Conceptualization of Nursing in Zimbabwe

Nursing in Zimbabwe is conceptualized within the context of primary health care (Mapanga, 1990) which was adopted when the country became independent in 1980 (World Health Organization, 1978). The nursing contribution to the health care delivery system focuses on ensuring that services offered are accessible, affordable, acceptable, and that they utilize appropriate technology, ensure equitable distribution, foster a multisectoral approach and employ community participation approaches with an overall emphasis on health promotion. Therefore nursing care activities concentrate on preventive, promotive, curative and rehabilitative measures for individuals, groups and communities across the lifespan.

Nursing is considered as a practice discipline which regards person, health and environment as central to its philosophical underpinnings. The person is believed to be a bio-psycho-social, cultural and spiritual being whose health and illness continuum are interactive with family and environmental conditions. Nursing practice reflects a self-care (Orem, 1991) orientation which compliments the primary health care approach. Furthermore nursing practice embraces the orientation of assisting (Henderson, 1966) the individual, group or community through the activities of living (Roper, Logan & Tierney, 1996) to actively participate in decision making processes regarding their health and well-being. Therefore nursing through its practice, facilitates individuals, groups and communities to attain the ability to exercise self-care. In this article nursing is discussed within the context of: the national health strategy, nursing education programs and nursing practice.

The National Health Strategy

The ten year National Health Strategy for Zimbabwe (Zimbabwe Ministry of Health & Child Welfare, 1999) and the Zimbabwe Patients Charter (Zimbabwe Ministry of Health & Child Welfare and Consumer Council of Zimbabwe, 1996) provide the overall framework for the health care delivery system. Primary health care continues to be the approach for the health care delivery system. Primary health care is regarded as a people-centred approach which encourages active participation in decision making in health promotion towards their own health (Zimbabwe Ministry of Health & Child Welfare, 1999). The major components of health promotion include: good housing, education, healthy lifestyles and clean environments. It is envisaged that health promotion can be achieved through the combined efforts of individuals, communities and health care providers. Furthermore, collaboration with other government ministries such as, agriculture, water development, rural and urban development and community development is considered an integral part of the primary health care approach (Zimbabwe Ministry of Health & Child Welfare, 1999). In addition, the contribution of nursing is considered part of the backbone of the primary health care approach particularly at the primary health care centre and district hospital levels (Zimbabwe Ministry of Health & Child Welfare, 1999).

In order to enhance active client participation in health, the Patient's Charter paves the way for a relationship between clients and health care providers. The objective of the Patient's Charter is to provide information to equip clients to make informed decisions about their health care thereby promoting self-care. It is emphasized that health is a responsibility of individuals, families, groups and communities and that health care providers facilitate the execution of that responsibility (Zimbabwe Ministry of Health & Child Welfare and Consumer Council of Zimbabwe, 1996). Continued strengthening of the implementation of the national health strategy and the patient charter will go a long way to achieve health for all in the 21^st century.

Nursing Education Programs

One strategy to empower women is participation in higher education. The majority of nurses in the East, Central and Southern Africa regions in general and Zimbabwe in particular are women. Regional cultural tendency favours men's progression to higher education particularly when this involves one member of the family having to leave home for study purposes. The introduction of the basic nursing degree, and post basic nursing degree and master's degree in nursing at the University of Zimbabwe as well as the post basic nursing degree at the Zimbabwe Open University has tremendously increased university opportunities for nurses. It is anticipated that other universities in the country will offer nursing degrees in the near future.

Nursing education programs take place within the context of the developments in the Zimbabwean society (Mapanga, 1996). In particular, the educational level of society continues to rise as well and the health needs are becoming more complex. Therefore there are high expectations regarding the quality of nursing practice rendered which necessitates that the discipline of nursing respond by developing programs that have social relevance.

Conversion Program Certificate to Diploma in Nursing

The discontinued two year certificate programme for state certified nurses has necessitated the provision for a one year conversion program to diploma level, thereby catering to nurses holding this professional qualification (see Fig 1). The conversion program certificate to Registered General Nurse Diploma is designed as a completion course. Candidates undertake the third year of the Registered General Nurse Diploma program curriculum. On completion of the program, graduates are awarded the Registered General Nurse qualification (Zimbabwe Health Professions Council, 1999). This program has unified the first level entry of nursing practice.

