Globally, Jordan has been recognized as a leading medical tourism destination...Jordan is a middle-income country located in the Middle East with an area of 89,342 km² and a population numbering about 10 million. More than 90% of people live in the urban areas; while 42% of the population resides in Amman, the capital of Jordan (Department of Statistics, 2015). Jordan is known for high-quality modern health services and infrastructure; and highly qualified nurses, physicians, and other healthcare providers who are well prepared at the national, regional, and international levels (High Health Council, 2015). Globally, Jordan has been recognized as a leading medical tourism destination due to its distinguished geographic location and political stability.

Jordan has been exposed to the consequences of numerous conflicts in many surrounding countries...Jordan has been exposed to the consequences of numerous conflicts in many surrounding countries and has hosted hundreds of thousands of refugees from neighboring countries such as Palestine, Iraq, and Syria (Al Maaitah & AbuAlRub, 2017). Non-Jordanians comprise 30% of the population in Jordan with 1.5 million Syrian refugees who have fled Syria since 2011 with the beginning of the Syrian civil war (Hadidi & Tarawneh, 2017). The continuous refugee influxes to Jordan have changed the epidemiology of the diseases, the population demography, and caused a rise in the population growth generating substantial pressure and demand on resources and infrastructure including water, energy, socio-economic, education, and health sectors (Ministry of Planning and International Cooperation, 2019).

The Ministry of Health (MOH) is supported by the military health sector which is represented by the Royal Medical Services (RMS) in providing healthcare services at refugee camps in Jordan. The RMS is fully prepared and trained to provide health and humanitarian support for refugees, displaced people, and zones of conflict at the national, regional, and global levels.

Improvement in the health status of the Jordanian population over time is reflected by the improvement of health indicators...Improvement in the health status of the Jordanian population over time is reflected by the improvement of health indicators, including the overall average life expectancy, which reached 72.8 for males and 74 for females; attainment of universal child immunization in 1988; and the decline in infant mortality rates as well as eradication of polio since 1995 (Jebreel, Tarawneh, & Abu-Shaer, 2018). The three main healthcare providers of the health system in Jordan are the public sector, private sector, and international and charity sectors. The public sector is the largest health sector in Jordan and it includes the two major health providers which are the MOH and the RMS, in addition to two public university hospitals. The High Health Council (HHC) is mandated to develop and enact national health policies and strategies while the MOH is required to supervise, monitor, and enact laws at the national level.

The three main healthcare providers of the health system in Jordan are the public sector, private sector, and international and charity sectors.Other institutions propose relevant health policies, including the Jordanian Medical Council, the Jordanian Nursing Council (JNC), the Supreme Council of the population, and Jordan Food and Drug Administration (Hadidi & Tarawneh, 2017). Similar to the MOH, the military sector, represented by the RMS, has its own health services and infrastructure of manpower, hospitals, health centers, and diagnostic and therapeutic centers and clinics. There are 16 RMS hospitals that accounted for 22.5% of the total beds in Jordan in 2018 (MOH, 2018). The RMS covers the health insurance of people who serve in the army and their families (about 38% of the Jordanian population); it is considered one of the main credible referral centers in Jordan for tertiary and secondary care services and advanced therapeutic procedures (Hadidi & Tarawneh, 2017).

An Overview of the Nursing Profession in Jordan

The nursing profession in Jordan has rapidly developed since the 1970s and currently enjoys a very good standing and status compared to other countries in the region.The nursing profession in Jordan has rapidly developed since the 1970s and currently enjoys a very good standing and status compared to other countries in the region. For example, the nursing regulatory body in Jordan is the only regulatory council in the region that directly reports to the prime minister. Jordan has also highly invested in the nursing workforce and in improving the image of nursing. Since the mid-1980s and in addition to increasing the number of highly educated nurses with masters and doctoral degrees from leading universities in the world, Jordanian students have been competing to enroll in baccalaureate nursing programs. Also, the ratio of male to female nursing students increased to 60/40 in 2009 (Al Maaitah & Shokeh, 2009; Shukri, 2005; Zahran, 2012). In addition, while the gulf region still faces the growing number of expatriate nurses, Jordan reported less than one percent of expatriate nurses (Khashman, personal communication, 2019; Shukri, 2005). This demonstrates the high political will in Jordan to enhance and empower the nursing profession.

Since the beginning of early 1980s, nurse leaders have worked with the power of unity to strengthen and regulate the nursing profession in Jordan. We cannot talk about this difficult and sensitive period in the history of nursing in Jordan without talking about the true champion for nursing reform in Jordan, Her Royal Highness (HRH) Princess Muna Al Hussein (The Mother of the King), who has sincerely led a group of nurse leaders and has been able to move the importance of forming a nursing regulatory body to the top of the health agenda, and the political agenda. HRH is the president of the JNC; the World Health Organization (WHO) patron of nursing and midwifery in the East Mediterranean Region; a former commissioner at the UN High-Level Commission on Health Employment and Economic Growth; and an influential advocate for nurses and midwives at the national, regional, and international levels (JNC, n.d.; Shukri, 2005; WHO, 2016a; Zahran, 2012).

Jordan has also highly invested in the nursing workforce and in improving the image of nursing.The JNC was established in 2002 in temporary law by a Royal Decree of King Abdullah the Second. The temporary JNC law was amended in 2003; the official letter of amendment was sent to the prime minister in January 2003 by the acting Minister of Health (who happened to be a nurse) and is the first author of this article. The permanent JNC bylaw was approved in 2006 after another round of advocating for more gains for the nursing profession. The nursing profession has been well positioned with the establishment of the JNC. Since 2002, nurse leaders in Jordan united together and worked in different taskforces under the umbrella of JNC to develop the bylaws and regulations for the nursing profession.

