A Global Profile of Nursing Regulation, Education, and Practice

Even before Nightingale, religious sisterhoods introduced nursing regulation in the mid-19th century by instituting female matrons in hospitals and empowering them with authority over training programs, nurses, and female servants. As a regulated profession, nursing is governed by a set of laws and rules that outline the core tenets of nursing practice, which include (a) profession entry requirements; (b) how nurses are authorized to practice; (c) what nurses are allowed to do; (d) whether continuing competence must be demonstrated and with what frequency; (e) which actions warrant discipline and the nature of that discipline; and (f) any other requirements deemed necessary to protect the public. This section presents an overview of the types of the governing bodies managing nursing regulation worldwide, their responsibilities and mandates and the composition and qualifications of their members.

Data on nursing licensure and the various requirements to practice and legislation in each jurisdiction, including how to obtain authorization to practice, are presented in this section. Additionally, data on mobility of the nursing workforce and compacts and mutual agreements are discussed.

Throughout the world, there are at least 220 unique nurse titles. Overall, most nurse types throughout the world fit into one of four categories: nurse, specialized nurse, midwife, or nurse assistant.

A diverse array of classifications for specialized nurses occupies a large proportion of the remaining unique nurse titles. For example, in addition to a general nurse, Saudi Arabia recognizes General Specialists 1 and 2 and First Specialists 1 and 2, which are all types of nurse specialists. These nurse specialists are categorized by education, training, and competence. Brunei recognizes children’s nurses, mental health nurses, and infectious disease nurses in terms of specialized nursing. In addition to a RN, licensed practical nurse (LPN), and nurse anesthetist, Liberia has an ophthalmic nurse. Malaysia recognizes public health nurses and community nurses, and Thailand also recognizes nurse anesthetists.

In the United States, there are three main nurse types: RNs, LPNs, and advanced practice registered nurses (APRNs). There are four different types of advanced practice nurses that includes certified nurse practitioners, certified nurse midwife, clinical nurse specialist, and certified registered nurse anesthetists.

In Lebanon, there are RNs and technique superior RNs—a form of specialty nurse. A Lithuanian general nurse is known as a nurse general practitioner, or general practitioner, and a nurse with a master’s in nursing is known as a nurse general practitioner and professional.

Several jurisdictions around the world incorporate educational levels into nurse titles (Table 1). Mexico incorporates educational levels into its nurse titles, which often results in designations such as master’s nurse, postgraduate nurse, and doctoral nurse. Macao has a Grade I Nurse, who must pass an entrance exam, and a nurse graduate, who is a Grade I Nurse with 3 to 4 years of experience. In Liberia, graduate nurses are graduates of a nursing program who are awaiting nursing licensure and may practice under the supervision of an RN or an LPN.

The approval and accreditation of nursing programs varies by jurisdiction. Figure 8 presents the general nursing (RN) programs worldwide and the average number of years it takes to matriculate.

Nurses throughout the world have numerous responsibilities and it is beyond the extent of this report to detail all the nursing activities that are performed throughout the world. We did, however, explore which nurses have expanded responsibilities that encompass three areas: diagnosis, prescribing, and referrals to another practitioner.

Although researchers in many jurisdictions were unable to gather these data, it was possible to determine that at least 52% (n = 167) of jurisdictions around the world allow nurses to prescribe medications or other types of treatment to some degree. In 37% (n = 117) of these jurisdictions, there is at least one nursing role with unrestricted prescribing authority.

Similarly, 51% (n = 165) of jurisdictions allow diagnoses to be made by at least one type of nurse, although in many cases, these jurisdictions place restrictions on the type of diagnoses the authorized nurse may provide.

Worldwide, 21% (n = 67) of jurisdictions permit RNs to diagnose, though often with limitations (Table 2). A “nursing diagnosis,” which is an evidence-based clinical judgment that allows a nurse to develop a care plan and select nursing interventions, is codified in at least 5% (n = 17) of jurisdictions.

Almost two-thirds of jurisdictions keep disciplinary records of actions taken against nurses (Figure 9). The NRBs in nine nations do not maintain records of disciplinary actions taken against nurses. These include Armenia, Cambodia, Chile, China, Georgia, Greece, Lithuania, Mongolia, and Russia.

Of the NRBs worldwide that keep records of disciplinary action taken against a nurse:

• •
  70% store disciplinary information in the same database that holds the nurse register
• •
  69% make their disciplinary records available to the public
• •
  58% of disciplinary record-keeping jurisdictions retain their disciplinary records indefinitely (Figure 9)
• •
  11% keep records for a defined number of years, ranging from 5 to 75 years (Figure 9).

   ²⁸

  Many jurisdictions referred to records retention statutes or stated that the length of time the record was retained differed depending on the nature of the offense. One jurisdiction retained the record for as long as the sanction was in place, while others destroyed such records at such time as the nurse was no longer authorized to practice or upon the nurse’s death.

