Skills and educational needs of accident and emergency nurses in Ghana: an initial needs analysis

Abstract

Background

The specialty of emergency medicine is highly reliant on a well-trained team of providers. Ghana has recently begun a specialist training program for physicians and the need to train specialist emergency nurses has been recognized. The first step to developing this training is to conduct a needs assessment. This study was conducted to elucidate current nursing functioning and gain knowledge of the educational desires and needs for nurses in the Accident and Emergency Center (A&E) at Komfo Anokye Teaching Hospital (KATH).

Methods

Three nurses from the University of Michigan (UM) worked collaboratively with the nursing leadership at KATH to conduct a needs assessment of currently practising nurses in the A&E. The UM nurses observed nursing practice in the department and KATH nurses participated in a multiple choice exam, a self-assessment questionnaire of educational desires, answered written open-ended questions and participated in focus groups.

Results

KATH nurses scored relatively low on a general knowledge multiple choice exam, and indicated through the self-assessment that they would like to learn more about many topics. Open-ended questions gave further insight into areas of knowledge gaps. Several themes including Cohesion, Carrying out Orders/Decision Making and Overwhelming Volume, emerged from observations in the emergency department.

Discussion

Current nurse knowledge and function as well as areas to focus on for future specialty training in emergency nursing have been identified by this needs assessment. The emergency department nurses shared an overwhelming interest in increasing their skill level, learning new methods of patient care and implementing new technologies into their clinical practice.

1. Background

The Republic of Ghana, located in West Africa, achieved independence from the United Kingdom in 1957. Although politically stable, similar to other countries in the region, Ghana has struggled with its health and economic indicators. According to the World Health Organization [1], Ghana has a population of approximately 23 million with a life expectancy of 56 for males and 58 for females. With a current gross national per capita income of $1,240, Ghana is in the top 30 of the world’s poorest countries [2].

Medical education in Ghana is located primarily in the two major cities of Accra and Kumasi. Postgraduate specialty training is available in many disciplines and in 2009, expanded to include Emergency Medicine. Emergency Medicine is in its infancy in the developing world. [3] Although established as a distinct specialty in the United States in the 1970s and in other areas of the developed world shortly thereafter, there are only two residency training programs in all of Sub-Saharan Africa; one is in South Africa and one now in Ghana. Although there are now physicians being trained in Kumasi and Emergency Medical Technicians (EMT) in Accra, other emergency personnel are without a formal training program.

The role of the emergency nurse is still developing in Africa and Brysiewicz and Wallis [4] noted there is a new push to formalize this role. To address this, the development of a professional body, the Emergency Nurses Society of South Africa (ENSSA), which is open to nurses in all African countries, was developed. Specialist emergency nursing training is growing in South Africa, where a post-registration diploma is offered in a number of nursing colleges and an advanced diploma or master’s degree in emergency nursing is offered at a few universities [5]. Elsewhere in Africa, the emergency nursing role is identified by Gondwe and Brysiewicz [6] as particularly challenging due to a high turnover rate of staff, limited specialty training and highly stressful patient care environment.

In Ghana, the Nurses and Midwives Council of Ghana (NMC) is the accrediting body for nurse training. Currently there is no distinct specialty body or pre-clinical training for nurses wishing to practice in the Accident and Emergency (A&E) Centers (the Ghanaian equivalent of Emergency Departments). There is no formalized association or society for emergency nurses within Ghana. The NMC is in the process of developing, with the leaders of the emergency medicine residency training program and Kwame Nkrumah University of Science and Technology, a specific curriculum and certifying exam for emergency nurses, signaling a country-led interest in developing this specialty.

This study was conducted to elucidate the current functioning and gain knowledge of the educational needs and desires for nurses in the A&E at Komfo Anokye Teaching Hospital (KATH).

2. Material and Methods

2.1 Setting

KATH is located in Kumasi, the second largest city in Ghana with a population of 1.17 million people [7]. The A&E opened in May, 2009 and is an approximately 150-bed facility staffed by physicians, house officers, and nurses, with various consulting services available. The A&E serves Kumasi and is a major referral center for the northern two thirds of Ghana. Patients arrive by private car, public transportation or ambulance. At the time of this study, the KATH A&E was serving approximately 25,000 patients per year.

