A Snapshot of Nursing in Qatar
Nehring, Virginia, Nursing Education Perspectives
Between September 2002 and February 2003, shortly before the military action in Iraq, Virginia Nehring served on the faculty of the College of Science in Doha, Qatar For her second experience as a Fulbright scholar--she taught nursing in Africa in 1994--Dr Nehring sought to experience an entirely different region of the world, one where English would be spoken and understood. When she made her decision to work in Qatar, a small peninsula nation off the coast of Saudi Arabia, the country was not well known to Americans. Now it is known as Central Command headquarters for the American military during the Iraq military action and as the home of Al Jazeera, the influential television news and opinion station for the Middle East. * During her stay in Qatar. Dr. Nehring became the fourth, and only non-Egyptian, doctorally prepared faculty person in the nursing unit of the College of Science. Besides teaching courses such as ethics and issues and trends, she carefully assessed the nursing program, much as an accreditation site visitor might do, with feedback to university administration as well as the nursing unit. She left the region shortly before the military action began.
QATAR IS A MODEL OF SOCIAL CHANGE. Its citizens have recently ratified the country's first constitution, which represents a first step toward democracy. A strong ally of the United States, Qatar is of great strategic importance and the source of the second largest gas reserves in the world. British and European companies, as well as American companies, have offices there.
Qatar is also of interest to nurses, if only because it is a strong competitor for recruiting nurses. Nurses from throughout the world, including the Philippines, are being recruited in large numbers to meet the health care needs of a rapidly growing country. While American nurses might be reluctant to accept employment in Qatar due to concerns about living in a dictatorship or a conservative Muslim country, Qatar is accepting of westerners. Its official faith is Wahhabi, the strictest variant of Islam, but almost 10 percent of the country are of other faiths. Tourist photos show women covered in abbayas, but non-Qatari women will feel comfortable and be culturally appropriate in modest western clothing, namely long skirts and long-sleeved, high-necked blouses that keep the sun off the skin.
Almost 80 percent of all people residing in Qatar are expatriates, recruited because of their professional expertise and credentials or to fill unskilled labor positions the Qatari do not wish to fill. Most expatriates eagerly accept employment opportunities in Qatar due to the high salaries offered and very low living costs.
Nursing Practices in Qatar Like many developed nations, Qatar has a national health program based on excellent primary health care. The capital and outlying cities are dotted with clinics that are totally free to citizens and available at unbelievably minimal cost to an expatriate or visitor. As Qatar is a wealthy country, physicians from all over the world are employed as specialists and assure the highest quality secondary care needed by residents.
Qatar has had a long-standing policy of sending its brightest students to English-speaking countries to obtain graduate degrees and bring their knowledge and expertise home. Thus, even while the focus on primary care is maintained, the health care provided in hospitals and health care agencies is excellent. Adequate funds are available to buy the latest technology.
Health care is rapidly becoming more westernized, with hospitals built on the Western model. After one of Saudi Arabia's major hospitals applied for, and received, JCAHO accreditation, Qatar's Ministry of Health decided that its primary governmental hospital, Hamad Medical Corporation, should be of equally high quality. The current director of nursing of Hamad Medical Corporation is Dr. Nabila al-Meer, who worked several years in the United States to obtain her graduate degrees. Dr. al-Meer is working closely with the director of the Ministry of Health, Dr. Hajar al Hajar, to upgrade nursing practices, policies, and procedures at the hospital.
Nursing, as practiced in Qatar, is very much in the handmaiden-to-physician and servant-to-hospital tradition. Policies are written to minimize decision making. The hospital policy book is a resource that allows staff to ascertain what should be done in most clinical situations.
Nursing is considered primarily a female occupation, and only women are admitted to the nursing program at the university. However, many nurses, both male and female, have been recruited from other countries and are skilled and knowledgeable. Although not discussed or publicized, male nurses work in Hamad Medical caring exclusively for male patients. The employment of male nurses represents a major change in gender roles for the Qatari.
