A professional uprising

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"We need educated nurses, not just basic level, but specialists too. I walk into the ICU of a new hospital and am struck by the technology," she reveals. "We'd better have nurses at the bedside that know how to work that technology, and the multi-dimensional needs of those patients and their families."

Some more forward thinking governments have already established specialist courses, Oman has one of the most comprehensive and long established schemes. The Oman Specialised Nursing Institute, set up in 2001, runs six specialist courses in midwifery, nephrology, mental health, nursing administration, and adult, paediatric and neonatal critical care.

Any nurse with a diploma and two years post-registration experience, or a bachelor's degree in nursing, with less experience, is eligible to apply. By the end of 2007 a total of 951 nurses had taken part in the programme - mostly nationals. A further six courses covering community health, diabetes, ophthalmology and theatre nursing are now in the pipeline.

"The aim is to keep pace with the trends in nursing education and technology at the international level, and to continue to develop new programmes to meet the needs of the public," explains the institute's dean Abdallah bin Ahmed Al Rubaiey.

Nursing their ambitions

Other countries in the region, however, are lagging behind in the professionalisation of the nursing role. Lebanon and Jordan, despite having long histories of nurse education, are seeing many of their nurses leave because of a lack of career opportunities.

Nurse migration, despite what people think, is not is not just about money, says Fadi El-Jardali, assistant professor at the department of health policy and management at The American University of Beirut.

A study by El-Jardali, published in the International Journal of Nursing Studies in March 2007, found that 42% of nurses who left Lebanon to work abroad had done so to develop professionally. Better career proepects were cited second only to pay (57%) as the reason for leaving.

"In Lebanon once you are a nurse you are always a nurse. There are no development programmes and few nurses have the opportunity to advance," El-Jardali explains.

"In other countries they have better career succession, career planning and development, this helps them. They say to themselves if I go abroad I could be at a different stage in my career."

Personal ambition is one thing nurses have never been short on. Tens of thousands have traveled from their homes in the past 20 years to other countries to better their career prospects. This enthusiasm for professional development is palpable, Brown says. "Nurses and midwives soak up any education we provide. We can not cater for the need. People want it, they're thirsty for it."

Medical mountain

Yet, the road to full professional status is not without its obstacles. One of the on-going barriers is the medical model of care that still exists within more traditional healthcare facilities across the region.

This culture dictates that the doctor is always the lead clinician and the nurse simply carries out his or her orders. "Nursing is not viewed as a high status profession here. The role reflects something seen 30 years ago in Australia and the UK," Wollin notes. "The doctor says, and you do it, and if the doctor doesn't say it then it just doesn't get done."

The idea of multidisciplinary teams and nurse autonomy are still a new concept in many countries, adds El-Jardali. "Multi disciplinary teams are not established in Lebanon, physicians are still the person that dictates everything, and the nurse is the one that helps the physician. The scope of practice of nursing is not well defined."

It's a battle nurses across the Western world have already fought and won. Things are slowly changing here too, confirms Brown. "We do have some very forward thinking medical colleagues that have worked in other countries who recognise nurses are not working to their full potential at present," she says.

What doctors have to understand is that nurses are not there to steal their roles or tread on their professional toes, but to be the second half of a whole, Evans says. "We do more in terms of prevention. We need each other to make a strong healthcare system."

Earning the trust and respect of other healthcare workers, and the public, is essential for the successful transition from task orientated worker to autonomous practitioner. Setting the academic standard at which independent and accountable practice is allowed and expected, is one of the main steps to achieving this.

It is particularly important in countries such as the UAE and Saudi Arabia, which rely heavily on expatriate nurses who have undergone various types of prequalification training, Wollin says.

"There's a mix of education, people say they are registered nurses, they have a piece of paper to say so, but in Australia they would be enrolled nurses. They're not being deceitful, it's just that their education is not a professional one, but a practical based one," she explains.

Entrance level requirements are just the tip of the iceberg, however, the professions also need legal powers to create curriculums, set professional development standards, draw up scopes of practice, monitor continuing education, and to discipline those whose practice falls below the bar.

These are key, Brown says, to maintaining high quality care. "If you call yourself a profession and do a professional role, then you have professional responsibilities," she notes. "And those are to maintain and increase your competencies across your practice area."

All these activities fall under the banner of self-regulation, which is presided over in more developed countries by Nursing and Midwifery Councils. Both Oman and Jordan have recently set up councils to work in this way with royal and ministerial support. In the UAE the go-ahead has just been given to establish one too, with the full backing of Princess Haya, wife of Sheikh Mohammed Bin Rashid Al Maktoum.

With such high profile support there's no doubt that nurses and midwives across the Middle East are set to experience, if they are not already, a new energy around the development of their roles. But what individuals must ensure now, is that they also believe in themselves, Wollin says.

"Until they see themselves as a profession equal, but with different skills, to other healthcare professionals they will still do the gofering," she warns. "But if they do aspire to it then we are at the beginning of a very positive era of growth in the professional identity of nurses."

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