Copyright eContent Management Pty Ltd. Contemporary Nurse (2012) 42(2): 247257.

The impact of nursing leadership and management on the control of HIV/AIDS: An ethnographic study
HANI NAWAFLEH, KAREN FRANCIS* AND YSANNE CHAPMAN+
Princess Aisha Bint Al-Hussien College of Nursing, Al-Hussein Bin Talal University, Maan, Jordan; *Midwifery and Indigenous Health, Charles Sturt University, Wagga Wagga, NSW, Australia; + School of Nursing and Midwifery, CQUniversity Australia, Mackay MC, QLD, Australia

Abstract: This paper reports on an aspect of a larger ethnographic study that sought to investigate the impact of HIV/
AIDS on the practice of primary care nurses in Jordan. Nursing leadership and the style of management adopted by senior nursing and medical administrators at the Ministry of Heath were identied as factors impacting on the practice of the nurses and their capacity to raise community awareness and contribute to the prevention and control of HIV/AIDS. The study was undertaken in three rural and three urban primary health care centres (PHCC). Data collection included participant observation, key informant interviews, and document analysis. These data informed the development of descriptive ethnographic accounts that allowed for the subsequent identication of common and divergent themes reective of factors recognized as inuencing the practice of the nurse participants.

Keywords: ethnography, nursing, leadership, management, Jordan, primary health

his study sought to investigate the impact of HIV/AIDS on the practice of primary care nurses employed in Comprehensive Primary Health Care Centres in Jordan. It is argued that HIV/AIDS is a global epidemic and that the burden of this disease can only be reduced if communities are familiar with the disease etiology and methods of preventing the spread of the disease (Fauci, 1999; Hassan & Wahsheh, 2011; Ouzouni & Nakakis, 2012; PetroNustas, 2000). The World Health Organisation maintained that health care workers, including nurses who are engaged in practice at the primary care level have the capacity to inuence community behaviors and therefore improve population health (World Health Organisation, 1998).

Preferable or Village Health Care Centres (VHCC) provide minimal levels of primary care. In 2010 there were 84 CPHCCs, 368 PHCCs and 227 VHCCs providing health services that include primary medical care, maternity and maternal child health care, dental therapy and a limited range of diagnostic services (Ministry of Health [MOH], 2011). The concentration of services is in the CPHCCs with limited levels of service delivery increasing with rurality. Medical doctors, nurses, midwives, dentists, technicians and a range of administrative staff are employed in the CPHCCs. LITERATURE REVIEW The practice of nurses globally is changing. Increasing consumerism, technological innovations, new managerial policy and the evidence based practice revolution are factors identied as impacting on the role nurses play and will play in the future (Williams & Sibbald, 1999). Leininger (1995, p. 27) asserts that nurses in the 21st century will be deeply involved in providing competent, sensitive, and responsible care to individuals, families, and cultures from different communities and institutions. The preparation of nurses and the manner in which they will keep their practice current are issues being debated by the profession. Professional nurses are accountable for their practice and therefore are obligated to ensure that

BACKGROUND Jordan is a small country in the Middle East. The total population of Jordan exceeded 6113.0 million with a 2.2% population growth rate per 1000 at the end of 2010 (Department of Statistics, 2010). To provide equitable services throughout the country the Ministry of Health (MOH) established primary health care centres (PHCC) in rural and urban areas. These centers are classied according to the range of service provided. The Comprehensive Primary Health Care Centres (CPHCCs) offer the broadest levels of service, the PHCC offer a mid-range level of services and the

