The essence, opportunities and threats to Advanced Practice Nursing in Sub-Saharan Africa: A scoping review.

BACKGROUND: The conditions that stimulated the implementation of Advanced Practice Nursing programmes all over the world have long been ignored in sub-Saharan Africa.
OBJECTIVE: This study sought to explore the essence, opportunities and threats to the implementation of an Advanced Practice Nursing (Child Health Nurse Practitioner) programmes in sub-Saharan Africa.
METHODS: A scoping review was conducted and findings reviewed by a multinational multidisciplinary health experts' team through a Delphi study.
RESULTS: Children are the majority of the 70-90% of the sub-Saharan African population who reside in the rural areas where access to timely, quality and cost-effective healthcare is poor. The Child Health Nurse Practitioner programme offers an opportunity to provide quality, timely and cost-effective healthcare to sub-Saharan Africa children. Limited resources, opposition from the medical profession, poor nursing governance and lack of context-specific Advanced Practice Nursing benchmark programmes constitute threats to the programme.
CONCLUSION: The sub-Saharan Africa context provides opportunities that the nursing profession can harness to surmount such threats. Nursing governance structures, however, need to advocate for government and other stakeholders' support for the Child Health Nursing Practitioner programme.

Introduction

The World Health Organization (2016) stated that about 20–40 % of the wastages in the health system is due to the workforce inefficacies and weaknesses in health workforce governance. Training the right quantity of needed cadres of the health workforce to respond to the Universal Health Coverage demands is a global challenge. Having the right skill mix of the appropriate cadres of health workforce with effective and accountable governance is essential for health systems to respond to the UHC challenges in each country. A key objective of the WHO 2030 health workforce strategy is to enhance the capacity of country level institutions for effective HRH governance (World Health Organization, 2016).

Sub-Saharan Africa (SSA) consists of forty-nine of the fifty-four Africa countries, representing the region of Africa to the south of the Sahara desert (Federal Ministry for Economic Cooperation and Development Germany, 2017). The production of appropriate cadres of health workforce who are willing to take rural posts is pivotal to the achievement of Universal Health Coverage especially in rural SSA (Hiatt et al., 2017; Soucat et al., 2013). Advanced Practice Nurses (APNs) are such cadre of health workforce capable of providing care to the underserved communities (Duffield et al., 2009; Kleinpell et al., 2014; Sheer and Wong, 2008; Swan et al., 2015). Advanced Practice Nursing (APN) programmes emerged because of the need for countries to improve access to quality and cost-effective healthcare services (Duffield et al., 2009; Sheer and Wong, 2008). Many studies (Hutt et al., 2013; Pirret et al., 2015; Swan et al., 2015) have shown that the care provided by the APN are of equal or higher quality to that of the general practitioner. Two major reports; the Boudreau Report in 1972 in Canada and the Post Registration Education and Practice Project (PREP) in the UK stated that the APNs demonstrated a higher level of thinking and clinical judgment in diagnosing and prescribing (Sheer and Wong, 2008). Despite the marked exclusion of the rural and hard to reach communities from quality healthcare in SSA, the implementation of APN programmes have not been approached with the urgency and commitment seen in other jurisdictions.

This study focused specifically on the introduction of APN programmes to prepare APNs to practice as child health nurse practitioners. The terms Advanced Practice Nurse and Child Health Nurse Practitioner are therefore used interchangeably in this paper.

Main text

Aim

The aim of this paper is to report on a study that explored the essence, opportunities and threats to the introduction of Advanced Practice Nursing (Child Health Nurse Practitioner) programmes in the sub-Saharan African context.

Methods

A systematic scoping review using the framework developed by Arksky and O'Malley was conducted to describe the essence, opportunities and threats to the introduction of Child Health Nurse Practitioner (CHNP) programme in SSA context (Arksky & O'Malley, 2005). The findings of the scoping review were reviewed by a multidisciplinary team for its representation of the SSA context through a Delphi survey.

Systematic scoping reviews are either stand-alone or pre-systematic reviews that aim to explore the breadth and depth (in-part) of a research area using both grey and peer-reviewed literature (Arksky & O'Malley, 2005). The review method focuses on complex and broad topic areas that lack comprehensive reviews. The concept of Advanced Practice Nursing is an emerging area in SSA, hence, the choice of scoping review rather than other review methods (Arksky & O'Malley, 2005).The framework comprises six stages: identifying the research question; identifying the relevant studies; study selection; charting data; collating, summarizing, and reporting results; and consultation (optional).

Forty-three experts (33 nurses, six public health practitioners and four medical practitioners) of the 49 multidisciplinary experts purposively selected from East, Central, West and Southern Africa reviewed the findings of the scoping review for context representation in the consultation phase of the scoping review methodology.

The review questions

The review questions explored in this study were:

‘Is CHNP programme relevant in SSA?

What are the opportunities and threats to the implementation of the Advanced Practice Nursing programmes in SSA?

Search and Inclusion

Seventy-six (76) studies were included from the 307 identified from EBSCO Host, ProQuest, PubMed, Science Direct and Google Scholar and hand search from ICN, WACN and ECSACON websites. A combination of three keywords (Advanced Practice Nursing, child health and Africa) were used. Studies were included if they were published in English; between January 2007 to December 2017; and were either published on SSA or part of the data collected in SSA if multicentre study (Fig. 1).

Fig. 1

Search and inclusion.

Data charting

Data were charted on a data matrix (Table 1). The matrix was divided into two sections: Advanced Practice Nursing and child health-related studies. Information charted from the studies included: author and date, setting, title, purpose, research design and the findings of the study regarding APN and child health in SSA.

