Nursing is the largest healthcare profession all over the world and currently it is gaining marked recognition globally. The demand of nursing is continue to rise. Nurses are not only providing direct primary patient care but are also engaged in performing non-clinical functions that are essential for any healthcare organization. A nurse is not only responsible for patients' care, treatment, recovery, health promotion, health maintenance and health restoration only but also for families and community at large ( Tomey & Alligood, 2006). Nursing is currently more accepted and favorable by the society because it offers job security and career development ( Mooneya, Glacken, & Brien, 2008). According to NSSRN (2004) as cited in U.S bureau labor statistics(2007) that more than one million nurses will be needed by the year 2016 in order to fulfill nation's healthcare requirements. However, there is an imbalance in the number of nursing personnel in both developed and developing countries. Pakistan is one of the developing countries that are extremely affected by shortage of nurses. In Pakistan, 13132 nurses per year from all fours provinces are produced. There is one nurse for every 3,175 people. This ratio signifies that nursing has remained a neglected area in Pakistan and healthcare system desperately requires nurses greater than ever before ( Seir, 2006 ). This paper mainly focuses on the healthcare system of Pakistan, nursing turnover, and nursing education in Pakistan.

The current health situation of Pakistan is not very promising. Pakistan is a developing country that bears the triple burden of diseases; communicable diseases continue to be a major threat, albeit non-communicable diseaserelated mortality and morbidity is predominating. In 2005 and 2006, less than 17$ was spent on each Pakistani's health, whereas the government should be spending per capita 30$ to 35$ as per the international standards ( Khowaja, 2009). Health care system of Pakistan is facing lots of challenges in fulfilling requirement of health care personnel and addressing health problems of the entire population. The major factors contributing in the shortage of nurses are low salary, lack of career development, migration, marriages, pregnancies, domestic problems, less educational opportunities, poor infrastructure of teaching and learning resources, lack of involvement in decision making at different level of healthcare system, and violence etc. There is a need to encourage young generation to have necessary qualification and enter in healthcare environment in order to aid in the shortage of health workforce with best practices. In addition, health care policy makers also need to understand the importance of nurses' human resource development.

Nursing is a noble profession and nurses are the backbone of any healthcare organization. Nursing shortage, nursing retention and recruitment always remain the foremost challenge for majority of the health care organizations nationally and internationally both. As stated by ( Khowaja 2009 ) “the Pakistani health care system is neither competent nor comprehensive to provide adequate services for the growing population” (p.263). According to ( Khowaja, Merchant and Hirani 2005), nurses reported that they feel dissatisfaction in their job because of work load due to understaffing. Nurses work 12 to 24 hours and attend so many patients at a time. According to Pakistan Nursing Council (PNC), one nurse is required for three beds and three nurses for ten beds ( Seir, 2006). However this is not the case. Nurse patient ratio has become unrealistic because the influx of patients has increased creating over burden of work on nurses. Another reason for nursing turnover is, the increased market demand of nurses' internationally with attractive salaries and benefits. Globally, nursing is considered a well-paid profession.

One more reason of nurses' turnover is the recognition or appreciation of nursing staff from nurse manager. Nonsupportive managers may influence motivation and satisfaction of nursing staff not individually but also the entire nursing unit ( Khowaja, Merchant, & Hirani, 2005). Nursing managers are the lever of an organization that can increase the impact of interventions with democratic approach and need to guard its employee for successful quality improvement of the facility.

Nursing has mostly received low public image in Pakistan. Nursing is considered as a female dominated profession and the clinical practice of patient care is apparently submissive to the medical practice ( French, Walters & Mathews. 1994 ). There are other factors which contribute to low status of nursing profession such as low socio economic background of nurses, poorly regulated and enforced educational standards, less power or authority in decision making in healthcare system and so forth. Differences in educational standard and job description of doctors and nurses also effect on public image of nursing. Generally, in healthcare setting physicians are the ones who plan treatment for patient and prescribe medication whereas nurses use to follow their instructions as ordered. This affects the public image, expectations and behavior towards nurses in work environment ( Helmsley-Brown, & Foskett, 1999 ).The discrimination in the work structure of nurses and physicians also let the public to view nurses as being less knowledgeable and skillful.

Another factor related to nurses' images in Pakistan is the lack of awareness among people about nursing practice and education ( Gul, 2008). Gul stated that majority of the people did not know about the duration of nursing education. This indicates that many misconceptions about nursing that exists among public, lead to poor image of nursing profession. There is a strong relationship between nurses' self-image with their job satisfaction and job performance.

Nurses are still striving to gain respect, dignity and professionalism in the society. In this male dominant society, public image of nursing in still undervalue. To improve quality of nursing, healthcare system requires qualified faculty members to promote maximum clinical expertise, empowerment, respect and a voice for nurses. Currently, Pakistan lacks such qualified teachers and therefore, it is difficult to implement degree programs at all level. Moreover, unfortunately the standard of nursing education in most of the institution in Pakistan is dishearteningly low. Over the next couple of years, the annual enrollmentof nursing students will be more and there will be additional need of Phd. Professors and atleast masters' degree faculty in nursing in Pakistan ( Khowaja, 2009 ). According to Manzoor, Daud and Hashmi (2010), only 33% nurses have acquired BScN degree in Pakistan and 1.3% nurses have master's degree in nursing.This data signifies that current demand of BScN and masters prepared nurses are needed to fulfill not only the requirement of healthcare system in providing quality care to the patients but also for advanced clinical practice, teaching, and research roles to have competence nurses for future.

Pakistan is deprived of healthcare facilities and resources, and healthcare professionals especially nurses, which severely affect the entire nation. Nurses are perceived as hard workers, patient centered and important partners of any healthcare organization. There is great need to change the public image of nursing in Pakistan in order to endorse respect to the nursing profession. It is important for the decision makers of healthcare sector to plan strategies and intervention to recruit and retain more nurses. PNC should take step in redesigning and restructuring nursing curriculum, improving nursing standards, and planning intervention to equip nurses for Pakistan. Healthcare system will progress more when nurses will be actively involved in decision making, development and implementation of quality initiatives of healthcare organization.