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understanding of daily life experiences of a cultural group within a specied context when extended periods of time in the eld are not warranted and/or are impracticable (Brewer, 2000; Darlington & Scott, 2002; Denzin & Lincoln, 2000; Jones, 2002; Leininger, 1985; Morse & Field, 1996; Savage, 2000). Understanding of the phenomena evolves following time spent by ethnographers in the eld observing daily activity within the specied context/s. Denzin and Lincoln (2000) advocate that data collection methods include watching, listening and asking questions. Spradley (1979) considers that when ethnographers undertake eld observations they should focus on the way people act and use artifacts. In this study data collection methods employed included: Participant observations, key informant interviews, targeted document analysis and eld notations (Hammersley, 1992; Hammersley & Atkinson, 1986). Ethnographic researchers review the data collected seeking to interpret why and how people act and proffer arguments for what motivates and sustains cultural practices evidenced through the analysis of the data. DATA COLLECTION Selection of data collection sites Following ethics approval from the host University and the Jordanian MOH six targeted CPHCCs, representative of three broad geographic regions, namely the north, the central, and the southern regions were invited to participate in the study. Three of the CPHCCs were located in rural areas and three in urban areas. The concentration of the Jordanian population is in the major urban areas where government, industry and the majority of services including employment, health, transport, and education are located; 71.4% of the Jordanian population live in the three major cities in Jordan1 (DOS, 2010). Rural Jordanians by comparison are considered disadvantaged and have limited access to the range of services taken for granted by urban counterparts.
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their practice is current (Chiarella, 2002; Daly, Speedy, & Jackson, 2009). Nurses practice in dynamic environments in which physical and drug and surgical therapies change daily and understanding of the psychosocial factors impacting on health are constantly being uncovered (Daly et al., 2009; Roberts & Taylor, 2002). It is accepted by the profession of nursing that employers can and should play a signicant role in supporting nurses expand their knowledge and skills. Jones and Cheek (2003) challenge nursing managers to be innovative and proactive in identifying nurses knowledge and skill needs and in developing and implementing appropriate programs. In environments characterized by shrinking resources and rigid structures the provision of effective professional development, training and education programs is difcult but not impossible. Nursing leaders in any health institution must provide clear direction that allows for the dening of nurses roles within the organization. Williams and Sibbald (1999) contend that nursing leaders are instrumental in the setting of professional boundaries, a strategy they consider limits workload overlap and ensure practice is undertaken within legally endorsed parameters. Castille (1999) argues it is important that staff is aware of professional responsibilities and organizational expectations from the commencement of employment. It is proffered that the employing organization (management) has a legal and moral obligation to provide staff with an orientation to the work environment. Management is responsible for ensuring that the work environment is safe and that staff members are aware of potential threats and methods of reducing risk (Cuthbert, Dufeld, & Hope, 1992). Management is also accountable for the standards of practice provided by employees. Nolan and Hazelton (1995) indicate that health managers must ensure that employees are able to meet job expectations, have the necessary qualications and are supported to meet job expectations. THE RESEARCH DESIGN An interpretive focused ethnographic methodology was chosen as the most appropriate design for this study. This approach allows for in-depth

The three major cities are Amman, Irbid and Zarqa. The estimated population there is (2,367,000, 1,088,100, 910,800) and the total Jordan is 6113,0 million in 2010 (DOS, 2010).

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To ensure that the context for data collection within the CPHCC services was appropriate the researcher spent time in one center in all clinical areas in which nurses were employed before isolating the emergency unit for eld observation (McFarlane, Bull, & Rietmeijer, 2002; Sarantakos, 2005; Tham, 2004). The emergency department was selected as the nurses provide direct patient care to ambulatory clientele and interact daily with medical and other colleagues and community service providers including the police and civilian defense personnel. Emergency departments provide primary medical care to the community with the majority of presentations being non life threatening acute medical conditions. Entering the eld The researcher spent 24 weeks in each of the six sites. On entering each site, the researcher was introduced to the senior nursing and medical staff, general staff and oriented to the setting. Staff were informed of the study and invited to participate. Written consent was obtained from staff in the emergency department/s prior to data collection commencing. If a staff member declined to be involved the researcher limited the period of observation when that staff member was working. The researcher engaged initially in general observation of the setting until familiar with the rhythms and patterns of the department. To limit the impact of researcher presence on data collection, several days were spent in each setting allowing for staff to become familiar with the process prior to commencing eld work (Morse & Field, 1995). Field notes were kept throughout data collection recording the setting, activities, overt roles of staff, interactions of staff with patients, and other staff. In addition, general impressions of what was being observed were documented and issues and events requiring clarication noted. At the conclusion of each day the researcher reviewed the notation and undertook a preliminary thematic analysis identifying issues to pursue. Once the researcher felt accustomed to the setting an intensive period of participant observations were completed. The researcher engaged with participants as they practiced, seeking conrmation of the rationale for observed activity as described

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by Williamson (2002). The participants included all levels of nursing staff namely registered nurses (RNs), practical nurses (PNs) and aide nurses (ANs)2. The researcher observed the ordinariness of daily life within the department/s and developed exemplars of usual practice and those that were unusual to guide observations and the development of vivid descriptive ethnographies. Body language, facial expression, communication techniques, and human interactions were observed and recorded allowing for elucidation of the culture of nursing practice within these settings (Gordon & Fleisher, 2002; Spradley, 1979). To conrm and further explore conceptual understandings of the emergent themes, key informants (internal and external to the data collection sites) were invited to participate in an in-depth interview. To conrm and further explore conceptual understandings internal key informants (nurse participants within the CPHCCs) who were identied as having insights required by the researcher to understand issues and/or events were invited to participate in an in-depth interview. These key informants were selected for their perceived capacity to provide further enlightenment of the culture (Leininger, 1985). External key informants who the researcher felt could conrm, explain or provide a different perspective were recruited and invited to participate in an in-depth focused interview (Denzin & Lincoln, 2000; Williamson, 2000). They were recruited from the Nursing Council, the MOH, the Nursing Directorate, Jordanian Universities and the Primary Health Care Initiative3 (PHCI). Selection of the external key informants was based on a perception that they either directly or indirectly inuenced the practice of primary nurses.
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RN 4 year training; PN 18 month training; AN 6 months hospital training Nursing Council is a Jordanian professional nursing organisation. The MOH is a government department responsible for health care in Jordan. The Nursing Directorate is a department of the MOH charged with the licensing of professional nurses, monitoring nursing practice and workforce planning (Haddad, 2002). The PHCI is a 5-year project funded by USAID which aims to develop primary health care services in Jordan (Primary Health Care Initiative [PHCI], 2002).

