Keywords

1 Introduction

This chapter describes the development of advanced practice nursing in the Eastern Mediterranean Region and delineates success stories and the challenges facing the nursing leadership in this regards. The chapter is based on a desk review of the reports on advanced practice nursing in the region, World Health Organization Regional technical papers and resolutions and responses were received from selected nursing leaders in the region to a questionnaire on advanced practice nursing and nurse prescribing.

2 Regional Context

The Eastern Mediterranean Region (EMR) of the World Health Organization (WHO) is comprised of 21 Member States and the Occupied Palestinian Territory (West Bank and Gaza Strip). It has a population of nearly 620 million people. Except for Afghanistan, Iran and Pakistan, all are Arabic speaking. Long standing political instability, conflicts and civil unrest are features of this region. Inequities in health, rising exposure to health risks, increasing health care costs and unacceptably low levels of access to quality health care represent the most important challenges facing many countries of the Region (World Health Organization-Eastern Mediterranean Regional Office 2012).

Recent events have added to regional instability and the significant conflicts taking place in some countries has resulted in the displacement of large numbers of the population, the exodus of a large percentage of the health workforce, disruption of supply systems, destruction and neglect of health infrastructure and the inevitable disruption to health services.

The Eastern Mediterranean Region suffers from the health problems similar to the rest of the world. Non-communicable diseases are the leading killers in the Region, while communicable diseases and nutritional disorders remain considerable and preventable deaths from injuries constitute a serious proportion of overall mortality (World Health Organization-Eastern Mediterranean Regional Office 2015a).

Nurses and midwives constitute 50–60% of the health workforce in the Region demonstrating the potential resources of the nursing profession.

3 Development of Advanced Practice Nursing: Early Years

In 1990, the Regional Advisory Panel on Nursing was formed by WHO. Since its establishment, the Panel has provided a regular mechanism for nurse leaders in the region to identify needs and priorities requiring action by the organization and to discuss issues and plans of action that could be positively affected by regional office support to strengthen nursing and midwifery in the region.

In 1998, resolution EM/RC45/R.12 on improving quality of nursing and midwifery in the Eastern Mediterranean Region was adopted by the Forty-fifth Session of the Regional Committee of the WHO. The Regional committee is the governing body of WHO in the Region and consists of Ministers of Health in the 22 Member States. During this meeting, the regional strategy for nursing and midwifery development and the educational standards for nursing specialization were set at the regional level as a result of advice and efforts of the Regional Advisory Panel on Nursing and adopted. The Eastern Mediterranean Region was the first region among the six regions of WHO to develop such a strategy (World Health Organization-Eastern Mediterranean Regional Office 1997, 1998a, b).

The countries of the region continue to invest in the development of nursing and midwifery resources as a critical component of the health system and health services development.

Since the first meeting of the Regional Advisory Panel on Nursing in 1990, tremendous progress has been achieved in nursing and midwifery development, both at the national and regional levels. The nursing leadership played a pivotal role in the development of nursing across all fields including advanced practice nursing; this was augmented by the technical support provided by the World Health Organization to the countries of the region. Several strategies were adopted to strengthen nursing including reforming basic nursing education and developing graduate programs, strengthening nursing structures in ministries of health and leadership development, strengthening nursing and midwifery regulation, establishing national strategic plans for nursing and midwifery development, and supporting countries in complex emergencies and conflict to build and rehabilitate their nursing and midwifery services. Nursing in the region, witnessed a growth in entry level BSN nursing programs, an increase in the number of nurses prepared at the graduate level and an increase in the number of nurses in leadership positions.

As a response to the challenge of providing timely and accessible service to clients, especially the more vulnerable members of the community in the region, the World Health Organization held the fifth meeting of the Regional Advisory Panel on nursing in June 2001 in Pakistan. The meeting and the consultation on advanced practice nursing and nurse prescribing in the Eastern Mediterranean Region discussed the scope of professional roles and responsibilities, regulation of advanced practice nursing and implications for nursing education and practice. This meeting was organized by the World Health Organization Regional Office for the Eastern Mediterranean Region. Chief nurses, deans of schools of nursing, presidents of national nursing organizations, regional and international nursing experts and a number of physicians and pharmacists participated in the three-day meeting.

The consultation led to a consensus on the following recommendations:

  1. 1.

    Member States should review the current practices in relation to advanced nursing practice and invest in systematic data collection and dissemination of information regarding cost-effective, best practices.

  2. 2.

    Member States should develop and strengthen educational programmes to prepare advanced practice nurses at all levels of health care (primary, secondary and tertiary) consistent with the regional educational standards for nursing specialization.

