Facilitating the development of emergency nursing in Africa: Operational challenges and successes.

The World Health Assembly declared 2020 as the 'Year of the Nurse and the Midwife' in recognition of the critical contribution of both professions to global health. Nurses globally are having to do more with less and in the already resource deficient African context, significant adaptation and leadership is required in the way emergency nurses work if they are to be effective in reducing mortality and morbidity within emergency populations. In 2011, an emergency nursing group, representing the largest group of nurses in Africa, swiftly engaged with this process by publishing the document 'Developing a framework for emergency nursing practice in Africa' (2012). From this document a strategic plan was devised within a tight timeframe, to operationalise the quest for enhanced emergency nursing in Africa. The purpose of this paper is to describe this development of emergency nursing in Africa and to explain the operational challenges and successes, as well as the lessons learnt in order to assist with future planning.

African relevance

2020 as the ‘Year of the Nurse and the Midwife’ was in recognition of the critical contribution of both professions to global health.

Nurses globally are having to do more with less, and often in already resource deficient contexts.

Significant adaptation and leadership are required in the way emergency nurses in Africa work, if they are to be effective.

Describing the development of emergency nursing in Africa and explaining the operational challenges, successes and the lessons learnt can serve to assist countries in Africa regarding ways in which to further develop emergency nursing.

Context of emergency nursing in Africa

Nurses have to do more with less and in the resource deficient African context, significant adaptation and leadership is required in the way nurses work if they are to be effective in reducing mortality and morbidity. The World Health Assembly declared 2020 as the ‘Year of the Nurse and the Midwife’ in recognition of the critical contribution of both professions to global health. The publication of the State of the World's Nursing Report – 2020 Investing in Education, Jobs and Leadership highlighted the need for 9 million more nurses and midwives in the quest for universal health coverage [1]. Further, the seventy-second World Health Assembly Resolution Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured was adopted in 2019 [2] to renew efforts arising from the previous resolution WHA 60:22 (2007) Health Systems: Emergency Health Systems. This document represented,

“…a unique opportunity for emergency care providers and other advocates for improved emergency care to engage with national and local health care officials and policymakers, as well as with the World Health Organization and leverage expertise within the emergency medicine community to make substantial improvements in emergency care delivery in places where it is most needed”

The African Federation for Emergency Medicine (AFEM) was launched in 2009 to advance emergency care across the continent of Africa through systems development and skills training. Nurses, often referred to as the “backbone” of the health care system, are especially important in the emergency care context where the nurse is usually the first, and maybe the only, point of care for a patient. The increasing demand on African emergency health care systems means that the development of emergency nurses has huge potential to harmonise standards of care for the benefit of African emergency populations. In a number of African countries the development of emergency nursing has taken place. For example, in Kenya, upon graduating as general registered nurses, nurses were previously placed in emergency centres (EC) with no additional emergency care training, however as the speciality of emergency medicine developed in the country nurses gained access to specialised short courses (e.g. Advanced Cardiac Life Support, Basic Life Support). The first formal emergency nursing programme in Kenya was established at the Kenyatta National Hospital in 1996, amongst other post basic specialised nursing courses [4]. In Ghana, the presence of emergency medicine residency, along with state-of-the-art EC's further aided the development of specialist emergency nursing. As a result of a successful multisectoral collaboration between the University of Michigan (USA), Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital (Ghana), a formal emergency nursing diploma programme was developed in Ghana [5]. Formalised specialist emergency care is developing in many African countries, such as Kenya, South Africa and Ghana etc., but while emergency medicine training programmes for physicians are increasing, many countries have not yet established emergency nursing.

Establishing a guiding framework

Nursing contribution to emergency care in Africa is essential, however when collaborating with nurses across Africa in 2009 it became apparent no consensus on minimum level of education and training, delineation of roles and responsibilities, and/or effective staffing patterns for emergency nurses in Africa existed. Such information was essential in establishing a common understanding to plan future work. In 2011, the AFEM Nurses Group published; Developing a framework for emergency nursing practice in Africa [6] to provide such guidance. The 2013 conference (South Africa) provided an opportunity for collaborative planning and discussion to operationalise this framework into a five-year strategic plan with specific objectives, deadlines and identification of key individuals/teams to lead aspects. The strategic plan comprised the following objectives:

Set up an African emergency nursing database of contacts

Conduct country specific analysis of emergency nursing

Establish regular communication between African emergency nurses, enabling cross-country dialogue

Develop and validate an emergency nursing conceptual framework to create a Pan Africa vision, mission and position statement on emergency nursing

Validate the African emergency nurse clinical competence framework.

In developing this framework and strategic plan it was essential to provide a supportive and collaborative environment to ensure buy-in by all participants. It was also important to ensure the country-specific language and to respect context; appreciating the various strengths and contributions from every country to collaboratively move emergency nursing forward in Africa. Finance was awarded through an international travel grant from the Burdett Trust for Nursing to facilitate the operationalization of the framework into a strategic plan with associated activities.

