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WHO/HRH/NUR/92.3
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A
,1
II
MANAGEMENT OF
HEALTH SERVICES BY
NURSES
t
Beverly Henry, RN, PhD, FAAN
Margarethe Lorensen, RN, PhD
Miriam Hirschfeld, RN, DNS
WORLD HEALTH ORGANIZATION
GENEVA, 1992
05251
1
Community Health Cell
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WHO/HRH/NUR/92.3
Distr. LIMITED
English only
WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
Management of Health Services by Nurses
by
Beverly Henry, RN, PhD, FAAN1
Margarethe Lorensen, RN, PhD2
Miriam Hirschfeld, RN, DNS3
Conducted under the aegis of the World Health Organization with additional support
provided by the US Education Foundation in Norway, through a Fulbright Grant, and the
University of Oslo, Institute of Nursing Science, Norway.
1 Professor and Head, Department of Administrative Studies in Nursing, College of Nursing
University of Illinois at Chicago, United States.
2 Professor of Nursing, Institute for Nursing Science, University of Oslo, Norway.
3
Chief Scientist for Nursing, Division of Development of Human Resources for Health
World Health Organization, Geneva, Switzerland.
Abstract
Nurses have many responsibilities within the health services. Because of the
wide range of these responsibilities, sound, effective management and leadership by
nurses is essential. However, relatively little systematic information of a global nature
exists on their management activities and management training. This study was
undertaken in 1990-1991 on the basis of material collected in 1988 for a conference
supported by the Rockefeller Foundation.
The report describes the major managerial functions of nurses in health systems,
and identifies major problems for nurses in management positions. Actions are
suggested to overcome them, including improving basic nursing education, developing
clear job descriptions, ensuring opportunities for career advancement, and improving
understanding of nurse migration. The report also makes recommendations for
appropriate management education at the basic, post-basic and university levels.
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WHO/HRH/NUR/92.3
Contents
Acknowledgements
Executive Summary
1.
Introduction
Study Purpose and Aims . . .
Background and Terminology
1
1
2
2.
Methodology and Participants
Method
Participants
Data Analysis and Validity . . . .
Study Strengths and Limitations
Organization of the Report . . .
9
9
10
10
11
12
3.
Nurses in Leadership and Management
Nurses’ Senior Leadership Positions
Functions of Chief Nurses in National Ministries . .
Characteristics of Successful Nurse Leaders . . . .
Nurses’ Involvement in Planning and Policy-making
13
13
13
14
16
4.
Management of Health Services by Nurses
Major Problems for Nurses in Management .
Actions to Overcome the Problems
19
19
21
5
Education for Improved Leadership and Management
Subject Content for Basic, Post-basic, University and Continuing Education
Home-study and Distance Learning Programmes
Education Guidelines
25
25
27
28
6.
Research and Theory for Leadership and Management
Nurses’ Education to Conduct Research
Important and Unimportant Research
Methodologies in Use And Those Useful For The Future
Recommendations to Improve Research
Useful Theories
Critique of a Model for Nursing Education
31
31
32
33
34
35
35
7.
Discussion, implications and Recommendations
Health Systems and Nurses’ Leadership and Management
Implications and Recommendations for Nurses’ Education
Implications and Recommendations for the Development of Knowledge
Concluding Remarks and Recommendations
37
37
42
46
48
References
Annex A
Annex B
Annex C
Final Chapter of 1988 Report
: .
Questionnaire . . s . .
,
. .
Study Countries and Participant Distribution Data
49
55
77
79
Acknowledgements
The authors wish to express their sincere appreciation to all who participated in the study,
both those whose names follow and those who prefer to remain anonymous. They are
indebted to Richard Heyden for his months of diligent programming and analysis, and to
Shirley Stinson and Margaret Truax for their comments on early versions of the study report.
A special word of thanks is due to the participants who also took the time from their full
schedules to evaluate the review edition of this final report.
Adebo, E. O., Nigeria
Alluard, E., France
Angerami, E. L S, Brazil
Antoney, A. India
Antoniou, M., Cyprus
Amarsi, Y., Pakistan
Arguedas, E. G., Costa Rica
Armstrong, D. M., United States
Ashkir, A. A., Somalia
Awasum, H. M., Cameroon
Aziz, F. A., Sudan
Bai, T. K., India
Bartholmeyczik, S., Germany
Ben-Dov, N., Israel
Bergman, R., Israel
Bhaduri, A., India
Bhattacharya, B., India
Bhattacharya, K., India
Biai, M. A. R., Guinea-Bissau
Bose, R., India
Brotherus-Kettunen, A., Finland
Brown, B. J., Saudi Arabia
Byahuka, E., Uganda
Caiman, K. C., Scotland
Chandrabha, V., Thailand
Chavasse, J., Ireland
Chick, N. P., New Zealand
Cho, W. J., South Korea
Clift, J. M., Austria
Corcega, T. F., Philippines
Dastoor, H. F., India
Dean, S. A., Yemen
Dechanoz, G., France
De lllueca, L.» Panama
Deiman, P. A., United States
De Vargas, I. G., Colombia
Dittrich, F., Austria
Durana, I. S., Colombia
Duxbury, M. L., United States
Erdil, F., Turkey
Fagin, C. M., United States
Franco, C. I. S., Colombia
Gardner, O., Antigua-Barbuda
Garzon, N., Colombia
Ghazi, C., Egypt
Ghosh, B., India
Gorajek-Jozwik, J., Poland
Grayson, J„ Trinidad/Tobago
Grybowski, J. A., U. S. Virgin
Islands
Gupta, G. S., India
Gupta, S., India
Hali, P. H„ India
Hamrin, E., Sweden
Haraldsdottir, R., Iceland
Harnar, R., Pakistan
Harun, S., Bangladesh
Hennessy, D., England
Hinohara, S., Japan
Huckabay, L. M. D., United
States
Huque, H., India
Ibrahim, C., Indonesia
Ingolfsdottir, V., Iceland
Irurita, V., Australia
Jagivandas, M. D., India
Jean-Nlemba, S., Haiti
Juul-Jensen, P., Denmark
Kadandara, J. C., Zimbabwe
Kalkovska-Miteva, E., Bulgaria
Kanellopoulou, M., Greece
Kappeli, S., Switzerland
Kentta E., Finland
Kihlgren, M., Sweden
Kim, M. S., Korea
Krishnan, S., India
Krohwinkel, M., Germany
Kurup, C. P. S.» India
Lapsley, H., Australia
Larena, S. P., Philippines
Layo-Danao, L., Philippines
Lenartowicz, H., Poland
Lin, J. Y., China
Lopez, M. A. G., Philippines
Luberenga, K., Uganda
Makutu, S. L., Fiji
Malcom, L., New Zealand
Malik, U„ India
Martikainen, T., Finland
Mathias, L., New Zealand
Mati, M. M., Kenya
M’Boge, B. H., Gambia
McLoughlin, E., England
Mehra, P., India
Mehta, P. S., India
Meyi-Jamir, L., India
Miller, A., Malta
Miloradovic, M., Yugoslavia
Misungu, S., Zaire
Moen, O. W., Norway
Mokabel, S., Egypt
Monzon, M. T., Spain
Mutabaruka, E., Rwanda
N’Djalawe, B. A., Togo
Namate, D. E., Malawi
Ndulo, J., Zambia
Nisce, Z. P., Philippines
Niyomviphat, S., Thailand
Nojima, Y., Japan
Orais, V. S., Philippines
Paccagnella, B., Italy
Park, J. H., Rep. of Korea
Patel, N. R., India
Pereira, T. Q., Portugal
Petersen, K. A., Denmark
Plati, C., Greece
Pluyter-Wenting, E., Netherlands
Poole, A. B., England
Quivey, M., Norway
Rispel, L, South Africa
Salgado, M., C., Honduras
Samarasekera, P.C.H., Sri Lanka
Samarasinghe, J., Ghana
Samuel, S. A., India
Sanchiz, B., Spain
Sansoni, J., Italy
Saxena, P., India
Schroder, K. E., Norway
Segers, W., Belguim
Seidl, E., Austria
Sermeus, W., Belgium
Shamian, J., Canada
Shrestha, R., C., Nepal
Sinkkonen, S., Finland
Slagveer-Sylvester, A.C.,
Suriname
Solvang, B., Norway
Sorvettula, M., Finland
Sotejo, J. V., Philippines
Sovenyi, K., Hungary
Sparos, L., Greece
Suliman, W., A., Jordan
Takahashi, A., Japan
Tapera, S. J. Zimbabwe
Thassu, R. B., India
Thomas, R., India
Thu, N. D., Viet Nam
Tiedemann, E., Denmark
Tiffany, B., England
Tsai, S. L., China (Taiwan)
Tsai, C. N., China (Taiwan)
Uyer, G., Turkey
Uys, L. R., South Africa
Valkonen, P., Finland
Vallejo, N. F., Ecuador
Van Der Walt, A., South Africa
Vuga, S., Yugoslavia
Wahlberg, V., Sweden
Walia, I., India
Wangsarahardja, M.A., Indonesia
Werley, H. H., United States
Wiedemann, U., Germany
Willoch, I. C., Norway
Yang, E. Y., China (Taiwan)
Yousef, F. H., Yemen
Zenaba, A. F., Chad
Zohra, B. M., Mauritania
WHO/HRH/NUR/92.3
page i
EXECUTIVE SUMMARY
Management of Health Services by Nurses
Nurses have many responsibilities within the health services. Because of the wide range of these
responsibilities, sound, effective management and leadership by nurses is essential. However, despite
the importance of the work of nurses, relatively little systematic information of a global nature exists on
their management activities and management training. In 1988, the Rockefeller Foundation supported a
conference for nurses, physicians, health service administrators, and management scientists from 20
countries. Five major problems in nursing management were identified and recommendations for
improved education and research were made. This study was undertaken in 1990-1991 to expand the
1988 effort. The specific aims were to:
1)
2)
3)
4)
broaden understanding of the management and leadership by nurses in organizations and
communities, and at district and national levels:
identify the major problems for nurses in management positions:
increase understanding of the content and design of nursing education programme;
hasten the development of knowledge for improved management by nurses.
The frame of reference for the study was developed on the basis of the 1988 conference report. Each
respondent read the report and then described for his or her country:
1)
2)
3)
4)
5)
the senior leadership positions for nurses, the main functions and characteristics of nurse leaders,
and their involvement in planning and policy activities;
the major problems for nurses in management positions and actions to overcome these;
the subjects covered in basic, post-basic, and university education and recommendations to improve
nursing management education;
the most important research topics and methodologies for the field;
useful theories for improving nurses’ management.
The study was an exploratory comparative survey, using a mailed, self-administered, 15-item
questionnaire. A network sample of 172 people in nursing (80%), management (9%), public health (8%),
and medicine (3%) was drawn from 76 countries in all six WHO regions and four development groupings.
The observational unit of analysis was individuals in four fields. The explanatory units of comparison
were country, regional and development groupings. Inter-rater reliability and a panel validation exercise
were used to ensure validity.
Sixty of the 76 countries had senior nurses in the ministry of health, but although least developed
countries had more nurses in the ministries, respondents from these tended to describe fewer senior
leadership positions overall than those from developed countries. Administrative and personnel functions
were reported most often for the least developed and developing countries. In Eastern European and
developed countries, determining organizational structure and policy, planning, setting standards, and
coordinating were described more often. Few functions were reported for all countries pertaining to
information flow, budgeting and accounting, and evaluating. The characteristics of nurses which
contribute to managerial success were identified as: being experienced and educated in nursing and
management; having planning, policy, and budgeting skills; being decisive, diplomatic, and collaborative;
and having access to human and material resources. It was found, especially at the national level, that
there was comparatively little involvement by nurses in health planning and policy activities. This
problem, in part, derives from nurses not being adequately prepared for management and the poorly
structured and managed health systems in many countries.
WHO/HRH/NUR/92.3
page ii
The 10 major problems for nurses in management positions were identified as being:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
the shortage of nurses;
a shortage of well-educated nurse managers;
little participation by nurses in planning and policy activities;
lack of recognition and low status of nursing;
poor working conditions;
the subordinate role of nurses;
inadequate information systems;
little interprofessional collaboration and teamwork;
the need for supportive legislation;
the lack of emphasis on primary health care.
Several of the actions suggested to overcome the problems included improving basic nursing
education, developing clear job descriptions, ensuring opportunities for career advancement, and
improving understanding of nurse migration. Also mentioned was the need to recruit nurses and foster
closer sectoral ties between education and service. The importance of nurses’ determining policy to
improve regulations and legislation was mentioned fairly often. Less mention was made of nursing
education that is relevant to community need. Other actions to overcome the problems included
improving nurses’ salaries and benefits and the safety of the work place, developing simple but useful
information systems, and promoting interdisciplinary education.
Although considerable knowledge and technical skill are required to identify health needs, manage
the nursing services to address these needs, and evaluate the results, the management content in
nursing programmes is poorly developed in many countries. There appears to be some basic leadership
and administrative content in nursing education, but the content relating to national health systems and
strategic management is generally weak. For developing countries, when research is taught, the
emphasis is on promoting awareness of the scientific method and basic research methodology. Research
is part of nursing education at the basic, post-basic and university levels in many developed countries.
The topics considered most important included: availability and deployment of nursing personnel, quality
and cost of care, and the organizational structure of delivery systems. The research methodologies most
often reported were firstly, descriptive studies and surveys, and secondly, programme evaluations. The
most useful theories related to such areas as leadership, management, organization design and
behaviour, clinical epidemiology, social equity, nursing, caring, and health economics.
The management role of nurses in the health services should be viewed in the context of the overall
health system. An important recommendation of the report was to develop education and research
programmes to promote greater understanding by nurses in management positions of the components of
health systems, the relationships of the component parts, and the influence of the main social, cultural,
political and economic factors that contribute to health for all. The major managerial functions of nurses
in health systems are described in the report and recommendations for appropriate management
education at the basic, post-basic, and university level are provided. Recommendations to build
knowledge for nursing management include:
1)
2)
3)
conducting studies and programme evaluations that are relevant to health needs and are
economically feasible;
encouraging interdisciplinary studies and policy and action research;
using existing theoretical knowledge from nursing, management, medicine, public health, and
economics to develop management capabilities of nurses.
WHO/HRH/NUR/92.3
page 1
SECTION 1
Introduction
Nursing is the largest sector of the health care workforce. In nearly all countries nurses give direct
care and supervise the work of others. They are responsible for many of the services provided to people
in communities and hospitals. Because of their wide responsibilities and large numbers, it is vital that
they have good leadership and effective management.
The leadership potential of well-prepared nurses for the implementation of primary health care and
for the achievement of the global strategy of health for all has been recognized by the World Health
Assembly.1 Primary health care is essential health care provided at a cost a country and community can
afford using practical, scientific, and socially acceptable methods.2 The Assembly urged Member States
to encourage the appointment of nurses to senior leadership and management positions and to facilitate
their participation in planning and implementing countries’ health activities. Member States were also
encouraged to support the education of nurses for research and to facilitate studies focusing on the
development of more efficient and effective methods of employment. This was intended to address the
need to recruit, retain, educate, and improve the motivation of nursing personnel. The Assembly also
requested the Director-General of the World Health Organization (WHO) to increase support to strengthen
the planning, implementation, and evaluation of the nursing component of national health programmes
and support nurses’ participation in health research including the development of information systems.1
Despite the need for leadership and management by nurses, relatively little systematic information
exists about nurses in management positions, including their participation in planning national health
activities and determining policy. The "Management of Health Services by Nurses” project was therefore
conducted in 1990-1991 to improve understanding of nurses’ leadership and management and the
changes required to develop these capacities and roles to meet the needs of health care services.
Study Purpose and Aims
In 1988, the Rockefeller Foundation supported a conference for 25 leading nurses, physicians, health
service administrators, and management scientists drawn from 20 countries. For the conference, a health
system model was presented by Milton Roemer3 and five major problems for nurses in management were
identified. Recommendations for improved nursing education were also formulated, as was a research
agenda. The purpose of the 1990-1991 project was to expand and extend the work begun at the
conference in 1988. The specific aims were to:
broaden understanding of the management and leadership role in the health services by nurses
in organizations and communities and at district and national levels;
identify the major problems for nurses in management positions;
increase understanding of the content and design of nursing education programmes;
hasten the development of knowledge for improved management by nurses.
The frame of reference was developed on the basis of the 1988 conference discussions which were
published as the final chapter in a book of solicited papers.4 This earlier work, found in Annex A, was the
point of departure. Each study respondent read the chapter and then described the following in his or her
country:
the leadership positions for nurses, the main functions and characteristics of nurse leaders, and
their involvement in planning and policy activities;
the major problems for nurses in management positions and actions to overcome these;
WHO/HRH/NUR/92.3
page 2
•
•
•
the subjects covered in basic, post-basic and university education and recommendations to
improve nurses’ educational preparation;
the most important research topics and the most appropriate research methodologies;,
proposals for improving nurses’ management of the health services.
Background and Terminology
There is a long tradition for management and leadership by nurses. Florence Nightingale, the
founder of modern nursing, established many of today’s guiding principles in the health services for
determining organizational structures and policy, managing personnel, setting standards, developing
information systems, and evaluating the quality of care.5,6 The Splanes of Canada, in their study of senior
nurses in national ministries, described Nightingale as a model leader worth emulating. They discussed
her policy activities at the highest level of government.7 Nightingale was also an international authority.
She collected information about people’s health and health care in Britain, France, Germany, India, New
Zealand, and Turkey.8,9 She was methodical as well. John Thompson, chief of the Division of Health
Services Management at Yale University in the United States, described research in his field as "merely
carrying out some of the ideas suggested in Miss Nightingale’s work."10,11
Roemer, a foremost authority on international health, stated that it is more and more common for
nurses in ministries of health and at provincial and district levels to have many management
responsibilities. He continued by describing the great need for nurses who are appropriately educated for
leadership and management in a health system.12 A "health system" has been defined by WHO as "the
complex of interrelated elements that contribute to health in homes, educational institutions, workplaces,
public places, and communities, as well as in the physical and psychosocial environment and the health
and related sectors."2 "Health services" consist of the institutions and organized activities through which
health care is provided.2
Definition of Management
Management can be defined as planning, organizing, operating, and evaluating.2 To plan,
information is needed about past events, their costs, benefits, and results. Skill in planning by nurses is
widely required in communities, hospitals, and at district and national levels to forecast personnel
requirements based on appropriate assessment of health needs, people’s readiness, and the available
resources.13 Planning skill is necessary to develop service and education openings and to formulate
budgets that can function as a guide to action. To organize, skill is needed to assess the capabilities of
people and the characteristics of the social and political environment. Knowledge of authority
relationships when combined with assessment skills make it possible to design the most appropriate
organizational structures and programmes for the delivery of health services. To operate a health service
and to contribute to the operation of a national health system, skill is needed to obtain and maintain
human and material resources, to work cooperatively with many individuals and groups of people who
often hold diverse views, to set standards, to develop useful information systems, to ensure adequate
levels of performance, and to coordinate people and activities. To evaluate people and programmes
requires skill in communicating and the expertise to assess the results or outcomes.14
A more precise definition of management, and the one used for this report, is that management is
determining organization structure, determining policy, planning resources and programmes, setting
standards, administering resources, ensuring information flow, budgeting and accounting, managing
personnel, training and developing staff, monitoring and evaluating, and coordinating.2,15
Determining organization structure involves understanding the work that needs to be done and the
reguired resources, then organizing the resources and activities in workable units where responsibilities
and authority are clear. Determining policy is gathering information about health and health delivery
problems, bringing these to the attention of officials, determining ways to alleviate the problems,
formulating general statements of courses of action to improve the situation, and being aware of political
factors. A national health policy is the decisions to pursue actions aimed at achieving defined goals for
improving the health situation.2 Planning for resources and programmes is developing standards and
t
WHO/HRH/NUR/92.3
page 3
deciding on the activities to achieve these within a specific time-frame. Plans show the main lines of
action to be taken, by whom, and when. Planning takes into account traditions, customs and the
available and future resource requirements. Resources in the health system most often are people,
information, funds, supplies and equipment, and facilities. A programme is an organized aggregate of
activities for achieving objectives. Setting standards is determining normal resource requirements and
acceptable costs for an agreed on level of performance and the desired quality of health care. Setting
standards involves obtaining expert opinion, the local experience of people, and the general consent of
practitioners. Administering primarily involves allocating resources, delegating responsibility, and
supervising others. Without getting lost in semantics, it is important to note that, for many, the terms
"administration" and "management" are interchangeable. However, the prevailing preference and
therefore the one for this report is to use "management" and "manager" to denote the position and person
engaging in higher and broader strategic activities, and to have "administration" and "administrator"
denote the position and person taking part in the more narrowly focused operational activities entailed
with allocating resources, delegating, and supervising.15 Ensuring information flow is promoting
communication and obtaining reliable and timely factual data about the performance of people,
programmes, organizations, and policies to judge whether goals and standards have been reached.
Budgeting and accounting is estimating for the future the income, cost, and output of resources.
Budgeting is a form of planning in which allotted resources are itemized for programmes and
organizational units so that these can be accounted for.
Personnel management involves deciding which personnel resources are required, recruiting and
selecting people, and designating their job functions through job descriptions. Rewards and disciplinary
action are also an important aspect as is strong leadership. Training and developing personnel involves
identifying the required education to ensure that people perform up to standard, then designing
programmes such as in-service training efforts or coordinating training in universities, and assessing the
results in terms of people’s development. Monitoring and evaluating is providing day to day oversight of
activities as well as more thorough in-depth assessment of people, programmes, and systems.
Evaluation for national health development is "the systematic assessment of the relevance, adequacy,
progress, efficiency, effectiveness and impact of a health programme."2 Coordinating is ensuring that the
many interdependent activities among the various categories of health workers, at the same and different
levels of the health system, are carried out without unnecessary duplication and in ways that are
generally considered effective, efficient, and equitable.2
Overview of Nurses’ Management Responsibilities
At the community and organization level, nurses in managerial positions design the organizational
structure of the nursing services designating lines of authority and responsibility. They assist in
determining policies that guide everyday practice. They engage in short-term planning activities focused
most often on obtaining personnel and information. Nurses at this level usually allocate personnel,
designating who will work where. They are responsible, too, for ensuring that people are supervised and
trained and that medical records are maintained. With strong technical nursing skills, nurses in lower
management positions are able to monitor nursing practice and assess the extent to which it meets the
standards that have been set When well-prepared, they also review budgets for nursing and coordinate
the activities of teams of personnel and people in communities.16
At the district level, management responsibilities are wider. For the purpose of this report "district"
signifies any country division such as a province or state. Well-prepared nurses at this level are involved
in determining the structure and policies for a number of units, in planning for longer periods of time, in
setting standards for a broader range of personnel and practices, and participating in the development
and critique of the budget plan for the nursing and other health services. There is also more coordination
of a wider variety of people and functions. Evaluation moves beyond the monitoring of daily individual
and unit performance to developing indicators to be used in programme evaluation.17 It should be noted
that in large, heavily-populated countries, management at the community or district level may be
comparable to management at the national level in smaller countries.
WHO/HRH/NUR/92.3
page 4
At the senior national level, nurses need more than technical nursing skill. Strong conceptual skills
are also needed, especially for strategic planning, for determining policy, evaluating, and coordinating.
There are three basic skills that every responsible manager of the health services must have - technical,
leadership, and conceptual.18 The level of skill for each depends on the level of management. Technical
skill for nurse managers is proficiency in the specialized techniques of nursing. Leadership skill is the
ability to understand and motivate people, to work effectively in groups, and to build cooperation.
Conceptual skill is the ability to see an enterprise as a whole and to coordinate all the many activities
towards a common goal. For lower managers, technical skill is the most important. For senior managers,
conceptual skill is. Interpersonal or leadership skills are necessary at all levels.19 Conceptual skill in the
health system includes recognizing the major elements in the system, understanding how each depends
on the other, and being able to visualize how the health services and community, and political, social, and
economic forces are related.
Definition of Leadership
Nurses in the health services must function as leaders. Leadership and management, while not one
and the same, nevertheless are closely linked.20 In 1988, Roemer said that nurses in management
should be leaders and that leadership requires, among other things, effective management.21 Christine
Hancock, General Secretary of the Royal College of Nursing in the United Kingdom, observed, "A health
service does not simply need management. It also requires leadership and leadership that considers first
the needs of customers."22
Leadership is moving people in the direction that is genuinely in their best long-term interest.23
Leadership is therefore defined for this report as moving people, services, and systems towards the
health for all strategy. The World Health Organization has described the purpose and skills of leaders in
the following terms:
"Persons in posts of leadership should have a comprehensive grasp of the processes involved in
developing and implementing the Global Strategy for Health for All. They should have a concern
for social justice, ability to communicate, courage to take risks and make bold decisions, and faith
in people’s ability to contribute to the improvement of their own health. They should be in a position
to motivate others and direct the national health development effort towards health for all."18
A basic assumption for this study was first, that all leaders, even those who are not in formal
management positions, to some degree, manage the activities of others because of their influence, and
second, that effective managers are also leaders because they motivate people, change systems, and
create fulfilment by holding people to their part in a common coordinated enterprise.24 Leadership varies
depending on the culture, time, and place.25 But leaders have more than technical skills. They also have
well-developed human and conceptual skills. Leaders are knowledgeable about people and their conduct.
