HEALTH FOR ALL THROUGH NURSING AND MIDWIFERY EXCELLENCE

News-Journal of the Global Network of WHO Collaborating Centres for Nursing and Midwifery Development

N O V E M B E R 2 0 0 2

• WHO Collaborating Centres for Nursing and Midwifery Development★ George Mason University, Global Network Secretariat

WHO Region for Africa (AFRO)WHO Region for the Americas (AMRO)WHO Region for the Eastern Mediterranean (EMRO)WHO Region for Europe (EURO)WHO Region for South East Asia (SEARO)WHO Region for the Western Pacific (WPRO)

Greetings from the Secretary General

Rita M. Carty, DNSc, RN, FAAN

The nursing workforce shortage isbeing felt around the globe. Fromthe countryside to large cities, al-most every country and region inthe world is experiencing the devas-tating effects of having an inad-equate number of qualified nursesand midwives to care for their popu-lations. The Global Network hasbeen busy working to address theseand other concerns with our mem-ber Collaborating Centres, ourWHO partners ICN and ICM, and asa technical support and expertisearm of WHO and the office of theSenior Scientist for Nursing andMidwifery, Dr. Naeema Al-Gasseer.We all confirmed our commitmentto these efforts during the GlobalNetwork’s fourth international con-ference held in collaboration withthe Midwest Nursing Research So-ciety (MNRS) in Chicago, February2002. We revitalized our strategicplan and spent a day discussing theNetwork’s support and affirmationof Resolution WHA 54.12:Strengthening Nursing and Mid-wifery. To date, we have partici-pated as a key stakeholder in theconsultation to develop the Strate-gic Directions for Nursing and Mid-wifery Services (SD) and played anintegral role in the Partners’ meetingsponsored by Dr. Naeema Al-Gasseer at WHO Headquarters, inFebruary 2002. Participating in themeeting were Global Network part-ners ICN and ICM and other spe-cialist, regional, and internationalnursing and midwifery organiza-tions. Outcomes included endorse-ment by the partners of the SD,development of a communicationsstrategy for dissemination, and rec-ommendations for monitoring andevaluation indicators. WHO is nowimplementing the SD and will keep usup to date at each stage of the process.

One thing we know for sure: thisnursing shortage is not like any othershortage witnessed in the history ofthe profession. Strong nursing lead-ership from around the globe is criti-cal to the future of our profession.We must be innovative and activelyinvolved in addressing and solvingthe economic and ethical issues cre-ated by this shortage. We have tolook within and beyond ourselves toaddress a critically significant issuerelated to the shortage; namely, themigration and recruitment of nursesfrom underdeveloped to developedcountries. This practice needs care-ful monitoring and control if it is toserve the profession and the worldpopulation well.

As we look to the future, the Glo-bal Network (now representing 30WHO Collaborating Centres world-wide) is playing a strategic role inaddressing the state of the world’snursing workforce. This issue ofNursing and Midwifery Links willreflect on the role of CollaboratingCentres and Global Network part-ners in developing innovative andcreative solutions to ensure qualitynursing care and adequate nursingworkforces throughout the world.One article takes a regional perspec-tive and directly addresses the im-pact of nurse migration on the

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Editorial OfficesGeorge Mason University

College of Nursing and Health Science4400 University Drive, MS 3C4

Fairfax, Virginia 22030-4444, USA

Tel: +1 703 993 3521Fax: +1 703 993 1908

Email: gnwhocc@gmu.eduWeb: http://cnhs.gmu.edu/whocc/

PublisherRita M. Carty, DNSc, RN, FAAN

Secretary GeneralGlobal Network of WHO Collaborating Centres

for Nursing and Midwifery Development

Editor in ChiefStephanie L. Ferguson, PhD, RN, FAAN

Deputy Head, WHO Collaborating CentreGeorge Mason University

College of Nursing and Health Science

Managing EditorLesley L. Arietti

Executive CoordinatorGlobal Network of WHO Collaborating Centres

for Nursing and Midwifery Development

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N O V E M B E R 2 0 0 2_________________________________

Inside this Issue

Greetings from the Secretary General . . 2

Message from WHO Senior Scientist . . 3

Members of the Global Network ofWHO Collaborating Centres for Nursingand Midwifery Development . . . . . . . . 4

Focus on TAJIKISTAN:The Nursing Development Project . . . . 5

The Impact of Global Nurse Shortagesand International Recruitment onCaribbean Countries . . . . . . . . . . . . . . . 8

Focus on UGANDA:Project Uganda Nursing Team(PUNT) . . . . . . . . . . . . . . . . . . . . . . . . 11

Millennium Development Goals: Policyimplications for Nursing and Midwifery Services

My message to you in the Februaryissue of Nursing and Midwifery Linksintroduced the “Strategic Directionsfor Strengthening Nursing and Mid-wifery Services.” These Strategic Di-rections, which have engaged manyWHO Collaborating Centres(WHOCCs) in the last six months, arein line with the Millennium Develop-ment Goals (MDGs) arising out of theMillennium Assembly of the UnitedNations, September 2000. There aremajor health related challenges in theworld such as HIV/AIDS, Tuberculo-sis, Malaria, and other risks to healththat populations face throughout theirlife cycle in different parts of theworld. Nurses and midwives’ effortsto address these challenges are neededin greater strength and numbersaround the globe.

The MDGs were formulated basedon resolutions of world conferencesorganized by the UN, and focus on theefforts of the world community toachieve significant and measurableimprovements in peoples’ lives. Aimsinclude peace, security and disarma-ment, reduction in poverty, protectingthe common environment, humanrights, democracy and good gover-nance, protecting the vulnerable, andmeeting the special needs of the devel-oping world, especially Africa. Thegoals (which can be reviewed in detailat http://www.developmentgoals.org),establish yardsticks for measuringoutcomes, and provide an opportunityfor funding development programs. Ahealth dimension has been incorpo-rated into all the goals; three of themare directly related to health. The cor-respondence between these threehealth goals and our own “Key ResultAreas to Strengthen Nursing and Mid-

Message from WHO Senior ScientistNaeema Al-Gasseer, RN, PhDSenior Scientist for Nursing and MidwiferyWorld Health Organization

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wifery Services” is notable. In addi-tion, the eighth and last MDG is “Glo-bal Partnership for Development,” anarea in which WHO has been workingextensively in the past decades.

Nursing and midwifery policies areespecially important in improvinghealth systems performance in orderto achieve the MDGs. They are alsoessential in the delivery of key healthinterventions to populations, particu-larly in priority areas such as HIV/AIDS, TB, Malaria and other majordiseases. WHO Collaborating Centersfor Nursing and Midwifery Develop-ment contribute toward the achieve-ment of the MDGs by analyzing anddisseminating knowledge and strate-gies at the country level. They can alsotake the lead in ensuring that nursingand midwifery expertise is developedas part of the coalition of activitiesaiming to meet the targets of theMDGs. At the Global Network meet-ing held in February of this year inChicago, WHOCCs committed theirwork to the ‘Evidence Base of Nurs-ing & Midwifery Services’. As thetechnical arms of WHO, they areworking towards achieving the ex-pected results of the Strategic Direc-tions in areas such as evidence basedpractice, education, leadership, regu-lation and policy.

The following three MillenniumGoals are in line with three of theWHO priority areas on which theWHOCCs have been asked to focus,namely: Maternal Health, HIV/AIDSand TB.

MDG 4: Reduce child mortality.

MDG 5: Improve maternal health.

MDG 6: Combat HIV/AIDS, malariaand other diseases.

WHOCCs are working towardsbuilding the evidence on effective in-terventions and models of care to ad-dress these diseases. They have alsoagreed on joint projects in the area ofsafe motherhood. But the above goalscan only be achieved if an immediatesolution to the severe global shortageof nurses and midwives is found.Nursing and midwifery institutionsare therefore invited to join forces tomeet the objective of MDG 8:Develop a Global Partnership forDevelopment.

