Challenges facing nurses' associations and unions: A ...

International Labour Review Vol 142 (2003) No 1

Copyright copy International Labour Organization 2003

Challenges facing nursesrsquo associationsand unions A global perspective

Paul F CLARK and Darlene A CLARK

ealth care systems around the world are facing very significantH challenges as they restructure and ldquoreinventrdquo themselves in aneffort to make more efficient use of available resources (ICN 2001) Ashealth care is a labour-intensive industry the stresses experienced bythese systems inevitably affect their employees

Nurses as the most highly trained caregivers with regular patientcontact are at the heart of any health care system Widespread anec-dotal evidence suggests that the problems in health care have had a par-ticularly negative effect on the workplace experience of nurses1 Newsaccounts regularly report on the challenges nurses face in the work-place These range from low pay in Ireland to safety and health prob-lems in South Africa to emigration in the Philippines to mandatoryovertime in the United States These stories suggest that nursing is aprofession in crisis and that this crisis extends around the world How-ever there is little systematic comparative evidence available as to thenature and extent of the problems nurses face and the strategies theyemploy to deal with those problems

This article reports the key findings of the World Nursesrsquo Asso-ciations and Unions Project which was conceived to gather informationsystematically about the employment issues nurses face worldwide andthe strategies their organizations employ to address those issues Thefirst and second sections of the article provide some background infor-mation on the worldwide crisis in health care and on the historicaldevelopment of nursesrsquo organizations Following an outline of the sample

1

Department of Labour Studies and Industrial Relations The Pennsylvania State Univer-sity University Park PA School of Nursing The Pennsylvania State University UniversityPark PA

1 For the purposes of this study the term ldquonurserdquo refers to a ldquoregistered nurserdquo as is thepractice in most of the countries included in this survey

30 International Labour Review

of organizations that participated in the project the third section ana-lyses the data collected by the survey in order to identify not only theproblems facing nurses but also the priorities and strategies of theirorganizations in dealing with those problems A final section offerssome concluding comments

The crisis in health careHealth care systems around the world are in crisis On all conti-

nents in developed and developing countries alike health care systemsare unable to meet the medical needs of the people who depend uponthem This crisis is caused by a number of factors

Many health care systems are experiencing shortages of trainedmedical personnel Both developed and developing countries appear tobe facing a serious shortage of nurses (and physicians) Developedcountries however are in a better position to attract health care pro-fessionals from abroad thereby exacerbating the shortage in less devel-oped countries (RCPSC 2001)

Epidemics are also contributing to the crises some health care sys-tems are experiencing In 2002 for example AIDS was the leadingcause of death in Africa and the fourth leading cause of death world-wide (WHO 2002a) In recent years there has been a significantincrease in the incidence of tuberculosis in eastern and central Europeas well as in developing countries around the world (WHO 2002b) andmalaria is on the rise worldwide having caused some 60000 deaths inrecent years (WHO 2002c) Such epidemics place significant stress onhealth care systems particularly in less affluent countries

Environmental problems (air pollution water contaminationetc) natural disasters and the consequences of war (civilian casualtiesrefugees etc) continue to burden health care systems around theworld And changing demographics particularly an increase in the eld-erly population have also placed greater demands on health care sys-tems (WHO 2002d)

Finally health care reforms introduced around the world includ-ing privatization and the introduction of market-based approaches tohealth care have brought new pressures to bear on health care systemsand health care workers (Clark et al 2001 WHO 2002e)

While the crisis in health care is a multifaceted phenomenon theroot of the problem can ultimately be traced to economics Developingnations do not have the resources to provide even basic care to their cit-izens In developed countries neither the public nor the private sectorcan keep up with the rapidly increasing cost of health care In short thedemand for health services exceeds the supply

When health care systems are stressed financially greater de-mands are inevitably placed on the individuals providing care particu-

Challenges facing nursesrsquo associations and unions 31

larly the medical professionals This can result in very low salaries forcaregivers or in some cases the inability to pay salaries at all And itmay also mean that fewer health care professionals are employed toprovide higher levels of care resulting in the deterioration of workingconditions for those still at work in the sector

As a result of this work environment many health care employeesleave their jobs while fewer and fewer people are attracted to take theirplace This puts greater stress on the system which then squeezes itshuman resources even more This in turn encourages still more peopleto leave the health care professions and discourages even more fromentering (AFT 2001)

While many employees have exited the field many of those whohave chosen to continue to work in health care have turned to collectiverepresentation as a means of improving the conditions under whichthey work The organizations they have formed pursue a number ofstrategies to defend their interests including collective bargainingpolitical action legislative advocacy and community organizing Inmany countries the entire range of health care employees ndash from non-medical support workers (eg maintenance dietary and housekeepingemployees) to non-professional medical personnel (eg nurse aidesand technicians) to professional caregivers (eg technologists andphysicians) ndash engage in collective action One of the most extensivelyorganized health care professions is nursing

The background of nursesrsquo organizationsSince the late 1800s nurses around the world have been organiz-

ing to promote the interests of their profession and its members Mostof the earliest nursesrsquo organizations took the form of professional asso-ciations with trade unions being a more recent development (Quinn1989)

Most nursesrsquo associations were originally established to set profes-sional standards for training licensing and practice The AmericanNurses Association (ANA) for example was founded in 1897 ldquotoestablish and maintain a code of ethics to elevate the standard of nurs-ing education to promote the usefulness and honor the financial andother interests of nursingrdquo (ANA 2002)

The earliest nursesrsquo associations pursued their goals by workingwith government agencies educational institutions and other profes-sional associations in the health care field Over time most haveadopted collective bargaining and many have resorted to strikes orother forms of industrial action as additional means of moving theirprofession forward and protecting the interests of their membersToday there are nursesrsquo associations in more than 124 countries aroundthe world (ICN 2002)


In many countries at least some nurses have pursued a differentpath and have created trade unions as a means of gaining greater influ-ence over their working lives Often this has occurred where nursesrsquo asso-ciations were either slow to engage in collective bargaining and industrialaction or not sufficiently aggressive in their use of these strategies (Quinn1989) Most trade unions employ collective bargaining as their primarystrategy and are less reluctant to strike than are associations

In some cases these unions represent only nurses In other casesnurses may belong to a union that also represents other health careworkers ranging from physicians to nursesrsquo aidesassistants 2 A thirdless common scenario is where nurses belong to a union whose mem-bers primarily work in a non-health care industry or industries 3

It is not unusual for countries to have both a nursesrsquo associationand one or more trade unions that organize nurses 4 Where this is thecase these organizations may compete with one another for membersIn some countries the nursesrsquo association also serves de facto as thenursesrsquo union (ICN 2001)5

Survey sample and data analysisData for this project was gathered through a worldwide survey of

nursesrsquo associations and unions Most of the organizations included inthe survey were identified through the membership lists of the Inter-national Council of Nurses (ICN) a world body of nursesrsquo associationsand the Public Services International (PSI) a world federation of pub-lic sector unions Additional associations and unions were identified byan extensive Internet search

The survey questionnaire was constructed in consultation withICN PSI and numerous nursesrsquo associations and unions around theworld6 The questionnaire was mailed to 298 nursesrsquo organizations in

2 Organizations responding to the survey were asked to classify themselves as either aunion or an association It is possible however that the terms may have different meanings in dif-ferent parts of the world

3 There are numerous examples of this in the United States the Teamsters the UnitedSteelworkers the United Mine Workers and the United Auto Workers all represent bargainingunits of nurses

4 This is the case in the United Kingdom where the Royal College of Nurses (an associa-tion) and UNISON (a union) both organize registered nurses

