Nurses and emergency nursing care in Botswana

Abstract

The emergency nursing role is incredibly challenging in Africa, and Botswana is no exception due to the lack of qualified nursing staff, the lack of specialty training, and the demanding work environment. Botswana's use of the primary healthcare system to provide treatment to all, including those in need of urgent care, demonstrates the necessity of integrating emergency care services into primary healthcare. Our objective with this manuscript is to demonstrate the value of emergency nursing as a specialty in Botswana.

African relevance

• •There is a need for formalized emergency nursing training in Botswana
• •In resource-limited settings, emergency treatment at the primary healthcare level is the first line of response to acutely ill and trauma patients
• •Integrating emergency treatment into primary healthcare is crucial in Botswana and other African countries.

Nurses and emergency nursing care in Botswana

Emergency care and nursing in Africa

In resource-limited settings, particularly in rural settings, emergency care demands have been a neglected public health concern [1]. Epidemiological changes in low- and middle-income countries (LMICs), together with a rise in disorders that may require emergency care, have called for adjustments in several healthcare facilities [2,3]. Emergency care is a crucial component of universal health coverage, yet most people in LMICs lack access to high-quality essential emergency care services [4].

The Emergency Care System Framework (ECSF), developed by the WHO, includes essential emergency care functions at the scene of an injury or illness, during transport, through the emergency department (ED) to inpatient care [5]. Effective emergency patient care requires a structured approach that commences before the ED. Nurses make up most healthcare professionals in areas with limited resources and are frequently the first clinicians to interact with patients in emergency care settings, they are exposed to most patient populations with rapidly changing and unpredictable clinical conditions [6]. They must be able to recognize and handle emergency situations in both the lowest facilities, which are typically primary healthcare facilities, and the highest level, the specialized hospitals [7].

Despite overall challenges in Emergency nursing training and care in Africa, there is a notable achievement in some countries in terms of training in the specialty and the recognition of the roles nurses play. Formalized specialist emergency nursing training is developing in some LMICs, such as Tanzania, Sierra Leone, Rwanda, Zambia, Ethiopia, Kenya, South Africa, and Ghana [8].

Healthcare delivery system in Botswana

Botswana has a population of 2.3 million people, with a density of 4.2 persons per km² [9]. In the 27 health districts, Botswana has a vast network of healthcare facilities, including hospitals, clinics, health posts, and mobile stops [10,11]. The health sector has been dominated by nurses, who make up over 70% of the health workforce [11]. Other healthcare professionals, such as physicians, pharmacists, lab technicians, lay counselors, and healthcare auxiliaries, make up the remaining 30%. The country's health system includes three national referral hospitals, 15 district hospitals, 17 primary hospitals, 311 clinics, 351 health posts, and 931 mobile stops [12]. A mobile stop lacks a permanent structure and is visited by a nurse, a lay counselor, and a mental health nurse in addition to a midwife, an eye nurse, and a mental health nurse. In contrast, a health post has no beds and is maintained by nurses¹⁰.

Extensive Primary healthcare is the cornerstone of delivery system of Botswana's decentralized healthcare system, with a population of 80–95% of the population within five to eight kilometers of a health facility [13]. The National Health Policy acknowledges that having access to a hospital does not ensure "high impact care," nonetheless [14,15]. The country's referral system is based on a ladder of service delivery [11], with tertiary hospitals at the top of the ladder, which are equipped to provide advanced and specialized services [12]. District hospitals are major hospitals just below the level of referral hospitals and equipped with more beds capable of managing long-term patients. On the other hand, primary hospitals are designed to cope with managing most diseases, trauma, and urgent health conditions [12]. (Mwandri and Hardcastle (2018) [16] evaluated the status of the resources and organizational structures necessary for optimal trauma care in Botswana. The two referral hospitals and one district hospital had all the necessary supplies, a good infrastructure, sufficient staff, and rehabilitation services, all of which met or exceeded WHO Essential Trauma Care recommendations. However, the three hospitals' employees lacked fundamental expertise in trauma care [16]. Despite that, it cannot be concluded that all healthcare facilities have the similar resources necessary for optimal trauma care.

The clinics primarily provide outpatient services within reach of communities, including general consultations, treatment of minor injuries, and severe cases referred to the hospitals for definitive care [12]. Health posts offer limited services, whereas mobile stops lack a permanent structure and are serviced by clinics and health posts within their catchment area. The lowest-level facilities, the clinics with no maternity and health posts, are each staffed by at least a general nurse, each of whom has at least a three-year nursing diploma [12]. Critical patients and those with severe injuries are typically referred to hospitals since doctors only work full-time in hospitals and only attend clinics two to three times each week [17]. However, sometimes the structure makes transfers take longer than necessary to reach definitive care [18]. Hospital emergency rooms are organized and staffed with at least two nurses each shift, plus one doctor in district hospitals. District hospitals have organized emergency rooms for walk-in patients and those needing immediate medical attention.

