Vol. 5(7), pp. 117-131, November 2013 International Journal of Nursing DOI: 10.5897/IJNM2013.0104 ISSN 2141-2456 © 2013 Academic Journals and Midwifery http://www.academicjournals.org/IJNM Full Length Research Paper Roles of nurses in Sub-Saharan African region C. G. Ugochukwu1, L. R. Uys2, A. K. Karani3, I. L. Okoronkwo1 and B. N. Diop4 1Department of Nursing Sciences, University of Nigeria, Enugu Campus, Nigeria. 2School of Nursing and Public Health, University of KwaZulu - Natal, South Africa. 3Department of Nursing, University of Nairobi, Kenya. 4National School for Health and Social Development, Dakar, Senegal. Accepted 19 September, 2013 The objective of this study was to create a model of nursing practice in Sub-Saharan Africa based on population needs, current practice and expectations of stakeholders. A three component study was done in eight sub-Saharan countries to ascertain (1) the health needs and the burden of disease in these countries, as well as evaluating the structure of their health systems; (2) the views on nursing functions held by opinion leaders in the community, other health professionals, patients and their families; and (3) to conduct a survey of nurses and midwives to determine the roles that they actually perform in hospitals and public health centres (PHCs). Four Anglophone and 4 Francophone countries were studied with a document audit, and 191 stakeholders included in focus groups. The current practice of 734 nurses in ambulatory and hospital settings was evaluated. Based on a triangulation of this data, 9 roles were identified: the provision of holistic care, health education, managing the care environment, as well as the advocacy and collaboration, providing emergency care, providing midwifery care, prevention and management of infectious diseases and diagnosis and treatment. Three contextual support factors (positive policies and practices, an enacted regulatory framework and an enabling educational system) were also identified. Key words: Africa, midwives, nurses, roles. INTRODUCTION Nursing has many similarities across the world based on are done regularly to inform educational decisions. Such the social expectations attached to the profession. role formulations underpin the regulation of nurses/ However, Squires (2004) points out that the role of midwives, in terms of both scope of practice and nurses tasked with acute care varies significantly from educational standards. country to country, because of different social expecta- For nursing care to be relevant and nursing education tions regarding the roles which nurses play in patient to be appropriate, the needs of the sub-Saharan African care. “These social expectations are influenced by histo- population and health services should play a major role in rical relationships between nurses and physicians, the defining nursing. health system, the level of country development, and the The human health resource challenges of Africa are public image of nurses, to name a few” (Squires, 2004). enormous and shortage of nurses is acute in many The roles of nurses are also shaped by professional countries, with little hope of a sudden alleviation of the si- considerations, human resource issues, patient demands tuation. Therefore, it is essential that these scarce health and cost implications as opined by Srivastava et al. care professionals may not only be appropriately trained, (2008). Nurse’s roles change over time and in some but also be creatively deployed. To achieve these objec- countriessuchastheUnitedStatesofAmerica,taskanalyses tives, the first step would be to understand exactly what *Corresponding author. E-mail: [email protected]. 118 Int. J. Nurs. Midwifery the job demands are for nurses. health care is also radically divergent and this has a Since regional bodies such as the African Union and profound influence on the care given by nurses and the world health organisation (WHO) African Regions midwives (WHO, 2009). The entire Sub-Saharan African play such a strategic role in driving change in health countries in this study utilize the primary health care systems, it is important to improve the understanding of approach, and all have services at primary, secondary nursing and midwifery across the region. This may allow and tertiary level (Table1). for the harmonisation of human resource strategies and Although not all the countries use the same terms for promote regional collaboration to improve quality of subdivisions, most have minimum of two levels of divi- education and service. sion, with a wide variation in numbers. Types of services, such as health posts, clinics, district hospitals and referral hospitals, are between five and seven, with about two BACKGROUND TO THE PROBLEM levels of primary health care services and three hospital levels. Internationally accepted descriptions of the roles and functions of nurses, delineations which inform definitions of, as well as textbooks and curricula on nursing, are The role of the family in hospital care almost exclusively based on the current experience of nursing in developed countries. This is because there are Although it is recognized that the family plays a role in the no known documentations on the roles that nurses care of ill family members around the world, this role is undertake within the health systems in Africa. The views more extensive and institutionalized in some countries. In and flow of information from the developed countries many low-resourced Sub-Saharan African countries, care have therefore strongly influenced sub-Saharan Africa in hospitals, including food and medication, is supplied by nursing, but the reality of health and illness, as well as the family and a family member stays with the patient health care in