  28Many jurisdictions referred to records retention statutes or stated that the length of time the record was retained differed depending on the nature of the offense. One jurisdiction retained the record for as long as the sanction was in place, while others destroyed such records at such time as the nurse was no longer authorized to practice or upon the nurse’s death.

Of all NRBs in this report, including those that do not keep disciplinary records, 43% allow members of the public to access the disciplinary records of nurses practicing in their jurisdiction.

An independent body—most commonly a nursing council—serves as the nursing regulatory body and governs the nursing profession in a majority of African jurisdictions. This body is generally a Nursing and Midwifery Council, National Board of Nurses, or National Order of Nurses. An independent body governs and regulates the nursing profession in Botswana, Burundi, the Democratic Republic of Congo (or simply Congo), Gambia, Ghana, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Nigeria, Rwanda, the Seychelles, South Africa, Eswatini (formerly known as Swaziland), Tanzania, Uganda, Zambia, and Zimbabwe.

In some jurisdictions, the nursing profession is overseen by a regulatory body that supervises other professions as well. In all these cases, nursing regulation is part of the Ministry of Health or a subdivision thereof. The jurisdictions of Benin, Burkina Faso, Cameroon, Cape Verde, Côte d’Ivoire, Djibouti, Egypt, Eritrea, Ethiopia, Gabon, Guinea, Libya, Mali, Mauritania, Morocco, Niger, and Tunisia have this type of structure. Most ministries or governing bodies hold the power to license/register nurses, administer nursing laws and regulations, discipline nurses, make decisions about the nursing scope of practice, and regulate for purposes of public protection and the promotion of the nursing profession. These bodies retain the power to create nursing legislation. Except for the Egyptian Ministry of Health and Population and the Ethiopian Health Professions Council, many larger agency bodies hold the authority to approve nursing education institutions and programs. Sometimes, each Ministry of Health works in cooperation with a Ministry of Higher Education or another government department in this approval process. Such is the case with Cameroon, Cape Verde, Congo, Côte d’Ivoire, Guinea, Libya, and Tunisia.

Regulatory bodies in eight countries (Cameroon, Cape Verde, Eritrea, Ghana, Guinea, Lesotho, Mozambique, and Tunisia) are also responsible for education and training matters. Ghana and Madagascar specifically mention disciplinary matters among their responsibilities. Eritrea’s regulatory body also promotes and finances healthcare in addition to matters related to nursing. Finally, in Ghana, facility inspection is also part of the regulatory body’s role.

The regulatory bodies in Burundi and Liberia possess authority regarding nurse education and training, and continuing competence or curriculum matters. The governing bodies of nursing in Botswana, Malawi, Mauritius, Mozambique, Rwanda, South Africa, Eswatini, and Tanzania retain the power to create nursing legislation. The governing bodies in Congo, Madagascar, Mozambique, Nigeria, the Seychelles, Uganda, and Zambia each hold additional authority over nursing work and labor matters.

Data on the regulatory body that governs the nursing profession in the Central African Republic, Comoros, and Congo are unavailable. Togo is unique as there is no official NRB; however, the National Association of Nurses of Togo is an important resource for nurses, members of the association, and authorities. Procedures are underway for the creation of the National Order of Nurses of Togo, which will serve as the official NRB.

The licensure and registration responsibilities of each NRB body vary according to jurisdiction. Several African countries have additional requirements for a nurse to be authorized to practice, beyond completion of education. Mauritius specifies the nurse must be a citizen who has never been removed from the register in any country where he or she has practiced and is physically and mentally fit. Seychelles sets a minimum age of 19 years for nurses.

Data were not always available as to practice requirements for nurses educated outside each African country. In some cases, proficiency in a specific language is required. For Ghana, South Africa, and Zimbabwe, English proficiency must be demonstrated prior to authorization to practice. Tunisia requires French. Cape Verde specifies a language certification must be issued (the official language of Cape Verde is Portuguese) and Madagascar specifies nurses must be able to communicate in the language of the patient (official languages of Madagascar are French and Malagasy).

Most jurisdictions in Africa require a national examination after education is completed before a nurse is authorized to practice; however, Cape Verde does not require examinations for authorization to practice in any nurse roles. There is no required national examination for the RN, registered midwife, enrolled nurse, or community health nurse roles in Gambia. Mauritius does not require a qualifying examination for its enrolled or assistant nurses, and Botswana does not have a qualifying examination for the psychiatric nurse role.

