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International Recruitment of Nurses: Policy and Practice in the United Kingdom Health Services Research; Blackwell Synergy 2007 Buchan J [Excerpt from author]Objective. To synthesize information about nurse migration into and out of the United Kingdom in the period to 2005, and to assess policy implications. Details
Nurse Migration: A Canadian Case Study Health Services Research; Blackwell Synergy 2007 Little L [Excerpt from author]Objective. To synthesize information about nurse migration in and out of Canada and analyze its role as a policy lever to address the Canadian nursing shortage. Details
Managed Migration: The Caribbean Approach to Addressing Nursing Services Capacity Health Services Research; Blackwell Synergy 2007 Salmon ME, Yan J, Hewitt H and Guisinger V [Excerpt from authors]Objective. To (1)provide a contextual analysis of the Caribbean region with respect to forces shaping the current and emerging nursing workforce picture in the region; (2) discuss country-specific case(s) within the Caribbean; and (3) describe the Managed Migration Program as a potential framework for addressing regional and global nurse migration issues. Details
International Migration of Nurses: Introduction Health Services Research; Blackwell Synergy 2007 Pittman P, Aiken L.H. and Buchan J [Excerpt from authors]The migration of highly skilled workers from less-developed nations to industrialized nations is an inevitable part of the process of globalization and has positive and negative aspects. Those potentially advantaged often include the individuals who move and the source, or home, country that receives capital in the form of remittances from those who have moved. At the same time, major disadvantages are incurred if departures impair a country's ability to deliver vital services in local communities. While nurse migration affects different countries in different ways, there is a troubling pattern of growing disparity in which poor nations with the fewest nurses are losing them to wealthy countries with the most nurses. As numerous reports have noted, developing nations often publicly fund nurse education, making the loss of nurses to wealthy countries in effect a massive public subsidy from the poorest to the richest areas of the world.1 This special issue includes a set of case studies for countries that represent a spectrum of different situations in relation to nursing shortages and migration. Details
Black and Minority Ethnic and Internationally Recruited Nurses - Results from RCN Employment/Working Well Surveys 2005 and 2002 Royal College of Nursing 2007 Pike G and Ball J [Excerpt from publisher] In order to help improve Royal College of Nursing understanding of the employment experiences of internationally recruited nurses and UK trained black and minority ethnic (BME) nurses, the RCN commissioned a secondary analysis to draw together commentary and analysis from previous surveys. Two main comparisons were drawn out of the data: 1) the differences between white and BME respondents (including differences between Afro-Caribbean and Asian respondents) and 2) differences between nurses who qualified in the UK and those who qualified overseas but started working in the UK since 1999. This group are classified as internationally recruited nurses (IRNs). The purpose of this paper is to collate and summarise existing data gleaned from previous RCN Annual Employment Surveys (AES) surveys and present additional secondary analysis of data covering IRNs and BME nurses where possible. A further purpose of this research is to point to areas where there are gaps in knowledge of the working lives of IRN and BME nurses. Details
International Council of Nurses: Nursing Leadership Blackwell Publishing; International Council of Nurses 2007 Shaw S [Excerpt from publisher] Nursing Leadership focuses on principles of effective leadership and leadership development in nursing, and is equally applicable for other professional groups. The book explores the importance of balancing leadership theory and knowledge with the development of leadership skills based on action-learning, and using a framework of three integrated components: the person who is the leader, the setting of leadership, and the followers. Nursing Leadership highlights the importance of preparing nurses for leadership in a global context in light of the challenge of changing health services and nursing roles. Nursing Leadership is brought to life with examples from the International Council of Nurses' experience with its 'Leadership for ChangeT programme (LFCT)' implemented in over fifty countries and in a variety of socio-political and cultural contexts. The book addresses principles of effective leadership that promote successful and sustainable outcomes across many different settings, including within resource-limited health systems. Details
Human Resources for Health Planning and Management in the Eastern Mediterranean Region: Facts, Gaps and Forward Thinking for Research and Policy Human Resources for Health 2007 El-Jardali F , Jamal D, Abdallah A and Kassak K [Excerpt from authors]The early decades of the 21st century are considered to be the era of human resources for health (HRH). The World Health Report (WHR) 2006 launched the Health Workforce Decade (2006-2015), with high priority given for countries to develop effective workforce policies and strategies. In many countries in the Eastern Mediterranean Region (EMR), particularly those classified as Low and Low-Middle Income Countries (LMICs), the limited knowledge about the nature, scope, composition and needs of HRH is hindering health sector reform. This highlights an urgent need to understand the current reality of HRH in several EMR countries. The objectives of this paper are to:(1) lay out the facts on what we know about the HRH for EMR countries;(2) generate and interpret evidence on the relationship between HRH and health status indicators for LMICs and middle and high income countries (MHICs) in the context of EMR;(3) identify and analyze the information gaps (i.e. what we do not know) and(4) provide forward thinking by identifying priorities for research and policy. Details
The Working Conditions of Nurses: Confronting the Challenges - Health Policy Research Bulletin Health Canada 2007 [Excerpt from publisher]This issue of the Health Policy Research Bulletin examines research on the state of working conditions facing Canada's nurses and discusses the implications for the larger health care system. Details
Better Data, Better Decisions: A Profile of the Nursing Workforce Nursing Health Services Research Unit; Hamilton Health Sciences 2006 Baumann A, Keatings M, Holmes G, Oreschina E and Fortier V [Excerpt from authors]Human resource data routinely collected by hospitals can be utilized in workforce planning, and for comparisons to provincial/territorial and national work forces. Of the various workforces in hospitals, nursing has the largest number of employees. The development and maintenance of hospital databases help planners monitor their workforces by better understanding their characteristics and dynamics. Details
Staffing Level: A Determinant of Late-onset Ventilator-associated Pneumonia BioMed Central Ltd; Critical Care 2007 Hugonnet S , U?kay I and Pittet D [Excerpt from authors]Introduction:The clinical and economic burden of ventilator-associated pneumonia (VAP) is uncontested. We conducted the present study to determine whether low nurse-to-patient ratio increases the risk for VAP and whether this effect is similar for early-onset and late-onset VAP.Conclusion:Lower nurse-to-patient ratio is associated with increased risk for late-onset VAP. Details