sub-Saharan Africa, differs profoundly from most of the time. Managing medication, a typical nursing that in developed countries. It is also pertinent to mention role, is also ascribed to the relatives who buy prescribed that an appreciable number of educators in sub-Saharan medication and administer it to the patient. This may be Africa obtained their education in developed countries. by default rather than design, but nevertheless, it reflects In the most affected regions of Sub-Saharan Africa and the reality for many nurses in Sub-Saharan Africa. The South-East Asia, the responsibilities of nurses have nurses actually oversee any aspect of care contribution increased in line with expanding health services to meet by the family. local, national and global health targets, including the United Nations Millennium Development Goals Personnel shortages (Nga’ang’a and Bryne, 2012). In a variety of ways, the burden of diseases, the health Another disparity is that the professional educational care delivery system, family involvement in care, staff background, skills and availability of various health pro- shortages, issues of task shifting/sharing all contribute to fessionals in Sub-Saharan Africa is vastly different from the reality of the unique nature of the health systems and that of developed countries (Aiken et al., 2008; Simoens the enormity of efforts required to make a change. The et al., 2005; Cho et al., 2003; Needleman et al., 2001). nurses’ roles in the health systems would need to be The difference in availability of health care teams in high reviewed delineated and recognized for better impact and and low income countries profoundly influence the health optimum contribution to positive health outcomes. care tasks and roles demanded from nurses. In the ab- sence of a comprehensive range of health professionals, the normal, legitimate role of the nurse is part of what Burden of disease would be considered the advanced practice role in some developed countries. The nurse within a primary health One of the differences is that the morbidity and mortality care system could function as a doctor, nurse, a pharma- statistics in Africa are very different from those of cist, laboratory scientist as from assessment of the client, developed countries. The greatest burden has always and/or diagnosis and prescription (where applicable), the involved infectious diseases and now, over the last 20 nurse not only dispenses medications, but conducts years, with the addition of HIV/AIDS and drug-resistant simple tests as deemed possible and as a first measure infections, an even more complicated pattern has of care before appropriate referral, transfer or continuity developed (WHO, 2004). of care based on the client situation. Health system structure Legal and regulatory framework Another difference is that in most developed countries, the organization of health services differs greatly from Furthermore, some of the countries in Sub-Saharan that in Sub-Saharan Africa. Similarly, the financing of Africa lack the regulatory frameworks to monitor the Ugochukwu et al. 119 Table 1. Summary of the structure of health services. No. of No. of No. of No. of service Beds/10000 of Country regions districts Ministries types people Botswana 9 28 2 7 24 Cameroon 10 - 1 5 11 DRC 11* 2 levels 1 5 11 Kenya 8 47 1 6 14 Niger 8 42 1 5 ? Nigeria 36 774 1 5 5 Senegal 14 69 1 5 1 Tanzania 26 127 2 6 11 Zambia 9 74 1 5 22 *Due to change to 24 in new constitution. Table 2. The nursing workforce categories and duration of training. Country Category 1 (year) Category 2 (year) Category 3 (year) Midwives (year) Botswana 3/4* - - + 1-2 Cameroon 3/4 2 1 + 1-2 DRC 3/4 2 - 3 Kenya 3/4 2.5 1 + 1 Niger 3 3 2 3 Nigeria 3/5 2 1 + 1 Senegal 3 years after 2 1 3 ** Tanzania 3/4 2 - 2 *** Zambia 3 2 - 2 *3 years by diploma and 4 years by BSN. **1 year for nurse training and 2 years of specialization. ***Enrolled Midwife only. the regulations and standards pertaining to nursing their basic care roles to less qualified health workers education and practice (Frenk et al., 2010). Regulation is (Munga et al., 2012). In some of the countries in Sub- the key to professional practice, protection and safety of Saharan Africa, the distribution of health workers and consumers of nursing and midwifery care and services. nurses at the various health levels and subdivisions Although this is being addressed by a range of initiatives reveal a shortage, and poor coverage for the services in Anglophone countries, like the work of the Nurse being provided. In order to ensure that care and services Education Partnership Initiative (NEPI, are still covered commendably, nurses take on extra www.icap.columbia.edu); the issue of regulation is getting tasks to theirs, and also facilitate delegation of tasks to little/very slow attention in Francophone countries, but other available staff according to their category and hopefully may be overcome with the multiple approaches training. being used to encourage maintenance of standards in service delivery. Categories of nurses Task shifting All but one of the countries in the study have more than one category of nurses with the highest category Nurses taking on the tasks of doctors or pharmacists, demanding 12 years of school for entry, category 2, and/or nurses shifting/sharing some of their tasks with between 10 and 12 years of school and category 3, other health workers, has also had an effect on the roles between 6 and 12 years. In most countries, midwifery is of nurses and midwives in Sub-Saharan Africa. Nurses an additional qualification to the nursing qualification have expanded their roles in areas such as surgical (Table 2) so that many nurses are also midwives. procedures (Chu et al., 2011) and anti-retroviral