Table 1

Data matrix.

Session 1: advanced practice nursing in SSA
No	(Study, Year),Setting“Title”	Purpose	Research Design	Contribution to APN Curriculum
1.	(Academy of Nursing of South Africa, 2015),South Africa“Summary Report: Academy of Nursing of South Africa Colloquium (2015)”	To obtain an overview of status of specialist nursing, discuss issues around generic competency framework, education and training, and matters relating to specialist training on South Africa.	Discussion paper	The specialist nurse is expected to help in improving the indicators of life expectancy, maternal mortality, HIV/AIDs burden, Tuberculosis burden in order to strengthen the health system.Minister of Health created categories of specialist nurses and Nursing Council developed competencies for the specialist categoriesThe nursing council have control over: conceptual clarification, scope of practice, competency framework, standard of practice, code of conduct, Continuing Professional Education.ICN's definition of Advanced Practice Nursing was adopted and adapted to the South African context, “An advanced Practice Nurse is a leader in clinical field, makes clinical judgement, develops or advices regarding policy development in clinical area, is an interdisciplinary consultant, initiates and places premium on research in the clinical area”.
2.	(Adjapon-Yamoah, 2015), Nigeria“Possibilities for advanced practice nursing through the eyes of physicians: a descriptive qualitative study”	To discuss how physician's views about the introduction of Advanced Practice Nursing in Nigeria.	Qualitative descriptive study.Data were thematically analysed.	The Advanced Practice Nursing programme is in high demand due to the physician shortage in Nigeria. Currently there is no APN in Ghana but nurses are deployed through task shifting to practice without proper documentation. APN is necessary for the upscaling of primary healthcare in Nigeria. If nurses could prove themselves worthy of the expanded roles, there will be physician support.
3	(Ahmed et al., 2011),SSA“Medical education: meeting the challenge of implementing primary health care in Sub-Saharan Africa”	Supporting PHC as a means of meeting SSA health needs	Position paper	Medical education must be focused on the needs of the people served. Primary healthcare is best suited for the special health needs of Africa.Population is largely rural, healthcare facilities allocated at city and towns, access to health care difficult due to bad transport system, fastest growing world region with 2.4% growth rate, population expected to double in 30 years (2040), more than 40% of population earn less than $1 daily, half the population is less than 18yrs, rapid urbanization. Estimated67% may city and town dwellers by 2050, Controlled HIV leading to high chronic disease burden, Maternal and neonatal mortality are on the rise despite worldwide decrease.Primary Health Care is very important in responding to the population health needs of Sub-Saharan Africa.
4.	(Currie, Chiarella and Currie, 2013),International“An investigation of the international literature on nurse practitioner private practice models”	To review literature on models used by APN in private practice	Literature review.Thematic content analysis was used to synthesize information from the studies identified in 2012	Only a few nurse practitioners are in private practice. The main location of private practice is clinic settings. There is difficulty with nurse practitioner private practice. Laws permitting NP private practice, acceptability by patients as care provider, and financial reimbursement.
5.	(Doodhnath, 2013),South Africa“Experiences of advanced psychiatric nurses on their practice in an Occupational Specific Dispensation hospital setting”	To describe how the experiences of psychiatric nurses practicing at an OSD clinic was used to develop guidelines to support nurses practicing in OSD wards	Qualitative, exploratory, descriptive and contextual design.In-depth interviews were conducted	The guidelines recommends the APN practice according to their scope of practice and enable the adoption of advanced practice nurse roles to allow the APN to practice advanced nursing skills.
6.	(Duma et al., 2012),South Africa“Specialist and advanced specialist nursing and midwifery practice”	To differentiate between the two levels of Advanced Practice Nursing in South Africa in line with ICN perspectives		There is much ambiguity in terms of roles and practice across the world. This ambiguity needs clarification in order to delineate scopes of practice.In South Africa, a “nurse/midwife specialist” is trained at the Advanced diploma level and is authorised to practice in a specialist field. Their roles including teaching, administration and research. The second specialist group (Advanced nurse/midwife specialist) is trained at the master's level with a broader autonomy in practice and can function in primary care. She or he needs enough knowledge attitudes and skills to assess, diagnose manage therapeutic regimen in a specialised area and in private practiceThe practices of this entire category must be founded on the context in which they are licenced to practice.The programme entails 180 credits a year with much of it being in clinical multidisciplinary team roles.The roles of the advanced nurse specialist should include: autonomy in assessment, medical diagnosis, management of caseloads, education, consultancy, primary care, development of best-practice guidelines and researchTopics to be studied include: ethics, professionalism, PHC, literature reviews, statistics, interprofessional skills, literature review, evidence-based practiceThe programme should have core courses taking 42% of the credits and the rest assigned to specialty courses and practice. It is proposed that for every 1-credit, three should be 4 clinical hours practice, making 480 clinical practice hours for a 120-credit year.About 50% of the advanced practice nursing training should be research based. But the research should be clinical/practice based. The programme should be less classroom-based and tailored towards the acquisition of clinical expertise and competencies. Final examination should be practical in nature.FUNDISA recommended that registrars' posts be created to enable the Advanced specialist nurses to focus on service delivery during their training.
7.	(East et al., 2014)Kenya“Exploring the potential for advanced nursing practice role development in Kenya: A qualitative study”.	To determine whether Advanced Nursing Practice existed or the potential to implement APN in Kenya	Exploratory qualitative design	Lower cadre of nurses have more autonomy in practice than highly qualified ones. Higher categories of nurses are either in managerial position or in education practice. There is a pressing need for ANP in Kenya. The existence of lower cadre physician ‘clinical officer’ threatens the APN programme. Private hospital nurses are more autonomous than those in public facilities.Perceived ANP roles taken by the participants are: providing specialised care, EBP practice leadership, collecting data, leading units, Consultant roles, healthcare advocacy, autonomous case management, teaching nursing students, nursing research.The law does not permit nurses acting in these roles to prescribe so they take the action and wait for the physician to document. There however is an allowance for Private Practice Nurses (PPNs with minimum of 5 years' experience and license from the Department of Health) who had the least requirements for APN by ICN standards.