Nursing Education There are three routes to education and employment as "nurse" in Qatari institutions. In lieu of what Americans would call high school, there is a diploma-type program in Doha, the capital city. Graduates are sought after by health care agencies but fill a very restricted role. Their position is similar to that of a patient care technician in the United States.
Very recently, the Ministry of Health worked closely with the director of nursing to establish an Institute of Health nursing program based in the Hamad Medical Corporation Hospital. The two-year nursing program uses hospital nurse clinicians as faculty and is similar to an American associate degree program. The curriculum is consistent with the World Health Organization's document Nursing Education in the Eastern Mediterranean Region: Prototype Technical Nursing Curriculum (1). It also includes beginning courses in research, leadership, and community health. Graduates are expected to assist as data collectors for research conducted in health care facilities and serve as team leaders and floor charge nurses.
Women interested in employment are applying to the program in such large numbers that almost 100 students are admitted each year. A monthly stipend is offered to nursing students to ensure that lack of financial resources is not a barrier to prospective students.
Individuals who meet the eligibility requirements are encouraged to apply to the Qatar University baccalaureate program in nursing. This program, although small, is designed to prepare future nurse leaders. The curriculum is consistent with a typical American baccalaureate curriculum except for the greater emphasis on, and practice in, primary health care and health education.
All students engage in health promotion community education projects early in the program and then later in their community health courses. During the 2002-2003 academic year, the curriculum was updated to emphasize critical thinking and clinical decision making in addition to the needed technical skills.
A major problem for the baccalaureate program is the recruitment of qualified nurse faculty. Although three persons assist with clinical courses, their role is very limited. Currently, excluding the author, the three nurse faculty are doctorally prepared Egyptian expatriates.
With the rapid expansion of the university, nursing students may have faculty from any Arabic or English-speaking country in their science courses as well as their general education courses. General education courses are offered in Arabic, but all science courses, including nursing, are in English, as are all the science and nursing textbooks.
Cultural Values A major issue for any expatriate teaching in Qatar is the need to recognize how cultural bias is embedded in textbooks. While most textbooks reflect a recognition of cultural diversity as a value, they strongly reflect Western culture. Westerners and Arabs agree on central concepts such as the desire to have strong family relationships, the value of children, and the value of living in peace. However, American nursing textbooks assume that health care is a business and that cost containment and quality control must be a major focus in planning appropriate care. In countries where health care is considered a basic human right, and the majority of care is government funded, the emphasis is on primary care and health promotion.
Similar conflicts may occur when case examples are used during class discussions. In an ethics class, for example, students responded to a case study on helping a patient find meaning in suffering by quoting the Qu'ran. The students stressed that suffering was a test from Allah and the patient's task would be to endure and not lose faith. They saw no other implications tot professional practice and could not grasp why the instructor saw a need for further discussion. If the Qu'ran gave the answer, there was nothing to discuss. The suggestion that a patient might be Christian and have a different perspective was met with the recommendation that someone with Christian faith be asked to talk with the patient. When issues arose that the Qu'ran did not address, the students did not know how to approach resolving them, other than to wait for a physician or hospital administrator to suggest appropriate action.
Legal concepts, which in Qatar are based on Islamic principles, are similar to those in the West in that they emphasize informed consent, autonomy, privacy, and confidentiality. However, the concepts of malpractice and negligence are not emphasized and lawsuits are rare. If a patient dies or a medical error is made, it is considered Allah's will and the family of the patient will accept the misfortune in that way. Students listened politely to a lecture on risk management, but their attention was retained only when a change in emphasis was made. The need to avoid errors to assure excellent patient outcomes and maintain one's own professional excellence was an acceptable approach. Students wanted to give superb care and uphold professional ethics.
Unlike American students, who are used to classroom discussion, the Qatari are not comfortable disagreeing with a colleague in an open forum. Breaking into small groups to discuss different options allowed students to decide on the best approach to a particular situation.
Approaches to Education Nursing education in Qatar focuses on technical skills. Although Western nursing textbooks are used, it is common to see students using older editions. Why current editions were not received when faculty ordered books was not apparent to the author.