5 This is common in Europe the Danish Nursesrsquo Organization for example functions bothas an association and as a union

6 These include the American Nurses Association the Federation of Nurses and HealthProfessionals (American Federation of Teachers) the New Zealand Nurses Organisation theNurse Alliance (Service Employees International Union) the Royal College of Nursing (UK)and the United Nurses of America (American Federation of State County and MunicipalEmployees)


157 countries All of them received a copy in English and organizationsin French- and Spanish-speaking countries also received a copy in theirrespective language Follow-up mailings and email communicationswere sent as reminders

Useable responses were received from 56 nursesrsquo associations and49 nursesrsquo unions in 76 different countries The sample had relativelygood geographical representation with every continent except Oceaniarepresented by at least nine responses7 Figure 1 shows the breakdownby geographic region

It should be pointed out that this sample is not necessarily re-presentative in a statistical sense nor was it intended to be The pur-pose of the survey was to gather as much information as possible on theworking experiences of nurses around the world and on the strategiestheir organizations employ to address the problems nurses face in theworkplace

One of the aims of the survey was thus to identify the workplaceproblems that nurses face and the degree to which these problems areshared by nurses in different countries Accordingly the questionnaireasked nursesrsquo associations and unions to identify the problems they faceand to rank them in terms of their seriousness It also asked them toprovide their assessment of nursemembersrsquo work-related priorities

Problems facing nursesThe nursesrsquo organizations participating in the survey were asked

to indicate whether they experienced each of 11 different problemsidentified in pre-survey discussions with international nursing expertsRespondents were also asked to indicate the level of seriousness ofeach problem on a four-point scale ranging from ldquonot seriousrdquo toldquoextremely seriousrdquo Table 1 provides the aggregate mean responses(based on 105 respondents) for each of the 11 problems by geographicregion Figure 2 shows the assessments of problems by all organizationsworldwide

The aggregate means for all respondents suggest that six of the11 problems are viewed as moderately serious to very serious in mostregions of the world Understaffing is rated as the most serious concernglobally and is viewed as a very serious to extremely serious concern bynursesrsquo organizations in North America In Central and South Americaand in Africa understaffing is seen as a very serious problem This issueis less of a concern to nurses in Asia Europe and Oceania but it is stillseen as a moderately serious problem

7 Only three responses were received from Oceania

34 International Labour ReviewF

igur

e 1

G

eog

rap

hic

dis

trib

utio

n o

f nur

sesrsquo

org

aniz

atio

ns in

sam

ple

Cou

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s w

ith a

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st o

ne r

espo

nden

t org

aniz

atio

n

Not

es A

frica

18

Asi

a 16

Cen

tral A

mer

ica

14 E

urop

e 31

Nor

th A

mer

ica

14 O

cean

ia 3

Sou

th A

mer

ica

9

Challenges facing nursesrsquo associations and unions 35Ta

ble

1

Mea

n as

sess

men

t o

f pro

ble

ms

faci

ng n

urse

s in

the

wor

kpla

ce

Pro

blem

Afri

ca(n

=18)

Asi

a(n

=16)

Cen

tral

A

mer

ica

(n=

14)

Euro

pe(n

=31

)N

orth

A

mer

ica

(n=1

4)

Oce

ania

(n=

3)S

outh

A

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(n=

9)

Ove

rall

(n=1

05)

All

asso

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=56

)

All

unio

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nder

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ng

27

(sd

=8

9)2

3(s

d=

87)

29

(sd

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97)

35

(sd

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d=

58)

28

(sd

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7(s

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92)

26

(sd

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y an

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alth

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8(s

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20

(sd

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21

(sd

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7(s

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23

(sd

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15)

22

(sd

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3(s

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83)

23

(sd

=8

9)2

4(s

d=

71)

3M

anda

tory

ove

rtim

e2

2(s

d=

108

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9(s

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106

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2(s

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8(s

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81)

33

(sd

=9

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0(s

d=

10)

20

(sd

=8

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1(s

d=

16)

22

(sd

=1

1)2

1(s

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11)

4P

rivat

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17

(sd

=8

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8(s

d=

103

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8(s

d=

113

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6(s

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70)

28

(sd

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3(s

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115

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3(s

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95)

21

(sd

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20

(sd

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2(s

d=

11)

5Fl

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g2

3(s

d=

69)

16

(sd

=9

3)1

9(s

d=

83)

16

(sd

=8

2)2

9(s

d=

79)

15

(sd

=7

1)2

5(s

d=

101

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1(s

d=

93)

21

(sd

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0(s

d=

91)

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ssig

nmen

t of n

ursi

ng a

ssis

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0(s

d=

117

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1(s

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70)

19

(sd

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6(s

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21

(sd

=9

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0(s

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00)

28

(sd

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20

(sd

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97)

18

(sd

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7B

ully

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21

(sd

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4(s

d=

72)

17

(sd

=4

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7(s

d=

78)

25

(sd

=8

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7(s

d=

58)

21

(sd

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9(s

d=

82)

18

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d=

85)

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mig

ratio

n of

nur

ses

22

(sd

=9

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4(s

d=

63)

22

(sd

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12

(sd

=5

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1(s

d=

10)

23

(sd

=1

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17

(sd

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16

(sd

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95)

9P

art-

time

nurs

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5(s

d=

78)

12

(sd

=4

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00)

12

(sd

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1(s

d=

12)

10

(sd

=0

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5(s

d=

130

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5(s

d=

82)

12

(sd

=5

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7(s

d=

92)

10

Age

ncy

nurs

es1

8(s

d=

93)

17

(sd

=9

8)1

5(s

d=

67)

16

(sd

=7

7)2

5(s

d=

82)

20

(sd

=1

0)2

1(s

d=

193

)1

8(s

d=

91)

14

(sd

=7

2)2

2(s

d=

94)

11

Rep

lace

men

t nur

ses

13

(sd

=5

2)1

7(s

d=

95)

13

(sd

=6

7)1

3(s

d=

72)

13

(sd

=4

9)1

0(s

d=

00)

10

(sd

=0

0)1

3(s

d=

68)

14

(sd

=6

6)1

3(s

d=

96)

40

= E

xtre

mel

y se

rious

3

0 =

Very

ser

ious

2

0 =

Mod

erat

ely

serio

us

10

= N

ot s

erio

us


Fig

ure

2

Ass

essm

ent

of p

rob

lem

s fa

cing

nur

ses

in t

he w

ork

pla

ce (a

ll re

spon

den

ts)

0123

Sca

le 1

= N

ot s

erio

us

2 =

Mod

erat

ely

serio

us

3 =

Very

ser

ious

Seriousness of problem (mean)

Under

staffin

g Safety

and he

alth

issue

s Man

dato

ry ove

rtime

Privati

zatio

n

Float

ing

Assign

men

t of

nursi

ng as

sistan

ts

Bullyin

g

Agenc

y nur

ses

Emigr

ation

of

nurse

sPar

t-tim

e nur

ses Rep

lacem

ent n

urse

s


The survey data also suggest that safety and health problems areseen as serious in all geographic regions These issues are seen as mostproblematic in Africa and North America and less problematic in Asiaand Europe

Overall mandatory overtime and privatization are perceived bynursesrsquo organizations around the world to be moderately serious prob-lems North American nurses view mandatory overtime as a particu-larly serious problem while South American nurses are more con-cerned with privatization than are nurses in other parts of the world Aswith the issues discussed earlier nurses in Asia and Europe expressedthe least concern with these issues