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DATA ANALYSIS Phase 1 All data including eld notes, interview transcripts and documentary evidence were imported as rich text format (RTF) into the computer software package QRS NVivo 7. Descriptive ethnographic accounts were developed for each of the six sites that explicated daily life within the emergency department. Phase 2 All data were scanned for signicant words (DeSantis & Ugarriza, 2000), phrases and themes that provided for clarication of the role and of the practice of the nurses in each of the six sites. The emergent role descriptions for each site were validated with internal key informants from each of the six CPHCCs. Next, a comparison of the role of nurses across sites was undertaken. This process resulted in the identication of role commonalities and differences. Phase 3 Covert and overt factors inuencing the role and practice of the PHC nurses were isolated following a secondary review of all data. These inuences on practice were subsequently considered with reference to the recommendations for practice articulated though relevant local, national and international policy, procedure manuals, participant and key informant reections and research. Phase 4 Cultural understanding emerged when the reality of daily life was described and rationales proffered to explain the inuence of HIV/AIDS on the practice of the nurses. RESULTS The CPHCCs provide a range of services to local populations. They are staffed by general medical practitioners, nurses, midwives, dentists, administrative support personnel and a limited number of diagnostic technicians. The CPHCCs were either two-storey or single-level constructions. The emergency department, ambulatory clinics and X-ray units were located on the ground oor of the two level buildings and maternity services, general administration and medical ofcer

Interview as a data collection technique is used by ethnographers to gain insider understanding (emic) of observed group interactions and behaviors (Baillie, 1995; Fiveash, 1998; Leininger, 2001; Morse & Field, 1995). The researcher sought clarication of issues as they were raised by each informant. Interviews continued until a level of data saturation was reached (Morse & Field, 1996; Seidman, 1998). Demographic data including age, gender, qualications, employment history were obtained from each key informant. Interviews lasted from 45 minutes to one hour and were audio-taped and subsequently transcribed for analysis (Morse & Field, 1996). The researcher believes that the practice of nurses is inuenced and directed by policy, research and tradition. It was therefore considered important that relevant localized and national documentation be identied and reviewed for impact on the role of the PHC nurses in this study. Documentation informing the study included CPHCCs documentation such as job descriptions, nursing notes, annual reports, inservice education records, meeting minutes, policy directives and practice procedure manuals, health information literature, communication from the MOH, published research reports and policy statements issued by the World Health Organisation and the International Council of Nurses. According to Lincoln and Guba (1985) existing records including les, reports, memos, public records etc. may provide insight into what is occurring in a setting, and/or within a group of people. Fetterman (1989) argues that personal documents can assist in understanding how people view and construct understanding while public records provide evidence of events that have occurred. The researcher was mindful of Spradley (1979) who suggests that ethnographers data collection and analysis must be guided by continually asking the data in what ways do members of the community (under investigation) actively construct their world, what is it like for a person in this situation, how do people actively shape their lives within this context and what environmental factors inuence coping and adaptation?

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accommodation were located on the second level. The emergency departments (EDs) in the single level CPHCCs were located at the front of the building allowing easy access. Other departments were adjoining. The CPHCCs located in urban areas were in better repair and were more contemporary buildings, than those located in the rural areas. Moreover, the equipment in the urban centers was newer and of a higher quality, than that provided in the rural CPHCCs. CHPCC management structures In each of the CPHCCs the head of the centre (HOC) was a medical doctor. The HOC was responsible for day-to-day management including clinical services and nances and reports to the MOH. The management structure in all the CPHCCs was hierarchal and dictatorial in nature with unit/ward and discipline heads reporting to the HOC. In each of the CPHCCs a RN was identied as the head of nursing (HON). In the absence of RN a midwife4 assumed this role. Within the EDs, a RN acted as the charge nurse. If a RN was not employed in the unit a practical or AN assumed this role. The head nurse was appointed based on longevity in the CPHCCs as indicated in Table 1. In four of the EDs, a PN held this position. This practice was criticized by a key informant from the MOH who argued that the level of education undertaken by this level nurse did not prepare them for a management role. Also justifying the continuation of this practice and stating that RNs will not accept positions in the CPHCCs because they value hospital practice and devalue practice in this context. Currently, in Jordan, there is underutilization of RNs in community health centers. There will be increased demand for more nurses; globally nurses are needed and employed in community health centers (Al-Maaitah & Shokeh, 2009, p. 12). Also there are imbalances in the distribution of health forces between hospitals and primary health care facilities and 90% of the MOH RNs work in hospitals, while only 6% work at PHC (Ajlouni, 2010, p. 7).
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TABLE 1: NURSING SKILL-MIX IN THE SIX CPHCC