Basic Diploma in Nursing

The registered general nurses diploma program has become the first level of nursing practice (see Fig 1). The minimum entry requirement for the program are Zimbabwe General Certificate of Education examinations at Ordinary level taken at the end of the eleventh year of schooling and with passes of grades A to C in at least five subjects, including English Language and a science (Zimbabwe Health Professions Council, 1999), out of a maximum of ten subjects. The program is offered by the Ministry of Health and Child Welfare at central and provincial hospitals throughout the country. Plans are underway for private and non-governmental health institutions to offer the program in collaboration with the government for man-power development of nurses. The duration of the registered general nurses diploma program is three years. The program themes comprise: biopsychosocial sciences of humans, art and science of nursing, and principles of illness including curative, preventive, promotive and rehabilitative measures. Appreciation of research in terms of a small descriptive project is introduced in the program.

Conceptualization of nursing in the program embraces primary health care, adaptation, and assisting individuals, families, groups and communities to acquire self-care for the maintenance and restoration of health (Zimbabwe Ministry of Health & Child Welfare, 1997). The conceptualization described reflects the Roy Adaptation model (Roy & Andrews, 1991), Model of Living, (Roper, Logan & Tierney, 1996) and Self-care model (Orem, 1991). The program is accredited by the Zimbabwe Health Professions Council. It is anticipated that once the Nursing Council of Zimbabwe is established, the responsibility of accreditation of the program will be assumed by that professional body. Currently there are plans to have the program associated with the University of Zimbabwe. The associate status of all institutions offering the program will enhance progression of the diploma-prepared nurse to undergraduate degree level. Graduates of the program mainly find employment in Ministry of Health and Child Welfare institutions in rural and urban settings. These institutions include: primary health care centres, district, provincial and central hospitals.

Basic BSc Nursing

The Bachelor of Science in Nursing Science Degree program requires the applicant to possess a minimum of a United Kingdom Cambridge General Certificate of Education examination at the Advanced level with two passes in science subjects out of a maximum of four subjects taken at the end of thirteen years of schooling. Currently the United Kingdom Cambridge General Certificate of Education at Advanced level is in the process of being localised to the Zimbabwe General Certificate of Education at Advanced level. The Bachelor of Science in Nursing Science Degree program is offered by the University of Zimbabwe. It is anticipated that other universities in Zimbabwe will soon offer the program. The progam has a duration of four years. The first year of the program is pre-clinical focussing on biological, physical and psychosocial sciences. The second to fourth year focuses on the art and science of nursing, the health-illness continuum, biomedical sciences, medical-surgical nursing, community health nursing, mental health/psychiatry nursing, maternal child health/midwifery, nursing education, nursing administration and nursing research. In addition, a descriptive level research project is carried out in the fourth year of the program (University of Zimbabwe, 1998). The program is based on the primary health care approach and utilizes the Model of Living conceptual framework (Roper, Logan & Tierney, 1996) and application of the nursing process. The theory is integrated with clinical practice. Furthermore, an introduction to other nursing models such as Activities of Living (Henderson, 1966), Adaptation (Roy, 1991), and Self-care (Orem, 1991) is incorporated. As in other nursing programs, the Bachelor of Science in Nursing Science degree program is accredited by the Zimbabwe Health Professions Council. As with other nursing programs, graduates are employed by the public and private health sectors. In addition, the program has been introduced to compliment the first level nurse practitioner qualification of Registered General Nurse (see Fig 1).

Post Basic Diploma in Nursing

The Post-Basic Diploma in Nursing programs require a minimum of the Registered General Nurse qualification. The programs offered by the Ministry of Health and Child Welfare institutions have a twelve month duration for specialization in: Midwifery, Community Health Nursing and Nursing Administration. Further Ministry of Health and Child Welfare programs include six month specialization in: Intensive Care Nursing, and Nurse Anaesthetist and Theatre Nursing at central hospitals. Plans are underway to introduce additional programs in pediatric and ophthalmic nursing. In addition, the University of Zimbabwe offers a twelve month full-time followed by a twelve month part-time program in Nursing Education (University of Zimbabwe, 1998). Therefore the post-basic programs provide a wide range of clinical specialization following completion of the Registered General Nurse Diploma. The content themes of the programs are accredited by the Zimbabwe Health Professions Council and explicitly address the relevant areas of clinical specialization which equip the graduates to function effectively in corresponding nursing environments. Employment of the post-basic diploma graduates as second level nurse practitioners occurs across the public and private health sectors (see Fig 1).

