WPRO 4401
NURSING WORKSHOP, SOUTH PACIFIC
Sponsored by the WORLD HFALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Suva, Fiji 11 to 22 September 1972
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FINAL REPORl'
NOT FOR SALE
PRINTED AND DISTRIBJ'l'ED
BY THE REGIONAL OFFICE FOR'I'HE WESTERN PACIFIC
of the World Health Organization Manila, Philippines March 1973
'n1e views expressed in tbi.. report are tbose of tbe advisers and. participants of tbe workshop and do not neoeSII&l'il7 ren.ot the offioial polio7 of the World Health Organ1zation.
'.this Offioe of State. in Workahop,
report baa been prepared 117 the We.tem Paoific :Regicmal. the World Health Organization for <JoYerraenu of lilellber the Region and. for those who part10ipated in tile )furaing SO\ltb Pacific, Suva, Fiji, 11 to 22 Se~r 1972.
CONTENTS
1.
INTRODUCTION ....................................... '" '" ............................ '" .. '" '" .............. '" ORGANIZATION .. '" .............. '" .......................................................................... . OONTEJlJT ...................................................................................................... .
1
2.
1
3.
3 3 4 .., I
3.1 Topic 1: Pacific
Health needs and services in the South ...................................... '" ...................................... '" .. .. .. .. . .. .
3.2 Topic 2:
Planning and progranming for nursing services ............................................................................................ . 3.3 Topic 3: Nursing manpower ••••••••••••••••••••••••••••• 3.4 Topic 4: Administration and supervision ••.••••••••••.. 3.5 Topic 5: Education and training of nurses in the South Pacific .................................................................................. ..
Y 11
3 .. 6 Resources .......................................................... "............................ .
14 15 15
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4.
OONCIlJSIONS ...................................... '" ........................................................ ..
4.1
Relating to nursing within the context of the South Pacific ................................................. '" .. . . .. . . . . . .. .
4.2 Relating to planning and programming for nursing ••••••• 4.3 Relating to nursing manpower ••••••••••••••••••••••••••• 4.4 Relating to administration and supervision of
16 16
4.5 4.6 5.
nursing services ••.••.•••••••••••••••••.• ~............. Relating to the education and training of nurses ••••••• Relating to the utilization of resources in the South Pacific Area .•........••.•..•......•...•..•.•....
16 17 18
EVALUATION OF THE WORKSHOP ANNEXES -
18
Annex 1 Annex lA Annex 2 Annex 3 Annex 4 Annex 5 Annex 6 -
List of Participants and Staff ••••• ; •••••••• Countries and Territories in the South Pacific Covered by the WHO South Pacific Area Office in Suva (Fiji) •••••••••••••••••• Nursing Workshop, South Pacific, Suva, JfiJ i (Agenda) ••••.•.•••.•.•••••••••••••••••• List of Working Documents ••••••••••••••••••• Planning and Programming for Nursing;' Midwifery Services •••••••••••••••••••••••••• Nursing/Midwifery Manpower •••••••••••••••••• Organization. Administration and Supervision of Nursing/Midwifery Services ••••••••••.••••
25 31 33 41
43 55
63
1.
INTRODUCTION
1.1 The Nursing Workshop held in Suva. Fiji. from 11-22 September 1972 was organized as part of the WHO ~rsing advisory services project, South Paoific. 1.2 The need for establishing closer contact between nurses holding positions of responsibility in nursing services and education in the countries of the South Pacific became evident in the early stages of this project. The findings of the Survey of Nursing Manpower 1971,1 jointly sponsored by the South Pacifio Health Service and WHO indicated, that nursing services in a number of territories shared certain oommon problems for which each was actively seeking solutions. With the limited resources available in nursing services in the area, there were obvious advantages in bringing together the different groups to share experienoes and learn to taokle problems in the workshop setting. 1;3 The objectives of the workshop were: (a) to exchange information and experience in nursing2 education and servioes in the context of health servioes in the South Paoific area; to identify the important problems of, and needs in, nursing services and to explore praotical means for their solution; to formulate guidelines for the education and training of nursing personnel at all levels to meet the changing demands of the health services; and to explore the means by which external agencies interested in health may oontribute to the strengthening of nursing education and services in the area. 2. ORGANIZATION
•
(b) (c)
Cd)
2.1 Countries and territories in the South Pacific (see in Annex la the list of countries and territories included in the South Pacific area in acoordance with WHO's designation) were asked to nominate nurses in positions of responsibility in nursing eduoation or services to participate in the workshop. Ten countries accepted and 20 participants attended the workshop.
lASsignment Report: Nursing Manpower and Nursing Education in some oountries and territories of the South Pacific (Results of a Survey sponsored by the South Pacific Health Service and assisted by the World Health Organization) March - May 1971 by Miss D.T. Manning (WPRO 440l-E). In this report where nurses or nursing servioes are referred to, these include midwives and midwifery servioes. as both professions and servioes are oombined in the South Paoifio area. 2
- 2 2.2 Preparation for the workshop had oommenoed several months previously with partioipating oountries preparing information on the organization of their nursing servioes and on nursing eduoation programmes. These doouments together with publioations provided by WHO were used extensively as resouroe material for group work during the session. 2.3 The workshop, and an exhibition depioting nursing servioes in the oountries of the South Paoifio, was opened at 9:00 a.m. on 11 September by Adi Lady tala Mara, the wife of Fiji's Prime Minister, in the presenoe of invited guests. The detailed agenda oan be found in Annex 2. 2.4 Plenary sessions were devoted to presentation of baokground papers by speoialist speakers, panel disoussions by invited speakers and partioipants, and oontributions by partioipants relating to speoifio topios. Other methods utilized inoluded "brain storming". "buzz sessions", "foous groups", "role play". Provisions were made for free interohange of ideas in each plenary session. 2.5 More than half of the total time was spent working in small groups. Membership of eaoh group provided geographio representation while permitting eaoh partioipant to work in the topio most relevant to his/her needs. Eaoh of the three main groups dealt with a major topio, from whioh members seleoted areas in which to oonoentrate in sub-group aotivities. First group sessions elioited the needs and oommon problems in the main groups and selected areas for oloser attention. Group reports at the oommenoement of each plenary session maintained contact between the groups and prevented undue duplioation of effort, although it was inevitable, and indeed desirable, that there was some degree of overlap of interest among members of different groups. 2.6 Visits arranged by the Division of Nursing Servioes of the Fiji Medioal Department were made to hospitals, sohools of nursing and oommunity health servioes in Suva and the surrounding rural areas. Return visits were made to the obstetrio servioe for brief studies by one sub-group. 2.7 The oonsultant and WHO staff were available as resouroe persons to assist group work. The Reader in Eduoation, University of the South Paoifio. the Government Statistician and the Law Officer also assisted in group work. 2.8 A preliminary questionnaire (unsigned) was oompleted by all taking part in order to elicit their expeotations of the workshop and to determine oommon problems, interests and needs.
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A modification of the same questionnaire was used at the end of the workshop to provide indications of changes in knowledge and confidence and also to allow partioipants to evaluate the workshop and suggest ideas for follow-up activities. Individual "comment" sheets canpleted by participants at the close of each day's session provided an ongoing evaluation of the workshop content and process and permitted modifications to be introduced where indicated.
3. 3.1 Topic 1:
CONTENT
Health needs and services in the South Pacific
3.1.1 Two plenary sessions were devoted to this topio which served to set ensuing work on nursing services in the wider oontinuum of the social and econanic background of countries of the South Pacifio.
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3.1.2 A panel discussion "Social and Economic Conditions in the South Pacif1o" between eoonanio planners and a sooial anthropologist, followed the presentation of a paper on the subject. This outlined the position of health servioes as a consumer and provider of resouroes, competing with other seotors for limited amounts of money and manpower. The priority aooorded to health servioes in government budgets varies widely between territories of the South Pa01fio, but the oontribution of other sectors, (e.g., education, agriculture, public works) to health must be recognized. Increasing population and urbanization impose strains on the -trad1t1onaLmeans of distribution of resouroes in the area. The disoussion which followed, emphasized the importanoe of clear presentation of seotoral needs in order to obtain an adequate part of the budget. A lively discussion on the " saored words " 0 f" deve1 opment " , and "progress" and their true meaning produced many questions (but few answers) on the effeots of increasing urbanization and the change from subsistenoe to oash eoonanies on the values and kinship systems of the peoples of the South Pacific. The following two papers fooussed mainly on the health problems and health services, first in the South Pacific area as a whole, and secondly in Fiji. The first outlined the influenoe of various faotors inolud1ng: the nature of health problems, economic and sooi&1 oonditions, geography
and history, on the type of health servioe being provided in different areas. While some maj or differenoes exist in the health problems of, for example, Melanesia and Polynesia (malaria being a prime example), respiratory diseases, inoluding pneumonia, rank h1gh as the cause of morbidity and mortality throughout the area.
- 4 It was suggested that high on the list of priorities for the health servioes in the south Pacific were: the development of basic health structures that are physioally, technically, and administratively able to deliver health services where they are needed. In developing this point the speaker emphasized the importanoe of the development of management and administrative skills at all levels, stressing that techniaal means for the control of many diseases (oiting tuberculosis as an example) eXisted, but programmes often falter for management or administrative reasons. Second on the list of priorities were planning for health manpower and the training of staff, suggesting that a choiae will have to be made between elaborate, professional training of a few, or more limited preparation adapted to local needs, for a greater number. The importanae of adequate guidanae to workers in isolated situations was stressed. The need for economies in the curative sector, particularly in hospital oonstruation, to allow of wider dispersion of less sophisticated, but effeotive, means of care and preventive services to the rural population was also stressed. In describing" the health serviaes in Fiji, the Secretary for Health illustrated a point brought out in the previous paper, namely, the almost oomplete absence of a private sector in medical oare in the South Pacifio. The provision of what amounts to a National Health Service by the Fiji Government requires extreme oare in fitting the medical service expenditure into the total demands on government resources in Fiji. He emphasized that in Fiji, training of all health personnel was a responsiblli ty of the Medical Department and considered that the question of having eduoational institutions directly under the control of the employing agency was dependent on a country's ability to pay. FollOwing these presentations the groups made field visits to seleoted services in SUva and the surrounding rural districts, including general, obstetric and psychiatrio hospitals, health centres, a rural hospital, a rural nursing station, the Central Sahool of Nursing, and the School for Public Health Nursing. 3.2 Topic 2: Planning and programming for nursing services
3.2.1 Presentation of this topic was based on the background paper (Annex 4). Partioipants developed steps of the planning process in the plenary session using the problem of obstetrical oare in Fiji for this exercise. Main pOints of the presentation and disoussion were: Steps in planning and programming nursing services within the terms of referenoe of an overall national health plan or in its absenoe based on directives fram the health authorities:
- 5 <a) pre-planning oonsideration - determine if essential basia oonditions are present for the proposed programme, e.g., interest of authorities, organizational framework, appropriate legislation; obtain an overview of the oommunity to inolude sooiodemographio variables, desoriptive and statistiaal data on health servioes and personnel; estimate "needs" (defioiencies identified by obJeotive data) and "demand" of the population for health services. Both aspects should be considered in planning as both are legi timate "requirements". Clarify which needs and demands are "nursing needs". These should be g1 ven priority over funations which can be carried out as well or better by other wolk ers; do a survey of resouroes to include health-related servioes suoh as education, health facilities, and personnel; other oommunity resouroes; establish priorities by weighing four main factors: importance of the needs, availability of resouroes, community readiness for servioe and legal implications; arrange for oontinuityaf existing needed servioes and prepare to develop or expand the priority serviaes; formulate broad alma for the new or expanded servioes. A tentative graph of the plan can help with various oomponents and alternatives in perspeative; develop operational obJeotives, so that outcome can be measured against antioipated aohievement; involve persons who will be part of the programme; represSl tatives of professions, agenoies, oommunity leaders and clients by partioipation in an advisory board, oommittees of specialists and implementing teams; prepare an operational plan with Job desariptions, standards for staffing, facilities, equipment, schedules and reoording; propose and obtain approval for the budget built on faots and logio; r.ecruit, train and orient personnel and volunteers. The role of families should be taken into aoaount in staffing;
(b)
(a)
(d)
(e)
(f) (g)
(h) (i)
(J)
(k) (1)
- 6 (m) implement the plan assuring communication between administration, staff and clients. Ongoing supervision and guidance for all levels of personnel will faoilitate safe, effective implementation and serve as a channel for new ideas; (n) evaluate achievement of the objectives against a baseline recorded at the beginning of the programme. Analyze the input in human time and effort, cost of equipment and faoilities, in order to determine if the results Justify the investment. Consider other changes suoh as relationships between staff and olients, ~ommunity self-reliance, staff development; and r.eport on the project to all involved and utilize the final report for replanning.
