Standing astride both Asia and Europe, Turkey is like a bridge that connects the two continents. Neighboring countries to Turkey include: Georgia, Armenia, Azerbaijan, Iran, Iraq, Syria, Greece, and Bulgaria. The Republic of Turkey was founded in 1923 on the 814,578 square kilometers that remained within the Ottoman Empire following the World War I Turkish (Geographical Society, 2007). The Turkish population in 2006 was 74.5 million (The Republic of Turkey Prime Ministry State Planning Organization, 2007). Turkey, which is divided into seven regions based on geography and climate, consists of a central government and 81 provinces. The three cities with the densest population are Istanbul, Ankara, and Ä°zmir respectively (DÄ°E: T.C. State Institute of Statistics, 2005).

This article will tell the story of the historical development and current status of nursing in Turkey. First it will present a historical review of the developments of modern Turkish nursing and describe the current status and continuing development of nursing education in Turkey. The article will then describe nursing regulation and nursing practice in Turkey, and conclude by explaining how the voice of nursing in Turkey is heard through the professional associations.

Historical Development of Nursing in Turkey

Although the nation of Turkey was the site for the birth of modern nursing, modern nursing itself did not begin in Turkey until 1912. Nightingale’s work in Turkey is often cited as the beginning of modern nursing. Although the nation of Turkey was the site for the birth of modern nursing, modern nursing itself did not begin in Turkey until 1912. At this time nurses began to provide care to wounded soldiers in the Balkan War I, during which time the Ottoman Empire and Balkan League countries sought fuller protection for the Christian majority and the status quo (Wikipedia, 2007a) and during the Tripolitan War, when Italy seized some Ottoman provinces which became known as Libya, the Isle of Rhodes, and the Greek-speaking Dodecanese archipelago near Anatolia (Wikipedia, 2007b). The Balkan War I brought a large number of immigrants and wounded to Istanbul; and soon a cholera epidemic broke out on the front line and in Istanbul itself, resulting in significant healthcare needs (See Figure 1). Although most of the governmental and official buildings were turned into hospitals where healthcare services were provided, there were still insufficient facilities to meet this challenge. The ladies of Istanbul nobility, influenced by the organized efforts of Florence Nightingale, who had recently decreased the death rate caused by wounds from 42 % to 2% and demonstrated an affectionate and warm attitude toward patients (Bayık, Erefe, & Altug Özsoy, 2002), participated voluntarily in the provision of healthcare services.

Soon charity organizations, set up by the Turkish women provided financial and material support to the soldiers at the front and coordinated voluntary nursing activities (Akçiçek 1983; Akgün & UluÄŸtekin, 2000; Bayık et al., 2002; Caka, 1948; ÅžehsuvaroÄŸlu & Demirhan, 1984). These women also were directly involved in the care of the patients.

Figure 1: The first volunteer Turkish nurses helping the patients (1912).

Physicians, Dr. Besim Ömer and Dr. Nihat ReÅŸat Belger, who attended the Red Cross Congress in Washington in 1912, observed that nursing was beginning to be regarded as a profession. Upon their arrival in Turkey, they contacted the Turkish Red Crescent Society, emphasized the need for nursing in Turkey, and encouraged the opening of a school of nursing. The Turkish Red Crescent Society responded by allocating money for a six-month nursing education course for volunteers in Kadırga Maternity Hospital. The first course was taught by Prof. Dr. Besim Ömer Akalın (Birol, 1975; Bayık et al., 2002; ÅžehsuvaroÄŸlu & Demirhan, 1984; Sarı & Özaydın, 1992; Kırca, 1991). A great many students attended these classes offered between 1913 and 1914. (See Figure 2) The graduates, including Kerime Salahor, Safiye Hüseyin Elbi, and Münire Ä°smail, then served as volunteers in Çanakkale and Balkan War II  (Kurnaz, 1993; Yıldırım, 1998) (See Figure 3).

Figure 2: The voluntary Turkish nurses, having taken courses offered by The Turkish Red Crescent Society, are shown here with the veterans (1913).

Figure 3: The volunteer nurses giving care to the wounded soldiers at the back of the frontline (1914).

During the World War I (WWI) five German and two Austrian nurses of the Red Cross, sent by the German Emperor in 1916, worked for the Army in Istanbul and looked after the wounded in Zeynep Kamil Hospital. They also provided nursing education for the Turkish women who had volunteered to help care for the wounded.

