EMPLOY DEGREE NURSES IN KENYA AFTER INTERNSHIP
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Training of nurses at degree level (BScN) commenced in 1988 in Baraton University then followed by the University of Nairobi in 1992. This was informed by the need to have more competent and well prepared nursing professionals to meet the dynamic needs of the Kenyan population. Since then, several private and public universities have successfully initiated training programs for this cadre of nurses progressively churning out considerable numbers of competent professionals who have been denied the chance to utilize their expertise in ensuring Kenyans have the highest attainable standards of health as enshrined in the constitution. Currently, over 2000 degree nurses have been licensed by the Nursing Council of Kenya to practice nursing. Nevertheless, the government has been very reluctant to employ degree nurses thus foregoing the potential benefits that come along with this cadre of professionals in its healthcare system. In 1996 and 1997, the Ministry of Health under President Moi’s administration, oversaw the direct absorption into public service of the pioneer groups of degree nurses.Since then, successive regimes only managed to employ 89 degree nurses in the year 2009 and very little effort has been put since then to ensure the healthcare system has adequately prepared nurses to address the population’s health needs.This situation has been worsened by the devolution of health services since very few counties have engaged degree nurses.
In Kenya, nurses are the frontline healthcare workers who are the most accessible to the citizens and contributing approximately 85% of all health outcomes. Most peripheral health facilities are manned by nurses who therefore are a major determinant of the health of this nation
JUSTIFICATION FOR EMPLOYING DEGREE NURSES
Existing evidence supports the need to employ degree nurses in the healthcare system
Over the years, there has been a growing body of evidence that shows that BSN graduates bring unique skills to their work as nursing clinicians and play an important role in the delivery of safe patient care.
According to the American Association of Colleges of Nursing (AACN, education has a significant impact on the knowledge and competencies of the nurse clinician, as it does for all health care providers. Clinicians with Bachelor of Science in Nursing (BSN) degrees are well-prepared to meet the demands placed on today's nurse. BSN nurses are prized for their skills in critical thinking, leadership, case management, and health promotion, and for their ability to practice across a variety of inpatient and outpatient settings. Nurse executives, federal agencies, the military, leading nursing organizations, health care foundations, magnet hospitals, and minority nurse advocacy groups all recognize the unique value that baccalaureate-prepared nurses bring to the practice setting.
In an article published in the March 2013 issue of Health Affairs, nurse researcher Ann Kutney-Lee and colleagues found that a 10-point increase in the percentage of nurses holding a BSN within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients—and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. The study is titled “An Increase in the Number of Nurses with Baccalaureate Degrees is linked to lower Rates of Post-surgery Mortality.”
In the February 2013 issue of the Journal of Nursing Administration, Mary Blegen and colleagues published findings from a cross-sectional study of 21 University Health system Consortium hospitals to analyze the association between Registered Nurse (RN) education and patient outcomes. The researchers found that hospitals with a higher percentage of RNs with baccalaureate or higher degrees had lower congestive heart failure mortality, decubitus ulcers, failure to rescue, and postoperative deep vein thrombosis or pulmonary embolism and shorter length of stay. This study is titled “Baccalaureate Education in Nursing and Patient Outcomes.”
In the October 2012 issue of Medical Care, researchers from the University of Pennsylvania found that surgical patients in Magnet hospitals had 14% lower odds of inpatient death within 30 days and 12% lower odds of failure-to-rescue compared with patients cared for in non-Magnet hospitals. The study authors concluded that these better outcomes were attributed in large part to investments in highly qualified and educated nurses, including a higher proportion of baccalaureate prepared nurses.
In a January 2011 article published in the Journal of Nursing Scholarship, Drs. Deborah Kendall Gallagher, Linda Aiken, and colleagues released the findings of an extensive study of the impact nurse specialty certification has on lowering patient mortality and failure to rescue rates in hospital settings. The researchers found that certification was associated with better patient outcomes, but only when care was provided by nurses with baccalaureate level education. The authors concluded that “no effect of specialization was seen in the absence of baccalaureate education.”
