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Fri 26 Dec 2008 04:00 AM

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Emergency on the wards

Why a well-trained and motivated nursing workforce is a key component in quality healthcare in the Middle East.

Well-trained and motivated nursing workforce is a key component in quality healthcare, but in much of the Middle East nurses are a transient workforce in short supply. In the first of a two-part series, Jo Hartley investigates the future of nurse recruitment and the moves to attract local talent.

Globally nurses make up the largest chunk of healthcare professionals and the middle east is no exception. Across the six member countries of the GCC there are around 130,000 nurses and midwives - about double the number of physicians.

In a region facing rapid population growth and soaring rates of chronic diseases, the need for qualified nurses and midwives is set to explode. Set this against the ambitions of some arab states to become world-renowned health hubs, add a worldwide shortage of nurses that has existed for more than 20 years, and the problem of nurse staffing becomes abundantly clear.

In a region facing rapid population growth and soaring rates of chronic diseases, the need for qualified nurses and midwives is set to explode.

Official figures show there is already a 100,000 strong nurse shortage in Saudi Arabia. A study published in human resources for health in march 2007 shows that the density of people working in health in the eastern mediterranean region is the second lowest in the world.

A quick Google search for ‘nursing jobs in the Middle East' brings up listings of recruitment websites offering all manner of nursing positions. These are hallmarks of an industry fuelled by international recruitment, the main method for shoring up nurse numbers in the region's shortage-plagued countries.

Saudi Arabia is a case in point. Seventy six percent of the nursing and midwifery workforce is made up of overseas recruits - just last month the government recruited another 2,000 Filipino nurses. The United Arab Emirates has 85% foreign nurses, while Qatar takes the number one spot with more than 95% of its nursing workforce recruited overseas, according to nurse sources.

Favoured countries for mass recruitment are the Philippines and India with Malaysia, Indonesia and China being the latest countries to join the nurse exporter list. More senior nurses typically come from the UK, South Africa and Australia. Even Middle East countries such as Jordon, Lebanon and Egypt export homegrown nurses to their neighbours.

As a result, the UAE hosts more than 50 nurse nationalities, according to Fatima Al Rifai, chief nurse at the UAE's Ministry of Health (MoH), who went to south India and the Philippines in June to recruit 800 nurses to work in hospital and clinics.

"We have a shortage of nurses that has to do with our culture and we always have to recruit from outside. So we really very much depend on what is happening around us in the whole world, as everyone is competing for nurses," she explains.

However, Bothyna Murshid, assistant professor at the school of nursing at King Saud University of Health Sciences, Riyadh, says it is getting harder to attract quality nurses. "I tried to recruit teaching staff for our college from everywhere but we had difficulty recruiting because of salaries."

Poor exchange rates mean Saudi Arabia is no longer as attractive a destination for Western nurses as it once was, Murshid adds, but it is still highly profitable for nurses recruited from less developed countries.

"The Filipino nurses are underpaid," she admits. "They get maybe 5,000 to 7,000 Saudi riyals a month compared with new Saudi graduates who get 10,000 riyals. But the exchange rate it is still good for them."

Money moves

As the worldwide shortage of nurses grows exponentially alongside demand, the issue of wages will become a crucial issue for Middle Eastern governments looking to attract nursing and midwifery staff.

Nurses in the UAE responding to an MT salary survey say they are thinking of resigning from their jobs because of low pay. A Filipino paediatric staff nurse with 16 years of experience says she earns under AED 5,000 per month.

"They are not paying me for my performance but for my nationality. I am looking for another job."

It's not only nurses from lower income countries that move for money - pay is the key driver for all nationalities when it comes to nurse migration, says Fadi El-Jardali, assistant professor at the department of a health policy and management at the American University in Beruit Lebanon.

A study of Lebanese nurses headed by Jardali, published in March 2007 in the International Journal of Nursing Studies, found that 19% of nurse graduates from the country's four leading nursing schools were working abroad.

The main reason for leaving Lebanon was financial, with 57% of nurses citing this as the key driver, closely followed by the desire to develop professionally at 42%.

"Many of the people that graduate in Lebanon migrate for different reasons; social, economic, political and workplace; to go to rich countries that can offer better opportunities for professional development and salaries and benefits," El-Jardali explains.

Jordan is another nurse exporter. The government marks nurse training and supply as an important part of its economic policy, says Osama Diadat.

Diadat left his native Jordon for Dubai 12 years ago and now works as a practice development nurse in mental health at the city's Rashid Hospital.

"Unemployment is a common problem, and in Jordon there is nurse exporting. They have made nurses a resource because Jordon is acknowledged throughout the world as having a good healthcare service," he explains. "All the good nurses depart abroad and they are playing an important role in our economic status."

