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.

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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;

with adoption of the Nurses Registration Act on the 12 September 1901. where the physicians are mentioned . In July 1775. 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. and Linda Richards who was officially America's first professionally trained nurse. 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". 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.Agnes Elizabeth Jones and Linda Richards. who established quality nursing schools in the USA and Japan. New Zealand was the first country to regulate nurses nationally. It was here in New Zealand that Ellen Dougherty became the first registered nurse. graduating in 1873 from the New England Hospital for Women and Children in Boston. This tendency is certainly not observed in Nightingale's Notes on Nursing.

and often in critical tones— particularly relating to bedside manner. standards.relatively infrequently. The aim of the nursing community worldwide is for its professionals to ensure quality care for all. nursing practice is defined and governed by law. which vary greatly worldwide. and entrance to the profession is regulated at national or state level. The modern era has seen the development of nursing degrees and nursing has numerous journals to broaden the knowledge base of the profession. In almost all countries. while maintaining their credentials. and competencies. but all involve extensive study . 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. Nurses are often in key management roles within health services and hold research posts at universities. code of ethics.There are a number of educational paths to becoming a professional nurse. and continuing their education.

). The profession combines physical science. intellectual. psychological. Clinical Nurse Specialist. nursing theory. Enrolled nurse. emotional. and spiritual needs. In order to work in the nursing profession. A Licensed practical nurse (LPN) (also referred to as a Licensed vocational nurse.of nursing theory and practice and training in clinical skills. . social science.etc. and technology in caring for those individuals. which determines entitlement for their scope of practice. and technological knowledge in the care of patients and families in many health care settings. Registered Nurse First Assistant. The most significant differentiation between an LPN and RN is found in the requirements for entry to practice. psychological. and State enrolled nurse) works independently or with a Registered nurse. social. Registered nurses may also earn additional credentials or degrees enabling them to work under different titles (Nurse Practitioner. A Registered nurse (RN) provides scientific. 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. Registered practical nurse. for example in Canada an RN requires a bachelors degree and a LPN requires a 2 year diploma. all nurses hold one or more credentials depending on their scope of practice and education.

Critically Consider The Impact Of The Large Number Of Recent Structural Changes.Nurses may follow their personal and professional interests by working with any group of people. Critical study on nursing services: 1. This is based around a specific nursing theory which is selected based on the care setting and population served. nurses implement the nursing care plan using the nursing process. targets and structural and organizational changes that can improve the quality of care received by patients through the NHS. in any setting. at any time. These changes are emphasized along with the need for multi-agency and multi-organizational . The Department of Health has laid down certain policy initiatives. In providing care. Nursing practice Nursing practice is the actual provision of nursing care. the nurse uses both nursing theory and best practice derived from nursing research. In providing nursing care. Policy Initiatives And Targets Imposed On Collaborative Working Of NHS Staff. Some nurses follow the traditional role of working in a hospital setting.

primary and secondary care.collaborative working across disciplinary boundaries. 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. 1996). In this article we will discuss: 1. and interface with carers (DoH. 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. policies. 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 four key interfaces for which collaboration and coordination measures are being suggested are health and social care. Our responses and analysis of the issues in consideration will involve these three major points and we will discuss the implications of strategies. general medical and community health services. structural changes and targets on collaborative working and how these issues are .

(ii) the commissioning process. (v) professional education and training. and Knowledge management resources. (vi) communication and information sharing. and (vii) research and development. (iii) inter. In fact collaborative working relates to knowledge management and structural and organisational .agency collaboration. However. in order to examine the policy and structural changes within the 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. Knowledge Management processes. Collaborative working in NHS . (iv) inter-professional collaboration and teamwork.related to the multi-organizational work culture as promoted in recent years by the Department of Health. the main structures and processes identified are : Organisational processes and Infrastructure.

Using management principles of knowledge management and coordination to achieve collaborative working and better interaction among patients. doctors and carers. nurses and other health professionals across departments and agencies.changes have been suggested to facilitate information sharing across departments. 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. Improving staff performance through performance management and optimising . 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. doctors. and professionals as well as to facilitate interaction between patients.

Motivating others to change. DoH 2000) power. The Department of . targets and changes as implemented by the NHS. At the heart of the collaborative working approach are policies. support to others. communication. organisational structures and resources. motivating others to change. training and development. 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. and support for others to help them manage their personal transitions. leadership and stakeholder management. The change model given by the NHS is External change.utilisation of processes. 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.

independent sector and voluntary organisations. not only illness. set out the next stage of the Government's plans for the modernisation of the health service. NHS Foundation Trusts. a focus on the whole of health and well-being. 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 . The Department of Health shows that this is happening in many parts of the country. and further devolution of decision-making to local organisations.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. Las (Local Authroities). 2004. NHS Trusts. 2004). It signalled three big shifts: putting patients and service users first through more personalised care. According to a DoH publication (2004). but needs to be made more consistent (DoH. the NHS Improvement Plan. All this requires much greater joint working and partnership between PCTs (Primary Care Trusts).

National standards are related to National targets as certain frameworks and acheivement objectives set. help in realising goals of the health department. All NHS employers for instance have difficult targets to maintain and the targets are set for NHS employers and health service agencies. 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. and all organisations locally play their part in service modernisation. there is greater scope for addressing local priorities. 2004) Despite all this. 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 . incentives are in place to support the system.standards are the main driver for continuous improvements in quality. there are fewer national targets. (DoH.

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. 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. improving health and . There was a grwoing recogntion to shift the focus of NHS from national targets in health care achievements to more local targets. 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.provide a framework for continuous improvement in the overall quality of care people receive. Health Secretary John Reid cut down the number of national targtes that should be reached by the NHS from 62 to 20. 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. In 2004.

the national targets will accelerate improvements in a small number of national priority areas. Some of the general National Targets given in the NHS plan were: . and over-centralisation and disempowered patients. The reduced number of national targets include: achieving year-on-year reductions in MRSA levels and future reductions in other hospital acquired infections. helping people to manage their long-term conditions so they spend less time in hospital. In the wake of several crticisms on the NHS regarding its lack of standards.reducing inequality. and improving the health of black and ethnic minority communities. security and independence in old age and setting up clinical priorities according to the reform program. According to the Department of Health. an 18 week maximum waiting target from start time to treatment by 2008. providing dignity. lack of clear incentives and levers to improve performance. old-fashioned demarcations between staff and barriers between services. the NHS plan was set up to improve health services in the UK.

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.falling in the cracks between the two services or being left in hospital when they could be safely in their own home. This will help prevent patients particularly old people .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. There will be new Care Trusts to commission health and social care in a single organisation. matched by regular inspection of all local health bodies by an independent inspectorate. . 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. 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. and the Commission for Health Improvement.