In addition to nurse leaders in academia, practice, and Jordan Nurses and Midwives council (JNMC), military nurse leaders have contributed to the regulation of the nursing profession in Jordan. Counting on her leadership experience, a military retired nurse, Major General Mrs. Daad Z Shokeh (the second author of this article), was appointed as the first secretory general for the JNC in 2002-2013. She set the ground for the regulation of the nursing profession in Jordan over a period of 11 years (2002-2013) of extraordinary work with the JNC board members and other nursing leaders under the leadership and guidance of HRH Princess Muna Al Hussein, the president of the JNC since its establishment in 2002. The Army sector is also represented in the JNC board by two nurses; the director of nursing at the RMS and the dean of nursing of the Princess Muna College of Nursing (PMCN) (JNC, n.d.).

In addition to nurse leaders in academia, practice, and Jordan Nurses and Midwives council (JNMC), military nurse leaders have contributed to the regulation of the nursing profession in Jordan.Many factors have contributed to the progress of the nursing profession in Jordan, including the establishment of JNMC in 1972; establishment of the JNC as a regulatory body in 2002; emergence of highly educated strong nursing leaders; emergence of baccalaureate programs that have led to increased investment in funding the education of nurses in masters and doctoral programs at American, Canadian, British, Swedish, and other universities worldwide; identification of two entry levels to nursing practice; and affiliation of community colleges of the schools of nursing with universities (Abushaikha, 2006; Sultan, 1998; Zahran, 2012). The entry to practice in nursing in Jordan is currently limited to two levels of education based on the recommendation of the Board of the JNC which was approved by the Ministry of Higher Education in 2002 (Al Maaitah & Shokeh, 2009; Zahran, 2012). However, Jordan still has more physicians than nurses. According to the MOH Annual Statistical Report for 2018, the total number of registered nurses (RNs) was 22,540 which is lower than that for physicians (23,756). The ratio of providers per 10,000 persons in 2018 was 21.9 for RNs compared to 23.0 for physicians (MOH, 2018).

They have emphasized that the health workforce is no longer a cost, it is an investment...While many resolutions, reports, and initiatives from all over the world have noted the importance of enhancing the status of nursing profession, nursing education in Jordan has made tremendous advancements over the last 30 years toward developing the nursing profession and status (Shukri, 2005; Zahran, 2012). Reports and calls for action from the High Level UN Commission on Health Employment and Economic Growth (WHO, 2016b); the All-Party Parliamentary Group on Global Health ([APPG], 2016); WHO, 2011); and Nursing Now Campaign (2019); have all called for proper investment in the nursing workforce by enhancing the status of the nursing profession and strengthening nursing education, practice, leadership, and research. They have emphasized that the health workforce is no longer a cost, it is an investment (WHO, 2016b). The APPG report (2016), stated that “Increasing the number of nurses, and developing nursing so that nurses can achieve their potential, will also have the wider triple impact of improving health, promoting gender equality and supporting economic growth” (p.3).

The Journey of Military Nursing in Jordan

It is important to note the challenge of documenting this journey in light of inconsistent information and lack of formal documentation of the status, development, and history of military nurses in Jordan. To address this gap in the literature, a focus group discussion was conducted with 12 retired military nurse leaders, in addition to the second author who is a retired military nurse. This discussion helped us to inform our writing and enrich the information discussed about military nursing and nurses. The retired military nurse leaders were asked to identify the most prominent historical stations and achievements of military nursing and to offer thoughts about current challenges that military nurses face. They were also consulted about known but inconsistent information related to nursing in the military sector.

For ethical consideration, the authors achieved informed consent by explaining the purpose of the focus group discussion and emphasized the value of participants’ views and information to enrich the information about military nurses in Jordan, given the fact that some have witnessed the evolution of nursing in the army sector since the 1960s. Participants were assured of confidentiality and their right to withdraw anytime.

Data from the focus group discussion were analyzed by the authors via content analysis. Three themes emerged, including enhancement of strong nursing leadership, policy, and decision making; proper investment in nursing education; proper investment in the nursing workforce and practice. In addition, participants identified current challenges of military nursing in light of the increasing demand for quality nursing care. In this article, we present the details from these three themes and discuss current challenges.

Enhancement of Strong Nursing Leadership, Policy, and Decision Making
...the military sector has played a significant role to enhance the image and status of nursing within the Jordanian community.According to Sultan (1998), the military sector has played a significant role to enhance the image and status of nursing within the Jordanian community. Military nursing in the RMS has started and developed in different phases. The main phase was in 1941, during which medical services were limited to providing medical and preventive healthcare to members of the armed forces with one doctor and two nursing assistants with simple training in nursing at MOH hospitals in Jordan. More trained nurses were recruited from the MOH with the establishment of the first military hospital in 1948 (Sultan, 1998).

To manage the increasing number of nurses, the position of Nursing Assistant Director was established in the RMS in 1959.More male nurses were recruited to meet needs of the military services, which were limited to caring for the military employees. With the extension of healthcare services to families of military employees and retired military personnel, as well as the rapid expansion of medical specialization, services, and coverage of the military health sector in Jordan, RMS leaders realized the pressing need to prepare well trained and competent nurses. In addition to nurse assistants and midwives, more male and female registered nurses were recruited after graduation from the 3-year diploma nursing program at the college of nursing, a hospital-based program at the MOH established in 1953, as well as the Baptist School of Nursing that bestowed a title of registered nurse upon graduation for the first time in Jordan.

To manage the increasing number of nurses, the position of Nursing Assistant Director was established in the RMS in 1959. The nursing position of Assistant Director of RMS was terminated in 1992 with the establishment of the Directorate of Nursing. Table 1 highlights the progress of nursing governance and leadership in the military sector from 1959 to the present.