(0)
3.2.2 Based on the background paper summarized above, two groups prepared projeots: the role of the most senior ("top") nurse in government; and implioations for nursing in policy and legislation. Proposed functions for the top level nurse (but not exclusive to her) were: (a) to.be administratively responsible to the Director of Health Services, while remaining aware of responsibilities to the oonsumers and providers of nursing service; to advise him on any aspeot of nursing that can oontribute to health in the country; to develop a philosophy, objeotives and an operational plan programme for a nursing service of optimal standard· within the soope of available resouroes and within the oontext of the overall heal tb plan; to organize and administer these services in suoh a way that they are available in all parts of the country; to oo-ordinate nursing with other groups, intra- and inter-departmentally, in and outside of government, at home and abroad; to assess the quality and to evaluate the effeotiveness of nursing care in meeting overall health goals; to promote and maintain an eduoational system oommensurate with the optimal standards of nursing care;
(b) (c)
(d) (e)
(f) (g)
- 7 (h) (i) (J)
to prepare, present and Justify the nursing component of the health budget; to ensure the reoording of all faots relating to nursing service and its personnel; and to promote oonditions which favour the attraotion and retention of suitable nursing personnel.
3.2.3 The group stated that nursing leaders must take an aotive role in poliay and legislation which affeat nursing such as health, labour, welfare and eduoation laws. Of immediate concern to nursing are policy and laws in nursing eduoation (entrance requirements, currioulum, examinations); nursing praotice (types of nursing personnel, scope and standards of praotioe); registration, lioensing, reciprocity; and sooial and eoonomio seourity (wageS, working oonditions. leave. retireJllent, eto.). The importanoe of nurses to be able to define nursing and to interpret it to health workers and the oommunity was emphasized. 3.3 Topic 3: Nursing manpower
3.3.1 Nursing manpower was introduced by a working paper (see Annex 5) followed by plenary disoussion, as SUllllll&I'ized below. Health ~power inoludes three groups: available - those presently working in health services; potential - those trained in health oocupations but not employed; prospective - those receiving education for health professions. Health manpower planning is to antioipate change in population growth. composition and health needs; to Judge what financial and other resouroes will be available to meet these needs; and to prepare the most appropriate quantity and "mix" of -health workers within the available resources. Some reasons for nursing personnel shortage may be: laak of adequate funds. insufficient suitable candidates and high drop-out from the education programmes; poor distribution, poor utilization and attrition of trained personnel from the work force. 3.3.2 Study of nursing manpower started in the early 1940's. The first studies "counted heads". Later, "time studies" fooussed on how the nurse spent her work day and were followed by "aotivity stUdies" which analyzed if time was spent at the appropriate levels and functions. The most reoent trend is to study nursing assignment based on consumers' needs (patients community ••• ). 3.3.3 Some principles of nursing manpower study and planning: is co-ordinated with health and health manpower planning; is based on the reality of the local situation. giving priority to felt problems on
- 8 which there is readiness to act; has long and short-tem objectives, with action following each phase; uses scientific methods; is subject to regular review and adapted to changing needs; involves wide participation of nurses, other health workers and community.
3.3.4 Steps in nursing manpower studies:
analysis of the demography and health needs of the population, health services and their utilization, available and potential nursing manpower and its utilization; study of resources (schools) for preparing nursing personnel, projection of the manpower required to meet expected health needs and the future supply of nursing personnel. detection of imbalance between expected need and supply, and ~onnulation of alternatives and reoommendation of polioies to prevent or correct imbalances. and discussed in plenary session. (1) The Report on Nursing Manpower and Nursing Education in some oountries and territories of the South Paoific issued on 22 February 1972 outlined the methods and findings of a survey conducted in 1971 in six oountries of the area. Present and expected demands for nursing services were studied in the light of aotual, potential' and prospeoti ve resources. Career structures and personnel policies showed oonsiderable variation among oountries in the area. Eduoation programmes for staff nurse in different oountries were being adapted to local needs. The entry standard for these programmes was being raised. In gener~senior nurses played little part in overall planning for health servioes. (2) Review of seleoted studies conducted in New Zealand highlighted the many sources for obJeotive data: Department of Health, universities, local agencies, nursing oounoil, professional association and national statistios. ElDphasizing the importanoe of s-wdy1ng nursing within the framework of all health oare, the following New Zealand studies were described: agenoy oare of well babies, qualifications and praotice of registered nurses, role of the supervisor in a general hospital, and patientnurse dependency stUdies. Findings from the studies were utilized in developing nursing eduoation and service programmes. (3) Additional studies mentioned were: in Papua New Guinea, on Nursing care Dependency; in Cook Islands and Western Samoa, Work Load Analysis; in Australia, on the Extended
3.3.5 A number of stUdies conducted in the South Pacific were presented
- 9 Role of the Nurse; in Fiji, on the amount of health eduoation undertaken by nurses, attitudes of nursing servioe staff to nursing eduoation; in Tonga, regarding attitudes of preliminary training sohool students on exposure to the clinioal field, reaotion of students to admitting mistakes, reaotion of students to objective oorrection; in British Solomon Islands Protectorate. on health manpower; in Amerioan Samoa, a survey has been oonducted on the waiting time in the emergenoy rooms. ).).6 One of the groups worked on a proposal for types of nursing personnel in the South Pacific, with a ladder for mobility. The proposal was a nursing personnel system with one to three types of workers. Different patterns would be needed in different oountries. Three major types were suggested with differentiation in the expeoted function, basic education requirement and nursing eduoation programme. The role of the nurse in primary health care was ino1uded. As isolated health workers are found in several of the South Paoifio oountries, the group believed that such a worker should have a basic nursing education with supplementary preparation related to speoifio needs. In plenary discussion it was questioned if this worker should be a nurse or another type of health worker. The groups stipulated that progression from one type to another should be enoouraged among those workers who have demonstrated ability and interest in continued eduoation. Assistanoe in meeting general education requirements should be extended by the agencies, and the nursing programmes should view this aspeot as liberally as possible. Exemption from some introductory courses and/or praotice should be granted on an individual basis to enable the oandidate to complete the programme without unnecessary duplioation. Review of the levels of positions ourrently found in most of the South Paoifiooountriesled the group to state that while the assisting level should be staffed with type 3 workers, and senior positions with type 1, positions in intermediary levels oould be held by more than one type depending on the individual's at llity. l
3.4 Topic 4:
Administration and supervision
3.4.1 A background paper (Annex 6). followed by disoussion in the plenary sessions,fooussed on the pOints given below. (1)
The aim of health services is to improve the well-being of the individual and community. Nursing as an integral part of all health services funotions within the social struoture. Nurses should actively participate in the overall planning and evaluation of health servioes. While aiming for excellenoe in long-range goals, administrators should know how to use temporary, palliative measures until resources are available.
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(2)
The purpose of administration is to carry out agreed upon plans in the most effective and efficient way, with maximum economy of resources while ensuring safe and acceptable standards. Nursing service administration is the process by which the nursing ser'vice department achieves its purpose, co-operates and co-ordinates its work with other departments. It involves planning, organizing, directing, controlling, co-ordinating and evaluating the nursing prograrm1e. Administrators should be aware of possible constraints and be able to adapt to changing conditions. Team work with two-way communication between those involved in the programme is mandatory. Levels in organisations are: administrative, managerial, operational. Authority and decision-making should be delegated to the lowest level at which competence can be found. Supervision is concerned with the individual's needs in the performanoe of his work and helps him oarry out the job to the best of his potential. ContiIU1ing eduoation is a means for staff to attain necessary knowledge and to identify wi th the service. It may be carried out through formal education provided outside the service or by in-service and orientation programmes within the agenoy. Continued education should involve the learners and provide for their active participation.
.
(3)
(4)
(5)
(6)
(7)
3.4.2 Several projects were prepared by sub-groups on this topic: supervision. staffing. job desoriptions and in-service education. (1)
The supervision projeot specified the place of nursing supervision within the total health service. The aims of the health service and nursl.ng service must be studied as well as data on the community. the nursing personnel and the facilities available. The group defined three factors in supervision of nursing servioes: personnel, nursing aspeots of health care and facilities. Programmes to be developed by supervision in relation to eaoh faotor were described. The group ooncerned with staffing developed a flow-chart from understanding the objectives for staffing to evaluation and replanning.
(2)
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(3)
Another group prepared mOdels for job description of various positions in nursing; the senior nurse (matron) in the Department of Health, a hospital matron and a clinical supervisor. Each description includes the job title, the employing agency, to whom the nurse was directly responsible, and the functions for which she was responsible. The fourth group project dealt with in-service education. Within the framework of an agreed upon definition of the conoept, attention was given to speoific objectives, organizational principles, types of programmes needed, methods of teaching and evaluation, and problems of motivation. Special consideration was also given to the needs for in-service education of isolated workers and some specific conolusions were issued. Education and training of nurses in the South Paoific
(4)
3.5 Topio 5:
3.5.1 Two papers, on basic and post-basic nursing eduoation, served as baokground to general discussion on the oontent, methods and standards of education programmes available for nurses in the South Pacific. 3.5.2 The first, which was based on findings of the 1971 survey of nursing in the South Paoific area posed questions on: the funotions for which nurses 'will need to be prepared in the future; the nature of "basio" programmes at country level; the organization of learning experiences, with partioular referenoe to the content and use of the syllabus, methods of teaching, the relevance of subjeots taught in class to the clinical experienoe of students, methods of evaluation and the control and financing of nursing education in the countries of the area. In the discussion which followed it was clear that in many areas students, instructors, medical and nursing servioe personnel, were not well informed on the aims and content of the curriculum as a whole. It was felt that the oommittee which reviews the syllabus should have representation of nurses, doctors, educators and stUdents. Involvement of nursing education with general eduoation was felt to be desirable in all oountries but the capacity of education departments to assume major responsibility for nursing education needed further investigation. An important aspeot of the absorption of nursing programmes into the tertiary education system of a country is the preparation of nurse educators with appropriate qualifioations.
3.5.3 The second paper on post-basic programmes, was introduced by a role play in whioh a group of participants (all of whom had completed post-basic preparation abroad) acted as a selection board interviewing a prospective student from a South Pacific territory. The problems of adequate information about courses for the candidate before leaving the country were highlighted. Points raised were the need for students to
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seleot programme areas relevant to their future funotions, and for oounselling and assistanoe during the oourse of the studies. The planning of post-basio nursing eduoation ourrioula was represented in a diagram.
PLANNING FOR POST-BASIC NURSING EDUCATION CURRICULA
Learner
Demands of Health Servioe
Cournunity Needs
Knowledge (content)
Institution Control
Graduate
~\ Aims and Objectives Value System
/ if
'1.,.' ObJeetive. ~ Curriculum Content
•
~
Learning Experiences
f
.,
Evaluation
,
Educational programmes for speoialists in clinical praotioe, teaohers or administrators, are important in the health care system of any country. The need for these programmes has provided the impetus for post-basio nursing education of many varieties. The rapid ohanges taking plaoe in basic nursing education make a review of post-basio education necessary. The diverse backgrounds of students in post-basio prograllllles present problems where staff and faoilities for individualized learning are limited. Admission oriteria,oontent and length of courses, and certificates awarded are faotors which influenoe reoognition of programmes between countries.
- 13 The arguments for and against single disoipline colleges were presented. Trends towards interdisciplinary education in basic and post-basic nursing programmes were described. In some respects the trend towards higher education may be an agent in the demise of post-basic nursing education as we know it. Nurses prepared in degree programmes will proceed to post-graduate eduoation. The qualifications required for teaching staff in colleges of advanced education or universities will be higher degree status. In the present structure of health care systems, however, the task of providing relevant post-basic education courses for nurse administrators and teachers remains a formidable one.
3.5.4 One group examined the question of nursing education in the South Pacific, and chose to work on the broad area of curriculum planning, with delegation to sub-groups of specific pOints of this projeot, 1.e., implementation of the curriculum; methods of teaching; development of a ourriculum for a regional nursing programme at registered nurse level. After studying a variety of curriculum guides one sub-group defined the attributes of a workable currioulum as one which had stated overall aims and objectives as well as objectives of each course. Course content needs to be clearly stated together with suggested learning experiences and methods of evaluation. There should be roan for flexiblli ty wi thin the total framework with continuous inter-actions between objectives, learning experiences, and evaluation. The group believed that the ourrioulum planning ooounittee should include representation of general and nursing edUcation, the senior nurse administrator, clinical instructor and nurses in hospital and extra-hospital services, a midwife, a stUdent nurse, dootors and consultants fran special fields of medioine. (A student nurse invited to join the group for the final reporting session removed any doubts as to the value of student representation on such a committee.) The sub-group which explored the development of a basic programme at professional level for the South Pacific, first investigated the needs of the area for this level of nurse and the resouroes in terms of possible recruits. With regard to needs, it was felt that there were sufficient common elements in health problems and in the pattern of health services to Justify the conduot of a programme at this level in the South Paoific and suffioient potential recruits in the area, as a whole, to warrant the programme being offered in one or two oentres to serve the whole of the South Paoifio.
