Nursing:

Nursing is a healthcare profession focused on the

care of individuals, families, and communities so
they may attain, maintain, or recover optimal
health and quality of life from conception to death.
Nurses work in a large variety of specialties where
they work independently and as part of a team to
assess, plan, implement and evaluate care.
Nursing Science is a field of knowledge based on
the contributions of nursing scientist through peer
reviewed scholarly journals and evidenced-based
practice.

Nursing specialties
Nursing is the most diverse of all healthcare
professions. Nurses practice in a wide range of
settings but generally nursing is divided depending
on the needs of the person being nursed.
The major divisions are:-
• the nursing of people with mental health
problems - Psychiatric and mental health
nursing
• the nursing of people with learning or
developmental disabilities - Learning disability
nursing (UK)
• the nursing of children - Pediatric nursing.
 • the nursing of older adults - Geriatric nursing
• the nursing of people in acute care and long
term care institutional settings.
• the nursing of people in their own homes -
Home health nursing (US), District nursing and
Health visiting (UK). See also Live-in nurse
There are also specialist areas such as cardiac
nursing, orthopedic nursing, palliative care,
perioperative nursing, obstetrical nursing, and
oncology nursing.
History of nursing
Main article: Timeline of nursing history
See also: Category:Nurses and Category:Nursing
museums

In fifth century BC, Hippocrates was one of the first

people in the world to study healthcare, earning
him the title of "the father of modern medicine".
[
Jesus Christ also taught that sick people should be
cared for; in around 370 AD, one of the first
Christian hospitals in the world was built in
Cappadocia. Western European concepts of nursing
were first practiced by male Catholic monks who
provided for the sick and ill during the Dark Ages of
Europe.
During 17th century Europe, nursing care was
provided by men and women serving punishment.
It was often associated with prostitutes and other
female criminals serving time[citation needed]. They had
a reputation for being drunk and obnoxious, a view
amplified by the doctors of the time to make
themselves seem more important and able.. It was
not until Florence Nightingale, a well-educated
woman from a wealthy class family, became a
nurse and improved it drastically that people
began to accept nursing as a respectable
profession. Other aspects also helped in the
acceptance of nursing. In 1853 Theodore Fliedner
set up a hospital where the nurses he employed
had to be of good nature. Many people were
impressed with this facility, and because of it, the
British Institute of Nursing Sisters was set up.
Prior to the foundation of modern nursing, nuns
and the military often provided nursing-like
service. The religious and military roots of modern
nursing remain in evidence today in many
countries, for example in the United Kingdom,
senior female nurses are known as sisters. It was
during time of war that a significant development
in nursing history arose when English nurse
Florence Nightingale, working to improve
conditions of soldiers in the Crimean War, laid the
foundation stone of professional nursing with the
principles summarised in the book Notes on
Nursing. Other important nurses in the
development of the profession include: Mary
Seacole, who also worked as a nurse in the Crimea;
Agnes Elizabeth Jones and Linda Richards, who
established quality nursing schools in the USA and
Japan, and Linda Richards who was officially
America's first professionally trained nurse,
graduating in 1873 from the New England Hospital
for Women and Children in Boston.
New Zealand was the first country to regulate
nurses nationally, with adoption of the Nurses
Registration Act on the 12 September 1901. It was
here in New Zealand that Ellen Dougherty became
the first registered nurse. North Carolina was the
first state in the United States to pass a nursing
licensure law in 1903.
Nurses in the United States Army actually started
during the Revolutionary War when a general
suggested to George Washington that the he
needed female nurses "to attend the sick and obey
the matron's orders. In July 1775, a plan was
submitted to the Second Continental Congress that
provided one nurse for every ten patients and
provided that a matron be allotted to every
hundred sick or wounded".
Nurses have experienced difficulty with the
hierarchy in medicine that has resulted in an
impression that nurses' primary purpose is to
follow the direction of physicians. This tendency is
certainly not observed in Nightingale's Notes on
Nursing, where the physicians are mentioned
relatively infrequently, and often in critical tones—
particularly relating to bedside manner.
The modern era has seen the development of
nursing degrees and nursing has numerous
journals to broaden the knowledge base of the
profession. Nurses are often in key management
roles within health services and hold research
posts at universities.

Nursing as a profession
The authority for the practice of nursing is based
upon a social contract that delineates professional
rights and responsibilities as well as mechanisms
for public accountability. In almost all countries,
nursing practice is defined and governed by law,
and entrance to the profession is regulated at
national or state level.
The aim of the nursing community worldwide is for
its professionals to ensure quality care for all, while
maintaining their credentials, code of ethics,
standards, and competencies, and continuing their
education.There are a number of educational paths
to becoming a professional nurse, which vary
greatly worldwide, but all involve extensive study
of nursing theory and practice and training in
clinical skills.
Nurses care for individuals of all ages and cultural
backgrounds who are healthy and ill in a holistic
manner based on the individual's physical,
emotional, psychological, intellectual, social, and
spiritual needs. The profession combines physical
science, social science, nursing theory, and
technology in caring for those individuals.
In order to work in the nursing profession, all
nurses hold one or more credentials depending on
their scope of practice and education. A Licensed
practical nurse (LPN) (also referred to as a
Licensed vocational nurse, Registered practical
nurse, Enrolled nurse, and State enrolled nurse)
works independently or with a Registered nurse.
The most significant differentiation between an
LPN and RN is found in the requirements for entry
to practice, which determines entitlement for their
scope of practice, for example in Canada an RN
requires a bachelors degree and a LPN requires a 2
year diploma. A Registered nurse (RN) provides
scientific, psychological, and technological
knowledge in the care of patients and families in
many health care settings. Registered nurses may
also earn additional credentials or degrees
enabling them to work under different titles (Nurse
Practitioner, Clinical Nurse Specialist, Registered
Nurse First Assistant,etc.).
Nurses may follow their personal and professional
interests by working with any group of people, in
any setting, at any time. Some nurses follow the
traditional role of working in a hospital setting.
Nursing practice
Nursing practice is the actual provision of nursing
care. In providing care, nurses implement the
nursing care plan using the nursing process. This is
based around a specific nursing theory which is
selected based on the care setting and population
served. In providing nursing care, the nurse uses
both nursing theory and best practice derived from
nursing research.

Critical study on nursing services:

1.Critically Consider The Impact Of The Large

Number Of Recent Structural Changes, Policy
Initiatives And Targets Imposed On
Collaborative Working Of NHS Staff.
The Department of Health has laid down certain
policy initiatives, targets and structural and
organizational changes that can improve the
quality of care received by patients through the
NHS. These changes are emphasized along with
the need for multi-agency and multi-organizational
collaborative working across disciplinary
boundaries. The four key interfaces for which
collaboration and coordination measures are being
suggested are health and social care; general
medical and community health services; primary
and secondary care; and interface with carers
(DoH, 1996).
In this article we will discuss:
1. the policy measures and guidance documents
provided by the Department of Health that stress
on the need for collaborative working and how this
approach could be implemented in the NHS
2. the targets set by the Department of Health for
achieving certain levels in the quality of services
and how an emphasis on collaborative working
could help in enhancing quality of care
3. the structural and organizational changes that
the Department of Health have specified to
implement collaborative working within the NHS
and how in turn these changes have influenced
collaborative and multidisciplinary working within
the NHS.
Our responses and analysis of the issues in
consideration will involve these three major points
and we will discuss the implications of strategies,
policies, structural changes and targets on
collaborative working and how these issues are
related to the multi-organizational work culture as
promoted in recent years by the Department of
Health.
Collaborative working in NHS - Key Issues and
Concepts
The Department of Health has identified seven
areas focused on cross boundary collaborative
working and these include:
(i) partnership with patients and carers;
(ii) the commissioning process;
(iii) inter- agency collaboration;
(iv) inter-professional collaboration and teamwork;
(v) professional education and training;
(vi) communication and information sharing; and
(vii) research and development.
However, in order to examine the policy and
structural changes within the NHS, the main
structures and processes identified are :
Organisational processes and Infrastructure,
Knowledge Management processes, and
Knowledge management resources. In fact
collaborative working relates to knowledge
management and structural and organisational
changes have been suggested to facilitate
information sharing across departments, and
professionals as well as to facilitate interaction
between patients, doctors and carers. Knowledge
management indicates the optimum use of
knowledge across departments to enhance quality
of care provided but relates not just people,
collaboration or work culture but also to technology
and upgradation of services provided. Knowledge
management is also directly related to
improvement of staff performance and the recent
empahsis on collaborative working has been based
on several objectives that the Department of
Health seems to have identified. These we can
enumerate as follows:
• Implementing a process of change within the
NHS
• Improving efficiency of services and quality of
care
• Encouraging advanced and technologically
superior equipment and clinical procedures as
seen in the NHS Modernisation Agenda.
• Using management principles of knowledge
management and coordination to achieve
collaborative working and better interaction
among patients, doctors, nurses and other
health professionals across departments and
agencies.
• Improving staff performance through
performance management and optimising
 utilisation of processes, organisational
structures and resources.
At the heart of the collaborative working approach
are policies, targets and changes as implemented
by the NHS. The change model given by the NHS is
External change, Problems & opportunities →
Recognition of the need for change → Start of
change process → Diagnosis (Review present state
↔ Identify future state) → Plan and prepare for
Implementation → Implement change → Review
The 'people' or personnel aspects of change
management have also been identified within the
NHS and these involve: (NHS plan, DoH 2000)
power, leadership and stakeholder management;
communication;
training and development;
motivating others to change; and
support for others to help them manage their
personal transitions.
Motivating others to change, support to others, and
communication all refer either directly or indirectly
to the need for a collaborative working approach
and coordination as a means to achieving the
standards and targets set. The Department of
Health has given National Standards of Care and
Planning Framework and in this context the NHS
Improvement Plan given in 2004 is of considerable
importance.
According to a DoH publication (2004), the NHS
Improvement Plan, 2004, set out the next stage of
the Government's plans for the modernisation of
the health service. It signalled three big shifts:
putting patients and service users first through
more personalised care;
a focus on the whole of health and well-being, not
only illness; and
further devolution of decision-making to local
organisations.
All this requires much greater joint working and
partnership between PCTs (Primary Care Trusts),
Las (Local Authroities), NHS Foundation Trusts,
NHS Trusts, independent sector and voluntary
organisations. The Department of Health shows
that this is happening in many parts of the country,
but needs to be made more consistent (DoH,
2004).
Howver there has been considerable shifts in focus
and in the way patient care services are being
delivered and a procedural change from a system
driven by national targets to a system in which
standards are the main driver for continuous
improvements in quality;
there are fewer national targets;
there is greater scope for addressing local
priorities;
incentives are in place to support the system; and
all organisations locally play their part in service
modernisation. (DoH, 2004)
Despite all this, the importance of national targets
cannot be downplayed and targets emphasised by
the Department of Health have always been
instrumental in shaping policies and have an
impact on collaborative working and modernisation
plans of the NHS. All NHS employers for instance
have difficult targets to maintain and the targets
are set for NHS employers and health service
agencies. National standards are related to
National targets as certain frameworks and
acheivement objectives set, help in realising goals
of the health department. The importance of the
National Standards of Health could be stated by
the facts that they
provide a common set of requirements applying
across all health care organisations to ensure that
health services are provided that are both safe and
of an acceptable quality
provide a framework for continuous improvement
in the overall
quality of care people receive. The framework
ensures that the extra resources
being directed to the NHS are used to help raise
the level of performance
measurably year-on-year.
In 2004, Health Secretary John Reid cut down the
number of national targtes that should be reached
by the NHS from 62 to 20. There was a grwoing
recogntion to shift the focus of NHS from national
targets in health care achievements to more local
targets. The NHS plan given by the Department of
Health in 2000 has been considered as the biggest
change to helathcare since the establishment of
NHS in 1948. The NHS plan
emphasised on a health service designed around
the patient with more investments in NHS facilties,
NHS staff and changes not oly in the systems of
the NHS but changes between health and social
services and changes in NHS doctors. Changes of
patients, nurses, midwives and therapists have
also been suggested along with changes in the
relationship between the NHS and the private
sector. Some of the other national targets set up
by the NHS and given in the NHS plan was cutting
waiting times for treatment, improving health and
reducing inequality, providing dignity, security and
independence in old age and setting up clinical
priorities according to the reform program.
According to the Department of Health, the
national targets will accelerate improvements in a
small number of national priority areas.
The reduced number of national targets include:
achieving year-on-year reductions in MRSA levels
and future reductions in other hospital acquired
infections;
an 18 week maximum waiting target from start
time to treatment by 2008;
helping people to manage their long-term
conditions so they spend less time in hospital; and
improving the health of black and ethnic minority
communities.
In the wake of several crticisms on the NHS
regarding its lack of standards, old-fashioned
demarcations between staff and barriers between
services, lack of clear incentives and levers to
improve performance, and over-centralisation and
disempowered patients, the NHS plan was set up to
improve health services in the UK.
Some of the general National Targets given in the
NHS plan were:
more and better paid staff using new ways of
working
reduced waiting times and high quality care
centered on patients
improvements in local hospitals and surgeries.
The monitoring of progress will be overseen by
several independent organizations controlling the
NHS and these include the Department of Health
that is responsible for setting national standards,
matched by regular inspection of all local health
bodies by an independent inspectorate, and the
Commission for Health Improvement. The NHS plan
also states the following changes and targets:
For the first time social services and the NHS will
come together with new agreements to pool
resources. There will be new Care Trusts to
commission health and social care in a single
organisation. This will help prevent patients -
particularly old people - falling in the cracks
between the two services or being left in hospital
when they could be safely in their own home.
Pooling of resources and using a coordinating
approach to bring health and social care services
together seems to have been the major first step
towards initiating a collaborative approach within
the NHS work culture.
Most current NHS targets were agreed under the
2000 NHS Plan. Access targets (such as those on
waiting times) run until 2008 while the outcome
targets (such as those on cancer, coronary heart
disease) run from 2000 to 2010 (DoH, 2004).
In this section we discussed the key policies,
national targets, changes in the targets and the
organisational changes following implementation of
policies and targets. We discussed the importance
of the NHS plan which seems to have initiated the
need for a collaborative approach through the
Modernisation agenda of the NHS that aims to
optimise the levels and quality of services.
The key issues and objectives we highlighted are
related to a growing need to change services
provided and improve the quality of care that
patients receive. The emphasis on collaborative
working and multi-disciplinary approach to patient
care seems also to be directed towards optimising
information and knowledge management.
Knowledge and information mangement have been
identified as important factors in improving
services, optimizing multiagency and
multiprofessional collaboration and co-ordination
and providing higher levels of quality of care to
patients.
In the next section we will consider the evidential
studies on collaborative working and the impact
and influence of procedural policies and structural
changes on NHS management approach and care
orientation.
Collaborative working in the NHS - Evidential
Clinical Studies
However despite the fact that the NHS stresses on
the importance of collaborative working, as many
authors have studied there are many challenges in
interdisciplinary working and Barr (1997) writes
that most services provided by the NHS require
considerable interdisciplinary working. Yet the
effectiveness of team structures and team
functioning can be variable and the services
provided can range in quality from very effective to
poor or fragmented service coordination. Although
there have been many developments in
establishing productive multidisciplinary team
working several key challenges as recognized in
the past decade will have to be considered. Barr
identifies the organizational, interpersonal,
professional and personal challenges of each
health care professional and team in general.
These challenges and issues will have to be
considered before any changes are implemented.
We will consider other studies to elaborate further
on these issues in collaborative practice.
An important aspect of collaborative working is
that it not only utilizes issues of knowledge
management but also brings in the necessity to
use the management perspectives, managerial
decisions and skills of clinicians as they are the
ones who coordinate and shape the working
approach within a clinical setting. In fact there are
several controversies as to whether it is proper to
draw in medical consultant and doctors into
managerial decision making in clinical settings.
Fitzgerald and Sturt (1992) examine the influences
and reactions on doctors when they are asked to
perform managerial tasks. The doctors have been
found to be reluctant to accept managerial roles
and responsibilities. The authors argue that the
adoption of the clinical directorate model as a
favoured mode of organization in acute units has
led to clinicians assuming general manager roles
purely on the basis of imitation rather than real
understanding. Fitzgerald and Sturt raise the
debate as to whether asking clinicians to be
managers is a good decision and whether this is
the best way to use the unique skills and time of
the clinicians. The authors suggest that
collaborative working between doctors and the
general managers is essential in health care and it
is advisable not to give the doctors too many
responsibilities related to management. The set of
tasks that should be exclusively for managers and
tasks exclusively for doctors are delineated and
separated although several researchers have
realized the need for good clinical managers and
have identified tasks that clinicians will have to
perform and might require training support and
development for effective performance of the
tasks.
According to some authors the competition based
market would slowly give away to more
collaborative working approach in which
partnerships and alliances would be important. This
is the new management trend whether within the
health sector or within any other industrial sector
for that matter. Children's nurses for example have
a much greater role to play as they are placed to
respond not just as counselors and responds to
NHS calls; they are also involved in commissioning
and service development decision making
processes. Giving the picture of a new NHS, Warne
(1998) suggests that primary care groups builds
upon existing practice and offer opportunities to
GPs and nurses who work in the community to
spread the benefits of working on a wider scale
more effectively.
Elston and Holloway (2001) performed another
relevant study in which they examined the
perspectives of professionals in primary care and
studied their opinions regarding the impact of the
changes in its organisation and interprofessional
collaboration in the UK. For the study, general
practitioners (GPs), nurses and practice managers
were interviewed in three primary cares and after
the interviews, the data or results were analysed
using various theoretical perspectives. The study
indicated that subcultures of GPs, ideologies in the
care environment as well perceptions of nurses
and other healthcare workers influenced reforms in
primary care. Professional identities were found to
be at loggerheads with traditional power structures
and this fact generated some conflict between the
three groups of GPs, nurses and practice
managers. This was found to be one of the factors
affecting collaboration and subsequently there
were many problems and obstacles in
implementing the reforms. According to Elston and
Holloway a completely new approach to care,
collaboration and management is necessary. The
authors conclude that it seems completely possible
that 'it will take a new generation of health
professionals to bring about an interprofessional
culture in the NHS'.
However some other obstacles to the development
of an inter-professional culture have been
identified since the beginning of services by the
National Health Service (NHS). Atwal and Caldwell
(2005) did an influential study on the improvement
of collaborative working practice if any within the
context of changes in policy and current policy
focus. The study was based on direct observational
method and the tool used was Bales Interaction
Process Analysis. This was carried out on two older
persons teams to explore patterns of interaction in
multidisciplinary team meetings to understand the
underlying dynamics of team collaboration and
practice. There were however major differences ion
the way people of different professions interacted
and communicated with members of other
professions and this was revealed by using the
analysis tool. Certain people in distinct professions
showed different approaches altogether as
Occupational therapists, physiotherapists, social
workers (SW) and nurses rarely asked for opinions
and orientation. Yet the consultant or the person in
charge of the medical team asked for orientation,
gave orientation and also personal opinions and
this trait was also found in some nurses who gave
orientation, and training. The data also indicated
that therapists, nurses and Social workers are
usually reluctant to voice out their opinions in
multidisciplinary teams and thus collaborative
working approach may have traditional issues of
power structure, domination by managers and
doctors and a hierarchical work culture that may
be a major obstacle to its complete development.
Several research studies have shown that
therapists, social workers, and nurses need to feel
more comfortable with collaborative working and
strive to facilitate a culture based on equality and
cooperation by voicing out their opinions and being
more dominating in order to be competent and
committed patient centered practitioners.
There are thus issues of hierarchy, power and
traditional roles of nurses and this difference in the
category of roles that nurses and doctors are
categorised by or even health managers are
identified by which may be both a deterrent and an
advantage. In the one hand collaborative working
approaches may bring in new roles for nurses and
health workers and give them more responsibilities
and managerial roles. This may be unnecessarily
time consuming for nurses and healthcare workers
who are already busy. On the other hand these
roles of clinical managers imparted through
collaborative working make new expectations and
stretch professional possibilities of doctors and
nurses and by being the new age clinical managers
they are able to coordinate in a successful manner
to improve care and quality of services. With
administrative and management powers a well, the
new nurse manger or doctor mangers are able to
improve the environment of clinical setting and
provide more patient centered care suited for the
21st century.
Jefferies and Chan (2004) have indicated that
multidisciplinary team working (MDT) or inter-
professional and collaborative working has been
the main mechanism that ensures holistic care of
patients as professionals form all field use their
expertise to provide a truly complete service of
healthcare. A seamless service for patients is thus
given through disease trajectory and merging
boundaries of primary, tertiary and secondary care.
The effectiveness of each team of professionals
however needs to be separately evaluated
according to Jefferies so that it is ensured that all
relevant disciplines and the relevant professionals
are able to participate equally in the management
and care of the patients. The authors use examples
of Cancer Services Collaborative at Birmingham
Women's hospital in the UK where a holistic model
of care has been developed along with a medical
model of disease cure. Thus providing collaborative
services in which inter-professional coordination
and information sharing is affected, can help
improve the quality of care by providing complete
holistic services as all aspects of patient problems
are considered and taken care of. This is on of the
unique clinical advantages of collaborative working
that is not available in compartmentalized
traditional method of clinical practice.
The importance of knowledge management
through collaborative working practice has been
emphasized by Booth et al (2003) who emphasize
that project staff and nursing staff must develop a
wide range of skills in order to work effectively in
collaboration. According to them , Project staff
must acquire rapidly a wide range of task-related
skills. The concern of these studies is that
conventional methods of training may not properly
train staff to use the various skills required for
collaborative practice. For example in collaborative
working approaches, the nurses and doctors may
not be trained to be managers in a clinical setting if
the situation demands. Action learning as
mentioned by Booth et al (2003) provides a group
based means of meeting the skills demands in
modern collaborative practice and is an effective
part of any knowledge management project within
a clinical setting. Action learning is thus one of the
alternative methods of training that can be used
for learning and be useful and enjoyable at the
same time. The content of action learning
approaches have been analyzed and has been
found to meet the diverse needs of project staff in
a modern clinical setting that is based on
collaborative approaches of working. This type of
learning also facilitates sharing of knowledge
within a virtual environment which can be
transferred to a real clinical setting. Booth et al
conclude by suggesting that, 'Knowledge
management does not merely involve
management and delivery within innovative
projects but also requires exploiting shared
learning across projects' (p.229).
There are also several studies that have
highlighted the many changes that have been
found within the nursing practice in the past
decade and some of thee relate to movement of
nursing education into higher educational section
and nursing being properly recognized as a
respectable profession and higher degrees are also
being awarded in nursing like any other profession.
These changes are within the educational aspects
of nursing studies. However considering the fact
that educational recognition of nursing being late
to develop when compared with medical
profession, the development of senior nursing roles
have in many cases led to isolation and there have
been some controversies on the role of nurses in
the clinical setting. However the new government
directive on collaborative working has only proved
that any demarcation between professions and
putting professionals along a hierarchy in a power
structure is not only detrimental but also
ineffective in a modern clinical setting. Mutual
support and encouragement are expected and this
has especially increased after the concept of
collaborative working which according to Cushen et
al (2002) can bring in possibilities of
transformational partnership which complement
any personal inadequacies. Transformational
leadership also provides effective clinical support
and there are any advantages to this form of
practice including professional and personal
development and reflections on practice. The
validity of the concept of professional support
across traditional boundaries has been
emphasized.
Conclusion:
In this essay we discussed the implications of the
new policy initiatives and structural changes within
the NHS as proposed by the Department of Health
on collaborative working and how these policies
and strategies have had an impact on collaborative
working and have shaped a completely different
work culture within the modernized clinical setting.
We have analyzed the policies given by the
Department of Health, the strategies and targets
identified by the DoH and we analysed whether
these targets have been reached and if not what
changes have been made to the clinical and
healthcare system. In this context we have
discussed the role of collaborative practice and
mutual work relations and have discussed the
importance of transformational leadership, learning
and recognition of the nursing profession in
bringing major changes to not just procedural
methods but also policy and organizational
structures that have been able to go beyond
hierarchical limitations to provide a truly holistic
quality to care services.
2. Nurses’ Ability to Assess Pain After Major
Surgery
Several studies have shown that many patients
receive inadequate treatment for their pain after
major surgery (Brown & Mackey 1993, Closs et al.
1993, Elander et al. 1993, Bamberger et al. 1994).
In spite of experiencing post-operative pain many
patients felt satisfied with their pain relief
(Donovan 1993). Meehan et al. (1995) investigated
patients' (n = 51) perception and satisfaction with
pain management for 5 days immediately after
thorax surgery. Despite the fact that several
patients in the group experienced severe pain,
96% of the patients experienced effective pain
management. Pain treatment after thoracic
surgery is particularly important in view of the
damaging effects of chest wall pain with the
increased risk of pulmonary complications
(Sebanathan et al. 1993). In a study by Puntillo &
Weiss (1994) the authors examined pain intensity
in 98 patients after coronary artery bypass graft
surgery or after abdominal vascular surgery. The
authors showed that patients with higher pain
intensity scores had significantly more atelectasis.
Moore(1994) interviewed 20 patients after
coronary artery bypass surgery, 1 day prior to
discharge. The patients described the pain from
their chest incision as 'grabbing', 'tight pressure'
and 'tingling', especially when turning in bed and
moving in and out of bed or chair. When coughing,
a sharp, short stabbing, knife-likepain was
perceived which made them feel as if they were
going to explode. In an extensive Swedish
investigation studying patients (n = 1161) after
coronary bypass grafting it was shown that 42% of
the patients had chest pain on various occasions
up to 2 years after surgery. Their chest pain was
well correlated with chest pain during the exercise
test but not with signs of myocardial ischaemia
(Brandrup-Wongsen et al. 1997).
Nurses have a very important function in the
treatment of patients' pain. Often they have to
administer prescribed drugs and to choose the
right dose for individual patients. Cohen (1998)
investigated patients (n = 109) with a structured
interview to ascertain the adequacy of pain relief.
Nurses (n = 121) were given a questionnaire
derived from Marks & Sachar (1993). This was a
written self-administered questionnaire consisting
of a series of clinical situations in the form of
vignettes and multiple choice questions which,
among other things, assessed how the nurses
decided on the doses of analgesics to administer.
Cohen showed that nurses selected dosages far
below the real needs of the patients.
McCaffery & Ferrell (1991) held pain control
workshops for 456 nurses in six cities in the United
States of America. The authors experienced that
nurses' decisions on pain control were influenced
by the patients' behaviour. Calvillo & Flaskerud
(1993) showed that in spite of the lack of
significant differences in postoperative pain by
Mexican American women and Anglo-American
women there was a significant difference in pain
scores between the two ethnic groups when
evaluated by the nurses. The authors concluded
that the nurses underestimate pain when they do
not recognize the way patients express their pain.
In a study by Zalon (1993) the author compared
nurses' assessment of postoperative pain with the
patients' own assessment. This study showed that
the majority of the nurses underestimated their
patients' pain. Similar results were found by
Sjostrom et al. (1997) which showed that both
nurses and physicians underestimated the
patients' pain, but nurses did so to a greater
degree.
The importance of nurses being educated in pain
and pain control is described in a study by
Foglesong et al. (1997). The authors described that
the nurses at two hospitals participated in a 6-hour
workshop concerning assessment of pain and
management of analgesics. One month after the
workshop it was shown that more patients than
previously received analgesics 4 hours after
recovery room discharge. It was also shown that
more patients received dosages of analgesics
equal to the maximum prescribed in a 24-hour
period (Foglesong et al. 1997).
The idea for this current investigation arose when
the thorax department in a university hospital, in
southern Sweden, decided to arrangea study day
about pain and pain treatment for all registered
nurses working at the department.
Study Aim and Questions