8.	(Essa, 2011)South Africa“Reflecting on some of the challenges facing postgraduate nursing education in South Africa”	To examine reasons why postgraduate students did not complete their degrees	Qualitative interpretive	All students are working: Part-time programme. Students are all adults: Students have family responsibilities. Students lack knowledge of teaching methods, examination policies, and programme structure. Many students realised they should have registered for a different programme. Some students do not have the necessary prerequisites to take on the programme. Students lack computer skills. Students lack resources: computer, transport, and internet. Students believe postgraduate programmes demand time management, hard work and sacrifices. Student felt lecturers are unapproachable and unavailable. Students were new to the telematic broadcasts and felt uncomfortable and distanced from lecturers. Network interruptions during online tests made students anxious. Students do not have enough information on the programme. Students receive study materials late
9.	(Heale et al., 2015),International“An international perspective of advanced practice nursing regulation”	To review Advanced Nursing Practice status globally	An online surveyData were analysed through descriptive statistics and thematic analysis	Responses from the 4 African countries involved-Angola, Batswana, Sierra Leone and Togo.The barriers detected are that of resistive legislation and unwelcoming organizational environment.25 of the programmes reviewed are at the master's level. In many of the programmes, there are roles but here is no regulation. The roles existing are “Nurse Practitioner; Clinical Nurse Specialist; Advanced Practice Nurse; Nurse Specialist”.
10.	(INEPEA, 2008),East Africa“Advanced Nursing Practice competence/capability in East Africa”	To describe Advanced Practice Nursing competency framework for east Africa	Synthesis competency framework	An advanced practice nurse must be registered and acquire complex decision-making skills and be competent clinically in his or her specialty field and the context in which he/she practices. AAPN is a master's level programme. There is the need for the APN to be experienced in clinical practice, be a critical thinking leader, and clinically competent.Levels of nursing in Africa can be classified as: “Support worker, Enrolled nurse, Registered nurse, Specialist nurse and Advanced practice nurse”.The lower cadre of recognised prescribers (clinical officers, medical assistants, physician assistants) stalls the expansion of roles for nurses for APN.In addition to ICT, there must be: ICT use, knowledge management, Research, innovation and change, Education and mentoring, Budget management and value for money, Human resource management, Biostatistics and other epidemiology, Report writing and presentation, working with international partners, Evidence based practice, Empowerment of staff and healthy communities, Patient and staff safety and infection controlThe domains of knowledge to studied by the APN include: Leadership and management, research and knowledge management, education and monitoring, empowerment and healthy communities, professional and ethics practiceThe programme should focus on maternal and child health among othersThe roles of Advanced Practice nursing should be distinguished from other levels of nursing.
11.	(Kleinpell et al., 2014), International“Addressing issues impacting Advanced Nursing Practice worldwide”	To describe the barriers to the APN roles worldwide	Discussion paper	APN include “certified nurse midwife, certified registered nurse anaesthetist, clinical nurse specialist, and nurse practitioner”.APN is a minimum of a master's level programme.The Institute of Medicine (IOM) stated that nurses need to be equipped and allowed to practice to their full potential in order to provide quality and cost-effectives services. Confusing scope of practice, role confusion, too many advanced practice nursing titles, inconsistent educational level of training, variable processes of training the APN are major challenges facing APN globallyGlobal characteristics of APN is to diagnose, prescribe medications and treatments, referral of clients, admission of patients, legislation regarding APN and the legal use of the Advanced Practice Nurse title,Difficulties encountered by the APN is the lack of education programmes, inability to understand the APN roles and disrespect to the nursing professionBecause countries are different in their level of health and healthcare capacity, the IOM stated that country specific regulations put restriction on the APN roles.Medical practitioner by-laws put restriction on APN. Authoritative medical leaderr5ship also inhibits interprofessional collaborationTo remove the barriers, it is important to communicate the APN roles, use of media campaigns, lobbying with stakeholders, publish and proclaim the achievements of APN, demonstration of the roles for the public to have confidence in the programme. There is the need to ask patients receiving care from APN to advocate for the programme
12.	(Kolars et al., 2012),USA and SSA“Partnering for medical education in sub-Saharan Africa: Seeking the evidence for effective collaborations”	To present the perspectives of collaborations between universities in the USA and Sub-Saharan Africa	Discussion paper	Good staff from SSA may be lured with inflated salaries. SSA cultures are influenced by colonial powers. SSA has 24% disease burden with 3% world health care personnel. Meagre financial support to produce health care workers in SSA. Most SSA schools suffer infrastructure, ICT, faculty and curricula issues.Curriculum is not developed to produce students with needed competencies in SSA. Curricula is not responsive to societal healthcare need. Some professions make it difficult for the roles of APN to be created. Some partnerships with USA undermine the needs of SSA healthcare system: another form of neo-colonialism.
13.	(Mccarthy, 2012),South Africa“Description of nursing regulation and nursing regulatory bodies in east, central, and southern Africa”	To survey the practices of nursing councils in East, Central and Southern Africa's regulations especially task shifting.	Nursing council registers and stakeholders were reviewed and Interviewed respectively	Task shifting existed in all the countries but the regulation and scope of practice have not been reviewed to confer the legal right on nurses to take on the roles they had already being performing.The nursing councils have major role to play in making nursing regulation to march up with the advancing roles of nurses. Only Tanzania had updated its regulation to cater for nurses managing HIV cases. There is need for nursing council to play their roles for the development of the nursing profession.
