NURSING EVOLVEMENT IN JORDAN: LOOKING BACK TO GUIDE THE FUTURE

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1 NURSING EVOLVEMENT IN JORDAN: LOOKING BACK TO GUIDE THE FUTURE Hania Dawani Jordanian Nursing Council Nursing Leadership in Global Health Developing Pathways for Effective Advocacy and Action February Nashville, Tennessee

2 Presentation Outline Context-Jordan Context health care system Nursing Evolvement in Jordan Evolvement of Nursing Practice/Education/Research Challenges to Nursing Development Practice/Education/Research Way Forward

3 Context: Jordan Jordan is a young small lower-middle income country of 89,300 square kilometers, of which only 7.8% is arable land. Its strategic location in the Middle East influenced its history and its present. Jordan's population is around 6.4 million people (2012) and another 1.2 million immigrants and foreign workers. The average annual population growth rate is 2.2%. Eighty two (82%) of Jordanians are below the age of 40, 37% below the age of 15.

4 Context: Jordan Life Expectancy rate in 2010 is 73 (71.6 years for men, 74.4 years for women). Infant mortality rate for 2010 was 23.0 per 1000 live births. Literacy rate for 2010 (15 years of age and older who are able to read and write) was 92%. The unemployment rate was 12.5% for the year 2010 (10.4 % for males against 21.7 % for females (DOS,2010)

5 Context- Health Care System 1 Jordan s health system consists of three major sectors: Public, private, and donors. The public sector consists of two major public programs : the Ministry of Health (MOH) and the military Royal Medical Services (RMS). Other smaller public programs include two university-based hospitals. Health expenditure, was 8.19% and 7.72% of GDP in 2010 and 2011 respectively; expenditure on curative care in 2011 is 74.77%, as compared to 16% on primary care. ( National Health Accounts,2013).

6 Context of Health Care System 2 Primary health care is served by 84 comprehensive health centers, 368 primary health care centers, 227 village clinics, 422 MCH Centers and 369 oral health clinics. The MOH owns and operates 31 hospitals in 10 governorates, RMS owns 12 hospitals, while private sector owns 60 hospitals and a large number of clinics. Jordan has 1.8 inpatient beds /1000 ; 14.5% of the population is admitted annually to hospitals. Jordan has 26.5 physicians, 38.5 (all levels) nurses, 21 RNs, 15 pharmacists and 9.3 dentists per ten thousand population.

7 Context- Health Care System: Challenges-1 Challenges are related to accessibility, equity, duplication of services. Poor coordination among major providers. Unregulated private sector, and low utilization rates. Limited quality improvement programs, inefficient use of available resources, inadequate centralized management. Inadequate health information system.

8 Context- Health Care System: Challenges-2 Health care providers lack information on cost- effectiveness and evidence-based practice. The demographic changes show increase in population and higher life expectancy. Changes in the pattern of disease characterized by a progressive increase of non-communicable diseases. (Ajlouni, 2011) Influx of refugees and immigrants.

9 National Health Strategy (MOH) Promote sustainable quality of health services to citizens Promote the infrastructure in primary and secondary care Support primary health care services Contribute to prevention of non-communicable diseases Promote reproductive health, family planning and child health Promote fiscal management and cost- effectiveness of health services Support national efforts toward national health insurance for all. Strengthen HR management Establish monitoring and evaluation systems Strengthen risk management, disaster and emergency preparedness. Promote effective leadership

10 National Nursing Strategy ( ) Two main domains Advancing Education Enhancing Competency of graduates Developing Competencies of faculty Revising legislation related to education Advancing Practice Legislation that governs the nursing profession Practice environment and safe nursing care Professional performance Health information technology and databases (www.

11 Evolvement of Nursing in Jordan Evolvement of nursing was ushered by development of nursing education. From mid fifties through mid seventies, diploma nurses were dedicated hospital trained nurses, loyal and subservient to medical doctors. Their roles were traditional and limited by the simplicity of the times in Jordan. The well-trained Diploma Army nurses (graduates of Princess Muna College of Nursing) who had opportunities for training abroad influenced the quality of care, however only within the RMS hospitals. By mid seventies, BSc. nurses began to join the nursing workforce.

