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The role of nursing placed in the current scenario has evolved over time, as it reported by Tanya Buchana, (1999) based on a true story. One fine day, there were hundreds of nurses gathering in a campaign holding posters and placard which had phrases written in it asking for raise in pay without added conditions. One speaker from the group in order to get a verbal response started reading the placard one by one. The nurses were excited and started cheering the speaker, who was not a nurse himself, after each placard was read. When he read the final placard, he questioned the nurses, “Is Florence Nightingale dead?” His idea was to kindle and create a spark among the group asking this stirring  final question The entire campaign of nurses went silent for a while, after which they started whispering among themselves in frenzy.

All the nurses were taken aback and silence prevailed for a very long time. After a few minutes, few of the nurses started laughing uneasily, and some even found the question offending. Some nurses from the crowd started asking the same question among them; “Is Florence Nightingale dead?”. But none of them from the crowd were able to reply back clearly. This showed the lack of certainty among the nurses when it came to the position of Florence Nightingale in the role of nursing. One possibility is that, none of them has thought about the role Nightingale has played in nursing or questioned themselves on the subjects. Further, there was not much distinction between the person Florence Nightingale was and the function her name has come to, in terms of her role of nursing.

Here, I would like to explain how nursing, an important the role in wars and military has evolved over time and the historiography of it linked to Florence Nightingale. There is a difference between history and historiography, because, history, simply means what has happened in the past, but on the other hand, historiography is what has been written about what happened in the past. History is a very vast term and it typically depicts what happened every day and most of it is not recorded.

According to the great historians Michael de Certeau, Hayden White and Michael Faucault, history is nothing but a recording or writing of what happened in the past. According to them, history, which is written, is greatly influenced by the political conditions as well as the power relations of the situation when it is written (Reznick,2011).

This paper does not praise or censure Florence Nightingale or her contribution to the field of nursing. This is just a mere attempt to represent the reader with an efficient history with no criticisms or credibility. As a matter of fact, it is not possible to ignore the existence of a Florence Nightingale, when we describe about the history of nursing. When we talk about nursing, it has been greatly influenced by her personality and her role. However, discourse will not be able to reproduce what Florence Nightingale had done in reality, as against what is produced arc virtual Florence Nightingale (cl. de Certeau 1988:8). The account in this is written by a nurse to be read by nurses to help them enhance the role and responsibility.

War nurse 5


The accounts of history of nursing written in both 19th and early 20th centuries have undergone a lot of criticism and were published somewhere in the 1980s. This resulted in the production of the revisionist accounts (Davies, 2007). Most of the reports that were published or recorded prior to 1960 were just used to rationalise the process of professionalization (Rafferty, 2000). As per the historians, this was the right approach and it was used to bring in more new entrants into this profession, and also to differentiate trained nurses, women who have been doing this without much training as they had claimed the title before the nursing reforms were introduced in the mid 19th century , (Nelson, 2002 ).

History was generally recorded and written in a congratulatory style. This was to provide a simple, precise and uncomplicated version of the history to the readers. It did not address the economic reality or complexity of the situation, social and other important conditions that influenced nursing. Further, it did not even account the role of gender or class or religion played (Mortimer, 2005; Sweet, 2007). This is not a single case that has to be ruled out while writing about the history of nursing. One can see that on the accounts of history of nursing in wars, it features a number of historical events and accounts, and it is even recorded in histories of hospitals written by nurses (Newby, 1985) and doctors (Granshaw, 1989). One can find that, the importance given to the mainstream society when describing how nursing operated or developed in minimal to nil(Margaret  et al 2002).

In this paper, we will discuss the important issues that had great amount of influence on evolution of nursing. Further, we can also discuss how the nursing management developed from its roots in the 19th century to the present stage. This will help us understand the organisation of nursing as a whole in a contemporary way.

When we take into account the development of management of nursing in the United Kingdom, there are 2 different periods that seem to have been mentioned over and over again in the literature. The 1st one is between the middle and the end of the 19th century and the 2nd one is between after the creation of National Health Service in 1940s and the introduction of General Management in 1980s ( Moiden, 2002).

war nurse 4

Role of Nursing during the Wartime

The role played by the American nurses during the wartime for the American military is undeniably one of the most important aspects. The nurse’s duty was very simple in military; which is to provide care and aid to all the soldiers who had wounded themselves in the war. Further, it was also their responsibility to take care of the casualties of the war. If we go through the history we will understand that the view of a military nurse has changed to a greater extent from that of a simple recyclable source used only during the military necessity to be called upon only during the time of crisis to part of the team.

Florence Nightingale, with a team of 38 nurses sailed a ship to Turkey to be an unwelcomed guest and provided with an appalled situation and very poor sanitary facility. Further, both the military doctors and the health officers had refused to take into account Florence’s attempts to revamp the military hospital. Only later, when Florence succeeded in the Crimean War, high standards for a nurse and the practice of nursing was established. Post which the number of nursing schools increased and the growth and development of the schools also improved the qualification of nurses and they came to be officially recognised, even in the military hospitals (Buchana, 1999).

war nurse 2

The American Civil War and Nursing

It was only during the American Civil War that women were offered responsibility and introduced as female staff, in the traditional male dominated military environment. This also had a significant improvement of women’s liberalisation in the later days in American society (“Civil War Nurses: The Angels of the Battlefield,” N.D.). The two most important women in revolutionising the nursing concepts were Dorothea Dix and Clara Barton. They were very powerful and changed the concept of nursing during the Civil War. Both of them worked independently in organising a nursing corps, which concentrated on taking care of the sick and wounded from the war. They were also given the title of Superintendent of Women Nurses. Dorothea Dix also known as the ‘Dragon Dix’ was worthy of the title. She also changed the concept and hired middle-aged women who had plain looks to serve as important nurses in Army Medical Bureau. She was proud of her nickname as she successfully created the country’s 1st professional nursing corps Army. Post-Civil War, Clara Barton headed the creation of American branch of the International Red Cross. She was a schoolteacher who shifted base from Massachusetts to Washington to provide nursing care for the injured soldiers of war. By the time, the Healthcare had improved nationwide better and this helped the nurses aid the injured and sick from the war disasters. Further, as they had developed experience, they were also well prepared to manage the future wars or similar conditions, according for a crisis situation ( Blum,2011)

The sign of health care

The World War- I

In 1917, when the United States joined the World War, the number of nurses was very low. However, over a period of time, the number of nurses recruited for active duty increased and it did not in decrease for over a year. When the war ended in November 1918, there are over 21,000 active nurses as part of the ANC and around thousand 400 nurses as a part of the NNC (Reznick ,2011; Cox, 2001).