Magnet Status and Registered Nurse Views of the Work Environment and Nursing as a Career. Lippincott Williams & Wilkins; Journal of Nursing Administration 2007 Ulrich B, Buerhaus P, Donelan K, Norman L and Dittus R [Excerpt from authors]Objectives: To compare how registered nurses view the work environment and the nursing shortage based on the Magnet status of their organizations. Background: The upsurge in organizations pursuing and obtaining Magnet recognition provides increased opportunities to investigate whether and how registered nurses who are employed in Magnet organizations and organizations pursuing Magnet status perceive differences in the nursing shortage, hospitals' responses to the shortage, characteristics of the work environment, and professional relationships. Methods: A nationally representative sample of registered nurses licensed to practice in the United States was surveyed. The views of registered nurses who worked in Magnet organizations, organizations in the process of applying for Magnet status, and non-Magnet organizations were analyzed as independent groups. Results: Significant differences were found. Although there is a clear Magnet difference, there are also identifiable differences that occur during the pursuit of Magnet recognition. Conclusion: Many organizations in the process of applying for Magnet status rated higher than Magnet organizations, indicating that there is much to do to maintain the comparative advantages for Magnet hospitals. Details
Health Worker Migration in the European Region: Country Case Studies and Policy Implications World Health Organization 2006 Buchan J and Perfilieva G [Excerpt from publisher] This report presents an overview of the policy implications of the international migration of health workers in Europe, based on case studies conducted in five countries - Estonia, Germany, Lithuania, Poland and the United Kingdom - and draws on information from other WHO European Region countries, such as Israel and Latvia. Details
Community Health Workers: What Do We Know About Them? World Health Organization 2007 Lehmann U and Sanders D [Excerpt from authors]The use of community health workers has been identified as one strategy to address the growing shortage of health workers, particularly in low-income countries. Using community members to render certain basic health services to the communities they come from is a concept that has been around for at least 50 years. There have been innumerable experiences throughout the world with programmes ranging from largescale, national programmes to small-scale, community-based initiatives. This review paper revisits questions regarding the feasibility and effectiveness of community health worker programmes. It was commissioned by the World Health Organization as a follow-up to the World health report 2006: working together for health, which identified as a research priority the feasibility of successfully engaging community health workers. This review aims to assess the presently existing evidence. It constitutes a desktop review, very broad in scope, as is evident from the title, which draws together and assesses the evidence as it can be found in the published and selected "grey" literature since the late 1970s. Details
Nursing Management Today: An ICN Viewpoint International Hospital Federation 2006 Judith Oulton [Excerpt from author]Population-based healthcare has become the focus of healthcare services around the world so there is an ever-increasing need to train and support nurse managers who can lead and nurture nurses as they work towards providing optimum levels of satisfaction and safety in the care they give to their patients. Details
Zambia Performance-Based Incentives Pilot Study Quality Assurance Project 2006 Furth R [Excerpt from author]There are many challenges to fostering performance improvement in resource-poor settings, and yet it is in these very contexts that staff are most in need of some sort of encouragement to perform their jobs well. Low salaries, poor working conditions, weak or non-existent management and supervision, and lack of decision-making authority, among other things, provide disincentives for staff to invest time and energy in improving health service delivery. The purpose of the Performance-based Incentives Pilot Study was to develop and test a process for motivating staff and increasing performance through financial and non-financial performance awards. The study was framed around two principal objectives: (1) To test the effects of financial and non-financial awards on healthcare worker motivation, and (2) To examine the impact of performance-based awards on health center performance and achievement of selected health indicators. Details
People In Aid Code of Good Practice in the Management and Support of Aid Personnel People In Aid 2003 [Excerpt from publisher] The People In Aid Code of Good Practice is an internationally recognised management tool that helps agencies enhance the quality of their human resources management. The Code provides a comprehensive and sector specific framework relevant to organisations of any shape or size. Also available in Deutsch, Espa?ol and Fran?ais Details
Strategic Management of the Health Workforce in Developing Countries: What Have We Learned? Human Resources for Health 2007 Fritzen S [Excerpt from authors] The study of the health workforce has gained in prominence in recent years, as the dynamic interconnections between human resource issues and health system effectiveness have come into sharper focus. This paper reviews lessons relating to strategic management challenges emerging from the growing literature in this area. Details
Health Human Resources Planning and the Production of Health: Development of an Extended Analytical Framework for Needs-Based Health Human Resources Planning SEDAP Research Paper No. 168 2007 Birch S, Kephart G, Tomblin-Murphy G, O'Brien-Pallas L, Alder R and MacKenzie A [Excerpt from authors]In this paper an analytical framework is developed based on the production of health care services and the multiple determinants of health human resource requirements. In this framework attention is focused on estimating the 'flow' of services required to meet the needs of the population that is then translated into the required 'stock' of providers to deliver this 'flow' of services. The requirements for human resources in the future is shown to depend on four elements: the size and demographic mix of the population (demography), the levels of risks to health and morbidity in the population (epidemiology), the services deemed appropriate to address the levels of risks to health and morbidity (standards of care), and the rate of service delivery by providers (productivity). Application of the framework is illustrated using hypothetical scenarios. Details
RWJF Research Highlight-Multiple Factors Affect Job Satisfaction of Hospital RNs Robert Wood Johnson Foundation 2007 Lewis D [Excerpt from author]Understanding factors that influence job satisfaction of nurses is critical to helping alleviate the increasing shortage of nurses. With a better understanding of the forces driving nurse employment, hospitals can implement strategies to improve the job satisfaction of nurses and reduce turnover. Details
Strengthening Health Professional Associations - Technical Brief 8 The Capacity Project; IntraHealth International 2007 McQuide P, Millonzi K and Farrell C [Excerpt from authors] Developing human resources for health (HRH) requires a multidisciplinary and multisectoral approach to ensure that health care consumers have access to high quality, cost-effective services (ICN, 2005). Professional associations for health care workers can promote high standards of practice, advocate for the needs of both consumers and providers, form networks with other professional associations and liaise with legislative and regulatory bodies. Strengthening professional associations is one strategy for addressing global HRH issues such as out-migration and the lack of an adequate supply of well-trained professionals to deliver HIV/AIDS services. This technical brief discusses various approaches for strengthening professional associations and outlines the benefits and challenges of such efforts. Details
