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ENCOURAGING SERVICE THROUGH COLLABORATION
Development of nursing and midwifery in Africa Adapted from keynote presentation at the annual conference of Tau Lambda-at-Large Chapter, Honor Society of Nursing, Sigma Theta Tau International by Leana Ria Uys In September 2000, the United Nations General Assembly adopted a resolution calling for an international effort to address poverty and underdevelopment worldwide. The Millennium Declaration announced eight development goals that the United Nations would strive to achieve by 2015, in partnership with member countries and international organizations. We are now six years into the new millennium, almost halfway to 2015. Progress toward these goals is being monitored country-by-country and region-by-region in terms of predetermined targets and measurable criteria. Little progress has been made in changing the situation. The poor stay poor or get even poorer, the poorly educated are still not schooled, and women remain unequal to their male counterparts in most underdeveloped countries. U.N. Secretary-General Kofi Annan observed that the goals contained in the declaration could only be achieved if “we break with business as usual.” The usual activities of governments and the interventions of donor countries and their nongovernmental organizations (NGOs) had not changed the basics. Something more and different was needed. The “more” was defined as international commitment that included financial and other support, and the “different” was a consolidated, comprehensive effort. Nursing and midwifery in Africa need a similar intervention. Over the first 100 years, we have achieved much, but we have also developed institutional and other constraints that we have not been able to overcome. Individual nurses, institutions, organizations and countries have made brave efforts but, across Africa, we have similar problems and a poor record of solving them. Achievements
These are impressive achievements, but still more needs to be done. Continuing challenges The first challenge of nursing in Africa is to unite the Anglo- and Francophone regions. We need to assist Francophone nations to achieve parity with Anglophone countries. Most of the achievements listed above do not pertain to Francophone Africa. Nurses and midwives in those countries are not in charge of their own education, very few nursing schools exist in their universities and nurses seldom speak for themselves at international forums. The Honor Society of Nursing, Sigma Theta Tau International has no subchapters in Francophone countries and few, if any, bridges span the language divide. Although this may appear to be a problem mainly for Francophone countries, rooted in their colonial pasts, I am convinced it weakens the position of nursing in all of Africa and impedes progress in forums such as the African Union and the World Health Organization’s Regional Office for Africa (WHO AFRO). If half of Africa’s countries have no nurses representing them in such forums, and the voices of nurses are not heard even on nursing issues, it is unlikely the needs of nursing and midwifery will be given priority. Another major challenge for African nursing and midwifery, if we are to become part of the solution, is to become more active and reflective about the way we do things. We are too narrowly focused in our education, practice and activism. We do not adequately understand or deal with the sociopolitical context of illness and health care. These shortcomings decrease our usefulness, not only at the local level, but also internationally. With this in mind, review the Millenium Development Goals (MDGs)—see sidebar—and reflect on the extent to which African nurses can help achieve these goals. The first goal, eradicating extreme poverty and hunger, relates directly to the way we teach community health nursing. If we place students in clinics or health stations and require them to learn how to do immunization and health education, we will make no contribution. If, instead, we teach them to work with communities to address priority problems, usually related to underdevelopment and poverty, we are getting closer. If we make sure they are taught enough about development and empowerment to understand the context of poverty and hunger and make a difference, we are on target. Or consider the third millennium goal—gender equality and the empowerment of women—in the context of a hospital setting. How are nurse managers in hospitals promoting gender equality? How many of them are empowered themselves, not only in their working world, but also in their communities and families? If nurses and midwives—the leaders of African communities—are not practicing equality, actively promoting it and teaching it to colleagues, how will communities change? And then there are the larger economic realities. We can never adequately address the health needs of people in Africa while our governments are dirt-poor, totally dependent on donors to run health services. It does not help to discuss nurse migration when our nurses are paid less than cleaners in developed countries, and work with such limited resources that job satisfaction is severely challenged. To address this part of the Millennium Development Goals, it was decided at a 2001 meeting of ministers in Doha, Quattar, to set up a round of talks, under the leadership of the World Trade Organization, to address factors that keep poor countries poor. These include issues such as agriculture, services and market access. In the talks that ensued, the developing countries refused to budge on opening their markets to industrial goods unless the developed countries were willing to compromise on the issues of agricultural subsidies and access to markets (The Economist, 2005). In 2006, five years after the trade talks were initiated, they were declared a failure. Although it may not be immediately apparent, this is a nursing issue, and we should be talking to nurses and midwives in our international organizations about this and other economic issues. They need to see the linkage among trade policies, health service delivery and the health of people in developing countries. We should not allow financial and political people to dominate this debate. We should make sure that nurses and midwives make their own contributions. We cannot continue with business as usual in nursing education, practice and management. We need to use every opportunity to direct our attention and energies at the major challenges of our continent. We cannot train nurses as we were