In general, registration is the means by which most nurses in Africa are authorized to practice. Djibouti, Guinea, Libya, Mali, and Mauritania are exceptions in that they have a licensing process, while Ethiopia, Gambia, Lesotho, and Rwanda require both licensure and registration. In Cape Verde, Mauritius, Niger, and Togo, nursing professionals are considered authorized upon completion of their nursing education and receipt of diploma. This is also the case for midwives practicing in Gabon, as they are authorized to practice after successful completion of education and training in midwifery. In Kenya, RNs must be registered in order to practice, while other types of nurses are granted authority by license. The Liberian Board for Nursing and Midwifery allows graduate nurses (nurses who have taken their examination but are not yet registered) to practice under the supervision of an RN while awaiting registration.

Once a nurse is registered and or licensed, a public database is the means by which a nursing professional’s credentials are verifiable. Africa generally relies on paper-based databases. Only Cameroon, Congo, Gambia, Kenya, Lesotho, Mauritius, South Africa, Tunisia, and Uganda have online systems. South Africa further restricts access to this information to employers.

As far as categorizing nurse types in Africa, there are generally no more than three or four types per country, including a nurse, midwife, specialized nurse, and nurse assistant (Table C1). Additionally, some jurisdictions designate specific specialty nurses (Table C2). Many jurisdictions recognize some sort of mental health or psychiatric nurse. Other specialized nurse designations may include an ophthalmic nurse, community health nurse/community nurse, reproductive health nurse, nurse anesthetist, master’s nurse, oncological nurse, theater (surgical) nurse, nurse clinician, nurse practitioner, licensed practical nurse, or post-basic nurse. Ghana provides nine specialty nurse type designations, including many of the types mentioned above, as well as a pediatric nurse and a critical care or perioperative nurse.

Interestingly, a few African jurisdictions designate a unique title to what is commonly referred to as a midwife (Table C3). The Cameroon Ministry of Public Health designates a qualified wise woman or a “qualified sage-femme” and Congo designates a wise woman as midwives.

In most African countries, the lowest level of nurse recognized is usually referred to as an auxiliary nurse (Table C4). Data about education requirements for this level of nurse were often unavailable.

To commence education as a general RN in some African jurisdictions (Table 1, Table 2, Table 3, Table 4), nearly all African NRBs require the completion of secondary education, usually specifying that 12th grade must be completed, a General Certificate of Education must be earned, or certain ordinary level (“O” level) examinations must be passed. Ethiopia and Niger allow nursing education to begin after 10th grade, although in Ethiopia, a prospective bachelor of nursing student must still complete 12th grade to commence education. In Tunisia, there is no reported school requirement, but applicants must be aged at least 17 years. In Zambia, working for 3 years as a medical assistant may stand in lieu of the secondary education requirement to begin nursing education at the regulatory body’s discretion. Burundi and Cameroon require an entrance examination prior to studying nursing, while other jurisdictions in Africa set grade requirements in science (as in Gambia, Malawi, Mauritius, Nigeria, Rwanda, Tanzania, Zambia, and Zimbabwe), mathematics (Gambia, Nigeria, Rwanda, and Zambia), or English (Gambia, Nigeria, Zambia, and Zimbabwe).

In African countries for which data are available, the mean length of a registered/general nursing program is 3.25 years. The vast majority of jurisdictions have 3- to 4-year programs, although Burundi and Gambia state that the low end of this range may be 2 years or 2.5 years, respectively.

In those African countries that recognize enrolled nurses (n = 9), education lasts 2 years. Information about what kind of secondary schooling, if any, is required prior to beginning education as an enrolled nurse in African jurisdictions is limited. Tanzania specifies a minimum grade in secondary science education for those wishing to study enrolled nursing. Zambia also specifies science and English education and has a minimum age of 17 years. For Rwanda’s associate nurse role, 3 years of secondary school must have been completed prior to beginning nursing education.

For those wishing to commence midwife education, African countries overwhelmingly require the completion of secondary school, although a few specify a subject or grade requirement, scores on O Level examinations, or set a minimum age. The exceptions are Botswana, Cameroon, Gambia, and Lesotho, where only practicing nurses can train for midwifery.

The average duration of education for midwives in Africa is 2.75 years. For the four jurisdictions where midwife roles require prior education as a nurse, there are varying lengths of additional education required. Registered midwives in Botswana must take 2 additional years. The qualified wise women in Cameroon must take 3 additional years, while Gambia and Lesotho require less additional education with 1.5 years and 1 year, respectively. For jurisdictions where students can enter directly into midwife programs, as little as 1 year of training (Namibia, Zambia) or as many as 4 years (Malawi, Mozambique) may be required. The Liberian-trained traditional midwife completes training at the community level, the length of which is not specified.

Overall, areas of authorized practice data vary across all nurse types in some African countries. Data related to specific areas of practice for RNs are unavailable. Such is the case in Mali, Mauritania, Mozambique, Niger, Nigeria, the Seychelles, Eswatini, Uganda, and Zambia. in nine countries where data was available, nurses have authority to prescribe medications, refer patients, and diagnose illnesses, but in varying circumstances and to varying degrees.