They are visionary about the changes that are needed and motivate others to achieve. They build
community relations and are trusted. They are able to put their vision into words that others
understand.26 It is interesting to note that in some languages "leader" and "leadership" are the only
available terms to denote "manager" and "management."
Overview of Nurses’ Leadership Responsibilities
At the community level, leadership by nurses requires an understanding of communities and having
good working relationships that go beyond those required in the job. This would include showing concern
for people’s working conditions and for the living conditions in a community. A good track record and
reputation are also needed to engender trust, as are intellectual and interpersonal skills.27
Providing leadership in district coordination involves giving people guidance and consultation,
teaching workers when referring problems to higher authorities is best, providing training, and helping
others understand why reports are necessary. It involves correcting mistakes, giving encouragement and
inspiring others to do good work. Any successful leadership depends on the recognition and acceptance
of the community.
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In senior management positions at the national level, a broad understanding of people, health, and
health care is required. National leadership demands a broad set of solid relationships, an excellent
reputation, a keen mind, and strong interpersonal skills. In addition, leadership at the national level
requires a strong sense of social justice and sufficient judgment to participate actively in determining
health policy and formulating legislation in support of the policy.23
Nurse Managers and Leaders:
Problems, Functions, and Skills
The American statesman, John Gardner, in his analysis of leadership, described Nightingale as a
"rugged spirit... a systems changer... a formidable authority on the evils to be remedied ... (who) knew
what to do about them and ... used public opinion to goad top officials to adopt her agenda."28 In the
present, Dame Nita Barrow, Governor-General of Barbados, is another nurse leader of great stature.
Dame Nita recently stated, "managerial or technocratic approaches alone will not get us to our goal ...
Primary health care must become a social movement... and such social movements demand leadership
at all levels."29
In national ministries, leadership is needed to formulate realistic human resource development plans,
to improve working conditions, to reduce the costs of hospital services, and to assist in coordinating the
work of governmental and nongovernmental agencies. According to the World Health Organization, the
greatest management deficiencies in ministries of health are in personnel administration, budget and
finance management, and information systems. Other problems include rigid bureaucratic structures, the
less than adequate management training of those in positions of authority, top-heavy administrative
frameworks, and the unequal distribution of resources. Joyce Kadandara, Director of Nursing Services in
the Ministry of Health, Zimbabwe, discussed the problems of a country organizing its health care
infrastructure from scratch. She described limited resources, increasing demand, rising costs, and high
rates of personnel turnover. She also discussed inequities noting that nurses carried the heaviest
workload and yet were the lowest paid.31 In her view, the major problems requiring national leadership,
were the subservient role of nurses, nurses not being sufficiently assertive, a lack of clear direction in
nurses’ education, and nurses’ lack of academic attainment. Kadandara emphasized nurses’ expanding
role. She stressed the importance of needs assessment and financial management.
"The move is towards nurses becoming totally involved in carrying out executive functions at all
levels of the health care system in Zimbabwe. Their role on the executive team is not only to look
at the health activities per se but to give management support. This entails an in-depth assessment
of the needs of their area of responsibility, ranking these needs according to priority, soliciting for
funds and expertly handling financial management and control."32
Nalini Patel33 described some of the major problems for the health services in India, namely, the
shortage of well prepared nurses and poor personnel management. Few opportunities for promotion, the
failure to make appointments to positions, and a lack of incentives are among the main personnel
problems. Patel also stated that nurse managers, even those in relatively high positions, are not always
involved in planning and determining policy.
The problems of pay inequity, poor working conditions, nurse migration, and changing health
systems have been discussed in developing and developed countries in the Americas, Europe, and the
Western Pacific. Janice Kopinak34 at the University of Toronto, Canada, described the problems in a
provincial health system and nurses’ low salaries. In Hungary, Katalin Mucha35 and colleagues identified
health system problems, particularly that the organizational structures vary greatly in the country’s health
institutions and some chief nurses lack the formal authority for nursing. Erlinda Ortin36 Chief Nurse,
Training and Education Division, University of the Philippines and Philippine General Hospital, described
the "brain drain" of nurses in her country where about 60 percent migrate, primarily to the United States
and resource-rich Arab countries. Skillful nursing leadership is needed to analyze and shape the
country’s labour export policies to ensure an approach that balances national and international
requirements. Gillian Biscoe, with the Department of Health, New Zealand, addressed the reorganization
of the national health system, strategic planning, and efficiency. According to Biscoe,
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"To rise to the challenge of leadership in health towards the next century requires ... that nurses
be strategic, focus on results, encourage and value risk taking, be future oriented, (and) always
come from an open systems perspective. And in general always have a mindset of "can do" and
not "can’t do.”37
Sally Shaw,38 a general manager, also at the New Zealand Department of Health, listed several core
functions for senior nurse managers: engaging in policy, planning and resource allocation; having
responsibility for nursing personnel and industrial relations; and monitoring and evaluating nursing
standards. The managerial characteristics that Shaw emphasized for national leadership included
creativity; commitment; sound judgment; being decisive and willing to try new things; being tenacious;
having experience in service, teaching, and management; and understanding personnel and consumers.
In communities and hospitals, leadership skill is required to improve the quality of administration,
personnel management, and budgeting. Nurses are needed who can work locally with community health
workers and delegate tasks to other less costly personnel. Helen Awasum,39 at the University of
Yaounde, in her discussion of the health system and nurses’ leadership in Cameroon, noted that nurses
often delegate direct care to lesser trained workers without carefully matching people’s needs and
workers’ competencies. She reiterated the importance of nurses orienting their leadership to primary
health care to ensure that manpower development and coordination of health activities are
population-based.
Education, Research, and Theory for Nurses’ Leadership and Management
To ensure that nurses have the required skills to address the problems in health systems and to plan
and implement countries’ health activities, improved academic and on-the-job training is needed. Ohlson
and Franklin40 in a landmark report on international nursing emphasized population-based nursing
education and the importance of preparing nurses for leadership and management. Basic education is
necessary to ensure that nurses understand how to encourage community participation and enhance the
performance of local health workers. Training in basic administration and leadership is required to ensure
that nurses at lower management leadership levels in hospitals plan for small groups of co-workers and
supervise teams of auxiliary workers.41 Advanced management education is needed at the post-basic
and university levels for nurses who will move to senior positions. These programmes should be
comprehensive, based on sound theoretical and empirical bases, and yet also practical.42 In a study of
senior nurse managers in Norway, the greatest demands were balancing resources, setting goals and
planning, and keeping on top of a large set of activities. A major recommendation for the future
education of nurse managers was to draw on knowledge in nursing, organization science, health care
finance, information science, and personnel management.43
Mary Jane Seivwright44 of Jamaica, provided a helpful road map describing how to develop nurses
as leaders. She listed ten knowledge and skill areas for basic nursing education. These were health
assessment, clinical nursing, holistic care, basic management, research and epidemiology, leadership,
community organization and mobilization, primary health care, macro and micro planning, and policymaking. In her perspective, future leadership requires people who have a well-rounded general academic
education, are committed to serving others, are self confident, display good communication and
interpersonal skills, and are oriented to group and community action.
The recommended subject content in the United States for nurses’ studying management includes
motivation, leadership, communication, change, conflict, employee appraisal, delegation, staffing and
assigning personnel, and group dynamics.45 The recommended content for nurses’ middle level
management in university masters level programmes includes health systems, research methods, health
policy, budgeting and health care finance, personnel management, organizational behaviour, and ethics.46
Wagner47 and colleagues did an analysis of nursing management education in the United States to
describe the curriculum content, programme structure, and instructional placement. An increasing
emphasis on information systems was found but there was almost no mention of international health.
Multidisciplinary studies and practicum experiences for students were recommended. For doctoral
WHO/HRH/NUR/92.3
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education, content focusing on national health systems, health economics, personnel administration,
research methods, and public policy analysis are recommended.
Ruth Harnar48 and colleagues at Aga Khan University analyzed the problems for nursing in Pakistan
including the nursing shortage, the image of nursing as a menial occupation, and the role of Pakistani
women. In addition to the difficulties in recruiting nursing students, the general educational backgrounds
of students are often poor. The lack of faculty and facilities is also a problem. However, staff
development programmes have helped nurses to pursue higher education in Canada and Wales.
Management teams have also been developed in some of the health services and attempts are being
made to bring nursing and medical students together in classes and field experiences.
One criterion for judging a country’s progress in health care is the extent to which curricula are
adapted to the country’s health needs and primary health care. An exemplary programme to prepare
nurse managers is the interdisciplinary one at the University of Kuopio, Finland where nursing practice,
management, and health policy are integrated.49 Robinson50’51 and colleagues in the United Kingdom
provided several analyses of national health policy and the implications of these for nursing. Jean
Nagelkerk52 and David Warner53 in the United States discussed policy research and nurses’ leadership.
Judith Clift54 described nursing and the health services in Austria and the effort to move nursing
education to the university. Health needs; the operating systems of health, education, and government;
and the level of nursing practice, are all factors in institutionalizing higher education for nurses.
In 1988, Roemer3 recommended that a broad professional doctorate in the management of health
systems should be developed, built on a basic foundation of professional nursing education. The goal of
the doctorate would be to prepare leaders with knowledge about health problems, health promotion, and
the health services. The four fields of knowledge were:
1)
2)
3)
4)
basic tools of social analysis
health and disease in populations
promotion of health and prevention of disease
health care systems and their management.
Several of the subjects, in the category of "Basic tools of social analysis," included population and
demography, biostatistical techniques, population sampling and surveys, programme evaluation, political
science of health systems, and principles of health economics. Subjects for "Health care systems and
their management" included national health care systems; workforce development; population-based
health planning; budgeting, cost controls and financial administration; health legislation and ethics;
comparative international health systems; health systems research; and records and information
programmes.
Information systems have been especially emphasized for nursing management education and
research in the United States and Europe.55,56 Priority research topics and methods in regard to health
information have been described by the European Regional Office of the World Health Organization in the
following statement:
Because adequate information is a prerequisite for making decisions on health policy and for
evaluating the existing health system and any structural changes in it, studies are urgently needed
to determine the gaps in the information needed ... The next task for research is to build up more
detailed and comprehensive information systems ...57
Grobe in the United States recommended that education and research is needed in nursing
management to improve understanding of how data and information can contribute to solving problems
and how information should be processed. "Nursing informatics is the application of the principles of
information science and theory in the study, scientific analysis, and management of nursing information
for purposes of establishing a body of nursing knowledge."58 Taking an informatics approach to the
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development of a knowledge base for nursing management, Heyden59 is developing a lexicon and
taxonomy of terms as a basis for the development of future theory and research.
Nursing management research can best be understood in the context of health systems, health
services, and nursing research. Health systems research focuses on the entire system or a part of it. 2
Health services research deals with the health services component of the broader health system.2
Nursing research addresses people’s health needs for nursing care and the results of nursing
interventions. For this report, nursing management research is scientific work that focuses on the nursing
service component of the health services and system and its effect on people’s nursing needs and
nursing care. Henry and colleagues, using national interdisciplinary panels in the United States, defined
nursing management research as:
"concerned with establishing the cost of nursing care, with examining the relationships between
nursing services and quality patient care, and with viewing problems of nursing services delivery
within the broader context of policy analysis and delivery of health care services."60
An analysis of nursing management research in the United States by Hermansdorfer61 and
colleagues showed that the problems most frequently addressed were evaluation of care, job satisfaction,
nursing productivity, interorganizational relations, and patient acuity. Nearly half the studies were
cross-sectional and descriptive. The theories used most often were motivation, role, decision making,
leadership, communication, and conflict. An analysis of nursing management studies conducted in
countries located in all world regions found that the main themes pertained largely to personnel
management. Cost-benefit or cost effectiveness analyses were not found and few studies involved
people in communities. Three-fourths of the studies were exploratory or descriptive and several were
programme evaluations.62
A programme evaluation conducted in Nigeria63 by a team of nurse researchers from Nigeria,
Switzerland, and the United States was undertaken to assess the effectiveness of a primary health care
project. The study demonstrated that nurses can plan, implement, and evaluate a project for primary
health care with comparatively few resources. Una Reid64 described a useful economic model for nurse
manpower development in the Commonwealth Caribbean. Jung-Ho Park65 at Seoul National University,
Republic of Korea described how research is integrated in the nursing curriculum. Park also discussed
the university’s course content for nursing leadership. These included administration, professional
adjustment, and leadership.
In summary, it is widely held that nurses’ management and leadership is required in the health
services but that these should be strengthened to assure that nurses assume their share of the
responsibility for overcoming the seemingly intractable problems that stand in the way of achieving health
for all. Leaders and managers are needed who can motivate and stimulate the required changes
including those involving new regulation and legislation and to reorient nursing practice, education, and
research. Judging from the literature, some progress in preparing nurses for their management
responsibilities has been made. However, health systems and the health services cannot be effective
without nurses’ fuller participation at every level, including the national. A purpose of this study was to
provide direction for future activities designed to strengthen the nursing potential.
*
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SECTION 2
Methodology and Participants
The study was broad and general. The goal was to understand some of the key variables in
sufficient depth that generalizations could be made about the differences and similarities in nurses’
management and leadership in a variety of contexts.
Method
The study was an exploratory survey using a mailed, self-administered, 15-item questionnaire with
open and "Yes/No" questions. The questionnaire was sent to selected nurses in leadership and
management positions in Member countries of the World Health Organization’s six regions. These
countries belong to four development groupings.
Pre-Study Procedure
In February 1990, a preliminary version of the questionnaire was sent to the 1988 conference
contributors and to ten other experts who were asked to critique its clarity and content. They were asked
to nominate individuals with the expertise required to complete the questionnaire. The final version of the
questionnaire is found in Annex B.
Sample
A sample list of prominent nurses, physicians, managers, and public health specialists in countries in
the six WHO regions was drawn up. To be included, a nominee met at least two of the following five
criteria. He or she was:
1) A manager of a nation’s leading health care institution such as a university school, hospital, or
primary health care unit
Employed as an educator or researcher and instrumental, at least at the national level, for
improving knowledge of the management of health services
3) Identified as an expert by WHO for consultation or leadership
4) Published in international journals
5) Involved in a national leadership capacity.
2)
In many countries it was difficult to identify individuals, especially outside nursing, who were well-versed
about nurses’ management, could read and write English, and were willing to take the time to share their
ideas. Therefore, the sample was obtained using non-probability selection. It was decided to gather
explorative information and then exercise all due caution when making inferences. The investigators
made the final decisions about participant selection to achieve adequate representation using the criteria,
and the distribution of nominees by professional field, country, region, and development grouping.
The observational unit of analysis for data collection was individuals describing nursing management,
education, and research in their countries from the fields of nursing, medicine, management, and public
health. These are the fields where people are usually most knowledgeable about the health services and
nurses’ management activities. A consistent attempt was made to identify potential participants outside
nursing and to have these individuals account for one-fourth of the final sample. The explanatory units of
comparison were regional and country groupings. The six WHO regions are Africa, the Americas, the
Eastern Mediterranean, Europe, South East Asia, and the Western Pacific.
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The four country groupings were: least developed, developing, Eastern Europe, and developed.
The investigators sought to include participants proportionate to a region’s and group’s number of
countries and population. But problems arose where a high number of nominees could not be identified
for countries with large populations, for example the Russian Federation and China. English language
competency was also problematic as an inclusion criterion, especially for the developing countries of
South America and for Francophone Africa.
Participants
Of the 330 people invited to participate from 119 of the 167 WHO Member States, 172 (52%) from
76 countries responded with usable questionnaires. For an international study with a heavy respondent
burden and open questions, 52% was judged as a better than average rate of return. The primary
professional field and the distribution of the 172 participants by their field was nursing (n=137),
management (n=16), public health (n=13), and medicine (n=6). Nurses were a substantial majority for all
regions. The primary roles of the respondents were administrator (n=73), educator (n=70), government
official (n=16), researcher (n=11), and roles obtained by election (n=2).
The distribution of the respondents by their country and the six WHO Regions was: Africa, 21
respondents from 17 of 45 countries; Americas, 21 from 12 of 34 countries; Eastern Mediterranean, 10
from 8 of 23 countries; Europe, 62 from 24 of 34 countries; South East Asia, 33 from 7 of 11 countries;
and Western Pacific, 25 from 8 of 20 countries. The largest number of participants was from the
European region which is the third most populous of the six regions. The fewest were from the least
populous Eastern Mediterranean region. More detailed information showing countries involved and
participant distribution by field, role, country, region, and development grouping are in Annex C.
The distribution of the 172 participants by their countries’ grouping was: least developed, 17 from 15
of 41 countries; developing, 82 from 34 of 90 countries; Eastern Europe, 4 from 3 of 9 countries; and
developed, 69 from 24 of 27 countries. At the time of the study, the World Health Organization
unofficially classified 131 of its 167 Member States as developing countries.66 The groupings are based
on social, economic, and political indicators. Therefore, the designations are not static, and there are
wide variations within each grouping just as there is regional variability.
Data Analysis and Validity
Data were entered manually and through optical scanning into computerized data files by survey
item and professional field, country, region, and development group. An initial analysis to discover
patterns and relationships was carried out by the three investigators working separately and then
together. This was validated by an independent expert. The responses were categorized separately and
together to reach 90% inter-rater agreement about the analysis. Throughout, the goal was to describe
the data using the most logical categories for each of the survey items. Where forced choice "Yes/No"
responses were obtained, the numbers in each category were summed by region and development
group. For narrative responses, logical categories were sought in the data, for example, the first question
asked about the senior leadership positions for nursing in a country’s organizations, communities,
districts, and national government. Categories of positions were developed by world region and group
showing the kind of positions as described by respondents, in organizations, communities, districts, and
at the national level. Another question asked how nurses were involved in planning and policy-making at
the community and national levels. For this, responses were categorized as planning in communities,
planning at the national level, policy-making at the community level, and policy-making at the national
level. Some of the categories used to structure the content in the 1988 work were also used as a logical
common framework. For example, Roemer’s categories of knowledge were used to cluster the education
subjects, as were the five types of research. With respect to the regional and development groups,
usually only one or the other of these analyses was selected for presentation to keep the report a
reasonable length. Participants’ narrative responses were selected for inclusion to improve the study’s
semantical validity from the content analysis, and were selected for region and groups that 1) represented
the array of concerns in the data, 2) summarized some of the most frequently expressed ideas, or 3)
addressed a unique idea that few others had mentioned.
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To further enhance validity, a preliminary copy of the study report was mailed to all participants for
their judgment and feedback. A review form asked for 12 "Yes" or "No" responses with comments about
the clarity, logic, completeness, or correctness of the major elements in the report. Two open questions
asked about the report’s strengths and weaknesses. Additional suggestions to improve the validity and
usefulness of the report were sought in a final item. A total of 76 (44%) reviews were returned by March
1992. This response rate (which was judged reasonable for the time-intensive evaluation) and the overall
positive feedback, precluded follow-up of non-respondents. The recommended changes were made in
the report as appropriate.
Study Strengths and Limitations
The practical and scientific need for comparative international nursing research is great. From a
practical point of view, nurses move among countries and regions. Economic upheavals in one part of
the world have an impact on the health needs and services of people in other parts. The globalization of
health problems and scarce resources makes the need for comparisons a social, economic, and political
reality. Moreover, broad comparative sweeps are appropriate for fields at the first stage of scientific
development, which is the case for nursing.67 A strength of this comparative international study is that a
number of patterns and several major variations were identified. Many studies described as international
deal primarily with developed countries, whereas countries from all world regions and levels of
development were included in this project.
♦
The investigators are aware of the many problems in doing international work, they realize that
comparative studies are different from other research and therefore chose of necessity not to be
paralyzed by the requirements for conceptual equivalence and experimental control. Judgments and
compromises were consciously made believing that this exploratory effort could provide useful, new
insights. Theoretical foundations to extend the scope of knowledge are needed in nursing based on
comparisons that show patterns and relationships. A goal in the study was to begin to discern patterns of
nurses’ managerial activity, responsibility, and skill and the relationship of these primarily to the required
education at three levels. For the ease of comparison, generally three geographic and three educational
designations were used. These were community (and organization), district, and nation; and basic, postbasic, and university. It should also be noted that in some countries post-basic nursing education is in
universities. For ease of comparison, post-basic education was equated to intermediate or masters level
university education, and high-level university education to the doctoral level.
Cautious and conservative approaches were taken throughout the analysis because of the study
limitations. Although criteria for inclusion in the network sample were used, the results are not
representative of nurse leaders and managers globally and over time. Second, the survey was written in
English and the burden on respondents to read the chapter and respond to open questions was heavy.
But by having respondents read and react to a single document, a common frame of reference was
provided and this was a strength. However, in the process, participants may have been biased by the
terms, the way they were used, and the main emphasis. Third, countries in the groupings, although
having some features in common, are by no means homogeneous. The groupings were used as logical
and convenient categories to facilitate the comparisons.
A final word should be added about the terminological difficulty with "management" and
"administration." As noted, the two terms are sometimes used interchangeably not only by lay people
and practitioners, but also in scholarly fields. In the field of public administration, for example, the
difference between the terms is acknowledged as imprecise. The reasons for the differences are
generally unknown beyond personal preference. In some countries, "management" denotes high-level
functions, for example, in the United Kingdom. While in others, for example, in the United States,
"administration" is used to signify higher level functions and "management" the lower or more operational
ones. For nursing in the United States, the term "nursing administration" continues to denote higher level
executive functioning, and "nursing management" is used as a more limiting concept to describe lower
level activities. The International Council of Nurses defines "nurse managers" in yet another way, as
those who are responsible for the standards of nursing practice. "Nurses in general health management"
denotes those who move beyond nursing into general health management.68
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To resolve some of the confusion with the different usage of these terms, "management" and
"administration" in this report have been used as defined by the World Health Organization. Nurse
manager refers to all nurses in managerial positions at the lower (organization, community), middle
(district), and senior (national) levels. The term denotes those who manage the nursing services as well
as those who have a broader range of health service responsibility. The authors tried to be consistent in
the use of these terms throughout.
Organization of the Report
The study findings are described in four sections: Sections 3 through 6. In each of these, the
findings are analyzed using the following study questions to guide the presentation.
Section 3. What are the senior leadership positions in nursing and what are the main functions?
What are the characteristics of nurse leaders? How are nurses at various levels involved in planning and
policy?
Section 4. What are the major problems for nurses in management positions? What actions are
suggested to overcome these?
Section 5. What is the nature of basic, post-basic, and university education for nurses’ management
and how can it be enhanced?
Section 6. How are nurses trained for research? What are the high priority research topics and
methodologies? What are the recommendations to improve nursing management research? What
theories may be most useful in guiding developments in nursing management?
A major question was: How do the problems, functions, and education for nurse managers
compare throughout the world? That is, how are they different and how are they similar? Therefore, in
Sections 3 through 6, the findings are presented and analyzed, for the most part, by comparing
responses from region or country groups. In each section, a number of patterns are highlighted and the
presentation closes with a summary of the main findings.
In the final Section 7, inferences are drawn, conclusions are reached, and recommendations are
made. Throughout, the major themes are related to the functions of nurse managers as well as to the
complexity of the problems they face in health systems.
♦
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SECTION 3
Nurses in Leadership and Management
Participants first described the senior leadership positions for nurses in the organizations,
communities, districts, and national governments of their countries. Next, they indicated if there was a
chief nursing officer in the national department or ministry of health, and if so, they described the main
functions. Two final questions concerned the characteristics of nurses in leadership positions and nurses’
involvement in planning and policy-making.
Nurses’ Senior Leadership Positions
Examples of positions in organizations included senior staff nurse, charge nurse, head nurse, nurse
supervisor, chief nurse, member hospital board of trustees, director of school of nursing, and nurse
teacher or tutor. Examples of positions in communities included community health centre nursing officer,
community chief nurse, community nurse inspector, director for primary health care, community chair of
rural management board, and director, home health care nursing. Positions in districts included member
of district health team, district nursing officer, district senior health visitor, chief nurse regional sector,
policy advisor for the provincial ministry of health, and state nursing officer. Examples of positions in
national governments included chief nursing officer in the ministry of health, national health board nurse,
director general of nursing, assistant surgeon general, controller of examination board, director of primary
health care, director for human resources, manager for training, nursing research director, deputy
president of the trade union for health service workers, and national planning board nurse. Other
positions included president of national and state nurses’ associations, president of nursing education
associations, and editor of professional journals.
Several differences in positions were apparent for the least developed and developing countries as
compared to the developed and Eastern European countries. The first was the higher frequency with
which nurse supervisor, head nurse, charge nurse, and staff nurse were mentioned in the former, but less
so in the latter. Moreover, for the least,developed countries it appeared that although many may have a
nurse in the ministry of health, there are comparatively few other nurses in positions-of national
leadership. A second difference pertained to the more frequent mention of senior leadership positions for
primary health care in the developing countries. Third, political restructuring activities were described in
Eastern European countries, as was nurses’ leadership in trade unions. Fourth, the problem of nurses in
advisory positions, rather than in positions with formal line authority, was addressed by some respondents
from developing countries but more often by those from the developed.
Functions of Chief Nurses in National Ministries.