Human resource management in the Georgian National Immunization Program: A Baseline Assessment Human Resources for Health 2007 Esmail LC, Cohen-Kohler JC and Djibuti M [Excerpt from authors]Background: Georgia's health care system underwent dramatic reform after gaining independence in 1991. The decentralization of the health care system was one of the core elements of health care reform but reports suggest that human resource management issues were overlooked. The Georgian national immunization program was affected by these reforms and is not functioning at optimum levels. This paper describes the state of human resource management practices within the Georgian national immunization program in late 2004. Details
Returning to Work, Working Longer, Working Healthier in the NHS: A Decision Making Framework to Support Line Managers and Staff NHS Employers 2006 [Excerpt from publisher] This decision making framework has been developed to help to steer line managers and staff through the various decisions they may need to make around returning to work, working longer and working healthier in the NHS. It may help managers and staff to make informed decisions and ask the right questions about situations they face now and in the future relating to health, age and diversity needs. This decision making tool does not offer solutions, it provides a framework to help identify the critical question that needs answering, and the range of potential option that can in turn inform a decision. Details
Closing the Management Competence Gap Human Resources for Health 2003 Filerman GL [Excerpt from author]The success of any organized health program depends upon effective management, but health systems worldwide face a lack of competent management at all levels. Management development for health systems, particularly at the first line of supervision, must be given much higher priority by senior leaders and for investment. Human resource development leaders must be the advocates for making the investment in managerial competence. Details
Clinical Supervision in the Workplace: Guidance for Occupational Health Nurses Royal College of Nursing 2002 [Excerpt from publisher] This leaflet has been developed by the RCN Occupational Health Managers forum and is designed as an introduction to clinical supervision. It aims to stimulate ideas and to encourage occupational health nurses to set up supervision practice in their workplaces. Clinical supervision isn't a management tool, but can be used as a support and prompt to professional practice in a creative way. Details
Addressing the Human Resources Crisis: A Case Study of the Namibian Health Service Human Resources for Health 2007 McCourt W and Awases M [Excerpt from authors] This paper addresses an important practical challenge to staff management. In 2000 the United Nations committed themselves to the ambitious targets embodied in the Millennium Development Goals (MDGs). Only five years later, it was clear that poor countries were not on track to achieve them. It was also clear that achieving the three out of the eight MDGs that concern health would only be possible if the appropriate human resources (HR) were in place. Details
Strengthening Human Resources Information Systems The Capacity Project 2007 McQuide P and Settle D [Excerpt from authors]Many low-resource countries are facing daunting obstacles to meeting the health care needs of their people. To ensure that the right health care provider is in the right place with the right skills, these countries need current, accurate data on human resources for health (HRH). A strong human resources information system (HRIS) helps health care leaders quickly answer the key policy questions affecting health care service delivery. Details
Using Nurses to Identify HAART- Eligible Patients in the Republic of Mozambique: Results of a Time Series Analysis Human Resources for Health 2007 Gimbel-Sherr SO, Micek MA, Gimbel-Sherr KH, Koepsell T, Hughes JP, Thomas KK, Pfeiffer J and Gloyd SS [Excerpt from authors] The most pressing challenge to achieving universal access to highly active antiretroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources. Details
Glossary of the World Trade Organisation and Public Health: Part 1 and 2 Journal of Epidemiology and Community Health 2006 Labonte R and Sanger M [Excerpt from authors]Part 1 of this glossary introduces the WTO and its origins as an institution, and summarises the WTO rules on trade in goods that are most relevant to public health. Part 2 considers rules specific to trade in services, intellectual property, investment, and government procurement. Details
Attracting, Retaining and Managing Nurses in Hospitals - Auditor-General's Report Preformance Audit NSW New South Wales Audit Office 2006 [Excerpt from publisher] This audit examines how nursing resources are managed in ten general wards at four hospitals - Royal Prince Alfred (RPA), Bankstown, Tamworth and Scone. We looked at this sample of hospitals to find out if:nursing resources are well managedhospitals effectively attracted and retained nurses.We also wanted to find out how well the Department of Health was addressing the risk of a future shortage of nurses in public hospitals. Details
Job Satisfaction Among Nurses in China SAGE Publications, Home Health Care Management & Practice 2004 Hu J and Liu H [Excerpt from publisher] This study examined job satisfaction among nurses in China. A nationwide survey was conducted with 403 nurses employed at hospitals in 16 provinces in China using the Job Descriptive Index Scale. The findings indicated that, overall, nurses were dissatisfied with work, pay, and promotions. Pay was rated as the least satisfying aspect of work followed by promotions. Nurses with more years of experience, higher professional titles, and more opportunities to attend continuing education programs were more likely to have a high level of job satisfaction than nurses with fewer years of experience, lower professional titles, and fewer opportunities to attend continuing education programs. Nurse managers should pay close attention to nurses'pay, career advancement opportunities, and promotions. They should recognize nurses' achievements and provide opportunities for continuing education programs and independent work with emphasis on critical thinking and decision making, autonomy, accountability, and delegation. Details
Improving Supervision: A Team Approach Management Sciences for Health 0 [Excerpt from publisher] This issue of The Family Planning Manager explores ways to improve supervision in family planning clinics. It focuses on developing an interactive team supervision strategy that can improve the supervision of activities and individual performance. The issue explains how clinic staff can work together as a team to provide ongoing supervision and improve the quality of family planning services. A supplement to this issue, the Pocket Guide for Service Improvement, is designed to be used by clinic staff to identify opportunities for improving family planning services. Details
Teacher Motivation and Incentives in sub-Saharan Africa and Asia Department for International Development , UK 2004 Bennell P [Excerpt from author] This paper focuses on teacher motivation and incentives in low-income developing countries (LICs) in sub-Saharan Africa and Asia. In particular, it assesses the extent to which the material and psychological needs of teachers are being met. This includes overall levels of occupational status, job satisfaction, pay and benefits, recruitment and deployment, attrition, and absenteeism. Unfortunately, despite the importance and complexity of these issues, there is very limited good quality published information. Details
Clinic Supervisor's Manual Management Sciences for Health 2006 [Excerpt from Preface] The Clinic Supervisor's Manual is a collection of adaptable tools and guidelines designed to help clinic supervisors and clinic managers achieve objective improvements in the quality of health care. The manual is especially useful for managers supervising integrated health services, who, on any given day, may be called on to support the provision of a full range of primary health services. The manual is designed to complement more detailed standard operating procedures that may be in use for specific services, for example, antiretroviral therapy. It is based on the belief that regular, systematic supervision is essential to upgrading clinic services and maintaining improvements. Details