Floating ndash ie the short-term transfer of nurses to parts of a healthcare facility with which they are unfamiliar (eg from obstetrics to theemergency room) ndash and the assignment of nursing assistants are alsoseen as serious problems across the world ldquoBullyingrdquo or workplace vio-lence while generally not deemed to be as problematic as other issuesis a serious concern in North and South America and in Africa

Because nursing skills are transferable from one national healthcare system to another nurses are increasingly leaving their homecountries for better paid jobs abroad The survey results indicate thatnurses in Africa Central America and Oceania ndash regions with manydeveloping countries ndash see emigration as a serious problem There alsoappear to be significant differences as to the seriousness of this problemwithin regions While not seen as a problem in most western Europeancountries emigration is viewed as more problematic in eastern EuropeIn North America Canadian nursesrsquo organizations are much more con-cerned about this issue than are organizations in the United States(Adcox 2002)

While a concern of some nursesrsquo associations and unions the useof part-time agency and replacement nurses (nurses employed asreplacements during strikes) is not seen to be as serious a problem bythe nursesrsquo associations and unions participating in this survey as theother issues outlined above

Because of the broad range of occupational health and safetyproblems experienced by nurses a more detailed analysis of this ques-tion was conducted Nursesrsquo associations and unions were asked to in-dicate which of ten occupational safety and health issues they con-sidered significant problems in the health care facilities in which theirmembers worked As the overall results in table 2 suggest stress isclearly seen as the most serious safety and health problem facingnurses around the world Nursesrsquo associations and unions on everycontinent identified this issue as the leading safety and health problemexperienced by their members The next four issues by order of im-portance were back and musculoskeletal problems needlestick in-juries excessive overtime and workplace violence


Table 2 also provides an assessment of safety and health problemsbroken down by continent The data indicate that nursesrsquo organizationsin some parts of the world perceive more occupational safety andhealth issues to be problematic than do their counterparts in otherregions A high percentage of nursesrsquo organizations in Africa and NorthAmerica see all ten of the issues as significant problems while those inAsia and Oceania see far fewer of these issues as serious concerns Stillthe data suggest that nursesrsquo associations and unions in every part of theworld feel that their members confront numerous occupational safetyand health problems

The survey included one additional question regarding the work-place problems that nurses face Specifically this question askednursesrsquo associations and unions whether their country was currentlyfacing a shortage of nurses Ninety nursesrsquo organizations representing69 countries and every geographic region of the world reported short-ages in their countries This suggests that the shortage of nurses is aworldwide phenomenon

The emigration of nurses exacerbates this problem in some partsof the world Forty-four nursesrsquo associations and unions in 31 countriesreported that the outflow of nurses to other countries was a serious toextremely serious problem This concern appears to be particularlyacute in Oceania Africa Central America (including the Caribbean)and in central and eastern Europe Several Canadian nursesrsquo organiza-tions also indicated that emigration was a concern in their countryNursesrsquo associations and unions reporting the outflow of nurses to othercountries as a serious problem are listed in Appendix I

Table 2 Safety and health problems identied by nursesrsquo unionsassociations 2001(percentage of unionsassociations that identied issue as a signicantproblem in the facilities in which their members work)

Issues Africa(n=18)

Asia(n=16)

CentralAmerica(n=14)

Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)

1 Needlestick injuries 944 813 714 516 944 100 100 774

2 Stress 944 938 100 100 944 100 100 981

3 Backmusculoskeletal problems 778 625 929 903 778 333 778 83

4 Toxic substances 722 375 643 548 722 667 667 562

5 Workplace violencebullying 889 438 714 581 889 667 667 695

6 Latex allergies 778 313 643 516 778 667 444 41

7 Exposure to radiation 667 375 50 258 667 333 444 40

8 Travelling to work 889 375 571 129 889 0 556 419

9 Contagious diseases 944 375 714 516 944 333 556 59

10 Excessive overtime 889 50 786 613 889 667 556 714


PrioritiesIn an effort to gain insight into the priorities of nurses globally the

survey asked the respondent organizations to rank a series of issuesbased on their assessment of their nursemembersrsquo concerns The ana-lysis of these data suggests that economic (salaries and benefits) andpatient care issues are generally the top priorities of nurses followed byprofessional development voice in the workplace safety and healthpolitical action and prescriptive authority (see table 3) This rankingdoes vary to some degree by geographic region but the results weregenerally consistent across regions

It should be noted that the data on problems and priorities areaggregates of the responses of all 105 respondents And while we founda fair amount of consistency globally there were individual countrieswhose assessment of problems andor ranking of priorities differedfrom the prevailing pattern8 Still these results suggest that nursesaround the world face similar problems and have similar priorities

StrategiesA third objective of the survey was to gather information on the

strategies that nursesrsquo associations and unions are pursuing to addressthe problems they face To this end respondent organizations were askedwhether they had found effective strategies to deal with the problemsidentified in the earlier analysis

Table 4 shows the percentage of organizations that indicated theyhad found an effective strategy for dealing with a given problem Theseresponses are reported both for the overall sample and by region Asthe table indicates in most regions only a minority of associations andunions have found an effective strategy for dealing with most of the11 problems The only exception relates to safety and health concernsAt least 50 per cent of organizations in five of the seven geographicregions reported finding an effective strategy to deal with this type ofproblem European nursesrsquo organizations generally reported greatersuccess in overcoming the problems their members face than did organ-izations in other geographic regions

Appendix II lists the strategies most often cited by respondents asbeing effective in dealing with five of the most common problems nursesexperience globally These problems are understaffing safety andhealth mandatory overtime privatization and bullying Because of the

8 An analysis was run comparing western European countries with countries in central andeastern Europe While the results were generally consistent it is notable that western Europeancountries together ranked salaries and benefits as their highest priority and professional develop-ment fourth while central and eastern European countries ranked professional development first


different economic social and cultural contexts in which nursesrsquo organ-izations around the world operate strategies effective in one countrymay not be effective in another The strategies listed do however sug-gest a range of options that nursesrsquo associations and unions might con-sider in addressing the particular problems their members face

Table 3 Ranking of nursemember priorities by geographic region

Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)

All asso-ciations(n=56)

Allunions(n=49)

1 Salariesand benets 1 2 2 1 1 2 1 1 2 1

2 Patient careissues 2 1 1 2 2 2 2 2 1 2

3 Professionaldevelopment 5 3 3 4 5 1 3 3 3 5

4 Voice in theworkplace 3 4 6 3 3 5 5 4 4 3

5 Safetyand health 4 4 4 5 4 6 4 5 5 4

6 Political action 6 7 5 6 6 4 5 6 6 5

7 Prescriptiveauthority 7 6 6 7 7 7 6 7 7 7

Table 4 Strategies for addressing problems facing nurses in the workplace(in percentage)

Effective strategy found to deal with

Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)

1 Understafng 19 40 14 56 39 33 44 38 28 49

2 Assignmentof nursingassistants 36 57 20 54 27 33 43 33 32 37

3 Safety andhealth issues 63 43 50 61 42 50 56 54 49 59

4 Bullying 36 38 20 45 39 50 13 35 27 42

5 Mandatoryovertime 25 40 20 50 36 50 20 36 32 40

6 Floating 25 22 0 33 25 0 50 27 21 31

7 Agency nurses 0 13 20 1 25 50 25 26 17 33

8 Part-timenurses 33 13 0 27 20 100 33 17 8 21

9 Replacementnurses 28 25 0 33 100 0 0 29 36 25

10 Emigrationof nurses 0 17 43 0 14 50 33 15 26 8

11 Privatization 25 25 0 46 18 50 33 26 16 37


Most of the specific strategies with which nursesrsquo organizations arehaving success fall into three broad categories ndash collective bargainingpolitical and legislative advocacy and community organizingoutreachNursesrsquo unions and associations may depend on one of these approachesto deal with a problem or they may use multiple approaches