A chief nursing officer in the national government was described by participants from 60 of the 76
countries. In the least developed countries, the functions of administrator, personnel manager, trainer,
and coordinator were described most often. Mentioned less often were determining organization
structure, policy, standards, information flow, and budget. Reports of planning functions usually focused
on personnel. Some mention was made of planning for nursing practice and education and for the
training of local women. Administrative functions included allocating financial and human resources for
the nursing services, delivering diplomas and licences, conducting interviews, and supervising
subordinates. Although determining policy was mentioned less often, occasional comments related to
monitoring legislation and representing the ministry to nurses and nurses to the ministry.
In the developing countries, a greater variety of functions was described. Determining the
organizational structure of health services was mentioned by several. Involvement with determining
policy was discussed by some as understanding the view of the nation about health, developing
legislation, and formulating health programmes. Planning functions most often pertained to nursing
WHO/HRH/NUR/92.3
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personnel, health programmes, nursing practice, and nursing education. Although little specific mention
was of budgeting, an occasional person described the importance of understanding cost effectiveness
and the quality of care. Understanding norms and setting standards was mentioned by several as were
the functions of compiling statistical data and managing personnel recruitment and deployment.
Comparatively few comments were made on functions related to information flow, evaluation, and
coordination.
For the Eastern European countries, the functions mentioned most often for nurses in national
ministries pertained to planning for the nursing workforce, nursing education, and personnel development.
Several comments also described developing and submitting proposals to the ministry and ensuring
nurses’ participation in health for all policies. Setting standards was mentioned, as was monitoring the
quality of nursing services and education. Evaluation functions were discussed in terms of assessing the
health service experience of other countries for comparative purposes. The functions discussed least
often were determining organization structure, ensuring information flow, budgeting, and coordinating.
From the developed countries, the function of determining organizational structure, although rarely
mentioned, was discussed by several in terms of developing nursing services for primary health care.
Several also mentioned determining policies, developing projects, providing expert advice, and lobbying
for health care legislation. Planning functions pertained to the organization of a health service, nursing
personnel, nursing research and education, and to international relations within Europe. Setting
standards was mentioned, as were the administrative functions of personnel supervision. Information flow
was discussed primarily in terms of publishing to disseminate information. Functions related to budgeting
and accounting were not found. Several coordinating functions were described, including that of councils
to provide national advisement, and linking regional and national levels of the health services.
Characteristics of Successful Nurse Leaders
Respondents were asked to describe the characteristics of nurse leaders that contribute to their
success in the operation of institutions and determining health care policy. The characteristics mentioned
most often by those from the African Region were "educated" and "highly experienced" as nurses and
managers and being "committed." Strong communication and interpersonal skills were mentioned next
most frequently. Several respondents mentioned being well-connected, assertive, ambitious, and
charismatic. Other characteristics included being respectful, patient, positive, creative, diplomatic, and
actively involved in the national nurses’ association or community. This comment was made about
diplomacy and the role of women:
"Due to the subservience of women in this country, they are extremely diplomatic and do a great
deal of personal lobbying to prevent open confrontation."
Characteristics that pertained more to the operation of institutions included being qualified to organize
seminars, assuming responsibility in the absence of doctors, and being qualified as a nurse or midwife.
Characteristics that pertained more to determining policy included being informed about health policy,
health structures, and nursing throughout the world; having political skills to negotiate and lobby; and
engaging in network building activities.
Being educated and knowledgeable about nursing and management was mentioned most often by
nearly all respondents in the American Region. Respondents from more than half the countries
discussed masters or doctoral level education. The fields for the degrees were nursing, public health,
and management. Having extensive networks and political connections were characteristics described
second most often by more than half of the participants, as was being intelligent, articulate, and clear.
Although native intelligence and academic preparation at the masters or doctoral level were widely
endorsed, several made comments such as:
Unfortunately compliance and subservience are essential for formal hierarchical promotion and
position security. This often results in the exploitation of nurses ... with the end result of inadequate
WHO/HRH/NUR/92.3
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and unequal provision of health services and an emphasis on curative approaches with minimal
attention to preventative or ameliorative services.
Other characteristics mentioned at least once included commitment, being respectful, honest, visionary,
energetic, and personable. On the importance of information systems for determining health policy, one
person indicated:
Still lacking to a large degree is the recognition that nursing contributes little towards policy
development without seeing to it that nursing care and resources are documented, computerized,
and readily retrievable on an ongoing basis so health policy can be influenced.
The characteristic skills that pertained more to the operation of institutions included having technical and
scientific confidence and being able to work with multidisciplinary groups. The characteristics relating
more to determining policy included being able to obtain information about health policy and the macro
system; being involved in top-level health policy planning, budgeting, and evaluation; and being
visionary and active nationally in professional associations in a variety of fields.
Being educated was also mentioned most often by those from the Eastern Mediterranean Region.
But respondents from three countries expressed these concerns:
There are no defined characteristics to Ministry of Health policy makers. Nurses are helpers for
doctors.
A problem is limited educational preparation. The majority were appointed to their positions through
seniority, their education does not exceed a diploma degree in nursing.
The status of nursing in the country is low. Even those in top positions have not been able to win
respect, in general. The leadership posts that have been filled have older nurses who have not had
the opportunity to keep abreast of developments.
Several of the characteristics mentioned at least once included being decisive, assertive, able to
negotiate, plan, and build networks. The characteristics that pertained more to operations included being
able to deal with both diploma and baccalaureate nurses, having experience in nursing and management,
and leading the health care team. Characteristics that related more to policy included being able to
bargain, and having a sound knowledge of nursing in the country, and acting as a national and
international spokesperson for nursing.
Being educated and prepared for leadership was the characteristic mentioned by more than one-third
of those from the European Region. Although higher post-basic and university education was referred to
frequently, masters level preparation was mentioned by participants from only one-fifth of the countries
and doctoral education by the respondents from three. One person in the field of management made the
following comments about the characteristics of nurses’ education.
Previously nurse leaders’ education concentrated on the micro level of management (personnel
management, etc.). It did not include the scientific basis of nursing or a macro level health policy
orientation. Therefore, our nurse leaders lack the knowledge, skills, and attitudes to really "lead"
nursing and to influence health policy making in any significant way. Nurse leaders are very much
withdrawn from policy making at all levels.
Building and maintaining wide networks to provide resources was mentioned second most frequently.
Being competent in nursing and management, having political connections, and strong communication
skills were also described. Being able to bargain and negotiate, being creative, open, and having vision
were each mentioned by at least four respondents. Other characteristics identified by one or more
included decisiveness, commitment, optimism, persistence, and adaptability. Stamina, common sense,
patience, integrity, intelligence, diplomacy and respect were also mentioned. A few described their
WHO/HRH/NUR/92.3
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concern about the relatively little emphasis on primary health care. One from the field of management
said:
The few nursing leaders I am thinking of are open minded, have been in other countries, are
involved in professional associations ... But most of them are too much hospital oriented.
Commenting on nurse-doctor relations and medical delegation, another said:
Nurse leaders in general are doing fairly well. However, there is a lack of willingness on the part
of physicians to delegate to other professions and a clear tendency to recapture the leadership
once taken by nurses.
The most frequently mentioned characteristics by those from the European Region, related more to the
operation of institutions, included implementing new management approaches and being able to adapt to
new organizational structures. Those pertaining more to policy included having broad power bases, being
internationally active, and advising national ministries.
As for all other regions, nurse leaders were described by at least half the participants from the
South-East Asia Region as being more highly educated than others. Masters and doctoral level
education was described by those from three of the seven countries. But the problems with nursing
education were apparent from the following:
Their status is much below their counterparts in medicine. Their knowledge and experience in
nursing contribute to their success but their low position is a hindrance. At the state level there is
no uniform pattern of qualification for these positions. Their low rank and inadequate educational
preparation adversely affects their functioning.
Experience in nursing and commitment and devotion were mentioned by nearly half the respondents.
The importance of strong interpersonal skills and networks was discussed by several, as were high
socioeconomic status, creativity, openness, decisiveness, optimism, and the ability to communicate and
collaborate with people in other disciplines. The characteristics relating more to operations included
taking daily responsibility. Those pertaining more to determining policy included being able to link higher
authorities and organizations and having plans to strengthen the nursing component of the health
services.
Being well-educated and knowledgeable were the characteristics mentioned most frequently by
nearly half the respondents from the Western Pacific Region. Advanced university education was
described by people from seven of the eight countries. Nursing and management experience,
intelligence, communication skills, and commitment were mentioned with equal frequency. Morality and
faith, optimism, being energetic and well connected socially were each mentioned by several. A
participant from the field of management added: "Breadth of vision and awareness of the legitimacy of
claims of all health professions" as a characteristic. The characteristics pertaining more to daily
operations included structuring organizations, hiring qualified people, and using nursing modalities that fit
with the organizational philosophy. Those pertaining more to determining health policy included setting
the goals for nursing in the context of the national health plan and cooperating with others with high-level
responsibility for health policy.
Nurses’ Involvement in Planning and Policy-Making
When asked how nurses were involved in planning and policy-making for health services at the
community and national levels, participants from about one-third of the least developed countries
described little or no activity. Some said that nurses were involved, but only indirectly. One stated:
Nurses participate indirectly in the planning and policy-making for health services by filling out forms
for the Ministry of Health which carries out data collection from time to time at the community level.
But they usually don’t know how this information is used. Nurses are, however, never involved at
WHO/HRH/NUR/92.3
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the highest level of planning since there is no important position available to them at the Ministry
of Health.
However, one person said, "At the national level, nurses in special programmes plan along side other
members, doctors primarily." And another commented, "The Chief Nursing Officer participates fully at the
central level to unify plans and prioritize activities." Community planning activities included working with
local and district health teams. National planning activities were for the schools of nursing and for
evaluation of primary health care. Policy-making in communities entailed filling out reports for the ministry
of health and being involved with political parties. Policy activities at the national level included
participation on policy-making committees, drafting curricula and nursing regulations, and conceptualizing
the standards for the quality of nursing services.
From the developing countries, one-fourth of the respondents discussed the involvement of a few
highly placed nurses, the activities of national nurses’ associations, and nurses’ work with local health
committees. But those from seven countries reported little or no involvement by nurses in planning and
policy-making and two described the following:
Only the nurses at the Ministry and in the provincial services are often invited by the medical
doctors and civil administration to participate in formulating policy for health. They are indirectly
involved because their bosses often solicit their opinions which may or may not be retained.
Nurses at the community level are always consulted and take part in the technical aspects of
planning and decision making. Those at the regional and national level continue to be involved in
technical work and participate more in interdisciplinary groups which have less decision making
power with respect to nursing but are more political in nature. The administrative structure of health
services is rigid and government budgetary problems have prevented an increase in job positions.
Consequently, there is little personnel rotation and limited innovation in the health services.
Community planning activities included working with local people for primary health care and serving as
members of community health development committees. When developing policies in communities,
nurses collect and analyze data and serve as members of district executive committees. At the national
level, nurses are involved with planning and evaluating health care programmes. For national policymaking, nurses in some developing countries serve as consultants to the ministry of health and as
members of health boards, national health councils, and nursing standards committees.
Two responses from Eastern Europe were:
Regretfully until now they have always been neglected and their problems have been dealt with by
managerial staff - physicians, pharmacists, economists, who have not been familiar with the
specifics of our profession.
Our country is undergoing deep changes. In order to meet its requirements, nursing badly needs
well-prepared leaders for planning and policy-making for health and nursing services.
The participants from Eastern Europe reported that nurses were involved with planning committees in
communities depending more on their personalities and skill than by official designation. A reason given
for the limited contribution of nurses to planning was in terms of their "unfamiliarity with planning
techniques."
Respondents from one-fourth of the developed countries reported that there was almost no
participation by nurses in planning and policy activities especially at the national level. Those reporting
little or no involvement made comments similar to this.
No nurses are involved in planning. The whole area of strategic planning is very underdeveloped.
The national health policy council, which is to ensure that the several authorities that render health
services shall take all measures to promote health ... is made up of white, male doctors.
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People from nine developed countries described a moderate amount of involvement and those from three
described a fairly substantial amount, including nurses’ election to national political offices and providing
lobbyists to monitor legislation. Involvement in community level planning is through membership on
senior management committees, hospital boards, and with community and city councils. Involvement in
community policy-making is through committee memberships, as civil servants, members of political
parties, and trade unions. Nurses are involved in national planning and policy making as advisors to
elected and appointed government officials, as managers in national health ministries, and as consultants
to national boards.
In summary, for the 76 countries, 60 have nurses in the national ministry of health. Examples of
positions in national governments include chief nursing officer, national health board member, controller of
the examination board, nursing research director, and director of primary health care. Even though there
are more chief nursing officers in the national ministries in the least developed countries, fewer senior
leadership positions overall were described than for the developed countries. Variations were also noted
with respect to the main functions of the chief nursing officer. In the least developed and developing
countries, the functions of administrator, personnel manager, and trainer were more apparent. In the
developing countries, a greater variety of functions was described including those to set standards and to
budget. For the Eastern European and developed countries, the functions mentioned most often included
planning, setting standards, providing supervision, managing personnel, training, monitoring and
coordinating. The functions mentioned least often were determining policy, ensuring information flow,
budgeting and accounting, and evaluating.
A summary of the key characteristics of nurses in leadership positions that contribute to their
success in operating institutions and determining health care policy is as follows:
Education
In nursing and management, especially at the post-basic and university level
Experience
In nursing and management; with local, regional, and national governments
and political groups; with national nurses’ associations and international
groups
Skills
In planning, policy-making, budgeting, and financing
Characteristics
Decisive, assertive, diplomatic, respectful, creative, trusting, trust-worthy,
energetic, enthusiastic, optimistic, ambitious, committed, charismatic; able
to negotiate, communicate, work collaboratively with those in other
disciplines as well as with nurses; build networks.
Connections
To political and governmental officials, influential families, those of a high
socioeconomic status, to resources, to other disciplines.
The involvement of nurses in planning health activities is fairly substantial in some communities and
organizations. But generally nurses are much less involved in planning and determining health policy at
national levels. A fairly common problem for nurses in national positions of leadership in ministries of
health is serving in an advisory capacity only, without line authority, and being only occasionally involved
in major managerial activities. This dilemma, in part, derives from nurses not being adequately prepared
for senior management and leadership and the poorly structured and managed health systems in many
countries.
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SECTION 4
Management of Health Services by Nurses
Participants were next asked to describe the major problems for nurses in management. Suggested
action to overcome the problems were also sought.
Major Problems for Nurses in Management
The five problems described in 1988 were:
1)
2)
3)
4)
5)
the shortage of nurses
the inadequacy of information and support systems
the few models of collaborative practice and education
a near absence of epidemiologic approaches in nursing management
nurses’ limited participation in planning.
The two problems mentioned most often in 1990-1991 from least developed countries were the
shortage of nurses and the shortage of well-educated nurse managers. The following are several
comments about both these problems.
Basically there are no nurses at present who are prepared to work in nursing administration.
In all the countries of my experience, shortage of nurses is definitely a problem. I believe there are
specific reasons for the shortage: people are not attracted to nursing because of the poor working
conditions, and the little chance of career advancement.
Other concerns from the least developed countries are apparent in the following statements.
There is no relationship between practice and education. Our nursing curriculum is not relevant
to primary health care. Nurses are not involved enough in health management.
Very few nurse administrators are aware of the importance of assessing organizational and
community need or of being able to analyse the systems that are already in place. They pay little
or no attention to health policy formation, to the resources needed to implement policies, and to
the costs of services.
There is a lack of authority due to the lack of administrative structures. Because of the lack of
administrative structures, planning cannot be done at the division level in the Ministry of Health,
thus resulting in enormous problems encountered at the level of services.
Added difficulties included strained relationships between nurses and physicians, the lack of information
systems, and nurses’ conflicts with auxiliary personnel.
For the developing countries, the major problems cited by more than one-third included the shortage
of nurses, nurses’ limited knowledge of management, and the limited participation of nurses in planning
and policy activities. One commented that shortages constituted a "... critical problem in the area of
primary health care and ambulatory programmes where positions have not been created on a par with
those in hospitals." A nurse from a developing country in the Eastern Mediterranean Region stated:
"There is a shortage of nurses especially because of its being an unwanted profession and
migration to Arab countries where better conditions are found."
Describing the cultural problems for women, migration, and political instability, another commented, "The
nurses are not working due to the cultural restrictions on women." Respondents from several of the
WHO/HRH/NUR/92.3
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developing countries described the shortage of nurses, not only in terms of the number of nurses but also
in terms of the number and distribution of available positions. Comments were also made about nurses’
limited participation in decision-making and their managerial skills. Two said, "In the political aspect,
there are no nurses in authoritative positions for the planning of health care," and, "Most nurse leaders,
apart from their basic professional training, have not been prepared for the positions they hold." Other
problems included nurses being subordinate to doctors, the poor image and low status of nursing, poor
working conditions, and excessive work-loads. A number of people also mentioned the problems related
to unstable national governments. With respect to political instability, one said:
The insurgency problem which our government has been trying to meet still poses a big problem
for nurse administrators. There are only a few takers of nursing jobs in certain rural and urban
depressed areas.
In developed countries, a shortage of nurses was reported most often. Comparing the responses
from all countries for educators and managers, the nursing shortage was mentioned by half the managers
and only slightly fewer educators. Representative comments describing some of the key local and
national factors in the shortage, included the following:
There is an important shortage of nurses and as a consequence the multiplication of auxiliaries
not always well-educated, especially for the care of the elderly.
A major shortage is in hospitals. We need a minimum of 30 new nurses for each hospital. Units
have been closed for up to four years due to the shortage. Community health has major problems
to fill available positions due to the needs of hospitals.
One of the major problems in my country is the shortage of nurses. There are two main factors
related to the problem: a decreasing birth cohort since the 1970s, and recently, fewer people who
choose nursing at age 18 ... more and more intelligent young girls choose the university and
medicine, psychology, dentistry, pharmacy instead of nursing. Nursing is not even in the
competition because there is no masters degree in nursing.
Shortage of qualified nurses will force us to take "everybody" into employment by public
intervention, the present standard cannot be maintained. The nurses have the image of not being
professionals. The candidates we need in nursing are fewer.
The shortage of nurses depends on the lack of capacity of nursing schools to train more students.
We have a large group of low-educated nurses with general schooling and basic training and a
high range of age.
The next most frequently mentioned problems for the developed countries pertained to the poor
image and low status of nursing, low salaries for nurses, weak information systems, and limited
collaboration with physicians. Representative comments describing the nuances of these problems are
as follows.
The image of nursing is as a low status vocation and a typical female vocation.
A lack of collaborative practice between physicians and nurses is due to the differences in
educational preparation, image differences, and an unwillingness of the medical staff to give due
credit, monetary and otherwise, to the nurse.
The lack of solid data on people’s need for nursing care and the effect of nursing interventions
makes standard-setting and decision-making difficult.
The crucial problem in hospital settings is the inability by the nursing service director or her
associates to interpret the available data - whether they are the results of audits, or costing the
nursing services - and to make a strong case for her requests for more resources and justifying
these. The majority of nursing directors have a maximum of a masters degree and don’t remember
a thing about statistics, to interpret the findings.
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The problems mentioned by several respondents from the developed countries related to poor
working conditions, the little emphasis on primary health care, and the few population-based approaches.
One person noted, "The integration of nursing and public health has not been very successful and
continues to be debated nationally." The need for management knowledge and skill in nursing was
mentioned somewhat less frequently. However, participants from several countries indicated:
There is a lack of business administration skills, a lack of educational background. Nurses in
management must contend with labour relations issues and manpower needs. Some get
ambitious action positions without the proper training.
There is a low level of general education and nursing is excluded from the general education
system. Therefore few young and middle-aged nurses are able and ready for leading positions.
Some young men fill the gap but they are not well prepared either.
Although poor working conditions were mentioned by some, long hours of hard work was mentioned more
often in the developed as compared to the developing countries where the shortage of equipment and
supplies was more apt to be described. Mention was also made of the need for nursing research. One
noted: "A management problem we experience in this country is the lack of systematic strategies to
develop professional theory and research-based nursing practice." Another stated:
A major problem facing nursing management is the need for better understanding through research
on the relationships among nursing care requirements, resource allocation, case management, the
costs of providing care, and quality of patient care outcomes.
Actions to Overcome the Problems
The ten major problems with the corresponding suggested actions were:
Major Problems
Shortage of nurses
Actions
Base nursing education on secondary education
Improve systems of admissions to schools of nursing
Create new schools of nursing
Develop and require university education for nurses
Improve working conditions
Improve the utilization of nurses
Encourage governments to develop clear job
descriptions for health personnel
Develop systems of career advancement
Encourage national governments to support nursing to
the same degree as medicine
Assess nurse migration patterns
Improve the image of nursing
Shortage of well-educated
nurse managers
Improve and increase basic nursing education,
on-the-job training, and continuing education
Ask the World Health Organization to provide shortand long-term experts in nursing management
Require university education
Foster close ties between educators and
administrators
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Major Problems
Actions
Actively recruit nationally, publicizing nursing as a
career
Nurses’ limited participation
in planning and policy
Assess resources and set priorities
Develop standards for the quality of nursing care
Support a distinct nursing division in the Ministry of
Health with funding
Work with officials in international associations to
improve understanding of nurses’ contributions to
health care
Foster an international association for nursing
administration
Lack of recognition and the
low status of nursing
Establish collaborative practice committees
Develop systems of interactions with other
professionals
Encourage careers and promotions based on merit not
only seniority
Develop or strengthen national nurses associations
Support national associations of nurse administrators
Poor working conditions
Add auxiliary nursing personnel
Provide adequate training for nursing auxiliary
personnel
Develop standards for safety, adequate equipment,
and work-load.
Improve nurses salaries and benefits
Provide child care and ensure safety
Provide special benefits to nurses in difficult, unsafe
locations
Transfer nurses giving respect to their needs and
wishes
Provide special management training for doctors and
nurses
Strengthen career guidance
Subordinate role of nurses
Provide management training for doctors, nurses and
lay managers
Foster the development of university education for
nurses including masters and doctoral programmes
Review existing organizational structures to strengthen
the placement of nursing in these
Hasten the development of nursing science and
research
WHO/HRH/NUR/92.3
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Major Problems
Inadequate information
systems
Actions
Develop simple, but useful information systems
Identify the most critical health-related data about
people, communities, and countries
Classify patients by acuity of nursing care needed
Assess costs of nursing care and nursing care
requirements
Little interprofessional
collaboration and teamwork
Develop criteria for delegation of tasks and strengthen
the required skills
Foster interdisciplinary education and training and
continuing education for nursing management
Improve communication between nurse educators and
managers in the health services
Strengthen ethical decision-making
Ensure a chief nurse administrator in every hospital or
community health service
Need for supportive
legislation
Collect useful data to support nursing positions
Engage in political activity and lobbying
Update existing outmoded legislation
Less than adequate
emphasis on primary health
care and epidemiology
Develop nursing education relevant to community
need and primary health care
Foster cornmunity participation in health planning
Articulate research, education, and practice
The problems identified by people from fields other than nursing were similar to those identified by
nurses. However, several of their suggestions are worth noting. With respect to hospital information
systems, budgeting, and national health systems, two in the field of management from the European
Region suggested:
Develop information and support systems. Head nurses of wards must be given more power and
made accountable for the care also in terms of the budget.
Increase nurses’ (and physicians’) understanding, which is now too limited, of social problems and
the importance of health system care in society. Increase the capacity to design and evaluate
alternatives to formal public health systems.
From the field of medicine, one said, "A wholly new system of appointments and promotion (should be
developed) on the basis of proven ability." And a second suggested:
Management programmes should be taught together to all health care professionals so that they
learn the same things and understand each other better. They must understand and communicate
better than today.
In summary, heading the list of problems for nursing management is the shortage of nurses and of
well-educated nurse managers. The challenge to nurses to improve decision-making by leading in
planning and policy activities at all levels was strong. The need for programmes and legislation to hasten
the development of women and nurses is viewed as a major problem as are the low status of nursing and
WHO/HRH/NUR/92.3
page 24
poor working conditions. The inadequacy of information systems in organizations and ministries was
identified and, judging from the responses, this will continue to be a major problem in many countries well
into the future. An additional problem is related to the comparatively little emphasis in some developed
countries on primary health care, identifying health needs, and measuring results.
A wide variety of actions to overcome the problems and improve health systems was provided by
those in all regions. To address the shortage of nurses, the activities that were emphasized included
improving nursing education, developing job descriptions, ensuring opportunities for career advancement,
and assessing the migration of nursing personnel. Actively recruiting nurses and fostering closer ties
between education and service were also mentioned. Improved education for nursing management was
widely discussed as was seeking increased national governmental support for nursing. The importance of
nurses engaging in political activity to improve regulations and legislation was described fairly often. Less
mention was made of nursing education that is relevant to community needs.
WHO/HRH/NUR/92.3
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SECTION 5
Education for Improved Leadership and Management
The third set of items was about education. The first question asked about the subject content to
prepare nurses for leadership in basic, post-basic, and university education. Next, participants were
asked to describe the distance learning and home-study programmes in their countries and then to
assess the usefulness of the 1988 education guidelines.
Subject Content for Basic, Post-basic, University and Continuing Education
Roemer’s categorizations of knowledge for health systems management were used to group the
subjects.