In an article published in Health Services Research in August 2008 that examined the effect of nursing practice environments on outcomes of hospitalized cancer patients undergoing surgery, Dr. Christopher Friese and colleagues found that nursing education level was significantly associated with patient outcomes. Nurses prepared at the baccalaureate-level were linked with lower mortality and failure-to-rescue rates. The authors conclude that “moving to a nurse workforce in which a higher proportion of staff nurses have at least a baccalaureate-level education would result in substantially fewer adverse outcomes for patients.”
In a study released in the May 2008 issue of the Journal of Nursing Administration, Dr. Linda Aiken and her colleagues confirmed the findings from her landmark 2003 study (see below) which show a strong link between RN education level and patient outcomes. Titled “Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes,” these leading nurse researchers found that every 10% increase in the proportion of BSN nurses on the hospital staff was associated with a 4% decrease in the risk of death.
In the January 2007 Journal of Advanced Nursing, a study on the “Impact of Hospital Nursing Care on 30-day Mortality for Acute Medical Patients” found that BSN-prepared nurses have a positive impact on lowering mortality rates. Led by Dr. Ann E. Tourangeau, researchers from the University of Toronto and the Institute for Clinical Evaluative Sciences in Ontario studied 46,993 patients admitted to the hospital with heart attacks, strokes, pneumonia and blood poisoning. The authors found that: "Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated thata 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."
In a study published in the March/April 2005 issue of Nursing Research, Dr. Carole Estabrooks and her colleagues at the University of Alberta found that baccalaureate prepared nurses have a positive impact on mortality rates following an examination of more than 18,000 patient outcomes at 49 Canadian hospitals. This study, titled The Impact of Hospital Nursing Characteristics on 30-Day Mortality, confirms the findings from Dr. Linda Aiken’s landmark study in September 2003.
In a study published in the September 24, 2003 issue of the Journal of the American Medical Association (JAMA), Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. In hospitals, a 10 percent increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5 percent. The study authors further recommend that public financing of nursing education should aim at shaping a workforce best prepared to meet the needs of the population. They also call for renewed support and incentives from nurse employers to encourage registered nurses to pursue education at the baccalaureate and higher degree levels.
These findings are consistent with findings published in the July/August 2002 issue of Nurse Educator magazine that references studies conducted in Arizona, Colorado, Louisiana, Ohio and Tennessee that also found that nurses prepared at the associate degree and diploma levels make the majority of practice-related violations.
Chief nurse officers (CNO) in university hospitals prefer to hire nurses who have baccalaureate degrees, and nurse administrators recognize distinct differences in competencies based on education.
In a 2001 survey published in the Journal of Nursing Administration, 72% of these directors identified differences in practice between BSN-prepared nurses and those who have an associate degree or hospital diploma, citing stronger critical thinking and leadership skills.
Studies have also found that nurses prepared at the baccalaureate level have stronger communication and problem solving skills (Johnson, 1988) and a higher proficiency in their ability to make nursing diagnoses and evaluate nursing interventions (Giger&Davidhizar, 1990).
Research shows that RNs prepared at the associate degree and diploma levels develop stronger professional-level skills after completing a BSN program. In a study of RN-to-BSN graduates from 1995 to 1998 (Phillips, et al., 2002), these students demonstrated higher competency in nursing practice, communication, leadership, professional integration, and research/evaluation.
Impact on quality of health care
1. Improved health outcomes
Data shows that health care facilities with higher percentages of degree nurses enjoy better patient outcomes and significantly lower mortality rates. Magnet hospitals are model patient care facilities that typically employ a higher proportion of baccalaureate prepared nurses, 59% BSN as compared to 34% BSN at other hospitals. In several research studies, Marlene Kramer, Linda Aiken and others have found a strong relationship between organizational characteristics and patient outcomes.
