Establishing Policy Foundations and Regulatory Systems to Enhance Nursing Practice in the United Arab Emirates.

In 2009, the United Arab Emirates (UAE) established a Nursing and Midwifery Council with a mandate to develop standards for the registration and regulation of nursing and midwifery and to strengthen the nursing and midwifery workforce. Priorities included workforce Emiratization and the development of regulatory standards to support advanced and speciality nursing practice and new models of care-particularly for the management of noncommunicable diseases. This article provides background, context for, and best practice inputs to the effort to provide one unified framework of nursing regulation and licensure across the whole of the UAE. This article is intended for nurse leaders, policy makers, and regulators who are reviewing or developing nursing regulatory processes and advancing nursing workforce capacity building activities; and nurse educators and nurses wishing to work in the UAE.

Introduction

Policy makers, government funders, and health-care teams in developed and developing nations are increasingly turning to the nursing and midwifery workforce in a bid to increase the accessibility and affordability of health services and to address burgeoning issues pertaining to noncommunicable disease prevention and management (Cuff, Patel, & Perez, 2015; Global Health Workforce Alliance and World Health Organization, 2013). Expanded scope of practice, new nursing roles, and redesigned models of care involving nurse-led services are now accepted health service delivery models in countries such as the United States of America (USA) and other nations that are members of the Organization for Economic Cooperation and Development (OECD), such as Australia, New Zealand, Finland, Belgium, Japan, Canada, Ireland, and the United Kingdom. These countries have well-established systems for licensing and regulating health-care professionals (Delamaire & Lafortune, 2010; Jokiniemi, Pietilä, Kylmä, & Haatainen, 2012). Similarly, expanded nursing and midwifery roles are emerging to address unmet health-care needs across developing nations, in areas such as Sub-Saharan Africa and India (Evans, Razia, & Cook, 2013; Ugochukwu, Uys, Karani, Okoronkwo, & Diop, 2013).

The practice of nursing encompasses care of individuals of all ages, families, groups, and communities—sick or well (International Council of Nurses, 2014). Contemporary nurses and midwives are involved in the provision of primary, secondary, and tertiary care across diverse health-care settings such as work places, schools, and the community (Day & Brownie, 2014; Philipsen, Lamm, & Reier, 2007). The International Council of Nurses (ICN) provides details regarding the role of nurses in promotion of health and prevention of illness, as well as care of ill, disabled, and dying people. Contemporary nursing roles also include advocacy for patients and families, research to strengthen evidence-based practice, promotion of safe environments in all practice settings, and demonstration of continuing competence (Delamaire & Lafortune, 2010; Philipsen et al., 2007). Opportunities exist for nurses to undertake significant leadership roles in health service delivery in all practice contexts. Nurses and midwives are expected to be autonomous, competent, and provide safe, evidence-based, holistic care that allows them to fulfil their ethical and professional obligations to the patients and communities they serve (Ellerbe & Regen, 2012; International Council of Nurses, 2010). The recent ICN report, Nurses: A Force for Change (International Council of Nurses, 2015) emphasizes that the projected future of nursing includes significant increases in leadership responsibility and scope of practice. It states, “Improving the quality of healthcare and access to health services depends on the extent to which the over 16 million nurses around the world are mobilized to be cost effective and care effective” (p 8).

The global need for nursing leadership and workforce capacity building with expanded practice roles is magnified in the United Arab Emirates (UAE) and neighboring Gulf Cooperation Council (GCC) countries due to factors such as the high burden of noncommunicable diseases (including diabetes) and the heavy reliance upon expatriate nursing workforces (S. M. Brownie, 2014; Hannawi & Al-Salmi, 2013). Against this backdrop, the role of professional nursing associations, professional regulators, and government legislators is increasingly important in maintaining an effective balance between community access to affordable health-care services and protection of the public.

The purpose of this article is to report progress to date in the advancement of nursing governance and regulation within the UAE. It describes best practices in nursing regulation and opportunities for expanded scope of practice and provides exemplars for individuals and organizations in other nations who are developing nursing and midwifery regulatory processes and advancing nursing workforce capacity building activities.