2.2 Population

The population for this study comprised all nurses working in the A&E (a non-probability, convenience sample). [8] The nurse manager manages all of the nurses who work in the A&E building which encompasses not only the Emergency Department, but also the Medical Observation Unit, the Intensive Care Unit, the Burns Unit and the Post-Operative ward. There were 172 total nurses working in all of those units at the time of the study. The number of nurses working in the A&E (conceptualized as working in one of the Triage, Red, Orange or Yellow areas) was 77 at the time of the study.

2.3 Recruitment

The A&E nurse manager contacted nurses and explained the study. She explained that participation was voluntary and that there were no penalties for not participating. A schedule for the various aspects of the study was created and A&E nurses signed up for specific times.

2.4 Survey Instruments

In order to get as complete a picture as possible of emergency nurse knowledge and functioning in the A&E, a five-pronged analysis approach was utilized. (See Table 1) These tools included a 50-question survey addressing the current nurse practice and what areas, if any, they would like to learn more about (referred to as a self-assessment), a 20-question multiple choice knowledge exam (MCQ), observation in the department by the study team, open-ended written questions where cases were presented and appropriate nurse interventions were asked for and focus group discussions to review the answers given to the above questions.

Table 1.

Assessment tools used

Tool	Source	Sample n	Results/Main Outcomes
Self-assessment	UM questionnaire	37	Nurses want to learn more about a wide range of topics and are willing to spend time to do so.
Multiple Choice Questionnaire	CEN study guide	30	KATH nurses scored lower than their UM counterparts, signaling a need for training.
Observations	Guided by checklist developed from UM orientation manual	45 hours	The themes of Cohesion, Carrying out Orders/Decision Making and Overwhelming Volume were observed.
Focus Groups	UM nurses with input from on-site EM physician		KATH nurses are eager to learn.
Open-ended written	Expert opinion and based on observations	50 scored answers	KATH nurses scored between 36–50% on this section.

2.5 Reliability and Validity

The closed questions in the MCQ were derived from the study guide published by the Certified Emergency Nurse exam [9] and the Trauma Nursing Core Curriculum course [10] and hence were considered to have a certain degree of face and content validity, although the statistical reliability and validity was not determined. Further, face and content validity were assessed by expert review provided by UM and KATH clinical nurses and nursing faculty.

2.6 Instrument Development

Self-assessment

This 50-question tool was initially developed by UM nursing leadership in the emergency department, and was modified by UM and KATH staff to be KATH-specific. Demographic information, including years of service in the emergency department, level of education, hours per week worked, shifts worked, and preferred learning methods, about each nurse was collected on the self-assessment form. Nurses were given potential educational areas that were grouped by body systems and then broken down further into life-threatening conditions. The nurses were asked to state whether they would like to learn more about each topic, and to rate their level of interest in each topic (High, Medium, Low).

MCQ

The 20-question multiple choice knowledge test included questions about body systems with potentially life-threatening situations. The questions were modified from the Certified Emergency Nurse exam study guide, [9] and the Trauma Nursing Core Curriculum course. [10] The questions were chosen by the UM nurses based on common presentations to the A&E and discussions with the Acting Head of the A&E at KATH.

Observations

A competency-based assessment tool was designed based on the orientation booklet used at University of Michigan to guide clinical observations.

Open-Ended Scenarios

The scenarios answers were adapted from relevant emergency nursing textbooks, the Trauma Nursing Core Curriculum, and personal experience. The goal of this section was to obtain a deeper understanding of the nurses’ knowledge base in emergency situations and to elucidate the steps that they take when treating patients.

2.7 Pilot Testing

A pilot test of the MCQ was conducted with eighteen ED nurses in the US before data was collected with Ghanaian nationals. Wording of questions was also checked with a physician and a nurse from Ghana. It was important to ensure that the questionnaire was appropriate, in terms of content and language, for Ghanaian nurses for whom English is an official language but was not necessarily their first language. Content was found to be valid by the pilot testing and as a result of piloting no changes to the surveys were made.

2.8 Instrument Implementation

Self-Assessment

The self-assessment was administered to KATH nurses by the study team over the span of the ten days they were onsite. This was not offered in a controlled setting and nurses were requested to complete it at their convenience.

