Total Quality Management And Health Care Nursing Essay

The health care industry has developed its service delivery system in order to survive in a tough environment resulting from industry maturation, less funds, and more competition (Williams, 1994; Cho et al., 2004). Total quality management (TQM) is a theory has the aim to achieve total performance. The TQM haveled to many benefits of more customer satisfaction, employee attention, motivation, less waste and overall performance is improved (Juran, 1988). The TQM has developed to improve the efficiency of health care areas and is very important for the successful functions of hospitals. Many hospitals have adopted for TQM to reduce costs and improvement in the quality of provided services. It is argued that in heath care industry the quality measurement is not well established measurement of quality is not yet well established in the health care industry so in place there are some measurement mechanisms (Huq, 1996; Yang, 2003; Huq, 2005). There is the growing consensus that the satisfaction of customer indicates properly the quality of health care and many hospitals are searching for ways to achieve this through TQM (Schalk and Dijk, 2005). However, TQM studies mostly consist of manufacturing sector with limited studies within the service sector. Therefore, it is imperative that a proper study is carried out to ensure that the adoption of TQM is a worthwhile initiative in public hospitals. Public hospitals have always been criticized for their poor service quality and to implement a quality improvement program management in public hospitals because of unawareness of benefits of adopting and implementing a quality improvement program. Thus this study was aimed to investigate the extent to which public and private hospitals in Peshawar are willing to adopt TQM as their main driver towards quality improvement. The perceptions of management and employees on the adoption of TQM in public as well as private hospitals are assessed in this study.

Total Quality Management

The TQM was a competitive strategy during the 1990s and has been applied world widely (Rad, 2006). However, TQM theory development is still in early stages in the service industry (Vouzas and Psychogios, 2007). The TQM is used to implement in the organization, where employees are motivated to improve their performance (Mohanty and Behera, 1996). Service in organizations is more difficult to measure than manufacturing organizations because of the updates and intangibility of the service characteristics.Toavoid management fad only mere adoption of TQM is not sufficient rather complete understanding and training of TQM concepts is necessary (Ehigie and McAndrew, 2005).

Total Quality Management and Health Care

Quality improvement in health care organizations is considered as a means to better meet the needs and expectations of patients. According to Yang (2003) in health care industry the adoption of TQM is so difficult as apposed to TQM implementation in manufacturing. As put forward by Huq (1996) The TQM is adopted to make the business more efficient and to perform all the operations properly in many hospitals. During the late 1980s this concept has became popular in health care industry (Garvin, 1988; Westphal, et al., 1997). The hospital successful operations depends on the customer satisfaction and becomes so important (Andaleeb, 1998; Yang, 2003; Cho et al., 2004). Yang (2003) further argues that the use of TQM has provided a partial cure to service quality problems in healthcare organizations. From history we found that the customer satisfaction is so much important for the representation of quality in health care. Huq(1996, 2005)argued that for the health care providers the customer satisfaction is the main issue. The TQM further aims at the success of organization through customer satisfaction. (Vouzas and Psychogios, 2007). However, the implementation of TQM in public organizations has some problems because of authoritative culture. Consequently TQM initiatives must include an in-built culture of continuous improvement, which can help an organization satisfy the needs of its customers on an ongoing basis (Walsh et al., 2002).

Nursingencompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles (ICN, 2004).

Role of the Nurse

In the health care nurses assume several important roles namely caregiver and knowledge worker. The nurses caregiver role include client needs, comfort and therapies (McFadden, 1989). The concept about nurses is of motherly caregiver about nurses from decades. According toRobb, caregiver should involve in their patients. Involvement means the caregiver should enjoy and take keen interest and have a craze of acceptance of a patient (child) (Robb, ed., 2003, p. 109). The communication is the best way to create a better understanding between the child, parents and staff to understand the medical procedure properly (Rodin, 1983). Müller et al., (1986) suggest that children in the pre-operational stage "conceive of illness as being the outcome of their wrong doing. Important aspects of hospital to children are likely at this stage to be external, observable events (e.g., equipment, surface wounds, food, nurses’ uniforms and strange beds) rather than a description of what is going on in the body". In this case, "a child’s understanding of explanations is influenced by the choice of words used. The words need to have only one possible meaning, or be very carefully explained".