Typically, faculty lecture, essentially from textbooks owned by the faculty, and students memorize the lectures. Students expect handouts as they are not skilled in taking notes. Tests are multiple-choice, true/false, and short answer. Until recently, most test questions have been at the recall level, with few at the application level.
As experts from around the world have come to Qatar to share ideas on effective education, Qatar University is rapidly changing, away from the faculty's traditional approach to education to a student-centered, problem-oriented approach that encourages critical thinking and emphasizes learning outcomes. The university as a whole has had American regional accreditation experts give feedback on meeting educational standards, which are increasingly becoming international in scope. In similar fashion, the university administration was very pleased that a doctorally prepared American nurse, who had been actively involved in the National League for Nursing Accreditation Commission process, had applied to come to Qatar under the Fulbright program. The author was asked to assess the nursing education program and make recommendations.
Since there are few graduate programs at Qatar University, Qatari students who are capable and interested may receive full funding and living expenses from the government to pursue graduate studies abroad. Those Qatari who received one or more graduate degrees in the United States are almost uniformly positive about America and Americans. It is unfortunate that the terrorism of September 11, 2001, resulted in major roadblocks for citizens of the Middle East to study in the United States. It may be years before Qatari once again live in the United States and carry back to Qatar firsthand accounts of the reality of American life. At the present time, most Qatari who pursue graduate education do so in Great Britain or Australia.
Factors Affecting Progress in Education Qatar University was created based on British principles, including the principle of civil service. Civil service staff will remain employed regardless of effectiveness and efficiency. The same is true for the Qatari University staff and the few faculty who are Qatari. They are employed for life, and the university truly is "their" university. Expatriates are employed to assist Qatari in university staff positions.
Another factor that interferes with the establishment of a merit system at the university is the tribal nature of Qatari society, where sheiks and their families are recognized leaders in their tribes. Cultural norms, as well as lack of experience with evaluation, result in acute discomfort in giving formative employee feedback especially if it involves constructive criticism. It would be essentially impossible to give negative feedback to a Qatari with higher social status. These social norms have resulted in uncomfortable distinctions between types of employees.
Most of the Qatar University faculty are expatriates employed on a one-year to three-year contract. To retain a position, non-Qatari must be effective at their positions. Expatriates dread the "thank you for your contribution" letter that may be received in lieu of another contract.
In a unique approach to resolving employment issues, the Sheik Hamad bin Khalifa al-Thani--the emir, or ruler, of Qatar--has established a foundation, supervised by his wife, that contracts with outside educational systems to offer superb education to Qatari. Being from westernized countries, such independent institutions rarely have problems with giving constructive criticism to employees. The employees are also almost exclusively from Western countries; they are accustomed to receiving feedback about their work and deal fairly well with merit systems.
An example is the Cornell-Weill Medical School, which has set up a branch campus in Qatar to educate a small number of Arabic students--not all from Qatar--who were selected on a very competitive basis. To house this endeavor, the Qatar Foundation has contracted with award-winning architects to build University City, a technologically state-of-the-art campus that is architecturally stunning.
The emir is committed to excellent health for all Qatari and has stated, as has the director of the Ministry of Health, that one cannot have excellent health care without excellent physicians. Not wishing to remain dependent on expatriates, the emir supports the education of Arabic students as physicians and other health care professionals.
Western hospitals and Western medicine require nurses educated in the Western tradition to assure smooth and successful functioning of the institution as well as superb, evidence-based patient care outcomes. Thus, the foundation is currently engaged in negotiations with a Canadian community college to assume responsibility for the current Institute of Health two-year hospital-based program. The goal is to make it a true associate degree in nursing program.
To date, no baccalaureate program from a Western country has been invited to establish a collaborative program. Current efforts focus on hiring nurse faculty with graduate degrees for the Qatar University program. Recruitment is relatively easy since salaries and other benefits, such as free housing and utilities, are more than competitive and Qatar has no taxes.
Cultural Influences on Health The health status of Qatari reflect their culture and lifestyle. Many examples demonstrate this clear link.
* The clothing worn by men and women outside the residence protects against the sun. Therefore, skin cancer, a common health problem in the West, is rare.
