An overview of nursing and midwifery leadership, governance structures, and instruments in Africa

Advancement of nursing and midwifery leadership remains a global impetus suggested by the recent 2020 State of the World’s Nursing report by the World Health Organization (WHO) [1]. The Nursing Now Challenge, previously known as the Nightingale Challenge has played a key role in raising the status of early-career nurses and midwives and generating leadership opportunities around the world with significant outcomes [2].

In 2022, a study was facilitated by the Nursing Now Challenge to map and document the existence or absence of nursing and midwifery leadership, governance structures, and instruments in Africa. Funded by the Burdett Trust for Nursing this work has provided an important starting point in identifying ways to harness and maximize nursing and midwifery leadership within Africa as a means of improving population outcomes. This paper reports the findings of the study.

There is relatively little evidence on the dynamics of nursing and midwifery leadership in Africa. However, there is a clear indication of nurses and midwives being less involved in health policy development in the sub-Saharan African countries included in this study [3]. This is largely attributed to the tendency for health sector leadership and policy decision-making to be led mainly by doctors globally including in Africa [4]. Furthermore, nurses and midwives in Africa often lack effective advocacy skills, mainly attributed to a lack of leadership training included in the nursing and midwifery curriculum at bachelor’s, diploma, and certificate levels [5]. The profession, whilst being female-dominated is also affected by gender inferiority where many times women are under-represented in health leadership positions [6]. This gender inferiority has created a challenging context for the nursing and midwifery professional bodies that govern the professions to advance and advocate for nurse and midwife involvement in key health sector policies and decisions. Yet it is nurses and midwives that serve on the frontline and typically have first-hand evidence to guide policy decisions.

Nursing and midwifery governance structures are the bodies or parastatals (state-owned organizations with political authority) put in place to run the functions of the profession [7]. The nursing and midwifery governance instruments are the tools used by each governance structure to guide its operations [8]. Effective leadership in nursing and midwifery globally and in Africa takes place through the existence of various governance structures [9] that include; a department of nursing and midwifery at the Ministry of Health (MOH), a nursing and midwifery regulatory body, education and examination body, nursing and midwifery professional associations, and nursing and midwifery labor unions [9]. The governance structures are guided by various governance instruments. These include [2] nursing and midwifery;

Scope of practice that highlights the role of each nursing and midwifery cadre based on their training level and license in a particular country [2].

Schemes of service that guide the deployment of nurses and midwives in the various health care centers [2].

Nursing and midwifery policy which is a set of overarching principles and goals that guides the various sectors of nursing and midwifery which include service and health care, education, regulation, research, ethical conduct, and quality assurance, among others [2].

Strategic plan which guides the implementation of the policy within a given time frame. It sets out a vision for the future and identifies goals and objectives to be achieved through a well-structured implementation approach [2].

Codes of conduct and ethics guide the professionalism as nurses and midwives perform their roles [10].

While the above nursing and midwifery governance structures and instruments are key in advancing nursing and midwifery leadership, little is known about their existence in Africa [11]. Furthermore, little is known about the state of their operationalization, and emphasis on promoting nursing and midwifery leadership skill acquisition.

This research study addressed this gap by mapping the state of nursing and midwifery leadership, governance structures, and instruments in Africa.

This section describes the findings from this study in line with existing nursing and midwifery leadership, governance structures, and instruments in Africa. Seventeen members of the Challengers’ Committee, Africa Hub, each from a different country, agreed to actively participate in the study. Out of the 17, 16 members were able to return their country profile securing a 94% response rate.

Nursing and midwifery governance across Africa is largely the role of the government. This is evidenced by the findings of this study and the WHO State of the World Nursing 2020 report where most African countries have nursing and midwifery governance structures as part of government institutions [14]. This study shows that nursing and midwifery structures are led by women. This can be attributed to the fact nursing and midwifery are female-led professions in Africa [15]. Nursing and midwifery leadership roles come with the expectation that one should be equipped with adequate skills to run designated tasks, including the development and implementation of governance instruments [16]. Nurses and midwives contribute the largest percentage of health workers on the frontline in Africa and globally [17]. Their ability to have effective leadership and management skills is critical in advancing universal health coverage and in situations of public health security [18].

In this study, three-quarters of the countries reported a lack of nursing and midwifery leadership training for their leaders and nurses. These findings are similar to the findings in the nursing and midwifery leadership predictors study in Uganda [3] and across the region [16] where lack of leadership training among nurses and midwives has posed challenges to health systems and workforce development in Africa [19].