Nurses are regularly faced with families feeling despair, fear, anger, and helplessness, and nurses are challenged to respond therapeutically, often without formal education in family dynamics or intervention (Goodelland Hanson, 1999). The nurse is not only responsible for the welfare of the patient, but also the family. "In pediatric nursing we do not nurse a child; we nurse a family whose sense of well-being is disrupted because one of its members is having a problem" (Coffin, 1970). "Health care involves both the person in need of care and that individual’s family, no matter how that individual defines the composition of his or her family" (Lynn-McHale andDeatrick, 2000). "When children are unexpectedly hospitalized, the nurse is particularly cognizant of the need for client advocacy. Children and parents are bombarded with personnel and stimuli and often the nurse is the only familiar, constant presence in their time of stress" (McFadden, 1989).

Critical Factors Influencing TQM

The TQM adoption and implementation requires changes in structure, system, and process as a necessary precondition to achieve improved business performance and changes in employee behavior (Yang, 2003). It is therefore important to find out all barriers to TQM in service of organization (Taylor and Wright, 2003). Some of these critical factors are briefly discussed.

Factor 1.Top management commitment

Management acts as the driver for TQM implementation, creating values, goals and systems to satisfy customer expectations and to improve an organization’s performance (Juran, 1988; Dale and Plunkett, 1990; Ahireet al., 1996; Huq, 2005; Rad, 2006) and responsible for providing direction and encouragement to the organization. Management commitment is crucial for a company’s quality development since, with their support and contributions, adequate resources will be allocated to enhance the training activities resulting in better quality measurement, improved customer satisfaction and benchmarking. Hospital directors are exposed to normative pressures to adopt innovative management practices such as TQM (Taylor and Wright, 2003; Huq, 2005).

Factor 2. Employee involvement

Employee involvement is a critical component of TQM. The TQM requires total management commitment to ensure employees indulge in quality work culture and hence create healthy corporate image by rendering quality services to the customers (Huq, 2005; Schalk and Dijk, 2005).

Factor 3. Customer satisfaction

The TQM makes customer satisfaction the number one organization priority, where an emphasis is placed on meeting or exceeding external customer expectations in every transaction (Kangi, 1998). A close relationship with the customers is necessary to fully determine their requirements, thus customer involvement is necessary in the product design and development process (Das et al., 2008). The TQM is one such philosophy which aims to provide organizations with a template for success through customer satisfaction (Arasli and Ahmadev, 2004). Customer focus is the emphasis placed by hospitals in meeting the unlimited expectations of its customers (Das et al.,2008).

Factor 4. Teamwork

Teamwork is a critical factor in TQM as teamwork is essential in having a fully functioning process management and improvement, especially in medical treatment; it requires cooperation among all related departments (Westphalet al., 1997; Huq, 2005; Vouzas and Psychogios 2007). According to Yang (2003), teamwork is important to overcome sectionalism and to strengthen cooperation for improving quality (Huq, 2005). The most difficult aspect of TQM is to create an environment of "all one team" (Rad, 2005).The author further adds that everyone throughout the organization must work together to improve processes and to execute them with energy and efficiency.

Factor 5. Training

Training is a very important tool for promoting and developing skills related to an organization’s beliefs and values to change to a culture that places high value on quality. Once management has the skills to lead the TQM process, the rest of the organization should be trained to ensure a systematic, integrated, consistent organizationwide effort (Rad, 2005). The author further asserts that an emphasis on continuous learning and improvement, induces a positive culture where there is sufficient behavioral modification to warrant a sustainable TQM climate. Providing training to employees in problem solving skills is one of the most important activities for organizational climate change (Taylor and Wright, 2003).


To investigate the professional skills and expertise of the nurses.

To identify the problems and constraints faced by the sampled area.

To study the role of organizational management to bring about improvement in the performance of nurses.

To suggest the recommendations for the concerned policy makers for improvement of the role of nurses in performing their duties.


The major objective of review of literature is to review the results of other studies, which are related with research problems under consideration. The review of literature for this study included nurses’job satisfaction, problems they faced their role in the hospital management. The review of the literature is presented as followings:

Concepts and theories related to nurses job satisfaction

Related researches of implementation of Total Quality Management.

Concepts and theories related to nurses role in hospital management.