For more than a decade, policymakers, healthcare authorities, and practice leaders have recognized that education makes a difference when it comes to nursing practice which forms the bulk of health services offered in any country. In September 2013, the Robert Wood Johnson Foundation (RWJF) released a publication which outlined how patients, employers, and the profession benefits when nurses advance their education. Articles focused on the evidence linking better outcomes to baccalaureate and higher degree nurses, educational pathways, and promising strategies for facilitating academic progression at the school, state, and national levels. RWJF also recommends that in order to respond “to the demands of an evolving health care system and meet the changing needs of patients, nurses must possess higher levels of education.” In May 2010, the Tri-Council for Nursing (AACN, ANA, AONE, and NLN) issued a consensus statement calling for all RNs to advance their education in the interest of enhancing quality and safety across healthcare settings. In the statement titled Education Advancement of Registered Nurses, the Tri-Council organizations present a united view that a more highly educated nursing workforce is critical to meeting the nation’s nursing needs and delivering safe, effective patient care. In the policy statement, the Tri-Council finds that “without a more educated nursing workforce, the nation's health will be further at risk.” Highly qualified personnel offering services in Australia has been strongly linked to the high quality of life and improved health of the citizens. The life expectancy as per 2006 was 78.7 years amongst the male and 83.5 years amongst the female population. This has been attributed to the care of the patient. According to 2005/2006 statistics, Australia has an average of 257,200 working nurses (Australian Institute of Health and Welfare-AIHW)
Similarly, employing degree nurses undoubtedly translates to improvement in the quality of care to the Kenyan citizens. The constitution of Kenya guarantees its citizens the access to the highest attainable standards of health. Vision 2030 seeks to transform Kenya into a prosperous and competitive nation with a high quality of life. In order to realize this noble objective, the government must invest heavily to ensure health personnel are adequately prepared and ready to meet the dynamic health needs of Kenyans. Employing degree nurses into the healthcare system is a step in the right direction that will ensure Kenyans have access to timely, affordable and high quality care.
The government is currently implementing a free maternity services policy which requires adequately and highly trained nursing professionals. Despite budgetary allocation to employ more nurses during the 2013/2014 financial year, the government is yet to actualize this promise to Kenyans and the implications have been evidenced by a rapid shift of maternal and neonatal mortalities from the communities to the over stretched health facilities. In addition, the health care consumers have been progressively developing some apathy towards the free maternity service due to the lack of quality assurance and standardization measures by the government. According to a survey conducted in 2013 by NNA-Kenya, lack of the appropriately trained nursing personnel, poor infrastructure, shortage of essential supplies and ineffective administrative structures are to blame for the dismal state of the free maternity services in the country. Deploying the right number of degree trained nurses into the system bears great potential to turn the misfortunes of the ailing health system and strengthen the delivery of high quality healthcare services.
2. Reduction of staff shortages
Kenya is currently experiencing a biting shortage of nursing personnel which has been orchestrated by lack of a sufficient number of trained nursing professionals as well as attrition causes mainly retirement, death, dismissal and out migration of nurses for greener pastures. Currently the public sector has a total number of 22,000 nurses overall against a population of approximately 43,000,000 Kenyans. Every year about 4,000 nurses graduate from the all the approved training institutions and directly absorbing these nurses into service will progressively ameliorate the acute shortage of nurses that also causes burnout to existing staff translating to poor quality services.
Today, majority of the nurses are approaching retirement age and will soon exit service creating serious transition challenges since the government has not been employing nurses for a long time with an evidently poor succession plan for nursing services.
The government is in the process of procuring equipment for specialized services across the country however the human resource capacity necessary to operate and maintain the equipment has not been carefully evaluated. Such equipment require highly trained professionals for significant impact to be realized. Lack of employing more nurses will worsen the existing shortage and further compromise the quality of healthcare hence the need to urgently employ the readily available degree nurses.
Economic sense of employing BScN graduates into mainstream healthcare service
1. Reduction of hospital expenditures
Degree nurses undergo rigorous training equipping them with a wide variety of skills hence have the capacity to deliver quality care in a multifaceted environment and make competent clinical decisions. Studies have proven that health facilities that invest in employing degree nurses record marked reduction of patients’ hospital stay as well as a minimal incidence of nosocomial (hospital acquired) infections that are responsible for the huge burden of hospital admissions. Undoubtedly, employing degree nurses will reduce the length of stay for patients in health facilities which translates to reduction of health expenses incurred by clients as well as maintenance costs for health facilities. If clients stay less in hospitals, they are able to actively contribute to the economic growth of the country by reducing the disability associated life years (DALYs) when they are entirely dependent on the country’s dwindling economy.
Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report “When Care Becomes a Burden” released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 – one by the state of New York and one by the state of Texas – clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level hence the direct impact on healthcare expenditures.
2. Improving access to quality healthcare and affordability
Most of the peripheral health facilities are manned by nurses who double up as the most accessible health professionals. According to recent studies, the only health professional that 40% of our population accesses their entire lifetime is a nurse. Having highly trained nurses at degree level distributed across the health care system will no doubt improve access to high quality health care. Ensuring nurses in both the peripheral and central health facilities are highly trained will definitely reduce the number of referrals to the central facilities thus easing pressure on them and designating them as referral centers for specialized services. Such accessibility will reduce the expenses incurred by citizens in search of quality services thus making healthcare affordable to Kenyans. The central facilities will be less strained contrary to the current situation where main health facilities are overwhelmed by the number of clients seeking services. Degree nurses are adequately prepared to make competent clinical decisions that will alleviate suffering and restore optimal functioning without the need to travel long distances.
3. Judicial use of training resources
The cost of training one degree nurse is approximately Kshs. 1,200,000 per year for five years totaling to Kshs. 6,000,000. Most of the degree nurses are trained through government sponsorship using tax payers’ money however, they are hardly accorded the opportunity to use their expertise in improving the quality of life for Kenyans. Instead, a significant proportion of these nurses are poached by developed nations with robust healthcare systems that acknowledge the value of such highly trained nurses. As such, Kenya remains a production unit for these countries in need of highly trained nurses whereas the Kenyan health care system continues to ail due to lack of the very highly trained nursing professionals. In order to revolutionize our healthcare system, the Kenyan government should focus on retaining in service these nurses trained using taxpayers’ money in order to enhance judicial use of its scarce resources bearing in mind Kenya is still a developing country. Otherwise the government’s efforts to train nurses with superior qualifications defeats the bear principles of logical reasoning and intuition.
The evidence supporting the dire need to employ nurses at degree level is overwhelming and the impact that such a cadre of nurses on the health care system is beyond imagining. Progressive nations have embraced the concept of ensuring their nursing personnel are adequately trained with apparent impact on the health status of their citizens. Kenya should make deliberate steps to improve the health of its citizens through ensuring the health system is adequately equipped with an efficient number of highly trained nurses. This will be realized through adequate budgetary allocation aimed at recruiting more highly trained nurses and equipping the health facilities.
MINISTRY OF HEALTH
1. The Ministry should entrench the employment of degree nurses in a Nurses employment policy with full stakeholders’ participation and fast track its implementation.
2. The MOH in collaboration with county governments should prioritize and budget for the employment of degree nurses during the 2017/2018 financial year to enhance realization of various policies under implementation such as the free maternity services policy.
3. Fast track the implementation of the approved schemes of service for nurses and re-designate all degree nurses currently in service to their appropriate job groups.
4. Retain all the BScN interns currently in public facilities and redeploy them accordingly after completion of their internship contracts.
5. Conduct a nursing personnel evaluation to ascertain the existing shortage and institute mitigation measures to correct the imbalance.
PUBLIC SERVICE COMMISSION AND COUNTY PUBLIC SERVICE BOARDS
1. Implement the approved scheme of service
2. Advertise vacant positions for degree nurses as provided for in the new schemes of service for nurses
3. Ensure improvement of the nurse to patient ratio in order to reduce incidences of burn out that are rife amongst the nursing personnel
4. Adopt, sign and jumpstart the implementation of the collective bargaining agreement for nurses negotiated by the Kenya National Union of Nurses
NURSING COUNCIL OF KENYA
1. Ensure adherence of all health facilities to standards particularly nurse to patient ratios and shut down non-compliant hospitals.
2. Revise the scope of practice for nurses taking into account the various competencies acquired through various training programs at the different levels.
3. Revise the BScN syllabus to take into account current trends in nursing education and practice in other progressive jurisdictions.
4. Regulate the employment of nurses to strengthen nursing practice and promote delivery of quality care
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