Achievements and challenges of formulating a strategic plan for nursing development at the national level in Bahrain

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Achievements and challenges of formulating a strategic plan for nursing development at the national level in Bahrain
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  Original Article © 2003 International Council of Nurses 148 Blackwell Science, LtdOxford, UKINRInternational Nursing Review1466-7657International Council of Nurses, 200350Original Article50Original Article Strategic plan for nursing development in BahrainN.Al-Gasseer et al. Correspondence address:  Naeema Al-Gasseer, World Health Organization, 1211 Geneva 27, SwitzerlandTel: + 41 22 791 2325Fax: + 41 22 791 4747E-mail: algasseern@who.ch 50Original Article Strategic plan for nursing development in BahrainN.Al-Gasseer et al. Achievements and challenges of formulating a strategic plan for nursing development at the national level in Bahrain N. Al-Gasseer  1   RN , P h D , F. Al-Darazi 2   RN , MS , P h D , B. Al-Kuwaiti 3   RN , MS , K. Al-Gaud 4   RN , BS c , B. Al-Muhandis 5   RN , MN  & L. Murad 6   RMN , SRN , A dv . N . A dmin . D ip 1 Senior Scientist for Nursing and Midwifery, World Health Organization, Geneva, Switzerland 2 Regional Adviser for Nursing & Allied Health Personnel, World Health Organization, Eastern Mediterranean Region, Nasr City, Cairo, Egypt 3 Deputy Principal Nursing Officer, Salmaniya Medical Complex, Ministry of Health, Bahrain 4 Principal Nursing Officer, Salmaniya Medical Complex, Ministry of Health, Bahrain 5 Dean, College of Health Sciences, Ministry of Health, Bahrain 6 Nurse Registrar, Office of Licensure and Regulation, Ministry of Health, Bahrain  Abstract  Background:  In this paper (initially presented at a symposium during the ICN Centennial Conference, 27 June - 1 July 1999, London), we describe nurses’ experiences in formulating a strategic plan for nursing development at the national level in Bahrain. Aim:  Specifically, we address the process undertaken to produce a comprehensive and integrated strategic plan directed at what nurses in Bahrain need to do in order to contribute to cost-effective and high-quality health service. Conclusions:  The following strategies are addressed: regulation of nursing; reform of nursing education; development of nursing services; development of a nursing information system, and development of nursing leadership. Keywords Bahrain, Education, Leadership, Nursing, Services Introduction The experience of developing a comprehensive andintegrated strategic plan for nursing development atthe national level to produce cost-effective andhigh-quality health service was a challenge willingly undertaken by nurses in Bahrain. Bahrain is anisland nation in the Arabian Gulf located approxi-mately 20km from the eastern shore of Saudi Arabiawith a population of 620000. The Ministry of Health and the Ministry of Defence provide approx-imately 92% of all health services.The Ministry of Health provides servicesthrough: 1 the Directorate of Public Health, which includesadministration and support, environmental health,food and hygiene, health education, control of com-municable diseases, and occupational health, 2 the Health Centres Directorate which providesprimary health care services through a network of 21 health centres and two clinics, and 3 Salmaniya Medical Complex, the psychiatrichospital, and the geriatric hospital which providefor secondary and tertiary health care services.  Strategic plan for nursing development in Bahrain149 © 2003 International Council of Nurses, International Nursing Review  , 50 , 148–155 Maternity services are provided through the Sama-laniya Medical Complex, peripheral maternity hos-pitals, and primary health care centres.The Ministry of Defence provides services throughthe Bahrain Defence Force Hospital and theShaikh Mohammed Bin Khalifa Al Khalifa CardiacCentre.Remaining health services are provided by pri-vate health care through hospitals such as the Amer-ican Mission Hospital, Bahrain InternationalHospital, and Awali Hospital, as well as private clin-ics. Privatization has been on the increase in the lastfew years.The health of the population has improved sig-nificantly since the 1950s as reflected in the increasein life expectancy from 51 to 72years in 1997 and adecline in infant mortality rate from 175 to 8.4deaths per 10000 live births in 1997. According tothe United Nations Development Fund (UNFPA1998), Bahrain ranked first among Arab countriesin human development, relying on such measuresas infant mortality, life expectancy, literacy rate, andgross domestic product. Table1 contains key healthindicator information for Bahrain.Factors that led to the development of the strate-gic plan for nursing