In Botswana, registered midwives, family nurse practitioners (NPs), and community health nurses may diagnose patients and refer them for additional medical care. Both Botswanan RNs and psychiatric nurses have prescriptive authority; however, the medications they can prescribe depend on the drug catalog. In Ghana, registered midwives and registered public health nurses may refer patients for additional medical care. Nurses and midwives in Benin have prescriptive authority and may refer patients for additional medical care. In addition, the Cameroon Ministry of Public Health grants ophthalmic nurses the authority to diagnose common eye problems and refer patients for care. Nurses, midwives, and specialist nurses in Lesotho are authorized to make nursing diagnoses and refer patients for additional medical care. In Namibia, nurses can prescribe medications under an issued license and administer standard prescribed medicines and treatment. They may refer patients but may not diagnose illnesses. In Madagascar, nurses can prescribe medications within legal limits, in addition to appropriate radiological or laboratory tests. They can also refer patients and diagnose illnesses. Similarly, nurses in Malawi can prescribe iron tablets, malaria dosage, automatic transport ventilators, all nonprescription drugs, and some prescription drugs, while also maintaining authority to refer and diagnose. In Togo, certified nurses may prescribe medications including antalgics, anti-inflammatories, vitamins, anti-anemic medications, antibiotics, anti-malarial medications, and anthelmintics; they are also authorized to refer patients and diagnose illnesses.

Practice data for an RN in Tunisia are unavailable, but a Tunisian midwife (wise woman) has the authority to prescribe medications and refer patients. In Cameroon, a qualified wise woman has the authority to refer patients for additional medical care. This type of midwife has prescriptive authority only as necessary for obstetric purposes. Similarly, in Congo, a wise woman can refer patients as necessary to the exercise of the profession and may diagnose pregnancies.

Governing bodies in many jurisdictions have authority to take disciplinary measures against nursing professionals who violate standards of professional conduct. In terms of discipline, the following actions are commonly taken in Africa: (a) suspension of practice, (b) removal of name from register/refusal to register/restricted registration, (c) revocation or denial of license, (d) warnings, (e) practice probation, (f) probation, (g) fine or civil penalty, (h) practice limitation with/without probation, (i) intensified supervision, (j) reprimand, and (k) imprisonment. Kenya, Lesotho, and Liberia use additional disciplinary measures inclusive of the requirement of additional training and education at the cost of the nursing professional.

Just as some jurisdictions offer a public registry of verified nursing professionals, some jurisdictions offer a public database where disciplinary records of nursing professionals are freely available. Disciplinary records are available to the public in a limited number of African countries, including Cameroon, Ethiopia, Gambia, Malawi, Morocco, South Africa, Uganda, and Zimbabwe. Jurisdictions where such records are available in the same source as the registry of nurses include Cameroon, Ethiopia, Gambia, and Uganda. However, Ghana and Malawi both hold disciplinary records of nursing professionals in a separate database, which is open to the public in the council offices and available by inspection. In Morocco, records of sanctions are published in the National Bulletin. South Africa’s disciplinary records against nursing professionals are stored in an online database, but the country is currently developing an integrated electronic system to include human resources, finance, registration, and examinations, among other areas. This comprehensive system allows accessibility of a nurse’s education and professional history from the training stage of nursing through retirement or death.

Most commonly, if an online database is not maintained, one can look to a jurisdiction’s national gazette or newspaper or file a request with a respective nursing council office to inspect a nursing registry. Such is the case in Ethiopia, Ghana, Guinea, Liberia, Mozambique, and the Seychelles. The Nursing and Midwifery Council of Botswana is in the process of establishing a system for public access to its registry. Other African nations simply restrict registry access altogether, or their level of transparency related to monitoring nursing professionals is unknown. Such is the case in Benin, Burkina Faso, Burundi, Cape Verde, the Central African Republic, Libya, Mali, Mauritania, Namibia, Niger, Rwanda, Eswatini, Tanzania, and Togo, which accounts for 25% of Africa.

Canada comprises 13 provinces and territories including Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, the Northwest Territories, Nunavut, Ontario, Prince Edward Island, Quebec, Saskatchewan, and the Yukon. For the purposes of this report, the Northwest Territories and Nunavut was considered one jurisdiction. All Canadian jurisdictions are members of the Canadian Free Trade Agreement (CFTA). Part of this agreement allows workers in a regulated profession, such as nursing, who are authorized in one province to have their qualifications recognized throughout all Canadian provinces without completing any additional requirements.

The Caribbean region comprises numerous islands in the Caribbean Sea off the east coast of Central America and north coast of South America, as well as some coastal countries on continental Central and South America, namely, Belize, Suriname, and Guyana, that are culturally connected to the island region. The majority of jurisdictions in this region participate to some degree in the Caribbean Community (CARICOM) compact. The jurisdictions are organized here as CARICOM member states, associate member states, and non-CARICOM nations.