EMERGENCY DEPARTMENTS

Health Nurses in the emergency unit centers RN PN AN Total (geographic region) M F M F M F North C1 (rural) North C2 (urban) Middle C1 (urban) Middle C2 (urban) South C1 (rural) South C2 (rural) Total 0 1 0 1 0 0 2 0 0 0 0 0 0 0 1 1 1 0 0 1 4 0 1 1 0 1 0 3 0 2 2 1 5 1 1 2 2 1 2 9 2 4 4 5 4 4

Nursing skill-mix in the CPHCCs Nurses employed in the CPHCCs included RNs, PN and AN. Table 1 describes the nursing skill-mix in each of the centers and classies the CPHCC as either urban or rural. Nurses employed in the CPHCCs were predominantly PN and AN. Urban CPHCCs employed higher ratios of RNs compared to rural centers and the numbers of aid nurses was higher in rural CPHCCs compared to urban centers. There was a general belief that the quality of nursing provided in the CPHCCs was inferior to that provided in the acute care hospitals. This belief was justied on the basis of the current nursing skill-mix. Informants claimed that unless RNs were employed, there was limited potential for practice development and that the quality of nursing care was compromised. They offered that having midwives in senior management positions within the CPHCCs was ineffectual as they did not have an understanding of the role of nurses who are the predominant workforce in this environment. Recruitment and retention The recruitment and retention of nursing staff was identied by many of the CPHCCs, particularly centers in the southern areas as a concern. It was

Midwives hold a 3-year diploma in midwifery practice only.

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primary health care is dened as a model that provides for medical interventions (that are) aimed at improving the health status of most individuals at the lowest costs (Wass, 2000, p. 13). Selective primary health care is claimed to operate in a way that assumes that medical care alone creates health and ensures that control over health is maintained by health professionals (Wass, 2000, p. 13). The MOH has focused attention on the provision of primary medical care, and largely ignored the role of non-medical interventions and community development. This ideology is pervasive within the health professions and contributes to the devaluing of clinical practice that is not concentrated on acute medical care. Consequently, the opportunity for career advancement in non-acute practice such as the CPHCC is limited and acts as a recruitment and retention disincentives. Nursing leadership Support from skilled experienced senior registered nursing staff in the rurally located CPHCCs was not available. It was noted that many of the clinical nurses engaged in uncacceptable and potentially dangerous clinical practices that included recapping used syringes, poor dressing technique, and inappropriate handling and disposal of potentially contaminated wastes. One of the key informants stated:
there are some common mistakes in our nursing practice like recapping the needles. Here most of the nurses recap the needles because it is a routine practice. [NVivo, Section 4.9, Paragraphs 2425]

argued that qualied nurses did not consider practice in the centers attractive. A nursing manager added:
the reason for this situation is that many skilled people do not like to work in the southern part because it is a remote area. [NVivo, Section 1.1.6, Paragraph 19]

A nursing supervisor from the southern area indicated that they were experiencing a shortage of nurses at all levels, particularly at the RN level. The supervisor offered that when they manage to recruit a RN, it is usually a new graduate who has been unable to secure a hospital position. This informant argued that the CHPCCs are unable to retain these recruits as there are no incentives provided by the MOH and that they accept hospital positions as soon as a vacancy becomes available. In addition, the MOH has adopted a practice of transferring RNs from CPHCCs to acute care hospitals when nursing staff are required. Many of the external informants and the heads of nursing were critical of the MOH for not considering the impact this policy has on the capacity of the CPHCCs. A key informant believes that this policy has eroded the ability of the CPHCCs to provide quality health care. Maintains that the practices of nurses employed in the CPHCCs are not valued and that the perpetuation of the current system raises the cost of health care services (NVivo, Section 1.9.11, Paragraphs 4243). Another informant argued that there is no consistency in the MOHs policies on health service provision. Expressed concern that the MOH devalues the CPHCCs stating:
the problem is that each (new) Health Minister has a different philosophy. For example, the previous Minister supported PHC services, but one year later, a new Health Minster changed all the policy. [NVivo, Section 5.1.9, Paragraphs 2526]

The recollections proffered by some of the informants indicate an acceptance that the MOH is not interested in the practice of nurses in the CPHCCs nor are they concerned with supporting the reorientation of the health care system and empowerment of the population. The system of health care delivery adopted in Jordan is similar to that described by Wass (2000). Wass (2000) outlines a model of health care service provision, selective primary health care that is a modication of the medical model and is inclusive of the principles of primary health care. Selective
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This nurse was aware that practice was inconsistent with published guidelines and justied non-compliance on the basis of ritualized practices. Many of the clinical nurses however, were unaware of practice guidelines. They confessed that they had not cited nor were they exposed through staff meetings to policy directives, practice standards or guidelines. The study highlighted that there is a gap in communication between the MOH and senior levels of nursing (nursing directorate) and clinical nursing staff in the CPHCCs. The MOH reported that standards for practice have been developed and circulated to all health facilities, a position supported by the Nursing Directorate (MOH, 2011). Data reveals that many clinical nurses are not familiar with standards for practice and that some CPHCC
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managers did not prioritize practice development. A nursing academic believed that:
the risk of (getting and spreading) AIDS is greater in the health care centres than the hospitals, because the staff there are not qualied [NVivo, Section 5.2, Paragraphs 4346]