Seki et al. (2008) studied that the most common reason for medical errors is a lack of crosschecking in Japan. To prevent errors, efforts to strengthen crosschecking behaviors are being adopted. However, time pressures also lead to errors, and increasing crosschecking activities leads to an increased workload and even greater time pressures. The purpose of this study was to identify working conditions that lead to time pressure for nurses, and to find ways to reduce time pressure and prevent subsequent errors. Self-reporting questionnaires were distributed over 10 days to 416 nurses working in 17 wards at two hospitals in Japan; 357 nurses (85.8%) responded anonymously, providing data on 2,150 person-days. In multivariate analyses, medical support services and the number of nurse calls answered were associated with subjective assessments of time pressures and nursing service delays due to busyness. Moreover, working the 'evening-day shift' (when a nurse works a day shift after working the evening shift with no days off in between) led to a high level of fatigue before work and was associated with nursing service delays due to busyness. Reducing time pressures and preventing errors require an adequate number of nurses, shift plans that consider rest periods and order of rotation, increased task discretion for nurses, and the prevention of chronic fatigue.

Schreieet al. (2008) analyzed in the hospital services, nutrition should be more closely watched because of the risk of malnutrition in the very ill and old patients. The role of the nurses in nutrition and assistance during mealtime or food intake should be considered in view of the upcoming discussion of the enlargement of the nurses' responsibilities in medical care, the personnel cutbacks in nursing and the increasing assignment of non-nursing support staff in hospitals. Traditionally, nurses have been responsible for the care of nutrition, the nutritional intake and the assistance of patients during mealtimes. Over the years, the involvement and influence on nutritional care has changed because other disciplines like dietetics and speech/language therapy have became 'an own body' of professional knowledge. In spite of this change in nutrition care, nurses still have the responsibility to fulfill once of their basic tasks: to enable the patient to eat and drink independently as well as to support diagnostics and nutrition therapy. It is regrettable that nurses frequently do not sufficiently emphasize nutrition care or feeding of impaired patients. Only when hospitals provide good conditions for nutrition care in nursing .Assisting and feeding, especially of impaired patients, during mealtimes will be considered a high-value qualification of nursing.

Masnyet al. (2008) studied that the nurses have been targeted to provide cancer risk assessment and counseling. To help prepare nurses for this role, a 5-day training in familial cancer risk assessment and counseling followed by a long-distance mentorship to support continued skill development in the work environment was conducted by FoxChaseCancerCenter, Philadelphia, PA. A four cohorts that is (n=41) method was applied and developed as either immediate or delayed guide. The nurse’s ability is assessed and self efficiency skills were built via questionnaire. An interview after the guidance or training shows the benefits, timing and interval of the training. It was concluded that both groups are self-efficient in skills to six months and large numbers of nurses are taking guidance from professionals of heath. The value of training was described by all nurses and those who have less experience needed prior training to improve the performance and skills for program development.

Moreno et al. (2007) studied how the nurses from a hospital school see the family as care participants. Six nurses from clinics of chronically ill patients were interviewed. The data analysis allowed inferring that the nurses had only little knowledge of the families thematic during graduation, making the relationship with the accompanying families very difficult. Daily care during hospitalization period is marked by easy moments when members are willing to participate in the process and by difficulties when they attempt to break institutional rules. It was suggested that new nurses have theoretical foundation to attend the family in several scenarios of care. It was considered the need of investments in professional training, and that the advance of humanization of services implies in exchange and integration of knowledge among patients, family members, health professionals, support staff and managers beyond the science field.

Bottorffet al. (2005) investigate the professional involvement and confidence of Canadian nurses and physicians in providing genetic services for adult onset hereditary disease. The methods: 1,425 physicians and 1,425 nurses received a mailed questionnaire with reminders. The response rates were 50% (n = 543) and 79% (n = 975), respectively. Forty-eight percent of physicians and 31% of nurses lacked formal education in genetics. Respondents reported being involved in caring for people at risk for adult onset hereditary disease. Their levels of confidence that they could perform tasks, such as counseling about predictive genetic tests, however, were lower than their levels of expectation that it would be important for them to provide these services. They conclude that the expected roles and educational needs of Canadian nurses and physicians have broad areas of overlap suggesting the possibility of combined professional education programs and multiple ways of organizing teams to provide genetic services to people at risk for adult onset hereditary disease.

