|Year : 2016 | Volume
| Issue : 4 | Page : 238-245
Clinical nursing and midwifery research in Middle Eastern and North African Countries: A Scoping Review
Malak Alashal Alhusaini1, Carolyn J Sun1, Elaine L Larson2
1 Columbia University School of Nursing, Columbia University, New York, USA
2 Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
|Date of Web Publication||12-Oct-2016|
Malak Alashal Alhusaini
Columbia University School of Nursing, 617 West 168th Street, New York
The professions of nursing and midwifery currently face many challenges, such as an increasing number of patients with communicable and non-communicable diseases, which strains resources and requires nurses and midwives to develop their knowledge and skills to a higher level. This is also true in the Middle East, including the Mediterranean East and North African regions, which means it is vitally important that nurses and midwives have access to and use current research to inform their practice, with research targeting the most relevant issues, including complex humanitarian emergency situations that increase health issues and challenge health infrastructure. For this to be achieved, a scoping review of the indexed clinical nursing and midwifery literature in the Middle East was performed to identify gaps in clinical nursing and midwifery research and areas requiring focus. A search of PubMed, CINAHL/EBSCO, EMBASE, the Jordanian Database for Nursing Research resulted in 210/1398 articles which met the inclusion criteria: (1) original research, (2) conducted in Middle Eastern countries as defined by the World Health Organization, (3) had at least one nurse or midwife author (but not limited to nurses in Middle Eastern countries), (4) published in an indexed, peer-reviewed journal between January 1, 2000, and December 31, 2015, (5) included patient outcomes in the results, (6) written in English or Arabic and (7) included an abstract. Studies were found from 10 of the 22 countries; the majority (n = 199; 94.76%) was conducted in three countries: Jordan, Iran and Lebanon. Most studies (n = 158, 75.24%) used quantitative designs, primarily cross-sectional, descriptive studies (n = 106) and the most frequently researched topics were related to maternal child health and women's health (n = 95, 48.5%). Strategies are needed to encourage collaboration between nursing and midwifery faculty members including clinicians to assure that clinical research is disseminated and used to improve patient care.
Keywords: Clinical nursing research, Mediterranean East, Middle East, midwifery, North Africa, nursing, nursing research, scoping review
|How to cite this article:|
Alhusaini MA, Sun CJ, Larson EL. Clinical nursing and midwifery research in Middle Eastern and North African Countries: A Scoping Review. J Health Spec 2016;4:238-45
|How to cite this URL:|
Alhusaini MA, Sun CJ, Larson EL. Clinical nursing and midwifery research in Middle Eastern and North African Countries: A Scoping Review. J Health Spec [serial online] 2016 [cited 2019 Apr 24];4:238-45. Available from: http://www.thejhs.org/text.asp?2016/4/4/238/191904
| Introduction|| |
Nurses and midwives practicing in Middle Eastern countries face challenging responsibilities with increasing communicable and non-communicable disease cases and lifespans as well as a decreasing nursing workforce.  For example, the International Diabetes Federation reported that as of 2010, the Middle East region included six of ten countries with the highest rates of diabetes in the world, with the United Arab Emirates (UAE) topping the list, followed by Saudi Arabia, Bahrain, Kuwait, Oman and Egypt, respectively.  Approximately 9.7% of the population of these regions have diabetes, with numbers expected to double over the next two decades.  Moreover, the Middle East has an urgent need to improve infrastructure and community-based programmes to respond to increased morbidity and mortality due to chronic diseases such as cardiovascular disease, stroke, cancer and diabetes mellitus.  For example, up to 50% of men in some countries in the region smoke,  and more than 50% of the women are overweight. 
These issues have been compounded by changing demographics. According to the latest available information, the Middle East has experienced one of the world's largest growths in population over the past century,  leading governments to struggle to meet the basic healthcare needs of their citizens. The life expectancy in the Eastern Mediterranean region increased more than 12 years between 1980 and 2007.  A growth in the elderly population in coming years will also create a healthcare burden that will impact the way health systems function. Furthermore, conflicts and wars in the region have resulted in population migration that has led to major and urgent health issues including the re-emergence of infectious diseases such as polio and measles.