In this section we discussed the key policies. optimizing multiagency and multiprofessional collaboration and co-ordination and providing higher levels of quality of care to patients. 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. 2004). The emphasis on collaborative working and multi-disciplinary approach to patient care seems also to be directed towards optimising information and knowledge management.Most current NHS targets were agreed under the 2000 NHS Plan. In the next section we will consider the evidential studies on collaborative working and the impact . Knowledge and information mangement have been identified as important factors in improving services. national targets. 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. coronary heart disease) run from 2000 to 2010 (DoH. Access targets (such as those on waiting times) run until 2008 while the outcome targets (such as those on cancer.

and influence of procedural policies and structural changes on NHS management approach and care orientation. 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. 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. These challenges and issues will have to be considered before any changes are implemented.Evidential Clinical Studies However despite the fact that the NHS stresses on the importance of collaborative working. Collaborative working in the NHS . An important aspect of collaborative working is that it not only utilizes issues of knowledge . 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. We will consider other studies to elaborate further on these issues in collaborative practice. professional and personal challenges of each health care professional and team in general. interpersonal. Barr identifies the organizational.

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. 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. managerial decisions and skills of clinicians as they are the ones who coordinate and shape the working approach within a clinical setting. The doctors have been found to be reluctant to accept managerial roles and responsibilities.management but also brings in the necessity to use the management perspectives. Fitzgerald and Sturt (1992) examine the influences and reactions on doctors when they are asked to perform managerial tasks. 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 . 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 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.

Giving the picture of a new NHS. they are also involved in commissioning and service development decision making processes. 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. 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. 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. 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 .have identified tasks that clinicians will have to perform and might require training support and development for effective performance of the tasks. This is the new management trend whether within the health sector or within any other industrial sector for that matter.

This was carried out on two older persons teams to explore patterns of interaction in . 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. 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'. According to Elston and Holloway a completely new approach to 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. collaboration and management is necessary. 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). the data or results were analysed using various theoretical perspectives. ideologies in the care environment as well perceptions of nurses and other healthcare workers influenced reforms in primary care.the interviews. nurses and practice managers. The study indicated that subcultures of GPs. This was found to be one of the factors affecting collaboration and subsequently there were many problems and obstacles in implementing the reforms.

Certain people in distinct professions showed different approaches altogether as Occupational therapists. social workers. gave orientation and also personal opinions and this trait was also found in some nurses who gave orientation. domination by managers and doctors and a hierarchical work culture that may be a major obstacle to its complete development. . 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. Several research studies have shown that therapists. social workers (SW) and nurses rarely asked for opinions and orientation. 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. and training. 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.multidisciplinary team meetings to understand the underlying dynamics of team collaboration and practice. physiotherapists. Yet the consultant or the person in charge of the medical team asked for orientation. The data also indicated that therapists.

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. This may be unnecessarily time consuming for nurses and healthcare workers who are already busy. 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.There are thus issues of hierarchy. A seamless service for patients is thus given through disease trajectory and merging . With administrative and management powers a well. Jefferies and Chan (2004) have indicated that multidisciplinary team working (MDT) or interprofessional 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. 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. 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.

tertiary and secondary care. Thus providing collaborative services in which inter-professional coordination and information sharing is affected. 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.boundaries of primary. 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. Project staff must acquire rapidly a wide range of task-related skills. For example in collaborative . This is on of the unique clinical advantages of collaborative working that is not available in compartmentalized traditional method of clinical practice. According to them . can help improve the quality of care by providing complete holistic services as all aspects of patient problems are considered and taken care of. 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 concern of these studies is that conventional methods of training may not properly train staff to use the various skills required for collaborative practice.

Booth et al conclude by suggesting that. 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 . 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. 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. the nurses and doctors may not be trained to be managers in a clinical setting if the situation demands. 'Knowledge management does not merely involve management and delivery within innovative projects but also requires exploiting shared learning across projects' (p.working approaches.229). This type of learning also facilitates sharing of knowledge within a virtual environment which can be transferred to a real clinical setting. 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.

The validity of the concept of professional support across traditional boundaries has been emphasized. However considering the fact that educational recognition of nursing being late to develop when compared with medical profession. These changes are within the educational aspects of nursing studies. 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. Conclusion: . 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. 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.being awarded in nursing like any other profession.

2. 1993. 1993. Closs et al. In this context we have discussed the role of collaborative practice and mutual work relations and have discussed the importance of transformational leadership. In spite of experiencing post-operative pain many . 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. Bamberger et al. 1994). Elander et al. We have analyzed the policies given by the Department of Health. 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. 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 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.

Despite the fact that several patients in the group experienced severe pain. Meehan et al. The authors showed that patients with higher pain intensity scores had significantly more atelectasis. 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. especially when turning in bed and moving in and out of bed or chair. 96% of the patients experienced effective pain management. (1995) investigated patients' (n = 51) perception and satisfaction with pain management for 5 days immediately after thorax surgery. When coughing. knife-likepain was perceived which made them feel as if they were going to explode. 1993). 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. 1 day prior to discharge. Their chest pain was . 'tight pressure' and 'tingling'. 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.patients felt satisfied with their pain relief (Donovan 1993). a sharp. Moore(1994) interviewed 20 patients after coronary artery bypass surgery. The patients described the pain from their chest incision as 'grabbing'. short stabbing.

Nurses have a very important function in the treatment of patients' pain. 1997). Cohen showed that nurses selected dosages far below the real needs of the patients. assessed how the nurses decided on the doses of analgesics to administer. The authors concluded .well correlated with chest pain during the exercise test but not with signs of myocardial ischaemia (Brandrup-Wongsen et al. Nurses (n = 121) were given a questionnaire derived from Marks & Sachar (1993). among other things. McCaffery & Ferrell (1991) held pain control workshops for 456 nurses in six cities in the United States of America. 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. This was a written self-administered questionnaire consisting of a series of clinical situations in the form of vignettes and multiple choice questions which. Cohen (1998) investigated patients (n = 109) with a structured interview to ascertain the adequacy of pain relief. The authors experienced that nurses' decisions on pain control were influenced by the patients' behaviour. Often they have to administer prescribed drugs and to choose the right dose for individual patients.

One month after the workshop it was shown that more patients than previously received analgesics 4 hours after recovery room discharge. (1997) which showed that both nurses and physicians underestimated the patients' pain. The authors described that the nurses at two hospitals participated in a 6-hour workshop concerning assessment of pain and management of analgesics. This study showed that the majority of the nurses underestimated their patients' pain.that the nurses underestimate pain when they do not recognize the way patients express their pain. It was also shown that more patients received dosages of analgesics equal to the maximum prescribed in a 24-hour period (Foglesong et al. in southern Sweden. but nurses did so to a greater degree. The idea for this current investigation arose when the thorax department in a university hospital. 1997). decided to arrangea study day about pain and pain treatment for all registered nurses working at the department. The importance of nurses being educated in pain and pain control is described in a study by Foglesong et al. Similar results were found by Sjostrom et al. In a study by Zalon (1993) the author compared nurses' assessment of postoperative pain with the patients' own assessment. (1997). .

