In April 1994, the Ministry of Health and Welfare abolished the patient attendant system in hospitals in order to decrease patients' expenditure and improve the quality of nursing services. The purpose of this study is to investigate the actual nursing services in three hospitals which have abolished the patient attendant system and to examine the administrative policy of hospital directors and nursing directors for managing patient care.

Method: We nursed as participant observers in wards and conducted semi-structured interviews with hospital directors, nursing directors, nurses, assistant nurses and nurse-aides.

Result and discussion: Assistant nurses accounted for more than 50 % of nursing staff. Almost all nursing staff had been working from the time before the abolishment of the patient attendant system. The characteristic of nursing services in these hospitals is summarized in five points: 1) lack of information exchange on patient care, 2) hard working conditions, 3) lack of planned nursing care, 4) lack of autonomy in decision making and, 5) poor teamwork among nursing staff.

Conclusion: Nursing services were not improved following the abolishment of patient attendant system in the three hospitals. Hospital directors and nursing directors did not recognize hard working conditions of nursing staff. Additionally, they were expecting nursing staff to raise the level of nursing services, but they neither prepared better working environment, nor exhibited their leadership to train nursing staff in accordance with their careers. Nursing staff mentioned that hospital directors and nursing directors did not listen to nurses' opinions. The attitude of hospital administrators seemed to strongly influence actual nursing service quality.

Purpose of this study is to clarify influence of nursing administration to nursing service and nurse's consciousness in a private hospital that succeeded to shift nursing service system from non-‘KIJUN-KANGO' to ‘special 2 rank' (TOKU 2 RUI)of ‘KIJUN-KANGO' for 6 months in 1993 and to discuss why that the hospital succeeded to shift. This study was performed 3 times (①July 1-14, 1992, ②November 1-13, 1992, ③March 1-14, 1993).

Methods are semi-structured interviews to hospital director, nursing director, nursing staffs, participant observation and work study of nursing job in one ward, job satisfaction study to nurses and assistant nurses in the ward that is subject for participant observation.

Nursing administration style of subject hospital changed at June 1, 1992. There are characteristics in nursing administration, nursing service and nurses' consciousness as follows. 1. Nursing administration: Policy of nursing director is to value self-esteem needs. At first, nursing director improved work condition. Nursing education is based on reality. 2. Nursing service: Increased direct nursing time. Changed nursing service that was done by nurses and assistant nurses who had careers. Changed nurses' and assistant nurses' attitude to value patients' personality. Poor teamwork among nursing staffs. 3. Nurses' and assistant nurses' consciousness: Increased job satisfaction. Increased assistant nurses who hope to go to school of higher grade. Increased dissatisfaction of head nurse.

As a result of discussion these results, the most important factor that subject hospital succeeded to shift to ‘TOKU 2 RUI of KIJUN KANGO' for 6 months is that policy of nursing director is to value self-esteem needs.

A training system called National Vocational Qualification (NVQ) was founded in 1986 in Britain. These are 300 types and five levels in the NVQs and currently being trained in 23 types in the field of health and social care. In this field, however, the NVQs are limited only to the levels 2 and 3 in which their autonomy and responsibility are comparatively restricted.

Among the NVQs who are engaged in care in this field, the Direct Care NVQ of the level 2 is mostly provided to the nurse assistant of Japan. Education for the NVQs is mostly provided to nurse assistants as part of their training at work in the facilities where they are currently employed. The person who plays an important role in such training of these NVQs is a nurse who has the qualification as an Assessor who plans and manages the training course. With respect to the job demarcation between NVQs and nursing staffs, job descriptions have been scrupulously and thoughtfully prepared.

It is considered in many cases that the training of NVQs provides nurses good opportunities to display their new abilities. There is, however, a high possibility that the NVQs of the levels of 4 and higher will be newly introduced to this field. At the same time, there are apprehension that there may be duplication and confusion between NVQs and nurses in the courses of education as well as at work.

We have developed our original outpatient nursing consultation system, outpatient primary nursing in our hospital in the background of new establishment of “Home health care guidance charge” in remuneration in 1992. We stated the outline of this system, and studied the activities during the past five years and the change in attitude of nurses.

The consultation is carried out in accordance with the standard of “Home health care guidance charge”. The necessity of consultation to each patient is assessed by nurse, asking a doctor the order of starting of consultation. Nursing service is controlled so as to be attended continuously by the same nurse. The number of patients to whom consultation was carried out was 615 persons, composed of patients in internal medicine, surgery and pediatrics in the orders of their numbers. The ratio of the number of patients with remuneration to the total numbers of consultation has a tendency to increase. Nineteen nurses had experience in this activity among 31 nurses who were assigned in the outpatient department. In their answers to questionnaire, comparing with the case before they participate in this activity, both answers of “I became a good listener to their talk as much as possible when patients and their families talked to me” and “I became to call to patients to get some information about their condition at home” increased “greatly”. Further, their teamwork became better and many of them answered that their self-studying promotion and satisfaction with and independence for their work increased “considerably” or “to a certain extent”.

As for the burden of their work, both answers of “increase” and “no change” were found. In free comments, they expressed such as “I am busy, but I am satisfied with my work”, “my attitude toward patients were changed”. The answers of 12 nurses who had no experience in this activity had a tendency as follows “it seems to be hard work for me”, but “I would like to try”. On the other hand, “it seems to be unable for me to do during working hours”. From these results, this activity seems to be useful for making good use of nurses and developing the ability of them, and we aim at increasing of this activity.