Understanding power and learning how to use it is critical if nurses' efforts to shape their practice and work environments are to be successful. As part of our efforts to develop a Fast-Track BSN-to-PhD nursing program, we met with nurse leaders from six organizations to explore what power means, how nurses acquire it, and how they demonstrate it in their practice. Through these discussions, we identified eight characteristics of powerful nursing practice that, together, form a framework that can guide nurses’ efforts to develop a powerful practice and shape the health care delivery settings and academic institutions in which they work. In this article we review recent studies of organizational power and share discussions which helped us better understand nursing power and the ways in which it is manifested. We also reflect on what power means for individual nurses and the profession and discuss how our insights influenced our Fast-Track program.
Key words: leadership, nursing power, nursing practice, power
Nursing power – what it is and how it is obtained and manifested – is an abstract concept for many nurses, even for those who hold substantial power and use it regularly. The confusion surrounding power is compounded by a profusion of sometimes conflicting definitions of power and by the negative connotations that power fosters for many nurses, including some nurse leaders (Maslin-Prothero, Ed, & Masterson, 2002; Sieloff, 2003). Increasingly, however, nurse leaders recognize that understanding and acknowledging power and learning to seek and wield it appropriately is critical if nurses’ efforts to shape their own practice and the broader health care environment are to be successful.
Our interest in understanding nursing power stems from our recent work to develop a Fast-Track BSN-to-PhD Nursing Program. Over the past few years, the University of Massachusetts Boston (UMB) School of Nursing and the nursing departments from the five hospitals affiliated with the Dana-Farber/Harvard Cancer Center (DFHCC) collaborated to develop a Fast-Track program that aims to increase the number of minority nurses on the School of Nursing’s faculty and in other nursing leadership roles in service, academia, and research. From the start, one of our primary objectives for the Fast-Track program was to help nurses develop and demonstrate characteristics that are associated with power and to help them attain positions of power within health care and academic systems. Although this is an objective for the entire Fast-Track program, it is particularly relevant to the program’s mentoring component in which PhD students are paired with nursing leaders from academic and health care organizations.
As we worked to develop the mentoring component, we debated how mentors would help students understand how to acquire and use power wisely. Through these deliberations we began to realize that our own understanding of nursing power was limited, and that to design a program that promotes the power of individual nurses we first needed to obtain a better appreciation for what nursing power means and how it is achieved and manifested by practicing nurses.
To explore the concept of nursing power, we reviewed the nursing literature and then conducted a series of discussions with practicing nurses and nurse leaders from the six institutions involved in developing the Fast-Track program. Through these conversations, we began to understand how nurses in clinical, administrative, and academic leadership positions view power and identified key characteristics of a powerful nursing practice. We also gained insights into how nurses use power to promote patient and family centered care, strong administrative leadership, excellence in teaching, and rigorous and innovative research. In this article we review recent studies of organizational power and share discussions which helped us better understand nursing power and the ways in which it is manifested. We also reflect on what power means for individual nurses and the profession and discuss how our insights influenced our Fast-Track program.
Literature Review Related to Organizational Power
Nursing power is a broad construct that has implications for health care policy, organizational structures, and nursing practice. Although operational definitions of power vary, they typically include the concepts of independence and being able to act independently (Salvadores, Schneider, & Zubero, 2001), and having control or influence over others (Zelek & Phillips, 2003). Underlying most discussions of nursing power is an appreciation for the interrelatedness of power and professionalism: having power allows nurses to guide nursing practice and function as professionals (Rutty, 1998); when power is absent or not utilized, others are more likely to step in and decide what nursing is and what nurses do.
...when power is absent or not utilized, others are more likely to step in and decide what nursing is and what nurses do.
The political power of nursing is of interest to numerous groups, including the many nursing organizations that advocate, at the state and federal level, for nursing and health care issues on their agendas. As part of their advocacy role, these organizations attempt to harness the collective power of nursing and involve nurses in speaking out on health care issues. To fully exercise their power, the organizations must overcome a number of potential barriers, including inter-organization power struggles; nurses’ lack of interest in legislative issues; and inadequate leadership, focus, or insight into what is necessary to build coalitions and reach consensus (Grindel, 2006).