As the number of casualties during the World War- I was very high, the number of nurses who were well trained and skilled was wanted in great demand. The American Red Cross served as a wing that supplied the well trained and skilled nurses to both the Army and Navy to serve as a part of the wartime nurse corps (“Health and Medicine: Red Cross and World War I,” n.d.). The duty of ANC was to serve in the evacuation zones, mobile travelling units or the surgical units which cared for the wounded. Further, the nurses who work in the hospital train and transport ships during the war throughout the European continent, attending to the soldiers were wounded and sick and those crossing the Atlantic Ocean back to the country (Cox, 2001). This was when the nursing profession had reached its new height. Further, it was the idea of the Navy to create base hospitals in Ireland, Scotland and France. Later they sent in small groups of nurses and mobile units to stay close to the battlefronts. Despite the fact that the nurses were able to provide onsite care for the wounded soldiers, their contribution to serving those returned soldiers back home was undeniably excellent and considered as an accomplishment by the nurse corps. Most of the nurse is in the team served in this providing the basic care to the soldiers and also training the new nurses in the corps. As this was the pre-antibiotic era, the nurses gave priority to clean and hygienic environments, the better chances of saving the wounded (“Nurses and the U.S. Navy, 1917-1919,” 2005).

After a few years, the number of active nurses decreased gradually as the need for them decrease as well. However, though military did not need the number of nurses, the government realised that no war can be won without the help of health care providers. So, this was one of the breaking point that gave the nursing profession a good recognition and was acknowledged for what it was worth.

war nurse 1

World War- II

For the Americans, the world was started on December 17, 1941, after the Pearl Harbor was bombarded by the Japanese army. Post which NNC and ANC recruited 69,000 nurses to take care of the wounded and sick soldiers.They were divided into groups and they worked in the field onsite, medical transport planes, evacuation, hospitals, hospital ships and hospital trains. The medical transport planes were launched as a new part and were called Flight Nursing (Commager, 2002).

When the war began, they were awarded the ‘relative ranking’ and recognised as officers and even provided uniforms. But, they were not eligible for commissions or privileges that were given to the men who served in the Army. Later in the year 1944 22nd June, the Congress government granted the nurses the same privileges and temporary officers rank to all the ANC and NNC nurses who deserved. They were also given the same benefits and commissions, rights and pay at par with the officer of the same cadre. The compassion and the hard work of the nurses had also received the acknowledgement and praises from the society (Blum,2011;Kalisch&Kalisch, 2004).

As the nurses were well-trained and able to provide proper nursing care to all the wounded in the World War II, almost 96 soldiers out of hundred who were wounded were saved. This means, only about a 4% of the injured and diseased soldiers died. After end of the war, the society looked upon the field of nursing and as a dignified profession and acknowledged the women who served as nurses in the war. The government announced free nursing education to be provided to all interested in deserving candidates till 1948. As the nurses from the military services had skills developed through experience, they were able to handle wounds and deaths better (Bellafaire, 1993).

War Nurse 3

The War of Vietnam

The Vietnam War which happened between 1959 and 1975 proved to be a very difficult time for the Americans. The need for nurses increased rapidly and the military started recruiting throughout the period. According to an account from, there was already a shortage of nurses in the society. Most of them were reluctant to go and serve in the army as they had opportunities to serve the civilians. The government announced financial aid to all the nurses who served in the Army during the Vietnam War. Recruitment of nurses in the military proved to be even difficult because, the civilian hospitals in the country offered better pay packages and also better working conditions (Teerawichitchainan, 2012; Kalisch&Kalisch, 2004)


Iran-Iraq War -1980-88

The Iranian nurses performed most important roles during Iran-Iraq war during 1980-88. The nature of nursing practice in chemical emergency departments was very crucial during this war. The clinical tasks were allocated to the specific nurses in a situation in which they become exposed to chemically contaminated patients and direct attacks on emergency department. Most of the nurses become affected from a gas “Mustard Gas” and suffered from eye, skin and respiratory system diseases. Many of them are still suffering from ill effects of that chemical.(Firouzkouhi et al 2013)


Gulf and Afghanistan war:

Around 1980s feminist movement has gained advancement in the country and hence women became more and more liberal. Most of them in when given an option to choose being just a mother/ housewife chose to be a business owner as well as a mother. During this time, the military nurses had to be deployed to Afghanistan in 1990s. It further complicated the family situation as Gulf War was the 1st incident in which mothers left their children behind to work in a different country (Schoenfeld, 2012).

During this period, 2200 nurses were recruited and appointed by the military moved to the Middle East under ‘Operation Desert Shield’ . As they had received ample training and prepared for the worst case scenario and distress situations they were able to handle the casualties better. This was the 1st war in American history in which the deployable medical systems were used and combat support hospitals were established. These combat support Hospital were called DEPMEDS and they were constructed using rigid aluminum tents. They were well equipped with pharmacy, radiology, laboratory, surgery departments and sterilisation departments. This was the 1st time when the infliction of diseases faced by the nurses was reduced to a greater extent due to high level of hygiene (Schoenfeld, (2012).

In this period of time, the US military was able to develop excellent combat surgical assets. In this, any injured member can be immediately drawn from the battlefield to the medical facility and at the same time treated during the transportation.

During Iran and Afghanistan wars in 1990s, the Critical Care Air Transport(CCAT) team were used to a larger extend. The critical care team had well-trained physician, respiratory therapist and a critical care nurse. These units are generally called to transfer those who have been wounded severely in the war and to stabilise physical condition of wounded soldiers. The team provides medical care, en route to the hospital, be it out of the war zone or back home to United States. The care given to the wounded patient might vary right from basic first aid care do even life support interventions. This depends upon the availability of the surgeons or the specialised physician (Schoenfeld, 2012).


