Essential nursing competencies related to HIV and AIDS.

With nearly 33 million global citizens living with HIV or AIDS, the need for a highly qualified, competent nursing workforce is critical. With the recent increase in global funding to expand access to antiretroviral therapy, there have been considerable efforts to improve the capacity of nurses to initiate and maintain antiretroviral therapy while evaluating its effectiveness, monitoring for side effects, reducing the incidence of drug-drug interactions (including drug interactions related to therapies provided by traditional healers), promoting adherence to therapies, and providing management of symptoms. Therefore, using a participatory action approach, nursing leaders from six sub-Saharan African countries collaborated to develop the essential nursing competencies related to HIV and AIDS. These competencies can help to guide preservice education related to HIV and AIDS, to strengthen in-service or capacity-building programs designed for already qualified nurses, and to guide policy and regulatory reform in the context of task-shifting, task-sharing, and scope of nursing practices.

Executive Summary

Introduction and Context

Worldwide, the Joint United Nations Programme on AIDS (UNAIDS) estimated that nearly 33 million adults and children (30.3-36.1 million) were living with HIV or AIDS in 2007 (UNAIDS, 2008), with sub-Saharan Africa continuing to be the most affected region. In this region, an estimated 22 million adults and children were living with HIV or AIDS in 2007 (20.5-23.6 million), whereas an estimated 1.9 million persons (1.6-2.1 million) became newly infected with HIV (UNAIDS, 2008). Overall, in 2007, sub-Saharan Africa accounted for 67% of all people living with HIV and 75% of AIDS-related deaths (UNAIDS, 2008, p. 30, 32).

Seven southern African countries—Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe—experience adult HIV prevalence rates exceeding 15% (UNAIDS, 2008). In Botswana, Malawi, and Zambia, recent surveillance data from antenatal clinics suggest that the epidemic might be stabilizing (UNAIDS, 2008). However, in Lesotho, prevalence rates among pregnant women continue to increase (UNAIDS, 2008). Although South Africa’s epidemic might not be growing in size, there is minimal evidence of significant change in HIV-related behavior that could decrease the magnitude of the epidemic. Subsequently, with nearly 6 million South Africans living with HIV or AIDS, it remains the nation with the largest number of people living with HIV in the global community. Comparatively, in 2006, Swaziland documented the highest ever seroprevalence rate in a national population-based sample at 26% (UNAIDS, 2008).

In 1990, southern Africans had a life expectancy of approximately 61 years at birth, an increase from approximately 45 years in 1950. However, as a consequence of the HIV and AIDS epidemics, life expectancy has declined substantially in many southern African countries (UNAIDS, 2008). In Swaziland, for example, the life expectancy for a child born today is estimated to be around 30 years, whereas in South Africa, it is around 45 years.

Although significant progress has been achieved in reducing mother-to-child transmission of HIV, the vast majority of children living with HIV or AIDS acquired the infection through this route. Globally, children under the age of 15 account for one in six AIDS-related deaths and one in seven new HIV infections. Furthermore, according to UNAIDS, “some 15 million children under age 18 have lost one or both parents to AIDS and countless children become responsible for the care of their siblings and other family members when parents are debilitated by poor health” (UNAIDS, 2009). Children who have lost one or both parents are frequently subjected to discrimination and are less likely to receive health care, education and other critical services. Additionally, child-headed households, or children living on the streets, are at an even higher risk for exploitation, abuse, exposure to HIV, and poverty (UNAIDS & UNICEF, 2004).

However, despite increased resources, the limited numbers of African health care professionals available to address the epidemic will only add to the challenges in the region. Critical to addressing these issues, but particularly the roll out of antiretroviral therapy (ART), is the availability of a competent, sustainable nursing workforce. In relation to ART, this workforce must demonstrate capacity to initiate and maintain ART while evaluating effectiveness, monitoring for side-effects, reducing the incidence of drug–drug interactions (including drug interactions related to therapies provided by traditional healers), promoting adherence, and providing management of symptoms.

Furthermore, comprehensive prevention programs require knowledgeable and skilled nurses and community health workers to provide evidenced-based interventions to prevent new infections while increasing individuals' knowledge of his/her serostatus through counseling and testing. For those at the end-of-life stage, palliative care nursing interventions require nurses who are not only available but also trained to coordinate, deliver, and evaluate state-of-the-science interventions that are culturally relevant and sensitive. Finally, preventing mother-to-child transmission also requires available nurses who are knowledgeable about reproductive health and the scientific basis of preventing HIV infection during pregnancy.

In much of sub-Saharan Africa, the physician workforce is limited or almost nonexistent. For example, in Lesotho, Malawi, and Zambia, the ratio of physicians to population is <1:10,000 (World Health Organization [WHO], 2008a). Throughout the region, nurses (registered, enrolled, and auxiliary) comprise the largest number of health care providers, although their shortage is also often extreme. Narasimhan et al. (2004) stated that “in most low-income countries, there is insufficient human capacity to absorb and apply newly mobilized resources because the workforce is unavailable” (p. 1469).

Throughout the region, the migration of nurses, not only from rural to urban, but also intercountry within as well as outside of the region, has reduced the availability of human resources addressing the HIV and AIDS epidemics (WHO & World Bank, 2002). Additionally, HIV and AIDS, as well as tuberculosis, is yielding monumental workloads, while simultaneously reducing the health care provider workforce (Narasimhan et al., 2004). Furthermore, Samb et al. (2007) stated that “poor working conditions and low pay conspire with the risk of occupational transmission and the stress of working in communities devastated by the HIV epidemic to drive up rates of attrition” (p. 2510).

In many countries, the number of nursing students completing their education and entering the workforce frequently does not equal the number of nurses leaving the workforce because of declining health (due to HIV, AIDS, tuberculosis [TB], or other chronic conditions), retirement, or migration (Hongoro & McPake, 2004). It is estimated that between 18% and 41% of the workforce, including health workers, is infected with HIV in many sub-Saharan African countries (Narasimhan et al., 2004, Cohen, 2002).