The situation, however, is now starting to have an impact on the quality of nursing care on offer in Lebanon. "It is at a very critical point," warns El-Jardali. "Talking to those people working at the front line they say the quality [of care] and patient outcomes have been suffering as a result."

El-Jardali believes that if workforce planning is not addressed at national levels in the Middle East, both exporting and importing countries could find themselves desperately short of nurses, and totally reliant on staff from less developed countries - while countries such as Lebanon will start having to import nurses themselves.

"Nurse migration is one of the critical challenges many countries in the region are facing," he tells MT.

"The problem here is there is no human resource planning in these countries; there is only a minimal database covering existing staff.

"There needs to be a plan because everyone is competing for the same existing nurses." Image conscious

Senior nurses agree that encouraging more locals into nursing and midwifery in countries such as Saudi, the UAE and Qatar is urgently needed. But a deep-rooted belief among many national populations that nursing is a lowly, undesirable job is proving a large barrier, discloses Murshid.

"One month ago I was very down so I sent a text to all the Saudi nurses I know asking if anyone one knew the future of nursing in this country," she says. "They replied, and some said there was no future, because this is a country that does not see nursing as a profession. Others said it will take a lot of effort, but there is a future."

The place is growing so much they’ve had to recruit from outside, but the worldwide shortage of nurses is having an impact, and so they wanted to grow their own Arab and English speaking registered nurses.

The stigma of nursing and midwifery as unacceptable occupations for women is even stronger in Qatar, which was forced to shut down its one and only nursing school for nationals because local fathers refused to let their daughters enroll there, Murshid adds.

Minority report

Both the Saudi and the UAE governments have launched schemes to encourage locals into the profession. Government-backed nursing institutes, colleges and universities have sprung up during the last fiveLast year just over 200 Emiratis qualified as registered nurses with a diploma or degree.

However, the number of local candidates completing the degree programme at the University of Sharjah's Nursing School has dropped from 15 to seven in the last seven years.

Meanwhile, Dubai is set to run the country's first postgraduate degree in midwifery for locals and Arab nationals, beginning in February next year. The course will hopefully be followed by an undergraduate midwifery degree.

In Abu Dhabi nurse education became an all-graduate affair at the beginning of September when the health authority scrapped diploma training in a bid to boost the image and quality of nursing.years, as part of widespread nationalisation programmes.

Judy Wollin, head of the nursing school at the Fatima College of Health Sciences in Abu Dhabi, says the health authority realised it needed to grow its own Arab and English speaking nurses.

"Nursing is not viewed as a high status profession here, and the role reflects something seen 30 years ago in the Australia and the UK," she observes.

"The place is growing so much they've had to recruit from outside, but the worldwide shortage of nurses is having an impact, and so they wanted to grow their own Arab and English speaking registered nurses."

The two campuses in Abu Dhabi and Al Ain are running undergraduate degree nursing programme for 54 students and a bridging programme for 35 students who wish to turn their diplomas in to a degree.

There are a "small" number of Emiratis on the course and the rest are mainly expatriate Arabs who have lived in the UAE for many years, Wollins says. "There's a lot of enthusiasm, the nurses on the wards want to upgrade - we have over 60 people queued up for the February intake."

Another scheme that trains Emirati nurses in leadership has been supported by the MoH for the past three years and run in collaboration with the International Council of Nurses. It trains up to 30 local nurses a year in leadership tolls, some of whom go on to qualify as trainers. So far the scheme has benefited 78 nurses, according to Al Rifai.

"It is very positive, and one thing about it to look at is that these are leadership skills that can be utilised anywhere, at all levels," she says. "The country will achieve two objectives: nurses taking on leadership skills as well as producing local trainers."

The situation in Saudi is not so positive, according to Murshid, who says similar schemes have been largely unsuccessful.

The Kingdom has supported nursing initiatives for almost 50 years and only last month announced the launch of a nursing scholarship scheme to train 1,000 Saudi girls.

It has also established five nursing colleges that run alongside five private institutes, offering degrees to Saudi nationals wanting to become nurses. Each is able to take around 100 students a year.

But, reveals Murshid, who was the only national to graduate from her degree class of 20 students in 1988, few actually go on to work as nurses, especially the males.

"On graduation you will find more males to females. However, the majority are not working in nursing positions, but working in administration positions over nursing."

Government policies preventing women from driving, a lack of public transport and failure to provide crèches facilities at work also disincentivise Saudi women to work as nurses or midwives, she adds.

A celebrity-led campaign, perhaps by a member of the royal family is the only way nationals will be encouraged into the profession, Murshid concludes.

"The image of nursing in the US is the best in the world and that did not come easily - but that's what we really need to see in this country."

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