You will recall that the followingprinciples guided WHO in developingthe Strategic Directions:

1. Partnership: Working together oncommon objectives, actingcollaboratively and supporting eachother’s efforts.

2. Relevance: Developing health ser-vices and systems guided by healthneeds, evidence and strategic pri-orities.

3. Ownership: Adopting a flexibleapproach sustained and led by na-tional authorities and implementedwith local involvement.

4. Ethical Action: Planning and pro-viding health care services, basedon equity and fairness and respectfor gender and human rights issues.

At WHO we count on WHO Col-laborating Centres for Nursing andMidwifery Development, Centers ofExcellence, and Partners, to conductmore research, and to reduce the gapbetween the developed and develop-ing world in the provision of excellentnursing and midwifery services. ■

3NOVEMBER 2002

4 NOVEMBER 2002

Greetings from the Secretary General from page 2

WHO Region for Africa (AFRO)BotswanaUniversity of Botswana Department of

Nursing Education, GaboroneSouth AfricaUniversity of Natal School of Nursing,

DurbanUniversity of South Africa, Pretoria

WHO Region for the Americas (AMRO)BrazilUniversity of São Paulo College of Nursing

at Ribeirão Preto, São PauloCanadaMcMaster University School of Nursing,

Hamilton, OntarioMount Sinai Hospital, The Gerald P. Turner

Department of Nursing, Toronto, OntarioColombiaColombian Association of Teachers of

Nursing, BogotaMexicoNational School of Nursing and Obstetrics

of the National Autonomous Universityof Mexico (UNAM)

Members of the Global Network of WHO CollaboratingCentres for Nursing and Midwifery Development

USACase Western Reserve University,

Frances Payne Bolton School of Nursing,Cleveland, Ohio

Columbia University School of Nursing,New York, New York

* George Mason University College of Nursingand Health Science, Fairfax, Virginia

Institute for Johns Hopkins Nursing,Baltimore, Maryland

University of Alabama at Birmingham Schoolof Nursing, Alabama

University of California San Francisco Schoolof Nursing, San Francisco, California

University of Illinois at Chicago College ofNursing, Chicago, Illinois

University of Michigan School of Nursing,Ann Arbor, Michigan

University of Pennsylvania School of Nursing,Philadelphia, Pennsylvania

University of Texas School of Nursing,Galveston, Texas

WHO Region for the Eastern Mediterranean(EMRO)BahrainCollege of Health Sciences, Nursing Division,

Ministry of Health, ManamaJordanJordan University of Science and Technology

(JUST), Faculty of Nursing, Irbid

WHO Region for Europe (EURO)DenmarkDanish Nurses Organization, CopenhagenFinlandNursing Research Institute, HelsinkiSloveniaHealth Centre MariborGermanyGerman Nurses Association, BerlinUnited KingdomGlasgow Caledonian University,

School of Nursing and Community Health,Glasgow, Scotland

The Royal College of Midwives, London

WHO Region for South East Asia (SEARO)ThailandMahidol University (Joint Center: Faculty of

Nursing (Siriraj) and Department of Nursing,Faculty of Medicine (Ramathibodi), Bangkok

WHO Region for the Western Pacific(WPRO)JapanSt. Luke’s College of Nursing, TokyoKoreaYonsei University College of Nursing, SeoulPhilippinesUniversity of the Philippines College of

Nursing, Manila* Secretariat of the Global Network of WHO Collaborating Centres for Nursing and Midwifery Development

Caribbean countries. The author,Thelma Henry, is one of the Interna-tional Council of Nurses (ICN) Lead-ership For Change Fellows, whoparticipated in the leadership programdesigned and implemented by ICNand sponsored by the W.K KelloggFoundation. Her article addressesglobal nurse shortages, their effects onindividual nurses and communities,and the impact of international recruit-ment on Caribbean nations.

Two collaborative projects from twodifferent WHO Collaborating Centresin different parts of the world are fea-tured. One is the Tajikistan Nursing

Development Project of the WHOCollaborating Centre at GlasgowCaledonian University. The articledescribes the role of nursing and mid-wifery in the Tajikistan Health ReformProgram. The other is from CaseWestern Reserve University, and de-scribes the education, research andprofessional service initiativeslaunched in Uganda by a collaborativeteam of faculty from nursing andmedicine at CWRU, New York Uni-versity (NYU) and Makerere Univer-sity in Uganda.

Our May 2003 issue will highlightsafe motherhood projects worldwide

and feature some of the programs ofour Global Network member, theRoyal College of Midwives.

As we prepare for the future, wemust look beyond our own image thatwe have created through the years andstrive to change the profession in away that meets the health care needsof a dynamic new century. The GlobalNetwork will continue to work with itsorganizational partners and WHO toensure that the Strategic Directionsfor Nursing and Midwifery Servicesare successfully implemented and re-ported at the World Health Assemblyin May 2003, as directed by WHAResolution 54.12. ■

5NOVEMBER 2002

Featured Collaborating Centre:Glasgow Caledonian University School of

Nursing, Midwifery and Community Health:WHO CC for Nursing and Midwifery Education,

Research and Practice

Background

Tajikistan lies immediately north ofAfghanistan, south of Kazakhstan andKyrgyzstan and West of Uzbekistan.It is mountainous country with thePamirs soaring to the south and theTian Shan Mountains to the north. It isbeautiful and tragic. With a proud his-tory reaching back to the Persian Em-pire, the culture is a combination ofancient Asian and Eastern Europeantraditions. Large sectors of the popu-lation were transported in both Rus-sian and Soviet times to grow cottonon its plains, while the indigenousTajiks continued with their mixed ag-riculture in the mountains.

Since the collapse of the SovietUnion, Europe has been challengedwith the needs of diverse and newlyincorporated countries stretching fromIceland to China. Many of these coun-tries previously benefited from a So-viet system of health care delivery thatwas professional but very resourceintensive. The Soviet Union withdrewfinancial and economic constraintswithin these countries. This led tovarying degrees of support for nursingand midwifery by individual countriesas part of their response to the healthchallenges that presented themselves.The developing role of the nurses andmidwives in these situations has beeninfluenced by the direct needs of eachcountry.

The GCU WHO Collaborating Cen-tre (WHOCC) worked closely withthe previous WHO/EURO RegionalNursing Advisor for Nursing and Mid-wifery, Ainna Fawcett Henesy, to de-velop a range of educational materialsfor nurses and midwives in Europe tohelp support the development of nurs-ing and midwifery practice. This wasdone in collaboration with WHOCCsin Europe, in particular, the WHOCollaborating Centre for Primary

Health Care Nursing at the HealthCentre Maribor in Slovenia.

The Nursing Role in theNew Health Reform Plan

The introduction of the TajikistanHealth Reform Plan is a major devel-opment in meeting the health needs ofthe population in Tajikistan. The Gov-ernment, with support from a numberof international agencies, is taking for-ward a program of reform that willbuild on the existing strengths of theSoviet system, while at the same timeemploying new ideas and technologywithin a modernized and primaryhealth care led service. This is ex-pected to offer maximum health ben-efits to the population.

Within the reform plan, nurses willplay a central role and their educationand re-training is given some impor-tance. Nurse training is to be up-graded and levels of educationimproved. A new educational pro-gram for nurses will be introduced andnurse teachers prepared. At present,all teaching of nurses is carried out bydoctors. This prevents the develop-ment of the discipline of nursing andthe promotion of the academic andprofessional development of nurses.