Nursing power as it relates to the structure of nursing departments and health care organizations has been examined by a number of investigators. Sieloff (2003) observed that a nursing department’s power is based on several factors, including the department’s position within the organization, its ability to manage the effects of external environmental forces, the importance of its role to the work of the organization, and the resources it has available to attain its goals. A department’s power can also be affected by the chief nurse executive’s (CNE) competency related to power (Sieloff, 2003) and by fragmentation related to clinical specialization, role differences, or other factors that prevent nursing from speaking with a united voice (Glouberman, 2002; Maslin-Prothero et al., 2002).
The effect of organization and department structure on staff nurse empowerment has also been explored. One study involved public hospitals in Spain and assessed the impact of changing the hospitals’ organizational structure from a hierarchical, physician-centric model to a one in which management responsibility was shared by the Nursing, Medical, and General Services and Administration divisions. An assessment of staff perceptions of power conducted 10 years after the structural change revealed that all three divisions attributed the least amount of power to themselves, and the non-medical divisions felt the medical division retained the highest degree of real power and influence (Salvadores et al., 2001). Another study examined the effect of CNE role structure (line vs. staff) on staff nurse perceptions of empowerment. This study found that nurses’ perceptions of power did not differ significantly under the different CNE role structures, although nurses whose CNE was in a line role felt they had better access to resources, an important factor related to power. In both models, having the opportunity to learn and grow was viewed as the most empowering element, while formal power was the least empowering (Matthews, Laschinger, & Johnstone, 2006).
Nurses’ perceptions of empowerment were also explored in a recent qualitative study involving Iranian staff nurses and nurse leaders. Drawing on interview and observational data, the investigators identified themes or factors that the nurses associated with power. These included having professional knowledge and skills, authority, self-confidence, professional unity, and supportive management. A sixth theme, organizational structure and culture, was also viewed as an important factor that affected nurses’ power and their participation in clinical decisions (Hagbaghery, Salsali, & Ahmadi, 2004).
Our review of the literature helped us understand how nurses perceive power and helped us appreciate factors that influence how nurses attain and use power. We felt, however, that we would benefit from speaking directly to nurses in different roles and settings to learn how they view power and how power is manifested in their practice. Our discussions with nurse leaders from the organizations involved in the Fast-Track PhD program were organized with this in mind.
Discussion Sessions about Power with Nurse Leaders
Our discussions with nurse leaders were guided by two specific aims: (1) to determine the characteristics of professional nursing power that practicing nurses believe are important at the individual level; and (2) to define strategies to help nurses attain power within their practice. The discussions were founded on the belief that understanding characteristics of power held by individual nurses and finding ways to help nurses achieve power is important, since individual power translates into greater power for nursing departments and for nursing as a profession. In addition, understanding the characteristics of professional practice that are associated with power and developing ways to help novice and experienced nurses adopt these practices offers nurse leaders in health care institutions and academia a way to promote the career advancement of individual nurses, advance nursing as a profession, and ultimately improve patient and family centered care and patient outcomes.
Eleven nurse leaders participated in our discussion sessions. Together, the nurse leaders reflected the diversity of leadership roles within the nursing profession. The group included a clinical nurse specialist, nurse manager, vice president, program manager, nurse scientist, dean, chief retention officer, and a nurse faculty member. Through a series of questions, the nurse leaders were asked to think about power in the broadest sense and to speak about what power means to them and how it is manifested in their practice and organization.
Questions posed to each nurse leader included the following:
- How do you define power?
- Define the power dynamics in your organization and how they are different from those found in other organizations that you have practiced in.
- How do other disciplines and department members view nurses’ power in your organization?
- Are you a powerful nurse?
- Do you think nurses are perceived as powerful in your organization?
- What strategies have you seen nurses in your organization use to increase their power?
- Do you believe that practicing nurses in your organization view the nurse leaders in your organization as powerful?
Insights gained through the discussions about what is meant by nursing power and what characterizes a powerful professional nursing practice are summarized below.
Characteristics of Nursing Power
The nursing profession as a whole...establishes power through the practice of individual nurses who are engaged in patient care, administrative leadership, teaching, and research.
