Presentation title

Nursing Workforce Capacity Building in the UAE Progress, Issues and Matters of Assessment

SEHA 5th Annual Research Conference, 15 December, Abu Dhabi, UAE Professor Sharon Brownie, Griffith Health, Griffith University Research Associate, Green Templeton College, Oxford University

Presentation Objectives To provide an overview of: • The history of nursing in the UAE • The role of Griffith University in supporting nursing workforce capacity building in Abu Dhabi • UAE achievements in nursing development over the past 5 years

To increase understanding of: • Current issues & policy considerations in nursing workforce development • Nursing licensure examination challenges • Best practices in high stakes nursing examination • Areas for future research

Expected Learning Outcomes At the conclusion of the presentation attendees will have and increased understanding of: • The history of nursing in the UAE • The role of Griffith University in supporting nursing workforce capacity building in Abu Dhabi

• UAE achievements in nursing development over the past 5 years • Current issues and policy considerations in nursing workforce development

• Nursing licensure examination challenges • Best practices in high stakes examination • Areas for future research

History of Nursing in the UAE      

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Middle East has its own history of nursing tradition and practices » Rufaidah Al-Islamiah recognized as the first practising nurse in Islam Rapid modernization increased demand for contemporary health services Expatriate nurses, mostly from the Indian subcontinent, started arriving to work in the region from the early 1960s before the establishment of the Federation. A desire for Emirati led nursing services following establishment of the Federation. 1992 the MOH established the Federal Department of Nursing by a ministerial decree to develop and manage the nursing services across the UAE 2001 the Emirati Nurses Association (EN)A was established under legislation by the Ministry of Labor and Social Affairs which approved its Articles of Association in January 2003 and election of the ENA’s Executive Board in 2004 The UAE Nursing and Midwifery Council (UAE NMC) was established by Cabinet Decree in 2009 to “regulate the nursing and midwifery professions, promote and advance nursing and midwifery services and protect and promote the health and safety of the public based on the highest standards. ” 2012-2013 the UAE NMC published strategy plan and educational standards for nursing and midwifery services in the UAE

Al-Rifai, F. et al. (1996) The Nursing Profession and Future Directions in Arab GCC States [Arabic Document]. Executive Board of the Council of Arab GCC States Health Ministers, Riyad. El‐Haddad, M. (2006). Nursing in the United Arab Emirates: an historical background. International Nursing Review, 53(4), 284-289. UAE Executive Council (2009) Establishment of the UAE Nursing & Midwifery Council, Pub. L. No. Decree no 10.

Nurses = 43% of UAE Health Workforce

Source: Health Authority of Abu Dhabi (HAAD) http://www.haad.ae/HAAD/

The UAE Nursing Workforce • In 2010 health professionals in the Emirate of Abu Dhabi reached 19,310 of which 8,221 were nurses • Nurses are licensed by the Health Authority of Abu Dhabi (HAAD) • Local graduates are required to complete a graduate induction (GNI)year and pass a licensure examination • Emirati nationals are exempted • Local workforce development, in particular increasing the participation of Emirati Nationals is a key priority • Local capacity building of nursing programs from BN to Masters to PhD level is a further priority Source: Health Authority of Abu Dhabi (HAAD) http://www.haad.ae/HAAD/

Percentages of Emirati National Nurses  Female local citizens (Emirati Nationals) are represented in the health workforce as follows: » 6% professional assistants » 7% dentists » 7% doctors » 1% nurses  Male local citizens (Emirati Nationals) represented in the health workforce as follows : » 4% doctors » 2% dentists » 1% professional assists » No nurses Source: Health Authority of Abu Dhabi (HAAD) http://www.haad.ae/HAAD/

Emiratisation ‘Health conceptions of healthcare professionals that differ substantially from the cultural groups they serve often lead to confusion, conflicting health-promotion goals and low adherence to treatment regimes’ Daly (1994)

 Emirati nationals constitute only 1% of current nursing workforce  Non-Arab speaking expatriate nurses are challenged to provide culturally appropriate health care in the UAE  Emiratisation is a high priority on the national agenda  SEHA is working to agreed Emiratisation targets  The Emirati Nurses Association is a strong leader in developing and advancing the Emiratisation strategy  FCHS an ongoing leader in educating Emirati and other Arab speaking nurses with expansion to training for male nurses Daly, E.B. (1994) Health meanings of Saudi women. Journal of Advanced Nursing 21 pp. 853–857. El‐Haddad, M. (2006). Nursing in the United Arab Emirates: an historical background. International Nursing Review, 53(4), 284-289 Warren, Claire (01/03/2012). "BORN IN THE UAE". People management (1358-6297), p. 36

