Verbally Communicated By The Representative Nursing Essay



Assignment 1: Report of the Organization Visit

Dr. Zeenat Khanu Kanji & Ms. Salma Rattani

Leadership & Management in Nursing Practice

The Aga Khan University School of Nursing and Midwifery

November 28th, 2012

Pledge of honor:

"I have fully acknowledged the work of others in an appropriate way. I have not used, received nor have I given material without permission while writing this assignment. I affirm that I have maintained the principles of honesty and integrity in my academic work."


Visiting to a Government organization always been an interesting experience to explore and compare the organization culture, norms and values, various aspects of organizational performances and its entire health care environment with other government and non-government health facilities. Nov 14th, 2012 we visited one of the first and largest Pakistani government hospital named Jinnah Postgraduate Medical Center (JPMC) in Karachi. The hospital was established in 1959 and owned by Federal Ministry of Health. In the beginning the hospital operated in a building, which was actually an army barracks constructed in 1865 and transferred to the Jinnah Postgraduate Medical Centre in 1959. However, the School of Nursing started with 7 nurses in 1949. We were welcomed by principal of JPMC School of Nursing Ms. Azra Naseem and Head Nurse Ms. Sharfunissa, who was the representative from the hospital side during our visit. The sitting arrangement was properly arranged in principal’s office and we tried to get comprehensive information about their organizational structure, operational framework and culture. There was no as such vision, mission and policy of the organization were well defined which is the crux to build the body of any institution and to work on organization standards. However, it is based on the health policy of Pakistan. The purpose of the organization is to give care to the patients and health for all which was verbally communicated by the representative.

Organizational Structure

The physical structure of the organization appears slightly old building in nature with open drainage systems including hospital, school of nursing, medical college and hostels. The hospital has altogether 1185 beds with mixed specialty of patient care which remain occupied almost all the time and each ward contains 50 patient beds. As far as the human resource is concerned, hospital has 425 nurses only, 40 head nurses and 230 student nurses. Apparently, the nurse patient ratio would be 3:50, as each ward has a capacity of 50 beds means 50 patients. According to the nursing representative, they keep 7 nursing staff in morning shift, 3 in evening shift whereas only 2 are assigned in night shift. It gives the impression of nursing shortage they are facing and deficient health care facility which ultimately leads to compromised quality of patient care. Nursing shortage always remains the major challenge for majority of the health care organizations nationally and internationally both. On the other hand, Khowaja (2009) stated that the Pakistani health care system is neither competent nor comprehensive to provide adequate services for the growing population (p.263). Organizations always foster and advance with efficient leaders and strong management. Chain of command and management hierarchy plays the fundamental role in order to support organization well-disciplined and well structured. Organizational structure in ancient times mainly consists of top manager who has all the power and authority to bring any change whether it is in the favor of employees or not. However, for me they are the lever of an organization which can increase the impact of interventions with democratic approach and need to guard its employee for successful quality improvement of the facility. According to the representative, in JPMC somehow the situation is relatively similar as mentioned above. It has a vertical hierarchy having top management on the position of chief nursing superintendent who is most experienced and has the authority power in nursing division, than comes deputy chief nursing superintendent, nursing superintendent, head nurses, charge nurses, registered nurses, midwives and assistant midwives. However, medical director and their committee’s chairs are also physicians who are mainly the decision makers. Some of the positions in nursing division are vacant as the culture of the government setup is such that they grade their nurses on clinical experience rather than qualification. Nevertheless, in my point of view, to bring change in any health care organization gets difficult when they lack well qualified and well experienced leaders as strategies change and advance with the demand of .We have explored on majority of the challenges that are faced by this organization e.g. lack of HR, lack of motivation, scarce recourses and management information system etc. Furthermore, in relation to leadership and management concept, the paper will highlight the concept of chain of command of power, politics in health care, image of nursing in Pakistan and challenges that is having a devastating effect on health care organization and nursing profession.