With decreasing life expectancies in many sub-Saharan African countries as a result of AIDS, at least 1 million additional health workers, including nurses, are needed to offer basic services as recommended by the World Bank (Chen et al., 2004, Sheldon, 2006). On the basis of the research in Tanzania and Chad, Kurowski et al. (2004) estimated that the sub-Saharan African countries need nearly 1.4 million health care workers, specifically, 720,000 physicians and 670,000 nurses (Hongoro & McPake, 2004). When examining the estimated number of people needing ART compared with those using it, there is a significant need for expansion of antiretroviral roll-out across the sub-Saharan African region. Again, expanding ART to persons eligible requires nurses to be available, knowledgeable, and retained.

Addressing the Problem

The President’s Emergency Plan for AIDS Relief (PEPFAR) is the U.S. Government’s international HIV/AIDS program. Under the leadership of Ambassador Eric Goosby, it works in partnership with host nations to support the (a) treatment for at least 3 million people; (b) prevention of 12 million new infections; and (c) care for 12 million people, including 5 million orphans and vulnerable children. To achieve these goals, PEPFAR will support training and retention of at least 140,000 new health care workers, including nurses, in HIV and AIDS prevention, care, and treatment. This is one component of many health systems strengthening activities that build local capacity to lead the response to the HIV pandemic and other health issues. PEPFAR’s health systems strengthening efforts include providing support to country governments, regulatory agencies, and educational systems.

In this context of global cooperation, a search conference of African nursing leaders from six countries as well as representatives from the International Council of Nurses, the Association of Nurses in AIDS Care (U.S.), and the Department of Health and Human Services (U.S.) participated in the Regional Leadership Summit on HIV and AIDS Nursing Education, Practice and Policy held in St. Lucia, South Africa in June 2008. The search conference approach (Emery, 1996), a type of participatory action methodology, was used to identify and critically examine issues, establish priorities, and formulate a plan for nursing's contribution in addressing these complex issues. At the closing session, summit participants identified a Regional Lead Team of nursing leaders to work collaboratively in formulating a work plan to prioritize and address the identified issues during the Summit. The members of the Regional Lead Team met throughout 2008-2009 to address the critical priorities identified from the Summit.

Using a participatory action framework, the members of the Regional Lead Team identified as priority the need “to strengthen capacity of nursing to address the HIV and AIDS epidemic through the establishment of core competencies specific to nursing” (Relf et al., 2011). As a result, The Essential Nursing Competencies related to HIV and AIDS were developed on the basis of the meetings held with nursing leaders in each of the six participating countries (Botswana, Lesotho, Malawi, South Africa, Swaziland, and Zimbabwe), the efforts of the Regional Lead Team, and an expert consensus panel convened in Durban, South Africa in March-April 2009.

Competencies: What Are They and Why Are They Important?

Over the past decade, accreditation and regulatory bodies providing oversight of institutions preparing health professionals; accreditation and regulatory organizations for clinics, hospitals, home health agencies, hospices, and clinical laboratories; governmental organizations regulating the practice of licensed health professionals; health profession’s councils and associations; and global health organizations, like WHO (WHO/AFRO, 2007a, WHO/AFRO, 2007b) and International Council of Nurses (International Council of Nurses (ICN), 2008a, International Council of Nurses (ICN), 2008b); have documented the need for competency-based preservice education, competency-based orientation of clinicians, continuing competency validation as part of licensure renewal, and the critical need to have clearly identified competencies to support the efficient and effective use of resources, including human resources, in the delivery of nursing care. As defined by WHO, professional competence “is the ability to effectively and efficiently deliver a specified professional service” (WHO, 1993b, p. 4). This “implies that the nurse is able to practise at a proficiency (mastery of learning) in accordance with local conditions to meet local needs” (p. 4). To achieve professional competence, or competencies required of a professional, students must demonstrate terminal competencies “upon completion of basic education which should match as closely as possible professional competencies” (WHO, 1993b, p. 4).

Competence is comprised of three elements—knowledge, skills, and attitudes (International Council of Nurses (ICN), 2008a, International Council of Nurses (ICN), 2008b, WHO., 1993b). Knowledge includes the mental abilities and cognitive learning that results from didactic instruction or continuing education and/or in-service education. Skills comprise the motor abilities to deliver care as well as the communicating and interacting abilities necessary to be a contributing member of the multidisciplinary team. Attitudes consist of the ability to use cognitive learning, to critically think in real life situations, and to make appropriate decisions on the spot (WHO, 1993b).

Consequently, in an era of scarce resources, combined with the complexities of nursing care of HIV and AIDS, it is essential that nurses demonstrate competence in the prevention, care, and treatment they provide in partnership with individuals, families, and communities infected and affected by HIV and AIDS. When competencies are identified, it is then possible to determine their application within the disciplines of nursing and midwifery to include not only the professional nurse and midwife but also the enrolled nurse, auxiliary nurse, health worker, home care attendant, and skilled birth attendant.

Competence Development Methodology

In developing the essential competencies for nursing related to HIV and AIDS, a participatory action approach of regional nursing experts from the sub-Saharan African region, including educators, clinicians, and policy/regulatory experts, was used. From the outset, the participating nurse leaders from the region viewed the competencies related to HIV and AIDS as supplemental to the general competencies expected of all nurses that were achieved as a result of education, training, examination, and licensure. The general nursing competencies serving as the basis for refinement in the context of HIV and AIDS were those published by the ICN entitled Nursing Care Continuum – Framework and Competencies (International Council of Nurses (ICN), 2008a, International Council of Nurses (ICN), 2008b).

The primary operating assumption of the regional nursing leaders involved in the development of the HIV and AIDS nursing competency process focused on regional collaboration. This collaboration was essential because of the following reasons:

It facilitated sharing of expertise and resources through a South-to-South collaboration of nursing leaders;

It expanded partnerships and networks to reduce duplication of efforts and to facilitate action;

It mitigated the effects of regional migration of nurses; and

It established a regional network for sharing best practices related to task-shifting.

The participating nurse leaders unanimously supported the development of essential nursing competencies for HIV and AIDS if the competencies were comprehensive in nature, holistic in approach, and not merely focused on ART delivery. To be comprehensive, the participating nursing leaders firmly articulated that the identified competencies must address the cognitive, affective, psychomotor domains specific to HIV and AIDS as well as the professional expectations of nurses related to HIV and AIDS. Finally, to address the complex issues associated with HIV and AIDS, the nurse leaders participating in the development process supported a holistic approach examining the contribution of nursing across the care continuum (prevention, care, and treatment) while also addressing the psychosocial, spiritual, ethical perspective, individual, and community level stigma associated with the disease as well as the essential leadership, mentoring, and professional development required of nurses and nursing.

