Advanced practice nurses (APNs) contribute to improvements in the healthcare system. The International Council of Nurses defines an APN as a "registered nurse (RN) who has acquired the expert knowledge base, complex decision-making skills, and clinical competencies for extended practice, governed by the context and country in which a practice is credentialed."1 Internationally, a master's degree is the recommended entry level for APN practice.1 Considering the pivotal roles and impact of an APN embedded in any healthcare system, and coinciding with the global trend toward embracing APN practice, the Sultanate of Oman created a mission of introducing APN practice within its healthcare system. Many factors facilitated the development of the APN into the Omani healthcare system. In addition, many factors lead to underutilization of the full scope of practice of APNs in Oman. This article highlights both types of factors.
INTRODUCTION
Background on the Sultanate of Oman
The Sultanate of Oman is one of the largest Arabic Gulf countries. It is located at the southeastern coast of the Persian Gulf region and borders Saudi Arabia and the United Arab Emirates on the west and the Republic of Yemen on the south. Muscat is the capital city of Oman.2 According to the 2013 national census, Oman covers an area of 309 500 km2, with census of 3 219 575.2 In contrast to Western countries where the population is aging, only 6% of the population of Oman is 60 years or older.2 The life expectancy of the Omani population is 71.6 years.3 Oman is a country consisting largely of sandy desert with rugged mountains and a small agricultural area. The main source of income for Oman comes from the sale of oil.2
THE HEALTHCARE SYSTEM IN OMAN
Healthcare in Oman Before 1970
Before the modernization of Oman in 1970, the healthcare system in Oman was one of the poorest in the world, with a high mortality rate among infants and children.4 The mortality rate among infants was estimated to be 159 per 1000 live births at the time. Communicable and infectious diseases, including diphtheria, mumps, malaria, neonatal tetanus, polio, diarrhea, and gastroenteritis, were the main causes of mortality among the Omani population prior to the 1970s.4 Before 1970, 2 hospitals with 12 beds, both located in the capital city (Muscat), served the entire population with only 13 physicians on staff.4 When His Majesty Sultan Qaboos bin Said became the ruler of Oman in 1970, he created a vision for his constituents of high-quality healthcare system and increased educational standards. The Ministry of Health was created and was responsible for providing high-quality patient care to all Omani citizens at no cost. Currently, in addition to the Ministry of Health, the Ministry of Defense and Sultan Qaboos University Hospital are the main healthcare providers in Oman.4
Healthcare in Oman After 1970
Health services in Oman have undergone radical changes since 1970. According to the 2013 annual health report, currently there are 49 hospitals, all overseen by the Ministry of Health, with a bed capacity of 4821.5 A large hospital built in 2003 serves the mental health needs of the country with a capacity of 220 beds. Throughout Oman, there are 195 health centers and 22 extended health centers containing specialized polyclinics.5 Because of these changes, Oman has succeeded in increasing the quality of healthcare delivered to its citizens, and many communicable diseases such as chickenpox have been eradicated.4 Similar to many industrialized nations, noncommunicable diseases such as diabetes, hypertension, and cardiovascular diseases have emerged to become the leading causes of death among the Omani population.6 The Ministry of Health has acknowledged the changing health issues and is now focusing on preventive care addressing diabetes and heart disease.
Healthcare in Oman Today
There are 3 integrated tiers of healthcare services in Oman today. They consist of primary, secondary, and tertiary/referral healthcare. Primary healthcare is provided by health centers, extended health centers, and local hospitals. These health institutes are located throughout the country. The health centers are usually located in low-population-density cities and provide basic health services with some specialization. The secondary level of healthcare is provided by specialized hospitals that are located in the main cities. These hospitals provide specialized health services for complex health issues. Comprehensive care that requires the use of advanced technology and treatments is provided by tertiary/referral hospitals in the capital city. These hospitals provide treatment for orthopedics, neurology, burn, cosmetics, renal, respiratory, and cardiac care.5 All of these levels of care are provided free to all citizens of Oman. In addition to the governmental healthcare institutes, there are some private clinics and hospitals operated by the private healthcare sector.4 Fee-for-service care is common for foreign workers in the private sector.
