Reconstructing a healthcare system in Iraq

New Haven, Conn. – Nurses in Iraq listed building new hospitals, English language training and creating more autonomy and respect for their profession as priorities in reconstructing a healthcare system in the war ravaged country, according to a study by researchers at Yale School of Nursing.

A total of 744 surveys were collected from nurses in the Dohuk and Erbil regions of northern Iraqi Kurdistan by field researchers working on the project with Yale. The region has remained stable with only sporadic violence because of creation of the "no-fly" zone in 1991.

"However, a functioning economy does not mean that the reconstruction is complete," said Allison Squires, R.N., doctoral candidate and lead author of the study in Advances in Nursing Science. "It will be an ongoing process. Including input from nurses will be important for ensuring the success of the policy choices made there."

Squires and co-author Ali Sindi, M.D., who is in Iraq, developed the survey. After the survey was translated into Arabic and Kurdish field coordinators distributed it to nurse participants at their place of work and the data was emailed to Squires.

In addition to new hospitals, language training and leadership development, nurses reported the need for new equipment and furniture for patient care, financial support for student nurses, more access to nursing and medical journals and improved laboratory services.

"Nurses repeatedly wrote down that they wanted more respect, not only in the workplace, but in society as a whole. They suggested that this could be accomplished through recognition for quality of performance," Squires said. "They also wanted respect from physicians, administrators and the public but did not offer solutions in this area."

The nurses also called for assistance with housing, child care and transportation to and from work and risk allowances to cover health benefits such as vaccinations. "We might assume from this that many nurses have not been properly vaccinated against infectious diseases, which increases their risk of contracting easily preventable illnesses on the job," Squires said.

The nurses' comments reflect the low public status of nursing and the lack of consistent authority. "We have more than one manager." "We are insulted and every guilt of the hospital eventually comes upon nurses." "We should be paid more than police and teachers because teachers have four days off each month and they are not tired like us." Currently nurses in Iraq earn an average of US$150 per month.

Diseases nurses listed as priority concerns were childhood illnesses, cancer and sexually transmitted diseases other than HIV/AIDS, of which the incidence rate remains low. Squires said cancer rates are high in the region due to a variety of factors including chemical warfare used by the previous authoritarian regime for ethnic suppression. Malnutrition was also a serious concern. It stems from both prolonged political sanctions in the region and mismanagement that impeded the success of the United Nations' oil-for-food program in the country during the 1990s.

"The feedback provided by the nurses in this study demonstrates clear priorities that can facilitate both the short-term working conditions of Iraqi nurses and the long-term plans for the development of the profession," Squires said.

The study was made possible by a collaboration facilitated by the Yale World Fellows program along with Internet access. This non-governmental collaboration added to the credibility of the study, although the study did have the support of the regional government. The authors believe the non-governmental collaboration increased the willingness of the nurses to participate.

The Internet provided a consistent means of reliable communication in a place where electricity and phone service are sporadic at best. And, although managing a research study without local site visits did require relinquishing a certain amount of control, "credible and useful results can still be generated with thoughtful, careful planning in the overall research design," Squires said.

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Advances in Nursing Science 29: 55-68 (Spring 2006)


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