In the case of understaffing for example many nursesrsquo organiza-tions argue that in order to address this problem it is necessary to stemthe tide of nurses leaving the profession attract former nurses back intothe workforce and encourage more young people to make nursingtheir career The New Zealand Nurses Organisation (NZNO) has takenthe position that increasing salaries and creating ldquoa work environmentthat promotes job satisfactionrdquo are the best ways to reduce turnoverand recruit new nurses (NZNO 2002) They have used the collectivebargaining process as a means of attaining those goals The Irish NursesOrganisation (INO) has pursued similar goals through bargaininggoing as far as to threaten industrial action when hospital managershave failed to address chronic understaffing (INO 2002)

Another approach that nursesrsquo organizations are taking to addressthe problem of understaffing is political and legislative action One ofthe goals of these efforts is to establish minimum nursepatient ratios bylaw Associations and unions in the United States have devoted a greatdeal of effort to this approach in recent years In 1999 the CaliforniaNurses Association (CNA) was instrumental in the passage of the first-ever staffing ratio legislation in the United States (DeMoro 2001)Although the law has run into some difficulties at the implementationstage other American nursesrsquo organizations have stepped up theirefforts to win such protection in other states

The use of public pressure and community support is a third ap-proach nursesrsquo associations and unions have taken to deal with theproblem of understaffing For example in 2001 the Canadian Fed-eration of Nurses Unions (CFNU) undertook an extensive media cam-paign to inform the public about the nationwide nursing shortage andthe consequent understaffing of health care facilities (CFNU 2002)

In an extension of this campaign the British Columbia affiliate ofthe CFNU held a public demonstration in 2002 in which it presentedBritish Columbia Premier Gordon Campbell with the ldquoHealth CareDemolition Awardrdquo in recognition of his governmentrsquos funding cut-backs and the resulting understaffing in the provincersquos hospitals(BCNU 2002) These efforts have helped the CFNU garner significantpublic support which in turn has helped it to influence governmentpolicy and to bargain collectively over provisions for staffing

As in Canada many nursesrsquo associations and unions have used allthree of the approaches outlined above in campaigns to addressthe problem of understaffing as well as the other major problemstheir members face In fact the responses received in the World Survey


suggest that those organizations that are having the most success inaddressing these problems have employed multiple strategies Thecoordinated use of these approaches seems to magnify the impact eachwould have if used individually

However it is important to reiterate that the majority of the105 nursesrsquo associations and unions that responded to this survey indi-cated they had not found successful strategies to deal with ten of the11 major issues facing their members This suggests that most organiza-tions are still looking for effective approaches In this process theyshould first look to those of their counterparts that have developed suc-cessful strategies and attempt to adapt those approaches to their owncircumstances Clearly learning from the experiences of other similarnursesrsquo organizations is a more efficient and less costly approach thantrial and error

Differences across nursesrsquo associations and nursesrsquo unionsIn many countries nursesrsquo associations and unions see themselves

as distinct from one another In order to examine the differencesbetween the two types of organization respondents were asked to iden-tify themselves either as an association or as a union Separate analysesregarding workplace problems priorities and strategies were con-ducted for each of the two categories The results of the analyses werethen compared

As shown in the last two columns of tables 1 and 4 this comparisonfound little difference in the identification of problems nurses face inthe workplace or in the strategies they employ to address their prob-lems or pursue their priorities This does not necessarily mean that sub-stantial differences may not exist between some associations and someunions particularly between those operating in the same country How-ever the results do suggest that on a global scale the differencesbetween the types of organization are minimal

There was a somewhat more substantial difference between asso-ciations and unions in their assessments of member priorities (seetable 3) Associations reported that their membersrsquo first priority waspatient care issues while unions reported salaries and benefits to betheir membersrsquo top concern Professional development was ranked as ahigher priority by associations than it was by unions while voice in theworkplace and safety and health were ranked as higher priorities byunions than by associations

Concluding remarksThe foregoing analysis suggests that despite differences in econ-

omics politics culture and health care systems across countries nurses


around the world face very similar problems and hold very similar pri-orities Understaffing safety and health mandatory overtime privat-ization floating and the assignment of nursing assistants are seen asserious problems by the overall sample Bullying nurse emigration andthe use of part-time agency and replacement nurses were not seen asseriously problematic by the entire sample though they were con-sidered serious problems in certain regions of the world

Nursesrsquo associations and unions in North and South America ratedthe issues facing their members as being more problematic than didorganizations in other parts of the world Conversely nursesrsquo organiza-tions in Europe and Asia assessed these issues as less problematic thandid their counterparts elsewhere

In discussions with the leaders of several nursesrsquo associations andunions a number of explanations were offered for these findings InNorth America the most consistent explanation was that the imple-mentation of ldquomanaged carerdquo ndash and its business-like approach to healthcare in the United States ndash is responsible for the perception that nursesin that region face very serious problems in the workplace

At the other end of the spectrum the leaders of nursesrsquo organiza-tions speculated that European associations and unions perceived theissues they were questioned about as less serious because those organ-izations are among the worldrsquos oldest and most effective As a resultthey have had greater success in addressing issues of concern to nurses

Organizational leaders offered a different explanation for theview among Asian associations and unions that the issues they face areless problematic Both Asian and non-Asian leaders speculated thatthis finding was partly related to the regionrsquos culture They suggestedthat Asian nurses were generally reluctant to be critical of their healthcare system and their employer and therefore tended to be less nega-tive when assessing the state of their workplace

The analysis also indicates that nursesrsquo associations and unions insome regions have been more successful at finding effective strategiesto deal with the problems of their members than were organizations inother regions Nursesrsquo organizations in Europe and Oceania generallyreported the greatest success in dealing with their membersrsquo workplaceproblems while African and Central American organizations reportedthe least success

The leaders of nursesrsquo organizations again point to the fact that theEuropean nursesrsquo associations and unions are among the oldest and mosteffective in the world It therefore makes sense that they should generallybe the most successful in finding effective strategies to deal with the prob-lems facing nurses The same explanation was offered for the reportedsuccess of nursesrsquo organizations in Oceania Nursesrsquo associations andunions in Australia and New Zealand are also among the most long-standing in the world and are perceived to be particularly effective


By contrast African and Central American nursesrsquo organizationsare among the most recently established in the world Most of the coun-tries in these two regions are developing countries without theresources to address the problems with which their nurses must con-tend Nurse leaders suggest this issue lies at the heart of the inability oforganizations in these regions to make more progress

In sum it must be reiterated that a majority of nursesrsquo organ-izations are still searching for effective responses to the workplace prob-lems nurses face Finding effective strategies presents a substantial chal-lenge to nurse leaders Such efforts however can be aided by awarenessof the successes and failures of similar organizations in other parts of theworld These lessons may have to be adapted to fit the circumstances dif-ferent nursesrsquo associations and unions face but the time effort andresources that can be saved through this approach are substantial

Unfortunately the opportunities for the leaders of nursesrsquo associ-ations and unions to learn from one another are limited The mosteffective forum for communication between nursesrsquo organizations is theICN The ICN has 124 members and through meetings conferencesand publications it facilitates communications between nursesrsquo organi-zations around the world Unfortunately the ICN Constitution limitsits membership to one nursesrsquo association per country (ICN 1999) Thismeans that nursesrsquo organizations that identify themselves as unions orare not the designated association in a country with more than one asso-ciation are unable to participate in this world body Our research foundat least 174 nursesrsquo organizations that fall into this category

