Critical care services are key components of modern healthcare delivery, with qualified and specialist nurses described as the core of service provision (Marshall et al, 2017). Globally, there is known to be a shortage of qualified nurses, and Zambia is recognised as having what the World Health Organization (WHO) classifies as a severe shortage (WHO, 2020). In addition, in Zambia, specialist fields of nursing practice such as critical care are relatively new (WHO, 2020), and across the country there are fewer than 200 trained critical care nurses (Ministry of Health (MoH), 2017). Zambia continues to face a high burden of disease, despite making progress in many of the internationally recognised indicators for HIV, malaria, under-five child mortality and maternal mortality ratio (MoH, 2017). In consequence, the achievement of targets set by the United Nations (UN) Sustainable Development Goals (SDGs) (2015) and the MoH, as well as the move to universal access to healthcare, will be delayed. As critical care is one of the few specialties that bridges both communicable and non-communicable diseases, it is essential that critical care services be prioritised when considering the allocation of resources.
One of the most urgent priorities in critical care is the shortfall of critical care nurses. To meet the demands of this shortfall, access to high-quality nurse education is required to provide specialised nurses to staff critical care units throughout the country. This article will provide a review of the activities undertaken that led to the development of the revised critical care nurse education programme in preparation for the transition to a bachelor's level qualification. To achieve these activities, a multidisciplinary stakeholder event that included representation from the MoH, General Nursing Council of Zambia (GNCZ), Zambian Union of Nursing Organisations (ZUNO), the University of Zambia (UNZA), the Lusaka College of Nursing (LUCON), the Ndola College of Nursing and an interdisciplinary panel of expert critical care nurses, renal specialist nurses, midwives and anaesthetists from the University Teaching Hospital in Lusaka were involved in the review and validation events. Support was provided by experts from Birmingham City University in the UK. This activity was part funded through the UK Department for International Development's (DFID) Health Partnership Scheme (HPS), and latterly by Johnson & Johnson's Africa Grants Programme.
The need for this project was identified by Zambian stakeholders who recognised that there was a need to increase and enhance critical care services to meet the needs of the nation. In Zambia, due to the limited number of critical care-trained and experienced doctors, critical care nurses are often the only professional group represented in intensive care units (ICUs) throughout the country. This is of concern because, within many African countries, nurses have traditionally been deemed subservient to doctors and, in some instances, the profession is seen only as a technical trade (Bultemeier, 2012). This has resulted in there being little focus on the education and training of nurses, with far less attention being given to developing specialist nursing roles such as critical care.
Justification for the review
The purpose of this activity was for key stakeholders to review and validate the current Advanced Diploma in Critical Care Nursing and to prepare a framework for a bachelor degree-level critical care nursing programme. This activity is part of a wider project to support the strategic capacity building of a career framework for critical care nursing in Zambia.
An initial literature review revealed a paucity of published articles in this area of nursing. With few results, the search was widened and included searching article reference lists, derived from CINAHL, Athens, British Nursing Index, PubMed and Medline, professional websites and signposting to other articles by experts in the field. This provided 22 studies to review. These articles were selected and assessed using an adapted research appraisal tool (Hawker et al, 2002). Following critical appraisal, eight articles were rejected and a total of 14 studies were included in this review. Examples are given in Table 1.