The Americans War on Terror

When the incidence of September 11 took place, the policies in establishing the Forward Surgical Teams (FST) and Combat Support Hospitals (CSHs) were in the infancy stage. Only during this incident, and after the establishment of global war on terror, the combat surgical units were used. As the military is aware of the nature of the war and the capability of the enemy, FST or CSHs has never been deployed for the intended purpose. However, it has been functioning as medical treatment centers, and combat support centers during a crisis situation. However, they have not come to a conclusion as to which model best suits the asymmetrical battlefield.  Responsibility was handed over to a team of experts to determine which would serve the purpose better. The mortality rates of people who went for initial treatment to an FST unit were compared to a member receiving all the treatments from CSH. Regardless of the differences, capabilities, as well as the supplies, they were not able to find any reportable statistical difference in terms of survival between the CSHs and FSTs (Garfield et al, 2003).

Nursing management & education in the 19th century

A defining feature of much of the literature about this period is its concentration on the actions and influence of Florence Nightingale. She indeed performed a leading role in nursing reformations and introduced the word “ matrons” in the  hospitals, as part of a new regime which constituted a clean break with the past (Girvin, 1996;Moiden, 2002). The skills introduced by Nightingale were marvelous and her supporters advocated her views, and emphasised  application in the success of the Nightingale School of Nursing (Margaret  et al 2002).

In 1854, she was appointed head of nursing school and she assumed the responsibilities when it was established in 1860. She held this office for 33 years, until some feminists started raising objection on failure and abilities along with Bonham-Carter who was secretary of the Nightingale Fund. However, Nightingale contributed a pioneer role in the reform of nursing to Wardroper in 1896 and depicted herself as a powerful force in its development.This positive presentation of Wardroper’s contribution, in contrast to Nightingale’s views of her qualities when she was alive, can be read as a selective reporting of events at a later point in order to enhance the celebratory (Baly, 1997).

In the19th century, attentions were focused on development and improvement of hospital nursing for the sick poor, both in the voluntary and poor public hospitals. These developments have attracted extensive attention from historians and consequently, the history of nursing become associated with the history of nursing in the voluntary general hospital in later decades of 20th century (Carpenter, 1980; Rosenberg, 1982).  Consequently, the management of nursing is discussed as a whole for volunteer hospitals and development of systems in general nursing (Margaret et al 2002).

In the voluntary hospitals, the medical staff acquired extra powers by their involvement in all decision making committees. Margaret et al (2002), emphasized on the role matron for nursing managements and other in house affairs of the hospitals. However, the role and function of the matron were affected by the constitution of rules developed by the National Health Service in 1948 which resulted into grouping of hospitals together for administrative purposes. The matron was forced to work in partnership with the senior administrations of the medical staff to manage the individual hospitals. In England and Wales the Matron was supposed to be present in committee meetings for involving nurses in any discussion regarding them which may be raised by the Governing Body. In this way the matron of the individual hospital became relegated in terms of decision and policy making at the highest level in the new local health service structure (Redman, 2008, Wildman and Hewison, 2009)

  1. Education and management in Australia

As per Margaret et al, (2010), the new nurses found difficulty in Australia while discussing the history of nursing. While most of the students valued teaching history of nursing, they found that the curriculum was over emphasising on technical skills and requirements. At the same time the new nurses were expected to be able to meet unrealistic work pressure. Further, they were also expected to be ready with little to no training at all. According to them, the history was only able to help them to develop the critical thinking and improve professional identity as a nursing student. Including nursing history in the curriculum will help the prospective nurses to prepare themselves to maintain professional ethics and also motivate them and reinforce their identity.

  1. Education and management in Egypt and China

Similarly, in countries like Egypt, the nursing education system developed based on the influence of social, political and economic structure of the current scenario. We can only conclude that most of the developing countries when compared to each other showed that the development of this is totally dependent upon the efforts put in to improve the educational background of the nurses. However, the countries that gave importance and improved their educational preparation based on the requirements of the population showed better nursing education system. Neither could Egypt nor China were able to increase the entrance requirements (Chenjuan et al 2012).

  1. Education and management in Iraq

The war inflicted country of Iraq has significantly suffered due to the wars and this in turn has taken a huge toll on the health system of the country. As the situation has been the same for over 20 years, there is tremendous stress on the health system. The health professionals are not well equipped or skilled as they need to improve their understanding on the current problems. First and foremost, they should take steps to review and improve the health care system and start supporting and accepting their nursing staff. Over the last 5 years, many organisations which include NGOs and union nation delegates have stressed the importance of health-care system and the improvement of the country has to make in it. The government should take measures to review and then take measures to strategise the development of health system, resolve current issues and also improve the quality of nursing (Garfield et al, 2003)

As  discussed, due attention was given for improvement of nursing practices, management, and education after Crimean War, consequently fatality rate dropped in subsequent wars.  The percentage of fatality rate in word war 11, Vietnam, Iraq (Operation desert storm),Gulf and Afghanistan war is presented graphically in figure-1(Schoenfeld, 2012).


Nursing Informatics

Nursing informatics is a technique which is developed to use nurse’s information by computer technology .Nursing informatics enhances nursing knowledge and practice by providing better management.

Baker (2012) studied nursing informatics and elaborates different effects on nurses. He considered system and science to coordinate arrangement of working elements for development of precise measurement of knowledge. He divided the research into cognitive, information, computer and nursing science and presented the data analysed in graphical form to evaluate overall nursing informatics. The graphical representation is shown in the figure by redrawing t data.

