Management in Health, Vol 15, No 2 (2011)

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Michael O'Rourke, MPH- Master of Public Health

Adjunct Senior Lecturer; Sydney School of Public Health; Faculty of Medicine, University of Sydney, Australia;


Nina Lukic, Pharmacist

Project Manager; GVG Health; Serbia;


Martin Jones, PhD

Visiting Professor of Mental Health Nursing

Surrey University, UK;


Nigel McCarley, PhD

Associate Lecturer; University of Ulster, UK;





Background: The role of nurses is underdeveloped in Serbia. This paper describes the situation of nurses in the Serbian health system; outlines activities to enhance nursing management; and identifies policies to strengthen the Serbian nursing profession.

Methods: Management training activities was undertaken to develop nursing knowledge and skills and to introduce international best practice in nursing management and governance. Data based on evaluations assessed effectiveness of the training and identified future education. priorities.

Results: Results indicate high levels of satisfaction with the management education and training approach, as well as the new ideas and concepts of management introduced. The training provided opportunities for enhancing the nurse management role in the everyday work setting and for articulating future education priorities for Serbian nurses.

Conclusion: Management education and training of this type provides a platform for further development of nurse managers and professionalization of nurses in Serbia. Other policies and strategies are needed to improve the management role and functions of Serbian nurses, including increased career opportunities; strengthened legal support; in-service training opportunities; and importantly, a single national professional organization to represent nurses' interests and to promote standards and competencies.


Keywords: Serbian nurse education, management training, professionalization, strengthening nurse role.






Since the conception of modern nursing as a discrete clinical profession in the 19th century to the present time, there has been a continuous strengthening of the nurse's role in most developed health systems. Nurses are widely accepted as partners in health, management, clinical governance and policymaking [1,2,3].


In many former socialist and Eastern European countries, however, the role of nurses is still underdeveloped. In the Republic of Serbia, nurses are the largest group of health workers but are still underrepresented in terms of influence, status and professional input.


This situation is currently being addressed. Initiatives are in place to strengthen the nurse management role in Serbia, with an emphasis on ongoing education. This paper describes the situation facing nurses in the Serbian health system; outlines current activities aimed at enhancing nursing management; and identifies additional steps and policies required to further strengthen the nursing profession in Serbia.

Serbian health care

Serbia, as in other parts of former Yugoslavia, inherited a centralized state health system financed by compulsory health insurance contributions. The system was intended to provide access to comprehensive health services for all the population.

Serbia has an extensive health network that (in principle) provides free health care for all citizens. There are 343 health institutions at different levels of care: 208 at primary, 76 at secondary, 27 at tertiary and 32 which cross more than one level of care. The health status of Serbia's population is comparable to other Central and Eastern European countries, but below that of Western Europe. Life expectancy at birth in Serbia is 71 years for males and 76 for women [4]. Tables 1 and 2 indicate comparative data on health in Serbia [5].


There has been some improvement in life expectancy in Serbia in recent years. Infant and post neonatal mortality rates are about half the corresponding rates for Eastern European counties, but are about twice as high as the corresponding rates in Western Europe. The risk of dying from cardiovascular disease in Serbia is almost 2.5 times higher than the average risk for Western Europe.


Serbia is a high smoking prevalence country. Estimates of Serbian smoking prevalence vary. In 2006, 38.1% of adult men and 29.9% of adult females smoked [4]. Tobacco contributes significantly to the burden of disease in Serbia: smoking is responsible for 13.7% of total years life lost [6] and at 80.9/100,000, Serbia has one of the highest age standardized lung cancer incidence rates in Europe [7].


Serbia's health system is financed by earmarked payroll taxes via the National Health Insurance Fund (NHIF) and out-of-pocket payments. Providers are mostly public and are contracted by the NHIF. The NHIF finances 66% of health expenditures; central government contributes 5.5%; and private expenditure (mostly on pharmaceuticals) is around 26% [8,9]. Health expenditure is around 9.4% of gross domestic product, but per capita expenditure on health is relatively low at $395 per person [5].