UAE Development of Nursing Education 

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1992 the MOH established the Federal Department of Nursing by a ministerial decree to develop and manage the nursing services across the UAE » MOH schools of nursing provided diploma level programs At the 4th annual meeting held in 2002 in the UAE, the Secretary General of the Scientific Association of Arab Nursing Faculties, in support of the WHO-EMRO (1998) recommendations, urged Arab countries to develop BSN programmes and ‘to produce qualified nurses capable of dealing with latest technologies’ 2008 BSN programs offered by four educational providers across the UAE » » » »

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2011 first Master of Nursing Program to receive initial accreditation in the UAE »

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Ras Al Kahaimah University of Medicine & Health Sciences Sharjah University Higher Colleges of Technology (HCT) Griffith University/Fatima College of Nursing Partnership

Ras Al Kahaimah University of Medicine & Health Sciences

2012 Closure of the Ministry of Health Diploma in Nursing Programs GU is honoured to have contributed to the development of Nursing in the UAE Al-Rifai, F. et al. (1996) The Nursing Profession and Future Directions in Arab GCC States [Arabic Document]. Executive Board of the Council of Arab GCC States Health Ministers, Riyad. El‐Haddad, M. (2006). Nursing in the United Arab Emirates: an historical background. International Nursing Review, 53(4), 284-289. Report re 4th Annual Meeting Scientific Association of Arab Nursing Facilities (Gulf News 2002, p. 5).

Griffith/UAE Capacity Building Partnership A five year capacity building contract followed by a 3 teach-out term aimed at:  Establishment and management of a Bachelor of Nursing Degree in the Emirate of Abu Dhabi (Undergraduate and post registration)  Enrolment of students into the GU degree 2008-2011  Last intake for GU degrees Sept 2011 with completion of final cohort June 2014 and further teach-out year to June 2015

 Support in the establishment of a College of Nursing capable of further expansion  Support in the achievement of initial accreditation  Hand-over to local management of the Nursing Department  To support full self management of the nursing program within FCHS & Abu Dhabi Emirate by the end of 2014  Continued quality advice to FCHS 2014-2015 and support for any remaining GU enrolled students

Griffith University 

Large, comprehensive University situated in South East Queensland

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Spread over 5 campuses from Brisbane to the Gold Coast

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4 Faculties: » » » »

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Arts, Education and Law Griffith Business School Science, Engineering, Environment and Technology Griffith Health

Griffith currently enrols >42,000 students Griffith Health is one of the largest and most

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comprehensive health faculties in the Australian higher education sectors spanning the biomedical, social and health clinical sciences Offshore nursing programs Singapore & UAE Nursing program for Kiribati Nationals •Griffith Health

Bachelor of Nursing Transition Period  GU approaching final phase of the contract period and now moved to advisory rather than management service for the program  Partners have worked together to transition BN program to full FCHS management  All GU key deliverables have been achieved

 On track for BN to be fully established and self managed within FCHS & Abu Dhabi Emirate by the end of 2014

GU/FCHS Partnership Outcomes  Initial CAA accreditation achieved  Bachelor of Nursing » 163 graduated » 37 completing final year  Bachelor of Nursing (Post Registration) » 274 graduated » 10 completing final year  Significant inputs to nursing workforce capacity building

A total 437 graduates have received dual degrees from GU & FCHS The majority of which are Arab speaking

GU/FCHS National Contribution No Students’ Numbers . 1 RAK College of Nursing 2 Higher Colleges of Technology

2009 2010

2011 2012 2013

Total

%

30

29

58

117

18%

0

8

0

8

1%

3 Sharjah University

44

20

42

106

16%

4 Fatima College of Health Sciences/Griffith University 5 Fatima College of Health Sciences/Griffith University (Bridging)

55

48

60

163

24%

274

41%

Total

8

108

78

45

35

8

108

207

150

195

100%

Total number (indicative) of nursing graduates 2009 to 2013 by “College” NB: Figures currently undergoing final confirmation