The work of a ooounittee to plan such a programme was outlined.
- 14 The inolusion of nursing education at this level in the proposed School for Health Soienoes attaohed to the University of the South Paoifio needs to be oonsidered.
3.5.5 Another SUb-group worked on an area of one syllabus, FUndamentals of Nursing, and developed a plan for implementation of this oourse in the first year of studies, dividing the total oourse into eight units, each with stated aims, expeoted levels of aohievement, oontent, relation to other subJeots, time and suggested learning experience. A teaoh1ng guide for one unit of this course was developed by the sub-group. 3.6 Resouroes 3.6.1 The resources available in the South Paoifio area to strengthen nursing education and services were disoussed during a plenary session, and referred to for group work activities. 3.6.2 The presentation of WHO role in this regard based on the paper entitled "The Role of WHO in Nursing Eduoation and Services in Western Pacific Region", whioh underlined the various forms of the WHO oontribution: in advisory servioes provided at oountry, inter-country or regional level; group educational activities suoh as workshops, seminars, courses; and in the fellowship programmes mainly oriented to post-basio nursing studies. These a~tivities aim at strengthening the nursing administration structures of the health services in specialized fields, to prepare nurse practitioners, nurse educators and nurse administrators. The value of WHO publications for nurses working at all levels and in every field was underlined. Speoial emphasis was given during the presentation to the need for individual governments to consider eaoh WHO service available in relation with others, and to derive maximum benefit from international collaboration through well planned requests and follow-up activities. The need to seleot and prepare fellows better prior to undertaking studies abroad was disoussed, as well as the responsibilities of the receiving countries. The objectives of advisory services provided through long-term assistance as distinot from short-term consultantships were defined. 3.6.3 The programmes of the University of the South Paoifio which oould be used in the area to prepare nurses for administration and teaching positions were desoribed by a member of the School of Education of the University. Opportunities offered by the Extension Services of the University in other oountries/territories were outlined.
- 15 An explanation of the courses and programmes, being planned or already implemented, to prepare teachers in various fields (including education), gave the participants an outline of the variety of ways in which the University is seeking to respond to the needs of the area. The discussion which followed showed the great interest of the participants in utilizing the facilities of the University.
3.6.4 The background, objectives and development of the Regional Teacher Training Centre for Health Professions to be established in Sydney at the University of New South Wales with WHO's support were explained. It wa~ emphasized that the_ Ce~tre aims at preparing educators to set up trair,ing centres in their own areas or countries.
3.6.5 The programmes offered in New Zealand at the School for Advanced Nursing Studies, including courses given at the University, to prepare nurse educators, administrators, and public health nurses, were oommented on. The facilities for basic and post certificate nursing studies available in Fiji were disoussed. The post certificate course in publio health nursing was also commented on. Some post-basic programmes in Papua New Guinea are also utilized by neighbouring countries.
3.6.6 Points raised by a panel of participants included
the value of fellowships, problems of adjusting to a new country, the student's objectives, plaoement on return to the country/territory, and, in more general terms, the responsibilities of government and nationals in planning for'and utilizing external resouroes.
4. 4.1
CONCLUSIONS
Relating to nursing within the context of the South Pacific
4.1.1 There is a need for clearer understanding of nursing functions, among members of the health professions, and by the general publio, in the South Pacific. 4.1.2 This workshop has demonstrated the value of regular meetings of leaders in nursing in the South Pacific. Future meetings should explore the possibilities of developing of a South Paoific Nursing Council which could regulate the exchange of nurses within the area.
4.1.3 There are advantages in convening smaller groups to deal with specific problems or topios, at both oountry and inter-oountry level, as an adjunct to the larger representative meetings. 4.1.4 Nursing in each OOlDltry and in the area will be promoted by the development and strengthening of national nurses' assooiations in relationship with the International Counoil of Nurses.
- 16 4.2 Relating to planning and programm1ng for nursing
4.2.1 Nurses need to be involved in the planning, implementation and evaluation of health services at national, regional and local levels. Preparation for this function should be provided in educational programmes. 4.2.2 Nurses need to be cognisant of policies and laws which affect nursing and nurses; attention is drawn to the need to inolude study of these subJeots in nursing eduoation programmes. 4.3 Relating to nursing manpower
4.3.1 Both men and women are needed in nursing. They should have equal eduoational opportunities, titles suitable for both sexes and equal responsibility, authority, and oareer prospeots. 4.3.2 A nursing personnel system whioh uses not more than three types of staff oould provide effeo~ive servioes in oountries of the area. Clear distinotions in levels of funotion and preparation for each are needed, with provision for progression after meeting educational requirements. 4.3.3 Where a nurse is required to provide health servioes in an isolated situation, it is essential that he/She receive specific preparaticn. 4.4 Relating to administration and supervision of nursing services 4.4.1 Quality nursing oare is promoted by the oontinuing education of nurses, the effectiveness of supervision, and the establishment of clear communications at all levels between members of the health team. 4.4.2 Staffing of nursing services is a continuous process. There is no ready-made formula whioh oan determine staffing needs for all situations. Nurses in positions of responsibility need to be able to colleot, use, and present data related to needs and resources in order to provide effective and efficient nursing services. 4.4.3 Authority and responsibility should be delegated to the lowest possible level at which competence can be found, with provision for staff guidance. 4.4.4 The fullest utilization of nursing knowledge and skills is an important factor in staffing nursing services. In order that nurses oan concentrate on nursing activities, adequate messenger, housekeeping and clerical services are needed. 1 2 1
"Types"refer to preparation "Levels" refer to function.
- 17 0,
4.4.5 Job satisfaotion among nurses oould be inoreased by the use of Job desoriptions Which provide guidanoe on responsibilities and relationships while allowing soope for individual initiative. 4.4.6 People have a right to expeot nursing servioes to be provided by personnel qualified for the type of servioe required. Where student nurses provide servioe as part of their learning experienoe they should reoeive adequate instruotion and supervision from qualified staff. 4.4.7 Supervisors in nursing servioes need further preparation in their olinical specialty, and for their supervisory role. Such preparation should be obtained through post-basic and in-service education programmes. 4.4.8 The importance of ongoing in-service eduoation programmes for all levels of nursing staff, wherever employed, requires wider recognition in the health servioes of the South Paoific. An organizational struoture for in-servioe education with adequate resources, needs to be established in all health servioes. 4.5 Relating to the eduoation and training of nurses 4.5.1 The professional preparation of nurses in the South Paoifio must be relevant to the health needs and the oulture of the peoples of the area. The group believes there is a need to provide two types of basic nursing eduoation programmes in the South Paoific, depending on the eduoational qualifioations of potential candidates. Type
A - A basic progr&nlDe organised in each country and intended to provide the major oomponent of that countryts nursing personnel. It Will admit stUdents with the highest level of general eduoation available, having regard to the numbers required • .While each oountry's programme should relate to its speoifio needs, efforts should be made to harmonize standards in all programmes in the area.
Type B - A basic programme at tertiary eduoation level intended to provide, in addition to the subjeots oommon to the Type A programme, learning in nursing and supporting subjeots at suffioient depth to provide a basis for advanoed nursing praotioe and eduoation. As this programme would reorui t students at a level of eduoation equivalent to University Entrance, the number of sohools providing it would probably be 11m! ted and each used by several countries. 4.5.2 Criteria should be established to permit progression from Type A to Type B programmes without the need for unneoessary repetition of oourses or olinical experienoe.
- 18 -
4.5.3 There are advantages in the establishment of a counoil or board which will have. among its functions.the setting and raising of standards for nursing eduoation in the South Pacific area. 4.5.4 Adequate preparation of sufficient numbers of administrators and teachers of nursing is essential to promote the development of nursing in the area.
4.5.5 Eduoation of nurses at all levels should include preparation and experience in budgeting for nursing services. 4.6 Relating to the utilization of resources in the South Paoific Area 4.6.1 Countries/territories in the South Paoific have available and potential human and material resources to develop sound basic nursing eduoation and servioe programmes. 4.6.2 The South Paoific University through the Suva campus and extension programmes is seen as an important resouroe for tertiary nursing eduoation.
4.6.3 Utilization of WHO resources for strengthening nursing eduoation and services needs to be planned on a long-term, comprehensive basis. 4.6.4 Additional resouroes for promoting advanced nursing education exl.at in Australia and New Zealand.
5.
EVALUATION OF THE WORKSHOP
Evaluation of the workshop ccntent ani prooeeding was oarried throughout the meeting. Pour aspects of evaluation were discussed: <a) (b) (c) (d) daily evaluation; end of workshop evaluation; subjective evaluation; and planned evaluation through follow-up.
The daily evaluation and end of workshop evaluation were analyzed by sub-group (education, service, administration, and by country participants, staff and observers). 5.1 Short, anonymous questionnaires were completed by the 20 partioipants at the end of eaoh of the first eight days of the workshop in order to learn the ourrent problems and oorreot them if possible.
- 19 The first question asked if the presentations (leotures, panels, etc. ) were reJa ted to the respondent's needs. After the first day - all answers were positive. The second question on usefulness of the presentations was answered on a three-point scale. On the first day, only ~ found the presentations useful, on the seoond day, 9~, and fran 95-l0~ on the remaining days. Physioal arrangements were graded as very sui table by 1/3 or less during the first four days. Changes in rooms for group work progressively corrected this situation from the fifth day on. Question five asked if the group was making progress. Analysis showed a block in two groups at different periods - which improved when add! tional resouroe people Joined the groups and ohanges were made in the projects. The last question related to the respondent's feeling about his ability to take part in his group. Pos~tive answers ranged from 11/15 to 17/19 •
•
Almost all responses were positive by the eighth day. The daily evaluation sheet permitted identification of problems and was used to correot same as early as possible.
5.2 The major tool prepared to evaluate the workshop was a two-part anonymous questionnaire completed on the first and last days. Each respondent used a number seleoted by and known only to him/her thus enabling oomparison of the "before" and "after" responses, as well as return of both questionnaires to the respondent for his perusal.
The first question of part one asked the respondent what major problems he faced in his work. A total of 84 answers were given by 20 partioipants. The following problems appeared most frequently: Shortage of qualified staff Long-term planning Job description Shortage of supporting staff ·Ccmnunications Teaohing strategies Student abilities 11
10 5 5 4
3 4
- 20 -
The second question asked what the respondent expected to gain at the workshop. Out of 67 answers those deemed of greater importance were: New ideas for problem solving Learn from experiences of others Broader outlook on the South Paoific Ways of continuing education Help in ourriculum development Organization of nursing services 12
9 7 7
6 3
These two questions served three purposes: they stimulated the respondents to define their needs as a base for projects in their group work; they enabled the staff to better understand the interests of the participants; they formed a baseline for comparing the responses given in the final questionnaire. Three of the last day questt ons related to the above. In response to "to what extent did the workshop meet your expectations?" 7 answered very muoh; 9 muoh; 4 some;
and none little.
"Please list the three most important ideas from the workshop that you would 11ke to implement in your work" e11ci ted 65 comments from 20 respondents as follows: aspeots of supervision such as Job description, organization of work, co-ordination, oommunication aspects of education such as currioulum development, teaching and evaluation methods, post-basic education aspects of top level responsibilities such as long-term planning, staff establishment, policy making, nursing legislation, oareer structure in-service education
22
18
13 12
- 2l -
Reapondenta were asked to list up to three areas not discussed in the workshop that were 1IIIportant to tbeIII. A total of 17 answers were eiven. of these: Educational ..pecta
5 4
AcIII1n1stratift aUls Opportun1 t7 to uplore peraonal work probl... Evaluatica methodolog
3 2
Aa a .ethod of .euur1ng ctwlge 111 aelf-peroeption. partioipants are uked to rate theaaelvea on a four-po1Dt soale on each of twent7two iteaa 111 relation to its importanoe to th8lll. their knowledge and underatanding and their level of ccafidenoe 1n working with the iteJII~_ Six it.s were grouped under the title - plann1 nc and progra-1ns. seven under adm1nistration. uu:\- D1De under echlcation. 'lbe i,dentical lists were used ca the first and last da78 of the workshop. ReapCllSes of the two periods were campared and showd the following: On the ailt ite.s related
to pJa nn 1ns and progra-1ng, the group
. . .bar sraded the.selvea higher on all iteas in all three oOllJ)ClUtl1ta of iJlportanoe. knowledge and oonfidenoe. Greater inorea.. was seen 111 knowledge and 1IIportanoe on the 1 teas than 1n oonfidenoe to pertora. Moat positive ctwlge ocourred in relation to retention -of staff. least in relatica to util1zatitll of ataff and long-tera planning. The silt items of planning and programming taken together showd the following per oent. obange frOll the pre- to post-questionna1res. _ 0..: • •
,.. _0_... ...... ____ __ _.~ ~
Knowledge change Very well Fairly well Not well Not at all Total
Importance Post .L
Confidence
.