Figure 1 illustrates the complex nature of HIV and AIDS nursing care. The client, delineated in the middle of the graphic, is defined as the individual, family, and/or community living with, at risk for, and/or affected by HIV and AIDS. Surrounding the client are the nursing care activities demonstrating the complex, multilevel needs of persons living with, affected by, or at risk for HIV or AIDS. In partnering with the client to address these needs, the nurse uses many roles, which are illustrated in the outer circles.

Figure 1

A holistic perspective of HIV and AIDS nursing practice.

The Essential Competencies for Nursing Related to HIV and AIDS

In accordance with the requirement self-imposed by the Regional Lead Team, and supported by the external stakeholders convened for the expert consensus panel, the identified essential competencies are holistic in nature and address the complex, multilevel issues surrounding the HIV and AIDS epidemics (please see Table 1 ). Both the Regional Lead Team and the expert consensus panel felt that to be meaningful and applicable, there were several issues that must be considered.

Table 1

The Essential Nursing Competencies Related to HIV and AIDS

Care, Treatment, and Prevention of HIV and AIDS

Distinguish between the normal functioning immune system and an HIV compromised immune system;

Appropriately stage the HIV client on the basis of analysis of clinical manifestations in accordance with WHO guidelines;

Develop with the client an individualized risk reduction plan for HIV to positively influence behaviors;

Consistently apply principles of prevention of mother-to-child transmission (PMTCT) of HIV;

Provide HIV counseling appropriate to client needs in all encounters with the health care system;

Make appropriate decisions in the provision of postexposure prophylaxis;

Make appropriate decisions to plan and implement evidenced-based nursing interventions in the clinical management of persons living with HIV- and AIDS-related conditions across the lifespan;

Make appropriate decisions regarding management of clients on ART (assessment, initiation, and follow-up).

Psychosocial, Spiritual, and Ethical Issues related to HIV and AIDS

Support clients to accept and positively cope with an HIV diagnosis and its psychosocial and emotional consequences;

Support clients spiritually;

Incorporate clients’ beliefs, values, lifestyles, and cultures into the holistic plan of care within evidenced-based standards;

Effectively support clients’ decisions regarding disclosure of their HIV serostatus;

Effectively support clients in their efforts to live positively with HIV and AIDS and plan for life events;

Positively influence perceptions and empower communities to reduce HIV-related stigma;

Effectively assist clients to address the consequences of HIV related stigma.

Psychomotor Skills Necessary to Provide HIV and AIDS Nursing Care

Demonstrate the correct technique for performing skills related to HIV and AIDS diagnosis and management;

Demonstrate the correct technique for specimen collection related to HIV and AIDS diagnosis and management;

Demonstrate the appropriate use of universal precautions and the principles of prevention and control of infection;

Demonstrate safe injection techniques to reduce the risk of HIV transmission;

Demonstrate safe use and disposal of sharps to reduce the risk of HIV transmission;

Demonstrate applicable and relevant clinical assessment skills required in the provision of nursing care for common opportunistic infections and diseases related to HIV and AIDS;

Demonstrate correct application and safe removal of condoms (male/female) in prevention of HIV and other sexually transmitted infections (STIs).

Professional Expectations Required of Nurses in the Delivery of HIV and AIDS Nursing Care

Translate evidenced-based knowledge to deliver quality nursing care for persons living with, at risk for, or affected by HIV and AIDS;

Clarify one’s own values, beliefs, lifestyle, and culture;

Adhere to the core ethical principles of the nursing profession in the provision of care for clients living with, at risk for, or affected by HIV and AIDS;

Effectively communicate, coordinate, and document the care of the client living with HIV or AIDS as a member of the multidisciplinary team;

Correctly collect, analyze, interpret, and communicate data for decision-making to improve health outcomes for clients with, at risk for, or affected by HIV and AIDS;

Facilitate linkages with community programs and local resources in the provision of care for clients living with, at risk for, or affected by HIV and AIDS;

Effectively supervise and mentor other health care providers involved in the spectrum of HIV and AIDS care and treatment; and

Take personal responsibility to proactively address the effect of the HIV epidemic on oneself as a care giver.

First, the essential competencies must be adapted to the spectrum of care delivery, the care setting, and within the scope and standards of care for nursing specific at a country, provincial, or local level.

Second, the essential nursing competencies related to HIV and AIDS must be leveled to the composition of the nursing workforce in the respective country, province, hospital, or clinic similar to the leveling done in the Nursing Care Continuum – Framework and Competencies (International Council of Nurses (ICN), 2008a, International Council of Nurses (ICN), 2008b). Thus, adaptation of these essential competencies for nursing related to HIV and AIDS needs to match the scope of practice and the composition of the nursing workforce so that they will be most meaningful and reasonable.

Third, when adapted to meet the needs at the regional, country, or local level, the following nursing competencies related to HIV and AIDS should be used to:

Redesign nursing curricula to produce a competent nursing workforce prepared to enter practice, ready to address the complex individual, family, community, and societal issues related to HIV and AIDS,

Evaluate nursing regulations governing nursing practice in the context of HIV and AIDS, and

Deliver capacity building programs that expand and validate the competence—including the knowledge, skills, and attitudes—of the nursing workforce already in practice.

Finally, these essential nursing competencies related to HIV and AIDS can help to clarify the role of the nurse in addressing the HIV and AIDS epidemics. Furthermore, they provide a mechanism for the discipline of nursing to strengthen its capacity to deliver and evaluate contributions to the health and well-being of individuals, families, communities, and societies that are affected by HIV and AIDS.

Summary

The identified essential nursing competencies related to HIV and AIDS are powerful instruments to strengthen the capacity of the nursing profession to address the HIV and AIDS epidemics in sub-Saharan Africa. These competencies can be a resource to practicing nurses, nurse educators, professional nursing associations, nursing councils, ministries of health, funding agencies, and health care agencies to support the ability of nursing to provide holistic care to individuals, families, and communities infected or affected by HIV and AIDS. A detailed description of the essential competencies as well as supporting references reviewed in their development and resources available for strengthening nursing capacity in the context of HIV and AIDS is provided in Appendix 2.

