KEY WORDS Nurse Migration Job Satisfaction Retention Workforce Planning Minimum Service Delivery Standards Punjab Nursing School Punjab Public Health Sector
Team Leader Dr Shabnum Sarfraz Team Members: Mr. Arshad Usmani, Deputy Director PDSSP Mr. Qurban Shah, Assistant Director PDSSP Mr. Jahanzeb Waheed, Project Analyst TAMA Mr. Omar Qasim, Research Associate
Authorship This report has been authored by Dr Shabnum Sarfraz, with support from the PDSSP, TAMA, ADB and the offices of the Director General Nursing, Punjab. Analysis of the qualitative data in this study was conducted with the assistance of the Nur Centre for Research and Consulting.
Contents ACRONYMS .............................................................................................................................................. i GLOSSARY OF TERMS ............................................................................................................................ iv RESPONSIBILITY ..................................................................................................................................... vi ACKNOWLEDGEMENTS ........................................................................................................................ vii EXECUTIVE SUMMARY ..................................................................................................................... viii 1.
CONCEPTUAL FRAMEWORK ........................................................................................................... 1 1.1
The Nursing Purpose ............................................................................................................... 2
1.2
Historical Perspective of the Nursing Profession .................................................................... 2
1.3
Context of the assignment ...................................................................................................... 3
1.5
Methodology & strategy employed ........................................................................................ 4
1.7
Achieving MDG........................................................................................................................ 6
1.8
Nurse Migration ...................................................................................................................... 7
1.9
Switching to opportunities in the private sector .................................................................... 8
1.10
Reconciling the demand with supply ...................................................................................... 8
2.
JOB SATISFACTION & MOTIVATION ............................................................................................ 10
3.
RECRUITMENT & RETENTION....................................................................................................... 14
4.
NURSE MIGRATION ...................................................................................................................... 19
5.
SITUATIONAL ANALYSIS .......................................................................................................... 24 5.1
Introduction: ......................................................................................................................... 25
5.1.1
Significance of the study ............................................................................................... 25
5.1.2
Objectives of the study ................................................................................................. 25
5.1.3
Research Questions....................................................................................................... 25
5.1.4
Scope of the Study ........................................................................................................ 26
5.2
Methods ................................................................................................................................ 26
5.2.1
Setting ........................................................................................................................... 26
5.2.2
Subjects and methods ................................................................................................... 26
5.3
Data analysis ......................................................................................................................... 28
5.4
Results ................................................................................................................................... 28
5.4.1
Reasons for selecting Nursing as a Career Option ........................................................ 28
5.4.2
Interest in acquiring higher nursing qualifications ....................................................... 29
5.4.3
Preference for working in the Public, Private Sector .................................................... 29
5.4.4
Nurse Migration ............................................................................................................ 30
6.
7.
8.
5.4.5
Working in the Rural Health Care Setting in Punjab ..................................................... 30
5.4.6
Job Satisfaction & Work Environment .......................................................................... 31
5.5
Discussion.............................................................................................................................. 31
5.6
Limitations of the study ........................................................................................................ 32
5.7
Conclusion/Recommendations ............................................................................................. 32
NURSING SCHOOLS IN PUNJAB .................................................................................................... 34 6.1
Educational Programs for Nurses in Punjab ......................................................................... 35
6.2
Accredited Schools and Colleges of Nursing in Punjab ......................................................... 36
6.3
Production of Nurses in Punjab ............................................................................................ 36
RECOMMENDATIONS ................................................................................................................... 39 7.1
General Overview of nursing workforce planning – International Perspective ................... 40
7.2
Existing mismatch between nurse production and absorption ........................................... 41
7.3
Nursing workforce planning for meeting the MSDS benchmarks ........................................ 41
EMERGING ISSUES ..................................................................................................................... 45
References: ........................................................................................................................................... 48 ANNEXURE……………………………………………………………………………………………………………………………………52
ACRONYMS
i
AD
Assistant Director
ADB
Asian Development Bank
HRP
Human Resource Planning
MSDS
Minimum Service Delivery Standards
M&E
Monitoring & Evaluation
NEB
Nursing Examination Board
PNF
Pakistan Nursing Federation.
AIMC
Allam Iqbal Medical College
BScN
Bachelor of Science in Nursing
BHU
Basic Health Unit
BPS
Basic Pay Scale
BS
Basic Scale
CN
Charge Nurse
CON
College of Nursing
CHC
Community health Center
CPD
Continuous Professional Development
CCU
Coronary Care Unit
DFID
Department for International Development
DOH
Department of Health (Punjab)
DCNS
Deputy Chief Nursing Superintendent
DD
Deputy Director
DGHS
Director General Health Services
DGN
Director General Nursing
DCO
District Coordination Officer
DHQ
District Head Quarters
DHDC
District Health Development Centre
DHIS
District Health Information System
DOH
District Officer Health
EDO
Executive District Officer
EDO-H
Executive District Officer Health
FGD
Focus Group Discussion
Induction & Retention of Nurses: Resolving the Planning Mismatch
ii
GoP
Government of Pakistan
GoPb
Government of Punjab
HHR
Health Human Resource
HIS
Health Information System
HMIS
Health Management Information System
HSRP
Health Sector Reforms Programme
HR
Human Resource
HRD
Human Resource Development
HRM
Human Resource Management
HRMIS
Human Resource Management Information System
IPH
Institute of Public Health
ICU
Intensive Care Unit
ICM
International Confederation of Midwives
ICN
International Council of Nurses
MScN
Master of Science in Nursing
MDGs
Millennium Development Goals
MOH
Ministry of Health (Pakistan)
NGOs
Non Government Organizations
NI
Nursing Instructor
PIMS
Pakistan Institute of Medical Sciences
PNC
Pakistan Nursing Council
PGCN
Post Graduate College of Nursing
PHC
Primary Health Care
PMO
Principal Medical Officer
PSON
Principal School of Nursing
PDSSP
Punjab Devolved Social Services Programme
PMDGP
Punjab Millennium Development Goals Programme
RN
Registered Nurse
RHC
Rural Health Centre
SON
School of Nursing
SHC
Secondary Health Care
SMO
Senior Medical Officer
TAMA
Technical Assistance Management Agency
Induction & Retention of Nurses: Resolving the Planning Mismatch
iii
THQ
Tehsil Head Quarters
TOR
Terms of Reference
UK
United Kingdom
UN UNICEF
United Nations United Nations International Children Education Fund
USAID
United States Agency for International Development
UHS
University of Health Sciences
VPSON
Vice Principal School of Nursing
WA
Ward Administration
WHO
World Health Organization
Induction & Retention of Nurses: Resolving the Planning Mismatch
GLOSSARY OF TERMS Accreditation
Accreditation Standards
The assessment and recognition of level of Quality of an organization such as an educational institution or a hospital by peer reviewers against a set of agreed standards, following a self-assessment by the organization. The recommendation by the peer reviewers is approved by an independent review board A standard is an established norm or requirement. Accreditation standards are contained in a formal document with uniform criteria, methods, processes and practices that an institution demonstrates in order to achieve the accreditation status. Standards cover management, service provision and user requirements
Clinical Placement
A period of time arranged for a student nurse, Lady Health Visitor or midwife to spend in a specified clinical area as part of their educational programme
Continuing Medical Education
Continuing medical education (CME) refers to a specific form of continuing education (CE) that helps those in the medical field maintain competence and learn about new and developing areas of their field
Continuous Professional Development
CPD can also be defined as the conscious updating of professional knowledge and the improvement of professional competence throughout a person's working life. It is a commitment to being professional, keeping up to date and continuously seeking to improve. It is the key to optimizing a person's career opportunities, both today and for the future (Chartered Institute of Professional Development (2000)) MSDS are defined as “minimum level of services, which the patients and service users have a right to expect�. MSDS include minimum package of services, standards of care (level specific) and mandatory requirements/system specifications that must be complied with and are vital to ensure the delivery of these services
Minimum Service Delivery Standards (MSDS)
Primary Health Care (PHC)
Registered Nurse Skill-mix
Standard Operating Procedure
iv
PHC is “Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families To be a registered nurse in Pakistan, one must complete a 3 year general nursing diploma, or a 4-year BScN degree This refers to the mix of health staff based on the roles, experience and activities that different categories of staff have. Rather than having all junior or all senior staff, or all nurses or all LHVs, a mix of experience and of staff type is used to achieve a more efficient workforce in a particular setting Detailed description of steps required in performing a task
Induction & Retention of Nurses: Resolving the Planning Mismatch
(SOPs) Standards of practice
v
Standards of practice describe the criteria, activities/ behavior and practices that a profession requires its members to meet. They are used to assess competency to practice within the discipline and are closely aligned to the scope of practice of the discipline
Induction & Retention of Nurses: Resolving the Planning Mismatch
RESPONSIBILITY "The contents are this study/report are the sole responsibility of the consultant and do not necessarily reflect the views of Punjab Devolved Social Services Program (PDSSP), Technical Assistance Management Agency (TAMA), Asian Development Bank (ADB) or the Government of Punjab."
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Induction & Retention of Nurses: Resolving the Planning Mismatch
ACKNOWLEDGEMENTS First & foremost we would like to acknowledge the Punjab Devolved Social Services Programme (PDSSP) & TAMA for taking up this assignment and several other recent health initiatives which we feel will make a vital contribution towards the provision of efficient and effective healthcare service delivery in Punjab. We are thankful to them for their support during this assignment. We are particularly thankful to the office of Directorate General Nursing who extended all possible facilitation towards data collection. We are most grateful to Prof Aman Ullah, Khan, the Senior Research Advisor at the Nur Centre for Research & Consulting for providing valuable inputs on developing the guiding framework for FGDs, on the findings, which helped improve the interpretation and analysis. The extensive review of relevant literature would not have been possible without the support of Miss Janet Maria Scott who provided extensive literature on nurses’ workforce planning, job satisfaction, retention and migration, which proved invaluable in developing insight into the subject issue. We must also acknowledge the contribution of all of the nurses who willingly participated in the study. We hope that their time and effort will result in improvements in the nursing profession in Punjab.
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Induction & Retention of Nurses: Resolving the Planning Mismatch
EXECUTIVE SUMMARY
viii
Induction & Retention of Nurses: Resolving the Planning Mismatch
In the recent years there has been an increased attention from local and international health community on a rather neglected resource of health systems, the Health Human Resource. The HHR shortage is now being identified as one of the major challenges for improving health outcomes in low-income countries. The Nursing workforce shortage was the focus of study. Against the internationally recommended nurse doctor ratio of 4 nurses to 1 doctor, the nurse doctor ratio for Pakistan is inverse i.e. 3.5 doctors to 1 nurse. Despite having half the total number of schools in Pakistan, the nurse population ratio for Punjab is worse than the overall nurse population ratio for Pakistan. The challenge confronting the Government of Punjab for addressing the situation remain the enhanced induction, absorption and retention of nurses in the public health sector. Focus Group Discussions were undertaken that provided a better understanding of the factors that influenced motivation, job satisfaction and retention of nurses in the public health sector. It further helped in the identification of the institutional and systemic problems in the public nursing sector. Based on the findings of the FGDs, recommendations are drafted for policy makers for addressing the existing situation. As part of the assignment, data was collected from the nursing institutes in Punjab and their annual intake and expected output was compiled. It became apparent that a mismatch existed between the output of the 56 public and private nursing training institutions in Punjab and the actual number of nurses absorbed by the Health Department of the Government of Punjab. At the present rate of output of the nursing schools in Punjab, in the next 5 years, about 6,000 nurses will have completed their training. With an annual increase of 10% in the annual intake every year, it is expected that an additional 19653 nurses will be added to the existing pool of 9000 nurses in Punjab over the next 10 years. This is essential for addressing the Nurse Population Ratio which at present is 1 nurse to 10,000 population. With a minimal annual increase of 10% in the nursing student intake this ratio is expected to improve to 1 nurse to 5000 population by the end of 7 years. It is evident that the existing nursing schools in the province produce a number of nurses that over the coming years will not be entirely absorbed by the public sector. The present assignments provided a 5 year plan keeping in view the intake and expected output of schools of nursing in Punjab, the present sanctioned posts for nurses in the public health sector and the required nursing posts as per the MSDS defined for the public health sector in Punjab. At the present nursing intake in the Schools of Nursing in Punjab, if the sanctioned posts are increased to absorb 25% of the annual output, the MSDS benchmark for Nurse Requirement will be met over the next 5 years. Increase in the sanctioned posts will however not address the present nurse population ratio of 1 nurse to 1000 population in Punjab. This will be addressed only if the annual intake of nurses is proportionately increased every year This plan will provide a foundation on the basis of which provincial stakeholders can design and implement strategies for adjusting the supply and demand of trained nurses in order to meet the provincial health sector requirements over the coming years as per the MSDS bench marks.
