Adelais Markaki

Municipal solid waste collectors are reportedly at risk
for Hepatitis A virus infection (HAV) as an occupational
hazard. We aimed to investigate the prevalence and
possible risk factors of HAV infection among solid
waste collectors in a municipality of the broader region
of Attica, Greece. A cross-sectional sero-prevalence
study was conducted. Fifty (n=50) waste collectors
participated in the study (response rate: 95%). The
group of municipal waste collectors was compared
to a convenient sample of workers not exposed to
solid waste (n=83). Municipal solid waste collectors
recorded a higher- but not statistically significant-
SummaRY
prevalence of anti-HAV(+) in comparison to subjects
without occupational exposure to waste (40% vs 34%
respectively p=0,4). No significant associations were
found between inappropriate work practices and anti-
HAV (+). Education was the only factor independently
associated with the risk of HAV infection. This study
did not corroborate previous reports of an increased
prevalence of Hepatitis A Virus infection among
municipal solid waste collectors.

Antibiotic resistance secondary to medical misuse
represents a worldwide phenomenon with far-reaching ramifications.
Thus, we read with interest the study by Wang and
colleagues1 describing trends of antibiotic overuse and misuse across primary health care (PHC) settings in China. According to the authors, up to 93% of respiratory tract infections (RTIs) were treated with antibiotics, with more than 6 of 10 prescriptions reported as inappropriate.1 Inadequate education and training of PHC personnel were also among the key findings.
It is estimated that more than 90% of antibiotics in PHC
are prescribed by general practitioners, with approximately
70% given for RTIs.2
Greece is among the countries with the highest antibiotic consumption and antimicrobial resistance rates in Europe.3,4  In Greece, access may be offered directly
from pharmacists without medical prescription, with the exception of fluoroquinolones and third-generation cephalosporins. Therefore, antibiotic misuse iswidespread and often underreported.
Inappropriate antibiotic prescription writing should be approached as a multifactorial problem where social norms play an important role.5
Primary care physicians frequently encounter non specific RTIs at the early stages. Faced with diagnostic
uncertainty and potential complications, as well as patients’
ill-founded demands and expectations, primary care
physicians are known to adopt a defensive medicine approach, prescribing antibiotics to ease fears. Despite absence of evidence-based need, physicians may choose a “clinically proactive” behavior through prescription writing in order to satisfy patients’ expectations. Anecdotal data from PHC settings in Greece show that a prescription is viewed by clients as a “substantial” and “tangible” consultation outcome, adding extra value to thephysician-patient encounter. Hence, “patient-induced” antibiotic prescription is seen as an essential intervention, potentially leading toward a faster recovery.
Education about antibiotic resistance and prudent use of antimicrobials, initiated at the undergraduate level for all health care professions, has to target both patients as well as practitioners.
Increasing awareness of primary care personnel is of great
importance. In this direction, multifaceted educational programs for primary care physicians on antibiotic use for RTI treatment are showing mixed results, with varying reduction in prescription rates.2,4
The necessity for culturally sensitive public health
campaigns in helping lay people recognize that antibiotic resistance presents a serious problem, not only for the affected individuals but also for a country, is clearly evident. Adopting a holistic and interdisciplinary approach could be
a new way to manage an old problem before it becomes too late.

References
1. Wang J,Wang P,Wang X, Zheng Y, Xiao Y. Use and prescription of antibiotics in primary health care settings in China. JAMA Intern Med. 2014;174(12):1914-1920.
2. Bjerrum L, Munck A, Gahrn-Hansen B, et al. Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT)—impact of a non-randomised multifaceted intervention programme.
BMC FamPract. 2011;12:52.
3. European Centre for Disease Prevention and Control. Annual epidemiological report: reporting on 2010 surveillance data and 2011 epidemiological data.
2012. http://ecdc.europa.eu/en/publications/Publications/Annual-Epidemiological-Report-2012.pdf. Accessed August 13, 2014.
4. Plachouras D, Antoniadou A, Giannitsioti E, et al. Promoting prudent use of antibiotics: the experience from a multifaceted regional campaign in Greece.
BMC Public Health. 2014;14:866.
5. McDonnell Norms Group. Antibiotic overuse: the influence of social norms. J AmColl Surg. 2008;207(2):265-275.

