Specialist Nursing in an African context. Busisiwe R Bhengu University of KwaZulu-Natal ANSA

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1 Specialist Nursing in an African context Busisiwe R Bhengu University of KwaZulu-Natal ANSA

2 Outline Semantic play Conceptual clarification Rationale for specialisation Essential characteristics of APN African Context in relation to above characteristics

3 Semantics Specialisation: Advanced practice Expanded role

4 Conceptual clarification Specialisation: concentrating or delimiting one s focus to part of the whole field of nursing Expansion: the acquisition of new practice knowledge and skills, including knowledge and skill legitimizing role autonomy within areas of practice that overlap traditional boundaries of medical practice Advancement: involves both specialisation and expansion and is characterised by the integration of theoretical, researchbased and practical knowledge that occurs as part of graduate education in nursing.

5 Specialisation & Related concepts: Nurse clinician, Clinical nurse specialist Nurse Specialist (Joel, 2013)

6 Specialisation defined Defined as a practitioner holding a masters degree with a concentration in specific areas of clinical nursing Defined by: the needs of select client population expectation of society and The clinical expertise of the nurse To differentiate CNS from NP CNS practice within the domain of secondary and tertiary care setting NP full range of primary health care services (outside secondary and tertiary settings) (Joel, 2013)

7 Advanced practice nurse Manifest high level of expertise in assessment, diagnosis and treatment of complex responses of individuals, families or communities or Potential health problems, prevention of illness and injury, maintenance of wellness and provision of comfort. Has a masters or doctoral education concentrating in a specific area of advanced nursing practice Had supervised practice during graduate education and has ongoing clinical experience Continues to perform many of the same interventions used in basic nursing practice Greater depth and breadth of knowledge Greater degree of synthesis of data and complexity of skills and interventions ANA cited in (Hamric, Spross & Hanson, 2000)

8 Rationale for specialisation Shortage of doctors (primary care physicians) especially in rural areas In anaesthesia initially not attractive to doctors because there was no incentive Interest more in surgery Female dominated then because of low pay and low status When interest arose nurses were forbidden to perform doctors work Thanks to the military though it promoted gender bias Physician extender perspective: through chronic illness management Consumer movement demanding accessible, affordable and sensitive health care (Hamric, Spross & Hanson, 2000)

9 Rationale for specialisation Women s movement increased the awareness of nurses and society that nurses are undervalued and underutilised Increasing health care costs, the solution being cheaper labour Introduction of physician assistant role (Clinical Associates) Increasing emphasis on primary health care (Hamric, Spross & Hanson, 2000)

10 Essential characteristics of APRN Completion of an accredited graduate level programme in one of the four areas Nurse midwifery Nurse anaesthesia Nurse practitioner or Clinical nurse specialist Various specialities grouped Successful completion of a national certification examination measuring APRN role and population of focus competencies and maintains competence through recertification Possession of advanced clinical knowledge and skills needed for direct patient care and a significant component of education and practice focuses on direct care of individuals (APRN Consensus Work Group cited Joel, 2013)

11 Essential characteristics of APRN Practice builds on RN competence and demonstrates depth and breadth of knowledge, data synthesis, complex skills, intervention and role autonomy Educational preparation for health promotion and maintenance, assessment, diagnosis, and management of patient problems including use and prescription of pharmacological and non-pharmacological interventions Possess depth and breath of clinical experience reflecting intended area of practice Possess license to practice as APRN, CRNA, CNM. CNP (APRN Consensus Work Group cited Joel, 2013)

12 The African Context Does it compare? Must it compare?

13 Issues in Africa Quadruple disease burden Communicable diseases Non- Communicable diseases Maternal and child mortality Injury and Trauma Limited resources Human resource shortage hence Limited mentors and preceptors to support learning

14 Rationale for specialisation Shortage of doctors in general not just family medicine especially in rural areas Compelled to utilise nurse anaesthetists in Africa Rwanda in 2009: 7 expatriate against 1 local in the whole country, Seychelles predominantly expatriate, Tanzania cardiac surgery in some newly introduced hospital postponed several times because there was no anaesthetist and, of course, the perfusionist to team up with. Anecdotal evidence says in Mozambique nurses perform Caesarean sections In South Africa nurses are forbidden to induce anaesthesia up to now. They are supported to specialise in the area as long as they are not going to be providers of anaesthesia. Nurse prescribing with a whole lot of issues Physician extender perspective: through chronic illness management

