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2017

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GOVERNMENT OF SIERRA LEONEMinistry of Health and Sanitation

NURSING AND MIDWIFERY POLICY

 

 

TABLE OF CONTENTS

TABLE OF CONTENTS..............................................................................2FOREWORD............................................................................................4REMARKS...............................................................................................6ACKNOWLEDGEMENTS............................................................................7ACRONYMS............................................................................................81. BACKGROUND................................................................................91.1 Introduction...........................................................................91.2 Purpose of the Policy............................................................101.3 The Policy Formulation Process.............................................111.4 Policy Context......................................................................112. SITUATION ANALYSIS OF HEALTH, NURSING AND MIDWIFERY SERVICES.............................................................................................122.1 Governance and Leadership of nursing and midwifery...........122.2 Provision of Nursing and Midwifery Services..........................132.3 Education and Training of Nursing and Midwifery Workforce. .142.3.1 Pre service:......................................................................................142.3.2 In-service training and continuous professional development........152.4 Regulation and Accreditation................................................152.5 Management of Nursing and Midwifery Workforce.................162.6 Partnership and advocacy for resource mobilization..............172.7 Information and Research for Nursing and Midwifery Workforce

172.8 The challenges.....................................................................173. NURSING AND MIDWIFERY SERVICES POLICY DIRECTION.................173.1 Vision..................................................................................183.2 Mission................................................................................183.3 Guiding Principles................................................................183.3.1 Ownership and Accountability.........................................................18

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3.3.2 Ethical Considerations.....................................................................183.3.3 Relevance........................................................................................183.3.4 Partnership......................................................................................183.3.5 Evidence-Based Approach...............................................................193.4 Goal.....................................................................................193.5 Objectives............................................................................194. NURSING AND MIDWIFERY SERVICES POLICY AREAS.......................204.1 Appropriate Leadership and governance for Nursing and Midwifery Services......................................................................204.2 Nursing and Midwifery Service Delivery................................204.3 Training and Continuing Education of Nursing and Midwifery workforce....................................................................................214.3.1 Pre-service training.........................................................................214.3.2 In-service training /Continuing Professional Education....................224.4 Regulation and Accreditation Systems for Nursing and Midwifery Workforce and Services................................................224.5 Management of Nursing and Midwifery Workforce.................224.6 Partnership for Nursing and Midwifery Services.....................234.7 Advocacy and Resource Mobilization.....................................234.8 Information and research for Nursing and Midwifery Workforce and Services................................................................................244.9 Quality Assurance and Quality Improvement.........................245. NURSING AND MIDWIFERY POLICY IMPLEMENTATION FRAMEWORK

255.1 Nursing and Midwifery Services Leadership...........................255.2 Nursing and Midwifery Services Partnership and institutional mechanisms................................................................................255.3 Nursing and Midwifery Services Strategic and Operational Plans...........................................................................................265.4 Monitoring and Evaluation Framework..................................266. ASSUMPTIONS..............................................................................26

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1.

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FOREWORDThe government has consistently shown our commitment to improving the health for all Sierra Leoneans. In 2010, we introduced the Free Health Care Initiative for pregnant women, lactating mothers and children under-five that led to over 50% increase in the number of women giving birth in health facilities (from 24% in 2008 to 54% in 2013)1. Under-5 mortality declined from 227 deaths per 1,000 live births in 1999 to 156 deaths per 1,000 live births in 2013, and infant mortality decreased from 152 to 92 deaths per1,000 live births in the same period . Nurses and midwives have been key personnel in these achievements. In the fight against the Ebola Virus Disease, our nurses and midwives showed bravery and commitment to their vocation and some even lost their lives in this battle. We will ensure their sacrifices do not go in vain. The Ministry of Health and Sanitation (MOHS) acknowledges that there is still much to do in equipping our nursing and midwifery workforce if we are to achieve the health outcomes we seek. This year, the President has set a vision of drastically reducing maternal and child mortality and maintaining a resilient zero. The senior leadership is well aware that we cannot achieve this vision without significant input into improving the quantity and quality of the nursing and midwifery workforce. As part of the District Capacity Strengthening Project, funded by the World Bank, financial support will be provided to improve quality of nursing and midwifery service through the continuous professional development programme. With support of our international partners, we are undertaking a robust verification of health workers to ensure that the resources we invest in human resources are paying for what we envisaged.My office has also developed six (6) flagship programmes all of which will work to ensure that nurses and midwives work in an enabling environment. The National Emergency Services will drastically improve referral of patients to appropriate level of care, sanitary inspectors will be re-introduced at a community level and we expect this to have a speedy effect on improving sanitation. The District Capacity Strengthening Project will inject foreign medical teams to ensure short-term service delivery and skill sharing.The proposed School of Health Services in Makeni and the Post-graduate Medical Training will ensure better trained doctors and auxiliary staff all of whom will complement the work of nurses and midwives. Finally, the Service Level Delivery Agreement will improve co-ordination in health sector and 1 Sierra Leone Demographic Health Survey 2013