-
Pre
!I
e
Pre
Post
!I change 70.0
Pre
Post
78.9 33.3 -TI.1 -45.4
19 54 35 11
34 72
30.3 18.4
66
86 31 1 1
10
17 59 34 8 118
3B 13 1 118
55.3 38 -32.0 50
8 r92.3 6 1a:l 0
o _
8 106
119
119
- 22 On seven items related to administration, the self-perception in general showed less change than in programming and planning on all three oomponents. Least change was on the items, supervision of staff, and most on supervision evaluation. Percentage change of all items of administration was: Knowledge Importance Post Confidence Post % change
% e Very well Fairly well Not well Not at all Total
Pre
% change
Pre
Pre
Post
66.7 1.7 -63.2 -72.7
ZT
45 59 14 3 121
22.0 -14.3 -81.8 0
82 35 11 0 128
100 30
50.0 94.7 -22.4 -85.7
12 38 49 28 lZT
18 74 38 4 134
58 38 11
2 0
134
132
On nine items of education, there was minimal change in knowledge and oonfidence, some change in importance particularly in relation to clinioal teaching and evaluation of programme. Knowledge Importance Post Confidence :J>
% change Very well Fairly well Not well Not at all Total
Pre
% phange
Pre
Post
change
Pre
Post
-4.2 8.5 -12.2 -33.3
48 71 49 12 180
46
34.1 -27.4 0 1-45.5
88 62 10 11 171
118 45 10
-7.1 57.1 -3.6
28 56 55 38 177
26 8853 11 178
77 43 8
6 -71.1 179
174
In conclusion, it appears that major change in self-peroeption occurred in relation to planning and programming, and minimal change in relation to education.
5.3 SubJeotive evaluation 5.3.1 One group evaluated its own work as: "We all appreoiated the exchange of ideas, knowledge and skills from the oonsul tants and from all the partioipants and observers.
- 23 "We attempted to identify important facts. relevant to our needs. mentioned in the plenary sessions and discussed how these could be utilized. "We practised many new skills in our group and sub-group work on methods of formulating plans, using many models as mentioned in the plenary sessions for collection of data. "Everyone learned various sources of obtaining resource material." 5.3.2 Impressions of the achievements of the workshop in the light of its stated objectives are: (1) The first objective seems to have been achieved. There was a free exchange of ideas, with no tendency for participants from anyone country/territory to dominate. All wished to benefit from the experience of others. More than one participant stated that the workshop would enable him to contact nurses in any country of the South Pacific for information in the futUre. Many problems were analyzed and some solutions proposed. If this objective was not fully realized it is because the main weakness of this workshop was in trying to be "all things to all people". The South Pacific countries are too small to have developed the highly specialized groups which make for clear-cut single topic conferences. While this is advantageous in the long-term, some people who came expecting to get help with a specific problem were disappOinted.
(2) "
(3) The guidelines for education were sufficiently developed in group work for national groups to follow through after the workshop. (4) There seems little doubt that participants are now much more aware of resources available in the area, particularly those for further education for nurses.
5.3.3 Although subjective evaluation has limited value, there is no other measure for the "feeling-tone" of the workshop. The overwhelming impression was one of initial hesitancy and reserved judgement. As the days progressed and involvement grew, enthusiasm was generated accompanied by hard work intermingled with excellent hospitality and recreation offered by the Fiji nurses. Friendship groups grew out of the work groups. By the end of the workshop there was frank discussion and a display of confident leadership abilities.
.
- 24 -
A few comments made by participants towards the end of and following the workshop best illustrate the atmosphere: "I suddenly realized that they is ~"
"I never realized my colleagues had so many good ideas - we will really do things." "I am gOing back to work with lots of ideas and a real need to improve things."
5.3.4 Respondents were asked for their suggestions on follow-up of the workshop. The major suggestions were: - Repeat a similar workshop one to two years. WHO staff follow-up in the countries to which they are assigned. hold workshops on selected topics. publish and distribute workshop reports. and follow-up by questionnaire. Most of the above are included in plans for follow-up by WHO. (1) (2) A report of the workshop will be distributed.
WHO nurses will work closely with their counterparts in implementing relevant learning and conclusions from the workshop.
(3) (4)
A follow-up by questionnaire by the nursing advisory services project. South Pacifio,is scheduled. Materials from the workshop will be included with the deliberations of the Technical Advisory Committee on Nursing to be held in Manila in 19r3. If additional workshops or similar activities are initiated by the South Pacific countries. WHO would consider assisting with the proJect.
(5)
- 25 ANNEX 1
LIST OF PARTICIPANTS AND STAFF 1. Participants AMERICAN SAMOA Mrs Josephine S. Hagedorn Clinical Supervisor LBJ Tropical Medical Centre pago-Pago Miss C. Acheson Superintendent of Nursing Services Honiara Mr John Sisiolo Nurse Tutor Nursing School Central Hospital, G.P.O. Box 69 Honiara COOK ISLANDS Mrs M. Matapo Matron Cook Island's Health Department Rarotonga Mrs Kuini T. Naqasima Controller of Nursing Services Medical Department Government Buildings Suva Miss C.K. Mani Ram Senior Matron C.W.M. Hospital Suva Miss Agnes Chandulal Principal Tutor Fiji School of Nursing Suva FRF..NCH POLYNESIA Miss Monique Poisbeau Monitrice Ecole d'Infirmieres B.P. 611 Papeete
BRITISH SOLOMON ISLANDS PROTECTORA TE
FIJI
- 26 Annex 1 oont'd. GILBERT AND ELLICE
ISIANDS
Miss Daphne A. Laity Matron Colony Central Hospital Bikenibeu, Tarawa Miss Alitake Mili Vaisua Principal Tutor Colony Central Hospital Bikenibeu Tarawa
NEW HEBRIDES
--
Mrs Simone Besson Infirmiere santo
Miss Dawn Petersen Sister Tutor Paton Memorial Hospital Port-Vila Miss E.C. Pyatt Matron Godden Memorial Hospital PAPUA NEW GUINEA Mr Reuben Tokome Officer in charge of Diploma Course in Community Health Konedobu Port Moresby Miss Dorothy Pirit Clinical Supervisor in Obstetrics Port Moresby School of Nursing Port Moresby Miss Tapore Lokoloko Principal Rabaul School of Nursing Rabaul
- zr Annex 1 cont'd. TONGA Mrs Akosita Fineanganofo Chief Nursing Officer Nursing Division Ministry of Health Nuku'alofa Mrs Siosiane Tongovua Bloomfield Senior TUtor Queen Salote School of Nursing Nuku'alofa WESTERN SAMOA
Miss Moana Matatumua Superintendent, Division of Nursing Health Department Apia Miss Noeline Rasmussen Principal, School of Nursing Health Department Apia
2.
Observers Mrs A. Dobui Matron Lautoka Hospital Fiji Miss Dorothy M. Holmes Deputy Matron representing N.S.W. College of Nursing Sydney, N.S.W.· Australia Mrs J.T. Koroi President Viti Registered Nurses' Association Fiji Miss Dorothy Williams Director of Nursing Department of Medical Services pago-pago TUtulla American Samoa
- 28 -
Annex 1 cont'd.
3.
Guest Speakers Dr Dharam Singh Secretary for Health Medical Department Government Buildings Suva Fiji Mr S. Siwatibau, M.Sc. M.A. Director of Economic Planning Government of Fiji Suva Fiji Dr R. CrocOlllbe Professor of Pacific Studies University of the South Pacific Suva Fiji Mrs T.F. Maleiotoa Director of !xtension Services University of the South Pacific Suva Fiji Mr I. Stewart Reader in !ducation University of the South Pacific Suva Fiji Mr B.C. Dommen Development Economist United Nations Multi-National Inter-Disciplinary Development Advisory Team, United Nations Development Programme South Pacific Suva Fiji Dr J.H. Hirshman WHO Representative for the South Pacific Suva Fiji
- 29 Annex 1 cont I d.
4.
Staff and Secretariat Workshop Director Miss O.T. Manning Senior Nurse Educator WHO nursing advisory services project, South Pacific Suva Fiji Dr Rebecca Bergman Head, Department of Nursing Faculty of Continuing Medical Education Tel Aviv University Tel Aviv Israel
WHO ConatUtant
Temporary Advisers
Mrs Shirley M. Bohm Director Division of Nursing Department of Health Wellington New Zealand Miss Ruth White Research Fellow in Nursing EdUcation Tertiary Education Research Center University of New South Wales Sydney Australia
WHO Staff/1tesource Persons
Miss J. Bentley Public Health Nurse/Midwife WHO public health advisory services project, South Pacific Suva Fiji Miss E. Brister Nurse Educator WHO nursing education project Apia Western Samoa
- 30 Annex 1 cont'd. WHO Staff/Resource Persons Miss J. Julian PUblic Health Nurse WHO development of health services project Port-Vila New Hebrides Miss M. Leavy Public Health Nurse WHO basic health services project Honiara British Solomon Islands Protectorate Miss T. O'Brien Nurse Educator WHO nursing education project Nuku'alofa Tonga Miss E. Will Nurse Educator WHO nursing education project Port-Vila New Hebrides Secretariat Miss Madeleine Lenoir Regional Nursing Officer WHO Regional Office for the Western Pacific Manila Philippines Mr R. Aouad Senior Translator WHO Regional Office for the Western Pacific Manila Philippines
Interpretation
- .31/32 , e
ANNEX 1a
COUNTRIES AND TERRITORIES IN THE SOUTH PACIFIC COVERED BY THE WHO SOUTH PACIFIC AREA OFFICE IN SUVA (FIJI)
Australia American Samoa British Solomon Islands Protectorate Cook Islands Fiji French Polynesia Gilbert and Ellice Islands Nauru New Hebrides New Caledonia New Zealand Niue Papua New Guinea Timor Tokelau Islands Tonga Wallis and Futuna Islands Western Samoa
- 33 • . ANNEX 2
NURSING WORKSHOP, SOUTH PACIFIC SUVA, FIJI 11 - 22 September 1972
AGENDA MOndaY, 11 September 8100 a.m. 9:00 a.m.
Registration Opening Ceremony Reception Plenary Session - Chairman: Recorder: Mrs K. Naqasima, Fiji Miss D. Williams, American Samoa
11:00 a.m.
Introduction of Members of the Workshop Adoption of Agenda Introduction to Workshop Methods Formation of Working Groups 12:00 noon 2:00 p.m. Library work and Lunch Plenary Session - Chairman: Dr J. Hirshman WHO Representative South Pacific
Recorder:
Miss D. Williams American Samoa
"Economic <'I: Sooial Conditions in the South Pacific" Panel Discussion - Dr R. Crocombe Professor of Pacific Studies University of the South Pacific
- 34 Annex 2 cont'd. Panel Discussion (cont' d. ) Mr E.C. DoIIInen Development Economist United Nations Development Programme South Pacific
Mr S. Siwatibau Director of Economic Planning Fiji Government Discussion
4:30 p.m. TUesday, 12 september
End of Session
8:15 a.m.
Plenary Session - Chairman: Recorder:
Miss M. Matatumua Western Samoa Miss E. Will WHO Nurse
"Major Health Problems and Deli very of Heal th Services in the South Pacific"- Presentation by Dr J. Hirshman, WHO Representative, South Pacific Discussion 10:00 a.m. 10:30 a.m.
!I i,
;,
Coffee "Health Problems and Services in Fiji" Presentation by Dr Dharam Singh, Secretary for Health, Fiji Discussion
II
12:00 noon 2:00 p.m.
Library Work and Lunch Visits to Fiji Health Services Cocktails offered by the Honol!' able Minister for Health, Government of Fiji
6:30 p.m.
- J5 Annex 2 cont'd. Wedneady, 13 September
8:15 a.m.
Plenary Se.aim - Chairman:
Miss C. Acheson British Solomon Islands Protectorate Miss E. Brister WHO Nurse
Recorder:
"Nursing Manpower" - Presentation by Dr R. Bergman Discussion
10:00 a.m. 10:30 a.m.