In responding to our opening question, "How do you define power?" the nurse leaders reflected on their own experiences and those of their nursing colleagues. They observed that the power of the nurse lies in his or her knowledge and expertise related to the technical, analytical, and interpersonal domains of nursing practice. This expertise, they observed, is uniquely interwoven into a collaborative, interdisciplinary effort focused solely on the patients and families that the nurse and care team serve and with whom they partner. The nursing profession as a whole, they said, establishes power through the practice of individual nurses who are engaged in patient care, administrative leadership, teaching, and research. The actions, behaviors, and comportment of each nurse contribute to or diminish the collective power that the profession of nursing holds in society, within a given organization, and in practice.
The nurse leaders’ observations regarding power underscored the power of individual nurses and highlighted how the practice of a single individual can impact patients and families, organizations, interdisciplinary colleagues, and the entire nursing profession.
Characteristics of a Powerful Professional Practice
Through our conversations with nurse leaders, we identified eight characteristics of powerful nursing practice – practice in which the nurse acts powerfully on behalf of patients and families and is recognized as powerful by others. The eight characteristics of powerful nursing practice are listed in the Table and are described in more detail below.
- Nurses with a powerful practice acknowledge their unique role in the provision of patient centered and family centered care.
The power of clinical nurses is significantly enhanced by the therapeutic, interpersonal relationships nurses establish with patients and families...
During our discussions, the nurse leaders observed that the nursing profession’s emphasis on partnering with and caring for patients and families distinguishes nurses from other health professionals and positions them to be extremely powerful. The power of clinical nurses is significantly enhanced by the therapeutic, interpersonal relationships nurses establish with patients and families and by a nurse’s expertise in relieving the burden of disease and helping patients and families cope with the continuum of health and illness. Nurses with a powerful practice, said the nurse leaders, recognize and readily acknowledge their unique contributions to patient care and realize that their relationships with patients and families put them in a position to influence the care delivery setting.
"What is good for patients and families is good for nursing practice," observed one nurse leader. This view, she explained, aligns nurses with the major priority of health care institutions and positions them to advocate from the perspective of patients and families – i.e., nurses listen to what patients and families need and then base their advocacy efforts on the needs that are expressed. While their ability to partner with patients and families puts nurses in a very powerful position, it also implies significant responsibility, since it demands that nurses continually validate their perceptions about what patients and families are telling them and communicate this information to other members of the care team.
- Nurses with a powerful practice commit to continuous learning through education, skill development, and evidence-based practice.
All of the nurse leaders identified knowledge and expertise as an essential element of the nurse’s power base and underscored the importance of continuous learning. Nurses who are powerful, they said, continuously seek new knowledge and base their practice on evidence. The educational level of nurses was also viewed as an essential element of a powerful professional practice. The nurse leaders agreed that attaining a BSN is essential, and that more education generally leads to greater power.
- Nurses with a powerful practice demonstrate professional comportment and recognize the critical nature of presence.
The nurse leaders noted that the professional comportment of nurses – their behaviors and how they carry themselves – is a key component of nursing power. Openness, transparency, authenticity, honesty, and integrity are some of the characteristics that the nurse leaders associated with powerful nurses.
...phrases, such as "I am only a nurse," or "She is just a nurse."...diminish individual nurses and the profession of nursing as a whole.
The nurse leaders also commented that the way nurses use language, particularly how they refer to themselves, can enhance or detract from their professional image. Nurses in powerful practices consistently acknowledge their own professional status and that of others by using first and last names during introductions, and by avoiding phrases, such as "I am only a nurse," or "She is just a nurse," that diminish individual nurses and the profession of nursing as a whole. The nurse, said the nurse leaders, brings a unique skill set, knowledge, and perspective to the care team, executive table, research team, or faculty – a contribution that nurses, themselves, must not doubt since self-confidence is linked to power. That said, nurses must work to sustain their credibility by maintaining competency and remaining current in their practice area and by remembering that they are professionals who work with others to meet the best interests of the patient and family.
- Nurses with a powerful practice value collaboration and partner effectively with colleagues in nursing and other disciplines.
Nurses with a powerful practice value collaboration and partner effectively with colleagues...
Many of the nurse leaders cited the ability to collaborate with nursing colleagues and those outside of nursing as a hallmark of effective nursing leadership and a characteristic of powerful nursing practice. They noted that collaborating does not mean acquiescing or giving in. Nor does it mean competing or engaging in divisive actions and behaviors. Rather, it involves authentic, transparent discussion, debate, and deliberation and striving to reach consensus-driven outcomes. A powerful professional, said the nurse leaders, works well with others, is fair, and has opinions and perspectives that are "sought out" by others. Leading and participating on teams and partnering with others is essential to sound, expert nursing practice and is a critical element of a nurse’s power base.