Table 1. Nursing Governance and Leadership in the Military Sector

Highlights of Progress	Year
Establishment of the position of Nursing Assistant Director of RMS in the military sector, which was assumed by a physician for the first 10 years	1959
The first nurse (a British retired nurse) assumed the position of the Nursing Assistant Director of RMS	1969-1974
The first Jordanian nurse (Colonel Zakieh Nassar) assumed the position of the Nursing Assistant Director of RMS	1976
Establishment of the Directorate of Nursing at the RMS	1992
Appointment of the Director of Nursing as a member of the higher national committee for professional liability, newly established in 2019	2019

...the culture of shared decision and collective actions for better health outcomes is a unique practice in the RMS.In the area of nursing governance and leadership, leaders of the RMS fully realize the importance of the status of their institution. They are not only committed to excellence, but also very alert for opportunities for further improvement of performance and health outcomes to sustain their status at the top of the health sector. Just recently, the director of nursing at the RMS has been appointed as a member of the higher national committee for professional liability, which was newly established in 2019 (R. Majali, personal communication, 2019). The retired military nursing leaders who participated in the focus group discussion indicated that the culture of shared decision and collective actions for better health outcomes is a unique practice in the RMS. Table 2, relating to the theme of enhancement of strong nursing leadership, policy, and decision making, shows the progress and selected specific achievements of military nursing in this area, as perceived by the retired military nurses.

Table 2. Examples of Military Nursing Achievements in Leadership, Policy, and Decision Making

Military Nursing Achievements

Promotion of a positive culture within formal hierarchical structures. Existence of management and leadership models within formal hierarchical structures whereby true partnerships of shared decision were manifested. Appointment of nurses at the highest pyramid in the administration and assurance of autonomy in their decision making. Increase in power and authority of army nurse leaders to develop and influence health policy. Appointment of the Director of Nursing as a member of the higher national committee for professional liability. Promotion of nurses to the highest military ranks with benefits similar to other health professionals. Demonstration of strong leadership by military nurses in the army as well as other health and education sectors after retirement. Change in the nursing recruitment process with target to focus on females from middle-class background who have successfully completed high school and demonstrate personalities appropriate to leadership.

...these nurses have changed the nursing recruitment process and target to maintain the legacy of military nursing.The retired military nursing leaders added that the RMS have utilized non-traditional management and leadership models within formal hierarchical structures; whereby true partnerships of shared decisions, work, and collaboration among doctors, nurses, managers, and educators occur, yet discipline and commitment prevail. They also acknowledged the strong leadership of military nurses in the army as well as other health and education sectors after retirement. They emphasized the fact that these nurses have changed the nursing recruitment process and target, as described in Table 2, to maintain the legacy of military nursing.

According to dos Santos & Erdmann (2015), support of the leadership and organization provided for the management practices of nurses is essential to enhance the structure and process of nursing governance. The Director of Nursing reports directly to the Director General of the RMS and has the responsibility of managing approximately 11,700 nursing and allied health professionals. At the higher level of policy-making (according to the nurse leaders in the focus group) former and current directors of nursing and allied health professionals have been keen enough to sustain their active voices at the policy and decision making table with their fellow directors since the establishment of the Directorate of Nursing in 1992 at the RMS. A weekly meeting with all directors is convened by the general director to discuss policy issues and urgent matters. At the second line level, the nursing director actively participates in the monthly regular meeting of all other hospital directors, with a goal to enhance the performance of health services and patient outcomes (R. Majali, personal communication, 2019).

As an integral component of the healthcare system, effective clinical leadership drives many hospital functions...Open communication between managers and healthcare professionals at the RMS, including nurses, reflects effective leadership that is well maintained for all structural and processes of clinical practice, education, and management. As an integral component of the healthcare system, effective clinical leadership drives many hospital functions; therefore, it is considered a crucial element for optimal hospital performance (Daly, Jackson, Mannix, Davidson, & Hutchinson, 2014). Together, empowered nurses at the RMS, who shoulder high responsibility and authority in provision of high quality nursing care, form a collective voice to improve patient outcomes through strengthening nursing education, practice, and leadership in the military sector.

Proper Investment in Nursing Education
Nursing education in Jordan has witnessed several reforms to meet the needs of the population, improve health outcomes, and enhance the nursing profession while ensuring that nurses have the right competencies with the right skills. As previously mentioned, the entry to practice in nursing in Jordan is currently limited to two levels of education based on the recommendation of the Board of the JNC which was approved by the Ministry of Higher Education in 2002 (Al Maaitah & Shokeh, 2009; Zahran, 2012). The professional level is a 4-year university baccalaureate of science in nursing (BSN) degree program and the technical level is a 2-year community college associate degree in nursing (ADN).

The first BSN program in Jordan started in 1972. Currently, Jordan has 15 baccalaureate programs; 7 programs in the public sector (including one BSN nursing program for the military sector at Mutah University) and 8 programs in the private sector. In addition, there are more than 10 masters' programs in nursing in the public and private sector, including only one master’s program for the military sector and only one doctoral program at a public university (Jordan University), established in 2005. Table 3 highlights the timeline of progress for nursing education at the national level.

Table 3. Timeline of Nursing Education Progress at the National Level

Highlights of Progress in Nursing Education in Jordan	Year
Establishment of the first 3-year hospital-based diploma program at the MOH.	1953
Establishment of the first BSN program in Jordan at Jordan University.	1972
Establishment of the first master’s nursing program at Jordan University.	1986
Termination of the practical nursing program at the national level.	1998
Termination of the diploma nursing program at the national level.	2002
Identification of two levels of entry to nursing practice (BSN and ADN) at the national level.	2002
Establishment of the PhD nursing program at Jordan university.	2005

The British and American education systems had positively impacted the preparation of military nurses in Jordan...In 1960, the military sector, represented by the Royal Medical Services (RMS), started training and production of healthcare providers through the establishment of its own RMS training centre. This centre was managed by RNs and mandated to prepare not only nurse assistants, but also other health technicians in different areas such as laboratory, radiology, assistant pharmacists, dental assistants, and mechanical dentists. Two years later in 1962, the Princess Muna College of Nursing (PMCN) was established under the supervision and management of retired British military nurses, to prepare female RNs at the diploma level (3-year program) to work in military hospitals in Jordan. The PMCN nursing program accepted students only who had successfully passed their high school national exam and enrolled them directly as cadet officers. The British and American education systems had positively impacted the preparation of military nurses in Jordan through nursing education and practice. Table 4 highlights the timeline of progress for nursing education in the military sector, including progression of educational levels and increased opportunities related to gender.