According to the social networks theory, people and events are interdependent and any simple act or omission can transcend the individual in a network ripple effect. Consequently, individual benefits and costs can affect others, near and remote. For countries caught in the midst of dramatic economic and social turmoil, acknowledging this, could offer a new perspective. In Greece, ongoing losses of established, mature professionals from academic, research and clinical settings, coupled by the deprivation of “new blood” entering the system, due to the hiring freeze in the public sector, present major challenges for Greek scientists and policy makers, but also for the international scientific community. Viewed from a social networks theory perspective, bold actions are urgently needed to safeguard the country’s precious research capital from a snowballing network effect.

Despite international interest on quality assessment systems (QAS) and their importance in health care accreditation, implementation of a Rehabilitation Services Quality Measurement System still remains a neglected subject in Greece. To identify appropriate tools for researchers and policy makers to assess the quality of rehabilitation services in Greece, within the current active debate on national health care reform. A critical review methodology was undertaken, using a systematic approach, aiming to identify the most appropriate tools in the field. Multi-step strategy was followed to gather relevant data, including bibliographical database, internet and hand searches. Twenty-two studies, articles and documents were identified as meeting all inclusion criteria, representing four QAS, compared according to appropriateness, efficiency, and feasibility for general use. The European Quality in Social Services (EQUASS) was evaluated as meeting all of the desired features, such as proper certification, objective measuring, equality, education and training, established guidelines and person-centered approach. EQUASS initiative, developed according to European standards and implemented in resource-limited settings, was recognized as the most adaptive and appropriate system for Greek rehabilitation settings. Health policy makers are urged to take findings into consideration in establishing an integrated, quality-assured rehabilitation system throughout the country.

Identified barriers of organ donation advancement include lack of knowledge, personal beliefs, and a negative attitude from health professionals. This article reports on current knowledge and attitudes toward kidney donation among nurses and physicians in a Greek general hospital. A previously used questionnaire was applied. More physicians than nurses were donor card holders, with registration rates being lower than expected. Over half of the participants did not consider themselves well informed about registering as a kidney donor. Older nurses differed significantly from younger ones in their willingness to become live donors if an adult required a kidney. Nurses who were blood donors had higher odds ratio of feeling well informed when compared with nurses who were not blood donors. Integrating organ donation issues into undergraduate health science curricula and continuous education interdisciplinary programs is essential in increasing awareness, eradicating negativism, and reversing inertia.

The objective of this brief communication was to tabulate common reasons for encounter in a Greek rural general practice, as result of a recently adopted electronic patient record (EPR) application. Twenty encounter reasons accounted for 3,797 visits (61% of all patient encounters), whereas 565 other reasons accounted for the remaining 2,429 visits (39%). Number one reason for encounter was health maintenance or disease prevention seeking services, including screening examinations for malignancies, immunization and provision of medical opinion reports. Hypertension, lipid disorder and ischemic heart disease without angina were among the most common reasons for seeking care. A strengths/weaknesses/opportunities/threats (SWOT) analysis on the key role of an EPR system in collecting data from rural and remote primary health care settings is also presented.

Many reports have commented on the decreasing level of humanity in healthcare, and that medical training has an increasingly scientific basis. This paper reports on a six-week elective on compassionate care, delivered to first year medical students at the University of Crete Medical School.The course proved highly popular, and may represent a starting point for emphasising the importance of compassionate care in the Greek healthcare system.

The population in the Gaza Strip has been living under chronically stressful conditions as a result of the ongoing Israeli-Palestinian conflict. To identify health complaints reported by attendants consulting primary care physicians in the Gaza Strip. The study took place in 10 governmental primary health care centres and 5 clinics of the United Nations Relief and Works Agency in the Gaza Strip, during autumn 2005. Self-reported health complaints were recorded through face-to-face interviews with 956 respondents using a validated and reliable questionnaire. Abdominal pain and headache were the most frequent complaints reported among patients aged 18 to 44 years, accounting for 23.3% and 22.7% of total complaints in males and females, respectively. Fatigue and joint pain were the most common complaints among patients aged 45 years and above, accounting for 26% and 33.9% of total complaints in males and females, respectively. The most common complaints, as reported by patients attending PHC facilities were stress-related and could be attributed to the ongoing conflict and high level of violence and uncertainty in the area. These complaints present a challenge to primary care providers in their efforts to improve the everyday quality of life of Palestinian residents with scarce means and resources.