CARICOM is comprised of Antigua and Barbuda, Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Suriname, and Trinidad and Tobago.

In addition to the 15 member states that comprise CARICOM, there are five associate member states: the British Virgin Islands, Anguilla, Bermuda, Cayman Islands, and Turks and Caicos Islands.

There are additional Caribbean nations outside of CARICOM. The following analysis focuses on Aruba, Cuba, Martinique, and the Dominican Republic, which are independent of CARICOM. For jurisdictional convenience, the Caribbean jurisdictions of the U.S. Virgin Islands and Puerto Rico are included in the analysis of the United States.

Central America includes Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama. Currently, these countries are not members of any regional compacts or mutual agreements that influence the nursing profession. The Central American nation of Belize is included among the CARICOM member states due to its membership therein, and is not discussed in this section. Information for Panama was not publicly available; thus, Panama is not in this report.

The United Mexican States (Mexico) is a federal republic composed of 31 states and the Federal District. The nursing profession is regulated at the federal level.

Jurisdictions in South America are Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Paraguay, Peru, Uruguay, and Venezuela. The Southern Common Market (MERCOSUR) is a South American regional compact whose member states participate in a common space to generate business and investment opportunities through the competitive integration of each national economy and the international market. Regarding nursing, member states are unified by an integrated educational and accreditation framework.

Member states of MERCOSUR include Argentina, Bolivia, Brazil, Paraguay, Uruguay, and Venezuela. Associate members of MERCOSUR are authorized to participate in meetings regarding common interests within the region and between member states, and they may enter into economic integration agreements. Associate states include Chile, Colombia, Ecuador, Guyana, Peru, and Suriname. Guyana and Suriname are included in the section on CARICOM member states, and are not discussed in this section.

The United States is made up of 50 states, the District of Columbia (or Washington, DC), and five U.S. territories: American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands (Table 10). Each jurisdiction within the US has its own set of nursing laws and regulations as well as its own nursing regulatory body or bodies.

The majority of US states are members of the Nurse Licensure Compact (NLC), a mutual recognition compact that allows RNs and licensed practical nurses (LPNs) to practice in other member states without having to obtain additional licensure. Nurses must still obtain individual additional licenses to be authorized to practice in jurisdictions that are not members of the NLC. Member states include Alabama; Arizona; Arkansas; Colorado; Delaware; Florida; Georgia; Idaho; Indiana; Iowa; Kansas; Kentucky; Louisiana; Maine; Maryland; Mississippi; Missouri; Montana; Nebraska; New Hampshire; New Jersey; New Mexico; North Carolina; North Dakota; Oklahoma; South Carolina; South Dakota; Tennessee; Texas; Utah; Virginia; West Virginia; Wisconsin; and Wyoming.

East Asia includes China (People’s Republic of China), Hong Kong (Hong Kong Special Administrative Region of the People’s Republic of China), Macau (Macao Special Administrative Region of the People’s Republic of China), Japan, Mongolia, North Korea (Democratic People’s Republic of Korea), South Korea (Republic of Korea), and Taiwan (Republic of China). At the time of publication, information on nursing regulation in North Korea could not be obtained; therefore, it is not included in this profile. This report includes the remaining countries, which are not members of any regional compacts or mutual agreements that influence the nursing profession.

Central Asia includes Afghanistan, Bangladesh, Bhutan, Kazakhstan, Kyrgyzstan, Maldives, Nepal, Pakistan, Sri Lanka, and Uzbekistan. Sufficient data could not be found on Turkmenistan or Tajikistan.

India is comprised of 28 states and nine union territories. Several of these states share mutuality in nursing governance with other Indian states or territories, namely Andhra Pradesh and Telangana; Assam and Nagaland; Gujarat, Dadra and Nagar Haveli, and Daman and Diu; Punjab and Chandigarh; Tamil Nadu, Puducherry, and Andaman and Nicobar Islands; and West Bengal and Sikkim. At the time of this analysis, Dadra and Nagar Haveli, existed as a separate territory from Daman and Diu; on January 26, 2020, these territories were combined into a single territory. This analysis reflects the state of nursing regulation in these territories prior to their union.

Southeast Asia includes Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, the Philippines, Singapore, Thailand, Timor-Leste (formerly East Timor), and Vietnam. Currently, all 10 of these countries belong to the Association of Southeast Asian Nations (ASEAN).

Independent nursing councils regulate the nursing profession throughout Oceania and Australia, governing approximately two-thirds of the region, including Australia, the Cook Islands, Fiji, Kiribati, the Marshall Islands, Micronesia, New Zealand, Samoa, the Solomon Islands, Tonga, and Vanuatu. Larger bodies, commonly the Ministry of Health, govern nursing in the remaining countries of Nauru, Palau, Papua New Guinea, and Tuvalu.