Saba (1997) provided overview of medical Informatics to focus the new nursing specialties. The researcher provided an overview of data standards, goals, and scope and research initiatives to design the advanced status of nursing informatics



 Fig-2:  Nursing Informatics

Background on the Crisis

Regardless of the need for war on Iraq, the nurses should be able to understand the health consequences that the Iraqi civilian population is facing. What kind of health facility should do the Iraqi health professional and provided to the civilians? First-hand accounts should be provided which includes historical context, cultural and unbiased observations. After the Iranian war ended in 1989, the number of nurses in the country had increased to about 12,687, out of which about 6000 of them were qualified. After the 1990, almost 20 universities offered bachelorette coldness in nursing. By the end of the year 2000, the number of nurses in the country increased to about 56,800 out of which about 50% of them hold bachelorette degree as per the country’s financial ministry. However, this information should be analysed as the available data between 1978 and 1997 shows a lower figure of prospective graduating trained nurses. As there are constraints on women in the country, both culturally and socially, the war has worsened the situation further and also reduced the economy. This is not a case of just the nursing but overall in a wider context (Hodgson, 2007; Garfield,2003).



The Famous Personalities in the History of Wars

A survey conducted by Margaret et al, 2010, on the Australian nurses and the role played by them showed the contributions made by a number of historical personalities, specifically those who served during the war period. The 1st name that is mentioned is Florence Nightingale, who is considered to be the lady who changed the outlook of nursing. Few other names are Mary Seacole, Edith Cavell, Mother Teresa and Dorothy Dix; they are internationally famous nurses. The 2 personalities who changed the face of nursing during the civil war in America; Clara Barton and Dorothea Dix get a special mention in our review (“Civil War Nurses: The Angels of the Battlefield,” N.D.). Another famous personality who came to be famous during the Vietnam War is Diana Carlson Evans. The Russian nurse Alexander Kerensky was the one who changed the face of nursing in Russia (Alexandra Feodorovna: Alix of Hesse”n.d). Likewise, 2 other famous personalities in the field of nursing are Cheryl Ruff ( Rushton et al, 2008) , who made tremendous contributions to nursing in the operation ‘Desert Storm’ that took place during the Iran War and Ana Justina Ferreira Neri who contributed from Brazil during the Paraguayan War (“Paraguayan War” n.d.)

However, it would be a difficult task to remember and mention the names of all the nurses who had served their duties and saved the lives of millions of soldiers and civilians during the wartime. The history behind their life can only be brought to limelight through biographical accounts, which in turn will inspire the aspiring nurses to contribute. Further, it will also help them be prepared, gain confidence, be resilient and at the same time overcome the challenges. However, one should understand that all achievements and struggles were not achieved by single personalities or in isolation.


An average American in the real sense witnessed the war or ‘saw’ the war and the effect it had on people via clips and pictures that were telecasted in the TV and published in newspapers. The Vietnam War showed the face of violence to the civilians who had no idea how wrathful a war would be in reality. When the soldiers returned back home from Vietnam they received a very low support by the civilians. However, this was the war in which the nurses who served in the military and helped millions of soldiers receive acknowledgement and praise. Vietnam Women’s Memorial shows the respect and support for all the military nurses who had worked in the war. One can say that though war brought about death, pain and tragedy, it also helped in improving the medical and nursing care. Further, this was also the time when the military personnel and the government understood the importance of nurses, as well as the effect of proper medical and emotional care to the wounded soldiers. After the Crimean war ended, the nursing profession gained new heights. To Support the war on terrorism by the Americans; over 2000 military nurses who are well trained and equipped, have been deployed to Iraq. One can never know what the positive or negative effects a war will have on any country, but nursing profession will definitely serve its purpose, just like it served in all its wars and crisis situations.




Alexandra Feodorovna (Alix of Hesse), Viewed on September, 04,2013

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A stroke is a phenomenon which is transpired by blockage of an artery or vessel due to a blood clot leading to interrupted blood supply in the brain. Brain cells start dying due to unavailability of oxygen and brain become damaged. When brain cells start dying during a stroke, abilities or functions controlled by that portion of the brain are lost. These abilities or function may include speech, movement and memory. Someone who has suffered a minor stroke may experience only minor problems such as weakness of a leg or arm. People who have suffered massive strokes may even get paralysed on one side or may suffer other types of malfunctions in his body. Some people may recover completely from strokes, but about two third of survivors will have some residual disability.

Automotive Nurse Travel

Types of stroke

According to medical point of view, the stroke is generally classified into Ischemic, Embolic, Thrombotic, and Hemorrhagic. In most cases, Thrombotic stroke happens in the large arteries and is caused by atherosclerosis followed by rapid blood clotting. Thrombotic stroke patients mostly suffer from coronary disease, and heart failure is a common reason of death in patients who have had this particular type of brain attack. When the stroke occurs due to blockage of small arteries, it is called lacunar infarction stroke and mostly associated with hypertension or high blood pressure.

Results and characteristics of stroke also varied based on sex of the patient. Maeda et al (2012) conducted a study to evaluate the effects of stoke by considering basic patient characteristics, subtype of stroke, results and conditions based on sex. They selected almost forty thousand patients, including 13,323 women suffering with acute ischaemic stroke. Their study used computerized database by using a multicenter, hospital-based registration in different institutes of Japan. The results showed that women were more prone to ischaemic stroke comparative to old men.

How to recognise an early stroke?

The prediction of stroke is tremendously variable and is subjective to availability of collateral circulation. Non-invasive tests are helpful to recognising patients with a poor collateral potential. These methods can be used to identify potential patients who are on risk of stroke.

Voice plays a pivotal role in recognition of stroke early. Acquainted voice is an achievement of the human brain that allows human beings to recognise familiar people even with closed eyes. Human voice recognition is a discrete process which is not associated to language comprehension (Habermann et al 2009).

Depression is another important cause of stroke which provides specific signs of depression present in potential patients. Whitney et al (1993) developed observational depression index  to exploit the measurable symptoms  of potential victims of a stroke.

Messe et al (2004) studied thrombolytic type of drugs which helps to reestablish the flow of blood flow to the brain by removing the clots, which block the flow of blood. The first established treatment for acute ischemic stroke to be approved by the Federal Food and Drug Administration (FDA) in June, 1996 is also known as the clot buster.



