A professional uprising

Press reports of nurse salary disputes, shortages and strikes in the past few months have painted a picture of a profession in turmoil. But on closer inspection Jo Hartley finds a far more positive reality.

On the surface it would seem that nursing is in a state of negative upheaval, with disputes over pay and on-going shortages. But these noises of discontent, say nurse leaders, are actually the soundings of two professions finally finding their feet.

Both nurses and midwives have woken up to the fact that they are in demand, and have an integral role to play in the new climate of quality driven healthcare, being set up all over the Gulf.

"We are at the tipping point towards professionalisation," says Lauren Arnold chief nursing officer at the Mohammed Bin Rashid Al Maktoum Academic Medical Centre in Dubai Health Care City.

The centre is behind the 400-bedded University Hospital development, which will become a centre of nursing excellence when it opens in 2011.

Arnold plans for the hospital to win ‘Magnet' recognition from its very inception. If acheived it will be the first Magnet hospital in the region. Singling it out as a place where nurses deliver excellent patient outcomes, carry out nursing research and are integral in decision-making on care.

"We want the endorsement that this is a unique hospital environment [for nursing] and that it is a Magnet organisation that has passed the international test for high quality nursing care," she tells MT.

Her plans are ambitious but Arnold is not alone in her aspirations for the professional development of nursing and midwifery. A ground swell of enthusiasm and activity around reevaluating the professions' roles is taking place in many countries in the Middle East.

The movement is being triggered to a large extent by government desires to establish international standards of healthcare.

"You can not have international levels of care unless you have quality nursing," points out Judy Wollin, head of the nursing school at Fatima College of Health Sciences in Abu Dhabi.

International forces

The United Arab Emirate's [UAE] for example has a target for all hospitals to be internationally accredited by 2010. Nurses working in acute care settings who have already taken part in the Joint Commission International [JCI] accreditation process say this alone has led to increased recognition and respect for their roles.

"JCI accreditation was mainly conducted by nurses, and there is now a good atmosphere here to give the nurses more responsibility and to extend the nursing role," says Osama Diabat, one of 17 newly appointed practice development nurses working across the Department for Health and Medical Services [DoHMS] in Dubai.

The practice development role requires post holders to act as mentors, to be responsible for professional development opportunities, to improve the quality of care by introducing evidence based practice, and to conduct research.

Diabat's remit is to improve the quality of mental health nursing throughout Rashid Hospital - a long neglected area of care.

"We are involved in quality, education and research activities - I have even been asked to give lectures on communication to the doctor's interns - the future looks bright," Diabat enthuses.

The JCI process also led to the rewriting of all nursing and midwifery policies to be evidence based, the development of specialist in-house training courses, and the up-skilling of nursing assistants, according to Judith Brown, director of nursing and midwifery development at DoHMS.

"It has provided the pressure - the work had to be done - and it gave the nurses and midwives support from management, and from the hospital as whole that the standards had to be developed," she tells MT.

An all graduate affair

Abu Dhabi has also made moves to prepare the nursing profession for future demand. Health Authority Abu Dhabi [HAAD] took radical steps in September to end all nursing diploma courses in favour of degrees.

This was to ensure the capital's healthcare facilities would be staffed by internationally educated nurses, according to Wollin, who was recruited from the school of nursing at Griffith University in Australia, which is accrediting the new undergraduate dgree and bridging courses.

"The government was looking at up grading nurse education from a diploma and they wanted to move to a bachelor's education to improve the quality of registered nursing. It is part of their plan to build Abu Dhabi as an international centre for healthcare, like Thailand," she reveals.

The courses put Abu Dhabi on a par with the most advanced countries for nursing and midwifery education in the world. The move is an important step in the professionalisation process, Wollin adds, because it trains nurses to think critically and to base care on evidence, rather than on learnt tasks.

"We have got to make sure nurses are well educated so they can think as a professional, and then they have the right to talk as a professional," she reasons.

Nurse education in Oman and Qatar, which have both suffered in the past from cultural barriers to women performing personal care, are also on the way to producing degree educated nurses. The University of Calgary in Doha opened the doors to its faculty of nursing just over a year ago, offering the first and only degree courses in the country. Oman is planning to follow suit once a tie in with Cardiff University, in the UK, is finalised next year.

"They are just starting to develop programmes here [Qatar] and the degree is the standard elsewhere. It's not just about a piece of paper but about the kind of teaching that goes with being a profession," says Sheila Evans, interim dean and chief executive officer of the faculty.

The same degree based education is now being applied to midwifery, which was seen as an extension of nursing rather than a separate profession, across the region until recently. Dubai is leading the way with the establishment of the first postgraduate degree specifically for midwifery. It will be open to national and Arab nurses, and should be up and running in February.

Nurses and midwives in the region are not stopping at degrees, however, more and more are taking their academic studies further, attainting masters degrees and PhDs, with some countries, such as Oman, UAE, Saudi Arabia and Qatar, paying for their top nurses to study abroad.

"These nurses are collecting evidence to help us understand things that affect patient care," Evans says. "We believe that the nursing we do should be based on theory and evidence and not just because other people have always done it that way."

Specialists in need

However, it's not just prequalification education that is being ramped up. Opportunities for qualified staff to gain specialist training, and management and leadership skills, are also popping up across the Middle East.

Such training is essential to meet the growing complexity of patient needs, and to use the high-tech equipment that has become part of everyday nursing and midwifery practice, Arnold says."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."