Objective Numerous studies have identified a reduced health-related quality of life (QoL) in patients with urinary incontinence (UI). The aim of this study was to assess and compare QoL in women with UI in the island of Crete, Greece, and in Turkey. Methods Incontinent women from two community-based primary health care (PHC) groups (Greece and Turkey) and one outpatient clinic-based group were studied. Results A total of 231 (24.7%) women out of 932 women from the PHC group in Greece and Turkey reported UI whereas another 38 incontinent women visited the secondary care outpatient clinic. Mean Incontinence Quality of Life questionnaire (I-QoL) total score of women visiting PHC centers was 73.8 (SD = 23.5). There was significant difference among the three groups regarding I-QoL total and subscale scores, with women from the Greek community-based group having the highest score (mean = 81.8, SD = 20.7, P < 0.001). Impaired QoL was significantly associated with severity (P < 0.001), incontinence type (P = 0.026), seeking secondary care, and Turkey as sample setting (P < 0.001). Conclusion Urinary incontinence is a frequent problem for women visiting PHC centers, affecting negatively their quality of life. Besides incontinence severity, Turkey as place of residence emerged as another essential predictor of impaired quality of life, suggesting that other social and cultural factors may also play an important role.

The purpose of this exploratory study was to assess occupational profile, level of performance, and on-the-job training needs of nursing staff employed in all government primary health care centers in rural Crete, Greece. The translated, culturally adapted, and validated Greek version of the Training Needs Assessment questionnaire was used. There were no significant differences between 2-year degree graduates (LPNs) and 3- or 4-year degree graduates (RNs, midwives, and health visitors) in terms of importance for 28 of 30 assigned tasks, whereas level of performance did not differ in any tasks. Significant training needs were reported by all staff, mainly in research/audit and clinical skills. Systematic overview of skill deficits in relation to skill requirements should be implemented by regional health authorities to enhance delivery of on-the-job training targeting group-specific, local needs.

Background. Although early detection and systematic prevention of cancer improves outcomes and reduces mortality, General Practitioners’ (GP) effectiveness remains an issue that merits further investigation. Methods. To explore cancer control practices of Greek GPs, a version of the Cancer Control Practices questionnaire, originally developed in Western New York in 2001, was translated and culturally adapted. Results. Its reliability was found satisfactory in most the items. Conclusions. The instrument can be useful in determining Greek GPs’ knowledge and application of internationally established cancer-related guidelines, barriers they face in daily practice, and educational or training needs.

Over the past years, Greece has undergone several endeavors aimed at modernizing and improving national health care services with a focus on PHC. However, the extent to which integrated primary health care has been achieved is still questioned. This paper explores the extent to which integrated primary health care (PHC) is an issue in the current agenda of policy makers in Greece, reporting constraints and opportunities and highlighting the need for a policy perspective in developing integrated PHC in this Southern European country. A systematic review in PubMed/Medline and SCOPUS, along with a hand search in selected Greek biomedical journals was undertaken to identify key papers, reports, editorials or opinion letters relevant to integrated health care. Our systematic review identified 198 papers and 161 out of them were derived from electronic search. Fifty-three papers in total served the scope of this review and are shortly reported. A key finding is that the long-standing dominance of medical perspectives in Greek health policy has been paving the way towards vertical integration, pushing aside any discussions about horizontal or comprehensive integration of care. Establishment of integrated PHC in Greece is still at its infancy, requiring major restructuring of the current national health system, as well as organizational culture changes. Moving towards a new policy-based model would bring this missing issue on the discussion table, facilitating further development.

Capacity building is defined as promoting an environment that increases the potential of individuals, organizations and communities to receive and possess knowledge and skills as well as to become qualified in planning, developing, implementing and sustaining health related activities according to changing or emerging needs. Research capacity that develops skills and structures to facilitate research can be viewed as a critical component of overall capacity building within a profession. Hence, the link between research capacity building and capacity building in primary health care (PHC) nursing practice presents an issue of the up-most importance for the discipline of nursing. Disseminating knowledge and applying experiences gained from countries with well-established, advanced practice nursing in PHC to other countries, such as Greece, where PHC nursing is still seeking recognition, poses a current European challenge.