Lyuet al. (2004) studied quantitative results from one of the three methods in need assessments for nutrition counseling in a research series between 1999 and 2000. Three structured, semi open-ended, self-administered questionnaires designed for dietitians (11 hospitals), gout patients (two clinics), and medical staff including physicians and nurses in internal medicine departments (four hospitals) were designed to collect opinions regarding nutrition counseling. Total 54 dietitians from nine hospitals, 124 gout patients from two physicians' clinics and 127 medical staff from three hospitals completed the questionnaires. Fifteen percent of the gout patients had experiences on nutrition counseling. The order of credibility for gout-related education information was from medical staff, dietitians, newspapers magazines, television radio, friend’s relatives, then traditional medicine staff and direct sales (with 60% participants considering direct sales to be an unreliable source). Almost half (48.6%) of patients had the opinion that the duration of nutrition counseling should be 15 to 30 min. Nearly half of the patients did not consider the fee charged to be the limiting factor for the motivation for nutrition counseling. Nevertheless, 38% of the participating patients thought that the charge would be an influential factor and the acceptable range was $ 50 to 200. Eight percent of the medical staff did not aware that the nutrition counseling service existed in the hospital, with 98% of them regarding this as a very important service to patients. The participating dietitians thought that communication skills, contents, human skills, and patient motivation were important contributing factors for the success of nutrition counseling. Moreover, most dietitians and medical staff did not have preferences for the charging systems. They suggested that the fee could be $ 100 to 300 per section. Most dietitians disagreed with providing free services; however, 85% of them agreed with the co-payment system.

Imai et al. (2004) examined whether prevalence of burnout is higher among community psychiatric nurses working under recently introduced job specific work systems than among public health nurses (PHNs) engaged in other public health services. They also identified work environment factors potentially contributing to burnout.Two groups were examined. The psychiatric group comprised 525 PHNs primarily engaged in public mental health services at public health centres (PHCs) that had adopted the job specific work system. The control group comprised 525 PHNs primarily engaged in other health services. Pines' Burnout Scale was used to measure burnout. Burnout score into three groups classified respondents: A (mentally stable, no burnout); B (positive signs, risk of burnout); and C (burnout present, action required). Groups B and C were considered representative of 'burnout'. A questionnaire was also prepared to investigate systems for supporting PHNs working at PHCs and to define emergency mental health service factors contributing to burnout. Results: Final respondents comprised 785 PHNs. Prevalence of burnout was significantly higher in the psychiatric group (59.2%) than in the control group (51.5%). Responses indicating lack of job control and increased annual frequency of emergency overtime services were significantly correlated with prevalence of burnout in the psychiatric group, but not in the control group. They concluded that the prevalence of burnout is significantly higher for community psychiatric nurses than for PHNs engaged in other services. Overwork in emergency services and lacks of job control appear to represent work environment factors contributing to burnout.

Inoue et al. (2004) surveyed the present conditions of occupational health nurses (OHNs) activity related to health committees (HCs) in Japan. Questionnaires that included items related to duties of the OH physician (OHP), those of the OHN, and their mutual duties within the HC, were mailed to 41 companies employing OHNs and questionnaires from 18 companies were analyzed. Comparison of the frequency of OHN attendance at health committee meetings (HCMs) revealed that 33.3% of OHNs attended the HCs when their companies employed full-time OHPs and 83.3% attended when their companies employed part-time OHPs. In a question about the OHN's opportunity to deliver a speech, give a report or make a presentation at their HCMs, 16.7% of OHNs in companies with full-time OHPs and 66.7% of OHNs in companies with part-time OHPs reported they had such opportunity. In companies with part-time OHPs, 50.0% of the OHNs reported that they were asked for their opinions at the HCMs, but OHNs at companies employing full-time OHPs were not asked for their opinions. It was considered that in the future, OHNs, particularly those working with a part-time OHP, would have an important role in the HC and developing OH services for their companies.

Ohidaet al. (2001) studied the relationship of night-shift work to sleep problems and work performance was examined in young female nurses in 11 hospitals in Japan. A cross-sectional study was conducted by means of anonymous self-administered questionnaires, carried out in July 1999. Subjects were 620 female nurses (Average age: 23.9) who started their careers in April 1997 and continued working in the same hospitals for two years and three months until the time of the survey. A questionnaire consisting mainly of items concerning sleep disorders from the Japanese version of the Pittsburgh Sleep Quality Index was distributed to the subjects. Significant associations were observed between working on night shift and the use of alcoholic beverages to help induce sleep, and between working on night shift and daytime drowsiness. Significant differences were also observed between two- and three-shift systems with regard to subjective sleep quality. Moreover, average hours of sleep were significantly associated with three related sleep items: subjective sleep quality, difficulty in getting to sleep, and daytime drowsiness. They concluded that in Japanese shift-work systems, sufficient sleep hours are needed for nurses who work night shift to ensure good quality of sleep and consequently better services for patients.