14.	(Madubuko, n.d.), West Africa“Nurse Practitioner/Advanced Nursing Practice development in West Africa: A proposal”	To propose that defines the roles, education and scope of practice of Advanced Practice Nurses in West Africa	Position paper	There is no advanced practice nurse in west African nursing registers.There is need for lobbying, advocacy for the practice to be recognised.All registered nurses in West Africa have one or more specialist training. There are about a 1000 registered nurse with a master's degree in West Africa.The nurse practitioner role already exists but not registered. The nurse practitioners work in PHC, assessment, medical diagnosis and Management of minor medical conditions, treatment of chronic illnesses.The programme for the APN should be at the Masters Level.The APN programmes should be developed in collaboration with universities, push the nursing councils to prepare registers for the category and motivate nurses to enrol in the programme.The broad learning objectives proposed by the West African Council of Nurses include: assessment, diagnosis, counselling, referral services, admission and discharge, evidence based practice.The shortage of medical profession creates a burden and a gap that the APN can easily fill and provide quality care for the neglected communities. The demand in PHC means there is the need to retrain nurses to take on the medical practice roles in PHC centres where the number of medical doctors cannot reach.The APN should be able to correctly request and interpret medical laboratory examination and results, give nutritional advice, promote health, involve in public screening services such as breast, cervical and prostate cancer screening.
15.	(Martel et al., 2014), Ghana“The development of sustainable emergency care in Ghana: Physician, nursing and prehospital care training initiatives”	To describe the process and initiative taken in the development of emergency care in Ghana	Discussion paper	Need assessment was conducted in 2010: nurses have interest in the emergency programme. 12 months emergency programme initiated: didactic, clinical and simulation based learning. South African emergency programme adapted for Ghana. South African experts were used to mentor Ghanaian. More emphasis on multi-disciplinary education.
16.	(Mutea and Cullen, 2012)Kenya“Kenya and distance education: A model to advance graduate nursing”	Developing a distance education model for advanced continuing nursing education	Discussion paper	Collaboration between four major stakeholders: health services, the community, the higher education institutions and the international partnersLessons: Distance education is economical, distance education increases access, advances in technology supports distance education; distance education has been successfully implemented in South Africa, Zimbabwe and china.
17.	(Mwangi, 2017),Africa“How International Council of Nurses can export Advanced Registered Nurse Practitioner Policies in Africa”.	To discuss how the Advanced Practice Nursing Policies can be exported to Africa	Discussion paper	Disease burden and health worker mismatch is profound in Africa. While the 25% global disease burden is being treated by the meagre 3% of the global health workforce in with 3% of the healthcare resources in Africa, 30% of the world's healthcare workforce uses 25% of the resources to treat only 3% of the disease burden in North America.The healthcare worker per population ratio in Africa is 2.3/1000. The majority of this being nurses. Nurses have played major roles in reducing the malaria endemic in west Africa and can do same for the general healthcare system if APN programmes are implemented.With Non-communicable disease burden rising despite the overwhelming communicable disease burden, it is important to implement health promotion services to respond to the healthcare needs of the population. This could easily be done by the APN. While more than ¾ of the medical doctors in SSA are concentrated in the cities, majority of the population are rural dwellers.The ICN should implement projects in which nurses provide care for communities in order to use the successes of those projects to advocate for ANP programmes.
18.	(Mwangi, 2016),Kenya“Why we need independent certified nurse practitioners /ARNP in Africa”	A memorandum from Kenya Nurses to Kenyan parliament on the need for independent certified nurse practitioners /ARNP in Africa.	Position paper	ARPN shall be a 2 years master's level programme. Advance Registered Nurse Practitioner, Certified Nurse Midwife, registered Nurses Anaesthetic. The curriculum content shall consist of: “Interpreting Laboratory findings, Pharmacothrapeutics, Nutrition and dietetics, Emergency treatment, Assessment of community resources and referral systems, Role re-alignment, Legal issues in ARPN, Health Care Systems, Management of selected diseases, Differential diagnosis related to specialty problems, and 500 h clinical education”. Nursing council shall regulate the practice of the ARPN. AARPN shall use a standard protocol in her practice. ARPN shall be supervised by a physician or dentist.
19.	(Ugochukwu et al., 2013)Sub-Saharan African“Roles of nurses in Sub-Saharan African region”	To describe what nurses do in Sub-Saharan Africa	A mixed method study involving document analysis, focus group interview and surveys	The role of nurses in sub-Saharan Africa consists of physical and psychological nursing care, community health education, advocacy, emergency care, enhancing healthcare through collaborations, provision of midwifery care, diagnosis and prescription, referral of clients, management of chronic illnesses in PHC, prevention and management of infectious diseases.The population is left suffering as governments and regulatory bodies admit that nurses are the major healthcare workers in sub-Saharan Africa but fail to make regulations to support nurses in their roles.There is the need for intensive advocacy by nurses to move the nurseing profession forward in providing quality care for the population.
20.	(Pulcini et al., 2010), International“An international survey on advanced practice nursing education, practice, and regulation”	To provide an overview of the development of APN worldwide with respect to naming, education, where they practice, their scope of practice, the laws and political environment within which it is practiced.	A web-based survey of APN was conducted.91 nurses from 31 countries responded.	There were 13 different names/titles given to APN discovered in this study.71% of the 32 countries have APN education programmes. 50 % of these programmes are at the Masters level. 23 of these countries had the role of APN officially recognised.48 % of these recognition and maintenance of registration status comes through licensure examinations.The programme is supported by local nursing organizations, nurses and the government whereas the greatest opposition came from the medical doctors and their organizationsThe APN programmes are gaining grounds all over the world as it has the potential to provide quality healthcare to the world, especially, the underserved communities.
21.	(Regan et al., 2016)Rwanda“Curriculum Development for Maternal, Newborn, Child Health: International Collaboration to Enhance Nursing Education in Rwanda”	To describe the collaboration between Rwanda and Canada to develop maternal, new-born, and child health curriculum for Rwanda	The development of the first bachelors in nursing curriculum in Rwanda	There was an extensive collaboration between the stakeholders of nursing education and practice.Needs assessment was done to set the foundation for the curriculum development. Then there was the revision of the curricula, the development of the programme, training of the lecturers in the paediatrics programme,The developed curriculum was also reviewed by international experts.Burundi has learned from Rwanda to also develop a similar type of curriculum in nursing.
22.	(SANC & South African Nursing Council, 2005)South Africa“Competencies for Paediatric Nurse Specialist	Competencies of the paediatric nurse specialist (PNS)	Nursing Regulation	The focus is primary healthcare but can practice at all healthcare levels.The PNS screens, assesses, diagnose, plan care, implement care, evaluate care provided and or refers client to the appropriate healthcare setting for specific care.A child is anyone less than 19 yearsThe competencies are in five domains: Professional, ethical & legal practice; Clinical practice; Quality of practice; management and leadership; and research.
