Skilled nursing professionals are a vital link to patient care and an essential component of any health system. In fact, nurses are often the first – and in some cases the only – healthcare provider many people around the world see when seeking care. In many developing and transitioning countries, however, nurses face a number of professional barriers. Some of these include a lack of professional standards and guidelines, absence of an independent nursing care structure based on critical thinking, systemic inability to engage in clinical or administrative decision-making processes, and a dearth of training and educational opportunities at all levels.
According to the World Health Organization (WHO), about 27 million women and men make up the global workforce of nurses and midwives. This cadre accounts for roughly 50 percent of the world’s healthcare workforce, but it also accounts for an equal portion of the current global shortage of health workers. And, the largest shortages of nurses and midwives are in countries with the greatest need, particularly throughout Africa and Southeast Asia.
“Nurses play a critical role in health promotion, disease prevention and delivering primary and community care. They provide care in emergency settings and will be key to the achievement of universal health coverage. For all countries to reach Sustainable Development Goal 3 on health and well-being, WHO estimates that the world will need an additional 9 million nurses and midwives by the year 2030.” – WHO Fact Sheet on Nursing & Midwifery (March 18, 2022)
Since 1992, AIHA has been successfully working to establish nursing as an independent and vital profession. By improving the qualifications and status of nurses, we have, by extension, helped improve the quality of healthcare in resource-constrained communities around the world.
Most recently, AIHA’s work empowering the nursing workforce has focused on training in HIV/AIDS-related treatment, care, and support, as well as nursing education, leadership, and association building – all to strengthen this critical healthcare cadre on both an institutional and national level.
Through AIHA’s HIV/AIDS Twinning Center Program, which supported PEPFAR’s objectives from 2004 to 2019, we implemented several highly successful projects to strengthen the nursing profession, including:
The Tanzania Nursing Initiative (2005-2019)
Nurses constitute the largest healthcare provider workforce in Tanzania. They are frontline caregivers providing specialized treatment and care to people living with HIV (PLHIV), as well as broader clinical services to the entire population. With support from PEPFAR and CDC/Tanzania, AIHA worked to strengthen the profession and ensure an adequate supply and quality of nurses in the country since 2005 through our dynamic Tanzania Nursing Initiative (TNI).
With its roots in an institutional twinning partnership linking Muhimbili University College of Health Sciences School of Nursing first with the University of California – San Francisco School of Nursing and later with a community-based consortium led by World Services of La Crosse in Wisconsin, the Tanzania Nursing Initiative evolved into a far-reaching technical assistance and support program that supported nursing education and professionalism throughout the country.
Driven by local needs and strategies, TNI transitioned from an institutional partnership created to strengthen nursing school capacity to equip students with the knowledge and skills they need to provide quality care, to a multi-pillared national project that supported improved recruitment, deployment, and retention for this critical cadre that has long been on the front lines of HIV/AIDS treatment, care, and prevention.
TNI stakeholders have included the Nursing Training Unit and the Directorate of Nurse and Midwifery Services at Tanzania’s Ministry of Health, Community Development, Gender, Elderly, and Children (MOH), the Tanzania Nurses and Midwives Council (TNMC), the School of Nursing at Muhimbili University of Health and Allied Sciences, the Tanzania National Nurses Association (TANNA), World Services of La Crosse, Inc., Winona State University College of Nursing, and the University of Michigan School of Nursing.
Together, AIHA and these broad-based partners provided the targeted and ongoing technical assistance needed to build capacity for sustainable, professional nurse training and practice in the country. The project encompassed faculty training and mentoring, development of competency-based curricula, and support for local training institutions.
A crucial initial accomplishment of TNI was the development and roll out of an HIV/AIDS care training package, which included creation of a multi-module curriculum, training more than 300 nurse tutors, and implementing the program at 72 nursing schools throughout the country.
Building on this initial success, AIHA worked closely with stakeholders to transition TNI to a structured and holistic approach to strengthen nursing practice in Tanzania focusing on the following four key areas:
curriculum and faculty development, school support
- Nursing Regulation
improving the safety of nursing service delivery and public protection through licensure and examinations
- Association Building
advocacy, improving the public’s perception of nurses and nursing care
- National Authorities
policy development, nursing leadership development
Partners also improved learning environments at targeted schools through the installation of skills labs, International Council of Nursing Mobile Libraries, and a pilot tablet project designed to strengthen nursing education by enhancing access to up-to-date texts and evidence-based resources.