""Objectives: to assess support given to COPD patients concerning smoking cessation and the role of general practitioners and nurses in Cretan primary care settings.
Design: A telephone based cross-sectional survey.
Setting: Two primary health care centres in rural Crete.
Participants: 110 patients with a confirmed diagnose of COPD.
Main outcome measure: A pre-tested questionnaire was used in assessing smoking cessation advice and intervention received by patients with COPD. Patients were recruited retrospectively using electronic chart review and a telephone survey.
Results: Mean age was 74.7 years (95% CI 73.0-76.3). Smokers accounted for 62.7% (n=69) of all subjects. Among them 68.1% (n=47) had received verbal advice from primary care physicians, while no advice had been given by a nurse. Two patients (2.9%) had received nicotine replacement therapy. Eighteen (36%) expressed difficulties in following the advice they had received. Respiratory symptoms and financial problems were the main incentives for smoking cessation while only 3 (6.3%) patients had stopped smoking as a result of professional support they had received.
Conclusion: Support of patients with COPD who are smokers is offered occasionally by primary care physicians as mere advice without follow-up, while nurses have marginal participation. There is a strong need for including smoking cessation programs in primary care practitioners’ professional training and research for identifying the determinants of poor compliance of patients with COPD.""

Aim: Implementation of a descriptive, exploratory study contributing to primary health care strategic planning within the 7th Health Region of Crete. Methods: The study population included all 112 nursing staff employed in 2002 at the 14 rural Primary Health Care Centres (PHCCs) and 121 Satellite Clinics, throughout Crete. An original, validated questionnaire was mailed and 92 completed questionnaires were returned and were analyzed, statistically and qualitatively. Results: Serious understaffing and skill mix issues were identified in all the rural units, with Licensed Practical Nurses (LPNs) outnumbering other nursing groups. With regard to everyday nursing practice, overall there were no significant differences among nursing professionals with different qualifications. Holders of nursing or midwifery certification differed from non-certified staff in terms of involvement in counseling of patients (p=0.04), assessment of risk factors (p=0.04) and home care visits (p=0.02). The most important recruitment incentives for nursing staff were the reputation of the unit (73.9%) and residence in (71.7%) or origin from (65.2%) the catchment are of the unit. Interaction with patients and families and community recognition were the most important job satisfaction sources (84.8% and 82.6%, respectively), but 65.2% of all nursing staff were very dissatisfied with opportunities for professional development and 62% with lack of everyday support in their work. Deficits in human resources and equipment-supplies were reported as major obstacles to satisfactory job performance, while recommendations included effective human resource management and legislative changes. Conclusions: Critical issues for effective management of nursing staff employed in Cretan PHCCs included the limited opportunities for professional development, absence of on-the-job support mechanisms, role confusion, collaboration problems and difficulties in recruiting qualified personnel. Key words: job analysis, community nursing, human resources, professional development.

The objective of this paper is to identify the level of patients’ satisfaction with primary care physicians. Data were gathered from an exit interview using a standardized questionnaire (EUROPEP) and background variables. A total of 956 patients in fifteen primary health care clinics in Gaza Strip participated. Outcome measures is positive patient satisfaction (good and excellent ratings in the EUROPEP Index). As a results, the mean percentage of positive satisfaction with medical services was poor (41.8%). The poorest performance was recorded for: getting through to the clinic on the phone, being able to speak to physician on the telephone, time spent in waiting rooms and helping the patient deal with emotional problems. The comparison between clinical behaviour dimension and organization of care showed that clinical behaviour was evaluated higher. In conclusion, Palestinian patients expressed overall dissatisfaction with services provided by primary care physicians. These findings present a real challenge for Palestinian authority policy makers and administrators in terms of designing appropriate quality improvement strategies.