Epidemiologic data on emergency clinical manifestations has rarely been recorded or published in Botswana [19]. Central Statistics Office of Botswana's health reports primary health care data in the aggregate, combining emergency care and outpatient non-emergency visits [20]. Trauma and abortion-related complications were the most typical reasons for referral to a tertiary hospital and a district hospital in Botswana [20,21,22]. Nonetheless, the country lacks a standardized method for reporting statistics in the health system [23,24].

Emergency nursing care in Botswana

The emergency nursing role is incredibly challenging in Africa [25], and Botswana is no exception due to the lack of qualified nursing staff, the lack of specialty training, and the demanding work environment. General nurses without emergency backgrounds were placed in emergency centers, where they were exposed to emergency care for only a few weeks on the job, leaving them unequipped to handle complex emergencies. The general nursing curricula offer limited exposure to basic care skills and many African countries do not recognize specialization in emergency care [7].

The shortage of health care providers including nurses, especially in rural areas is still a challenge in Botswana [26]. The country continues to rely on nurses from neighboring countries like Zambia, Zimbabwe, Kenya, and others for nursing specialties like critical care nursing and theater nursing because most hospitals lack the necessary nursing skill mix to meet patients' demands.

The emergency medicine specialty was developed in 2011 at the University of Botswana [27], and since then, nurses have gained access to specialized short courses such as Advanced Cardiac Life Support and Basic Life Support. However, nurses are not mandated to be certified in such courses by their employer or the nursing council and yet literature has shown that Botswana nurses are lacking in that regard [28,29].

The training of nursing staff for the care of acutely ill or injured patients has traditionally received little attention in Botswana and other developing and middle-income countries [8,30]. The recent allocation of substantial scholarships by the country's Ministry of Health to nurses interested in emergency nursing indicates that emergency nursing is gradually gaining some recognition in the country. However, as none of the institutes of health training in the country offer emergency nursing, all these nurses must receive their training elsewhere, placing financial hardship on the country.

Despite the development of the African Emergency Nursing Curriculum (AENC) developed by The Emergency Nursing Group for the African Federation for Emergency Medicine (AFEM) intended to serve as a foundation and a starting point for the development of emergency nursing curricula in African countries, including Botswana, there is currently no institution in Botswana that offers emergency nursing. The dearth of skilled nurse educators with expertise in emergency nursing also exacerbates the difficulties of emergency nursing education in Botswana.

The Nursing and Midwifery Council (NMCB) of Botswana now has 11 critical care nurses registered; these include three with trauma and emergency nursing, five with intensive care nursing, and three with critical care nursing. Most of these nurses were trained in South Africa, and some of them work in the EDs and others nursing training facilities. The emergency nurse training programs in South Africa prepare students for careers in prehospital care, emergency rooms, intensive care units, and trauma wards [8,30].

The nurses are registered with NMCB, even though they lack a defined scope of practice at the moment, a problem that is shared by the majority of African countries [31]. The lack of the scope of practice leads to the ED nurses not functioning to the best of their capability since they operate with the same scope of practice as the registered nurses. The nursing staff at government facilities are paid for their specialty despite the lack of scope of practice, indicating that the Ministry of Health recognizes their area of expertise.

Primary healthcare and emergency nursing care

The quality and safety of healthcare depend on the prompt identification and treatment of those who are seriously ill or injured at all levels of the healthcare system [18]. Primary Health Care services in the country have also been integrated into outpatient departments of hospitals [11].

Primary healthcare in Botswana is led by nurses like it is in most resource-constrained countries. Catchment areas for healthcare facilities are vast, and most nurses are assigned to isolated rural clinics and health posts with little to no access to prehospital transportation to more definitive care [13,14]. Each facility has at least two nurses assigned to it. Patients are transported by nurses using an ambulance that is assigned to their cluster, which consists of three to five health facilities. The Botswana Primary Care Guideline, an integrated, symptom-based primary care guideline for the adult patient, guides the practice of these nurses [32] These nurses also provide care to patients in need of urgent care. Therefore, Primary healthcare systems in Botswana, like in most LMICs, need more advanced care capacities to manage emergency conditions [33]. In most LMICs, specialty services are available in referral hospitals, and patients with acute care need to access the healthcare system via primary healthcare facilities frequently. Therefore, emergency care interventions and services must be integrated with primary care to achieve the comprehensive strengthening of health systems.

Primary healthcare places registered nurses in a position where they must perform tasks outside of their scope of practice and expertise but are protected by the law because the Botswana Nurses Act states that nurses are not allowed to practice outside the scope unless there is an emergency or where a medical practitioner is not present [34]. However, providing emergency care in such a setting is particularly difficult, especially for those with limited expertise. Additionally, neither a standing order nor an extension of the prescription authority are provided for under the Act. The majority of nurses working in primary healthcare, especially in emergency care, are general nurses Kironji et al. (2018) [35] reported an unskilled workforce as the main problem that led to personnel's inability to prioritize and their inability to identify life-threatening problems that needed definitive care. Those nurses are also responsible for transporting the patients to the hospitals for definitive care.