Although health facilities are relatively well staffed, with doctor-to-nurse ratios around 1:2, the quality of care is considered generally poor [10]. Services are not patient-centred or outcome oriented and there is a lack of governance, monitoring and clinical supervision [11]. Equipment and buildings are often in poor condition or poorly configured, especially in regional areas. Rates of pay for health professionals are low by European standards, and low pay exacerbate the pressure on patients to make informal payments to access health care. Many health staff work in parallel in the private sector grey economy to increase their incomes [11]. Hospitals have fairly low occupancy rates (around 70%) and length of stay is high by Western European standards [5].There are 114,300 permanent staff in the public health care system in Serbia [12] including around 39,000 nurses, aggregating to around 558 nurses per 100,000 population [5].

Health care organizations are often hierarchal, poorly organized structures and face problems in setting priorities and making efficiencies [13]. Staff attitudes are poorly developed with little professional satisfaction; there are high sickness and absentee rates; and few incentives for performance or efficiency. Hospitals are generally run by doctors with no formal management training and little experience of modern ma-nagement practices [13].There is little evidence of multi disciplinary management and key functions like human resources and information technology are rudimentary.

Other Serbian health management and organizational problems include rigid regulations constraining autonomy and decision-making; lack of coordination of activities and systems; poorly developed quality systems; and little use of evidence based approaches and international best practice [13].


Problem areas for nursing in Serbia

Nurses comprise nearly half the health workforce in Serbia, but as a group are significantly undervalued and inappropriately utilised. This is primarily a function of the weak and medically focused management structures prevailing. Nursing as a profession is completely subordinated to medical management and nursing input on clinical issues is minimal. Hospitals have little in the way of formal delegations or written and agreed administrative policies and protocols, so there is a lack of a formal structure to support stronger nursing involvement and inputs.

There is no systematic quality approach. Quality activities are basic and unguided - e.g. little prevention focus; no continuous improvement concepts; no designated quality personnel and no overall systematic quality improvement framework. Data are limited and data already available are seldom used in operational management.

The lack of quality and improvement approaches in Serbian health organisations means that nurses have few opportunities to contribute to system improvement and patient focused service delivery.


Table 1. Comparative morbidity and mortality





Infant deaths

per 1000 live


Life expectancy

at birth,

in years

Standardised death rate, ischaemic heart disease, all ages per 100,000

Standardised death rate, cerebrovascular diseases, all ages per 100,000


6.7 1

74 1

120.6 1

146.4 1












9.7 3

72.8 3

147.8 3

197.5 3


10.9 1

73.5 1

194.3 1

173.5 1


2.8 2

78.5 2

67.2 2

56.5 2






W -Europe






3.5 2

81.5 2

35.4 2

27.6 2


3.8 3

79.9 3

99.5 3

43.4 3


3.8 1

81.5 1

43.3 1

32.3 1








7.9 1

75.4 1

197.8 1

116.7 1

1=2008 , 2 =2007 , 3 = 2006; Source of data: Health for All database 2008. WHO Regional Office for Europe [5]


Table 2. Comparative health resources and utilization

Selected comparative country

Nurses per 100,000

Doctors per 100,000

Bed occupancy rate (%) acute hospitals

Average length of stay, acute hospitals

Acute hospital beds per 100,000

Total health expenditure, PPP$ per capita


557.4 2

271.2 2

69.8 1

7.7 1

557 4

395 1















420.9 2

364.4 2




734 1


397.4 3

192.1 3



505.2 3

507 1


764.8 3

237.3 3

71.5 1

5.7 1

376.7 2

1959 1
















780.4 2

336.1 2


5.9 2

361.8 3

3406 1


781.2 3

348.3 2

76.2 1

7.6 1

572.9 3

3250 1


1505 2

393.2 2

68.1 3

6.6 3

340.2 2

3187 1








European Region

725.9 2

339.2 2

79.8 2

8.3 2

541.9 2

1748 1

1=2008 , 2 =2007 , 3 = 2006 , 4=World Bank 2005

Source of data: World Bank. Baseline Survey on Cost and Efficiency in Primary Health Care Centers before Provider-Payment Reforms; 2009 [9]

In primary care - organised through Dom Zdravlja, large polyclinics with numerous specialist primary care doctors with nursing and diagnostic support - nurses face additional problems. Productivity varies widely, with some nurses underutilised and undirected. Many nursing functions are routine and could be undertaken by nursing assistants, thus freeing up skilled staff for more complex tasks.