The aims of this investigation were: to describe

patients' evaluation of pain and the treatment of
pain after thorax surgery via sternotomy; to repeat
the evaluation with another group of patients
following a study day for nurses, featuring pain and
pain treatment; and to examine whether the study
day influenced the nurses in their treatment of
pain.
Research Questions

• How do patients evaluate their pain after

thorax surgery via sternotomy, during the
second to the sixth postoperative day, and also
retrospectively before discharge?
• In what way does a study day on the theme of
pain affect the patients' experience of pain and
pain treatment?
• Which dosages do the nurses wish to give and
what dosages do nurses actually choose to
give from the standing order, both before and
after a study day?
• Does a study day influence the nurses'
attitudes to pain and knowledge of pain
treatment?
Methodology

Sample
The patient investigation included two groups of
patients: group 1 consisted of 39 patients prior to
the study day for the nurses and group 2 consisted
of 41 patients after this had taken place. The
patients were included consecutively, from a
surgical department at a university hospital in
southern Sweden. They were recruited during two
3-week periods and with selection criteria: mentally
healthy adults who had had thorax surgery via
sternotomy. Transplant patients were excluded
since they generally had a more severe form of
treatment both before and after the surgery and
also needed further time in ICU.
In group 1 (prior to the study day), one patient
decided not to participate in the investigation with
daily pain evaluation and with the interview before
discharge. In group 2 (after the study day), four
patients chose not to participate.
All nurses in the thorax department (n = 75)
received a questionnaire prior to the study day, 74
questionnaires were returned, of which five were
removed as they were incomplete. The
questionnaire was answered by 38 nurses from ICU
(intensive care unit) and 31 nurses from the thorax
surgical ward. Three months after the study day
the same questionnaire was given to the same
nurses by the ward sisters. On this occasion 26 ICU
nurses and 23 ward nurses answered the
questionnaire. No reminder was given. Finally, a
retrospective study of the case notes of the
patients included in the study was carried out.
Instruments

A visual analogue scale (VAS) (Huskisson 1974)

was used for daily pain evaluation. VAS is a scale
stretching from no pain to pain as bad as it could
be and described as mild, moderate and severe.
The visual analogue scale is graduated from 0 to
100 mm.
During the interview with the patients before
discharge, a questionnaire previously used in a
study by Donovan (1993) was utilized. The
questionnaire had not been validated by Donovan.
To check validity of the Swedish version it was
given to three patients.
The nurses answered a questionnaire formulated
by Marks & Sachar (1993), adapted by Cohen
(1998) and Lavies et al. (1992). Cohen (1998)
validated the questionnaire with the help of a panel
of nurses. The questionnaire was translated into
Swedish and adjusted to Swedish conditions.
Validity of the translated version was checked with
a small group of nurses familiar with the area but
not working on the wards taking part. The
questionnaire consisted of 13 questions and was
designed to give information about nurses'
attitudes and their knowledge about pain and
treatment. It also included questions concerning
their interpretation of the standing orders.
Ethical Considerations

The patients in this study received information

from the investigator about the aim and procedure
of the study. This was given to them on the same
day they returned to the ward from the ICU after
surgery. Informed consent was obtained and the
patients were informed that the participation was
optional and if they choseto participate they could
discontinueat any time. The patients were also
informed that their answers were confidential and
that all identification was removed from data
collection tools and that only code numbers were
used. When the patients, during the daily
evaluation of pain, stated that they were in pain,
they always were asked by the investigator: Would
you like me to contact the nurse so you can get
some treatment for your pain?
The study was approved by the Medical Research
Ethics Committee of the University Hospital, Lund,
Sweden.
Procedures and data collection

Daily evaluation of pain by the patients themselves

was conducted by the investigator and took place
once a day during their stay on the thorax ward.
This was always performed directly after lunch.
This time was chosen as it suited both the ward
routine and the investigator. One group of patients
(group 1) were questioned prior to the study day
and another group (group 2) were asked the same
questions 3 months after the study day. The time
period of 3 months was chosen to allow for the
possible effects of the study day to reach a steady
state for the nurses and therefore reflect the
present reality.
The investigator conducted a short interview with
the patients before discharge. They were asked to
review their pain and the pain treatment. Pain
assessment retrospectively was carried out to gain
knowledge about patients' experience of pain as a
whole. In connection with the daily visits,
memoranda were written about special
occurrences and observations by the investigator.
The nurses from the thorax surgery department
answered a questionnaire at the start of the study
day and again 3 months later. The study day dealt
with: physiology and pharmacology associated with
pain, assessment of pain, strategies for the
treatment of pain, presentation of a study about
ICU nurses' attitudes towards pain treatment, and
a study of patients' experience of the pain
treatment at the clinic.
Statistical Analysis

For statistical analysis of the doses, the Mann-

Whitney test was used. Comparison between
retrospective pain evaluation and pain evaluation
during daily visits was performed by means of a
stratified Mann-Whitney test with patient as
stratum. Pain was analysed by first computing a
Mann-Whitney rank sum for each day separately,
and then adding the five rank sums quantities
obtained (one for each day). The significance of
that sum was assessed by the Monte Carlo
technique (Good 1994), i.e. the 75 patients were
randomly divided into two groups of 38 and 37
patients, respectively, and the corresponding sum
of five test quantities was computed; this
procedure was repeated 1000 times, and the P
value is the relative frequency of the test
quantities exceeding that from the actual data set.
Results

Patients' experience of pain after thorax surgery

via sternotomy
Patients' experience of pain was registered once a
day, from the second to the sixth postoperative
day. This was done with group 1 before and with
group 2 after the study day on the theme of pain,
which was held for all the nurses at the clinic
(Figure1).
The diagram shows a low evaluation of pain by
most patients during the daily visits and an even
lower evaluation after the study day. This
difference is significant (P = 0.006 according to
one sample Mann-Whitney test for repeated
observations).
Pharmacological treatment of pain

The pharmacological treatment of pain, as used in

the thorax department during the time of the
study, consisted mainly of three drugs,
ketobemidone, an opioid for parenteral
administration, dextropropoxyphene (so-called
'weak' opioid) and paracetamol for oral treatment.
The nurses were delegated to administer
analgesics according to standing order which
prescribed ketobemidone 2.5-5 mg, intravenously
administered while on the ICU and the same dose
subcutaneously administered while on the ward,
sometimes together with paracetamol 0.5-1 g
orally. When given an opioid per oral
administration, the choice would
bedextropropoxyphene 50-100 mg. All drugs were
prescribed to be given as required.
The patients' daily amounts of respective drugs,
obtained from their case notes, are presented
below (Figures 2-4). The increased amount of
ketobemidone administered during days one and
two was reflected in the reduced amount of
dextropropoxyphene given.
Retrospective evaluation of pain and viewpoints
about pain relief

