The development of critical care nursing education in Zambia

Evaluation of an international health partnership to capacity build emergency, trauma and critical care nurse education and practice in Zambia: An experience from the field

AIM

To evaluate an international health partnership project to capacity build emergency, trauma and critical care nurse education and practice in Zambia.

BACKGROUND

Zambia continues to face a significant workforce challenge and rising burden of communicable and non-communicable diseases, compounded by the COVID-19 pandemic. In response to these, the Zambian Ministry of Health is investing in specialised nurses. Emergency, trauma and critical care nursing education and training were seen as one of the solutions. North-south partnerships have been identified as a force for good to capacity build and develop emerging specialities.

SOURCES OF EVIDENCE

We use an evaluative approach, which includes desk research, a rapid literature review and documentary data analysis from published papers, government reports and project documentation. Ethics committee approval was sought and gained in both Zambia and the UK.

DISCUSSION

A critical review of the evidence identified three key themes: challenges with changing education and practice, developing Zambian faculty for sustainability and the effect of an international health partnership project on both Zambia and UK. The outcomes from this project are multifaceted; however, the main achievement has been the implementation of emergency, trauma and critical care graduate programmes by the Zambian faculty.

CONCLUSION

This experience from the field outlines the benefits and limitations of a north-south partnership and the importance of transparency, shared ownership and collegiate decisions. It has facilitated knowledge exchange and sharing to capacity build emergency, trauma and critical care nursing.

IMPLICATIONS FOR NURSING PRACTICE

Lessons learned may be applicable to other international nursing partnerships, these include the need for deep understanding of the context and constraints. Also, the importance of focusing on developing long-term sustainable strategies, based on research, education and practice was noted.

IMPLICATIONS FOR NURSING POLICY

This paper outlines the importance of developing nursing education and practice to address the changing burden of disease in line with Zambian national policy, regional and international standards. Also, the value of international nursing partnerships for national and international nursing agendas was described.

A health systems approach to critical care delivery in low-resource settings: a narrative review

There is a high burden of critical illness in low-income countries (LICs), adding pressure to already strained health systems. Over the next decade, the need for critical care is expected to grow due to ageing populations with increasing medical complexity; limited access to primary care; climate change; natural disasters; and conflict. In 2019, the 72nd World Health Assembly emphasised that an essential part of universal health coverage is improved access to effective emergency and critical care and to "ensure the timely and effective delivery of life-saving health care services to those in need". In this narrative review, we examine critical care capacity building in LICs from a health systems perspective. We conducted a systematic literature search, using the World Heath Organisation (WHO) health systems framework to structure findings within six core components or "building blocks": (1) service delivery; (2) health workforce; (3) health information systems; (4) access to essential medicines and equipment; (5) financing; and (6) leadership and governance. We provide recommendations using this framework, derived from the literature identified in our review. These recommendations are useful for policy makers, health service researchers and healthcare workers to inform critical care capacity building in low-resource settings.

Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training

BACKGROUND

Pulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists' perioperative care and what, if any, capacity gaps remain.

METHODS

We identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa > 0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care.

RESULTS

Ten of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial.

CONCLUSION

Among a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.

Current State of Critical Care Nursing Worldwide: Current Training, Roles, Barriers, and Facilitators

This review provides insights on the current state of roles and responsibilities, on-the-job training, barriers, and facilitators of critical care nursing (CCN) practice. Some of the established roles and training of CCN were providing care for acutely ill patients, delivering expert and specialist care, working as a part of a multidisciplinary team, monitoring, and initiating timely treatment, and providing psychosocial support and advanced system treatment, especially in high-income countries. In low-resource settings, critical care nurses work as health care assistants, technical or ancillary staff, and clinical educators; manage medications; care for mechanically ventilated patients; and provide care to deteriorating patients.

Service evaluation of a COVID-19 critical care orientation programme

BACKGROUND

During the first wave of the COVID-19 pandemic in the UK, south London had the highest number of COVID-19 patients admitted to critical care. At one hospital, staff being redeployed to critical care were invited to attend an orientation to critical care workshop.