Essential Nursing Competencies Related to HIV and AIDS

Worldwide, the Joint United Nations Programme on AIDS (UNAIDS) estimates that nearly 33 million adults and children (30.3-36.1 million) were living with HIV or AIDS in 2007 (UNAIDS, 2008), with sub-Saharan Africa continuing to be the most affected region. An estimated 22 million adults and children in this region were living with HIV or AIDS in 2007 (20.5-23.6 million), whereas an estimated 1.9 million persons (1.6-2.1 million) were newly infected with HIV (UNAIDS, 2008). Overall, in 2007, sub-Saharan Africa accounted for 67% of all people living with HIV and 75% of AIDS-related deaths (UNAIDS, 2008).

Seven southern African countries—Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe—experienced adult HIV prevalence rates exceeding 15% (UNAIDS, 2008). In Botswana, Malawi, and Zambia, recent surveillance data from antenatal clinics suggest that the epidemic might be stabilizing (UNIAIDS, 2008). However, in Lesotho, prevalence rates among pregnant women continue to increase (UNAIDS, 2008). Although South Africa’s epidemic might not be growing in size, there is minimal evidence of a significant change in the HIV-related behavior that could decrease the magnitude of the epidemic. Subsequently, with 5.7 million South Africans living with HIV or AIDS, it remains the nation with the largest number of people living with HIV in the world. Finally, in 2006, Swaziland documented the highest ever seroprevalence rate in a national population-based sample at 26% (UNAIDS, 2008).

In 1990, southern Africans had a life expectancy of approximately 61 years at birth, an increase from approximately 45 years in 1950. However, as a consequence of the HIV and AIDS epidemics, life expectancy has declined substantially in many southern African countries (UNAIDS, 2008). In Swaziland, for example, the life expectancy for a child born today is estimated to be around 30 years, whereas in South Africa it is around 45 years.

Although significant progress has been achieved in reducing mother-to-child transmission of HIV, the vast majority of children living with HIV or AIDS acquired the infection through this route. Globally, children aged <15 years account for one in six AIDS-related deaths and one in seven new HIV infections. Furthermore, according to UNAIDS, “some 15 million children under age 18 have lost one or both parents to AIDS and countless children become responsible for the care of their siblings and other family members when parents are debilitated by poor health” (http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/ChildAndOrphans/, accessed 1 December 2009). Children who have lost one or both parents are frequently subjected to discrimination and are less likely to receive health care, education, and other critical services. Additionally, child headed households or children living on the streets are at an even higher risk for exploitation, abuse, exposure to HIV, and poverty (UNAIDS & UNICEF, 2004).

These epidemiological trends indicate that a response to HIV and AIDS will be challenging because of the magnitude of the pandemic. Increased funding for prevention, care, and treatment from governments within the sub-Saharan African region as well as globally has increased resources to comprehensively address the epidemics in sub-Saharan Africa. As a result, programs to prevent mother-to-child transmission are expanding, services for orphans and vulnerable children are being implemented, and access to antiretroviral therapy (ART) is now being rolled out across the region with the goal of improving life expectancy, decreasing suffering, and providing hope.

However, despite increased resources, the limited numbers of African health care professionals available to address the epidemic will only add to the challenges in this region. Critical to addressing these issues, but particularly to the roll out of ART, is the availability of a competent, sustainable nursing workforce. In relation to ART, this workforce must demonstrate the capacity to initiate and maintain ART while evaluating effectiveness, monitoring for side effects, reducing the incidence of drug–drug interactions (including those drug interactions related to therapies provided by traditional healers), promoting adherence to therapies, and providing management of symptoms.

Furthermore, comprehensive prevention programs require knowledgeable and skilled nurses and community health workers to provide evidenced-based interventions to prevent new infections while increasing patients’ knowledge about their serostatus through counseling and testing. For those at the end-of-life stage, palliative care nursing interventions require nurses who are not only available but also trained to coordinate, deliver, and evaluate state-of-the-science interventions that are culturally relevant and sensitive. Finally, preventing mother-to-child transmission also requires available nurses who are knowledgeable about reproductive health and the scientific basis of preventing infection during pregnancy.

In much of sub-Saharan Africa, the physician workforce is limited or almost nonexistent. For example, in Lesotho, Malawi, and Zambia, the ratio of physicians to population is ≤1:10,000 (World Health Organization [WHO], 2008a). Throughout this region, nurses (registered, enrolled, and auxiliary) comprise the largest number of health care providers, although their shortage is also often extreme. Narasimhan et al. (2004) stated that “In most low-income countries, there is insufficient human capacity to absorb and apply newly mobilized resources because the workforce is unavailable” (p. 1469).

Throughout the region, the migration of nurses, not only from rural to urban, but also from intercountry within as well as outside of the region, has reduced the availability of human resources addressing the HIV and AIDS epidemics (WHO & World Bank, 2002). Additionally, HIV and AIDS, as well as tuberculosis, are yielding monumental workloads, while simultaneously reducing the workforce of health care providers (Narasimhan et al., 2004). Furthermore, Samb et al. (2007) stated that “poor working conditions and low pay conspire with the risk of occupational transmission and the stress of working in communities devastated by the HIV epidemic to drive up rates of attrition” (p. 2510).

In many countries, the number of nursing students completing their education and entering the workforce frequently does not equal the number of nurses leaving the workforce because of declining health (HIV, AIDS, TB, or other chronic conditions), retirement, or migration (Hongoro & McPake, 2004). Furthermore, it is estimated that between 18% and 41% of the workforce, including health workers, is infected with HIV in many sub-Saharan African countries (Cohen, 2002, Narasimhan et al., 2004).

With decreasing life expectancies in many sub-Saharan African countries as a result of AIDS, at least 1 million additional health workers, including nurses, are needed to offer basic services as recommended by the World Bank (Chen et al., 2004, Sheldon, 2006). On the basis of the research in Tanzania and Chad, Kurowski et al. (2004) estimated that the sub-Saharan African countries need nearly 1.4 million health care workers, specifically, 720,000 physicians and 670,000 nurses (Hangoro & McPake, 2004).