In 1920, during the Ottoman Era and after WWI, the Admiral Bristol Nursing School was opened by nurses from the United States. It offered education for secondary school graduates for two years and six months. The Turkish Republic was founded in 1923, establishing what is called the Turkish Republican Era. The Turkish Red Crescent Society opened the first Turkish nursing school in 1925 (see Figure 4). Soon some of the graduates of this school were sent abroad to the United Kingdom and United State for additional education that enabled them to become faculty members in various nursing schools throughout Turkey, and also the directors of the hospitals around the country (Akgün & UluÄŸtekin, 2000; BaÅŸ, 1992; Caka, 1948).

Figure 4: The students and the instructors of The Turkish Red Crescent Society Nursing School (1925).

The military continued to play a strong role in nursing education. The first Military Nursing School was established by the Ministry of National Defense in 1939 and continued until 1972. In 1985, the Military Nursing School at Gülhane Military Medical Academy was opened for undergraduate, baccalaureate education and the training of nurse officers. Nursing has been considered as a profession in Turkey since the opening of nursing schools in university settings. The maturing of the Turkish Nursing Association (as described later in this article) also contributed to the recognition of nursing as a profession.

Nursing Education in Turkey

The military continued to play a strong role in nursing education. In Turkey three types of basic educational programs have been offered since 1920: diploma programs, associate-degree programs, and baccalaureate programs. Graduate education in nursing has been offered since 1968. Each of these types of programs will be described below.

Basic Nursing Programs

Various types of basic (preparatory) nursing programs have been offered in Turkey over the years. These programs have included the diploma-based programs, the associate-degree programs, and the baccalaureate programs.

Diploma-based programs. The three-year, diploma-based programs began in the 1920s. These schools, which early on were offered at the high-school level, taught nurses how to give injections and vaccinations, change dressings, and provide general patient care. Upon receiving their diploma, graduates from these programs were given the authority to provide the care for which they had been prepared.  In 1958, the program was extended to 4 years. Half of the existing programs then began to offer general nursing topics as high school courses, and the other half began to offer midwifery programs. Graduates of these programs received diplomas after receiving 3,700 hours of training. These high-school level curricula were prepared by officials of the National Ministry of Health.

The nurses who graduated from these programs were appointed to the profession at the average age of 18. Soon the leaders in nursing recognized that 18 was really too early an age to begin practicing as a professional nurse. They began advocating for professional nursing to be offered at the university level. Also in the 1990s, the Ministry of Health began to recognize the need for to provide programs offering a university degree, instead of a high school degree, in order to standardize the nursing education. In 1997, nursing education began to be offered following graduation from high school. After students graduated from high school, they took the University Entrance Exam, and upon passing this exam began to pursue an education in nursing. After many years of political activity by various nursing associations and nursing educators, high-school level educational programs provided by The Ministry of Health were totally abolished in 2005 (Ülker et al., 2001).

Associate-degree programs. The two-year, associate-degree programs, modeled after associate-degree programs in the United States, were offered between 1985 and 1996. These programs were launched as two-year programs within universities in order to meet the demand for nurses which arose after the authorities abolished nursing education at the high school level. However, by 1996 it was recognized that a two-year program did not provide nurses with adequate preparation to perform as a professional nurse. While some associate-degree programs were closed, others were converted to four-year baccalaureate programs.   

Baccalaureate degree programs started in 1955, and soon the baccalaureate degree became required for entry into professional nursing practice in Turkey. Baccalaureate degree programs. Baccalaureate degree programs started in 1955, and soon the baccalaureate degree became required for entry into professional nursing practice in Turkey. Admission requirements for baccalaureate programs, until 2007, included satisfactory scores on the ÖSS (general exam for entrance to universities) and also being female. Since April of 2007, men have been accepted into nursing programs. OSS scores are now required for acceptance for both male and female students. Until 1990, only five universities in Turkey offered nursing programs. However the number of baccalaureate programs increased rapidly as associate-degree programs were closed. Today, education for nursing is provided in four-year programs at universities following high school graduation. There are now 85 nursing schools offering baccalaureate programs, most of which are in state universities. These programs provide 4600 hours of theoretical and applied nursing education, thus meeting the European Union (EU) requirement for the number of hours of nursing education. Some schools, as they now meet the EU accreditation criteria for total course hours, participate in student and academic staff exchange programs with European countries (Abant Ä°zzet Baysal University, 2007; BaÅŸkent University, 2007; Cumhuriyet University, 2007; Hacettepe University, 2007; Istanbul University, 2007; Mersin University, 2007).