23.	(Sastre-Fullana et al., 2014),International“Competency frameworks for advanced nursing practice: a literature review”	To review literature of ANP worldwide	Literature review	There were six roles identified throughout the world. These include: “nurse practitioner, clinical nurse specialist, nurse midwife, nurse anaesthetist, consultant nurse and nurse case manager”.The APN role is the most common in all the countries included in the review.There were controversies surrounding the introduction of the programme as the medical doctors are not willing to allow nurses to take on diagnosis and prescription roles. More and more countries are turning to APN as the right category of health workers to respond to the inequality in the healthcare system.The APN are expected to be competent in leadership, interprofessional collaboration, clinical judgement, Ethico-legal practice, teaching, EBP, health promotion, cultural sensitivity, healthcare advocacy and healthcare change management.There is much commonality in competencies in APN across the world.There is need for policy makers to develop tools to compare APN in different jurisdictions.
24.	(Seboni et al., 2013)SSA“Shaping the role of sub-Saharan African Nurses and Midwives: stakeholder's perceptions of the Nurses' and Midwives' tasks and roles”	To describe nurses function in the healthcare system of sub-Saharan Africa to help policy on future nursing education	Qualitative descriptive study.253 participants from 8 countries were involved in focus group discussions	The common nursing activities in SSA are: patient care, health education, care environment management, patient advocacy, involving in policy making, emergency care, stakeholder consultation and collaboration, midwifery services and child healthcareThe stakeholders could not reach agreement on the diagnosis and prescription as roles of nurses. There need for the roles to be made explicit for the benefit of our societies we serve.
25.	(Sheer and Wong, 2008), International“The development of advanced nursing practice globally”	Examining how Advanced Practice Nursing has developed worldwide	Literature review.Documents available to ICN on 14 countries and 3 regions were analysed.	APN roles are evolving in Botswana and South Africa. In Swaziland, the Family Nurse practitioner programme has been discontinued. There is an indication of re-establishing the course in Swaziland at the postgraduate level. Botswana is moving towards PHC.In Botswana, the APN programme is confronted with lack of role model and reimbursement
26.	(Sietio, 2000),Botswana“The Family Nurse Practitioner in Botswana: Issues and Challenges”	To describes the issues and challenges faced by the Family Health Practitioner programme in Botswana	Discussion paper	Nurses form about 70% of the healthcare workforce and therefore serve as the first contact to patients entering the health system. Achieving success in PHC, therefore, is highly dependent on nurses.The curriculum of the Family Health Nurse places emphasis on skills such as assessment, medical diagnosis, management of common illnesses, preventive health and health promotion. The skills are acquired through theoretical nursing training, courses in social and medical sciences, public health courses, and an intensive clinical practice.The one-year programme was extended to 18months to better train the family health nurses to respond to the needs of the Batswana. A master's level has been proposed for this programme. There is lack of faculty to deliver the programme.The courses taken include: “Family Nurse Practice 1/Health Assessment; Communication in Health Intervention; Family Nursing; Maternal and Child Health; Pharmacology; Public Health Sciences (Epidemiology, Research, Statistics); Clinical Nutrition; Mental Health Intervention; Dental Health Intervention; Laboratory Intervention; Maternal and Child health; Family Nurse Practice 11/Disease Diagnosis and management; Role Development; Practicum 11”The nurse practitioners mostly practice in the underserved community where they are the most qualified and therefore lead the PHC team. They also work in the OPD of higher-level hospitals, in industries, rehabilitation clinics and in private care. Private practice is difficult due to lack of reimbursement policies.The National Standing Drug Committee rated the family health practitioners high concerning their assessment, diagnosis and appropriateness of prescriptions in comparison to medical doctors in Botswana.The challenges faced by the family nurse practitioners include lack of clarity in their roles, no pathway for carrier progression, and ambiguity in legislation regarding their practice. The scope of practice is silent on prescription by the family health practitioners
27.	(So et al., 2016), International“Enhancement of oncology nursing education in low- and middle-income countries: Challenges and strategies”	To discuss challenges and recommend strategies to enhance oncology nursing education in developing countries	Discussion paper	Challenges: Lack of educational specialization in oncology, lack of legal framework for oncology specialization education, limited opportunities of continues education, difficulty in recruiting general nurses to oncology nursing.Strategies: Incorporate basic cancer care into preregistration programme, develop nursing faculty, establish programme sharing collaborations, involve international organizations, emphasises best practices, sustain oncology nursing programme by local involvement
28.	(Terry et al., 2012),SSA“Task shifting: Meeting the human resources needs for acute and emergency care in Africa”	To describe the effect of task shifting on emergency nursing care.	Literature review	Task shifting has been successful in the management of many conditions where there are less prepared health professionals. It is the potential solution in meeting limited access emergency care in SSA.
29.	(Klopper and Uys, 2013)SSA“Role analysis of the nurse/midwives in the health services in Sub-Saharan Africa”	To describe the roles that nurses play in the healthcare system of Sub-Saharan Africa.	A survey was conducted with 734 nurses from 9 SSA countries	Nurses are mostly functioning in general nursing services and less in maternal and child health care services. Those in French countries have lesser scopes of practice compared to English speaking countries. It is important for the regulatory bodies to develop roles beyond that of general nursing practice. There is also need for the nursing profession in French speaking countries to be assisted to develop.
30.	(Wolf et al., 2012),Africa“Developing a framework for emergency nursing practice in Africa”	To discuss how an emergency nursing practice framework was developed for Africa	Discussion paper	Challenges facing emergency nursing: Nursing and physician shortage leading to understaffing and heavy workloads and task shifting, nurses are practicing outside their scope of practice, high occupational hazards. critical thinking in insufficiently taught in training, poor pre-registration emergency nursing training, no scope of practice, inconsistency in terminology across Africa, nurses are disrespected by some members of the multi-disciplinary team, nurses are poorly remunerated, only one emergency nursing professional body in Africa.. The roles and responsibilities must be assigned according to the level of the nurse within the framework. Banner's framework was used to describe the emergency nursing various level of competency.