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Indicated that the MOH and the nursing directorate were negligent and should be directing resources to these centers to up-skill the nursing and medical staff. Argued that the MOH and the nursing directorate must develop strategies to improve the attractiveness of the CPHCCs for RNs. Another informant suggested that action is required by the MOH to ensure that nursing practice improves and stated:
we need a system to organise nursing practice at the CPHCCs; strong regulation supported by a reward and punishment system (if we are to have) best practice in the health centres. [NVivo, Section 1.1.6, Paragraphs 1617]

involved in center management, the development and implementation of policy and/or practice guidelines. Nursing knowledge and skill in these centers was observed to be limited. The nurses did not initiate interventions unless directed by the attending medical practitioner. Moreover, they did not utilize the opportunity to provide patients with information on broader health issues when interacting with them. The nursing directorate was criticized for continuing to support the practice of appointing nurses not qualied for the positions they held. There was strong support from the external key informants and some of the CPHCC heads of nursing or the nursing directorate to regulate nursing practice. Chiarella (2002) maintains that regulation of the nursing profession assists the community to understand what they can expect of a professional nurse. Regulation authorizes the profession to set standards for practice and to drive the evolution of the profession (Pearson, 2002). An informant argued that:
without a clear system or policy, the staff will not apply the standards or even any instruction. [NVivo, Section 1.1.11, Paragraphs 2627]

One of the CPHCC, HON believed that substandard nursing practice continues to prevail because the system does not enforce compliance with practice standards:
it is the same for nurses if they do the right or the wrong thing because no one comes and questions them and there is no legislation to protect the patient from malpractice. [NVivo, Section 1.9.8, Paragraphs 2931]

While another informant offered:

a more regulated system would keep the staff aware of the standards, improves compliance and would help to empower the head nurses and encourage them to manage their staff more effectively. [NVivo, Section 5.1.8, Paragraphs 2324]

In ve of the emergency departments, effective nursing role models were not obvious. There was no evidence of nursing leadership. Nursing practice was directed by the medical ofcers and nurses were discouraged from questioning and/or seeking clarication of allocated duties. Nursing care was task oriented and dialog with patients was focused on treatment regimes only. The nurses in these EDs indicated that they had not been given an orientation to the unit when employed, and had learned what to do on the job. The opportunity to participate in professional development activities was not provided and the nurses understanding of occupational risk was not well developed. In the CPHCCs that did not have a RN appointed as the charge nurse, the role was diluted. The charge nurse in these CPHCCs had limited inuence on the HOC and was not
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Resourcing The CPHCCs that were located in the urban areas were better resourced than the rural centers. It was noted that in the rural EDs necessary equipment including sterilizing units were not operational and/or obsolete designs. In these EDs the nursing staff adopted innovative and sometimes dangerous practices including the disposal of potentially lethal wastes such as used syringes in improvised containers and or directly into domestic waste receptacles that were unmarked. The domestic waste was subsequently collected by local waste disposal authorities for dumping locally. The reuse of equipment for example dressing sets was a regular practice in all the EDs irrespective of geographical location. However, monitoring that the sterilization processes were consistent with

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performance appraisal is a useful approach to foster practice development. The literature suggests that performance appraisal can be a positive strategy if the staff has the opportunity to identify their goals and objectives and target outcome measures of performance (Cuthbert et al., 1992). The performance appraisal should allow staff to raise their concerns and negotiate workplace terms and conditions including training and continuous education. Key informant described how a HON supported practice development:
when I joined this centre, I found the nurses (were not knowledgeable about their practice). I started to teach them in groups about infection control standards, the concentration of the cleaning solution. I show(ed) them how to dilute (the cleaning solution) and I gave them a basin and brush to use when they clean the used instruments (I check that the solution is diluted correctly). [NVivo, Section 5.1.2, Paragraphs 4041]

recommendations was not consistent and potentially exposed patients and staff to unnecessary risk. Risk management There was limited evidence of risk management policies and procedures in the CPHCCs. Staff engaged in risky practices that exposed them to unnecessary dangers. The potential for exposure to harmful pathogens and injury by community members involved in handling waste disposal was considerable. It was found that the CPHCCs in rural areas were less well resourced compared to urban CPHCCs. These centers resorted to makeshift practices that were not always in accordance with recommendations for workplace safety. The majority of the CPHCCs did not have liquid soap or disposable paper towels available for staff to wash and dry their hands between procedures. Some of the CPHCCs experienced ongoing shortages of supplies and equipment such as: dressing sets; bandages; syringes; needles; and medications. One of the HON complained that in their CPHCC there was a shortage of dressing sets. Argued that this was one of reasons for poor sterilization:
we have only two dressing sets, which is not enough for an emergency unit. I asked many times for more dressing sets. we sterilize the equipment many times a day and reuse them how am I comply with infection control policies when we do 14 dressing for different patients? [NVivo, Section 1.13, Paragraphs 3233]