Coffee "studies on Nursing in the South Pacific" (a) WHO/SPHS Survey on Nursing Manpower in the South Pacific: Miss O.T. Manning New Zealand Studies: Other Studies Mr. S. Bohm
(b) (c)
12:00 noon 2:00 p.m. 5:00 p.m.
Library Work and Lunch Group work End of 91188ion
'!buras. 8:15
14 September a.lII.
Reports fro. groups Plenary Session - Chairman: Recorder: Mias A. V&1sua Gllbe.rt It: Ellice Ialanda Mrs S. Bohlll
8.30 a.m.
New Zealand "Basic lifm'aing E41tcation in the South Pacific" Presentation by Min O.T. Manning Disoussion
- 36 Annex 2 oont'd. Thursday, 14 September (oont' d. )
10:00 a.m.
Coffee by
10:)0 a.m.
"Post Basio Education in Nursing" - Presentation Miss R. White
Disoussion 12:00 noon 2:00 p.m.
Library Work andLunoh Group· work End of Session
5:00 p.m. Friday, 15 September
8115 a.lI.
Reports from groups Plenary Session - Chairman: Reoorder: Mrs A. Fineanganofo Tonga Miss R. White Australia
8:30 a.m.
"Organization, Administration 8; Supervision of Nursing Services" - Presentation by Dr R. Bergman Discussion 10:00 a.m.
Coffee "rn-servioe Eduoation" Experience of partioipating oountries Lunoh Group work End of Session Mag1ti offered by Fiji Nursing Division at the Central School of Nursing, Tamavua
10:30 a.m. 12:00 noon 1:00 p.m. 4:00 p.m.
6:30 p.m.
- 37 -
Annex 2 oont'd.
9:00a.m. to
Combination reef viewing and picnic on Nukulau Island Hosts - The Nurse-Midwives. Anderson Maternity Hospital
4:00 p.m.
Mondy. 18 September 8;15 a.m. 9:00 a .• m. to Reports from groups (Summary of First Week) Plenary Susion - Chairman: Mr R. Tokome
Papua New Guinea Reoorder: Miss O.T. Manning WHO Nurse Educator
. 12:00 noon
"Planning and Programming for Nursing Servioes" Presentation by Dr R. Bergman Discussion (Coffee break from 10:00 a.m. - 10:30 a.m.)
12:00 noon
Library work and Lunch Group wolit End of Session Afternoon tea at the Grand Paoifio Hotel Hosted by the Retired Qualified Nurses' Assooiation of Fiji
2:00 p.m.
5:00 p .•m. 5::W p.m.
Tuesdaz. 19 September
8:15 a.m. 8:30 a.m. to
Reports from groups Plenary 8ession - Chairman: Mi~
E. Pyatt New Hebrides
Reoorder:
Miss E. Will WHO Nurse
12:00 noon
"Resouroes for Nursing in the South Paoific"
- 38 Annex 2 cant' d.
,
.
TuesdaY. 19 Septelllber (cant' d. )
(1) Resources available: The World Health Organization Regional Office for the Western Pacific: Miss M. Lenoir University of the South Pacific: Mrs T.F. Maleiotoa Mr I. stewart Australia: Fiji: Miss R. White
Miss K. Naqasima Mrs S. Bahm Mr R. Tokome
New Zealand:
Papua New Guinea: (2)
Use of resources - Panel of Participants
(Coffee break from 10:00 a.m. to 10:30 a.m.) 12:00 noon 1:00 p.m.
Lunoh Group work End of Session Tea offered by Matron and Sisters of the Colonial War Memorial Hospital
3:15 p.m. 3130 p.m.
Wednesday. 20 September 8:15 a.m. 8:30 a.m. to 5:00 p.m. Reports from groups Group work (including field visits as required) j I
7:30 p.m.
Island Night, Club Hotel. Organized by the Viti Registered NUrses' Association
Thuradaz, 2l September
~-
Annex 2 cClDt'·d.
8:15 a.m.
Pl!1!!!7 Seaaion - Chairman:Mra M. Matapo Cook Iabnda Reoorder: Report from Group A Dis0U8aion Miaa E. Brister WHO Nurae Educator
10:00 a.m.
Corree Report from Group B Dia0U8aion
10:30 a.m.
12:30 p.m. 1:30 p.m.
Lunch
Report from GrCNp C Discuaa10n Plenary Discusaion
5:00 p.m.
End of Seaaion Cocktails at the Tradew1nda Hotel, offered by the WHO Nuraea in the South Pacific
6:30 p.m.
Fri., 22 September 8:15 a.m. 10:00 a.m. 10:30 a.m. Group work. Coffee Plenary Seasion - Cha1naan: Recorders: Mrs J. Hagedorn Amerioan Samoa Dr R. Bergman Mills J. Julian Miss M. Leno1r Miaa O.T. Manning Mrs K. Naqasima Mr J. S1aiol0 Miss R. White Drafting of Conclusicns
Presentation of draft Conolusiona
- 40 Annex 2 cont'd. Friday,22 September (cont'd.) 11:30 a.m.
SUmmary and Evaluation of workshop Farewell Luncheon, Tradewinds Hotel, Suva Island Style Cocktail Party at the Club Hotel,Suva Hosted by the participants in the workshop
1:00 p.m.
6:30 p.m.
- 41 -
ANNEX 3
LIST OF WORKING DOCUMENTS
A.
Working papers presented and disoussed during the workshop 1.
1
Major Health Problems and Delivery of Health Servioes in the South Paoifio Area by Dr R. de Wilde, WHO Medioal Offioer, and Dr J.H. Hirshman. WHO Representative. Suva Planning and Programming for Nursing/M1dwifery Services by Dr Rebecca Bergman", Head, Department of Nursing. Faculty of Continuing Medioal Education. Tel Aviv University. Tel Aviv. Israel (see Annex 4) Nursing/Midwifery Manpower by Dr Rebecca Bergman. Head. Department of Nursing. Faculty of Continuing Medical Education. Tel Aviv University. Tel Aviv, Israel (see Annex 5) Organization. Administration and Supervision of Nursing,! Midwifery Services by Dr Rebeooa Bergman. Head, Department of Nursing. Faculty of Continuing Medical Education. Tel Aviv University, Tel Aviv, Israel (see Annex 6)
2.
3.
4.
B.
Other papers discussed 1.
lhe Education of Nurses - Some Issues in the South Pacifio by Miss Olive T. Manning. WHO Senior Nurse Eduoator. Nursing Advisory Servioes ProJect, South Paoific Post-Basic Nursing/Midwifery Education by Miss R. White, Tertiary Education Research Centre. University of New South Wales, Sydney, Australia lhe Role of WHO in Nursing Eduoation and Services in the Western Paoifio Region by Miss Madeleine Lenoir. Regional Nursing Offioer. Regional Offioe for the Western Paoifio, Manila
2.
3.
Copies available in WHO Regional Office for the Western Paoifio. These should not be reviewed, abstraoted or quoted without the agreement of the World Health Organization. Authors alone are responsible for views expressed in signed articles.
1
- 42 Annex 3 oant' d.
c.
Group proJeots prepared and disoussed during the workshop Guidelines an Currioulum Planning Proposed categories and eduoation for nursing personnel steps in curriculum planning Curriculum implementation Implementation of "Fundamentals of Nursing" fran FiJ1 Programme 1970 Samples of Job desoript1ons Report of group work on "In-service eduoation for nursing personnel"
- 43 ANNEX
4
PLANNING AND PROGRAMMING FOR NURSING/MIrMIFERY SERVICES
by Dr Rebecca Bergman Head, Department of Nursing Faculty of Continuing Medical Education Tel Aviv University, Tel Aviv, Israel
Planning and programming for nursing/midwifery services are built upon the foundation of administration and supervision, within the philosophy and aims of nursing and health services. The following steps are suggested as a framework for such planning: (a) pre-plan - determine if essential basic conditions are present for the proposed programme, e.g., interest of authorities, organizational framework, appropriate leg~slation;
(b) (c)
identify kinds of data needed and sources for obtaining such information; gather general baseline data on community (socio-demographic, health, etc.). After analysis, select those priority areas which can be realistically planned for change; in these priority areas gather additional data on needs, resources and community readiness and develop clear (but flexible) aims and operational objectives; Conceptualize the plan with alternatives: involve others - clients, agencies, professionals; prepare an operational plan for implementation; prepare budget and obtain approval; recruit and train (or retrain) personnel and volunteers (if needed), prepare facilities; implement plan, on-going supervision and evaluation;
(d)
(e) (f) (g) (h) (i) (j)
- 44 Annex 4.cont'd.
P1gure 1 - FlCllf Chart ot: Planning and Pro~
Pre-planning re-oonditiona exist?
- resources
- readiness
Medium priority
High
sustain present
priori tl develop proJeot
status
SuperviSion) guide ----f~~~~:..J~-----teaoh oo-crcl1nate
f
Administration Dil'eot Control
- 45 Annex 4 cont'd.
(k) (1)
final evaluation; report on project to staff, agencies and community 1. PRE-PLANNING CONSIDERATIONS
The first step of pre-planning will probably be done within the wider framework of health planning, but nursing must be cognizant of: (a) (b) (c) attitudes of the decision-makers to nursing; existence of laws that can promote or restrict the programme (e.g. laws limiting nursing practice); availability or potential of an organizational framework to implement the programme (e.g. a system of school health services, health insurance, educational centres for educating personnel).
!
Presence of most of the pre-conditions permits the planners to continue as envisioned. Partial existence may require modification or limitation of the tentative plan. Absence of the pre-oonditions may require time and effort to create change in the pre-conditions or the plan may be given up for the time being. 2. DATA GATHERING - NEEDS AND RESOURCES
The next step is to obtain an overview, with emphasis on health, of the oommunity for whom the services are planned. Data should include present status and projected trends. The "oommunity" may be nationwide, regional, distriot, local, or even one institution or clinic. It should be emphasized that much valuable data, often unused, are available in official reports, special studies, etc. Categorization of data into broad topics will help prepare a clearer picture and avoid duplication, for indices commonly used in public health. A health guide wa~ developed by the WHO Expert Comi ttee on Public Health Administration at its third meeting. It includes socio-demographic variables, descriptive and statistical data on health services and personnel. 2.1 Needs Freeman 2
suggests analysis of:
WHO Expert Committee on Public Health Administration, Local Health Services, Wld H1th Org. tech. Rep. Ser., 1960, 194, p. 33.
1
~eeman, R., Community Health Practice.
SaWlders, 1970.
Chapter 17.
- 46 -
Annex 4 cont'd. Human health status (a) population growth (birth, death, migration', demograohic variables (age, sex, rac'e). and socie-economic information (education, occupation); death trends specific to groups, geographic areas, season, etc., and by single or multiple causation; pre-symptomatic illness (hypertension, cholesterol rates); groups at risk (age groups, multi-problem families, delinquent ~roups); people functionin~ below a desirable level (fatigue, depression, tension).
(b) (c) (d) (el
Environment health status (al (bl physical environment (water or air pollution, waste disposal, unsatisfactory housing); social environment (family instability, lonely aged, discrimination).
Freeman's categorization is extremely heleful in that it includes areas and groups that are often missed although they may have serious health needs that can be corrected if recognized and given appropriate care, However, it would be difficult to obtain much of these data exceet by subjective imoression or highly sophisticated research. Many needs arelnot recognized because they have not manifested themselves. Connor has conceptualized the iceberg analogy of needs.
I
" II
,,
Figure II - Community Needs Overt needs (1) felt by worker and commun1ty. (2) felt by community only. (3) felt by worker onl~' (4) unf€lt by worker or community
Covert needs
I
Connor, D., Diagnos1ng
Co~~nity
Problems.
Development Press, 1966,
p.
15.
- 47 Annex 4 cont'd. Many planners differentiate between "needs'which represent deficiencies in health as identified by objective (professional) data that call for care and/or control. and "demand" of the population by their use of certain health services or request for the establishment of services. Both aspects should be considered in planning as both are 1egi timate "requirements f! • Nurses should clarify which needs and demands are "nursing needs". A nursing need is defined by Freeman as a "health need where nursing can make a difference". While nurses should be flexible in accepting functions. they must recognize that better utilization and satisfaction can be attained by focussing on services for which the practitioners have been prepared. They must also assume that needs wi thin the areas of nursing competence should not be neglected at the expense of functions which can be carried out as well or better by other workers. Nurses all too often take over housekeeping. clerical. pharmacy and other duties at the expense of personal care, teaching patients/ families and providing emotional support. 2.2 Resources
Overview of the community should include a survey of resources for health care., These include health-related services such as education, social welfare. and health programmes/facilities such as hospitals. clinics. etc. Attention should be given to the nursing component in each of these. However. human resources must also be noted such as health professionals (employed. unemployed and in training). volunteers, cOJllllUnity groups and leaders. Detailed analysis of nurSing personnel by age, sex, education, experience, employment, etc., should be done in co-operation with the nursing association if possible. While it is desirable to obtain as much data as possible in order to obtain an. overview of the community for planning, it should be recognized that data are valuable only if they are reasonably up-to-date. As stated earlier, much material can be obtained through available reports. Additional methods of gathering data are by limited studies on a selected problem area or on a small random sample, opin1on (impression) of reliable persons, and observation of the nurse and health team. Extensive studies which may take years or use resources needed for delivery of care should be avoided unless essential to 10ngtem planning.