Table 4. Timeline of Nursing Education in Jordan in the Military Sector

Highlights of Progress	Year
Establishment of specialized RMS training centre at the army sector for all technical healthcare providers.	1960
Establishment of the Princess Muna College of Nursing (PMCN) with a three-year nursing diploma program.	1962
Appointment of the first British nurse director of the PMCN (3-year diploma program).	1962
Appointment of 3 British nurse directors of the PMCN (3-year diploma program) and adoption of the British nursing system.	1962-1971
Appointment of the first Jordanian nurse as director of the PMCN (3-year diploma nursing program).	1972-1974
Appointment of an American nurse expert for one year as director of the PMCN (3-year diploma nursing program).	1975
Appointment of Jordanian nurses as director of the PMCN.	1976-2003
Adoption of the credit hour system at the PMCN to facilitate the process of bridging for diploma nurses with BSN programs at other public universities.	1986
Establishment of the first ADN program at the RMS.	1992
Termination of the diploma nursing program and identification of two levels of entry to nursing practice (BSN and ADN) at the RMS	1998
Establishment of the first BSN program at the PMCN at the RMS with affiliation of Mutah University.	1998
Appointment of military non-nursing leaders as deans of the PMCN (BSN program).	1998-2008
Establishment of the military bridging program at the PMCN to allow progress of diploma nurses to BSN level.	2002
Appointment of the first military nurse with doctorate degree (a male nurse) as the dean of the PMCN (BSN program).	2009-2013
Appointment of Jordanian nurses as deans of the PMCN (BSN program)	2009-present
Establishment of the first master’s of nursing program at the PMCN.	2013
Appointment of the first military female nurse as a dean of the PMCN (BSN program).	2017-present

The nursing curriculum was characterized by its British model with English as the language of instruction.A group of seven British army retired nurses were recruited to the RMS between 1962 to 1971 to establish and manage the nursing education program at PMCN, in addition to managing other nursing units in the hospitals of RMS (Sultan, 1998). Hence, a British retired nurse expert was appointed as the first director for the PMCN in 1962. The nursing curriculum was characterized by its British model with English as the language of instruction. The British education system provided the opportunity of a double nursing registry for RNs who completed the diploma program at the PMCN where they acquired their licensure and registration from the MOH in Jordan, as well as the British Nursing and Midwifery Council in England and Wales. Diploma nurses had a great opportunity to practice and work with a full salary in England through a specialized training course for each graduate of the the Princess Muna College of Nursing (PMCN) during the period 1965–1974. Thus, Jordanian novice nurses left for England after graduation.

The main features of the reform included the introduction and integration of the nursing process into nursing curricula and strengthening the practicum and clinical placement.In 1975, an American nurse expert was appointed for one year as the director of the PMCN (H. Obeidat, personal communication, 2019). A major reform in nursing education was witnessed during that year with the adoption of the American nursing education system. The main features of the reform included the introduction and integration of the nursing process into nursing curricula and strengthening the practicum and clinical placement. In 1986, the PMCN implemented the credit hour system to facilitate the process for diploma nurses to achieve the BSN degree at other public universities, because the bridging program at the military sector was not yet established (Mutah University, 2019b). Management and teaching of nurses were also supported by several Jordanian military physicians who were trained in the United Kingdom and the United States of America and thus played a significant role in nursing education at the PMCN (Sultan, 1998).

Enhancing the image of nursing was concurrent with the development of nursing education in the army sector.A new salary scale was established for nursing students at the Princess Muna College of Nursing (PMCN) and benefits were extended after graduation. These benefits included higher salaries and higher rank to second lieutenant, which was bestowed upon graduation from the school. Enhancing the image of nursing was concurrent with the development of nursing education in the army sector. His Excellency the Former Prime Minister in Jordan, Dr. Abd Alsalam Al Majali, contributed significantly to the development of the nursing profession in Jordan in his capacity as the director of the RMS and later president of Jordan University. According to Dr. Abd Alsalam Al Majali, parallel to the establishment of the program and throughout the education process, several meetings were held with doctors to clarify the role of the nurse and relationship between nurses and physicians, focusing on the fact that quality patient care could not be delivered and maintained without nurses. Progress required a radical change in negative stereotypes and physician attitudes about nurses and nursing at that time (Sultan, 1998). This change was a remarkable milestone to enhance the image of nurses and nursing profession.

...several meetings were held with doctors to clarify the role of the nurse and relationship between nurses and physicians, focusing on the fact that quality patient care could not be delivered and maintained without nurses.As shown in Tables 3 and 4, while the decision of terminating the practical and diploma nursing programs was taken at the national level in 1998 and 2002 respectively, the RMS was the pioneer in terminating its diploma nursing program in 1998, limiting the entry to practice to two levels. The 2011 Institute of Medicine (IOM) on the future of nursing emphasized the importance of investing in nursing education (IOM, 2011). Evidence shows that there is a strong and positive relationship between RN level of education at the baccalaureate level and patient outcomes (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). Military nursing leaders focused on what was best for patients and decided, with support from the RMS administration, to consider a standardized educational preparation for RNs at the baccalaureate level.

To that end, the RMS had developed robust academic partnerships with the higher education sector in Jordan to establish its first BSN program at the PMCN in 1998 under the umbrella of a public university called Mutah University. This university offers two academic tracks for civilian and military sectors (Mutah University, 2019a). However, it was not until 11 years later with the establishment of the BSN program at the Princess Muna College of Nursing (PMCN) that a military male nurse with a doctoral degree was appointed dean of nursing in 2009. This delay was due to the rules and regulations of the Ministry of Higher Education and Scientific Research, which requires a doctorate for the dean position for any faculty in Jordanian universities.