Post Basic BSc Nursing

The Post-Basic Bachelor of Nursing Science Degree minimum entry requirements are registration as a General Nurse and two United Kingdom Cambridge General Certificate of Education Advanced level passes in two subjects of which one must be a science. The program is offered by the University of Zimbabwe over a period of three years of full time study. The first year of the program is pre-clinical focussing on biological, physical and psychosocial sciences and maternal child health/midwifery. The second and third years comprise biomedical sciences, medical-surgical nursing, community health nursing, health planning and nursing ethics, mental health/psychiatry nursing, nursing education, nursing administration and nursing research. A descriptive research project is carried out in the third year. This program also offers optional specialization in community health nursing, nursing education or nursing administration (University of Zimbabwe, 1998). Nursing is conceptualized within the context of primary health care and an appreciation of nursing conceptual frameworks suitable for implementation in the areas of specialization is emphasized. The Zimbabwe Health Professions Council accredits the program and the majority of graduates as third level nurse practitioners (see Fig 1) are employed within the public health sector as the Ministry of Health and Child Welfare is the major sponsoring body. In addition, the newly established Open University of Zimbabwe has created the opportunity for the Post-Basic Bachelor of Nursing Science Degree to be offered to Registered General Nurses by distance learning modules. The program has a duration of four years of part-time study. The content of the program is the same as the University of Zimbabwe Post-Basic Bachelor of Nursing Science Degree of three years full-time study.

MSc Nursing

The Master of Science in Nursing Science Degree entry requirement is a Bachelor of Science in Nursing Science Degree or its equivalent. The program is offered by the University of Zimbabwe and has to date also admitted candidates from Lesotho, Swaziland and Zambia. The program's duration is eighteen months of full time study. The structure of the Masters of Science in Nursing Science degree program includes core courses, clinical major supporting courses, clinical major courses and functional major courses. The core courses include: statistics, informatics and epidemiology, advanced health assessment, nursing research and a dissertation, and health economics and budgeting. The clinical major supporting courses include applied neuroscience for mental health/psychiatric nursing, pathophysiology for medical/surgical nursing as well as community health nursing and the anticipated child health/pediatric nursing, embryology and neonatology for maternal child health/midwifery. The dissertation is undertaken within the clinical major. Finally the functional major courses include either nursing administration or nursing education (University of Zimbabwe, 1998).

The master's degree students carry out dissertations utilizing correlational statistics. The objective of correlational research at the Masters level is to enable students to examine the relationship between nursing variables in their clinical majors and health outcomes, in order to provide the basis for evidence - based practice. Conceptual frameworks commonly utilized in the designs of the studies include, Orem's self-care model (Orem, 1991), Roy's adaptation model (Roy & Andrews, 1991), Pender's health promotion model (Pender, 1987), King's theory of goal attainment (King, 1991) and Roper, Logan and Tierney model of living (Roper, Logan & Tierney, 1996). Examples of dissertation topics have included: a) activities of living and rehospitalization of schizophrenic patients, b) perceived family communication and health promotion seeking behaviours in primigravida adolescents, c) peer support and alcohol use among adolescents, d) patient participation in mobilization and length of hospital stay in hospitalized adults with fractured tibia and fibula, and e) perceived family reactions, beliefs and coping on quality of life in adults with epilepsy. Although these themes address respective clinical majors they are studied within the context of the primary health care elements namely:

• Health education - prevailing health problems
• Promotion of food supply and proper nutrition
• Provision of safe water and basic sanitation - environmental health
• Maternal & child health care including family planning
• Imunization against the major infectious diseases
• Prevention and control of locally endemic diseases - eg. malaria, TB, HIV/AIDS
• Appropriate community based curative services
• Provision of essential drugs at community level
• Oral health
• Prevention of blindness
• Mental Health
• Care of the physically disabled
• Provision of occupational health
• Care of the elderly

