This framework should present principle reflections on nursing practice and the aim of increasing the quality of nursing care informed by the ethics of caring. The ethics of caring in leadership is a reflection of the ability of the leader to motivate and empower. To assure successful adoption the ethical issues concerning the consecration of the caring framework in the organization must be made clear, and the main steps to evaluate and monitor the project must be established for systematic adoption in Kurdistan, with periodic review.

The paper presents the main rationale for the changing in nursing education in Iraqi Kurdistan and defines the current health situation using SWOT analysis. It next describes the strategic role of leaders in innovation and the qualities for implementation and the context of this innovation in Kurdistan. The objective for implementation the framework is to develop nursing education in Sulaimani University, providing nurses with new competencies and improved ethical behaviour, knowledge and skills concerning patient safety, as well as contributing to theoretical research on nursing leadership (Sawatzky et al., 2009).Lee-Hsieh, 2004 found that a caring framework course in teaching excellence improved student caring knowledge, attitudes and behaviour.

Teaching philosophy in nursing education

Beliefs about teaching and learning provide aspirations and drive one’s practice, and facilitate student teaching(Sawatzky et al., 2009).The concept of caring as an aspect of nursing education was pioneered by Grams et al., 1977 and it now represents:

“The formation of a humanistic (altruistic) system of values; the instillation of faith-hope; the cultivation of sensitivity to oneself and others; the development of a helping-trusting (human caring) relationship; the promotion and acceptance of the expression of positive and negative feelings; systematic use of creative problem-solving caring process; promoting transpersonal teaching-learning; provision for a supportive, protective, and/or corrective mental, physical, sociocultural, and spiritual environment; assistance with gratification of human needs; and allowance for existential-phenomenological-spiritual forces” (Watson, 2010).

Conceptual framework of caring for nursing teaching excellence in teaching leadership

The foundation of teaching excellence is provided by the ethicof caring, which underpins teaching philosophy in nursing education (Figure 1). Excellence in teaching leadership is constructed to recognise the roles of leaders in course organization and curriculum design, organizing courses and mentoring students. Caring in teaching excellence of leadership reflects the ability of the leader to motivate and empower others, making decisions based on skill development, developing teaching theory to embed caring in the curriculum (Sawatzky et al., 2009).

A caring framework permeates every part of the nursing curriculum, recognising the significant role of leaders in guiding the implementation of a caring framework as part of teaching in surgical nursing (Sawatzky et al., 2009).

Rationale for the change and analysis of the current situation

Current state of nursing education in Iraqi Kurdistan

Over three decades of international conflict have affected an exodus of nursing leaders from Iraq and a decline in nursing education and training. As part of the general dearth of health care provision in the country, there is a dearth of leaders and health care managers (Al Hilfi et al., 2013).Garfield and McCarthy (2005) arguedthat Iraq needs to prepare new graduates with new competencies fromnursing education to subsequently develop primary health care and health education up to international standards. Most institutions of nursing education are for military nursing, and recent curriculums continue to entrench self-directed and participative learning, alongside a lack of modern educational resources, particularly electronic libraries, with the result that Iraq lags behind regional and world norms.Another reason for selecting the School of Nursing inSulaimaniyah (hereinafter SNS) to implement the caring framework for teaching excellence is that SNS seeks to pioneer modern nursing education in Kurdistan, particularly evidence-based practice (EBP) within a rich curriculum, with research and teaching reflecting an obligation to excellence in teaching.

Description and analysis of the current state of nurse education in Kurdistan

Figure 2 shows a SWOT analysis of nursing in Kurdistan

One of the strengths of this project relates to the budget, given the independent financial plan of the Kurdistan Regional Government (KRG)independent of Bagdad (Al Hilfi et al., 2013). Furthermore, the Kurdistan Federal Region (KFR) has benefitted from an inflow of health specialists and professional nurses fleeing from other parts of Iraq (e.g. four assistant professors and five professors in SNS migrated from Bagdad). Numerous organizations conduct training and scholarships (domestic and international) to improve technical skills. These factors could minimize the threat of many people being resistant to change in new subjects in nursing. Al Hilfi et al., 2013noted that the Iraqi government must preparenew graduates with new competencies from nursing education, entailing development of programmers in nursing leadership and community health nursing.

In this regard, Cetorelli and Shabila, 2014 noted that despite the expansion of the public and private health sectors in Kurdistan, development remains lagging behind neighbouring countries, mainly attributable to the weakness of the health education process, thus this project is vitally important (Shabila et al., 2010). The KRG pioneered the Human Capacity Development Program (HCDP), which has sent many nurses to complete higher degrees (MSc and PhD) in developed countries, such as the UK and USA. This can facilitate the current project, as returning nurse leaders will be more receptive due to their exposure to advanced nursing in developed countries (UNESCO, 2011).Another weakness of the project is that the nursing curriculum is poorly integrated with innovative technologies and electronic resources (Garfield and McCarthy, 2005). However, one should not overlook the impressive achievement of SNSin continuing to provide nursing graduates in the most adverse circumstances (i.e. the disintegration of Iraq). The SNS curriculumwas devised by two international nursing organizations in the USA, which supported the library with new educational resources.