  3. 3.

    Member States should develop and strengthen legislation and the nursing regulatory framework that supports advanced practice nursing within the overall health system.

  4. 4.

    Member States should create a career structure for advanced practice nursing within health systems in the Region.

  5. 5.

    WHO should provide guidelines to assist countries in the process of developing and strengthening advanced practice nursing at all levels of health care.

  6. 6.

    WHO should assist Member States in their efforts to develop and strengthen advanced practice nursing (World Health Organization-Eastern Mediterranean Regional Office 2002).

    This meeting created an opportunity for discussing advanced practice nursing in different countries and was the first milestone in the development of advanced practice nursing in the region. Over the years, the World Health Organization and the nursing leaders in the region advocated for advanced practice nursing. Historically, nurses in the region have been recognized as key practitioners in community and public health. The progress has been slow but steady.

The second milestone was the Regional committee resolution adopted in October 2008 EM/RC55/R.5 on promoting nursing and midwifery development in the Eastern Mediterranean Region, which called for advocating for new and specialized roles. It called for establishing family health nursing, including the educational programmes and service delivery structures to support the role and development of advanced practice nursing at the primary, secondary and tertiary levels of care (World Health Organization-Eastern Mediterranean Region 2008).

4 Development of Advanced Practice Nursing: Recent Developments

The contribution of nurses to the health outcomes of populations and to a well-functioning health system is crucial for any country. In order to identify the challenges facing nursing in the countries of the region, ‘In late 2014, the Regional Office undertook the Eastern Mediterranean Nursing and Midwifery Survey as well as a desk review of WHO reports on missions to countries of the Region in the previous four years and data from the nursing country profiles provided by key informants from Member States. The overall aim was to assess the current status of nursing and midwifery in the EMR and to identify the key challenges facing these services. The survey was delivered as an online questionnaire and 20 of the 22 EMR member countries responded’ (Raising the profile 2015).

As a follow up to these activities, a report was produced and a regional forum, entitled future of nursing and midwifery in the Eastern Mediterranean region, was held in Amman-Jordan in April 2015. Nurse leaders from the region and regional and international experts participated in the meeting, discussed the challenges facing nursing in the region and proposed actions to address the challenges (World Health Organization-Eastern Mediterranean Regional Office 2015b, c).

Although half of the countries surveyed stated that nurses practiced at the advanced level in their country, the description of what these roles actually entailed indicates that there is quite a varied understanding of the nature and scope of advanced practice. For some it meant nurses working in a specialist or supervisory role or carrying one or two ‘advanced’ tasks (e.g. prescribing, suturing, venepuncture), some of which are seen as advanced in some countries but are part of the general nurse’s repertoire of skills in others.

International consensus has established that the advanced role includes the capacity to integrate research, education and clinical management, a high degree of autonomy and independent practice, advanced assessment and decision-making skills, and recognized advanced clinical competencies (Schober and Affara 2006).

Based on the survey results and the situation analysis of nursing in the region in 2015, the regional framework for action for strengthening nursing and midwifery in the EMR was developed to address the five main challenging areas facing nursing and midwifery including governance and regulation; workforce management systems; practice and services; access to quality education and research.

Results from the online Eastern Mediterranean nursing and midwifery survey identified key challenges for nursing and midwifery in the region. With regards to the domain of practice and services, most of the countries believe that there is potential for the development of the advanced practice role especially within primary health care and the management and control of non-communicable diseases. However, constraints to the evolution of this role are considerable, including low governmental and organizational support, confused public perception, role ambiguities, a scarcity of well-educated nurses experienced in the role, physician domination and opposition, and a lack of resources.

The framework entitled, ‘Strengthening nursing and midwifery in the Eastern Mediterranean Region: A framework for action 2016-2025’ was published in 2016. The regional framework serves as a roadmap to guide Member States in transforming nursing and midwifery in the Region with short-term and medium-term actions.

The strategic direction under the domain of practice and services in the regional framework states that nurses and midwives should practice to the full extent of their education and experience to deliver quality care. Short-term and medium-term actions aimed at introducing expanded or advanced practice role in nursing have been identified and form a basis for further development of advanced practice nursing in the region (World Health Organization-Eastern Mediterranean Regional Office 2016).