Basic Nursing Education
The following subjects5 were described for basic nursing education.
Health Care Systems and Management
Leadership
Management
Supervision
Administration
Communication
Group dynamics
Basic Tools of Social Analysis
Sociology
Psychology
Social policy
Political science
Statistics
Evaluation
Historical analysis
Inter-sectoral teamwork
Decision-making
Organization of health services
Professional development
Ethics and law
Interpersonal relations
Research methods
Community diagnosis
Problem-solving
Philosophical analysis
Computer science
Teaching methods
Promotion of Health and Prevention of Disease
First-aid
Health promotion
Hygiene
Preventive social medicine
Health education
Primary health care
Health and Disease in Populations
Epidemiology
The subjects mentioned most frequently were basic management and leadership. The subjects rarely
mentioned included health economics, financial administration, or information management. Computer
science as a subject was mentioned in one reply from the European Region.
§ Respondents were asked to describe the subjects specifically for leadership. Therefore, as
anticipated, subjects pertaining more directly to clinical nursing, nursing science, health and disease, or
health promotion were mentioned less often.
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Post-basic Education
The following subjects were described for nurses’ education at the post-basic level:
Health Care Systems and Management
Leadership
Management
Administration
Organization of health services
Supervision
Budgeting
Communication
Human relations
Interpersonal skills
Team building
Assertiveness
Basic Tools of Social Analysis
Sociology
Psychology
Social psychology
Medical psychology
Philosophy
Demography
Politics and law
Political economy
Statistics and biostatistics
Research
History
Promotion of Health and Prevention of Disease
Public health nursing
Health and Disease in Populations
Epidemiology
As for basic nursing education, the subjects mentioned most often, by nearly all, were management and
leadership. One reply from the Americas indicated:
In the last semester of the nursing pre-graduate programme, students receive their preparation in
nursing administration. The course includes 500 hours of training. The experiences are theoretical
and practical. These are applied in the hospital, health centres, and communities. Emphasis is
made in applying the administrative process to improve the patient and community care, decision
making, characteristics of the leader, and usage of developmental strategies.
Two respondents from countries in the Eastern Mediterranean Region made these comments: "There is
a 1-year diploma in administration, a tailored 4-month course for leadership in primary health care, and
several 3-week workshops on leadership", and "There are two programmes; both train nurse educators
in the course named Nursing Education Administration." For basic and post-basic education, respondents
from roughly one-fourth of the countries either provided no information or reported little to no content for
leadership and management.
University Education
The following subjects were described for university education:
Health Care Systems and Management
Leadership
Management
Administration
Health care systems
Organizational behaviour
Information technology
Industrial relations
Supervision
Guidance and counseling
Planning and organizing
Communication
Decision making
Professional development
Human relations
Ethics
Personnel staffing
WHO/HRH/NUR/92.3
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Basic Tools of Social Analysis
Sociology and Social Administration
Psychology
Behavioural Sciences
Education
Biostatistics
Research
Health economics
Cost benefit analysis
Demography
Political and legal aspects
Social policy
Quality Assurance
Systems planning
Promotion of Health and Prevention of Disease
Public health
Health and Disease in Populations
Epidemiology
Management and leadership was described most often. Health economics, finance, and content for
social analysis was mentioned to a greater degree. However, respondents from one-third of the countries
either provided no response or said that programmes are not as yet available.
Continuing Education
Numbers of replies on continuing education varied considerably between country groupings, with the
fewest in the least developed countries and the highest number in the developed. Participants from
nearly half of the least developed countries, either provided no information or noted that continuing
education was limited or non-existent. One from the African Region stated, "There is as yet no policy for
continuing education for nurses. There are from time to time regional and national seminars and
occasionally nurses may be sent to seminars abroad." The content described where courses exist
included ward management, programme management, communication, and community health. In onefourth of the developing countries participants commented that there were few if any continuing education
opportunities to prepare nurses for leadership. The content that was described included management,
administration, leadership, communication, development, accountability, supervision, and research.
Respondents from the three Eastern European countries described some continuing education activities
and content pertaining to management, organization, and health promotion.
For four of the twenty-four developed countries, respondents either provided no information or said
there was little continuing education with the exception of inservice training. The remaining described the
following subjects for continuing education:
Management
Public administration
Organization
Information systems
Communication
Ethics
Interpersonal Skills
Assertiveness Training
Negotiation
Legislation
Finance
Economics
Planning
Quality assurance
Patient classification
Research
Work-load measurement
Personnel staffing
Home-study and Distance Learning Programmes
The next question asked whether home-study or distance learning programmes were available to
educate nurses for management. For the least developed countries, only about ten percent appear to
have these programmes, cpmpared with one-fourth of the developing countries. The programmes were
available in two of the three Eastern European countries and in nearly one-half of the developed
countries.
WHO/HRH/NUR/92.3
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The programmes are sponsored by universities, governments (usually the ministry of health), nurses
associations, hospital associations, medical centres, and international agencies such as the Pan
American Health Organization. A variety of instructional technologies was described including case
studies, television aided instruction, tutorials by telephone, auto-instructional materials, self-learning
packages and manuals. Home-study with lectures, correspondence courses, and video-taping was also
mentioned.
Education Guidelines
The usefulness of the 1988 education guidelines for nursing management were next assessed and
additions or deletions were discussed. The major problems for nurses in management, as identified in
1988, and a summary of the corresponding recommendations, which served as the guidelines, are shown
below:
Problems
Shortage of nurses
Guidelines
Emphasize primary health care and manpower goals,
planning
Develop collaborative education and practice models
Raise standards of admission and performance
Use home study and distance instruction
Develop commitment to life-long learning
Recruit experienced nurse managers as members of
faculty teams
Inadequate information and
support systems
Emphasize management information systems and
information processing
Use interdisciplinary faculty with expertise in
communication, computers, systems analysis
Emphasize delegation of responsibility and follow-up of
auxiliary workers
Address technology transfer, socio-cultural bases,
international connectedness, and history
Few models of collaborative
interdisciplinary practice and
education
Develop new, improved programmes using faculty from
nursing, medicine, management and public health
Improve understanding of epistemological approaches
to interdisciplinary education, cooperation, negotiation
Have students from each field in courses with joint
practicums in primary health care
Understand the advantages and limits of hierarchy
Near absence of clinical
epidemiologic approaches
Emphasize the assessment of health needs, disease,
and environment
Emphasize economics, statistics, epidemiologic trends
and programme planning, implementation and
evaluation
Balance public and private sector management
perspectives
WHO/HRH/NUR/92.3
page 29
Problems
Limited participation in
planning
Guidelines
Include population-based forecasting, planning,
decision-making
Emphasize citizenship and leadership responsibility,
and national and international policy making,
implementation, and evaluation
Encourage inclusion of consumers in health planning
through direct contact
Consider ethical-moral implications of decisions and
policies.
Four-fifths of the participants provided assessments. While most of them found the guidelines useful, the
following comments should be noted from the different regions:
African Region
‘) our reality. Adjust the major curriculum units to
They are very useful but need to be adapted to
We would add: sanitation, economics, and group
the country’s specific needs and resources. V.\
dynamics.
These are useful, but perhaps easier said than done. I believe teaching methods using adult
education techniques are as important as the curriculum content. The recommendations are
rather non-specific. Perhaps there should be a strategy section on how these could be achieved
given the rigid nature of some training programmes.
American Region
Women’s studies should be added to give female nurses a sense of themselves.
The guidelines could be useful when planning educational programmes for nursing leadership
and management. However in small island states, implementation could prove difficult due to the
limited resource personnel and practice sites. A regional institution (university) would be better
able to implement the guidelines.
Eastern Mediterranean Region
All are relevant except for the use of home study and distance instruction. The nature of the
educational system within the country does not facilitate the adoption of such a system.
Most nursing education programmes have a long way to go before all the suggestions can be
implemented and a lot of international assistance will be needed.
They are very useful and relevant. But as suggested in the text, there is a need for each country
to adapt to local conditions and need. The issue, management of health services by nurses,
should be discussed in the general assembly meeting of WHO. The World Health Organization
must take the lead in ensuring nurse managers become health service leaders.
European Region
Economic and political developments should be included...how to develop political strategy is
important. To emphasize citizenship is probably not too relevant. To emphasize responsibility
for each other, regardless of citizenship, is important.
WHO/HRH/NUR/92.3
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The educational guidelines emphasizing the necessity of nurses’ education together with
physicians and other medical professions are extremely useful though in many respects it very
difficult to implement them in practice.
A physician stated:
The recommendations are not very useful. They start at a level which assumes knowledge which
is not usual here.
South-East Asia Region
Though very idealistic and rational, most of the guidelines seem appropriate for more advanced
nursing situations than ours. Our nursing units are overwhelmingly overcrowded with patients
and problems, struggling with meagre resources in terms of space, sanitation, eguipment, nursing
manpower, and other kinds.
Western Pacific Region
History should include history of the women’s movement, feminism, power, and politics.
I would like to see more explicit reference to theory development and organization of nursing’s
body of knowledge. This is a necessary co-reguisite to developing collaborative and
interdisciplinary models.
In summary, there is widespread agreement that strong programmes of education are needed to
ensure intelligent management and leadership by nurses in health systems. For population-based health
services, a vast amount of knowledge and many human, conceptual, and technical skills are reguired to
identify health needs, plan, procure and maintain resources, organize and manage, and then evaluate the
results. The management education content in nursing programmes is uneven or poorly developed in
many countries. There appears to be some basic leadership and management content in nursing
education in some countries. But the content pertaining to national health systems and evaluating the
guality and costs of health care is especially weak.
Subjects which were either not mentioned or mentioned infreguently for university education, included
national health care systems; comparative international health systems; population sampling and
surveys; and programme evaluation. Judging from the number of people who did not respond to the
education guestions and from the comments, even though many subjects were listed, the management
and leadership content in nursing education is poorly developed and not well integrated into the nursing
curricula at the basic, post-basic, and university levels.
WHO/HRH/NUR/92.3
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SECTION 6
Research and Theory for Leadership and Management
The final items were about research and theories for nursing leadership and management. Questions
were asked about nurses’ education for research and about important research topics and methods.
Several items asked about useful theories and for a critique of a model to guide nursing education.
Nurses’ Education to Conduct Research
Respondents were asked to indicate if nurses were taught how to conduct research and then briefly
to describe that education. Those from 80 percent of the countries said "Yes’', nurses were taught how to
conduct research. However, research was less likely to be taught in the least developed countries. But
one made the following comment.
New courses will be introduced in the near future in the nursing school programme aiming to teach
students the basic ideas of research. Meanwhile students are used by certain services of the
Ministry of Health in working on research reports.
Education for nursing research in the least developed countries, when it exists, is usually comprised of
introductory research courses to promote awareness and provide beginning skills.
The education for research described for the developing countries included courses in scientific method,
research methodology, project development, social epidemiology, management research, biostatistics, action
research, and multivariate analysis. Learning experiences included writing proposals, data collection, data
analysis, presentation of results before a review panel, external examiner reviews, obtaining funding, writing
articles for publication, and field trips to research institutes.
In Eastern Europe, one respondent, when describing basic preparation, stated, "Our nurses have some
basic knowledge of research." Another, describing a university programme, indicated: "The nursing
curriculum contains 30-hours of nursing research methodology, 120-hours of graduate seminar, statistics,
informatics, and a master’s thesis."
The following educational courses and activities for research were described for developed countries:
Basic Education
Courses
Introductory research methodology
Statistics
Research applications
Research awareness
Activities
Small research project
Applying research
Participate in a study as a research
assistant
Post-basic Education
Elementary research and methodology
University Education
Courses
Statistics
Biostatistics
Epidemiology
Activities
Thesis
Research project or mini-thesis
Research project assistant
Doctoral dissertation
Implement research results
Ml loo
0525’;
WHO/HRH/NUR/92.3
page 32
Continuing Education
Research methods
Research skills
Computer training
Important and Unimportant Research Topics
Next, participants were asked to review the research priorities described in 1988 and then to signify
which they considered to be "Very Important" or "Not Important" for their countries. The 1988 priority topics
were as follows:
Nursing Service Research
Studies
• Developing and testing models on the availability and allocation of nurses, nurses’ productivity, and
the quality of care delivered to consumers
• Developing and testing models to improve understanding of the balance or ratio of quality of care to
the cost of care
• Developing and testing delivery systems of varying organizational designs which facilitate the
provision of high-quality professional practice and successful outcomes
• Investigating the education of nurses for general and specialty roles in relation to societal expectations
and resources, levels of performance, and quality of care
• Developing and testing organizational models for the effective facilitation of clinical nurse specialists
and examine the influence on professional performance and programmes of nursing care
• Examining communication within organizations and communities, within and across disciplines, and
across national boundaries for improved nursing and patient services
• Developing models and programmes for the transition of patients from one health service to another.
Nursing Administration Research
Studies
• Examining the relationship of administrative style and the productivity and satisfaction of workers
• Testing decision-making models for all levels of nursing administration and examining the relationship
of decision to outcomes, including the quality and cost of care
• Describing the characteristics of nurse administrators and high levels of managerial productivity
• Analyzing the influence of nurse managers’ strategic planning on the commitment of co-workers and
programmes of care
• Describing the strategies to motivate workers and increase levels of productivity
• Describing and analyzing leadership.
Respondents from all countries stated that nursing service research is more important. One said, "The
topics listed under Nursing Administration Research, although important, cannot be looked at until the topics
related to Nursing Service Research have been greatly improved".
The research topics considered most important to those from the least developed countries, were those
addressing the availability and allocation of nurses, nurses’ productivity, quality of care, and models to
improve understanding of the balance of quality and cost of care. One made the following statement:
Since no valuable research has been done on nursing, all topics appear to be very important. This
is more so when one considers the moral decay coupled with low working morale. However,
research on the shortage of nurses and retention of high performing nursing personnel to effect
quality of nursing care, would be very relevant.
One respondent in the field of pubic health offered the following advice:
I would stress that while nurses should certainly be involved in research in nursing, they should also
be more involved in general health services research. At the same time, researchers with a
WHO/HRH/NUR/92.3
page 33
non-nursing background, including social scientists, need to do more work in nursing research. I
would stress the need for interdisciplinary research.
Respondents from developing countries identified the same research topics as very important.
However, study of organizational designs and structures to facilitate high-quality practice was mentioned
to nearly the same extent. Utilizing nurses for primary health care, health promotion, and disease
prevention was also often mentioned. After describing research on the availability and allocation of
nursing personnel as important, one participant from a developing country in the Eastern Mediterranean
Region said:
Of almost equal priority is developing and testing models to improve understanding the balance and
ratio of the quality of care to the cost of care. This country has a very low percentage of its total
budget allocated for health services. But the National Health Policy very recently passed proposals
for a great expansion in the number of rural health facilities, increases in the number of nursing
personnel at all levels, and changes in the curricula to prepare for PHC.
Another stated:
At present the women and children are very much neglected and one major cause of this seems
to be the dearth of women health personnel in government facilities. The basic cause of this is
rooted in the culture of the Region. What can be done to overcome these problems, and what
education is required by nurses, doctors, and auxiliary personnel needs to be determined through
appropriate research.
According to the respondents from Eastern Europe, the availability of nurses and balancing cost and
quality are the most important topics. There were similar responses from developed countries, although
there was wider variation in the topics identified as important. Nearly all the research topics categorized
as nursing service research were mentioned, with availability and allocation of nursing personnel,
balancing quality and cost, nurses’ education and performance, organizational models, and
communication listed as most important. With respect to research on the performance of nurses in
specialty roles, one respondent from Europe in the field of management commented:
I think there is already too much specialization, fragmentation, and self-interested professional
thinking in the health sector. Collaboration, integration, inter-sectorality should be emphasized.
Nurses should not be trained and nursing should not be organized according to the very specialized
and fragmented medical model. It hampers realization of holistic care.
Methodologies in Use and Those Useful for the Future
The third question about research asked which methods were used most often and which were likely
to be used in the future. The five methodologies in 1988 included descriptive studies and surveys,
hypothesis-testing research, programme evaluation, policy studies, and diffusion and utilization projects.
Seven respondents from least developed countries and ten from developing countries provided no
information. One said, "Nurses are not doing research in my country. Most of the research is done by
other professionals." On the methods that may be used in the future, descriptive studies and programme
evaluation were mentioned most frequently for the least developed countries. In the developing countries,
if descriptive work was underway, then hypotheses-testing, programme evaluation, and policy studies
were described for the future. Several people also discussed the importance of historic and philosophic
inquiry and the use of qualitative approaches. The reports from developed countries varied widely. A
number from western Europe that said little to no nursing research was being conducted. Describing the
methods now and for the future, one stated
Nursing administration research in this country is not very advanced. Essentially the area of interest
has been staffing, that is, patient classification and various studies of how nurses use their working
hours. Quality assurance studies are now developing. In the future, from an administrative point
of view, I think descriptive, policy, and programme evaluation will be very important.
WHO/HRH/NUR/92.3
page 34
Many commented that more hypothesis-testing, programme evaluation, and policy research was
anticipated in the future. For all countries, diffusion of knowledge and technology research was
mentioned least often.
Recommendations to Improve Research
The final item about research asked about ways to improve future research for the management of
health services by nurses.
From the least developed countries, the recommendations were to:
• Integrate research in general nursing education and at all levels;
• establish focus groups which can provide leadership, for example, for AIDS control and other
primary health care research;
• ensure that nursing research is relevant to national needs and priorities;
• develop a national nursing research group and a research information centre;
• systematically disseminate research results;
• create a post for nursing administration in the ministry of health;
• encourage nurse researchers in developed countries to assist their peers in developing nations.
From developing countries, the recommendations were to:
• Solicit funds for nursing management research from the national government and local institutions;
• introduce an inter-country exchange of research reports through journals and the development of
information centres;
• promote interdisciplinary research with health services administration with an emphasis on primary
health care;
• create a research unit at the directorate level to conduct and compile research then to plan for
implementation and evaluation;
• foster the procurement of more fellowships for study abroad;
• ensure a positive attitude about research among nurse managers;
• feature research in the nursing curriculum from the basic to the higher levels; Ensure training in
biostatistics and data processing;
• make evaluation research imperative in every programme.
Three recommendations from Eastern Europe were to:
• increase the number of experimental studies;
• heighten the awareness among nurse managers that they have a duty for both theory and
practice;
• develop nursing administration research on an international scale.
Recommendations from developed countries were to:
• improve the access for obtaining permission to do nursing research form health service
authorities;
• ensure that students focus on relevant research;
• encourage nurses to obtain education in mathematics, critical thinking, and history;
• encourage post-doctoral research training and greater interdisciplinary education;
• hasten improvements in nursing documentation, information management, and the
computerization of data for national and international comparative studies which can affect health
policy;
• convene workshops and seminars on specific research methods in the Workgroup of European
Nurse Researchers and through WHO;
• identify opportunities for nursing research through the European Economic Community;
WHO/HRH/NUR/92.3
page 35
• encourage an action research orientation;
• select likely researchers early and plan career accelerated pathways;
• ensure cooperation with the medical professions for holistic approaches to health care.
Useful Theories
Next, descriptions of useful theories for improving the management of health services by nurses were
sought. The theories mentioned by several from the least developed countries included those of primary
health care, clinical epidemiology, and organizations. Administration, and management and leadership
theories were also mentioned, as were communication, power, roles, organizational development, caring,
health, and environment. The concepts of quality, interdependence, and nursing requirements were
noted.
The theories mentioned by about one-fourth from developing countries included leadership,
communication, organization and organization design, and motivation. The theories mentioned by about
10 respondents listed: power, control, authority, clinical epidemiology, and role, while several included
development administration, economics, systems, change, primary health care, decision-making, health
promotion, health behaviour, nursing, and caring. Other theories mentioned at least twice included quality
of care, environment, public health, health care administration, cultural diversity, commitment, education,
public administration, and performance evaluation. An insight shared about theory by one nurse from a
developing country in the Western Pacific Region was as follows.
Development administration: In developing countries the nursing administration role must be
conceived and developed and implemented in the context of development taking place in the
country. This means recognizing national development goals within the political, economic, and
socio-cultural values of the people. This also implies that the development nurse administrator is
primarily engaged in the management of change and growth that will improve the quality of life of
the people bearing in mind the impact of such sectors as agriculture, housing, sanitation, education,
and so forth.
All participants from the Eastern European countries responded. The theories they listed included
those of nursing, organization, equity, motivation, autonomy, decision-making, and leadership. For the
developed countries, organization theory and general management or administrative theories were most
often mentioned as useful, by about one-fourth of the participants. The theories described by several
were those of organization design, economics, quality, communication, motivation, and leadership.
Theories mentioned by a few included those of systems, development administration, power, role, and
clinical epidemiology. Other theories mentioned once or twice included those of equity, decision-making,
change, planning, ecology, labour-management relations, primary health care, stress, and multi-sectoral
collaboration.
Critique of a Model for Nursing Education
The two final questions asked for assessment of a model meant to show the key contextual factors
(outer circles), the main bodies of knowledge (the five triangles), and the domains of application for
nursing management education.
In response to the query as to whether the model provided a useful guide for the education of nurse
leaders and managers, more than three-fourths responded "Yes."
Among the comments were:
It might be helpful also to reflect in a sub-model the process aspects of nursing service
administration such as the managerial processes, policy analysis, impact evaluation.
Well suited to educational interpretation. The guide is useful for the education of senior leadership
in nursing in my country.
WHO/HRH/NUR/92.3
page 36
Environment
World
Country
Nursing
Economy
Technology
Management
Medicine
Nursing
Management
Region
Community
Economics
Public
Health
Organization,
Home
Government/
Politics
Society
In summary, for the developing countries, when research is taught, the emphasis is on promoting
awareness of scientific method, basic research methods, and report preparation. Some research content
is part of nursing education at the basic, post basic and university levels in nearly all developed countries.
The topics for research in nursing management considered most important included those focusing on the
availability and allocation of nursing personnel, the quality and cost of care, and the organizational
structures in health systems. From all regions, descriptive studies and surveys were reported most
frequently and programme evaluations second. Hypothesis-testing research was reported more often
from the developed countries where policy research and diffusion projects were also occasionally
reported. Several of the more prominent recommendations to improve research for nursing management
included ensuring the focus on relevant problems, promoting interdisciplinary research and evaluation
projects, and using focus groups. Several of the theories mentioned most often were leadership,
management, organization design, organization behaviour, clinical epidemiology, development
management, social equity, nursing, caring, and health economics.
WHO/HRH/NUR/92.3
page 37
SECTION 7
Discussion, Implications, and Recommendations
Countries in all regions need nurses who understand health problems and can manage the health
services. It is not possible to effectively implement the health for all strategy effectively without the full
participation and leadership of nurses. And yet, judging from the study findings, the problem of too few
well-prepared nurses for management and leadership is widespread and complex. Many of the social,
cultural, economic, and political origins of the shortage of nurse managers were described, including
those related to national health systems. Some discussed absent or weak organizational structures.
Others described their rigidity with nearly all power centralized and little dispersed to districts and
communities. A number expressed their concern about how little attention is paid to people’s health
needs and to costs. Others noted that nurses are unable to analyze and evaluate the quality of
programmes.
Future action is necessary to recruit qualified people into nursing, to educate them to meet health
needs, and ensure their contribution to the protection and promotion of health. But to begin with, nurses’
management of the health services should be viewed in the context of the health system, not separate
from it. A future challenge in all countries is to develop education programmes that reflect an
understanding of the components of health systems, the relationships of the component parts, and some
of the main socio-cultural, economic, and political factors that contribute to a country’s health activities.
Health Systems and Nurses’ Leadership and Management
A "health system," to reiterate, is the complex of activities that result in the health services. In 1988,
the following model of a health system by Roemer, which can apply to nearly every country was
discussed.11
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w For a fuller discussion of the model see "International Health Care Systems, Their Management and
the Role of Nurses,” by M. I. Roemer in International Administration of Nursing Services edited by B.
Henry, R. Heyden, and B. Richardson and published by the Charles Press, Philadelphia, 1989.
WHO/HRH/NUR/92.3
page 38
The model shows the five main parts of the system and their relationship to health needs and results.
The parts are: resources, management, economic support, organization, and service delivery. The
model can serve as a guide to show where nurses’ leadership and management is necessary. Moving
from left to right, leadership entails identifying health needs and empowering individuals and communities
to identify their own health needs and to take the necessary steps towards better health. Leadership and
management skill is then required for procuring and distributing resources through effective management,
ensuring an appropriate organization of programmes and economic support for service delivery, and
evaluating the health results.
Health needs are the single most salient preceding factor. Within the system, those in leadership
positions manage and share information with policy-makers for improved governmental regulation and
legislation. Effective management entails planning for and obtaining personnel, information, and
monetary resources. It involves gaining the economic support of governments, developing programmes
and designing organizations at the national, district, and community levels by involving public and private
organizations. Effective management also involves delivering the most appropriate services through
primary, secondary, and tertiary care and evaluating the outcomes or results in terms of health status,
costs, and quality of life.