| Author/date | Date of research | Country | Study design | Description | Sample size | Aim | Key findings |
|---|---|---|---|---|---|---|---|
| Dart et al (2017) | 2014 | Zambia | Quantitative | Point prevalence study | 120 medical and surgical admissions over 48 hours to 3 wards | To objectively measure demand for critical care services in a tertiary referral centre | 45% had objective evidence of requirement for intensive care unit (ICU) admission. Greater than expected HIV rate (71%) |
| Bould et al (2015) | 2011–2012 | Zambia | Qualitative | Semi-Structured interviews | 14 visiting and local faculty members supporting the Masters in Medicine Anaesthesia course | To investigate experiences of both visiting and local faculty in the first year of an externally supported postgraduate programme | Themes: |
| Lillie et al (2015) | 2012 | Zambia | Quantitative | Retrospective cohort study | 59 cases in one hospital | To compare recent avoidable perioperative mortality at University Teaching Hospital Lusaka, Zambia, with historical data from 1987 | Incomplete records available making it difficult to undertake analysis. From data available: |
| Mwewa and Mweemba (2010) | No information | Zambia | Quantitative | Descriptive study | 50 randomly selected nurses from emergency departments, obstetrics, medical and surgical wards and theatres | To determine nurses' knowledge and utilisation of ICU admission criteria and guidelines | Awareness of emergency and ward nurses of critical care provision and admission criteria. Respondents had no training in managing critically ill patients prior to admission to ICU |
Results of the literature review
The literature review results have been divided into three key sections. First, the context of critical care in Zambia; second, local, national and international guidelines, policies and service provision; and third, education.
The context of critical care in Zambia
Sub-Saharan Africa (SSA) critical care services face significant health-related challenges, with high incidences of HIV/AIDS, malaria and tuberculosis. These additional challenges have seriously impacted the delivery and development of healthcare services and the professional development of nurses in SSA (Mutea and Cullen, 2012). The research evidence available demonstrated limited use of national and international protocols, with those being used often developed in high-income countries (HICs) where medical challenges differ.
In a retrospective audit into avoidable mortality in Zambia, Lillie et al (2015) found that 62% cases of identified deaths that they reviewed were either avoidable or potentially avoidable, and many records were incomplete. They cited repeated incidences of limited staff capability and access to intensive care. Weiser et al (2015) pointed out that, without standardised medical records within Zambia, accurate collection, analysis, interpretation and reporting of perioperative statistics must be treated with caution. Nevertheless, Lillie et al's (2015) study raised important points that cannot be ignored in terms of workforce planning, access to education and critical care provision. They identified that some countries, such as Zambia, have little or no continuing professional development and had resource-restricted specialist education programmes for both doctors and nurses. As a result, doctors and nurses must travel to other countries to study postregistration specialisms, a situation that the UN (2015) has stated must change.
Zambia is making efforts to enhance and develop critical care services. The country now adheres to international priorities regarding the standardisation of medical records (MoH, 2017), but has yet to develop a national reporting system from which to measure current and future impacts (MoH, 2016). Murthy et al (2015) pointed out that this finding is reflected across the continent, with few instances of published national statistics, no regionally agreed definitions and standards for critical care, making comparisons across the continent difficult. The lack of consensus impacts on implementation of services because the workforce, having trained in different countries, brings back different concepts for practice. On the positive side, this creates fresh ideas and new initiatives. Conversely, it can delay decision making as providers have to adapt their knowledge and expertise to fit within the Zambian health systems, resources and context.
Most of the Zambian population live in rural areas, making access to the critical care services difficult. Dart et al's (2017) quantitative audit of adult medical and surgical patients in a tertiary referral hospital, found that 45% of patient observations revealed evidence of the need for admission to critical care, which was beyond the critical care capacity of the hospital, where only eight critical care beds were available. This study supported the internal audit of Zambia's critical care services, which found a total of 70 beds across the whole country (MoH, 2016). The result is that many critically ill patients are cared for on wards where staff have limited or no critical care training or experience (Lillie et al, 2015; Dart et al, 2017).
Local, national and international guidelines, policies and service provision
Studies focusing on local, national and international protocols were few, although several studies discussed the need to develop these (Towey and Ojara, 2008; Gondwe et al, 2011; Adipa et al, 2015; Murthy et al, 2015; Lillie et al, 2015). Only two studies reviewed admission criteria, clinical care and standardised reporting on critical care capability, and, of these, one was Zambian based (Mwewa and Mweemba, 2010). Riviello et al (2016) developed and trialled a risk-prediction model to estimate expected hospital and critical care mortality based on patients' characteristics. They highlighted the importance of developing context-specific protocols, as those based on HIC protocols are not appropriate, as they either require significant data collection and resources, which are not available, or they cite conditions and comorbidities not routinely seen in LMICs. Thus, although these studies had small sample sizes, they were innovative and provided a baseline for further research, which needs to be designed for translation across the continent.