15 Rationale for specialisation Emphasis on WHO member states having to comply with PHC principles of accessible, affordable and sensitive health care as primary health care principles. Women s movement not played a role in health issues but women and children abuse and predominantly politics Introduction of physician assistant role in Africa including South Africa. Seemingly South African Nurses reacted vehemently but with no results: Problem? Increasing emphasis on primary health care 100% in Africa (Hamric, Spross & Hanson, 2000)

16 Educational preparation Completion of an accredited graduate level programme in one of disciplines but not grouped as in America Driven by interest groups sometime some strong individuals International collaborators bringing funding: e.g. CHENMA, American consortium of universities: HRH Project in Rwanda However, diplomas and certificates still dominate and produce more specialists National certification examination measuring APRN role and population of focus competencies and maintains competence through recertification not yet in African countries exposed to Possess license to practice in each of the chosen areas

17 Essential characteristics of APRN: Competences Practice builds on RN competence and demonstrates depth and breadth of knowledge, data synthesis, complex skills, intervention and role autonomy Not consciously done Educational preparation for health promotion and maintenance, assessment, diagnosis, and management of patient problems including use and prescription of pharmacological and non-pharmacological interventions, Adoption of ICN competency framework vs collaborators Possess depth and breath of clinical experience reflecting intended area of practice level descriptors but so far HEIs (APRN Consensus Work Group cited Joel, 2013)

18 Essential characteristics of APRN: Competences Possession of advanced clinical knowledge and skills needed for direct patient care and a significant component of education and practice focuses on direct care of individuals Emphasis on this

19 Congruence with Rationale for Specialisation Is the rationale for the programmes in line with African problems? Botswana: Diplomas: FNP, Midwifery, Community Health Degrees: FNP, Community Health Nursing, Padiatrics, Mental Health, Adult Health/Medical Surgical Nursing Rwanda: Medical Surgical Nursing, Critical Care Nursing, Nephrology, Perioperative Care, Oncology, Paediatrics, Neonatology, Education Leadership and Management Imagine an African country with no Primary Care/FNP, Community Health, Advanced Midwifery: is it accommodating what the collaborators can offer?

20 Offering of Specialist Programmes APN at both diploma, undergraduate and graduate levels but not differentially recognized Conducted in various levels of institutions: Colleges: public and private Universities Strength: Research versus direct clinical care Is there no way of rationalization/clustering of institutions to share? Rural institutions versus urban with collaboration Colleges versus universities with collaboration

21 Content of Specialist Programmes Required experience for entry into the programme Core content versus elective clinical content, Can we stagger the content starting with more clinical then more core after better understanding of the area of specialisation? Groundedness in your area Promotes application Higher level reasoning

22 Regulation of Specialisation Most African countries do not regulate and register additional qualifications How far must this regulation and registration go versus academic recognition Are regulatory concepts and roles clear: Scope of practice: who takes responsibility? Who develops the curriculum?

23 Research and Publication Less outcomes research to support the APN roles (Kleinpell (2009) International authors write for us but how true is the evidence : Article by Sheer, B and Wong, KY (2008) report that the following about Africa APNs for the places reviewed globally Countr y Historical development Role titles used Regulator y measures Highest education Africa Commenced in 2000 to improve access NP No reported document Master level Is this true, South Africa? Why can t we write ourselves

24 Employment opportunities Under supervision and direction by protocol approved by our medical counterparts Primary care comparing to NP in Western countries Specialist programmes equally recognized in SA with no special recognition for Primary care in terms of medical aid, etc. NPs better recognized Therefore very limited autonomy in employment

25 Conclusion Let us consciously educate and train for Africa influenced by dynamics in the continent Benchmark principles like philosophies, models, theories, approaches and APPLY in the context rather than Transplant programmes from the first world countries that do not serve our purposes. While appreciating westernization that has landed us with non-communicable diseases, of course

26 References Dunn, L. (1997) Literature review of advanced clinical nursing practice in the United States of America Journal of Advanced Nursing, 1997, 25, Hamric, AB, Spross, JA & Hanson CM (2000) Advanced Nursing Practice: An Integrative Approach 2 nd edition. Philadelphia: WB Saunders Company Joel, LA (2013) Advanced Practice Nursing: Essentials for Role Development 3 rd edition, Philadelphia: F.A. Davis Company. Sheer, B and Wong KY (2008) The development of Advanced Nursing Practice Globally (Anniversary series) Journal of Nursing Scholarship 2008, 40 (3)

Perspectives on Nurse Practitioner/Advanced Practice Nursing in the USA-2012 Update

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