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Induction & Retention of Nurses: Resolving the Planning Mismatch
1. CONCEPTUAL FRAMEWORK
1
Induction & Retention of Nurses: Resolving the Planning Mismatch
1.1
The Nursing Purpose
Nursing is a profession concerned with the provision of services essential to the maintenance and restoration of health by attending the needs of those who are sick. Nurses are with people during the most critical times of their lives; when they are born, are injured or ill and when they die. There are many roles in nursing. The nurse cares for the patient, carries out procedures ordered by the doctor and as a member of the healthcare assesses the patient and treats his or her problems as per advice and guidelines provided by the doctor. The nurse coordinates the work of others healthcare professionals involved in caring for the patient, including the patientâ€&#x;s family. The nurse also protects the patient from infection and ensures a safe, healthy environment in the hospital. Finally, the nurse educates the patient and their family about health-related matters and plays a vital role in promoting patientsâ€&#x; well-being. The primary purpose of nursing is the promotion and maintenance of an optimal level of wellness. The professional nurse participates in a multi-disciplinary approach to health in assessing, planning, implementing, and evaluating programs in regards to how they affect optimum wellness for patients. When assessing health care needs, the professional nurse incorporates the physical, emotional, social, environmental and spiritual aspects of the profession into her daily routine. Being an important member of the healthcare professional team, it is important to retain them by better understanding the factors that contribute to their job satisfaction and elevates their motivation at work.
1.2
Historical Perspective of the Nursing Profession
Nursing is one of the oldest professions known to human kind. The first woman on earth provided care to her newborn child and family during illness or otherwise. It was not until the 19th century that a formal nursing college was established in the Indian subcontinent. More specifically in the northern India, now Pakistan, the first nursing school was established at Mayo hospital in 1884 and Miss Pesikaka has the honor of being the first Indian parsi girl who finally was accepted for training as nurse in 1934. When Pakistan came into being, the health sector had severe resource shortages. There were only three hospitals in Lahore: Mayo Hospital, Lady Aitchison Hospital and Lady Wellington Hospital. To make matter worse, majority of the nurses had migrated to the newly formed India, leaving Pakistan with a total number of 350 registered nurses that included retired nurses or those who were not in service. To resolve this acute shortage of nurses, a nursing school was established at Sir Gangaram Hospital, Lahore in December 1948. In 1952, the first batch of trained nurses completed the general nursing program. Next year, a post basic college of nursing was established in Karachi. Later years brought about the establishment of a second college of nursing at Lahore that taught specialist training programs to post basic students. In 1973, Pakistan Nursing Council was established which governed all nursing affairs, rules and regulation within the country.
2
Induction & Retention of Nurses: Resolving the Planning Mismatch
Today in Punjab there are a total of 51 schools of nursing, 76 schools of midwifery, 12 primary health schools, and 3 colleges of nursing. Nationally, there are 118 schools of nursing. These include those established by the government, armed forces and private sector. In addition to these, there are colleges of nursing which offer specialized courses to the nursing diploma holders and nursing graduates. The total number of students in nursing schools is a very important indicator to determine the number of faculty and administrative staff required in these institutions, both currently, and in the future.
1.3
Context of the assignment
Several factors identified as impacting the nurse retention in the public health sector include working environment, career perspective, education and training opportunities, human resource management protocols and the availability of perceived more attractive alternatives. These factors might be true and relevant but it was fundamental for the present assignment to undertake a more objective study where the issue was presented before the nurses and management of the nursing institutes, who were given an opportunity to identify the main factors that are affecting their job satisfaction and motivation at work and how that is changing the nursing labour force dynamics in Punjab. It is evident that a disparity exists between the turn-out of the public and private nursing training institutions and the actual number of nurses absorbed by the Health Department of the Government of Punjab. It is equally apparent that the existing nursing schools in the province produce a number of nurses, out of which majority are not being absorbed by the public sector. This leads to the problem of identifying whether the number of sanctioned posts for nurses will increase sufficiently to keep at par with this output of the training institutions. This is mandatory if we are to meet the Minimum Service Delivery Standards defined for the number of nurses in each level of healthcare facilities. At individual level, the decision to enter, remain and serve in the health sector workforce is influenced by a series of social, economic, cultural and gender-related determinants. At healthservice level, the commitment of health staff is determined by a number of organizational and managerial factors. The workplace environment has a great impact not only on health worker performance, but also on the comprehensiveness and efficiency of health service delivery. At the health-sector level, the use of tangible and intangible incentives is of crucial importance for having the accurate skill mix at the appropriate place. Factors that have led to a planning mismatch in nurse recruitment identified include: working environment, career perspective, education and training opportunities, human resource management protocols and the availability of perceived more attractive alternatives. The objectives of this assignment are summarized as under:
3
Induction & Retention of Nurses: Resolving the Planning Mismatch
1.4
Consultantâ€&#x;s comments on the terms of reference
The TORs were comprehensive and clearly indicated the two major activities that were to be undertaken: 1. An assessment of the existing situation in the nursing sector through secondary data analysis and focus group discussions 2. Provision of data of the annual output of nursing schools and colleges and the expected output over the next 5 years; To provide an analysis of the gap between the available number of nurses and the actual requirement for nurses in the public health sector to implement the MSDS in the next three to five years As the present assignment was for a duration of 48 days, it was requested that to facilitate the achievement of the objectives of this assignment, in this limited time frame, a senior nurse expert from the DG Nursing Office be nominated, to facilitate the process. The Research Assistant directly coordinated with the DG Nursing Office, under the guidance and supervision of the Team Leader for retrieval of information and requisite data. The support of the PSU and DG Nursing Office in sourcing relevant information and documents remained vital, throughout the course of the assignment, in meeting the deliverables. Based on the above findings, report was drafted, which included recommendations for policy makers for addressing the existing situation, along with a proposed 5 year plan for better adjusting supply and demand for trained nursed in order to meet the provincial public health sector as per the MSDS bench marks. The Consultant also provided an analysis on the basis of nurse population ratio, accepted internationally.
1.5
Methodology & strategy employed
Week
Target Activity
Week 1
Developing of Weekly Plan
4
Methodology & Strategy
Deliverables
Broad Review of TOR; Meeting with Detailed Work plan PDSSP-TAMA representatives
Induction & Retention of Nurses: Resolving the Planning Mismatch
Week 2
Week 3
Developing Inception Report Review of International Literature Review Best Practices
Inception Report Reference List Articles/ Books
of
Prepare a brief synopsis of the findings and recommendations Developing framework for FGDs for 4 target stakeholders Gather the views and Focus Group Discussions perspectives of qualified nurses in the public sector (2 FGD)
Reference List Articles/ Books Brief Synopsis FGD Framework
of
Transcriptions FGDs held
of
Focus Group Discussions
Transcriptions FGDs held
of
Focus Group Discussions
Transcriptions FGDs held
of
Data Collection and analysis
Final Report
Gather the views and perspectives of qualified nurses in the private sector (2 FGD) Week 4
Week 4 -5
5
Gather the views and perspectives of senior managers of training institutions (10) Gather the views and perspectives of trainee nurses (3 FGD) Provide data of the annual output of nursing schools and colleges in the province over the next 5 years Establishing the expected requirement of nursing posts (all categories) for the coming 5 years as per the benchmarks established by the MSDS Provide an analysis of the gap between the available number of nurses and the actual requirement for nurses in the public health sector to implement the MSDS in the next 3-5 years
Meetings with stakeholders, Final Report esp PNC and Nursing Advisor MOH
Data Collection and analysis
Induction & Retention of Nurses: Resolving the Planning Mismatch
Final Report
Provide a five-year plan on how to better adjust supply and demand for trained nurses in order to meet the provincial public health sector requirements Consultative Workshop Prepare in consultation with the relevant departments/stakeholder s, the expected requirement of nurses in the province in the public sector in the next five years Finalization and submission of Report
Week 6
Week 7
1.6
Data Collection and analysis
Final Report
Developing the Power point Final Report Presentations; Guided Questioning formats.
Compiling the stakeholder Final Report feedback received
Motivation of Nurses
Developing countries are faced with the compounding problem of poor pay, lack of professional development and career structure, unsafe or undesirable domestic conditions and poorly resourced and equipped health facilities. Nurses are also perceived as lacking “meaningful participation� in health care decision making, public policy, and research initiatives. These are seen as de-motivating factors for nurses and could result in skill loss from the public sector. At individual level, the decision to enter, remain and serve in the nursing health sector workforce is influenced by a series of social, economic, cultural and gender-related determinants. At health-service level, the commitment of health staff is determined by a number of organizational and managerial factors. The workplace environment has a great impact not only on health worker performance, but also on the comprehensiveness and efficiency of health service delivery. At the health-sector level, the use of tangible and intangible incentives is of crucial importance for having the accurate skill mix at the appropriate place.
1.7
Achieving MDG
Scaling up of priority interventions is likely to require significant investments in pre service and continuous professional development programs for nurses. At the same time coherent national Human Resource for Health (HRH) policies are required for giving direction on HRH development and linking HRH into health-sector reform issues. Key determinants of success for achieving Millennium Development Goals are closely related to human-resource development as well. The commitment of the national & international community to achieve the MDGs offer a unique opportunity to strengthen health services in low-income countries.
6
Induction & Retention of Nurses: Resolving the Planning Mismatch
These initiatives put human-resource issues at the forefront, but need the corresponding leadership and strategic vision of government and decision-makers. While there are signs of general interest on the parts of professionals and the public, nursing care has not received the same degree of attention as the medical cure. Many speculative questions concerning this worldwide problem exist. For example, does cure receive more attention than care because cure has been traditionally associated with males who get public recognition for their efforts? The public tends to reinforce dramatic cures that use new technologies; such new methods generally receive high “payoffs” and quick recognition in the media. People vaguely know that care is vital to recovery from illness and to maintenance of healthy life ways. A question to ponder upon is: What would the world be like today without human caring services? There can be no curing without caring, but there may be caring without curing.
1.8
Nurse Migration
The migration of health professionals from developing countries to the developed world has been a controversial problem for over three decades now, but the magnitude of the problem and its implications have changed due to the rapid pace of globalization. Countries of South Asia are victims of both internal migration (from rural, backward areas to the cities) as well as external migration (from country of origin to the Western countries in search of opportunities). The migration of nurses can be attributed to both external „pull‟ and internal „push‟. The external „pull‟ comes from globalization and the free market economy. While opportunities for professional training, higher salaries, perks and better living conditions act as “pull” factors, surplus production of health personnel, resultant unemployment, less attractive salaries, stagnation or underemployment coupled with lack of infrastructure act as “push” factors for the nurses to migrate. The United States, United Kingdom and Ireland recruit significant proportion of nurses from lower income countries. About 11% of nurses practicing in the United States are foreign-born, out of which 80% are from developing countries. Similarly, in 2000, the United Kingdom hired more than 8000 nurses and midwives from outside the European Union. Pakistan despite a critically low nurse population ratio is ironically losing its capable and competent nurses to the developed world (Adkoli, 2006). Western recruiting agencies and countries have been blamed for the „brain drain‟ of nurses from developing countries. The increasing demand for skilled human resources and better remuneration of the developed countries coupled with the poor work environment and low remuneration of the developing countries militate against the retention of skilled human resources in the developing countries. For example, in 2000 more than 500 nurses left Ghana to work in other industrialized countries: that is more than twice the number of new nurses who graduated from nursing programs in the country that year. In the last six years, the Nursing Advisor, Ministry of Health, Islamabad issued (NOCs) to 1916 nurses to proceed abroad for employment in different countries.
7
Induction & Retention of Nurses: Resolving the Planning Mismatch
1.9
Switching to opportunities in the private sector
Nurses in the developing countries are also leaving the public sector in search for better remuneration in the private sector including non-governmental organizations within their countries. This has obvious equity implications as the majority of the population especially in rural areas cannot access the public sector health facilities, as they may have been shut down due to lack of health personnel. For those health facilities still operational, the quality of care provided is compromised. Furthermore, those health workers that remain in the public sector have an ever-increasing burden of work.
1.10
Reconciling the demand with supply
Change is the only constant for health and social care. The challenge is to meet future needs and demands given the available resources in the most effective and efficient manner. It is important to understand the changes in the way care is delivered. The delivery and provision of health care services is dependent on the number of people employed and how they contribute to the healthcare service delivery. The demand for registered nurses is dependent on both the higher population growth rate in Pakistan as well as an ageing population. The supply is determined by the problems of intake and output of nursing students, retention and recruitment of nursing staff, migration of nurses to international labour markets and an overwhelming majority of females who are vulnerable to social/cultural factors that affect not only their decision to work but also their performance at work. At the crux lies the fact that there are not enough registered nurses in Punjab to effectively contribute towards the health care service delivery and this trend is expected to continue into the future, unless some drastic actions are taken. The internationally required nurse-patient ratio in a given population is 1:35. In Pakistan, the nurse patient ratio is 1:4500 (PNC, 2009). According to the Population Census Organization, the population of Punjab in year 2009 was approximately 90 million. With only 9,000 nurses working in Punjab, the ratio for Punjab is even worse i.e. 1:10,000. Though Punjab is producing nurses in a variety of health care settings, they are however not being absorbed effectively in the public health sector and quite a few are leaving for more lucrative opportunities in the private sector as well as overseas. This is putting continuous strain on the health care system to meet its demand with the aim of achieving the MDGs for health by 2015. To find equilibrium in the demand and supply of registered nurses, some important key strategies proposed in the literature will be mentioned here. Firstly, from the supply perspective, there should be an increase in the intake of nursing students in the schools of nursing. In Punjab this will be restricted by the availability of proper infrastructure and faculty to accommodate the increasing number of students in various nursing programs as well as by the financial implications of increasing the number of stipend seats in the schools.