Most studies found that it was normal practice to admit both adult and paediatric patients, and that there were no separate units for paediatrics (Towey and Ojara, 2008; Ttendo et al, 2016; Muteya et al, 2013; Tomlinson et al, 2013; Murthy et al, 2015). In addition, as they are frequently the only hospital department that can offer specialist care, admission criteria are broad, including both communicable and non-communicable diseases, a relatively high incidence of malaria, trauma, maternal complications and patients with complex postoperative needs (Towey and Ojara, 2008; Jacob et al, 2009; Kwizera et al, 2012; Muteya et al, 2013; Tomlinson et al, 2013; Ttendo et al, 2016).
Education
In addition to limited critical care services, only two studies focused specifically on the development of critical care education programmes (Towey and Ojara, 2008; Bould et al, 2015). However, others argued for the importance of developing a specialist critical care workforce (Adipa et al, 2015; Dart et al, 2017). However, parallels can be drawn from within the continent as a whole. Towey and Ojara's (2008) prospective qualitative study in Uganda highlighted that nurses who had received specialist critical care nurse training reported increased morale and that this had a ‘ripple’ effect because knowledge then cascaded to other areas of the hospital. Conversely, Gondwe et al's (2011) exploratory study of 10 critical care nurses in Malawi, found significant challenges and occupational stress when providing family support while simultaneously delivering complex care to critically ill patients. This led to compassion fatigue and resulted in nurses considering leaving the profession or working in another specialty. The researchers found nurses reported limited training in psychological care and few protocols to help them support families.
Bould et al's (2015) evaluation of an internationally supported postgraduate anaesthesia programme in Zambia reported the same range of clinical issues, including variations in practice. Their concern was that there was no orientation programme that enabled staff trained in HICs to adapt to service provision in limited-resource countries. Although this was a medical education programme, the issues are the same for critical care nurses trained abroad. Adipa et al's (2015) study of ward nurses in Ghana also commented on the fact that interventions taken for granted in HICs, are often not available in LIMCs. Overall, it appears that experienced nurses argue that their experience does not compensate for limited education and training (Chiarella and White, 2013).
Critical care nurse course review 2018
In recognition of the need for Zambia-specific trained critical care nurses, a 12-month full-time Advanced Diploma in Critical Care Nursing began in 2012 at the LUCON following the development of the curriculum by the GNCZ, with support from the Tropical Health Education Trust (THET) and the Brighton-Lusaka Link. However, since then, there have been challenges in course delivery as the original teaching team changed, leaving insufficient tutors to revise the content to reflect current and future healthcare provision in Zambia. In recent years, there has been a rapid expansion in critical care education and services. There was recognition that, in line with GNCZ regulations and WHO (2009) best practice, the curriculum urgently needed revision to meet these requirements and the changing burden of disease.
Education programmes are inextricably linked to safe practice, public accountability and the healthcare context in which the nurses practise. Therefore, all validations and reviews must be multidisciplinary and include representatives from nursing regulatory and professional organisations, the MoH and clinicians of all grades, including doctors. In consequence, education providers must develop curricula that balance the different requirements arising from health politics, the realities in current practice and workforce funding. It was agreed that to provide peer review and external scrutiny to the process, the review, finalisation and validation events required representatives from all the key stakeholders involved in critical care nursing. To provide governance, terms of reference were developed and adhered to by all participants through each process. The review and validation events each took 5 days and involved changes in the course ethos, structure and content, and changes in practice. To reflect the revised programme, the procedures manual, assessment processes, and teaching materials were all reviewed and amended.