both before and after a study day? Does a study day influence the nurses' attitudes to pain and knowledge of pain treatment? • • • . during the second to the sixth postoperative day. featuring pain and pain treatment.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. 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. Research Questions • How do patients evaluate their pain after thorax surgery via sternotomy. to repeat the evaluation with another group of patients following a study day for nurses. and to examine whether the study day influenced the nurses in their treatment of pain.

four patients chose not to participate. one patient decided not to participate in the investigation with daily pain evaluation and with the interview before discharge. 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. 74 questionnaires were returned. The patients were included consecutively. from a surgical department at a university hospital in southern Sweden. of which five were removed as they were incomplete. In group 1 (prior to the study day). Three months after the study day the same questionnaire was given to the same . The questionnaire was answered by 38 nurses from ICU (intensive care unit) and 31 nurses from the thorax surgical ward.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. In group 2 (after the study day). All nurses in the thorax department (n = 75) received a questionnaire prior to the study day.

nurses by the ward sisters. To check validity of the Swedish version it was given to three patients. Instruments A visual analogue scale (VAS) (Huskisson 1974) was used for daily pain evaluation. Finally. The questionnaire had not been validated by Donovan. adapted by Cohen (1998) and Lavies et al. moderate and severe. No reminder was given. a retrospective study of the case notes of the patients included in the study was carried out. The nurses answered a questionnaire formulated by Marks & Sachar (1993). The questionnaire consisted of 13 questions and was . a questionnaire previously used in a study by Donovan (1993) was utilized. The questionnaire was translated into Swedish and adjusted to Swedish conditions. The visual analogue scale is graduated from 0 to 100 mm. (1992). 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. On this occasion 26 ICU nurses and 23 ward nurses answered the questionnaire. Cohen (1998) validated the questionnaire with the help of a panel of nurses. During the interview with the patients before discharge. VAS is a scale stretching from no pain to pain as bad as it could be and described as mild.

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. Informed consent was obtained and the patients were informed that the participation was optional and if they choseto participate they could discontinueat any time. 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. It also included questions concerning their interpretation of the standing orders. This was given to them on the same day they returned to the ward from the ICU after surgery. Procedures and data collection Daily evaluation of pain by the patients themselves was conducted by the investigator and took place . Sweden.designed to give information about nurses' attitudes and their knowledge about pain and treatment. Ethical Considerations The patients in this study received information from the investigator about the aim and procedure of the study. When the patients. during the daily evaluation of pain. stated that they were in pain.

Pain assessment retrospectively was carried out to gain knowledge about patients' experience of pain as a whole. presentation of a study about ICU nurses' attitudes towards pain treatment. 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.once a day during their stay on the thorax ward. The investigator conducted a short interview with the patients before discharge. This was always performed directly after lunch. memoranda were written about special occurrences and observations by the investigator. and a study of patients' experience of the pain treatment at the clinic. The nurses from the thorax surgery department answered a questionnaire at the start of the study day and again 3 months later. . They were asked to review their pain and the pain treatment. strategies for the treatment of pain. The study day dealt with: physiology and pharmacology associated with pain. In connection with the daily visits. assessment of pain. This time was chosen as it suited both the ward routine and the investigator. 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.

this procedure was repeated 1000 times. Pain was analysed by first computing a Mann-Whitney rank sum for each day separately. the 75 patients were randomly divided into two groups of 38 and 37 patients. . This was done with group 1 before and with group 2 after the study day on the theme of pain. from the second to the sixth postoperative day. The significance of that sum was assessed by the Monte Carlo technique (Good 1994). which was held for all the nurses at the clinic (Figure1). and the corresponding sum of five test quantities was computed. the MannWhitney test was used. respectively. 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. 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.Statistical Analysis For statistical analysis of the doses. i. and then adding the five rank sums quantities obtained (one for each day).e.

All drugs were prescribed to be given as required.The diagram shows a low evaluation of pain by most patients during the daily visits and an even lower evaluation after the study day. the choice would bedextropropoxyphene 50-100 mg. an opioid for parenteral administration. The nurses were delegated to administer analgesics according to standing order which prescribed ketobemidone 2.006 according to one sample Mann-Whitney test for repeated observations). This difference is significant (P = 0.5-5 mg. Pharmacological treatment of pain The pharmacological treatment of pain. obtained from their case notes. dextropropoxyphene (so-called 'weak' opioid) and paracetamol for oral treatment. are presented below (Figures 2-4). sometimes together with paracetamol 0. consisted mainly of three drugs. as used in the thorax department during the time of the study. The patients' daily amounts of respective drugs. The increased amount of ketobemidone administered during days one and . When given an opioid per oral administration. ketobemidone. intravenously administered while on the ICU and the same dose subcutaneously administered while on the ward.5-1 g orally.

two was reflected in the reduced amount of dextropropoxyphene given. Thirty-eight per cent of the patients evaluated their pain retrospectively to 50 mm or more. In the interview immediately prior to discharge 95% of the patients said they were satisfied with their pain relief.0003) the study day.0017) and after (P = 0. 46 mm (mean) was estimated before (group 1) and 43 mm after the study day (group 2). This result was the same both before and after the nurses' study day. six of the patients . according to VAS. 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). Retrospective evaluation of pain and viewpoints about pain relief When the patients were asked during the interview to recall their pain experience. retrospective pain evaluation by these patients. 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. Patients' retrospective evaluation of pain was significantly higher than during the daily visits both before (P = 0. According to VAS.

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.

Further more there is no difference between the answers given before and after the study day. (1990) pointed out that one problem is that nurses have not been sufficiently prepared to take . On the above questions there was no obvious difference between the answers given by the nurses from the ICU and those on the ward. 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. This is due to the fact that the nurses work closer to the patients at the bedside. McCaffery et al. Most physicians believed that nurses should have more control over patients' pain relief (Lavies et al.Almost all of the nurses (93%) thought that a simple pain-scoring system would be helpful in assessing patient's pain. It is possible that the increased supply of parenteral administered opioids might have had an effect on the patients' experience of pain. No definite conclusions can be drawn from these results as the patients in the two groups were not the same individuals. 1992). 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.

1987). According to the results of the questionnaire. on the other hand. which show that physicians also have inadequate knowledge and under-treat patients' pain (Marks & Sachar 1993. This may indicate that one single study day is not sufficient to contribute to changes in the . can also be due to a difference between the two groups of patients. The results. the study day had had no influence on nurses' knowledge and attitudes to pain treatment.on an increased responsibility for pain control. a significant difference when compared to before. The nurses in ICU gave larger dosages of opioids after the study day. 1992). Lavies et al. both earlier and current. 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 objective of postoperative pain management is to provide adequate analgesia. The authors were of the opinion that it would be beneficial to invest in higher quality pain education for nurses. Patients in group 1 (before the study day) evaluated their pain higher than patients in group 2 (after the study day) did. The present investigation focused on nurses' management of pain control but there are also studies. This perhaps needs to be more strongly defined in nursing education (Chapman et al.