Treatment and preventive measures for stroke

Activase is used by the medical professionals to enhance dissolving of a blood clot and should be given within three hours of initial attack of stroke. Patients are advised to go hospital when they feel signals of stroke. Activase is known as tissue plasminogen activator .Thrombolytic therapy should be given as soon as possible to ensure results (Maeda et al 2012).

Messe et al (2004) focused on Concentric Medical’s innovative for patients who are not eligible for receiving recombinant tissue plasminogen activator (RTPA). The system is suitable for patients who get the treatment after the 3-hour. This method is meant to restore blood flow in larger vessels of brain by dissolving blood clots. In this process, a tiny cork-screw shaped device wraps around the clot and traps it for removal.

Maeda et al (2012) introduced another system for treatment named “Penumbra”. This system provides provision for safe revascularization of blocked vessels in case of an ischemic stroke. The system also ensures restoration of brain blood flow by suction to remove the blood clots in the brain in case of stroke.  This system is much revolutionary as before introduction of this system, treatment and rehabilitation was seemed to be limited. This system is a device which is effective even if used within eight hours of the onset of the symptom.

Gotoh et al (2000) conducted the first large scale study by multi-center trials in Japan as a randomized double blind investigation in order to determine the effectiveness of Cilostazol, which is an antiplatelet drug, for preventing the recurrence of cerebral infarction in case of patients who had suffered from cerebral infarction in 1 to 6 months before the entering the trial.


Preventive measures for Stroke

Preventive measures which should considered by a patient are as below:

  1. A person of over age 18 years, good blood pressure is considered to be lower than 120/80. A blood pressure reading or regularly higher than 120/80 and up to 139/89 is considered to be pre-hypertension. High blood pressure situation is when a measurement of 140/90 or more is reached.
  • Be aware about blood pressure. In case of high blood pressure, immediately consult with the doctor.
  • Keep himself relaxed to avoid hypertension.
  • Keep blood pressure apparatus at home for frequent self-monitoring.
  • Keep diet balanced with consultancy of your physician.
  • Get your blood pressure checked at least once a year , more often in case you have a history of high blood pressure or have a background of  a heart attack or a stroke, are diabetic, having kidney disease, high cholesterol, or overweight.
  • Adopt habit of regular exercise besides medicines that facilitate for maintaining blood pressure.

2    In case of fibrillation which is an irregular heartbeat, consult with your physician prescribing medicines.


  1. Smoking habits
  • Smoking multiplies the risk for a stroke.
  • Stop smoking to drop the risk of stroke.
  • Within five years of quitting, the stroke risk is similar as that of a person who has never smoked.
  1. Drink alcohol within a moderate limits.
  • Drinking a glass of beer, wine, or one peg of mixed drink in a day may lower your risk of stroke, provided there is no other medical reason for not drinking alcohol.
  • Heavy drinking can increase the risk for stroke.
  • Remember alcohol is also a drug and it can interact with the other prescribed drugs that you are taking. If you do not drink then don’t start.
  1. Cholesterol level should within standard limits:
  • Lowering your cholesterol will reduce the risk of stroke. High cholesterol level puts you at a greater risk of heart disease, which might increase the stroke risk.
  • LDL and HDL cholesterol should be below 200.
  • High cholesterol may be controlled with exercise and diet; though some time medication become unavoidable.
  • Recent studies have also shown that some individuals even with normal cholesterol levels may lower their risk of stroke by taking certain cholesterol lowering medication.
  1. In case of diabetes, follow doctor’s advice in order to get your blood sugar number under control because:
  • Diabetes puts you at an increased risk of stroke.
  • Exercise healthy diet and medicine with consultancy of your physician..
  1. Inclusion of exercise in your daily routine is highly desirable.
  • Minimal Exercise like a brisk walk, swimming or bicycling can improve your health and reduce the stroke risk.
  • According to the Centers for Disease Control and Prevention, adults should ideally perform moderate level physical activities for at least 30 minutes for five or more days in a week.
  • Before starting an exercise program it is advisable to consult with your physician.
  1. Enjoy a low sodium and low fat diet.
  • Cutting down salt and fat in your diet, you may reduce your blood pressure and lower your risk for stroke.
  • Eat a balanced diet every day, with adequate amount of fruits, vegetables, whole grains and a moderate quantity of protein like meat, fish, milk, nuts, eggs, tofu, and beans.
  1. A fatty deposit can block the arteries that carry blood from your heart to the brain. If left it untreated, these blockages can result in a stroke.
  • Get tests conducted for such problem. Doctors can even listen to the arteries, just like they listen to the heart or look at pictures of the arteries with the help of medical equipment.
  • Circulation problems can mostly be treated with medication. When your doctor prescribes the medicine, take it exactly as recommended.
  • Surgery is necessary in some cases to correct circulation problems such as blocked arteries.
  1. In case, you feel symptoms of stroke, call for immediate help to save your life.


Conclusively, a stroke is a life threatening phenomena with long term acute effects and even death. When a person feels symptoms like numbness or weakness of face, arm or leg especially on one side of the body, trouble in speaking or understanding and loss of balance, he should consult with physician immediately to prevent himself from a stroke. Though, many techniques have been developed for treatment of stroke, but still this a harmful disease due its effects. The physical, cognitive and emotional functioning is influenced by different parts of the brain. The effects are experienced in different degrees at various phases of recovery. Stroke is a trauma and can take long time for recovery..



Work Cited

Andrei  V. Alexandrov, Louis R. Caplan, Merrill P. Spencer Charles H. Tegeler , Viken L. Babikian, and Robert J. Adams,(1998) ,’ The Evolving Role of Transcranial Doppler in Stroke Prevention and Treatment’, Journal of Stroke and Cerebrovascular Diseases, Vol. 7, No. 2,  pp 101-104.

Fay W. Whitney, and  Eileen Michaels Burns (1993), ‘Recognizing depression: Preliminary testing of the Whitney Observational Depression Index’, Journal of Stroke and Cerebrovascular Diseases,Vol.3, No.3, pp.193-201.