The Middle East has also experienced some emerging infectious disease threats, some of which are found primarily in this region, such as Middle East Respiratory Syndrome.  Furthermore, despite making significant strides in decreasing under-five mortality by 58% between 1990 and 2013, the Middle East still lagged behind the 65% decrease achieved by Latin America and East Asia.  In countries such as Egypt, Iran and Syria, chronic malnutrition affects more than a quarter of children under 5 years old, with that number reaching as high as 58% in Yemen.  In the Eastern Mediterranean region of the Middle East, the World Health Organization (WHO) reported that in 2010, 1.8 million infants failed to receive the third dose of DPT vaccine and the target to eliminate measles was not achieved.  Furthermore, Jordan saw a re-emergence of polio and measles in 2015 after the influx of Syrian refugees.  The region of the Middle East has been defined by WHO as the following: Bahrain, Kuwait, Qatar, Saudi Arabia, UAE, Afghanistan, Djibouti, Egypt, Iran, Iraq, Jordan, Lebanon, Libyan Arab Jamahiriya, Morocco, the Sultanate of Oman (Oman), Pakistan, Somalia, Sudan, Syrian Arab Republic, Tunisia, Palestine and Yemen. 
In response to these issues, governments have increased spending on healthcare services and access. However, due to challenges such as inadequate staffing and infrastructure, as well as a shortage of well-educated nurses and midwives who can inform their practice with current research, closing the gap between the current state of healthcare and the targets set by governments remains a major challenge. 
As healthcare professionals who provide support, care and advice to women during pregnancy and labour, as well as newborn care, midwives are well-situated to provide many interventions that could address many of the issues affecting these regions, not limited to promoting normal birth, detecting any complication for the mother and/or baby, providing appropriate assistance and performing emergency procedures when necessary,  which could, in turn, reduce maternal mortality and under-five mortality.  In the Middle East, there are several categories of healthcare workers who are considered midwives. These include registered midwives (who have completed a formal educational programme), enrolled midwives (midwives currently enrolled in an educational programme), community midwives (registered midwives attached to a general practice) and traditional birth attendants (untrained midwives), along with a number of other community health professionals with backgrounds in fields such as nursing and public health who may or may not have completed educational programmes.  Midwifery in some countries in the region is often considered a low-status job as midwives are perceived as being obstetric assistants and, therefore, subordinate to physicians or nurses.  However, in recent years, the situation for midwives has improved because they have become more organised in the Middle East and North Africa, have more advanced educational opportunities and have begun to be more autonomous in their practice.  Jordan, which has a diploma programme for midwives who play a major role in labour/delivery for women, plans to develop a bachelor's degree programme in the near future to expand the midwifery cadre with increased competencies. Midwifery bachelor's programmes exist in countries such as Tunisia, and in many countries, the costs are low, but in some countries, the programmes lack sufficiently qualified teachers.  One exception is Oman, which requires advanced level qualifications for the teachers and has invested in midwifery resources for students. 
Despite the fact that nurses and midwives are vital for the improvement in healthcare, a shortage remains in many Middle Eastern countries.  The WHO's 2015 'World Health Statistics' report reported that Lebanon has an estimated 27 nursing and midwifery personnel for every 10,000 people, Egypt 35, the UAE 32 and Saudi Arabia 49 - just over half that of the United Kingdom (88 per 10,000). 
As frontline, healthcare staff, nurses and midwives need to be prepared for these changes and use principles of evidence-based practice to guide clinical practice.  They are particularly well positioned to provide primary care and aid in improving vaccination compliance, reducing infant mortality, diabetes and obesity and many other healthcare conditions for which nurses and midwives routinely provide care; however, their practice needs to be informed by relevant, up-to-date research.  If the healthcare challenges facing the Middle East are to be overcome, it is imperative that research specific to the region be conducted and used to inform evidence-based practice.  To do this, nursing and midwifery research is critical because nurses and midwives are the primary care providers and have unique insights into health needs of the populations they serve.  Due to their high level of patient involvement, nurses and midwives play a key role in the clinical management of patients and need to rely on evidence to guide their decision-making. Thus, it is essential that the nursing and midwifery workforce both produces and has access to relevant evidence-based resources and is empowered to use them at the point of care. 