12 Evolvement of Nursing in Jordan- 2 Since mid seventies, nursing witnessed rapid development. Moving education to higher education, and emergence of BSc. programs led to preparation of nurses in higher education. Opportunities for graduate education for BSc. nurses mostly in USA and UK. Local graduate programs at the MSc. and Doctoral level Specialization in nursing at the MSc. Level. Early doctoral prepared nurses formed the core of nurse leaders in the country. Establishment of the Jordanian Nursing Council as an independent regulatory body. Support of HRH Princess Muna Al-Hussein, President of JNC and the true leader at the national and regional level.

13 Evolvement of Nursing Leadership in Jordan Since early seventies Nursing Leadership was most evident at the Royal Medical Services. The preparation and return of doctoral faculty heralded nursing leadership that took control of nursing education, and modeled leadership for other domains. Leadership then introduced strategic planning and demonstrated exemplary models of leadership, represented on various national committees, and led many strategic planning of non nursing services. Two nurses served in highest ranks in the government as Ministers and as Senators. One of nurse leaders directed a major hospital and became the president of a main public university. Nursing leadership mostly resides in academia, while it is yet to be developed in practice settings and in service

14 Nursing Evolvement in Jordan: Workforce Nursing work force increased from few hundred nurses in 1950s and 1960s to a total of 23,891 nurse. Nursing is limited to two levels BSc. and AD. Fifty five (55.5% )of workforce are RNs, 25% are ADNs, and 12% are practical nurses. The percentage of RNs continues to be below recommended Royal College of Nursing of 68%. RNs increased from 44% in 2003 to 45% in Annual increase of about 1000/year.

15 Nursing Evolvement in Jordan: Workforce -2 Diploma nurses decreased from 18% of work force in 2003 to 5% in 2012 after the closure of diploma programs in Associate Degree nurses increased from 9% in 2003 to a 26% in 2007 and 25% in This increase was a result of proliferation of these programs to a current total of 27, since the establishing of the first program at RMS in Midwives increase has been very slow. Practical nurses decreased from 37% in 2003 to 20% in 2007,and 12% in 2012, due to closure of the programs between 1998 and 2002.

16 Nursing workforce by level Year Year 2007 Year RN MW AND PN

17 programs Termination Programs Started Chronology of Evolvement of Nursing Education in Jordan 1950s 1960s 1970s 1980s 1990s No. of Current Program s First diploma nurses 1953 Second diploma 1962 Practical nursing program. LPN 1960 First BSc 1972 High school program. (Tawjehi) 1974 Second BSc program First MSN 1986 Thirteen BSc programs ( ) Second MSN in 1997 Associate program PhD program Two more MS program. 27 Associate in program PhD 15 BSc programs 4 MSN programs. 27 AD programs. Faculty at University 200PhDs 124 MSN second diploma termination in 1998 first diploma nurses termination in 2002 LPN 1998 High school programs 2003 closed

18 Evolvement of Nursing Research in Jordan Before s 1990s Chronology of Published Nursing Research) The noted increase in number of published research parallels the increase in faculty and graduate students since Research Data base is established at the University of Jordan. ( Thirty percent (30%) of research is collaborative. (Khalaf, 2013)

19 Nursing Evolvement in Jordan: Milestones The clear Milestones of development in nursing in Jordan 1) Establishment of reputable schools of nursing that prepared registered nurses. Princess Muna College of Nursing began a new era of nursing development. 2) Moving of nursing education to higher education institutions. 3) The establishment of a Nursing Association ( Jordanian Nurses and Midwives Council). 4) The establishment of a regulatory body: the Jordanian Nursing Council (JNC) in 2002.

20 Jordanian Nursing Council Established by a Royal Decree of His Majesty King Abdullah II to act as the the regulatory body of Nursing in the country. The same decree named HRH Princess Muna Al Hussein president JNC provides leadership at the national level. Devises national strategies that aim at regulating and advancing nursing. Devises and Influences policy development to serve its aims of education and practice development. Sets scope and standards of practice. Supports continuing education. Accreditation from the American Nursing Credentialing Center (ANCC), and the official approval of the Jordanian Nursing Council by the International Council of Nursing (ICN) as a Provider for "Leadership for change program"

21 Jordanian Nursing Council Legislatively regulates and promotes specialization and certification. Establishes strong partnerships at the national,regional and international levels. JNC served as a member of the Global Observatory for the International Council of Nursing for registration and licensure. Member of the Governing Council of the Institute for Credentialing (ANCC) JNC was also a member in the committee of the international year of nursing for the year An observer member of the Global Advisory Group (GAG) of the World Health Organization. The council provides consultations on legislations and nursing professional standards for nursing regulatory bodies at the regional level.