When examining the estimated number of people needing ART compared with those already using it, there is a significant need for expansion of antiretroviral roll-out across the sub-Saharan African region. Again, expanding ART to persons eligible requires nurses to be available, knowledgeable, and retained.

To address these complex issues, a group of nursing leaders participated in the Regional Leadership Summit on HIV and AIDS Nursing Education, Practice and Policy held in St. Lucia, South Africa, in June 2008. Summit participants identified a Regional Lead Team of nursing leaders, from Botswana, Lesotho, Malawi, South Africa, Swaziland, and Zimbabwe, to work collaboratively to formulate a work plan for the issues identified from the Summit. The members of the Regional Lead Team met throughout 2008-2009 to address the critical priorities identified from the Summit.

Using a participatory action approach, the members of the Regional Lead Team identified the need “to strengthen capacity of nursing to address the HIV and AIDS epidemic through the establishment of core competencies specific to nursing” as a priority. As a result, The Essential Nursing Competencies related to HIV and AIDS were developed on the basis of the meetings held with nursing leaders in each of the six participating countries (Botswana, Lesotho, Malawi, South Africa, Swaziland, and Zimbabwe), the efforts of the Regional Lead Team, and an expert consensus panel convened in Durban, South Africa in March-April 2009.

Over the past decade, accreditation and regulatory bodies providing oversight of institutions preparing health professionals; accreditation and regulatory organizations for clinics, hospitals, home health agencies, hospices, and clinical laboratories; governmental organizations regulating the practice of licensed health professionals; health profession’s councils and associations; and global health organizations, like WHO and International Council of Nurses (ICN) have documented the need for competency-based preservice education, competency-based orientation of clinicians, continuing competency validation as part of licensure renewal, and the critical need to have clearly identified competencies to support the efficient and effective use of resources, including human resources, in the delivery of nursing care.

In 1993, the Regional Office for the Western Pacific of WHO released the Integrating HIV-related Content into a Competency-Based Curriculum (WHO, 1993b). This document declared that nurses require more and different knowledge and skills than what were needed in the past as a result of societal change, technological advances, the changing patterns of disease, and scientific progress. After almost 20 years, societies continue to change as a result of globalization of economies, civil unrest, and global migration, even that of health care workers. Simultaneously, as societies change so do patterns of the disease.

The global community collectively and the sub-Saharan African region in particular continue to be challenged by the changing patterns of the disease, especially communicable diseases like HIV, H1N1 influenza, severe acute respiratory syndrome (SARS), multi-drug-resistant tuberculosis (MDR-TB), extreme drug-resistant tuberculosis (XDR-TB). Furthermore, technological advances, such as electronic medical records and point-of-care testing, as well as requirements to demonstrate the outcomes and effectiveness have necessitated the integration of informatics into clinical practice. Specifically, in relation to HIV and AIDS, scientific advances have yielded a better understanding of the mechanisms associated with viral replication resulting in the development of new classes of antiretroviral drugs, the mechanisms associated with resistance and strategies to manage it, and evidence-based interventions to promote antiretroviral readiness and adherence. However, just increasing the awareness, knowledge, and skills of these issues and advances among nurses does not automatically result in proficiency, mastery, or competence.

As defined by WHO, professional competence “is the ability to effectively and efficiently deliver a specified professional service” (WHO, 1993b, p. 4), which “implies that the nurse is able to practise at a proficiency (mastery of learning) in accordance with local conditions to meet local needs” (p. 4). To achieve professional competence, or competencies required of a professional, students must demonstrate terminal competencies “upon completion of basic education, which should match as closely as possible professional competencies” (WHO, 1993b, p. 4).

The ICN (2008a) defines competence as “the effective application of a combination of knowledge, skill, and judgment demonstrated by an individual in daily practice or job performance. In nursing definitions, there is wide ranging agreement that, in the performance of nursing roles to the standards required in employment, competence reflects the following:

Knowledge, understanding, and judgement;

A range of skills, cognitive, technical or psychomotor and interpersonal; and

A range of personal attributes and attitudes” (ICN, 2008a, p. 40).

Therefore, competence comprises three elements—knowledge, skills, and attitudes (International Council of Nurses (ICN), 2008a, International Council of Nurses (ICN), 2008b, WHO., 1993b). Knowledge includes the mental abilities and cognitive learning that results from didactic instruction or continuing education and/or in-service education. Skills comprise the motor abilities to deliver care as well as the communicating and interacting abilities necessary to be a contributing member of the multidisciplinary team. Attitudes consist of the ability to use cognitive learning, to critically think in real life situations, and to make appropriate decisions on the spot (WHO, 1993b).

Consequently, in an era of scarce resources, combined with the complexities of nursing care of HIV and AIDS, it is essential that nurses demonstrate competence in the prevention, care, and treatment they provide in partnership along with individuals, families, and communities infected and affected by HIV and AIDS. When competencies are identified, it is then possible to determine their application within the disciplines of nursing and midwifery to include not only the professional nurse and midwife but also the enrolled nurse, auxiliary nurse, health worker, home care attendant, and skilled birth attendant.

Intended Use and Application of this Article

Whether at a birthing center or hospice, acute care setting or primary care clinic, an urban university teaching hospital or a rural infirmary, a neonatal care unit or an adult palliative care unit, nurses are caring for individuals, families, and communities both infected and affected with HIV and AIDS. Furthermore, across the globe, there are, and will continue to be, nurses who are also living with HIV or AIDS, caring for a child or family member with HIV or AIDS, living in a community devastated by HIV or AIDS, and struggling with the epidemic grief associated with HIV and AIDS. Consequently, regardless of the practice setting or the client population, the application of essential competencies related to HIV and AIDS nursing practice is critical to provide holistic, comprehensive care (Relf et al., 2011).

In 2008, the ICN published Nursing Care Continuum – Framework and Competencies (ICN, 2008a). In this document, competencies were identified for the range of nursing personnel—nursing support worker; enrolled, registered, or license practical nurse; registered or licensed nurse; nurse specialist, and advanced practice nurse—most commonly found in the 129 ICN member countries. This document identified “competencies expected of a generalist nurse at the point of entry into professional practice” (p. 9), which fall under the three following domains: professional, ethical, and legal practice; care provision and management; and professional, personal, and quality development. Furthermore, the ICN has published various other documents in its ICN Regulation Series or its Standards and Competencies Series that are important documents to refer to in relation to competencies. They include the following:

The Scope of Practice, Standards, and Competencies of the Advanced Practice Nurse (ICN, 2008b);

ICN Framework of Competencies for the Nurse Specialist (ICN, 2009);

International Competencies for Telenursing (ICN, 2007); and

The ICN Framework and Core Competencies for the Family Nurse (ICN, 2003).