When the patients were asked during the interview

to recall their pain experience, 76% of the patients
had had pain post-operatively (six patients were
not available for interview before the study day
and three were not available after the study day).
According to VAS, retrospective pain evaluation by
these patients, 46 mm (mean) was estimated
before (group 1) and 43 mm after the study day
(group 2). Patients' retrospective evaluation of pain
was significantly higher than during the daily visits
both before (P = 0.0017) and after (P = 0.0003)
the study day.
Thirty-eight per cent of the patients evaluated their
pain retrospectively to 50 mm or more, according
to VAS. This result was the same both before and
after the nurses' study day. In the interview
immediately prior to discharge 95% of the patients
said they were satisfied with their pain relief. The
patients who had said that they were in pain
postoperatively where also asked 'Why were you
satisfied if you still had pain?' To this question most
of the patients answered that it was because they
had expected pain after surgery, six of the patients
said their reason was that they did not want to
bother the nursing staff by asking for analgesics.
Patients with evidence of severe pain

A small group (8%) of the patients experienced

more pain daily than the others. They evaluated
their pain during the second to the sixth
postoperative day as being, on average, more than
40 mm (range 48-73 mm), according to VAS. The
retrospective pain evaluation by these patients
was 51 mm (mean) measured by VAS. According to
daily memoranda the common observation
concerning these patients was that they behaved
or expressed themselves in a way such that the
nurses had difficulty in recognizing and interpreting
their pain behaviour.
Nurses' choice of dosage related to their opinion of
intravenous opioid

On ICU the standing order recommended

ketobemidone, as first choice, intravenously with
dose-interval 2.5-5 mg. When the ICU-nurses were
asked in the questionnaire 'Which dose of
ketobemidone do you choose for a 60-year-old
man weighing 70 kg?', they chose a dose of just
above 3 mg. This they chose both before and after
the study day. When studying the case notes it was
obvious that the ICU nurses often chose to deviate
from the standing order and gave a lower dose of
ketobemidone than prescribed. The doses of
ketobemidone, titrated intravenously and given
within half an hour, or doses given as one dose
subcutaneously in combination with an intravenous
dose, has been regarded as one dose. Before the
study day, the patients received a mean dose of
2.0 mg ketobemidone intravenously. After the
study day they received 2.4 mg which is a
significant increase (P = 0.0047). The difference
between the nurse's choice of dose, according to
the questionnaire, and the given dose, according to
case notes, is significant both before (P < 0.00005)
and after (P < 0.00005) the study day. The ward
nurses administered doses which were in
accordance with standing orders.
The nurses were asked the following:
After thorax surgery a patient received, as
required, 5 mg ketobemidone intravenously (at the
ICU)/5 mg ketobemidone subcutaneously (at the
ward) every fourth hour. If he complains of pain
already 3 hours after his last doseand asks for a
new dose would you: request the patient to wait
another hour; give a reduced dose; givea dose of
pethidine (at the ICU); give oral analgesics (at the
ward); give another 5 mg ketobemidone; ask the
physician for advice?
The majority of ICU nurses (39%) chose to give a
reduced dose, 24% would give another 5 mg and
21% would ask the physicians for advice. Sixteen
per cent of the ICU nurses did not answer the
question or chose more than one alternative. Of
the ward-nurses 7% chose to give a reduced dose,
42% would give another 5 mg, 19% chose to give
analgesics 'per os' and 13% would contact the
physician for advice. Of the ward nurses 19% did
not answer the question or chose more than one
alternative. After the study day 63% of the ICU
nurses and 30% of the ward nurses did not answer
this question or chose more than one alternative.
Before the study day the nurses were asked in the
questionnaire to evaluate doses of the analgesics,
whether they felt these to be over-prescribed,
under-prescribed or about the right amount. About
55% of the clinics' nurses answered that the
prescriptions were right and the remaining nurses
thought the doses were underprescribed. On the
question 'what is the probability of a postoperative
patient, given 5 mg ketobemidone every fourth
hour for a week, becoming addicted', the
alternatives for this answer were 100%, 50%, 10%
or < 1%. Most of the nurses (66%) thought that the
risk of addiction was under 1%. It was also noted
that 12% of the nurses answered that 50% of the
patients were at risk of addiction. Nineteen per
cent of the nurses thought that addiction occurs in
10% of the patients and 3% did not answer the
question.
Almost all of the nurses (93%) thought that a
simple pain-scoring system would be helpful in
assessing patient's pain. On the above questions
there was no obvious difference between the
answers given by the nurses from the ICU and
those on the ward. Further more there is no
difference between the answers given before and
after the study day.
Discussion

The current study shows that the patients (group

1) before the study day had evaluated their pain to
a higher score at VAS compared with the patients
(group 2) who evaluated their pain after the study
day. No definite conclusions can be drawn from
these results as the patients in the two groups
were not the same individuals. The study day
contributed to an increased supply of parenteral
administered opioids during the first two
postoperative days and to a reduced supply of oral
opioids. It is possible that the increased supply of
parenteral administered opioids might have had an
effect on the patients' experience of pain.
Most physicians believed that nurses should have
more control over patients' pain relief (Lavies et al.
1992). This is due to the fact that the nurses work
closer to the patients at the bedside. McCaffery et
al. (1990) pointed out that one problem is that
nurses have not been sufficiently prepared to take
on an increased responsibility for pain control. The
authors were of the opinion that it would be
beneficial to invest in higher quality pain education
for nurses.
The objective of postoperative pain management is
to provide adequate analgesia. This perhaps needs
to be more strongly defined in nursing education
(Chapman et al. 1987). The present investigation
focused on nurses' management of pain control but
there are also studies, both earlier and current,
which show that physicians also have inadequate
knowledge and under-treat patients' pain (Marks &
Sachar 1993, Lavies et al. 1992).
Patients in group 1 (before the study day)
evaluated their pain higher than patients in group
2 (after the study day) did. This can be due to the
fact that the study day contributed to the
increased intravenous administration of opioids
during the first and the second postoperative days.
The results, on the other hand, can also be due to
a difference between the two groups of patients.
The nurses in ICU gave larger dosages of opioids
after the study day, a significant difference when
compared to before. According to the results of the
questionnaire, the study day had had no influence
on nurses' knowledge and attitudes to pain
treatment. This may indicate that one single study
day is not sufficient to contribute to changes in the
attitude of nurses working with pain and pain
control. Foglesong et al. (1997) indicated that the
continuous education of nursing staff had an
impact on nurses' attitudes.
Another way is to teach patients preoperatively
about pain and pain relief and to illuminate the
importance of pain relief so that they will feel free
to request analgesics when they feel they need
them, and not try to 'bebrave' (Cohen 1998).
Conclusion

This investigation shows that after a study day on

the theme of pain arranged for all registered
nurses in the thorax surgery department of one
hospital, a group of patients evaluated their pain
after the study day to be lower than another group
of patients who completed evaluations prior to the
study day. Results showed that the ICU nurses
consistently gave lower doses than the lowest
recommended dose according to standing orders
both before and after the study day. However, the
results also illustrated that after the study day the
patients received an increased amount of
intravenous administered analgesics on the first
and second postoperative days.
Retrospective pain evaluation after cardiac surgery
by patients just before discharge was significantly
higher than the daily measurements. In this study
a small group (8%) of patients suffered more
evident pain daily. There was no difference
between the answers to the questionnaire,
regarding attitudes and knowledge, from nurses in
ICU or from the ward. According to answers given
in the questionnaire the study day did not influence
the nurses' appraisal of dosage, or their attitudes
and knowledge regarding opioids and assessment
pain.
3. Retention of Nursing Personnel and Job
Satisfaction
Abstract

The difficulties confronted by a number of hospitals

around the world are high nursing turnover and
shortage of nursing personnel. Hospital
administration is loosing highly trained and
experienced personnel. Although, the recruitment
of agency and foreign nurses has solved the
problem to an extent, yet it is not the solution to
this problem. The paper discusses various
strategies to help the hospital administration to
retain the nursing staff. Hospital administration
should fully focus on the work environment and
employment level of the nurses. It should also pay
attention to the psychological contract if it needs
to retain and motivate the nursing personnel.
Introduction

Today’s world poses a challenge for hospital

administrators as the turnover rate for nurses is
increasing and there is a shortage of nurses in the
hospitals. For example, for the last five years, the
figures for graduating nurses have declined by 20
percent in the United States and the vacancy rate
for nursing position has increased to 10 percent
(Silby, 2003). The 2006 predictions of the Council
of Nurses in Australia are that it will have only 60
percent of the registered nurses it needs. Similar
situation prevails in Europe, Asia and Africa also.
As a result to this, hospitals in developed countries
are obliged to recruit foreign nurses from
developing countries. But, there is another set of
challenges for hiring the foreign nurses. For
example, if hospitals in developed countries fill the
vacancies from the developing countries, this will
reduce the number of qualified nurses in the
developing countries (World Health Organization,
2003). Discrimination faced by foreign nurses and
wage exploitation (i.e. less pay to foreign nurses
than domestic nurses) are the important ethical
complications associated with the movement of
nurses (Kline, 2003).
For the societal consolidation of the nurses from
foreign countries and for reducing the difficulties in
language and communication, the hospitals need
to introduce diversity management initiatives.
Such nursing initiatives exemplify how nursing
turnover and shortage has the attributes of a
global crisis. To look after this problem, hospital
management is encouraged to support or reassess
crisis management plan that looks after labor
shortage.
Prevention, preparedness, responsiveness and
recovery are the four steps for effective crisis
management ( Sapriel 2003, Sheaffer & Mano-
Negrin 2003). These 4 stages look at how an
organization may cut down or decimate risks, plan
for the worst case scenario and respond to the
critical situation. The health care department is
continuously looking for strategies to cope up with
the shortage of nurses and crisis of turnover and
similar is the case in the responsiveness stage. The
hospital administrators should search some
productive initiatives taken in other hospitals that
have shown useful results in retaining nurses (e.g.,
flexible rostering system, including the use of web-
based rostering).
The environmental pressures regarding nurse
turnover and shortages should be clearly
understood before deciding retention strategies for
nurses. The government and management led
initiatives of providing quality patient service at
low cost have deeply affected the nursing work
(Bolton 2004). Performance indices and quality
inspection are considered as Taylorist form of
‘performance control’ by some commentators.
These forms of ‘performance control’ weaken
nurses’ occupational autonomy and increase the
workloads of nurses. The new public sector
management practices are perceived as alien by
the nurses, especially when there are not enough
resources available to fulfill the promise of a
quality service (Armstrong, 2003).
There will be a decreased commitment along with
an increased frequency of industrial actions, low
morale, increased job dissatisfaction and high
frustration among the nurses because of radical
changes in the health care environment (Ribelin,
2003) .The psychological declaration between the
nursing personnel and the administration is being
affected by the change in the expectations of
nurses. Promotion of the ways to analyze the
arising levels of dissatisfaction among nurses along
with their feeling of the work is possible through
the concept of psychological contract and
perceptual experience, which has been more and
more outraged in recent years. The ‘psychological
contract’ can be defined as the individual
employee’s subjective perceptual experience of
the reciprocal responsibilities among employer and
employees. As it is subjective, it contemplates the
employee’s incomplete, exclusive and potentially
deformed perspective of the relationship.
The psychological contract helps in fulfilling the
perception gap in the employment relationship and
determines the day-to-day employee behavior.
Contravention of psychological convention may
bring out negative emotional effects such as
feelings of disagreement, bitterness and distrust.
As a result of these emotions, behavior at work
becomes negative, which in turn develops a wide
category of these behaviors such as reduced
commitment, interruption and higher absenteeism.
Inconsistency in the real execution of
responsibilities by the organization has resulted in
the act of violation by the employees. Change is
another factor, which is responsible for the
violation, as it enhances the chances of clashes
between promise and execution. Changes with
regard to the hospital management and its
budgeting affect the performance of nurses on the
job by reducing the time that is used by them to
counsel on the matters required for the caring of
patient. Input changes in psychological agreement
also lead the feeling of disagreement among the
nurses with regard to the intrinsic reward. Changes
also add extra responsibility for nurses in decision
making with regard to managing agency of nurses
who are junior or fresher (Gormley, 2003).
Changes in work practices such as more shifts,
working load and pressure also contribute to the
feeling of disagreement among nurses and they
might think that they are not receiving full
attention and respect along with less opportunities
for career advancement, which further results in to
reduced job satisfaction.
This paper provides the base for understanding the
nature of present scenario of nursing turnover and
shortages. This paper presents a detailed survey of
the nursing staff with a particular sample size
describing the type of questionnaire used for the
survey. It also describes the methodology used in
the survey along with the important conclusions
derived from this survey.
The paper also describes the job satisfaction
among the nurses regarding the prevailing
scenario. Job satisfaction is a significant part of
nurses' lives that can affect patient security,
productivity, functioning, turnover, quality of care,
retention and commitment to the organization and
the profession. This paper looks into how the
elements of job satisfaction change during early
career in newly qualified UK nurses.
This paper gives a detailed analysis of the present
situation of nurses and their level of satisfaction
from their job. It mentions the rate of turnover
among nurses and the expected costs of that
turnover. It also explains the way in which job
satisfaction is related to retention. It identifies the
trends in the nursing employment and the possible
reasons behind those trends.
Study population