A HISTORY OF NURSING IN OMAN
The modernization of nursing started in the 1950s when a group of American nurses from the American Missionary Association trained Omani nationals to become nurses. In 1959 a 6- to 9-month hospital training program was established by the American Missionary Association to educate 16 Omani nurses. In 1970, the nursing training program was extended to a 2-year program under the Ministry of Health. Eventually, the Ministry of Health opened the country for significant advances in the nursing program and established a 31/2-year diploma program. Despite the additional Omani nursing programs, the number of national nurses was insufficient to meet the healthcare needs for staff nurses and nurse educators. The gap was filled with foreign nurses from India, Philippines, and Sri Lanka.4 In the last 15 years, the Oman government has aimed to decrease the shortage of nurses and increase the number of nursing students admitted to nursing programs. An estimated 6689 RNs are required in the next 5 years to close the gap.5
Nursing Education in Oman
Similar to the United States, the bachelor of science in nursing degree (BSN) is not the most common entry into nursing practice in Oman. There are 11 diploma-nursing programs in Oman. The largest program is situated in the capital city and graduates approximately 100 RNs each year.5 The other programs are located in the large cities, graduating approximately 35 RNs per year from each program. All of the programs share the same curriculum.5 The most recent 5-year strategic plan by the Ministry of Health in Oman recognizes the need for all nurses to be educated at the BSN level and has proposed that the BSN will become the minimum entry level for nursing practice.7
There is a plan to close the diploma programs and transition them to bachelor degree programs. A transition for current diploma nurses via a bridging program is also offered in Oman. The uniqueness of Oman in terms of cultural and social needs makes this challenging, as it has been reported that women in Oman have less autonomy in decision making than do men, and many require the approval of their spouse to complete their education or enroll in a program.8
The first bachelor program in nursing was launched in 2002 in Sultan Qaboos University.4 It currently requires 41/2 years to complete the program. Niswa University, a private university, also launched a BSN program. Graduate study for nursing in Oman is expected to be launched in spring 2016. The college of nursing in Sultan Qaboos University will commence the first master of science degree with a major in nursing. The degree will focus on acute care advanced practice nursing. This signifies the beginning of advanced nursing practice for RNs in Oman. Currently, there are no PhD nursing programs in Oman.
Licensure and Nursing Practice
In Oman, upon graduation from the diploma of nursing or BSN degree, the nursing graduate is an RN and is allowed to practice in Oman.4 There is no national examination required for nursing graduates upon graduation. Foreign nurses, however, must successfully pass a national licensure examination from their native country prior to working in Oman. There is no professional body or federation in Oman that governs or guides professional practice for the RN. The nursing directorate of the Ministry of Health or Sultan Qaboos University Hospital regulates the nursing practice of RNs in their respective institutes. Consequently, the nursing profession in Oman is still in its infancy, and nurses do not have strong professional authority. At the current time, very little nursing research is conducted in Oman by Omani nurses.
ADVANCED PRACTICE NURSING IN OMAN
Like most developing countries, advanced practice nursing in Oman is still in its infancy. The Ministry of Health, Sultan Qaboos University Hospital, and Ministry of Defense, the main healthcare providers in Oman, send nurses each year to complete their graduate study in nursing outside Oman. The common countries utilized for higher education are the United States, United Kingdom, and Australia.4
Similar to the United States, there exists a shortage of medical professionals in Oman. According to the 2005 World Health Organization census, the country has 17 physicians per 10 000 populations, and the proportion of nursing and midwifery professionals is 37 per 10 000.8 The geographic nature of Oman contributes to the shortage of physicians in Omani cities. The significant shortage of physicians, both in number and in specialty experience, has opened opportunities for advanced practice nursing. With skills in dealing with complex populations, APNs have the body of knowledge and advanced skills required to deal with complex health problems among the Omani population.
Emergence of noncommunicable diseases and increased prevalence of chronic diseases such as diabetes and heart disease among the Omani population are another factor that can be addressed by APNs. Advanced practice nurses can be utilized to educate, treat, and manage these chronic diseases. With the global trend to move care from traditional hospital settings to the community environment, another arena for APN practice has emerged in Oman. The APN roles of nurse practitioner and clinical nurse specialist (CNS) are not yet distinguished in the Omani healthcare system.
There are many factors that necessitate the development of CNSs in Omani hospitals. There is a strong need to increase awareness among other healthcare providers of the different critical roles of nurses. Clinical nurse specialists as APNs serve as leaders and consultants and would significantly assist in changing the perception of nursing among the Omani public and interdisciplinary healthcare teams. Integrating the CNS into the Oman healthcare delivery system will elevate the nursing profession and provide evidence-based practice resources for the bedside RN. Because of the fact that most nurses in Oman are educated at the diploma level into nursing, expert consultation is needed as the complex needs of patients increase. Facilitating research from the bedside clinician is important to improve quality and outcomes. The CNS plays a pivotal role in encouraging basic clinical research. Also because of the fact that there are no PhD programs in Oman currently, the CNS can serve as the researcher and develop programs of research focused on evidence-based practice. The RNs who return with their CNS credential have a responsibility to use that knowledge to further improve the healthcare delivery of Oman.
CONCLUSION/RECOMMENDATIONS
The country of Oman is transitioning its nursing profession to align them with the other developed countries. Establishing a legislative body that regulates and supports the nursing profession in Oman is very crucial. Increasing the number of Omani nurses with graduate degrees is highly recommended. Conducting workshops or forums that aim to increase the awareness of nurses and other healthcare professionals about the CNS and the impact on quality outcomes is essential to further developing their position in Oman's healthcare delivery system.
ACKNOWLEDGMENT
Ms Almukhaini would like to acknowledge Sultan Qaboos University for honoring her with the postgraduate scholarship that allowed her to complete her graduate study in the United States.
References