To provide guidance to the countries in the region on advanced practice nursing and nursing specialization, a framework for the development of nursing specialties and advanced practice was developed as an outcome of the regional consultation on nursing education in 2013 (World Health Organization-Eastern Mediterranean Regional Office 2013). Participants included selected deans of nursing, experts in nursing education, selected members of the Regional Advisory Panel on Nursing, the Chairperson of the Global Advisory Group on Nursing and Midwifery, representatives of the WHO collaborating centres for nursing in the Region, a representative of the Scientific Society of Arab Faculties of Nursing, as well as WHO staff from headquarters and regional (African and Eastern Mediterranean) levels. Consensus was reached on what is considered as a nursing specialty, the definition of a nurse specialist, criteria for designating a speciality and levels of nursing specialist practice; description of the level of practice; proposed professional titles; educational requirements and the regulatory mechanism.

The guide, published in 2018, was used to foster development of advanced practice nursing in the region (World Health Organization-Regional Office for the Eastern Mediterranean 2018). The following figure illustrates the level of specialist practice, which was adopted by the region (Daly and Carnwell 2003) (Fig. 8.1).

Fig. 8.1
figure 1

Continuum of the levels of nursing specialist practice. (Adapted from Daly and Carnwell 2003)

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5 Current Status

To obtain further information about the recent developments related to advanced practice nursing, a questionnaire was sent to a selected group of nurse leaders in 11 countries of the region (Annex 1). The questions addressed nurse prescribing and advanced practice nursing.

5.1 Educational Preparation, Definition, Scope of Practice and Practice Settings

Table 8.1 illustrates the status of advanced practice nursing in the region. With regards to the educational preparation for the APN role, six of the countries responded that a master of science in nursing with a clinical focus has been identified as an educational requirement for the role and the remaining countries had not defined the educational preparation. Only three countries had an approved definition of APN while four had a written definition which has not been approved yet. Three countries did not have a definition of advanced practice nursing. Only four countries had a written and approved scope of practice for the role (Iran, Jordan, Oman and Qatar). Lebanon and the UAE have a written scope of practice, which has not been approved yet. Five countries have identified the core competencies for the role including Iran, Jordan, Lebanon, Oman and Qatar.

Table 8.1 Status of advanced practice nursing in the Eastern Mediterranean Region
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Most of the countries indicated that advanced practice nurses practice in a wide variety of settings such as hospitals, primary health care centres and community settings in different specialty areas such as paediatrics, midwifery, gerontology, mental health, emergency care, family health and public health.

5.2 Regulation of APN and Nurse Prescribing

Only in two countries, Jordan and Qatar, the APN role is regulated; Iran and Oman are in the process of establishing the process for regulating the role.

With regards to nurse prescribing, nurses do not prescribe medicines in all the countries that responded to the questionnaire except Oman whereby primary health care nurses prescribe a list of 22 drugs in primary health care settings. So far, the system is not ready to allow APNs to prescribe except under the approval of the consultant physician. Whereas midwives can prescribe a list of drugs that have been pre-authorized and the prescription is regulated in Tunisia, Qatar, Iran and Pakistan. In Pakistan, lady health visitors are the primary community health workers who have completed 53 weeks of training and who work in rural community services taking care of the healthy and sick individuals and families. The lady health workers can prescribe a predefined list of drugs; also in Iran, the community health workers (Behvarz) can prescribe a predefined list of drugs. In the UAE, what nurses can prescribe will be defined and will be part of a collaborative agreement for each practitioner within the institution. In Iran, Qatar Tunisia and Oman, the Ministry of Health grants the legal authority for prescribing to the categories mentioned previously.

The drugs prescribed by midwives, lady health visitors and community health workers range from vitamins to ante-natal vaccinations, contraceptive methods and drugs for treating minor childhood illnesses. Midwives in Tunisia also prescribe some obstetrical medicines.

In Iran, nurses can refer patients from home health care settings to health care professionals or health facilities. Also, in Qatar and Pakistan nurses can refer patients to physicians. Whereas in Oman PHC nurses refer patients to the secondary level of care and in other specialties, APNs refer patients to consultant physicians e.g. emergency.

In a few countries, the standard protocols for specified cases are set within the institutions, thus allowing nurses and midwives to prescribe especially in emergency cases and in the absence of physicians (Bahrain, Oman, Qatar, Tunisia and the UAE).

6 Development of Advanced Practice Nursing in Oman: A Case Study

In this section, the journey of the Sultanate of Oman as one of the first leading countries that has systemically developed the APN role in the Eastern Mediterranean Region will be described.

In Oman, the fifth meeting of the Regional Advisory Panel on Nursing in 2001 provided the impetus for advocacy and discussion of the advanced practice nursing role and its significance in ensuring access of the population to health care. Nurse leaders from Oman, who participated in the meeting, were able to discuss the challenges faced by them with nursing colleagues from the other Eastern Mediterranean countries and with international nursing experts in the field.

