International Journal of Nursing Practice 2001; 7: S11–S13

The third in our series of supplements focuses on the organization of nursing around the world. Specifically,we asked our participating countries to provide details ofhow hospital and community nursing are organized intheir country. (As the findings of Supplement 2 show,these are the two areas where nurses are most commonlyemployed).

Two questions were put to our respondents:1. How is hospital nursing organized?2. How is community nursing organized?

Their answers varied in amount of detail but mostoffered a basic outline of their ‘hierarchy’ or system ofmanagement. In integrating these responses, a number of commonalties across countries became apparent.

THE ORGANIZATION OF NURSING IN HOSPITALS

The majority of countries (28/36) involved in our studydescribe a nursing service managed predominantly and at a senior level by nurses and nurse-administrators. Thenumber of countries whose hospital nursing service ismanaged at the most senior level by nurses with a varietyof titles is shown (Fig. 1).

Only four of the participating countries still have a hos-pital nursing system that is managed at a senior level by amedical officer. These countries also describe themselvesas striving for greater autonomy for nurses and for morediversified roles and better education. One such countryis the Slovak Republic, the response of which emphasizedthat it is impossible for nurses to lobby for, and gain, posi-tions of influence in any areas of the health system if theyare not given the necessary education and training.Another is Chile, that states not only is their systemmanaged predominantly by a medical director, but also

there is very little in the way of a framework or manage-ment system designed to focus on the organization of hos-pital nursing.

Some responses we received in answer to this first ques-tion also show movement away from traditional medicalmodels in other ways. In New Zealand and Estonia, forexample the emphasis in hospital organization is on team-work and on collaboration.A combination of managementprinciples are used in order to organize nursing andmedical care in hospitals—rather than operating indepen-dently, respective medical, administrative and nursingdepartments are being asked to collaborate to providebetter patient care.

Organization at ward levelOur responding countries describe a variety of organiza-tional structures in terms of middle- and lower-level man-agement. There are those countries that can identify awhole hierarchical system from directors of nursing (orequivalent) through to assistant/auxiliary nurses, witheach specified level being under the supervision of a des-ignated position; and those countries that claim to have nospecified structure or framework between senior man-agement and ward-level management.

When focusing on ward-level management, responsesfrom all participants were similar. Hospital nursing at anurse–patient level is identified as being most often orga-nized according to medical specialties. Wards are usuallynot ‘general’ wards but are organized into areas such asacute, critical care, paediatrics, orthopaedics etc. Thesewards or areas are allocated specialist nurses who aresupervised by a senior specialist ward nurse. This seniorward nurse is identified by a variety of titles across theworld according to the countries surveyed but most of

✠ S P E C I A L S U P P L E M E N T ✠

3:The organization of nursing

Alan Pearson RN, ONC, DipNEd, DANS, MSc, PhD, FCN(NSW), FINA, FRCNA, FAAG, FRCNEditor, International Journal of Nursing Practice, and Professor of Nursing, La Trobe University, Melbourne,Victoria, Australia

Stephenie Peels BAEditorial Assistant, International Journal of Nursing Practice, School of Nursing, La Trobe University, Melbourne,Victoria, Australia

S12 IJN Supplement 3

109876543210

No.

cou

ntrie

s

Chiefnurse

Medicaldirector

Directorof nursing

Matron Teamwork/combination

Ministryof health

Senior manager

Figure 1. Senior managers of nurses in hospitals.

them carry out the organization of nurses in hospitals ona practical day-to-day level (Table 1).

THE ORGANIZATION OFCOMMUNITY NURSING

Many respondents report that there has been a trans-formation in the health-care delivery system with the

8

7

6

5

4

3

2

1

0

No.

cou

ntrie

s

Through hospital/outpatients

Independent service

Extension ofGP services

How community nursing is organised

Figure 2. How community nursing is organized. GP, Generalpractitioner.

establishment of community nursing. Providing largelypreventative services, the introduction or expansion ofcommunity nursing has seen an increased movementtowards offering a majority of health care within the com-munity and the home, rather than in hospitals, in manydeveloped countries. Maternal and child health, schoolhealth, preventative health care such as vaccinations andeducation programmes, and palliative care are frequentlythe domain of public health nurses working autonomouslyin collaboration with the local general practitioner (GP).Japan offers an advanced community nursing programmefor aged care that has been set up in response to the chang-ing health-care needs of an ageing population. Publichealth nurses coordinate services required to fulfil ade-quate home nursing care and liaise between the patient,physicians and social services to make sure patient needsare met in the home, rather than in a hospital or clinic situation.

There are still many countries, however, where there is resistance to the diversified roles for nurses that thisinvolves and encourages. The Slovak Republic is anexample of a country where community nursing simplydoes not exist—all local health care is carried out bymedical doctors. In Estonia, the process of establishingcommunity nursing is in its very early stages with pilotprojects planned for 2001, with nurses fully supervised byfamily doctors. Austrian nurses practise within a commu-nity nursing system presided over by GPs who are unwill-ing to accept extended or diversified roles for nurses.

Most community health services are paid for and runby government or welfare agencies and, as such, appear to be managed out of either hospital outpatient facilitiesor independently run community centres or offices (or a

Table 1. Manager at ward or lower level by country

Country Manager (ward/lower level)

Italy Head nurse

Democratic Republic of Congo Head nurse (for each ward)

Spain Nursing supervisor (for each

clinical specialty)

Germany Ward manager

Bolivia Charge nurse (for each ward)

Ireland Unit and clinical managers

Macau Head nurse (for each ward)

Mauritius Ward manager

St Lucia Ward sisters

Andorra Coordinator (for each area/

specialty)

Ethiopia Head nurse

Denmark Head nurse (for each floor/

unit)

Austria Ward sister

Republic of Korea Head nurse (for each ward)

Samoa Divided into specialties

Japan Divided into specialties

Australia Nursing unit manager or

clinical nurse consultant

(depending on state)

Nursing—A global perspective S13

combination of both). In this way, they can be seen to beacting as a liaison between hospitals, government and thecommunity.

Seven countries responded that community nursing isorganized through hospital outpatient facilities, six coun-tries that it is run as an independent service and only threecountries that it is organized as an extension of localgeneral practice by medical doctors (Fig. 2).

Management of nursing careFew of our respondents describe systems of care delivery.In Australia and New Zealand, team nursing, primarynursing and patient allocation are the common forms ofcare delivery within nursing services in both the hospitaland the community but no reference to these methods oforganizing nursing care is made by any other country.

DISCUSSIONSince its emergence as an occupation in the nineteenthcentury, nursing has tended to focus on a hierarchical

approach to the management of nurses and the organiza-tion of nursing care. The responses in this survey suggestthat internationally nurses still focus on a system of hier-archical management, where senior nursing managerssupervise head nurses or charge nurses who, in turn,supervise registered nurses and other nursing workers. Anumber of countries have yet to achieve a position wherenurses lead nurses; medical practitioners are still seen inthese countries as the legitimate leaders of nurses.

The expansion of care in the community appears to begenerating greater opportunities for nurses to expandtheir role and increase their autonomy, especially in coun-tries where nursing has been slower to develop thanothers in terms of power, education and role develop-ment. The relationship between nursing education, therole of the nurse and the management and organization ofnurses is the most striking finding in this study, and thiswill be the focus of the next supplement in this series.