This situation suggests a need for an organization that would bringtogether all of the 300 or more associations and unions that representnurses worldwide This body could take the form of an expanded ICNalternatively it could be an entirely new body similar to the EducationInternational a world body that brings together 311 teachersrsquo associa-tions and unions (Education International 2002)

In any event nurses and the organizations that represent themare confronted with a multitude of problems as they endeavour to carefor patients at the beginning of the twenty-first century The challengesthey confront are significant and complex And they appear to be com-mon to nurses around the globe For this reason nursesrsquo organizationsneed at a minimum to learn from one another They also may need toconsider confronting those problems on a global basis

ReferencesAdcox Seanna 2002 Hospitals try to ll shortage with Canadian nurses Associated Press

July 10AFT (American Federation of Teachers) 2001 The nurse shortage Perspectives from current

direct care nurses and former direct care nurses Washington DC AFT


ANA (American Nurses Association) 2002 In the beginning httpwwwnursingworld orgcentenncentbegnhtm [visited 7 Mar 2003]

BCNU (British Columbia Nurses Union) 2002 Nurses present second-ever ldquoHealth CareDemolition Awardrdquo to BC Premier Gordon Campbell BCNU Press Release 12 June2002 Vancouver BCNU

CFNU (Canadian Federation of Nurses Unions) 2002 A national voice for nurses A voicewith power httpwwwnursesunionscaaboutindexshtml [visited 7 Mar 2003]

Clark Paul F Clark Darlene A Day David V Shea Dennis G 2001 ldquoHealthcare reformand the workplace experience of nurses Implications for patient care and unionorganizingrdquo in Industrial and Labor Relations Review (Ithaca NY) Vol 55 No 1(Oct) pp 133-148

DeMoro Rose Ann 2001 ldquoNursing shortage A demand for actionrdquo in San FranciscoChronicle (San Francisco CA) 16 Aug p A-25

Education International 2002 EI member organizations httpwwwei-ieorgmainenglishindexhtml [visited 7 Mar 2003]

ICN (International Council of Nurses) 2002 National nursing associations in membershipwith ICN httpwwwicnchaddresslisthtm [visited 7 Mar 2003]

mdash2001 Outstanding African nurse Sheila Tlou delivers Virginia Henderson Lecture at ICNConference ICN Press Release 12 June Geneva ICN

mdash1999 ICN Constitution httpwwwicnchconst_membershiphtm [visited 7 Mar 2003]INO 2002 INO to ballot members for industrial action in Castlecomer District Hospital INO

Press Release May 2002 Dublin INONZNO 2002 NZNO Election Manifesto 2002 httpwwwnznoorgnz electionwageshtml

[visited 7 Mar 2003]Quinn Sheila 1989 ICN Past and present Middlesex Scutari PressRCPSC (Royal College of Physicians and Surgeons of Canada) 2001 ldquoEthical implications

of international recruitmentrdquo in Annals of the Royal College of Physicians and Sur-geons of Canada (Ottawa) Vol 34 No 4 (June) [also available online at httpwwwrcpscmedicalorgenglishannalsvol34-4eindexphp3]

WHO (World Health Organization) 2002a African AIDS vaccine programme needs US$223million WHO Press Release 30 May Geneva WHO

mdash2002b Tuberculosis on the increase in Europe Press Release Regional Ofce for Europe6 June Copenhagen WHO

mdash2002c Epidemics httpwwwrbmwhointnewdesign2epidemicsepidemicshtm [visited7 Mar 2003]

mdash2002d Statement on healthy ageing httpwwwwhointhprarchivedocsjakartastatementsageinghtml [visited 7 Mar 2003]

mdash2002e WHO consultation on imbalances in the health workforce httpwwwwhointhealth-services-delivery imbalances [visited 7 Mar 2003]

Appendix I

Nursesrsquo associations and unions reporting the outflow of nursesas a serious to extremely serious problem

Extremely serious

Canadian Nurses AssociationHealth and Other Service Personnel Trade Union of South AfricaPublic Services Association of Trinidad amp Tobago


Sierra Leone Health Services Workers UnionSt Vincent and the Grenadines Nurses Association

Very serious

Alliance of Filipino WorkersAsociacioacuten Nacional de Enfermeras de PanamaAsociacioacuten Nacional de Enfermeras de ColombiaBarbados Registered Nurses AssociationBermuda Public Services AssociationBritish Columbia Nurses UnionBulgarian Nursesrsquo AssociationColegio de Enfermeras de Costa RicaColegio de Enfermeras del UruguayDemocratic Nursing Organization of South AfricaManitoba Nursesrsquo UnionNew Brunswick Nurses UnionNew Zealand Nurses OrganizationNurses Association of MoldovaSamoa Nurses AssociationSyndicat unique de la santeacute et de lrsquoaction sociale Association nationale des infirmiegraveres

du NigerTrinidad and Tobago Registered Nurses AssociationZambia Nurses Association

Serious

East Central and Southern Africa College of NursingEthiopian Nurses AssociationFeacutedeacuteration nationale des travailleurs des services sociaux et de santeacute et Union nationale

des infirmiegraveres de CentrafriqueGovernment Workers Association (Zimbabwe)Lithuanian Trade Union of Health Care EmployeesMalayan Nurses UnionNational Union of Public and General Employees (Canada)National Union of Public Workers (Barbados)Nova Scotia Nurses UnionNurses Association of BotswanaNurses Association of JamaicaNurses Association of the Commonwealth of the BahamasPhilippine Nurses AssociationSaskatchewan Union of NursesSingapore Manual and Mercantile Workersrsquo UnionSouth African Municipal Workers UnionSwaziland Nurses AssociationTrade Union for the Municipal Sector ndash KTV (Finland)Trade Union of Health and Social Care Employees of LatviaUganda National Association for Nurses and Midwives


Appendix II

Effective strategies for addressing common problems

Understaffing

ndash establish minimum nursepatient ratios by contract or legislationndash increase salaries and benefitsndash establish on-site childcarendash pay significant shift differentials to attract nurses to less popular shiftsndash improve professional image and respect for nurses through advertising cam-

paigns and television and newspaper featuresndash provide part-time nurses with benefitsndash use above to attract former nurses back to the professionndash use demonstrations picketing and strikes to publicize understaffing and the

danger it presents to patients

Safety and health

ndash seminars continuing education expert advice and training and preventive actionndash strong contract language on safety and health issuesndash provision of appropriate technical equipment in workplacendash legislative guarantees of safe work environmentndash health and safety committees for both labour and managementndash contractual or legislative ban on mandatory overtimendash public campaigns action days demonstrations etc

Mandatory overtime

ndash contractual ban on mandatory overtimendash contractual provision for greatly increased overtime payndash lobbying for government restrictionsndash campaigning for 32-36-hour work weekndash use of ldquoassignment despite objectionrdquo formsndash contractual provision for right to refuse except in bona fide emergency

Privatization

ndash increase public awareness and activismndash solidarity by nurse unionndash negotiation and strikesndash education and legislationndash non-strike actiondemonstrations and hunger protestsndash lobby with state and county officials and mobilize the publicndash work with other unionsagencies to lobby governments