Background The translation and cultural adaptation of widely accepted, psychometrically tested tools is regarded as an essential component of effective human resource management in the primary care arena. The Training Needs Assessment (TNA) is a widely used, valid instrument, designed to measure professional development needs of health care professionals, especially in primary health care. This study aims to describe the translation, adaptation and validation of the TNA questionnaire into Greek language and discuss possibilities of its use in primary care settings. Methods A modified version of the English self-administered questionnaire consisting of 30 items was used. Internationally recommended methodology, mandating forward translation, backward translation, reconciliation and pretesting steps, was followed. Tool validation included assessing item internal consistency, using the alpha coefficient of Cronbach. Reproducibility (test – retest reliability) was measured by the kappa correlation coefficient. Criterion validity was calculated for selected parts of the questionnaire by correlating respondents' research experience with relevant research item scores. An exploratory factor analysis highlighted how the items group together, using a Varimax (oblique) rotation and subsequent Cronbach's alpha assessment. Results The psychometric properties of the Greek version of the TNA questionnaire for nursing staff employed in primary care were good. Internal consistency of the instrument was very good, Cronbach's alpha was found to be 0.985 (p < 0.001) and Kappa coefficient for reproducibility was found to be 0.928 (p < 0.0001). Significant positive correlations were found between respondents' current performance levels on each of the research items and amount of research involvement, indicating good criterion validity in the areas tested. Factor analysis revealed seven factors with eigenvalues of > 1.0, KMO (Kaiser-Meyer-Olkin) measure of sampling adequacy = 0.680 and Bartlett's test of sphericity, p < 0.001. Conclusion The translated and adapted Greek version is comparable with the original English instrument in terms of validity and reliability and it is suitable to assess professional development needs of nursing staff in Greek primary care settings.

In Greece, unlimited access to all health care services offered by insurance carriers and the National Health System has brought about an absurd situation, with use of technologically advanced services in managing even minor health problems. With their focus on highly technical care, the involvement of physicians and nursing staff in disease prevention and health promotion is not adequate. For historical reasons, nursing personnel do not have either the requisite experience or the acceptance by the general population, within a mainly physician-oriented health care system. The resulting increases in health care costs and congestion have created a picture of a health care system in crisis. Open health care networks have been developed in an attempt to control the demand for services for minor health problems sought through Emergency Departments (ED), and in response to the information deficit regarding major health risks and the rational use of health services. The operation of such settings as the “walk-in centres”, has reduced the hospital outpatient and ED load, while establishing high patient satisfaction. The current proposal encompasses a medical component similar to settings operating in Canada, and an information and orientation component according to US standards, while being based on the UK open access operational framework. The proposal also explores the potential contribution of regional and local authorities to health and welfare services, and the prerequisites for development of the necessary experience and skills by local government for involvement in the operation of primary health care services. Key words: community, health networks, primary health care, health policy.

"Background:
In 2001, the newly established Regional Health and Welfare System of Crete commissioned the first
needs’ assessment study of nursing personnel employed in the public sector of primary health care (PHC).
Aim:
To capture the profile and professional needs of nursing staff working in Health Centers throughout the
island of Crete and explore variations in nursing practice by educational preparation.
Methods:
A newly developed, psychometrically tested questionnaire, was administered to all nursing staff in 14
rural Health Centers.
Findings:
Vacancy rates are high, indicating a serious staffing deficit. The type of degree earned (2-year vs. 3 or
4-year program) does not differentiate nursing practice, with only two exceptions (obtaining a patient’s history and
counselling patients). The majority of respondents assess their existing knowledge and skills as ‘
adequate
’ while
indicating a strong desire for continuing education. Job satisfaction is high in terms of interactions with clients and
community recognition, while it is rated ‘
low
’ in terms of daily interactions with colleagues and support from work
environment.
Conclusion:
Cretan nursing staff in PHC operate within a restricted and task-orientated framework. Their
educational preparation has little effect in practice role variations and professional needs. The Regional Health and
Welfare System of Crete should address daily supervision and support issues, on-the-job training, continuing
education needs, while taking immediate action to avoid potential turnover of existing staff and to aggressively
recruit young, qualified nursing staff who will choose a career in PHC nursing."