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Induction & Retention of Nurses: Resolving the Planning Mismatch
Secondly for attracting nurses for filling the vacant posts, there is a need to offer competitive pay, family friendly policies, and a flexible career structure with accessible educational support. These factors contribute to higher levels of job satisfaction for the nurses. The third strategic option focuses on limiting the demand for registered nurses. This concentrates on reducing demand for health services by preventing disease and illness and managing the early stages of disease more effectively within primary care settings. It is important to note that there is a distinction here between the early diagnoses and early management of illness. Another strategic option is to increase the number of posts per health facility to absorb the nursing output from schools of nursing. This again is restricted by financial implications. All these key strategic options are mutually dependent. A balanced mix of these is recommended to be used by the policy makers for shaping health care demands, effectively using registered nurse time and for the recruitment and retention of nurses.
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Induction & Retention of Nurses: Resolving the Planning Mismatch
2. JOB SATISFACTION & MOTIVATION National & International Perspective
10
Induction & Retention of Nurses: Resolving the Planning Mismatch
To achieve optimum health for all, Pakistan needs to invest in enhancing the motivation and job satisfaction of its health care professionals in order to retain them and avoid problems that arise when there is an imbalance between the number of health professionals and the population of a country. Where this is true for all health care professionals, it is especially important in the context of nurses who are considered to be on the forefront of efficient and effective health care service provision. Job satisfaction is very important in health care because of its impact on patient satisfaction and quality of care (Newman et al. 2002). It is important to understand how we feel in life, if it is not possible to feel good about a job well done or to feel dissatisfied with some aspect of a job; it becomes worthwhile for the individual to re-evaluate their work position (Cowin, 2002). In nursing, a number of factors have been linked to job satisfaction including autonomy, respect and recognition, social integration, stress and organizational commitment, communication with supervisor, communication with peers, fairness and management style. In an article „Motivation and Personality‟, Maslow describes job satisfaction as an individual‟s evaluation of how well the job meets the personal expectations and needs, or more generally, as the employees‟ feelings and emotions towards their work experiences. Job satisfaction could also be explored with two aspects of values: intrinsic and extrinsic. Intrinsic values refer to immaterial aspects of the job, such as job variety and autonomy, while extrinsic values refer to material work aspects, such as salary and opportunity for promotion. Job satisfaction in turn has been identified as one of the most important predictors for nurses‟ intentions to remain employed (Cowin, 2002). There are a number of theories relating to job satisfaction. Herzburg‟s (1966) theory of motivation relates job satisfaction with extrinsic and intrinsic conditions. He argues that if certain extrinsic conditions are absent then dissatisfaction is more likely to occur. Extrinsic factors include salary, job security, working conditions, status, company procedures, quality of technical supervision and quality of interpersonal relations among peers, with superiors and with subordinates. Job performance generally tends to increase when certain intrinsic conditions are present. These are most commonly recognized as achievement, recognition, responsibility, advancement, the work itself and the possibility of growth. Susman et, al. (1979) supports the need/value fulfilment theory which relates job satisfaction to the individual‟s needs. The study demonstrated that nurses with better need fulfilment were more satisfied with their jobs and were likely to perform better. According to Borda and Norman (1997), job satisfaction in nursing was an important variable for retention of staff. They suggested that job satisfaction and turnover behaviour had a negative correlation. Job satisfaction has been associated with work over-load and autocratic management styles. Both intrinsic and extrinsic factors were associated with varying job satisfaction and affecting nurse retention. However, very few studies have found material factors such as salary to be a significant factor in determining job satisfaction and increasing retention. Cavanagh (1992) reinforces this point by depicting that nurses found other reasons apart from salary to be a major aspect in causing discontent at work. In a study conducted by Collins et, al and funded by the Department of Health (UK), views of 452 nurses were considered on job satisfaction, career development, intentions for leaving
11
Induction & Retention of Nurses: Resolving the Planning Mismatch
the profession and those factors that may cause hindrance in the workforce to work effectively. Levels of job satisfaction were high for nurses who felt an increase in freedom and autonomy at work, independence in managing their own cases and increase in responsibility put on the nursing staff. They found that nurses who were provided with role clarity and boundaries of practice felt more fulfilled at work as they felt more secure to practice independently within those boundaries. Similarly, those nurses who felt that the training that they had received in preparation for the role was sufficient felt more proficient at delivering services at workplace and thus were more satisfied. The study also found that nurses who felt more integrated within their own professional group and with immediate colleagues depicted higher levels of satisfaction. On the other hand, more than one in four nurses agreed with the statement that they would leave the profession if they could. The reasons for this statement are manifold. These included lack of career prospects and financial rewards, stress related to the role and low morale associated with continuous systematic and organizational changes in the health system. It is important to note that the study found a strong positive correlation between job dissatisfaction and intention to leave. According to Shields & Ward (2001), job satisfaction is a primary factor of nursesâ€&#x; intent to leave. A study conducted by them in the United States showed that dissatisfied nurses were 65% more likely to have intent to leave compared to their satisfied co-workers. There is a strong link between retention and migration. Globally, a common trend that is gaining ground is that of developed countries recruiting nurses from developing countries. The developed countries are positioned to take advantage of factors that encourage migration among those agreeable and able to relocate. These include relatively low pay, poor career structure and the lack of professional development opportunities. Such characteristics are very commonly found in the developing countries (Buchan, 2004). The migration flow is becoming significant in a number of instances. For example, in Malawi between 1991 and 2000, 114 nurses (60% of the total staff of registered nurses) in a single tertiary care hospital left for jobs in other countries (Martineau T, 2002). Similarly, in 2000-2001, 10% of the nurses in Barbados left the nursing sector to pursue profession abroad (Buchan J, 2004). According to figures published by World Health Organization (WHO), there is a significant increase in the flow of nurses into certain destination countries, both in terms of actual numbers and as a proportion of all new nurses becoming eligible to practice. They depict that there has been a rapid rise in the number of international nursing staff since the 1990s. The decision to migrate is essentially a personal one, however it is important to consider the overall economic and social context in which decision to migrate are made. These include active recruitment from countries such as India and the Philippines (which have an oversupply of nurses), social unrest, wars, deprivation etc. In studying the motivation of nurses in developing countries, it is important to observe that low job satisfaction and motivation affect the performance of nurses as well as acts to push people to migrate. Non-financial incentives as stated earlier, play a pivotal role in retaining staff and limiting the flow of workers to opportunities abroad. Therefore, it is important to note that these accelerated levels of nurse migration may be a symptom of systemic problems in the nursing workforce in both the source and destination countries.
12
Induction & Retention of Nurses: Resolving the Planning Mismatch
According to Buchan, J (2004), various focus groups and case studies of foreign nurses have unveiled that majority of the nurses were receptive to stay in their home country if their quality of life at work had been fulfilling. It is a widely accepted phenomenon that higher levels of job satisfaction are associated with lower levels of stress and that there is a positive association between job satisfaction and a nurse‟s commitment to the organization (Buerhaus, 1991). At the same time, there is a strong positive relationship between intention to leave and actual turnover. Perrin, Hagopian, et al. (2007) conducted a survey mailed to 200 Philippine hospitals chief of nurses and reported that RN staffing in government hospitals is more favorable than in private hospitals. They found that higher salaries, better benefits, and good career opportunities were the most effective incentives for both recruitment and retention. Khowaja (2007) states that “The nursing profession demands respect and recognition. Conducive working environment is mandatory for nurses to do their jobs happily.” Ghaffar (2007) found low salaries, poor working conditions, poor image of nurses, less opportunities for advancement and lack of educational opportunities as causes of job dissatisfaction in Pakistan. The “sad state of affair” in terms of salaries, benefits, working conditions and hostel facilities among nurses in Pakistan has also been described by Nasreen (2007). In the context of the present assignment, it is important to point out that career opportunities and work environment have a strong relationship with job satisfaction and can act as a trigger for qualified and competent nurses for migrating abroad. If both the government and the relevant national and international agencies wish to create an “ethical” environment in which the individual is under no pressure to leave and desire to respect the rights of an individual nurse to migrate, they must engage actively and positively in understanding these dynamics and respond by implementing strategies that work towards enhancing motivation and job satisfaction of the nursing staff. The first most fundamental answer to this problem is for the Government of Punjab is the continual support towards improvements in working conditions, scheduling, career prospects, security, prestige and pay of nurses especially working in the Rural Punjab. It is evident that the flow of nurses from developing to the developed countries is a byproduct of the active recruitment by the Middle Eastern and western agencies. However, it is crucial to understand that the underlying problem can be solved only by making local-level and country-level improvements in the status of nursing. This includes workforce planning and investment in the health human resource protocols directly linked with job satisfaction and motivation of the nursing workforce.
13
Induction & Retention of Nurses: Resolving the Planning Mismatch
3. RECRUITMENT & RETENTION Taking lessons from international models
14
Induction & Retention of Nurses: Resolving the Planning Mismatch
As established earlier in this report; job satisfaction leads to retention and recruitment which are a policy outcome of a well developed and successful nursing workforce planning. In January 1999, a report “Good Nursing, Good Health: an Investment for 21 Century” was presented by the Nursing Task Force, which was accepted by the government of Ontario, Canada and immediately put into implementation. After this report, the committee of RNAO (Registered Nurses Association of Ontario) decided to conduct a survey on 549 nurses (93% of them members of RNAO) to determine the extent to which registered nurses have seen specific changes in their work environments and whether these changes improved their level of satisfaction at work (RNAO, 2002) The results of the report suggest that nurses found; being valued, of having their knowledge, skills and expertise recognized, and their contribution to the welfare of patients as a major factor in affecting their job satisfaction. The term „meaningful participation‟ is extremely crucial as it implies not only on involving the nurses in the decision-making process but also having their role in influencing the overall decision taken. The work environment was made more attractive by providing nurses flexibility in working hours, and more control over practice and workload management. The report found that opportunities to continue education were a major catalyst in strengthening the bond between the nurse and his/her profession. Majority of nurses would leave the profession if prospect of continuing education were not provided to them. The report suggested that with the increase in population and increasing patients‟ need, the necessity for retaining existing nurse workforce and making it more attractive to prospective nurses is ever growing. The major purpose of the recommendations is to ensure satisfactory working conditions for all nurses, which include:
Adequate allocation of targeted resources by the Government to restore nursing staff level to acceptable levels. This is needed to suffice the demands of a growing population. The government to address the exacerbating reality of wage inequities across the health-care professions, and within public and private sector. Employers to develop guidelines to assist in determining adequate nurse-patient ratios. The drastic impact of this ratio on mortality rates have been highlighted by Tourangeau et al (2002). Improvement in the job satisfaction by providing flexibility in work schedule, and establishing mechanisms to facilitate staff nurse participation in key organizational and unit committees. Employer to support for orientation, mentoring, on-the-job training and academic upgrading, where the government should extend its support for formal nursing education at the baccalaureate and graduate levels.
In a report by the Audit Commission UK on warding staff (2001), focus was given to the difficulties in the recruitment and retention of nurses, caused by stringent shift patterns. The trusts were encouraged to offer flexible shift patterns to enable staff to work at times that fit align well with their other obligations. Moreover, the ward managers were provided with more freedom to organize shifts to suit both the temperament of the work in their particular
15
Induction & Retention of Nurses: Resolving the Planning Mismatch
specialty and the preferences of their ward staff. This was an initiative taken to facilitate those nurses to continue working who would have otherwise quit their jobs due to pressing personal commitments and obligations by offering them with the flexibility essential to adjust their professional and personal commitments. For a more equitable, efficient, effective, and sustainable healthcare delivery system, following factors are identified in the literature as major drivers that affect the recruitment and retention of nurses in primary care:
Recruitment policies, Job satisfaction, Positive working environment, Career prospects, Education and training opportunities, Human resource management protocols and Availability of perceived more attractive alternatives
Bishop and Jones (2001) put some light on the aspect of recruitment and retaining strategies that primary care health managers could adopt. They highlight the importance of career pathways, a flexible retirement project and a tailored primary care clinical orientation program. Edwards (2002) has described the need to establish rotational placement scheme that could help positively address the issue of retention and make the profession more attractive. Drennan et al (2006) identified six types of initiatives that were targeted at qualified nurses in UK for achieving efficiency in recruitment and retention. These are depicted in the table below:
TABLE 1 : Initiatives Induction courses and training posts for registered nurses entering practice nursing, some linked to degree module Rotational training posts, providing clinical experience in more than one area of primary care nursing (sometimes into the acute sector) and linked to education pathways Supported work-based learning programs, clinical induction programs, formal preceptor schemes for registered nurses new to primary care and nurses returning to practice Return to primary care nursing courses and associated bursary schemes Work-based education programs to degree level education for registered nurses working in primary care Other recruitment and retention initiatives across primary care nursing, e.g. marketing campaigns, flexible retirement projects, primary care health-care assistant development programs.