Descriptions of the roles of nurses in Africa have treatment (Shumbusho et al., 2009), while delegating usually been based on the opinions of expert groups such 120 Int. J. Nurs. Midwifery as East, Central and Southern African College of Nursing current roles of nurse/midwives in Sub-Saharan Africa (ECSACON) who stipulated that nurses’ and midwives’ health services, and the role expectations of stakeholders roles fall under three broad areas; namely, provider and for nurses in Sub-Saharan Africa; the health, illness and collaborator, professional role and advocacy role care needs of the Sub-Saharan Africa population in the (ECSACON, 2001). light of the type of health workers and their availability (skills mix) in the health team, with special reference to nurses. CONCEPTUAL FRAMEWORK AND DEFINITION OF The study focuses on all categories of nurses, and not TERMS exclusively on registered nurses. It also focuses on the clinical roles of nurses, and not on management, According to Lynch (2007), traditional role theory is education or research. based on either a functional or an interactionist perspective. The functional perspective sees roles as normative, created by society, and relatively inflexible. LITERATURE REVIEW The interactive perspective sees roles as more changeable, continually being negotiated between the In the USA, the National Council of State Boards of individual and social structures. More recent approaches Nursing (NCSBN) does a periodic practice or job analysis to role theory focuses strongly on the role transitions of in order to ensure that the licensure examinations are individuals (Neale and Griffin, 2006) and the continuous valid measures of the actual current practice of nurses in movement between roles and even enactment of different the country. Using questionnaires distributed throughout roles at the same time (Lynch, 2007). the country and developed by experts, they obtained data The functional approach was chosen for this study, from approximately 20,000 nurses regarding the because the focus is on the more long-term, socially frequency with which they engaged in some 153 nursing sanctioned roles of the nurse, which are given expression activities. This well-developed methodology provides a in scope of practice regulations developed by national valid description of general nursing practice in the USA. regulatory bodies and which underlie the educational A more specialised study was done by Abdallah et al. programmes of nurses. This approach is also appropriate (2005) using a tool, the EverCare Nurse Practitioner Role to the idea of a social contract on which the and Activity Scale (ENPRAS), with six subscale roles and establishment of a profession is based, that nursing was describing the practice of nurses in five sites. EverCare is established to serve a specific need in society. The a management care model which has been implemented expectations attached to the role of nurses are based on in the USA and the UK for the care of institutionalized the health needs of the population (the focus of elderly patients. Both of these studies were based in the component 1 of this study). USA. A role is an organized collection of behavioural In Sub-Saharan Africa, in a study in South Africa for a expectations (Neale and Griffin, 2006). A role consists of job analysis of health workers in a district health system specific tasks, responsibilities and traits essential to its (Uys et al., 2003; Mbambo et al., 2003), an instrument performance (Dierdorff and Morgeson, 2007). Biddle and was used. The instrument was developed based on the Thomas (1966) identify seven ways of describing roles, Primary Health Care Package of South Africa and inclu- two of which will be used in this study; namely, overt ded 141 tasks. Nurses responded to the four point scale prescriptive and overt descriptive roles. In this study, questionnaire as they performed each task (four-point overt prescriptive roles are those tasks that are directly scale from “less than once per week” to “over ten times given to a set of people, e.g. nurses (the focus of per week”) and how important they thought each task component 2 of the study), while overt descriptive roles was (two-point scale being “could sometimes be omitted” are the tasks that are observably performed by the group or “could never be omitted”). Two samples were used (the focus of component 3 of the study). The aggregate and a mail survey including 42 nurses working in district overt roles of nurses, rather than individual nurses and hospitals and 61 nurses working in primary health care covert aspects of roles, such as motives and values, are clinics, representing 19 and 22% of the randomly sam- addressed in this study. Similarly, the more long-term pled nurses, respectively. In this study, observation was roles which are captured in regulations and laws are also done to identify environmental factors influencing the addressed, rather than the continually changing role task performance. The same list of tasks were used, but enactment of individuals with multiple other roles as well. observers also made notes on physical and social environments, interruptions, control over speed of task performance and task demands. This was useful in Objectives of the study validating the data from the questionnaires as well as providing additional information. The objectives of this study were to develop descriptions Another study in Mozambique identified the knowledge of nursing roles in Sub-Saharan Africa that is based on the and skills necessary for all categories of nurses in that Ugochukwu et al. 121 country Ministry of Health (MOH, Mozambique, 2010). midwifery programmes. One of the recommendations of The researchers developed a tool based on