Human Resource Management Rapid Assessment Tool for Public - and Private- Sector Health Organizations - A Guide to Strengthening HRM Systems Management Sciences for Health 2005 [Excerpt from publisher] The Human Resource Management (HRM) Assessment Tool offers a method for assessing what an organization's Human Resources Management system consits of and how well it functions. The HRM Assessment Tool helps users to develop strategies to improve the human resource system and make it as effective as possible. It can also serve as a basis for focusing dicusssions, brainstorming, and strategic planning. It is designed to be used in public and private-sector health organizations. Details
Gender Equality, Work and Health: A Review of the Evidence World Health Organization, Department of Women, Gender and Health 2006 Messing K and ?stlin P [Excerpt from Preface] This publication documents the relationship between gender inequality and health and safety problems. It reviews gender issues in research, policies and programmes on work and health, and highlights some specific issues for women, including the types of jobs they do, as well as their need to reconcile the demands of work and family. Biological differences between women and men also are considered in relation to hazards they face in the workplace. Implications of the findings and recommendations for legislation and policy are discussed. Details
Monitoring the Effect of the New Rural Allowance for Health Professionals Health Systems Trust; National Department of Health 2004 Reid S [Excerpt from author] The maldistribution of health professionals between rural and urban areas in South Africa demands specific strategies to address the imbalance. Financial and non-financial incentives have been used in other countries to recruit and retain health professionals in areas of need, and in 1994 a rural recruitment allowance was instituted in South Africa. However, this allowance was granted only to medical doctors and dentists, and remained at the same fixed rate since the time of its inception. It was perceived to be ineffective as an incentive for retention of professional staff, and despite the introduction of community service for all health professionals except nurses, it remains difficult to recruit and retain professional staff at rural hospitals, health centres and clinics. Details
Structural Empowerment, Magnet Hospital Characteristics, and Patient Safety Culture: Making the Link Lippincott Williams & Wilkins, Journal of Nursing Care Quality 2006 Armstrong KJ and Laschinger HKS [Excerpt from publisher] Nurse managers are seeking ways to improve patient safety in their organizations. At the same time, they struggle to address nurse recruitment and retention concerns by focusing on the quality of nurses' work environment. This exploratory study tested a theoretical model, linking the quality of the nursing practice environments to a culture of patient safety. Specific strategies to increase nurses' access to empowerment structures and thereby increase the culture of patient safety are suggested. Details
A Longitudinal Analysis of the Impact of Workplace Empowerment on Work Satisfaction John Wiley & Sons, Ltd., Journal of Organizational Behavior 2004 Laschinger H K S, Finegan J, Shamian J and Wilk P [Excerpt from publisher] A longitudinal predictive design was used to test a model linking changes in structural and psychological empowerment to changes in job satisfaction. Structural equation modeling analyses revealed a good fit of the data from 185 randomly selected staff nurses to the hypothesized model. Changes in perceived structural empowerment had direct effects on changes in psychological empowerment and job satisfaction. Changes in psychological empowerment did not explain additional variance in job satisfaction beyond that explained by structural empowerment. The results suggest that fostering environments that enhance perceptions of empowerment can have enduring positive effects on employees. Details
Relationships of Work and Practice Environment to Professional Burnout: Testing a Causal Model Lippincott Williams & Wilkins, Nursing Research 2006 Leiter M P and Laschinger H K S [Excerpt from publisher]Objective: To test a nursing worklife model that defined structured relationships among professional practice environment qualities and burnout. Results: A causal model was used to confirm the factor structure of the Professional Environment Scale (NWI-PES) on a subset of NWI items and the factor structure of the MBI-HSS. The analysis provided support for a structural model (nursing worklife model) linking the five worklife factors used to define a fundamental role for nursing leadership in determining the quality of worklife regarding policy involvement, staffing levels, support for a nursing model of care, and physician-nurse relationships. The analysis supported a direct path (negatively weighted) from staffing to emotional exhaustion and a direct path (positively weighted) from nursing model of care to personal accomplishment. Details
Job Satisfaction Among Nurses: A Literature Review Elsevier Ltd , International Journal of Nursing Studies 2004 Lu H, While AE and Barriball KL [Excerpt from publisher]The current nursing shortage and high turnover is of great concern in many countries because of its impact upon the efficiency and effectiveness of any health-care delivery system. Recruitment and retention of nurses are persistent problems associated with job satisfaction. This paper analyses the growing literature relating to job satisfaction among nurses and concludes that more research is required to understand the relative importance of the many identified factors to job satisfaction. It is argued that the absence of a robust causal model incorporating organizational, professional and personal variables is undermining the development of interventions to improve nurse retention. Details
The Motivation of Health Personnel in Uganda World Health Organization, Regional Office for Africa - Best Practices in Human Resources for Health Development 2006 This video examines Uganda's pay reforms and other financial and non-financial incentives for health personnel in the public sector. Note: Access to a media player is required to veiw this clip. Details
Wastage in the Health Workforce: Some Perspectives from African Countries Human Resources for Health 2005 Dovlo D [Excerpt from author] Background: Sub-Saharan Africa faces a human resources crisis in the health sector. Over the past two decades its population has increased substantially, with a significant rise in the disease burden due to HIV/AIDS and recurrent communicable diseases and an increased incidence of noncommunicable diseases. This increased demand for health services is met with a rather low supply of health workers, but this notwithstanding, sub-Saharan African countries also experience significant wastage of their human resources stock. Conclusion: The paper reviews strategies that have been proposed and/or implemented. It suggests areas needing further attention, including: developing and using indicators for monitoring and managing wastage; enhancing motivation and morale of health workers; protecting and valuing the health worker with enhanced occupational safety and welfare systems; and establishing the moral leadership to effectively tackle HIV/AIDS and the brain drain. Details
Preservice Implementation Guide: A Process for Strengthening Preservice Education JHPIEGO 2002 Schaefer L (ed) [Excerpt from Preface] This Preservice Implementation Guide describes the step-by-step process used to create a positive environment on the national level for strengthening preservice education and the steps taken on the institutional level to impove the existing curriculum and its implementation. Details