Profile of the UAE

The UAE, located on the Arabian Peninsula, was formed in 1971 in a spirit of harmony and cooperation between the seven independent, neighboring emirates, namely, Abu Dhabi, Dubai, Sharjah, Ajman, Umm al Quwain, Fujairah, and Ras Al Khaimah. The emirates are federated for the achievement of common goals, particularly in areas such as foreign affairs, defence, security, and social services. Common immigration policy is adopted across the emirates, but other administrative issues are left to the jurisdiction of each emirate (Sheik Mohammed Bin Rashid Al Maktoum, 2014). While each emirate retains sovereignty, cooperation occurs at the national level through the Federal Supreme Council, which elects a president and vice president on a 5 yearly basis. In 1996, the UAE Federal Supreme Council adopted a constitution, and Abu Dhabi became permanent capital of the Union.

UAE includes a small local Emirati population, estimated at 11.5% of total population in 2010 (UAE National Bureau of Statistics, 2010) and a large expatriate population of many nationalities. Arabic is the national language, and English is widely spoken.

The UAE works closely with its neighboring nations. The GCC, established in 1981, includes the UAE, Oman, Qatar, Bahrain, Kuwait, and Saudi Arabia. Its goal is to achieve solidarity and cooperation in the pursuit of common interests among the Gulf nations.

In the UAE, matters of law are issued by decree with a secondary legal layer of laws. A decree is an official order, which has the force of law. Each ruling Sheikh is able to issue decrees pertaining to his specific emirate. Federal decrees are discussed at the Federal Supreme Council and frequently issued by either the UAE President, His Highness Sheikh Khalifa bin Zayed Al Nahyan or the UAE Vice President and Prime Minister, His Highness Sheikh Mohammed bin Rashed Al Mouktoum, the Ruler of Dubai. In addition to Emirate and Federal decrees, the UAE also has a secondary legislative layer for formal laws (UAE Government, 2014). Decrees and policies are also issued at regional and local government agency level.

The UAE Health-Care Sector

In December 2013, UAE rulers held a 2-day strategic planning retreat to develop a vision of the nation’s priorities to 2021 (Samir, 2013). During this retreat, His Highness Sheikh Mohammad Bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai, stated that health care is a human right and indicated that further development of health services is a high priority for the UAE (Salama, 2013).

The UAE health-care sector has developed rapidly in response to UAE federal government strategic directions for enhancing the quality of health care (Koornneef, Robben, Al Seiari, & Al Siksek, 2012). Health-care facilities and services have expanded in both public and private sectors. New facilities include acute care hospital facilities and additional community-based clinics. Mobile primary health care and screening services to remote and rural communities have been expanded (Staff Reporter, 2015).

Government agencies (i.e., Health Authority of Abu Dhabi [HAAD], Dubai Health Authority [DHA], and the UAE Ministry of Health [MOH]) are in place to coordinate health professional licensure, accreditation, quality oversight of health service standards, and evidence-based care (Health Reporter, 2015; Moopen, 2015; Van Leijen, 2013; see Figure 1). Additionally, there is the Dubai Healthcare City (DHCC), a market ‘Free Zone’ which must comply with Free Zone rules and regulations but has independent authority in the regulation of its professional health-care workforce (Dubai Healthcare City Authority, 2015). The position of the military sector in the regulation of its nursing workforce is not publically available.

Figure 1.

UAE Emirates and health regulatory and health professional licensing entities.