A key informant considers that effective management within the CPHCCs is dependent on the HON. Argued that if the head nurse models best practices and provides opportunties for nursing staff to evaluate their own practices; and facilitates access to in-service training; the skills and knowledge of the staff are raised. The informant reected on the processes used to assist nursing staff stating:
the nurses applied 21 tasks such as hand washing and vital signs...etc. I (had) them present these skills one by one to ensure that they were able to perform the task. When every new instruction is issued, I call them into my ofce and explain the directives; usually I explain at the morning meeting. [NVivo, Section 5.4, Paragraphs 1516]

A physician (acting as the HOC) supported the concerns raised by nurses regarding poor resources and stated that the quality of nursing practice was compromised by:
insufcient equipment for the number of patients attending the clinic/s. [NVivo, Section 4, Paragraphs 8082]

Practice development Findings support the perception of the nursing directorate and the MOH that nursing practice in the CPHCCs requires improvement. Many informants argued that practice will only improve when the nursing skill-mix is modied and the ratio of RNs increases. Others identied the regulation of nursing practice, rewards for exceptional practice and the imposition of penalties for poor practice. Some argued that introducing
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Informants recognized that the CPHCCs have the potential to positively impact on the health of the communities they serve, yet realized that change must occur to meet this expectation. A consultant from the PHCI and an informant from the MOH believed that a factor restricting the capacity of the nursing supervisors to effect positive changes was the absence of a clear vision of their role and/or their health service. Offered that:
I met some nursing supervisors to nd out their needs, some of them said I am a nursing supervisor (at the health directorate) but I do not know what to do when I go to the CPHCC I am sure this is the reason why they do not visit the centres regular(ly) This
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problem directed us to work with this group of nurses and see their ideas of how to (provide effective) supervision. There was a very (positive) response and a wonderful workshop (was) conducted here. [NVivo, Section 4.14, Paragraphs 4546]

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The nursing skill-mix within the CPHCCs was consistently identied as a factor associated with poor recruitment and retention of professional nurses. Senior nursing staff, academic and the nursing directorate staff believe that increasing the number of RNs employed in each CPHCC is the most effective tactic to improve service delivery. Demands on the existing trained nursing staff are onerous as one incharge nurse in an emergency unit described:
my role here is everything: housekeeping, physician, nursing aide and in-charge nurse, what more do you want? I have two nurses aide and they are a burden to me; I prefer to do the work by myself rather than asking them to do it. [NVivo, Section 1.3, Paragraphs 1112]

RN comments are similar to those expressed by the majority of senior nurses involved in this study. There was an overwhelming perception that the existing nursing workforce was responsible for the devaluing of the CPHCCs, by the MOH and the nursing profession in general. There was little sympathy expressed for the lack of support provided to the existing staff who are employed in the CPHCCs and limited appreciation for the role that these nurses have played in meeting service needs. There was agreement by the nurses that an orientation program for new staff recruited to the CPHCCs was essential. The criticisms raised regarding the practice of many of the nurses, particularly their lack of understanding of risk management procedures, highlights the potential danger these nurses, their colleagues and the broader community face. It was evident that without effective leadership, access to training, education and professional development and improved center infrastructure, the existing nursing workforce is unable to practice safely. There was no evidence of nursing staff at any level engaging with the community in raising awareness of infectious diseases including HIV/AIDS. DISCUSSION The employment of nurses with limited nursing skills to ll vacancies, was identied by the nursing profession as undermining the potential of nurses to inuence health outcomes of the Jordanian people. It
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was argued that the employment of nurses with limited education and skill to ll immediate vacancies in the CPHCCs was a short-term necessary strategy that has been allowed to continue for an extended, unwarranted period of time (Ajlouni, 2010; Al-Maaitah & Shokeh, 2009; Hijazi & Al-Maaitah, 1999). Moreover, the capacity of the existing nursing workforce to direct their own practice and to inuence policy at the CPHCC, Directorate of Nursing and MOH levels has been eroded by this dictum. Participants alluded to the need for the profession of nursing to challenge this strategy by increasing the numbers of graduate nurses, promoting PHC as a desirable practice and encouraging the MOH to address the needs of the existing nursing workforce. The capacity of the CPHCC nurses to participate in management and policy formation dialog is limited because of the dominance of medicine that supports restricted education of nurses (Chan, 2002). In many countries, for example, Austria, Denmark, Estonia and Italy, doctors dominate leadership positions and have a greater impact on the drafting and implementation of healthcare legislation and are better represented politically (Pearson, 2002). Jones and Cheek (2003) argue that nurse managers must be involved at all stages of practice development and remain involved in ongoing workplace debates in order that accurate, effective decisions are made which are reective of nursing concerns. Leadership and management issues impacted on the CPHCC nurses ability to practice at an acceptable standard and therefore inuence the management of HIV/AIDS. Ensuring that appropriately qualied nurses are employed in the CHPCCs and that all staff have access to continuing education, training and professional development activities is essential if practice is to improve and health outcomes for the community advance (Ajlouni, 2010; Al-Maaitah & Shokeh, 2009; Hijazi & Al-Maaitah, 1999; Mrayyan, 2004). Mrayyan and Acorn (2004) indicated that government, all health care professions, employers and administrators must work together to ensure quality health care is available for all Jordanian people. Creating and sustaining healthy safe work environments is required if staff are to be retained and services sustained. It is recommended that the Directorate of Nursing or a similar government authority regulate nursing practice to ensure that standards for practice are upheld. Also