3.
PRIORITIES
Overview of the community, its needs and resources permits recognition of specific problems which need attention. Priorities are established by w*1ghing four main factors: importance of the needs,
- 48 Annex 4 cont'd. availability of resources, community readiness for service and legal implications. A very urgent need, such as a high infant death rate from malnutrition, will receive priority even if resources have to be developed and if the cOlllDUnity does not demand the project. On the other hand, a service desired by the community such as institutionalization of retarded persons may be given a low need value by the professionals but raised in the priority scale because of public demand. Specific points to be considered in setting priori ties are: (a) Need of the service - communicability - transmission of disease, infectious conditions, effect of medications on pregnancy; - number of persons affected - food contamination, dental caries, endemic goitre; - severity of the illness - acute kidney conditions, coronary infarct; - resulting disability - mental retardation from genetic causes, hemiplegia following CVA; - impact on community functioning - high accident rate in industry, use of drugs by young and working people; - long-term value for improved health - pre-natal care, family planning. (b) Resources . - availability of resources (available, potential or need to be initiated); - cost in terms of money, personnel, facilities; - diversion of resources from other needs; - duplication of services already available for similar purposes by other agencies. (c) Readiness of the community - to recognize the need (intellectual); - to accept (emotional) the need for service which may be in conflict with values and customs (e.g. family planning);.
- ~q ~.
- ability of the community to take part in the programme (e.g., home care of the patient suffering from tuberculosis). (d) Legal implications - who is legally responsible for this area of care? - do laws. exist that support/conflict with the project? l The WHO Expert Committee on Public Health Administration at its fourth meeting recommended the following five points for consideration in setting priorities: (a) (b) (c) (d) (e) emphasis on prevention; service for persons engaged in productive work; provision of services for vulnerable groups; affect the he.alth of maximum number of people; improve the nutritional standard of the population. 4. DEVELOPING THE PLAN
,
Once the present status and projected health trends of the community have been studied specific areas can be chosen for priority action. The planners arrange for continuity of existing needed services and prepare to develop or expand the priority services. Additional data on the selectedprogramm~s will usually be needed. Such materials may not be available to the same extent as general statistics and additional time and manpower will be needed to obtain them. Selection of the most appropriate methodes) should be carefully conSidered, and several methods may be combined. For example, a programme for the aged might. be built on a door-to-door census of selected streets as well as leal~ng from community leaders and professionals. It will include a survey of available and potential resources with attention to the attitudes/knowledge/ desires of both the public and the nursing personnel who may be involved in the programme. Literature review is essential in order to up-date knowledge on the condition to be treated, to understand the population groups involved (age, ethniC, etc.) and to learn how similar problems have been approached by others. The literature will often provide reports of expert committees and research studies with standards and guidelines that can be used as a base against which to plan within the reality of the communi t,'" unde r revi ew •
WHO Expert Committee on Public Health Administration, Planning of Public Health Services, WId "Hlth Org. tech. Rep. Ser., 1961, 215, p. 12.
1
- 50 -
Annex 4 cont'd.
5.
CONCEPrUALIZATION - AIMS AND OBJECTIVES
The more detailed data allows for selecting priorities within the specific area. The problem of the aged may emerge primarily as one of the lonely and handicapped aged, but it should not exclude consideration of the other aged groups who need preventive and supportive care. At this point, it would be desirable for the planning team to formulate broad aims. In a programme for aged it might include such statements as: (a) (b) (c) develop education for aging from elementary school through retirement groups; provide preventive health services for aged such as geriatric clinics; provide a spectrum of services for aged including home services and institutional care.
Out of the aims, which are actually statements of what it is hoped can be accomplished, a set of operational objectives are developed. These are clear statements of what is planned to be achieved in terms of quantity, quality, time, etc. Such objectives would be: (a) develop and carry out in-service training between October-December 1972 on nursing care of aged in the home for twenty nurses in area x; home visits by public health nurse between JanuaryApril 1973 to all residents over sixty years of age in area x to learn their nursing needs.
(b)
Although the objectives are stated very specifically so.that outcome can be measured against anticipated achievement, it does not mean that they cannot be changed if there is good reason for same. If it is found that many aged need immediate care, thus extending the time allocated to each home visit (objective b), the period planned may have to be lengthened and the fact-finding survey turned into an action survey. The total range of objectives should include: - short and long-term plans; - aspects of preventive, curative, rehabilitative and custodial care; J
- education for patients, families, community, staff; - services focussed on individual, family, special groups, community as a whole.
- 51 Annex 4 cont'd.
6.
INVOLVING OTHERS
It is most desirable, as early as possible, to involve those persons who will be part of the programme. This includes other professionals. other agencies, community leaders and representation of the clients. Written aims and objectives can help determine whom to include. There should also be some hard data and a conceptual framework to present to the co-operating groups. However, the planners can obtain valuable new ideas from the newco'mers and, should be ready to change plans should a concensus be reached on other realistic aims, objectives or methods. The following framework is suggested for activating persons concerned with the project: (a) advisory board which will include a broad spectrum of agenCies, professions, community leaders and clients. From this group, it is expected to learn different points of view, establish co-operative relationships and obtain feed-back from the community; ad ~ workcomm1ttees of specialists to work on particular problems, to develop standards, procedures, etc.; implementing teams of persons (including paid staff and volunteers) Who will carry out the programme.
(b) (c)
Cardinal to the involvement of others is an efficient communication system. Each person/group should know on what and with whom to communicate. The format for and distribution of minutes of meetings, records, reports, etc., should be clear. Before the planner approaches individuals or groups to partiCipate in the project he should know what he thinks that person/group can contribute, and what partiCipation can reasonably be requested. These expectations may change on involvement, but people should not be invited to give of their time or resources without some pre-planning and defini tion.
7.
OPERATIONAL PLAN
The operational plan should be worked out together with the speCialist work committee and implementing teams. Some questions to ask are: (a) What media are desirable for implementing the programme: home visits. group work, cliniCS, lectures, mass communication media or working through other agents such as teachers in the school systems? One or more methods may be used, depending on the purposes and the availability of resources. Each m~thod has its advantages and
- 52 Annex 4 cont'd. disadvantages. What standards .of care are desirable and possible? What sh.ould a prenatal check-up include? Hew .often should it be done? (b) How should standards fer staffing be set up: on rec.ommended ratios, by using a unit functioning satisfactory as a model. or on the basis of analySiS of a~tivities of staff? The first two methods are time-saving. and can be effective if tempered with common sense and adjusted to the local situaticn. What positicnsneed job descriptions? What activities need to be described? How flexible can they be? What facilities and equipment are needed? Can the present centre be adapted or is a new building/space needed? What transportation and/or mobile clinics are required? What teaching space/facilities lire essential? What schedules are best fcr public and staff? Is this a 24-hour service. a weekly clinic, a morning .or evening activity? What kinds of rec.ording are needed fer assuring safe care, continuity, data for epidemiclcgical reports, research and teaching? Are the purposes .of the rec.ording clear? Is it Simple tc carry out?
(c) (d)
(e)
(f)
8.
BUOOET
The budget is built on the items develcped in the .operati.onal plan; staffing (including staff development), facilities, equipment, transport, etc. The proposed budget must be built on facts and logic. ·If cars are requested it should be shown how transp.ort can extend services and save cest .of persennel. If secretaries are included - the amount and kind of werk te be dene by them and the profess~enal time thereby saved shculd be cemputed. The planners must be able to justify the budget if they hepe te get approval. Budgets that allow fcr flexibility with transfer of funds between items are desirable.
9.
PERSONNEL AND VO WNTEERS
It is possible that all .or part .of a propesed programme can be carried cut by existing personnel and volunteers. Changes might be made in the scope .of service in an existing programme, .or pers.onnel might be freed fer new aSSignments by improved efficiency in their present j.obs.
- 53 Annex 4 cont'd. More and different people will usually be needed for a new programme. Based on the job descriptions in the operational plan, criteria for recruiting and selection are determined. If personnel are available but lack some of the needed qualifications for the proposed positions, an educational programme may be needed to prepare personnel in areas in which they are deficient. Lack of candidates with adequ<l.te qualifications may necessitate preparing auxiliaries in short-term courses for limi t€·d acti vi ties or on programmes for broader functions. Criteria for staff selection include education, experience, personality, interest, in the programme and readiness to work in the required location and within the planned schedules. Volunteers can be drawn from any sources; retired persons, housewives, schOolchildren, etc. Motivation for giving services shoUld be considered. A co-ordinater is essential who will organize the volunteers, orient them and accord the rewards and satisfactions due. The role of families in the care of home-bound or institutionalized patients is important and should be taken into account. Training of both staff and volunteers should relate .to the overall programme as well as their specific roles. If students participate, their learning experiences have to be defined and provided for.
10.
IMPLEMENTING PLAN
The first step in implementation, if not already done, is to inform the public of the service to be introduced. Facilities and equipment are to be prepared during the recruiting-training period. At every stage of the programme there should be open two-way communication between administration, staff and clients. On-going supervision and guidance for all levels of personnel will facilitate safety, effective implementation and serve as a channel for ideas growing out of the experience. All involved should regularly evaluate the process and outcome of their work, and use these for flexible replanning at any stage and level as indicated.
11.
EVAllJ;\TION
The final evaluation should measure the achievement of the objectives against a baseline recorded at the beginning of the programme. Evaluation should analyze the input in human time and effort, cost of equipment and facilities, in order to determine if the results justify the investment. Evaluation should also consider other types of change. Have relationships between staff and clients been established that have won trust and will permit health intervention in future programme?
- 54 -
Annex 4 cont'd. Has the community in general grown in terms of co-operative planning, self-reliance? Have the staff involved learned from the experience, broadened their attitudes and perspectives, become more sensitive to the community? In addition to measuring outcomes - there are other helpful sources for evaluation. Client satisfaction as directly stated or implied by increased response to service is one such item. Another is staff satisfaction which can be seen in low turnover, low absence rate, personal development. The opinion of experts in the field who have not been involved and do not have vested interests can offer comparison of the success of this programme with other similar programmes.
A method of evaluation of the nursing service, rather than the project, may be done by checking it against standards. 12. REPORr
The final report is the major tool for replanning, continuing or terminating the programme. It can also be used as a modei or guide 1n planning other programmes. It should be comprehensive, covering the entire plan from the pTe-planning to completion. It should be objective and honest, basing conclusions on reliable data. The report should be clear, written in a readable style. Graphs and tables will he1p~sent data. The report should be made available to staff, committees, co-operating agencies and groups, and finally to the general public. Before publication it should be checked for accuracy by the responsible authority. 13. SumARY
Twelve steps in planning were reviewed and illustrated: pre-planning, identification of ..kinds and sources of data, analysis of data, priorities, aims and objectives, involving others, operational plan, budget, personnel and volunteers, implementation of plan, evaluation. report. Methods and tools for planning and programming appear in the text and annexes.
- 55 -
ANNEX 5
NURSING/MIDWIFERY MANPOWER by Dr Rebecca Bergman Head, Department of Nu~sing f<'aculty of Continuing Medical !<:ducation Tel Aviv University, Tel ~viv. Israel
1.
INTRODUCTION
Most countries of the world aim for health services which will positive health, apply preventive measures against illness, facilitate early detection of disease and provide effective treatment and rehabilitation. Such services should be available to and intelligently utilized by all groups of the population. Within the framework of such comprehensive care, nursing fUlfills a key position by virtue of being an integral part of all aspects of care and having the most sustaining contact with persons receiving care. pl~mote
1.1
Manpower defined The two major components of delivery of health care are: (a) (b) human resources or manpower: material resources, such as money, facilities, supplies, etc.
The material resources will be well or poorly used depending on the competence of the manpower that manipulates them. Manpower supply for health services includes three groups: (a) (b) (c) available potential prospective those presently working in health services; those who have the ability to engage in health occupations but are not at present doing so; these who are undergoing education and/or training that will permit them to join the health services .