development were at two con-textual levels: 1 the national level within Bahrain, and 2 the subregional and regional levels within the six Gulf Cooperation Council (GCC) countries andwithin the World Health Organization (WHO)Eastern Mediterranean Region.Nurse leaders in Bahrain felt an urgent need todevelop a strategic framework to guide nurses in asystematic manner toward developing effective andefficient nursing services (Youssef 1994).At the subregional and regional levels, two majorinitiatives provided an impetus for developing thenursing strategic plan in Bahrain. The first was theestablishment of the GCC Nursing Technical Com-mittee by the Ministers of Health of Bahrain,Kuwait, Oman, Qatar, Saudi Arabia, and UnitedArab Emirates. This committee has become a forumfor nurse leaders in the six countries to share infor-mation, exchange views, and recommend strategiesto enhance development of nursing to the Ministersof Health. Through a series of workshops with tech-nical assistance from the WHO Regional Office inEgypt, a GCC strategic framework for nursingdevelopment was created in 1992 and targeted forthe 5-year period from 1992 to 1996. That strategicframework was adopted by the six countries andreviewed and readopted for the period from 1997 to2000.The second major initiative was the 1997 WHOEastern Mediterranean Regional Office (EMRO)strategy for nursing and midwifery developmentpertaining to 23 countries. This regional documentwas developed by the EMRO with extensive consul-tation from the Regional Advisory Panel on Nurs-ing and Midwifery and the chief nursing officers inthe region. The authors of the publication haveidentified areas that need to be addressed, objec-tives to be achieved, and guidelines on action to betaken to make high-quality nursing and midwifery services a reality in the EMRO (WHO – EMRO1997). The planning structure and national workshop The Nursing Development Committee (NDC),established in 1992 with membership from nursingservices, education, regulation, and human re-sources development, was a major force in devel-oping the plan (GCC Nursing Committee 1992).The NDC reports to the Minister of Health andconstitutes a forum for nurse leaders to discuss anddebate issues affecting nursing and make recom- Table1Health indicators in Bahrain, 1997 Population620000Crude birth rate22.2/1000 populationCrude death rate3.3/1000 populationTotal fertility rate3.3/womanInfant mortality rate8.4/10000 live birthMaternal mortality rate3.1/10000 live birthLife expectancy at birth72.4yearsMale70.0yearsFemale75.3yearsNurse per 10000 population36.2Physician per 10000 population14.2Source: United Nations Development Fund (1998).  150N. Al-Gasseer et al. © 2003 International Council of Nurses, International Nursing Review  , 50 , 148–155 mendations to improve nursing services in thecountry.The NDC formulated a strategic plan to developnursing in the country, guided by the regional nurs-ing strategies with an emphasis on the local situa-tion. Nurses, having spent a considerable amount of time on nursing issues to enhance practice, alsostarted looking to other health system issues whichaffect nursing and vice versa to forge new partner-ships with other health professionals and policy makers to contribute further to the health of Bahr-ain’s population.A national workshop to develop a strategic planfor nursing development was facilitated by a WHOnurse consultant in 1996 (Biscoe 1996). This work-shop was designed to integrate previous reports,identify and fill gaps, and produce a comprehensiveapproach to what nurses in Bahrain needed to dobetter in order to contribute to a cost-effective andhigh-quality health service.A non-nurse from the personnel area attendedthe workshop together with 42 nurses from the pub-lic health system (hospital and primary health caresectors), the military hospital, and the private hos-pitals. Five medical practitioners also joined theworkshop for a morning, enriching the discussionsand role-modelling a multidisciplinary approach.Both the minister and the undersecretary for healthaddressed the workshop and their input was signifi-cant to the workshop’s success.A vision statement for nursing in Bahrain and astrategic plan framework were developed in theform of key results and ways to achieve those results.The statement stressed that the nursing professionin Bahrain would work collaboratively and interde-pendently to achieve high-quality and cost-effectivehealth services in Bahrain (WHO 1996). Key resultareas were: 1 increased quality and efficiency of nursingservices; 2 improved contribution to the reduction of spe-cific mortality and morbidity trends and the pro-motion of health and well-being; 3 improved health services with nurses working asa team with other health professionals; 4 increased use of