Health System Problems
Authorities on national health systems have described the major problems in these systems.69 Some
were discussed or alluded to in the study. Among the most prominent of the problems are inefficient
organizational structures. In many countries, authority is dispersed among a variety of public and private
agencies, often with little coordination. This problem results in costly duplication of effort or little to no
effort where it is most greatly needed, especially in rural areas. Because of the poorly designed
structures the provision of health care is problematic. Some health needs are neither recognized nor
treated and there is little continuity of care. Community care is often inadequate and services are
provided by personnel whose qualifications are poorly matched with people’s need. This mismatch
results not only in poor care but also in ineffective and costly use of the workforce. Another problem is
that lines of authority are not always clear or, as some participants in the study noted, organization
structures are rigid, weak, or even nonexistent. Who reports to whom is hard to discern and there is little
understanding about how to make and implement useful policies. Inter-sectoral linkages, as noted in the
study, between service and education and between nursing and medicine are also weak. Policies
affecting multiple sectors either are not formulated or, if they are, they are often not implemented.
Another problem is that in nearly all countries the people in the communities served by the health care
system only rarely participate in health planning and policy-making. The channels of communication
among the sectors of the health system and the public seldom convey information in a timely fashion.
With only limited information, sound planning that begins with assessment of health needs and ends with
the evaluation of results is unlikely.
Casting the study findings in terms of the health system, the shortage of nursing resources in relation
to health care needs is a major problem. The geographic distribution of nurses is highly problematic with
some rural and economically deprived areas remaining underserved because of nurses’ concerns about
safety. In addition, some of the nurses who are available have not been educated in accordance with the
health needs of the country. As several in the study noted, nursing education has tended to focus heavily
on tertiary services and less on the delivery of primary health care. In part, this is because of the
shortage of well-prepared nurse educators and managers and because nurses have participated
comparatively little in national planning and policy activities. Added to these problems are the low status
of nursing, poor working conditions, subordination of nurses to medical doctors, little collaboration among
professionals, less than adequate economic support for nursing education, and inadequate information on
which to base sound decisions.
Planning for Resources and Programmes
Decisions are made by managers to assess health needs, to plan, organize, operate programmes,
and evaluate the results. Planning improves decision-making. Improved decisions are needed in health
WHO/HRH/NUR/92.3
page 39
systems more than in almost any other domain. Yet in the study, for nearly one-third of the countries in
all Regions, nurses rarely take part systematically in planning, especially at the national level, even
though planning is one of the main management functions.
Planning is thinking about what lies ahead before taking action. To plan requires, first, that the
purpose of what is to be accomplished in order to achieve a goal is understood. Second, relevant
information is gathered about pertinent past events and their costs, benefits, and results which can then
be used to set the goals. The following is a useful three-step formula for planning.70,71
1.
State the purpose
Decide what is important, what is to be accomplished, and why
2.
Create a planning system
Develop broad goals.
Write specific statements of expected results
Develop methods for achieving the goals and a time-frame
3.
Foster motivation and
evaluation
Formulate objectives, targets, and standards of
performance
Communicate the goals, objectives, and targets to all who are
involved
Develop reward systems tied to achieving the goals
Evaluate the adequacy of resources in terms of the purpose, goal,
and performance indicators.
National health plans and health policy are related to one another in the following way: each
government needs a national health policy that conveys the course of action required to achieve the
defined goals for improving health. A national health policy provides the overall framework and is usually
stated in general terms. A national strategy delineates more specifically the action that will give effect to
the policy, including the specific programmes, their objectives (or end results), and targets (or
intermediate results). Once the strategy is defined, a national plan of action is developed. National plans
specify the steps that should be taken to achieve the objectives and targets.2 Planning in a health
system may be comprehensive, with planning activities at all levels, or centralized in the national ministry,
depending on the planning ideology and economic situation.
The Forty-second World Health Assembly specifically urged Member States to support the
appointment of nurses in senior leadership and management positions and to facilitate their participation
in planning and implementing national health activities.1 Based on the findings, the planning activities for
which senior nurses in the health services should be skilled include:
planning the organization of programmes for service delivery;
planning health education and research programmes;
planning the number, quality, and distribution of nursing personnel;
planning the content and design of information systems;
planning for resource allocation and consumption through budgeting;
planning for programme evaluation.
Examples of the local planning activities for which nurses in communities should be skilled include:
planning to improve and measure the quality of a nursing service;
planning for the recruitment and allocation of personnel resources;
planning training and other personnel development activities;
planning manual and computerized record systems;
planning for the purchase and maintenance of supplies and equipment;
planning for evaluation of the nursing service.
WHO/HRH/NUR/92.3
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Determining Health Policy
It is equally essential that nurses take part in determining health policy. And yet in many countries,
judging from the responses, nurses in senior positions implement national health policy but usually do not
participate in determining policy. As noted, a policy is a course of action chosen by an organization,
community, or government. Policies can be spelled out or simply be implied by the major decisions that
are made. When policies are explicitly made, there are five stages and activities in the policy process:
problem formation, policy formulation, and policy adoption, implementation, and evaluation.72 The most
basic stage-one activity is problem formation. At the first stage for determining health policy, information
is gathered about major health problems and needs as shown here.
Stage 1
Problem
Formation
Stage 2
Policy
Formulation
Stage 3
Adoption
State 4
Implementation
Stage 5
Evaluation
Gathering information
about the major health
problems and health
needs in the Society
In the study, relatively little discussion was found of health needs analysis as a nursing activity in the
health services or as a component of nursing management education and research. Yet, participants
expressed their concern that the health services and nursing education were not population-based, that
is, they were not aligned with the health needs of the people. Therefore, a recommendation to nurse
managers is to include health needs analysis in planning and policy activities. And a recommendation
to nurse educators is to include course content, especially at the post basic and university levels, about
health needs and the relationship of these to determining policies and plans.
Analysing health problems and needs is a strategic management task. A study finding was that
nurse managers in leadership positions in many countries engaged more in daily operating than in
strategic tasks. For nearly all countries, administrative functions were described more often than
managerial ones. Variations in the patterns of functions inferred from the findings are illustrated here.
Manager-Operations/Policy-Strategist Continuum
>
Nurse Managers in
Developing Countries
ManagerOperations
Nurse Managers in
Developed Countries
PolicyStrategist
The use of a continuum illustrates the idea that management and determining policy are not two
isolated activities. Recalling the earlier definition of management, determining policy is one of the
essential managerial functions. Effective managers, those who are capable of compiling the most useful
data and efficiently managing complex operations, should also have an impact on national health policy.
However, the findings suggest, as shown by the continuum, that the main functions of nurses in
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leadership positions in many countries may be more confined to the basic administrative activities of daily
operations rather than to the strategic policy-determining tasks. In the study, several observed that
nurses’ participation in operations "is much bigger than in the strategic area."
In 1988, two categories of tasks for nurses in leadership positions were described: "critical operating"
and "strategic management" tasks.73 Critical operating tasks are basic functions that must be done to
implement policy. Examples of activities in this category, which were described in the study, included
developing standard operating procedures, providing supervision, implementing licensing regulations, and
developing continuing education programmes. Strategic management tasks on the other hand are the
functions that determine policy. Some examples of the strategic activities that were described included
setting standards for nursing education and practice, representing nursing to governmental agencies,
supporting changes in health care legislation, developing new services for primary health care,
disseminating timely information, participating in evaluating health problems with the public, and
promoting international relations. To participate fully in determining policies, nurses need well-developed
political skills. Political skill entails being able to negotiate and bargain, having the time and ability to
develop strong networks, being persuasive, and understanding people’s values. Political skill requires
being able to understand who stands to gain or lose if an existing policy is changed or a new one is
adopted. For determining governmental policy, it is also necessary to understand how regulations and
legislation are developed and adopted.
Engaging successfully in strategic management activities is especially important for senior nurses in
national ministries. Judging from the study findings, having nurses in these positions is a help or a
hindrance depending on their knowledge, motivation, and strategizing skills. While the fact that such
positions exist is of major importance, there are disadvantages to having them filled by nurses with less
than adequate experience and education. Reacting to the problems in health systems, prominent among
which is the shortage of personnel, many in the study suggested that nurse managers should be more
strategic and progressive if a balanced nursing manpower pool is to be achieved. The following definition
of health manpower imbalance is recommended for understanding the nursing shortage and its health
policy implications:
"Health manpower imbalance is a discrepancy between the numbers, types, functions, distribution
and quality of health workers, on the one hand, and on the other, a country’s needs for their
services and its ability to employ, support and maintain them."74
The personnel resource problems in nursing pertain to many of the key factors in the definition. The
number, type, function, quality, and distribution of nursing personnel often does not match the health
needs and a country’s ability to employ or support and maintain them. For many of the countries in all
regions, as respondents noted, even though the need for nursing services is high, the ability to provide
safe employment with reasonable working conditions and adequate salaries is low. Nurses comprise the
largest pool of human resources in health systems. Therefore, a recommendation to senior nurses is to
develop and scientifically test need-driven nursing manpower models to address and correct the current
shortages whenever possible. And a recommendation to nurse educators is to include course content,
especially in university programmes, on the economics of supply and demand and the methods of human
resource analysis.
Any resource analysis, judging from the findings, will have to consider the poor image or low
standing of nursing. Identification of nursing with women’s work and the lack of value accorded to such
work is a major factor in the shortage. This holds true for most countries including several in Europe, for
example, Austria, France, Germany and Italy. Nursing’s image is equally poor in some developing and
resource-rich countries in the Eastern Mediterranean Region. In these, the social position of women and
religious custom seem to be major factors contributing to the standing of nursing and therefore to the
imbalance of nursing resources.
Women are about one-third of the world labour force. According to predictions about the global
labour market, in the future women will enter the workforce in greater numbers, especially in developing
countries and in Germany, Italy and Spain, where there are still fairly low rates of female participation.75
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The World Health Assembly has recognized the problems for women at work. It has expressed concern
about the decline in the number of nursing personnel, the declining number of students being recruited,
and the few nurses in management positions.1 The study results show that leadership is required at all
levels of the health system if these trends are to be reversed. Policy reforms are necessary. Leadership
of nurses is widely needed, especially to improve personnel management, to determine organization
structures and policy, to plan programmes, set standards, ensure the flow of information, budget, and
evaluate. Women have become part of the political life in many European countries, but they are almost
absent from top power positions in many African and Arab countries, for example.
Implications and Recommendations for Nurses’ Education
A shortage of well-educated nurse managers in leadership positions is a frequent problem. However,
this shortage is not limited to nursing as is apparent in these statements from the World Health
Organization:
"The training of health professionals in the past did not prepare them to assume leadership roles
and carry out the managerial functions expected of them in striving toward the goal of health for all.
There is therefore a need to assess and revise the curricula of training programmes for health
professionals so that they meet present needs."76
Many suggestions were made in the study of ways to strengthen the training for nurses to increase
the likelihood of their being more efficient and effective. Efficiency is expending the best possible effort in
relation to the resources consumed. Effectiveness is achieving results in accordance with the objectives
for improving a situation.2 An important recommendation was to increase governmental support for
schools of nursing and for nursing management programmes. However, improvements in nursing
education are directly related to the progress in primary and secondary education which is slow for
women in some countries. When creating programmes to foster the development of nurses’ management
skills, remedial preparation may be necessary. Slightly more than one-third of all the world’s women are
unable to read and write. In the developing countries of Africa, the figure jumps to two-thirds, and in Asia
nearly half the women are illiterate. For the least developed countries, three-quarters of all women
cannot read or write,77 a situation that poses a great challenge to all concerned with a country’s
development. There are also barriers to nursing education in universities in developed countries where
women’s early education is well-established. The need to plan university programmes with a
well-designed management component remains a major challenge in nearly all developed and developing
countries, as does educating men and women equitably.
Nursing education for management begins with knowledge of people’s health problems and needs, of
health systems and of the research and theories that pertain to managing. If the health services are to
become more efficient, effective, and equitable, the task ahead is to prepare students who are able to
analyze health needs and understand the basics of management, including how to determine organization
structure. Some health systems are highly centralized with most of the authority vested in a few people
at the top. This is likely to be the case in developing countries where health care is centrally planned.
Others are decentralized with authority vested in individuals or groups at the district and community
levels. There are advantages and disadvantages to centralized and decentralized structures, but
excesses in either direction lead to inefficiencies. Decentralization tends to work best in fast-changing
environments with well-educated personnel who are able to be self-directed and tolerate uncertainty.
Centralization on the other hand works best where the sense of nationhood may not yet have developed
but the political and economic infrastructures are sensible and stable.78 However, as a general rule,
national health development is hastened when the authority to make decisions is delegated to the district
and community levels.2
Judging from the study findings, nurses participate little in determining the structures of services and
systems. Therefore, a recommendation to nurse managers is to ensure that appropriate organizational
structures are designed so that the needs of the population for nursing services are adequately
addressed. For education, it is recommended that concepts of organization structure be introduced in
basic programmes in terms of small nursing organizations and expanded in university courses to include
WHO/HRH/NUR/92.3
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the components and design of national health systems. To understand how to analyze environments and
match the design of organizations with these, course content, as was found in the study, is needed that
focuses on theories of systems, organization design, and organization behaviour. Important concepts
include those of authority, power, communication, group dynamics, and decision-making. Content
addressing population demographics, social indicators, and vulnerability analysis is also recommended
to improve nurses’ understanding of organization structures, and their effects on the quality and cost of
people’s health care.
There is little doubt that educating nurses for management can also have a favourable impact on
working conditions and personnel management. The conditions at work for nurses in many countries are
a problem. Work-sites are often unsafe and lack support services and good supervision. Job
descriptions to guide workers in their daily activities often do not exist. Positions at the senior level are
sometimes filled based on seniority and political connections rather than on meritorious performance. In
addition, nurses’ relationships with doctors are often problematic. Without well-prepared nurse managers,
productivity and morale can quickly fall because of the inappropriate mix of personnel, poorly organized
job assignments, and the unwillingness or inability of doctors or nurses to delegate non-technical tasks to
less costly workers.
Frequently, too, the flow of information is poor. When describing the functions of senior nurses,
participants from all the regions mentioned ensuring information flow comparatively less often than other
functions. But the "lack of solid data about people’s need for nursing care" was mentioned by several, as
was the importance of information for measuring results. Therefore, it is strongly recommended that
nurses’ education include subject content pertaining to the types of information, information systems, and
the management of information.
Well-designed information systems get the right information, to the right people, at the right time.
Having inadequate information in the health services can be a major problem because timely information
in a useable format is essential if each part of the system is to function well. Managers without
information about health needs, resources, quality, costs, and results cannot plan or develop useful
budgets. They are unable to set appropriate standards and monitor performance. As a consequence
they are unlikely to succeed in providing the required services, of a reasonable quality, at an appropriate
cost. Intelligent planning and policy-making as well as daily decision-making are dependent on having an
adequate supply of valid information that is available when needed, is uniform, and is neither too detailed
nor overly aggregated.79
Another recommendation to nurse managers and educators in all countries is to ensure that
information is transferred between the service and education sectors. The problem was expressed in the
study that often there is little relationship between the service and education sectors. Information about
the problems and changes in practice should be channeled to nurse educators. Likewise, information
about the problems and changes in education should be available to those in the health service if the
practice of nurse managers and their basic, post-basic and university education is to be relevant.
Information from service and education is also required for the advancement of nurses’ knowledge
through research and theory-development. Information systems that are elegant in their simplicity can
also enhance the collaboration of nurses, physicians, and others and thereby increase the efficiency of
working arrangements in which there is the best use of nursing and medical skill and successful team
functioning.80
In the following three subsections recommendations are made for nursing education at the basic,
post-basic and university levels based on the inferences and conclusions drawn from the findings.
However, future decisions about education programmes to improve nurses’ management should be made
on a country-by-country basis. It cannot be over-emphasized that decisions about the required
knowledge and skill depend on the needs, values, goals, requirements, and resources in a country.
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There is wide variation in people’s early education and national resources. Therefore, the following
provides a set of general guidelines.
Recommended Basic Skills and Basic Education
Because of the problems in the health services, basic nursing programmes should introduce some of
the key concepts of management and leadership. Basic training is needed to improve local
administration and as preparation for future higher managerial responsibilities. At the lower level, nurses
in communities and hospitals are responsible for the performance, supervision, and training of community
health workers and auxiliary personnel. Therefore, they should be skilled in engendering community
participation, delegating and monitoring performance, motivating others, and coordinating the activities of
small groups. It is strongly recommended that education programmes prepare nurses who can
collaborate with members of health care teams and develop short-term plans for ways to improve care.
Nurses are needed who can collect basic information and keep records on people’s health problems and
their response to medical and nursing care. Equally necessary are nurses at this level who can
implement policies appropriately in local communities and contribute to determining organizational policies
that guide daily activities.
In addition to basic nursing content, the following is recommended for nurses’ in junior managerial
positions:
1)
2)
3)
4)
5)
Include theories of leadership and administration with the topics of basic supervision, delegation,
communication, interpersonal relations, and group dynamics,
Include elementary content about the national health system and health services to enable
young nurses to place themselves, their role, their organization, and community in the larger
context of their country’s health care system,
Include basic content about health needs assessment, health teaching, personnel development,
performance evaluation, and health legislation,
Design curricula with separate management courses or integrate the management content
throughout a programme of study,
Require interdisciplinary courses and first-hand clinical experiences that involve faculty and
students from several fields to ensure that, from the very beginning, health workers understand
the differing values and contributions of those with whom they will ultimately work.
Recommended Middle Level Skills and Post-basic or University Masters Education
Post-basic and university education for middle level positions should be more in-depth and of a wider
range. Preparation at this level is for the managerial skills required at the district level and in high-level
management positions in large tertiary hospitals. In addition to skills for patient and ward management,
nurses in middle level positions should be prepared to supervise groups of nurses and others such as
physical therapists and radiology technicians. At this level, effective nurse managers engage in
personnel development activities by providing career counselling and leadership training. They are also
responsible for improving records and information flow and for creating information systems for the
nursing services. At this level, nurses collaborate with others through committee work and taskforces.
They also engage in long-term planning. Skill is required for assessing health needs, determining
organization structure and policy, then setting goals, and implementing and evaluating the quality and
costs of programmes. Nurses at this level also develop standards of nursing practice. They develop
budgets for one or several organizational units and evaluate the quality of worker performance, and may
be responsible for coordinating intersectoral linkages, most usually those between hospitals and
communities, service and education, and medicine and nursing.
The following, therefore, is recommended to prepare nurses with middle level skills in post-basic
and university programmes:
WHO/HRH/NUR/92.3
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1)
2)
3)
4)
5)
Include theories of management addressing in-depth those of motivation, decision-making, and
information processing; also include health care finance; budgeting and accounting; and
forecasting,
Include content about the national health system and the basis for its organizational structure;
emphasize primary health care and include basic principles of personnel management with an
emphasis on job analysis, job descriptions, development of equitable salary scales, promotion
criteria, and labour relations,
Include basic research methods and methods of social analysis such as population
demographics, vulnerability analysis, human resource analysis, programme evaluation, and
basic policy analysis,
Design programmes that include knowledge of advanced nursing, health, and disease in
populations, and primary, secondary, and tertiary health care delivery. Include ample
opportunity for first-hand managerial experience,
Design single discipline programmes with a heavy emphasis on interdisciplinary knowledge
development or multidisciplinary programmes with management, public health, and medicine.
Recommended Senior Skills and University Doctoral Education
Preparation for senior management in national governments requires in-depth knowledge of nursing,
health and disease, methods of social analysis, and health systems and their management. With the
prerequisite knowledge and skill, nurses in senior positions will be prepared to participate in determining
national health policy, strategies, and plans. They will be prepared to participate fully in the development
of information systems, in financial planning, and programme evaluation. Nurses at this level should also
have strong coordinating skills to ensure that a variety of workers provide quality services in rural and
urban communities and hospitals and skills to improve intersectoral linkages.
The following is recommended to train nurses with the required skills for national leadership
positions:
In addition to the education for middle level management:
1)
2)
3)
4)
5)
Include political science and theories of resource dependence,
Add comparative health systems, national health planning and financing, policy science, and
health workforce development,
Include health systems research, biostatistical techniques, principles of health economics, and
epidemiology,
Design programmes that include the theoretical and empirical bases of nursing and health
systems knowledge,
Design multidisciplinary programmes with knowledge and practice in nursing and health systems
management.
Equity and ethics should be emphasized in nursing education at all levels but nowhere more so than
in university programmes. The graduates of these programmes will be in positions of responsibility for
ensuring the equitable distribution of resources and services. Content is also recommended that will
teach nurse managers to understand the relationships between the public and private sectors and how to
improve cooperative efforts. There is a scarcity of resources, especially in the public sector, as the
findings showed. Some governments, especially in the least developed countries, have very few
resources. Therefore leadership is needed to find additional resources.
A great deal of work for the education of nurses for management has been done in the United
States.81 Some of this can be adapted for other countries. The guidelines prepared by the International
Council of Nurses and the Canadian Nurses Association are also useful.82
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Recommendations for On-the-Job Training and Continuing Education
Training and developing personnel is one of the major managerial functions. Therefore the idea of
life-long learning and adult education should permeate nurses’ education at every level. Nurses in middle
and senior management positions are needed who will promote and coordinate training activities. Some
of the required management training in communities and hospitals can best be done by knowledgeable
senior nurses. This may be the case especially in some of the least developed countries where there are
few nurses who have an academic background and are able to plan and conduct the required
programmes. For the academic programmes, an interdisciplinary approach is highly recommended.
Plans for training should address health needs, learner needs, types and goals of programmes, and their
cost and evaluation. In countries where there is little management content in basic nursing education, the
subjects recommended for on-the-job training include basic leadership and administration,
communication, delegation, interpersonal relations, and team-building. The development of standards,
performance evaluation, programme evaluation, and budgeting is also greatly needed and therefore highly
recommended for more advanced continuing education opportunities.
Implications and Recommendations for the Development of Knowledge
As the study findings showed, knowledge-development through research in nursing is in its first
stage. A great deal of descriptive research remains to be done. It is unrealistic to expect predictive work.
Health and nursing services research is complex and expensive. If study methodologies are
unnecessarily elaborate and costly, beyond what is affordable and scientifically appropriate in a country,
problems will result. If nursing management research does not address the most troubling health and
health system problems, then projects are unlikely to find support. Therefore a recommendation is to
ensure that nurses’ education for research and research in the workplace is relevant to national need and
appropriate within the frameworks of not only scientific progress but also of national resources.
Those who plan future studies should bear in mind that governments in many developing countries
consider research an unattainable luxury.77 Developing countries annually spend about 2.5% of their
gross national product (GNP) on all research and the equivalent of about $.30 (US thirty cents) per
person for health research. This is as compared to about $30 per person in developed countries for
health-related studies.83 The comparative size of these expenditures and the scarce resources for
research in nearly all countries underscores the need for nurses to consider not only the scientific merit of
their work but also its social benefit and economic feasibility.
In this study, descriptive approaches and programme evaluation were discussed most often. More
policy research is anticipated for the future. Carefully conducted programme evaluations and policy
research, where feasible, can be beneficial. Both types of research often involve networks of
investigators from a number of fields working collaboratively, a feature that can be especially helpful for
junior scientists. Programme evaluation is a method for assessing health results. There are four basic
elements in evaluation:
1)
2)
3)
4)
setting objectives and standards,
undertaking an activity,
identifying the results,
measuring the results.84'88
The purpose of programme evaluation is to improve future health service activities and to help gauge
the kind of resources that are needed and their cost. Quality assessment and assurance are forms of
programme evaluation. Quality in health care is "concerned with the degree to which the resources for
health care or the services included in health care correspond to specified standards."89 The purpose of
quality assessment of the health services is to improve their results or effectiveness. Assuring quality
involves understanding the health service or system, how services are distributed, the availability and use
of resources, the policies that affect the health system and service, and the types of activities that may be
necessary to correct any deficiencies.90 In this study, comparatively little discussion was found about
setting standards. Standards are statements of an acceptable level of quality. In nursing, the main
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concern is setting and maintaining standards for appropriate nursing education, personnel performance,
and nursing service programmes.
Policy research is the study of a fundamental social problem with the specific goal of providing
policy-makers with recommended solutions.91 The focus in policy research is action-oriented
recommendations made by teams of investigators from a variety of disciplines. Policy research involves
selecting a social problem, analyzing its legislative history, interviewing stakeholders, collecting and
analyzing the data for both the statistical and political significance, developing recommendations in a
simple, understandable form, and then submitting the recommendations to policy-makers.91 Hinshaw
made the following observations about nurses collaborating in relevant research with implications for
health policy.
"The collaborative model of research links nurse scientists either with clinicians, in the case of
clinical policy, or with administrators, in the case of executive policy, for the clarification of the
original question, planning, and implementation of the study, and discussion of the use of research
findings once the project is completed".92
Two types of analyses that are useful for programme evaluations and policy research are those to
determine the cost-benefit and cost-effectiveness of programmes. Neither is easy to do in the health
services but it is important to understand the basic ideas. Cost-benefit analysis is a method in which all
costs and benefits of programmes are expressed in monetary terms and then compared. Cost
effectiveness analysis measures the relative cost of different ways to achieve an objective. The degree
of effectiveness is determined by the extent to which a programme contributed to the achievement of
objectives and targets for reducing the dimensions of a problem or improving a situation.2 Both methods
can contribute to the efficiency and effectiveness of the health services by improving managers’
understanding of the relationship of quality and cost.