Emerging Roles for Nurses in the UAE

Increasingly, nurses around the world have expanded health-care roles, which address prevention and management of complex chronic diseases. The UAE is no exception in this (S. M. Brownie, 2014; Inhorn, 2010; Micha, Danaei, Powles, Ezzati, & Mozaffarian, 2011). High rates of childhood obesity, diabetes, renal failure, and other chronic conditions are of key concern within the UAE. While it is difficult to access valid and contemporaneous data (S. Brownie et al., 2014; Hunter, Robb, & Brownie, 2014) that permits the comparison of the health of the UAE population against the health of other countries, in 2014, the comparative prevalence rate of diabetes (among the adult population) in UAE (at 19.02%) was more than double the global comparative prevalence (International Diabetes Federation, 2014). Obesity and overweight amongst children and adolescents, increasing the risk of metabolic and chronic diseases, has also attracted much attention in the UAE (Al Junaibi, Abdulle, Sabri, Hag-Ali, & Nagelkerke, 2013; Al-Haddad, Little, & Abdul-Fhartoor, 2005; Al-Sharbatti et al., 2011; Hajat, Harrison, & Shather, 2012; Katsaiti & El Anshasy, 2013). To adequately address the disease burden, “all staff … need to be viewed as part of the solution and encouraged to innovate and search for better ways of delivering appropriate care”— (Nolte, Knai, & McKee, 2012, foreword, p. xiv). Enhancement of nursing and midwifery roles is essential for the UAE to meet the high-priority challenges within the current context of care (Global Health Workforce Alliance and World Health Organization, 2013; International Council of Nurses, 2015).

In the UAE as elsewhere, nurses and midwives are the dominant force and backbone of primary health care, taking an increasing leadership role in the provision of services for public health prevention and chronic disease management (Chiarella, 2008; Colyer, 2009). The current UAE nursing workforce is composed almost entirely of expatriates (El-Haddad, 2006; Kronfol & Athique, 1986; Percot, 2006). Sheikh Khalifa bin Zayed Al Nahyan, President of the UAE, has placed priority on the socioeconomic development of the UAE citizens and Emiratization of the UAE workforce (Sinclair, 2013). While still small in numbers, Emiratization has led to the participation of locally trained Emirati and other Arab-speaking nurses in the UAE health workforce (Claire, 2012; UAE Nursing & Midwifery Council, 2010). It can be anticipated that Emirati nationals will increasingly assume the management and leadership roles in nursing in UAE.

Nurse leaders are emerging within the Middle East and developing models of care specific to and respectful of the physical, spiritual, and psychological care of Arab Muslim patients. Sandy Lovering, who practices in the Kingdom of Saudi Arabia, developed the Crescent of Care nursing model based on her ethnographic research there. Lovering’s (2008, 2012) model places the patient and family at the center of care and promotes concepts of shared spirituality and meaning among nurse, patient, and family. The Crescent of Care model integrates cultural, professional, and spiritual values and holds each as fundamental. The Crescent of Care concepts are of particular importance to the health and well-being of Arab Muslims and to the development of local nursing education programs and nursing services (Lovering, 2012).

It is important that those engaged in nursing workforce policy developments consider local cultures and contexts, particularly those of relevance to the educational preparation and practice of nurses in an Arab Muslim context (S. Brownie et al., 2015; Lovering, 2008, 2012). Although Florence Nightingale is widely recognized by western nations as a founding leader of the nursing profession, the Gulf nations and UAE have their own rich and deep roots in nursing planted by Rufaidah, the first known nurse in Islam. Historical accounts highlight how the Prophet Mohammad (Peace Be Upon Him) commissioned the establishment of a field unit in Medina for the care and treatment of the injured during the fifth- and sixth-century pre-Islamic and Islamic eras (El-Haddad, 2006; Kronfol & Athique, 1986). These roots give strength to the enduring ethos of care and accountability that remain central to 21st-century best nursing practice in the UAE.

Nursing Regulation and Licensure

Initially, the UAEMOH was responsible for regulating health care and providing the overarching management of all public hospitals and primary health-care centers across the seven emirates (UAE Ministry of Health, 2014). Abu Dhabi and Dubai later took operational control of their own public health services, and in 2007, assumed regulatory control of their own health-care sector (both public and private) and established their own policies, laws, regulations, inspections, and audits (Government of Dubai, 2014; Health Authority of Abu Dhabi, 2014). MOH retained responsibility for the other five emirates.