- Nurses with a powerful practice position themselves to influence decisions and resource allocation.
A number of the nurse leaders observed that powerful nurses typically position themselves to provide direction, input, and information about decisions affecting their practice, including decisions related to resource allocation. Such nurses recognize that decisions regarding staffing, technology to support practice, salaries, wages, and other factors that affect the practice environment should be in the hands of the nursing professionals who work in that environment; and if they are not, powerful nurses question whether it is because the organization does not value professional nursing practice.
- Nurses with a powerful practice strive to develop an impeccable character; to be inspirational, compassionate, and to have a credible, sought-after perspective.
A number of the nurse leaders observed that nurses with a powerful practice are grounded by a set of values and principles that they freely share with others and that guide their decisions and actions. The values and principles also help foster compassion, make the nurses less fearful and more open to others’ ideas, and help nurses stay the course during times that may be tumultuous for patients, families, and colleagues. Nurses who are open to others and who use a values-based approach also find that others often seek out their perspective; this not only brings the nurse more power, but is the antithesis of using power as a coercive strategy.
- Nurses with a powerful practice recognize that the role of the nurse leader is to pave the way for nurses’ voices to be heard and to help novice nurses develop into powerful professionals.
Many of the nurse leaders noted that helping novice nurses develop a voice that is based on professional credibility and expertise is a responsibility of nurse leaders at the unit, practice, program, and institutional levels. Powerful nurses, they said, recognize this and know that by fostering a nurse’s professional development they promote the power of the individual nurse, enhance their own power, and strengthen the power of nursing as a profession. Powerful nurses in leadership positions also avoid using phrases such as, "My nursing staff," or "My faculty." Although unintentional, phrases like these suggest that a nurse is subservient to others and can diminish the professional stature of the individual.
- Nurses with a powerful practice evaluate the power of nursing and the nursing department in organizations they enter by assessing the organization’s mission and values and its commitment to enhancing the power of diverse perspectives.
Many of the nurse leaders observed that nurses with a powerful practice tend to seek out and work in environments that support nurses and nursing practice, and that are led by strong nurse leaders who are themselves respected and valued by the institution. Such organizations place a high value on nurses and nursing care and, by design, uphold and contribute to the power of nurses that practice within them.
All of the nurse leaders agreed that institutions that value diversity and respect are more likely to value nursing and are stronger organizations as a result. They noted that in organizations where the power of nursing is diminished, nurse leaders and nursing staff must develop strategic plans that promote respect and diversity, and must work to elevate the nursing profession and nursing practice through leadership development, establishing a strong research base, and creating programs that foster the professional development of nurses at all levels.
During our discussions, the nurse leaders described their experiences in their current places of work and compared and contrasted these to their experience in general and in other organizations. While all but one nurse leader described their current nursing department and nurse leaders as powerful, perceptions of the power of nursing seemed to vary across organizations. For example, in the comprehensive cancer center where "the cure of cancer through research" was the dominant mission, nurses felt less powerful than in the academic medical center where "patient care" was the prominent mission and nurses’ role in the around-the-clock care of patients gave them greater power as a group and as individuals (this was particularly true for nurses who had established themselves as expert, compassionate professionals). Nurse leaders from the university/college setting noted that the power base of nurses in academic settings depends on the dean of the school of nursing and on the mission of the college/university. These two factors, they said, play a significant role in determining the nursing school’s esteem and credibility within the organization.
Many of the insights gained through our discussions with nurse leaders complement and expand on observations about nursing power that are discussed in the literature. Like Hagbaghery et al. (2004), we found that knowledge, self-confidence, and supportive management are important factors related to nursing power and to using power effectively. Our discussions also highlighted the link that others have noted between power and professionalism and underscored how the actions and behaviors of individual nurses affect the collective power of nursing as a profession.
