ICAP News - March 2010

Harnessing the Power of Nurses in Africa

Lugile Dlamini’s first job was not what she dreamed it would be. Though her nursing degree had taught her almost nothing about HIV, the 25 year-old found herself in an HIV clinic in the southern Swaziland town of Hlathikhulu. Dlamini had little understanding of HIV services or even the drugs that she was to provide to patients. She was so lost she simply copied patients’ last prescriptions without assessing if there had been side effects or opportunistic infections. The clinic, with one doctor and two others nurses, was so overstretched, Dlamini had no time to ask for help.

By the time David Schulman, project coordinator for the ICAP Nursing Capacity Initiative or INCI in Swaziland, met her, she was frustrated and demoralized. “A few months into the job she was already burned out,” says Schulman. “She was desperate to be transferred somewhere else.”

Nurses like Dlamini have long been the primary providers of health care in sub-Saharan Africa. That has only been exacerbated with the arrival of HIV/AIDS. In Swaziland, there is roughly one doctor for every 5,350 people; in Rwanda one doctor serves 50,000. (In the U.S. that figure is 1 doctor per 400.) To address this shortage, one of the main strategies is “task-shifting,” where nurses are provided with enough training to take on some of the duties traditionally performed by doctors.

After this training, these nurses can provide counseling and HIV testing for prenatal transmission prevention, assess HIV disease stage, provide HIV care and antiretroviral therapy (ART), and monitor the progress of these patients.

In Swaziland, where one-quarter of adults are estimated to be HIV-positive, nurses’ duties don’t end with the workday. Within their own families and communities, they are called upon to provide advice to HIV-positive relatives and neighbors. In some cases, they are also coping with HIV infection themselves.

“It’s an unimaginable situation,” says Dr. Jennifer Dohrn, program director for ICAP’s INCI. “Nurses are burned out, unable to take care of their families, stressed. And patients’ health suffers because the community depends on the nurse knowing everything.” These nurses are also burdened with small salaries and limited appreciation by society. In response, nurses are leaving their jobs. According to the South African Health Ministry, the rate at which nurses are leaving the profession is a “serious crisis.”

INCI is a three-year project funded by the U.S. Health Resources and Services Administration. The project focuses on the challenges faced by the nursing profession in the context of the HIV epidemic. It aims to tackle nurses’ challenges from beginning to end, from training them with the right skills to providing incentives to retain them.

The INCI began its work in Swaziland in August 2009 with enthusiastic support from the Ministry of Health. With the goal to enhance pre-service training, INCI is supporting the country’s three nursing colleges to create a curriculum that includes the latest information on HIV. The curriculum will likely be ready for the 2010-2011 academic year.

For nurses already working in clinics and hospitals, INCI seeks to move beyond traditional didactic training that often takes the nurses away from their work places. This deprives facilities of badly needed health care providers, and denies nurses the richness of training that comes in the context of a specific work site. INCI is offering an initiative to develop a nurse mentor program where nurses with increased HIV competencies will mentor other nurses at their places of work.

To help retain nurses, the INCI has established a partnership with Swaziland’s Wellness Center, established by the country’s Nurse’s Association to support the mental and physical health of health workers, with an emphasis on nurses. Since November 2009, the partnership has provided Hepatitis B vaccinations to 95 percent of Swaziland’s 1,800 nurses, a major accomplishment.

Schulman is most proud of a plan to provide "Post-Exposure Packs" to clinics across the country. The idea came about after he met a nurse in a rural clinic who had sustained a needlestick injury from a syringe previously used on an HIV-positive patient. Since she had no immediate access to ART, he recalled finding her “confused, frustrated and overwhelmed by the situation.”

Evidence suggests that initiating post-exposure prophylaxis through ART within a few hours of exposure can significantly reduce the risk of infection. Schulman happened to be visiting the clinical site the day the nurse was injured, and started her on ART. Six months later, she remained HIV-negative.

That experience convinced Schulman that clinics needed packs providing everything staff would need to initiate ART promptly for occupational and non-occupational exposure.

Beyond Swaziland, INCI have already begun activities in South Africa and Rwanda and by April 2010, will expand to Ethiopia and Côte d’Ivoire. In December 2009, the first INCI conference was held in Swaziland on how to deliver better HIV services and retain top nursing talent. Attendees from several countries facilitated a rich conversation on some of the challenges faced by the nursing profession and exciting opportunities offered by the Initiative. “Working with nurses and nursing organizations is very exciting,” says Dohrn. “The established partnerships point to an exciting and vibrant future for the profession.”

Lugile Dlamini has blossomed with INCI training and support. She is now happy, says Schulman and is a real asset to the clinic where she works. “She feels empowered and is, once again, excited to be a nurse.”

Photo captions: Nurses serve vital roles in HIV programs in Africa, assuming many of the more specialized tasks that doctors traditionally performed.

ICAP Country Program: Swaziland

Swaziland faces many challenges in tackling the HIV epidemic. While facing the world’s highest HIV prevalence, it suffers from severe shortages in the healthcare workforce. There are only an estimated 187 doctors, 1,238 nurses, and 372 nurse assistants providing health care services for the country’s 1.2 million people. Against this backdrop, ICAP is working closely with 31 of the 144 public sector HIV service sites to assist them in becoming more effective. By the end of 2010, the team plans to expand support to 47 facilities.

In 2009, ICAP-Swaziland was awarded three grants, including a five-year grant for up to $25 million from the U.S. Centers for Disease Control and Prevention, to support decentralization of HIV services throughout the country and to enable an indigenous clinical mentoring structure.

A new focus of ICAP’s work will involve building local clinical mentoring, to help Swazi professionals train each other. “We are excited to work with the Ministry of Health to develop clinical mentoring at the regional level,” said Country Director Kerry Bruce. “The vision is to enable ICAP staff with Swazi physicians, nurses, psychosocial and health information systems to establish and support high-quality services for HIV/AIDS, as well as other conditions.”


ICAP-supported sites in Swaziland
For more about ICAP-Swaziland, visit here.