Action research is another form of collaborative activity that was mentioned in the study. The action
approach is considered beneficial because of the way people are linked together to merge the talents of
practitioners and scientists.93 Scientists who engage in action research examine problems in
organizations or total systems hand-in-hand with practitioners. In action research, the scientist is not
viewed as an expert conducting a study to simply find facts and make recommendations. Instead, he or
she serves as a partner in practice. Action research is appealing because it is a method that is scientific
yet practical and exceptionally high in its potential to hasten the development of the investigative and
team skills of everyone involved. Several in the study commented that steps should be taken to ensure
that nurse managers have a positive attitude-toward research. Encouraging action research can be one
such step.
A number of other activities suggested in the study were to hasten the development of scientific
knowledge for nursing management by internationalizing its scientific enterprise. International research
usually is the comparison of a common activity in two or more countries. An increase in international
nursing management research may be more feasible in the future as electronic communication improves,
information is comparable, and more nurses elect to take part of their educational training in countries
outside their homeland. A great deal of beneficial knowledge can be gained by nurses in developed
countries from those in the developing about primary health care and managing with scarce resources.
And nurses in some developing and least developed countries can benefit from what has already been
learned about designing nursing organizations, analyzing human resource requirements, developing
information systems, managing complex health systems, and analyzing the costs of nursing. Finding
appropriate ways to transfer knowledge from one setting or country to another may also result in better
dissemination of research, reported only rarely in the study.
A variety of theories and concepts can be used to guide nurses’ management and their education
and research programmes. Although some knowledge for nursing management may vary from country to
country, much of the theoretical knowledge that seems most useful is similar: it derives mainly from the
fields of nursing, management, economics, medicine, and public health. A central concern for educators
should be how best to blend and balance the most appropriate knowledge from each of these fields. An
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especially important body of theoretical knowledge is development management. This is an applied field
for the study of social and economic change in developing countries. The main goal in the development
perspective is encouraging activities that lead to self-sustaining dynamics for improved human
well-being.94 As one participant rightly noted, "In developing countries the nursing administration role
must be conceived, developed, and implemented in the context of development taking place in the
country." Another important body of knowledge is clinical epidemiology. This approach to epidemiology
is concerned with the application of epidemiological statistics to the solution of health and management
problems in communities, hospitals, and countries.95
Concluding Remarks and Recommendations
A great deal more information is needed to fully understand nurses’ leadership and management and
how these can be improved. International research is difficult and time-consuming. It is often criticized
because of the difficulties of comparing activities from different cultures and countries. This exploratory
study is a beginning. Several differences and similarities in nurses’ leadership and management and the
training and research pertaining to these have been identified. The data-based guidelines for education
provide a general direction for future planning. When asked in the study validation exercise if this report
would be useful for their countries, nearly all those who responded said "yes".
Strong leadership and management are required to reorient the health services to primary health
care and to face the new realism addressed by the Director-General of the World Health Organization,
Hiroshi Nakajima, in his paradigm for health.
"Everywhere a new realism is setting in. It is quite clear that resources are not limitless. In the
health sector this has forced planners and decision-makers to look at priorities, efficiency,
cost-effectiveness and better delivery through the better management of resources, without
compromising quality.96
The World Health Organization has taken a lead to ensure that nurses develop as managers and
leaders for health-for-all activities. Member States have been urged to develop strategies to improve the
qualifications of nursing personnel to meet national needs. They have been encouraged to support the
appointment of nurses to senior leadership and management positions and facilitate their taking part in
national planning.
Throughout the report, recommendations have been made for nurses in service and education.
However, nurses’ leadership potential will be fully realized when nurses’ associations, and other health
professions - especially medicine and health services management - as well as universities and national
governments, take an active part in bringing about positive change. Several concluding
recommendations for the professions and governments, arising from the study, are to:
Encourage and facilitate the development of nurses for community, district, and national
leadership;
Develop and improve education for nursing management at the basic, post-basic, and university
levels:
Provide funding for the advancement of nursing science.
Well-prepared nurses are needed in all countries to improve the efficiency, effectiveness, and equity
of the health services. It is apparent that, with assistance, nurses are willing and able to achieve their
leadership potential to improve the quality of health services, at a reasonable cost, for health for all.
WHO/HRH/NUR/92.3
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WHO/HRH/NUR/92.3
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WHO/HRH/NUR/92.3
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ANNEX A
Final Chapter (30) of:
International Administration of Nursing Services*
FUTURE NURSING SERVICE ADMINISTRATION
EDUCATION, RESEARCH, AND THEORY
BEVERLY HENRY
THE CONTRIBUTORS** to this book share the belief that many of the problems confronting nurses today are
common to nurses through the world. Each country represented has extremely complex problems. But a major
premise of this book is that the dilemmas all nurses face are not purely domestic, and that they cannot be
adequately solved by the citizens of any single nation. We believe that a science of nursing administration must be
international.
THE MANAGEMENT OF NURSING SERVICES
The beginning point has been the problems nurses in management positions find most perplexing in hospital
and community settings throughout the world. The five most prominent are (1) the shortage of nurses, (2) the
inadequacy of information and support systems, (3) the new models of collaborative practice and education for
nurses, physicians, and health care administrators, (4) a near absence of epidemiologic approaches in nursing
administration, and (5) limited participation by nurses in planning health services at local, national, and international
levels.
Shortage of Nurses
In most regions of the world, there are too few people entering nursing to keep pace with the demand, the
shortage seems related to a number of factors, not least of which is the image of nursing as a low-status vocation.
Seivwright notes that many schools of nursing have academic entrance requirements that are well below those of
other programmes. She continues by stating, "It is still common practice for ’not-so-bright’ high schoolers to be
counselled into nursing."(1)
Some countries, like those in the Middle East (Saudi Arabia, for example), have traditions regarding the status and
seclusion of women that make recruiting nurses from local populations highly problematic. In the United States
during the last decade, many more career opportunities generally considered of a higher status have been made
available to women - in law, theology, medicine, and engineering, and this, too, has had an impact.
Low salaries, salary compression, and less than satisfying work conditions are also factors. And problems in the
workplace that nurses find unsettling are discordant relationships with doctors; the high stress that accompanies
caring for the sick, contagious, and dying; and the alienation many feel from work where what they have been
taught to believe about basic services is idealistic and far exceeds what is actually possible with the available
resources.
The distribution of nurses is another aspect of the shortage. Approximately 26% of the people in the world live
in industrialized nations, while 74% live in developing countries. Yet more than 80% of the world’s nurses work in
* Henry, B. et al. eds. Charles Press, Philadelphia, 1989
** Acknowledgements. Much of this chapter summarizes what has been discussed in earlier sections. Therefore I am indebted
to all those who contributed, and especially to the leaders and recorders of the four small groups at the conference who worked
so diligently to develop the recommendations. Respectively, they were Vernice Ferguson and Barbara Brown (Practice), Shirley
Stinson and Mary Seivwright (Education), Robert Veninga and Ada Sue Hinshaw (Research), and Moses Kiggundu and Joanne
McCloskey (Theory). I would also like to express my sincere appreciation to those who took the time to provide me with in-depth
reviews of drafts of this chapter: Barbara Richardson, Shirley Stinson, and Milton Roemer. And I extend a special word of
thanks for the generous encouragement of Gillian Biscoe, Yvonne Moores, Ndiki Ngcongco, Henedina Suanes, and Bob Veninga.
WHO/HRH/NUR/92.3
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industrialized states and of these, the majority are employed in large urban centers, leaving rural communities in
short supply. There are approximately 65 nurses per 100,000 inhabitants in developing countries, whereas in
developed nations the ratio is 175 nurses for every 100,000 persons.(2)
The few entering nursing compared to the number leaving, whether for economic or personal reasons, is
especially disconcerting for countries like Botswana, for example, where Ngcongco states that 90% of the health
care needs of citizens do not require medical intervention. Most of the required health care services can be
provided by nurses.
Inadequacy of Information Systems and Support Services
Throughout the world, health care providers, including managers, doctors, and nurses, are often unable to
assess organizational and community needs, or to analyze the systems that are already in place, which could in
some cases, with slight modification, meet those needs. Faced with an array of computerized and statistical
approaches to information, there is confusion with respect to hardware and software alternatives, and uncertainty
about applications. The absence or lateness of useful organizational, national, and international data regarding
sanitary conditions, treatment modalities, the incidence of disease, and costs, make the possibility of timely
improvements almost nil.
Technical, economic, and political factors appear to contribute to the problems of inefficient management
information and support systems. In some nations, where advanced information technologies are affordable and
available - in Australia, the United States and Canada, for example - nurses are sometimes unable or unwilling to
identify the data that are necessary to increase the efficiency of operations under their control. Unclear about their
goals and functions, they sometimes mismanage the information they do have, and are reluctant to delegate support
tasks to less highly trained and less costly auxiliary workers. And often hospital administrators and doctors, for a
variety of political and economic reasons, many of which have to do with control over financial income, do not
marshal the data necessary to lower costs of care through the delegation of medical tasks to nurses. At the 1988
World Conference on Medical Education, in Edinburgh, Scotland, WHO Director-General Nakajima challenged the
medical profession with respect to the contribution of nurses to the effectiveness of health care.
There has been a lack of willingness on our part to delegate functions to other professionals. I recall too
well situations in some countries where even highly qualified nurses were not allowed to give intra
muscular injections. Sad to say, the only reason for the proscription seemed to have been due to the fact
that there was a fee paid to the person injecting. Perhaps it is now the time to rationalize the functions of
doctors so that their skills and time are devoted to the special tasks which they have been trained to
perform.(3)
The systems-analysis and information-processing capabilities of most health care services lag woefully behind
what is needed. Although many requirements for the management of programmes to control communicable disease
and prevent chronic maladies have certain uniform aspects throughout the world, it is often the case that each
organization and state approaches these differently. The consequent variations in standards and data make the
failure to communicate within nations and across national boundaries almost a certainty.
Few Models of Collaborative Practice and Education
Physicians historically have been heavily involved in the evolution of nursing practice and education in most
countries. Judging from reports, from Italy and the West Indies, for example, doctors have been among our earliest
teachers, supervisors, and, in some cases, our mentors.
But there are countries where the relationships between nurses and physicians have been perniciously
contrary. Weak, adversary relationships have often been the norm where health systems policies are those that
Roemer, in his chapter, classifies as entrepreneurial and permissive. In countries where doctors and nurses
compete for recognition and remuneration, successful models of collaborative education and practice have been
less likely. For these countries especially, more concerted effort is needed to find ways of working cooperatively
and efficiently in teams.
More effort is needed, too, in countries where the majority of nurses are women and the majority of physicians
are men, as is the case in most nations of the world, except for the Soviet Union. Finding ways of functioning as
colleagues where relationships between men and women have traditionally been characterized by female
subservience, in countries such as Italy, France, Germany, and Spain, for example, requires enormous patience and
creativity if inter-disciplinary team work is to be improved and new models of collaborative practice are to be
developed.
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Good communication is tantamount to high quality care for patients, as we know intuitively, and as the recent
research of Knaus, Draper and others has demonstrated.(4) When members of the health care team talk together
sharing observations from their unique perspectives about the varying aspects of health and illness for individuals
and communities, knowledge expands, interventions are better understood by consumers, and the probability of
correct action is enhanced.
When nurses, physicians, and health service managers are educated together in interdisciplinary programmes,
the values of each become clearer to others, and the contributions of all are more readily understood and
respected. There are problems, however, not the least of which is the day-to-day confusion about roles and the
costs of such programmes in terms of the time it takes to coordinate cooperative and synchronized academic
activities. Moreover, it is easy to talk blithely about collaborative endeavours that are interdisciplinary when, for
most, mastering a single discipline may be the work of a decade, and integrating knowledge for interdisciplinary
endeavours may take a lifetime.
Few Clinical Epidemiologic Approaches In Nursing Administration
Nightingale is well known for her impact on the clinical practice of nursing. We read and reread her Notes on
Nursing and are familiar with her treatise on hospital administration. She is less well known, however, for her use of
statistics and epidemiology. Yet Nightingale believed that efficient nursing should be based on observation,
experience, valid statistical data, knowledge of sanitation and nutrition, and sound management. In the Crimea,
before she cared for the sick and dying, she first organized an effective hospital by using the most compelling of
statistical arguments - those related to mortality.(5)
Clinical epidemiology is concerned with the application of epidemiology and biostatistics to the solution of
diagnostic and management problems at the bedside, in communities, and nations.(6) According to Evans, the
most pressing problem in both industrialized and developing nations is:
more effective management of health services at all levels. Management in this context involves the
evaluation of health needs, rational allocation of resources, and successful implementation of
programmes that depend on human service organization^?)
There is a long, if uneven, tradition in nursing of using statistics, as well as clinical and management
knowledge, to analyze social conditions in terms of health care to change public policy and to influence the
allocation of resources. Nightingale has provided us with a model where clinical, managerial, political and
epidemiologic skills are combined.
Nurse administrators at all levels in organizations and communities need to base their decisions about
organizational structures, the services offered, personnel used, and measures of effectiveness and efficiency, on the
health needs of the populations they serve, in accordance with the Health for All strategy. Demographic and
epidemiologic trends, environmental situations, lifestyles, ethical considerations, the availability of qualified
personnel, and economics must all be considered in management decisions.(8)
Nurses - especially those at the first-line and middle administrative levels, where there is little opportunity to
interact with executive managers - have been quick to eschew the importance of understanding the economics of
health care. Until the 1980s, little attention was paid by nurses to health policy formulation, to the resources needed
to implement policies, and to the costs of services. Satisfied to focus primarily on the clinical aspects of care,
nurses often shunned responsibility for taking part in policy analysis and financial planning.
Nurses’ Limited Participation in Planning
Large-scale planning for health care has met with limited success in most western industrialized nations.
People in these countries tend to be oriented primarily to the here-and-now, to the present. Consequently, planning
for the future requires active, far-sighted leadership.
Where planning for health services in primary care has been successful, is in Cuba and Costa Rica. In
socialist nations of Europe health care planning has also been successful until recently, judging from reports of poor
health services and a declining life expectancy in the Soviet Union, for example.
Although nurses’ minimal participation in thinking about the future needs to change, few of us believe that
plans should be sacrosanct. Ruinous problems have resulted in some countries where large-scale, bureaucratic
planning takes precedence over local forecasting and day-to-day reassessment of programmes and outcomes. As
Mikail Gorbachev has stated, planning needs to be democratized by having plan-making begin with enterprises
where levels of productivity are based on social need determined through direct contacts with consumers.(9)
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Resources Available to Address the Problems
In 1978, with the Declaration of Alma-Ata of Health for All by the Year 2000 through Primary Health Care, the
independent functions of nurses pertaining to health promotion and maintenance were more widely acknowledged.
Nurses in 1989, by virtue of their existing numbers, are in a strong position to move health services beyond the
medical sector and into communities and homes where power to improve health and health care is in the hands of
the people.
In the United States, in many western European nations, Japan, and south Africa, curative medical
technologies designed to treat disease have reaped great economic and social rewards for doctors, drug
companies, and manufacturers of automated equipment. Highly complex medical and surgical interventions have
become possible with billions of dollars in funding from governments and private enterprises. Although the length of
life in industrialized nations has been extended as a consequence, the low quality of life in polluted environments,
the increase in chronic disease, and the stress of living in highly competitive societies have diminished many of the
strides in modern medical technology.
Nurses today are in a unique position to provide health services that are not currently viewed as within the
boundaries of medical science, but which are desperately needed by the populations of industrialized and
developing countries. Since the 1960s, the emphasis in some university nursing programmes has been on thinking
along new lines, other than those of the traditional medical care system, to understand what is causing the health
problems in societies that are gaining, growing richer, and becoming more culturally heterogeneous: Populations
are more migratory than ever. Visualize for example, the influx of Southeast Asians to Australia; the high portion of
immigrant workers from Turkey in Germany; the aliyah to Israel from Yemen; the western specialists imported by oil
rich Arab states; and the war-weary Nicaraguans in Honduras.
Throughout the world, nurses, consumers, and governments are moving to achieve higher levels of Health for
All Through Primary Health Care. Some academic programmes have been reoriented, especially in developing
countries. But for the most part nurses’ unique contributions have not been sufficiently emphasized, as they must
be in the future, if more well-qualified people are to be attracted and retained in nursing.
Every professional discipline has its unique language, its jargon, quite legitimately developed to improve and
hasten communication among like-minded people within the discipline. Nurse administrators who are leaders are
sensitive to the differences in terminologies. They are aware of subtleties and shades of meaning. This linguistic
keenness goes a long way toward developing cooperation between nurses and physicians, as it has in Botswana:
toward incorporating nurses on executive teams as has been done in New Zealand: and toward building a
collaborative model of nursing and medical education like the one at the University of Honduras.
In terms of the goal of Health for All, nurses must not countenance a slippage in educational standards. Much
can be learned from Japan about setting and maintaining high standards of academic achievement.
The situation described by Seivwright, where the weakest students are counselled into nursing, is widespread,
and nurses must hold themselves responsible. In the name of being humanistic, kind to those who are less
talented, generous to late-bloomers, and because of declining enrolments, too many educators, including those who
teach nursing administration, have lowered admission standards, thereby allowing nursing education, in some
cases, to become little more than watered-down vocational training.
Under such circumstances, is it any wonder we face the problem of attracting sufficient numbers of wellqualified people to nursing? Who should be admitted to the university is a very difficult question. It is one with
which every society must struggle. But in terms of what is best for the public, capable nurse administrators in
nations throughout the world must engage in the struggle because they are in an eminently strong position to arrest
the fall in the level of knowledge. They are in a position to require that students in nursing administration enrol in
joint degree programmes, meeting the requirements of nursing schools and schools of management or public
health, thereby gaining access to the information and technology in these domains.
There is sufficient evidence that interdisciplinary education of the type suggested makes better use of scarce
and costly academic resources. Moreover, it increases the likelihood that nurses, doctors, and managers will
understand one another to a greater extent than they have in the past. Thus making more likely the interdisciplinary
and intersectoral models so desperately needed. Interdisciplinary studies also have the potential of raising the
status of nursing because of a close proximity to more prestigious fields where standards of academic performance
have traditionally been higher, where the student bodies are populated more by men than by women, and where
knowledge is more advanced.
Nursing knowledge is sufficiently developed: worry lest nurses lose sight of the unique aspects of their
profession through mingling with those in related disciplines during their formative years is no longer warranted.
New models of collaboration are within our grasp. Great achievements and excellence for nursing is possible
through cooperative endeavours.
Excellence, however, must be manifest at every level of nursing. Nursing assistants, technical nurses, and
professional nurses each have standards of high performance. Nurse administrators in the past have been prone to
think that societies expect, want, and need the services of only those who are highly educated - university-trained
WHO/HRH/NUR/92.3
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professional nurses, when in fact this may not be the case. In nations where the people have a say about the type
of workforce and services rendered, the public appears less and less willing to pay the high bill for health care,
which suggests that they may be willing to assume more responsibility for their own health at home, and to value
and use the services of auxiliary workers.
Citizens of many countries - both industrialized and developing - appear more agreeable to using the services
of auxiliary personnel who work under the supervision of professional nurses. Nurse educators and administrators
once again seem amenable to recognizing the supervisory functions of professional nurses so clearly spelled out by
Nightingale and to educating nurses at basic (undergraduate) and post-basic (graduate) levels for these functions.
Nurse throughout the world are paying more attention to what economists refer to as "allocative efficiency" - getting
the most out of the resources that are available.
To rectify the problems of a nursing shortage, inadequate information systems and limited interdisciplinary
education, to use clinical epidemiologic approaches for nursing administration, and to improve short- and long-range
planning for health services, requires an understanding of health economics, especially by those in executive
management. As Gavin Mooney, professor of health economics at the University of Copenhagen, stated in his
1988 presentation at the European conference on nursing in Vienna, "The discipline of economics in health and
health care is just as much about delivering good quality patient care as is nursing." (10) All resources - whether
we are talking about manpower, information, time, equipment, space, or buildings - are limited. And human wants
are infinite. Effective management of health services, therefore, entails making extremely tough choices about what
should be done, how, by whom, and who should benefit.
These choices, although difficult, must be made. They are made by nurse administrators who are welleducated, courageous, and willing to be held accountable. Based on the problems and resources that have been
identified with respect to the administration of nursing services throughout the world, the following recommendations
are made to nurses who manage.
Recommendation One. Develop and sustain multiple strategies to attract, recruit, and retain nurses, including
enhancement of the image and status of nurses, and the provision of preferential financial resources.
Recommendation Two. Encourage the development of improved information systems and other support
services to enable professional nurses to increase their productivity in their principle work using up-to-date, valid
information.
Recommendation Three. Develop collaborative models for the education and functioning of nurses,
physicians, and administrators in the health care delivery system.
Recommendation Four. Increase the use of clinical epidemiologic approaches in conjunction with medicine
for strategic planning and resource allocation.
Recommendation Five. Ensure that appropriately educated nurses are included as members of all health
planning groups and committees at the local, regional, national, and international levels.
EDUCATION FOR NURSING ADMINISTRATION
With respect to nursing administration education, the discussions which follow pertain to (1) the need for longrange planning and manpower studies, (2) guidelines for nursing administration education which can constitute
international standards, (3) the nature of academic programmes in nursing administration, (4) the design and
placement of these programmes, and faculty qualifications.
Manpower' Planning, Health Needs, and Management
There are few systematic manpower studies and long-range planning projects addressing the number and
competence of students who should be recruited for nursing administration. The paucity of planning data is
especially problematic in view of the shortage of nurses who can mange, the disproportionately low number for
populations with the greatest health needs, and the maldistribution of nurses with rural areas being left under- or
unserved.
* The author acknowledges the sexist connotation of the word "manpower" and substitutes "workforce" and
"human resources" where possible.
WHO/HRH/NUR/92.3
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The upsurge in long-range planning as we understand it today, is a phenomenon of only the last few decades.
In the 1980s, it is the rare private sector corporation in Japan, the United States, Canada, Australia, and Western
Europe that does not formulate long-range plans. But strategic planning in the public sector, and in health care in
particular, is more recent and complex. It is highly essential none the less, as Peter Drucker states with a touch of
irony.
Management has no choice but to anticipate the future, attempt to mold it, and to balance short-range
and long-range goals. But lacking divine guidance, management must make sure that these difficult
responsibilities are not overlooked or neglected but taken care of as well as in humanly possible.(11)
Planning for human resources helps change the current trends which have not
proved effective so that in the future the services provided are delivered to the appropriate segments of the
population, using the most efficient work methods, performed by the most appropriate category of worker, and
allowing for evaluation of the resources used and the outcomes. Hinshaw stated in her chapter, and it bears
repeating
The important message is that new roles as developed in health care need to be systematically evaluated
and studied in terms of their effectiveness on the quality of care for patients and positive impact on
building professional practice environments. Because of the resources (money, time, individuals) which
are invested in new roles, partially effective and questionable roles can no longer be allowed.(12)
Manpower planning involves continuous, systematic decision making, and measuring results against the
resources used, and goals and expectations. Health manpower plans begin with goals - in an organization, a
nation, and in the world - for health care. Goals, however, are not always clearly spelled out for a variety of
political, cultural, and economic reasons. People in positions of power may deliberately keep goals fairly ambiguous
to give those providing services at local levels a wide latitude, or, on the negative side, to avoid being held
accountable for outcomes should they prove ineffective. In addition, each culture’s orientation to the past, present,
and future is somewhat different. The inclination to be fatalistic also varies. In countries where a sense of the
future exists, and where it is believed that people can make a difference, setting goals and planning for the long
term is more likely. The value placed on centralized government planning and local efforts is a factor as well, as is
cost. Useful studies to assess the availability and need for human resources can be expensive.
In the absence of health manpower planning, and of policies that designate responsibilities to categories of
personnel, much uncertainty may be generated about what the qualifications and standards should be for students
who will eventually work as managers in primary and tertiary settings. In most countries, the national health policy
changes from one government administration to the next, depending on the political parties and principles of those
elected to office. Although some workforce planning takes place, the education of nurses for managerial positions
focuses almost exclusively on preparing nurses to function in hospitals. There are at least 65 master’s and 12
doctoral programmes with an emphasis in nursing service administration in universities throughout the United
States. Only a small portion of these, perhaps as few as 10%, offer courses in management for nurses in
community health agencies, long-term care facilities, and primary care. Yet hospital occupancy rates average only
65% nationwide and are falling, a trend that is expected to continue as hospital costs and the number of outpatient
services increases. There is a desperate need for well-educated nurse administrators capable of managing
ambulatory and long-term care health services for about 15% of the country’s aged are provided in nursing homes
where the quality of care is severely criticized by the public.
However, even when policies are agreed on at the highest levels of governments or organizations, changes in
the use of nursing resources are not automatic. For example, six years after participants in the 1977 World Health
Assembly asked governments to increase the number and use of nurses and midwives in the management of
primary health care services, and five years after the 1978 Alma Ata conference - at which the representatives of
member countries were encouraged to consider the health need of all populations - nurses in most countries still
were not actively involved in the management of health care delivery. Therefore, in 1981, the Division of Health
Manpower Development of the World Health Organization convened a group of experts to consider the role of
nurses with respect to the goal of Health for All. Five strategies were identified.