Kgapholaet al. (1997) studied nutrition-related health problems in South Africa, particularly in the black communities in the Homelands and black rural areas.They determine the current nutrition knowledge of clinic nurses in Lebowa. Clinic nurses (n = 99) in Lebowa answered a 40-item nutrition knowledge test (NKT) and five demographic questions. They general performance of the clinic nurses on the NKT was poor, 14 +/- 3.8 (35%) answers correct, with scores ranging from 4 to 25 (10% to 63%) answers correct. They concluded that the responsibility of nurses are entrusted with regarding nutrition care, the current nutrition knowledge of clinic nurses is a cause for concern. The results of this study provide a basis for nutrition education efforts directed at community health nurses.

Kodaet al. (1991) analyzed medical services and nursing system was being reformed due to high medical costs and shortage of clinical nurses. The shortage of clinical nurses influences not only their working conditions but also their own health problems. In European countries and the United States, low back pain (LBP) has been reported to be one of the most common and costly health problems among clinical nurses. To estimate the occupational risk factors of LBP among nurses, a questionnaire survey of LBP and occupational risk factors was carried out in 1987 on 947 clinical nurses and as well as on 300 female clerical workers of three local governments. First, to examine the prevalence and the magnitude of the problem, we analyzed several kinds of prevalence rates of LBP and its characteristics among nurses and clerical workers. Second, a case-control study was conducted to investigate the relationship between LBP and occupational risk factors. In analyzing occupational risk factors of LBP, odds ratios, age adjusted odds ratios and 96% confidence intervals were computed. Finally, to estimate simultaneously the effect of multiple risk factors of LBP and to confirm univariate age adjusted odds ratio analyses, several multivariate analyses were performed. Point, period (a month), and lifetime prevalence rates of LBP and prevalence rate of severe LBP among clinical nurses were significantly higher than those of clerical workers (p<0.05-0. 001, respectively). Demographic and occupational items, such as being an assistant nurse (as opposed to a registered nurse), and working in certain departments (internal medicine, orthopedic surgery, neurosurgery, psychiatry, tuberculosis ward) showed significantly higher odds ratios for LBP (p < 0.05-0.001, for all). Intensity of work loads estimated subjectively such as 'caring for patients who are in bed', 'supporting patients when transporting and bathing them', 'preparing drugs and injections, and treating', 'observing and monitoring patients' conditions', 'instructing and explaining procedure to patients and their family' and so on also had significantly elevated age adjusted odds ratios (p < 0.05-0.01, for all). Moreover, many items on the problems connected with working life and interpersonal relationships showed significantly higher age adjusted odds ratios (p < 0.05-0.001).

Thomas et al. (1985) studied that if nurses used on hospital aero medical evacuation services perform advanced trauma life support (ATLS) procedures usually reserved for physicians. Forty-seven hospital programs responded to our questionnaire. Flight nurses on programs (26) in which physicians were frequently used were significantly (p<0.05) less likely to perform cricothyreotomy, esophageal obturator airway placement, oral intubations, and pericardiocentesis than flight nurses of programs (21) not using flight physicians. Except for cervical tong placement (p<0.05), central line placement (p<0.05), and the performance of saphenous vein cutdown (p<0.05), no differences were found in procedures performed by flight nurses of programs not using physicians and those performed by flight phycisians. They concluded that flight nurse abilities are expanding into areas traditionally set aside for physicians in providing advanced trauma life support procedures on hospital aeromedical services.

Sezer et al. (2007) obtained baseline information on smoking among nurses. An attempt was made to contact, in person, all 301 nurses working for the university hospital in Sivas, Turkey, and when contacted they were asked to complete an anonymous questionnaire. Each unit of the hospital was visited three times, and 239 (79%) nurses were reached who all completed the questionnaire. Of the 239 respondents, 107 (45%) were current smokers, reflecting a substantially higher prevalence compared to that among the adult female population. The quit ratio was 22.5%. Of 127 ever-smoker nurses who responded to the related item, 90% started smoking during or after nursing education. This pattern of smoking initiation was different from the pattern in developed countries where nurses had already started smoking before beginning that training. Nurses with a high school education had a significantly higher prevalence of ever-smoking. Most respondents frequently or sometimes saw doctors smoking in rooms for nurses and in rooms for doctors in inpatient services. In-depth qualitative studies are needed to determine the reasons for the different smoking-initiation pattern.