From 2007, the UAEMOH, DHA, and the HAAD separately established mandatory registration requirements (with forms available online), licensing examinations for expatriate nurses, and reregistration requirements, which included continuing professional development (CPD). Figure 1 displays the seven emirates within the UAE and entities by which nurse licensing and regulation is currently governed. However, these independent developments created significant challenges in workforce flexibility between Emirates.

In 2009, the ICN undertook an international comparison of the roles and identities of nursing regulators (International Council of Nurses, 2009b). The ICN reported that within the UAE, nursing regulation was developing independently and separately across the various emirates, in the absence of publicly available information to analyze and assess the power of the regulators. Fragmented development was further complicated by provisions in Dubai Healthcare City (DHCC; International Council of Nurses, 2009c).

By 2014, it became clear that the registration and licensure of health service professionals, including nurses, was a matter of common interest to all emirates. Agreement was reached on nationally consistent requirements for licensing of medical professionals (Ali Zain, 2014). This agreement to nationally unify regulations and processes governing the medical practitioners would “be more flexible” and “guarantee to the quality of work” (Ali Zain, 2014). The UAEMOH is now responsible for unifying health policies across the emirates. The agreement for unification of registration processes for medical professionals across all emirates (Ali Zain, 2014) extends to nursing and midwifery.

Since 2009, the UAE has made significant progress in establishing and enhancing systems for the regulation and licensure of its nursing and midwifery workforces, and advancing the unification of health-care professional licensing requirements across the emirates (Ministry of Health, Health Authority of Abu Dhabi, & Dubai Health Authority, 2014). Government health entities and the UAE Nursing and Midwifery Council (UAENMC) collaborate. Regulatory structures are being designed and implemented; roles for specialization are being developed; and standards for the clinical practice environment are being sculpted; all with the goal of increasing quality and promoting and protecting the health of the public. Recently published national health professional qualifications requirements have provided an opportunity for nurse practitioner pilot programs to be established within the emirate of Abu Dhabi (Ministry of Health et al., 2014). Development of clear regulatory and licensing standards will enable newly established professional and regulatory entities to fulfil their mandated obligation to “protect and promote the health and safety of the public” (UAE Nursing & Midwifery Council, 2010, p. xiv). Yet, despite the unification of nursing regulation across UAE, UAE still lacks legislation pertaining specifically to nursing practice.

Current State of Regulation of Nursing and Midwifery in the GCC

Progress across other GCC nations regarding the development of regulatory entities and systems for the nursing and midwifery workforce varies (Almalki, FitzGerald, & Clark, 2011; Eman, Cowman, & Edgar, 2012; Ghosh, 2009; see Table 1).

Table 1.

Current State Assessment Regarding the Regulation of Nursing and Midwifery in the Nations of the Gulf Cooperation Council (GCC).

Nurses and midwives in GCC	Kingdom of Bahrain	State of Kuwait	Sultanate of Oman	State of Qatar	Kingdom of Saudi	United Arab Emirates
Regulatory environment
Formal regulation setting body	MOH/NHRA	MOH	MOH/MLD	SCHQ/PLC	MOH/SCFHS	MOH/DHA/HAAD
Registration and licensure
Mandatory	Yes	Yes	Yes	Yes	Yes	Yes
License issuing body	NHRA/PLC	MOH/MLD /PLC	MOH/PLC	SCH/PLC	SFCH/SHC	MOH/DHA/HAAD
Citizens are preferred applicants (may incl. targets and quotas)	Yes	Yes	Yes	Yes	Yes	Yes
On-line registration and renewal	No	No	No	No	No	No
Download application form and instructions—then mail or deliver	Yes	Yes	Yes	Yes	Yes	Yes
Licensure requirements for expatriate nurses
Work visa	Yes	Yes	Yes	Yes	Yes	Yes
Residency visa	Yes	Yes	Yes	Yes	Yes	Yes
English language	Unclear	Unclear	Yes	Yes	Yes	Yes
Current license from home country	Yes	Yes	Yes	Yes	Yes	Yes
Recent clinical experience	Yes	Yes	Yes	Yes	Yes	Yes
Licensing exam	Yes	Yes	Yes	Yes	Yes	Yes
Data sources
Country	Authority and Web sites (accessed 20 February 2015)
Bahrain	MOH: Ministry of Health: http://www.health.gov.bh NHRA: National Health Regulatory Authority: www.nhra.bh PLC: Permanent Licensing Committee: www.nhra.bh PLCP: Registered Nurse undergoing Pre-Licensure Clinical Practice (PLCP) Assessment: www.nhra.bh
Kuwait	MOH: Ministry of Health: http://www.e.gov.kw/MOH_en
Oman	MOH: Ministry of Health: https://www.moh.gov.om/en/ MLD: Medical Licensing Department OMSB: Oman Medical Specialty Board: http://www.oman.om
Qatar	SCHQ: Supreme Council of Health, Qatar: http://www.sch.gov.qa/sch/En. PLC: Permanent Licensing Committee: http://www.sch.gov.qa/sch/En.
Saudi	MOH: Ministry of Health: http://www.moh.gov.sa/en/ SCHS: Saudi Commission for Health Specialities: http://www.scfhs.org.sa/en/
UAE	MOH: Ministry of Health: http://www.moh.gov.ae/en/ DHA: Dubai Medical Authority HAAD: Health Authority Abu Dhabi