The NRB mandate in all of Australia and Oceania is public protection. In fact, this is the only mandate in seven countries (Australia, New Zealand, Papua New Guinea, Samoa, Tonga, Tuvalu, and Vanuatu).

Eight NRBs have additional mandates that include promotion of the nursing profession (Cook Islands, Fiji, Kiribati, Marshall Islands, Micronesia, Nauru, Palau and the Solomon Islands). Additional mandates of Oceanic NRBs include workforce, labor, and union issues (Fiji and Nauru); developing administrative procedures and disciplinary measures (the Marshall Islands); and creating, developing, and amending nursing regulations and standards (Micronesia).

All NRBs in Oceania have the responsibility of administrating nursing laws and regulations, and disciplining nurses. Thirteen NRBs have the additional responsibility of making decisions about scope of practice (Australia, Cook Islands, Fiji, the Marshall Islands, Micronesia, Nauru, New Zealand, Palau, Papua New Guinea, Samoa, Tonga, Tuvalu, and Vanuatu). Ten NRBs are also responsible for matters related to nursing education or training (Cook Islands, Fiji, Kiribati, the Marshall Islands, Micronesia, Nauru, Palau, the Solomon Islands, Tonga, and Tuvalu). Five NRBs have the additional power to create legislation (Fiji, Papua New Guinea, Samoa, Tonga, and Vanuatu). Tonga’s NRB has the additional responsibility of advising the minister on nursing matters.

The powers and responsibilities granted to the NRBs in Australia and Oceania are broad and include the responsibility of licensing/registering nurses, the authority to require a national examination to practice nursing. Most Oceania NRBs require a licensure examination (or its equivalent) for their nurse types. The exception is New Zealand, where RNs, enrolled nurses, and NPs must pass an examination, but there is no required examination for RN prescribers in primary or community health. Apart from the payment of applicable fees, the only other requirement for authorization to practice among Oceanic jurisdictions is, in the case of Nauru and Palau, that nurses carry malpractice insurance.

Australia and Oceania recognize authorized nursing professionals who have completed their mandatory education and other requirements in the granting of nursing licensure and/or registration. Nearly all nursing governing bodies in Australia and Oceania use registration to authorize at least some nurse roles for practice, but there are a few exceptions. In Papua New Guinea, nearly all nurse roles must be both licensed and registered. The exception is registered midwives who may practice immediately upon completing their education. Likewise, Micronesia requires its RNs, LPNs, and advanced practice nurses to be both licensed and registered, while NPs, nurse midwives, and nurse anesthetists need only register. Additionally, to have the title of “enrolled nurse” in Kiribati, only a diploma is required, and to be a medical assistant, an additional certificate is needed after registration. Nurse aids in the Solomon Islands must also obtain both a certificate and registration. In New Zealand, all nurse roles are issued an annual practicing certificate.

Once registered and/or licensed, a public database is typically the means by which a nursing professional’s credentials are verified. In general, most countries in Oceania do not use an online public database. Instead, they make such information available in physical form, such as in a newspaper or gazette. Australia and New Zealand are the only two countries in the region that employ an online system. Micronesia makes its nursing registry available only to employers or other licensing boards outside of Micronesia, but not to the general public.

In addition to nurse, midwife, specialized nurse, and nurse assistant categories, some countries—such as the Marshall Islands—recognize as many as nine nurse types (Table C24, Table C25, Table C26, Table C27).

Australia and Oceania have the authority to approve nursing schools and programs. Table C24, Table C25, Table C26, Table C27 show the requirements for entry into each type of nursing education program within Australia and Oceania.

Publicly available areas of authorized practice data for nurses across Australia and Oceania are limited. For eight NRBs, no information is publicly available as to what type of authority RNs have across countries (Fiji, Micronesia, Nauru, Samoa, the Solomon Islands, Tonga, Tuvalu, and Vanuatu). In Australia and New Zealand, RNs can only diagnose illnesses, while NPs may diagnose illnesses, prescribe medications, and refer patients. Mental health nurses in the Cook Islands may prescribe medications and refer patients in accordance with Community Treatment Order guidelines.

In addition to verifying a nursing professional’s credentials, notifications of past or current disciplinary actions are also publicly accessible as part of a nursing registry. In terms of discipline, the following actions are commonly taken in Australia and Oceania: reprimand, suspension, fine or civil penalty, revocation, surrender or denial of license, removal or refusal of name from register, imprisonment, license restriction, and medical or psychological treatment. There is no information available as to whether Fiji, the Marshall Islands, Palau, Papua New Guinea, or Samoa make their disciplinary records publicly accessible. Most others do so, except New Zealand.