Nurse preparation at higher levels includes research knowledge and skills in clinical specialities. The focus is on studying clients and potential clients in clinical areas of specialization. Research provides scientific understanding of clients' health problems and a sound basis for the appropriate nursing care. Nurses as professionals must continuously search for a scientific basis for the nursing actions that they utilize in their nursing practice in order to have effective outcomes. Research has shown that numbers alone do not improve the quality of nursing care given. Numbers of nurses must be complimented by elevation of knowledge and skills through levels of educational preparation. The quality and levels of preparation have a bearing on the quality of nursing care our communities receive.

Students are facilitated and encouraged to present their research findings at national and international forums. In addition, students are assisted to publish their research studies in local and international nursing journals. It is anticipated in the future that there will be regular national nursing research conferences to facilitate dissemination of findings and to enhance evidence - based practice.

The program is accredited by the Zimbabwe Health Professions Council. The majority of graduates as fourth level nurse practitioners are employed within the public health sector as the Ministry of Health and Child Welfare is the major sponsoring body (see Fig 1). The graduates are prepared to display competencies such as:

1. participating in national health policy development, monitoring and evaluation
2. providing leadership in curriculum development and evaluation for nursing programs
3. providing leadership in clinical specialty
4. providing leadership in professional quality assurance
5. initiating and utilizing nursing research
6. utilizing qualitative and quantitative data and information technologies to analyse nursing problems

Currently, nurses holding Doctorates in Nursing with a special focus in a clinical major and research are prepared in either the United States of America or the United Kingdom. The majority of these graduates are employed by the University of Zimbabwe. It is anticipated that a Doctorate in Nursing program with a clinical focus and research preparation will be offered in the country in the near future.

The major weakness of nursing education in Zimbabwe has been the provision of programs promoting horizontal progression. Therefore most of the nursing education programs have been developed within the basic and post-basic diploma levels. As a result, a normal pyramid distribution, showing vertical progression with most nurses prepared at the diploma level followed by an appropriate proportion prepared at the first degree level and at masters level and some prepared at the doctoral level, has been lacking.

Access to university education for degree level preparation has been limited and the provision of clinical specialization at the masters level was previously nonexistent in the country. Current changes and future plans are aimed at reversing the situation from a horizontal to a vertical progression thereby providing Zimbabwe with a potential educational pyramid of appropriately prepared nurses. It is anticipated that a well distributed pyramid of prepared nurses should enhance the quality of nursing care that clients receive.

Nursing education and the options for vertical progression have never been as accessible as they are today. The strength of nursing education in Zimbabwe lies in the availability of candidates for recruitment into the programs. As a result several schools of nursing for diploma programs have been introduced in all provinces of the country to compliment the four traditional central hospitals' schools of nursing. Both non-governmental and private health institutions including missions are also encouraged to introduce schools of nursing at diploma level to compliment those provided by the government. A further strength is an initiative for all diploma schools of nursing to be associated with the University of Zimbabwe. Such an association will make the University the overall examining body for all nursing programs. The association structure is intended to unify nursing education and enhance vertical progression. In addition, the provision of the post-basic Bachelor of Science in Nursing degree by the Open University of Zimbabwe has increased access to first degree level for the diploma prepared nurses. Therefore, the diploma prepared nurses have two channels to progress vertically either through the Open University of Zimbabwe distance part-time learning program or the University of Zimbabwe full time program. However, vertical progression through diploma to first degree and master degree remains slow and lengthy but ideal for those who wish to undertake the diploma route.

Currently a much shorter progression has been developed by the introduction of a four year full time Bachelor of Science in Nursing Science degree undertaken directly from high school for those holding the appropriate entry qualifications. Clinical specialization for this new approach will take place at masters level and therefore progression vertically will be much shorter. However, the three options namely: direct entry into university, the distance learning and the full time Post- Basic Bachelor of Science in Nursing preparation will substantially increase nurses prepared at the first degree level. The masters program with clinical majors that commenced in 1995 provides adequate vertical progression for nurses holding a first degree. A further strength is the inclusion of health assessment and nursing research which have been systematically integrated in all nursing education programs. The anticipated doctorate program in nursing will also provide vertical progression for nurses holding a master's degree.