information to improve manage-ment and clinical practice; 5 active participation by nurses towards improvingthe health services; and 6 resolving to address factors specific to satisfactionand dissatisfaction.The strategic plan assumes a systematic approachover time to achieve the vision. In addition to thenational workshop, several working groups and task forces have been established to work on certainissues that would address the key result areas andinclude action plans for achievement. This includesimproving the working conditions for nurses’ entry level into practice, nursing education reform,nurses role in various specialties, and nursinghuman resource planning.It was decided to produce a comprehensive docu-ment that could contain the strategic plan and holda series of short seminars to further present the planand exchange views with nurses and other key stake-holders identified during the workshop. The strate-gic plan covers four major areas: nursing regulation,nursing education, nursing services, and leadershipdevelopment. Nursing regulation The initial focus of the regulatory system has beenensuring the competence and safety of nurses andmidwives entering practice. To meet this goal, theoffice of licensure and registration for all health pro-fessionals was set up and a nurse registrar appointedto head the nursing licensure unit. The new law (enacted in December 1987) made the provision forestablishing a nursing and midwifery licensure andregistration committee. The two key factors thatinfluenced development of the regulatory systemwere public protection and perseverance of theprofession.When the first nursing law was enacted in 1977,the focus was mainly to strengthen the practice of midwifery, which was going through a criticalphase, and ensure the protection of the public. Inthose days many women chose to deliver at home(especially in rural areas) because qualified mid-wives’ practice was confined to hospital facilities.Therefore, the women who chose to deliver at homehad to depend on traditional birth attendants(TBAs). In spite of numerous efforts made by the  Strategic plan for nursing development in Bahrain151 © 2003 International Council of Nurses, International Nursing Review  , 50 , 148–155 Ministry of Health to upgrade the education andclinical standards of TBAs, the situation remainedrisky in terms of subjecting women and babies’ livesto unsafe practice. When the TBAs were reviewedby the ministry, many were found to be unfit forpractice in terms of medical fitness and standard of care. Therefore, issuing of the midwifery law wascritical for protecting mothers and babies. Thepublic protection strategy led to enactment of theumbrella law currently governing the practice of allallied health professions, including nursing andmidwifery.The perseverance of the Bahrainian nurses innegotiating a system for regulating the practice of their profession with policy makers was a major fac-tor behind the decision to enact the law for the alliedhealth professions in 1987. Before this law, no sys-tem existed to ensure the qualifications and compe-tencies of people entering the practice of nursing.Between 1977 and 1987, several proposals were pre-sented to policy makers either to modify the mid-wifery law in order to include provisions forregulating the nursing practice or to enact a separatelaw for nursing.The aim of the nursing licensure committee wasto protect the public from unacceptable practice.Objectives of the committee were to: 1 promote good practice standards, approveschools of nursing, and so on, 2 prevent poor practice by updating nurses andhelping them practice effectively, and 3 intervene in unacceptable practice and review professional conduct.The plan of action for developing nursing regula-tion was to create an awareness of the value of nurs-ing regulation, establish standards for practice,education, and conduct, and develop regulatory mechanisms (Standards for Nursing Post Registra-tion Education and Practice 1994). Also incor-porated in activities of the nursing licensurecommittee were key points of the GCC code of professional conduct including accountability,patients’ dignity, and confidentiality. The organiza-tion of the office of licensure and registration isshown in Fig.1 and the licensing process is shown inFig.2.Challenges concerning nursing regulationincluded being able to implement changes accord-ing to the action plan; expanding the scope of nurs-ing and midwifery practice based on nursingeducation reform; obtaining approval for a pro-posed standard of nursing education and code of conduct; developing, implementing, and maintain-ing a national standard for nursing and midwifery practice; and contributin  g   to the development of aregional regulatory network by which Bahrain couldbecome a model as a