the this study was to develop competency-based curriculum International Council of Nurses (ICN) Framework of framework to provide guidance to these countries. It Competencies, and a number of WHO AFRO documents. would be essential to base such competency frameworks The final instrument contained 233 items organized into 9 on empirical evidence of the current health care and domains and addressed both frequency and importance. health service needs. The World Health Assembly (WHA) Data was collected through interviews with 1,295 resolution 62.12 urges member states to provide individuals representing all regions of the country. Based universal access to comprehensive public health centre on their results, they made recommendations about the (PHC) services. This calls for adoption of appropriate curricula of different categories of nurses, identifying both delivery models which are people centred and promote the unique and common roles. participation, ensure appropriate skill mix of workers in a Parent et al. (2006) did a study to describe the multidisciplinary context. competencies of different categories of nurses in the Very few studies seem to have been undertaken to Democratic Republic of the Congo. They studied nursing describe and analyse the tasks and roles of nurses in curricula and then observed nurses in health settings to Sub-Saharan Africa (MOH, Mozambique, 2010; Parent et compare what they did with their knowledge. Based on al., 2006) and the change in roles with time (Natan and this study, they identified four essential components for Meir, 2011; Wendt and Eich, 2007). the development of the profession-analysing problems, implementing plans, managing resources and communi- cation skills which were used to develop curriculum MATERIALS AND METHODS guidelines. The model is derived from a mixed-method involving an The WHO AFRO developed an “action framework” for explanatory, comparative country-wide case study of the role of the strengthening of nursing and midwifery in 2007. In the nurses in the Sub-Saharan Africa region (Yin, 2009). Each case document they produced, the roles of the nurses and study therefore included three components: (1) a document review midwives in Africa was summarized as follows by the to establish the health and illness needs and describe the health services, (2) a qualitative study to establish the expectations of WHO AFRO: “the care they provide includes, inter alia stakeholders (Seboni et al., 2013), and (3) a quantitative survey to health promotion, prevention measures, the detection of describe the current practice of nurses (Uys et al., 2013). abnormal conditions within the family and the community, Each of the three components of the study used a different data the procurement of medical assistance and the execution collection methodology and was described in separate articles, as of emergency measures in the absence of medical help. reflected earlier. In this regard, the work of nurses and midwives also The study involved eight African countries as set out in Table 3. It was assumed that countries with the same national language (e.g. extend to issues such as gynaecology, family planning English or French) would share similar nursing histories, have and childcare. They are expected to do basic diagnostics, similar health care systems and nurses would assume similar roles. and must be able to confidently provide counselling on a An effort was made to include at least four Anglophone and four variety of ailments especially those pertaining to the Francophone countries, because each country has its own history mother and child. In addition, the nurse and midwife that was moulded by colonialism that also impacts on health and should be able to manage a basic health facility within a illness. Since it was also possible that health services and health/illness patterns differed by region, all four regions of Africa community, generate and interpret health statistics and were included in the sample. submit appropriate reports as required” (WHO AFRO, In each country sampled, a nurse with at least a Bachelor’s quali- 2007). The ECSACON with Nursing and Midwifery fication was invited to participate in the study as a co-investigator Professional Framework (2001) stipulate that nurses and through a local university. This country investigator then assembled midwives’ roles fall under the three broad areas of a country team who included opinion leaders in nursing and midwifery from the regulatory body, the nursing organization, provider and collaborator, professional role and advocacy nursing management and nursing education who advised on role. The interventions should focus on promotive, cu- different aspects of the study. rative, preventive, rehabilitative and palliative care within All the instruments were translated into French by two the primary health care framework. Both the WHO AFRO independent translators, and a third independent linguist compared frame work and the ECSACON roles appear the two translations, and in consultation with the research team, complementary to each other, and are all relevant in the decided on the most appropriate translation (Swaine-Verdier et al., 2004). Translations of different sentences or items are usually very Sub-Saharan Africa. similar, but in some cases, one is clearly more appropriate for WHO AFRO (2008) conducted a survey of education conveying the meaning of the original. In such cases, this version programmes in nursing and midwifery in Francophone was accepted. Consultation with the translators and the research African countries, because of “perceived gaps in meeting team only took place when the third translator could not decide the health needs of the community and inadequate capa- which of the