Eastern Europe is comprised of Albania, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Estonia, Greece, Latvia, Lithuania, North Macedonia (former Yugoslav Republic of Macedonia), Moldova, Montenegro, Romania, Russia, Serbia, Turkey, and Ukraine. Of those countries, Bulgaria, Croatia, Cyprus, Estonia, Greece, Latvia, Lithuania, and Romania are members of the EU.

The Nordic region encompasses Denmark, the Faroe Islands, Finland, Greenland, Iceland, Norway, and Sweden. Of these, Denmark, Finland, and Sweden are members of the European Union (EU).

Western and Central Europe are comprised of Andorra, Austria, Belgium, the Czech Republic, France, Germany, Hungary, Ireland, Italy, Liechtenstein, Luxembourg, Malta, Monaco, the Netherlands, Poland, Portugal, San Marino, Slovakia, Slovenia, Spain, Switzerland, and the United Kingdom. Of those 22 countries, Andorra, Liechtenstein, Monaco, San Marino, Switzerland, and the United Kingdom are the only countries that are not part of the EU. As of January 31, 2020, the United Kingdom has left the European Union; the data in this report reflects its prior status as a EU member.

The majority of the regulatory bodies that govern nursing in the Middle Eastern jurisdictions are a cooperation between a larger agency and an independent body. Georgia does not have a regulatory body that oversees nursing, and there is no information publicly available about the nursing regulatory body in Palestine.

In many jurisdictions, an authorizing agency body of the national government such as the Ministry of Health or general medical or health authority is the governing regulatory body. This is the case in Armenia, Azerbaijan, Bahrain, Iraq, Kuwait, Palestine, Qatar, Saudi Arabia, and Yemen. Lebanon and the United Arab Emirates have NRBs that are independent of those for other health professions.

The respective Ministry of Health, in cooperation with a medical or health authority or council governs the nursing profession in Iran, Israel, Jordan, Oman, and the Syrian Arab Republic. In Israel, The Nursing Administration within the Ministry of Health governs the nursing profession. In Iran, the Ministry of Health and Medical Education works in conjunction with the Nursing Board of the Ministry of Health, which approves nurse education institutions, whereas the Ministry holds other powers. In Oman, the Directorate General of Nursing Affairs, under the Ministry of Health, governs the profession. The Syrian nursing profession is regulated by its Council of the Branch, which is a regional body under the Ministry of Health. Regulations and standards are set through the Ministry of Health, but the regional Council of the Branch executes registrations and approves the applicant for practice of the profession. The nursing profession in Jordan is regulated by the Ministry of Health, the Jordanian Nursing Council, and the Jordanian Nurses and Midwives Council.

All regulatory bodies license nursing professionals and all (except for Kuwait) make decisions about authorizing practice responsibilities. Most (except for Kuwait and Oman) hold the responsibility to administer laws and regulations. The Yemeni Medical Council and the Azerbaijan Republic Ministry of Public Health hold additional authority to participate in nursing labor and work-related matters. Most jurisdictions except for Iran, Palestine, Syria, and the United Arab Emirates also discipline nurses. In just over half of the Middle Eastern countries (Armenia, Azerbaijan, Bahrain, Iran, Israel, Jordan, Lebanon, Qatar, and the United Arab Emirates), the NRB also has the ability to create legislation.

No information is publicly available about the mandate, or mission, of the Palestinian regulatory body. Of the fifteen other Middle Eastern countries with an NRB, all state that public protection is a part of their mandate. Eight countries (Armenia, Azerbaijan, Iran, Israel, Jordan, Lebanon, Oman, and Saudi Arabia) also promote the nursing profession, and five (Azerbaijan, Jordan, Lebanon, Syria, and Yemen) also handle nursing workforce and labor matters.

All regulatory bodies license nursing professionals. Eleven of the 17 Middle Eastern jurisdictions require a qualifying examination for certain nurse types leading to authorization to practice in the profession (Table 21).

For nurses wishing to practice in the Middle East, a language proficiency examination is required in Iran and Israel. Information is not publicly available as to whether a language proficiency examination is required in other Middle Eastern jurisdictions. All Middle Eastern jurisdictions require some form of evidence of good moral character in order to practice within the profession.

Overall, nearly all nurses in this region must take a qualifying examination before they are authorized to practice. In addition to the Type 1 Practice Nurse in Georgia, for which an examination is not required, Iran’s practical nurse, nurse anesthetist, and operating room nurse do not require an examination. Additionally, Jordan’s RN, associated nurse or practical nurse roles, Qatar’s clinical nurse specialist or nurse practitioner roles, and Oman’s nurse and midwife roles do not require an examination.

In the Middle East, an NRB may grant authorization to practice in the nursing profession by license, registration, or registration followed by a license (Table 22). Authorization to practice may also be granted by a certification followed by registration, or nurses may simply be authorized to practice when their education and training has been successfully completed. The 17 Middle Eastern jurisdictions are split as to the means by which they grant authorization to practice nursing.