Unfortunately, a serious gap in clinical nursing and midwifery research still exists. In a paper published about a decade ago, fewer than 5% of published papers in the world's leading 200 medical journals were produced in Arab countries.  Of 682,000 publications, only 341 (0.05%) were focused on nursing in the Middle East, but even among the published papers, the majority were focused on education and healthcare professional attitudes rather than on clinical nursing or midwifery research.  While one study in the past decade reviewed nursing research in Jordan,  we found no comprehensive review of the status of clinical nursing and midwifery research in the entire Middle East. A scoping review is necessary to include a wide variety of research that has not previously undergone a comprehensive review and can be useful to inform future research.  Therefore, the aim of this project was to conduct a scoping review of articles indexed in major health services literature search engines published between 2000 and 2015 to evaluate existing clinical nursing and midwifery research in 22 Middle Eastern countries and identify gaps in the literature. Furthermore, the results of this review may serve to guide the development of clinical research priorities for the region.
| Materials and methods|| |
Search strategy and study selection
With consultation from a health sciences librarian at the Columbia University Medical Center, a literature search was conducted using the following databases: PubMed, CINAHL/EBSCO and EMBASE. In addition, the Jordanian Database for Nursing Research was used to maximise the number of relevant articles found. Keywords and medical subject heading terms were used to search for articles in the first three databases while a search by year was used to find articles in the Jordanian Database for Nursing Research. Inclusion criteria determined a priori: (1) original research, (2) conducted in Middle Eastern countries as defined by WHO, (3) had at least one nurse or midwife author (but not limited to nurses in Middle Eastern countries), (4) published in an indexed, peer-reviewed journal between January 1, 2000 and December 31, 2015, (5) included patient outcomes in the results, (6) written in English or Arabic and (7) included an abstract. Articles were excluded if they were not research (e.g., reviews, commentaries, editorials, reports, conference abstracts, theses, discussion papers, instrument development and case studies). The complete search strategy is listed in Appendix 1 [Additional file 1].
Because authors may not be identified as nurses on publications (i.e., they may simply provide their academic credential such as PhD), we also vetted our results with five core collaborators, who are known nursing experts within the region to elucidate research that may have been missed. We defined an expert as (1) a professional nurse or midwife, (2) with a doctoral degree, (3) holding a leadership role such as a dean within a school of nursing or holding a high-ranking position within the Ministry of Health, (4) who conducts or directs those conducting research and (5) in a country within the defined region.
Results of searches were imported into EndNote and duplicates were eliminated. One researcher reviewed titles and abstracts of the remainder for possible inclusion, a second reviewer independently confirmed the results. Any discrepancy was reviewed collectively until consensus was reached. Data from EndNote were exported into an Excel workbook (author, year, title, journal, issue, volume, language, country of publication, country of study, study design, sample size, population and author affiliation) and summarised. Each publication was assigned one to four topics independently by two researchers using a constant comparative method.  One researcher reviewed the results and categorised up to four topics covered in each publication. Categories were reviewed by both researchers until consensus was reached.
| Results|| |
The search resulted in 1398 articles (78 articles from PubMed, 7 articles from CINAHL/EBSCO, 708 articles from EMBASE, 411 articles from the Jordanian Database for Nursing Research and 194 articles collected through direct contact with core collaborators in the region). After removing duplicates, 1299 abstracts remained. Subsequently, 1089 were excluded: 16 articles because they had no abstract, 162 were not conducted in a Middle Eastern country, 670 were not clinical (i.e., research related to policy, workforce or pedagogy), 74 were non-nursing or midwifery, 114 were non-research (e.g., editorial, programme evaluation, conference and proceedings), 17 were relevant to nursing but not conducted by nurses and 36 were published before 2000. After these had been eliminated, a total of 210 articles were included in this scoping review [Figure 1].