In January 2017, AIHA graduated TNI partners involved with the education pillar when priorities for technical assistance shifted to the development of regulatory mechanisms to support Tanzania’s new task sharing policy, which empowers nurses, social workers, and allied health cadres to provide HIV/AIDS-related services.
This new focus entailed revising existing scopes of practice to incorporate HIV counseling and testing services, nurse initiated and managed ART (NIMART), pharmaceutical dispensing, and adherence counseling, as well as providing training to up-skill these cadres in preparation for their expanded roles in the provision of treatment, care, and support services for PLHIV.
NIMART: A GAME-CHANGER IN THE PROVISION OF HIV TREATMENT IN TANZANIA
As the largest health workforce cadre in the country, nurses play a critical role in providing care and treatment services for the 1.7 million people living with HIV in Tanzania. AIHA supported the Ministry of Health’s task-shifting efforts as a way to ensure proper training for nurses as frontline caregivers and, consequently, ensure better access to high quality HIV treatment through NIMART – Nurse Initiated and Managed Anti-retroviral Therapy. Our long-term technical assistance included:
- Support for the development of a national task sharing policy that provides the legislative and regulatory framework for nurses and other cadres to take on additional responsibilities in the provision of treatment and care for PLHIV;
- Support for the development of the NIMART Handbook, which was approved by the Tanzanian Government in 2018 and made NIMART part of the country’s strategy for scaling up enrollment of PLHIV on ART;
- Support for the development of NIMART training materials, including the facilitator guide and participant manual;
- Development of a National NIMART Monitoring and Evaluation Framework to ensure data-driven implementation and continuously measure the impact of NIMART interventions on epidemic control;
- Support for the development of a NIMART clinical mentorship package designed to impart crucial skills in quality HIV service delivery and training of 64 NIMART mentors; and
- Development and operationalization of a Scope of Practice Addendum for Nurses and Midwives that incorporated expanded roles for NIMART and other HIV/AIDS services.
In support of the other three key areas, AIHA:
- Provided direct technical assistance to Tanzania’s Directorate of Nursing and Midwifery Services to bolster its capacity to oversee the provision of quality nursing and midwifery services throughout the country;
- Helped strengthen TNMC’s ability to build capacity of nursing supervisory authorities at the regional and district levels; and
- Built TANNA’s capacity to promote nursing excellence, influence health policy, and advocate for its 13,000 members nationwide.
Key accomplishments of this dynamic initiative included identifying HIV/AIDS competency gaps and working with the Ministry of Health to upgrade training in prevention of mother-to-child transmission (PMTCT), gender based violence (GBV), violence against children (VAC), family planning, voluntary medical male circumcision (VMMC), and services for key populations for both certificate and diploma-level curricula.
Partners also conducted PMTCT Option B+ trainings for 100 nurse tutors from high-burden districts across Tanzania, while AIHA provided technical support to the Ministry’s Directorate of Nurse and Midwifery Services on the development of the national nursing scheme of service, updates to the scope of practice for nurses and midwives, and revised job descriptions for nurses and midwives based on the task sharing policy. In addition, AIHA helped to develop Respectful and Compassionate Care Guidelines for Nurses and Midwives, which help nurses improve quality of and retention in care for PLHIV.
In response to Tanzania’s new task sharing policy, TANNA developed an advocacy plan that is guiding the association’s advocacy efforts to strengthen and promote the professional development of nurses, advance their economic and general welfare, and increase and strengthen the positive image of nurses in Tanzania.
To read two impact stories about AIHA’s work through TNI, check out the following blog posts:
Twinning Partnership: Mozambican National Nursing Association (ANEMO) / St. Luke’s Hospital School of Nursing at Moravian College (2008-2012)
In 2007, the year before AIHA launched this twinning partnership, the UNDP’s Human Development Index ranked Mozambique 172 out of 177 countries. The 15-year civil war resulted in population displacement and marked increases in makeshift settlement around cities and towns – a situation that remained long after the end of the conflict. The years of conflict devastated the health system with current reports from Mozambique’s Ministry of Health noting that there are just 3.1 general nurses per each 10,000 people across the country.