Introduction
Primary health care (PHC) is closely tied to universal health (UH) aiming to reform universal coverage, service delivery, public policy, leadership, and stakeholder participation. Nurses’ and midwives’ actual and potential contribution towards UH and PHC is considerable. In light of the “2020 Nursing Now Campaign” and the “Triad meeting of Nursing and Midwifery”, administrators and faculty in Latin American and Caribbean (LAC) countries are urged to re-examine and re-align their educational program orientation and preparation of graduates.
Aim: To identify quality improvement (QI) resources for LAC schools of nursing and midwifery in order to strengthen UH and PHC outcomes.
Methods
Following a 2016 survey, all identified areas in need for improvement as well as recommendations were extensively studied by an expert group. A self-assessment QI tool guided the narrative literature review and website search. Identified resources were evaluated through a Cognitive Debriefing form.
Results
Using the Model For Improvement (MFI), QI resources were selected if addressing one or more of the following: a) “What are we trying to accomplish?”, b) “How will we know a change is an improvement?”, c) “What change can we make that will result in improvement?”. Resources were grouped under: 1) evidence, 2) best practices, 3) case studies, 4) consultation, 5) curriculum plan development, 6) measures, and 7) implementation. During the ongoing phase, a reconciliation list is developed for final review from stakeholders, including resources in Spanish and Portuguese. The outcome will be disseminated through the PAHO website.
Conclusions
Growing emphasis on UH and PHC signals an urgent need to re-evaluate priorities and goals for nursing and midwifery programs. Being knowledgeable and having easy access to linguistically and culturally adapted QI resources is a start. Integrating seamlessly throughout the plan of study, motivating faculty and students, and changing the organizational culture are the next steps towards truly embracing. Both nursing and midwifery are well equipped to make this paradigm shift.

Moving forward the United Nations (UN) 2030 Sustainable Development agenda within a higher education institution requires commitment, championship, engagement and innovation. For schools of nursing (SON), demonstrating the linkages among the Sustainable Development Goals (SDGs) and their implications for nursing and midwifery is critical. This SON practice innovation adopted an operational framework for global health (GH) action, disseminated the SDG agenda, and showcased how SDGs can be inter-linked with faculty productivity and documentation.

"Despite the scope and sophistication of contemporary health care, there is increasing international concern about the perceived lack of compassion in its delivery. Citing evidence that when the basic needs of patients are attended to with kindness and understanding, recovery often takes place at a faster level, patients cope more effectively with the self-management of chronic disorders and can more easily overcome anxiety associated with various disorders, this book looks at how good care can be put back into the process of caring.

Beginning with an introduction to the historical values associated with the concept of compassion, the text goes on to provide a bio-psycho-social theoretical framework within which the concept might be further explained. The third part presents thought-provoking case studies and explores the implementation and impact of compassion in a range of healthcare settings. The fourth part investigates the role that organizations and their structures can play in promoting or hindering the provision of compassion. The book concludes by discussing how compassion may be taught and evaluated, and suggesting ways for increasing the attention paid to compassion in health care.

Developing a multi-disciplinary theory of compassionate care, and underpinned by empirical examples of good practice, this volume is a valuable resource for all those interesting in understanding and supporting compassion in health care, including advanced students, academics and practitioners within medicine, nursing, psychology, allied health, sociology and philosophy."