Data analysis

The data synthesis employed in this study consisted of five stages namely data reduction, data display, data comparison, drawing conclusions and verification (Miles et al., 1994; Whittemore and Knafl, 2005). The major findings and recommendations from the studies regarding Advanced Practice Nursing and child health charted in the data matrix were colour coded. This made it easy for comparing studies with each other based on the giving characteristics-relevance, opportunities and threats to CHNP programme in SSA. The codes were categorised into sub-themes and sub-themes into three main themes as described in the results section.

Results and discussion

This study outlined the significance of child healthcare and the need for CHNP in the SSA context. The opportunities and threats that SSA countries face in the development and implementation of APN programmes were also outlined. Three themes were presented from a combination of related sub-themes that were deduced thematically from key findings in the included studies. The expert committee reached consensus on all the themes below.

Theme 1: essence of the CHNP programme in SSA

Population dynamics, socioeconomic factors, poor access to healthcare and the need to reduce the cost of healthcare were the indicators for the introduction of CHNP programme in SSA.

Population dynamics

The population of Africa increased about five times in the past seven decades (Liu et al., 2016). By the middle of this century, the population of Africa will double from its current 1.2 billion people to about 2.4 billion people. Africa accounts for 41% of all births in the world resulting in about half of the SSA population being less than 18 years (Ahmed et al., 2011). By 2050, there will be nearly a billion children in Africa (O'Malley et al., 2014), constituting 37% of the population of children in the world (UNICEF, 2014). The majority of the population of SSA being children requires making children a priority in healthcare and other sectoral policies (Liu et al., 2016; World Bank Group, 2015).

The United Nations reported that 1 in every 12 children in SSA will die before the age of 12 years. Children in SSA are 14 times more likely to die before the age of 5, compared to their counterparts in developed countries (SOS Children's Villages, 2016). About 95% of malaria deaths in children under the age of 5 years occur in SSA. With the dominance of preventable communicable disease in SSA, the population distribution (more rural) and poor access to quality healthcare services, the Advanced Practice Nursing programmes will be most appropriate to the healthcare needs of the region. Since children are the majority of the population and are the population at the highest risk of disease and death, the CHNP is essential to the region.

Socioeconomic factors

Poverty is extreme in SSA. About 70% of SSA population live on less than $2.00 per day whereas about 48% of those living in SSA live on $1.25 per day (ECOSOC, 2017; Liu et al., 2016). African children are fraught with conflicts, wars and other forms of abuse (Avogo, 2010; Minoiu and Shemyakina, 2014; Mokomane et al., 2017). Many children are AIDS orphans and at many times are burdened with acute and chronic diseases (Kidman et al., 2010; Vaaltein and Schiller, 2017). Vogenberg and Cutts (2009) posited that poor economic status affects the healthcare access and choices of people as basic needs such as food and shelter tend to compete with healthcare among poor populations.

About 70–90% of the population of SSA countries live in rural and hard to reach areas, the highest rural population in the world. The rural population suffers the consequences of poverty, such as poor housing and lack of access to vital social amenities, for example, electricity, hygienic water, good schools, roads and health services (Msuya et al., 2017; Shumbusho et al., 2009). Contrary to SSA, only 19.3% of the population of the United States of America live in rural settings (US Census Bureau, 2016) and are most likely to own their own houses and have a lower rate of poverty (18.9%). North America has only 3% of the world's disease burden but 25% of the healthcare workforce. By contrast, Africa has about 24% of the world's disease burden but only 3 % of the world's healthcare workforce (Kolars et al., 2012; Mwangi, 2017). The training and recruitment of a cadre of a health workforce that can provide quality cost-effective care to children is critical in SSA.