In this study a small group (8%) of patients suffered more . 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. 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. Foglesong et al.attitude of nurses working with pain and pain control. 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. (1997) indicated that the continuous education of nursing staff had an impact on nurses' attitudes. Retrospective pain evaluation after cardiac surgery by patients just before discharge was significantly higher than the daily measurements. 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. 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). However.

3. Although. . According to answers given in the questionnaire the study day did not influence the nurses' appraisal of dosage. The paper discusses various strategies to help the hospital administration to retain the nursing staff. the recruitment of agency and foreign nurses has solved the problem to an extent. There was no difference between the answers to the questionnaire. or their attitudes and knowledge regarding opioids and assessment pain. Hospital administration is loosing highly trained and experienced personnel. yet it is not the solution to this problem. It should also pay attention to the psychological contract if it needs to retain and motivate the nursing personnel. Hospital administration should fully focus on the work environment and employment level of the nurses. regarding attitudes and knowledge. from nurses in ICU or from the ward.evident pain daily. 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.

For example. this will reduce the number of qualified nurses in the developing countries (World Health Organization. Asia and Africa also. the hospitals need . if hospitals in developed countries fill the vacancies from the developing countries. As a result to this. there is another set of challenges for hiring the foreign nurses. For the societal consolidation of the nurses from foreign countries and for reducing the difficulties in language and communication.e. Discrimination faced by foreign nurses and wage exploitation (i. Similar situation prevails in Europe. 2003). 2003). hospitals in developed countries are obliged to recruit foreign nurses from developing countries. 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. But. For example.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 the last five years. less pay to foreign nurses than domestic nurses) are the important ethical complications associated with the movement of nurses (Kline. The 2006 predictions of the Council of Nurses in Australia are that it will have only 60 percent of the registered nurses it needs. 2003).

Performance indices and quality . Such nursing initiatives exemplify how nursing turnover and shortage has the attributes of a global crisis.. 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.g. Sheaffer & ManoNegrin 2003). including the use of webbased rostering). responsiveness and recovery are the four steps for effective crisis management ( Sapriel 2003. hospital management is encouraged to support or reassess crisis management plan that looks after labor shortage. flexible rostering system. plan for the worst case scenario and respond to the critical situation. The hospital administrators should search some productive initiatives taken in other hospitals that have shown useful results in retaining nurses (e. These 4 stages look at how an organization may cut down or decimate risks. The government and management led initiatives of providing quality patient service at low cost have deeply affected the nursing work (Bolton 2004). preparedness. Prevention. To look after this problem. The environmental pressures regarding nurse turnover and shortages should be clearly understood before deciding retention strategies for nurses.to introduce diversity management initiatives.

it contemplates the employee’s incomplete. 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.inspection are considered as Taylorist form of ‘performance control’ by some commentators. 2003) . The ‘psychological contract’ can be defined as the individual employee’s subjective perceptual experience of the reciprocal responsibilities among employer and employees. which has been more and more outraged in recent years. exclusive and potentially deformed perspective of the relationship.The psychological declaration between the nursing personnel and the administration is being affected by the change in the expectations of nurses. 2003). . As it is subjective. There will be a decreased commitment along with an increased frequency of industrial actions. These forms of ‘performance control’ weaken nurses’ occupational autonomy and increase the workloads of nurses. low morale. 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. increased job dissatisfaction and high frustration among the nurses because of radical changes in the health care environment (Ribelin.

behavior at work becomes negative. 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. which is responsible for the violation. Input changes in psychological agreement also lead the feeling of disagreement among the nurses with regard to the intrinsic reward. Contravention of psychological convention may bring out negative emotional effects such as feelings of disagreement. As a result of these emotions. Changes also add extra responsibility for nurses in decision making with regard to managing agency of nurses who are junior or fresher (Gormley.The psychological contract helps in fulfilling the perception gap in the employment relationship and determines the day-to-day employee behavior. Inconsistency in the real execution of responsibilities by the organization has resulted in the act of violation by the employees. interruption and higher absenteeism. which in turn develops a wide category of these behaviors such as reduced commitment. 2003). Changes in work practices such as more shifts. as it enhances the chances of clashes between promise and execution. bitterness and distrust. Change is another factor. working load and pressure also contribute to the feeling of disagreement among nurses and they might think that they are not receiving full .

which further results in to reduced job satisfaction. This paper gives a detailed analysis of the present situation of nurses and their level of satisfaction from their job. This paper provides the base for understanding the nature of present scenario of nursing turnover and shortages. This paper looks into how the elements of job satisfaction change during early career in newly qualified UK nurses. turnover. This paper presents a detailed survey of the nursing staff with a particular sample size describing the type of questionnaire used for the 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. It also describes the methodology used in the survey along with the important conclusions derived from this survey. productivity. It identifies the trends in the nursing employment and the possible reasons behind those trends. retention and commitment to the organization and the profession. quality of care. functioning. It mentions the rate of turnover among nurses and the expected costs of that turnover.attention and respect along with less opportunities for career advancement. . It also explains the way in which job satisfaction is related to retention.

The nurses from many colleges. . which reflects fresh experience. Adult and mental health branch’s estimation was much larger (4550 & 940) than the children and learning disability branch. The number of colleges of children’s nurse. For adult and mental health. were qualified from England. adult and mental health branch was 36. It was a mixed sampling approach and the samples were taken from each branch of nursing. half and two third of the colleges of each region (three to eight colleges in each region) were sampled respectively. fresh experience with first promotion and stability respectively. The nurses. learning disability. eight regional health authorities and intakes were assigned to adult and mental health branch.Study population The population for this study is having the qualification and experience of 6 months. The estimates of nurses’ population from children and learning disability branch were quite low (425 & 150). The division of samples was based on the information gathered from own queries to nursing colleges and from England National Board. who qualified their nursing diploma in England in 2005. 18 months and 36 months. This sample was taken from the population of nurses. who were assigned to children and learning disability branch.

Study Branches Children Learning Disability Adult No. There were some cases of non-response due to change in address of nurses. 1942) and 36 months (45 %.e. we have chosen questionnaire method of data collection. 6 months (64%. i. 2345). Mail survey and group administered questionnaire were the important . of Nurses 2000 760 200 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. interview and questionnaire. 2748). 1650). 46 and 24 and the eligible recruitments were 2000. 200 and 705 respectively (total 3665).39. 760. The percentage of every part is as follows: qualification (75%. For the purpose of literature review. 18 months (53%.

. questions are set in a definite pattern. Structured questionnaire: In this form of questionnaire. a group of nurses was brought together and asked to respond to a structured pattern of questions. 2005). Group administered questionnaire: In this method of data collection. 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. Hence. Characteristics of Questionnaire used in the survey for literature review Questionnaire is considered to be the heart of survey report. response can be of yes or no type but in open ended questions. this should be constructed in a well defined manner. Questionnaires have different forms such as structured and unstructured. which we used in the questionnaire.types of questionnaire. which was meant for the purpose in the questionnaire itself (Kothari. free response is invited. In close ended questions. The questions should be stated in advance and in a well defined way. They are either open ended or close ended. with close and open ended questions.