Fumio Gotoh, YastloOhashi,(2000),’Design and Organization of the Cilostazol Stroke Prevention Study’,  Journal of Stroke and Cerebrovascular Diseases, Vol. 9, No. 1,pp. 36-44.

Koichiro Maeda, Kazunori Toyoda, Shotai Kobayashi,and Kazuo Minematsu,(2012), ‘Effects of Sex Difference on Clinical Features of Acute Ischemic Stroke in Japan, journal of Stroke and Cerebrovascular Diseases, Vol. Nill,pp.1-6( Article in Press).

Paelecke-HabermannY, K. Somborski,,  M. Paelecke, M. Knörgen, O. Kneidel, C. Gaul,(2009), ‘Recognizing people by their voices: An fMRI-study of healthy people and patients after stroke’ Clinical Neurophysiology, Vol. 120,N0.1,pp.69-88.

Steven R. Messe´, Steven R. Levine,  David Tanne, Andrew M. Demchuk, Scott E. Kasner, and Brett L. Cucchiara (2004), ‘Dosing Errors May Impact the Risk of rt-PA for Stroke: The Multicenter rt-PA Acute Stroke Survey’, Journal of Stroke and Cerebrovascular Diseases, Vol. 13, No. 1,pp. 35-40.

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Palliative care is well defined by the World Health Organization, and is “The active total care of patients whose disease is not responsive to curative treatment.” In 21st century, many plans have been designed to enhance the quality of life for the survival of affected patients. But a reliable epidemiological study is required for evidence and assessment of expected survival of the patients.

Main objective of palliative care is to achieve the quality of life for the patient and his family. Since the building of first ever modern hospital in 1960, the number of incurable cancer patients and palliative care units have been increased manifold, especially in countries having sufficient funds for health care. But qualitative and quantitative scientific research is still unable to meet the expectations and fundamental goals.

History of Palliative Care

White et al (2004) reported flaws prevailing in remote areas of Australia and public facing life threat disease. Disease progression is high in absence of palliative care and patients died in loneliness away from their homes. Furthermore little research is available regarding these remote communities which consequently challenged by palliative care patients. The situation is much different in comparison with urban area which is unjustified. This devaluing and underneath resourcing of remote area palliative care and research, the discreet response from health and social policy is inequity in social background. However, keeping in view social and health policy, improving access to palliative care services conveys some requirement need to be addressed in the surrounding issues and expenses. Moreover, it enabled more cultured and geographically appropriate palliative care research in remote areas. It is accompanied by the potential to improve clarity about needs and issues with the possible increase in costs. Though few areas have access to devoted and soothing care services, but they declared it persistent underprivileged and deprived social environment for native Australians living in remote areas even.

Radbruch et al (2002) reported in his article that the resolved question about permission for omission of therapy is not much clearly documented in Germany. They found that rejection of recovery for any patient was not documented in some units and 78% of patients in other units. In the different units consent on omission between varied from 0% to 88% of patients for additional chemotherapy .They indicated that documented direction were only 18% in Germany compared to United States which was up to 79% of patients. In addition, more specific research and setting of the fundamental documentation is required in this area in Germany for better assessment. The survey showed high rate of outcome of inpatient palliative care and large percentage of patients with good symptom control, minimal or no residual pain and high satisfaction with therapy. The relationship between assessment by staff and self-assessment were available only for few patients, and showed moderate association of outcome ratings with the omission of a higher correlation for pain relief.

In late 20th century, United Kingdom started providing death service and this idea got inspiration for improved care for fatally ill patients. One of the basic philosophies is to provide relief of stressful symptoms, the incorporation of mystical and psychological aspects of care, and the provision of a supportive system to ill patients. In addition, reports have been considered to access and the provision of sanatorium care to all fatally ill patients rather than only cancer patients. The philosophy and goals of palliative care are unquestionable. Efforts have been made to fulfill rules within a severe setting (Willard, 1999).

Current Scenario of Palliative Care in Australia

Palliative care has been developed across Australia in variable ranges and ways by healthcare professionals working in general practice settings, hospitals and clinics. Cancer patients constitute the mainstream of the palliative care patient inhabitants in Australia (Mitchell, 2011). Brooma et al (2013) outlined palliative care units and reported availability of superior palliative care units with specialised and comprehensive facilities both for in-patient and community based palliative care. More than 80% of patients are initially referred to such units by medical specialists instead of general practitioners. In some cases, patients rely on personal specialist due to their established relationship and for limited palliative care requirements. Their study focused on a specialist palliative care unit situated within a particular private hospice run government funding and community contribution.

Role of Emotion in Palliative Care

Palliative care is one area of medical science where emotions play a significant and inevitable role. Most often, the referral to a specialized palliative care system is seen as a step towards ‘letting go’. This is why transferring patients under active treatments to palliative care is an emotionally challenging and complex clinical practice. However, sociological research on emotions and forms of sentimentality with reference to discussions about referral to palliative care remains a hitherto unexplored domain (Brown, 2009). Taking into consideration various academic disciplines, though they might differ tremendously in their specializations, it is possible to gain some insights into the intricacies of how end-of-life discussions can be embedded in emotional and inter-subjective challenges. For example, the clinical trajectory adopted by some doctors in the case of small cell lung cancer patients is a good illustration of medical activism that is designed to aid them as well as their patients into channeling treatment procedures into a smaller, less emotionally charged path that has more optimistic end points. Such practices also make it clear that there is a potential possibility of optimism coproduced as a result of a collusion founded in emotionality and rationality in medical contexts. Given the potential for emotion and sentimentality in palliative care related discussions, how is the need for such a specialized system of care tropicalised and dealt with by doctors? Surprisingly, no significant studies have been carried out in this area (Brooma et al, 2013).

In short, each of the factors contributes to a complex interpersonal as well as highly charged situation. In such conditions, most of the medical specialists take approaches or make decisions patient based on the subjectivity and emotional mindset of the patient. In most cases, subjective influences have a subtle influence on the treatment decisions specifically, the timings, choices made and the route or trajectory taken. However, it is not applicable to medical practitioners who have a distant relationship or are dispassionate with the patients as they take decisions based on the condition and not based on the objective benefit or the quality of life.