In order to develop a modern nurs-ing service it is recognized by theMinistry of Health in Tajikistan thatnurses must develop their nursingrole, update and improve their techni-cal skills, and take responsibility formanagement, leadership and organi-zation within the reformed health ser-vice. Family Health Nurses will needto develop clinical, diagnostic, healthpromotion and technical skills, as wellas an understanding of primary healthcare and family medicine.

continued next page

Focus on TAJIKISTAN:The Nursing Development Project

The School of Nursing, Midwifery andCommunity Health at Glasgow CaledonianUniversity was designated as a WHOCollaborating Centre for Nursing and MidwiferyEducation, Research and Practice in 1993. TheCentre’s key areas of activity are:

(i) development and promotion of nursing andmidwifery education that supports areorientation towards Primary Health Care;

(ii) the use of Evidence Based Practice(iii) collaboration in research and educational

activities with other Centres.The first of these activities has been the focus

of a major development project in Tajikistan forthe past five years. Professor Barbara A. Parfitt,Dean of the School of Nursing, Midwifery andCommunity Health at Glasgow CaledonianUniversity (GCU) and Director of the GCUCollaborating Centre, has played a key role inthis work, which includes monitoring progressof the Nursing Centre in Tajikistan, reviewing thedevelopment program for Centre Nurses,evaluating the Health Nursing re-trainingprogram, and curriculum development.

The WHOCC at Glasgow CaledonianUniversity became involved following a visit toTajikistan in 1997 by Ainna Fawcett Henesy, theprevious WHO/EURO Regional Nursing Adviser.Ms. Fawcett Henesy recognized the need for amajor redevelopment of nursing and midwiferyservices in Tajikistan following a period of majorchange, civil war and unrest, which had led to abreakdown of health services. She askedDr. Parfitt if the GCU would be prepared to‘adopt’ Tajikistan and assist them in thisprocess. Dr. Parfitt was familiar with the areahaving previously worked in Afghanistan. Shewas also able to speak Farsi, which is virtuallythe same as Tajik. The GCU School was pleasedto accept this supportive role as part of its planof work as a WHO Collaborating Centre. Thisarticle describes these activities in detail andspecifically the role of nursing and midwifery inthe Tajikistan Health Reform Plan.

Professor Parfitt has served as Europeanrepresentative on the Global Network’s ExecutiveCommittee since 2000 and has just been electedto this position for a further four years.

6 NOVEMBER 2002

Focus on TAJIKISTAN continued

The Current Situation

Prior to the development of the healthreform plan, WHO and the WorldBank supported the Ministry in carry-ing out an analysis of current needswithin the health service. A number ofidentified shortcomings are listed be-low and it is recognized that thesehave resulted in the reduced impact ofthe health service on the health gain ofthe population.

• Fragmentation of the managementof health services

• Centralized decision making• Poor management capacity• Under-resourcing of the Primary

Health Care (PHC) system• Curative orientation of the PHC sys-

tem• Curative orientation to care• A reliance on specialization in

medicine• Under utilization of nurses• Severe financial constraints

In reviewing the place of nurses inthe current situation the following ob-servations were made:

The immediate health status of thepeople of Tajikistan is deteriorating.Health services are directed almostexclusively to curative approaches tocare, and programs that are introducedto prevent disease and illness are ver-tically managed. In particular, the ma-ternal mortality rate is increasing andwill continue to increase as more andmore women have home births with-out adequate supervision. Some birthsare probably unregistered so a truemeasure of infant mortality cannot bemade but it can be estimated that it ismuch higher than figures suggest.Family planning is largely ineffectivewith a population increase of 16 per1000, and women giving birth to 6-8children. There is a resurgence ofcommunicable diseases with fewdrugs and no follow up.

The PHC situation was effectiveduring the Soviet period. The cura-tive/specialist approach with highmanpower levels and secure resourcesdid provide an adequate health servicefocused on the physicians. There is noevidence that nurses have had any rolebeyond that of fulfilling physicians’orders. ‘Basic nursing care’ wasrarely discussed as part of the nurse’srole. Physicians hold an extremelypowerful position and control thenursing profession. Physicians carryout all teaching of nurses and anynurse with ability would be expectedto develop academically and become aphysician. Within this climate, to gen-erate a culture where nursing hassomething to offer beyond medicine isunthinkable; the extended role of thenurse is seen almost entirely as nursestaking on part of the medical role.

Physicians carry out activities thatin other countries a nurse would do.For example, a ‘surgeon’ is appointedat a Health Centre to incise abscessesand suture wounds, dealing with mi-nor injuries.

Addressing the Problems

The Minister of Health is committed toaddressing these problems, and theHealth Reform Plan has been devel-oped to make fundamental changeswithin the current system and espe-cially those relating to the role andcontribution made by nurses. The Min-ister of Health has signed the MunichDeclaration(1) and supported the devel-opment of a Nursing Centre to pro-mote professional nursing practice.

The development of Family Practiceis a new and key area within PrimaryHealth Care services. The shift toFamily Health Nursing and changingthe role of specialist doctor to familyphysician will in the long term assist inthe provision of more comprehensiveservices.

It has been recognized that in orderto prepare nurses and physicians forthese major changes in their role, it isnecessary to develop a program thatemphasizes the development of lead-ership, management, and decision-making skills for nurses. Jointworkshops with nurses and familyphysicians, which facilitate shareddecision-making, will help to create aprofessional environment wherenurses will feel confident in develop-ing their role and physicians will sup-port them.

The key objectives of the Projectwere defined as follows:

• To advise the Minister of Health inTajikistan on the development ofnursing and midwifery to supportthe health reform plan.

• To support the development of theNursing Centre and facilitate thedevelopment of leadership skillsamongst nurses in the Centre.

• To provide nurse teacher training fornurses.

• To facilitate the development of theintegrated nurse training program,leading to General Nurse after threeyears and the additional qualifica-tion of Family Health Nurse after anoptional fourth year.

• To support the introduction of thenew curriculum in the medicalschools and colleges.

• To evaluate the new curriculum.• To participate in the WHO/EURO

Multi-Centre Evaluation Project forFamily Health Nursing.

Professor Parfitt has to date been theprimary contributor to this programfrom within the School. The AgaKhan Foundation has supported theproject as part of its strategic develop-ment of health in Tajikistan. TheFoundation has also funded two nurseteachers to provide a program of de-velopment for the nurses in theTajikistan centre. It has assisted in thesupport of visits by potential nurseleaders to Glasgow and Moscow.These visits provided an opportunityfor these new nurse leaders to further

7NOVEMBER 2002

their experience. The Foundation alsofunded the preparation and translationof learning materials to support thecurriculum.

The Health Reform Plan

In the initial stages of the program thedesignated Chief Nurse and ProfessorParfitt examined the Health ReformPlan and identified the key areaswhere nursing and midwifery devel-opment was necessary. Proposalswere made and these were incorpo-rated within the program. This pro-vided a clear framework for thedevelopment of nursing and mid-wifery in Tajikistan that included notonly the development of educationand training but also the licensure ofnurses and midwives and the overalldevelopment of capacity within thehealth service.

The establishment of the NursingCentre is central to the nursing devel-opment work within Tajikistan. Theprimary focus of the Centre is to leadeducational initiatives for nurses anddevelop appropriate curricula for bothpre- and post-basic training programs.

The first major step to be accom-plished was the approval by theMinister of Health for the establish-ment of the Centre. The establishmentof the Centre marked a major changeinthe official perception of nursingand nurses. It confirmed anacknowledgement of the key role thatnurses have to play not only in the de-livery of health services but also themore strategic contribution influenc-ing how care is carried out. There wasalso a recognition that nurses must be-gin to take responsibility for the edu-cation of their own profession. Thiswas previously the responsibility ofthe medical staff.