Associação Nacional dos Enfermeiros de Moçambique (ANEMO) – the National Association of Mozambican Nurses – collaborated with St. Luke’s Hospital School of Nursing at Moravian College in Pennsylvania between 2008 and 2012 to strengthen ANEMO’s capacity as the leading autonomous professional nursing association in the country.
In 2009, a reported 4,000 nurses were working in Mozambique – the equivalent of one nurse for every 5,400 people living in the country. These nurses – 17 percent of whom were living with HIV themselves – faced many challenges as they provided frontline care to patients. ANEMO was striving to strengthen nursing as a profession and empower nurses with opportunities for continuing education, development, and support. Their AIHA partnership helped ANEMO build its own organizational capacity so it could better meet it’s goal of improving nursing care in Mozambique.
The American Organization of Nurse Executives (now known as the American Organization of Nurse Leaders) also supported the work of this partnership, providing technical assistance on nursing leadership, including the implementation of the Mozambican Nursing Leadership Institute (MNLI), a program based on AIHA’s International Nursing Leadership Institute (INLI) implemented with USAID support between 1999 and 2003 in Eastern Europe and Central Asia.
Other key objectives of this partnership were to increase ANEMO’s organizational capacity and infrastructure and to elevate the association by strengthening the relationships, linkages, and visibility among both national and international stakeholders.
The successful completion of the year-long pilot MNLI program in 2010-2011 represented a major achievement of this partnership. Some 43 Mozambican nurses – along with a small number of international participants – graduated from MNLI in August 2011 and ANEMO faculty who had been trained through the process conducted the first training for the second, locally-facilitated MNLI session.
In addition, both U.S. and Mozambican partners attended and co-facilitated workshops and presentations during ANEMO’s regional Inhambane general assembly meeting. They also completed development of ANEMO’s website and began disseminating quarterly newsletters to ANEMO members.
“Nursing can truly be called a multidisciplinary profession and our teams are complex. Each member approaches things from a different angle, with a different perspective. MNLI helped me understand these differences among people and within my team, which – in turn – has really helped improve service delivery in the Unit.” – Safira Cuna, Chief Nurse, Reference Health Unit, Maputo Central Hospital
At the time of graduation from AIHA’s Twinning Center Program, ANEMO staff were planning to conduct local nursing events during International Nursing Week and National Nursing Week; facilitate two additional MNLI sessions; and participate in AONE’s annual meeting. They also planned to conduct health fairs and other community service projects to raise the profile of the nursing profession and help improve public health throughout the country.
Follow the link to read U.S. partner Dr. Lori Hoffman’s first-hand account of the January 2011 MINLI session.
Twinning Partnership: Institute for Health Sciences in Gaborone (IHS) / Ohio University College of Health Sciences (2014-2017)
In response to local needs and health strategies, AIHA implemented this nursing project through our Twinning Center Program as a way to HIV/AIDS care and treatment competencies into nursing education and training in Botswana. We linked the Institute for Health Sciences in Gaborone (IHS) with Ohio University College of Health Sciences to build the institutional and human resource capacity to upgrade IHS’s nursing diploma program to a full degree program.
The U.S. partners supported a core team of IHS faculty, who themselves were pursuing Master’s Degrees through Ohio University’s online programs. Upgrading the qualifications and skills of these faculty members was essential to improving the quality of teaching needed to successfully implement a degree program.
Experts from Ohio University also provided technical assistance to improve clinical teaching methodologies utilizing simulation and skills labs, as well as the clinical assessment of students.
AIHA further supported learning and teaching resources for the nursing program, including the use of tablet devices to facilitate access to evidence-based, point-of-care information during clinical training.
In alignment with PEPFAR 3.0 priorities, partners conducted a workshop on HIV integration and subsequently jointly developed two new HIV nursing courses – one entry-level course that is now required for all basic diploma students at IHS and one advanced course that is required for all post-basic diploma students.
