The physical structure of the organization appears like an old building with open drainage systems including hospital, school of nursing, medical college and hostels. The hospital has altogether 1185 beds with mixed specialty of patient care which remain occupied almost all the time and each ward contains 50 patient beds. As far as the human resource is concerned, hospital has 425 nurses only, 40 head nurses and 230 student nurses. Apparently, the nurse patient ratio would be 3:50, as each ward has a capacity of 50 beds means 50 patients. According to the nursing representative, absenteeism is one of the major challenges for them to accommodate patient's requirement and assigns nurses when any disaster in the city occurs. They keep 7 nursing staff in morning shift, 3 in evening shift whereas only 2 are assigned in night shift. Additionally, in disaster or crises situations they assign student nurses as 'Labor' to overcome staffing shortage (Safrunnissa, personal communication, November 14, 2012). It gives the impression of nursing shortage and deficient health care facility which ultimately leads to compromised quality of patient care. However, in my assumption if student nurses are working independently without under supervision, then the possibilities of clinical errors and patient safety remain a question. Pakistan is a developing country that bears the double burden of diseases and its population. On top of it JPMC being a government hospital usually have the abundant influx of patients in such scarce resources and nursing staff. Nursing shortage always remains the foremost challenge for majority of the health care organizations nationally and internationally both. On the other hand, Khowaja (2009) stated that "the Pakistani health care system is neither competent nor comprehensive to provide adequate services for the growing population" (p.263).
Organizations always foster and advance with efficient leaders and strong management. Chain of command and management hierarchy plays the fundamental role in order to support organization well-disciplined and well-structured. Organizational structure in ancient times mainly consists of top managers who have all the power to bring any change whether it is in the favor of employees or not. However, for me they are the lever of an organization which can increase the impact of interventions with democratic approach and need to guard its employee for successful quality improvement of the facility. In JPMC somehow the situation is relatively similar as mentioned above. According Safrunnissa (personal communication, November 14, 2012) "It has a vertical hierarchy having top management on the position of chief nursing superintendent who is most experienced and has the authority power in nursing division, than comes deputy chief nursing superintendent, nursing superintendent, head nurses, charge nurses, registered nurses, midwives and assistant midwives. However, medical director and their committee's chairs all are physicians who are mainly the decision makers. Some of the positions in nursing division are vacant as the culture of the government setup is such that they grade their nurses on years of clinical experience rather than qualification." Nevertheless, in my point of view, to bring change in any health care organization gets difficult when it lacks well experienced as well as qualified leaders since the requirement of the professional advancement increase with the demand of time. Therefore, it is desired to educate and empower nurses so that they can share the governance and enhance nursing image for which nurses are still striving hard to achieve respectable position in society. We have explored on majority of the challenges that are faced by JPMC for e.g., lack of HR, lack of motivation, scarce recourses and management information system etc. Furthermore, in relation to leadership and management concept, the paper will mainly highlight the concept of chain of command of power, politics in health care, image of nursing and challenges that is having a devastating effect on health care organization and nursing profession.