Source: Drennan et al (2006)
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Induction & Retention of Nurses: Resolving the Planning Mismatch
Drennan et al (2006) formulated a model for attracting and retaining registered nurses in primary care. This model provided a different insight as to the ones provided by its predecessors on the subject issue. It not only focuses on the career development of nurses already present in the health sector but also on those nurses who are inclined towards entering the primary care workforce or who are at a transition point in life. The objective was to accommodate all these groups simultaneously in the model, hereby enhancing the attraction for nurses to work at the primary healthcare level.
TABLE 2: A model for attracting and retaining registered nurses in primary care Preregistration nurses
Newly qualified Experienced nurses and nurses registered nurses in new to primary care primary care (e.g. long experience as a „staff nurse‟ in community nursing)
Registered nurses at life transition points (e.g. leaving or have left primary care for parenthood, dependent support or retirement)
Recruit from a pool of support workers working in primary & community settings
Market job Market job Market different opportunities and opportunities and typed of job flexible working flexible working opportunities, flexible through universities working & flexible retirement options
Increase learners‟ Establish primary knowledge of the care registered nurse range of nursing training posts work in primary care
Increase nurses‟ Set up „keep in touch‟ knowledge of the schemes while they range of nursing are on career breaks work in primary care & develop rotational posts
Create clinical skills learning opportunities in primary care services rather than just observation
Support first months in post through preceptors and clinical induction programs
Provide opportunities to work/shadow in different primary care services
Increase nurses‟ knowledge of the range of nursing work in primary care
Market primary care job opportunities, clinical induction programs and flexible working through primary care nurse mentors and prequalification opportunities
Increase nurses‟ Provide clinical knowledge of the induction programs range of nursing work in primary care, including developing rotations
Help address continuing professional development needs while on career breaks
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Induction & Retention of Nurses: Resolving the Planning Mismatch
Utilise a wide range of clinical placements including general practice
Providing opportunities to work/shadow in different primary care services
Address continuing professional development needs that link to career progression and educational portfolios
Link nursesâ€&#x; learning Link learning activities to accredited accredited educational educational programs programs
Increase knowledge of career progression routes, including specialist and advanced practice.
Establish return to primary care courses/opportunities for those out of nursing work for more than 5 years.
to Establish clinical induction and supported entry routes for those returning to work after shorter breaks
Identify career development and progression routes, including specialist and advanced practice and consultant practice.
Source: Drennan et al (2006) The advantage of having a multifaceted model such as the one depicted above is that it employs strategies that are cross cutting and impact job satisfaction of nurses who are at different stages of their career. As the strategies are cross cutting, therefore the model becomes even more cost effective because the design and implementation costs would only have to be incurred once. It further provides a very clear guideline for the policy makers to understand the evolution of nursing career path and the obstacles that the nurses encounter as they climb up the career ladder. This and several similar models are poised to resolve the issue of retention and recruitment by providing a solution at all levels of nursing career. It focuses on understanding of the choices confronting prospective, registered nurses and those nurses who are in a transitional career phase and hereby facilitates optimal utilization of the available resources through a system which nourishes their self development and is productive.
18
Induction & Retention of Nurses: Resolving the Planning Mismatch
4. NURSE MIGRATION National & International Perspective
19
Induction & Retention of Nurses: Resolving the Planning Mismatch
A critical aspect of nursing profession in Pakistan is the outflow of nurses from the country. Due to lack of favourable opportunities available nationally and overall increase in demand of nurses in the international sphere, retention of nurses within the country has become a major concern. A large proportion of trained nurses drop out due to multiple factors like marriage, social stigma, lack of career plans and unavailability of jobs locally and of further academic training programs. Buchan, Jobanputra, Gough & Hutt (2005) describe nurse migration as “the movement of nurses from one place/country to other place/country for nursing practice.” Western recruiting agencies and countries have been blamed for the „brain drain‟ of nurses from developing countries. The increasing demand for skilled human resources and better remuneration of the developed countries coupled with the poor work environment and low remuneration of the developing countries militate against the retention of skilled human resources in the developing countries. Immigration of healthcare professionals illustrate that there is both, a national and international perspective of the socio-political and economic context in a country. Recruitment policies and immigration laws and regulations in developed countries influence whether there is a demand for health professionals in these countries. On the contrary, living conditions in a low income country determine whether health staff is de-motivated and intends to leave their country of residence. The shortage of nursing staff is a global issue and is affecting both the developed as well as the under developed countries. There is a growing concern that developed countries absorb large numbers of health staff from low-income countries. In particular, high-income countries such as France, UK and the USA have a high demand for nurses trained outside their own country. It is reported that in USA being the high demand for medically trained staff is likely to increase in the coming years (Wyss, 2004). In Europe, statistics from UK shows that the number of overseas nurses entering the border has risen by 48% at the end of the 1990s. Most of these nurses have emigrated from Philippines, South Africa & the West Indies (Buchan & Dovlo, 2004). In Africa, Ghana estimates that over 50% of locally-trained nurses are living and practicing outside the country (Dovlo D, 1999). For example, in 2000 more than 500 nurses left Ghana to work in other industrialized countries i.e. more than twice the number of new nurses who graduated from nursing programs in the country that year (Zuchary, 2001). It is fundamental to understand the importance of addressing the pull and the push factors simultaneously; pull factors of migration to high-income countries and push factors in low-income countries. Unless and until these are not dealt with concurrently, investment in nursing training is likely to be unproductive. Ross, Polsky and Sochaksi (2005) reported that among several developed countries the UK and US are currently experiencing the majority share of shortage of nursing staff and as such they have been encouraging nurse migration for fulfillment of their needs. There is a need for addressing the migration issue primarily because it puts a strain on the already deprived health resources of the low income countries and in turn affects how health care service delivery impact the health related outcomes.
20
Induction & Retention of Nurses: Resolving the Planning Mismatch
In Pakistan for the attainment of the health related Millennium Development Goals (2005) three tiers are found contributing towards the high maternal mortality ratio. First was the delay in seeking professional care. Second was related to logistics of providing care in rural areas and third was from the lack of adequate human resources and trained personnel available at the health care centers. In reality nursing shortage is often a symptom of wider health system or societal ailments. Nursing in many countries continues to be undervalued as womenâ€&#x;s work and nurses are given only limited access to resources to make them effective in their jobs and careers. Displeasure with working conditions in many countries has also meant that many qualified nurses do not work in nursing (Park & Choi 2001) and at the same time international migration has increased (Hawthorne, 2001). This motivation to migrate stems from the desire for professional development and for a better quality of life. Nursing has evolved into an international profession with interdependence found between the developing and developed countries. Many developed countries are competing for a limited supply of nurses. For example, in the UK a sixth of all registered nurses were from overseas (Downie & Langman 1999). In the early part of the 21st century international recruitment continues to grow. Between 1998 and 2002, UK recruited 33,033 nurses from outside Europe. In 2002 alone, there were 15,065 newly recruited registered nurses (NMC 2002). The International Council of Nurses acknowledges and understands the gravity of this issue. In 2002, it proclaimed that governments of the developed countries should monitor and evaluate the shortage of nurses based on a local context, rather than simply relying on international recruitment without clearly understanding the deficiencies in their local health/nursing system (ICN, 2002). It is crucial for this assignment to understand the factors causing the flight of trained nurses from developing to developed nations. Although in Punjab the nurses are bonded to serve in the Public Health Sector but are allowed to find a job in the private sector or overseas if the Government is unable to find them employment within 6 months of graduating. In the absence of a proper absorption plan and inadequate sanctioned posts an increasing number of nurses are expected to migrate in the coming years. According to Brown & Connell, 2004, in the Pacific Islands the inclination of nurses to migrate abroad were influenced by a consortium of issues: income factors, close relatives already living abroad, gaining international training & experience and working in much superior conditions. While economic gain was a crucial reason, it would be wrong to assume that this is the one and only motivation for emigrating. Movement of nurses is also an indication of deteriorating health systems in many poor countries where wages are low, working conditions dreadful and there are a few perks gained from the job. Chapman, 2000 argues that nurses in nations with conservative societies would emigrate to gain political or religious freedom. In a study conducted by Thomas (2006) on “International Migration of Indian Nursesâ€?, out of 448 respondents, 63% expressed their intention to migrate. The major factors contributing to this intention were dissatisfaction with present working conditions and displeasure with prevalent social attitudes towards nurses.
21
Induction & Retention of Nurses: Resolving the Planning Mismatch
Developing countries have a problem of poor pay, lack of professional development and career structure, unsafe or undesirable domestic conditions and, poorly resourced and equipped health facilities. Nurses are also perceived as having inadequate input in health care decision making, public policy, and research. These are seen as a de-motivating factor for nurses and results in flight of registered nurses for better opportunities abroad. Surplus production of health personnel and the resultant unemployment, less attractive salaries, stagnation or underemployment coupled with lack of infrastructure act as “push” factors for the nurses to migrate. Evidence of this is found in a study conducted by Fang (2007).The study states that in most regions and cities in China, the average monthly salary of nurses is USD 200-300. To accelerate the predicament, there were high levels of unemployment of nurses prevailing in the country. Apart from low income, the nurses were concerned with poor working conditions and lack of job security. Major destinations for registered nurses from the developing countries are Australia, New Zealand, Belgium, Canada, France, the United Kingdom, Northern Ireland, and the United Stated of America. The developed countries have been blamed for the loss of health human resources from Africa, Asia & South America, to service their requirements. In many extreme cases, some have described developing countries subsidizing health care delivery of the developed nations in a form of reverse donations (Aitkin, 2003). Brain drain of health professionals from such low income countries has resulted in various equity issues. However, on the other hand, while developed nations have a role to play in ensuring retention of skilled health workers in developing countries, the governments of such countries also have a part to play in improving the job satisfaction and hence the retention of their employees. Pakistan has its own share of nurse migration problems. Although it is impossible to provide accurate statistics about the number of Pakistani nurses working in other countries, Usher (2004) highlighted that, “about a quarter of Pakistani nurses are working abroad”. According to available statistics, 15% of nurses from the developing countries like India, Philippines and Pakistan are moving to developed countries every year. Graduate nurses have a greater potential for moving abroad compared to other professions. The poor image of nursing in Pakistan is harming the nursing profession and is one of the major reason for competent and well qualified nurses to advance professionally since the community looks down upon nursing. According to Khowaja, and Jan (2007), „There is no denying in the fact that nurses play a major role in delivering health care services. No other health care professional has such a broad and far-reaching role. Yet, the irony is that in our part of the world, they are still struggling against the norms which have denied them their due place among the professionals. This sad state of affair has compelled a number of qualified nurses to migrate abroad for better prospects - creating a vacuum in Pakistan‟. Khowaja (2007) pointed out that “Pakistan needs to adopt a policy of retaining nurses through a provision for improved working conditions, better remuneration, quality education and training - above all recognition and respect to nurses.” Afzal (2008) in his detailed study on “Nurses Moving Abroad” concluded that „the reasons for Pakistani nurses moving abroad are linked to the fulfillment of basic human needs, self esteem, safety and security needs. These issues are similar to the reasons of nurses in other source countries. The more
22
Induction & Retention of Nurses: Resolving the Planning Mismatch
developed countries continue to attract nurses from less developed countries. This scenario brings in serious implications to nursing practice and the health care needs of the source countries. Addressing this long term problems in nursing migration and nursing shortage requires the concerted efforts of all stakeholders.â€&#x; An interesting finding to be cited from the focus Group Discussions that were held with nurses as part of this assignment is that nurses working in government sectors were less keen to migrate as compared to those in the private sector. However majority were keen to go for attachment overseas if sent by the Government itself. The reasons cited for migration included a better salary package, good nursing image, opportunities for higher qualification and career advancement. The political and economic conditions of the country were also found to be a contributing factor while taking a decision of migration to another country.
23
Induction & Retention of Nurses: Resolving the Planning Mismatch
5. SITUATIONAL ANALYSIS Studying the factors affecting job satisfaction, motivation and retention of nurses through Focus Group Discussions
24
Induction & Retention of Nurses: Resolving the Planning Mismatch
5.1
Introduction:
This study was done in response to Punjab Health Department (and other stakeholder) concerns about nursing workforce satisfaction, motivation, intent to stay in the public sector and migration to other countries. The minimum service delivery standards cannot be achieved without improving the retention and absorption of nurses in the public health sector. There are many assumptions and speculations about what factors contribute to nurse satisfaction and intent to continue in their jobs, but little or no data is available about specific motivators and disincentives. This data is particularly scarce at the provincial level. PDSSPâ€&#x;s commitment to improving health service delivery is real, but the success will be significantly enhanced if the policies are designed on the bases of current evidence and accurate information.