Progress required a radical change in negative stereotypes and physician attitudes about nurses and nursing at that time.Three different military male nurses assumed the position of dean of nursing at the PMCN from 2009- 2017, as they were the first military nurses to obtain doctoral degrees in nursing with full scholarships from the army. Since 2017 to the present, the first military female nurse has been appointed as dean of the PMCN. Therefore, non-nurse leaders ran the PMCN from 1998-2009. It is interesting to note that with the transformation of the Princess Muna College of Nursing (PMCN) from a 3-year diploma nursing program in 1998 to 4-year baccalaureate nursing program, two high leadership positions have been assumed during the period from 1998-2003. One position was assumed by the dean of nursing of PMCN (a non-nurse) while the position as the Director of Nursing of the PMCN (assumed by nurses with diploma or a BSN degree) continued to function until the director’s vacancy at the PMCN was cancelled in 2003. Retired military nurse leaders in the focus group reflected on the most important achievements of military nursing on the theme of proper investment in nursing education as shown in Table 5.

Table 5. Important Achievements of Military Nursing in Nursing Education

Establishing the BSN program at the PMCN, affiliated with Mutah University. Establishing the bridging programs for diploma nurses in the PMCN. Identifying entry to practice in the nursing profession to two levels. Establishing the ADN program and termination of diploma program. Preparing a cadre of nurse educators by supporting their education at the master’s and doctoral levels. Providing full scholarships for military nurses for undergraduate and graduate education. Maximizing the benefits of the exposure to British and American experiences in nursing care to strengthen nursing education in Jordan. Actively participating in national taskforces to develop and update nursing competencies for the education and practice sectors; set accreditation standards for nursing practice and education; and develop competency exit national exams for BSN prior to graduation from the university. Including representation from military nurses on many of the faculty of nursing councils at different universities. Assuring active involvement in the preparation and training of nurses from other sectors by supervising and training nursing students from public and private universities in the different Army specialty areas. Maintaining active nursing practice of military nurse educators, including those with doctoral degrees in nursing, by working side by side with students during their practicum. Promoting valuable leadership and management experiences to enhance nursing careers of faculty and students while in the army, as well as their future endeavors in the education and practice sectors after retirement from the army. Assuming leadership positions in the education and practice sectors promptly after retirement from the army. Empowering nursing students to improve skills and ensure future job security with increased monetary benefits and status during their nursing careers.

Disaster preparedness remains a unique feature of nursing education in the military sector...Academic partnerships between the military sector and other schools of nursing in universities in the government and private sectors have a long-standing history. According to the retired military nurse leaders, the contribution of military nurses to nursing education is evident through their active participation in national taskforces and other activities described in Table 5. Military nurses have provided quality mentorship and have offered clinical placements for students enrolled in other public universities in a variety of speciality areas at the RMS. Of note, in the early 1970s, the RMS facilities were the only available highly specialized training sites for nursing students from all Jordanian universities in psychiatry, cardiac care, rehabilitation, tertiary care, and disaster preparedness. Disaster preparedness remains a unique feature of nursing education in the military sector, preparing competent nurses to provide humanitarian nursing care during and after natural and manmade disasters.

Sponsored undergraduate nurse education, job security, nursing status, and economic benefits are key incentives for high school students and nurses in Jordan to pursue a military nursing career.The military sector has also invested in students from other universities in the public sector. Due to the nursing shortage in the RMS, there has been increased recruiting of high school students to study at the PMCN. The RMS has recruited and sponsored around 400 undergraduate nursing students from the public universities, with an obligation for military service upon graduation (Al Maaitah & Shokeh, 2009; Zahran, 2012). Sponsored undergraduate nurse education, job security, nursing status, and economic benefits are key incentives for high school students and nurses in Jordan to pursue a military nursing career. In addition, with their rich clinical nursing experience, and teaching and leadership skills, military retired nurses continue to influence and provide further service to the healthcare sector in Jordan by opting new careers in nursing education, practice, and leadership. According to the retired nurses in the focus group, recruitment of retired military nurses with doctorate and master’s degrees from different Jordanian universities might also attest to the quality and capabilities of these nurse educators from the army sector, who continue their contribution to the preparation of Jordanian nurses to meet the health needs of the country.

Proper Investment in the Nursing Workforce and Practice
Actions have included operationalizing and updating the standards of care for nursing and other professions.As part of the RMS competitive culture, nurses in uniform have taken the lead in Jordan by taking immediate actions to implement all related regulatory policies to strengthen nursing practice, education, and leadership. Actions have included operationalizing and updating the standards of care for nursing and other professions. Related nursing policies and procedure manuals have been put in place for general and specialized nursing roles to guide advanced nursing practice and professional development. Furthermore, for the first time in Jordan, military RNs and midwives lead and manage 12 wound management, diabetic, and midwifery clinics, which is considered a significant step toward the realization of the advanced role of nurses (R. Majali, personal communication, 2019).

Nurses at the RMS have also been pioneers in establishing the clinical ladder...Al Maaitah & AbuAlRub (2017) emphasized the need for a stronger role of Advanced Practice Registered Nurses (APRNs; equivalent to Advanced Practice Nurses in Jordan) to accelerate the progress toward universal health coverage (UHC) by transforming nursing practice, education, leadership, research, and the regulatory system. They stated that the development of solid nursing competencies for APRNs, primary health care (PHC), UHC, leadership, and policy making will strengthen nurses’ positions as main actors in influencing the healthcare system. Nurses at the RMS have also been pioneers in establishing the clinical ladder, which has been in place since 1994, prior to the establishment of the JNC in 2002. Table 6 highlights the progress of professional development in the military sector.