The Nine Step Guide to Implementing Clinic Supervision Health Systems Trust 2005 Davids S and Loveday M [Excerpt from authors] This booklet focuses on how to implement clinic supervision. Although it does not go into any great depth or detail, it aims to assist managers, programme coordinators, clinic supervisors and facility managers find their way in the day to day supervision of quality of care. The Nine Step Guide addresses implementation in an easy to follow method, using a number of tools and practical examples gathered from the districts where HST has worked over the last three years. Details
The Influence of Manager Behavior on Nurses' Job Satisfaction, Productivity, and Commitment Lippincott Williams & Wilkins, Journal of Nursing Administration 1997 McNeese-Smith DK [Excerpt from publisher] How do managers influence their nurses' job satisfaction, productivity, and commitment to the organization? The author discusses the findings of her study, drawing comparisons to other studies and suggesting implications for improving managerial supervision, organizational performance, and outcomes. Details
Pay and Non-Pay Incentives, Performance and Motivation World Health Organization 2001 Hicks V and Adams O [Excerpt from authors] This paper provides an overview of evidence of the effects of incentives on the performance and motivation of independent health professionals and health workers. Incentives are viewed in the context of objectives held by paying agencies or employers. The review defines the nature of economic incentives and of non-financial incentives. Particular attention is paid to the need for developing countries to understand the impacts of health reform measures on incentives. Details
Making Supervision Supportive and Sustainable: New Approaches to Old Problems Management and Leadership Program, Management Sciences for Health 2002 Marquez L, and Kean L [Excerpt from authors] This paper distills lessons from recent efforts to improve the supervision of family planning and health programs in developing countries and identifies approaches that may be more effective and sustainable. It describes supportive supervision, an approach to supervision that emphasizes joint problem-solving, mentoring, and two-way communication between supervisors and those being supervised. It also expands the concept of effective supervision by exploring how self-assessment and peer assessment, as well as community input, can be seen as vital components of results-oriented, supportive supervision. Details
Health Sector Reform and Public Sector Health Worker Motivation: A Conceptual Framework Elsevier Science Ltd., Social Science and Medicine 2002 Franco LM, Bennett S and Kanfer R [Excerpt from authors] Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers' willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance. While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture. Details
Addressing the Health Workforce Crisis: Towards a Common Approach Human Resources for Health 2006 Dal Poz MR, Quain E, O'Neil M, McCaffery J ,Elzinga G and Martineau T [Excerpt from authors] The challenges in the health workforce are well known and clearly documented. What is not so clearly understood is how to address these issues in a comprehensive and integrated manner that will lead to solutions. This editorial presents - and invites comments on - a technical framework intended to raise awareness among donors and multisector organizations outside ministries of health and to guide planning and strategy development at the country level. Details
HIV/AIDS, Human Resources and Sustainable Development Joint United Nations Programme on HIV/AIDS (UNAIDS) 2002 [Excerpt from publisher] AIDS is sapping vital components and attributes of potentially successful development strategies. By draining human resources, the epidemic distorts labour markets, disrupts production and consumption, and ultimately diminishes national wealth. Some countries bearing the brunt of such effects now face the prospect of 'un-developing'-of seeing their development achievements dissolve in the wake of the epidemic. Details
Exploring the Influence of Workplace Trust Over Health Worker Performance - Preliminary National Overview Report : South Africa Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine 2004 Gilson L, Khumalo G, Erasmus E, Mbatsha S and McIntyre Di [Excerpt from authors]A study exploring the influence of workplace trust over health worker performance at primary care level was undertaken in South Africa and Tanzania in 2003. The study aimed to:review the policy environment and contextual factors influencing primary care delivery and health worker motivation;explore the managerial and organizational influences over workplace trust at primary care level;consider the influence of workplace trust over health worker motivation and performance, with particular regard to attitudes and behaviours towards patients;draw preliminary recommendations for improving primary care managementestablish a foundation for future investigation of the workplace trust and health worker performance. Details
Exploring the Influence of Workplace Trust Over Health Worker Performance - Preliminary National Overview Report: Tanzania Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine 2004 Manzi F, Kida T, Mbuyita S, Palmer N and Gilson L [Excerpt from authors] A study exploring the influence of workplace trust over health worker performance at primary care level was undertaken in Tanzania and South Africa in 20031. The study aimed to:review the policy environment and contextual factors influencing primary care delivery and health worker motivation;explore the ma nagerial and organizational influences over workplace trust at primary care level;consider the influence of workplace trust over health worker motivation and performance, with particular regard to attitudes and behaviours towards patients;draw preliminary recommendations for improving primary care managementestablish a foundation for future investigation of the workplace trust and health worker performance. Details
Health Worker Motivation in Africa: The Role of Non-financial Incentives and Human Resource Management Tools Human Resources for Health 2006 Mathauer I and Imhoff I [Excerpt from authors] Background: There is a serious human resource crisis in the health sector in developing countries, particularly in Africa. One of the challenges is the low motivation of health workers. Experience and the evidence suggest that any comprehensive strategy to maximize health worker motivation in a developing country context has to involve a mix of financial and non-financial incentives. This study assesses the role of non-financial incentives for motivation in two cases, in Benin and Kenya. Details
A Comprehensive Systematic Review of Evidence on the Structure, Process, Characteristics and Composition of a Nursing Team that Fosters a Healthy Work Environment Blackwell Publishing, Inc., International Journal of Evidence-based Healthcare 2006 Pearson A, Porritt K, Doran D, Vincent L, Craig D, Tucker D and Long L [Excerpt from authors] The overall aim of this systematic review was to identify the best available evidence on the relationship between the knowledge, competencies and behaviours of nurses exhibiting professional practice in their workplace; and the development of a healthy work environment. The results of the review suggest a number of recommendations for practice and research on creating a healthy work environment. Details
Worlds Apart? The UK and International Nurses Royal College of Nursing, UK 2006 Buchan J and Seccombe I This interim commentary provides an overview briefing on the UK nursing labour market, with a specific focus on international issues. The commentary is being published in advance of a full labour market review, due out later in the year. Details
Managing Health Professional Migration from sub-Saharan Africa to Canada: A Stakeholder Inquiry into Policy Options Human Resources for Health 2006 Labont? R, Packer C and Klassen N [Excerpt from authors] Background: Canada is a major recipient of foreign-trained health professionals, notably physicians from South Africa and other sub-Saharan African countries. Nurse migration from these countries, while comparatively small, is rising. African countries, meanwhile, have a critical shortage of professionals and a disproportionate burden of disease. What policy options could Canada pursue that balanced the right to health of Africans losing their health workers with the right of these workers to seek migration to countries such as Canada? Details