translations was most appropriate. Translation of focus city of health care providers”. They found that “neither groups data were done by the researcher and reviewed by the co- presenter of the groups. nursing nor midwifery has clearly defined competencies The study protocol was approved by the Ethics Committees of that students should exhibit on graduation” and also a the Universities of the four principal investigators. Participation of all lack of regular/systematic evaluation of nursing and nurses and others was voluntary, and they were fully informed 122 Int. J. Nurs. Midwifery Table 3. Sample of countries. Region Francophone Anglophone Total West 2 (Niger and Senegal) 1 (Nigeria) 3 Central 2 (Cameroon and DRC) - 2 East - 2 (Kenya and Tanzania) 2 South - 1 (Botswana) 1 Total 4 (50%) 4 (50%) 8 about the study. nurses were studied using a qualitative method involving focus group discussions with the following stakeholder groups in each country: patients, their families, community members/leaders, other Component one: Health, illness and care needs health workers and professionals, nurses and health service managers (Seboni et al., 2013). Other health professionals were The data was derived from a document review based on the included since the roles of nurses include interacting with them, following case protocol, according to which each country was patients, their families and community members since they are the described: health system components at all levels of service; health consumers of care by nurses. Health service managers were in- statistics; mortality rates; health services coverage; health system cluded since they understand the human resource and cost factors resources; health workforce. which impact on the roles and senior nurse, especially from the In order to obtain comparable descriptions, a model country regulatory bodies, were included to reflect the professional’s views. description was developed addressing the case protocol headings The focus group discussions dealt with the following questions: and the country teams were then asked to populate the description (1) What do you think are the most important roles or functions of with country data. the nurse in (country name)? (2) What should they be doing that they are not doing? (3) What are they doing that they should not be doing? Document sampling The focus group discussions were facilitated by the national investigator from each country with a co-facilitator who was not a In each country, the country team had to identify and find the most nurse. All sessions were tape-recorded and transcribed. Consent recent and reliable data addressing each of the case protocol was obtained from all the participants as explained in the earlier categories. This usually included reports from governments and paragraph. non-governmental organizations, data bases to which they had access. The health care needs of the population were described based on a range of indicators from the World Health Organization Focus group samples website (WHOSIS, www.who.int/whosis/en/index.html) and the WHO Global Burden of Disease (GBD) website The focus groups participants were purposively selected by the (www.who.int/healthinfo/global_burden_diseases/2004_report_upd country research advisory group as a credible group of opinion ate/). leaders from the identified groups. They included professional asso- ciation members, representatives of regulatory body (in countries that have regulatory bodies), educators, health service managers, Data analysis patients and care givers, community members and other health professionals (pharmacists, doctors, and others). They were chosen Having completed a case study for each of the eight countries, a and invited according to their ability to articulate the expectations of cross-case analysis was conducted using a nominal group. A a particular group and their knowledge of the health care system of nominal group technique was used to identify the implications of the the country, and in relation to the role of nurses in that system. In cross-case analysis for the role of the nurse. A group of 17 nurse some cases, invitees brought additional members of their group to and midwifery leaders from 13 Sub-Saharan Africa countries were these meetings and such people were included in the focus groups. brought together for the nominal case analysis, after having been requested to read the cross-case description. The purposively selected group included academics, health service managers, Data analysis consultants and clinicians to represent the main sectors in nursing and both Anglophone and Francophone countries in Africa. A content analysis was conducted, based on role statements The nominal group was asked to list the implications for the role identified in the transcripts. Each statement that alluded to what of nurse of each of the four sections of the case description outlined nurses should do or are doing was classified as a role statement earlier. The themes that emerged from the discussions were and the support or lack of support for such a role was noted. No discussed, and statements for which role implications were not particular role template was used. Role statements from different identified were deleted. Finally, the group formulated the refined groups and countries were then compared and both role consensus implications that adequately captured their perspective of the and lack of agreement described. Furthermore, concerns around implications for the role of the nurse. consensus roles were identified and described. Component two: Role expectations of stakeholders Component three: Task analysis The role expectations of selected stakeholders with regard to The current roles of nurse/midwives were described using