22 Bringing Magnet to Jordan (2013-) A major specialized health care center ( King Hussein Cancer Center) chose to venture the Magnet Journey with the support of ANCC. Recent evidence revealed that they are at an early implementation of shared governance. They are committed and plan to continue with their journey. This new experience is modeling culture of quality, and self governance. In a competitive environment of health care delivery, this initiative will be dupliated (Mouro et al. 2013)

23 Hospital Accreditation Movement (2007-) Hospital accreditation is run by the Health Care Accreditation Council (HCAC) that was founded in Seventeen hospitals and 40 primary health care centers have been accredited. Nurses play key roles in preparation to meet HCAC standards. Annually set national goals, include nurse-sensitive indicators including falls, pressure ulcers and infection rates. The MOH plans to generalize accreditation to all its hospitals, which undoubtedly will contribute to creation of quality care culture.

24 Nurses Champion Mental Health Reform 2008-) Strong Advocacy a) to establish a model unit to advance quality of services, b) clinical placement for training of future mental health teams. HRH s continued support is making the difference in the lives of users Partnership with WHO in devising policy and plan, most active advocacy for implementation; establishing Inpatient units in general hospitals Governing body ( not budget holder,...) Downsizing tertiary care Integration of mental health in primary health care, > 20 primary health care center integrated mhgap Patient Association very effective advocate and public awareness Human Resource Development for team, focus on nurses

25 Challenges to Nursing Development in Jordan

26 Challenges to Development of Nursing Practice Nurses are licensed without a national exam. There are no re-licensure requirements; nurses are licensed forever; they only need to renew registration. Only 55.5 % of nursing workforce are RNs; 9% of which are diploma nurses. Over 50% (51.2%) of nurses are males. Practice and service are dominated by medical doctors; nurses have no autonomy and no control over patient care. Most nurse administrators are not highly educated. High attrition rate. Immigration of qualified nurses is at 20%. (JNC data)

27 Challenges to Development of Nursing Practice-2 Development introduced at the institutional level is not strategic. Nursing practice did not develop new models of care, or nursing administration in hospitals. Nursing continues to be task and doctor-order oriented, very few nursing administrators succeeded to negotiate nursing control. Different levels of nursing /nurses need clear role delineation.

28 Challenges to Development of Nursing Practice-3 Health care organizations, so far, do not recognize the advanced nurse roles nor identify the need for these roles. (JNC grants certification for specialized nurses). Specialized units in hospitals lack specialized nurses. With the exception of two post-basic diplomas in midwifery, and one in diabetic care, nurses learn through hands on experience. Nursing practice development in health settings usually is limited to continuing education activities within the hospital itself, since there is no licensing requirements, continuing education does not have a system.

29 Challenges to Development of Nursing Practice-4. RMS nursing administration in the 90s introduced nursing standards and a career ladder. Standardization was not institutionalized; however the career ladder is institutionalized and supported by both JNC and JNMC. The Jordanian Nursing Council initiated a project -in collaboration with USAID -on introducing EBP to support nursing development in selected 15 hospital. Evaluation is yet to take place!.

30 Challenges to Development of Nursing Education Nursing curricula in Jordan are traditional and are yet to explore competency and evidence-based models of education. Meaningful education- practice partnerships are yet to be developed. Inter-professional models of education are not available. Educational resources and methods are not always culturally relevant; might need to be contextualized. Curricula are not necessarily responding to rapid changes in health care, technological and epidemiological evolvement.

31 Challenges to Development of Nursing Education - 2 Faculty needs development in teaching methodology, especially clinical teaching and facilitation. Faculty clinical competency in both BSc and MSc programs needs strengthening. Currently accreditation tends to be quantitative, its criteria does not guide education for practice development. Clinical placement is one of the biggest challenges for nursing education in Jordan.

32 Challenges to Development of Nursing Education-3 Master programs that aim at graduating Advanced Role Nurses need to have more faculty prepared in Advanced Roles. High intake/high number of students; some BSc programs have over 1100 students. Bridging programs admit graduates of non regulated Associate degree programs of un-established credibility. Centralized admission for BSc students in public universities, brings in students who are not committed to nursing.

