plans. As mentioned, this is a global movement, not just a European one.
Evidence collected by WHO suggests that the scope and purpose of the plans also vary. Some countries, such as the United Kingdom, have de-veloped comprehensive strategies, including targets for practice, educa-tion and management. Others take a more narrowly focused starting point; for example, Greece proposes starting with the establishment of a national council for nursing development. In addition, strategies are being developed at subnational or regional level. All four parts of the United Kingdom have developed their own strategies; some cantons in Switzerland have specific nursing plans, as do some provinces of Spain and some oblasts in the Russian Federation, such as Tyumen. Accord-ing to their replies to a 1994 survey conducted by WHO headquarters, the following European countries have developed and adopted plans:
the Czech Republic, France, Greece, Hungary, Kazakstan, Latvia,
Lithuania, Poland, Sweden, Slovenia, Turkey and the United Kingdom.WHO also knows of development activity in this area in Belarus, Bel-gium, Croatia, Estonia, Finland, Kyrgyzstan, the Netherlands, Romania,
Slovakia and Tajikistan, and work beginning in Armenia, Bulgaria, Georgia, the Republic of Moldova, Turkmenistan, Ukraine and Uzbek-istan.
Some examples of the ways in which three countries have tackled the need for strategic planning are given below. The descriptions are not comprehensive or detailed, but intended both to give a flavour of differ-ent approaches and to encourage countries to documdiffer-ent their own de-velopments in case studies.
England
In 1989, the Nursing Division of the Department of Health (England's equivalent of a health ministry) issued a unique blueprint for the pro-fession entitled A strategy fir nursing (14). Designed to be an integral part of government health policy, it was widely circulated and debated within nursing and midwifery. Mindful of the changes facing the
pro-fessions, a seminar chaired by Anne Poole, then government chief
nurse, highlighted ten key issues ranging from the reform of nursing ed-ucation to the management of standards of practice. A steering group was appointed with wide representation from different branches of the professions. It took the work forward and produced 44 targets for action under the headings of practice, personnel, education, and leadership and management.
After the strategy document was launched there were many changes in NHS policy, producing a host of innovations. The new chief nurse, Yvonne Moores, thought it timely to consider the implications of these changes for nursing and to provide a new framework for nursing, sum-marized as A vision for the future: the nursing, midwifery and health vis-iting contribution to health and health care (15). This 1993 document set out 5 key areas and 12 targets. The first year's activity was moni-tored; a survey showed that good progress had been made towards some of the targets, but that more work needed to be done (16). Three project development sites were selected because of their involvement in the im-plementation of the steering group programme. Each was to examine a different aspect of the national action plan and report on the progress made.
Estonia
Nursing leaders from Estonia were introduced to the idea of national ac-tion plans at WHO meetings. They expressed keen interest in working on their own plan and, with encouragement from the chief nurse, Ester Puusepp, the Minister of Social Affairs agreed to include the project in the 1994 /1995 medium -term programme of cooperation between WHO and Estonia, thus securing some funds to start the activity. Following discussions, it was agreed that WHO and the chief nurse would arrange a workshop to take forward the ideas and strategies developed at WHO meetings.
Estonia was already developing strong nursing networks. It had es-tablished an NNA, and reforms in nursing education and practice were being initiated, sometimes with the help of nurses from neighbouring countries such as Finland and Sweden. These activities were not yet well coordinated, however, and there was no recognized leadership group in nursing. It was decided to use a WHO workshop to create a leadership group. Using the WHO guidelines, the chief nurse identified 20 nursing leaders: nurses, midwives and doctors from health service management, practice, education, the NNA and the Estonia LEMON Group. The group met before the workshop to prepare, and materials were translat-ed into Estonian and circulattranslat-ed in advance. With WHO's help, links had
been established with a group of nursing leaders in Finland who were also embarking on the development of a national action plan; these lead-ers helped to develop the workshop programme and acted as facilitators.
The workshop, held in May 1995 and led by the WHO Regional Ad-viser for Nursing and Midwifery, Jane Salvage, was evaluated by par-ticipants as extremely successful. It helped them to clarify their visions and goals, and to formulate specific objectives. It also introduced them
to democratic planning processes and ways of achieving consensus
through open discussion and acknowledgement of different perspec-tives, not only by discussing this in theory but by using it as the work-ing method of the workshop. A group was formally established to carry forward the work, with members drawn from among the participants, and specific themes were identified as priorities for work by subgroups.The participants agreed on a programme of future meetings and decid-ed that the Finnish experts would be consultdecid-ed on particular issues as the need arose. They forwarded their recommendations to the Minister of Social Affairs, including a request for administrative and financial support in developing the national action plan. They agreed to publicize the outcomes as widely as possible, and both Ms Puusepp and Ms
Sal-vage discussed the issues in the national mass media. (There was widespread interest in nursing at that time as Estonian nurses were
threatening strike action over pay.)The new group met again less than a month later to draw up more detailed plans and establish subgroups to look at education and training, leadership and legislation, terminology in Estonian, and practice stan-dards. A timetable of meetings was agreed until the end of 1995. The chief nurse reported that there had been two radio broadcasts to intro-duce listeners to the objectives and results of the seminar, which were followed by numerous approving phone calls. Nurses were also invited to give talks in different institutions. The activity looks set to continue and flourish, and has been included in the 1996/1997 medium -term pro-gramme of cooperation between WHO and Estonia.
Finland
In 1994, with WHO support, Finnish nurses set up a nursing expert group to develop a strategic plan for their country. It was felt that the achieve-ments and energy of the 1980s, when a strong nursing plan was developed as part of the overall strategy for health for all, were being lost in the 1990s and that a fresh start should be made. The secretariat for the new initiative was based at the National Board for Research and Development in Health (STAKES). Work began with the compilation of a country
nurs-ing and midwifery profile for Finland, as suggested by WHO, to brnurs-ing to-gether systematically data that had not previously been assembled. The completed profile would be disseminated to a wide audience and re-viewed at intervals to assess progress. Meetings of the expert group have been held with wide representation - of practice, education, research, ad-ministration and regional nurses - to identify and discuss problems.