Once approval had been granted,three senior nurses and six recentlyqualified nurses were identified. Theappointment of a number of young,able and enthusiastic newly qualifiednurses who can be developed as lead-ers of the future was seen as essential

for future development. These staffmembers were allocated to the Centrewith a view to training them as nurseteachers and educators. Accommoda-tion for the Centre was found in thePost-Graduate Institute and a range ofmodels, books and equipment was do-nated.

Nurse Training

Once the Centre was established a pro-gram of development was commencedwith a series of training sessions onteaching and learning methods as wellas workshops on leadership and deci-sion making. The latter was multidis-ciplinary including both nurse leadersand medical staff. This was critical asmedical staff are still largely in controlof developments in nursing and haveownership of the changes that will betaking place. Many of those medicalstaff involved are committed to nurs-ing and have clearly identified the de-velopment of nurses as critical tohealth improvement.

Curriculum Development

An outline curriculum for the FamilyHealth Nurse program and the Gen-eral Nurse program was developed incollaboration with the teaching teamat the Dushanbe Medical College. Astructure and core content were agreedand the team worked together over anumber of days. There was a greatdeal of healthy discussion on the na-ture of the program and the prepara-tion of materials for it. The need toincorporate the requirements of theMedical University into the programwas accepted and taken into consider-ation. This allows nurses to access apathway of educational developmentotherwise denied them.

A key requirement of the programhas been to develop a cohort of teach-ers who can provide the nursing mate-rials and teaching. Traditionally theprogram has been medically orien-tated with the nursing contributionconsisting primarily of instruction on

nursing procedures. A series of work-shops has been held introducing keynursing concepts and refocusing theattention of the teachers on nursingobjectives rather than medical ones.They have responded enthusiastically,and quickly absorbed the fundamen-tals of the nursing process and the uti-lization of an Activities of Living(AOL) approach to assessment ofnursing needs.

The curriculum document was pre-pared over a number of months and isnow completed. The teaching staff isbusy preparing the lecture content fora launch in October 2002.

Support Materials for theIntroduction of the Program

In order to introduce the program,preparation of support was essential.There is virtually no nursing literatureavailable in Tajikistan. In order toguide teachers through the new sub-jects, teaching materials were neces-sary. Teaching notes have beenprepared for each lecture and thesehave been translated into Russian.This work was carried out by an expe-rienced nurse teacher funded by theAga Khan Foundation and Zdrav Plus,a USAID program. The developmentof placements and the training of men-tors is also a major task to be com-pleted and again the Aga KhanFoundation’s funding of two experi-enced nurse teachers to prepare appro-priate mentorship training programsand run workshops has been vital forthe work. Previously students hadlimited time for supervised practicewithin the clinical setting but gainedlimited experience by touring thewards with the doctors and observingprocedures. Students in the new pro-gram will spend twelve weeks eachyear in practice over two six-week pe-riods. During this time they will besupervised by mentors working along-side them in the clinical areas andmonitored by their college lecturers.

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8 NOVEMBER 2002

By: Thelma Henry, RGN, MA(see author details below)

During the late 1980s and early 90s, the Interna-tional Council of Nurses (ICN) recognized that amajor focus on leadership and managementdevelopment was needed in order to meet theneeds of nursing and health care worldwide inthe 21st century. The Leadership for ChangeProgramme was designed to meet this need,while at the same time responding to ICN mem-ber-association concerns and complementingcountry level programs. ICN envisioned an in-novative leadership and management programthat would equip selected nurses with the knowl-edge, strategies and strength to lead andmanage complex health services and in so do-ing, institute change to ensure a healthy futurefor all populations. The first projects wereimplemented in 1996 with the Caribbean regionparticipating in the first cohort of nations. Theprogram has proven to be adaptable to the needsof a wide variety of countries and health sys-tems, having been successfully carried out innearly fifty countries and through the develop-ment of regional projects in several parts of theworld. For more information about the Leader-ship for Change Programme, contact ICN NurseConsultant Sally Shaw: shaw@icn.ch.

Over the last few years, the nursingshortage has become a perplexingproblem for health care managersworldwide. The reasons for this aremulti-factorial and must be viewed ina global context. This article reflectsmy personal experiences as a Barba-dian, who migrated to the UnitedKingdom and pursued a professionalcareer in nursing for thirty-three yearsbefore returning to Barbados to con-tinue my career in the broader healthcare environment of staff develop-ment and hospital administration. Myperspective is influenced by my par-ticipation in the ICN Leadership forChange Project, 1996-2000 (see box),and as leader of the Caribbean Re-gional Leadership for Change project,which is a continuance of the ICNprogram.

Two important elements of theLeadership for Change training pro-vided by ICN were instrumental informulating my views on nurse short-ages globally and in the Caribbean. InPhase 1 of the project, workshopswere held in four different CaribbeanCountries. This provided me with amacro view of health service provi-sions in those countries. Phase 2 of theProject was held in conjunction withLatin America, which deepened myinsights on health care issues in thatregion. The workshops provided byICN explored the common issues inthe nursing profession and health carein these developing states. The nurs-ing shortage was a recurring topic.After observing at first hand and

studying the issues related to the glo-bal nursing workforce shortage (notonly in the Caribbean and LatinAmerica, but also via a study tour toZambia and Zimbabwe), I identifiedthree important triggers for the presentnursing shortage and the resultingconsequences: health sector reform;disenchantment with the nursing pro-fession; and globalization.

As a nurse working in Britain in thelate 80s and 90s, I witnessed the ef-fects of health sector reform. Wide-spread downsizing, while intended touse resources more efficiently andprovide patient-centered care, in factresulted in an insecure health care en-vironment. Changes in traditionalnurse and nurse manager roles, theconstant requirement to do more withless, and the poor image of the healthcare system perpetuated by the media,all led to the public perceiving thehealth care system to be in crisis. In

most instances the nurses took thebrunt of the public’s displeasure. Thisset of events had two negative out-comes for the profession: (i) fewer andfewer well-educated, bright youngadults chose to go into nursing; and(ii) there was an exodus of experi-enced nurses out of the system to pur-sue other careers.

Simultaneously, in the Caribbean,governments were also under pressureto cut costs. The International Mon-etary Fund was advising on structuraladjustment in order to bring econo-mies under control. Health care ser-vices were being expanded, yet healthbudgets were static. Nurse staffinglevels were not increased and it wasno longer automatic for newly quali-fied nurses to obtain jobs in the sys-tem. In the meantime, criticisms bythe public on the poor standards ofhealth care were on the rise. Disen-chanted with the ability of the deci-sion makers to get the health caresystem sorted out, they complainedof negligent or non consumer-focusedcare. Nurses too, excluded from con-sultations and decision-making onhealth reform, became dissatisfiedwith the lack of recognition for theircontribution to health care, their frus-trations centering on terms and condi-tions of service, unsatisfactoryworking environment, and bureau-cratic management.

The current surge of recruitmentfrom international agencies has there-fore come at a time when health caredelivery in the Caribbean is at its mostvulnerable. On the one hand, the newgeneration of nurses in the Caribbean,like their counterparts internationally,are being prepared to meet the chal-lenges of change in health care deliv-ery. They are receiving an educationthat equips them to be critical thinkersand to challenge practices that are un-acceptable. They are also being en-couraged to be patient advocates.

The Impact of Global Nurse Shortages andInternational Recruitment on Caribbean Countries

There were three triggersfor the present nursingshortage and resulting

consequences.

9NOVEMBER 2002

Thus they expect to be part of the deci-sion making process, particularlywhere clinical care is concerned andwhere policies are made that impacton their ability to deliver quality care.Additionally, they expect to providecare in a safe and secure environment.