Health manpower planning is to anticipate change in population growth, composition and health needs to judge what financial and other resources will be available to meet these needs: and to prepare the most appropriate quantity, quality and "mix" of health workers within the available resources.
Scientific Group (1971) The Development of Studies in Health Manpower, WId Hlth Org. tech. Rep. Ser., ~, p. 10.
lwHo
Annex 5 cont'd. 2. NURSING MANPOWER SHORTAGE
We sppak a great deal about nursing manpower shortage. and it sometimes seems that the greater the increase in the ratio of nurses to populatton. the greater the "shortage". Shortage may be looked at in several ways: (a) Are enough nursing personnel available to meet the nursing needs of the population as established by study of the health of the population and acceptable standards of care? Are there enough budgeted poSitions for nursing personnel and are they filled? Are employed nursing personnel utilized effectively?
(b)
(c) 2.1
Reasons for shortage Some reasons for nursing personnel shortage may be: (a) (b) insufficient suitable candidates (because of educational level. cultural attitudes to employment of women); candidates are available but do not enter nursing (because of low status of nursing. alternative opportunities in other occupations): candidates available but insufficient schools for nursing or prohibitive cost of educational programme; high drop out from the nursing education programme (poor selection. quality of educational programme): low entrance of nursing graduates to the labour force (lack of budgeted positions, emmigration. unsatisfactory employment conditions); poor distribution of nursing persunnel (shortage in selected clinical fields. geographic areas); poor utilization (staff are not used at their proper level. lack of equipment or transport); perpetuation of services that could be cut down or discontinued; attrition of trained personnel from nursing workforce (low morale. lack of.facilities to care for children. unsatisfactory working schedules. little opportunity for advancement, attraction of nursing rewards in other countries. attraction of other kinds of employment) .
(c) (d)
(e)
(f) (g) (h) (i)
- 57 Annex 5 cont'd. Correction of causes of attrition from schools of nursing and the labour force and improved utilization of working nurses can ~reatlv increase the supply of nursing personnel. Adding new recruits to a pool of workers that leaves nursing or the country will not correct the problem. 2.2 Among the most preSSing problems of nurse manpower in developing countries today are: (a) (b) (c) (d) (e) need to Justify, differentiate and stabilize levels of nursing personnel: brain drain of qualified nurses to countries with higher salaries and other rewards; poor distribution of nurses, particularly to rural areas; need for career advancement programmes for auxiliaries into higher levels of nursing; need to integrate, train and utilize traditional indigenous health workers into the health system.
3.
PLANNING KiR NUTISING MANroWER
In order to plan for nursing manpower, it is desirable to know: (a) (b) (c) (d) characteristics of the nursing manpower; projected health needs and demands of the population; attitudes and organization of SOCiety in relation to heal th manpower; utilization of nursing manpower.
3.1 Characteristics of nursing manpower will give a picture of the present situation to be used as a base for planning. It is desirable to include working and inactive personnel, trained and untrained. The data 'of major interest are: age, sex, marital status, general education, professional education, eXperience, geographic location, present work status, and if working: Job level, area of nursing, employing agency. Information received from employing agencies will include those persons who are working; licenSing bureaus will give information on those registered and interested in maintaining same; lists of graduates of schools will cover nurses with formal preparation.
- 58 Annex 5 cont'd. In a district or country with limited nursing personnel, it would be desirable to obtain complete coverage and then keep the register up to date by adding data on new ~raduates and other employees. In larger units,· study of a representative sample of employed worker~ and indigenous traditional healers could give an approximate picture of the situation. 3.2 Projected health needs
Health needs are influenced by social change. Industrialization accompanied by migration from farms to urban shanty towns create public health needs. On the other hand, education and higher standards of living are usually followed by a reduction of communicable and nutritional diseases. Study of population trends may reveal increased longe·~i ty which usually means more chronically ill patients in need of nursing care. Careful perusal of the vital (birth, death) and morbidity statistics (clinic visits, hospitalization) should indicate the incidence of illness as well as the demand for care. As most countries cannot undertake to meet all health needs, priority areas are selected as target programmes and the additional resources channelled to them. Manpower, therefore, may be planned on one of the following founda tions: (a) retain present standards, and increase number of nursing personnel in proportion to the expected increase in population; increase nursing manpower by population plus new target programmes; increase manpower by population, raise the standard of care by new services (targets) and and a higher standard in the present and/or planned services.
(b) (c)
3.3
Attitudes and organization of society
SOCiety should be considered in planning for nursing manpower. Is the community interested in the services offered and ready to use them? Does the law permit nursing practice in the areas planned? Are candidates available who can be recruited for the service? Are there existing organizations that are able and willing to administer the proposed plans? 3.4 Good utilization of nursing manpower is very important, for the misuse of nursing personnel is legendary. Even in times of extreme shortage we find nurses being. the "Jack-of-all-trades" and replacing housekeeping, clerical, laboratory and other workers at the expense of badly needed nursing care. Using nurses at less than their capacity is
- 59 -
Annex 5 oont'd. wasteful. On the other hand·, nurses often take on care for which they have not been prepared and this practice can be dangerous. The above statement does not mean that nurses should remain within a restricted group of aotivities but rather that they should be well used, their work expanded after additional education, and that they be supported with services of auxiliary personnel. The modern approach to allocation of functions among workers of different disciplines is that of a "fluid" team, with members able to replace each other in various functions, after they have received suitable preparation. The team concept also requires planning for nursing manpower within the total health manpower with a balanoe between doctors and nurses, supervisors and staff, nurses and auxiliaries. 4. NURSING MANPOWER STUDY
4.1 Methods of study of nursing manpower have been developed since the early 1940's. (a)
The first stUdies "counted heads". They record.ed the distribution of nurses by age, sex, location, job level, etc., and often computed important ratios such as: nurse: population, public healthnurse:population, nurse:hospital patients (by wards), supervisor: staff, teacher:student nurses; The second type of study placed emphasis on how the nurse spent her time,e.g~how much time in public health went for clinics, home visits, travel; how much time to .orbidity care, to school health, to prenatal care, etc.; The next type of study was more complicated and required obserVers to record and interpret what the nurse did. Her activities were analyzed into time spent at various levels such as head nurse, professional nurse, praotical nurse, aide, housekeeping ,. clerical, etc.: and at different functions such as teaching, patient care, administration, etc.: The most recent trend is to study nu~sing based on patient needs. Here we have three kinds of stUdies. One categorizes hospitalized patients into "need" groups
1
(b)
(c)
(d)
Arnstein, Margaret G., ~973), Guide for National Studies of Nursing Resources. Bull. Wld Hlth Org •• Supple 7.
1
- 60 Annex 5 cont'd. as a basis f(j[' compu ting staffing. The second meaGUY":3 patient needs b'~f()re and after CclC'e in order t.c lE-iF'n what care was mcst suitable to meet the need~. The third measures nursinv, needs of a community. 4.2 Principles of a n'..lrsing manpower study and planning: 'a) (b) is co-ordinated with health planning and health manpower planning: is based on the reality of the local situation, giving priority to felt problems on whi~h there is readiness to act: has short and long-term objectives, with action following each phase: uses scienti fic methods; uses available data from reports, studies, etc.: is subject to regular review and adapted to changing health needs, trends and socio-economic factors:, involves wide participation of nurses, other health professionals and community.
(c) (d) (e) (f) (g)
11.)
Objectives of a nursing manpower study: (a) to provide a basis for the preparation and employment of nursing personnel in line with the health needs and resources: and to identify methods of improving utilization of nursing services.
(b) 4.4
Steps in nursing manpower studies: (a) (b ~ (c) analysis of the demography and health needs of the population: analysiS of hf>2.1 t,h services an'j their utilization: analysis of available and potential nursing manpower and its utilization;
:'obeY'ts, D. (1962) "How Effective is PHN", Amer. , 1077-1083.
,I.
?ubI. Hlth.
- 61 Annex 5 cont'd. (d) study of resources (schools) for preparing nursing personnel; (a, b, c, and d (e) (f) (g) (h) (1) may be done concurrently).
projection of future needs of the population; projection of the manpower required to meet these needs; projection of future supply of nursing personnel; detection of imbalance between expected need and supply; formulation of alternatives and recommendation of policies to prevent/correct imbalances. The steps are
4.5 A model for studying manpower is included. outlined in 4.4.
Much of the data needed for the study is often available from government, agency or nursing association reports. Gathering new data and projections on health trends and needs can only be undertaken with an adequate team of researchers and usually should not be attempted by a nursing unit without sufficient help. Research of crucial problems - such as the reasons why graduates leave nursing - are important to planning. Such studies should be undertaken if it is feasible to carry out the study with available resources and if it is expected that the findings can be applied to help solve the problem.
5.
SUMMARY
This paper defined manpower and discussed the question of nursing shortage. Major components for planning nursing manpower were presented. ll.. short review of the methods of studying nursing manpower was followed
by principles, objectives, steps and models for same.
MODEL I
NURSING MANPOWER STUDY
~
::3 ::3 Cl)
~ SUP,iLY-~ rl-A-V-A-IL-A-B-L-E'I PERSONNEL
DEMAND
>< V1
J PCYl'ENTIAL I , PERSONNEL i ' •
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IMPROVE NURSING, TRAINING, UTILIZATION
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ANNEX
6
ORGANIZATION, ADMINISTRATION AND SUPERVISION OF NURSING/MIDWlFERY SERVICES
by
Dr Rebecca Bergman Head. Department of Nursing Faculty of Continuing Medical Education Tel Aviv University. Tel Aviv. Israel
1.
INl'RODUCTION
Organization, administration and supervision of nursing/midwifery are built upon the concepts of nursing, health services and administration. 1.1 Nursing
The following definition of nursing is based on Lambertsen: "Nursing plays a _Jor role in meeting the health needs of SOCiety through care, cure and education. NUrsing is dynamic, developing and adapting to social and scientific change. "Effective nursing is built on close co-operation with the patient, family, nursing personnel and members of the other helping professions. Within the health team the distinctive function of nursing is to assist the patient/f&lllly to llAXiJIIum independence within their potential when their psychological, phYsical, mental and/or social health status is impaired. The needs of the patient/family are the basis for the plan and delivery of nursing care. The quality of nursing is dependent on the nurses knowledge. skill, Judgement and values."
1
Reiter specifies six _Jor functions in nursing; three are focused on direct patient care - care, cure and counselling; and three on the organizational aspects of service - continuity, co-ordination and collaboration •
2
• 1
Lambertsen, E.
Education for Nursing Leadership. AJN, ~2):
Lippincott.
1958, pp. 88-90. 2
Reiter, F.
The NUrse Clinician.
274-280, February 1966.
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Annex 6 cont'd. Lesnik and Anderson have identified seven functions in nursing. Of these, six are classified as independent and one as dependent. Administration of nursing services should use these definitions of nursing as a guide, and develop programmes that will be in line with the purposes for which the profession exists. 1. 2 I .',;:
Health services
Health services are a means to an end, and not an end in themselves. Their purpose is to improve the well-being of the individual and community. One side of the coin is the humanistic aspects of good health and long life for the individual, with health care as a basic right. The other side is emphasis on the community in which the individual is seen as a unit within the community. For example, malaria can ravage the individual patient and it also has an impact on the community by reducing work productivity. Health services, while aiming for excellence in long-range goals. should know how to use temporary, palliative measures in the interim. "Best may become the enemy of the good"; for example, if organized midwifery services would be postponed until such time as registered nurse-midwives could be trained in sufficient numbers instead of starting the service by instructing the traditional midwives to work under the supervision of the available nurse-midwives. The four main components of health services are: (a) (b) (c) (d) 2
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constructive: environmental such as safe water supply, developing food sources; personal preventive: immunizations and mass screening for specific conditions; curative: diagnosis and care for diseas~
and injury;
restorative:
rehabilitation services.
As nursing plays a major service role in the latter threF! categor! P!-j and a teaching function in the first, nurses should be involved in all such services from early planning to evaluation.
Lesnik, N. and Anderson, B. NUrsing Practice and the Law. Lippincott, 1955, pp. 259-268. WHO Expert Committee on Public Health Administration, Planning of Public Health Services, WId Hlth Org. tech. Rep. Ser., 1961. 215, p. 5. 2
1
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." 2. A~INISTRATION
Annex 6 cont' d.