To identify and verify those nursing professionals who are authorized to practice, some jurisdictions retain a register containing the names of those authorized. Sometimes, this register is made available to the public. In the Middle East, four jurisdictions that strictly grant authority by license (Palestine, Yemen, Kuwait, and Jordan) do not offer a publicly available register. The exception to this rule is Bahrain, whose registry of nursing professionals is published online. Armenia does not offer a publicly available registry. In Lebanon, the Order of Nurses publishes public information on its website related to the number of nurses per nursing degree and the distribution of those nurse across different healthcare sectors; however, specific identities of nursing professionals are not publicly included. Remaining Middle Eastern jurisdictions are divided as to whether a register of nursing professionals is freely available to the public.

The Middle East uses common nurse types such as RNs, practical nurses, and midwives; however, some nurse types and categories are very detailed (Table C35, Table C36, Table C37, Table C38). For example, Israel recognizes a particularly specialized nurse—the academic registered lactation consultant. There are two types of registered nurses, RNs and technique superior registered nurses, in Lebanon. The four types of nurse specialists in Saudi Arabia are General Specialists 1 and 2 and First Specialists 1 and 2. These nurse specialists are categorized by education, training, and competence. For instance, Nurse Specialist 1 requires successful completion of a bachelor’s degree program in a specialty for entry into the Nurse Specialist 1 program, whereas a master’s degree or equivalent in a specialty is required for entry into a Nurse Specialist 2 program. Furthermore, 2 years of post–master’s degree experience in nursing is required for First Specialist 1 program entry, and 3 years of post–master’s degree experience in nursing is required for First Nurse Specialist 2 program entry.

Georgia has two types of general nurse, a Type 1 practice nurse and a Type 2 practice nurse. The Type 1 practice nurse requires completion of secondary education before program entrance, whereas and Type 2 practice nurse requires passage of the National Entrance Examination.

Oman requires the demonstration of English language proficiency including admission interviews held in both Arabic and English languages for psychiatric nurses, infectious disease nurses, and pediatric nurses.

Most Middle Eastern jurisdictions also recognize a general midwife and some form of nurse assistant. In Bahrain, Iran, Israel, Jordan, and the United Arab Emirates, a nursing assistant is also called a Practical Nurse. Jordan has suspended its practical nursing program from new applicants.

In a majority of jurisdictions, education programs are approved by each jurisdiction’s respective Ministry of Health, Ministry of Education, or in a cooperation with both. The regulatory boards in Iran, Qatar, and Oman hold exclusive authority to approve nursing education programs.

Regarding nurse education, requirements vary depending on nurse type (Table C35, Table C36, Table C37, Table C38). Overall, general nursing programs range between 3 to 4 years. In Israel, the core curriculum for the nursing program is 4 years for a degree program and 2.5 years for a diploma program. In addition, each nursing institution may enhance that curriculum. To become a nursing professional in a specialty, such as an operating room nurse in Iran or a nurse-midwife in Azerbaijan, a minimum of an additional 1 or 2 years of education and training is required.

From the limited data, the scope of practice varies depending on nurse type across the Middle Eastern region. In Azerbaijan, a midwife may diagnose pregnancies and refer patients for additional medical care. In Syria, a nursing professional may perform all urgent medical assistance only after the arrival of a physician. Furthermore, in Syrian villages and areas where there is no pharmacy, it is permissible for a nursing professional to sell medicines after obtaining permission from the Ministry of Health. In Qatar, a nurse practitioner may prescribe medication, and nurse practitioners, registered midwives, and clinical nurse specialists can refer patients to other services.

Nearly all Middle Eastern jurisdictions take disciplinary measures against nursing professionals when necessary. Sanctions are more extensive in some jurisdictions. For example, sanctions in Azerbaijan include a fine or civil penalty, revocation of the authorization to practice, and a denial of the Certification Certificate. Sanctions in Armenia include a limitation and probation on the professional’s ability to practice and a denial of authorization to practice. Other sanctions employed in the Middle East include denial of registration, warnings, remediation, suspension of authorization/license, removal of the professional’s name from the register, reprimands, and imprisonment.

Some jurisdictions enlist broad sanctions. Disciplinary measures in Iran include varying forms of probation, suspensions, and limitations on practice. Jordan’s regulatory system may implement any and all sanctions because the Ministry of Health disciplines on matters relating to licensing and the Jordanian Nursing Council disciplines on matters relating to a professional’s specialization and professional classification. Disciplinary records in a majority of the jurisdictions are not available to the public; however, the Saudi Arabia Health Commission makes disciplinary records of health professionals public. The Qatar Council for Healthcare Practitioners has an online registry of nurses, accessible with an account, but it is unclear whether the same registry contains discipline information or whether that information is available to the public. In Lebanon, disciplinary records are considered strictly confidential.