* The Muslim faith proscribes the consumption of alcohol. Therefore, there is little alcoholism.
* Although many expatriates smoke, cigarette smoking is forbidden in public places. Young men are just beginning to take up smoking; women are rarely seen to smoke except in private settings (although some young women enjoy a hubby-bubbly, a water pipe). Currently, there is little lung cancer, although recent trends suggest this could be a problem in the future.
* There is little violence in the culture and gunshot or knife wounds are rarely seen. However, emergency rooms are extremely busy, almost entirely due to the large number of automobile accidents. These remain a major cause of death despite many attempts to improve driving conditions and encourage driver education.
* As the country welcomes the knowledge and skills of expatriates, the item most widely sought from American culture is fast food. A popular area of Doha is known jokingly as "Cholesterol Corners" because it has almost every fast food restaurant available in the United States. A frightening trend is obesity, especially in children, and cardiac disease statistics are on a steep upward climb.
* Qatar, a small country, has the resources to control immigration and require a health examination for anyone wishing employment. Therefore, there is very little tuberculosis or HIV. Homosexuality is rarely discussed and, if practiced, is done so quietly. Officially, HIV is not present in Qatar; it was not possible to obtain exact figures about HIV-positive status.
At the university, there is a women's campus and a men's campus separated by entrance roads for automobiles and a wall with a control gate. As administrators, staff, and faculty may have to interact with both genders, all offices have one wall of glass to ensure appropriate behavior at all times. Single men and single women are almost never alone and unobserved. Premarital sex is not common and illegitimate pregnancy is extremely rare. Abortion is illegal according to both religious law and Qatari law.
Marriages take place at a relatively young age and are arranged by families, typically within their own tribe, so newly created couples have common traditions, customs, and expectations. By Qatar law, babies are citizens of their father's country. Due to the wealth resulting from natural gas income, all Qatari citizens receive a stipend, and family income increases with each birth. A Qatari woman married to a non-Qatari knows in advance that her children will be citizens of the father's country, and the family will be ineligible for Qatari citizenship benefits. Consequently, marriages between Qatari women and non-Qataris are rare. Qatari males, on the other hand, may marry a woman from any country.
Divorce, although allowed, is relatively rare. Domestic violence is also relatively rare, although exact statistics are not available. Because families choose spouses for their children from within the tribe, the rate of birth defects is distressingly high.
Looking to the Future Nurses in Qatar have recognized major barriers to progress for the nursing profession. There is no nurse practice act that sets criteria for a person to be called a registered nurse. There is no national licensure exam or board of nursing. There is no professional nursing association in Qatar. To date, the profession has relied, as have all the Gulf countries, on input from short-term (one year or less) experts in the field and on documents and consultants available from WHO.
While the helpfulness of such resources is recognized and appreciated, it is clear that Qatari nurses themselves must act to improve nursing practice in Qatar. Nursing classes at Qatar University now discuss the need for a nursing alumni organization and, someday, a nursing honor society to join Sigma Theta Tau International. Top leaders are meeting to create a Qatar professional nursing organization. In addition, discussions are being held to create a model nursing practice act and begin the political process to assure its passage.
In order that there might be consistency among Arabic countries, some of the top nursing leaders have met with their counterparts in the other six Gulf countries. One of their first efforts to improve professional nursing was the Code of Ethics for Nurses in the Gulf Countries, published and widely distributed in 2002. It is an exciting time for nursing in Qatar. [NLN]
World Health Organization, Regional Office for the Eastern Mediterranean. (2000). Nursing education in the Eastern Mediterranean Region: Prototype technical nursing curriculum. (EMRO Technical Publications Series, available Arabic & English). Cairo, Egypt: Author.
About the Author Virginia Nehring, PhD, RN, is an associate professor at Wright State University College of Nursing, Dayton, Ohio.…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: A Snapshot of Nursing in Qatar. Contributors: Nehring, Virginia - Author. Journal title: Nursing Education Perspectives. Volume: 24. Issue: 5 Publication date: September-October 2003. Page number: 226+. © 2009 National League for Nursing, Inc. COPYRIGHT 2003 Gale Group.
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