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It is argued that the nursing workforce and the CPHCCs management must be cognizant of the environmental and practice related threats to staff and community safety, and adopt and monitor risk management policies. Nursing leaders must be supported if they are to facilitate practice development and embrace management opportunities. Nurses must be given immediate access to staff development, training and education initiatives. Management processes in the CPHCCs must be enhanced if health outcomes are to be improved and the spread of preventable diseases including HIV/AIDS is to be contained. REFERENCES
Ajlouni, M. (2010). Human resource for health country prole Jordan Geneva, Switzerland: WHO. Al-Maaitah, M., & Shokeh, D. (2009). The nursing workforce in Jordan: A policy oriented approach. Amman, Jordan: The Jordanian Nursing Council. Baillie, L. (1995). Ethnography and nursing research: A critical appraisal. Nurse Researcher, 3(2), 521. Brewer, J. (2000). Ethnography. Understanding social research. Buckingham, England: Open University Press. Castille, K. (1999). Infection control: To reuse or not to reuse that is the question. Nursing Standard, 13(34), 4852. Chan, S. (2002). Factors inuencing nursing leadership effectiveness in Hong Kong. Journal of Advanced Nursing, 38(6), 615623. Chiarella, M. (2002). The legal and professional status of nursing. Edinburgh, Scotland: Churchill Livingstone. Cuthbert, M., Dufeld, C., & Hope, J. (1992). Management in nursing. Sydney, NSW: WB Saunders. Daly, J., Speedy, S., & Jackson, D. (2009). Contexts of nursing. Sydney, NSW: Elsevier Churchill Livingstone. Darlington, Y., & Scott, D. (2002). Qualitative research in practice: Stories from the eld. Crows Nest, NSW: Allen & Unwin. DeSantis, L., & Ugarriza, D. N. (2000). The concept of theme as used in qualitative nursing research. Western Journal of Nursing Research, 22(3), 351372. Denzin, N. K., & Lincoln, Y. S. (2000). A handbook of qualitative research. Thousand Oaks, CA: Sage. Department of Statistics. (2010). Jordan in gures. Amman, Jordan: Author. Dozier, A. (1998). Professional standards: Linking care, competence, and quality. Journal of Nursing Care Quality, 12(4), 2229. Fauci, A. S. (1999). The AIDS epidemic Considerations for the 21st century. New England Journal of Medicine, 341(14), 10461050.
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improving health indicators argues Wass (2000) is dependent on empowering communities to manage change that inuences well-being. The results revealed that many of the CPHCCs do not have standards for practice or protocols to guide nursing practice. Nursing staff must be assisted to gain skills to develop local policies and strategies and to ensure that government policy and directives are accessible to all CPHCC employees (Dozier, 1998). Hirschfeld (1998) recommends that regular evaluation of the organizations (CPHCCs), work conditions and productivity of employees should occur to ensure quality services and best practice. CONCLUSION Maintaining the existing services provided by the CPHCCs in Jordan is compromised by health personnel shortages, particularly nursing shortages and scal constraints. The CPHCCs provide a broad range of health care services to diverse populations throughout Jordan. This study has highlighted that with increasing rurality the level of service provision decreases. The capacity for the CPHCCs to meet expectations and improve health outcomes for local communities is exacerbated by the current nursing shortage. The MOH has employed large numbers of nurses with limited qualications to work in the CPHCCs and has not been proactive in supporting them gain and expand their clinical knowledge and skills. This strategy has limited the ability of the CPHCCs to provide comprehensive primary health care services that are inclusive of health education and promotion. Nursing staff working in the EDs of the CPHCCs are in an ideal location to provide health information to patients and the broader community; however, they are not prepared for this role. Insufcient numbers of qualied nurses to lead nursing practice, and the perpetuation of a medically dominated approach to service delivery are cited as factors limiting their capacity to promote health and well-being. Populations serviced by the CPHCCs are not receiving necessary health information. The probability of infectious diseases including HIV/AIDS to inltrate and spread is high. Nurses engaged in providing direct patient care must be prepared to provide medical intervention but also offer global health information.
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The impact of nursing leadership and management on the control of HIV/AIDS