|Figure 1: Flowchart of articles selected for inclusion in scoping review|
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Articles were published in journals from Austria, Australia, Bosnia and Herzegovina, Canada, China, France, Germany, Lebanon, New Zealand, India, Iran, Ireland, Jordan, the Netherlands, Pakistan, Romania, Switzerland, Taiwan, Tanzania, the UK and the United States. Of the 22 Middle Eastern countries defined by WHO, 10 (Iran, Jordan, Lebanon, Morocco, Pakistan, Saudi Arabia, Sudan, Syria, the UAE and Yemen) were the focus of these studies, with the majority (n = 199; 94.76%) relating to Jordan, Iran and Lebanon [Table 1]. Although the search included both Arabic- and English-language publications, all articles identified were published in English.
|Table 1: Middle Eastern countries (n =10) from which clinical nursing research was published between 2000 and 2015|
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The majority of the studies (n = 158, 75.24%) used quantitative designs, primarily cross-sectional (n = 106). Other quantitative designs were randomised controlled trials (n = 21), quasi-experimental (n = 7), secondary data analysis (n = 6), case-control study (n = 9), retrospective cohort (n = 4), prospective cohort (n = 2), non-randomised comparison (n = 1), longitudinal prospective (n = 1) and clinical audit (n = 1). Six studies (2.86%) included both qualitative and quantitative components. Approximately one-fourth (n = 46, 21.90%) of the studies used qualitative research designs. Twenty-four studies used descriptive exploratory designs and semi-structured interviews. Other qualitative designs include phenomenology (n = 10), grounded theory (n = 7), longitudinal narrative (n = 2), ethnonursing and microethnographic (n = 2) and focus groups (n = 1) [Figure 2]. Studies were published in ninety different journals, the most frequent of which was International Journal of Nursing Practice (n = 27; 30%).
|Figure 2: Study designs of clinical nursing research studies from Middle Eastern countries published between 2000 and 2015 (n = 210)|
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Topics researched most frequently were related to maternal child health (n = 57, 27.14%); women's health (n = 38, 18.1%); mental health (n = 35, 16.67%); patient experience including patient satisfaction (n = 34, 16.90%); health belief/health behaviour (n = 30, 14.28%); cancer (n = 29, 13.81%); family caregivers' health (n = 22, 10.5%); paediatrics (n = 21, 10%); cardiac diseases, especially myocardial infarction (n = 21, 10%); pain including symptom management, self-care and quality of life (n = 20, 9.52%); chronic diseases, including hypertension and diabetes mellitus (n = 17, 8.1%); acute care (n = 15, 7.14%); community health including disease prevention and health promotion (n = 11, 5.24%); pulmonary diseases (n = 9, 4.3%); adolescent health (n = 8, 3.81%); abuse including violence and sexual assault (n = 7, 3.33%) and war/conflicts (n = 6, 2.86%).
Other topics that were researched less frequently were complementary and alternative medicine (n = 5, 2.38%); HIV/AIDS (n = 4, 1.90%); obesity (n = 4, 1.90%); culturally relevant care (n = 4, 1.90%); palliative care (n = 3, 1.43%); men's health (n = 3, 1.43%); infectious diseases (n = 2, 0.95%); oral health (n = 1, 0.48%); health technology (n = 1, 0.48%); end-stage renal diseases (n = 1, 0.48%) and substance abuse (n = 1, 0.48%) [Table 2]. It must be noted that in articles fitting into more than one category, such as paediatric cancer, the article was counted twice, once for cancer and once for paediatrics, making the total percentage for topics more than 100%.
|Table 2: Clinical nursing research topics (n = 28) published between 2000 and 2015 from middle Eastern countries (n = 210)|
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| Discussion|| |
In this comprehensive scoping review, the majority of the studies was quantitative and cross-sectional in design and was published in journals published outside the Middle East, suggesting a possible need for more journals that include clinical nursing and midwifery research to be published within the region. Despite the increasing prevalence in the region of chronic diseases such as cardiovascular disease, stroke, cancer and diabetes mellitus,  a limited number of studies on such conditions have been conducted. Furthermore, although a search for articles in Arabic was conducted, none were found, which could limit access to the studies that have been conducted if nurses and midwives lack the English needed to read and understand research, or present difficulties for nurse and midwifery researchers who do not speak English fluently. Furthermore, fewer than half of the 22 Middle Eastern countries included (10/22, 45.4%) had published, indexed research. This is important to note as the economies in the Middle East range from extremely poor (e.g., Yemen) to extremely wealthy such as Qatar and the UAE,  resulting in wide variations in healthcare systems. Yemen, for example, has a ratio of three physicians for every 10,000 people as compared with Qatar with a well-developed healthcare system including 23.1 physicians and 61.8 nurses per 10,000 people.  However, we found one midwifery article from Yemen and no clinical nursing or midwifery research from Qatar in this scoping review.