The Globalization of the Labour Market for Health-Care Professionals International Labour Organization, International Labour Review 2006 Clark PF, Stewart JB and Clark DA [Excerpt from publisher]The worldwide shortage of health-care workers has led to a brain drain that is negatively affecting the health-care systems of less affluent countries. The authors study the factors encouraging nurses and doctors to migrate, measure the costs and benefits of such migration and analyse methods of foreign recruitment. They then look at the theories that help explain this phenomenon: human capital theory, theories of neo-colonialism and of globalization. They conclude with a policy discussion of possible strategies, which include addressing the "push" factors motivating migration, focusing training on local health-care needs, signing bilateral agreements that limit migration, etc. Details
Positive Practice Environments - Key Considerations for the Development of a Framework to Support the Integration of International Nurses International Centre on Nurse Migration 2006 Adams E and Kennedy A [Excerpt from authors]This paper focuses on nurses who have migrated and are registered/licensed/authorised to practice, post-adaptation/orientation, and are working as a nurse in a given country. The term international nurse is used for nurses who have been educated abroad and have either been recruited or have chosen to migrate. This paper aims to provide an overview of the influences of international policies and agreements, the social and personal benefits and costs of migration for international nurses based on their experiences, and to outline a possible framework to develop positive practice environments to support long-term integration and the retention of this valuable resource. Details
ICN on Occupational Stress and the Threat to Worker Health International Council of Nurses 0 This Nursing Matters fact sheet provides quick reference information and international perspectives from the nursing profession on occupational stress. Details
The Financial Losses from the Migration of Nurses from Malawi BMC Nursing 2006 Muula AS, Panulo B Jr and Maseko FC [Excerpt from authors]Background: The migration of health professionals trained in Africa to developed nations has compromised health systems in the African region. The financial losses from the investment in training due to the migration from the developing nations are hardly known. Conclusion: Developing countries are losing significant amounts of money through lost investment of health care professionals who emigrate. There is need to quantify the amount of remittances that developing nations get in return from those who migrate. Details
Assessing Human Resources for Health: What Can Be Learned From Labour Force Surveys? Human Resources for Health 2003 Gupta N, Diallo K, Zurn P and Dal Poz M [Excerpt from authors]Background: Human resources are an essential element of a health system's inputs, and yet there is a huge disparity among countries in how human resource policies and strategies are developed and implemented. The analysis of the impacts of services on population health and well-being attracts more interest than analysis of the situation of the workforce in this area. This article presents an international comparison of the health workforce in terms of skill mix, sociodemographics and other labour force characteristics, in order to establish an evidence base for monitoring and evaluation of human resources for health. Details
Qualitative Study of Iranian Nurses' Understanding and Experiences of Professional Power Human Resources for Health 2004 Hagbaghery MA , Salsali M and Ahmadi F [Excerpt from authors] Nurses are expected to empower their clients, but they cannot do so if they themselves feel powerless. They must become empowered before they can empower others. Some researchers have emphasized that understanding the concept of power is an important prerequisite of any empowerment program. While many authors have tried to define the concept of power, there is no comprehensive definition. This paper is an attempt to clarify the concept of power in nursing. It also would present a model describing the factors affecting nurse empowerment. Details
The Match Between Motivation and Performance Management of Health Sector Workers in Mali Human Resources for Health 2006 Dieleman M ,Toonen J , Tour? H and Martineau T [Excerpt from authors]Human resources for health (HRH) play a central role in improving accessibility to services and quality of care. Their motivation influences this. In Mali, operational research was conducted to identify the match between motivation and the range and use of performance management activities. Details
Identifying Factors for Job Motivation of Rural Health Workers in North Viet Nam Human Resources for Health 2003 Dieleman M , Viet Cuong P , Le Vu Anh2 and Tim Martineau3 [Excerpt from authors] Background: In Viet Nam, most of the public health staff (84%) currently works in rural areas, where 80% of the people live. To provide good quality health care services, it is important to develop strategies influencing staff motivation for better performance. Method: An exploratory qualitative research was carried out among health workers in two provinces in North Viet Nam so as to identify entry points for developing strategies that improve staff performance in rural areas. The study aimed to determine the major motivating factors and it is the first in Viet Nam that looks at health workers' job perception and motivation. Apart from health workers, managers at national and at provincial level were interviewed as well as some community representatives. Results: The study showed that motivation is influenced by both financial and non-financial incentives. The main motivating factors for health workers were appreciation by managers, colleagues and the community, a stable job and income and training. The main discouraging factors were related to low salaries and difficult working conditions. Conclusion: Activities associated with appreciation such as performance management are currently not optimally implemented, as health workers perceive supervision as control, selection for training as unclear and unequal, and performance appraisal as not useful. The kind of non-financial incentives identified should be taken into consideration when developing HRM strategies. Areas for further studies are identified. Details
Factors Affecting the Performance of Maternal Health Care Providers in Armenia Human Resources for Health 2004 Fort AL and Voltero L [Excerpt from authors] Over the last five years, international development organizations began to modify and adapt the conventional Performance Improvement Model for use in low-resource settings. This model outlines the five key factors believed to influence performance outcomes: job expectations, performance feedback, environment and tools, motivation and incentives, and knowledge and skills. Each of these factors should be supplied by the organization in which the provider works, and thus, organizational support is considered as an overarching element for analysis. Little research, domestically or internationally, has been conducted on the actual effects of each of the factors on performance outcomes and most PI practitioners assume that all the factors are needed in order for performance to improve. This study presents a unique exploration of how the factors, individually as well as in combination, affect the performance of primary reproductive health providers (nurse-midwives) in two regions of Armenia. Details