On the other hand, Caribbean nursesperceive that they are neither valuednor respected and this perception isreinforced by the slow pace at whichGovernments address their concerns.Nurse managers feel powerless tohandle what they view as enormousand complex issues. The response istherefore closed: directive and reac-tive, rather than pro-active, open andflexible. This has created a communi-cation gap, which neither managersnor nurses seem prepared to close.The result is de-motivated nurses,who are stressed and burnt out. Thishas led to a decline in nursing stan-dards, high sickness and absenteeism,and industrial disputes. Additionally,in more and more instances our mostproductive nurses are leaving the pro-fession to take up alternative employ-ment, seeking opportunities abroad, ortaking early retirement. This has led toan acute shortage of nurses; so muchso that Caribbean countries also haveto recruit nurses from other countriessuch as Cuba and Guyana. Retirednurses are also being invited to returnto nursing.

Impact of Nurse Shortages on Health Care in the CaribbeanHealth care consumers in the Carib-bean today have far greater accessthan in the past to medical informationthrough the media, internet and healthNGOs. They are demanding betterquality health services in spite of theescalating cost. Nurses are the singlelargest group in the provision and de-livery of health services. It is thereforereasonable to argue that the shortageof nursing personnel will have a sig-nificant effect on the quality of health

care delivery and consequently on theproductivity and economic viability ofthe Caribbean countries.

More than ever before, the Carib-bean needs its nurses to help improvethe health status of individuals andnations. The Caribbean has the highestincidence of HIV/AIDS outside ofsub-Saharan Africa. Communitynurses, through health education andhealth promotion, are the first-lineprofessionals in the reduction oflifestyle diseases such as diabetes, hy-pertension, cardio-vascular diseasesand cancer. Treatment of these dis-eases absorbs the majority of the Car-ibbean health care budget. Caring forthe elderly with these chronic diseasesdemands unique nursing skills.

Nurses also have a contribution tomake on issues such as women’s

health, education and employment.They are well placed in the commu-nity to observe the factors that influ-ence health status such as housing,water; sanitation, poverty and childabuse, and can contribute to healthpolicies on these issues. While Carib-bean Governments have long recog-nized that there is a strong linkbetween national productivity, eco-nomic viability and good health, theyhave failed to recognize nurses’ con-tribution to the state of the nation’sgood health. This is partly due to thefact that nurses themselves do not re-alize their value as the linchpin ofquality health care for the population.Like other nations’ nurses, Caribbeannurses have never been able to articu-late or demonstrate clearly their valuein the overall delivery of health careand so they have been viewed as anadjunct to medicine and a ‘jack of alltrades’ rather than a partner and leaderin the delivery of quality health care.

It is time for nurses to step back andreview their role in the changing envi-ronment in which they deliver care.One of the most challenging areas innursing in the Caribbean is that ofleadership. We must prepare a newgeneration of nurses with the ability toarticulate their value and to be recog-nized and consulted on issues ofhealth care planning, policy develop-ment and management of services.

Recruitment Patterns

Recruitment of nurses and potentialnurses is not a new issue in the Carib-bean. During the 1950s, young womenwith the appropriate educational abili-ties and credentials left the Caribbeanto be trained as nurses in the UnitedKingdom. Persons with fewer qualifi-cations were directed to the secondlevel of nurse training (‘EnrolledNurses’) without the necessary coun-seling as to the limited opportunitiesthat pathway offered for upward mo-bility. As Caribbean countries gainedtheir independence from Britain, mi-gration to the UK decreased, but theCaribbean had benefited on at leastthree levels: (i) Caribbean nurses re-ceived training; (ii) foreign exchangesent back to the Caribbean helpedbuild the economy and the develop-ment of these countries; and (iii) themigration of Caribbean workers freedup employment for those left behind.

Today, the profile of nurses who arebeing recruited is different. Well-qualified experienced nurses with twoor more years’ post-registration expe-rience are emigrating to the UK andUSA, and to a lesser degree Canada,where they foresee enhanced educa-tional opportunities, more choices incareer pathways, better terms and con-ditions of service, and higher financialrewards. Unfortunately, the number ofnewly qualified nurses does not matchthe numbers leaving, nor do these

continued next page

Caribbean governmentshave failed to recognize

nurses’ contribution.

10 NOVEMBER 2002

The Impact of Global Nurse Shortages and InternationalRecruitment on Caribbean Countries continued

nurses have the experience to meet theneeds of the health care consumer. Thelatest upsurge in the overseas recruit-ment of Caribbean nurses thereforehas both negative and positive effects:

Negative• Loss of nurses with high potential to

other countries;• Poorer Caribbean countries pay

high training costs to the benefit ofwealthier countries, with no recipro-cal arrangements;

• Shortage of nurses contributes todeclining standards of health caredelivery;

• Heavier workloads placed on localnurses result in stress, burn-out, andhigh absenteeism due to sickness;

• Resentment shown to returningnurses by local counterparts, mak-ing it difficult to integrate and makea meaningful contribution;

• Loss of contribution of well-qualifiednurses to the development of the pro-fession and wider Caribbean society;

• Disruption of family units.

Positive• Broadened horizon to nursing and

health care practices through inter-national exposure;

• Exposure to leading edge healthcare developments and increasededucational opportunities;

• Increased knowledge and skills ben-efiting health care on return to homecountry;

• Opportunities for professionalbenchmarking against internationalprofessional colleagues;

• Positive image of Caribbean healthprofessionals internationally, thanksto their excellent reputation for care;

• Better pay and conditions of service;• Opportunities to work towards a se-

cure financial future;• Pensions and savings of returning

nurses contributing significantly tohome countries’ economy.

Thus globalization has opened upnew markets for nursing skills andthere is a major movement of nursesglobally in search of new experiencesand better conditions of employment.The challenge for the Caribbean is toensure that there are enough nurseswith the knowledge and skills neces-sary to meet the needs of health care inthe Caribbean, while facilitating themobility and entrepreneurship ofthose who seek such opportunities.Some trade in health services has al-ways been present and increasingly,specialist and private care is beingmade available in the Caribbean boththrough local professionals and busi-ness investors. This has a number of

benefits for health care consumers,health professionals and the Govern-ment, but critical to its success is hav-ing the number of skilled nursesavailable to provide quality care.

The shortage of nurses in the Carib-bean cannot be addressed solelywithin the context of the region. Solu-tions must take into account the globalmarket and its impact on Caribbeancountries. There are obvious benefitsto be gained from nurses migrating,and the Caribbean countries need tocapitalize on these, while seeking cre-ative methods to ensure that there is aconstant supply of nurses to meet thepopulation’s needs. Private/publicpartnerships in the provision of nursetraining and continuing educationmust be agreed upon as an option. Re-ciprocal agreements between the re-cruiting countries and Caribbeancountries are another area for consid-eration. A paper presented at the 2001

Commonwealth Health MinistersConference in New Zealand, outlininga Code of Practice for internationalrecruitment of health workers, is oneuseful tool in highlighting the moraland ethical obligations in recruitmentof this nature.

Nurses will continue to seek inter-esting and different experiences innursing and health care delivery asopportunities are presented in the glo-bal market. In so doing they enrichthemselves, the nursing profession,and deliver quality care to consumers.The challenge for the Caribbean is tobe strategic in its response, flexiblein its approach and willing to buildalliances.

A planned approach to the develop-ment of health services coupled witheffective manpower planning must beseen as an essential element in bring-ing solutions to the problem of thenursing shortage in the Caribbean. En-hanced communication with all inter-ested parties using a variety oftechnological support systems will benecessary. Managers must be compe-tent and comfortable with informationtechnology in planning and forecast-ing needs.

Leadership training too, is essentialin bringing about the paradigm shiftthat is required to respond effectivelyin today’s rapidly changing environ-ment. Managers must articulate notonly what they need but be able tosupport their claim with factual re-search-based evidence. Furthermore,in managing health care, they need tobe visionary—looking beyond theirimmediate environment to the widerrealities—and proactive in planningservices.