Economics may also have an impact on the level of education achieved by most nurses/midwives. For example, affluent Middle Eastern countries such as Gulf countries have established numerous scholarship programmes to support citizens to study nursing abroad at the bachelor's, master's and doctoral levels.  These nurses may be better equipped to conduct research; however, the differences among countries in the region may mean that the results in one country are not generalisable to the entire Middle East. More research is needed to determine whether wealth has had an influence on either research output or the generation of new nurses and midwives.
As noted, the high level of wealth of some countries has not necessarily translated into an increase in clinical nursing research as yet. This review found that the majority (80%) of clinical nursing studies emanated from Jordan, Iran and Lebanon (n = 106, 58 and 35, respectively), with very few studies originating in the Gulf. A possible reason for this may be the length of time that nursing education has been a major focus in the various countries. For example, several undergraduate and graduate programmes have been established in Jordan since 1972, and the first Jordanian student with PhD graduated in 1986, followed by many others.  These nurses often work as nurse educators in Jordanian nursing programmes, with a part of their role being dedicated to conducting research. This increased productivity has been boosted by a nursing PhD programme which was established in Jordan in 2005.  On the other hand, a bachelor nursing degree in Saudi Arabia has been recently made mandatory to practice nursing, but there is no nursing PhD programme available in the country.  In addition, the master's degree in nursing is still not offered to males in Saudi Arabia. 
Similar to Jordan, nursing education in Iran has undergone major changes since the revolution in 1979, moving from an apprenticeship training model to an academic model.  A series of changes transformed educational programmes, enabling nursing students to undertake study up to and including the PhD level, and Iranian nursing students also now have full access to professional journals.  Lebanon has an even longer history of nursing education, as the School of Nursing at the American University of Beirut was established in 1905. In 2005, there were eight universities with Bachelor of Science in nursing programmes, three of which also had masters programmes.  Although PhD level study is not yet available in Lebanon, nursing law states that nurses should conduct research on nursing care to improve themselves and scientifically evolve.  On the other hand, in Saudi Arabia, it was not until 2005 that the late King Abdullah Bin Abdulaziz Al Saud introduced the King Abdullah Scholarship Program in response to an identified need to develop human resources in the Kingdom including nursing workforce.  Other Gulf nations then followed suit. Because many nursing students started in baccalaureate degree programmes and are progressing through masters and doctoral programmes, the impact of these scholarships on clinical research may not yet be observable.
In regards to the topics of the clinical nursing research, although emerging and re-emerging communicable diseases have a significant impact on countries in the Middle East, they have not frequently been the focus of nursing research.  Instead, clinical nursing research has remained primarily focused on reproductive health. While important, with the emerging prevalence of chronic diseases such as diabetes, cardiovascular disease, stroke and cancer, there is a need to widen the focus of nursing research to include these as well. Although a large body of knowledge regarding the aetiology and biology of such diseases exists through clinical research conducted by physicians and other scientists,  the lack of nursing research means that findings regarding nursing implications are lacking. As nurses are front-line healthcare staff who have extensive contact with patients, this gap could negatively impact patient outcomes and satisfaction.
There were also interesting findings regarding the studies that did not fit the inclusion criteria for this review. In our initial search, we also found 78 articles related to nursing workforce, 25 of which focused specifically on challenges to nursing recruitment and retention in the region. Thirty articles referred to the nursing shortage and 38 articles reported negative perceptions of nursing/midwifery as a career choice, leading to a high reliance on expatriate workers. This indicates two major and related problems facing nursing and midwifery in the Middle East: (1) Difficulties in recruitment and retention and (2) nursing and midwifery being considered a low-status job in the region. The reason that these issues have been a focal point of nursing and midwifery research may partially explain the lack of clinical nursing and midwifery research in the region. These challenges also illustrate that nursing/midwifery is still at an early stage of development in the Middle East, with many social and cultural obstacles to overcome. When these are viewed as more desirable professions, and nurses and midwives are regarded as well-educated professionals, there may be more support and opportunities for them to carry out clinical research.