Eriksen (2006) identified work factors that predict persistent fatigue in nurses' aides. The sample comprised 5547 Norwegian nurses' aides, not on leave when they completed a mailed questionnaire in 1999. Of these, 4645 (83.7%) completed a second questionnaire 15 months later. The outcome measure was the occurrence of persistent fatigue, defined as having felt 'usually fatigued' or 'always fatigued' in daytime during the previous 14 days. In respondents without persistent fatigue at baseline, medium and high work demands, heavy smoking, being single, and having long term health problems were associated with increased risk of persistent fatigue at follow up. Medium and high rewards for well done work, medium levels of leadership fairness, and regular physical exercise were associated with reduced risk of persistent fatigue at follow up. In respondents with persistent fatigue at baseline, medium and high levels of positive challenges at work, high support from immediate superior, medium feedback about quality of one's work, and changes of work or work tasks that resulted in less heavy work or lower work pace were associated with increased odds of recovery (no persistent fatigue at follow up). Working in a nursing home and being intensely bothered by long term health problems were associated with reduced odds of recovery.

Eriksen (2006) studied the prevalence of tobacco smoking in nurses aides (assistant nurses) is high. Many smokers make attempts to stop smoking, but a large portion of these relapse after some period of time. Of 1,373 Norwegian nurses' aides - who were former smokers, not current smokers, and not on leave when they completed a questionnaire in 1999-1,203 (87.6%) filled in a second questionnaire 15 months later. A wide spectrum of physical, psychological, social, and organizational work factors were assessed by validated questionnaires at baseline. Respondents who reported smoking at least one cigarette per day at the follow-up were considered having resumed daily smoking (relapse). Results shows Social climate in the work unit (index with 3 items: supportive, trustful, relaxed) and frequency of exposure to threats and violence were the only work factors that were Associated with the occurrence of relapse after adjustments for background factors. In a logistic regression analysis, frequent exposure to threats and violence at work (odds ratio (OR) = 2.08; 95% confidence interval (CI): 1.01-4.29), and the lowest quintile of the social climate index (OR = 2.12; CI: 1.03-4.36) were associated with increased risk of smoking relapse, after adjustments for age, gender, marital status, and having preschool children. He concluded that poor social climate in the work unit and frequent exposure to threats and violence at work may be predictors of smoking relapse in nurses aides. It is essential that leaders in the health services put more emphasis on creating a supportive, relaxed, and trustful social climate in the work unit.

Green et al. (2000) examined HVs and PNs knowledge concerning the assessment and management of obesity by use of a questionnaire. A postal questionnaire was sent to 35 HVs and 49 PNs based at 24 practices within one regional health authority.The practices had participated in a previous survey. A 54% (17 HVs and 28 PNs) response rate was achieved. Responses indicated that little education concerning obesity had been received since professional registration, and a need for this was identified. Most respondents used a computer or chart to calculate BMI of patients/client. Three HVs and 21 PNs correctly identified that a BMI of > 29 or 30 indicated obesity, and six HVs and 21 PNs identified that centrally distributed obesity is associated with a greater risk of metabolic disease. Most respondents indicated they would advise a person with obesity to follow a low-fat diet; however, a low-energy diet was indicated by some. The majority were able to identify which of a number of foods were high in fat, although some low-fat foods were frequently misclassified. Most respondents mentioned the importance of lifestyle change and physical activity. Recommended weight loss generally followed current guidelines. Recommendations for practice are outlined. These include closer liaison with dietetic services, more emphasis on the assessment of eating habits and lifestyle, greater use of a client-centered approach and use of appropriate guidelines on physical activity.

Skirtonet al. (1998) studied genetic nurses and counselors work as part of the professional team providing clinical genetic services from regional centre in the United Kingdom. The education and training needs of genetic nurses and counselors have not previously been formally identified. The guidelines presented have been devised to equip practitioners to fulfill their professional role as defined in a previous study, by identifying objectives, educational pathways, and means of assessment. While academic courses provide an essential framework, experiential learning in a clinical setting is also considered a vital component of the preparation for practice.