This article is meant to serve as a compendium to these and other articles that describe the scope of practice, standards of practice, and competencies essential for clinical practice related to nursing. Specifically, the members of the Regional Lead Team developing this article and the expert consensus panel endorsing the essential nursing competencies related to HIV and AIDS used the Nursing Care Continuum – Framework and Competencies published by ICN in 2008 as a building block (ICN, 2008a).

Furthermore, both the Regional Lead Team and the expert consensus panel felt that to be meaningful and applicable, there were several issues that must be considered.

First, the essential competencies must be adapted to the spectrum of care delivery, the care setting, and within the scope and standards of care for nursing specific at a country, provincial, or local level.

Second, the essential nursing competencies related to HIV and AIDS must be leveled to the composition of the nursing workforce in the respective country, province, hospital, or clinic similar to the leveling done in the Nursing Care Continuum – Framework and Competencies (ICN, 2008a). Thus, adaptation of these essential competencies for nursing related to HIV and AIDS needs to match the scope of practice and the composition of the nursing workforce so that they will be most meaningful and reasonable.

Third, when adapted to meet the needs at the regional, country, or local level, the following essential nursing competencies related to HIV and AIDS should be used to:

Redesign nursing curricula to produce a competent nursing workforce prepared to enter practice, ready to address the complex individual, family, community, and societal issues related to HIV and AIDS,

Evaluate nursing regulations governing nursing practice in the context of HIV and AIDS, and

Deliver capacity building programs that expand and validate the competence—including the knowledge, skills, and attitudes—of the nursing workforce already in practice.

Finally, these essential nursing competencies related to HIV and AIDS can help to clarify the role of the nurse in addressing the HIV and AIDS epidemics. Furthermore, they provide a mechanism for the discipline of nursing to strengthen its capacity to deliver and evaluate contributions to the health and well-being of individuals, families, communities, and societies that are affected by HIV and AIDS.

Application to Preservice Nursing Education

In 2008, WHO and the Global Health Workforce Alliance stated, “pre-service curricula that emphasize lifelong learning and relevant health issues and competencies better prepare graduates for in-service work and on-going training” WHO/GHWA, 2008, p. 50. Similarly, the African office of WHO (WHO/AFRO, 2007a), in its 2007 document, WHO Guidelines for Implementing Strategic Directions for Strengthening Nursing and Midwifery Services in the African Region, 2007-2017, declared that “promoting the development of competent practitioners who have the required core competencies (skills and knowledge) for all nursing and midwifery practice at pre-registration and post-registration levels” is essential (WHO/AFRO, 2007a, p. 15).

In 2007, WHO/AFRO (2007b) released guidelines for evaluating basic nursing and midwifery education and training programs for the African Region. This document established the basic standard for educational outcome as follows:

“The nursing and midwifery school must define the competencies that students should exhibit on graduation in relation to their subsequent training and future roles in the health system” (p. 20).

These competencies, building upon the evidence documented by the WHO and the ICN, can serve as a tool for preservice nursing programs to critically evaluate current curricula in the context of HIV and AIDS. Particularly, in sub-Saharan Africa where the epidemics are so great, it is essential that these competencies build upon the competencies required of all nurses as outlined by ICN in 2008 (ICN, 2008a).

Application to In-service Education or Capacity Building

Across the sub-Saharan African region and across the globe, there has been significant investment in activities that increase the nursing capacity. Many of these early activities focused on increasing the workforce capable of supporting ART roll-out. With an increasing number of individuals on ART and as a consequence of task shifting, nurses are now initiating ART, evaluating effectiveness, managing side-effects, and coordinating the care for persons stabilized on ART. However, the HIV and AIDS epidemics need more than just pharmacologic intervention. New HIV infections are reported daily, requiring nurses to individualize prevention efforts on the basis of evidences that are grounded in the cultural context of the community and remain sensitive to the gender roles and norms of the society. The ethical, spiritual, legal, and societal responses to HIV and AIDS have always been, and continue to be, complex. Consequently, nurses must be prepared to protect the autonomy of the individual yet facilitate planned disclosure anticipating the many negative consequences in partnership with the person living with HIV or AIDS.

As described by WHO and the Global Health Workforce Alliance in 2008, lifelong learning is fundamental to professionalism and optimizing the quality of care delivered regardless of the disease (WHO/GHWA, 2008). Therefore, with ongoing advances in preventing, diagnosing, treating, and supporting persons living with HIV or AIDS, including those affected, it is critical to support lifelong learning through capacity building or in-service programs. Again, as in preservice education, these competencies can serve as a framework to health care organizations validating the competencies of nurses in relation to HIV and AIDS or to capacity building programs funded to enhance the ability of nursing to comprehensively address the complex issues related to the HIV and AIDS epidemics.

Application to Regulation and Policy

With the shortage of health care providers, task sharing and shifting becomes essential in the delivery of services and care. However, many national nurse practice acts and regulatory documents are outdated and do not match the contemporary scope of practice demands of nurses. With the identification and acceptance of essential competencies for nursing related to HIV and AIDS, it is possible to revise regulations to ensure and accept competencies as a framework to ensure a standard of care, it is possible for policy makers to refine regulations and practice acts. Furthermore, these competencies can serve as a tool for regulatory bodies to qualify (or certify) nurses in the practice of HIV and AIDS nursing. Additionally, regulatory bodies can use these competencies as a mechanism for curricular restructuring to prepare the next generations of nurses skilled to care for persons infected or affected by HIV and AIDS.

Competency Development Methodology

In developing the essential competencies for nursing related to HIV and AIDS, a participatory action approach of regional nursing experts including educators, clinicians, and policy/regulatory experts was used.