For the effective deployment of the nursing and midwifery profession in any country, there should be a department of nursing/ midwifery at the MOH to lead and develop policies to govern the profession and the nursing and midwifery care given to the population [3]. The nursing /midwifery department should be able to work in unison with other bodies like the professional regulatory body to ensure effective workforce regulation and licensure and work with the body in charge of education to ensure quality education and standardized proficiencies and competencies are clearly established and assessed [20].

In this study, we found that almost a quarter of the countries surveyed lacked a department of nursing/ midwifery a chief nurse/ midwife at the MOH, a regulatory body, and a body in charge of nursing and midwifery education and examination. This gap leads to inadequacy in the advancement of the profession characterized by inadequate planning and structuring of the nursing and midwifery health workforce required to meet the health needs of the population in Africa [21]. This also leads to less representation and involvement of nurses and midwives in key decision-making platforms leading to the nursing and midwifery concerns being less prioritized [16]. In the long run, this leads to nursing and midwifery workforce shortages which directly impede the ability to achieve universal health coverage [20]. A stronger and better-led nursing and midwifery profession largely starts with the existence of the Department of Nursing and Midwifery at the MOH. This is because it is charged with the role of developing the nursing and midwifery policy and strategic plan that guides the nursing and midwifery services, regulation, and education in each country [9]. This eventually determines the quality of health care and health outcomes.

Nursing and midwifery regulation is a key construct in any country to ensure that the population gets quality nursing and midwifery care from a well-trained and registered nurse/ midwife competent to provide the required nursing/midwifery services. Furthermore, it performs regulatory visits to the health facilities, and training facilities to ensure the minimum standards are adhered to [20]. To strengthen regulation and harmonize standards across Africa, development of joint bodies like the African Health Profession Regulatory Collaborative for Nurses and Midwives was developed in partnership with 14 countries to strengthen nursing regulation needs across various African countries in partnership with Emory University [22]. This began in 2011 as a four-year initiative funded by the United States of America Centers for Disease Control and Prevention and ended in 2015. This led to the advancement of leadership development, shared learning, and support across countries for regulatory reforms [23]. It is such initiatives that should be strengthened and expanded to more African countries including the francophone speaking countries to support countries that are lacking regulatory bodies just like those reported in this study.

The most dominant levels of education and training of the nurses/midwives in this study were diplomas and bachelors. These findings are similar to those in the World Bank report in partnership with the East, Central, and Southern Africa College of Nursing (ECSACON) where diploma training was the most dominant form of training [24]. Although the majority of the countries in this study reported the existence of training in nursing/ midwifery at the master's and Ph.D. levels, the most recent World Bank report showed a need for scaling in these levels of training [24]. Nursing and midwifery education across Africa remains an area that needs scaling and harmonization to address nursing and midwifery health workforce shortages across Africa. Although the East African community has made an effort to harmonize training standards across five countries [25], the gap remains broader given that Africa has over 54 countries with 47 being under the WHO AFRO region [26].

The Nursing and midwifery labor union's main role is to advocate for the welfare and rights of nurses and midwives. Their existence is critical in lobbying for better work conditions and remuneration for the nurses and midwives. This enables a collective voice for the nursing and midwifery profession in addition to the nursing and midwifery associations in the various countries that enable collective joint efforts in all matters concerning the profession, including aspects of professionalism. Although these are key, over half of the countries in this study mentioned that both the labor union nor associations were not active in influencing nursing /midwifery policies and advancing the interests of nurses and midwives. This is mainly because many of these are often under-resourced and lack enough financial support to advance their work [27]. Furthermore, since the association and labor union leaders are also nurses/ midwives serving in various nursing/ Midwifery sectors, balancing out time to advance issues is challenging since these roles are often taken on voluntarily on a part-time basis.

The nursing and midwifery governance instruments that were studied included the nursing and midwifery policy, the strategic plan, the scope of practice, schemes of service, and codes of ethics. These instruments enable the nursing and midwifery structures to perform their roles adequately. However, in this study, most of the instruments currently being used had wide mean confidence intervals with some being as old as more than 10 years. These findings are similar to those in a recent report on the state of the health workforce in the WHO Africa region, which also found gaps in governance instruments and structures [28]. The evidence suggests that the existing policy documents, strategy, and related instruments are outdated and no longer represent contemporary thought, knowledge, and best evidence. A future-facing stance must be formulated via which to structure preparations and readiness for potential, actual, or foreseen socio-political, economic, health, and environmental challenges ahead.