Graduate Degree Programs

Master of Science degree programs. In Turkey, the master of science (MS) degree programs started in 1968. Once nursing schools are approved by Higher Education Board as have adequate numbers of faculty, they may establish master’s or doctoral programs (OSYM; Higher Education Board Student Selection and Placement Office, 2007). Admission Requirements for master’s programs include: BS in Nursing degree, satisfactory scores on the LES (Graduate Studies Entrance Exam) and the English language proficiency test, and a test of general nursing knowledge that is administered by each school. Master’s programs in Turkey include the following eight departments: Fundamentals of Nursing, Medical Nursing, Surgical Nursing, Women’s Health and Gynecology Nursing, Pediatric Nursing, Psychiatric Nursing, Public Health Nursing, and Nursing Management. MS study consists of two stages: completing a number of courses and research. Students are required to take 21 credits minimum in two semesters. The students have to complete all the requirements for an MS degree in four semesters (YOK: Higher Education Board, 2007).

PhD Programs. Nursing doctoral programs started in 1972 and today nine nursing schools offer a doctoral program. Criteria for admission to doctoral programs include: MS degree in nursing; satisfactory scores on the LES and the English language proficiency test; and a test of general nursing knowledge that is administered by each school.

Doctoral study also consists of two stages: completing a number of courses and research. Students are required to take a minimum of seven-credit hours for each of three semesters (total of 21 credits). Students are evaluated according to the course grades received each semester; they need to complete each course successfully in order to continue the program (YÖK: Higher Education Board, 2007). When students successfully complete the first stage (course stage), they need  to take a comprehensive/qualifying exam (comprehensive written and oral examination conducted by a committee of five examiners at least one of whom is external to the university) to pursue PhD thesis work. Students must complete their course work, their thesis research, and the writing of their dissertation within eight semesters. If students are judged by the jury to be successful in the defense of their thesis, they are awarded a PhD degree (YÖK: Higher Education Board).

Regulation of Nursing Practice in Turkey

The first legislation regulating professional nursing in Turkey was passed in 1954...With the introduction of the 2007 law, the specific responsibility and authority of nurses will be determined according to their educational level. The first legislation regulating professional nursing in Turkey was passed in 1954. The law outlined educational requirements for those desiring to become professional nurses. The requirements stipulated that the nurse have completed a three-year program post high school, be under the age of 25, and be of the female gender. This early law described a nurse as one who performs subcutaneous, intramuscular, and intravenous injection in accordance with the directions or prescriptions by the physician and one who can apply dressings in emergencies. However, this law has not been comprehensive enough to meet societal needs for some time now. Efforts to propose a new bill regarding nursing since have been ongoing since 1992 (Ülker, Kocaman, & Özkan, 2003). In April 2007, a revision of the 1954 nursing law was passed. This revised law provides the following:

• A description of nursing
• Criteria for entrance to a nursing school
• Criteria for nursing educational program content
• Criteria for graduate specialist education
• Clarification of nursing roles and responsibilities

According to the new regulations, nurses are authorized to: (a) implement any treatment assigned in writing by a physician (with an exception providing for a non-written treatment during an emergency), (b) determine the health-related needs of the individual, family, and community that can be met through nursing, and (c) plan, implement, supervise, and evaluate nursing care within the framework of needs identified by the nursing diagnostic process. Initial education for nursing must be offered in an undergraduate program within a university. Nurses...can work as a “specialist nurse” after they complete graduate education and specialize in a given clinical area. Nurses who hold a baccalaureate degree in nursing can work as a “specialist nurse” after they complete graduate education and specialize in a given clinical area. Following graduation from a baccalaureate program, nurses receive an authorization document which allows them to practice within a given framework of standards that is determined at the unit level, based on the care required by patients in a specific unit, for example occupational health, emergency care, stoma care, and diabetes care, as determined by the Ministry of Health. The revised law also states that nurses’ authority and responsibility will be determined by their educational level (Official Journal of Turkish Republic, 2007).This updated law of 2007 will strengthen nursing care in Turkey in several ways. The fact that roles and responsibilities of nurses who had graduated from schools with differing levels of educational preparation had never been completely described had caused serious problems in the working area. With the introduction of the 2007 law, the specific responsibility and authority of nurses will be determined according to their educational level. Additionally, the authorization document for specific clinical areas, and the acknowledgment of the specialization of nurses with graduate education in a given nursing specialty will make important contributions to the development of the nursing profession in Turkey and to the health of our society. 