Beyond this, the nurse leaders participating in our discussions emphasized the importance of the relationships that nurses have with patients and families, and described how these relationships are central to the power base of individual nurses and the profession. Nurses enhance their power and assure that the power of professional nursing practice is realized across all settings by focusing on patients and families and on improving patient and family centered outcomes; by sharing information and communicating effectively with colleagues; by using their knowledge of patients, families, and treatment plans to assure safe, high quality care; and by consistently demonstrating professionalism in their interactions with patients, families, and other members of the team. Nurses’ knowledge of the health care delivery system is also a source of power. When coupled with their clinical expertise and strong collaborative skills, this knowledge allows nurses to play an active role in making the care delivery more patient and family centered. A powerful nurse – one who is confident in her knowledge of what patients and families need and her ability to respond to those needs – is an invaluable asset to organizations who place a premium on high quality care and who strive to put patients and families at the center of what they do.
...the practice of a single individual can impact patients and families, organizations, interdisciplinary colleagues, and the entire nursing profession.
Nurses who recognize and use their power are more apt to achieve personal and professional goals and help the nursing profession meet its goals of serving society and advancing nursing practice, education, and research. Developing a power base requires time, but the process can be helped along by experienced colleagues who are willing to serve as role models and mentors. As we considered the insights we gleaned from our discussions with the nurse leaders, we realized that students in our Fast-Track BSN-to-PhD program would benefit from two mentors: one to mentor them through the research process, and another to offer guidance and mentoring in the areas of nursing practice and leadership. In addition, we realized that the characteristics of a powerful practice form a framework that will help our program’s mentors as they work with less experienced nurses to create a powerful practice and presence. We believe the framework will also be useful to any nurse who is interested in enhancing his or her own practice, advancing the nursing profession, or influencing the organizations that provide care and that train the nurses of tomorrow.
Finally, we encourage other groups to engage in discussions similar to those we conducted. By discussing power with leaders in your organization, you can help your nurse leaders clarify what power means to them and which of their behaviors enhance their power. Similarly, sharing these insights with practicing nurses and nursing students in your organization will help them appreciate the power of the individual nurse and of nursing as a profession, and will help them identify ways they can increase their power and use it within their practice.
Table. Properties of a Powerful Professional Nursing Practice
Nurses who have developed a powerful nursing practice...
Pat Reid Ponte, RN, DNSc, FAAN
Dr. Reid Ponte received a BS from the University of Massachusetts – Amherst and an MS and DNSc from Boston University. She is Senior Vice President, Patient Care Services and Chief Nurse, at the Dana-Farber Cancer Institute, and Director, Oncology Nursing and Clinical Services at Brigham and Women’s Hospital. Pat feels personal power is the basis of courageous leadership.
Greer Glazer, RN, CNP, PhD, FAAN
Dr. Glazer received a BSN from the University of Michigan and an MSN and PhD from Case Western Reserve University. She is Dean and Professor at the University of Massachusetts-Boston, College of Nursing and Health Sciences. Greer notes that power is a key to her success in her job as dean.
Ms. Dann received a BS in Nursing from the University of New Hampshire. She is Nursing Director of Oncology Services at the Maine Medical Center and a graduate student at Northeastern University. Emma finds it intriguing to explore how various nurses perceive and utilize power differently.
Ms. McCollum received a BA in Psychology from Northeastern University. She is an Administrative Specialist at the Dana-Farber Cancer Institute. Kathleen comments, "I am intrigued by the way nurses have looked for ways to increase the power of the profession as a whole." She is especially interested in the ways the power of nursing translates into power for patients and families.
Ms. Gross received a Master of Science – Nursing from Boston College; a BS in Nursing from St. Louis University; a BA in Psychology; and an Associate of Arts – Nursing from Maryville College. She is Vice President, Adult Ambulatory Services and Director, Adult Ambulatory Nursing at the Dana-Farber Cancer Institute and a PhD Student at the University of Massachusetts-Boston, College of Nursing and Health Sciences. Anne notes that as nurse leaders, we need power to influence the practice environment where our staff works to deliver care to patients and families, to influence the curriculum development and education of nurses in training and within the world of research to advocate for the funding for research put forth by nurse scientists.
Ms. Tyrrell received an MS in Psychiatric-Mental Health Nursing from Boston University and a BSN from Niagara University. She is a Professional Development Coordinator for Massachusetts General Hospital. Rosalie is interested in enhancing nursing power by "passing the torch" of accumulated wisdom, knowledge, and expertise from the baby boomers to the next generation of nurses, thus furthering and increasing nurses' cutting-edge, positive influence on patient/family care.