Table 6. Professional Development in the Military Sector

Highlights of Progress	Year
Establishing the continuing education system for military nurses.	1980
Pioneering the establishment of the clinical ladder in Jordan.	1994
Military nurses (initial group) joining the International Council of Nursing Leadership for Change (LFC) program.	2005
Granting of the license as a provider of continuing education by the American Nurses Credentialing Center (ANCC) to the Directorate of Nursing at the RMS.	2017

These highlights have had a positive impact on professional development in nursing. For example, the clinical ladder has offered more recognition and incentives for nurses. In another example, nurse quality coordinators in each hospital monitor quality indicators to enhance nursing practice and patient safety; the first example of this in Jordan was the initiation of hourly rounding in 2015. This process will be applied at a larger scale in the public and private sectors (R. Majali, personal communication, 2019). Retired military nurse leaders in the focus group reflected very proudly on the way they managed to make proper investment in nursing workforce, practice, and continuing professional development for military nurses as shown in Table 7.

Table 7. Achievements of Military Nurses on Proper Investment in Nursing Workforce and Practice

Providing strong commitment, discipline, and credibility of military nurses in all areas of practice and leadership while adhering to professional nursing and military ethics. Taking immediate actions to implement all related regulatory policies to strengthen nursing practice, education, and leadership. Maximizing the benefits of the exposure to the British and American experiences in nursing care to strengthen the nursing profession and provide quality care for Jordanian population. Providing quality and cost-effective nursing care by exposing Army nurses to different international experiences and practice, including the chance for double nursing registration in England and Jordan. Strengthening the skills and knowledge acquired to align nursing practice and leadership with increasing specialty areas. Enhancing solid continuous professional development (CPD) programs to build the capacity of nurses at all levels and across all areas of practice, and management at the national level and international levels. Implementing a recognition and rewarding system for military nurses. Pioneering several initiatives in Jordan to set the ground for quality nursing practice by developing the clinical nursing ladder, nursing incentives, nursing standards, and protocols. Strengthening the role of advanced practice nursing (e.g., pioneering nurse led clinics in Jordan). Offering leadership in education for nurses about emergency preparedness. Expanding the scope of practice for nurses in some specialties (e.g., cardiac and mental health nursing). Assuring active involvement of nurses in primary healthcare, including patient and family education, since the beginning of nursing practice in the military sector. Increasing confidence of military nurses to provide and manage nursing care, including emergencies and disasters. Encouraging appreciation of the transition from military nurse to retired nurse in different areas of service, education, or management.

Nurses who complete a BSN program in the military sector are expected to acquire nursing competencies that enable them to promote health and well-being throughout the health continuum with a focus on individual, family, and community needs. Although the retired military nurse leaders in the focus group discussion showed some concerns about the skills of newly graduated RNs, the BSN military program at the PMCN refines the student’s knowledge, skills and competencies and facilitates smooth transition to the real life of work after graduation. However, these concerns need to be considered to strengthen the ability of the nursing program to respond to the needs of the population during a very challenging era of healthcare system and services. On a positive note, the focus group participants expressed that the exposure of nursing students and RNs to nursing care in difficult times, such as emergencies and disasters, has strengthened and sharpened nurses’ competencies and confidence in the provision and management of nursing care.

It is the dedicated investment in human resources that has given the military sector the strength to strive in the health sector at the national and regional levels.It is the dedicated investment in human resources that has given the military sector the strength to strive in the health sector at the national and regional levels. The first heart transplant in the Middle East region was done at the RMS and was performed by Jordanian specialist surgeons in 1985; and the first kidney transplant was performed in 1972 at the RMS (R. Majali, personal communication, 2019). Therefore, it is not by chance that a solid continuing education system for nurses has been in place since 1980, and has continued to flourish. Continuous professional development (CPD) in the RMS is the backbone of the clinical ladder established in 1994. The appointment of staff development coordinators in each hospital started in the early 1980s to strengthen the capacity of military nurses at all levels of practice and management. Continuing education and training packages include training courses, seminars, in-service education, and nursing grand rounds and also conferences and scientific days. The first national conference was convened in 1987 and the first international military nursing conference in 1998, the latter attracting military nurse experts from 14 countries.

Currently, nursing international conferences are organized every two years back to back with the Royal Medical Congress to enhance research and evidence-based practice and share knowledge and experiences with world-renowned nursing pioneers and health leaders. The Directorate of Nursing continues to convene scientific days every year and keep strong partnership and collaboration with other international nursing conferences offered by other national institutions such as the JNC and the academic sector. In recognition of the quality of continuing education at the RMS, the Directorate of Nursing was licensed as a provider of continuing education by the ANCC in 2017.

Strengthening the management and leadership skills of nurses has been a priority for the department of nursing since 1987 at the RMS...The MOH approved the licensure bylaw in 2018 for all health professionals, including nurses, which requires higher accountability by healthcare professionals for their own professional educational development and commitment to lifelong learning. Strengthening the management and leadership skills of nurses has been a priority for the department of nursing since 1987 at the RMS, and started with a collaborative project with the University of Maryland in the United States. Military nurses have the opportunity to join the International Council of Nursing Leadership for Change (ICN LFC) program. Since 2005, 27 military nurses (from a total number of 85 Jordanian nurses) have graduated from this program (Jordanian Nursing Council, 2015; O. Kanani, personal communication, 2019).

Nurses in the army enjoy not only the military ranks and associated authority as they move to higher ranks, but also high salaries, benefits, and incentives with more chances for professional development.According to participants in the focus group, nurses in the military sector are active coordinators of care, and needs of both patients and staff are fully recognized. Adherence to practice standards; collaborative teamwork; assuring a supportive environment; increased opportunities for professional development; active participation in policy making; strong monitoring and evaluation system; high recognition; and solid leadership at the military hospitals are all factors that enable practicing nurses at all levels of care to excel and maintain high standards in quality nursing care and patient safety. This may explain the low attrition rate among military nurses. Nurses in the army enjoy not only the military ranks and associated authority as they move to higher ranks, but also high salaries, benefits, and incentives with more chances for professional development. The recognition and reward system of military nurses’ expertise is an example of a unique support from higher leadership at the RMS. In their review of 21 studies, Zangaro and Kelley (2010) revealed that nursing research reported several factors related to nursing satisfaction, including teamwork, work environment, payment and benefits, promotional chances, and leadership, as well as management experiences offered to novice officers. According to the same study, lack of support from leadership was identified as a major factor for dissatisfaction.