Management Concept

Chain of command of power and politics in health care system provides a foundation for front line leaders, physicians and nurses to accomplish their desired goals for the organization. Nevertheless, political ideas, economy and health care system for the country like Pakistan sometimes act as precursors to conflict amongst them. JPMC nursing division does have vertical management hierarchy which starts from the chief nursing superintendent whose qualification is BScN but has vast experience whereas under her, a nursing instructor works, whose qualification is MScN but has less experience than her. According to the nursing instructor (representative), "in government setup, only people with enormous experience can be the front line leaders or people who are recommended from known sources. On the other hand, physician’s group is usually appointed at the higher management than nurses and has given authority because managements believe that they are the most educated and knowledgeable of all healthcare providers". Therefore, favoring physicians increased distribution of power amongst them and despite changes; physicians remain powerful in the healthcare. The question arises that is it a battle of distribution of power among nurses and physician, or socio-cultural and political influence that does not allow people to come forward? In our context it is both. Historically, nurses have had limited power in the healthcare system and still they are striving for it. According to Falbe and Yukl (as cited in Boonstra & Gravenhorst, 1998) in change processes, power and influence can equally well lead to compliance even a commitment to the change efforts. However, change may not occur as rapidly as desired, and nurses often are frustrated because of their inability to influence the system. The rigid hierarchy still placed physicians firmly in charge. Nurses consistently affirmed feeling dissatisfied with working relationships that devalue their professional worth. Nurses report that these negative behaviors appear to be related to gender issues, power gaps, hierarchical traditions, or an attitude that nurses are their handmaidens rather than valued professional collaborators (Sirota, 2007, p.53).

During the visit to the ward side of JPMC, the representative also commented that "physicians always degrade nurses by saying that nurses just need to learn how to take temperature only, there is no need to educate or empower them". Furthermore she stated that "in our government setup physicians never let nurses to come forward and to raise their concerns, they never get happy for their government grades, and they feel jealous of them and never encourage donors even to provide adequate funds for the nursing division". By understanding the power and political realities and the ways in which the decisions are made in this system, nurses cannot increase their power and act as change agents in such healthcare delivery system. In many countries, nurses are recognized as direct care provider professionals, with an important role in maximizing the quality of the delivery of patient care, whereas in Pakistani hospitals, nurses still rely on physician assessment and orders… (Khowaja, 2009, p. 264). Nurses are still in the early stage of gaining respect and professionalism, the poor public image of nursing in male dominant Pakistan has not changed. Besides this, there is still a severe nursing shortage, with only 46,331 registered nurses for a population of 150 million. This issue has worsened because of nurse immigration to other countries (Pakistan Demographic Survey, 2006). Similarly, in JPMC, they do have nursing shortage due to nurses migration despite of having excellent staff retention strategy e.g. government grades and post retirement pension.

The issue of socio-cultural and political influence also has an impact on the infrastructure of the system. Poor governance has affected the prevalent social, economic and health infrastructure existing in the country. Moreover, inefficiency, scarce material and human resources, deficient health infrastructure, inequitable distribution of government allocations to hospital and hospital personnel, minimal attention of government physicians to public service, lack of accountability and corruption in the system further made it worse. Likewise, JPMC is also facing the above mentioned challenges in their system. Political concern as an external force is not controllable in this current situation of the country. However, internally collective bargaining and shared governance can be provided to overcome conflict and challenges in the healthcare system.

Gender related power issues still create problems, especially for female nurses in their working relationships with both male and female physicians. Nurses report that male physicians continue to exercise control over the largely female nurse group (zelek & Phillips, 2003, p. 53). In addition, the traditional dominance of physicians resulted in a situation where they are represented on other health professional registration boards, health policy advisors board and funding bodies.


In Pakistan, moving the nursing profession into the mainstream of healthcare, empowering nurses to act as advocates and change agents and changing the image of nursing in population need to be deal with respect. Furthermore, the functions, roles and kind of expertise nurses and physicians have may be different but they are equally important to consumers and patient care. The successful organization is the one whose top management lies on providing equality, support, empowerment, commitment and dedication of multidisciplinary team i.e. physicians, nurses and paramedical professionals.