The population for this study is having the

qualification and experience of 6 months, 18
months and 36 months, which reflects fresh
experience, fresh experience with first promotion
and stability respectively. This sample was taken
from the population of nurses, who qualified their
nursing diploma in England in 2005. It was a mixed
sampling approach and the samples were taken
from each branch of nursing.
The estimates of nurses’ population from children
and learning disability branch were quite low (425
& 150). Adult and mental health branch’s
estimation was much larger (4550 & 940) than the
children and learning disability branch. The nurses,
who were assigned to children and learning
disability branch, were qualified from England. The
nurses from many colleges, eight regional health
authorities and intakes were assigned to adult and
mental health branch. For adult and mental health,
half and two third of the colleges of each region
(three to eight colleges in each region) were
sampled respectively.
The division of samples was based on the
information gathered from own queries to nursing
colleges and from England National Board. The
number of colleges of children’s nurse, learning
disability, adult and mental health branch was 36,
39, 46 and 24 and the eligible recruitments were
2000, 760, 200 and 705 respectively (total 3665).
The percentage of every part is as follows:
qualification (75%, 2748), 6 months (64%, 2345),
18 months (53%, 1942) and 36 months (45 %,
1650). There were some cases of non-response
due to change in address of nurses.

Study No. of
Branches Nurses

Children 2000

Learning 760
Disability

Adult 200

Mental Health 705

Instruments for data collection

There are various methods of data collection for

the research based on literature review to find out
the relationship between job satisfaction and
retention. Survey mainly consists of two methods,
i.e. interview and questionnaire. For the purpose of
literature review, we have chosen questionnaire
method of data collection. Mail survey and group
administered questionnaire were the important
types of questionnaire, which we used in the
questionnaire.
Mail survey: Questionnaire was mailed to the
nurses who were expected to read and interpret
the questions and write down the reply in the
space, which was meant for the purpose in the
questionnaire itself (Kothari, 2005).
Group administered questionnaire: In this method
of data collection, a group of nurses was brought
together and asked to respond to a structured
pattern of questions.
Characteristics of Questionnaire used in the survey
for literature review
Questionnaire is considered to be the heart of
survey report. Hence, this should be constructed in
a well defined manner. Questionnaires have
different forms such as structured and
unstructured, with close and open ended
questions.
Structured questionnaire: In this form of
questionnaire, questions are set in a definite
pattern. They are either open ended or close
ended. In close ended questions, response can be
of yes or no type but in open ended questions, free
response is invited. The questions should be stated
in advance and in a well defined way.
Unstructured questionnaire: In this form of
questionnaire, there is no definite set of questions
as all the questions are unorganized and not
formulated in the exact way as in the case of
structured questionnaire.
We have chosen the structured form of
questionnaire as it could easily be interpreted by
the nurses. The method of data collection with the
help of questionnaire was relatively cheap and
there was no personal contact of respondent
involved in this method. It included wider and more
representative distribution of samples. It was free
from any personal bias of the interviewer and the
nurses as they had enough time to give well
thought out answers. All the questions related to
the job satisfaction and retention were asked in a
structured form. These questions were asked with
regard to the control and independent variables.
Control variables were stress, support at work &
position and independent variables were workload,
resources & external work environment. On the
basis of these variables, the layout of questions
(close or open) that were used in questionnaire
was formed (Kothari, 2005).
Data Collection Method or Research Methodology

The methodology used in this case is questionnaire

survey method because this is very popular and
helpful in case of big enquiries. Questionnaire is
often considered as the heart of a survey. In this
method, a questionnaire is mailed to the
respondents who are expected to answer these
questions. The method of collecting data by the
questionnaires is most extensively employed in
various economic and business surveys. The
rationale behind using this methodology is as
follows:
• Its cost is low even when the population is
large and is widely spread geographically.
• It is free from the bias of the interviewers and
answers are in respondents’ own words.
• Respondents have adequate time to give their
thoughts and answers (Kothari, 2005).
• Respondents, who are not easily approachable,
can also be reached conveniently.
• Large samples can be made in such a way so
that the results can be made more dependable
and reliable.
The questionnaire research methodology and the
data collection plan used by the researcher also
have some limitation, which are as follows:
• Low rate of return of the duly filled in
questionnaires and bias due to no-response is
often determined.
 • It can be used only when respondents are
educated and cooperating.
• The control over questionnaire may be lost
once it is sent.
• There is an inbuilt inflexibility because of the
difficulty in amending the approach once
questionnaires have been dispatched.
• There is also a possibility of ambiguous replies
or omission of replies altogether to certain
questions and interpretation of omissions is
difficult.
• It is difficult to know whether willing
respondents are truly representatives.
• This method is likely to be the slowest of all the
methods.
Results

It is customary to point out that turnover is not

always taken as negative in terms of its impact.
Turnover may be useful or wasteful depending
upon the situation. It is undesirable when its
purpose is to search for entire removal labor
consumption. Turnover is definitely positive and
useful for the employee as well as for the
organization if it happens early in the service
relationship when it has become clear that there is
no matching between the individual’s properties
such as skills, abilities & other characteristics and
the job requirements of the organization. These
suggestions will assist the organization to focus on
different approaches in order to reduce the
wasteful turnover attitude among the nurses.
In spite of standard significant costs related to
nurse turnover, the cost of substituting a nurse is
expected to range from $US10000 TO $US 145000
or up to 150 percent of the nurses’ annual
consumption. This cost depends upon the type of
job, clinical competency and experience. Only 10
percent out of 20 percent of the US health care
setting is supposed to be effective in their nurse
retention program. A program of health care
settings and hospitals that is common in nature
having retention activity is called culture research
and is used to test the views of nurses in context of
their work culture. Apart from this, there is another
approach, which emphasizes on the effective
communication between manager and nurses.
Results of study, which was performed to find out
the causes of leaving the organization by nurses
interpret that the reasons told to third party are
different than those told to the employer on the
time of exit. This is concluded that there is a lack of
trust and effective communication within the
organization. As a result of this, the feeling of
reduced job satisfaction has developed (Cline,
Reilly & Moore, 2003).
It is necessary for the management of hospital to
understand that nurses who are experienced and
trained should be given enough authority and
chances to offer their suggestions in order to
improve the work environment (Lacey & Ribelin
2003). Some interviews should be conducted
outside the organization with those nurses who left
the hospital through the third party in order to find
out the causes behind their exit or turnover. It is
not possible for the management to develop
effective strategies in order to decrease the rate of
turnover without knowing the original costs and
results linked with losing their staff of nursing.
There should be a proper attention of seniors
towards the nurses as they need support from their
seniors in context of relationship with the physician
and it is found that this constitutes the main
reason behind the stay of nurses in the health care
setting. Only few of the organizations include this
factor in their retention program. According to the
survey, it was concluded that most of the nurses
like to stay in those hospitals where the
relationship with the supervisors are positive. In
the increasing competition in hospital business, it
is necessary for the management to focus on the
behavior of physician, which is not healthy or
respectful for the nurses and take some effective
measures in order to retain them in the
organization for a long time period.
Disagreement of physicians on the matter of
viewing nurses as the important and key member
of the organization automatically develops an
environment, which facilitates nurses to leave the
organization (Kimura, 2003). Feelings such as
depression, anger and resentment are resulted
from this environment among the nurses. It is
responsible for the decreased performance level,
higher rate of absenteeism and job dissatisfaction
that further results in to higher turnover rate.
Physicians, who harass the nurses and exhibit the
aforesaid behavior, must be tackled and directed
to replace their behavior with written warnings.
Ways of nurses for leaving the organization are the
same like they are in other groups and
organizations (Lacey 2003). These results interpret
that in the selection procedure; there should be
some improvements in order to hire the suitable
candidates as well as to conduct some induction
programs for the newly selected employees.
Strategies of retention with regard to part time job
of nurses should include the implementation of
flexibility so that their job can be matched with the
pattern of their livings.
The most effective way for the managers to retain
the nurses or to reduce the rate of turnover is to
perform greatest efforts in hiring nurses in order to
achieve the most suitable fit between the nurses
and the requirements of their job. The
implementation of actual job sample in the
selection procedure of nurses assists the manager
to reduce the chances of unrealistic expectations
with regard to the job, which further reduces the
chances of job dissatisfaction and subsequently the
rate of turnover. Orientation programs should be
conducted in such a fashion, which provides full
information to the new employees in order to
reduce the depression and to achieve a grip on the
job environment effectively (Waters 2003).
Various programs such as leadership programs
should combine the junior nurses with the senior
nurses in order to provide the new one full
counseling with regard to the job and its
obligations (Lacey 2003). Many health care
settings achieve their goal to reduce the turnover
rate of nurses by the implementation of this
program. Selection procedures such as team
membership, work teams and work tours are also
effective procedures in order to reduce the
turnover rate of nurses within the hospitals and
health care settings.
These are the strategies, which should be
implemented effectively for the retention of nurses
for long time period and to reduce the turnover
rate of them in the organization in an efficient way.
Conclusion

From the above discussion and findings, it is

concluded that job satisfaction differs largely from
one job to another and it even differs within the
same profession. The vocation of nurse also falls in
this category. Nurses have to deal with all types of
patients whether he is a small child, an adult, an
old person or a mental patient. They have to work
in different contexts and settings and with entirely
different organizational cultures, which give a
varied experience to them in the profession.
Not only the settings, work environment and
organizational culture differ but the individuals
choosing this career path also differ in
characteristics and aspirations and this might
influence their level of satisfaction. According to
the present situation and ongoing trends, no such
single answer can be quoted to describe the level
of job satisfaction.
The research focuses on understanding the
particular job characteristics and the level of
satisfaction derived from them. The increasing
shortage of nurses is resulting in recruitment of
nurses from foreign countries, which in turn results
in dearth of nurses in foreign countries. Nurses
constitute to the success of hospitals rendering
their services for the all types of patients. So the
hospital management should take great care for
the satisfaction among the nurses (Moody, 2003).
The conditions should not be such that frustrate
the nurses, lower their morale and decrease their
interest and motivation towards their job. The
foreign nurses are even exploited with regard to
wages, which shows that they are treated with
discrimination. The hospital management should
try to maintain the present number of nurses and
retain the lost ones. For the shortage of nurses, the
hospital management should take appropriate
steps and try to provide maximum job satisfaction
to the nurses (Robinson, Clements, & Land, 2003).
Teamwork should be encouraged and the quality of
work life should be improved to retain the nurses in
the employment. The administration should take
the necessary steps to enhance and increase the
talent supply among nurses. Regular training
sessions should be conducted to keep them
updated (Sapriel, 2003).
It is very important for the hospital management to
implement proper human resource practices, which
will help in retaining the high performing nursing
personnel presently employed in the organization
and attracting new nursing talent.
Other relevant point

