Introduction

A long-term and well-qualified education level of professionals is one of the accepted and acknowledged criteria in considering work as a profession. Education process and associated knowledge is one of the main features that distinguish professions from work. After a long training process, professions include a systematic knowledge on the related skill as well as the completion of a minimum undergraduate degree. More advanced knowledge, experience and qualified education are also vital in professionalism (1,2).

Nursing education is comprised of the delivery and provision of related scientific information that guide the nursing practises. When used together with theory, practice and research, nursing turns into a mental activity that correlates with information whereas nursing is defined as an art that requires skills in implementation and a field of science that means an occupation (3). The development of nursing science had reached to a milestone in history when nursing education and practise that were an approach followed by hospitals in a doctor-oriented method become an independent domain at universities where students are trained by professional academicians (4,5).

Problem: The literature on the history of nursing education in Cyprus is not sufficient. The possibility that future generations would not learn the background of nursing education is considered to be the research problem. Therefore, it has been decided to conduct a scientific study with the awareness that the nurses, who experienced the transformation in nursing education, has the duty to tell the developments of nursing education in Cyprus and then Turkish Republic of Northern Cyprus.

Developments

Nursing Education Between 1800-1935

The authorities in 1800s organised training courses to meet the huge need for healthcare professionals. At that time, Turkish and Greek Cypriots communities used to live together and use the same hospitals. When Ottomans ceded the administration of Cyprus to Britain in 1878 as a colony, many hospital administrators, including doctors and nurses needed at the hospitals were brought to Cyprus from Britain. Moreover, there were some training offered at the Department of Health and Nicosia General Hospital in the areas of nursing, midwifery, health inspector, pharmacist and chemist, which would improve the competences of related people (6).

In 1896, “The Colonial Nursing Association” was established in Britain to eliminate the problem of personnel insufficiency and solve the healthcare problems encountered by the community. This association also aimed to provide assistance, when requested, to British people that were assigned to foreign countries and British colonies. It also helped fulfill the need for nurses in Cyprus through the association itself and its Cyprus branch.

The actions to train caregivers and nurses in Cyprus was initiated by 7 British nurses, who came to Cyprus in 1927 (7). In that time, people that served as nurses were called caregivers. The lack of nursing schools and university graduated nurses were both obstacles in training nurses. In 1927 Dr. Horn, a professional from Britain, wrote a report called “Healthcare Service Reforms in Cyprus” proposing that nurses, who were then called as caregivers, had insufficient knowledge, and should be trained for three years; their food and accommodation should be covered as well as to be paid with a low fee. The report also indicated that “male nurses” or “dressers” might also participate to the three-year training program.

People with nursing education were mainly British while Turkish and Greek Cypriots were trained to be caregivers as they had almost no chance to be provided with nursing education.

Until 1930s, courses were considered enough for nurse education, yet there were problems. Then a nursing school was opened in Nicosia Hospital to enhance the healthcare service standards and meet the need for nurses.

Nursing Education Between 1935-1960

Between the years of 1930-1940, students with increasing numbers went to Beirut-one of the developed cities in the world and Britain, which was an attractive destination, to study at nursing schools. Within the framework of reform in 1935, 3 Cypriot females (2 Greek Cypriots and 1 Turkish Cypriot) were sent to study at Beirut American University Nursing School with scholarship. “Türkan Aziz” was the only Turkish Cypriot granted this scholarship. Known as the first Turkish Cypriot nurse graduated from a nursing school, she completed her university education in 1938 and worked at the Limassol State Hospital (7).

The education duration of the nursing school was two years. Primary school graduates were also accepted to study there, however; the secondary school graduates were started to be accepted in order to enhance the education quality. Turkish Cypriots were unsuccessful at the school as the education language was Greek. In order to tackle this issue, Dr. Fikret Rasim launched Turkish courses in 1948 for Turkish Cypriot midwives and nurses. With an increased interest to the profession, a three-year English education was also provided after high school education where people were called sister and they started to work as supervisors when they graduated (8).