Improving Motivation Among Primary Health Care Workers in Tanzania: A Health Worker Perspective Human Resources for Health 2006 Manongi RN, Marchant TC and Bygbjerg IC [Excerpt from authors]In Tanzania access to urban and rural primary health care is relatively widespread, yet there is evidence of considerable bypassing of services; questions have been raised about how to improve functionality. The aim of this study was to explore the experiences of health workers working in the primary health care facilities in Kilimanjaro Region, Tanzania, in terms of their motivation to work, satisfaction and frustration, and to identify areas for sustainable improvement to the services they provide. The primary issues arising pertain to complexities of multitasking in an environment of staff shortages, a desire for more structured and supportive supervision from managers, and improved transparency in career development opportunities. Further, suggestions were made for inter-facility exchanges, particularly on commonly referred cases. The discussion highlights the context of some of the problems identified in the results and suggests that some of the preferences presented by the health workers be discussed at policy level with a view to adding value to most services with minimum additional resources. Details
Public Sector Nurses in Swaziland: Can the Downturn be Reversed? Human Resources for Health 2006 Kober K and Van Damme W [Excerpt from authors] The lack of human resources for health (HRH) is increasingly being recognized as a major bottleneck to scaling up antiretroviral treatment (ART), particularly in sub-Saharan Africa, whose societies and health systems are hardest hit by HIV/AIDS. In this case study of Swaziland, we describe the current HRH situation in the public sector. We identify major factors that contribute to the crisis, describe policy initiatives to tackle it and base on these a number of projections for the future. Finally, we suggest some areas for further research that may contribute to tackling the HRH crisis in Swaziland. Emigration and attrition due to HIV/AIDS are undermining the health workforce in the public sector of Swaziland. Short-term and long-term measures for overcoming this HRH crisis have been initiated by the Swazi government and must be further supported and increased. Scaling up antiretroviral treatment (ART) and making it accessible and acceptable for the health workforce is of paramount importance for halting the attrition due to HIV/AIDS. To this end, we also recommend exploring ways to make ART delivery less labour-intensive. The production of nurses and nursing assistants must be urgently increased. Although the migration of HRH is a global issue requiring solutions at various levels, innovative in-country strategies for retaining staff must be further explored in order to stem as much as possible the emigration from Swaziland. Details
The Importance of Human Resources Management in Health Care: A Global Context Human Resources for Health 2006 Kabene SM, Orchard C, Howard JM , Soriano MA and Leduc R [Excerpt from authors]This paper addresses the health care system from a global perspective and the importance of human resources management (HRM) in improving overall patient health outcomes and delivery of health care services. Various key success factors emerge that clearly affect health care practices and human resources management. This paper will reveal how human resources management is essential to any health care system and how it can improve health care models. Challenges in the health care systems in Canada, the United States of America and various developing countries are examined, with suggestions for ways to overcome these problems through the proper implementation of human resources management practices. Details
Iranian Staff Nurses' Views of Their Productivity and Human Resource Factors Improving and Impeding It: A Qualitative Study Human Resources for Health 2005 Nayeri ND, Nazari AA, Salsali M and Ahmadi F [Excerpt from authors] Nurses, as the largest human resource element of health care systems, have a major role in providing ongoing, high-quality care to patients. Productivity is a significant indicator of professional development within any professional group, including nurses. The human resource element has been identified as the most important factor affecting productivity. This research aimed to explore nurses' perceptions and experiences of productivity and human resource factors improving or impeding it. Details
Identifying Nurses' Rewards: A Qualitative Categorization Study in Belgium Human Resources for Health 2006 De Gieter S , De Cooman R, Pepermans R, Caers R , Du Bois C and Jegers M [Excerpt from authors]Rewards are important in attracting, motivating and retaining the most qualified employees, and nurses are no exception to this rule. This makes the establishment of an efficient reward system for nurses a true challenge for every hospital manager. A reward does not necessarily have a financial connotation: non-financial rewards may matter too, or may even be more important. Therefore, the present study examines nurses' reward perceptions, in order to identify potential reward options. Details
Economic Incentive in Community Nursing: Attraction, Rejection or Indifference? Human Resources for Health 2003 Kingma M [Excerpt from author] It is hard to imagine any period in time when economic issues were more visible in health sector decision-making. The search for measures that maximize available resources has never been greater than within the present decade. A staff payroll represents 60%-70% of budgeted health service funds. The cost-effective use of human resources is thus an objective of paramount importance. Using incentives and disincentives to direct individuals' energies and behaviour is common practice in all work settings, of which the health care system is no exception. The range and influence of economic incentives/disincentives affecting community nurses are the subject of this discussion paper. The tendency by nurses to disregard, and in many cases, deny a direct impact of economic incentives/disincentives on their motivation and professional conduct is of particular interest. The goal of recent research was to determine if economic incentives/disincentives in community nursing exist, whether they have a perceivable impact and in what areas. Details
Nurse: Patient Ratios - ICN Fact Sheet International Council of Nurses 2003 [Excerpt from publisher] This Nursing Matters fact sheet provides quick reference information and international perspectives from the nursing profession on nurse: patient ratios. Details
Health Human Resources Trends in the Americas: Evidence for Action (Draft for Discussion) Pan American Health Organization's Observatory of Human Resources in Health - PAHO/WHO 2006 Cameron R [Excerpt from author] This collaborative review of human resources for health in the Americas was undertaken in follow-up to the Toronto Call to Action, the Seventh Regional Meeting of the Pan American Health Organization's Observatory of Human Resources in Health, held in Toronto, Ontario, Canada, October 4-7, 2005 [....] The report recommends that: a clear determination of the region's supply of health human resources be undertaken; a code of practice for the management of the internal recruitment of health care professionals be collaboratively developed and implemented; community-based workforce recruitment and retention mechanisms be supported that are responsive to local workforce needs; total enrollments and student mix in professional schools be closely linked to identified community needs and that policies and incentives be introduced to reduce student attrition and to enhance the geographic distribution of the health workforce; primary health care delivery teams, that emphasize an increase in both nursing numbers and their competency ranges to maximize service delivery flexibility should be supported and promoted at the community level; and, an inter-regional expert team be struck to develop a human resource planning framework, to identify regional planning priorities, to conduct country assessments in the areas of highest need, and, to promote the development of a health human resource minimum data set to support the region's current and long-term planning processes. Details