Significance of the study
5.1.1
This study will be a significant endeavor in identifying the problems being faced by the nurses employed in public and the private sectors. Along with this, it will also try to identify the factors which influence the career choices made by nurses. It is expected to provide policy makers with useful insights in the areas of motivation, job satisfaction and retention of nurses. The study makes an attempt to highlight the institutional and systemic issues confronting the nurses in the public nursing sector that de-motivate the nurses who are then compelled to look for job opportunities, either in the private sector or abroad. It highlights the improvements which should be brought in the terms and conditions of nursing service in the public sector if the aim is to attract and retain a large number of nurses in public sector institutions in order to meet the MSDS benchmarks. By understanding the needs of the nurses, the policy makers are expected to be better equipped and make evidence based decision making while carrying out reforms which are expected to be in line with the need priorities of the nursing workforce.
Objectives of the study
5.1.2
The study aims to undertake an assessment of the existing situation in the nursing sector through focus group discussions and to contribute towards developing an insight in order to formulate recommendation for the policy makers to create strategies that will lead to nurse retention and absorption.
Research Questions
5.1.3
The research questions which have been taken into consideration for this study are: 1) What is the motivation of nurses for joining the nursing professions? 2) What are the reasons behind the career choices made by newly trained nurses?
25
Induction & Retention of Nurses: Resolving the Planning Mismatch
3) What improvements should be brought in the terms and conditions of nursing service in the public sector? 4) What are the institutional and systemic problems in the public nursing sector that force the nurses to look elsewhere for a job; private sector or abroad? 5) What are the perceptions about the benefits of nursing jobs in the Public and Private sector?
5.1.4
Scope of the Study These focus group discussions covered nursing stakeholders working in the public and private sector in Punjab as well as nurse students in final year of both public and private nursing schools in Punjab.
5.2 Methods This study uses the qualitative investigation method known as the focus group discussion. Eight groups were formed. The focus group method is a meeting of a select group of people who discuss and elaborate on a topic based on their own personal experience. During the group interaction, information about reasons behind joining the nurse profession, factors related to job satisfaction and motivation among nurses working both in the public and private sector was gathered. This technique, particularly given the lack of information on the topic and the limited time available for the assignment, was considered the most appropriate for this study.
5.2.1
Setting The province of Punjab
5.2.2
Subjects and methods Data entry, focus group transcription and analysis were conducted in May 2010, with results reported to the PDSSP- TAMA in June 2010. The private sector nurses were contacted by telephone, informed of the project and invited to participate in the study after being told it was voluntary and that the information was confidential. The participation of the public sector nurses and senior nurse professionals was facilitated by the office of the Director General Nursing. The students of the public and private sector nursing schools were approached after taking consent from their principal for undertaking the FGDs. The composition of the groups is shown in Table 3. The sessions were moderated by the team leader. A focus group moderator's guide was used,
26
Induction & Retention of Nurses: Resolving the Planning Mismatch
including a list of topics, attached as Annex I, which were configured based on the existing literature on the object of this study. Table 3: Focus Group Composition Target Group
No of FGDs/Interviews
Nurses working in the Public Sector
2 FGDs
Nurses working in the private sector
2 FGDs
Trainee students in their final year(Public and Private Sector)
3 FGDs
The senior management of nurse training institutes
10 interviews
Table 4: Selected analytical categories used for studying job satisfaction, motivation and retention of nurses Analytical category Reason for joining the nursing profession
Interest in acquiring higher nursing qualifications
Preference for working in the Public or the Private Sector
Possible Reason Wanted to serve the ailing humanity Attracted by well developed career opportunities in nursing now Motivated/inspired by somebody Wanted to support the dependent family members Could not afford the fees to other colleges offering healthcare education As a means to settling abroad as nurses are in high demand worldwide PhD MScN Post RN BScN Post basic specialty diploma BScN
27
High salary package Job security Positive work environment Good nursing image Good health care facilities (Health insurance) Higher educational facilities Shift Flexibility Equal rights as part of healthcare team in decision making Better Autonomy and control in senior position Retirement and pension benefits Team work
Induction & Retention of Nurses: Resolving the Planning Mismatch
Prominent issues related to the working environment
Equal opportunities for career progression Housing facility Effective Rewards & Recognition Mechanism
Level of communication with your immediate supervisor Level of communication with your co-workers Recognition of efforts Amount of workload Learning opportunities Amount of respect at your workplace
Benefits of working in other countries
High salary package Good health care facilities Job security Positive working environment Higher educational facilities Good nursing image Politically and economically stable Equal rights to all
What would make nurses stay in Pakistan?
High salary package Good health care facilities Job security Positive working environment Higher educational facilities Enhance nursing image Politically and economic stability Residential facilities Transportation facilities Equal rights to all civilians
5.3 Data analysis
Data analysis was done using content analysis. The information was analysed by examining the audio tape transcripts systematically and exhaustively and the topics were identified and grouped with the assistance of the Nur Centre for Research & Consulting. They were subsequently coded, identifying themes and patterns and areas of convergence and divergence. The analysis was independently reviewed by another member of the research team, and the discrepancies were discussed until a consensus was reached.
5.4 Results 5.4.1
Reasons for selecting Nursing as a Career Option
The explanations related to the reasons for selecting nursing as a career option according to the perceptions of participants are presented below. These results emerged as below:
28
Induction & Retention of Nurses: Resolving the Planning Mismatch
Serving the ailing humanity was the main reason quoted by majority of the participants. This indicated that the nobleness associated with the profession stands unchanged. „I always wanted to take care of the sick and helpless and no other profession does it better than nursing‟. Majority of the subjects were also attracted by the career opportunities that are presently being offered in nursing for personal and professional advancement. This clearly depicts that the continuous and arduous efforts by the Government of Punjab towards launching MScN, Bachelors Degree Programs and Post Basic Specialty Diplomas are being acknowledged by prospective nurses. "Today a nurse can do a BScN, MScN and even a PhD. This was not possible 10 years back." The other reasons quoted by some included inspiration to follow a nurse role model and a way of supporting their dependents. "My mother was a nurse. I was inspired by the noble work she did all her life and wanted to follow in her footsteps"
5.4.2
Interest in acquiring higher nursing qualifications
When the participants were asked about different types of qualifications which they would like to acquire in the future for advancing their careers, most of the participants wanted to acquire a Bachelors and a Masters Degree in Nursing. “I would like to be the first PhD nurse in Punjab”. Few of the respondents talked about some professional development programs for nurses and the refresher courses that are being offered off and on by the government and other national and international donor agencies. The need for linking the CPD program to promotion was felt by majority of the senior nurses interviewed.
5.4.3
Preference for working in the Public, Private Sector
When the participants were asked about their preferences to work in the public, private sector or to migrate abroad, majority of the respondents preferred to work for the Public Sector. When the participants were asked about the main benefits of working in the Public Sector, majority perceived job security as the main attraction. Other benefits mentioned included health insurance, opportunities for higher education and retirement and pension benefits. Low pay scale in public sector appears in nurses' opinions as a factor of major concern. “Our salaries and benefits should be at par with the doctors serving in the rural areas.
29
Induction & Retention of Nurses: Resolving the Planning Mismatch
When we work as much as them, we deserve the same.” On the other hand when enquired about the main benefits of working in the Private Sector, majority perceived high salary package as the major attraction. When enquired about the number of years spent in one single position/rank, majority of the respondents in the public sector expressed stagnation in promotion for nurses and almost half of them were working on the same post for more than 10 years. The same query when put across the nurses working in the private sector generated a response from only a very few nurses being in the same post for over ten years. It can be inferred that in terms of career growth the private sector fared better than the public sector. 5.4.4
Nurse Migration
Only a minority of the participants showed a preference for migrating overseas for better career opportunities. “I would not be able to leave my children and my old mother even if offered a better salary overseas” On further probing majority of nurses in the public sector appeared to be keen in taking up overseas employment opportunity, if offered by the Government on a fixed term contract. “If the Government sends me, I will accept the offer as it will be secure and will not carry the risk of a fraud which we commonly hear off and faced by many trying to go overseas” Decent working environment, better pay scales, enhancement of current skill set and higher educational opportunities are features that seem to influence nurses‟ decision for working abroad. Majority considered high salary to be the most important motivator for applying overseas. 5.4.5
Working in the Rural Health Care Setting in Punjab
It was observed that under the current rural conditions most of the nurses were not willing to work in the rural areas. The reasons identified by the participants that contributed to their reluctance for working in rural health settings included lack of proper residential or transport facilities, lack of educational facilities for their children, lack of proper incentives, lack of professional development opportunities, security concerns and political scenarios. “It takes half of our salary to reach some of the health facilities. Why cannot the nurses be given a travel allowance as compensation?”
30
Induction & Retention of Nurses: Resolving the Planning Mismatch
5.4.6
Job Satisfaction & Work Environment
When enquired about their satisfaction with specific aspects of their work environment, nurses from the public and private sector displayed significant divergences in their responses. A number of public sector nurses pointed out that a significantly dissatisfying aspect of their job was their relationship with their immediate supervisor. Nearly half of them indicated resentment towards their existing salary, level of communication with their supervisor, lack of recognition and acknowledgement of their input by their respective supervisor. They further showed discontent with inadequate involvement and improper weightage of their opinion in health care decision making, policy framing, and research. “We were never consulted while the job descriptions of nurses were recently redrafted.� Majority of the participants pointed out that factors such as autonomy, respect and recognition, communication with supervisor and peers are fundamental in determining job satisfaction and retention of nurses. The observations extracted from the focus group discussions with the private sector nurses indicated that the single most dissatisfying aspect of work was lack of job security. Interestingly this factor was the most attractive aspect of working in the public sector as discussed above.
5.5 Discussion
It was heartening to note that vast majority of the respondents had acquired a higher qualification after their basic general nursing diploma. It however has to be kept in mind that the FGD participating nurses are working in the urban areas where the opportunities for higher educational attainment are more prevalent as compared to the rural areas. However it speaks of the interest of the nurses in advancing their educational qualifications and could prove to be an important area to be explored further in the context of job satisfaction and retention of nurses working in rural settings as to how they can be provided continual professional development opportunities. The progressive attitude and interest in acquiring further training and professional development opportunities should not only be credited and acknowledged but also further reinforced through the introduction of institutionalized continual professional development programs linked to their careers.
31
Induction & Retention of Nurses: Resolving the Planning Mismatch
The recent initiative taken by the government to regularize all the nursing contractual appointments needs to be applauded as it is a positive step forward that will help in not only attracting but also retaining nurses in the public health sector. It seems that private sector offered better career growth opportunities as compared to the public health sector. This lack of opportunities for fast track career growth could be a potential reason for competent and qualified nurses not opting for the public health sector jobs. There is a positive association between job satisfaction and a nurseâ€&#x;s commitment to the work in a particular healthcare setting. It is important to note in the context of this assignment that job satisfaction is directly related to motivation which is essential for the provision of effective and efficient healthcare service delivery as well as for retaining nurses in the public health sector. As the majority of the available sanctioned posts that are vacant and needs to be filled out on priority basis are in the rural health care facilities, it was of great interest for the consultant to study the factors that would help fill up these posts.
5.6 Limitations of the study The main limitation of this study was the short time available for the assignment because of which broad generalization have been made based on the data received from a small group of 69 respondents which may not reflect accurately for several parts of Punjab. Given more time, it would have been possible to conduct an in depth study for a more valid data. The present data was collected primarily from Lahore, although FGDs were conducted in Vehari and Bhawalnagar as well. A more detailed study would help identify the grass root problems which may be specific to a particular area and need to be resolved in order to attract nurses to the available posts there.
5.7 Conclusion/Recommendations The findings of the FGDs point towards a number of significant and interesting conclusions. It was observed that, with a few significant exceptions, nursesâ€&#x; preferences and choices regarding their careers appear to be largely homogenous across public and private sector work settings. One of the recurrent observations throughout the focus groups was that the public sector was still perceived by the nursing community as a focal avenue for employment. The public sector is sought after because of dominant perceptions regarding its job security, benefits, opportunities for further education and pension and retirement benefits. While it was generally acknowledged that the private sector offered better salaries and work environments; the majority of the nursing community still preferred to work for the public sector.