The Governments of the Caribbeanmust recognize the contribution ofnurses to the health care system andby extension to the economy of these

continued page 15

Globalization hasopened up new markets

for nursing skills.

11NOVEMBER 2002

Featured Collaborating Centre:Case Western Reserve University

Frances Payne Bolton School of Nursing:WHO CC for Research and Clinical Training in

Home Care Nursing

Focus on UGANDA:Project Uganda Nursing Team(PUNT)

The Frances Payne Bolton School of Nursing atCase Western Reserve University (CWRU) wasdesignated as a WHO Collaborating Center forResearch and Clinical Training in Home CareNursing in 1993 . The Centre works nationallyand internationally in the analysis and develop-ment of home care policies, the development ofeducational programs for nurses and otherhealth care personnel who provide home care,and conducts collaborative research and con-sultation on evidence based practice for homecare and other health related issues. The Head ofthe Centre is Dr. Elizabeth Madigan, AssistantDean for International Programs and AssociateProfessor of Nursing. The AIDS InternationalTraining and Research Program described inthis article – Project Uganda - includes educa-tion, research and professional service initia-tives launched collaboratively among a team offaculty from nursing and medicine from CWRU,Makerere University in Uganda, and New YorkUniversity (NYU).

For more information please contact:Dr. Elizabeth Madigan, Head, WHOCC,Assistant Dean for International HealthPrograms. Email: eam13@po.cwru.edu.

Makerere University, the oldest uni-versity in Uganda and site of thecountry’s major health science aca-demic programs, including nursing,medicine, dentistry, and public health,is located in Kampala, Uganda’s capi-tal city. The current population ofUganda is 23,985,712; fifty-one per-cent of the population is aged 0-14years (CIA World Factbook, 2001).

Among the Ugandan people, HIV/AIDS represents the most significantcurrent health and social challenge.The estimated number of people liv-ing with HIV/AIDS in Uganda as ofDecember 2000 is 1,107,644, ofwhom 110,880 are children aged 15years and younger. The cumulativetotal number of persons with AIDSas of December 2000 was 58,165.

Approximately 500,000 Ugandanshave already died of AIDS. Ugandahas succeeded in decreasing HIVprevalence from approximately 30%in the early 1990s to approximately10% in 1999. In spite of the observeddecrease in the HIV/AIDS infectionrates, it is important to note that therates remain unacceptably high. AIDShas caused a reduction in life expect-ancy from 54.1 years to 42.6 years. Inaddition, crude death rates with AIDSare 19.0% compared to 12.5% withoutAIDS (Ministry of Health, 1999).

WHY UGANDA?

Case Western Reserve University(CWRU) Schools of Nursing andMedicine have had a long-standingcommitment to Uganda. As early as1988 a memorandum of agreementwas signed between CWRU and theUganda Ministry of Health. TheCWRU School of Nursing assisted inestablishing the first baccalaureateprogram in nursing in Uganda in1993. Faculty from the CWRU Schoolof Nursing participated as visiting fac-ulty at Makerere University (MU) toteach the first BSc students in the newnursing program and six Ugandannurses studied for their master’s de-grees at CWRU School of Nursing.Since the early 1990s the partnershiphas flourished. Currently efforts areunderway to develop new initiativesfor collaboration in nursing education,practice and research.

Why Nursing and HIV/AIDS?

Presently, nurses comprise the largestgroup of health professionals, both inthe US and in Uganda. While theUgandan population per physician is19,759, the population per nurse is

4,730. HIV/AIDS, one of the mostpressing health problems in Uganda,should be addressed by nurses, mostespecially those in leadership posi-tions. Nurses are in a key position toimplement primary, secondary andtertiary prevention programs to helpcontain the spread of HIV/AIDS. Fur-ther, as nurses play a key leadershiprole in community outreach, they canteach the public about HIV/AIDS pre-vention, treatment and care.

What is Project Uganda?

Project Uganda includes education,research and professional service ini-tiatives launched collaborativelyamong a team of faculty from nursingand medicine from CWRU, MakerereUniversity, and New York University(NYU). The Project Uganda NursingTeam (PUNT) consists of the nursemembers of the team who have cometogether to “to maximize the contribu-tion of nursing and midwifery in orderto advance Health for All.” (VisionStatement of Global Network, 2002).

The CWRU-NYU-MUPartnership

As indicated above, the partnershipbetween CWRU and MU Nursing be-gan in 1993 with the development ofthe BSc in nursing program - a projectthat was generously supported by theRockefeller Foundation. The relation-ship between CWRU and NYU beganin 1997 through a formal partnershipthrough the WHO Collaborating Cen-ter for Nursing and Midwifery basedat CWRU. Building on the initial col-laboration between CWRU and MU,and enhanced through the expertisein HIV/AIDS of the NYU faculty

continued next page

12 NOVEMBER 2002

Focus on UGANDA: Project Uganda Nursing Team – (PUNT) continued

members, the partnership has ex-panded. In the fall of 2000, one of thefirst MU graduates of the BSc pro-gram became the first nurse to besponsored by the CWRU AIDS Inter-national Training and Research Pro-gram funded by the NIH FogartyInternational Center grant to pursueher master’s degree at CWRU. WithFogarty grant support, Ms. Walusimbicompleted her master’s degree innursing at CWRU in May 2002.Throughout her experience at CWRU,the PUNT team launched severalprojects; each of these projects buildson the strengths of the partners: MUDepartment of Nursing, CWRUSchool of Nursing and NYU Divisionof Nursing. Two recent site visits havebeen conducted: one in summer 2001and the most recent in March 2002, toformalize relationships between theUS participants and MU, the UgandaMinistry of Health and colleagues innursing and medicine throughoutUganda. The PUNT projects include:the Komamboga Health Center(KHC), the NYU Study AbroadCourse (Summer, 2002), collaborativeresearch projects, and HIV/AIDS con-tinuing education workshops forUgandan nurses.

What are the projects proposed by PUNT?

1. Komamboga Health Center

With the emergence of the HIV/AIDS epidemic, first reported inUganda in 1982, came an increase intuberculosis, sexually transmitted dis-eases, and maternal child transmis-sion. Through KHC, a primary healthcare model of service delivery will beimplemented. The goals of KHC are:

• to improve delivery of services;• to establish new community-based

outreach programs;• to use preventative measures such

as vaccinations, health literacy pro-motion, and early screening for ill-nesses both curative andrehabilitative;

• to determine the impact of the HIV/AIDS epidemic on community andfamily issues.

The project will enhance patientcare and community involvement andtarget improvement of health out-comes by increasing quality and ac-cess to care.

KHC is a collaborative endeavor ofthe CWRU Schools of Medicine andNursing, the Uganda Ministry ofHealth, and Makerere University. Theproject team has secured the commit-ment of the Uganda Ministry ofHealth and the Kawempe Divisiongovernment officials for this project.

Advanced practice nurses from theCWRU faculty and faculty membersand students from Makerere Univer-sity (Uganda) will serve as nursingstaff. The US nurses will undergotraining in Ugandan health settings inorder to improve the cultural rel-evance of their care and to become fa-miliar with the diseases, conditions,diagnostic methods, and treatmentsthat are more common in Uganda.The KHC will provide an educationalsetting for CWRU and Makerere Uni-versity students of nursing, medicine,and public health. Located in theKawempe Division of Kampala, KHCcurrently is staffed by one physician,two midwives and three nurses. Theydeliver care to 70-100 individuals perday. Financial resources, personnel,and medical supplies are limited. A

health needs assessment of theKomamboga/Kawempe communityhas not been performed; this will beconducted in summer 2002 to appraisethe community’s current demograph-ics, resources, needs, and desires. Theresults of this assessment will directfuture programs and services atKomamboga Health Center. It is an-ticipated that these services will in-clude family planning;immunizations; tuberculosis screen-ing, treatment, and prevention; nutri-tion assessments and interventions;and treatment of opportunistic infec-tions associated with HIV/AIDS. Fur-thermore, in the long term, KHC canserve as a site from which to provideanti-retroviral therapy to AIDS clientsin the community.