From the outset, the participating nurse leaders viewed the competencies related to HIV and AIDS as supplemental to the general competencies expected of all nurses that were achieved as a result of education, training, examination, and licensure. The general nursing competencies serving as the basis for refinement in the context of HIV and AIDS were those published by the ICN entitled Nursing Care Continuum – Framework and Competencies (ICN, 2008a).

The primary operating assumption of the nursing leaders involved in the development of the HIV and AIDS nursing competency process focused on regional collaboration. This collaboration was essential because of the following reasons:

It facilitated sharing of expertise and resources through a South-to-South collaboration of nursing leaders;

It expanded partnerships and networks to reduce duplication of efforts and to facilitate action;

It mitigated the effects of regional migration of nurses; and

It established a regional network for sharing best practices related to task shifting.

Furthermore, the participating nurse leaders unanimously supported the development of essential nursing competencies for HIV and AIDS if the competencies were comprehensive in nature, holistic in approach, and not merely focused on ART delivery. To be comprehensive, the participating nursing leaders firmly articulated that the identified competencies must address the cognitive, affective, and psychomotor domains specific to HIV and AIDS as well as the professional expectations of nurses related to HIV and AIDS. Finally, to address the complex issues associated with HIV and AIDS, the nurse leaders participating in the development process supported a holistic approach examining the contribution of nursing across the care continuum (prevention, care, and treatment) while also addressing the psychosocial, spiritual, ethical perspective, individual, and community level stigma associated with the disease as well as the essential leadership, mentoring, and professional development required of nurses and nursing.

Figure 1 illustrates the complex nature of HIV and AIDS nursing care. The client, delineated in the middle of the graphic, is defined as the individual, family, and/or community living with, at risk for, and/or affected by HIV and AIDS. Surrounding the client are the nursing care activities demonstrating the complex, multilevel needs of persons living with, affected by, or at risk for HIV and AIDS. In partnering with the client to address these needs, the nurse uses many roles, which are illustrated in the outer circles.

Competencies as a Focus

In June 2008, The Regional Leadership Summit on HIV and AIDS Nursing Education, Practice and Policy was convened by the nurse capacity building program, Nurses Strengthening our AIDS Response, and the Department of Nursing Science from the University of Zululand (Republic of South Africa). The Summit organizers used a participatory action approach, which allowed the regional nursing leaders to identify contextual, system, professional, and regulatory issues affecting nursing education, practice, and policy related to HIV and AIDS to identify a way forward for the Southern Africa region.

To achieve the summit goal of engaging in a dialogue and discussion to build consensus on the critical issues related to HIV and AIDS nursing education, practice, and policy, the summit was organized to include a broad representation of nursing leaders throughout the region. Over 30 nursing leaders from Botswana, Malawi, South Africa, Swaziland, Zambia, the United States of America, and the ICN met for 3 days.

For this summit, the search conference approach was used (Emery, 1996). This methodology supported participatory action facilitating sustainability of action over time. The “searching” format brings together relevant stakeholders for a 2- to 3-day meeting to examine critical issues that are common to the stakeholders and where the opening session focuses on elucidating the factors of the contextual environment, in this case, the HIV and AIDS epidemics in sub-Saharan Africa.

Through the sessions with small and large groups, the “searching” format examined current contextual issues and challenges and identified the issues most likely to affect the future. The content was contributed entirely by the members. In this participatory action approach, the staff—in this case, the staff of Nurses Strengthening our AIDS Response! and representatives from the United States—acted as facilitators only. The agreed-upon priority issues were listed without skepticism or criticism in the plenary session and then critically examined in greater depth in small groups with the composite regional picture being established by the large group. At the end, action steps were identified and a Regional Lead Team (see Appendix 4) was appointed to establish priorities and formulate a work plan.

The Issues

As identified through consensus by the Summit participants, the prioritized goals to be addressed by the Regional Lead Team were as follows:

Goal 1: To strengthen the capacity to integrate HIV, AIDS, tuberculosis, and palliative care into pre-service nursing education.

Objective 1: To identify core competencies of licensed nurses related to HIV, AIDS, TB, and palliative care.

Objective 2: To develop a standardized curriculum for adaptation related to HIV, AIDS, TB, and palliative care.

Objective 3: To enhance partnerships between education, practice, national nursing associations, and national nursing councils that facilitate knowledge, skill, and ability of preservice students to deliver evidenced-based care related to HIV, AIDS, TB, and palliative care.

Goal 2: To strengthen and enhance the Southern African nursing community’s response to HIV and AIDS through development of a postgraduate nurse specialist program in HIV and AIDS.

Objective 1: To identify core competencies of advanced practice nurse specialists related to HIV and AIDS nursing.

Objective 2: To formalize regional partnerships to jointly design and implement a postgraduate nurse specialist in HIV and AIDS.

In October 2008, the Regional Lead Team met in Pretoria, South Africa. During the deliberations at this meeting, the representatives reviewed the preliminary summit report and provided guidance on areas to expand. Additionally, the group critically reviewed the many priorities identified by the June 2008 Summit Participants and determined that the first priority was to identify the essential competencies for nursing related to HIV and AIDS. Therefore, the Regional Lead team developed a comprehensive work plan to address this identified priority.

Further discussions focused on Goal 2, which relates to strengthening and enhancing the Southern African nursing community’s response to HIV and AIDS through development of a postgraduate nurse specialist program in HIV and AIDS. After the essential competencies for nursing related to HIV and AIDS are endorsed by the countries participating in the Regional Summit, the Regional Lead Team then recommended conducting a needs assessment of key informants and stakeholders to determine the needs for a nurse specialist in HIV and AIDS. If there is identified need and support for a nurse specialist in HIV and AIDS, then the Southern African Nursing Leaders must reassemble to develop a work plan.

In February 2009, the Regional Lead Team met again and continued work on developing the essential competencies. At this meeting, the country representatives updated the group on the results of the meetings held with key stakeholders in the respective countries. At this meeting, the members of the Regional Lead Team critically examined the evidence supporting the need for essential competencies (Appendix 1) as well as the existing training and/or education programs identified that were related to HIV and AIDS nursing practice (Appendix 3). At the closure of the February 2009 meeting, the first draft of the essential nursing competencies related to HIV and AIDS was prepared.