32
Induction & Retention of Nurses: Resolving the Planning Mismatch
Nurses working in government sectors were keen to work overseas, if the government had provided them with the opportunity to work abroad. They perceived this as an offering for better opportunities in terms of pay scale, relaxed working environment and job security. The major factors identified with the discontentment of nurses the poor pay scales which were not corresponding to the rising inflation, lack of professional development opportunities and career structure, unsafe work environments or pressing domestic conditions and poorly resourced and ill equipped health facilities. Nurses are also perceived as having inadequate input in decision making and are not found to be aware of strategies related to them. This is seen as a de-motivating factor and results in decreased commitment and efficiency to work. These factors also appear to be stifling the absorption of nurses into public sector positions. This study has made it possible to identify some explanations about factors affecting job satisfaction, motivation and retention of nurses. The importance of this study lies in the possibility of increasing our knowledge about designing policies related to nurses especially working in the rural health settings. The strategies must be oriented to nurse retention in the public health sector. Although it might be difficult to affect beliefs, perceptions, etc., related to working in the public and private health sector and overseas employment, it is necessary to better educate the nurses on the initiatives being undertaken by the Punjab Health Department towards safeguarding their interests as majority seems to be unaware of them. It is recommended that a more comprehensive study be conducted with a bigger sample size and representation from all over Punjab, along the same parameters for generating data essential for evidence based decision making.
33
Induction & Retention of Nurses: Resolving the Planning Mismatch
6. NURSING SCHOOLS IN PUNJAB Intake & Output
34
Induction & Retention of Nurses: Resolving the Planning Mismatch
6.1 Educational Programs for Nurses in Punjab For the nursing profession, following basic and higher education professional training courses are available in Punjab: Table 5: Nursing Programs in Punjab
1.
S.No Nursing Program Duration 1. Basic Diploma, General Nursing *4 years 2. Post Basic Diploma programme 1 year 3. Post RN B.Sc Nursing 2 years 4. Generic B.Sc Nursing 4 years 5. M.Sc. Nursing 2 years *This includes 3 years nursing and 1 year midwifery
A total of 56 Schools of Nursing are at present offering the 4 year Basic Diploma in General Nursing. Out of these, 46 are Public, 3 are Private, 5 are run by the Armed Forces and 2 by the Missionaries. The total annual intake of these Schools for the Basic Diploma in General Nursing is 1806. The following Colleges of Nursing are offering one year post basic diploma programmes in various specialities. i. Saida Waheed FMH College of Nursing ii. Post Graduate College of Nursing iii. Pakistan Institute of Medical Sciences The diploma programs presently in the offering include:
Paediatrics Psychiatry Coronary Care Unit Intensive Care Unit Community Health Accident and Emergency Ophthalmology Nursing Management, Ward Administration Neurosciences Nursing Education (Teaching and Administration) Advanced Midwifery
Presently 3 degree programmes are being offered in nursing: 1. Post RN BSc Nursing 2. Generic BSc Nursing 3. M.Sc. Nursing
35
Induction & Retention of Nurses: Resolving the Planning Mismatch
Only five institutes in Punjab are offering BSc Nursing and Post RN BSc Nursing, producing less than 340 graduate nurses annually. A two year MSc Nursing program is being offered by only one institute in Punjab, i.e. the University of Health Sciences in Lahore.
6.2 Accredited Schools and Colleges of Nursing in Punjab Out of all the provinces, Punjab has the highest number of nursing educational institutions. The output of nurses is therefore higher in this province as compared to other provinces. On the contrary, Punjab has less than one fourth of the total number of nurses registered with the PNC, working in Punjabâ€&#x;s Public Health Sector. This is indicative of the fact that despite having the highest output capacity, there is an absence of a well developed absorption plan for these nurses who are qualifying from these institutes every year. TABLE 6: Accredited Schools and Colleges of Nursing in Pakistan Province
School of Nursing
College of Nursing
Punjab Sindh Khyber Pakhtoon Khawa Baluchistan Total
56 41 11 6
3 3 1 0
114
7
Source: Pakistan Nursing Council 2010 Educating an increased number of nurses is not leading towards achievement of the MSDS benchmark for nurse requirement in the Healthcare facilities at a pace that is expected as there are insufficient numbers of nurses being absorbed by the Public Health Sector due to an inadequate number of sanctioned posts.
6.3 Production of Nurses in Punjab In recent years, Government of Punjab has taken several initiatives to increase its nursing production capability considerably. 5 seats were increased in every school in 2007 and the Government entered into Public Private Partnership with the Saida Waheed FMH College of Nursing. 58 students were enrolled alone through this institute. The total intake of Nurses over the last 4 years is highlighted below: Table 7: Nursing Intake in Basic General Nursing Diploma Program Year
Intake
2006
1290
2007
1607
2008
1572
2009
1773
Source: Office of Director General Nursing, June 2010
36
Induction & Retention of Nurses: Resolving the Planning Mismatch
The expected output over the next 4 years for the General Nursing Diploma Program would therefore be as outlined in the table below: Table 8: Nursing Output Year
Output
2010
1290
2011
1607
2012
1572
2013
1773
Source: Office of Director General Nursing, June 2010 Keeping 1 % as the attrition rate for drop outs during training and failures, 9 Million as the present population for Punjab with a population growth rate of 2.2% and an estimated number of 9000 nurses presently working in Punjab, the expected output of Nurses qualifying the General Nursing Diploma Program over the next 5 years and the Nurse Population Ratio for Punjab is depicted in Table 19: Table 9: Expected Output of General Nursing Diploma Program over the next 5 years:
Population No. of Nurses at beginning of year Attrition Annual Ouput No. of Nurses at end of year Nurse per 100,000 Population
Year 1 91,980,000 9,000 90 1,290 10,200 11.1
Year 2 94,003,560 10,200 102 1,607 11,705 12.5
Year 3 96,071,638 11,705 117 1,572 13,160 13.7
Year 4 98,185,214 13,160 132 1,773 14,801 15.1
Year 5 100,345,289 14,801 148 1,773 16,426 16.4
It is evident that with the present intake, neither the nurse population ratio be drastically affected and nor will the Government of Punjab achieve the MSDS benchmarks for nurse requirement over the coming years for the required number of beds. With a 10% increase in student intake every year the expected output of General Nursing Diploma Nurses is calculated in Table 20:
37
Induction & Retention of Nurses: Resolving the Planning Mismatch
Table 10: Expected Output of General Nursing Diploma Program with 10% Increase in annual Intake every year
Population Additional Nurses Attrition No. of Nurses Intake (2009 onwards) Nurse to Population Ratio
2009 90,000,000 9,000 1,773 10,000
2010 91,980,000 1,290 90 10,200 1,950 9,018
2011 94,003,560 1,607 102 11,705 2,145 8,031
2012 96,071,638 1,572 117 13,160 2,360 7,300
2013 98,185,214 1,773 132 14,801 2,596 6,634
2014 100,345,289 1,950 148 16,604 2,855 6,044
2015 102,552,885 2,145 166 18,583 3,141 5,519
2016 104,809,049 2,360 186 20,757 3,455 5,049
2017 107,114,848 2,596 208 23,145 3,801 4,628
2018 109,471,375 2,855 231 25,769 4,181 4,248
2019 111,879,745 3,141 258 28,653 4,599 3,905
With an annual increase of 10% in the annual intake every year, it is expected that an additional 19653 nurses will be added to the existing pool of 9000 nurses in Punjab over the next 10 years. This is essential for addressing the Nurse Population Ratio which at present is 1 nurse to 10,000 population. It can be seen from the table above that a minimal annual increase of 10% in the nursing student intake will improve this ratio which is expected to be 1 nurse to 5000 population by the end of 7 years.
38
Induction & Retention of Nurses: Resolving the Planning Mismatch
7. RECOMMENDATIONS A 5 years plan for meeting the provincial public health sector nurse requirements
39
Induction & Retention of Nurses: Resolving the Planning Mismatch
7.1 General Overview of nursing workforce planning – International Perspective Trends in the nursing workforce planning has far reaching implications for patient care, for other healthcare professionals working together as a team and for the provision of equitable, efficient, effective, and sustainable healthcare service delivery mechanisms. It is rudimentary for effective workforce planning to have ample, accurate, timely demographic and workforce information. In Punjab, like many other developing countries, the availability, reliability and validity of the nursing data is a major concern for workforce planners. In most developing countries, such data set either does not exist, or is prone to discrepancies. The skill mix has to be efficiently managed and the role of nurses and their value needs to be quantified. According to Richardson (1998), “The dynamic variables to be considered in the skill mix equation include the experience of the staff involved, the type of work to be undertaken, the length of time it takes to provide a service and the work that the original professional is now undertaking. The delegation of tasks may also require supervision of other workers”. Globally, there is evidence of proposed initiatives within the health services for placing nurses at the forefront of delivery. Proponents of this idea postulate that nurses should provide more comprehensive services and professional restrictions should be softened. This goes hand in hand with the demographic changes in the nursing workforce; with their numbers, working practices and education of the medical profession, which are all constantly changing. Finlayson (2002) argues that the service delivery benchmarks of nurses have drastically evolved with an increase in health care workload, partly due to an ageing. Similarly, technological advances and shorter hospital stays have made it rudimentary to closely examine the composition and number of nurses in the workforce in relation to other health professionals. Richardson (1999) claims that substituting one type of worker for another in the health field has not been thoroughly evaluated. For some time, policy makers have seen nurses as a cheaper alternative to physicians. The only cost of substitution taken into account is that of providing education and training for physicians‟ extended roles. Various studies have proposed that all coordination of care can be undertaken by registered nurses, but few have examined the implication that it might have on the nursing workforce (BMA, 2002). Robinson (2002) strongly suggests that internationally nurses cannot normally be substituted for physicians. Generally, physicians are employed first and the number of nurses required is calculated in relation to the physicians‟ enrolment. A study by Sharples et al (2002) found that whilst the level of care provided to the patients by nurses was similar to that provided by the physicians, the total cost per patient increased because the former used greater levels of resources. However, in the long run with accumulation of experience the cost of having this skill mix could be decreased. The optimal physician/nurse ratios that are predetermined for countries are feasible, but it is important to note that there are socio-economic factors that need to be taken into account. Therefore, careful assessment and analysis of the social environment must be taken into consideration before setting these optimal ratio levels. There is a direct link between skill substitution and
40
Induction & Retention of Nurses: Resolving the Planning Mismatch
devolution of higher level skills. This is being propagated at a time when there are a declining number of highly skilled senior nurses, worldwide. Internationally, nurses have not been empowered in delegating their own workload. Hayes (2002) depicts that in relation to the medical staff, there have been no specific directives for the job role of nurses at every grade/level. Some institutions have addressed this issue by recruiting larger numbers of support staff who relieve nurses to carry out devolved services. This has led to problems in supervising the support staff whilst providing decent work time for nurses to offer high level of care. From a managerial point of few, various changes in healthcare service delivery have been introduced in the National Health Service, UK and internationally. This viewpoint should be analyzed from a spectrum of stances. For instance, Roberts (1994) argues that at least in the short run, nursing staff can save money by undertaking managerial duties. However, this could lead to a digression in their role as their direct interaction with the patient will be minimized. The capacity of nurses to fulfill all these demands is questionable especially at a time when there are considerable problems with present recruitment and retention mechanisms in place for the qualified nursing staff. Internationally, nursing managers are coming under increasing strain to use available nursing resources efficiently and design an efficient workforce plan. The benefits of a successful workforce plan are manifold. It can free the skilled practitioners, from low skilled tasks, that could otherwise degenerate efficiency. A well balanced team of healthcare professionals can work together in a more interdisciplinary fashion and can improve the quality of service that is delivered. Finally, and most importantly in the context of this report, it can ease recruitment and retention difficulties (Reid, 2007).
7.2 Existing mismatch between nurse production and absorption One of the most critical problems being faced by the Public Health Sector of Pakistan is the disparity between the supply and demand of the Nursing labor force. There exists a mismatch between the turn-out of the Public and Private sector nursing training institutes and the actual number of nurses absorbed by the Health Department of the Government of Punjab. At the present rate of output of the nursing schools, it is estimated that about 15000 nurses will have completed their training in the next 10 years, but still it is unclear at this stage whether the sanctioned nursing posts will increase sufficiently to absorb these newly trained nurses.
7.3 Nursing workforce planning for meeting the MSDS benchmarks Calculating the present and future work force requirement for the Punjab Public Health Sector was one of the objectives of the present assignment. The MSDS provided benchmarks for both the minimum services package and standards of care to be provided at all levels, as well as the minimum mandatory requirements/ system specifications for ensuring the delivery of quality health care services. Development of the MSDS was an important starting point for setting the road map for achieving the health related MDG.
