Abstract
BACKGROUND: Many low and middle income countries lack the human resources needed to deliver essential health interventions. A health care system with a limited number of nurses cannot function effectively. Although the recommended nurse to doctor ratio is 4:1, the ratio in Pakistan is reversed, with 2.7 doctors to one nurse. METHODS: A qualitative study using narrative analysis was undertaken in public and private tertiary care hospitals in Pakistan to examine and compare job satisfaction among nurses and understand the factors affecting their work climate. Interactive interviews were conducted with nurses working with inpatients and outpatients. RESULTS: All of the respondents had joined the profession by choice and were supported by their families in their decision to pursue their career, but now indicated that they were dissatisfied with their jobs. Three types of narratives were identified, namely, "Working in the spirit of serving humanity", "Working against all odds", and "Working in a functional system and facing pressures of increased accountability". Nurses working in a public sector hospital are represented in the first two narrative types, whereas the third represents those working in a private sector hospital. The first narrative represents nurses who were new in the profession and despite hard working conditions were performing their duties. The second narrative represents nurses working in the public sector with limited resources, and the third narrative is a representation of nurses who were working hard and stressed out despite a well functioning system. CONCLUSION: The study shows that the presence of a well trained health workforce is vital, and that certain aspects of its organization are key, including numbers (available quantity), skill mix (health team balance), distribution (urban/rural), and working conditions (compensation, nonfinancial incentives, and workplace safety). This study has identified the need to reform policies for retaining the nursing workforce. Simple measures requiring better management practices could substantially improve the working environment and hence retention of nurses.