Developing a corps of nurses in each country who are informed about primary nursing
Including nurses in policy making and administration in all health services
Changing all levels of nursing education to be sure priority needs of populations are met
Involving nurses in starting and supporting primary care.
Doing research on nursing administration, practice, and education to demonstrate and evaluate the
contribution of nurses to primary health care.(13)
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Future assessments of manpower needs to implement the above strategies for nursing administration, may
best be done using the clinical epidemiological model. Clinical epidemiology integrates social, behavioral, and
biomedical science. Manpower studies taking an epidemiological approach link the evaluation of health needs with
resource allocations and existing and future health service programmes.
Setting goals and making plans, as noted earlier, requires forecasting skill and sound analytic thinking. But it
is absolutely imperative that we realize that successful planning demands more than technical, tool-using
manipulations. Judgment, courage, experience, and intuition are equally essential. When giving direct care to
people, in the absence of systematic data, nurses act on their hunches. In nursing administration, if carefully
conducted studies do not exist and if the likelihood of their being done is slim, then we, too, have to use our intuitive
know-how and act on our hunches.
Nursing administration, like clinical practice, is both art and science. Vision and leadership, as Veninga
emphasizes in his chapter, are essential when it comes to planning for the future workforce. And this is especially
true where the cost of systematic studies is prohibitive or where values are antithetical. The epidemiologic model,
guidelines from the World Health Organization, from national nurses’ associations, and from the international
Council of Nurses, may have to suffice if we are to work as effectively as possible with communities and
governments to plan for and educate competent workers in a variety of managerial roles.
International Guidelines for Nursing Administration Education
There is little question that guidelines for changes in nursing administration education are necessary. In 1985,
Ohlson and Franklin made the following comments.
Nursing curricula in most countries need to be changed radically to prepare nurses to meet the health
needs of the greatest number of people ... Not only must they be taught to give direct care ... they also
must be prepared to teach, supervise, and work with various auxiliary personnel and community health
workers ...(14)
Dame Nita Barrow, Permanent Representative of Barbados to the United Nations, in 1988 stated
Changes in curricula are needed in schools of medicine, schools of nursing and other health institutions in
order to give priority to primary care and develop the leadership skills and managerial tools required.
Such tools . . . include the ability to consider health in the context of development, analyze policies and
intersectoral links, manage health information and reorganize health services. They also need to be
familiar with analysis and management and manpower needs and training, development of technologies,
and alternative methods of financings 5)
Guidelines with applicability to all nations are necessary for the education of nurses who manage at the first,
middle, and executive levels. If we believe that the problems in health care cannot be solved in isolation - on a
purely domestic basis by each of our nations - and that the only possible science of nursing administration is
international, then a set of guidelines which can serve as standards throughout the world should be formulated.
Guidelines such as those developed in Canada should prove useful in this endeavour.(16)
The reasonableness of approaching nursing administration as an international and comparative field is
suggested by the findings of management scientists who have examined the usefulness of western ideas. In
investigations of administrative theory and practice in developing countries, Kiggundu and associates state that
existing management theories focusing on organizational tasks and technologies, which have been developed in
western industrialized nations, "fit" developing countries. Where adjustments of theories are needed, however, is
with respect to ideas about the relationships between organizations and their environments.(17) Some nursing
theories developed in the West have also been found to be universally applicable. The work of Florence
Nightingale and Virginia Henderson has been useful to nurses in non-western nations - in Yugoslavia and the
Philippines, for example.
A logical beginning point for a set of guidelines which can serve as standards is to identify and use what has
already been done and seems to be working. In a world as complex and diverse as ours, no single set of
standards will be universally applauded. Nevertheless, guidelines that are helpful worldwide will be based on the
premise that whatever we do domestically has international implications, and that one of the biggest changes that
affects the lives and work of all of us is the widespread dissemination of information. With existing communications
technology, none of our countries, cities and towns, no matter how remote, is shielded from changes taking place
elsewhere in the world.
Formulating guidelines to serve as international standards for nursing administration education requires, as
Cleveland (18) suggests in his discussion of international governance, that we
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Focus on both the present and future functions of those who manage health services
Anticipate changing trends in nursing, health, medicine, and management
Consider our mutual needs for cooperation to assure cleaner environments, security and peace, and
safety from atomic hazards
Value alternatives to hierarchic, bureaucratic organizations
Hasten the flow of better, more valid and useful computerized data across domestic borders and
professional disciplines, and
Rethink what we mean by equity and citizenship
Programmes and events that should be useful in developing a set of standards include the leadership
development programmes held during the 1980s in nations throughout the world, supported by the Canadian
International Development Agency, the Norwegian Agency for International Development, the Untied Nations
Children’s Fund, and the International Council of Nurses; the experiences of the World Health Organization (WHO)
Network of Collaborating Centres for Nursing Development, the cooperation among the Western European nations
for the advancement of primary nursing and nursing research, and the subsequent recommendations in the WHO
Summary Report of the 1988 European Conference in Austria. Once international standards are developed, nurses
in every country can refine or create unique concepts, within the context of the more broadly-stated, global
guidelines, to give language and meaning to how nurse administrators in each nation are educated, how they think,
function, and are connected. Ours is not a vision of homogenized humanity, but one where the best of our
differences are identified, valued, and preserved.
The specific knowledge categories within which the guidelines are framed could be those suggested by Kim’s
four domains of knowledge for nursing administration, nursing requirements, nursing services practice, nursing
organization, and environment. Or perhaps merging Kim’s with Roemer’s categories of public health knowledge
would provide a useful structure and mark the terrain and borders of nursing administration education with a public
service perspective as Stinson emphasizes in her chapter.
When developing the statements of standards for each country, care must be taken to avoid forcing ideas into
well established social forms.(19) Nurses and others, as Kiggundu mentions in his chapter, must beware of the
tendency to simply transfer the conceptions of one society to another without an in-depth understanding of their
environmental, technological and socio-cultural differences. At Alma Ata, Mahler talked about the tendency to
transplant solutions from industrialized countries to developing nations and said our motto should be: "Don’t Adopt Adapt."
Education Programmes for Nursing Administration*
If the goal of Health for All is not being met, some of the blame lies with those of us who design the curricula
for our schools of nursing, as well as with the graduates. Throughout the world relatively little attention has been
paid to educating nurses for management functions. And the few nurses who have managerial skills stay in cities,
work in hospitals where salaries are comparatively higher, and focus largely on systems in support of curative
medical functions.**
The contributors, however, have not belaboured either of these points: they were taken as givens, as basic
problems and fundamental reasons for this volume. It should be noted, too, that an attempt has not been made to
delineate highly specialized concepts as is typically done when developing a framework to assure the coherence of
an academic curriculum. Instead, the focus is the needs of nurse administrators throughout the world - in
communities and when managing care for people in their homes - and the educational strategies required to ensure
that those needs are met. The focus is on basic essentials.
There is general agreement that if nurses are to play a more significant role in the development of health
policy, then they are going to need a larger and longer-range orientation. They will have to focus on nursing,
health, and illness, for societies and specific sub-populations, on health programme implementation and evaluation,
and on resource allocation. Special qualities are needed to be successful in policy-formation activities at local,
national, regional and international levels. To prepare for these functions, the following overall goals are suggested
for educational programmes in nursing administration.
1. Students should understand the nature of decision making and be capable of thinking creatively and solving
problems in complex, unstructured situations where few precedents exist, using innovations rather than playing it
“ * The author acknowledges a generous reliance in this section and the one following on the special report in
the January-February 1984 issue of the Harvard Business Review entitled, "Are business schools doing their job?
written by J. N. Behrman and R. I. Levin.
WHO/HRH/NUR/92.3
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safe. In our programmes they should learn about taking risk when making choices and recognize what it means to
be held responsible for the decisions they and those working for them make. They should recognize there is an
ethical-moral aspect to every decision and the importance of identifying what this is. A textbook that faculty may
find useful on this topic is the one by Burke, entitled Bureaucratic Responsibility.(21)
2. Knowledge should be incorporated in the programmes from the fields of nursing, management, economics,
medicine and public health, and from the liberal arts. Nurse administrators need the tools of social analysis. They
need to understand how science develops: the characteristics of health services: and the environmental, political,
technical, and cultural factors at home and abroad which affect them. An integrative programme like the one
established in Canada in 1969 (22), which Stinson describes in her chapter, is recommended because the problems
nurses face cannot be solved with nursing knowledge alone. A word of warning, however; the knowledge added to
our programmes from other disciplines and professional fields should be guided by foundational concepts which are
aligned in a logical way with those in nursing, lest our educational endeavours become little more than piecedtogether "crazy quilts," without core, clear purpose, or coherency.
3. Organizational structures where workers become involved through participation and influence the future of
the organization should be emphasized. The study of reactions to hierarchy among industrial workers and
managers in Italy, Austria, Yugoslavia, Israel, and the United States, by Tannenbaum and Rozgonyi, may be
especially useful in this regard.(23)
4. Students also need to be knowledgeable about face-to-face and electronic communication: interpersonal,
inter-organizational, and international communication should be emphasized to assure that the interconnectedness
of all communities and nations is understood and enhanced. Negotiation also needs to be stressed in the context of
varying cultural traditions. Understanding how to bargain, make trade-offs, and reach compromises using a wide
variety of resources to achieve one’s goals is essential. Preparedness and knowing when to remain stalwart is
equally necessary.
5. A balance of public- and private-sector approaches to financing and managing health care also should be
found, depending on the extent to which the health services of a nation are largely market-oriented and
entrepreneurial (as they are in the United States, Thailand, the Philippines, South Africa, Nepal), welfare-oriented
(West Germany, Canada, Japan, Malaysia, and India), comprehensive (Great Britain, New Zealand, Norway, Saudi
Arabia, Kuwait), or centrally planned (Soviet Union, Czechoslovakia, China, Cuba, People’s Republic of Korea.(24)
Even though there is a renewal of interest in market mechanisms around the world, texts like the one by Bozeman
entitled, All Organizations are Public: Bridging Public and Private Organization Theories, are strongly
recommended.(25)
6. A commitment to life-long learning should be fostered. In a world changing as rapidly as ours, the half-life
of technical knowledge is rarely more than a few years. Education and learning must take place continually over
each person’s lifetime. Organizations and societies in which continual learning is fostered will provide programmes
and funding for continuing education and on-the-job training and retraining; and home study and distance learning
techniques will be used.
7. History and art should be included in education for nursing administration. Students and graduates need to
have a "sense of the sweep of history" in health services, and their employing organizations and societies, if they
are to bring a holistic understanding to bear on the decisions they make.(26)
Education for the management of patient services should begin in basic (undergraduate) programmes. As
Herman Finer stated in his famous book, Administration and the Nursing Services.
Administration will not find its rightful place in the education for nursing unless it is decisively put there,
and unless the burden of the practical adjustments are courageously undertaken ... Administration is a
power that binds people together in the interest of a common enterprise ... The ground floor of my
recommendations is the basic professional course. If what should be done at this level is rightly
conceived, all the other problems of the other levels will fall into their place.(27)
Controversy in nursing about the management knowledge that should or should not be part of basic training
saturates the discussions of educators throughout the world. Some argue that leadership, for example, cannot be
taught; that people are born with qualities that propel them to positions of leadership. Others say it should not be
taught because it is not a legitimate component of academic disciplines. Conversely, others tensely insist that there
should be a leadership course in every programme of study.
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Our recommendation is that the nature of leadership should be an element of a separate basic
(undergraduate) course in nursing management where introductory information to human relations, communication,
and group dynamics is included. Students should also be introduced to such concepts in economics as supply and
demand, resource analysis, production, consumption, capital, and investment. Being familiarized with population
growth, the relation of populations to resources and forces that determine wages and salaries is essential.
Knowledge from philosophy, psychology, and history is also needed. The most illuminating biographies of historical
and contemporary figures from all world regions should be required; those of Florence Nightingale, Winston
Churchill, the Mahatma Ghandi, Franklin Roosevelt, Golda Meir, Vladimir Ulyanov (Lenin), Joseph Tito, Anwar
Sadat, to name a few.
In all programmes, at the basic and post-basic levels, and in continuing education, more emphasis is required
on speaking well and writing concisely and clearly. Instructional technologies must be found to develop students’
skills to write succinct reports; to prepare memorandums others can understand, find interesting, and be willing to
act on; to speak well under pressure when leading groups and when asked to talk extemporaneously. There is little
that can sabotage our chances of becoming part of policy-making more than being unable to convey ideas clearly
and imaginatively when writing and speaking. Moreover, good writing is essential for scientific accountability. The
maxim of Francis Bacon is worth pondering: Reading maketh a full man and writing an exact man.
Students in our programmes who aspire to become researchers and teachers of nursing administration should
be expected to develop as full and exact people. To enlarge the world views of students - because of a
commitment to improved international understanding - required reading should include novels written by great
authors from throughout the world. Once again, Finer's suggestions are worth contemplating.
I do not expect a nurse to become a novelist...! hope only that a nurse will become a better nurse. The
path is toward making the mind and judgment of the nurse adequate to the patient. Multiply her
hypotheses about human nature and you multiply her capacity to solve problems....It is the novel that can
get below the skin when the textbook cannot. The more men and women the nurse meets and is
agitated and impressed by, the better prepared will she be to meet more men and women and minister to
them in terms of their specific individual selves....Accordingly, it is recommended that during the years of
basic education, the student nurse shall be expected to read 37 novels - one a month.(28)
Legendary novels like Love in the Time of Cholera, by the Colombian, Gabriel Garcia Marquez, winner of the 1982
Nobel Prize for Literature, should be a part of nurse administrators' education.(29).
Programme Placement, Design, and Faculty
Part of the education for nursing administration should, as suggested earlier, be spent in courses and
practicums with students in the fields of medicine and management. Interdisciplinary education is strongly endorsed
because of the benefits that accrue to students where learning and life experiences are shared.
Faculty in interdisciplinary programmes also gain. Through their association with others, they take off their
disciplinary blinders and "see” reality in ways they may not have before, new insights are gained about the linguistic,
ethical, and cultural aspects of nursing administration - an especially important benefit if our aim is to expand
nursing administration to a universal field and have an impact on national and international strategies and policies.
Interdisciplinary approaches can also be economical. There is a world-wide shortage of faculty able to teach
nursing administration by virtue of their past work experience or academic credentials, interdisciplinary education
where courses are taught by teams or specialists - nurses, health administrators, and physicians - makes economic
sense.
Faculty are needed who have managed nursing services and who can establish contacts with practitioners in
the workplace, thereby enabling students to have the most useful and informative first-hand experiences in clinical
settings. Moreover, having educators with work experience also increase the likelihood that research will be done
where the most important questions are addressed. Intradisciplinary teams of nurse executives and faculty in
nursing administration, as McCloskey has suggested in her chapter, is an excellent idea and one strongly endorsed.
Where possible, faculty should also be encouraged to take a leave of absence and spend time in another
country working on joint research projects with educators and practitioners who are addressing problems which are
cross-national. Faculty should also encourage students to study abroad. Those students who engage in practicums
under the tutelage of nurse administrators in countries throughout the world, can benefit greatly in developing their
understanding of other political, economic, and health systems.
There is a growing realization in nursing that travel and international study enhance understanding and trust
among people from different societies. The insights that are gained are not only a precondition for additional
exchanges of knowledge, but they also provide a foundation for the furtherance of a universal science for nursing.
WHO/HRH/NUR/92.3
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Louis Brandeis, one of the world’s great thinkers, said there can be no true community "save that built upon the
personal acquaintance of each with each."
In view of the problems and resources identified for education in nursing administration, the following
recommendations are made.
Recommendation One. Support and conduct long-range planning and the development of manpower studies
at local, state and national levels using forecasting techniques and the clinical epidemiologic model as a guide to
improve understanding of the number and kind of nurses that are needed for management positions.
Recommendation Two. Develop guidelines which can serve as international standards for nursing
administration education at the basic (undergraduate), post-basic (graduate), and continuing education levels.
Recommendation Three. Foster intra- and interdisciplinary education - with involvement of faculty from
nursing, medicine, management, and public health - for the academic preparation of nurse administrators with
clinical nursing and management knowledge.
To summarize at this point, a cross-classification of the major categories of problems in nursing administration
and the recommendations for nursing education are shown in Table 30-1.
Problems
Shortage of nurses
Guidelines
Emphasize primary health care and manpower goals,
performance, planning
Develop collaborative education and practice models
Raise standards of admission and performance
Use home study and distance instruction
Develop commitment to life-long learning
Recruit experienced nurse managers as members of
faculty teams
Inadequate information and
support systems
Emphasize management information systems and
information processing
Use interdisciplinary faculty with expertise in
communication, computers, systems analysis
Emphasize delegation of responsibility and follow-up
of auxiliary workers
Address technology transfer, socio-cultural bases,
international connectedness, and history
Few models of collaborative
interdisciplinary practice and
education
Develop new, improved programmes using faculty
from nursing, medicine, management and public
health
Improve understanding of epistemological approaches
to interdisciplinary education, cooperation, negotiation
Have students from each field in courses with joint
practicums in primary health care
Understand the advantages and limits of hierarchy
Near absence of clinical
epidemiologic approaches
Emphasize the assessment of health needs, disease,
and environment
Emphasize economics, statistics, epidemiologic trends
and programme planning, implementation and
evaluation
WHO/HRH/NUR/92.3
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Problems
Guidelines
Balance public and private sector management
perspectives
Limited participation in planning
Include population-based forecasting, planning,
decision making
Emphasize citizenship and leadership responsibility,
and national and international policy making,
implementation, and evaluation
Encourage inclusion of consumers in health planning
through direct contact
Consider ethical-moral implications of decisions and
policies.
RESEARCH IN NURSING SERVICE ADMINISTRATION
The 1985 report of the WHO Expert Committee on Health manpower requirements for the achievement of
health for all by the year 2000 through primary health care states:
There are far too few people with managerial skills at all levels for planning, administration and evaluation
of the implementation of national strategies to achieve health for all. However, a majority of countries
have recognized that strengthening of health management, and within it the management of health
personnel, is a priority activity.(30)
The report continues by emphasizing the importance of research for improved health care management, noting,
however, that only small portions of health system budgets are allocated for health services research.
Health services research is the systematic study of the means by which medical and management knowledge
is applied to improving the distribution, quality, effectiveness, and efficiency of care.(3) Nursing service
administration research adds to nursing knowledge as it focuses on the organization and distribution of quality
nursing care using efficient and effective management methods for individuals and communities in varying settings
and circumstances. In terms of the epidemiologic model, research in nursing administration involves the evaluation
of health and nursing care needs, rational allocation of resources, and the implementation and evaluation of
programmes in nursing. Bamisaiye of Nigeria has observed that senior nurses in developing countries, although
ideally placed to use and conduct research focusing on the nursing services to bring about improvements, do not
have the skills and resources to carry out projects. Without the depth of understanding possible through scientific
studies, the limited resources which are available are used less effectively and large populations go without health
care.(32)
Bergman (33) of Israel, in her discussion of research, identifies three problems; nurses have not identified their
research needs and communicated these to people in positions of influence, they are reluctant to read and criticize
research, and they are hesitant to use the few valid findings that do exist. She continues by stating that studies of
the cost-effectiveness of nursing care modalities are needed, as are master plans for research.
Bergman describes two major roles relevant to research for executive-level nurse administrators. The first is to
develop mechanisms to facilitate studies; assuring entry to organizations, providing access to records and key
individuals, and gaining financial support. The second role pertains to designing organizational structures to assure
that nursing research is undertaken as a regular part of a nurse's job; providing personnel with the time and
materials necessary for careful investigations and including research activity in position descriptions.
There is ample evidence that scientific investigations are needed by nurse administrators. It is increasingly
apparent, too, that the organization and management of health services has an impact on the well-being of mankind
- an insight, as Salmon and colleagues note, that nursing and other professions are only now beginning to
recognize.(34)
Standards of Significance for Nursing Administration Research
Significance is usually a matter of degree. Studies are generally thought of as more or less significant. For
most research, there is no absolute standards.(35). The goal, therefore, is to describe the multiple dimensions of
WHO/HRH/NUR/92.3
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significant research, which, when taken together, provide useful criteria for evaluating studies in nursing
administration.
Throughout the world, research that is significant in a professional discipline such as nursing should both meet
the test of scientific validity, and be useful for solving the problems that practitioners encounter.(36, 37) Nursing
administration studies can be conducted for a variety of reasons and audiences, but two are usually most apparent:
for science and for practice. A scientific investigation may be primarily intellectual and explanatory, providing valid
explanations of theoretically significant phenomena, or it can be primarily practical, analyzing existing practices with
the objective of finding ways of improving how, for example, nurses are managing organizations.
The first standard of significance for studies in nursing administration conveys a recognition of nursing as a
scientific discipline.
Nursing administration research should contribute to the development of nursing administration theory.
Two of the recommended standards depict the practical, problem-solving orientation of nursing administration.
Nursing administration research should focus on problems that nurses can influence.
Nursing administration research should improve the functioning of the health care system.
Three standards could apply to either the research needs in science or the problems in practice, depending on the
terms of reference and audience.
Nursing administration research should provide direction in the delivery of care.
Nursing administration research should contribute to the development of nursing administration education.
Nursing administration research must be relevant to the setting and culture in which it is conducted.
The combined emphasis on inquiry for improved explanation and theories, and on solving problems in practice,
is important. It reflects a belief that nursing administration research can serve not only science, but also those in
the workplace for whom the effectiveness of organizations is of immediate concern. The six standards indicate that
a master plan for nursing administration research should contribute both to theory and practice.
This dual perspective is a view aligned with that of others. Gortner, for example, in her discussion of research
for a practice profession stated
As nurses, we ought to be able to accomplish research in our practice concomitantly with the evolution and
verification of nursing theory as a science of practice and concomitantly with research into the educational
system that is charged with the responsibility of preparing practitioners. We must move on all fronts
vigorously and not allow one to fall behind the other. This is the particularly heavy charge of all
service-oriented professions.(38).
To ensure research that is practical yet theoretical, nurse educators and practitioners must spend time together
in classrooms and work settings. If investigators are to focus on new nursing and patient-care enterprises, and
individual as well as organizational responses to changing patterns of disease and health - rather than on just a few
restricted concepts - a dynamic, open, perspective of inquiry for nursing administration needs to be fostered. A
limited range of research interests is not appropriate if nurses who manage are to have greater opportunity in the
future than they have had in the past of influencing the delivery and policies of the health and nursing services.
In a practice discipline, the tension between scientific need and the usefulness of knowledge is great. But it is
one with which nurses must struggle. And we are not alone, as Mechanic’s description of the identical predicament
for health services administration attests.
Not only must health services research achieve a level of scientific rigor satisfactory to other professionals
who scrutinize its theories and research efforts, but it must also pose issues in ways that appear
reasonable to decision makers. Demands for scientific rigor from one’s colleagues often interfere with
meeting the expectations of simplicity, comprehensibility, and need from the policy makers.(30).
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Priority Research
Suggesting research priorities is as problematic as deciding what is significant. The two are closely related
because studies undertaken to solve high-priority problems tend to be viewed as more significant. It is essential,
therefore, that the recommendations be prefaced with the following comments.
Most importantly, it is acknowledged that a high-priority research topic in one country may be of a lower
precedence in another. The goal in prioritizing has been purely to provide readers with beginning guidelines which
can be adapted to each unique situation, depending on the domestic health needs, resources, and socio-cultural
circumstances. Those contributing recognize the constraints people face and have tried to be sensitive to the
differences in cultural values and how knowledge is transferred across boundaries.
With these limitations in mind, priority topics in two categories have been identified. Studies are classified
either as nursing administration research, where the foremost emphasis is the behavior of nurses in management
positions, their decision making, productivity, and overall functioning; or as nursing service research, where the
emphasis is on the components and arrangements of organizational systems; manpower assessment, allocation and
evaluation; the quality and cost of programmes of care; and models of professional nursing practice.
The two categories are used to organize the following research topics in a way readers will find helpful. For
the remainder of the book, however, the terms "nursing administration" and "nursing service administration" are
used interchangeably.
Nursing Service Research. Of high priority are studies that develop and test models addressing the
availability and allocation of nurses, nurse' productivity, and the quality of care that is delivered to consumers.
Research in this category considers the
•
Shortage of nurses
•
Rationale for predicting the number and kind of nurses that are needed
•
Mix of professional and non-professional (auxiliary) workers
•
Identification of the care needed by patients and other consumers, and identification of nursing care
requirements
•
Use of auxiliary workers of different types who can extend the work of nurses in a variety of hospital and
community settings, and the
•
Use of nurses for primary health care, health promotion and disease prevention.
Also of high priority are studies that develop and test models to improve understanding of the balance or ratio
of quality of care to cost of care. Research in this category focuses on
Costing of nursing services
Developing different models for the ratio of quality to cost. Some of the questions that must be asked are,
What services are needed, at a minimum, by the population of interest? What is the financial and human
cost of services at varying levels of quality? What can the population afford to pay and what will they pay
directly or through taxation?
Identifying and operationally defining quality-of-care indicators. Included in this category are studies that
develop measures of quality nursing and/or patient care, and use multiple indicators including those that
are physiological and behavioral.