Introduction: The present action research study was conducted to contribute to primary health care (PHC) planning within the 7th Regional Health System of Crete. The methods “job analysis” and “needs assessment” were used, as suggested by the international literature for effective human resource management. Aim: To describe nursing practice in regards to roles, clinical tasks, responsibilities and to explore continuing education (CE) needs, on-the-job training and professional development of nursing staff employed in primary health care centers (PHCCs) of Crete, as well as to formulate recommendations. Targets: 1) To describe demographic characteristics, individual abilities and job performance of nursing staff employed in PHCCs of the 7th Regional Health System of Crete. 2) To explore duties and responsibilities (roles, clinical tasks and scope of practice) in terms of frequency and self-assessed competence based on educational preparation (2 year vs. 3 or 4-year degree) and professional category. 3) To explore the applicability of a standardized, international tool assessing on-the-job training needs in Greek PHC settings, following translation, cultural adaptation and validation. 4) To assess attitudes and perceptions of nursing staff in regards to CE and on-the-job training. 5) To assess CE needs according to educational preparation and professional category. 6) To explore professional development needs (administrative-supportive, technical-resources, organizational). 7) To formulate recommendations and measures that would lead to improved PHC nursing care throughout PHCCs in Crete. Subjects and methods: Target population was all nursing staff (registered nurses, midwives, health visitors and and licensed practical nurses) of all 14 PHCCs and 121 Satellite Clinics of the 7th Regional Health System of Crete. Data collection was completed in two phases. During phase 1, the original, validated questionnaire “Assessment of Nursing Practices and Needs in Primary Health Care” was used and 92 completed questionnaires were returned. During phase 2, the translated, culturally adapted and validated tool “Training Needs Assessment” was used and 55 questionnaires were completed and returned. Data from both phases were analyzed statistically, according to educational preparation (group A=2-year degree graduates, group B=3 or 4-year degree graduates) and professional category, as well as qualitatively, according to the content analysis method. Results: There were serious understaffing (49.5% vacancy rates) and skill mix issues in all rural units, with licensed practical nurses (LPNs) being the most numerous (41.3%), in contrast to health visitors (5.4%). In regards to everyday practice, there were no statistically significant differences among nursing professionals according to educational level or category. Only exceptions were the counseling role which was assumed less frequently by LPNs (p=0.01), the teaching role which was assumed more frequently by midwives and health visitors (p=0.03) and obtaining a patient’s health history which was undertaken less frequently by RNs and LPNs (p=0.04). Holders of a nursing specialty certification differed in terms of the frequency of counseling (p=0.04), assessment of risk factors (p=0.04) and home care visits (p=0.02). The most important recruitment incentives were the unit’s reputation (73.9%) and residence (71.7%) or origin (65.2%) from the unit’s catchment area. The most important reasons for dissatisfaction were the lack of opportunities for professional development (65.2%) and lack of everyday support (62%). Deficits in human resources (53.6%) and equipment-supplies (36.2%) were reported as major obstacles in job performance. Professional development opportunities were very limited, fragmented and offered mostly off-site. Although the majority of staff had a positive attitude towards CE, family obligations, distance of CE site and lack of free time were identified as primary barriers. Inability to speak English, lack of basic computer skills or facilities and absence of professional guidance were all implied hindering factors. Self-assessed competence from both study phases was high, regardless of educational level or position held. Exception were midwives who in comparison to RNs exhibited higher competence in select activities, such as “gaining access to literature related to clinical work” (p=0.019), “statistically analyzing own data” (p=0.052) and “undertaking health promotion activities” (p=0.01). In terms of importance of assigned tasks , there were no significant differences between group A and B, except of the following two tasks rated as more important by group B: “communicating with patients face-to-face” (p=0.034) and “undertaking health promotion activities” (p=0.043). Last, job importance and level of performance for research/audit activities differed according to professional category (p=0.039 and p=0.001, respectively). During phase 1, the top 3 training priorities included “emergency services”, “screening programs”, “prevention-health promotion” and “ethics”. Individual ability to use a computer, roles and responsibilities assumed and the scope of nursing practice were significantly related to priority level assigned to specific training needs. During phase 2, significant differences in training needs emerged on 14 tasks for the whole sample, categorized into research/audit, clinical, management/supervision, communication/ teamwork and administration/business related activities. Training needs did not differ according to age or work experience. The psychometric properties of the Greek version of the TNA questionnaire for nursing staff employed in primary care were good. Internal consistency of the instrument was very good (Cronbach's alpha=0.985 p<0.001) and Kappa coefficient for reproducibility was found to be 0.928 (p<0.0001). Significant positive correlations were found between respondents’ current performance levels on each of the research items and amount of research involvement, indicating good criterion validity in the areas tested. Factor analysis revealed seven factors with eigenvalues of >1.0, KMO (Kaiser-Meyer-Olkin) measure of sampling adequacy = 0.680 and Bartlett’s test of sphericity, p<0.001. Discussion-Conclusions: Analysis of select variables portrayed with clarity PHC nursing practice and professional development needs of nursing staff employed in PHCCs throughout Crete. Everyday practice focused on technological care and the clinical role, whereas health promotion and prevention activities were carried out occasionally and opportunistically. Professional characteristics and level of performance among the four professional categories were similar, with minor differentiation, whereas statistically significant training needs were identified for all nursing staff, with minor differences among the four categories. Training in research/audit skills was rated as the most needed, along with continuing education in emergency nursing care, prevention, health promotion and screening programs. Critical issues for effective human resource management in rural settings included: understaffing and skill mix unbalances, difficulties in recruiting personnel with more advanced educational preparation, limited professional development opportunities, absence of resources offering support and consultation at work, role confusion/conflict and last, failure to implement a health team approach. Based on study findings, strategic planning at a regional level of continuing education and on-the-job training needs is essential in providing a standard framework for professional development, investing in trainees’ positive attitudes and in the “Training Needs Assessment” tool, found to be suitable for Greek PHC settings.