Health management training and education in Serbia

The need for stronger management generally in Serbian health care is well recognized and the European Union (EU), in particular, is supporting management capacity building programs [14].


An EU funded Training in Health Service Management in Serbia project is developing a comprehensive management education program in the Serbian health system to help overall reform by improving management and governance.


By institutionalizing Health Management training (through a formal postgraduate qualification - the Master of Health Management) and focusing on capacity development, improved management skills and better practice in human resources and planning, the EU project aims to help in improving the Serbian health system.


Mid level and senior nurses and nurse managers are key target groups under the management education program. This focus on capacity development for nurses is novel in Serbia. Nurses have long been neglected in terms of training and continuing education to advance into senior levels in the health system.


The next section describes the education program developed for Serbian nurses and details results and evaluations by participants.


Serbian nurse management education and training

Between February 2010 and March 2011, 45 two-day workshops were conducted by a team of experienced UK nurse educators. The target group was mid level and senior nurses from hospitals and primary care centres nationally. Workshops were held throughout Serbia, including remote and rural areas and urban centres. Over 1500 nurses participated in the training program.


The training undertaken was aimed at maximizing interactivity and participation (relatively new concepts in Serbia, where training traditionally is didactic and passive for participants). Based on research and a training needs assessment, the following program was developed for the workshop training:

-          International approaches to training and organisation of nursing services;

-          Analysis of current nursing organisation in Serbia and how improvements could be made;

-          Principles of management and leadership;

-          The management of change;

-          Team building;

-          Nursing models to organise nursing care;

-          Optimising nurse staffing establishments;

-          Defining quality in nursing;

-          Risk management in nursing;

-          Risk assessment.

The learning objectives were to (i) make nurses in Serbia aware of how nursing management has developed internationally, (ii) introduce best practice management concepts and (iii) provide nurses with a range of management knowledge and skills that could be applied within their work environment.


Evaluations were aimed at assessing effectiveness of the training and at identifying future education priorities.




The results of the workshops are set out below. Evaluations were based on a Likert Scale format, with 5 = Highest and 1 = Lowest.


Evaluation criteria




Overall approach taken in the training


Materials presented


Method of working


Explanations given


Quality of facilitators


Usefulness to the participant's work situation


Participants' overall assessment




The evaluations elicited the following qualitative respon-ses from participants.


New ideas and concepts introduced by the training (N = 1150)

The new ideas most frequently cited were:

-          Improving work organization/nursing care process (e.g. via Donabedian models);

-          Calculation of nurse staffing ratios;

-          Risk assessment/risk management;

-          Problem solving methodologies;

-          Increasing independence/rights of nurses;

-          Professional nurses' associations.


New applications for the everyday work setting in Serbia (N = 1222)

The most important applications cited were:

-          Change management techniques for nurse managemen;

-          Quality improvement techniques;

-          Developing standards;

-          Importance of team work and communication;

-          In service training and continuous professional development (UK and EU models);

-          Management and leadership (Lewin theory);

-          Care planning.


Future training priorities for Serbian nurses (N = 864)

Nurse staffing and planning models;

-          Team building/communication/conflict resolution;

-          Quality improvement;

-          Developing and implementing standards;

-          Changing the legal framework to enhance nursing;

-          Change management/(re)organization of health care services;

-          Strengthening independence and autonomy of nurses;

-          The potential for nurses' associations;

-          Risk management;

-          Using data and developing information systems.



As described above, nurses in Serbia have traditionally been professionally neglected, undervalued and not utilised to optimal effect to impact on overall improvement and patient care.


As well as the prevailing management and system deficiencies in the Serbian health system which have militated against development of nursing potentials, a number of other factors have contributed to the relative management weakness of Serbian nursing.