Current Challenges for Military Nursing in Jordan

The retired military nurse leaders shared that challenges and constraints still exist. They were highly concerned about the current challenges facing military nurses in light of increasing demand for quality nursing care. The discussion focused on the lack of adequate training in some areas. Also mentioned were decreased opportunities for capacity building, including a lack of specialized courses and training at the international level. Other possible factors include new strict regulations for retirement, a different ranking system, and insufficient skills for evidence-based research and pursuit of higher education. Table 8 offers a summary of the challenges identified by the focus group participants.

Table 8. Summary of Current Challenges

Lack of adequate training for communication, management, and leadership skills in recent years. Limited opportunities for specialized courses and training at the international levels, possibly due to lack of funding and increasing number of training courses and programs at the different universities and nursing institutions in the country. Rigid regulations for continuing higher nursing education, compared to a flexible system in the past. Early retirement from the army which impedes proper investment in nursing and rich expertise of first-class nurses in the military healthcare system. Shortage of nursing staff. A change in the ranking system for nursing students and practicing nurses with fewer benefits for career development compared to the previous ranking system. Assignment of nurses to work in specialty areas based on the administrative decision rather than the interest of nurses. Weak orientation program for new graduate nurses in various basic and specialty areas of practice. Lack of skills for evidence-based research.

The aforementioned challenges are not limited to the military sector, they indeed reflect the main concerns in Jordan at the national level.The aforementioned challenges are not limited to the military sector, they indeed reflect the main concerns in Jordan at the national level. Hence, a recent publication, the “Jordanian National Strategy for Nursing and Midwifery: A Road Map to 2025” (Jordanian Nursing Council, 2016) has developed four priority strategic areas for further improvement: (1) effective regulation and governance of nursing and midwifery professions, (2) innovative and quality nursing and midwifery education, (3) responsive, dynamic, and evidence based nursing practice, and (4) visible and empowered nursing and midwifery workforce. These challenges across the board suggest that all nursing sectors need to continue to work together to further improve the nursing profession in Jordan.

Ideas for the Way Forward

Military nurses’ contributions are evident in education, practice, professional development, and leadership.Military nurses’ contributions are evident in education, practice, professional development, and leadership. These nurses have strengthened nursing practice by enhancing the image and status of nursing in Jordan; setting the groundwork for nursing clinical standards, clinical ladder, and continuing professional development; enhancing the expanded role of nurses; and developing clinical specialities in different areas of practice. They have also contributed to the progress of nursing education in Jordan through active participation to establish accreditation standards and competencies for nursing practice and education; curriculum development; evaluation of nursing programs; development of competency exit national exams for BSN students; and sharing of knowledge and skills beyond the military zone. They have a remarkable role in leadership and policy influence in health and nursing issues, and have been keen to offer contributions to strengthen the nursing profession and increase professional autonomy. Military nurses prepare a cadre of highly qualified professional nurses and nurse leaders who increase the visibility of nursing leadership at different levels of policy making. They are great role models, not only in the nursing profession, but also among other health professions.

Military nurses often assume leadership and management roles in the private, education, and public sectors after retirement from the army. Contrary to the findings of Chargualaf, Elliott, & Patterson (2017), who found that the transition from military nurse to nurse faculty was difficult partly due to cultural and leadership differences between academia and military sectors, retired military nurse leaders in Jordan have demonstrated high enthusiasm for their current careers in the public and private sectors. Those in the focus group discussions noted that they are self-confident in practice, management, and leadership roles. They appreciated the transition from military nurse to retired nurse in different areas of practice, education, management, and/or leadership as they continue to strive for a stronger nursing profession with increased autonomy in areas beyond the military setting. For example, one participant noted, “I do appreciate the journey from the military to civilian life because I am so confident in my knowledge and skills in any area of practice, education, and leadership. I have a lot to give to young nurses and nursing profession.”

Although negative image and stereotypes of nurses might occasionally surface, there is a great awareness among Jordanian community about the value of nurses...Although negative image and stereotypes of nurses might occasionally surface, there is a great awareness among Jordanian community about the value of nurses and nursing profession for the health of individuals and community. The increasing number of nurses and student applications to military and other public university nursing programs are a positive indicator of the improvement of nursing image and status in Jordan.

A very important issue was raised in the focus group discussions regarding the competence and leadership skills of new nursing generations and their influence on nursing practice. Such concerns need further explanation and study, especially with the increasing complexity and challenges of future healthcare systems. Another focus group discussion that includes both retired and novice nurses might be helpful to consider concerns of novice nurses together with established nursing leaders. Such conversations could light the spark for innovative solutions to ensure solid preparation of the younger generation of nurses at all levels of practice, education, and leadership, helping them to achieve their full potential to improve population health.

The new generation of military nurse leaders need to revisit and reinvest in nurses and the nursing profession in the military sector.Retired nurse leaders in the focus group emphasized the need for more advocacy, specifically more active engagement of nurses at decision making levels in health and non-health sectors to be sure that nurses maintain their influence in the development and implementation of health policies. To this end, they offered several suggestions. The new generation of military nurse leaders need to revisit and reinvest in nurses and the nursing profession in the military sector. They need to work to maintain the legacy of the nursing profession in the military sector, as well as other health sectors. Likely they will have to do much more than military nurses of the past, in light of the rapid growth in technology and healthcare systems. In addition, they will need to work to raise awareness in the population about health rights.

Researching, revision, and reconsideration of several main issues is important to maintain the legacy of military nursing. These issues include innovative training in communication, management, and leadership skills for nursing students and practicing nurses; transformation of nursing curricula and nursing competencies; strengthening the orientation program for novice nurses; and finding funding support for professional development at the national and international levels. Military nurse leaders work hard to empower and strengthen nursing leadership skills. There must be flexibility for young military nurses to choose a practice area of interest and assurances of support to pursue their career. Reflecting on the current shortage of senior nurses in the army, retired military nurses and necessity of mentoring and supervising younger nurses to strengthen and empower the nursing profession.