Kodaet al. (1991) studied recently medical services and nursing system are being reformed due to high medical costs and shortage of clinical nurses. To estimate the occupational risk factors of low back pain (LBP) among nurses, a questionnaire survey of LBP and occupational risk factors was carried out in 1987 on 947 clinical nurses and as well as on 300 female clerical workers of three local governments. First, to examine the prevalence and the magnitude of the problem, we analyzed several kinds of prevalence rates of LBP and its characteristics among nurses and clerical workers. Second, a case-control study was conducted to investigate the relationship between LBP and occupational risk factors. In analyzing occupational risk factors of LBP, odds ratios, age adjusted odds ratios and 96% confidence intervals were computed. Finally, to estimate simultaneously the effect of multiple risk factors of LBP and to confirm univariate age adjusted odds ratio analyses, several multivariate analyses were performed. Point, period (a month), and lifetime prevalence rates of LBP and prevalence rate of severe LBP among clinical nurses were significantly higher than those of clerical workers (p < 0.05-0. 001, respectively). Demographic and occupational items, such as being an assistant nurse (as opposed to a registered nurse), and working in certain departments (internal medicine, orthopedic surgery, neurosurgery, psychiatry, tuberculosis ward) showed significantly higher odds ratios for LBP (p < 0.05-0.001, for all). Many items pertaining to working conditions connected with shift work, hospitalized conditions of patients, taking breaks and holidays, working postures, weight of patients and equipment lifting and moving, working environments and so on had significantly elevated age adjusted odds ratios (p < 0.05-0.001, for all). Intensity of work loads estimated subjectively such as 'caring for patients who are in bed', 'supporting patients when transporting and bathing them', 'preparing drugs and injections, and treating', 'observing and monitoring patients' conditions', 'instructing and explaining procedure to patients and their family' and so on.

Chandra (2001) studied that with the advancement in health care technologies, the quality and the quantity of the health services have improved a lot. At the same time the health care providers such as doctors, nurses, technicians etc. are more and more exposed to the professional risks due to working environment of the hospital. The common hazards/risks which may occur in a hospital are hospital acquired infection, radiation, fire, etc. Health care providers are most exposed to the professional risk such as hospital acquired infection (eg. hepatitis B, HIV infection) and radiation due to close approximacy with the patients or by product of the human body. Though the universal precaution, sterilization/disinfection, waste management are the sound practices adopted to prevent infections, still the chances of developing these infections are not zero. It is very difficult to prove the attributability if any employee is found positive with these infections, unless the accident was reported.

Jung (1999) analyzed that in Korea, nurses perform their services in different ways according to the scale of the workplace: In large workplaces they work as full-timers and in small and medium ones they work as visiting nurses, placed by health management agencies. Regardless of their ways of service, occupational health nurses conduct a large part of health management affairs. Health management affairs have so far aimed at decreasing occupational diseases, but when working conditions are improved and occupational diseases decrease, their goals will be changed, aiming at the health promotion and the prevention of general diseases which have been steadily increasing. As occupational health nursing activities are expected to be changed to accomplish such goals, the roles of nurses are also expected to be expanded. The expected role of nurses is to provide high quality professional services suitable for the scale of the workplace, the nursing activity methods and the goals of health management. In practice, however, there are not a few restraints on them to adequately perform such roles. Most of all, because of poor working conditions, their turnover is high and their term of service is short. In relation to this, the tendency to replace them with less experienced nurses may give rise to quite a few problems in maintaining reliable relationships with workplaces as well as providing professional services. Therefore, in order to produce high-quality professional services, it is necessary to improve the working conditions of nurses so as to secure nurses who can work for a long time.

Sato (1997) studied that occupational health nurses currently perform numerous activities, such as direct care services, administrative tasks for the management of the occupational health department, and collaborative tasks with other health disciplines. A descriptive study was conducted of 32 occupational health nurses working in North Carolina, 54 of their employers and 87 of their company employees, by using self-administered questionnaires, subjects were assessed as to the level of performance in 16 occupational health nursing activities to examine their current perceptions and future expectations for occupational health nursing roles. It was found that comparing the perceptions in the three groups, employees perceived greater needs than nurses with respect to planning and developing educational programs (p<0.05) and conducting research (p<0.01), whereas employers perceived the occupational health nursing roles similarly to nurses. Occupational health nurses, employers and employees had high expectations for the future in all activities. Among 16 activities, in particular, health policy development was reported as the priority activity by the nurses, in which they reported a significantly higher mean score for expectation than the employers (p<0.05). Occupational health nurses need to develop their ideal roles to meet the high expectations of employers and employees.