33 Challenges to Development of Nursing Research Lack of research programs, and system-based research. Need for intervention and experimental research, meta-analysis or meta-synthesis studies, that produce strong evidence for nursing practice and education development. The published research did not build on previous research; it is mostly descriptive, mostly used convenient sampling which limits generalizability of the results. Most studies were not guided by theory. Only few focused on patient and staff outcomes. Most published research is conducted by Faculty in academia; few written by nurses in practice settings (Khalaf,2013).

34 Challenges to Development of Nursing Research-2 Underutilization of funds, only 29% of published research was funded. (Funds were not sought to avoid demand and challenges of funded research, and opt for ease! ) Study results are not translated for use in practice. Research is driven by promotion requirements not based on priorities and needs. Lack of updated specific nursing priorities,/practice development research needs are not identified

35 The Way Forward

36 Revisiting the national nursing strategy Align nursing strategy with, national, regional and global agendas. Focus on enhancing populations health widen scope with public health perspective Promote nursing roles in NCDs, primary health care, community health models of care, these are important opportunities to demonstrate nursing contribution Amend laws and bylaws to support the regulatory functions of JNC. Dedicate a domain specific to leadership development in strategy;(strengthen current competencies of nurses and start now to groom our future leaders). Emphasize evidence based practice and production of evidence to advance practice

37 Developing Nursing Practice Developing nursing practice in Jordan will require legislative intervention to mandate licensure exams, and re-licensure. Addressing legislative action in education to increase the quality of nurse graduates fit for purpose. Nursing practice development calls upon patient-centered care models and moving away from functional and medical models. Support a work environment that motivates nurses to action, promote nurses control over practice and provides the infrastructure that support nurses. Nurse leaders,in practice and in service,need to be better educated and empowered to effect change. Align the workforce needs and demands with education

38 Developing Nursing Practice-2 Explore social structures, and the social world of nursing, barriers and influence on autonomy and transformative action. Interdependence and interrelatedness among all areas is required to effect practice development. Nursing education needs to serve practice development, in the real sense (impact patient outcomes) research, has to serve education and practice, and inform policy, education and practice development. Nursing need to revise policies and strategies to enter the inter into the national strategic directions.

39 Developing Practice Development Embrace Practice development and implement models that accommodate all practice development elements including Evidence-based practice that is delivered by competent nurses who are prepared to deliver quality patient-centered care that focuses on patient and nurse outcomes. Supportive, enlightening, empowering work place environment that grants nurses the infrastructure, autonomy and control over practice. A culture that shares values of best practice and shared governance. Strong leadership with clear vision and goals and coherent methodology for nursing practice development. Opportunities to demonstrate nursing contribution to patient outcomes.

40 Nursing Practice Development Create a Nurse Educator role, staffed from within the institution, is able to support evidence based practice, train facilitators, advocate for infrastructure, systematize time allocated for EBP development; this implies increasing number of nurse to patient ratios. ( Educate Empower and Emancipate). Nursing development is a shared goal and responsibility of academia. To hold academia accountable for preparation of nurse graduates fit for the purpose, ready to engage at the entry level, confident, value who they are and what they do, and able to engage in evidence-based practice. Advocate for Advanced Nursing Practice role in health care, while preparing for desired level of competency.

41 Developing Nursing Education Regulate Associate Degree programs/?? Phase out Introduce evidence and competency based curricula, develop capacity of faculty, revise admission policies for BSc. Programs. Strengthen the MS programs and revise to meet JNC certification requirements All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team emphasizing evidencebased practice, quality improvement approaches, and informatics. Accreditation processes should address core competencies associated with practice development and encourage adoption of the five core competencies.

42 Developing Nursing Research JNC to take the lead to prioritize, and support research development. Nursing research should serve nursing development goals, produce the evidence for practice and for education according to identified needs and priorities Research needs to partner with service and needs to inform policy. Standardize healthcare practices to science and best evidence to produce predictable health outcomes. Develop competencies and command of nursing research methods to produce needed system research

43 Nursing Moral Imperative To improve patient outcomes: Educate for practice development Educate and emancipate for practice development Lead for practice development. Research for practice development Partner for practice development. Devise policies for practice development.

44 Moral Imperative Moral obligation, must be universalizable. Universalizability has its appeal to what can be willed for all rather than what actually is or hypothetically would be willed by all. Kant, cited in Khan, 2001

45 Thank you and God bless