In March/April 2009, the Regional Lead Team convened a regional stakeholders meeting (see Appendix 5) to critically examine the drafted essential competencies for finalization. At the closure of this meeting, through a participatory action approach using a consensus development methodology, the finalized essential competencies for nursing related to HIV and AIDS was prepared.

Figure 2 provides a graphic illustration of the methodology used in developing the essential competencies for nursing related to HIV and AIDS.

Figure 2

Competency development methodology.

In accordance with the requirement self-imposed by the Regional Lead Team, and supported by the external stakeholders convened for the expert consensus panel, the identified essential competencies are holistic in nature and address the complex, multilevel issues surrounding the HIV and AIDS epidemics.

Table 1 lists the identified essential competencies statements for nursing related to HIV and AIDS. In Appendix 2, a detailed description of the essential competencies is provided as well as references related to the competency element in brackets.

The identified essential nursing competencies related to HIV and AIDS are powerful instruments to strengthen the capacity of the nursing profession to address the HIV and AIDS epidemics in sub-Saharan Africa. These competencies can be a resource to practicing nurses, nurse educators, professional nursing associations, nursing councils, ministries of health, funding agencies, and health care agencies to support the ability of nursing to provide holistic care to individuals, families, and communities infected or affected by HIV and AIDS. A detailed description of the essential competencies as well as supporting references reviewed in their development and resources available for strengthening nursing capacity in the context of HIV and AIDS is provided in Appendix 2, Appendix 3.

Disclosures

Michael V. Relf, Julia Mekwa, Cynthia Chasokela, Christina Booth, Lisa Deng, R. Kevin Mallinson, Keabitsa Ramantele, Elizabeth Letsie, Jasintha Mtengezo, Winnie Nhlengethwa, Dorothy Powell, Adele Webb, Tony Diesel, Amanda Liddle, Janette Yu-Shears, Carolyn Hall, Barbara Aranda-Naranjo, and Deborah Parham Hopson report no real or perceived vested interest that relate to this article including relationships with pharmaceutical companies, biomedical devices, manufactures, grantors or other entities whose products or services are related to topics covered in this manuscript that could be construed as a conflict of interest.

Endorsements

The Essential Nursing Competencies related to HIV and AIDS has been endorsed by the International Council of Nurses, the Elizabeth Glaser Pediatric AIDS Foundation, and the Association of Nurses in AIDS Care.

Funding

This work was supported by grant number U92HA07230 awarded to Georgetown University (PI: R. Kevin Mallinson) with a sub-contract to Duke University (PI: Michael V. Relf) from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), funded by the President’s Emergency Plan for AIDS Relief (PEPFAR). Additional financial support to facilitate the dissemination of this document was obtained from the Office of Global and Community Health Initiatives at Duke University School of Nursing. This report’s contents are the sole responsibility of the authors and do not necessarily reflect the official view of PEPFAR, HRSA, or the authors’ organizations.

BotswanaKeabitsa RamanteleVice-Chair, Regional Lead TeamPresident, Botswana Nurses Association	LesothoElizabeth Mabereng LetsieChairperson, Lesotho Nursing Council
MalawiJasintha MtengezoDirector of Educational Programs,Nurses and Midwives Council of Malawi	South AfricaChair, Regional Lead Team:Julia Nobelungu MekwaHead, Department of Nursing ScienceUniversity of Zululand
SwazilandSecretary, Regional Lead Team:Winnie NhlengethwaRector, Nazarene Higher Education Consortium &Principal, Nazarene College of Nursing	ZimbabweCynthia ChasokelaDirector of Nursing Services/Chief Nursing OfficerMinistry of Health and Child Welfare
Nurses SOAR! ProgramTony DieselRegional Program Director, Nurses SOAR!	Nurses SOAR! ProgramMichael V. RelfDirector, Leadership Sector Nurses SOAR!Assistant Dean, Undergraduate Education at the Duke University School of Nursing

BotswanaKeabitsa RamantelePresident, Botswana Nurses AssociationGaleagelwe BaikepiChief Health Officer, Ministry of Health, Curriculum UnitJohannah Boingotlo MakhwadeChief Nursing Officer, Ministry of Health	LesothoElizabeth Mabereng LetsieChairperson, Lesotho Nursing Council(Invited, Unable to Attend)Amelia RanotsiLecturer, National University of LesothoFelicity MotsekoLecturer, Paray School of NursingMannuku MokebisaSecretary, Lesotho Nurses Association & Spokesperson of HIV & AIDS in the Workplace, Lesotho Nurses Association Wellness Centre
MalawiJasintha MtengezoDirector of Educational Programs, Nurses and Midwives Council of MalawiMartha MondiwaRegistrar, Nurses and Midwives Council of MalawiImmaculate KambiyaAssistant Deputy Director, Care and Support, Ministry of Health	South AfricaJulia Nobelungu MekwaHead, Department of Nursing Science, University of ZululandAbel PienaarConsultant on HIV/AIDS & Member, South African Nursing Council Educational Committee(Invited, Unable to Attend)Nonhlanhla MakhanyaPresident, South African Nursing Council (SANC)(Invited, Unable to Attend)Busi BhenguHIV/AIDS Nurse Expert & Faculty, School of Nursing & Midwifery, University of KwaZulul Natal(Invited, Unable to Attend)Eva ManyediFaculty, Northwest University
SwazilandWinnie NhlengethwaRector, Nazarene Higher Education Consortium & Principal, Nazarene College of NursingGlory MsibiRegistrar, Swaziland Nursing CouncilPhumzilie N. DlaminiProfessional Vice President, Swaziland Nursing Association & HIV Expert at the Wellness Centre of the Swaziland Nursing Association	United States of AmericaJanette Yu-ShearsPublic Health Analyst/Project Officer, HIV/AIDS Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services
ZimbabweCynthia Chasokela, Director of Nursing Services/Chief Nursing OfficerMinistry of Health and Child WelfareKhumbulani MbuyaHIV/AIDS Focal Person & Principal Tutuor, United Bulawayo Hospitals School of NursingRegina Nsipa KanyembaChair of the Nurses Council of Zimbabwe and HIV Integrative Curriculum	Nurses SOAR!Michael V. RelfDirector, Leadership Sector, Nurses SOAR! &Assistant Dean, Undergraduate Education, Duke University School of NursingTony DieselRegional Program Director, Nurses SOAR!