Suggestions for Good Palliative Care Services in Future  

Different parameters and suggestions should be developed for good palliative care services in future to meet the scarcities and needs. A framework can be formulated for good and effective palliative care to meet the challenges. A comprehensive and centered approach is need of the time to meet future challenges of palliative care patient as mentioned below:

  • Develop effective information practices among staff and patients palliative care units.
  • Need to conduct specific research in palliative care.
  • Provision of basic elements based on community initiative as a group.
  • Avoid over sighting of therapeutic options without the consent of the patient palliative care unit.
  • Avoid decisions regarding end of life and develop aggressive directions.
  • Advance documented directions should be present in palliative care units.
  • Careful documentation should be exercised for effective goals in palliative care units.
  • Need to develop correlation between assessment by staff and patients at the time of admission.
  • Use specific and advance instrument for better correlation and staff ratings in palliative care units.
  • The implementation of the framework by assessment questions, guiding principles, and strategies for interpretation of framework suitable for the local needs of the community.
  • Appointment of competent facilitators for identification and development of essential resources both material as well as inspiration for the expansion of palliative care network.
  • Provision of initial leadership to start the building process, and keep liaison with the key stakeholders.
  • Facilitator should be accountable for getting the community group together and creating awareness palliative care.
  • Evaluation of guidelines to maintain and construct good services.

Medical sign

Role of Palliative Care in Residential Aged Care Services

For implementation of customised care planning for residents who are dying in aged care units, some programs were written like “Palliative Care Quality Resource Guide” known as toolkit. This toolkit provides help to assist health care providers to apply the National Palliative Standards and helping improved quality service to end of life care. More comprehensive study is still required to develop a mechanism for dying in sophisticated manner. Nurses need to acquire skills and knowledge for retrieving professional development by workshops and seminars. Skilled professionals working in palliative care units are another choice of learning for nurses (Allen et al, 2008).


History of palliative care showed that people living in remote areas are facing comparatively more problems than modern urban areas. This study emphasised that prevailing conditions in palliative care units in Germany are far below than United States and United Kingdom. Palliative care has been developed across Australia in variable ranges and ways by healthcare professionals working in general practice settings, hospitals and clinics. A framework can be formulated for good and effective palliative care to meet the future challenges.




Alex Brooma, Emma Kirby, Phillip Good, Julia Wootton , and Jon Adams,(2013), ‘The art of letting go: Referral to palliative care and its discontents’, Social Science & Medicine, Vol. 78 pp. 9-16.

Brown, R., Dunn, S., Byrnes, K., Morris, R., Heinrich, P., & Shaw, J.(2009),‘Doctor’s stress responses and poor communication performance in simulated bad-news consultations’,  Academic Medicine, Vol. 84,pp. 1595-1602.

Carole Willard (1999), ‘Caring for patients and relatives: an appraisal of palliative care philosophy European’, Journal of Oncology Nursing, Vol.3,No.1 pp. 38-43.

Kate White, David Wall, Linda Kristjanson,and Edith Cowan University(2004),‘Out of sight out of mind: reframing remoteness in providing palliative care in remote Australia Collegian’, Vol. 11,No.4,pp.29-33

Lukas Radbruch, Gabriele Lindena, , Martin Fuchs,KarlNeuwöhner, FriedemannNauck and  Schulenberg, , and Working Group on the Core Documentation for Palliative Care Units in Germany, (2002), ‘What Is Palliative Care in Germany? Results from a Representative Survey’,Jr. of Pain  & Symptom Mgm., Vol. 23 No. 6 pp.471-487.

Mitchell, G. (2011), ‘Palliative care in Australia’, The Ochsner Journal, Vol. 11,pp. 334-337.

Sonia Allen, Ysanne Chapman, Margaret O’Connor, and Karen Francis, (2008), ‘The evolution of palliative care and the relevance to residential aged care: Understanding the past to inform the future’, Collogian,Vol.15,pp.165-171.

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The profession of Nursing – approbated as one of the key roles of health care sector- is focused on providing a wide range of health care services to individuals, their families as well as to the community as a whole. Florence Nightingale, an English nurse who was serving during the Crimean War, had laid the foundation for the professional nursing through her famous book titled “Notes on Nursing”.

The duties and responsibilities of nurses diverse across different countries and in specialties, thus defining ‘nursing’ is quiet challenging. Among other definitions, International Organization of Nurses defined that is “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.”

NUrse cartoon image

Services of a nurse

The service of nurses witnessed in wide range of settings; starting from hospitals to home visits and also places such as schools, home for elders, military camps, cruise ships, free-standing clinics and pharmaceutical research companies. Even the scope of practice of nurses spread from assisting other health care workers to a certain level of prescriber authority. The key factors on which nursing profession emerged or can be categorized are their role, knowledge and attitude.

Compared to other health care providers, nurses must possess traits that help them get on with people by communicating effectively, being empathic and patient. Further, they require standard level of education followed by a clinical training as well as legal recognition (through registering as nurse practitioners at different levels) in performing their role. The ability to be efficient and self controlled in decisive situations, problem solving skills, right attitudes, same careful attention on each individual without any prejudice and the willingness to work any time shift during the day are some of the ingredients of a professional nurse.

Working environment of nurses

In modern world, a serious scarcity of nurses reported in many countries. One of the major reasons is the poor work related environment. Lucia et al (2009) highlighted the fact that nursing professionals are overloaded with work due to shortage of nurses. The high ratio between nurses-to-patients and the number of tasks handled by a single nurse resulted in cognitive work load. A high incidence of musculoskeletal disorders (MSDs) reported among nursing professionals due to long working hours and demand for handling multitasks with frequent interruptions.

The United Kingdom, USA, Australia, France, Germany, Canada and Ireland are some of the leading developed countries that attract the largest numbers of migrant nurses in their health sector in bridging the employment gap. Between 1995 and 2000 Australia received 11,757 nurses from various other nations. More than 10,000 foreign nurses were accepted to enter the United States, while 1998 to 2002, United Kingdom admitted 26,286 foreign nurses. The American Hospital Association reported 168,000 open positions in 715 US hospitals and 126,000 (75% of total) positions were vacant for registered nurses (Kline, 2003).