MCQ

The nurse manager at KATH requested that participants attend a session where the MCQ was administered.

Observation

The research team completed a total of 45 hours in the various sections of the emergency department observing practice patterns of nurses. Each observer rotated through the various sections of the department, which are divided into treatment areas based on the Cape Triage Score [11, 12] and include Triage, Red, Yellow and Orange. The most time was spent observing the Red area, as this is where the critical patients are located, and Yellow as this area has the highest volume. Observations were recorded on the core curriculum checklist. Included observations were nursing assessment, use of nursing process, types of nursing interventions, patient and equipment types, medications used, and communication between nurses and physicians. Daily debriefing sessions included discussing themes that were observed and recorded by each member. During the analysis period, written observations were read by all study team members and themes were extracted from these written records.

Open-Ended Scenarios

KATH nurses were invited to attend groups where scenarios of patients who were presenting to the A&E were posed to them. The nurses were asked to list the priority nursing intervention in each scenario in a paragraph or list form. Four to five staff nurses were assigned to each study facilitator. Each of the ten scenarios was presented to two groups of KATH nurses. The written answers were collected for analysis. Answer keys were developed for each scenario by consensus among the study team. Each scenario was scored by a member of the UM study team and reviewed by at least one other nurse.

Focus Group Discussions

Following the written portion of the scenarios, nursing interventions were discussed in small groups and the facilitators took notes on answers which were used to analyze verbal answers.

2.9 Ethical Review

Study procedures were approved and conducted in compliance with the Committee on Human Research Publication and Ethics, School of Medical Sciences, Kwame Nkrumah University of Science and Technology and the University of Michigan Institutional Review Boards for Human Subjects.

3. Results

Self Assessment

A total of 37 nurses (response rate: 48%) completed the self-assessment questionnaire. The majority (70.3%, n=26) have diplomas, while 1 (2.7%) has a certificate, 8 (21.6%) have degrees and 1 (2.7%) has a master’s degree. The majority of the nurses (54.1%) reported working at KATH for less than a year with another 37.8% working at KATH for less than five years, signaling a large turnover recently. Only 8.1% have worked at KATH for over five years. 75.7% report working 40 hours or more (18.9% of the nurses report working 48 hours per week). In general, the majority are willing to come in early, stay late or come in on a day off to attend a class (ranging from 64.9% being willing to come in on a day off, 73% being willing to stay late and 86.5% being willing to come in early). The nurses indicate wanting to learn more about all the topics offered, with the lowest “yes” answer being for Acute Coronary Syndrome (58.6% reported that they would like to learn more about this) and the highest being meningitis (83.8% reported they would like to learn more about this). Those who answered that they would like to learn more about a particular topic then ranked the priority they set to them, High, Medium or Low. See Table 2 for complete results.

Table 2.

Self-Assessment Results

	Category	Percent “Yes”	Priority
			Percent (of the total) High	Percent Medium	Percent Low
Trauma Care	Abdominal	67.6	54.1 %	13.5	0
	Geriatric	59.5	18.9	35.1	10.8
	Pediatric	81.1	70.3	13.5	0
	Orthopedic	67.6	45.9	16.2	5.4
	Ob/Gyn	59.5	35.1	13.5	13.5
	Compartment Syndrome	67.6	32.4	29.7	10.8
	Spinal Cord	78.4	56.8	18.9	5.4
	Burns	64.9	48.6	16.2	2.7
	Optic	67.6	43.2	21.6	5.4
Cardiovascular	Acute Coronary Syndrome	56.8	40.5	18.9	5.4
	Pacemaker	73.0	62.2	13.5	0
	Acute Myocardial Infarctions	62.2	54.1	16.2	2.7
	Arrhythmias	78.4	70.3	10.8	0
	Cardiac Medications	73.0	59.5% high	16.2	0
	Congestive Heart Failure	78.4	64.9	18.9	0
	Defibrillation	70.3	62.2	8.1	0
	Cardiogenic Shock	81.1	67.6	13.5	5.4
Neurological	Post Arrest	73.0	54.1	13.5	2.7
	Stroke	64.9	40.5	29.7	0
	Intra-Cranial Hemorrhage	73.0	54.1	21.6	0
	Headache	70.0	54.1	0	18.9
	Meningitis	83.8	75.7	10.8	2.7
Respiratory	Arterial Blood Clots	67.6	43.2	21.6	2.7
	Ventilators	75.7	70.3	5.4	0
	Pneumonia	81.1	59.5	13.5	5.4
	Pulmonary Embolism	81.8	67.6	16.2	0
	Breath Sounds	70.3	56.8	10.8	2.7
	Asthma	62.2	43.2	18.9	2.7
	Chronic Obstructive Pulmonary Disease	78.4	64.9	8.1	5.4
	Trachs	78.4	67.6	10.8	5.4
Other	Poisoning	62.2	37.8	16.2	8.1
	Diabetes	67.6	62.2	5.4	2.7
	Transplants	62.2	21.6	27.0	16.2
	Wound Care	64.9	37.8	21.6	2.7
	Street Drugs	78.4	70.3	8.1	2.7
	Autoimmune	75.7	62.2	10.8	5.4
	Pain Management	62.2	73.0	8.1	0
	Hepatitis	75.7	62.2	10.8	2.7