a Ugochukwu et al. 123 quantitative task analysis survey of nurses in each of the countries, its essence are summarized in Table 4. The evidence for describing the frequency and importance of tasks performed by each role from each of the study components is reflected nurses according to their own perspective (Uys et al., 2013). as the following. The instrument was based on a primary health care questionnaire developed by Mbambo et al. (2003) which had an overall Cronbach’s Alpha of 0.990 and 0.98 for the frequency Provide physical and psycho-social care for patients variable and 0.988 for the importance variable. Section one has five in hospitals in an ethical and professional manner demographic questions (gender, age, professional rank, nurse type (taking care of patients) and service setting). Section two consists of a list of 156 tasks that describes the nursing practice in a particular setting, covering the Role expectations: Basic nursing care is the component following seven roles: general care and treatment, general assess- of care that deals with the assistance in self-care that ment, health education, planning and management, mother and constitutes the activities of daily life performed by per- child health, mental health and rehabilitation. For each task, three questions are asked: whether the task applies to the setting; how sons who are either physically or mentally compromised. frequently it is performed (less than once per week, 1 to 5 times per Providing care in an ethical manner means that it is week, 6 to 10 times per week, more than 10 times per week); and offered according to the values of the profession, in- lastly how important the task is (whether it can sometimes be cluding aspects such as confidentiality, treating all people omitted or should never be omitted). as equal, respecting the privacy and choice of persons. Providing care in a professional manner means that it is Sample provided according to the standards of evidence-based care, timely care, efficient use of resources and conti- A stratified convenient sample of nurses was used for the task analysis survey with nurses from targeted health services were nuous monitoring and improvement. Based on the role of approached by the country principal investigator on a certain day nurses at all levels of the health service, the need to and asked to participate. No power analysis was done due to prepare the nurse for this role in all settings, and not only limited funding being available. A total of 927 nurses were included in hospitals, was emphasized as shown in the following in the sample, with samples ranging from 79 to 122 per country. statement by a patient: The samples in each country were stratified for levels of health setting, with more than one service level included. “To me a nurse, just from the word itself “nurse” makes you expect that she will take care of you. When you get Data analysis to the health facility, you expect a warm welcome from your nurse, such that even if you are in pains you feel For each task, a score was calculated taking into account both frequency and importance (task index) (Uys et al., 2013). A well from the reception. So we expect humbleness, standard score was calculated for each role based on the mean humility, and for the nurse to provide counseling and that task-index scores of the sum of the tasks assigned to each role. you do not feel rushed. You hope to be cared for towards recovery”. RESULTS Health, illness and care needs: The disease burden in Triangulation of the data the countries studied indicates that nurses/midwives need to be competent in communicable, chronic and The results of the three component studies were syn- emergency conditions, and aware that the particular thesized using an adaptation of the thematic synthesis disease burden in each country might be slightly different. approach recommended by Thomas and Harden (2008) For instance, in some of the countries, the tropical cluster for the synthesis of qualitative research in systematic diseases (Trypanosomiasis, Chagas disease, reviews to augment the cross-case synthesis suggested Schistosomiasis, Leishmaniasis, Lymphatic filariasis, by Yin (2009). The nine roles identified by the stake- Onchocerciasis) are in the top ten diseases impacting the holders (component 2) were taken as the analytic themes disability adjusted life-years (DALYs) in children, but it for the synthesis, since it was the most comprehensive. does not feature in others. The other important factor is The role implications identified through the document re- the high proportion of young people in Sub-Saharan view (component 1) and the findings of the qualitative Africa, with 43% of the population being under the age survey (component 3) was coded according to these of15 years. The high percentage of children suggests an themes (roles). Each role was then defined and important need for nurses to focus on child health care described, and descriptors provided for the role from one and the promotion of child health. or more of the components of the study (Table 3). Two additional themes were identified: a role that addresses Task analysis: From the survey of the current roles infectious diseases and the contextual factors influencing practiced both in hospital and ambulatory settings, the the role of the nurse/midwife. general assessment (57.4 and 53.3%, respectively) and general treatment and care (58.9 and 55.8%, respec- Identified roles: Description and supportive evidence tively) roles were the most common, and was significantly higher in frequency and importance than some of the other The role descriptions or aspects of the role that describes roles. 