Fatima College of Health Sciences  Established during the term of the GU contract, Fatima College of Health Sciences (FCHS) is designed to meet the United Arab Emirates' growing need for skilled healthcare professionals now and into the future  The College presently offers the Bachelor of Science in Nursing degree delivered from two campuses namely, Abu Dhabi & Al Ain » More than 20 partner providers of clinical experience » Completion of first BN post registration cohort - Nov 2009 » Graduation of first BN undergraduate cohort – Nov 2011  Also offers a growing range of Allied Health degrees  Developing additional campuses  Progressing to post graduate courses  Increasing Emirati enrolments  Preparing for full accreditation http://www.fchs.ac.ae/FCHS/

Challenges Ahead There is good cause for celebration. Much has been achieved and the foundation is built for continued development of UAE nursing education & the nursing workforce BUT capacity building and development is hard work and a number of challenging policy considerations and issues are ahead The path ahead is not always clear

Further Work & Research

Workforce Planning & Research  Currently the new BN programs are producing 120 -170 graduates pa Ques: Is this sufficient given the size of the nursing workforce?  The UAE nursing workforce has a high level of turnover Ques: What graduate tracking processes are in place? Is retention better among locally education nurses?  The UAE has a high level of diabetes and chronic disease Ques: What workforce numbers and speciality groups are needed to address health service demand in this area?  The post registration program appears to be being phased out? Ques: On what basis is the PR program, what is the demand among Arab speaking nurses in the country?  At 1% UAE has the lowest rate of national/locals in the nursing workforce  Ques: What factors influence Emirati career choices?  Ques: What assistance can be gained from review of neighbouring workforce development models such as Oman (now at 54% local nurses)? Ghosh, B. (2009). Health workforce development planning in the Sultanate of Oman: a case study. Human resources for health, 7(1), 47-63.

A Vocation or a Profession  Globally, nursing is recognized as a profession and degree-based nursing education is delivered within university rather than VET sector contexts  The VET sector governance of nursing education in Abu Dhabi is a national exception and global outlier

 Faculty research activity is not supported in a VET sector context  The CAA standards for Academic Accreditation have specific requirements related to the delivery of degree-based programs including the development of a research culture and activities » Standard 10 Research & Scholarly Activities » Standard 3.7 Graduate Programs  Further discussion & consideration is needed locally https://www.caa.ae/caa/images/Standards2011.pdf

Further Work & Research PROGRAM DEVELOPMENT  The UAE NMC Council Educational Goals include educational goals for the continued development of nursing. Goals include: » Development of programs to Masters and PhD Level » Continued provision of bridging programs » Introduction of speciality nursing programs

PROGRAM ACCREDITATION  Jointly enrolled GU/FCHS students are covered by the initial accreditation status  Achievement of full in-country accreditation is an important underpinning for ongoing functioning  Consideration of international accreditation is an important consideration for global recognition of UAE-based nursing qualifications UAENMC. (2012). Education Strategy . http://www.uaenmc.gov.ae/en/Publications.aspx UAENMC. (2013). Education Standards http://www.uaenmc.gov.ae/en/Publications.aspx.

Further Work & Research FACULTY DEVELOMENT  Areas for faculty development include : » Core competencies for nurse educators (National League of Nursing) » Currency of practice – nursing licensure » Delivery of competency vs skills-based curriculum (how to teach critical thinking skills) » Research competencies for delivery of degree-based programs NATIONAL UNIFICATION  UAENMC has confirmed the goal to unify standards and processes across all Emirates » Consistent national exam for initial licensure » Consistent national standards and processes for licensure renewal Kalb, K. A. (2008). Core Competencies of Nurse Educators: Inspiring EXCELLENCE in Nurse Educator Practice. Nursing Education Perspectives, 29(4) (Jul/Aug 2008): 217-219. National League of Nursing. (201). Core Competencies for Nurse Educators. http://www.nln.org/profdev/corecompetencies.pdf www.uaenmc.gov.ae/

Matters of Assessment

HAAD Nursing Licensure Exam 

To obtain a nursing license Non-Emirati graduates of UAE nursing schools must successfully pass the HAAD (HAAD Authority of Abu Dhabi) nursing licensure exam

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Graduates who are Emirati Nationals are exempt from the examination process

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The graduate nurse induction and prelicensure examination requirements of nonEmirati graduates is outlined in HAAD’s Professional Qualification Requirements (PQR) documents

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To date, the glow of achieving good graduate outcome numbers is marred by a history of poor performance in the HAAD examination http://www.haad.ae/haad/

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The highest performing cohort achieved a 40% pass rate on 1st attempt.