Across the GCC, provision for nursing regulation is usually wrapped up within a Decree to implement registration and licensure of all types of health professionals and is handled administratively. Decrees governing nursing exist within the UAE and for each of the GCC nations, and these are enacted administratively, and often without the overt involvement of the nursing profession. In the absence of specific nursing legislation, governance, regulation, and licensing of the profession is primarily undertaken by government officials.

The UAENMC

The UAENMC was established in 2009 by Supreme Council by Cabinet Decree 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 (UAE Nursing & Midwifery Council, 2010). The Council’s mission is to protect and promote the health of the people of the UAE by unifying standards for nursing and midwifery practice, education, and licensure (UAE Nursing & Midwifery Council, 2010). Led by its President, Her Royal Highness, Princess Haya Bint Al Hussein, wife of His Highness Sheikh Mohammed Bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai; the UAENMC is the authoritative policy setting body overseeing standards for the regulation and licensure of nurses and midwives across the UAE. Its purview includes strengthening the nursing and midwifery workforce in keeping with requirements for a UAE-prepared nursing workforce and global trends in contemporary nursing practice.

Since its inception in 2009, the UAENMC has made substantial progress. The Council’s agenda for 2015 includes completion of regulation and licensing standards for nurses and midwives. It also encompasses development of standards for effective clinical learning environments, which will guide providers of nursing education and health service clinical placement providers.

The official Web site of the Council now contains formally approved publications (UAE Nursing & Midwifery Council, 2014a). Documents pertaining to nursing and midwifery scopes of practice (UAE Nursing & Midwifery Council, 2012), code of conduct (UAE Nursing & Midwifery Council, 2013a), educational standards (UAE Nursing & Midwifery Council, 2013b), and an educational strategy (UAE Nursing & Midwifery Council, 2013c) for the preparation and ongoing support of the nursing and midwifery workforce are available. Through its Regulation and Licensure Committee, the Council has progressed the development of UAENMC standards for registration, initial licensure, reentry into the profession and maintenance of practice.

In undertaking this work, the UAENMC discusses developments with its neighboring GCC colleagues, and carefully considers global best practices in professional regulation and licensure. The history of nursing in the UAE (El-Haddad, 2006), UAE context of care, and current goals of the UAE government regarding Emiratization are central to these developments (Claire, 2012).

UAE nurses and midwives aspire to self-govern. The essential precursors in attaining self-governance include drafting nursing-specific legislation, and the UAENMC’s completion of standards for regulation and licensure. UAE Government agreement would then be required to transfer current emirate-based regulation and licensing functions to a unified national profession-led entity, namely the UAENMC. The pros, cons, and timing of such developments are matters of current consideration among involved stakeholders, including regulatory authorities, government leaders, and nursing and midwifery professionals.