Workplace Violence in the Health Sector: Country Case Studies: Brazil, Bulgaria, Lebanon, Portugal, South Africa, Thailand, and an Additional Australian Study International Labour Office; International Council of Nurses; World Health Organization; Public Services International 2002 Di Martino V [Excerpt from author]The International Labour Office (ILO), the International Council of Nurses (ICN), the World Health Organization (WHO) and Public Services International (PSI) launched in 2000 a joint programme in order to develop sound policies and practical approaches for the prevention and elimination of violence in the health sector. When the programme was first established and information gaps were identified, it was decided to launch a number of country studies as well as cross-cutting theme studies and to conclude by drafting guidelines to address workplace violence in the health sector. This working paper presents the Synthesis Report of the commissioned country reports to stimulate further discussion in the area of workplace violence, encourage fact-finding research in other countries and support sound policy-making. Details
ILO Nursing Personnel Convention No.149 - Recognize Their Contribution Address Their Needs International Labour Office 2005 [Excerpt from publisher] In 2002, the ILO classified the Nursing Personnel Convention (C 149) as an up-to-date instrument, reaffirming its relevance in today's socio-economic realities. This Convention is nearly 30 years old, yet sadly not much progress has been made in many countries towards improving working conditions in nursing. The same concerns that prompted international attention on working conditions in health services in the 1970's unfortunately still prevail today. The health care profession is not attracting enough recruits in both developed and developing countries to keep up with demand, and in addition, it is also losing large numbers of trained personnel to areas outside the sector. Details
Framework Guidelines for Addressing Workplace Violence in the Health Sector - The Training Manual International Labour Organization; International Council of Nurses; World Health Organization; Public Services International 2005 di Martino V [Excerpt from author] The Guidelines provide definitions of workplace violence and guidance on general rights and responsibilities; best approaches; violence recognition; violence assessment; workplace interventions; monitoring and evaluation. This Training Manual is a complement to the Framework Guidelines. It is a practical, user-friendly tool that builds on the policy approach of the Framework Guidelines. Representatives of governments, employers and workers would be well served to use the Manual in training situations, so as to encourage social dialogue among health sector stakeholders and develop, in consultation, approaches to address violence in the workplace. Details
Working Well: A Call to Employers - A summary of the RCN Royal College of Nursing, UK 2002 [Excerpt from publisher] [This paper provides]a summary of the RCN Working well survey into the wellbeing and working lives of nurses, plus recommendations for employer. This document summarises the key findings from the survey. It looks at: - the rationale for undertaking the survey - what makes a good employer - detailed findings from each of the employment practices covered in the survey - nurses' psychological health and wellbeing - recommendations for consulting on and implementing employee-friendly working for nurses, negotiators and employers. Details
Dealing With Bullying and Harassment : A Guide for Nursing Students Royal College of Nursing UK, Working Well Initiative 2002 [Excerpt from publisher]This guide is aimed mainly at nursing students. It should help you to:recognise if you or a colleague are being bullied or harassedtake action against bullying and harassment We also want to:raise awareness of the problem of employers and educators as well as students-if people are aware of the problem, then they can take steps to stop it happeningencourage nursing educators and employers to carry through anti-harassment policies. Details
Implications of Organizational Learning for Nursing Managers From the Cultural, Interpersonal and Systems Thinking Perspectives Blackwell Publishing, Inc., Nursing Inquiry 2001 Chan C-PCA [Excerpt from author] This paper discusses the implications of organizational learning to healthcare administrators, in particular nursing managers, from the cultural, interpersonal and systems thinking perspectives. In the various perspectives the reasons for organizational ineffectiveness and remedies are presented. There is little doubt that pressure for nurses to perform is escalating as healthcare institutions attempt to improve the quality of service through restructuring and change, which leads to greater job dissatisfaction, higher turnover, lower morale and increased industrial actions of nurses. An integrated approach to organizational learning is arguably important for the effective management of nurses during periods of transition. Details
Primary Nurses' Performance: Role of Supportive Management Blackwell Publishing, Inc., Journal of Advanced Nursing 2004 Drach-zahavy A [Excerpt from author] Background: Most studies examining primary nursing focus on outcome variables such as enhanced patient and staff satisfaction with care, perceived autonomy and quality of care, whereas only limited research has examined processes of implementing and maintaining primary nursing. In addition, the few studies that have explored process variables discuss only direct relationships between the design of the primary nursing care-delivery system, process and nurse outcomes, and disregard how such variables interact. Aim: This study sought to address previous inconsistent findings about the impact of primary nursing care-delivery models on the performance of nurses by incorporating the moderating role of supportive management practices. Details
Framework for Developing Nursing Roles Scottish Executive Health Department 2005 [Excerpt from publisher] The purpose of this document is twofold. It presents a generic framework which can be used to guide the development of new roles. The framework has been developed in partnership with representatives from other staff groups. It may be applied equally to role development in nursing as well as, for example, the Allied Health Professions or Pharmacy. It can be used to assist in the planning process to ensure that roles are needs led, meet governance requirements, are sustainable, as well as ensuring that the development is supported by the whole team thus ensuring its success. The rest of the document contains a rationale for structured role development in nursing. It describes the context and drivers for change, principles which should underpin nursing roles, and emphasises the importance of a career structure within which new roles may sit comfortably. The framework is aimed at four key groups:Patients and carers, their representatives and voluntary organisationsNurses, midwives, other health professionals and social care professionalsEducation providers and researchersManagers of services and service providers. Details
A Methodology for Assessing the Professional Development Needs of Nurses and Midwives in Indonesia: Paper 1 of 3 Human Resources for Health 2006 Hennessy D, Hicks C, Hilan A and Kawonal Y [Excerpt from authors] Despite recent developments, health care provision in Indonesia remains suboptimal. Difficult terrain, economic crises, endemic diseases and high population numbers, coupled with limited availability of qualified health care professionals, all contribute to poor health status. In a country with a population of 220 million, there are currently an estimated 50 nurses and 26 midwives per 100 000 people. In line with government initiatives, this series of studies was undertaken to establish the training and development needs of nurses and midwives working within a variety of contexts in Indonesia, with the ultimate aim of enhancing care provision within these domains. Details