41
Induction & Retention of Nurses: Resolving the Planning Mismatch
MSDS emphasized on the adequacy and appropriateness of the Human Resource essential for the provision of efficient and equitable health care service delivery. For optimal utilization of the existing resources, it is essential to have a work plan in place that would calculate the number of nurses required as per the MSDS benchmarks. This is expected to provide rationale to the Government of Punjab for increasing the production of nurses as well as enhancing the number of sanctioned posts in the public health sector. It is evident that a disparity exists between the output of the public and private nursing institutions in Punjab and the actual number of nurses being absorbed by the Health Department of the Government of Punjab. The output of the existing nursing schools in Punjab, despite the critical nursing deficiency may not be possibly absorbed by the public sector as it is fully realized that meeting the MSDS benchmarks is limited by several factors including the availability of human resource, affordability in terms of public funds and health needs of the population. However, if the number of sanctioned posts for nurses is increased sufficiently to keep at par with the increasing output of the training institutions, the objective of achieving the number of nurses for meeting the MSDS can be achieved over the coming years. The following 5 year work plan is absolutely crucial not only for achieving MDGs but also for the long term sustainability of the health system in Punjab. As per the MSDS, the requirement of nurses in primary and secondary healthcare facilities is calculated on per bed basis i.e.
1 charge nurse per 8 hospital beds per shift 1 charge nurse charge nurse per 2 beds for ICU 8 charge nurse charge nurse per 4 beds for CCU(2per shift + 2 relievers)
Table 11: MSDS Benchmark for Nurse Requirement S.No 1. 2. 3. 4. 5. 6. 7. 8.
42
Type of Facility DHQ Hospital Category A DHQ Hospital Category B DHQ Hospital Category C THQ Hospital Category A THQ Hospital Category B THQ Hospital Category C RHC- Former/Markaz Level BHU
MSDS requirement for Nurses 136 86 47 16 14 12 10 0
Source: Minimum Service Delivery Standards
Induction & Retention of Nurses: Resolving the Planning Mismatch
Table 12: Number of beds in Punjab Public Health Facilities S.No 1. 2. 3. 4. 5. 6. 7.
Type of Facility Number DHQ Hospital Category A 3 DHQ Hospital Category B 6 DHQ Hospital Category C 24 THQ Hospital Category A 11 THQ Hospital Category B 22 THQ Hospital Category C 32 RHC- Former/Markaz Level 298 Total Number of beds
Beds 1323 1848 3569 1081 2107 1265 5,986 17179
Source: Minimum Service Delivery Standards
Table 13: Sanctioned Posts of Nurses in the DHQ, THQ and RHCs Type of Facility DHQ THQ RHC
Sanctioned Posts 2155 1040 1748
Filled Posts 1932 738 1120
Vacant Posts 223 302 628
Source: Data collected from Health Sector Reforms Programme, June 2010
Table 24 highlights the gap between the available number of nurses and the actual requirement for nurses in the public health sector to implement the MSDS. Table 14: Additional Nurse Requirement for meeting MSDS benchmarks Type Facility
of Number of Beds
Sanctioned Posts
Filled Posts
Vacant Posts
Additional Posts Required to meet MSDS Benchmarks
DHQ
6740
2155
1932
223
373
THQ
4453
1040
738
302
630
RHC
5986
1748
1120
628
1232
Total
17179
4943
3790
1153
2235
Out of a total of approximately 9000 nurses working within the health sector of Punjab for a population of an estimated 90 million, it is interesting to note that a total of only 20 male nurses are working as Charge Nurses.
It is imperative to mention here that MSDS for nurses is calculated as per number of beds in the healthcare facility. It is strongly felt that the number of beds in Punjab is critically deficient for a population of 9 million. Also the 5 year plan to meet the MSDS is only focussing on increasing the absorption of nurses qualifying from the nursing schools. An average value of 1500 for annual nursing output is being taken for the calculation of an absorption % of nurses in the Public Health Sector on annual basis.
43
Induction & Retention of Nurses: Resolving the Planning Mismatch
At the present nursing intake in the Schools of Nursing in Punjab, if the sanctioned posts are increased to absorb 25% of the annual output, the MSDS benchmark for Nurse Requirement will be met over the next 5 years. Increase in the sanctioned posts will however not address the present nurse population ratio of 1 nurse to 1000 population in Punjab. This will be addressed only if the annual intake of nurses is proportionately increased every year as discussed in the previous section. Table 15: 5 year plan to better adjust supply and demand for trained nursed in order to meet the provincial nursing public health sector requirements and implement MSDS
Absor ption Rate
Cumulative Increase in Posts Year 1
Cumulative Increase in Posts Year 2
Cumulative Increase in Posts Year 3
Cumulative Increase in Posts Year 4
Cumulative Increase in Posts Year 5
Deficiency as per MSDS Benchmar ks
10%
150
300
450
600
750
1,485
20%
300
600
900
1,200
1,500
735
25%
375
750
1,125
1,500
1,875
360
44
Induction & Retention of Nurses: Resolving the Planning Mismatch
8. EMERGING ISSUES
45
Induction & Retention of Nurses: Resolving the Planning Mismatch
In the light of the extensive literature review, the Focus Group Discussions conducted as part of this assignment and the insight gained through data collection and analysis, several issues have emerged that would require further study; some are linked to the recommendations already cited in this report others have emerged during the course of the information gathering, analysis and review processes. The following issues are recommended for further study. 1. A study of the health facilities at district level to identify the reasons behind the unfilled vacant posts of nurses Study Area: Nurses in DHQs, THQs and RHCs at district level Gap Identified: Unfilled vacant posts despite an annual output of 1500 nurses every year who are bonded to serve the Punjab Health Department Key Objective: o o o
To identify systemic and institutional factors that need to be addressed for attracting nurses on these unfilled posts at District Level. To recommend incentives to attract nurses to these unfilled posts To recommend regulatory mechanisms for posting freshly qualified nurses to serve in the areas close to their residential districts.
2. A 5 year plan for training nurses for overseas employment. Study Area: Overseas Employment of Nurses Gap Identified: The expected nursing output from the Nursing Institutes will not be 100% absorbed by the Government of Punjab Key Objective: o o o
o o
To study the nurse migration models prevailing internationally To explore training and employment opportunities in South Asia, Japan, Middle East, Europe, USA, Canada, Korea, and African countries To calculate the number of nurses who are under a bond to serve the GoPb but will not be absorbed by the Punjab Public Health Department due to limited sanctioned posts. To define the selection criteria and process for the overseas employment of nurses. To propose a 10 year plan for the overseas employment of nurses who are available after filling of the available sanctioned posts
3. 5 year absorption plan for nurses with financial costing for increasing the sanctioned posts of nurses in the Punjab Public Health Department. Study Area: Financial Implications of increasing the sanctioned posts of nurses on annual basis. Mapping of Nursing Requirement in Education as well as Service Delivery Gap Identified: Limited number of sanctioned posts in the Punjab Public Health Department
46
Induction & Retention of Nurses: Resolving the Planning Mismatch
Key Objective: o o o
o
To analyse the financing consequences of increasing sanctioned posts of nurses To map out the posts that need to be increased for absorption of nurses across the Punjab Public Health Facilities to implement the MSDS To determine the number of faculty staff required and map out the posts that need to be increased for absorption of nurses in the Nursing Institutions in Punjab to meet the PNC benchmarks To propose a 5 year plan with identified position in every district that will be filled by the freshly qualified nurses who are under a bond to serve the Government of Punjab
4. To develop a mechanism to encourage those qualified nurses who could not join/continue in service, to rejoin the the Punjab Public Health Department. Study Area: Reasons behind not pursuing the nursing career after qualifying Gap Identified: The number of qualified nurses in Punjab who are unable to work due to pressing domestic and personal obligations Key Objective:
47
o
To conduct a survey for identifying the problems because of which nurses are unable to work despite having acquired the relevant qualifications
o
To study the international models for encouraging nurses to join back the profession
o
To propose an incentive package for married and mothers with young children to join back nursing.
Induction & Retention of Nurses: Resolving the Planning Mismatch
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NMC (2002) Statistical analysis of the register 1 April 2001 to March 2002 The Nursing and Midwifery Council London http;//www.nmc-uk.org/cms/content/archives/news National Reconstruction Bureau Report. (2009, November). Nursing Education and Employment in Pakistan Pakistan Millennium Development Goals Report. (2005, September). Planning Commission Centre for Research on Poverty Reduction and Income Distribution Islamabad. Retrieved August 28, 2008, from http://www.pndpunjab.gov.pk/user_files/File/PMDGR05.pdf Park H-A & Choi E. (2001) Projected supply and demand for nurses in Korea by 2015 Journal of Nursing Scholarship 33:4, 387-388 Perrin, M.E., Hagopian, A., Sales, A., Huang, B. (2007). Nurse migration and its implications for Philippine hospitals. International Nursing Review, 54 (3), pp. 219-226. Pittman, P., Aiken, L.H., & Buchan, J. (2007). International Migration of Nurses. Health Services Research, 42 (3), pp. 1275-1280. Polit, D.F., & Beck, C.T. (2003). Nursing Research: Principles and Methods. (7th ed.). Lippincott Williams & Wilkins: London. Population Census Organization (2008). Retrieved July 11, 2008, from http://www.statpak.gov.pk/depts/pco/index.html Reid et al (2004) District nursing workforce planning: a review of the methods British Journal of Community Nursing Vol 13, No 11 Richardson G. (1999) Identifying, evaluating and implementing cost-effective skill mix Journal of Nursing Management V7 (5), 265-270 Richardson G., Maynard A., Cullum N., Kindig D., (1998) Skill mix changes: substitution or service development Health Policy V 45 Issue 2 August, 119-132 Roberts I.L (1994) The Health Care Assistant: Professional Supporter or Budget necessity? International Journal of Health Care Quality Assurance V7 No 6, 20-25 Robinson J. & Wharrad H. (2000) Invisible nursing: exploring health outcomes at a global level. Relationships between infant and under 5 mortality rates and the distribution of health professionals, GNP per capita and female literacy, Journal of Advanced Nursing 32 (1), 28-40 Ross, S. J., Polsky, D., & Sochakski, J. (2005). Nursing shortage and international nurse migration. International Nursing Review 52, 253-262 Royal College of Nursing (2004). The Future Nurse: RCN vision explained. Sharples L.D., Edmunds J., Bitton D., Hollingworth W., Caine N., Keogan M., & Exley A. (2002) A randomised crossover trial of nurse practitioner versus doctor led outpatient care in a bronchiectasis clinic Thorax 57:8, 661-66 Shields, M.A., & Ward, M. (2001) Improving nurse retention in the National Health Service in England: the impact of job satisfaction on intention to quit. Journal of Health Economics, 20, 677-701. Slocum J.W., Susman G.I. & Sheridan J.E. (1972) An analysis of need satisfaction and job performance among professional and paraprofessional hospital personnel. Nursing Research, 21 (4), 338–342. Stilwell, B., Diallo, K., Zurn, P., Vujicic, M., Adams, O., & Poz, M.D. (2004). Migration of health-care workers from developing countries: strategies approaches to its management. Bulletin of the World Health Organization, 82, 595-600. Retrieved March 24, 2007, from http://www.scielosp.org/pdf/bwho/v82n8/v82n8a09.pdf. The American Heritage (2007). Dictionary of the English Language (4th ed.). Houghton Mifflin Company. Retrieved July 17, 2008, from http://www.answers.com/topic/extended-family
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The Registered Nurses Association of Ontario (RNAO) (2002) Tracking the nursing task force: RNs Rate Their Nursing Work Life Thomas, P. (2006). The international migration of Indian nurses: International Nursing Review 53, p. 277–283 Tourangeau, A.E., Giovannetti, P., Tu, J.V., Wood, M. (2002) Nursing-Related Determinants for 30-Day Mortality for Hospitalized Patients. Canadian Journal of Nursing Research, Vol. 33, No. 4, 71-88. U.S. Census Bureau, International Database (2007). Usher, S. (2004). WHO report sheds light on why doctors and nurses leave poor countries. National Review of Medicine. 1 (22) 1-2. Retrieved July 11, 2008, from http://www.nationalreviewofmedicine.com/issue/2004/10_30/ government_medicine_20.html World Healt Organization (1997).Nursing care of the sick: A guide for nurses working in small rural hospitals. www.wpro.who.int/internet/files/pub/85/1-6.pdf World Health Organization (2005). Core health indicators. Retrieved June 16, 2008 from http://www.who.int/whosis/database/core/core_select_process. cfm?country=PAK&indicators=health personnel World Health Organization. (2006). Millenium Development Goals. Retrieved July 19, 2008, from http://www.who.int/reproductive_indicators/indicator.asp?indicator =IMR Wyss, K (2004): An approach to classifying human resources constraints to attaining health-related Millennium Development Goals, BioMed Central Zachary, G (2001): Labor movement: shortage of nurses hits hardest where they are needed most. Wall Street Journal 2001; January 24:1
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ANNEXURE
I
Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
TABLE OF CONTENTS ANNEX I A1
Guided Framework for FGDs
1
ANNEX II A2 A3 A4 A5 A6 A7 A8 A9
Vacancy Status (Jan 2010) Vacancy Status District wise Programs offered by Schools and Colleges of Nursing Student Strength in SONs and CONs DHQs Bed Strength Category Wise THQs Bed Strength Category A THQs Bed Strength Category B THQs Bed Strength Category C
4 5 6 7 8 9 10 11
ANNEX III A10 Human resources for SHC and PHC Facilities
12
ANNEX IV A11 Stakeholder list A12 Workshop Participant List A13 Workshop Slides
II
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14 16 17
ANNEX I A1: GUIDED FRAMEWORK FOR FOCUS GROUP DISCUSSIONS Welcome Participants, Good evening and welcome to our focus groups. We appreciate your willingness to take the time to join this discussion. I am Dr. Shabnum Sarfraz and I will be moderating this discussion on behalf of PDSSP-TAMA for a research study. Assisting me is Mr. Omar Qasim who will take notes during the session.