Bullyingworkplace violence

ndash contractual provision that ldquoemployer must provide safe work environmentrdquondash increased security at workplacendash regular training programmes on how to deal with violencendash meetings with employers to increase awarenessndash report and charge violent individualsndash work with community activists to inform the public and develop solutions


of organizations that participated in the project the third section ana-lyses the data collected by the survey in order to identify not only theproblems facing nurses but also the priorities and strategies of theirorganizations in dealing with those problems A final section offerssome concluding comments

The crisis in health careHealth care systems around the world are in crisis On all conti-

nents in developed and developing countries alike health care systemsare unable to meet the medical needs of the people who depend uponthem This crisis is caused by a number of factors

Many health care systems are experiencing shortages of trainedmedical personnel Both developed and developing countries appear tobe facing a serious shortage of nurses (and physicians) Developedcountries however are in a better position to attract health care pro-fessionals from abroad thereby exacerbating the shortage in less devel-oped countries (RCPSC 2001)

Epidemics are also contributing to the crises some health care sys-tems are experiencing In 2002 for example AIDS was the leadingcause of death in Africa and the fourth leading cause of death world-wide (WHO 2002a) In recent years there has been a significantincrease in the incidence of tuberculosis in eastern and central Europeas well as in developing countries around the world (WHO 2002b) andmalaria is on the rise worldwide having caused some 60000 deaths inrecent years (WHO 2002c) Such epidemics place significant stress onhealth care systems particularly in less affluent countries

Environmental problems (air pollution water contaminationetc) natural disasters and the consequences of war (civilian casualtiesrefugees etc) continue to burden health care systems around theworld And changing demographics particularly an increase in the eld-erly population have also placed greater demands on health care sys-tems (WHO 2002d)

Finally health care reforms introduced around the world includ-ing privatization and the introduction of market-based approaches tohealth care have brought new pressures to bear on health care systemsand health care workers (Clark et al 2001 WHO 2002e)

While the crisis in health care is a multifaceted phenomenon theroot of the problem can ultimately be traced to economics Developingnations do not have the resources to provide even basic care to their cit-izens In developed countries neither the public nor the private sectorcan keep up with the rapidly increasing cost of health care In short thedemand for health services exceeds the supply

When health care systems are stressed financially greater de-mands are inevitably placed on the individuals providing care particu-































igur

e 1

G

eog

rap

hic

dis

trib

utio

n o

f nur

sesrsquo

org

aniz

atio

ns in

sam

ple

Cou

ntrie

s w

ith a

t lea

st o

ne r

espo

nden

t org

aniz

atio

n

Not

es A

frica

18

Asi

a 16

Cen

tral A

mer

ica

14 E

urop

e 31

Nor

th A

mer

ica

14 O

cean

ia 3

Sou

th A

mer

ica

9


ble

1

Mea

n as

sess

men

t o

f pro

ble

ms

faci

ng n

urse

s in

the

wor

kpla

ce

Pro

blem

Afri

ca(n

=18)

Asi

a(n

=16)

Cen

tral

A

mer

ica

(n=

14)

Euro

pe(n

=31

)N

orth

A

mer

ica

(n=1

4)

Oce

ania

(n=

3)S

outh

A

mer

ica

(n=

9)

Ove

rall

(n=1

05)

All

asso

-ci

atio

ns(n

=56

)

All

unio

ns(n

=49

)

1U

nder

staf

ng

27

(sd

=8

9)2

3(s

d=

87)

29

(sd

=7

3)2

3(s

d=

97)

35

(sd

=6

5)2

3 (s

d=

58)

28

(sd

=8

3)2

7(s

d=

92)

26

(sd

=9

3)2

7(s

d=

91)

2S

afet

y an

d he

alth

issu

es2

8(s

d=

81)

20

(sd

=9

7)2

2(s

d=

73)

21

(sd

=7

3)2

7(s

d=

65)

23

(sd

=1

15)

22

(sd

=8

3)2

3(s

d=

83)

23

(sd

=8

9)2

4(s

d=

71)

3M

anda

tory

ove

rtim

e2

2(s

d=

108

)1

9(s

d=

106

)2

2(s

d=

117

)1

8(s

d=

81)

33

(sd

=9

7)2

0(s

d=

10)

20

(sd

=8

9)2

1(s

d=

16)

22

(sd

=1

1)2

1(s

d=

11)

4P

rivat

izat

ion

17

(sd

=8

5)1

8(s

d=

103

)2

8(s

d=

113

)1

6(s

d=

70)

28

(sd

=9

4)2

3(s

d=

115

)3

3(s

d=

95)

21

(sd

=1

06)

20

(sd

=1

0)2

2(s

d=

11)

5Fl

oatin

g2

3(s

d=

69)

16

(sd

=9

3)1

9(s

d=

83)

16

(sd

=8

2)2

9(s

d=

79)

15

(sd

=7

1)2

5(s

d=

101

)2

1(s

d=

93)

21

(sd

=9

7)2

0(s

d=

91)

6A

ssig

nmen

t of n

ursi

ng a

ssis

tant

s2

0(s

d=

117

)2

1(s

d=

70)

19

(sd

=9

0)1

6(s

d=

78)

21

(sd

=9

9)2

0(s

d=

00)

28

(sd

=1

09)

20

(sd

=9

6)2

1(s

d=

97)

18

(sd

=9

5)

7B

ully

ing

21

(sd

=7

0)1

4(s

d=

72)

17

(sd

=4

7)1

7(s

d=

78)

25

(sd

=8

7)1

7(s

d=

58)

21

(sd

=9

3)1

9(s

d=

82)

18

(sd

=7

7)2

0(s

d=

85)

8E

mig

ratio

n of

nur

ses

22

(sd

=9

5)1

4(s

d=

63)

22

(sd

=1

05)

12

(sd

=5

1)2

1(s

d=

10)

23

(sd

=1

15)

17

(sd

=8

2)1

7(s

d=

91)

16

(sd

=8

8)1

9(s

d=

95)

9P

art-

time

nurs

es1

5(s

d=

78)

12

(sd

=4

4)1

0(s

d=

00)

12

(sd

=4

3)2

1(s

d=

12)

10

(sd

=0

0)2

5(s

d=

130

)1

5(s

d=

82)

12

(sd

=5

9)1

7(s

d=

92)

10

Age

ncy

nurs

es1

8(s

d=

93)

17

(sd

=9

8)1

5(s

d=

67)

16

(sd

=7

7)2

5(s

d=

82)

20

(sd

=1

0)2

1(s

d=

193

)1

8(s

d=

91)

14

(sd

=7

2)2

2(s

d=

94)

11

Rep

lace

men

t nur

ses

13

(sd

=5

2)1

7(s

d=

95)

13

(sd

=6

7)1

3(s

d=

72)

13

(sd

=4

9)1

0(s

d=

00)

10

(sd

=0

0)1

3(s

d=

68)

14

(sd

=6

6)1

3(s

d=

96)

40

= E

xtre

mel

y se

rious

3

0 =

Very

ser

ious

2

0 =

Mod

erat

ely

serio

us

10

= N

ot s

erio

us


Fig

ure

2

Ass

essm

ent

of p

rob

lem

s fa

cing

nur

ses

in t

he w

ork

pla

ce (a

ll re

spon

den

ts)

0123

Sca

le 1

= N

ot s

erio

us

2 =

Mod

erat

ely

serio

us

3 =

Very

ser

ious


Under

staffin

g Safety

and he

alth

issue

s Man

dato

ry ove

rtime

Privati

zatio

n

Float

ing

Assign

men

t of

nursi

ng as

sistan

ts

Bullyin

g

Agenc

y nur

ses

Emigr

ation

of

nurse

sPar

t-tim

e nur

ses Rep

lacem

ent n

urse

s













Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


2 Stress 944 938 100 100 944 100 100 981




6 Latex allergies 778 313 643 516 778 667 444 41

















Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)










Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)

1 Understafng 19 40 14 56 39 33 44 38 28 49



4 Bullying 36 38 20 45 39 50 13 35 27 42


6 Floating 25 22 0 33 25 0 50 27 21 31

7 Agency nurses 0 13 20 1 25 50 25 26 17 33

8 Part-timenurses 33 13 0 27 20 100 33 17 8 21



11 Privatization 25 25 0 46 18 50 33 26 16 37




















































Appendix I


Extremely serious




Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization


































igur

e 1

G

eog

rap

hic

dis

trib

utio

n o

f nur

sesrsquo

org

aniz

atio

ns in

sam

ple

Cou

ntrie

s w

ith a

t lea

st o

ne r

espo

nden

t org

aniz

atio

n

Not

es A

frica

18

Asi

a 16

Cen

tral A

mer

ica

14 E

urop

e 31

Nor

th A

mer

ica

14 O

cean

ia 3

Sou

th A

mer

ica

9


ble

1

Mea

n as

sess

men

t o

f pro

ble

ms

faci

ng n

urse

s in

the

wor

kpla

ce

Pro

blem

Afri

ca(n

=18)

Asi

a(n

=16)

Cen

tral

A

mer

ica

(n=

14)

Euro

pe(n

=31

)N

orth

A

mer

ica

(n=1

4)

Oce

ania

(n=

3)S

outh

A

mer

ica

(n=

9)

Ove

rall

(n=1

05)

All

asso

-ci

atio

ns(n

=56

)

All

unio

ns(n

=49

)

1U

nder

staf

ng

27

(sd

=8

9)2

3(s

d=

87)

29

(sd

=7

3)2

3(s

d=

97)

35

(sd

=6

5)2

3 (s

d=

58)

28

(sd

=8

3)2

7(s

d=

92)

26

(sd

=9

3)2

7(s

d=

91)

2S

afet

y an

d he

alth

issu

es2

8(s

d=

81)

20

(sd

=9

7)2

2(s

d=

73)

21

(sd

=7

3)2

7(s

d=

65)

23

(sd

=1

15)

22

(sd

=8

3)2

3(s

d=

83)

23

(sd

=8

9)2

4(s

d=

71)

3M

anda

tory

ove

rtim

e2

2(s

d=

108

)1

9(s

d=

106

)2

2(s

d=

117

)1

8(s

d=

81)

33

(sd

=9

7)2

0(s

d=

10)

20

(sd

=8

9)2

1(s

d=

16)

22

(sd

=1

1)2

1(s

d=

11)

4P

rivat

izat

ion

17

(sd

=8

5)1

8(s

d=

103

)2

8(s

d=

113

)1

6(s

d=

70)

28

(sd

=9

4)2

3(s

d=

115

)3

3(s

d=

95)

21

(sd

=1

06)

20

(sd

=1

0)2

2(s

d=

11)

5Fl

oatin

g2

3(s

d=

69)

16

(sd

=9

3)1

9(s

d=

83)

16

(sd

=8

2)2

9(s

d=

79)

15

(sd

=7

1)2

5(s

d=

101

)2

1(s

d=

93)

21

(sd

=9

7)2

0(s

d=

91)

6A

ssig

nmen

t of n

ursi

ng a

ssis

tant

s2

0(s

d=

117

)2

1(s

d=

70)

19

(sd

=9

0)1

6(s

d=

78)

21

(sd

=9

9)2

0(s

d=

00)

28

(sd

=1

09)

20

(sd

=9

6)2

1(s

d=

97)

18

(sd

=9

5)

7B

ully

ing

21

(sd

=7

0)1

4(s

d=

72)

17

(sd

=4

7)1

7(s

d=

78)

25

(sd

=8

7)1

7(s

d=

58)

21

(sd

=9

3)1

9(s

d=

82)

18

(sd

=7

7)2

0(s

d=

85)

8E

mig

ratio

n of

nur

ses

22

(sd

=9

5)1

4(s

d=

63)

22

(sd

=1

05)

12

(sd

=5

1)2

1(s

d=

10)

23

(sd

=1

15)

17

(sd

=8

2)1

7(s

d=

91)

16

(sd

=8

8)1

9(s

d=

95)

9P

art-

time

nurs

es1

5(s

d=

78)

12

(sd

=4

4)1

0(s

d=

00)

12

(sd

=4

3)2

1(s

d=

12)

10

(sd

=0

0)2

5(s

d=

130

)1

5(s

d=

82)

12

(sd

=5

9)1

7(s

d=

92)

10

Age

ncy

nurs

es1

8(s

d=

93)

17

(sd

=9

8)1

5(s

d=

67)

16

(sd

=7

7)2

5(s

d=

82)

20

(sd

=1

0)2

1(s

d=

193

)1

8(s

d=

91)

14

(sd

=7

2)2

2(s

d=

94)

11

Rep

lace

men

t nur

ses

13

(sd

=5

2)1

7(s

d=

95)

13

(sd

=6

7)1

3(s

d=

72)

13

(sd

=4

9)1

0(s

d=

00)

10

(sd

=0

0)1

3(s

d=

68)

14

(sd

=6

6)1

3(s

d=

96)

40

= E

xtre

mel

y se

rious

3

0 =

Very

ser

ious

2

0 =

Mod

erat

ely

serio

us

10

= N

ot s

erio

us


Fig

ure

2

Ass

essm

ent

of p

rob

lem

s fa

cing

nur

ses

in t

he w

ork

pla

ce (a

ll re

spon

den

ts)

0123

Sca

le 1

= N

ot s

erio

us

2 =

Mod

erat

ely

serio

us

3 =

Very

ser

ious


Under

staffin

g Safety

and he

alth

issue

s Man

dato

ry ove

rtime

Privati

zatio

n

Float

ing

Assign

men

t of

nursi

ng as

sistan

ts

Bullyin

g

Agenc

y nur

ses

Emigr

ation

of

nurse

sPar

t-tim

e nur

ses Rep

lacem

ent n

urse

s













Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


2 Stress 944 938 100 100 944 100 100 981




6 Latex allergies 778 313 643 516 778 667 444 41

















Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)










Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)

1 Understafng 19 40 14 56 39 33 44 38 28 49



4 Bullying 36 38 20 45 39 50 13 35 27 42


6 Floating 25 22 0 33 25 0 50 27 21 31

7 Agency nurses 0 13 20 1 25 50 25 26 17 33

8 Part-timenurses 33 13 0 27 20 100 33 17 8 21



11 Privatization 25 25 0 46 18 50 33 26 16 37




















































Appendix I


Extremely serious




Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization





ble

1

Mea

n as

sess

men

t o

f pro

ble

ms

faci

ng n

urse

s in

the

wor

kpla

ce

Pro

blem

Afri

ca(n

=18)

Asi

a(n

=16)

Cen

tral

A

mer

ica

(n=

14)

Euro

pe(n

=31

)N

orth

A

mer

ica

(n=1

4)

Oce

ania

(n=

3)S

outh

A

mer

ica

(n=

9)

Ove

rall

(n=1

05)

All

asso

-ci

atio

ns(n

=56

)

All

unio

ns(n

=49

)

1U

nder

staf

ng

27

(sd

=8

9)2

3(s

d=

87)

29

(sd

=7

3)2

3(s

d=

97)

35

(sd

=6

5)2

3 (s

d=

58)

28

(sd

=8

3)2

7(s

d=

92)

26

(sd

=9

3)2

7(s

d=

91)