Health policy makers in Oman sought WHO’s technical support to assess the status of primary health care, community needs and the potential for developing the advanced practice nursing role in the country. The journey started with a situational analysis of the national status, site visits by experts and a presentation to the senior policy makers about the relevance of the implementation of advanced practice nursing in Oman. The journey started in 2004 after an in-depth assessment of primary health care in the country. One of the strategic objectives for primary health care in Oman was to expand the role of nurses in care delivery by developing advanced practice nurses. The argument for establishing the role was clearly stated in the PHC assessment report, “the need to develop a more cost-efficient mode of PHC delivery which could be deployed to move PHC provision closer to the community”.

The experience of other countries in this field point to advanced nursing practice as a successful, affordable and reliable mode of PHC provision. The unrecognized independent practice of nurses takes place without adequate technical support and leaves the nurse legally unprotected’ (Abdel Rahim Ebrahim 2004). The assessment report recommended initiation of the advanced practice nursing role in primary health care as a priority for introducing the APN role.

The APN development journey in Oman included review of the literature about APN, workshops, focus group meetings and a consultation process with a multidisciplinary group of health professionals to discuss advanced practice nursing and the justification and feasibility for introducing the role within the health system in the country. The multidisciplinary team included primary health care nurses, educators, senior managers, physicians, pharmacists and regulators. Also WHO supported several missions to the country (Ghebreiwet 2005; Schober et al. 2012).

By 2012, the outcome of the expanded assessment and the situational analysis of APN and a way forward were presented to the policy makers and key stakeholders in the country. As a result, a resolution was issued by the relevant section within the Ministry of Health to study the steps for the implementation of the APN role in hospitals. The national taskforce, which was formed in 2013 based on the ministerial resolution, proposed the scope of practice, educational requirements, service delivery structures, criteria for selection of nurses for the role, career structure, and inclusion of the category within the workforce plan.

Evidence of why the role should be initiated to PHC and educational opportunities for nurses to be trained for this role in Oman and in the International level was shared with the decision-makers in the Ministry of Health. As no educational program for preparing nurses for the role was available in Oman, visits to various universities outside the country were made to familiarize with APN programs in 2014.

In 2016, a WHO consultant worked with the national taskforce to guide the integration of the APN role within the existing primary health care setting in Oman. By this phase, the legal framework for practice, job description, standards of practice, required competencies, practice environments and service delivery structure required for the implementation of the role had been developed. On the job training programs for nurses practicing the advanced practice role in PHC were developed by the taskforce.

Seven nurses were sent on scholarships outside the country to be prepared for the APN role by obtaining a master of nursing in a specialty field, they returned and are currently attached to various facilities. Many of these nurses went on to become leaders.

A comparative situational analysis of nurses practicing APN roles beyond their scope of practice in primary health care settings between 2010 and 2016 revealed that the number of nurses practicing advanced nursing roles in primary health care institutions has increased from 19% in 2010 to 35% in 2016 (Al Maqbali 2018). Nationally, the role is practiced in 60% of the primary health care institutions.

In summary, the results of this comparative situational analysis suggest that nurses need to be provided with appropriate educational preparation and advanced skills in order to function in this advanced practice role. Legitimizing the role with adequate training and supervision will surely serve as an innovative way of ensuring quality of care, system efficiency and cost effectiveness. This process paves the way forward to go ahead with the proposed plan of action.

The case study from Oman, illustrates that Oman is prepared to proceed with the inclusion of the APN role in health care facilities especially in the PHC setting. Once the ANP role is implemented, the other countries in the Eastern Mediterranean Region can look to Oman to provide a model that can be replicated elsewhere.

7 Conclusion

The progress of advanced practice nursing in the region has been slow but steady. A lot of advocacy and role clarification has taken place among nurses, health professionals and health policy makers within the region. Advanced practice nursing deserves particular attention. Recently, the region has shown interest in developing the family health nursing role with an MSc in nursing, where these nurses can perform their roles in collaboration with family physicians and contribute to better health outcomes. The push for family health nursing in the Region includes changing health care systems, epidemiological and demographic changes, an increased focus on primary health care, rising demand for specialization, the growing need for home care and escalating health costs (World Health Organization-Eastern Mediterranean Regional Office 2013).

Political commitment and nursing leadership is required to move forward with the agenda on nursing specialization in the Region. Currently, policy makers have made a clear commitment to this process. However, educational preparation, legal framework and necessary administrative support need to be examined. Priorities for nursing specialization and advanced practice nursing in the Region are mental health nursing, community/public health and family health nursing, midwifery, critical care nursing, oncology nursing and gerontological nursing.