Challenges and rewards in working abroad

Nurses having opportunities to work overseas are two-fold; those who work in developed countries with advanced technical environments and in remote areas with less facility under local & international development organizations. There will be many more motivation factors for nurses to work abroad such as better standard of living, higher salaries, good climate conditions, and the experience of working in different culture in another country.

Kline (2003) depicted the fact that both push and pull factors resulting in nurse migration. On one hand, nurses migrate due to the desire of developing their professional skills and knowledge that would not be achievable in their current position or the country. On the other hand, nurses are attracted to countries with higher standards of living, personal safety and better wages compared to their native countries.

The reality of nursing abroad could be very different from what it first appeared.  Though there are many personal rewards and development opportunities in the profession of ‘abroad nursing’, many challenges and risks also involved in the work. Every day across the world, humanitarian aid activities take place in many locations where there are potential risks of serious accidents and life losses for aid workers. These include exposure to war torn areas, exposure to natural diseases, risk of travelling unsafe routes, and also threat of sexual abuse, abduction or permanent disability.

Nurses are supposed to work long hours that doubles the risk of developing a cancer. Charles (2013) concluded the potential risk of breast cancer among shift-working nurses, based on research conducted among total sample of 2313 women in Canada. UK health authorities introduced a compulsory test of HIV for all foreign health staff recruiting in the country, after discovering 10 South African nurses with HIV positive(Stubbings et. al.2004).

There is a great concern of the possibility for exploitation of foreign nurses. Brubaker (2001) stated that hospitals in Washington have paid less salary to overseas nurses that were less than those paid to comparable US nurses. Foreign nurses are excluded from jobs in leading facilities and tended to fill entry level positions as they are not US origins. (Brown et al, 1998)

The job satisfaction and perceptions among current nursing professional would set the trend for future generations to enter in to the profession. In a survey conducted among Registered Nurses, 36% of respondents claimed that they would not recommend nursing as a career option for young people (Charles, 2013). In another study, Stubbings et. al. (2004) reported that 25% of nurses actively discourage someone from going into nursing.

Even though there are many risk factors involved in abroad nursing, many find it as a life changing experience to gain many personal rewards to their life. At the same time it will add an extra value to the country that they are working for. Migrant nurse is a good source for knowledge transferring. The knowledge experiences and health practices which brings from the native country can be merged with the existing county health care facilities and finally go to a better methods or well organized health services.

With the developed skill set of abroad nurses will be extremely resourceful in terms of having direct impact on individuals and communities. While providing the healthcare services there are chances to experience the culture of an international locale. Exposing to traditions and customs as well as rituals and believes of a foreign country will be added benefit.

Most of the time nurses who are working for humanitarian organizations, recruited for under development countries suffering from many issues. Personal skills and attributes some of less tangible benefits can be absorbed from abroad nurses to develop those poorly resourced communities while paying them high salaries.

The effect on receiving countries is positive in that countries receive skilled nurses who can enter the workforce with minimal preparation to fill critical shortages. On an average day, the UK uses 20,000 temporary or agency nurses to fill shortage positions in hospitals, costing the NHS $1,235 million USD a year ( Stubbings et al, 2004;Kline,2003).

In the US, agency nurses can earn $50 per hour or $104,000 per year. Nurses who work as traveling nurses can earn $75 per hour or $156,000 per year (Gamble, 2002). The cost of employing foreign nurses is a much less expensive method of filling vacant positions. One hospital in Kentucky recently recruited 50 nurses from the Philippines at the cost of $300,000, which was roughly what the hospital paid for agency nurses for 1 month (Brown, 1998).

Abroad nurses are truly impacted by the developed, industrialized countries and there are many learning opportunities for them. Before returning back home they are able to develop and sharpen their skills. The medical case and extreme circumstances that nurses may come across in host countries prepare them to   overcome obstacles, handle emergencies and tackle challenges.

Working abroad often produce unique challenges as many underdeveloped, impoverished regions without adequate running water or electricity – sense candle light may use to deliver a baby or stitch wounds.

Hibbert (2003) mentioned to the “First trip of many for volunteer nurse”, in the Australian Nursing Journal article about the prevalence of ‘jiggers’ (a type of parasitic flea) burrow under the skin.  He further stated that   cutting jiggers from under the skin of locals is not something nursing courses taught, but a challenge that volunteer nurses face.

The sign of health care


All things considered, there is no doubt that the duties and responsibilities of nurses working across different countries and in specialties are quite challenging. They have to face a lot of challenges during their work. Though, they got personal rewards and development opportunities but risks are also involved in their work. They gain experiences and health practices which brings from the native country can be merged with the existing county health care facilities and finally go to better methods or well organized health services.




Brubaker, B (2001), ‘Hospitals go abroad to fill slots for nurses; wide pay gap exists between US foreign workers in D.C. area’, The Washington Post, June, pp. A.1.

Charles, S (2013), ‘Nurses working night shifts at greater breast cancer risk’, ‘Viewed 23 August 2013 <>.

Donna S. Kline., (2003),’Push and pull factors in international nurses migration’, Journal of Nursing Scholarship.Vol.35, No.2, pp.107-11.

Gamble, D (2002), ‘Filipino recruitment as a staffing strategy’, Journal of Nursing Administration, Vol.32, No. 4, pp. 175-177.

Glaessel-Brown, E. (1998), ‘Use of immigration policy to manage nursing shortages’, Journal of Nursing Scholarship, Vol.30, pp. 323- 327.

Hibbert, R (2003), ‘First trip of many for volunteer nurse’, viewed 24 August 2013.


Liz Stubbings and Janet M. Scott, (2004), ‘NHS workforce issues: Implications for future practice’, Journal of Health Organization and Management, Vol. 18, No.3, pp.179 – 194.

Lucia, PR, Otto, TE. and Palmier, PA, (2009), ‘Chapter 1 Performance in Nursing’. Reviews of Human Factors and Ergonomics, Vol.5, pp. 1–40.



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