African Emergency Nursing Curriculum (AENC)

The AENC introduced a harmonised theoretical and competence-based framework to assist countries in the process of developing formal emergency nursing programmes or short courses. Conceptual analysis identified specific knowledge and practice which emergency nurses should acquire. Three key themes were included; physiological sentinel conditions, unique circumstances of emergency nursing and, essential elements of emergency nursing. Clinical emergency nurse competencies were divided into basic, intermediate and advanced management [7]. Concurrently, the AFEM medical curriculum was developed so, as medical and nursing teams work closely in the emergency context, it was appropriate to mirror using the following sentinel physiological conditions namely; respiratory distress, shock, altered mental status, dangerous fever, severe pain and trauma [8]. The AENC underwent a global consultation period where comments were received from emergency nursing/medicine societies and individuals globally and the finalised document received endorsement for five years by the AFEM President. For access to the AENC please see http://afem.co.za/wp-content/uploads/2017/10/AFEM-African-Emergency-Nursing-Curriculum.pdf.

In Tanzania, the AENC helped guide the development of a currently existing short course focused on improving emergency nursing skills in marginalised locations [9]. These primarily rural nurses are important to target as they confront many emergency cases, practice alone, and take responsibility for patient care for extended periods.

It has also been noted that the AENC requires an accompanying guidance document to provide additional assistance to those countries who might be uncertain as to how to make use of it. This document is currently under development.

Global Emergency Nursing Mentorship Africa (GENMA)

The emergency nursing mentorship scheme was not initially planned but arose as a response to the development and dissemination of the AENC. It was swiftly realised that additional supportive structures should be available for emergency nurses to access expertise to enhance their learning, particularly as many worked in isolation. Such expertise is sought through international and regional arrangements, from peers around the globe who are willing to voluntarily give their time and expertise. A pilot mentorship activity, pairing ten individual mentees to mentors, showed a mixed experience was gained, with some mentees finding it extremely beneficial to their own development, but also quite a challenge to maintain due to resource deficiencies [10]. The idea to formalise this project required further development, as well as the need to secure further resources in the form of administrative support to identify mentors and mentees, match them and then follow up on progress at regular intervals. While the GENMA programme was intended to roll-out in 2019, ongoing resource constraints to run such a programme were observed, however AFEM interns have provided valuable support. Additional support is still being explored.

Emergency nurses induction booklet

The Nurses Induction Booklet (NIB) outlines the uniqueness of the specialty of emergency nursing and prepares nurses working in the EC for the first time. The development of this booklet arose following concern raised by an emergency medicine specialist that nurses in his own country needed better preparation to work in newly established ECs. This booklet was developed using the document, World Health Organization – International Committee of the Red Cross document in collaboration with the International Federation of Emergency Medicine entitled, ‘Basic Emergency Care: approach to the acutely ill and injured, Participant Workbook’ [11] and was guided by the AENC. The NIB details the importance of being orientated to the work environment, to review specific standard operating procedures and policies pertinent to ED work and, to get to know the ED team so that care is well-coordinated. Access to the NIB is available at the following website: https://www.dropbox.com/s/u0gx9d6p39oi3hr/AFEM%20NIB.pdf?dl=0.

Operational challenges

In carrying out this work the AFEM Nurses Group experienced a number of challenges.

Lack of resources

While a small number of emergency nurses in influential roles, within Africa and beyond, put much effort into pushing forward the emergency nursing agenda, it remains questionable whether this is enough. Wholescale African emergency nursing system reform is needed to realise full benefit however, the lack of co-ordinators (champions) inhibits this. For this initiative to succeed we need to identify committed individuals, willing to devote the time, with the requisite knowledge and skills to implement such activities regionally. It would be appropriate for each AFEM region to identify co-ordinators to help disseminate resources and information pertaining to the activities of the AFEM Nurses Group. In many countries however, there is a monthly or yearly reshuffling of nurses through the EC thus making the development of a specialised group of expert emergency nurses very difficult.

Communication challenges

Communication disruption remains a major barrier. Participation in activities is generally hindered because a) not many of the nursing contacts are registered with AFEM as individual members; b) the bulk of the nurses on the database seldom responded to emails and c) the nurses may have been moved out of the EC or their details changed. Many parts of Africa are not resourced with a constant supply of electricity and mobile service providers that are reliable and/or affordable networks for the use of data bundles. This makes it more difficult for digital learning and communication with individual nurses, thus, resources may not reach the wider audience. Instead, the use of social media e.g. WhatsApp, Facebook should be maximized to ensure a successful communication strategy to enable regular communication and follow-up. Maintaining a database of contacts requires regular administrative upkeep and resources to manage this.

Education uptake is slow

While much effort focuses on the delivery of educational programmes in emergency nursing it is important to recognise that securing accreditation to recognise and run such programmes is very time consuming and demanding. Further, finding in-country experts to teach, even only short course, may be difficult. Regarding the AENC, emergency facilities seem slow to take up the document. Indeed, to gain reach, a top down approach from policy to university, with essential clinical area input, may provide a more effective strategy whereby each country identifies individuals responsible for leading such initiatives. It is also important to consider the role research pays in the further development of emergency nursing in Africa.