Monetary consideration can be taken as an

important point because there are people who are
satisfied by their job, but due to monetary
dissatisfaction they might not prefer to continue
with the same job. Hospital management should
pay attention towards increasing the pay of the
nursing personnel. As it is already mentioned in the
research that the foreign nurses suffer from wage
exploitation and discrimination, the hospital
management should avoid such injustice and
monetary satisfaction should be considered
important to retain the nursing personnel.
4. Implementing Effective Faculty Practice in
Nursing
The phenomenon of faculty practice is a
fundamental component of nursing academia. I
believe that an effective nursing teacher is not
complete with out performing faculty practice. This
paper will address this concept not only as a
personal but an organizational issue because this
concept at many places is not known or not well
understood. During my three years experience in
school of nursing, I observed that faculty practice
has not received the deserved significance and
importance by the faculty members. My intuition to
inquire about this important phenomenon led me
not only to understand this concept in depth but to
strive for bringing about some planned change.
Huber (2006) identified the planned change as “a
leadership strategy that requires planning and
action, problem solving, decision making, and
interpersonal competence” (p. 806). The purpose
of this paper is to take a position to propose and
recognize effective understanding of faculty
practice to implement in our context. This paper
will discuss the description, analysis, strategies and
recommendations to implement effective faculty
practice in nursing education.
Description of Faculty Practice

Faculty practice is inseparable from faculty’s role

and should be considered an integral part of it. This
concept is defined and explained by several
authors but here few definitions have been shared.
Saxe et al., (2004) defined faculty practice as “A
formal arrangement between a school of nursing/
academic health center and a clinical
facility/enterprise/entity that simultaneously meets
the service needs of clients, while meeting the
teaching, practice, service, and research needs of
faculty and students” (p. 166). Rudy, Anderson,
Dudjak, Kobert, and Miller (as cited in Ward, 2001)
explained faculty practice as a patient care
responsibility. Marion (as cited in Sawyer,
Alexander, Gordon, Juszczak, & Gillis, 2000)
integrated faculty practice into different ‘roles’,
‘settings’ and ‘models’.
Analysis of the Issue in our Context
Significance of the issue.

This issue is highly significant in the world of

nursing education. I strongly feel that clinical
practice of faculty members equally contributes
and puts impact on their all other roles such as
teaching, research, scholarly activities, and
administration. Nursing faculty members who are
involved in clinical teaching can not survive
without clinical practice. This notion is well
supported by various literatures which specify it as
a core element of excellence in nursing education.
Background of the issue in our context.

This section of the paper will focus on the

contextual importance of the issue in government
and private nursing education settings in Pakistan.
Unfortunately at most of the places in Pakistan this
practice is considered apart from other faculty
roles. Dracup (2004) mentioned “Nursing faculty
members struggle to balance multiple professional
and personal roles and are worried (appropriately)
that time spent in faculty practice will not lead to
academic advancement, particularly in research-
intensive environments” (p. 174). Herr (as cited in
Paskiewicz, 2003) reported that some faculty
members take it as a ‘threat’ to their other work
load. Rayburn (as cited in Paskiewicz, 2003) shared
that sometimes universities do not give value to
faculty practice as it has been given to other tasks.
Another impression in most of the developing
countries like Pakistan about nursing profession
follows a hierarchical structure, especially at
government setting, where nursing educators are
regarded as having higher position than bed side
nurses Upvall et al (2002). Due to this kind of
perception, nursing faculty feel hesitate to initiate
this important feature of their roles. The other
reason of its ineffectivity could be the acceptance
of faculty members by clinical setting staff. Here I
would also like to draw attention to the existence
of faculty practice at Aga Khan University School of
Nursing (AKU-SON), where luckily this concept is
offered. Faculty practice at AKUSON comprises
10% of faculty workload. The recommended time
duration for faculty practice is expected to spend
two weeks per year in any clinical area of their
interests. Being part of the same system I feel that
the faculty practice is still not completely
understood by the entire nursing faculty and is not
fully integrated into the system considering its
overall purposes. Along with it, this particular
system does not follow any specific model of
faculty practice; preferably the practice is done
during summer breaks when students are not
around. To recognize the understanding of faculty
practice into Pakistani context Upvall et al, (2002)
revealed that there is a need for culturally relevant
definition and model to implement faculty practice
in nursing organizations.
Purposes and advantages of faculty practice.

Besides understanding the need and meaning of

faculty practice, it is equally essential to know the
purposes for its effective implementation. In our
context too, the purposes and rationale for faculty
practice are not clear. Few nursing faculty
members go for faculty practice just considering it
as a part of requirement from department or
thinking that it will help in their clinical teaching.
But in general this concept also has some other
reasons and advantages to perform. The first
purpose to apply faculty practice is the provision of
service to patients and community by nursing
educators. This provides adequate opportunity to
nursing faculty to fulfill both educational and
service needs. Mackey and McNiel (as cited in
Sawyer et al., 2000) supported that faculty practice
helps to provide clinical service and teaching. The
other significant advantage to perform faculty
practice is to upgrade faculty members’ knowledge
which ultimately could improve their research and
teaching capacities. Budden (as cited in Ward,
2001) also supported this opinion. Not only this, it
further provides platform for joint researches and
projects. Furthermore, it enhances the ability of
reflective practice and serves as a mean to
develop leadership and management skills.
Challenges of performing faculty practice.

On the contrary of advantages of faculty practice,

various literature provides different barriers and
challenges of it. Ward (2001) summarized different
challenges in terms of increased workload,
scheduling, selecting clinical setting, less time for
scholarly activities due to inculcating faculty
practice as a faculty role.
Faculty Practice Outlook in Developed World

Literature review suggests availability of different

models of faculty practice widely adopted by
developed world. Each model has a separate
structure to follow, improving the efficacy of
faculty practice. According to Hutelmyer and
MacPhail (as cited in Upvall et al, 2002) ‘unification
model’ is one of the models that suggests a same
administrator of hospital and school of nursing.
Another model described by them is ‘integrated
model’ which follows faculty and student’s
participation during patient care. The next model is
‘collaboration model’ which Budden; Barger,
Nugent and Brides; Walker, Starck and McNeil;
Campbell and King; Patton and Cook (as cited in
Saxe et al., 2004) explained that this model takes
care of joint appointments where some percentage
of time is given to service and some to education.
They also explained another faculty practice model
that is based on entrepreneurship which offers
liberty to faculty members to select any approach
for their practice. One more model explicated by
Free and Mills (as cited in Stainton, Rankin &
Calkin, 1989) called ‘private practice’ through
which faculty can choose their own private practice
during school hours and negotiate their other roles.
In Pakistan there is no evidence of using these
models, even at AKUSON no particular model is
utilized completely. But one can see different
glimpses of these models chosen by individual
faculty.
Organizational Framework of Faculty Role

To maintain my position supporting enhancement

of effective faculty practice, I would like to
integrate here an organizational framework (see
figure 1) which is based on Boyer’s model of
scholarship, illustrating the importance of faculty
practice and its impact on other different faculty
roles. Paskiewicz (2003) placed clinical practice in
the center and showed its direct bidirectional
relationship with other roles such as teaching,
service, professional development, and research. It
has been explained that if a faculty member is
thorough in his/her clinical practice then it will put
positive impact on his/her other roles. The
framework shows an outer ring that surrounds all
of the above mentioned roles; this ring represents
administration, covering the overall outcome of
faculty’s performance. The other outermost ring
represents university mission which reflects the
overall faculty role discussed earlier.
I strongly believe that this framework does justice
with the area of clinical practice, which otherwise is
left isolated and not seen as a core constituent of
faculty roles. It can be recommended that in our
context, there is a desperate need to recognize
faculty roles from this perspective starting from
university mission and then its shadow on all other
tasks of faculty members.
Application of leadership Model with the Issue

Nursing leadership has a great role in establishing

effective nursing faculty practice system in schools
of nursing. Once it is acknowledged that faculty
practice is an entity which combines university
mission of education, research, teaching and
service, then it definitely requires transformational
leadership to have positive outcomes. Avolio (as
cited in Northouse, 2007) incorporated different
factors in the model of transformational leadership.
According to him the first factor is ‘idealized
influence charisma’ which portrays the need of
strong role model. In respect to faculty practice, to
have an efficient process, the leader must show
the real and strong role modeling for the need of
clinical practice. The next factor is ‘inspirational
motivation’ where leader keeps high expectations
from the team. Same goes with implementing
faculty practice, once the need has been shared;
now this is leader’s role to motivate others for the
same. The other factor is based on ‘intellectual
stimulation’ where leaders intellectually stimulate
others to perform the task keeping its importance
and value. ‘Individualized consideration’ is the last
but not the least factor, where leaders provide
supportive environment to each individual. In
regard to faculty practice again this is leader’s
responsibility to help others to understand their
objectives and to help individual faculty to identify
the need of improvement in their clinical practice
and to help them in negotiating their other roles.
Strategies to implement Faculty Practice

After analyzing the need to have an effective

faculty practice system, there are several
strategies following the process of assessment,
planning, implementation, and evaluationto
making it happen.
Assessment.

The strategic process begins with assessment of

understanding the concept by the faculty
members. One needs to make sure that what are
the purposes, objectives, and goals of a faculty
member who chooses to go for clinical practice.
Along with it, the other thing important to assess
for faculty practice is the setting, which should
match with individual’s objectives. Upvall et al
(2002) revealed from their research in Pakistani
context that “From a faculty perspective, a
successful faculty practice model would include
faculty taking control by setting their own
objectives, going to a different hospital setting
from the one in which they taught”(p. 322).
Moreover, faculty members should also be aware
of the benefits and the challenges of doing faculty
practice.
Planning.

Planning is the most vital step of executing faculty

practice. Planning includes several components
which help in ensuring the thorough action. The
first activity is scheduling, which according to Ward
(2001) is when, how and where that are taken care
by scheduling. One has to also see the time
duration spend by hours per week or per year, or
as percentage of workload. After setting up the
schedule, the other main strategy is the selection
of clinical area for practice. Numerous literature
suggests that selection of clinical setting should be
matched with the objectives and should be
relevant to the area of interest. The choice of
clinical placement should also reflect the improved
efficiency at classroom and clinical teaching. The
other strategies explained by Ward also indicated
the planning for the rich and beneficial outcomes
of faculty practice. It is said that faculty members
should look for opportunities to share their
experiences along with scientific knowledge to the
staff through their scholarly work. The final step of
planning emphasized by Ward is about making
linkages with the relevant authorities who will help
in adaptation and adjustment of faculty’s role at
practice settings.
Implementation.

The implementation phase for this task is a crucial

stage. The purpose is not to make a list of
strategies to carry out, because that will add on
the burden of faculty members. But, there are very
few simple strategies suggested based on the
mentioned planning. During implementation stage
it is expected from faculty members to have full
advantage of the practice. On clinical placement
she could carry out different presentations and
publications to share her experiences integrated
with theory to staff and students. Reflective
practice is another key attribute which can make
the practice more effective. Boud (as cited in
Budden, 1994) highlighted the advantages of
reflective practice as “The reflective process uses
effective and intellectual processes of the
individual to engage in experience to gain new
understandings in learning” (p. 1243). The other
strategy to make faculty practice more useful is by
writing anecdotal notes on patient information and
then analyzing them in the light of literature. This
strategy will further help them to generate
research questions which can be conducted
collaboratively with service staff.
Evaluation.