The purpose of administration is to carry out agreed upon plans in the most effective and efficient way, with maximum economy of human and material resources while ensuring standards of service that are safe and acceptable. Listed below are guidelines of administration to be considered in nursing/midwifery services. (a) Nursing/midwifery services are integral part of all health services which should be developed within the framework of total national development planning. Plans for health and nursing must be in harmony with the economic, social, legal and political structure. Nurses should actively participate in the overall planning and evaluation of health services. They should contribute objective data and realistic suggestions, serving as the primary spokesman for the nursing component of the programme. The focus of health/nursing services is the well-being of the popula tion to be served. This aim should take precedence over interests of professions, agencies or political groups. IThe rights of patients have been listed as follows: The patient has a right to expect that: - he will receive the nursing care necessary to help him regain or maintain his maximum degree of health; - the nursing personnel who care for him are qualified; through education, experience and personality, to carry out the services for which they are responsible; - the nursing personnel caring for him will be sensitive to his feelings and responsive to his needs; - within the limits determined by his doctor, the patient and his family will be taught about his illness so that the patient can help himself, and his family can understand and help him;
(b)
NLN, Department of Hospital Nursing, In Pursuit of Quality, National League for Nursing, N.Y., 1964, p. 5.
1
- 66 Annex 6 cont'd. - plans will be made with him and his family or, if necessary for him, so that, if possible, continuing nursing and other necessary services will be available to him thrOUghout the period of his need. These plans will involve the use of all appropriate personal and community resources; - nursing personnel will assist in keeping adequate records and reports and will treat with confidence all personal matters that relate to the patient; - efforts will be made by nursing personnel to adjust the surroundings of the patient so as to help him maintain or recover his health. (c) The organization should be flexible and capable of adaptation to changing conditions. It should: - be comprehensive, including preventive and curative aspects; co-ordinate service, education and research; grow out of needs, resources and readiness of the community to be served; - have long and short-term goals; - define the geographic and pragmatic scope of activities; - include interim and final evaluation. (d) Team-work of members of the health disciplines, other community workers and clients is essential. Social and scientific developments have had considerable impact on traditional roles which are moving towards expanding and overlapping functions of professionals as well as the evolution of new categories of workers. Close co-operation and co-ordination will facilitate more efficient delivery of service within available resources. There are several levels in organizations. Clear understanding of the purposes of each level will contribute to better utilization of staff. These levels are: - administrative (led by chief administrator) - responsible for broad spectrum policy and long-range planning; - managerial - provides methodology for implementation, on-going expert supervision and evaluation;
(e)
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Annex 6 cont'd. - operational - adapts, implements and evaluates services. Serves as grass root for information used in policy-making. As the level of competence of personnel at the operational level rises, it permits a reduction in the scope of activities at the managerial level. Some functions remain within the specific level, others such as staff developm,erlt involve all levels. l Authority and decisl'on-making should be delegated to the lowest level at which competence can be found. This may vary with the abili ties of personnel. The principle of "least control" holds that rules be kept to the minimum needed to safeguard the service. Functions of levels, departments and agencies should be defined, but left flexible for redefinition as circumstances change. (f) Administrators should be aware of possible constraints (restriction imposed by society, nature or circumstance), and develop plans to work within these limitations and/or make efforts -to overcome them. Alternative plans should be made to be implemented if needed. Elizabeth Hillborn2 lists the constraints on nursing programmes as follows: lack of epidemiological data; natural opposition to change; low priority accorded to health by politicians and public; frequent government change; lack of tools for planning and measuring; time lag between planning and implementation; division and poor communication among professions; inflexiblli ty of educational system; inefficient administrative practices. (g) On-going open two-way communication is essential between those involved in the programme between staff and clients, between disciplines, between agencies. Such communication includes personal interaction, conferences, recording and reporting; (h) Evaluation should primarily study the results achieved
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(output), followed by review of the use of resources (input) and methods (process) to explain the outcome. Where possible expert consultation is desirable in developing methods and measures for evaluation. •
Freeman and Holmes, Administration of Public Health Services. Saunders, 1960, p. 100.
1
~HO, Planning and Programming for Nursing Services, WHO, Geneva, 1971, pp. 18-19.
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Annex 6 cont'd.
3.
NURSING SERVICE ADMINISTRATION
NUrsing service administration is the process by which the NUrsing Service Department achieves its purpose. co-operates and co-ordinates its work with other departments. It involves planning. organizing. directing, controlling, co-ordinating and evaluating the programme. Planning is the outline of what needs to be done and how to do it. Organizing is the recruitment and assignment of appropriate manpower and other resources. Directing is leading the group in its activities in an environment which promotes growth and goodwill. controlling is the application of authority to ensure the implementation of plans. Co-ordinating is harmonizing the parts to each other and to the whole. Evaluating is the continuous study of purposes. processes and outcomes as a base for continued provision of the best possible service. 3.1 Function of the nursing administrator
The Committee on Practice of the Nursing Service Administrators Section of the American Nurses' Association listed 24 functions for the nursing services administrator: l II
(a)
Develops a written philosophy and objectives for the nursing department which are compatible with the purpose of the health care facility. Establishes and implements standards which insure safe and therapeutically effective nursing care of patients. Develops nursing service policies which focus on the oare of the patient. favour the practice of nursing. and help attract and retain qualified nursing service personnel. Participates in the establishment and promotion of administrative policies and practices which favour the practice of nursing and provide a climate which helps nursing p·ersonnel to increase their professional. technical and psycnosocial skills.
(b)
(c)
(d)
lANA, reprint N-6lOM 8/66.
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Annex 6 cont'd.
(e)
Participates in reviewing and revising the personnel policies of the health care facility and establishes criteria and procedures for the recruitment, selection, promotion and termination of employment of nursing personnel. Establishes the functions and qualifications for each nursing position. Determines a staffing plan which will accomplish the stated objectives and standards of the nursing services and promotes the maximum utilization of all nursing personnel. Directs the nursing personnel and the activities of the nursing department. Organizes the nursing department to delineate authority, functional responsibilities, lines of relationship and communication to provide safe and therapeutically effective nursing care. Evaluates nursing care and the climate in which it is practised to identify achievements and problems, and to provide data for forecasting and planning. Develops and maintains an effective system of nursing records and reports. Collaborates with the administrative staff, other department personnel and representatives of allied groups in planning for co-ordinated services to patients. Provides for nursing personnel to plan with the medical staff and other patient care disciplines for the total needs of patients. Participates in the assessment of community health care resources for provision of continuity of care for patients within the agency, on discharge and on referral to another health or nursing care facility. Detennines and recommends a departmental budget to implement stated objectives.
(f) (g)
(h) (i)
• (j)
(k) (1)
(m)
(n)
• (0) •
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Annex 6 aont'd. ~.
(p) (q)
Controls and evaluates the allocated budget for adequacy for the present and the future. Plans with representatives of administration and other appropriate groups for the development of new and effective use of existing facilities needed to attain service and educational objectives. Partiaipates in the planning and maintenanae of quality pre-service training programmes for nursing personnel. Provides for orientation and in-servioe programmes for all nursing personnel. Develops agreements with educational agenoies for the use of the alinical facilities by nursing students. Initiates. promotes and participates when necessary in studies and research designed to assess nursing administrative practices and nursing oare. Promotes utilization of the applicable findings of the studies and research for the improvement of nursing administrative practices and nursing care. Collaborates in other suitable studies and research. Participates in activities which promote his/her own professional growth and development. Participates and promotes membership interest and participation in the activities of the professional nursing association. in allied health organizations and supportive community activities."
(r)
(s) (t)
(u)
(v) (w) (x)
4.
NURSING SUPERVISION
Supervision, which is the major link between administration and staff, is a co-operative relationship which stimulates the supervisee and pranotes efficiency of the service. It is concerned with the individual's needs in the performance of his work and in assisting him to attain knowledge and sk11ls for carrying out the Job to the best of his potential.
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Annex 6 cont t d. 4.1 Some concepts of supervision professional philosophy are: (a) 1
derived from general and
Supervision is essentially concerned with working with and through others. The supervisor works with the staff in the achievement of the objectives the agency and deoisions are. wherever possible. shared deoisions. The authority of the supervisor is limited downward as well as upward. The staff worker must have responsibility for his own work as a professional person. The supervisor should not make a decision which the staff worker is able to make with reasonable capability - even though the supervisor would decide differently. The supervisor recognizes and respects the individual worker as a person. Supervision implies technical. professional as well as general leadership ability. comp~tence.
(b)
(c) (d) (e)
Each professional discipline should have supervision available from within its own discipline. 2
4.2 The functions of the supervisor include: (a) (b) (c) Cd) (e) facilitation of the flow of work;
establishing qualitative and quantitative controls of the work; promoting the effectiveness of the individual worker; promoting the effectiveness of the group; serving as a link between field and administrative staff in agency planning and programme implementation.
•
Freeman. R. &: Holmes. E •• Administration of Public Health Services. Saunders 1962. p. 282 •
1
..
~eman. R. 4: Holmes, E., Administration of Public Health Services. saunders. Philadelphia • 1960, p. 281.
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Annex 6 oont'd. Of the above functions, the distinotive oontribution of the supervisor to the nur.tng service department is the liaison role between administration and the nursing servioe personnel responsible for direot servioes to olients.It requires skills in evaluation of, and leadership in, the immediate situation, as well as skills in oommunioations and human relationships whioh lead to professional growth and improved nursing praotioe on the part of those supervised. 5. ASPECTS OF PERSONNEL AIlt1INISTRATION
As personnel is the prime faotor in achieving the objeotives of the servioe, three aspects will be oonsidered briefly: oategories of nursing personnel, appraisal systems and oontinued eduoation. 5.1 Categorization of nursing personnel, within three major levels was reoommended by the Fifth WHO Expert Committee on Nursing.l A nursing personnel system is desirable also to prevent or restrain undue proliferation of oategories of nursing persc;mnel. Where suoh proliferation already exists, oonsolidation of the system would have to inolude safeguards for the individuals likely to be affeoted. Carefully oonoeived long-range plans will be needed to olarify the meaning of eaoh oategory, to develop training methods for new entrants to each group and to upgrade those who oan be prepared, through supplementaryeduoation, to aooept greater responsibilities. There has been a growing movement for more eduoation and promotion in "01inica1" in addition to "fUnotional" lines. This system enables nurses to attain higher rewards, status, carry greater responsibility on reaohing expertise in direot patient oare in a special area, without beo<Ding involved in supervision and adminis.tration fUnotions. 5.2 Performanoe appraisal
The tem "staff evaluation" has been broadened in purpose and method to serve as a two-way ongoing camnunication between staff and administration/supervision, with the primary purposes of improvement andclevelopment. Toda7, performanoe appraisal systems are used in organizations for many different purposes. The Foundation for Research on Human Behaviour 2 defined these purposes as: to determine salary standards
,
1966,
lWHO Expert Committee on Nursing. Wld Hlth Org. tech. Rep. Ser •• ~ pp. 11-14. 2
The JQUrnal of Nursing Admin.1stration, 2, No.2, Maroh-April
1972. p. 30.
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Annex 6 cont'd. and to award merit inorease; to select qualified individuals for promotion and transfer; to identify unsatisfactory employees for demotion or termination; to make inventories of talent within an organization; to determine training and developmental needs of employees; to improve the performanoe of work groups by examining and oorrecting the inter-relationships between members; to improve communication between supervisor and employee, and to reach an Imderstanding on the objectives of the job; to establish standards of supervisory job performance; to discover the aspirations of the employee and to reconcile them with the goals of the company; to provide the employee with recognition for accomplishments; to inform employees "where they stand". 5.3 Continuing education
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Continuing education is a means for staff to attain knowledge needed for their work, to develop identification with the service. Administration oan learn staff needs, interests and abilities and can improve service through increased staff knowledge and morale. It may be carried out through formal education provided outside of the service in educational institutions, courses, workshops, etc., or by in-service and orientation programmes within the agency. Continued education, see Figure I. should be planned at several levels (a) (b) (c) those areas of concern to the whole staff such as plans, policy; areas of interest to special groups such as head nurses or nurses working in a clinical area; needs of individuals such as preparation for a new job.
~ontinued education should involve the learners from the early planning stages. and provide for their active participation. Working time facilities, reading materials should be provided. Evaluation of outcome in terms of improved practice, personnel growth and satisfaction should be planned as part of the programme outline.
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Annex 6 cont'd. FigUre II - Plow Chart ot CODtlnued Education Comments Dependant on philosophy of organization Full-part-time worker; co-ordinator should not be the director Include persons trom various
Decision for continued education
! Appoint co-ordinator
disoiplines. departments. levels ot nursing By questionnaire. interview ~or group discussion with
IEa1:bl' -h
starf committee
I • •
1 Study staff learning
staff. other disciplines. adm1nistration Several programmes can run aimul taneously to groups and individuals
needs and interests Prepare Master Plan based on priorities
Develop programmes objectives content teacher method sohedule - budget evaluation
Aotivate participants Evaluation by co-ordinator; committee. participants. observed changed behaviour. etc.
! Implement Evaluate Replan