Overall, there is no single professional organization responsible for advancing nursing or focusing on standards or improvement. Instead, there are at least 27 different organizations presenting a myriad of local, regional and even intra-organizational interest groups representing nurses. These groups have different emphases - for example, some are professionally oriented, while others are more like conventional trade unions advocating better rates and conditions. Nurses are not covered by specific legislation to improve standards or practices or to enhance professional development. Instead, they are included under blanket provisions of generic Health Laws (the latest in 2006) and regulations.


While nurses are now required to undergo degree level training at designated nurse training schools, further specialist training opportunities are limited and Serbian health organizations appear reluctant to allocate funding for additional nurse training programs.


In the authors' view, a number of key changes are needed to improve the management role and functionality of nurses in Serbia.

First, there needs to be a single national professional organization to represent nurses' interests and to promote management standards and competencies.

Next, development of specific legislation to cover nursing issues (e.g. like the UK Nurses, Midwives and Health Visitors Act 1992 and the Nursing and Midwifery Order 2001 setting up the statutory Nursing and Midwifery Council) is essential to ensure a legal basis for certification, accreditation and professional competencies with delineated standards.


Nursing also needs a wider functionality to reflect modern health needs and interventions, such as health protection and prevention; extending clinical work to ease workloads on doctors; and increased chronic disease and case management roles. These extended nurse roles need to be promulgated and supported by regulations and legislation where appropriate.


Dedicated funding - either centrally from the Ministry of Health or from institutions' budgets - is needed to support ongoing nurse management education and career development. Funding would need to be clearly earmarked for this purpose to ensure a sustainable basis for the future.


Finally, senior health system roles and positions need to be opened up to appropriately qualified nurses and other health professionals. Until recently, only medical doctors were appointed as managers. The Health Law of 2006 allowed non-medically trained personnel with health management training to hold senior management positions, but this aspect has not been purposefully implemented as yet in Serbia. More definitive and decisive action is necessary to allow appointment of non-medical managers, particularly nurses.


Given the current situation in Serbia, there would appear to be reasonable grounds to be pessimistic about these important changes occurring. However, there are encouraging signs that the potential for strengthening Serbian nurse management is gaining momentum.


The response to the education program outlined in this paper has been overwhelming. Word of mouth communication among nurses has stimulated demand for more training and opportunities. Thus, the Nurse Management training program has contributed to a bottom up ground swell from nurses for recognition, for increased professional advancement, for ongoing in-service training and particularly, for involvement in management and clinical decision making.


The education program described has been accepted by the Serbian National Health Council as an accredited continuing education course. This means that the Clinical Centre of Serbia (the country's largest hospital) is now accredited to undertake ongoing Nurse Education based on the program developed. This provides a platform for further nurse management education activities.


Another positive development is the establishment of a formal accreditation framework in Serbia under the Agency for Accreditation of Health Care Institutions [15]. Accreditation will be achieved through external assessment of organizations against internationally based standards. These standards emphasizing continuous quality improvement; teamwork and collaboration; and patient centred approaches (familiar to Western European health workers) will help to bring Serbia into the European health mainstream [16].


Introduction of quality improvement processes in health institutions will have an immediate and positive impact on nurses. Nurses will have additional responsibility for compiling and analyzing data; developing care plans and pathways; system improvement; and developing a prevention and safety focus.


Building teamwork in the organization will ensure inclusion and involvement of nurses in key clinical and management areas. Combined with new knowledge and awareness from the training program, the emphasis on teamwork and collaboration will provide significant opportunities to raise nursing profiles and management status.




Serbian nurses have long been neglected in terms of professional opportunities and career pathways for partnership in governance and management. The situation is beginning to change. Recent education initiatives aimed at enhancing the nurse role have stimulated interest both at grass roots and at policy levels. There is a developing awareness of the need to strengthen nursing in the health system generally. A number of positive developments in raising the profile of nursing in Serbia are underway, including a focus on quality improvement and accreditation, additional training activities and acknowledgment by the Ministry of Health that Serbian nursing will have to conform to EU directives in future [16,17]. This means an increased emphasis on nursing competencies, professional development and international best practice that will lead to acceptance of Serbian nurses as full partners in health management and organization in future.



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