Emergency departments and emergency nursing care

In Botswana, primary hospitals, district hospitals, and tertiary hospitals all have emergency rooms that are also known as accident and emergency (A&E) departments. In a typical Botswana emergency department, there are beds for patient assessment and observation, a designated triage area, and a resuscitation segment [36] These emergency departments function as both a point of admission for walk-in patients and a point of entry for patients transferred from lower-level facilities [19,22].

Nurses serve as the first contact for patients presenting with emergencies at the hospitals in Botswana, and they are responsible for triaging patients and monitoring patients awaiting disposition in the ED [37]. These nurses have not received specialized training in this area, despite being acknowledged as essential team members in emergency care. Students are taught the fundamentals of patient prioritization and triage in the ED, not necessarily the modified South African Triage Scale (SATS) adopted used to triage patients by most institutions in the country. These students have only been exposed to SATS and the triage process during clinical rotations in the ED. Since there is no formal training for triage and the modified SATS utilized by most hospitals is not included in the basic nursing curriculum, the triage system is not always applied correctly. This improper triaging, however, has an impact on the timely management of patients [38].

Emergency medical services in Botswana

Botswana's first Government emergency medical system (EMS) was initiated by Botswana in 2012 [39] and comprised of nurses, EMTs, healthcare assistants, and drivers; they were stationed in six centers covering significant towns and villages. Pre-hospital care has not been centrally coordinated, and government ambulances are used to transport most patients needing emergency care in rural areas [24,40]. There is no clear standard of pre-hospital care training, and general nurses provide most of the ambulance care [26]. Moreover, the scope of practice for these providers is unclear. Emergency medical services only provide ambulance services in a limited number of major towns and villages and do not provide services to most smaller villages and settlements [27]. Therefore, in the absence of EMS, nurses working for those health facilities are responsible for providing ambulance services [23,26].

Recommendations

Nursing education

• •There is a need for emergency nursing as a specialty in Botswana. The nursing school should provide short courses such as Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS) and Trauma Nurse Core Course (TNCC)  so that nurses can constantly access them and stay updated on new advancements in the field. The pre-licensure nursing curriculum for nurses should include training in BLS.
• •Priority needs for trauma and abortion care should be the emphasis of education, and procedures including cannulation for IV fluids/blood, managing abortion-related complications, and prompt patient referral should be emphasized for nursing practice.
• •Although it might be challenging to get the experts to teach, it might be necessary to collaborate with the experts from Africa through African Federation for Emergency Medicine. Collaboration with specialists from Africa via the African Federation for Emergency Medicine may be required since it might be challenging to get the professionals to teach the short courses.

Nursing practice

• •For nurses who have received formal training in emergency nursing to practice to the fullest, the scope of their practice must be expanded. Therefore, it calls for a review of the Nursing and Midwifery Act of 1995.
• •There is a need to expand the scope of practice for general nurses working in facilities without medical doctors, such as primary healthcare to include lifesaving procedures such as cannula insertion.
• •Nurses working in the ED should be granted extended prescriptive authority because, in most EDs, in district hospitals, only one doctor is scheduled per shift.

Nursing administration

• •There is a need to develop standing order protocols for nurses working in emergency settings. In cases where nurses are compelled to attend to a patient whose needs are beyond the scope of the nurse's practice, the standing order will be available to guide practice. The standing orders should include but are not limited to the initiation of CPR in cases of cardiac arrest, including prescription of medications, hypoglycemia protocol, electrolyte protocol, and even initiation of time-specific antibiotics.
• •The country needs proper record-keeping to generate the data required to enhance emergency care and guide policymaking. This can also develop a connection between patient care and nursing education.

Nursing policy

• •In contrast to the Emergency Nurses Society of South Africa, Botswana has no professional organization that can provide leadership in defining the scope of emergency nursing practice. To secure shared governance and give emergency nurses a voice, Botswana must establish a group of emergency nurses to take the initiative in formulating emergency nursing standards, procedures, and guidelines.

Nursing research

• •There is limited research in emergency care, particularly nursing emergency research in Botswana. It is crucial to explore emergency nursing in Botswana as well as the possibilities for improvement.

Dissemination of results

The recommendations from this paper will be presented to the Nursing and Midwifery Council of Botswana, the Ministry of Health, hospital authorities, and other nursing schools.

Author's contribution

Authors contributed as follows to the conception or design of the work; the conceptualisation, acquisition, analysis, or interpretation of data for the work; and drafting of the work or revising it critically for important intellectual content: TTM contributed 50%; KSD contributed 35% and DBMP contributed 15%. All authors approved the version to be published and agreed to be accountable for all aspects of the work.

Declaration of Competing Interest

The authors declare no conflicts of interest.