Developments to enhance the quality and access to health services require a strong and capable nursing and midwifery profession, organized and committed to protecting and promoting the health of the public.

Global Best Practices in Regulation and Licensure

Regulation of health professionals is a dynamic process, with the primary purpose of protecting the public through maintaining professional standards of practice and care (International Council of Nurses, 2009a; World Health Organization, 2002). A comprehensive search of published literature regarding best practices in regulation of health professionals, for the years 2000 to 2015, was undertaken. The intent of the search was to identify frequently highlighted best practices and standards in nursing, midwifery, and health professional regulation. Sources accessed included search and alert engines, electronic databases (CINAHL, MEDLINE, and Cochrane), journal Web sites, and gray literature.

The search revealed that regulatory practices are primarily embedded within the legislation of specific host nations. In developing policies to regulate health professionals in the UAE, certain guidelines were noted of particular relevance. These include the ICN guidelines and principles regarding the regulation of nursing (International Council of Nurses, 2009a, 2009c) and World Health Organization (WHO) guidelines specifically for the Eastern Mediterranean Regional Office (EMRO; World Health Organization, 2002).

Global practices in the regulation and licensure of nursing and midwifery include moves away from state and emirate-based models toward nationally consistent regulation and licensure. Recent examples include the introduction of the American Multistate Licensure Compact (National Council of State Boards of Nursing, 2015; Philipsen & Haynes, 2007) and the establishment of the Australian Health Practitioners Regulation Authority (Khoury, 2008; Lamp, 2010). The European Union (EU) also faces issues of cross-border education, practice, and professional qualification recognition to allow migration across the EU. The USA faces similar issues in relation to unifying nursing standards.

Development of Nursing-Specific Legislation

A nursing and midwifery practice act is an important component in guiding best practices in nursing and midwifery regulation. These laws can be separate pieces of legislation for a particular profession, or one law that combines legislation for both nursing and midwifery. The WHO guidelines for the EMRO region recommend that legislation for regulating health professionals covers core topics, specifically, the role, purpose, and scope of power of the regulatory authority; processes guiding establishment of the regulatory body; the method of appointment to the governing board or council; processes guiding establishment of the regulatory body, such as method of appointment to the governing board or council; and information about the regulatory body structure and organization along with definitions of nursing, its roles and responsibilities, and levels of nurses (World Health Organization, 2002). The same document highlights the need for standards for undergraduate prequalifying education; standards for attaining, maintaining, and renewing registration and licensure; practice standards for nurses; and the role of those not covered by the Act, for example, nursing assistants. A nurses’ practice act should also detail the authority granted to the regulatory body for education, licensure, practice, and censure; plus the authority granted to the regulatory body to develop policies and procedures and collect fees (World Health Organization, 2002). Different countries will be on different trajectories in respect to either the development or review of their country-specific policy and statutory frameworks.

ICN guidelines include 12 principles (International Council of Nurses, 2009a), which the WHO and EMRO have endorsed and which have direct applicability to the UAENMC’s work in establishing a regulatory and licensing framework for the nation (see Table 2).

Table 2.

International Council of Nurses (ICN) Recommended Principles for Best Practice in Nursing and Midwifery Regulation.

Principle	Description
Purposefulness	Nursing should have a specific purpose and be regulated to ensure that is of service to and protection of the public
Relevance	Nursing should have statutory regulation to ensure its relevance as a health profession
Definition	Standards should clearly define the professional scope and accountability of nurses
Professional ultimacy	Regulations should provide for nursing to develop itself professionally in line with its contribution to society
Multiple interest and responsibilities	Regulations should promote professional governance by incorporating interested parties, the public, government, employers and the profession
Representational balance	Regulatory systems should balance the needs of the profession with that of society
Flexibility	The regulation of nursing should be such that it achieves the objective of best practice while at the same time allow for innovation, growth, and change
Professional optimacy	The regulation of nursing should encompass efficient, effective, and economic processes to ensure competent and accessible care
Efficiency and congruence	Regulations systems should be streamlined and uniform to ensure a coordinated approach across interested partied to deliver best practice care
Universality	Nursing regulatory systems should promote universal standards of performance to foster professional identity and mobility of practitioners
Fairness	Nursing regulatory systems should be transparent and provide just treatment for nurses
Interprofessional equality and compatibility	Nursing regulation systems should not be at odds with other health professionals and should promote collaborative interprofessional working relationships that enhance patient care