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Multiple attempts at the examination are common

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Graduates who have not passed within the 12 graduate induction period experienced a 12 month stand down

http://www.haad.ae/haad/tabid/37/Default.aspx?Search=Professional+Qualifications+Requirements

HAAD Nursing Licensure Exam  HAAD exam is a 3 hour assessment involving 150 MCQ’s

 Apart from a small number of test questions for registered candidates, practice exams are not available

 The exam is offered on-line via  Candidates receive a pass/fail a PearsonVue platform message at completion of the exam  The exam is described as an assessment tool designed for  No feedback is available for candidates or faculty regarding nurses with 2 years practice areas of strength and weaknesses experience but also used as the competency assessment tool for new graduates  Little is else is formally known about exam

Student and Faculty Feedback Failing students express frustration re:  Paucity of information about the exam

Faculty express frustration re:  Lack of information to help prepare students

 Lack of practice exams

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Same frustrations as students

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‘Feeding students into an unknown maze ‘

 Lack of feedback

 No information regarding areas of strength or areas of weakness  Unable to determine if they are close to passing or a long way off  Regular anecdotes of duplicated questions or questions perceived as faulty

Exam Transparency The more educators know about what will make students successful on the licensure exam, the better the chance that interventions will be successful Elizabeth Zweighaft, EdD, MEd., RN (2011) re improving predictive exit exam scores

Fair Testing  Increased information is needed about the HAAD licensure exam to meet basic examination standards such as: » Standards for high-stakes testing » Fair testing standards » Globally accepted best-practice assessment standards

 GU team has recently worked with a group of students who had sat the exam on multiple occasions  Many insights have been gained. A follow-up report with recommendations will be prepared. Spurlock, D. (2006). Do No Harm: Progression Policies and High-Stakes Testing in Nursing Education. Journal of Nursing Education. 45(8), 297-30. National League of Nursing. (2012). The Fair Testing Imperative in Nursing Education. http://www.nln.org/aboutnln/livingdocuments/pdf/nlnvision_4.pdf

Congratulations for the achievements to-date Progressing the future vision and meeting the ongoing challenges is all achievable The remarkable history of progress provides the foundation for future success

References 

Daly, E.B. (1994) Health meanings of Saudi women. Journal of Advanced Nursing 21 pp. 853–857.



El‐Haddad, M. (2006). Nursing in the United Arab Emirates: an historical background. International Nursing Review, 53(4), 284-289.



Ghosh, B. (2009). Health workforce development planning in the Sultanate of Oman: a case study. Human resources for health, 7(1), 47-63.

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Hajat, C., Harrison, O., & Shather, Z. (2012). A profile and approach to chronic disease in Abu Dhabi. Globalization and health, 8(1), 1-12.

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Health Authority of Abu Dhabi (HAAD) http://www.haad.ae/HAAD/

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Iglesias, B., F. Ramos, et al. (2013). "A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care." Journal of Advanced Nursing 69 (11): 2446-2457

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Kalb, K. A. (2008). Core Competencies of Nurse Educators: Inspiring EXCELLENCE in Nurse Educator Practice. Nursing Education Perspectives, 29(4) (Jul/Aug 2008): 217219.



National League of Nursing. (201). Core Competencies for Nurse Educators.

http://www.nln.org/profdev/corecompetencies.pdf

References 

National League of Nursing. (2012). The Fair Testing Imperative in Nursing Education. http://www.nln.org/aboutnln/livingdocuments/pdf/nlnvision_4.pdf

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Al-Rifai, F. et al. (1996) The Nursing Profession and Future Directions in Arab GCC States [Arabic Document]. Executive Board of the Council of Arab GCC States Health Ministers, Riyad.

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Spurlock, D. (2006). Do No Harm: Progression Policies and High-Stakes Testing in Nursing Education. Journal of Nursing Education. 45(8), 297-30.

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UAE Executive Council (2009) Establishment of the UAE Nursing & Midwifery Council, Pub. L. No. Decree no 10.

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UAENMC. (2012). Education Strategy . http://www.uaenmc.gov.ae/en/Publications.aspx

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UAENMC. (2013). Education Standards http://www.uaenmc.gov.ae/en/Publications.aspx.

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Warren, Claire (01/03/2012). "BORN IN THE UAE". People management (13586297), p. 36

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Wollin, J. A., & Fairweather, C. T. (2012). Nursing education: a case study of a Bachelor of Science Nursing programme in Abu Dhabi, United Arab Emirates. Journal of Nursing Management, 20(1), 20-27.

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