124 Int. J. Nurs. Midwifery Table 4. Roles and role descriptors. S/N Role Role descriptors Ensure and/or provide basic nursing care to patients (SH*); Ensuring a clean and hygienic care environment (SH); Giving emotional support through talking and listening to patient concerns (SH); Treating all patients and families with respect and kindness (SH); Assist with self-care of physically and mentally compromised patients (SH); Provide physical and psycho-social care for patients in Being available and close to the patient and family (SH); 1 hospitals in an ethical and professional manner (taking Doing home visits to provide continuity of care (SH); care of patients) Provide necessary and correct treatment for illness as prescribed (SH); Providing community-based mental health care (HN); Manage old and emerging chronic illnesses at PHC level (HN); Structure and develop the management of communicable diseases (HN); Provide care to children and young people according to their particular health needs (HN). Providing information to communities about how to protect themselves from illness (SH, HN); Educate patients and their caregivers about Provide health education to communities, care providers, the illness, treatment and self-management/care (SH, HN); 2 clients and patients Teach other caregivers on proper care approaches (SH); Inform patients, clients, families and communities about available services and programmes (SH). Provide a welcoming and supportive care environment (SH); Ensure the availability of supplies and equipment to enable good care (SH); Manage the care environment of patients and clients to 3 Promote the economical use of resources (SH); optimize care delivery Manage the care giving routines well and efficiently (SH); Provide supervision of other categories of health workers, e.g., community health workers. Talk on behalf of patients and clients who cannot do this for themselves due to some incapacity (SH); Advocate for adequate resources for care, including promoting appropriate policies (SH and HN); Advocate on behalf of patients to ensure that health needs 4 Advocate for an adequate mix of health professionals in adequate numbers to ensure successful health outcomes (HN); are addressed appropriately Advocate for access to appropriate and timely care (SH); Blow the whistle on practices that exploit patients, clients and their families (SH). Provide timely emergency care in health care settings to handle medical, surgical and mental emergencies (SH); 5 Provide emergency care Provide timely emergency care in community and home settings before referral, where necessary (SH). Collaborate with the nursing and multi-professional team to ensure that patients and clients access the appropriate care (SH); Ensure good collaboration with health service managers to promote continuing care, resources and support (SH); Collaborate with the community, the family, the individual, Collaborate with family and other informal care providers to limit the use of professional resources for basic care while promoting good 6 other health workers and sectors as well as other nursing quality care (SH); colleagues to enhance health and health care Intervene when care by other providers is not being provided as expected (SH); Work with other sectors in the promotion of health, prevention of illness and provision of health care (HN). Ugochukwu et al. 125 Table 4. Contd. Provide midwifery care to women and infants up to the Care of the pregnant woman and the family (SH, HN); 7 postnatal period.. Provide delivery and post-natal care (SH, HN); Take a thorough and appropriate history and do a appropriate physical examination (SH); Making a diagnosis and prescribing and giving treatment in Diagnose what is wrong (SH); 8 an ethical and professional manner. Treat the problem or refer if appropriate (SH); Manage chronic illnesses at PHC level through treatment, education and support (HN) Implement individualized strategies to prevent infection (HN); Engage in strategies to prevent and/or manage 9 Educate individuals, families and communities to prevent infection by diseases prevalent in the community (SH, HN); communicable diseases Manage community-based campaigns or programmes to prevent or manage infections (HN) *The reference source of each aspect of a role is indicated by initials: SH for stakeholders, HN for health needs and CR for the current roles. Mental health care was found to be one of the about the burden of each disease should play a Manage the care environment of patients and least prevalent roles used in either the hospital or major role in the content of health education. clients to optimize care delivery ambulatory settings (49.5 and 45.1, respectively). Prevention, early detection and treatment, long- Performing the tasks in the mental health care term management and rehabilitation are all Role expectations: Nursing care is provided or role seems to be more prevalent in Anglophone dependent on an adequate knowledge and within an environment to which the patient, client countries, with three of the four Anglophone understanding by the general and affected family come for assistance. The service countries revealing significantly higher incidences populations. environment is the first aspect of care of these tasks than their Francophone counter- experienced by the patient or client, and may parts (Anglophone 56.2% and Francophone determine their response to intervention. In most 34.8%). cases, the nurse is the line manager in charge of Task analysis: According to the practice survey the health service environment and is the only on current roles, out of seven, health education is health worker who can ensure that the physical Provide health education to communities, the fourth most common role (hospital 51.7% and and emotional environments are up to standard care