Characteristics of the Nursing Workforce in Turkey

Nurses who do hold baccalaureate degrees work primarily in big cities and at university and private hospitals. This next section will describe various characteristics of the nursing workforce in Turkey today. Nurses’ educational preparation, continuing education, age, and gender will be addressed in turn.

Most of the nurses actively working in nursing are graduates of associate-degree programs. In 1985, upon the launch of associate-degree programs in universities, nurses who were then working as graduates of health professional high schools desired to also hold an associate-degree. Because of the availability of open education, most of the nurses who were initially educated in high schools completed associate-degree programs. However, only a small portion of all practicing nurses hold a baccalaureate degree. Nurses who do hold baccalaureate degrees work primarily in big cities and at university and private hospitals.

Graduates of nursing schools have to pass the Exam for Public Personnel Selection (KPSS), which is specific to Turkey, in order to serve in public services. Candidates who pass this examination are eligible to start working in public institutions if they are successful in the interview examination conducted by the institutions. Those working in the public sector are called nursing candidates for one year. The diplomas of those candidates who are successful at the end of the one-year period are approved by the Ministry of Health. Although no central and periodic examinations are provided to evaluate the proficiency of nurses, other than the initial employment exams, institutions offer continuous education programs for their employees. The Ministry of Health, the largest employer, carries out continuous education for its employees in line with its own regulation for in-service training (The Ministry of Health, 2007).

Until recently men were not permitted to work as nurses in Turkey. Turkey’s nursing workforce is relatively young due to retirement laws and to the early age at which many nurses started their careers. Before 2000, the compulsory service for any job in Turkey was 20 years for women and 25 for men. It was common for nurses who began the profession at a young age to retire immediately after the completion of compulsory service (around the age of 40). The retirement age was raised to 58 for women and 60 for men with the Law of Labor in 2000 (Turkish Employment Organization, 2000). However, the majority of nurses in Turkey today are still under the age of 30 (Ülker et al., 2001).

Until recently men were not permitted to work as nurses in Turkey. However, males sometimes became male health officers, working sometimes as technicians in laboratories, radiology, anesthesia, or environmental health, and working often in orthopedic clinics and intensive care units. Eighty percent of these health officers had graduated from schools with the same curricula as nursing schools, but were not allowed to work as nurses due to legal prohibitions against males being nurses. However, in 2001, Ülker et al. stated that 114,235 nurses would be needed to provide adequate healthcare in 2005. The new nursing law, passed in 2007, permits the employment of these men as nurses, thus allowing them to help meet the need for nursing care providers. It also allows males to be educated in baccalaureate nursing programs along with female students. In Turkey, today, male and female nurses have the same responsibilities.

Continuing Challenges in the Workforce

One challenge in the Turkish workforce is the inappropriate distribution of healthcare workers throughout the country (Öztek, 2007). In the year 2003, there were 97,703 doctors in Turkey (721 doctors per capita), 82,246 nurses (868 nurses per capita), and 50,432 health officers. Forty-three percent of the doctors and 27% of the nurses worked in primary healthcare institutions (health centers), while 57% of doctors and 73% of nurses work in treatment institutions (hospitals) (The Ministry of Health, 2000). Additionally 20% of the nurses work in three main cities, while only 12% of the Turkish population lives in these three cities. According to the 2001 figures of the Ministry of Health, while there is one physician for 4435 people, there is one nurse per 6302 people for all of the Turkish population (DÄ°E, 2005).

Another issue in the workforce is the shortage of senior nursing faculty. According to the 2006 figures, the number of teaching staff in four-year baccalaureate programs within universities of the Higher Education Board (YÖK) is 701, yet 4,625 students entered the nursing program in Turkey during Academic Year 2007-2008 alone. The professors are very unequally distributed among the 85 nursing programs. For example, Gazi University School of nursing has 15 teaching staff and 280 students, while Hitit University School of Nursing has two teaching staff and 190 students. Fortunately, those schools with a shortage of teaching staff do receive support from other schools in nearby cities having more staff.