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. resources & external work environment. All the questions related to the job satisfaction and retention were asked in a structured form. support at work & position and independent variables were workload. It was free from any personal bias of the interviewer and the nurses as they had enough time to give well thought out answers. Questionnaire is . 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. the layout of questions (close or open) that were used in questionnaire was formed (Kothari. It included wider and more representative distribution of samples. 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. Control variables were stress. 2005). These questions were asked with regard to the control and independent variables. On the basis of these variables. We have chosen the structured form of questionnaire as it could easily be interpreted by the nurses.

. Respondents have adequate time to give their thoughts and answers (Kothari. which are as follows: • Low rate of return of the duly filled in questionnaires and bias due to no-response is often determined. • • • • The questionnaire research methodology and the data collection plan used by the researcher also have some limitation. can also be reached conveniently. 2005).often considered as the heart of a survey. a questionnaire is mailed to the respondents who are expected to answer these questions. Respondents. The rationale behind using this methodology is as follows: • Its cost is low even when the population is large and is widely spread geographically. Large samples can be made in such a way so that the results can be made more dependable and reliable. The method of collecting data by the questionnaires is most extensively employed in various economic and business surveys. In this method. It is free from the bias of the interviewers and answers are in respondents’ own words. who are not easily approachable.

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. 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 . Turnover may be useful or wasteful depending upon the situation. It is difficult to know whether willing respondents are truly representatives. This method is likely to be the slowest of all the methods. It is undesirable when its purpose is to search for entire removal labor consumption.• It can be used only when respondents are educated and cooperating. There is also a possibility of ambiguous replies or omission of replies altogether to certain questions and interpretation of omissions is difficult. • • • • • Results It is customary to point out that turnover is not always taken as negative in terms of its impact.

This cost depends upon the type of job. 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. These suggestions will assist the organization to focus on different approaches in order to reduce the wasteful turnover attitude among the nurses. Reilly & Moore.such as skills. abilities & other characteristics and the job requirements of the organization. the feeling of reduced job satisfaction has developed (Cline. As a result of this. there is another approach. In spite of standard significant costs related to nurse turnover. Apart from this. Results of study. . 2003). Only 10 percent out of 20 percent of the US health care setting is supposed to be effective in their nurse retention program. 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. which emphasizes on the effective communication between manager and nurses. clinical competency and experience. This is concluded that there is a lack of trust and effective communication within the organization. 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.

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 was concluded that most of the nurses like to stay in those hospitals where the relationship with the supervisors are positive.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). According to the survey. Only few of the organizations include this factor in their retention program. In the increasing competition in hospital business. 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. 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. 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.

anger and resentment are resulted from this environment among the nurses. These results interpret that in the selection procedure. which facilitates nurses to leave the organization (Kimura. Feelings such as depression. 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.Disagreement of physicians on the matter of viewing nurses as the important and key member of the organization automatically develops an environment. higher rate of absenteeism and job dissatisfaction that further results in to higher turnover rate. Physicians. The . must be tackled and directed to replace their behavior with written warnings. 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. 2003). 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. It is responsible for the decreased performance level. Ways of nurses for leaving the organization are the same like they are in other groups and organizations (Lacey 2003). who harass the nurses and exhibit the aforesaid behavior.

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. 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). Selection procedures such as team membership. Many health care settings achieve their goal to reduce the turnover rate of nurses by the implementation of this program. which further reduces the chances of job dissatisfaction and subsequently the rate of turnover. 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.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.

According to the present situation and ongoing trends. The vocation of nurse also falls in this category. So the . no such single answer can be quoted to describe the level of job satisfaction. an old person or a mental patient. 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. The increasing shortage of nurses is resulting in recruitment of nurses from foreign countries.Conclusion From the above discussion and findings. They have to work in different contexts and settings and with entirely different organizational cultures. which in turn results in dearth of nurses in foreign countries. which give a varied experience to them in the profession. an adult. The research focuses on understanding the particular job characteristics and the level of satisfaction derived from them. Not only the settings. Nurses constitute to the success of hospitals rendering their services for the all types of patients. it is concluded that job satisfaction differs largely from one job to another and it even differs within the same profession. Nurses have to deal with all types of patients whether he is a small child.

The conditions should not be such that frustrate the nurses. which will help in retaining the high performing nursing personnel presently employed in the organization and attracting new nursing talent. the hospital management should take appropriate steps and try to provide maximum job satisfaction to the nurses (Robinson. Teamwork should be encouraged and the quality of work life should be improved to retain the nurses in the employment. Regular training sessions should be conducted to keep them updated (Sapriel. 2003). For the shortage of nurses. The hospital management should try to maintain the present number of nurses and retain the lost ones. 2003). which shows that they are treated with discrimination. Clements. . & Land. lower their morale and decrease their interest and motivation towards their job. The administration should take the necessary steps to enhance and increase the talent supply among nurses. 2003). It is very important for the hospital management to implement proper human resource practices.hospital management should take great care for the satisfaction among the nurses (Moody. The foreign nurses are even exploited with regard to wages.

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. I believe that an effective nursing teacher is not complete with out performing faculty practice. I observed that faculty practice has not received the deserved significance and importance by the faculty members. but due to monetary dissatisfaction they might not prefer to continue with the same job. 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. My intuition to inquire about this important phenomenon led me not only to understand this concept in depth but to . Implementing Effective Faculty Practice in Nursing The phenomenon of faculty practice is a fundamental component of nursing academia.Other relevant point Monetary consideration can be taken as an important point because there are people who are satisfied by their job. Hospital management should pay attention towards increasing the pay of the nursing personnel.

and research needs of faculty and students” (p. (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. Marion (as cited in Sawyer. problem solving. strategies and recommendations to implement effective faculty practice in nursing education. decision making. and interpersonal competence” (p. 2000) integrated faculty practice into different ‘roles’. Dudjak.. Description of Faculty Practice Faculty practice is inseparable from faculty’s role and should be considered an integral part of it. Huber (2006) identified the planned change as “a leadership strategy that requires planning and action. analysis. Saxe et al. 2001) explained faculty practice as a patient care responsibility. This concept is defined and explained by several authors but here few definitions have been shared. Alexander. ‘settings’ and ‘models’. Anderson. 806). service.strive for bringing about some planned change. Kobert. Juszczak. The purpose of this paper is to take a position to propose and recognize effective understanding of faculty practice to implement in our context. and Miller (as cited in Ward. Rudy. practice. . 166). This paper will discuss the description. Gordon. while meeting the teaching. & Gillis.

I strongly feel that clinical practice of faculty members equally contributes and puts impact on their all other roles such as teaching. 2003) reported that some faculty members take it as a ‘threat’ to their other work load. Rayburn (as cited in Paskiewicz. particularly in researchintensive environments” (p. 174). This notion is well supported by various literatures which specify it as a core element of excellence in nursing education. Unfortunately at most of the places in Pakistan this practice is considered apart from other faculty roles. scholarly activities. 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. Herr (as cited in Paskiewicz. 2003) shared that sometimes universities do not give value to . This section of the paper will focus on the contextual importance of the issue in government and private nursing education settings in Pakistan. and administration. Background of the issue in our context. This issue is highly significant in the world of nursing education. Nursing faculty members who are involved in clinical teaching can not survive without clinical practice.Analysis of the Issue in our Context Significance of the issue. research.