MCQ

30 KATH nurses (39% of the total) completed the MCQ. The average correct score was 44.5% with a range from 25–60%. This is in contrast to the 18 UM nurses who took the exam and scored an average of 83% with a range from 75–100%. See Table 3 for full results.

Table 3.

MCQ Results

Topic	No. of questions	Average score (range)
Shock	2	63.8
GI/GU	2	50.0
Respiratory	3	48.9
Cardiac	4	46.5
Trauma	3	43.2
Musculoskeletal	2	32.2
Toxicology	1	22.2
ENT	3	14.4
Overall	20	44.5 (25–60)

Open-Ended Scenarios

The scenarios for the focus groups discussed priority nursing interventions for commonly seen presentations at KATH. There were an average of 10.1 participants who completed each open-ended questionnaire (range 6–14) and the average score across all answers was 43% (range 36%–50%). Participants scored highest on the burn-related scenario (50%) and lowest on a gastrointestinal emergency-focused scenario (36.3%). See Table 4 for complete results.

Table 4.

Open-ended scenarios

Topic	N	Possible score	Min	Max	Average score	Average score—combined	Std Dev
Trauma 1	10	17	12%	82%	48.8%	44.0%	23.7
Trauma 2	12	13	23%	54%	37.2%		10.3%
Trauma 3	10	10	20.0%	80.0%	46.0%		19.0%
Respiratory 1	6	13	23.0%	62.0%	37.2%	44.25%	17.1%
Respiratory 2	8	10	23.0%	70.0%	51.3%		17.2%
Cardiac	10	9	22.0%	56.0%		36.7%	10.5%
Gastro-Intestinal	14	12	8.0%	83.0%		36.3%	24.2%
Interview/Triage	8	7	0.0%	57.0%		37.5%	20.1%
Malaria	10	10	18.0%	82.0%		49.1%	22.4%
Burn	14	12	25.0%	75.0%		50.0%	17.0%

Focus Group Discussions

During these discussions, the KATH nurses began by discussing the nursing interventions from the above scenarios. These talks organically shifted to the KATH nurses discussing their educational desires. Most notably, nurses expressed a strong desire to practice according to international standards. They noted wanting to be internationally qualified.

Observations

Several themes, Cohesion, Carrying out Orders/Decision Making and Overwhelming Volume, emerged from observations in the A&E. Each theme is closely interrelated with the next, and at times multiple themes were observed to be at work. First, cohesion, rather than formal teamwork, was observed. Nursing staff appear to enjoy working with each other and other ED staff. It was observed that there was a clear hierarchy with physician-driven care that precluded being described as a team environment.

The second theme noted was conceptualized as Carrying out Orders or Decision Making. The nurses’ role in the department was observed to be based on physician orders or following algorithms such as the Cape Triage scoring system. Nurses were observed to be so involved with carrying out orders that they were unable to perform other key elements of nursing care such as conducting a detailed physical assessment. Some of the observed algorithms have been implemented with the added intent of creating more nursing autonomy, such as structured nurse-driven triage [13].