Ms. Branowicki received a BSN from Assumption College and an MS in Management from University of Massachusetts-Worcester. She is Vice President, Medicine Patient Services at Children’s Hospital-Boston and Director, Nursing and Patient Care Services, Pediatric Oncology at the Dana-Farber Cancer Institute. Patti feels that, without power, the unique perspective of nurse leaders relative to patient care will be lost and our ability to influence the practice environment at a local and national level will be minimized.
Ms. Noga received an Associate in Liberal Arts degree from Elmira College, a BSN from Skidmore College, and a Master of Business Administration from Suffolk University. She is Chief Retention Officer at Beth Israel Deaconess Medical Center and a PhD Student at University of Massachusetts-Boston, College of Nursing and Health Sciences. Patricia considers the components of knowledge, integrity, credibility, fairness, trust, and influence essential to building and sustaining effective power that makes a difference to those who receive care and those who provide, lead, and advance care in the health care industry.
Dr. Winfrey received a BS in Nursing from Hunter College/Bellevue School of Nursing; an MS in Medical/Surgical Nursing - Teaching Tract from Boston College; and a EdD in Higher Education Administration from George Peabody College for Teachers. She is Associate Dean at the University of Massachusetts-Boston, College of Nursing and Health Sciences. Marion notes that there are various types and levels of power that too often remain unutilized or underutilized by nurses, regardless of their organizational rank or title.
Dr. Cooley received a BSN from Thomas Jefferson University; an MSN, Oncology Nursing, and CRNP, Adult Nurse Practitioner, from University of Pennsylvania; and a PhD, Psychosocial Oncology, from University of Pennsylvania. She completed a Post-doctoral Fellowship in Psychosocial Oncology at University of Pennsylvania. She is a nurse scientist at the Dana-Farber Cancer Institute with a primary focus on the care of lung cancer patients and their families. Mary feels that one way for the profession to gain power is by conducting research that helps build a scientific basis for nursing practice and is committed to finding new ways to improve cancer nursing care throughout the illness continuum.
Ms. Saint-Eloi received a BS from Northeastern University and an MS from University of Massachusetts-Boston. She is Nursing Quality Program Manager at the Dana-Farber Cancer Institute. Suzelle believes that power translates into the knowledge and access to resources necessary for nurses to advance the profession and better advocate for patients.
Dr. Hayes received a BSN from Georgetown University, an MS from University of Illinois at Chicago, and a PhD from Boston College. She is Director, Oncology Nursing and Patient Care Services and Director, Center for Patients and Families at the Dana-Farber Cancer Institute, Brigham and Women’s Hospital. Carolyn notes her Masters Degree in Nursing Service Administration provided her first exposure to the idea of power as essential to creating environments conducive to the provision of excellent patient care and the advance of nursing science and practice through direct patient care or systems work.
Dr. Nicholas received a Bachelor of Science in Nursing from Fitchburg State College; a Master of Science in Nursing and a Doctor of Nursing Science from Boston University; a Certificate of Advanced Study in Adult Primary Care from the MGH Institute of Health Professions; and a Master of Public Health degree in International Health from Harvard School of Public Health. She is Director of Global Health and Academic Partnerships, Center for Nursing Excellence and Division of Social Medicine and Health Inequalities at Brigham and Women's Hospital. Patrice is interested in how nursing power translates into power for patients and families.
Ms. Washington received a BSN from Boston University; an MS from Boston College; and is a PhD candidate at Boston College. She is Director of Diversity at Massachusetts General Hospital. As an African American nurse, Deborah has a specific interest in the definition and use of power from a diversity perspective; specifically she hopes to better understand what facilitates or limits the actualization of power for these new, nontraditional voices.
Article published January 31, 2007
Hagbaghery, M.A., Salsali, M., & Ahmadi, F. (2004, June 24). A qualitative study of Iranian nurses’ understanding and experiences of professional power [Electronic version]. Human Resources for Health, 2(1), 9.
Matthews, S., Laschinger, H.K.S., & Johnstone, L. (2006) Staff nurse empowerment in line and staff organizational structures for chief nurse executives. Journal of Nursing Administration, 36, 526-533.
Salvadores, P., Schneider, J., & Zubero, I. (2001, September 4). Theoretical and perceived balance of power inside Spanish public hospitals [Electronic version]. BMC Health Services Research, 1(1), 9.