This program incorporates a com-prehensive approach to healthcareboth through its broad-based primarycare model and through its consider-ation of individual, family, and com-munity needs. Such an approach willallow an extensive assessment of theimpact of HIV/AIDS on families andcommunities in the area. In the future,this assessment will serve as the foun-dation on which to construct focusedand appropriate HIV/AIDS interven-tions. The proposed endeavor will im-prove and enhance health servicesprovided by KHC, encourage commu-nity involvement in health promotionactivities, create a milieu from whichto thoroughly assess the HIV/AIDSepidemic in this area, and provide sup-port and resources to KHC.

2. Study Abroad Program

The NYU six-credit graduatecourse: HIV/AIDS Pandemic: HealthCare Strategies for the Promotion ofWellness was held in Kampala,Uganda July 8-August 2, 2002. Fac-ulty and students from NYU andCWRU were hosted by their col-leagues from MU. Summer 2002

U.S. nurses will undergotraining in Ugandan healthsettings to improve cultural

relevance of care.

13NOVEMBER 2002

marked the launching of the course; itwill be offered annually. As part of thecourse, students explored the histori-cal, political, behavioral, ethical, eco-nomic, and biomedical elements thatcontribute to the spread of the AIDSpandemic. Prevention and policy is-sues were analyzed, as well as healthrelated and non-governmental organi-zations’ responses to the crisis.Makerere University faculty and com-munity leaders from throughoutUganda served as guest lecturers forthe course. The needs of HIV-infectedand -affected clients were consideredin the context of cultural, gender, anddevelopmental issues. The programincluded collaboration among US andUgandan students to design educa-tional intervention projects and iden-tify research questions for futureinvestigation.

3. Research

Walusimbi Study: Knowledge andattitudes of Nurses toward NursingCare of Patients with HIV/AIDS inMulago Hospital, Kampala, Uganda(Master’s thesis, CWRU School ofNursing 2001-2002). The purpose ofthis study was to assess knowledgeand attitudes of nurses in Mulago Hos-pital towards nursing care of patientswith HIV/AIDS. Data was collected inthe summer of 2001; 477 nurses com-pleted the surveys (86% responserate). Approximately 95% of thenurses (n = 452) had provided care toHIV/AIDS patients. Yet, 81.3% (n =388) felt resources to obtain HIV/AIDS information were inadequate.Forty-seven percent (n=232) ex-pressed fear of contagion. Knowledgegaps were identified in areas of Pre-caution and Prevention and Agent andImmunology aspects of the assess-ment. Respondents who were moreknowledgeable had less fear of conta-gion. HIV/AIDS knowledge deficitsexist among nurses and midwives

working in Mulago Hospital. Positiveattitudes towards patients with HIV/AIDS were displayed despite fears ofcontagion.

Salyer Study: Knowledge and Atti-tude of Ugandan Midwives RegardingHIV/AIDS (to be conducted in sum-mer 2002). This study will be a repli-cation of the Walusimbi study, withthe focus of surveying Ugandan mid-wives. The results will build on theexisting data we have obtained fromthe Walusimbi study and enable us todevelop appropriate education pro-grams in collaboration with the Ugan-dan nurses that will address theknowledge needs of the midwives.

Be Proud! Be Responsible! (BPBR):A designated “CDC Program thatWorks”, this intervention is targeted at

the prevention of HIV. The purpose ofthe program is to delay the initiation ofsexual activities, to reduce rates of un-safe sexual practices, to facilitate asense of pride and self efficacy, andunderscore that responsibility and ac-countability should be consideredwhen contemplating decisions aboutsexual matters (Jemmott, Jemmott, &McCaffree, 1999). Originally de-signed for inner city, African-Ameri-can males (Jemmott et al, 1992), thesix-hour curriculum has been used in avariety of US inner-city settings withmales and females. BPBR currently isbeing implemented by Dr. Tufts in sixCleveland public schools and four sub-urban schools in the Cleveland area aspart of an NIH funded study. The pur-pose of the proposed research will beto culturally adapt and assess the effec-

tiveness of BPBR when implementedwith Ugandan adolescents. BPBR willbe implemented in the Kawempe divi-sion of Kampala, Uganda with adoles-cents 13-16 years old.

4. Continuing Education Work shops for Nurses and Midwives

The dramatic reduction in HIVprevalence in Uganda is attributed tothe Ugandan government’s high-levelcommitment to HIV prevention andcare that involves a wide range ofpartners in all segments of society.Despite this success, important ad-vances in HIV/AIDS care must con-tinue for the disease to be effectivelycontrolled (Walusimbi et al, 2002).Based on the work of Walusimbi(2002), it has been found that an HIV/AIDS knowledge deficit exists amongthe nurses at Mulago Hospital inKampala. Attitudes about caring forthose with the disease are generallyfavorable among this group of nursesand the nurses are eager for more edu-cation. Workshops are being devel-oped to increase HIV/AIDSknowledge and quality of care amongUgandan nurses and midwives. Seedfunding will be provided through theCWRU School of Medicine Fogartygrant.

What are the future plansfor PUNT?The immediate priority is to continueto develop KHC through developmentof community outreach and healtheducation programs. Long-term goalsof PUNT include building accommo-dations for the KHC staff and studentsfrom MU and the US. In addition tothe projects for KHC, PUNT will ex-pand the continuing education work-shops for nurses to offer astandardized curriculum for nurses

continued next page

Workshops aim to increaseHIV/AIDS quality ofcare among Ugandannurses and midwives.

14 NOVEMBER 2002

Jennifer Okonsky, MA, APRN, BC,clinical faculty member at CWRUSchool of Nursing and Coordinatorof PUNT projects.

Mariam Walusimbi, RN/M, BSN,MSN, the first nurse to receive aCWRU Fogarty fellowship,received her MSN from CWRUSchool of Nursing in May 2002.

Joseph P. Colagreco, MS, APRN, BC,NP-C, is Assistant ClinicalProfessor at New York UniversityDivision of Nursing and Director ofthe HIV/AIDS study abroadprogram.

Speciosa Mbabali, SRN, SCM, CNE,McommH, is the Department Headof Nursing, Makerere University.

Jemimah Mutabuzzi, URN, URM,NTD, BSN, MSN, is a full timelecturer at the Department ofNursing, MU.

Jennifer Salyer, RN, MSN, is a doctorof nursing student at CWRU Schoolof Nursing.

Focus on UGANDA

continued

_______________________________________________Reference

(1) Munich Declaration: Nurses and Midwives: a Force forHealth, 2000. Second WHO Ministerial Conference onNursing and Midwifery in Europe, 15 - 17 June 2000.

Focus on TAJIKISTAN

from page 7

Evaluation of the Project

It is important to evaluate the impactof the new program and to review theappropriateness of the new curricu-lum. Tajikistan is part of the Multi-Centre Evaluation Project withinEurope evaluating the introductionand education of Family HealthNurses. Professor Parfitt will beevaluating the new program and itseffectiveness in preparing studentsfor practice within the new HealthReform system. A systems evalua-tion approach is to be used and thiswill assist in the comparison of dataacross Europe with the introductionof similar programs in other Euro-pean countries.