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. preferably the practice is done during summer breaks when students are not around. especially at government setting. where luckily this concept is offered. nursing faculty feel hesitate to initiate this important feature of their roles. this particular system does not follow any specific model of faculty practice.faculty practice as it has been given to other tasks. Faculty practice at AKUSON comprises 10% of faculty workload. The other reason of its ineffectivity could be the acceptance of faculty members by clinical setting staff. Another impression in most of the developing countries like Pakistan about nursing profession follows a hierarchical structure. Here I would also like to draw attention to the existence of faculty practice at Aga Khan University School of Nursing (AKU-SON). Due to this kind of perception. where nursing educators are regarded as having higher position than bed side nurses Upvall et al (2002). (2002) revealed that there is a need for culturally relevant . To recognize the understanding of faculty practice into Pakistani context Upvall et al. Along with it.

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

scheduling. Barger. selecting clinical setting. They also explained another faculty practice model that is based on entrepreneurship which offers .. various literature provides different barriers and challenges of it. 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. 2004) explained that this model takes care of joint appointments where some percentage of time is given to service and some to education. Patton and Cook (as cited in Saxe et al. Ward (2001) summarized different challenges in terms of increased workload. improving the efficacy of faculty practice. On the contrary of advantages of faculty practice. Campbell and King. less time for scholarly activities due to inculcating faculty practice as a faculty role. Walker.Challenges of performing faculty practice. 2002) ‘unification model’ is one of the models that suggests a same administrator of hospital and school of nursing. Nugent and Brides. Faculty Practice Outlook in Developed World Literature review suggests availability of different models of faculty practice widely adopted by developed world. Starck and McNeil. According to Hutelmyer and MacPhail (as cited in Upvall et al. Each model has a separate structure to follow.

But one can see different glimpses of these models chosen by individual faculty. even at AKUSON no particular model is utilized completely. 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. In Pakistan there is no evidence of using these models. service. Organizational Framework of Faculty Role To maintain my position supporting enhancement of effective faculty practice. this ring represents administration. illustrating the importance of faculty practice and its impact on other different faculty roles. professional development. I would like to integrate here an organizational framework (see figure 1) which is based on Boyer’s model of scholarship. Paskiewicz (2003) placed clinical practice in the center and showed its direct bidirectional relationship with other roles such as teaching. The framework shows an outer ring that surrounds all of the above mentioned roles. Rankin & Calkin. covering the overall outcome of . and research. 1989) called ‘private practice’ through which faculty can choose their own private practice during school hours and negotiate their other roles.liberty to faculty members to select any approach for their practice. One more model explicated by Free and Mills (as cited in Stainton.

Once it is acknowledged that faculty practice is an entity which combines university mission of education. The other outermost ring represents university mission which reflects the overall faculty role discussed earlier. Avolio (as cited in Northouse. then it definitely requires transformational leadership to have positive outcomes. research. to have an efficient process. It can be recommended that in our context. In respect to faculty practice. Application of leadership Model with the Issue Nursing leadership has a great role in establishing effective nursing faculty practice system in schools of nursing. which otherwise is left isolated and not seen as a core constituent of faculty roles. 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. 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. I strongly believe that this framework does justice with the area of clinical practice. The next factor is ‘inspirational motivation’ where leader keeps high expectations .faculty’s performance. the leader must show the real and strong role modeling for the need of clinical practice. teaching and service.

Along with it. Same goes with implementing faculty practice. 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. ‘Individualized consideration’ is the last but not the least factor. and goals of a faculty member who chooses to go for clinical practice. One needs to make sure that what are the purposes. there are several strategies following the process of assessment. now this is leader’s role to motivate others for the same. once the need has been shared. the other thing important to assess . Strategies to implement Faculty Practice After analyzing the need to have an effective faculty practice system. Assessment.from the team. objectives. planning. The strategic process begins with assessment of understanding the concept by the faculty members. The other factor is based on ‘intellectual stimulation’ where leaders intellectually stimulate others to perform the task keeping its importance and value. where leaders provide supportive environment to each individual. and evaluationto making it happen. implementation.

how and where that are taken care by scheduling. which according to Ward (2001) is when. Planning is the most vital step of executing faculty practice. Upvall et al (2002) revealed from their research in Pakistani context that “From a faculty perspective. Planning. Planning includes several components which help in ensuring the thorough action. The choice of clinical placement should also reflect the improved efficiency at classroom and clinical teaching. The first activity is scheduling. The other strategies explained by Ward also indicated the planning for the rich and beneficial outcomes . One has to also see the time duration spend by hours per week or per year. or as percentage of workload. faculty members should also be aware of the benefits and the challenges of doing faculty practice. Moreover.for faculty practice is the setting. the other main strategy is the selection of clinical area for practice. which should match with individual’s objectives. 322). Numerous literature suggests that selection of clinical setting should be matched with the objectives and should be relevant to the area of interest. After setting up the schedule. 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.

The other strategy to make faculty practice more useful is by writing anecdotal notes on patient information and . Reflective practice is another key attribute which can make the practice more effective. But. The purpose is not to make a list of strategies to carry out. Implementation. there are very few simple strategies suggested based on the mentioned planning. The implementation phase for this task is a crucial stage. Boud (as cited in Budden.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. On clinical placement she could carry out different presentations and publications to share her experiences integrated with theory to staff and students. 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. During implementation stage it is expected from faculty members to have full advantage of the practice. because that will add on the burden of faculty members. 1243). 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.

Evaluation. et al (2004) shared various methods of evaluation which were utilized in their studies. there are some recommendations which could be achieved at organizational level. Saxe. The purpose of this phase is to estimate the meeting of expected objectives. The last phase of the process should be based on ongoing evaluation. 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. 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. These approaches are self evaluation. Recommendations In addition to the strategies discussed above. I would also like to support a recommendation provided by Upvall et al (2002) . from staff and from students could be performed to have complete picture of faculty’s performance.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 from clients.

Several strategies and recommendations have been suggested to effectively implement faculty practice in organizations. To bring amazing outlook of nursing profession. . This core characteristic of faculty’s workload must receive equal worth as it has been given to other tasks of faculty. it is obligatory to bridge this gap. 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. 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. the orientation package for new faculty members should also include the complete awareness module of faculty practice. furthermore that should be reflected in individual department’s policy.who recommended that in Pakistani context Pakistan Nursing Council should set a requirement to make faculty practice mandatory for each nursing teacher. Conclusion Faculty practice is an integral aspect of faculty’s role in the field of nursing. 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. At school of nursing level.

