By- Abdul-Hameed A. Manae, 
Manager, Nursing & Midwifery Department,  
Ministry of Health. 

Nursing is a highly respected profession all over the world. Nurses are known as the angels on earth, giving their tender care and bringing comfort to people in pain. 
Somehow the picture is different here in Yemen, and that might explain why not many people are attracted to this profession, especially females. That is because of society's attitude towards nurses, and because they look down at them, especially if they have to spend night-shifts at the hospital. This not-so-helpful value system and many other reasons explain the frustrations and disappointments in nursing here over the last three years. 
Given my personal and direct involvement in this sector, I will try to summarize our predicament in the following four points: 

1- The failure to segregate nursing positions from technical positions is a major problem. The Department of Nursing proposed changes to the existing law regarding disengagement of nursing posts from technical grades and updating each group's minimum requirements in order to incorporate higher degrees of nursing education and experience levels, and to attract and retain qualified nurses. This proposal was submitted in 1995 and has still not been acted upon by the Ministry of Health. 
2- The number of Yemeni nationals choosing nursing as a profession remains low. The social stigma associated with the job requires some awareness and effort to overcome. 
3- Though salaries for the whole sector remain low, those of the nursing cadres are especially low compared to medical and some paramedical personnel. 
4- There is no specific budget for nursing services, particularly for training purposes, which makes implementation of plans a very difficult exercise. 

While there is is lots of praise and discussion enshrining the objectives and goals of health services, using such phrases as holistic care, a multi-disciplinary team approach, nurses as leaders of care and other such jargon, nothing is done to convert these talks into realities. 
Nursing is a difficult job. It requires knowledge, skills and self-perception which lead to the ability to work through a broad spectrum of relations. At times, these relations are independent as in the delivery of care, they are also occasionally dependent, as in theater wards, and they are often mutually interdependent. 

Understanding the driving forces of the health system in general, and within nursing in particular, are important factors in the way health services are delivered. As the person in most contact with the patient, the nurse is a vital factor in the speedy and proper recuperation of patients. To be able to deliver on her job, the nurse's abilities are shaped by her education, experience, and standing in society. 

The performance of nurses, therefore, is dependent on the maturity of the profession as a whole; the ability of individual nurses to work in a world of tension and pressure; in building lines of trust, cooperation and teamwork in meeting challenges; and in a socio-culture that offers enough understanding and appreciation. It all has to come together and make sense to all partners. 
It is for those reasons that our attitude towards and approach to nurse training and education is so important. Such approach encompasses all levels - from entry into nursing, to basic nursing education program, and to the opportunities for lifelong learning. 

The founder of modern nursing, Florence Nightingale was a highly independent person moving easily through society exerting great influence. Nonetheless she structured a nursing profession which was highly structured and disciplined, and which was exclusively made up of women. It is only in recent times in some countries that nursing has become less structured, less rigid, less hierarchical. It is also in recent times that the percentage of men in nursing has increased. Men in nursing usually hold a disproportionate number of senior roles in nursing. 
None of the above is to highlight any superiority of either sex. It is merely to highlight that the perception of nursing is often associated with a society's general attitude towards women. 

Where women are being viewed with respect and understanding, the perception of nursing as a valued and respected profession has also come. Whether there is any causal relationship is a matter of debate, but nonetheless the two are associated. This is evidenced not only by such things as improved payment, payment beings a reflection of society's value of a profession or trade, but also by greater collegiality and interaction between nurses and other health professionals such as doctors, physiotherapists etc. and by nurses taking up senior positions in government and in business. 

As socio-economic pressures achieve greater intensity and complexity, knowledge increases, the demands placed on health professionals and nurses increase, and the many roles and relationship increase in number and complexity for the nurse and other medical personnel. A significant failing of health systems is the lack of cross fertilization between the health professions, resulting in a lack of understanding of each others roles which can have impact on the oft-quoted "team approach" to health care. 
The concept of coordination of care is central to the philosophy of nursing yet there is little emphasis on the skills and knowledge needed to achieve this. Both basic and advanced nursing education programs are often more remarkable for the absence of any focus on interpersonal skills, group/organizational behavior and cultural perspectives than they are for their inclusion. 

Today, health services across the world are having to find significant new ways of organizing and coordinating. In the future we will need to move away from talking of coordinating to making it become a reality. 
Beverly Henry in her editorial in the Winter 1993 edition of Image, a journal of nursing scholarship states: 
"Inter-organizational, inter-sectarian, and inter-disciplinary relationship all need to function properly. Unnecessary duplication has to be recognized and done away with. Conflict has to be minimized so that the sick and vulnerable conserve their precious energy for getting well, for staying healthy, or for dying decently. These gaps in caring and curing have to be brought to light. And for high-quality health results at reasonable cost, nursing and medical services have to be modified so as to facilitate the procedures and performance of each. 

I would like to conclude my humble efforts by throwing some light on the challenges that the Department of Nursing is likely to face in the coming few years 
1. Attempting to attract more nationals to the nursing profession. 
2. Enacting the Nursing Practice Act. 
3. Raising the awareness of the public regarding nursing's role within the Health system. 
4. Introducing the necessary changes into the civil service laws to support nursing efforts in attracting, retaining and developing qualified nurses. 
5. To reorient nursing services and education towards primary health care strategies. 
6. To introduce more quality improvement programs to reach to desired standards of nursing. 
7. The Department of Nursing will study and review in collaboration with the department of employment and personnel affairs the current nursing posts, and the obstacles for proper human resources management and man power development. 
Increasing nursing posts and making changes in the present grades and salary scale are pre-requisites to encouraging females to join the profession. 
8. Nursing units in governorates (in the hospitals) are not established properly, chief nurses in some hospitals are not nurses, and staffing level requirements is not accurately established. As a result certain health centers and health units suffer from shortage of staff. The department will carry out studies on staffing levels in governorates, hospitals and health centers, and set up methods to be undertaken by the department in order to establish proper staffing levels for all hospitals and health centers. 
9. The current nursing staff performance is to be properly appraised. Nursing management has no means of identifying levels of performance and taking the necessary actions to respond to it. 
There is no structure for professional development such as opportunities for training and education and career development. 
10. The absence of nursing legislation in the Republic of Yemen subjects the public to the risk of unsafe practices and leaves the nurses without a legal cover for their actions. 
11. The department has many responsibilities and objectives to meet without the authority and resources to accomplish the desired goals. The role of the department of nursing is not yet defined. This has lead to the interference of other disciplines with nursing responsibilities. 
12. The department of nursing will establish the nursing registration system to register all nurses wishing to practice in Yemen, these who are working in the Ministry of Health as well as in the private sectors. 
The challenge for the department of nursing is to register nurses and update the system in order to maintain a detailed and accurate profile of nurses in the Republic of Yemen. Let us all remember that this is for the good of everyone.