Conclusion

This is an exciting program that theGCU Nursing School is pleased tobe part of. Already we see majorchanges taking place and both nursesand doctors within Tajikistan arebeginning to take forward their owninitiatives for change. Our role willbe to continue to act as an advisor andsupport the provision of educationaland leadership development wherenecessary. The Aga Khan HealthServices and other aid organizationshave made major commitments tothis nursing development program.Their support has been critical for thesuccess so far as they have providedfinancial support for keydevelopment work. ■

PUNT Team Members and contributors to this article:

Sabrina Eagan, RN, is a graduatestudent at CWRU in the joint MSN/MPH program.

Danielle Olds, RN, is a graduatestudent at CWRU in the joint MSN/MPH program.

Karen Johnson-Guy, RN is a BSNgraduate of CWRU School ofNursing; she is now a nursemidwifery graduate student atCWRU.

Joshua Muliira Kanaabi, RN, BSN, aTeaching Assistant in the MUDepartment of Nursing, is a FogartyFellow enrolled in the bioethicsgraduate program at CWRU as ofFall 2002.

Kimberly Adams Tufts, ND, RN,WHNP, is Associate Professor at theCWRU School of Nursing.

Joyce J. Fitzpatrick, PhD, MBA,FAAN, RN, Elizabeth Ford BrooksProfessor of Nursing and formerDean of the CWRU School ofNursing. ■

_______________________________________________

References

CIA - The world factbook - Uganda. (2001). Retrieved March 28, 2002 from http://www.odci.gov.cia/publications/factbook/geos/ug.html.Jemmott, J. B., Jemmott, L. S., & Fong, G. T. (1992). Reductions in HIV risk-associated sexual behaviors amongblack adolescents: Effects of an AIDS prevention intervention. American Journal of Public Health, 82, 372-377.Jemmott, J. B., Jemmott, L. S., Fong, G. T., & McCaffree, K. (1999). Reducing HIV risk-associated sexual behavioramong African-American adolescents: Testing the generality of intervention effects. Journal of Community Psychol-ogy, 27, 161-187.Ministry of Health, Uganda. (1999). Retrieved from www.health.go.ug, March 28, 2002.Walusimbi, M. (2002). Knowledge and attitudes of nurses toward nursing care of patients with HIV/AIDS in MulagoHospital, Kampala, Uganda. Unpublished master’s thesis, Case Western Reserve University Frances Payne BoltonSchool of Nursing, Cleveland, OH.Walusimbi. M., Okonsky, J., Colagreco, J. P., Kirton, C., and Fitzpatrick, J. J. (2002). Nursing in Uganda in the realmof HIV/AIDS. Applied Nursing Research, 15, 194-196.

throughout the country. In additionto the summer study abroad courseoffered jointly by CWRU andNYU, another study abroad pro-gram is in development that willfocus on health, human rights andsocial justice in the realm of HIV/AIDS. This second course will be

offered collaboratively between theSchools of Nursing and Medicineat CWRU in summer 2003. Fund-ing for course development hasbeen obtained from a Nord Founda-tion grant provided to the CWRUUniversity Center for Innovationsin Teaching and Education.

15NOVEMBER 2002

countries. Pay and conditions of ser-vice must reflect the value of nurses tothe health of the nation. Moreover,nurses themselves must be self-em-powered through currency in theirpractice and up to date knowledge.They must show a strong united front,a spirit of professionalism and a com-mitment to give of their best to theirpatients. Clinical preceptorships andmentorships are key strategies thatnurses can adopt to ensure that nursesat all levels are socialized into the pro-fession.

National nurses’ associations, tradeunions, and non-governmental organi-zations must be vigorous in negotia-tions on behalf of nurses and market apositive image of the nursing profes-sion to the public and school leavers inorder to recruit the brightest and best. They must look beyond the traditionalrecruitment markets and target moremales as well as more mature persons.The consumers too, should lobby par-liamentary representatives on behalfof nurses and show solidarity in pro-grams and other media.

Nurse education and continuingeducation/training must continue toprepare nurses with high academicand professional standards. Nursesmust also be customer-focused andadvocate on behalf of their patientsand their professional colleagues.Nurses who are empowered will makeinformed choices on their career ad-vancements but above all, nurses whoare motivated and proud of their pro-fession will contribute to the health ofthe Caribbean nations.

There are several initiatives inprogress in the region. The first is theCaribbean Regional Leadership forChange Project (1999): “Empoweringnurses to deliver customer focusedcare”. This is a collaborative projectdesigned by nurses from eight Carib-bean countries who were trained in the

ICN Leadership for ChangeProgramme. The goal of the programis to develop customer-focused char-acteristics in Caribbean nurses.

The second initiative is the Man-aged Migration Project (2001). Thisproject is a collaborative one involv-ing key stakeholders in the Carib-bean, including regional nursingbodies, national nurses’ associa-tions, Caribbean Government repre-sentatives, Barbados CommunityCollege, unions, CARICOM, WorldHealth Organization, Pan AmericanHealth Organization and the Univer-sity of the West Indies. The goal ofthis project is to design a migrationplan to address some of the nursingshortage issues outlined in this ar-ticle.

Hopefully, these initiatives willmake a difference in the Caribbeanregion. In this evolving global mar-ket, we each have a responsibilityfor providing quality nursing care toour nations. Alone we can do verylittle; together we can make the dif-ference, remaining constantly vigi-lant that neither by our actions noromissions do we endanger the healthcare system of other nations. ■

AUTHOR DETAILS:Thelma Henry RGN, ITU Cert, Cert Ed, RNT,Dip Ed Man, MA (PCET), Kellogg/ ICN Fellow,is Consultant in Health Care Services and HumanResource Development and former AssistantHospital Director at the Queen Elizabeth Hospitalin Barbados.

Note: This article was adapted fromthe Evelyn Ellis Cohelan Lecture,given by Ms. Henry on March 19,2002 at George Mason UniversityCollege of Nursing and Health Sci-ence, sponsored by the Epsilon ZetaChapter of Sigma Theta Tau Inter-national.

The Impact of Global Nurse Shortages and InternationalRecruitment on Caribbean Countries from page 10

_________________________________

Global NetworkExecutive Committee

Terms of Office_________________________________

AFRO (2000-2004)Professor Laetitia King

Director, WHO Collaborating CentreProfessor and Head of Department

Department of Advanced Nursing SciencesUniversity of South Africa

Pretoria, South Africa

AMRO(concurrent with term as Secretary General)

Dr. Rita M. CartyDirector, WHO Collaborating Centre

Professor and Dean EmeritaCollege of Nursing and Health Science

George Mason University, Virginia, USA

EMRO (2000-2004)Dr. Mouza Abdulla Suwaileh

Director, WHO Collaborating CentreChairperson, Nursing Division

College of Health SciencesMinistry of Health, Bahrain

EURO (2002-2006)Dr. Barbara A. Parfitt

Director, WHO Collaborating CentreProfessor and Dean

School of Nursing and Community HealthGlasgow Caledonian University

Glasgow, Scotland

SEARO (2000-2004)Associate Professor

Kobkul PhancharoenworakulChair, Joint WHO Collaborating Centre

Dean, Faculty of Nursing (Siriraj)Mahidol UniversityBangkok, Thailand

WPRO (2002-2006)Professor Michiko Hishinuma

Head, WHO Collaborating CentreDean and Professor

St. Luke’s College of NursingTokyo, Japan

WHO HEADQUARTERS(EX-OFFICIO)

Dr. Naeema Al-GasseerSenior Scientist for Nursing and Midwifery

WHO, Geneva, Switzerland

Secretariat of the Global Network of WHO CollaboratingCentres for Nursing and Midwifery Development

College of Nursing and Health ScienceGeorge Mason University4400 University Drive, MS 3C4Fairfax, Virginia 22030-4444, USA

Tel: +1 703 993 3521Fax: +1 703 993 1908Email: gnwhocc@gmu.eduWeb: http://cnhs.gmu.edu/whocc/

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