Nursing Profession Care: Introduction Nursing profession is the largest force in health care system holding the central role as health care providers. visionary. Effective nursing leadership supports the collaborative. 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. innovative and evidence based work environment that helps nurses to feel respected and valued in their positions. Especially nursing leaders who run professional organizations at national level have to acquire these characteristics. federal and professional bodies at national level. Nursing profession needs dynamic. In addition they advocate for the public and the professional’s rights. In our country health care system is decentralized at provincial level. According to Huber (2006) “leader use their power to bring teams together.4). spark innovation. So nursing leadership comprises provincial. Our people’s health depends on competent and highly educated nurses. create positive communication and drive forward toward group goals (p.” Nursing leadership must possess these characteristics. “Director General Nursing” is the highest rank in each of the four provinces responsible for health and nursing .

1973. 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. Likewise. While addressing the issue related to “Challenges of nursing leadership” I will be focusing on professional bodies PNC & PNF only. PNC is an autonomous body that functions under the Pakistan Nursing Council Act. These are comprised of nursing council. identify the key issues and recommend strategies to resolve the issues.matters in their particular area. nursing education. professional bodies are the most important pillars of the nursing profession at national level in any of the country. The purpose of this paper is to describe the challenges related to leadership at national level. 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 Act 1973 authorized the Council fully to make the independent decisions related to public health rights. nursing association and nursing union. Pakistan Nursing Council (PNC) and Pakistan Nursing Federation (PNF). nursing practice . being the national level leadership. Where as in federal “Nursing Advisor” is the top position directly working with ministry of health in close coordination with other nurse leaders.

making new rules for betterment and addressing patients and professionals needs timely. monitoring of health and educational institutions. Since the partition it was functioning in a small borrowed space in one of the government’s building. For two nurses holding the extensive functions of the Council is humanly impossible. 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.standards. disciplining for mal practices. PNC office is located in Islamabad. Similarly. However. The structure of the Council is President ( Director General Health) Vice President (one of the Senior Nurse) and Registrar along with Ex – Officio members. Recently one more BScN prepared nurse has been inducted as Assistant Registrar. federation is responsible to advocate the . PNC Act 1973 also gives the full authority to the council to establish and maintain its prescribed infrastructure with extensive range of functions.15 years. According to PNF Constitution and Bye-laws 1949 spelled out functions and authority. licensing nursing professionals and recognizing or derecognizing educational institutions. At present only one senior nurse in Registrar position with diploma qualification is working for the last 10 . recently the office has been moved to a new permanent building fully allocated for council’s functions in Islamabad.

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. For PNF functions we do not have separate office as the positions are held by the nurses who are already in government job. First Vice President. 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. Second Vice President. Secretary General. Editor of the Professional Magazine. Trained Nurses Association India (TNAI).professionals and execute it’s duties in true spirit. President of the Provincial Association. According to the PNF Constitution it’s structure comprises (1) National Executive Board of PNF is president. 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. . Unfortunately this is not the case in our country. American Nurses Association (ANA). Treasurer. Representative from PNC and Chairmen of Standing Committees (2) Governing body of PNF is the National Executive Board.

org/.nmc-uk. NMC ensures safe and quality care for public health by maintaining it’s professional standards. Six institutions has been approved by the Indian national association for Ph.au/ . So ANA prepares “an annual legislative agenda” (p.Literature review Hood and Leddy (2003) discussed that political situation in the country move so fast that polices changes with in no time. Being a Muslim country with the support of King Abdullah nursing profession in Jordan plays a central role in health care system.asp. India being our neighbor country. 5000 fee per annum to the respective study centerhttp://www. NMC develops standards for professional conduct and guides nurses and midwifes on regular bases http://www.indiannursingcouncil. 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.338) to update its polices congruent with circumstances.org. ANMC was established in 1992 to function as regulatory body for nursing and midwifery in Autralia. INC has planed to commence the Nursing Ph.org/Nation_ Consortium_PhD_Nursing.D program all over the country. Nursing regulatory body has the full authority to develop national standards . Silmilarly.D program to promote research activates. Over the decades nursing profession proved it’s importance.anmc. Student will pay Rs.

Nursing leadership at national level and their input in health policy. succession planning. Similarly. who believes that nursing is the vital partner in health care system of the country http://www.jnc. 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.and activate resources to uphold transformation of nursing education. professional recognition. forum to address the public health rights and professional’s rights.jo/english/home.htm.gov. It is therefore very crucial to link up policies. educational opportunities for nurses. Jordan is top one country in Muslim world to recognize nursing as an selfgoverning profession through the clear vision of King Abdullah. and the level of nursing education in India has had far . Hemani (2003) explained “India where independence was gained at the same time. trainings and commitment of all concerned parties together (p. 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. mal practices. According to Ladhani (2002) “issues in nursing are very complex and are like web of causes interlinked and interconnected. true recognition of BScN & Masters prepared nurses.9)”.

Root causes of present scenario There are political. . As the present leadership lack the capacity to take the lead in progressing the actions further. Furthermore. educational and personal reasons hindering the nursing development in the country. 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. PNC Act Revision ( 5th session 2004) and Nursing Organizations workshop (2000) are just kept in the shelves with out any follow-up work. Report of Visioning workshop: (2000). patients safety is also at risk due to absence of professional accountability. Minutes of Senior Nursing Advisory committee meeting July 4-6 (2000). no control over mal practices and sub standard educational institutions.more recognition internationally than Pakistan” (p. cultural. 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). it creates poor nursing image nationally and internationally.

There is no projection of the profession at . no involvement in decision making at institutional level and absence of professional autonomy. competent and ethical nursing care. It is evident that nursing professional bodies in Pakistan are far behind to address the future health care demands of the society. 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. It gives great impact on nurse’s job satisfaction and self esteem.Analysis of the situation According to PNC Act (1973). Due to this compromised education level nurses are unable to play the effective role in health care system. shortage of nurses at bed side. Though nurse’s role is limited to the tertiary care only. Nurses have no professional platform to unite and address the health related issues. 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. nurses have the responsibility to their patients to provide safe. lack of resources to provide safe care. nurses working in hospital setting face numerous challenges related to safe provision of care. compromised nursing education. This damages the image of nursing profession in our society despite of nurses working so hard.

involvement in decision making at institution level. safe patient care. promotion and benefits. nursing image and . During that period I conducted a survey in 3 provinces. Lack of visionary nursing leadership and infrastructure at PNC & PNF level affects quality care.all. They wanted to see the positive change that could provide them the better work environment. These mid level nursing leaders exhibited helplessness and hopelessness working in the existing system. job satisfaction of nurse’s. job satisfaction. Quality of nursing education. The mid level nursing leaders from all 3 provinces verbalized the issues they were facing during their nursing practice. Frontier and Sindh in major hospitals. image of nursing in our society. In 2003. poor nursing regulatory and advocacy mechanisms were the 10 emerging themes of the high area of concern among all mid level nursing leaders. job satisfaction. succession planning. The mid level nursing leaders (chief nursing superintendents. principals and nursing teacher) were interviewed to explore their job satisfaction level. higher education opportunities and better career structure. Punjab. shortage of nurses on bed side. I got the opportunity to work in Women health project under Ministry of Health. career path. even we do not have any publication and web site developed for our professional bodies yet. supervisors. opportunities for continue education and higher education.