AIM

To carry out a service evaluation of the training outcomes from rapidly redeployed staff who completed the workshop during the first wave of the COVID-19 pandemic (March-July 2020).

METHODS

Two stages were used, the first was a post-workshop evaluation questionnaire completed immediately after the training, with the second involving a single centre e-survey questionnaire two months later.

FINDINGS

In total 131 health professionals attended the workshop, and 124 (95%) post-course evaluations were completed. Some 116 staff were contacted for the e-survey, with a response rate of 34% (n=40). Overall, the training was well evaluated. Of the 40 respondents, 70% (n=28) had volunteered, but only just over half (n=21, 52%) went on to work in critical care.

CONCLUSION

This article describes the organisational response of one NHS acute hospital to the unprecedented challenges that arose from the COVID-19 pandemic. The service evaluation identified the importance of a pedagogical approach, which not only delivered clinical content, but also allayed anxiety for health professionals preparing to work in a new environment.

Critical care nursing role in low and lower middle-income settings: a scoping review

OBJECTIVES

A scoping review was conducted to answer the question: How is critical care nursing (CCN) performed in low-income countries and lower middle-income countries (LICs/LMICs)?

DESIGN

Scoping review guided by the JBI Manual for Evidence Synthesis.

DATA SOURCES

Six electronic databases and five web-based resources were systematically searched to identify relevant literature published between 2010 and April 2021.

REVIEW METHODS

The search results received two-stage screening: (1) title and abstract (2) full-text screening. For sources of evidence to progress, agreement needed to be reached by two reviewers. Data were extracted and cross-checked. Data were analysed, sorted by themes and mapped to region and country.

RESULTS

Literature was reported across five georegions. Nurses with a range formal and informal training were identified as providing critical care. Availability of staff was frequently reported as a problem. No reports provided a comprehensive description of CCN in LICs/LMICs. However, a variety of nursing practices and non-clinical responsibilities were highlighted. Availability of equipment to fulfil the nursing role was widely discussed. Perceptions of inadequate resourcing were common. Undergraduate and postgraduate-level preparation was poorly described but frequently reported. The delivery of short format critical care courses was more fully described. There were reports of educational evaluation, especially regarding internationally supported initiatives.

CONCLUSIONS

Despite commonalities, CCN is unique to regional and socioeconomic contexts. Nurses work within a complex team, yet the structure and skill levels of such teams will vary according to patient population, resources and treatments available. Therefore, a universal definition of the CCN role in LIC/LMIC health systems is likely unhelpful. Research to elucidate current assets, capacity and needs of nurses providing critical care in specific LIC/LMIC contexts is needed. Outputs from such research would be invaluable in supporting contextually appropriate capacity development programmes.

The 'sleeping elephant': The role of mentorship of critical care nurses in Zambia

AIM

To develop and evaluate a Zambian context-specific mentorship model that supports registered nurses completing emergency, trauma and critical care programmes in Zambia.

BACKGROUND

In Zambia, emergency and trauma and critical care nursing are relatively new specialties, with education and training programmes less than a decade old. A train the trainer mentorship programme was developed and delivered at two colleges of nursing. Ethics approval was gained in both Zambia and the UK.

SOURCES OF EVIDENCE

Documentary data analysis and focus groups were used. Focus groups included stakeholders and nurses in practice who had completed the train the trainer programme and were using the mentorship model.

DISCUSSION

The critical review of the literature revealed there was a paucity of evidence on the role of mentors in critical care. However, national documentation identified that most post basic education programmes are at Diploma Level with limited content that focuses on bedside teaching, mentorship and assessment content.

CONCLUSION

Feedback from representatives attending the stakeholder workshops and focus groups which included participants who had completed the training programme enabled the mentorship model and workshop to be developed and evaluated.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are the backbone of healthcare systems in Africa and the world. Mentorship and assessment in practice enables nurses to develop the competence and skills to lead practice, support peers and junior colleagues.

IMPLICATIONS FOR NURSING POLICY

This paper has identified the need for a context-specific formalised mentorship model to support specialist practice and this project has provided the foundations for mentorship of emergency, trauma and critical care nurses in Zambia.