Professional Organizations

It has been through this Turkish Nurses Association that the nurses in Turkey have been able to have their voice heard by the Ministry of Health and other official organizations within the Turkish government. The first Turkish Nurses Association was established in 1933 and it has been a member of the International Council of Nurses since 1949. Currently there are about 6000 members of the Association (Turkish Association of Nurses, 2007). It has been through this Turkish Nurses Association that the nurses in Turkey have been able to have their voice heard by the Ministry of Health and other official organizations within the Turkish government. In addition to the Turkish Nurses Association, there are about 25 special branch associations plus the Association of Research and Development in Nursing, the aim of which is to support and develop research in nursing. Examples of special branch associations include the following: the Association of Occupational Health Nursing, the Association of Children’s Surgery Nursing, the Society of Turkish Surgery Nurses, the Association of Intensive Care Nurses, the Association of Nephrology, Dialysis, and Transplantation Nurses, the Association of Psychiatry Nurses, the Association of Neurosurgical Nurses, the Association of Diabetes Nurses, the Association of Oncology Nurses, and the Association of Child Nursing. 1953 the Journal of Turkish Nurses was founded; this journal has been published continuously since 1953 (Bayık et al., 2002; Eren & Uyer, 1986).

Even thought the Turkish Nurses Association is the strongest political voice for nurses in Turkey, the Association is not a union. Legislative activity in Turkey is moved forward primarily by the Turkish Nursing Association, guided by academicians in the field and by some of the specialty (special branch) associations. These groups have enabled the nurses’ voices to be heard regarding needed improvements in working conditions and the development of the profession through the Association. Efforts continue to form a united union including the Turkish Nurses Union and unions representing other associations. A draft bill for this Nurses’ Union has been prepared, and if the bill is legalized, the Union of Nursing Associations will be established.

Conclusion

...the inadequate number...and the unbalanced distribution of nurses in Turkey remain as significant barriers to providing quality nursing care throughout the country.The development of professional nursing in Turkey began with the Turkish wars in the early 1900s. Although the wars resulted in considerable personal injury and death, they also offered significant opportunities for the development of modern nursing. The year, 1912, in which Turkish women began to work in the hospitals to assist in the war efforts, is considered as the beginning of professional nursing in Turkey. Although early on the educational requirements for nursing included only three years of nursing preparation in a high school, today all new professional nurses must complete a  four-year educational program which follows graduation from high school. After many difficult struggles, nursing education in Turkey today compares favorably to international educational standards for nursing. Although the new nursing law now provides a written description of professional nursing, along with the opportunity to specialize in areas, such as transplantation nursing, home health nursing, and diabetes nursing, the inadequate number of nurses and the unbalanced distribution of nurses in Turkey remain as significant barriers to providing quality nursing care throughout the country.

Authors

Ümran Dal
E-mail: umran_dal@yahoo.com

Dr. Dal graduated from the School of Nursing at AtatÃrk University in 1989 and has worked as a nurse in a variety of hospital departments. She completed her doctoral training in surgical nursing in GÃllhane Military Medical Academy School of Nursing in 2002. In 2005, she became an Assistant Professor at the School of Nursing at Gazi University in Turkey. Her special interests are orthopedic nursing, trauma nursing, and accident and emergency nursing.

Yeter KitiÅŸ PhD
E-mail: yeterkitis@gazi.edu.tr

Dr. KitiÅŸ received her BSN and MSN from Ege University. She worked as a staff nurse until 1994 and then as an instructor in Hacettepe University until 2005. She holds a PhD degree in Public Health, completing her dissertation, The Effects of Home Monitoring by Public Health Nurse on Individuals' Diabetes Control, in 2002. Since 2005, she has been working as an Associate Professor of the College of Nursing at Gazi University in Turkey. Her areas of expertise include public health and epidemiology.

OSYM (ÖÄŸrenci Seçme ve YerleÅŸtirme Merkezi). (2007). Higher education board student selection and placement office.  Retrieved April 20, 2007 from the world wide web at: http://osyspuanlari.osym.gov.tr/tablo4.aspx