IHS integrated related HIV/AIDS course modules on:
- HIV epidemiology and pathophysiology;
- Clinical manifestations of HIV;
- Diagnosis and staging;
- Assessing readiness for ART;
- HIV/AIDS counseling;
- Pediatric and adolescent issues in HIV;
- Comprehensive clinical assessment;
- ART management;
- Treatment failure and/or resistance;
- HIV-related malignancies;
- HIV and nutrition; and
- Ethical, legal, and human rights issues in HIV.
In addition, partners helped to establish a research culture in Botswana. In early 2016, experts from Ohio University conducted the third in a series of research training workshops. The event was attended by 14 IHS faculty drawn from various disciplines, including dental therapy, medical laboratory technology, midwifery, nursing, nurse anesthesia, pharmacy technology, and public health. Research skills developed through these workshops provided IHS faculty with the skills they need to more effectively plan and conduct research on their training programs, including the programs with updated HIV and palliative care content that were previously supported by AIHA.
Russia HIV/AIDS Treatment, Care, and Support Initiative (2008-2012)
This HIV/AIDS Twinning Center project built on the efforts of four successful USAID-funded HIV/AIDS partnerships AIHA previously implemented in Russia, focusing on the PEPFAR target regions of St. Petersburg and Orenburg Oblast.
Technical assistance focused on strengthening education and training for health and allied professionals – including nurses – on a broad range of HIV-related clinical care and social support.
A key accomplishment of this initiative included the graduation of a group of 21 nurses who worked at district-level infectious diseaseclinics and the St. Petersburg City AIDS Center and completed a training course titled “HIV Palliative Care for Nurses” conducted by AIHA and its partners with support from PEPFAR through USAID/Russia.
Held March 22-24, 2010 at the City AIDS Center’s Inpatient Department, the course was the culmination of a three-part HIV/AIDS training series that led to official certification from St. Petersburg’s Pavlov State Medical University. The first two courses in this series were “Basics of HIV Infection: Improving Tolerance to PLWHIV” and “Adherence to ART Regimens.”
The course included lectures, interactive role plays, case studies, and group activities, as well as hands-on clinical sessions conducted at the AIDS Center’s Inpatient Department.
Topics covered during the three-day course included an overview of palliative care concepts, managing chronic versus acute conditions in HIV patients, the nurse’s role in outpatient care and support for PLWHIV, and patient stages, from recovery to hospice care. Group discussions and role plays were used to demonstrate effective methods of delivering bad news to patients and their families, as well as to highlight the importance of psycho-social and spiritual support for people living with, or affected by, HIV/AIDS.
Based on analysis of pre- and post-training tests, the nurses who participated demonstrated an impressive increase in knowledge, improving their scores by 68 percent. They received their certificates from Pavlov State in May 2010.
Twinning Partnership: Addis Ababa University School of Medicine / University of Wisconsin – Madison (2009-2017)
AIHA initiated this partnership between Addis Ababa University School of Medicine; the University of Wisconsin School of Medicine and Public Health; and People to People, an organization dedicated to linking the Ethiopian diaspora with Ethiopian institutions to strengthen human resource development, healthcare, and education in 2009. The partnership’s objective was to improve Adult Emergency Medicine services at Addis Ababa University Tikur Anbessa Specialized Hospital and to improve the clinical care of people infected with and affected by HIV/AIDS.
One aspect of this partnership was to establish an Emergency Medicine Nursing Masters Degree Program at AAU. With support from PEPFAR and CDC/Ethiopia, partners focused on curriculum development and revision activities, faculty mentorship and development, and supervision for the department to support a quality pre-service Masters-level emergency medicine nursing degree program with both didactic and bedside components.
The first group of 18 nurses – hailing from different parts of the country, including Gondar, Tigray, Hawassa, Haromaya, Afar, Adama, and Addis Ababa – graduated from the program in July 2012. By July 2014, 38 nurses had earned their Masters in emergency medicine nursing.
To learn more about AIHA’s earlier efforts to strengthen the nursing profession in Central and Eastern Europe and Eurasia, please click here.
Updated Nov. 30, 2023