Key changes to the critical care course
Course structure
The new programme reflects the MoH changes in healthcare provision to meet the changing demography and disease burden (Carter et al, 2018). Care was taken to check that the revision enabled the advanced diploma to meet the UN Educational, Scientific and Cultural Organization (2011)International Standard Classification of Education (ISCED) for level 5 study, which aims to provide students with ‘professional knowledge, skills and competencies’, that are practice based and occupational specific. Nurse education in Zambia follows an integrated programme whereby students must successfully complete both theory and practice components. These comprise 19 weeks (665 hours) of theory and 32 weeks (1255 hours) in practice. During the course both formative and summative assessments are used. Summative assessments form the intermediate, hospital and GNCZ written examination and the Objective Structured Clinical Examination (OSCE) practical examinations (Muldoon et al, 2014).
The underpinning educational theory follows the principles of constructivism, in a format Biggs (2018) described as constructive alignment. This approach is referred as an ‘ecosystem for learning’ (Weller, 2016) and involves balancing all the components to support each other by structuring the specific learning outcomes through effective assessment and feedback (Biggs, 2018). It promotes self-directed study, with the student developing the academic and clinical skills to ‘construct’ their own path through the various learning activities. The teacher is the catalyst for learning, creating a learning environment that enables the student to ‘align’ their learning to the learning outcomes (Biggs, 2018).
Overall, learning objectives have been designed to facilitate the process through which the nurse can ‘acquire the specialised knowledge, skills and attitude to recognise, respond appropriately and care for acutely or critically ill patients in a range of settings, including intensive care, high dependency ward and emergency areas’ (GNCZ, 2018). Specific learning objectives have been differentiated to provide clear direction on the requisite outcomes for successful completion of the programme.
Placements
Critical care nurses work not only in the ICU, but are often called upon to support the care of a deteriorating patient on a ward or in an emergency department. In many hospitals, with limited numbers of health professionals, the critical care nurse may be the only practitioner trained and experienced in this area and will be called upon to support decision making and provide advice to both doctors and nurses (MoH, 2016). In consequence, students need to have a variety of practical experiences to help prepare them for their future role.
Students must undertake a major component of their programme in practice. Placements include adult, paediatric and neonatal ICUs, anaesthesia/operating theatres, renal units, cardiac catheter laboratories, radiology, special observation units (midwifery), emergency departments and medical emergency units. Many of these placement areas were added in recognition of the need to increase students' exposure to a broader range of experiences. Each placement area was evaluated to confirm its appropriateness and to identify the learning needs.
Students also now undertake an attachment at an ICU in a rural district hospital. The rationale for this is that the majority of the programme is delivered in an urban, tertiary referral hospital, but many students come from and will return to district hospitals. On successful completion of the course, students returning to their hospitals may be required to set up and lead units (Carter, 2016). This placement, in addition to providing students with exposure to a different setting, enables tutors to share advances in critical care education with those in practice, so providing an element of continuing professional development for staff. During the review, feedback from stakeholders identified that clinical practice mentors had limited skills in supporting students in practice; this is a key element of the educational approach chosen. In response, a ‘train the trainers’ programme on mentorship in practice was developed and delivered. Key stakeholders have undertaken to cascade this to all nurses involved in the mentorship and assessment of students within the clinical practice area.
Competencies
In Zambia, nursing is regulated by the Nurses and Midwifery Act (2001), which provides nurses with a scope of practice that includes prescribing drugs in accordance with the Nurse and Midwifery Formulary and to undertake therapeutic interventions, which may include insertion and removal of devices, intubation, resuscitation and infusions. In consequence, all nurse education and training programmes must be competence based if nurses are to provide comprehensive care to the critically ill patient.
During the review and validation events, all existing competencies were assessed, revised and peer reviewed. As a result of this process, identified gaps in education and training needed to be addressed, and, in addition to the previous critical care nursing procedures, 11 new competencies were developed and ratified. These were neonatal resuscitation, neonatal continuous positive airway pressure (CPAP), paediatric assessment, paediatric cardiopulmonary resuscitation (CPR), dealing with postpartum haemorrhage, pre-eclampsia and eclampsia, plus transfers, sedation scoring, pain management, and use of syringe drivers and volumetric infusers.