Lack of monitoring and evaluation of initiatives

Individual member countries and institutions have not reported back on their use and or adaptation of initiatives such as the AENC, and NIB so the working group cannot readily assess or evidence the use and outcomes of such adaptations. Indeed, initiatives may not have been fully applicable to all countries so will need the countries to refine them to suit their circumstance. A reporting mechanism needs to be developed so that impact of initiatives is adequately assessed.

Successes

Growth of emergency nursing champions

There is a growing sense that a sustainable AFEM Nurses Group, made up of a core team of members, has been formed with representation from numerous African countries and beyond. This group has been responsible for developing a number of emergency nursing products, and through their visibility as the AFEM Nurses Group, their work has served to guide and support (and mentor) other emergency nurses in Africa with their own development. Member of this group have also been involved in the development of other AFEM educational resources, for example the AFEM Paediatric Curriculum thus promoting interdisciplinary collaboration within the organization.

Development of educational resources

In particular, the AENC has helped to start to harmonise standards of emergency nursing theory and practice across Africa and is due for evaluation and renewed endorsement to ensure it remains suitable in shaping emergency nursing education for the next five years. It is also very encouraging that an in-country short course developed using the AENC and taught by local emergency nurses has been so successful and sustainable in addressing relevant emergency care needs locally. Since 2014 this short course continues to be delivered regularly and many nurses have successfully exited.

Appropriateness and accessibility of resources

The AFEM Nurses Group has endeavoured to ensure that all strategies undertaken are respectful of different countries and contexts they may be used in. In terms of reach, it is important that all activities be accessible to all practitioners in the countries where they practise using their local language. The aforementioned documents were translated into French to facilitate emergency nurses working in Francophone countries and will soon be available in Portuguese.

Lessons learnt

Following the work by the AFEM Nurses Group a number of lessons have been learnt;

An established group of emergency nursing champions within Africa is essential in order to develop and progress these endeavours. It is necessary to continue to identify such nurses, and to encourage them to become actively involved in the AFEM Nurses Group initiatives.

The framework and strategic plan proved an extremely useful strategy in guiding the development of emergency nursing in Africa by ensuring a coordinated and orderly path towards defined objectives. In hindsight, a shortened interval between publishing the framework and commencing work on the strategic plan would have been beneficial however this was dependent on availability of expertise and financial resources. Further work is needed to take forward the next phase of the framework and strategic plan and to create guidance documents to interpret use at individual country level.

A regional collaborative approach helps to acknowledge and value strengths apparent in each country by celebrating and sharing expertise while remaining sensitive to the uniqueness of each country/context. It is important to continue to create opportunities to empower emergency nurses, as policy makers with a voice, and for them to work together.

Establishing interdisciplinary support; enabling e.g. nurses, doctors and pre-hospital staff to work towards the common goal of the development of emergency care, has mobilised the support needed to collectively lobby for change. Such experiences need to be showcased to provide encouragement and motivation for others.

Working under the auspices of AFEM, which is a multidisciplinary emergency care organization, has been essential in providing support and credibility, thus ensuring the success of the AFEM Nurses Group strategy. On reflection, a more comprehensive communication approach could have established wider reach across Africa earlier in the process. It remains important to encourage emergency nurses throughout Africa to join AFEM and become actively involved.

Global support from international emergency nursing organisations and individuals provided vital guidance regarding the best way to proceed. These networks need to be nurtured.

Improving the visibility and accessibility through career days, community forums etc. of emergency nursing as a career option for student nurses potentially provides a real investment to strengthen the emergency nursing workforce.

Conclusion

It is eight years since the development of the emergency nursing framework and some important steps have since been made in the quest to enhance emergency nursing. The development of the African Emergency Nursing Framework served as a template to visualise the direction of emergency nursing development and was key to the creation of subsequent activities. The support of AFEM leadership and the AFEM interns needs to be acknowledged for the essential part they have played in ensuring the success of the AFEM Nurses Work Group.

As new countries come on board and share the ideals of AFEM, emergency nurse champions will need to be identified. It is therefore dependent upon the willingness of the African emergency nursing fraternity to embrace the spirit of change for the benefit of emergency populations and this is achieved by increased reach, collaboration with policy makers and governments as well as health service employers.

The question is how best to further develop and coordinate emergency nursing energy across Africa to develop emergency nursing practice? There is still much work to be done.

Dissemination of results

In preparing this manuscript for publication, results from this article have been presented and shared through conferences including: AFCEM 2020.

Authors' contribution

Authors contributed as follow to the conception or design of the work; the acquisition, analysis, or interpretation of data for the work; and drafting the work or revising it critically for important intellectual content: PB contributed 35%; TS 35%; EA 15% and IM 15%. All authors approved the version to be published and agreed to be accountable for all aspects of the work.

Declaration of competing interest

All authors are members of the African Federation for Emergency Medicine.