Note. Adapted from “The Role and Identity of the Regulator: An International Comparative Study,” by International Council of Nurses, 2009b, ICN Regulation Series. Geneva, Switzerland: International Council of Nurses.

Recommended Regulation and Licensing Standards

Analysis of other sourced standards for nursing and midwifery regulation allowed distillation of essential areas for standard formulation. Table 3 provides a summary of the areas in which standard development is recommended.

Table 3.

Standards for Nursing and Midwifery Regulation.

Standards	Authors recommended inclusions
Definitions	A definition of nursing and midwifery; definition of the nursing and midwifery role; and the categories/levels of nurses and midwives
Education	Entry requirements; content and length of educational program; clinical training requirements; academic level of qualification, allowable breaks in training; competencies for levels nurses/midwifes; and final qualification
Registration and license to practice	Criteria for initial registration and licensure to practise; criminal history clearance; criteria for maintenance and renewal of registration and licensure to practise; requirements for malpractice insurance; and criteria and processes for loosing registration and licensure to practise
Practice	Code of conduct and ethical practice; defined scope of practice; and defined practice standards
Continuing nursing and midwifery education	Definition of specialist and advanced qualifications and practice; continuing professional development requirements to maintain practice; and advanced qualification requirements for practice in specialist areas
Discipline and conduct	Benchmark/standards against which to assess misconduct; mechanisms for investigation, judgment and appeal; schedule of possible sanctions (e.g., caution, fine, removal of license); and processes for reinstatement
Language	Defined language competencies and defined communication competencies

Recommended standards for nursing and midwifery regulation include standards defining nursing and midwifery; prequalifications and education requirements for registration; processes for achieving and maintaining registration; and standards for practice which should include language competency requirements (International Council of Nurses, 2009c; World Health Organization, 2002).

Recommendations regarding inclusion of language standards have emerged over the past 10 years, in line with the increasing mobility of the global health workforce and the growing diversity of global populations. Examples of regulatory responses to language requirements can be seen in the Nursing and Midwifery English language registration standard set by the Australian Health Practitioners Regulatory Authority (Australian Health Practitioner Regulatory Authority, 2011) or the Japanese requirement for all foreign nurses to successfully pass the Japanese Language Proficiency Test (JLPT) level N1 (Global Visa Support, 2014). In both cases, a national regulatory authority has established clear language expectations for communication in the health-care setting.

Current Policy and Statutory Considerations Specific to the UAE

Priority considerations for the UAE include.

Language Standards

Language standards are a critically important part of the UAE regulatory framework for health professionals. While the official language of the UAE is Arabic, nursing personnel are drawn heavily from the Philippines and India (El-Haddad, 2006). Moreover, English is the official language within the context of health-care delivery. The use of English in UAE health-care settings does not detract from the respect and enormous value of the national Arabic language. Rather, it is an important safety consideration in the context of a multinational health workforce. Having one common language ensures that all members of the health-care team are able to effectively communicate with each other.

Uniform Regulatory Systems and Nursing Standards

Uniform nursing regulation and standards support increased mobility of the nursing workforce across state/emirate borders and increased flexibility for health-care employers. The first step has included unification of licensing process (Ministry of Health et al., 2014). The next steps in unification of examination processes for licensing is signaled to take a minimum of 2 years before factors such as the HAAD nursing license exam and DHA nursing exams could be unified as a national exam. The projected implementation timelines are due to the detailed work required to ensure a robust examination process that is contextually and culturally relevant. Reliable and valid assessment items should be included to ensure balance between the demands of ensuring an adequate health workforce supply and providing regulatory process that ensures protection and safety of the public.