The nursing/ midwifery policy is a critical instrument for any country to effectively govern the profession. It ensures all areas of nursing and midwifery are addressed and streamlined for effective nursing and midwifery care for the population. Despite its importance, more than a quarter of the countries in this study lacked a nursing/midwifery policy. These findings relate to many of the challenges of the nursing/midwifery profession mentioned in the region including the significant gaps in maternal and child health services, largely the remit of midwifery [29]. The policy gives direction to the profession and its implementation is guided by the nursing and midwifery strategic plan. However, in this study more than half of the countries lacked strategic plans and almost three-quarters did not have their strategic plans being operational and implemented. These findings are similar to the broader challenges of health workforce governance in Africa and thus undermine the ability to effectively meet the demand for nurses and midwives in the various countries which eventually leads to difficulty in strategic capacity development and financing [30]. The development of the nursing and midwifery policy and strategic plan is mainly a role of the department of nursing/midwifery at the MOH led by the chief nurse/midwife whose absence in some of the countries in this study, explains the lack of nursing/ midwifery governance instruments (Nursing policy and strategic plan).

The nursing and midwifery scope of practice is an important instrument to effectively ascribe roles for nurses and midwives trained at different levels to provide nursing and midwifery care. This is usually dynamic and influenced by nursing and midwifery health workforce shortages, workforce planning by governments, task shifting, and healthcare technology among others [31]. Although most of the countries mentioned have a scope of practice that is effectively operational, the majority of the countries reported that on the frontline in daily hospital practice, there is no difference in roles based on education—the same roles are provided by all nurses/ midwives irrespective of educational background and qualifications. Furthermore, from a desktop review of the various scopes of practice, several countries have only a limited general description of the roles of a registered nurse or registered midwife without a clear explanation of the categories of registered nurses/midwives by the level of training. This points to a weakness in effectively structuring roles in alignment with the level of training which is key in the differentiation of skills and competencies accrued at different levels. This undermines the aspiration of nurses/midwives to upgrade their training since there is no difference in roles in practice and most likely a lack of additional remuneration with increased competence or specialization. Furthermore, these findings point to the weakness of the nursing and midwifery leaders in understanding what roles should be given to the various cadres of nurses and midwives trained at different levels. Despite the gaps, the most recent scope of practice in Kenya highlights the roles of nurses and midwives according to their training levels [32]. It is hoped that this can be effectively implemented at the grassroots level to enable benchmarking by other African countries.

One of the key strengths across almost all countries was the existence of the codes of conduct and ethics for nurses and midwives in this study. These are critical in providing moral and professional guidance and a means of holding nurses and midwives accountable as they perform their roles to meet the healthcare needs of the population, work with other nurses as they perform their roles, and adhere to nurses' and midwives' professional requirements [33].

Despite all the gaps, Lesotho is one country that reported having all the nursing and midwifery governance structures and instruments. This could be attributed to the fact that Lesotho reported the presence of leadership across all the governance structures. However, Lesotho just like the majority of the countries in this study also reports a lack of differentiation in roles for the nurses and midwives at the frontline with all nurses and midwives, irrespective of the level of training doing the same roles at the frontline in various health care facilities.

One of the key ways to generate a change to advance and develop the missing nursing and midwifery governance structures and instruments is through advancing nursing and midwifery leadership training to enable nurses and midwives to gain effective leadership skills like advocacy, decision-making, and development of policies among others [17]. Furthermore, synergies can be harnessed through regional collaborations that enable regional standardization and quality assurance of nursing and midwifery governance through the development of a nursing and midwifery governance accrediting body that works with governments to enforce quality checks and the existence of structures. The starting point could be strengthening the College of Nursing for east,central and southern Africa and the West African College of Nursing to take up this role in these regions and possibly expand to other regions and countries where they are not currently operating.

This study indicates that the crucial governance structures and associated instruments required for effective nursing and midwifery leadership, development, and strategic workforce deployment are, absent or outdated within many of the 16 African countries sampled herein. Failure to utilize and harness the full potential of these professions in pursuit of improved population health outcomes is a significant negative consequence of this neglect. Addressing the existing gaps requires a multipronged approach with the need to strengthen regional collaboration, advocacy, creating awareness, and advancing nursing/midwifery leadership to enable nursing and midwifery governance capacity development in Africa.