The last phase of the process should be based on

ongoing evaluation. The purpose of this phase is to
estimate the meeting of expected objectives. Saxe,
et al (2004) shared various methods of evaluation
which were utilized in their studies. These
approaches are self evaluation, evaluation from
clients, from staff and from students could be
performed to have complete picture of faculty’s
performance.
Recommendations

In addition to the strategies discussed above, there

are some recommendations which could be
achieved at organizational level. The first and
foremost suggestion is to articulate importance of
faculty practice regarding medical and nursing into
university mission or atleast in our context it could
be the integral part of school of nursing’s vision.
Dracup (2004) supported this idea and emphasized
that it should not only be the part of vision and
mission but should be reflected in hiring and
promotion processes. I would also like to support a
recommendation provided by Upvall et al (2002)
who recommended that in Pakistani context
Pakistan Nursing Council should set a requirement
to make faculty practice mandatory for each
nursing teacher, furthermore that should be
reflected in individual department’s policy. The
next recommendation which is now became a
demand of the time and has been always likewise
is the productive collaboration between nursing
services and nursing education. To bring amazing
outlook of nursing profession, it is obligatory to
bridge this gap. At school of nursing level, the
orientation package for new faculty members
should also include the complete awareness
module of faculty practice. Besides this, senior
faculty members or those who are already the part
of schools of nursing should also get informatory
sessions on the entire process of faculty practice.
Conclusion

Faculty practice is an integral aspect of faculty’s

role in the field of nursing. This core characteristic
of faculty’s workload must receive equal worth as it
has been given to other tasks of faculty. Several
strategies and recommendations have been
suggested to effectively implement faculty practice
in organizations. Organizational framework should
be followed to facilitate the process of faculty
practice and to assist faculty members to integrate
theory and practice with collaboration of nursing
services and nursing academia.
Nursing Profession Care:
Introduction

Nursing profession is the largest force in health

care system holding the central role as health care
providers. Our people’s health depends on
competent and highly educated nurses. Nursing
profession needs dynamic, visionary, educated and
committed leaders who can protect the public
health rights through productive input in national
health policy. Effective nursing leaders also ensure
the quality nursing education for safe nursing
practice. In addition they advocate for the public
and the professional’s rights. Effective nursing
leadership supports the collaborative, innovative
and evidence based work environment that helps
nurses to feel respected and valued in their
positions. According to Huber (2006) “leader use
their power to bring teams together, spark
innovation, create positive communication and
drive forward toward group goals (p.4).” Nursing
leadership must possess these characteristics.
Especially nursing leaders who run professional
organizations at national level have to acquire
these characteristics. In our country health care
system is decentralized at provincial level. So
nursing leadership comprises provincial, federal
and professional bodies at national level. “Director
General Nursing” is the highest rank in each of the
four provinces responsible for health and nursing
matters in their particular area. Where as in federal
“Nursing Advisor” is the top position directly
working with ministry of health in close
coordination with other nurse leaders. Likewise,
professional bodies are the most important pillars
of the nursing profession at national level in any of
the country. These are comprised of nursing
council, nursing association and nursing union. The
role of these professional bodies slightly varies
country to country depending on their scope of
responsibilities and need of the time. In Pakistan
we have two professional bodies; Pakistan Nursing
Council (PNC) and Pakistan Nursing Federation
(PNF). While addressing the issue related to
“Challenges of nursing leadership” I will be
focusing on professional bodies PNC & PNF only,
being the national level leadership. The purpose of
this paper is to describe the challenges related to
leadership at national level, identify the key issues
and recommend strategies to resolve the issues.
Background

The role of nursing professional bodies in any

country is vital as council regulates nursing
education and practice and association advocates
for trained nurses. PNC is an autonomous body that
functions under the Pakistan Nursing Council Act,
1973. PNC Act 1973 authorized the Council fully to
make the independent decisions related to public
health rights, nursing education, nursing practice
standards, licensing nursing professionals and
recognizing or derecognizing educational
institutions, monitoring of health and educational
institutions, disciplining for mal practices, making
new rules for betterment and addressing patients
and professionals needs timely. PNC Act 1973 also
gives the full authority to the council to establish
and maintain its prescribed infrastructure with
extensive range of functions. PNC office is located
in Islamabad. Since the partition it was functioning
in a small borrowed space in one of the
government’s building. However, recently the
office has been moved to a new permanent
building fully allocated for council’s functions in
Islamabad. The structure of the Council is President
( Director General Health) Vice President (one of
the Senior Nurse) and Registrar along with Ex –
Officio members. At present only one senior nurse
in Registrar position with diploma qualification is
working for the last 10 - 15 years. Recently one
more BScN prepared nurse has been inducted as
Assistant Registrar. For two nurses holding the
extensive functions of the Council is humanly
impossible.
Similarly, PNF Constitution and Bye-Laws 1949
authorized the federation to act independently in
the light of full range of functions with it’s agreed
infrastructure. According to PNF Constitution and
Bye-laws 1949 spelled out functions and authority;
federation is responsible to advocate the
professionals and execute it’s duties in true spirit.
For PNF functions we do not have separate office
as the positions are held by the nurses who are
already in government job. According to the PNF
Constitution it’s structure comprises (1) National
Executive Board of PNF is president, First Vice
President, Second Vice President, Secretary
General, Treasurer, Editor of the Professional
Magazine, Representative from PNC and Chairmen
of Standing Committees (2) Governing body of PNF
is the National Executive Board, President of the
Provincial Association, Secretaries of the Provincial
Associations and Delegates from the Provincial
Associations (3) Provincial Nurses Associations and
(4) the Branch Nurses Associations as described in
the Constitution and bye-laws 1949. As mention
above the role of nursing professional bodies in
any country is vital as council regulates nursing
education and practice and association advocates
for trained nurses. Unfortunately this is not the
case in our country. American Nurses Association
(ANA), Trained Nurses Association India (TNAI),
Indian American Nursing Association (IANA) Indian
Nursing Council (INC) Australian Nursing and
Midwifery Council (ANMC) and Nursing Midwifery
Council United Kingdom (NMCUK) are the few
examples of its models who work commendable for
the profession and the public.
Literature review

Hood and Leddy (2003) discussed that political

situation in the country move so fast that polices
changes with in no time. So ANA prepares “an
annual legislative agenda” (p.338) to update its
polices congruent with circumstances. ANMC was
established in 1992 to function as regulatory body
for nursing and midwifery in Autralia. ANMC
develops standards and protocols according to it’s
peoples need and plays a key role as professional
regulatory body at national level
http://www.anmc.org.au/ . Silmilarly, NMC ensures
safe and quality care for public health by
maintaining it’s professional standards. NMC
develops standards for professional conduct and
guides nurses and midwifes on regular bases
http://www.nmc-uk.org/. India being our neighbor
country; INC has planed to commence the Nursing
Ph.D program to promote research activates. Six
institutions has been approved by the Indian
national association for Ph.D program all over the
country. Student will pay Rs. 5000 fee per annum
to the respective study
centerhttp://www.indiannursingcouncil.org/Nation_
Consortium_PhD_Nursing.asp. Being a Muslim
country with the support of King Abdullah nursing
profession in Jordan plays a central role in health
care system. Over the decades nursing profession
proved it’s importance. Nursing regulatory body
has the full authority to develop national standards
and activate resources to uphold transformation of
nursing education. Jordan is top one country in
Muslim world to recognize nursing as an self-
governing profession through the clear vision of
King Abdullah; who believes that nursing is the
vital partner in health care system of the country
http://www.jnc.gov.jo/english/home.htm.
Present scenario

Dormant role of professional bodies and slow

development in nursing profession is alarming
situation in Pakistan on way forward to meet the
demands of 21st century. Nursing leadership at
national level and their input in health policy,
succession planning, educational opportunities for
nurses, professional recognition, true recognition of
BScN & Masters prepared nurses, forum to address
the public health rights and professional’s rights,
mal practices, implementation of PNC Act 1973 and
PNF Constitution 1949 in its true spirit and absence
of true professional projection remains a high
concern to all Pakistani nurses. According to
Ladhani (2002) “issues in nursing are very complex
and are like web of causes interlinked and
interconnected. It is therefore very crucial to link
up policies, trainings and commitment of all
concerned parties together (p.9)”. Similarly,
Hemani (2003) explained “India where
independence was gained at the same time, and
the level of nursing education in India has had far
more recognition internationally than Pakistan” (p.
122).
Impacts of present scenario

Lack of true commitment and clear vision of the

professional bodies leads to violation of public and
professional’s rights, no control over mal practices
and sub standard educational institutions. patients
safety is also at risk due to absence of professional
accountability. Furthermore, it creates poor nursing
image nationally and internationally.
Some facts

Following are few examples of piling up of work at

professional organizational level that was planned
but never turned in to actions: Consultancy PNC &
PNF (John knapp 1997 & 1998), Report of Visioning
workshop: (2000), Minutes of Senior Nursing
Advisory committee meeting July 4-6 (2000), PNC
Act Revision ( 5th session 2004) and Nursing
Organizations workshop (2000) are just kept in the
shelves with out any follow-up work. As the present
leadership lack the capacity to take the lead in
progressing the actions further.
Root causes of present scenario

There are political, cultural, educational and

personal reasons hindering the nursing
development in the country.
Analysis of the situation