The third theme noted was one of Overwhelming Volume. Due to the high patient volume, nurses were observed to be strictly task-oriented. In addition to the significantly large patient-to-nurse ratio in most areas, the nurses are responsible for obtaining medications from the pharmacy which is located in separate area of the department, discharging patients and other patient care details that are often performed by assistants in advanced emergency departments. These tasks take the nurses away from the bedside and thus away from their patients. In the Yellow area nurses were typically responsible for more than 15 patients.

There were times when a nurse was interacting with another nurse, with a physician or with a patient in a language other than English, which made some observations more difficult.

4. Discussion

The results of this assessment identified areas to focus on for future specialty training in emergency nursing. As Gondwe and colleague [6] found in Malawi, having no specialty training in emergency nursing is a challenge for KATH A&E nurses. Although all KATH A&E nurses have passed a registration exam given by the NMC and are thus qualified to be practicing as nurses, with the advent of a more formal and structured system of emergency care, patient care needs are increasing and require a more complex understanding of nursing principles. Further, the concepts of autonomy and critical thinking and decision making are fairly new in nursing education and the clinical atmosphere in Ghana. Thus, these skills and concepts will have to be developed in the trainers and trainees.

The major practice gaps that were identified by observation were lack of a team-based nursing approach, as well as a team-based departmental approach encompassing all staff in the A&E. Better team functioning leads to fewer errors and therefore better patient outcomes in emergency care. [14] In terms of team function and team training there were instances where responsibilities were not well defined and resulted in confusion. Nurses followed set protocols for certain nursing tasks, such as all patients seen in triage received a temperature check, however if a patient needed something outside of the protocols, such as immediate IV access or spinal immobilization, this was generally left to the physician to decide and implement. It appears however, that in order to effect change in the nursing role, the knowledge and clinical skill base of the nursing staff will need to be upgraded. Once this has been achieved and it is clear that the nurses are capable of making decisions and not just carrying out orders, a truly collaborative emergency medical system can be implemented. This current physician-driven model of care is a part of the culture of care, just as it was in the United States some 30 years ago. Nurse autonomy, built on increased knowledge and clinical skills and the associated confidence, is a major target for future nurse training.

From the vast majority of nurses who report being willing to come in early, stay late or come in on a day off to attend an educational session, it is clear that KATH A&E nurses desire to learn more about many topics. This desire mirrors the results found by Bolin and colleagues [15] among a population of rural US-based emergency nurses who rated continuing education as highly important. Patient assessment and advanced life support principles such as defibrillation and rapid sequence intubation were the most common areas nurses requested for further training. As the emergency department becomes more and more modernized, nurses will be required to update their current skill and knowledge set.

While this study represented an initial effort as part of a larger study, limitations were present. First, the MCQ and open-ended questions were not linked to demographic information, so it was not possible to determine whether the education and experience level of the nurses was correlated with score. This information would have been very helpful in planning further interventions, as well as for post-test follow up. Secondly, fewer nurses than expected completed the open-ended scenarios which offered a richer sense of knowledge than did the MCQ. Finally, the language barrier hindered observations. Use of a translator would have allowed a greater understanding of nurse to patient and nurse to physician communication.

5. Conclusion

An understanding of the educational desires and skill level of emergency nurses at the KATH A&E was obtained from this experience. The A&E nurses shared an overwhelming interest in increasing their skill level, learning new methods of patient care and implementing new technologies into their clinical practice. The concurrent training of emergency physicians has brought about the opportunity for the advent of team training and function. A structured approach that will both expand nurses’ fund of knowledge and increase their clinical nursing skills will put them in a position to assume the role assigned to their international counterparts. With further specialty training in emergency nursing, this new cadre of nurses has the potential to make a positive impact on health in Ghana.

Highlights.

• Emergency nurses at Komfo Anokye Teaching Hospital are highly motivated to learn more about their field

• Specialty and team-based training of emergency nurses in the Accident and Emergency Center are important areas to focus on

• Nurses are a currently underdeveloped resource for the provision of high quality emergency care

• An integrated training approach has the potential to improve the provision of emergency care in Ghana

Relevance to Africa.

• Emergency nursing is a new specialty in Africa and requires specialty training

• The explicit training of high-quality nurses is especially critical in Africa due to the enormous shortage of healthcare workers across the continent

• Emergency medicine represents a new model of care in Africa and training nurses alongside physicians is imperative to implement this new model of care