providers, clients and patients ambulatory 52.8%). No significant difference was and promote good quality care. found between hospital and ambulatory settings They do not play their role as supervisor, Role expectations: Although nurses are in this role presentation. The need for health controller health. The functions of these providers responsible to give services to patients but also literacy in order to empower communities, revolve around the administration and manage- they are required to provide health education to families and individuals to prevent illness and ment of care appropriate to the level described. the communities. They can educate community self-manage their own care, demands a level of on how to protect themselves against diseases health education, techniques of behaviour change such as, educating community on importance of and interactive teaching from the nurse that may Health, illness and care needs: Focus group using boiled water to avoid cholera and other not be part of current education and practice. This participants were very conscious of the limited diseases. role again points to the need to train and educate resources available for health care in their own nurses, not only in ambulatory and hospital countries. The case studies indicated that much settings, but also to work directly in the of the health care was currently paid for by con- Health, illness and care needs: What is known community. sumers (58%), mainly in the form of out-of-pocket 126 Int. J. Nurs. Midwifery payments (80%). The role of the nurse in ensuring that of violence and natural disasters. The high levels of care is planned and executed as efficiently as possible to intentional violence (one of the top 10 causes of mortality limit costs is therefore an important one for consumers. It and impact on DALYs in adults) would also benefit from is one, however, that will require development. forensic nursing skills and the ability to develop multi- sectoral collaboration with law enforcers and social services. Task analysis: This role was the fourth or fifth most common role in hospital and ambulatory settings (51.8 and 47.8%, respectively) and is commonly associated Task analysis: Two tasks dealt with this role: provide with nurses. emergency care before referral (task index 6.34, standard deviation (SD)=3.03) and administer cardio-pulmonary Advocate on behalf of patients to ensure that health resuscitation (task index 5.00 and SD=2.9). Both of these needs are addressed appropriately are above the 0.5 level. Role expectations: Since nurses are often the only health workers in rural areas and rural services, their Collaborate with the community, the family, the intervention is essential on behalf of such populations. individual, other health workers and sectors as well The nurses, however, must raise this issue or at least as other nursing colleagues to enhance health and participate, enlightening, because they have a duty to health care inspire public policies in their field. Role expectations: The nurse collaborates with the community and other care providers to enhance service Health, illness and care needs: Since financial delivery. investments of governments to the promised level is Some of us ensure close cooperation with head nurses essential for the health of the people, the nurse/midwife at the regional level for patients who were hospitalized at has to play an active role in advocating for increased our services to ensure the continuum of health services, investment in countries where the promised level has not particularly in diseases such as sore pot, hemiplegia, but been reached. In 2001, the also the nutritional hygiene and food. Heads of States made a promise to allocate 15% of their annual budgets to health care. This has been called the “Abuja Target”, but in 2009 it was recognized that very Health, illness and care needs: Since nurses often few countries had achieved this target (African Union, have to assume the roles of other health professionals 2009). due to severe personnel shortages, the range of tasks included in the roles of nurses/midwives is very extensive. This makes it possible to prepare and utilize Task analysis: This role was not addressed in the task more than one category of nurse, which allows for their analysis. recruitment from a wider pool, thus resulting in a more economical health service. However, this also demands that nurses be able to work closely with colleagues who Provide emergency care have different levels of preparation and to optimize their use within safe parameters of care. Role expectations: Stakeholders see the provision of emergency care as the responsibility of nurses. A nurse still needs to attend to emergencies at home so that they Task analysis: The task analysis did not include such can rush a patient to a doctor if that is needed, the health tasks. education officer may have difficulty in making such decisions. Provide midwifery care to women and infants up to the postnatal period Health, illness and care needs: Intentional and unintentional injuries are among the 10 most common Role expectations: The provision of midwifery services conditions in the nine countries studied, both in adults is seen as part of the role of nurse and midwives. and children. This means that there is a need for health When it comes to women’s health, it is the professionals working in these communities to be well responsibility of the midwife to care for the woman during prepared to handle emergencies. pregnancy and delivery, to make sure that the pregnancy Emergency care might include medical, surgical, psy- is safe, and the delivery is also safe to prevent death for chiatric and obstetric emergencies, as well as the results the mother and her baby.