Healthcare service and nursing education remains underdeveloped in the KFR as most nursing leaders and specialistsleft Iraq due to conflict and general brain drain phenomena, resulting in a dearth of effective leadersto meet the growing healthcare service needs of the country (Woodring, 2004; Huston, 2008; Mintz-Binder and Fitzpatrick, 2009). As well as a disproportionately low ratio of nurses to population, qualified nurses in Iraq have minimal standards of professional practice compared to other countries (Garfield and McCarthy, 2005). Thus this project targets the SNSto prepare nursing leadershipto motivate nursing teams and improve their skills within a coherent vision of nursing leadership (Al-Haddad, 2003). Table 1 shows a PESTLE analysis of external factors that affect the organisation and the development of nursing education in Kurdistan (Dyson, 2004).

Leadership approach and qualities for study context

Stakeholder analysis and communication theory

According to Mitchell et al., 1997, stakeholdersare groups or individual who “can affect or is affected by the achievement of the organization's objectives”. In this project the stakeholders include student nurses, the Head of School, the Head of Surgical Nursing Department, the professional (administrative) body of SNS, nurse educators, and the KRG Chancellor, Ministry of Higher Education (MoHE) and UoS. Stakeholder facilitation is essential to successful adoption and management of change projectsand innovation (Assudani and Kloppenborg, 2010; Aaltonen, 2011). Successful projects should clearly ascertain and incorporate the concerns and objectives of stakeholders(Stephens, 2005).

According to Greenbaum, 1974, “organizational communication consists of various message sending and receiving phenomena affecting formal social units in which individuals work toward common goals”. Organizational communication system includes four main subsystems (Table 2). This project uses organizational communication to connect the purpose, operational procedure and structure. The operational procedures in organizational communication include the utilization of networks for organizational goals. The structure component of organizational communication includes the unit communication, activities communication, communication policiesand networks functional communication (Greenbaum, 1974).

The stakeholder power/ interest matrix of Savanovic, 2014was used to identify the roles of stakeholders in this project, as shown in (Figure 3), and the communication method is shown in Table 3.

The Head of Surgical Nursing Department, nurse educators and student nurses, with low power and high interest in projects, need to be informed. Communication with this group of stakeholdersinvolves communication by face-to-face meetings, e-mail and presentationsto introduce the new model of teaching framework, explaining the project and its objectives, and the ways in which it affects them and the expectations of their cooperation (i.e. their responsibility). The Head of School and professional bodies are high power, low interest stakeholders, who should be satisfied. Communication with them also involves face-to-face meetings, and workshops and presentations to ascertain their written support for the UoS. The UoS, the MoHEand the Chancellor (KRG) have high power and high interest, and should be kept satisfied by communication via a letter stating our purpose to solicit their support and enablement of the project.

Justification of the leadership strategies and qualities of the leader

Albeit leadership is often analysed in terms of traits and behaviours in the literature, the basic principle of achievingpractical organizational objectivesconsiders leadership to be an on-going process relating to the particular context (Grojan et al., 2004). Transformational leadership theory should be useful to manage and develop the change and innovation for the caring framework in teaching excellence, as it is about the inspiration of followers with a vision, motivating them to creatively and actively contribute to achievement of this vision (Curtis et al., 2011). These characteristics are needed for academic leadership to oversee the project. Nurse educators who excel at leadership play a central role in this (Sawatzky et al., 2009).Leadership in the caring framework in teaching excellence can prepare the structure and design of the course, and contribute to its evaluation. The leader role can be manifest by nurse educators motivating and encouraging students to partake in decision-making (Sawatzky et al., 2009).

According to Bass, 1991, transformational leaders present leadership behaviour regarding for the four elements of transformational style (Table 4).

Leadership is process for teaching and empowering human beliefs and abilities using an appealing vision, motivating strong feelings and inspiring others to work towards a common goal. Understanding the meaning of excellence among leaders firstly entails understanding the basic meaning of leadership, which involves skills such as responsiveness and dynamism in decision-making (Abed, 2014).

Transformational leadership theory is suitable to support the project of teaching excellence and advancing nursing leadership because it attempts to change society and individuals, and it can be used to guide nurse leaders. Transformational leadership behaviour has been found to improve the work of nursing units. For instance, a study conducted in the UK by Curtis et al., 2011 compared two groups of nurses, the experimental group (Nurse Development Unit) and the control group (non-Nurse Development Unit). The Nurse Development Unit is an organisational component in the UK to prepare innovation in nursing practice by increasing the quality and quantity of nurse leaders (i.e. pertaining to transformational leadership behaviours). The study found that nurses in the Nurse Development Unit rated more highly than those in non-Nurse Development Units, with greater observer evaluations and enhanced transformational leadership behaviours (Curtis et al., 2011).