Ground Rules We will meet for about 1-1/2 hours during which time we will ask you several questions. Everything that is said here is confidential and neither you nor we should repeat any personal information when outside of this room. There are no right or wrong answers to the questions, only opinions. We encourage you to offer those opinions even if they differ from what someone else has said. As moderator and research assistant, our role is to listen to your views and ideas and record them as accurately as possible. Sometimes we will ask you followup questions so we can make sure that we understand what you have said, or we may ask that you give us a specific example. We encourage everyone to participate. We realize that some people like to talk in groups and some people are less comfortable. We want you all to feel comfortable sharing your views. We ask that you speak one at a time, again so that we can be sure that your views are heard.
Confidentiality As I said, you may be assured of complete confidentiality. Everything that we say is confidential and no one‟s name will be listed with any written summaries of the discussion. We will only report on the issues cited for this group as a whole. We also need your agreement not to discuss any information shared by individuals in the group with anyone outside of the group. Will everyone indicate their agreement by nodding their head? We‟ve also given you a copy of the questions that we will be asking so that you can follow along during the session and for keeping your own notes, if you like. If you have any responses that you do not feel comfortable sharing in the group, write them on this questionnaire and place it in the envelopes placed on the table, at the end of the interview. The questionnaire is anonymous. Do not write your name on it.
Opening Question 1. Let‟s go around the room and have each one of you introduce yourself and tell us about your most favorite thing about nursing?
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Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
Introductory Question 2. What was your reason for joining the nursing profession? Possible Prompts:
Did you want to support your dependent family members? Did you always like nursing? Did you join you nursing because you could not get admission into other fields/professions? Did you join nursing because you could not afford the fees to other colleges offering healthcare education Were you attracted by well developed career opportunities in this profession? Were you attracted by good salary packages for senior nurses? Did you join nursing as a means to settling abroad? Did you want to serve the ailing humanity? Were you motivated or inspired by someone from the nursing profession?
3. What were the other options available to you besides becoming a nurse? 4. Did you want to primarily join any other paramedical professions available prior to selecting nursing?
Key Questions 5. Did you receive any additional training in nursing after your basic qualification? 6. What further qualification would you like to acquire? Possible Prompts:
How many How many How many How many
of you would like to do a Bachelors Degree Program in Nursing? of you would like to do a Masters Degree Program in Nursing? of you would like to do a PhD in Nursing? of you would like to do a Specialty Diploma in Nursing?
7. Which sector do you prefer to work in? (Public Sector, Private Sector or Work overseas) Possible Prompts:
What do you think are the benefits of working in the Public Sector? What do you think are the benefits of working in the Private Sector? In your opinion what are the benefits of working overseas?
8. For how long have you been employed in the present post? 9. Were you offered any chances to undertake higher qualification and training? Possible Prompts:
If yes, did you avail it? If no, why did you not avail it?
10. What skills and qualifications have you enhanced in the last 5 years?
2
Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
11. Have you ever applied for job overseas? Possible Prompts:
If the government offers you an overseas employment, would you be willing to take up this opportunity? Why would you take up this opportunity to work overseas? Which country would you like to work in?
12. Would you like to work in Rural Health Centers? Possible Prompts:
What facilities should be provided to encourage nurses to work in rural areas?
13. Can you give us some details about some of the prominent issues related to your work environment? Possible Prompts: Are you satisfied with the standard of supervision at you workplace? Are you satisfied with the level of communication with your immediate supervisor? Are you satisfied with the level of communication with your co-workers? Do you feel if your efforts are being recognized by your superiors? Do you feel that you have the necessary equipment to do your work properly? Do you think that you are overworked? Does your work impact your family life in any way? Do you feel that you are provided with ample learning opportunities? Do you feel that you receive adequate amount of respect at your workplace? Do you ever think about leaving your job and going abroad for better opportunities?
Ending Questions 14. What would make nurses stay and practice nursing in Pakistan? 15. is there anything else you would like to add, or you think would be helpful for us to know?
After the Focus Group Thank you for participating in our discussion today. Your responses will be summarized along with those of other focus groups. The results will be shared with PDSSP to help them understand the systemic and institutional issues related to the work environment so as to design policies to address them effectively.
3
Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
ANNEX II A2: Vacancy Status (Jan 2010) Districts Attock Bahawalnagar Bahawalpur Bhakkar Chakwal D.G. Khan Faisalabad Gujranwala Gujrat Hafizabad Jhang Jhelum Kasur Khanewal Khushab Lahore Layyah Lodhran M.B. Din Mianwali Multan Muzaffargarh Nankana Sahib Narowal Okara Pakpattan Rahimyar Khan Rajanpur Rawalpindi Sahiwal Sargodha Shiekhupura Sialkot T.T.Singh Vehari GRAND TOTAL
4
NURSES DHQ
NURSES THQ
NURSES RHC
S F V S F V S F V 52 34 18 58 32 26 30 8 22 43 8 35 48 7 41 60 6 54 20 75 22 53 60 17 43 343 323 28 28 0 14 14 0 24 24 0 34 34 0 19 13 6 54 29 25 34 32 2 16 9 7 54 10 44 109 109 0 83 77 6 66 42 4 176 176 0 43 43 0 54 48 6 78 78 0 10 10 0 54 49 5 46 46 0 14 3 11 24 24 0 60 58 2 24 22 2 90 82 8 58 46 12 22 14 8 30 21 9 22 22 0 32 26 6 72 60 12 15 15 0 29 29 0 24 24 0 16 15 1 34 26 8 30 22 8 2 2 0 21 21 0 36 31 5 40 40 0 20 20 0 18 18 0 13 10 3 20 13 7 24 6 18 6 6 0 13 13 0 48 44 4 48 46 2 14 8 6 54 45 9 16 5 11 27 5 22 42 12 30 26 26 0 22 19 3 78 39 39 33 32 1 54 54 0 54 38 16 7 7 0 10 10 0 42 39 3 36 36 0 26 26 0 60 52 8 18 0 18 14 0 14 24 0 24 231 166 65 48 36 12 114 21 93 18 2 16 26 4 22 36 4 32 111 105 6 45 32 13 60 36 24 92 89 3 18 18 0 60 31 29 147 141 6 39 31 8 84 74 10 77 75 2 11 11 0 44 33 11 74 74 0 27 27 0 48 48 0 15 15 0 33 13 20 36 27 9 31 31 0 31 30 1 60 56 4 2155 1932 223 1040 738 302 1748 1120 628 Data Collected for SP 45 assignment from HSRP. (May-June 2010)
Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
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ANNEX III A10
Source: Minimum Service Delivery Standards
12
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Source: Minimum Service Delivery Standards
13
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A11:Stakeholder list S.No
Name of stakeholder
Designation/organization
1
Augistina Roy
DCNS, Lahore General Hospital
2
Bushra Anwar
Nursing Supervisor, Lahore
3
Dr Amjad
HSRP, Lahore
4
Dr Syed Talat Iqbal
EDO Health, Sialkot
5
Dr. Haroon Ihsan
Syeda Waheed College of Nursing
6
Fazeelat Begum
Nursing Instructor, School of midwifery Lahore
7
Hamida Sarwar
PSON, Jhelum
8
Irshad Javed
Director Nursing Education, Development and Clinical Services, Saida Waheed, FMH College of Nursing
9
Ishrat Ishaq
PSON, Lahore General Hospital
10
Kalima Asra Minhas
DCNS, Multan
11
Kalsoom Akhtar
Head Nurse, Lahore
12
Kausar Parveen
PSON, ALMC Lahore
13
Kausar Sardar
Nursing Instructor, Lahore
14
Khalid Mahmood Cheema
Head Nurse, Lahore
15
Kisnwar Iman
Nursing Instructor, Lahore
16
Kubra Bibi
Nursing Instructor, Lahore
17
Maaz Gardezi
Syeda Waheed College of Nursing Lahore
18
Mr Javed Iqbal
Ag Team Leader/M&E Specialist TAMA
19
Mr Jhanzeeb Waheed
Project Analyst, TAMA, Lahore
20
Mr Qurban Shah
Assistant Director, PDSSP, Lahore
21
Mr. Arshad Rashid
Deputy Director, PDSSP, Lahore
22
Munawar Sultana
DCNS, Punjab Institute of Cardiology Lahore
23
Nazir Begum
VPSON, Children Hospital Lahore
24
Shaheen Akhtar
Deputy Director Nursing, Directorate General Nursing, Lahore
25
Nighat Durrani
Registrar PNC, Islamabad
26
Stella Nazir
Nursing advisor, MOH, Islamabad
14
Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
27
Muhammad Afzal
Senior Instructor, Syeda Waheed College of Nursing Lahore
28
Nargis Parveen Butt
Directorate General of Nursing, Lahore
29
Naveed Saleh Siddique
ADB Consultant
30
Nisab Akhtar
DON, Syeda Waheed College of Nursing Lahore
31
Parveen Hidayat
SON, DHQH Vehari
32
Rashida Ayub
Controller NEB
33
Rashida Beghum
A.D.N Director Nursing
34
Rubina Jabeen
Nursing Instructor, College of Nursing Lahore
35
Rukhsana Kanwal
Head Nurse, Lahore
36
Samar Javed
PSON, DHQH Bhawalnagar
37
Shagufta Yaseen
Nursing Supervisor, Lahore
38
Shahida Nisar
Nursing Instructor, Children Hospital Lahore
39
Shahida Parveen
Nursing Instructor, College of Nursing Lahore
40
Shahnaz Akhtar
Nursing Instructor, Lahore
41
Shahnaz Zaidi
Contractor NEB, Lahore
42
Shahnaz Zaidi
Controller NEB
43
Shamim Afzal
PSON, Sahiwal
44
Shamim Akhtar
Assistant Controller NEB
45
Syeda Tasneem Kausar
46
Tasneem Khanum
47
Tasnim Kausar
Nursing Instructor, College of Nursing Lahore Nursing Superintendent , Children Hospital, Lahore PSON, B.B.H Rawalpindi
48
Zahida Parveen
PSON, Holy Family Rawalpindi
49
Zubaida Begum
Nursing Instructor, Sir Ganga Ram Hospital Lahore
15
Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
A12: Workshop Participants list S.No
Name of participant
Designation/organization
1
Augistina Roy
DCNS, Lahore General Hospital
2
Dr Syed Talat Iqbal
EDO Health, Sialkot
3
Dr. Haroon Ihsan
Syeda Waheed College of Nursing
4
Fazeelat Begum
Nursing Instructor, School of midwifery Lahore
5
Hamida Sarwar
6
Irshad Javed
7
Ishrat Ishaq
PSON, Jhelum Director Nursing Education, Development and Clinical Services, Saida Waheed, FMH College of Nursing PSON, Lahore General Hospital
8
Kalima Asra Minhas
DCNS, Multan
9
Kausar Parveen
PSON, ALMC Lahore
10
Maaz Gardezi
Syeda Waheed College of Nursing Lahore
11
Mrs Munawar Sultana
DCNS, Punjab Institute of Cardiology Lahore
12
Mrs Nazir Begum
VPSON, Children Hospital Lahore
13
Muhammad Afzal
Senior Instructor, Syeda Waheed College of Nursing Lahore
14
Nargis Parveen Butt
Directorate General of Nursing, Lahore
15
Naveed Saleh Siddique
16
Nisab Akhtar
17
Parveen Hidayat
ADB Consultant DON, Syeda Waheed College of Nursing Lahore SON, DHQH Vehari
18
Rubina Jabeen
Nursing Instructor, College of Nursing Lahore
19
Samar Javed
PSON, DHQH Bhawalnagar
20
Shahida Nisar
Nursing Instructor, Children Hospital Lahore
21
Shahida Parveen
Nursing Instructor, College of Nursing Lahore
22
Shahnaz Zaidi
Contractor NEB, Lahore
23
Shamim Afzal
PSON, Sahiwal
24
Syeda Tasneem Kausar
25
Tasneem Khanum
26
Tasnim Kausar
Nursing Instructor, College of Nursing Lahore Nursing Superintendent , Children Hospital, Lahore PSON, B.B.H Rawalpindi
27
Zahida Parveen
28
Zubaida Begum
16
PSON, Holy Family Rawalpindi Nursing Instructor, Sir Ganga Ram Hospital Lahore
Induction & Retention of Nurses: Resolving the Planning Mismatch- ANNEX
A13: Workshop Slides
17
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