Currently, accreditation of all nursing programs are undertaken by one body called the Zimbabwe Health Professions Council which is composed of representatives of all health professions in Zimbabwe. In order to strengthen the activities of each profession it has been proposed that separate councils be created. Currently a Bill is in progress to address this issue, legislating a nursing act that will enhance the establishment of a nursing council that will accredit all nursing programs. Such a development will further strengthen nursing education in Zimbabwe.

Nursing Practice

All practising nurses, approximately 17,000 in number, are required to register with the Zimbabwe Health Professions Council irrespective of their professional educational level. Furthermore all nurses have to renew their practising certificates annually. Therefore it is possible to know the number of practising nurses in the country through the Zimbabwe Health Professions Council which serves as the regulatory body. There are currently imminent prospects of the establishment of a nursing council that will solely concentrate on the control of the professional practice of nursing. The Zimbabwe Nurses Association through its own activities and via the Zimbabwe Health Professions Council continues to promote excellence in the practice of professional nursing.

Nursing practice takes place at various levels in the primary health care delivery system. The areas include urban and rural health centres which constitute the primary level of, and the first contact for, the client in the health care delivery system. Nurses constitute the health care professionals who provide first line care. A referral system based on the need and complexity of the client's problem takes place from the urban and rural health centres to district hospital level of care and subsequently to provincial hospital level of care which may then lead to central level hospital care (Zimbabwe Ministry of Health & Child Welfare, 1999) (see Fig 2).

Since nurses practice at all health care system levels their educational levels of preparation provide a unique, dynamic and holistic mix of knowledge and skills to capture the quality of nursing care required. Nursing practice has a unique contribution which compliments other health disciplines towards the health and wellbeing of individuals, groups and communities. The structure of nursing practice and educational programs is intended to maximize the unique contribution of nursing and facilitate efforts of other disciplines within the primary health care delivery system.

Nursing practice is guided by the health assessment which leads to nursing diagnosis followed by a nursing care plan. The nursing care plan includes the following components: setting of client-centred objectives based on the nursing diagnosis, the nursing activities, and evaluation utilizing a criteria described in terms of client positive health outcomes. This process forms the basis of a problem-solving approach in the provision of quality nursing care.

Nursing practice in urban and rural primary health care centres is undertaken by the first level nurse who may be either a basic diploma nurse or a basic BSc nurse as well as the second level nurse who may be either a post-basic diploma nurse or a post-basic BSc nurse (see Fig 1). A primary health care centre as the entry point to the health care delivery system provides nursing services focusing on the elements of primary health care both at the centre and the surrounding community. The services include curative, preventive, promotive and rehabilitative measures undertaken at the centre, as well as outreach activities to the surrounding community described as a 'catchment area' (Zimbabwe Ministry of Health & Child Welfare, 1992). The role of the nurse at the health centre is fully autonomous in terms of assessment, diagnosis, planning, implementing and evaluating care provided for clients' health concerns. Clients presenting with serious health concerns are referred to the district hospital. Nursing research activities at the primary health care centre involve data collection and evaluation to determine trends in health concerns, utilization of services and client satisfaction for the purpose of quality assurance control. Promotion of self-care of clients is a major activity undertaken at the primary health care centre (Zimbabwe Ministry of Health & Child Welfare, 1992). The nurse assumes the role of facilitator for clients' active participation and partnership through mutual goal setting and implementation of healthy lifestyle activities. The nurse's role as a facilitator is undertaken with individuals, families, groups and communities in health promotion. The objective of the nurse's role is to empower actual and potential clients to take care of their own health through engaging in self-care health activities to enhance wellness. Both the primary health care approach and Orem self-care theory assume that human beings have the inherent capability to exercise self-care (Orem, 1991).