Fetterman, D. M. (1989). Ethnography: step by step. Applied social research methods series. Newbury Park, CA: Sage. Fiveash, B. (1998). The experience of nursing home life. International Journal of Nursing Practice, 4, 166174. Gordon, N., & Fleisher, W. (2002). Effective interviewing & interrogation techniques. San Diego, CA: Academic Press. Haddad, L. (2002). First annual report, nursing and midwifery in Jordan: Its reality, needs & strategies ambition with no limits. Amman, Jordan: Jordan University of Science & Technology, Jordan Nurses & Midwives Council. Hammersley, M. (1992). Whats wrong with ethnography? Methodology explorations. London, England: Routledge. Hammersley, M., & Atkinson, P . (1986). Ethnogaphy principles in practice. London, England: Tavistock Publications. Hassan, Z., & Wahsheh, M. (2011) Knowledge and attitudes of Jordanian nurses towards patients with HIV/AIDS: Findings from a nationwide survey. Issues in Mental Health Nursing, 32, 774784. Hijazi, S., & Al-Maaitah, R. (1999). Public service reforms and their impact on health sector personnel in Jordan (pp. 98150). Geneva, Switzerland: World Health Organisation, & International Labour Ofce. Hirschfeld, M. (1998). WHO priorities for a common nursing research agenda. Image the Journal of Nursing Scholarship, 30(2), 114117. Jones, J., & Cheek, J. (2003). The scope of nursing in Australia: A snapshot of the challenges and skills needed. Journal of Nursing Management, 11, 121129. Jones, S. R. (2002). (Re) Writing the word: Methodological strategies and issues in qualitative research. Journal of College Student Development, 43(4), 461473. Leininger, M. (1985). Qualitative research methods in nursing. Orlando, FL: Grune & Stratton. Leininger, M. (1995). Transcultural nursing concepts, theories, research & practice. New York, NY: McGraw-Hill, College Custom Series. Leininger, M. (2001). Culture care diversity and universality: A theory of nursing. Boston, MA: Jones & Bartlett. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. Beverly Hills, CA: Sage. McFarlane, M., Bull, S., & Rietmeijer, C. (2002). Young adults on the Internet: Risk behaviours for sexually transmitted diseases and HIV. Journal of Adolescent Health, 31(1), 1116. Ministry of Health. (2011). Annual Statistical Report 2002. Amman, Jordan. http://www.moh.gov.jo/ MOH/En/publications.php Morse, J. M., & Field, P. A. (1995). Qualitative research methods for health professionals. London, England: Sage. Morse, J. M., & Field, P. A. (1996). Nursing research: The application of qualitative approaches. London, England: Chapman & Hall.

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Mrayyan, M. (2004). Perceptions of Jordanian head nurses of variables that inuence the quality of nursing care. Journal of Nursing Care Quality, 19(3), 276279. Mrayyan, M., & Acorn, S. (2004). Nursing practice issues in Jordan: Student-suggested causes and solutions. International Nursing Review, 51, 8187. Nolan, A. M., & Hazelton, L. (1995). The practicing nurse. Sydney, NSW: W.B. Saunders Baillere Tindall. Ouzouni, C., & Nakakis, N. (2012). HIV/AIDS knowledge, attitudes and behaviours of student nurses. Heath Science Journal, 6(1), 129150 Pearson, A. (2002). The competent nurse? International Journal of Nursing Practice, 8(5), 233234. Petro-Nustas, W. (2000). University students knowledge of AIDS. International Journal of Nurses Studies, 37, 423433. Primary Health Care Initiative. (2002). Primary health care gets national standards of care. PHCI Innovations in Primary Health Care, 2(2), 1. Riin, S. B., & Walt, G. (1986). Why health improves: Dening the issues concerning comprehensive primary health care and selective primary health care. Social Science Medicine, 23(6), 559566. Roberts, K., & Taylor, B. (2002). Nursing research processes: An Australian perspective. Melbourne, VIC: Nelson Thomson Learning. Sarantakos, S. (2005). Social research (3rd ed.). London: Palgrave Macmillan. Savage, J. (2000). Ethnography and health care. BMJ British Medical Journal, 321(7273), 14001402. Seidman, I. (1998). Interviewing as qualitative research: A guide for researchers in education and the social sciences. New York, NY: Teachers College Press. Spradley, J. P. (1979). The ethnographic interview. New York, NY: Holt, Rinehart & Winston. Tham, K.-Y. (2004). An emergency department response to severe acute respiratory syndrome. Annals of Emergency Medicine, 43(1), 614. Wass, A. (2000). Promoting health: The primary health care approach (2nd ed.). Sydney, WB Saunders. Williams, A. & Sibbald, B. (1999). Changing roles and identities in primary health care: Exploring a culture of uncertainty. Journal of Advanced Nursing, 29(3), 737745. Williamson, K. (2002). Research methods for students, academics and professionals: Information management and systems. Wagga Wagga, NSW: Charles Sturt University, Centre for Information Studies. World Health Organisation. (1998). The world health report 1988: Life in the 21st century. A vision for all. Geneva, Switzerland: Author. Received 08 September 2011 Accepted 16 May 2012

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