Although research by other healthcare professionals such as physicians can make important contributions to nursing and midwifery, it is vital that nurses and midwives also conduct research to address the clinical issues specific to their profession and provide support for evidence-based practice. This was an overall major gap in existing nursing and midwifery research in the Middle East; to date, clinical nursing and midwifery research have targeted a limited number of issues and been published primarily from a few countries in the region.
While there is undoubtedly other nursing and midwifery research within the region, we focused specifically on clinical nursing and midwifery research. This paper reports on midwifery and clinical nursing research identified by searching only four databases: CINAHL, EMBASE, PubMed and the Jordanian Database for Nursing Research between the period of 2000 and 2015, along with articles collected directly through core collaborators that were published during the same period. Other databases may have revealed additional results. Furthermore, in some cases, it was difficult to identify whether a nurse or midwife was an author as this was not clearly stated. Because of this, the articles provided by the core collaborators were vital; it is possible that other research was conducted by nurses or midwives but was not readily identifiable as such and was inadvertently excluded. Other articles may also have been excluded due to the author's lack of affiliation with a school of nursing, or when credentials were omitted by the publisher. Finally, we only included complete original research articles, not abstracts from conference proceedings. Despite these limitations, this review reflects what nurses or midwives seeking evidence may reasonably expect to find when seeking culturally and regionally relevant nursing and midwifery research and provides insight into the overall state of nursing and midwifery science within the region.
| Conclusions and recommendations|| |
This scoping review examined the nursing and midwifery literature published over a 15-year period. One hundred and five clinical nursing and midwifery articles were found covering nine clinical topics, the majority focusing on reproductive health. Studies were published in just a few Middle Eastern countries, and national differences in levels of wealth and development of healthcare systems may mean that the results are not easily generalisable. This lack of clinical nursing research may be one factor leading to difficulties in implementing evidence-based nursing practice. Future studies could include assessments of other areas of nursing and midwifery research, as well as analyses to determine associations between country wealth and culture, research output, and/or nursing and midwifery workforce volume. Furthermore, it is recommended that nurse and midwife authors are identified as such through their titles to provide clarity to those seeking to utilise the research.
Based on this review, more clinical research needs to be conducted by nurses and midwives; the scope of that research needs to be widened to respond to health needs and improve the standard of nursing care in the Middle East. To facilitate this, nursing and midwifery education programmes and healthcare organisations need to create a culture that emphasises the importance of research by providing nurses and midwives with the support and resources they need to carry out clinical studies. Nursing and midwifery education programmes should equip nurses to carry out research and conduct clinical research should be a vital part of the role of nurses and midwives in academic positions. Healthcare organisations should allocate funding to ensure nurses can conduct clinical research and research mentors should guide nurses who are interested in conducting research for the first time. Protected research time also needs to be allocated to nurses and midwives conducting clinical research, which would alleviate the stress of trying to conduct research while providing care to a full patient load or fulfilling teaching requirements.
While many of these issues are present globally, this scoping review confirmed their existence in the Middle East, and the acute need for change. Furthermore, strategies need to be developed that encourage collaboration between nursing and midwifery faculty members and clinicians to assure that clinical research is disseminated and used to improve patient care.
We would like to acknowledge our core collaborators Professor Fathieh Abu-Moghli (Dean of the Faculty of Nursing at the University of Jordan), Dr. Huda Abu-Saad Huijer (RN, PhD, FEANS, FAAN, Professor of Nursing Science and Director of Hariri School of Nursing at the American University of Beirut) and Arwa Oweis (RN, DNSc, Regional Adviser for Nursing, Midwifery and Allied Health Personnel, WHO) for their valuable contributions to this manuscript.
Financial support and sponsorship
The financial support was provided by A President's Global Innovation Fund, Columbia University.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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