Poor access to healthcare in SSA

The majority of the healthcare facilities and practitioners are located in the cities and towns, thus denying the larger proportion of the population who live in rural communities quality healthcare (Ahmed et al., 2011; Tong, 2015). Nannan et al. (2012) reported that about a quarter of the deaths are avoidable also, 31% of the children die within 24 hours of admission into the hospital. Nannan et al. (2012) also reported that about 64% of the children died of preventable diseases (acute respiratory and gastrointestinal infections) and many died before reaching the hospital. Coetzee (2014) also found that 50% of the child mortality cases occur before children reach the hospital. Mulaudzi (2015) also added that the poor management of Integrated Management of Childhood Illness (IMCI) at the PHC before referral led to 55% child deaths. Most importantly, healthcare professionals are responsible for about 55% of the cause of child deaths in South Africa (Nannan et al., 2012). It is imperative that CHNPs are trained to respond to the needs of the children within SSA.

Children's condition deteriorates faster than adults (Cootes, 2010). The consequences of diseases suffered by children in early life have devastating effects on their adult life, therefore it is important to provide quality and timely healthcare for children (Delaney and Smith, 2012). Unfortunately, healthcare services for children in SSA are not responsive enough to child healthcare needs.

Need to reduce the cost of healthcare in SSA

If 70% of SSA population live on less than $2.00 per day, then there is the need to put strategies in place to protect them against the cost of ill health. To access healthcare, the majority of the population who live in rural settings will have to spend extra money on transport to the urban centres, as well as the cost of accommodation and living expenses in the urban centres while receiving care. Primary Health Care service settings where the APNs function effectively is essential in UHC. A study conducted in South Africa demonstrated that 10% of the children admitted to hospitals were not expected to be on admissions whereas many district hospital patients were admitted into regional hospitals (Thandrayen and Saloojee, 2010; Westwood et al., 2012). This may be due to the poor services provided at the PHC level by incompetent staff. Having a competent CHNP at the PHC clinics will encourage service utilization, which will in turn protect the population against the high cost of healthcare.

Theme 2: opportunities

The quality and quantity of the nursing workforce, steady growth of APN Programmes across sub-Saharan Africa, resource sharing among institutions and the outcomes of APN programmes across the world indicated that APN is possible for SSA.

Quality and quantity of the nursing workforce

Nurses constitute about 70–80% of the human resource for health in SSA (Duma et al., 2012; Rispel et al., 2014; Sietio, 2000). This means that nurses form the foundation of the healthcare system and by extension, the foundation of the child healthcare in SSA (Davis et al., 2014). To be successful, Universal Health Coverage must be largely driven by the nursing workforce (Sietio, 2000). Nurses, therefore, are at the fulcrum of UHC but will need adequate capacitation through appropriate nursing programmes, advocacy and commitment to steer UHC in sub-Saharan Africa.

Steady growth of APN programmes across Sub-Saharan Africa

There is a progressive recognition of the APN roles in some African countries. For example, the Nurse Practitioner programme started in Ghana in the year 2001 received recognition from the Nursing and Midwifery Council of Ghana in the year 2014 (Nursing and Midwifery Council, 2014). The Family Nurse Practitioner programme, which was started as a one-year post registration programme, had been added to the Master of Nursing programme as a speciality in the University of Botswana. Botswana also introduced Clinical Nurse and Midwifery Specialist programmes at the master's level with recognition and licensing from the Nursing and Midwifery Council of Botswana. The Family Nurse Practitioner programme that was introduced in the year 1979 as a one-year certificate and suspended in the year 1995 due to lack of faculty was revived in the year 2009 by the help of Seed Global Health in the Kingdom of Eswatini (Anathan, 2018). The Nurse Anaesthetist programme, which was suspended in 1990 due to civil war, has also been reinstated but had to be paused during the Ebola outbreak in Liberia. The curriculum has been improved and the programme is currently being implemented. In Tanzania, Kilimanjaro Christian Medical University College collaborated with Duke University School of Nursing to start a three-year bachelor's degree Nurse Practitioner programme in 2018 (Mtuya and Blood-Siegfried, 2018). There is a continuous effort by international and local institutions and stakeholder groups to see the APN programme instituted in other countries in sub-Saharan Africa. The difficulty is the poor publicity given to these efforts in the region.

Resources sharing and institutional collaborations

Resources from South Africa were used in developing specialist programmes in Ghana, Malawi, Botswana, and Zambia (Bell et al., 2014; Coetzee, 2014; Martel et al., 2014). South African resources could be leveraged to develop faculty for other countries. An NGO (Improving Nursing Education and Practice in East Africa) and Universities such as Michigan University, University of Alberta, Nottingham University, Western University (Canada) have collaborated with universities in SSA to develop nursing programmes. There is a positive working relationship between the health facilities, communities of interest, educational institutions, and international partners in SSA (Mutea and Cullen, 2012). These can drive the development and implementation of APN programmes.