With the termination of British colonial administration in 1960, the nurses had the opportunity to apply to the Nursing Schools in the United Kingdom and get the Midwife Nurse Diploma through a document issued by “Cyprus Nursing and Midwifery Council” stating that they worked at the state hospitals for nine months. It was possible since Britain had still bases on the 3% of the island as a guarantor country.

Bi-zonal Status of Cyprus in 1963-1974 and Nursing Education

After Turkish and Greek Cypriots had conflict in 1963 and were divided into two zones on the islands, the great need for nurses on the Turkish Cypriot side reached to another level. In order to meet this greater need, individuals that were not graduated yet were provided with a certificate following an accelerated training. In 1971, nurses and midwifery schools at the secondary school level were established and this school continued its activities until 1974 (8). Since 1960s, very few female students completed their education at the nursing school in Turkey with scholarship and then started to work at the hospital and nurse and midwifery school. Such people were Senior Nurses. This number elevated in years as students were sent to Hacettepe University, Gülhane Medical Academy and Florence Nightingale Nursing School with full scholarship.

Nursing Education Between 1974-1994

After 1974, secondary school graduates were trained for two years at the nursing and midwifery school on the Turkish side. There had been many challenges at the delivery of the courses. While university graduate nurses had the biggest responsibility, a number of doctors and other personnel from the hospitals of the Ministry of Health and Social Welfare were assigned as part-time lecturers. Certain courses and examinations were provided by the doctors for many years. (9).

In 1984, the related challenges and discussions on the status of profession led the pursuit of new ways that would bring the profession up to modern levels. Post-high school nursing education was launched as a result of the Ministry of Health in the same year, yet the department was closed in 1988 due to some legal barriers. Nurses that graduated were assigned to the positions covering the former graduates.

In 1990, the applicable nursing education after secondary school became three years to minimize the variances in nursing education and make nursing education above high school education. The name of school was changed to “the school of nursing and midwifery”. However, the graduates were recruited from the same salary levels since there were still political and legal barriers, and it was not possible to make any political amendments. The only difference was that graduates were named as “nurse” rather than “caretakers”, which removed the latter from the organisational scheme.

By the years of 1992-1993, nurses, who graduated from the high school and nursing department, were given the opportunity to study the associate’s degree at the Anadolu University Open Education Faculty provided that they passed the first level of ÖSYS (Student Selection and Placement Examination).

In 1994, the law on the nursing vocational school with regarded to the 2-year education for the citizens of the Turkish Republic of Northern Cyprus after high school education was adopted. With the adoption of law, the high school graduated could only enrol to the associate’s degree with an examination. With significant developments in the profession, the number of students had also increased without any increase in the number of trainer nurses, which caused a major burden on the trainers (10).

Nursing Education Between 1994-2006

While an associate’s degree was still available in 1994, the efforts to increase the education duration to four years gained momentum. In November 2004, a protocol regarding a better provision of nursing education was signed between the Near East University and Ministry of Health, and the school was moved to the university campus. Upon the adoption of YÖDAK (Higher Education Planning, Evaluation, Accreditation and Coordination Council) law in 2006, students were accepted to the universities and nursing vocational school through an examination held by YÖDAK.

Modern Nursing Education Between 2007-2021

In 2007, Near East University initiated its action to establish a health sciences faculty, which was opened in the same year following the authorization of YÖK (Council of Higher Education). The faculty of nursing was then opened under the faculty and nursing education was provided as an undergraduate degree.

The last students graduated from the nursing vocational school in the academic year of 2007-2008. It is considered very crucial for the development of nursing education that nurses with an associate’s degree working at the hospitals completed their education and the associate’s degree programs were terminated in the TRNC. The traditional education was delivered by the lecturers of the Ministry of Health and lecturers from Turkey. In 2010, the protocol with the Ministry of Health was terminated, but the protocol on the practical work stayed valid (11,12). In addition to the undergraduate programs, the university also started to offer master’s degree programs in nursing in 2007 in order to enhance the quality in nursing education and train lecturers. The master’s degree program was approved by YÖDAK. YÖDAK approved PhD program was launched in 2009 without any graduates until now. With the commencement of postgraduate degree programs, the number of significant scientific, professional researches and publications on nursing have increased in our country.