trained. We cannot raise our children as we were raised. We cannot allow men to treat women as they always treated them. We cannot allow donor countries to feel good about giving us handouts while ensuring that their economic policies keep us poor. We have to become more political, more informed, more proactive. Another challenge for nurses and midwives is to give research and evidence the roles they deserve in daily practice. For a profession to thrive, it has to be based on up-to-date knowledge. To improve their professions, nurses and midwives have to continually question what they do. Change must be so continuous that resistance to change cannot develop. Unfortunately, this is seldom the case in nursing. In my field—psychiatric nursing—I can probably walk into a ward today, 30 years after leaving active clinical practice, and find very few changes to what nurses do. There are several reasons for this. As far as I know, the idea of research as comprising part of the role of a professional nurse or midwife is almost unknown in Africa. There is rarely a position for a nurse-researcher in hospital settings, or even in head office settings. The whole body of knowledge about research utilization or translation of research into practice has not penetrated nursing and midwifery practice in Africa. I can only suggest that we begin to lobby very actively for this to change. Nurses in academia should have joint appointments that give them the power to lead practice in teaching hospitals, as is the case in medical education. In South Africa, some nurse-academics have joint appointments, but they have no power in clinical settings. We need a new model that allows academic nurses to influence nursing and midwifery practice in teaching hospitals, directly and emphatically. Research translation positions should be created in health services, attached to staff development units. We need to train nurses and midwives for these positions by focusing on researching evidence, evaluating practice, developing best-practice protocols, managing change and promoting research that is practice-relevant. We also need to develop nursing and midwifery research programs in our university nursing schools that address the health problems of our continent. Because human and knowledge resources are scarce in Africa, we cannot afford:
What we need instead is a nurse-academic who decides on an area of research, systematically maps out a plan for the next two or three projects and shows how each project relates to the previous study. This person then needs to gradually create a group of people around him or her who are interested in the same area of research, initially directing postgraduate students into the field and then involving clinicians and academics from other disciplines. Lastly, this nurse academic needs to link internationally with others who are working in the same area, so that the work of one builds on the work of another and becomes cumulative. Such a sustained research program is what will build nursing and midwifery knowledge in Africa and create nurse researchers who are leaders in their field.
In conclusion, I suggest we formulate a set of development goals for nursing and midwifery in Africa that addresses our major challenges. The Africa Honor Society for Nursing [also known as Tau Lambda, an at-large chapter of the Honor Society of Nursing, Sigma Theta Tau International] is an organization that can make a difference—for our members and for our countries. We are the leaders of our profession, not because we were elected to leadership, but because we are part of a very small group of nurses and midwives who have had the benefit of a university education. We should lead because we owe it to the people who supported us in acquiring our educations. For example, with regard to the issue of the language divide in Africa, Tau Lambda could help bridge this gap by setting the following goal: Eradicate the language divide in nursing and midwifery in Africa. Ways to measure success in achieving this goal could include: 1) The number of subchapters of Tau Lambda that collaborate with one or more Francophone universities, 2) the number of French subchapters that are part of Tau Lambda, and 3) the number of nursing conference proceedings in Africa that are translated into French. The United Nations’ Millennium Development Goals were developed in a consultative fashion over time, and I suggest that the Africa Honor Society for Nursing do the same. We should partner in this regard with other nursing organizations in Africa, including national nurse organizations; the International Council of Nurses; the East, Central and Southern African College of Nursing; and the West African College of Nursing. We can perhaps do this by forming an alliance and linking our conferences to theirs. We also need to involve partners from outside Africa, including the Honor Society of Nursing, Sigma Theta Tau International; the International Council of Nurses; and the International Council of Midwifery. In addition, we need to involve the many NGOs and universities across Africa in education and health services. We should support other organizations in setting development goals for the profession, so that each organization makes the contribution it is most equipped to deliver. The Africa Honor Society for Nursing is an academic organization with a strong focus on higher education, research and leadership. Its development goals should therefore focus on such issues. National nursing organizations have much larger membership bases and may therefore be better suited to address needed societal changes, such as the empowerment of women. Probably all of these organizations can unite around such issues as evidence-based practice. Again, I quote U.N. Secretary-General Annan: Leana Ria Uys, RN, RM, DSocSc, is professor, deputy vice-chancellor and head of the College of Health Sciences at the University of KwaZulu-Natal in Durban, South Africa. References The Economist. (2005, January 6). Delivering on Doha’s promise. Retrieved July 12, 2006. International Council of Nurses. (2006). ICN position statements. Retrieved July 11, 2006. Sigma Theta Tau International. (2003). Arista3 nurses and health: A global future. Retrieved July 12, 2006. United Nations General Assembly. (2000, September 18). 55/2. United Nations millennium declaration. Retrieved December 7, 2006. World Trade Organization. (2001). DOHA WTO ministerial 2001: Ministerial declaration. Retrieved December 7, 2006.
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Eradicate extreme
poverty and hunger