WHO Collaborating Centre forestablishing a database for nursing human resourcesfor the entire Eastern Mediterranean Region. Nursing education Formal nursing education started in 1959 with theaim of preparing qualified nurses to cater to the Fig.1Office of licensure and registration organizational structure. Ministry of healthundersecretaryChief licensureand registrationPhysicians & dentistslicensure unitNursing & midwiferylicensure unitAllied healthlicensure unit Fig.2Licensing process. Temporarycertificateof registrationPrelicensurecompetencyassessmentLicence for practiceRenewal of licence  152N. Al-Gasseer et al. © 2003 International Council of Nurses, International Nursing Review  , 50 , 148–155 needs of the people and the developing health ser-vice. In 1990, the Nursing Division at the College of Health Sciences was designated as a WHO Collabo-rating Centre for Nursing Development, as a firstWHO Collaborating Centre for Nursing in theEastern Mediterranean Region. Objectives of theCentre for nursing education were to assume aleadership role in preparing nurses at basic andpostbasic levels; to collaborate with the WHO toestablish a nursing databank, to collaborate withthe WHO to conduct nursing and health research;and to promote the sharing of information. As partof the strategic plan, a process was developedfor reviewing the existing nursing curriculum(McElmurry 1995) and preparing for the reform of nursing education. This was further followed upby the NDC as part of its terms of reference toreview and assess the nursing education strategy inBahrain. Between 1997 and 1998 a main curricu-lum planning task force, which was formulated by the NDC, held a series of extensive meetings andseven workshops that constituted the planningphase aimed at reforming nursing education inBahrain. The documented outcomes of these delib-erations included the following: • analysing existing situations and perceptions, • reviewing educational mission and philosophy, • developing a statement of purpose, • defining care, nurse, nursing, client, environ-ment, health, well-being, and illness, • developing a conceptual framework, • developing scenarios – critical-incident stories,and • establishing faculty and student competencies.Consensus was reached to adopt the case-based,community-orientated curriculum in the new cur-riculum (Uys 1998). The cases used in the new reformed curriculum are real individual client, fam-ily, or community cases. This reality-based charac-ter provides simulation of action from the realworld. The new curriculum fosters the methodol-ogy of student-centred, self-directed learning, criti-cal thinking, and the problem-solving approach.The strong foundation of this curriculum makes foran easy transition into the baccalaureate pro-gramme. The integration of nursing education andservices at both the levels of planning the educa-tional programmes and implementation of theseprogrammes continually was strengthened over the years and a focus of the strategic plan.Challenges of nursing education reform are tohave one level of nurse, the baccalaureate level, andto develop advanced nursing roles for Bahrain.Other challenges include: 1 reviewing the strategic plan periodically, 2 improving college reorganization and structure, 3 improving research and other scholarly activities, 4 improving cost-effectiveness, 5 reorienting the educational programme so thatstudents have a direct path toward a baccalaureatedegree instead of first having to obtain an associatedegree, 6 continuing to develop nursing education leader-ship, and 7 continuing to develop local, regional, and globalinvolvement, and partnerships. Continuing education Nurses are provided with opportunities to continuetheir education in various specialties needed by health services through scholarships to study inBahrain or abroad. To maintain the nursing work-force’s competence, an in-service education pro-gramme was established at the Ministry of Health,Directorate of Training (Kellehear 1992). A variety of short-term courses are provided to meet the con-tinuing education needs for nurses. In addition,1-year, post-basic courses are available in the spe-cialties of midwifery, psychiatric nursing, cardiaccare, and community health nursing.Challenges for the nursing services in Bahraininclude providing and maintaining high profes-sional standards of care with limited humanresources; placing nurses on the professional cadre,expansion of career mobility; providing evidence-based practice; and increasing knowledge of nursesabout economic and business aspects of health careorganizations (Nursing Profession Levels 1991). Nursing services Primary, secondary, and tertiary health services areprovided through health centres and hospitals in
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