Clients with health concerns not managed at the primary health centre level are referred to the second level of the health care delivery system known as the district hospital. Nursing activities have a bias to curative interventions but still engage in health promotion activities to compliment those provided by various health centres in the district as a whole. The nurse in this setting may be a holder of a post-basic diploma, post-basic BSc nursing or MSc nursing. In addition quite a large percentage of first level nurses practice at district level hospital. The nurses role at district hospital is to provide primarily medical-surgical nursing and maternal, child health/midwifery for hospitalized clients. There is also a special nursing service division headed by a District Nursing Officer which provides community health nursing support to the district primary health care centres. District hospital nurses have partial autonomy as they function in collaboration with medical personnel. However the District Nursing Officer in conjunction with community nurses function more independently in their health promotion outreach activities. Research activities include data collection, assessment of actual and potential clients' concerns, implementation of appropriate outreach programs, such as immunizations, followed by evaluation. All health promotion activities focus on healthy lifestyles through empowerment of communities in the district to enhance community as client self-care.

Clients health concerns not managed at district level are referred to the provincial hospital. All levels of nurses function in the provincial hospital setting. The nurse's role is to provide primarily medical-surgical nursing, mental health/psychiatric nursing and maternal, child health/midwifery to hospitalized patients. Community health nursing services are headed by the Provincial Nursing Officer who is a holder of an MSc nursing degree. All community nursing services in the province are coordinated through the Provincial Nursing Officer in collaboration with District Nursing Officers following the primary health care approach and empowering communities to engage in self-care. Research activities include proposal development, data collection, data analysis and dissemination of findings aimed at improving the health status of all communities in the province.

It is anticipated that nursing practice in Zimbabwe in the next ten years will continue to strengthen the primary health care approach. The emphasis of nursing activities will focus on empowering individuals, families, groups and communities to actively participate in healthy lifestyles through self-care practices for the promotion of their own well-being (Zimbabwe Ministry of Health & Child Welfare, 1999). Furthermore, it is envisaged that nursing practice will continue to strengthen evidence-based practice, utilization of nursing process and self-care frameworks which seem to compliment the primary health care approach. The current developments in accessibility to undergraduate and graduate education for nurses and the overwhelming enthusiasm for higher education should in the next ten years strengthen the unique contribution of nursing practice in the health care delivery system.

Summary

Currently the Zimbabwean society is becoming more and more educated and highly enlightened about the degree of quality of nursing care they deserve. If the quality of nursing care provided is to be socially relevant, nurses need to be prepared at levels which are congruent to the general educational pattern of the society which they serve. It is the high level application of knowledge and skills that results in excellent competencies in assisting individuals, sick or well, in activities contributing to health, its recovery or peaceful death. Both the nursing profession and individual nurses recognize excellence in nursing when the society is speaking positively about the nursing care it receives. The challenging realities call for initiatives on the part of the nurse to advance in his or her preparation to attain cost effective nursing practice and to adapt to the changing society and provide socially and culturally relevant nursing care. In particular, emphasis on Orem's self-care approach will enhance empowerment of actual and potential clients towards their own health promotion.

Authors

Kudakwashe G. Mapanga, PhD, RN
E-Mail: kg@nursesc.uz.zw

Kudakwashe G. Mapanga, PhD, RN has been a University Lecturer in nursing at the University of Zimbabwe since 1986, and department chairman from 1995 to 1998. He is a member of the Health Professions Council of Zimbabwe, the Zimbabwean Nurses Association, and the East Central and Southern African College of Nursing. Dr. K. Mapanga holds both a BSc and a MSc in nursing from Welsh Medical School in the United Kingdom and a PhD in Nursing from Case Western Reserve University in the U.S.A.

Margo B. Mapanga, PhD, RN
E-Mail: mb@nursesc.uz.zw

Margo B. Mapanga, PhD, RN has been a University Lecturer in nursing at the University of Zimbabwe since1995. She served as a Nurse Educator for the Zimbabwe Ministry of Health from 1985 to 1995 and is an Examiner of the Health Professions Council of Zimbabwe. Dr. M. Mapanga is also a member of the Zimbabwean Nurses Association and the East Central and Southern African College of Nursing. She has been prepared in the United Kingdom as a Registered General Nurse, a Registered Midwife, a Registered Clinical Nurse Teacher and a Registered Nurse Teacher. She holds a nursing MSc degree and a PhD from Case Western Reserve University in the U.S.A.