Priority research will also including studies that develop and test delivery systems of varying organizational
designs which facilitate the provision of high-quality professional practice and successful outcomes. Research
pertaining to systems of organization examines
Organizational structures in hospitals and community agencies where participation in decision making is
enhanced--where authority and responsibility are shared at each level of the hierarchy, and
Systems of organizing that are viable alternatives to rigid bureaucratic forms, and attract and retain highperforming nurses.
Of priority, too, are studies to investigate the education of nurses for general and specialty roles in relation to
societal expectations and resources, levels of performance, and quality of care. For these, the designing of health
care systems to enhance the efficient use of nurses educated at various levels should be considered.
WHO/HRH/NUR/92.3
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Researchers should also conduct studies that develop and test organizational models for the effective
facilitation of clinical nurse specialists, and examine the influence on professional performance and programmes of
nursing care, considering
Organizational designs that facilitate specialization, and
Administrative styles that enhance the productivity of nurse specialists
Other priorities are studies of factors that enhance communication within organizations and communities, within
and across disciplines, and across national boundaries for improved nursing and patient care services, and studies
to develop models and programmes for the transition of patients from one health service to another.
Nursing Administration Research. Of priority in this category are studies of the relationship of administrative
style and the productivity and satisfaction of workers. Factors to emphasize are the
Attitudes and satisfaction levels of the workers for whom mangers have responsibility
Quality of patient and nursing care
Variations in managerial style by society and culture, the relation of these to values and expectations as
well as to level of productivity, and the
Decentralization of decision making to various categories of workers, and levels of productivity.
Another priority is studies testing decision-making models for all levels of nursing administration and examining
the relationship of decisions to outcomes, including the quality and cost of clinical care. Special attention should be
accorded
Descriptions of decision processes using models of classical decision making, bounded rationality,
incremental approaches, and information processing
Decision making and organizational designs, and
Intuition and cognitive process models.
Of priority too, are studies of the characteristics of nurse administrators related to high levels of managerial
productivity, which examine such contextual and process factors as personal characteristics, agendas, networks,
organizational units and domains, accomplishing tasks, planning, and building and maintaining networks.
Other priorities are studies of the influence of nurses managers’ strategic planning on the commitment of
co-workers and programmes of care; studies of strategies to motivate workers and increase levels of productivity
using the theoretical perspectives of needs, equity, expectancy, goal-setting, behavior modification, and social
learning; and studies of leadership. For research addressing leadership, the 1987 text by Doig and Hargrove,
Leadership and Innovation, (40) and McCall and Lombardo’s Leadership, Where Else Do We Go? (41) are
especially important. Lanara’s (42) analysis of the philosophical perspectives of heroism as a nursing value also
appears essential for discovering new ways of understanding nurses who are leaders.
Building Theories Through Research
To build useful theories for nursing administration through empirical studies, investigators should be reasonably
clear about (1) the functions of empirical research in nursing administration, about (2) the strengths and weaknesses
of various methodologies and the appropriateness of each for the research questions being addressed, and about
(3) the characteristics of significant theories.
Functions of Research In Nursing Administration. Mechanic (43) describes five basic functions of
health-services research which are applicable to nursing administration. The functions are (1) to provide factual
information, (2) to test hypotheses, (3) to evaluate programmes, (4) to suggest the costs and benefits of policy
initiatives, and (5) to study the problems of implementation and diffusion. In the discussion that follows the functions
have been adapted from Mechanic for nursing service administration.
Descriptive Studies and Surveys. Nurses in management positions need factual information to plan for the
future. They need to know, for example, how many patients are being cared for, the range of needs for nursing
care, the costs of procedures, variations in these by locality, rates of admission, salary schedules of various types of
workers, and the like. Much of the data necessary for manpower planning falls into this category, as do consumer
WHO/HRH/NUR/92.3
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and industrial market surveys. Periodic surveys are needed in most countries to provide descriptive data about the
epidemiology of disease in communities, and the case mix in various types of settings.
Hypothesis-Testing Research. Analytic, hypothesis-testing research is also necessary to advance the
science of nursing administration. Research serving this function comprises more conceptually complex basic
studies whose relevance is less for the short term than for the future of knowledge development in the discipline.
Studies analyzing the outcomes of nursing interventions fall into this category. Research that hypothesizes the
effects of various types of nursing personnel, performing at varying levels of efficiency, on the quality of care as
measured by mortality and morbidity, is an example of research that can be strongly theory-building. Correlation
methods, regression models and econometric models that combine history and economic theory are the association
and causal methods often used. Edwardson, in her chapter, provides a helpful discussion of effectiveness
measures which are useful for hypothesis-testing studies, and for programme evaluation and policy analysis as well.
Programme Evaluation. Nursing administration research also involves evaluating new and on-going
programmes. Perhaps the single best example of evaluation studies in the United States is that of quality
assurance programmes. The goal of these is to improve nursing practice on a daily basis by collecting data to
pinpoint unanticipated problems in practice, and their consequences.
Policy Studies. Although little research qualifying as policy analysis has been done in nursing administration,
this too is a function, and one that should be expanded in the future, as many have noted throughout the book.
Policy studies apply social and analytic techniques to the assessment of cost/benefit data, usually for governmental
initiatives. Studies in this category require a thorough understanding of the problems being addressed, of how
policies are made and implemented, and of government. As the education for nursing administration improves, and
the right balance of private and public administration theory is struck in curricula, useful policy studies may be
forthcoming.
Diffusion and Utilization Projects. Last, there is research to demonstrate how knowledge (ideas, facts and
principles) and technology (work methods and industrial operations) are diffused from one setting to another and
how they are utilized. Nursing services are provided in a wide variety of settings within any single country. Projects
that compare how work is accomplished and how it changes over time, although difficult to conduct, are useful for
understanding decision making, responsibility, and leadership. Time-series methods such as moving averages, time
services extrapolation, and the Box-Jenkins method may be appropriate. Understanding the diffusion of technology
and knowledge between countries is complex, but this very complexity in the way concepts, for example, are
changed as nurses adapt to differing cultures and economies suggests how extremely rich international studies of
the diffusion of knowledge may be for future theories of nursing administration. In addition, replication studies to
assess how innovations in technology begin and vary in diverse environments throughout the world are needed to
improve understanding of nurses managing the health services.
Methodologies for Nursing Administration
To test and build useful theories for international nursing administration, the contributors strongly support
research conducted in traditional and non-traditional settings—in communities, hospitals, and homes. Emphasis is
placed on the importance of research methods matching the research questions and being appropriate, given the
state of knowledge in nursing and in the disciplines from which additional knowledge is selectively drawn. The need
for historical and philosophic inquiry is also emphasized. Significant research will consistently synthesize knowledge
from multiple disciplines, then manipulate that information from a nursing perspective.
Diverse research methodologies and strategies described as convergent validation or triangulation are
encouraged. These approaches share the idea that both qualitative and quantitative research methods should be
used to complement the respective strengths and weaknesses of each.(44) In nursing administration, for example,
to study the effectiveness of leaders, the researcher could begin with an individual or group interview, during and
after which observations of behavior patterns are recorded, and reports of performance, both of the leaders and
others, are evaluated. Using this approach, the effectiveness of those being studied is the central focus, but the
methods vary, providing the investigator with multiple and independent measures, the convergence of which
provides a more valid description of nursing leadership than if a single method was used.
Ethnography, a qualitative method, is important for developing a valid body of knowledge for international
nursing administration. Ethnographic methods attend to the context within which diseases occur, health services are
WHO/HRH/NUR/92.3
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provided and management values and practices evolve. Leininger’s (45) theory of cultural care in nursing
administration could serve as a starting point.
To hasten the building of strong theories for nursing administration we also need to push for greater predictive
capabilities, whenever appropriate and possible, to test the outcomes of nursing practice. In nursing, the causal
modeling studies of Hinshaw and colleagues is especially useful in this regard.(46, 47).
Although secondary data have been fairly widely used in management science, as noted earlier, secondary
data analysis in nursing is relatively new and also worth considering. This is especially true in view of our need for
manpower planning studies. Secondary data analysis, involves using data collected for one purpose, for another.
As an example, large-scale demographic data bases generated for a population census by a country’s national
government could be accessed by nurses to analyze the ages, incomes, education levels, and employment of
people with the goal of training or retraining select groups for positions in the health services.
Significant Theories and Research
One of the criteria for determining what constitutes significant theories in sociology that has not often been
mentioned in nursing administration is the extent to which a contribution is "interesting." Davis argues that the
significance of a theory often has little to do with the research methods used or a theory’s verifiability because easily
verifiable ideas are soon forgotten. What is remembered is work that is interesting. Interesting theories deny some
of the assumptions people hold.(48)
Daft connects research and theory in a memorable way, as quoted in the excerpt below.
The scientific method is more like guess work, the making up and revising of stories. Storytelling means
explaining what the data mean, using data to describe how organizations work. Stories are theories.
Theory need not be formal or complex. Theories simply explain why. The "why" is important, and
researchers should be creative and ruthless in the pursuit of it (Weick, 1974). The why, not the data, is
the contribution to knowledge.(49)
Comparative, cross-national studies in nursing administration that are descriptive, analytic, or evaluative can
convey some wonderful stories to the world about nurses’ operating and management tasks, about the integrating
mechanisms they use, and about present and future collaborative arrangements. International research and
theorizing in nursing administration will help people of all nations better understand the "why" in nursing and health
services.
Recommendation One. Nursing administration research should be a top priority for nurse managers and
educators in positions to generate, facilitate, and utilize the research process and its outcomes.
Recommendation Two. Multiple, diverse research methodologies should be supported, including descriptive,
analytic, comparative, and other types of approaches such as policy analysis, programme evaluation, and diffusion
and utilization methods.
Recommendation Three. The International Council of Nurses (ICN) should consider forming a special
interest group for nursing administration, focusing on service, education, theory and research.
Recommendation Four. All governments and other funding agencies concerned with the organization and
management of health services should be encouraged to provide financial support for research in nursing services
administration.
THEORY DEVELOPMENT IN NURSING ADMINISTRATION
Accounts of the most highly significant studies consistently suggest that the best, most relevant research has
roots in the practical world as well as in the academic, and that it is conducted not for the sake of quick returns and
short-term expediency, but for useful, theoretical explanation.(50, 51) In a field where there are very few if any
systematic theories, all of the problems that could be investigated seem more or less equal.
Therefore, "Nothing is as practical as a good theory."(52) Kurt Lewin’s observation of nearly a half century ago
still sums it up best. Theories that are practical help people make sense of what is going on around them and
enable them to predict with a degree of confidence what will happen in the future, given what exists in the present.
WHO/HRH/NUR/92.3
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Sound theories tell interesting stories beautifully and simply.(53) The best and most useful theories represent
intelligent surmising, conjecture, and explanation about how to solve problems. They provide "patterns within which
data appear intelligible." (54).
Concepts and Theories for Nursing Administration
Nursing as a professional discipline is a young field, and nursing administration is even less developed. The
first textbook focusing on theoretical nursing appeared a little more than two decades ago. What some consider the
first theory text for nursing administration, by Arndt and Huckabay, was published as recently as 1975.(55) Theories
can range from unscientific speculations to sophisticated sets of facts, propositions, and hypotheses. In nursing
administration at the present time there are a number of nurses whose work qualifies as speculative. But there is
some early research which, if eventually extended, may prove useful not only for practice, but also for the
advancement of knowledge in nursing and nursing administration. In these studies, in the literature, and in practice,
the concepts of quality, interdependence, caring, health, environment, nursing requirements and nursing
organization appear to be foundational for the development of useful theories. Questions, however, that must be
addressed are, what criteria should be used to delineate concepts for theories in nursing administration? And, how
should the concepts in use and the theories applied or adapted be changed to fit the phenomena of nursing
administration?
Compared to nursing, public administration and management science have developed an abundance of
excellent research and many useful theories in the public sector, the emphasis on policy analysis, equity, and
citizenship has much to offer international nursing administration where an attempt is made to understand what it
means to have rights and obligations to the world as well as to one’s community and country.
The sub-discipline, in the public sector, of development administration is also useful. Suanes refers to the
development perspective in her chapter. Development administration is concerned with providing support for
interventions designed to lead people to being self-sustaining in their homes and communities.
In both public administration and management science, principles of human behavior are set forth in the body
of knowledge called organization theory. The principles of human behavior are sufficiently basic and can guide
research in any region of the world. The concepts identified most often in nursing administration are leadership,
motivation, communication, power, roles, organization, technology, and career commitment. The recent research in
organizational communication, the dependence aspect of power and resource-dependence, as well as population
ecology, suggest additional concepts that may prove useful and empirically testable in the future. Other useful
concepts are networks, coalitions, global cooperation, and the idea of the electronic cottage, where work is done
primarily at home with workers interconnected by personal computers and telecommunication devices.
As discussed, the concepts of primary care and clinical epidemiology appear to have much to offer a model of
international nursing administration. Drawing on the fields of medicine, economics, and public health, clinical
epidemiology emphasizes heavily the application of biostatistics for solving management problems at every level - in
the home, community, and country. Measurement is relied on for the evaluation of health needs. In order to
allocate resources in rational and equitable ways. Programme implementation is also key. The concepts drawn
from economics include, among others, those of costs, labour, manpower, consumption, and productivity. Primary
care emphasizes many of the same concepts at the individual and community levels.
Bronowski says that science is the "creation of concepts and their exploration in facts."(56) Concepts and the
theories of which they become a part need to be examined and developed for the individual, organizational and
professional levels. Multiple approaches to theory-building for nursing administration that are inductive and
deductive and that begin with concept clarification are appropriate. Middle-range theories of nursing administration
are needed that link the administration of nursing services to the care people receive and their health.
International Nursing Service Administration
The model developed in this chapter represents an effort to synthesize a number of factors considered useful
for understanding international nursing service administration. This new framework is appealing for a number of
reasons.(1) It makes sense to have a model in light of the essential nature of nursing services for the health of all
societies, and the related responsibilities and many resources controlled by nurses throughout the world. (2) The
framework is consistent with the major recommendations of reputable scientists and practitioners. (3) Yet it is unique
- we know of no previous model for nursing administration where there is so heavy an emphasis on medicine,
epidemiology, and primary care as there is in this one.
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There are three dimension to the model; the contextual factors, the fields for interdisciplinary inquiry and
practice, and the spheres of application.
Contextual Factors. The five contextual variables (environment, economy, technology, government and
society) have been articulated in some of the professional sciences. In nursing, a great deal of attention has been
paid to socio-cultural factors. But there has been relatively little attempt in nursing administration to attend seriously
to environments that are external to organizations. We are unaware of any perspectives that comprehensively
address intersectoral concerns: the connections between, for example, housing and climate; and the implications of
these for the management of nursing services in hospitals and communities.
By no means is it absolute that the five variables and connections are the right or only ones. But that they
exist appears to be logical and testable. It seems logical to say that to understand how nurses manage, careful
attention must be paid to governments, economies, environments, technologies, and cultures. Analyzing the
connection of each with all other factors is equally essential because it illustrates interdependence and where the
intersectoral relationships lie. Throughout the world, in all settings, when we conceive of how nurses manage and
how nursing services are organized, it is in terms of people's values, available resources, health and disease,
environmental threats to which people are exposed, protective or restraining governmental regulations, the
technologies and manpower available for work, the costs entailed, and the anticipated level of labour productivity.
Fields for Inquiry and Practice. The second aspect is the representation of the fields for interdisciplinary
inquiry and collaborative practice in nursing service administration. Five fields are illustrated at the intersections
formed by the lines connecting the contextual factors.
In the five-point figure, the practice and inquiry of nursing services administration is depicted as aligned with
medicine, public health, economics, management, and nursing. These disciplines provide fundamental sources of
knowledge for nursing administration. Medicine has the needed knowledge of diseases and their cure. Public health
and medicine provide the perspective of clinical epidemiology, which also incorporates knowledge of resources and
their allocation using theories of economics. Public administration supplies the knowledge about public finance,
public service, equity, development administration and citizenship. Business administration improves our
understanding of how to balance supply and demand to assure fiscal strength. And nursing provides knowledge of
how people respond to illness, how they maintain their health, and how they care for themselves and are cared for.
Model of International Nursing Administration. The contextual variables and fields of inquiry are combined
to form the model of international nursing administration. Completing the model are spheres of application: the
world, country, region, community, and organization or home.
Environment
World
Country
Nursing
Economy
Technology
Management
Medicine
Nursing
Management
Region
Community
Economics
Public
Health
Organization,
Home
Government/
Politics
Society
WHO/HRH/NUR/92.3
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The model says that the practice and inquiry (education, research and theory) for international nursing service
administration is related to and synthesizes knowledge from nursing, medicine, management, economics and public
health. Another set of relationship exists for nursing administration between its practice and inquiry and the five
contextual variables. Nursing administration is at the hub of these for the management of the nursing services that
people receive throughout the world, and in every region, country, community, and organization or home.
Recommendations
Recommendation One. For responsible practice of nursing administration throughout the world, resources
should be invested in the development of theory and research in nursing services administration.
Recommendation Two. To develop and improve theories of nursing administration, the relationships with
colleagues in related disciplines such as health services administration, public health administration, management
science, and medicine should be encouraged, increased, and strengthened.
Recommendation Three. Because theories are usually studied and developed in graduate programmes
(advanced post-basic), and since the preparation of theorists and researchers entails advanced education, nursing
service administration as a major focus of study should be offered at the graduate university level to hasten theory
development in nursing administration.
Recommendation Four. A small group should be established to work on theory development in nursing
services administration with similar working groups in each country.
Recommendation Five. Means should be developed for the dissemination of information about theory
building research in nursing administration among countries.
What has been written for this volume represents the initial thinking of people from more than 20 countries, in
nearly every major world region, who are extremely interested in how nursing services are managed. Our firstgeneration effort provides the rudiments of an understanding of international nursing administration.
In the words of Victor Hugo, "Nothing in the world is more powerful than an idea whose time has come." The
time has come for the idea of international nursing administration.
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WHO/HRH/NUR/92.3
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ANNEX B
QUESTIONNAIRE
MANAGEMENT OF HEALTH SERVICES BY NURSES
Name (Print or type in all upper case letters):
Title:
Address:
Telephone:
Telefax:
Your primary professional field (Check one)
_______ Nursing
_______ Medicine
Management
Public Health
Your primary role (Check one)
Education
________ Administration
Government official
Elected or appointed political official
_______ Research
May we list your name and place of employment in reports and publications?
Yes
No
Instructions:
Read the chapter in the blue folder. Then answer each question.
The pages referred to in some questions are in the chapter.
Develop your responses as fully as you can.
Where possible, attach documents describing your country, its health services, and nursing written in
English.
NURSES IN LEADERSHIP AND MANAGEMENT
1.
What are the senior leadership positions in nursing in your country’s organizations, communities, districts, and
national governments?
Do you have a Chief Nursing Officer (or an equivalent) in the Ministry or National Department of Health?
Yes
No
If you have, briefly describe the main functions of the person in this position.
2.
What are the characteristics of your nurse leaders which contribute to their success in the operation of
institutions and making health-care policy?
Include information about their education, skills, attitudes, and connections.
3.
How are nurses involved in the planning and policy-making for health services at the community and national
levels in your country?
WHO/HRH/NUR/92.3
page 78
ADMINISTRATION OF HEALTH SERVICES BY NURSES
4.
Compared with the problems described on pages 262-269, what are the major problems nurses now in
management positions face in your country?
5.
What actions do your suggest to overcome the problems you have described above?
EDUCATION FOR IMPROVED NURSING LEADERSHIP & MANAGEMENT
6.
What subjects in your country are included at the education levels listed
below to prepare for leadership?
Basic nursing education
Post-basic education
University education
Continuing education
7.
Do you have Home-Study and Distance Learning Programmes to educate nurses for management? (Check
one)
Yes
No
8.
How useful are the educational guidelines for nursing administration on pages 272-279 for your country?
What would you add or delete?
RESEARCH FOR NURSING LEADERSHIP AND MANAGEMENT
9.
Are nurses taught how to conduct research in your country?
No
Yes
10. Research topics are described on pages 283-288. Which ones are very important for your country? What
topics are not important?
11. Which methodologies, as described on pages 285 and 288, are used most often in your country, and which
may be used in the future?
12. What further recommendations do you have to improve the research for management of health services by
nurses?
THEORIES FOR LEADERSHIP AND MANAGEMENT BY NURSES
13.
Describe the theories you think are most useful for improving the administration of health services by nurses
for your country. Refer to pages 289-291.
14. A model to understand nursing administration throughout the world is described on pages 291-295. Although
we are interested in unique variations by country, our goal is to have a model that is useful for everyone who is
interested in understanding nurses’ management.
Does the model summarize the major ideas for nurses who manage?
Yes
No
If "No,” what would you add or how would you change the picture?
15. Does the model provide a useful guide for the education of nurse leaders and managers in your country?
Yes
No
If "No," please explain.
WHO/HRH/NUR/92.3
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ANNEX C
COUNTRIES OF STUDY AND PARTICIPANT DISTRIBUTION DATA
The 76 countries In the WHO Regions were: Africa: Cameroon, Chad, Gambia, Ghana, Guinea-Bissau,
Kenya, Malawi, Mauritania, Nigeria, Rwanda, Seychelles, South Africa, Togo, Uganda, Zaire, Zambia, and
Zimbabwe. Americas: Antigua and Barbuda, Brazil, Canada, Colombia, Cost Rica, Ecuador, Haiti, Honduras,
Panama, Suriname, Trinidad and Tobago, and the United States of America. Eastern Mediterranean: Cyprus,
Egypt, Jordan, Pakistan, Saudi Arabia, Somalia, Sudan, and Yemen. Europe: Austria, Belgium, Bulgaria, Denmark,
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Malta, Netherlands, Norway, Poland,
Portugal, Spain, Sweden, Switzerland, Turkey, United Kingdom of Great Britain and Northern Ireland, Yugoslavia.
South-East Asia: Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand. (The response for
Myanmar was provided by a non-national consultant.) Western Pacific. Australia, China, Fiji, Japan, New Zealand,
Philippines, Republic of Korea, Viet Nam. Responses were also obtained from Bermuda and the US Virgin Islands.
The countries of the respondents by country group, at the time of the data analysis, were as follows.
Least Developed*: Bangladesh, Chad, Gambia, Guinea-Bissau, Haiti, Malawi, Mauritania, Myanmar, Nepal, Rwanda,
Somalia, Sudan, Togo, Uganda, and Yemen. Developing: Antigua and Barbuda, Bermuda, Brazil, Cameroon,
China, Colombia, Cyprus, Ecuador, Egypt, Fiji, Ghana, Honduras, India, Indonesia, Jordan, Kenya, Malta, Nigeria,
Pakistan, Panama, Philippines, Republic of Korea, Saudi Arabia, Seychelles, Sri Lanka, Suriname, Thailand,
Trinidad and Tobago, Turkey, Viet Nam, Yugoslavia, Zaire, Zambia, and Zimbabwe. Eastern Europe: Bulgaria,
Hungary, and Poland. Developed: Australia, Austria, Belgium, Canada, Denmark, Finland, France, Germany,
Greece, Iceland, Ireland, Israel, Italy, Japan, Netherlands, New Zealand, Norway, Portugal, South Africa, Spain,
Sweden, Switzerland, United Kingdom of Great Britain and Northern Ireland, and the United States of America.
* WHO Least developed countries in World Health, Geneva, March 1990, p.5.
Study Participants’ Fields and Roles
Participants’ Professional Fields by WHO Region
Europe
SouthEast
Asia
Western
Pacific
27
19
Field
Africa
Americas
Eastern
Mediterr.
Nursing
17
20
9
45
1
5
Medicine
Management
1
Public Health
3
Column Totals
21
(12%)
1
21
(12%)
10
(6%)
Total
137
(79%)
6
(4%)
8
3
3
16
(9%)
4
3
3
13
(8%)
62
(36%)
33
(19%)
25
(15%)
172
(100%)
WHO/HRH/NUR/92.3
page 80
Primary Professional Field of Participants by Country Development Group
Least
Developed
Developing
Eastern
Europe
Developed
Nursing
13
70
4
50
137
(79%)
Medicine
1
1
4
6
(4%)
Management
1
5
9
15
(9%)
Public Health
2
6
5
13
(8%)
Column Totals
17
(10%)
82
(48%)
69
(40%)
172
(100%)
Field
4
(2%)
Total
Primary Role of Participants by WHO Region
Field
Africa
Americas
Eastern
Mediterr.
Europe
S.East
Asia
Western
Pacific
Education
11
8
6
17
17
11
70 (41%)
Admini
stration
8
10
3
27
15
10
73 (42%)
Gov.
Official
1
1
1
9
1
3
16
(9%)
2
(1%)
1
11
(7%)
Elected
Total
2
Research
1
2
Column
21
21
10
62
33
25
172
Totals
(12%)
(12%)
(6%)
(36%)
(19%)
(15%)
(100%)
7
Primary Role of Participants by Country Development Group
Least
Developed
Developing
Eastern
Europe
Developed
Education
6
40
2
22
70 (41%)
Administration
9
36
1
27
73 (42%)
Gov. Official
2
5
1
8
16 (9%)
2
2 (1%)
10
11 (7%)
Field
Elected
Research
Column Totals
1
17 (10%)
82 (48%)
4 (2%)
69 (40%)
Total
172 (100%)
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