Finalizing Standards for Nursing and Midwifery Regulation and Licensure

Completion of regulations and standards for nursing and midwifery licensure is a priority for the UAEMOH. The Council progresses and publishes its work though a formal structure that includes committees for education, practice, regulation and licensure, research, and Emiratization (UAE Nursing & Midwifery Council, 2014b). The completion of standards for regulation and licensing are currently being progressed by the Council’s Regulation and Licensing Committee. Balancing of competing policy priorities is a particular challenge facing the committee. Achieving Emiratization targets in the nursing workforce is challenging because of the relatively low interest of Emirati in undertaking the nursing profession and the need to maintain high levels of safety and protection of the public.

Currently, UAE nationals are exempted from nursing or midwifery licensing examination processes (Ministry of Health et al., 2014) because high priority is placed upon increasing Emirati participation in nursing and midwifery. Nurses from Australia, New Zealand, Great Britain, Ireland, Canada, USA, and South Africa are also exempt from examination—on the basis that UAE regulator authorities have examined the nurse education and examination systems from these countries and identified a consistent level of educational standards and quality systems to assure safety of the public.

Expanding the Scope of Nursing and Midwifery Practice

The UAE lacks registration categories for advanced or speciality nursing and midwifery practice. The UAENMC is working on a standards to define advanced and speciality practice, and two of the UAE’s providers of degree-level nursing programs are now offering postgraduate options such as a Masters level programs in nursing; renal care nursing; and diabetes management and care. While new health professional qualification requirements (Ministry of Health et al., 2014) provide opportunity for pilot roles for nurse practitioners, this is not implementable because prerequisite nursing legislation is not yet developed. Introduction of nursing-related legislation and endorsement of standards, as outlined in Table 3, will complete the regulatory foundations needed to establish advanced and speciality practice roles. Once uniform laws are implemented, opportunities for the registration and licensing of advanced and speciality nursing and midwifery roles in the UAE will be facilitated, and the mechanism by which nurses and midwives could make significant contributions to the prevention and management of preventable noncommunicable and chronic disease and the development of public health services across the UAE will be established (S. Brownie, Lebago, & Hag-Ali, 2014).

Aligning Educational Institutions and Efforts

New educational institutions have opened to address the growing demand for well-educated health-care professionals and to introduce local provision of Bachelor-level nursing programs on which postgraduate programs can then be built—an essential precursor to the development of advanced and speciality scopes of practice. Table 4 includes details of the three major government owned or affiliated higher education providers currently offering a Bachelor-level nursing program within the UAE.

Table 4.

UAE Providers of Degree-Level and Postgraduate Nursing Programs.

Fatima College of Health Sciences	http://www.fchs.ac.ae/En/Pages/home.aspx
University of Sharjah	http://www.sharjah.ac.ae/en/academics/colleges/ healthsciences/dept/nu/Pages/default.aspx
Ras al Khaimah Medical and Health Sciences University	http://www.rakmhsu.com/nursing-scholarship-colleges-in-dubai-uae

UAE nursing Program providers are now planning the development of postgraduate programs in nursing (at Masters Level), in readiness for a practice context that includes licensing of advanced and speciality practice. Priority areas for continued development to PhD-level include midwifery, intensive care nursing; mental health nursing; diabetes management and care; and other speciality areas directly related to the current burden of noncommunicable and chronic disease across the UAE.

Conclusion

Effective health workforce quality assurance and capacity building is dependent upon clear and effective regulatory and licensing processes. Establishment of comprehensive regulatory and licensing systems is detailed and time-intensive work, which takes several years to fully develop and implement (World Health Organization, 2002). The UAE and neighboring GCC nations have made significant progress in developing and implementing key components of regulation and licensing practice.

The best practice guidelines outlined in this article provide useful inputs to this work and may be of use to health regulators and policy makers in other regions. Implementation of best practice standards in nursing regulation and licensing will provide a strong platform for the UAE’s aspiration of excellence in health-care delivery and the primary obligation of regulators in respect to safety and protection of the public.