Transformational leaders are more effective in driving change in nursing education. Leaders are effective in environmental communication and motivators who focus on team-building and collaboration among staff and encourage innovation. Furthermore, it can be argued that this type of leader is needed to implement this project. A transformational leader is a good individual to change the environment by using the strategic flexibility to recognize and respond to problems quickly. Sometimes this response is changing the external environment (Navis and Ozbek, 2016).

In the project,nurse educators are leaders, who plays a central role in modelling course such as prepare material, of course and performed the workshop, evaluating the model and evaluating other teachers,and the curriculum projects managed by the leader. Nurse educators play the lead role in the preparation and adoption of nursing students for the purpose of providing optimum healthcare outcomes. These targets can be achieved by nurse educators if they strongly attempt to increase their own knowledge and illustrate strong leadership skills consistently (Sawatzky et al., 2009; Storey and Holti, 2013).

Ethical issues and monitoring the project

Ethical considerations

The education systemin Kurdistan, including innursing, has faced numerous challenges that have affected the quality of nursing care in Kurdistan, especiallyregarding ethics of non-maleficence and beneficence. Non-maleficence refers to respecting and honouring the well-being of research participants and others; this project’s research methods and intended outcomes pose no risks to anyone, and are in the interests of wholly beneficent aims (to improve nursing education and healthcare quality). Beneficence concerns philanthropic actions that remove harm by supporting and helping, preventing harm, and finally removing harm and promoting good, such as compassion and taking positive actions to help others. Clearly the fundamental nature of the project is beneficent (Silva and Ludwick, 1999).

Lee-Hsieh, 2004 noted that caring is the principle of nursing and caring in nursing education is a core, with a conceptual framework of caring that includes ‘love and sincerity’, ‘caring communication’, ‘empathy and respect’, ‘acceptance and trust’, and ‘offering of self’. The structure of a caring curriculum concerns complex qualities but it nevertheless comprises a tangible body of professional knowledge. The leaders of projects should be stimulated more dialogue with fellow educators in preparing students' caring competencies. For example, some ethical issues arise as a result of competence, which some educators seek to prioritise (e.g. biomedical nursing roles) at the expense of caring, which they take for granted (and which results in the deficiency of caring in education and subsequently in practice, ultimately undermining patient outcomes and health system efficiency in the long term).

Ethical principles in nursing education include caring, integrity, diversity and excellence. These principles are used as a framework for administrative the environment for promoting academic program in nursing education, and provide quality care. Conversely, the ethical barriers to the development of nursing education include ‘‘academic dishonesty, incivility, abusive and bullying behaviour, breaches in confidentiality, and defamatory statements’’ (NLN, 2012).

Rather than balancing between competence and caring, caring curriculums seek to embed caring itself as a core competency with which all aspects of nursing should be imbued. Nurse educators must be instructors in care for students, which injects a traditionally clinical attribute into the academic context and helps mitigate the universally acknowledged theory-practice gap in nursing. The educational institution itself should support instructors’ caring behaviours, so caring can be easily inculcated among students. Students who learn caring only as an abstract theoretical concept face greater barriers to manifesting truly caring care in their later practice.

Monitoring and evaluation

The project needs to evaluate data outcomes in terms of the project objectives, rationale, utility and credibility (Pross, 2010). It is crucial include the perceptions and satisfaction of all project stakeholders in the evaluation, including nurse educators, student nurses, the Head of Schooland related institutions. The curriculum is required to evaluate the curriculum and identify its strengths and weaknesses for student education, such as a national standardized test, not to examine students/nurses but to guide curriculum development. If a few students cannot pass the exam, highly likely this is signal of an individual student understanding deficit. On the other hand, if large number of students cannot pass the exam for several times, then this might be a significant point of program problem.Sometimes it is also helpful to meet with the appropriate project leader who can provide the necessary assistance and guidance for success (Pross, 2010).

In Iraq UNESCO contributes to evaluate education system within the MoHEand Ministry of Healthto evaluate and monitor nurse education under the National Education, Planning, Monitoring and Evaluation programme (e.g. curriculum review and development of a new modern curriculum). The SNS curriculum was evaluated using a specific method, as shown in Figure 4 and Appendix 1 concerning monitoring the surgical nursing curriculum. This process is undertaken by UNESCO every year and the progress of the project of the caring framework of teaching excellence can be evaluatedin this way, although it is not without drawbacks – for instance, some students are randomized or selected by the head of department (UNESCO, 2011).

Conclusion

A caring framework in excellencefor teaching in nursing education is an innovative process for nursing education to maintain the ethic of caring in health care by embedding it in nursing education. This project instils new qualifications and competencies in graduate nurses and prepares them for leadership, to ultimately increase quality of care. The project of teaching excellence emphasises teaching leadership, which is a principle for leaders and the management of professional nursing education. This paper explains the current states of nursing education with main reasons for implementing the project in Kurdistan. Furthermore, it explains the role of stakeholders and identifies the method of communication. This project will play a strategic role in transformational leadership for advanced nursing in Kurdistan.

Conflict of Interest

Authors declare that there is no conflict of interest.

Acknowledgement

Not declared.

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