Many foreign funding agencies and universities have collaborated with local institutions in the development of the APN roles in Africa. These include United States Agency for International Development in Botswana; the University of British Columbia in Ghana; Denmark and Seed Global Health in the Kingdom of Eswatini, Global Health Service Partnership visiting faculty, Seed Global Health and Northeastern University Nurse Anesthesia programme in Liberia; Seed Global Health and Queen Elizabeth Central Hospital in Malawi; and Duke University School of Nursing in Tanzania (Anathan, 2018; GhanaWeb, 1999; Mtuya and Blood-Siegfried, 2018; Seed Global Health, 2017; Sietio, 2000). It is important to keep the inflow of funds and other forms of support from these foreign sources while ensuring that the programmes are locally owned.

The track record of Advanced Practice Nurses globally

About 23 countries have improved access to quality healthcare at an affordable cost through the APN programmes. Many studies have shown that the care provided by the APN are of equal or higher quality to that of the general practitioner (Hutt et al., 2013; Pirret et al., 2015; Swan et al., 2015). The nursing leadership within sub-Saharan Africa need to capitalize on these achievements to lobby for the programme within the region.

Theme 3: threats

Limited resources, opposition from the medical profession, inefficient nursing regulation and regulatory bodies, and lack of context-specific APN benchmark programmes constitute the challenges faced by the CHNP programme.

Limited resources

There is lack of human resources especially the faculty to teach in the APN programmes due to lack of preparation (Kolars et al., 2012; Regan et al., 2016). Only a few Universities within SSA countries have the physical infrastructure and financial resources to implement APN programmes (Terry et al., 2012). For example, the initial nurse practitioner programme in the Kingdom of Eswatini had to be terminated in 1995 due to lack of human resources (Dlamini et al., 2018; Mathunjwa and Potgieter, 2004). Good HRH governance and advocacy are necessary to produce and manage appropriate workforce for the Nursing Education Institutions. There must also be a tailored succession plan such as tthe one in Botswana to produce local capacity for the University of Botswana to sustain the nurse practitioner and clinical nurse specialist programmes (Sietio, 2000).

Opposition from the medical profession

The existence of lower cadre physicians whose training is less rigorous and shorter than APN threatens the APN programme (East et al., 2014; INEPEA, 2008; Kleinpell et al., 2014; Sastre-Fullana et al., 2014). The medical profession protects the roles of their members, therefore, posing the greatest opposition to the introduction of APN programmes in SSA (Kolars et al., 2012; Pulcini et al., 2010).

Inefficient nursing regulations and regulatory bodies

Nursing councils lack the resources and autonomy to expand the scope of practice of APN to reflect their extended roles. This creates role confusion among nurses and other healthcare professionals, placing a restriction on the Advanced Practice Nurses (Duma et al., 2012; East et al., 2014; Kleinpell et al., 2014). For example, the nurse practitioner programme in Ghana started in the year 1999 but could not be regulated until 2014 partly due to the fact that the Nursing and Midwifery Council thought the medical council is best suited to regulate their practice while the medical council demanded to change the name of the programme for them to regulate (Nursing and Midwifery Council, 2014).

Poor governance of nursing workforce

The highly qualified nurses are posted to a higher level of care settings whiles the lower cadre of nurses are posted to community health settings, which require much autonomy, leading to inefficiency in PHC services. Society tends to be sceptical about extending the roles of nurses for diagnoses and prescription (East et al., 2014). Even though task shifting is necessary to meet HRH demands at certain periods, it should not have been a regular phenomenon. In many countries nurses are in task shifting extended roles without license (Duma et al., 2012; Heale et al., 2015; Kleinpell et al., 2014; Mccarthy, 2012; Sietio, 2000; Wolf et al., 2012). This creates delicate legal issues as any acts of omissions and commissions could be to the disadvantage of the nurse. The nursing governance structures should demand a permanent extension of the roles of nurses to cover their task shifting duties.

Lack of context-specific APN benchmark programmes

Nursing training in SSA has been benchmarked on Western material and philosophy (Coetzee et al., 2016; Kolars et al., 2012). It is reasonably certain that the nurses produced from the neo-colonial curricula are less responsive to the special healthcare needs of SSA because the healthcare needs and challenges of SSA are different from those of the Western world (Ahmed et al., 2011; Coetzee et al., 2016). Apart from South Africa, all the APN initiatives in Africa were through foreign donors or institutions. The initial faculty that teach in the programmes were also foreign-trained, creating the opportunity for benchmarking the programmes on foreign programmes and materials that might not respond to the local context (Coetzee et al., 2016).

Conclusion

The threats to the introduction and implementation of the CHNP programme are generic and were faced by all the countries that had implemented APN programmes. This study demonstrated the crucial need for competent CHNPs in SSA countries. The CHNP programme offers an opportunity to provide quality, timely and cost-effective healthcare to the deprived and vulnerable children in SSA. It is essential, therefore to find ways of implementing the programme despite the existing constraints. There are opportunities that the nursing profession can harness to surmount such threats. Responsibility, however, lies with the nursing councils to develop scopes of practice that enable the APNs to practice to their full capacity. The greatest support for the APN programmes comes from national nursing organizations, nurses and governments. These groupings are in a powerful position to influence change and have an obligation to fulfil their advocacy roles to lobby for, and assist in, the implementation of these programmes. A shared effort amongst SSA countries will enable a coalition to facilitate cost-effective and shared programmes. An initiative by the national nursing governance structures to gain the trust and support of government and other stakeholders for the APN programmes is necessary to initiate dialogue which should then lead to joint planning and implementation of APN programmes (Pulcini et al., 2010).

Declarations

Author contribution statement

All authors listed have significantly contributed to the development and the writing of this article.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Competing interest statement

The authors declare no conflict of interest.

Additional information

Data associated with this study has been deposited at https://doi.org/10.17632/2kmpt2wg9s.1.