Task shifting and educating workers to safely and effectively assume additional responsibilities are uniformly recognized as vital components in realizing PEPFAR and other global health targets. However, our understanding of how best to strategically involve stakeholders in updating the nursing and midwifery regulation to support task shifting in sub-Saharan Africa is weak. We report the results of a survey of stakeholders in nursing and midwifery regulation from 13 countries in the ECSA region designed to increase our understanding of their roles and activities with regard to regulation. More than two-thirds of respondents stated that task shifting to nurses and midwives took place in their country, yet less than half stated that regulations for practice and education accounted for task shifting. These data suggest there may be gaps between the services provided by nurses and midwives and their authorized scopes of practice and the training that initially prepared them for practice.
The highest ranked challenge to transforming nursing and midwifery regulation in the ECSA region was the limited capacity of the national councils to carry out their regulatory functions. With task shifting and pre-service reform creating an urgency to update regulations, the perception that the capacity of the regulatory body is sub-optimal is concerning. If councils do not have the resources or capacity to create supportive regulatory frameworks for nursing practice, it could slow efforts to ensure the sustainability of task shifting and pre-service reform. Our data indicate that stakeholder groups play complementary roles in regulation with some redundancy in activities, suggesting that appropriately involved stakeholders could assist the council with implementing complicated or time consuming regulation activities, such as continuing professional development. However, our findings indicate that only 60% of association presidents felt engaged in regulation activities with the council, and only 78% of academicians felt adequately represented on the regulatory council. These findings suggest that councils could benefit from ensuring these stakeholder groups are represented on the council and more fully engaged in decision making related to task shifting and pre-service reform.
This study supports literature from the normative international nursing and midwifery groups with regard to the roles of stakeholder groups and their specific roles in creating or adapting regulations. The findings of this study are consistent with those from similar studies that investigated the challenges faced by CNOs in their role [28, 29]. Our findings also confirm previous reports in the literature that the regulatory frameworks in some countries need updating. While guidelines on task shifting and recommendations on transforming health professional education exist, this study provides new evidence that countries in the ECSA region face obstacles to adapting their practice and education regulations accordingly. This study provides information for effectively engaging these leaders in regulatory reform by clarifying their roles, responsibilities, and activities regarding regulation overall as well as their specific perspectives on task shifting and pre-service reform. This evidence has reinforced the ARC initiative's approach of equally engaging these three stakeholders, along with the council, in support of concerted national regulatory reform efforts.
Limitations to this study include the small number of respondents (10 or 11 in each stakeholder group), potential selection bias because of the use of a convenience rather than representative sampling approach, and instances in which some respondents did not answer every question on the survey. As a result, the generalizability of findings is potentially limited by the personal or professional bias that may have influenced survey responses. Additionally, because of the open-ended nature of certain survey questions, some responses were unique to one individual, contributing to small modes and long tails in frequency of responses. This study was not able to clarify or solicit more information from survey respondents nor cross-check statements about task shifting and the currency of national regulations. While number of respondents from each group was not large, it nevertheless provides a regional representation of nurse and midwifery leadership opinion. It is also noteworthy that the responses were fairly consistent within groups, suggesting that the number of respondents was sufficient to capture a consensus within each respective stakeholder group.
The findings of this study have implications for the growing number of global health initiatives encouraging task shifting and global efforts to transform health professional education. Because wide-scale adoption, institutionalization, and sustainability of these workforce strategies depends on updating regulatory frameworks, it is essential that regulatory councils engage these key stakeholder groups at an early stage and recognize and clarify their roles and responsibilities on these issues. Amid calls to strengthen regulatory frameworks and engage regulatory councils, global health agencies may find that regulatory councils lack the necessary resources or capacity, as documented in our survey findings. Planning for the success of global health initiatives, including PEPFAR, will require capacity building of councils as well as greater involvement of stakeholders from the ministry of health, professional associations, and the education sector who can complement, advocate, and lend technical support to the diverse work of the council. Future research is needed to understand what regulatory changes task shifting and pre-service reform require and the barriers regulators face in attempting to make them. Additional studies could be enhanced by engaging these stakeholders to examine potential strategies to overcome barriers to reform and to measure the effectiveness of efforts aimed at building regulatory capacity.