The IOM report (2011) emphasized the role of nurse leaders to influence policy at all levels and across all health political sectors. With their collective power, all nurses must take every available opportunity to further strengthen their presence and visibility at the policy table to shape health policy.

Finally, military nurses and Jordanian nurses at large need to invest in their unique knowledge, practice, lifelong learning, and leadership to create evidence for innovative, cost effective nursing care to improve the health outcomes in the country. Innovation is the key for contemporary nursing practice and leadership; this was well said by Thomas, Seifert, & Joyner (2016) who noted that, “nurse leaders need to continue as innovators by directing change, developing policies, and creating innovative technological advancements throughout the nursing profession” (p. 18). Wilson et al. (2016) also emphasized that “Preparing nurse educators, practitioners, researchers and leaders for the future is essential and requires the development of innovative models to enhance nurses’ abilities to play integral role in leading change and influencing health policy to shape the global health agenda. (p.10). Innovation will enhance nurses’ abilities and visibility and maximize their opportunities to influence evidence-based health policy.

Conclusion

...military nurses have demonstrated, and continue to demonstrate, a unique and dynamic state of excellence by extending their contributions and skills beyond the military zone.The three themes that emerged from focus group discussion highlight the considerable contribution of military nurses to nursing profession in Jordan. Moulding their tremendous experience in practice and management at different specialty areas with their strong education system, military nurses have demonstrated, and continue to demonstrate, a unique and dynamic state of excellence by extending their contributions and skills beyond the military zone. They have been integral in the redesign of education and health reforms to improve nursing care, and thus the health outcomes at organizational and national levels. Therefore, the military sector must continue to produce nursing leaders, not only for military service, but also to support other healthcare sectors in Jordan. This legacy of the military nursing will be maintained by making a solid investment in and providing close mentorship for young nurses in the military sector, offering them the opportunity to excel in their nursing careers in practice, education, research, and leadership.

It is true that Jordanian nurses, including military nurses, have come so far from where they started. Yet, they still have a long way to go to keep pace with the rapid advancement of technology and healthcare innovation. Although military nurses are well represented at all levels of policy making and across all sectors, there is still a need for a critical mass of nurses in the highest leadership positions. Finally, a very important lesson learned from writing this article is that we in Jordan should collaborate to formally document the history and development of nursing in our country to lay the foundation for a better future for nurses and the nursing profession.

Authors

Rowaida Al Maaitah, DrPH, MPH, RN
Email: maaitah@just.edu.jo

Rowaida Al Maaitah, a Professor and Faculty of Nursing at Jordan University of Science and Technology (JUST); a member of the Higher Council of the National Centre for Curriculum Development; and Consultant for HRH Princess Muna El–Hussein for Health and Social Development. She earned her master’s and doctoral degrees in Public Health from Tulane University in 1982 and 1989, respectively and her B.Sc. in Nursing from The University of Jordan in 1978. She was also a post-doctoral fellow in nursing school administration at Louisiana State University in 1989, and attended Senior Executive leadership courses at Harvard Kennedy School. She was first woman and nurse in the region to take over the portfolio of the Ministry of Higher Education and Scientific Research and the first to serve as a president of university (The Hashemite University), first woman and nurse in Jordan to serve as Vice-President of a university (JUST), and DG of King Abdullah University Teaching Hospital at JUST. She has held numerous political and academic key positions that have helped her to influence education, health, and social policies and decision making at the executive and legislative branches. In addition, she assumed the following positions: Senator in the Upper House of the Parliament; Minister of State for Government Performance; Minister of Social Development; Dean of Nursing; Founder and Director of the WHO Collaborating Center; Vice President and Secretary General of the National Council for Family Affairs; and Chairperson of the National Agenda Technical Committee on Poverty, Health, and Social Security. She is a board member of the JNC; member of the Regional Technical Advisory Committee to the WHO Eastern Mediterranean Region; board member of the global Nursing Now Campaign; member of the Global Advisory Panel on the Future of Nursing; and board member of the Health Care Accreditation Council. She is a former Minister of Higher Education and Scientific Research and former president of the Hashemite University.

Daad Z Shokeh, MSc, APN, RN
Email: daad.shokeh@gmail.com

A retired Major General from the Royal Medical Services, Daad Z Shokeh has a MSc in Nursing Administration from the University of Edinburgh, UK; Post Registration in mental health nursing from Canterbury Kent; and currently works as an advisor of HRH Princess Muna for Jordanian Nursing Council to support regulatory and policy issues and introduce innovative quality care models in nursing for the military and public hospitals. In her capacity as a former secretary general of the JNC for eleven years, she developed regulatory policies to strengthen the nursing profession in collaboration with nurses and nurse leaders in Jordan. As a former director of nursing at the RMS, she worked to introduce a clinical ladder for nurses; limit the entry level of nursing to two levels; transform the Princess Muna College of Nursing, with the support and oversight of HRH Princess Muna, to a baccalaureate program under the umbrella of Mutah University; and transform the training center to a community college currently affiliated with Balka University. She is a former member of ICN registration and licensure observatory and former member of the Institute for Credentialing International Governing Council, ANCC, USA. She actively participated in various WHO EMRO regional advisory panels. She served on a part time basis as consultant at King Abdullah University Hospital and as a short term consultant for WHO EMRO Iraqi and Syrian desk on nursing regulations.

Saba A. Al-Ja'afreh, RN, MSc
Email: hrhpmn@rhc.jo

Saba Al-Ja'afreh works as a Clinical Nurse Consultant at the office of HRH Princess Muna Al-Hussein, she has Master’s in Health Services Management from the Royal College of Surgeons in Dublin and Bachelor’s in Nursing from Mutah University in Jordan. She is a Major in the Jordanian armed forces with 20 years of experience in clinical nursing. She worked previously as Administrator of the Royal Clinic at the Private Medical Office in the Royal Hashemite Court.

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