In addition to that I could not get any educational opportunity for advance nursing education on time as it was hardly available. We can imagine it’s affects on health system. In my . I would like to share my own work experience. team leader manager and acting chief of nursing. salary and benefits and professional conduct. During my professional journey. professional growth. Because nursing professional bodies fall short to respond to the call of society and the nursing professionals. 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. Infrastructure of PNC is equal to none. I have worked as an intensive care nurse. I faced high expectation and high work load without adequate preparation in every assigned role. 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. In every role I have experienced different challenges and problems. I faced many issues related to provision of safe care and professional autonomy.public health. 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. nurses and society as a whole. Managing high turn over /shortage of nurses.

But again there is no effective check and control for such a major offence. regulate quality care. professional conduct and quality nursing education by implementing PNC Act 1973 and PNF Constitution 1949 in its true spirit. In short. nursing leadership at national level whose mandate is to hold up and advocate the public and professional rights. Even senior nurses having more than twenty five years and plus experience holding leadership positions have no access to continue .personal experience I have seen nurses working with fake diploma (even working abroad) but there is no regulatory mechanism to control such practices. 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. All practicing nurses and faculty are diploma prepared. Similarly. 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. These short comings at top level are truly reflected right down the level in hospitals and nursing educational institutions. there is mushrooming of nursing schools for male nursing in the country just to earn the money . lacks the qualified visionary leadership and adequate infrastructure that causes serious health care affects through out the country.

This drawback is a major threat to public health as well as country’s economics. 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. 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? .education and preparation for their leadership role at institution level. To look for the solution of prevailing situation many questions arise in my mind that. How can we establish adequate infrastructure at PNC level. institutional and unit level. In result the whole society is at high risk along with nursing professional.

What is required Immediate and effective action is needed to respond the existing situation. one day will be holding key positions in health sector as well as political representation. Indian Nursing Council. Beside that university based education must be ensured to raise the professional standard. This is how change will take place. 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. Transformational Theory The present nursing leadership at national level is ineffective and unproductive due to lack of team work and coordination. To take all these positive steps a strong commitment and clear vision of policy maker and nursing professional bodies is required. There is intense and immediate need to improve the productivity of professional bodies in the light of other countries. I hope that new nursing generation who are getting better opportunities for education. These characteristics are . Australian Nursing Council. Canadian Nursing Council. change is inevitable. I am sure that time is not far. In addition to that Pakistan Medical Dental Council infra structure could be studied that may be replicated straight away at PNC level. We can learn the lesson from Nursing Midwifery Council in United Kingdom.

Conclusion We all know that nursing professional bodies in any country breath oxygen to professional’s and the public. net working. Having infrastructure improved at national level will be the first step towards the success and to address and engage in health care system. ensure right person at the right place and create 4 MScN and 2 Ph. To bring about the positive change we need to adopt leadership style that is role modeling leadership inspiring people focusing the processes. public policy issues and collaboration with government. Recommendations Ministry of health to show the commitment by immediate action to correct the situation as follow: Revise criteria for key positions.D nursing positions at national level in initial phase.similar to laissez –faire leadership style as described by Tomy (2000). Intellectual and source of motivation that is transformational theory support by Tomy. sharing. So they could work to improve the existing situation of nursing profession in Pakistan. Existing nursing leadership at national level must take immediate action to . Suggested plan is to advertise the new positions 2nd quarter 2008 and ensure hiring in the beginning of the 3rd quarter 2008.

hospitals are usually funded by the public sector. established in 1681 to house veteran soldiers. Today. including by direct charitable donations. there are various Catholic religious orders. in the modern sense. Historically. but not always providing for longer-term patient stays. this work was usually performed by the founding religious orders or by volunteers. by health organizations (for profit or nonprofit). surgeons. hospitals were often founded and funded by religious orders or charitable individuals and leaders. and often. however. . There are over 17. Otherwise.000 hospitals in the world. and nurses. is an institution for health care providing patient treatment by specialized staff and equipment. modern-day hospitals are largely staffed by professional physicians. (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. Tichy. Conversely. whereas in history. health insurance companies or charities. such as the Alexians and the Bon Secours Sisters which still focus on hospital ministry.resolve the situation. was "a place of hospitality". until relatively recent times. Today. Its historical meaning. for example the Chelsea Royal Hospital.

and other health professionals. the first teaching hospital. nurses. Some teaching hospitals also have a commitment to research and are centers for experimental. and may be owned by a university or may form part of a wider regional or national health system. innovative and technically sophisticated services.Teaching hospital A teaching hospital is a hospital that provides clinical education and training to future and current doctors. The Middle Persian word Bimaristan literally translates into "land of sickness". in addition to delivering medical care to patients. was reportedly the Academy of Gundishapur in the Persian Empire during the Sassanid era. They are generally affiliated with medical schools or universities (hence the alternative term university hospital). where students were authorized to methodically practice on patients under the supervision of physicians as part of their education. . History Although institutions for caring for the sick are known to have existed much earlier in history.

According to Sir John Bagot Glubb: "By Mamun's time medical schools were extremely active in Baghdad. and 'Ala ad-Din Ibn al-Nafis (d. 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. the famous medical historian. The first free public hospital was opened in Baghdad during the Caliphate of Haroonar-Rashid. al-Nuri hospital. A number of Muslim physicians and physicists graduated from there. 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). physicians and surgeons were appointed who gave lectures to medical students and issued diplomas to those who were considered qualified to practice. built by the famous Nur ad-Din Zangi. The hospital's medical school is said to have had elegant rooms. Abu alMajid al-Bahili." Etymology . Among the wellknown students are Ibn Abi Usaybi'ah (1203-1270). As the system developed. and a library to which many books were donated by Zangi's physician.In the medieval Islamic world. was made a teaching hospital and renowned physicians taught there.

"in/to hospital"). The latter modern word derives from Latin via the ancient French romance word hostel. . friendliness. signifying a stranger or foreigner. The German word 'Spital' shares similar roots. hospital usually requires an article. in Britain and elsewhere. hostel and hotel. hence a guest. The word hospital comes from the Latin hospes. being almshouses for the poor. Another noun derived from this. which letter was eventually removed from the word..S. the loss of which is signified by a circumflex in the modern French word hôtel. which developed a silent s. in Canada. that is the relation between guest and shelterer.During the Middle Ages hospitals served different functions to modern institutions. 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. Hospes is thus the root for the English words host (where the p was dropped for convenience of pronunciation) hospitality. both uses are found. hospitable reception. hospice. or hospital schools. In the U. Grammar of the word differs slightly depending on the dialect. an inn. hospitium came to signify hospitality. guest's lodging. hospitality. By metonymy the Latin word then came to mean a guestchamber. hostels for pilgrims.

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 pretwentieth-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.
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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,

Maintenance. . Dining Services. and Security departments.Facilities Management.