Future developments
During the validation events, the MoH and GNCZ agreed with the existing provider LUCON that additional education provision was needed and approved the Ndola College of Nursing, located in the Copperbelt Province, to deliver critical care nursing courses from mid-2018 onwards. The introduction of this second training institution has increased opportunities for nurses to train in critical care, with students undertaking their main clinical placements at the Ndola University Teaching Hospital and the Arthur Davidson Children's Hospital.
Essential to the success of education is a highly skilled education workforce. The academic staff supporting these courses include principal tutors, nurse tutors and clinical instructors. It is recognised that, for sustainability and future proofing, additional teaching staff will be needed, but currently there are no in-country Bachelor of Science (BSc) or Masters programmes in critical care nursing. In consequence, these tutors will need to be trained outside Zambia, which increases the costs and reduces the numbers who can access the appropriate level of training to maintain and further this specialist field of practice.
The WHO (2009) has recommended that all nursing programmes are at bachelor level (ISCED level 6). Following the successful validation and implementation of the new programme, the MoH has supported the development and validation of its own BSc in Critical Care Nursing, which needed to be developed within the context of Zambia and not based on Western or medical models (Munjanja et al, 2005). The MoH requested that the same key stakeholders who had successfully completed the revision and validation of the Advanced Diploma be reconvened to develop the proposed BSc in Critical Care Nursing. Linked to this, was its recognition that, for sustainability, this BSc needed to be part of a career framework for critical care nurses, through which it could extend and develop its own long-term workforce. It accepted that international evidence has shown that ICUs with an increased number of degree-level trained nurses were associated with reduced mortality among ventilated patients (Kelly et al, 2014). This is supported by international evidence from other nursing specialisms, which has also revealed that the relationship between mortality and adverse events was linked to nurse staffing and educational level (Rafferty et al, 2007; Diya et al, 2012; Aiken et al, 2014). Although the methodologies of some of these studies may have been challenged by critics arguing against the transition to bachelor programmes (Whitehead, 2010), the evidence consistently demonstrates that a graduate-level nursing workforce makes a difference in terms of reducing complications, hospital stay and mortality (Rafferty et al, 2007; Diya et al, 2012; Aitken et al, 2014).
Training a critical mass of nurses to BSc level will support those who wish to remain in the clinical environment, and also facilitate roles in education, for example, clinical instructors, lecturers and roles in research and leadership to develop. In time, this will enable critical care nurses, with enhanced leadership roles, to become involved in strategic decision-making processes related to service provision, which at present is often the domain of physician anaesthetists. As nurses have been described by the MoH as their major workforce in healthcare provision, this in turn will result in improved care.
Conclusion
Education and training in critical care in Zambia has advanced rapidly. In the past two years, the revised and validated Advanced Diploma has been implemented and the newly validated BSc degree has a planned start date of July 2020. Formative evaluation of the course's accessibility, appropriateness and acceptability has been completed for the Advanced Diploma. Summative evaluation of the effectiveness, efficiency and extent to which the programme meets its objectives is now in progress. The same systematic approach will in due course be followed for the BSc programme. At this stage summative evaluation is not complete and therefore minor adjustments may need to be made to the programme once all monitoring and evaluation processes are complete. It should also be noted that as this was the first BSc programme, there was no comparative degree programme on which to build. Nevertheless, the activities completed indicate that the programme has been well received and that the nurses who graduate will have the competencies necessary for specialist critical care practice.
It is hoped that this article will add to the growing body of knowledge on critical care nursing in Zambia and other LMICs and has outlined a clear rationale for a BSc-level programme in critical care nursing in Zambia. Critical care provision in Zambia has changed and advanced both academically and clinically since the initial introduction of critical care nursing as a specialty in 2012. However, the numbers trained are still small.
The new programmes will transform care provision, offering evidence-based, knowledgeable and skilled specialist critical care nurses. This investment in developing critical care nurses, in terms of knowledge and professional opportunities, will not only impact on the ICU but the wider hospital setting. It therefore has the potential to improve the outcomes of the critically ill in Zambia and should prove a major achievement for the country.