According to PNC Act (1973), nurses have the

responsibility to their patients to provide safe,
competent and ethical nursing care. But most of
the time nurses are unable to provide safe care to
the patients due to lack of back support from the
professional bodies. One of the reason is
compromised quality of nursing education and lack
of opportunities in higher education as nursing
faculty is not adequately equipped with required
knowledge and skills but they are teaching all
nursing programs. Due to this compromised
education level nurses are unable to play the
effective role in health care system. This damages
the image of nursing profession in our society
despite of nurses working so hard. It gives great
impact on nurse’s job satisfaction and self esteem.
Though nurse’s role is limited to the tertiary care
only; nurses working in hospital setting face
numerous challenges related to safe provision of
care; shortage of nurses at bed side, lack of
resources to provide safe care, compromised
nursing education, no involvement in decision
making at institutional level and absence of
professional autonomy. Nurses have no
professional platform to unite and address the
health related issues. It is evident that nursing
professional bodies in Pakistan are far behind to
address the future health care demands of the
society. There is no projection of the profession at
all, even we do not have any publication and web
site developed for our professional bodies yet.
In 2003, I got the opportunity to work in Women
health project under Ministry of Health. During that
period I conducted a survey in 3 provinces; Punjab,
Frontier and Sindh in major hospitals. The mid level
nursing leaders (chief nursing superintendents,
supervisors, principals and nursing teacher) were
interviewed to explore their job satisfaction level.
The mid level nursing leaders from all 3 provinces
verbalized the issues they were facing during their
nursing practice. Quality of nursing education,
image of nursing in our society, job satisfaction,
career path, promotion and benefits, succession
planning, opportunities for continue education and
higher education, involvement in decision making
at institution level, shortage of nurses on bed side,
poor nursing regulatory and advocacy mechanisms
were the 10 emerging themes of the high area of
concern among all mid level nursing leaders. These
mid level nursing leaders exhibited helplessness
and hopelessness working in the existing system.
They wanted to see the positive change that could
provide them the better work environment, safe
patient care, job satisfaction, higher education
opportunities and better career structure.
Lack of visionary nursing leadership and
infrastructure at PNC & PNF level affects quality
care, job satisfaction of nurse’s, nursing image and
public health. During my professional journey, I
have worked as an intensive care nurse, team
leader manager and acting chief of nursing. In
every role I have experienced different challenges
and problems. After working more than 20 years in
nursing I realize that nursing profession in Pakistan
could not earn the respect and the recognition it
deserved. Because nursing professional bodies fall
short to respond to the call of society and the
nursing professionals. Infrastructure of PNC is
equal to none. We can imagine it’s affects on
health system, nurses and society as a whole. I
would like to share my own work experience. I
faced many issues related to provision of safe care
and professional autonomy. I faced high
expectation and high work load without adequate
preparation in every assigned role. Managing high
turn over /shortage of nurses, and ensuring safe
care remained questionable throughout my work
life due to unfavorable work environment that
affected me right from the bed side nursing to
leadership role. In addition to that I could not get
any educational opportunity for advance nursing
education on time as it was hardly available. Being
a nursing leader in my institution it was difficult for
me to advocate nurses and patients rights
effectively due to absence of nursing standards
and regulatory mechanism in the country in term
of professional autonomy, professional growth,
salary and benefits and professional conduct. In my
personal experience I have seen nurses working
with fake diploma (even working abroad) but there
is no regulatory mechanism to control such
practices. I can share another example that nurses
working in public sector even senior nurses having
more than 25 years experience are not registered
with PNC yet. Similarly, there is mushrooming of
nursing schools for male nursing in the country just
to earn the money . But again there is no effective
check and control for such a major offence. In
addition to that Health Care Institutions are hiring
untrained personals and giving them the name of
nurses and they are wearing the nurse’s uniform
creating bad impression of the profession and
putting patient’s safety at risk.
In short, nursing leadership at national level whose
mandate is to hold up and advocate the public and
professional rights, regulate quality care,
professional conduct and quality nursing education
by implementing PNC Act 1973 and PNF
Constitution 1949 in its true spirit; lacks the
qualified visionary leadership and adequate
infrastructure that causes serious health care
affects through out the country. These short
comings at top level are truly reflected right down
the level in hospitals and nursing educational
institutions. All practicing nurses and faculty are
diploma prepared. Even senior nurses having more
than twenty five years and plus experience holding
leadership positions have no access to continue
education and preparation for their leadership role
at institution level. Existing scenario presents that
both professional bodies that are pivotal in health
care system are severely deficient in their
professional commitment and competence that
lead to dearth of visionary nursing leadership at
national, institutional and unit level. In result the
whole society is at high risk along with nursing
professional. This drawback is a major threat to
public health as well as country’s economics.
To look for the solution of prevailing situation many
questions arise in my mind that, How can we
establish adequate infrastructure at PNC level.
What can we do to have visionary and qualified
leadership at national level. How can we take the
example of nursing regulatory bodies in other
developed countries? How can we ensure effective
leadership at institutional and unit level that gives
direct impact in quality patient care? What we can
do to improve staff satisfaction and productivity?
How can we address the issue of compromised
nursing education? What measures we can take to
protect the public and professional’s rights? How
can we change the nursing image in society? How
professional autonomy could be possible? How can
research based nursing practice be introduced?
What is required

Immediate and effective action is needed to

respond the existing situation. There is intense and
immediate need to improve the productivity of
professional bodies in the light of other countries.
We can learn the lesson from Nursing Midwifery
Council in United Kingdom, Canadian Nursing
Council, Australian Nursing Council, Indian Nursing
Council. In addition to that Pakistan Medical Dental
Council infra structure could be studied that may
be replicated straight away at PNC level. Beside
that university based education must be ensured
to raise the professional standard. To take all these
positive steps a strong commitment and clear
vision of policy maker and nursing professional
bodies is required. My suggestion to BScN and
Masters nurses is that they must prefer to work
with donor agencies like World Health Organization
(WHO) UNICEF and other significant. This is how
change will take place. I hope that new nursing
generation who are getting better opportunities for
education; one day will be holding key positions in
health sector as well as political representation. I
am sure that time is not far; change is inevitable.
Transformational Theory

The present nursing leadership at national level is

ineffective and unproductive due to lack of team
work and coordination. These characteristics are
similar to laissez –faire leadership style as
described by Tomy (2000). To bring about the
positive change we need to adopt leadership style
that is role modeling leadership inspiring people
focusing the processes, net working, sharing,
Intellectual and source of motivation that is
transformational theory support by Tomy.
Recommendations

Ministry of health to show the commitment by

immediate action to correct the situation as follow:
Revise criteria for key positions, ensure right
person at the right place and create 4 MScN and 2
Ph.D nursing positions at national level in initial
phase. So they could work to improve the existing
situation of nursing profession in Pakistan.
Suggested plan is to advertise the new positions
2nd quarter 2008 and ensure hiring in the beginning
of the 3rd quarter 2008.
Conclusion

We all know that nursing professional bodies in any

country breath oxygen to professional’s and the
public. Having infrastructure improved at national
level will be the first step towards the success and
to address and engage in health care system,
public policy issues and collaboration with
government. Existing nursing leadership at
national level must take immediate action to
resolve the situation. Otherwise, Tichy, (1993)
warns that “Control your Destiny or Someone Else
Will as three act play: (1) the awakening (2) the
vision (3) revolution as a way of life” cited in Tomy.
HOSPITAL: A hospital, in the modern sense, is an
institution for health care providing patient
treatment by specialized staff and equipment, and
often, but not always providing for longer-term
patient stays. Its historical meaning, until relatively
recent times, was "a place of hospitality", for
example the Chelsea Royal Hospital, established in
1681 to house veteran soldiers.
Today, hospitals are usually funded by the public
sector, by health organizations (for profit or
nonprofit), health insurance companies or charities,
including by direct charitable donations.
Historically, however, hospitals were often founded
and funded by religious orders or charitable
individuals and leaders. Conversely, modern-day
hospitals are largely staffed by professional
physicians, surgeons, and nurses, whereas in
history, this work was usually performed by the
founding religious orders or by volunteers. Today,
there are various Catholic religious orders, such as
the Alexians and the Bon Secours Sisters which still
focus on hospital ministry.
There are over 17,000 hospitals in the world.
Teaching hospital

A teaching hospital is a hospital that provides

clinical education and training to future and current
doctors, nurses, and other health professionals, in
addition to delivering medical care to patients.
They are generally affiliated with medical schools
or universities (hence the alternative term
university hospital), and may be owned by a
university or may form part of a wider regional or
national health system.
Some teaching hospitals also have a commitment
to research and are centers for experimental,
innovative and technically sophisticated services.

History
Although institutions for caring for the sick are
known to have existed much earlier in history, the
first teaching hospital, where students were
authorized to methodically practice on patients
under the supervision of physicians as part of their
education, was reportedly the Academy of
Gundishapur in the Persian Empire during the
Sassanid era. The Middle Persian word Bimaristan
literally translates into "land of sickness".
In the medieval Islamic world, al-Nuri hospital, built
by the famous Nur ad-Din Zangi, was made a
teaching hospital and renowned physicians taught
there. The hospital's medical school is said to have
had elegant rooms, and a library to which many
books were donated by Zangi's physician, Abu al-
Majid al-Bahili. A number of Muslim physicians and
physicists graduated from there. Among the well-
known students are Ibn Abi Usaybi'ah (1203-1270),
the famous medical historian, and 'Ala ad-Din Ibn
al-Nafis (d. 1289) whose discovery of pulmonary
circulation and the lesser circulatory system
marked a new step in the better understanding of
human physiology and was the earliest explanation
until Miguel Servet (1553).
According to Sir John Bagot Glubb:
"By Mamun's time medical schools were extremely
active in Baghdad. The first free public hospital was
opened in Baghdad during the Caliphate of Haroon-
ar-Rashid. As the system developed, physicians
and surgeons were appointed who gave lectures to
medical students and issued diplomas to those who
were considered qualified to practice. The first
hospital in Egypt was opened in 872 AD and
thereafter public hospitals sprang up all over the
empire from Spain and the Maghrib to Persia."
Etymology
During the Middle Ages hospitals served different
functions to modern institutions, being almshouses
for the poor, hostels for pilgrims, or hospital
schools. The word hospital comes from the Latin
hospes, signifying a stranger or foreigner, hence a
guest. Another noun derived from this, hospitium
came to signify hospitality, that is the relation
between guest and shelterer, hospitality,
friendliness, hospitable reception. By metonymy
the Latin word then came to mean a guest-
chamber, guest's lodging, an inn. Hospes is thus
the root for the English words host (where the p
was dropped for convenience of pronunciation)
hospitality, hospice, hostel and hotel. The latter
modern word derives from Latin via the ancient
French romance word hostel, which developed a
silent s, which letter was eventually removed from
the word, the loss of which is signified by a
circumflex in the modern French word hôtel. The
German word 'Spital' shares similar roots.
Grammar of the word differs slightly depending on
the dialect. In the U.S., hospital usually requires an
article; in Britain and elsewhere, the word normally
is used without an article when it is the object of a
preposition and when referring to a patient ("in/to
the hospital" vs. "in/to hospital"); in Canada, both
uses are found.
Types
Some patients go to a hospital just for diagnosis,
treatment, or therapy and then leave
('outpatients') without staying overnight; while
others are 'admitted' and stay overnight or for
several days or weeks or months ('inpatients').
Hospitals usually are distinguished from other
types of medical facilities by their ability to admit
and care for inpatients whilst the others often are
described as clinics.
General

The best-known type of hospital is the general

hospital, which is set up to deal with many kinds of
disease and injury, and normally has an emergency
department to deal with immediate and urgent
threats to health. Larger cities may have several
hospitals of varying sizes and facilities. Some
hospitals, especially in the United States, have
their own ambulance service.
District

A district hospital typically is the major health care

facility in its region, with large numbers of beds for
intensive care and long-term care; and specialized
facilities for surgery, plastic surgery, childbirth,
bioassay laboratories, and so forth.
Specialized

Types of specialized hospitals include trauma

centers, rehabilitation hospitals, children's
hospitals, seniors' (geriatric) hospitals, and
hospitals for dealing with specific medical needs
such as psychiatric problems (see psychiatric
hospital), certain disease categories such as
cardiac, oncology, or orthopedic problems, and so
forth.
A hospital may be a single building or a number of
buildings on a campus. Many hospitals with pre-
twentieth-century origins began as one building
and evolved into campuses. Some hospitals are
affiliated with universities for medical research and
the training of medical personnel such as
physicians and nurses, often called teaching
hospitals. Worldwide, most hospitals are run on a
nonprofit basis by governments or charities. Within
the United States, most hospitals are nonprofit.
[citation needed]

Teaching

A teaching hospital combines assistance to

patients with teaching to medical students and
nurses and often is linked to a medical school,
nursing school or university.
Clinics

medical facility smaller than a hospital is generally

called a clinic, and often is run by a government
agency for health services or a private partnership
of physicians (in nations where private practice is
allowed). Clinics generally provide only outpatient
services.
Departments
Hospitals vary widely in the services they offer and
therefore, in the departments they have. They may
have acute services such as an emergency
department or specialist trauma centre, burn unit,
surgery, or urgent care. These may then be backed
up by more specialist units such as cardiology or
coronary care unit, intensive care unit, neurology,
cancer center, and obstetrics and gynecology.

Some hospitals will have outpatient departments

and some will have chronic treatment units such as
behavioral health services, dentistry, dermatology,
psychiatric ward, rehabilitation services, and
physical therapy.
Common support units include a dispensary or
pharmacy, pathology, and radiology, and on the
non-medical side, there often are medical records
departments, release of information departments,
Facilities Management, Maintenance, Dining
Services, and Security departments.