The following strategies are used by the institution in material management;
Demand estimation- identifying the requirements or needs
Procurement- after listing the required materials, procurement or ordering is done.
Major expenditures are handled by the hospital procurement teams and are guided by

the procurement laws and requirement. A procurement committee is mandated to

procure goods and services for the departments following laid down procedures;

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Tendering
Quotation
Bidding
Opening of tenders and awarding of tenders
Contracting of suppliers for a period of one year

Receipt and inspection- the materials received are subjected to physical and chemical
inspection to ensure the right quality of material is received therefore the direct user who is a
nurse must be there to verify the quality of purchased materials.
Storage- the materials are stored within the institution and they are stored according to
requirements for example, some are stored in the fridge like drugs, shelves or cupboards.
Inventory control- the institution stocks adequate number of materials to allow availability
whenever required. Close supervision of movement of materials or consumption rate is done
to ensure proper control.

Maintenance and servicing of hospital equipment is done as need arises.

2. WASTE MANAGEMENT
The hospital has a system of waste segregation according to the principles of infection
control where some waste is burnt in the incinerator while food stuffs are disposed separately.

3. CHANGE MANAGEMENT
Change management is an approach of shifting/transitioning individuals, team and organization
from current state to a desired future state. Nakuru County referral hospital has various
departments which work together to achieve the common goal of providing compassionate,
affordable and quality care to those requiring health services. Once the organization identifies the
need for change, it assesses its implications. This may require; definition of alterations in

operational methods, staffing levels, employees attitude and perspective necessary to implement
alterations, new equipment and systems.
The organization reduces or avoids resistance to change by going through a change process. The
Kurt Lewin three step approach is used to overcome resistance to change;
a

Unfreezing-the organization gets rid of existing practices and ideas that stand in the way
of change. This requires a high level of communication with employees to convince them
that change is necessary.

Changing- this involves teaching employees to think and perform differently.

Refreezing- establishing new norms and standard practices.

To implement the above process, the employees undergo education and communication to make
them fully aware of all the aspects of the situation and convince them that change is essential.
The employees are also actively involved and participate from the beginning so as to stimulate
commitment. They are also given support and assistance as needed.
At the beginning of the year the Nursing department and the Hospital made changes at the
institution with an aim of improving service delivery standards. Some of the changes took effect
immediately and others are on-going. The Changes were made depending on the prevailing
circumstances and not necessarily communicated to the staff.
The changes were made after undergoing a process and identification of gaps through:
-

Departmental reports
Regular meetings
Complaints from the patients
Bench marking done in other successful hospitals

Some of the changes made in the recent past include:

-

Change in management teams: the Nursing managers and assistants were removed and

replaced by a new team of nurse managers.

Improvement of infrastructure and additional of wards and specialized units, this was
made to expand services at the hospital e.g. expansion of inpatients wards and dialysis
unit.

The changes made have been a success and staffs embraced the changes and are now
motivated.

THE MEDICAL UNIT- WARD 5

-

The medical ward is a department that admits and manages patients with medical
conditions.

The unit is structured in a way that the service delivery and emergencies are coordinated.
The unit is headed by a physician and a Nurse in charge of the ward who are responsible
in ensuring that patients care is provided according to the set standards, they also take
charge of the human resource and manage all resources in the unit.

The ward in-charge is answerable to the Nurse Manager through the unit in charge and is
responsible for the overall management of the ward and patients.

The medical unit has 13 qualified nurses who are deployed to the ward to cover a 24 hour
schedule.

The medical unit has a bed capacity of 34 and an average number of 35 patients.

The medical unit also consist of several health care personnel who work as a team in
provision of patient care , they include:
o Medical officers
o Clinical officers
o Physiotherapists
o Nutritionists
o Laboratory Technologists
o Health information officers
o Clerical officers
o Supportive staff
o students

Duties and responsibilities of the Nurse in-charge of the ward

-

The nurse manager plans and does budgeting for the ward and submits it to the Hospital
Nurse manager who then compiles the same and presents to the executive expenditure

committee for approval.

Carries out administrative duties of the ward in collaboration with a resident physician.
Participates in mentorship and clinical teaching of nursing staff and students
Management of the nursing staff at the ward level i.e. deployment, development,

supervision and motivation

Compiles nursing reports and data on monthly basis and submits them to the hospital In-

charge
Supervises the implementation of nursing policies and guidelines at the ward level
Allocation and deployment of nurse practitioners to cover the ward in 24 hours
Ordering of supplies from the nurse manager office and hospital stores and ensuring that

they are properly utilized.

They form an emergency response team that deals with cases of mass emergencies.
ORGANOGRAM OF THE MEDICAL WARD

Medical Unit
Nurse in charge

Nurse in charge Medical

Nurse practitioners

Physiotheraphist

Physician/Medical
Officers

Nutritionist

Patients / care
takers

Laboratory Staff

other
medical/health
team

Clinical case management

The nurses in the medical ward are each allocated duties on daily basis and the nurse in-charge
takes the overall responsibility in ensuring that the shift is fully covered and that all care plans
are implemented and evaluated daily.
The nursing team utilizes the Nursing care process in patient management, this include:
o Assessment
o Nursing diagnosis
o Planning
o Implementation
o Evaluation
All the 13 nurses in the ward have undergone training in use of the nursing care process and are
able to plan using the tools provided.
Daily patient returns are filed to the office of the Hospital Nurse manager.
Continuing medical education is being carried out every Wednesday of the week to refresh the
nursing staff on the new developments in patients care and other changes.
Clinical rounds are conducted daily by a team of consultants and other specialists where they
discuss the patient management and prognosis.
Infection preventions and control in the medical unit
-

The ward has a Quality Control Team that takes care of infection prevention and setting
standard operating procedures for the department.

Waste segregation is done at the ward, these include use of color coded bins and safety
boxes.

The support staff handling the wastes are adequately trained and provided with personal
Protective Equipment i.e. gloves, gumboots and aprons.

Medical ward-Conclusion
-

Coordination at the medical ward is well done under the nursing manager and the medical
team, all duties and responsibilities are shared out appropriately.

Staffing is adequate to manage the high workload at the ward Nurse patient ratio = 1:3

- Though Infection control measures are in place, there are still serious cases of
contamination cross infections- some staff especially new interns are not trained on
infection prevention control.

GENERAL HOSPITAL CONCLUSION

-

The nurse managers and nurse practitioners at the referral hospital are dedicated in
ensuring that nursing services meet the set standards despite the limitations they face

especially human and material resources.

Political interference in human resource leading to staff demotivation in terms of

promotions, salaries remunerations and staffing.

Devolution of health services was not well done, since there are no structures put in place
pertaining transfers, promotions and staff development. Staffs are tossed between the
county government and central government; without clear communication which has led

to mass resignation especially doctors.

Staff patient ratio is wanting, putting in mind this is a teaching and referral hospital, so
many patients are seen, with a limited number of staff leading to burn out and

underperformance hence poor quality of services.

In some wards, nurses lack knowledge on nursing process.

GENERAL HOSPITAL RECCOMENDATION

-

Deployment of more staff to the hospital

More nurses should be trained on implementation of the nursing process in patient management.
Staff should be promoted timely for better motivation.
Student interns should be motivated by being given tea at break time

References

Basavanthappa. B P ( 2000) Nursing Administration. New Delhi. Jaypee Brothers

Medical Publishers Ltd.

Swayne, W: Duncan, J. & Ginter, P. M. (2005) STRATEGIC Management of Health care

Organizations .Blackwell Publishing Co.

Linda J. Knodel (2010), Nurse to Nurse Nursing Management, MC GRAW HIL