2S

afet

y an

d he

alth

issu

es2

8(s

d=

81)

20

(sd

=9

7)2

2(s

d=

73)

21

(sd

=7

3)2

7(s

d=

65)

23

(sd

=1

15)

22

(sd

=8

3)2

3(s

d=

83)

23

(sd

=8

9)2

4(s

d=

71)

3M

anda

tory

ove

rtim

e2

2(s

d=

108

)1

9(s

d=

106

)2

2(s

d=

117

)1

8(s

d=

81)

33

(sd

=9

7)2

0(s

d=

10)

20

(sd

=8

9)2

1(s

d=

16)

22

(sd

=1

1)2

1(s

d=

11)

4P

rivat

izat

ion

17

(sd

=8

5)1

8(s

d=

103

)2

8(s

d=

113

)1

6(s

d=

70)

28

(sd

=9

4)2

3(s

d=

115

)3

3(s

d=

95)

21

(sd

=1

06)

20

(sd

=1

0)2

2(s

d=

11)

5Fl

oatin

g2

3(s

d=

69)

16

(sd

=9

3)1

9(s

d=

83)

16

(sd

=8

2)2

9(s

d=

79)

15

(sd

=7

1)2

5(s

d=

101

)2

1(s

d=

93)

21

(sd

=9

7)2

0(s

d=

91)

6A

ssig

nmen

t of n

ursi

ng a

ssis

tant

s2

0(s

d=

117

)2

1(s

d=

70)

19

(sd

=9

0)1

6(s

d=

78)

21

(sd

=9

9)2

0(s

d=

00)

28

(sd

=1

09)

20

(sd

=9

6)2

1(s

d=

97)

18

(sd

=9

5)

7B

ully

ing

21

(sd

=7

0)1

4(s

d=

72)

17

(sd

=4

7)1

7(s

d=

78)

25

(sd

=8

7)1

7(s

d=

58)

21

(sd

=9

3)1

9(s

d=

82)

18

(sd

=7

7)2

0(s

d=

85)

8E

mig

ratio

n of

nur

ses

22

(sd

=9

5)1

4(s

d=

63)

22

(sd

=1

05)

12

(sd

=5

1)2

1(s

d=

10)

23

(sd

=1

15)

17

(sd

=8

2)1

7(s

d=

91)

16

(sd

=8

8)1

9(s

d=

95)

9P

art-

time

nurs

es1

5(s

d=

78)

12

(sd

=4

4)1

0(s

d=

00)

12

(sd

=4

3)2

1(s

d=

12)

10

(sd

=0

0)2

5(s

d=

130

)1

5(s

d=

82)

12

(sd

=5

9)1

7(s

d=

92)

10

Age

ncy

nurs

es1

8(s

d=

93)

17

(sd

=9

8)1

5(s

d=

67)

16

(sd

=7

7)2

5(s

d=

82)

20

(sd

=1

0)2

1(s

d=

193

)1

8(s

d=

91)

14

(sd

=7

2)2

2(s

d=

94)

11

Rep

lace

men

t nur

ses

13

(sd

=5

2)1

7(s

d=

95)

13

(sd

=6

7)1

3(s

d=

72)

13

(sd

=4

9)1

0(s

d=

00)

10

(sd

=0

0)1

3(s

d=

68)

14

(sd

=6

6)1

3(s

d=

96)

40

= E

xtre

mel

y se

rious

3

0 =

Very

ser

ious

2

0 =

Mod

erat

ely

serio

us

10

= N

ot s

erio

us


Fig

ure

2

Ass

essm

ent

of p

rob

lem

s fa

cing

nur

ses

in t

he w

ork

pla

ce (a

ll re

spon

den

ts)

0123

Sca

le 1

= N

ot s

erio

us

2 =

Mod

erat

ely

serio

us

3 =

Very

ser

ious


Under

staffin

g Safety

and he

alth

issue

s Man

dato

ry ove

rtime

Privati

zatio

n

Float

ing

Assign

men

t of

nursi

ng as

sistan

ts

Bullyin

g

Agenc

y nur

ses

Emigr

ation

of

nurse

sPar

t-tim

e nur

ses Rep

lacem

ent n

urse

s













Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


2 Stress 944 938 100 100 944 100 100 981




6 Latex allergies 778 313 643 516 778 667 444 41

















Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)










Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)

1 Understafng 19 40 14 56 39 33 44 38 28 49



4 Bullying 36 38 20 45 39 50 13 35 27 42


6 Floating 25 22 0 33 25 0 50 27 21 31

7 Agency nurses 0 13 20 1 25 50 25 26 17 33

8 Part-timenurses 33 13 0 27 20 100 33 17 8 21



11 Privatization 25 25 0 46 18 50 33 26 16 37




















































Appendix I


Extremely serious




Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization





Fig

ure

2

Ass

essm

ent

of p

rob

lem

s fa

cing

nur

ses

in t

he w

ork

pla

ce (a

ll re

spon

den

ts)

0123

Sca

le 1

= N

ot s

erio

us

2 =

Mod

erat

ely

serio

us

3 =

Very

ser

ious


Under

staffin

g Safety

and he

alth

issue

s Man

dato

ry ove

rtime

Privati

zatio

n

Float

ing

Assign

men

t of

nursi

ng as

sistan

ts

Bullyin

g

Agenc

y nur

ses

Emigr

ation

of

nurse

sPar

t-tim

e nur

ses Rep

lacem

ent n

urse

s













Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


2 Stress 944 938 100 100 944 100 100 981




6 Latex allergies 778 313 643 516 778 667 444 41

















Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)










Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)

1 Understafng 19 40 14 56 39 33 44 38 28 49



4 Bullying 36 38 20 45 39 50 13 35 27 42


6 Floating 25 22 0 33 25 0 50 27 21 31

7 Agency nurses 0 13 20 1 25 50 25 26 17 33

8 Part-timenurses 33 13 0 27 20 100 33 17 8 21



11 Privatization 25 25 0 46 18 50 33 26 16 37




















































Appendix I


Extremely serious




Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization
















Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


2 Stress 944 938 100 100 944 100 100 981




6 Latex allergies 778 313 643 516 778 667 444 41

















Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)










Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)

1 Understafng 19 40 14 56 39 33 44 38 28 49



4 Bullying 36 38 20 45 39 50 13 35 27 42


6 Floating 25 22 0 33 25 0 50 27 21 31

7 Agency nurses 0 13 20 1 25 50 25 26 17 33

8 Part-timenurses 33 13 0 27 20 100 33 17 8 21



11 Privatization 25 25 0 46 18 50 33 26 16 37




















































Appendix I


Extremely serious




Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization
















Issues Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)










Africa(n=18)

Asia(n=16)


Europe(n=31)

NorthAmerica(n=14)

Oceania(n=3)

SouthAmerica(n=9)

Overall(n=105)


Allunions(n=49)

1 Understafng 19 40 14 56 39 33 44 38 28 49



4 Bullying 36 38 20 45 39 50 13 35 27 42


6 Floating 25 22 0 33 25 0 50 27 21 31

7 Agency nurses 0 13 20 1 25 50 25 26 17 33

8 Part-timenurses 33 13 0 27 20 100 33 17 8 21



11 Privatization 25 25 0 46 18 50 33 26 16 37




















































Appendix I


Extremely serious




Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization























































Appendix I


Extremely serious




Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization






Very serious



Serious




Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization





Appendix II


Understaffing




Safety and health


Mandatory overtime


Privatization




Challenges facing nurses' associations and unions: A ...

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Transcript of Challenges facing nurses' associations and unions: A ...