In addition to the Near East University Nursing School at the Girne American University opened in 2009 while the nursing programs have been introduced at the Faculty of Health Sciences, Eastern Mediterranean University in 2010 and Faculty of Health Sciences, European University of Lefke in 2013.

As the Near East University Faculty of Health Sciences is the pioneer in the field, the nursing department in English was also opened in the academic year of 2013-2014.

Transition from Nursing to Modern Education-opening of the Faculty of Nursing in 2018

Until 2018, nursing department was under the Faculty of Health Sciences at the Near East University but then it has become completely independent as the faculty of nursing providing quality education with its experienced and qualified staff.

Since there are nursing departments at various universities in TRNC, some problems emerged about the internships of students. Due to the insufficient clinical practice opportunities, some universities started to send its students to the hospitals in Turkey either for compulsory internship or summer internship.

Students that come from Turkey for their university education are accepted under the supervision of YÖK based on their university admission exam scores within the framework of system in Turkey. On the other hand, the students with TRNC citizenship are admitted to the nursing department based on the examination held by the university under the supervision of YÖDAK.

The nursing education is executed in a traditional, face-to-face approach. However, online education method was introduced to the Coronavirus disease-2019 pandemic that surrounded the world in 2020.

Conclusion

In addition to the problems as an island, the nursing profession in Cyprus has experienced many significant problems from past to present due to the religious, nationality and population structure on the island, with two different communities living together, and lack of development in the educational dimension.

The interest towards nursing was emerged when a Turkish Cypriot girl sent to the nursing school in 1935. Since Türkan Aziz’s father Mehmet Aziz was a respectable health inspector, Turkish Cypriot families were more willing to send their daughters to the nursing schools. However, nurses continued to their education under challenging circumstances and showed too much effort to improve themselves starting from the colonial times to the Republic of Cyprus (Greek and Turkish Cypriot) when both communities used to live together until post-1974 Turkish Republic of Northern Cyprus.

The initiative led by Near East University- with the idea of considering nursing as an important profession evolved nursing education to the undergraduate level where many more peers benefited from their professional field. The Faculty of Nursing reached its highest number of students in 2021 bearing the pride of raising successful students with its full-time lecturers.

The opening of new hospitals and COVID-19 pandemic have increase the need for intensive care unit staff, which have reiterated the need for nurses and significance of our profession. We showed a great progress in TRNC as nursing education stretched from the undergraduate level to being a specialty.

Recommendations

In addition to the problems arising from the structure of Cyprus, its being an island, and its religion, race and population structure and the fact that two different peoples live on the island, the nursing profession has been the most important profession that has experienced the difficulties of not being able to develop in terms of education from the past to present.

Healthcare authorities should revise the legal regulations in the field of nursing. The continuous improvement of the quality in healthcare services should be considered by all health disciplines through performing the necessary adjustments where nurses should be a part of decision-making mechanisms. In order to introduce standards in the duties of nurses, universities and active nurses should cooperate accordingly.

Peer-review: Externally peer-reviewed.

Author Contributions: Conception – Ö.N., S.E.; Design – Ö.N., S.E.; Supervision – Ö.N., S.E.; Fundings – Ö.N., S.E.; Materials – Ö.N., S.E.; Data Collection and/or Processing – Ö.N., S.E.; Analysis and/or Interpretation – Ö.N., S.E.; Literature Review – Ö.N., S.E.; Writing – Ö.N., S.E.; Critical Review – Ö.N., S.E.

Declaration of Interests: No conflict of interest was declared by the authors.

Funding: The authors declared that this study received no financial support.