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reduce distractions of health workers from competing priorities of health implementing partners.For many years, some of our donor partners have not been able channel funds through the Ministry of Health and Sanitation; we have established the Integrated Health Projects Administration Unit (IHPAU) to improve financial management in the Ministry.I am very pleased with technical leadership shown by our senior management team here at the MOHS and I am confident that this team will lead us towards the goals defined by HE the President of Sierra Leone.___________________________Minister of Health and SanitationFreetown2017 

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REMARKSThe MOHS is committed to achieving the WHO minimum standards for staffing. Over past few years, with support from our partners we have been able to establish a Midwifery School in Makeni that has produced over two hundred and fifty midwives since it was set up in 2010. We have developed specialist programmes and trained specialist in Anaesthesia, Ophthalmology, Paediatric and Mental Health removing the need for training abroad. We have even developed a Nursing Education Programme that has produced a dozen Nurse Trainers.Yet we are aware that there is much to do. We need to better track our health workers and ensure that staff remain in their posts. We understand that the conditions of work especially for those in rural areas need to be improved to ensure staffare retained. The Directorates of Primary Health Care and Directorate of Hospital and Laboratories in conjunction with the newly established Infection Prevention Control Unit are working assiduously to improve the work environment of nurses and midwives so they can perform their jobs safely and effectively.I have also recently re-organised the Ministry to bring Health Systems Strengthening directly under my control; this will ensure that the very important issues such bottlenecks supply chain are solved. In the long-term it is necessary to ensure the regulation of nursing and midwifery is improved. The Chief Nursing Officer has strong vision for the nursing and midwifery workforce that I believe the development of this policy is an important starting point for the realisation of this vision.____________________________Dr Brima KargboChief Medical OfficerMinistry of Health and Sanitation

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ACKNOWLEDGEMENTS

Development of this Nursing and Midwifery Policy has been a collaborative and consultative process involving different stakeholders including: the Nursing and Midwifery Council, Nursing and midwifery training institutions, Directorate of HRH, Health Services Commission, WHO, UNFPA, UNICEF, CHAI, nursing and midwifery professional associations, West African College of Nursing and other health and matrons from Regional Hospitals. On behalf of the Ministry of Health and Sanitation, let me acknowledge the invaluable support of all those who have contributed to the development of this policy. Sincere appreciation is extended to CHAI, UNFPA, WHO for technical and financial support.The Directorate of Nursing and Midwifery Services look forward to continued collaboration and support for operationalization of this policy.

____________________________Mrs Hossinatu Koroma Chief Nursing OfficerMinistry of Health and Sanitation

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ACRONYMS

BPEHS Basic Package for Essential Health ServicesCHAI Clinton Health Access InitiativeDHS Demographic Health SurveyEmONC Emergency Obstetric and Neonatal CareSDNM Strategic Direction for Nursing and MidwiferyNHSSP National Health Sector Strategic PlanPRP Presidential Recovery Priorities HRH Human Resources for HealthMOHS Ministry of Health and SanitationNGOs Non- Governmental Organizations UNFPA United Nations Population FundWHO World Health Organization

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1. Background

1.1 Introduction

Despite encouraging gains that the government has made in the health sector, levels of child and maternal mortality remain intractably high - 156/1,000 and 1165/100,000 live births respectively (Measure DHS and Statistics Sierra Leone, 2013). These poor health indicators are as a result of a range of implementation challenges including the critical shortage of health workers that the country in facing. Currently there are only 185 doctors in-post in the entire country (MOHS, 2012), and only 288 midwives with 48% serving in Freetown (draft UNFPA midwifery mapping, 2014).

Nurses and midwives constitute the majority of frontline health workers and are contributing to the quality of health care services at primary, secondary and tertiary health care levels. It has also been shown that nursing and midwifery services, when supported adequately, are cost-effective, affordable and can improve access to quality care.2

Nursing and midwifery services are a vital resource for achieving health and development goals for any nation. They constitute the backbone of health systems in any country and provide a platform for supporting efforts to tackle the diseases that cause poverty and ill health. It has been proved that nursing and midwifery services are cost effective, affordable, accessible and sustainable. Acting both as individuals and as members and coordinators of inter-professional teams, nurses and midwives bring people- centred care closer to the communities where they are needed most, thereby helping improve health outcomes and the overall cost – effectiveness of services (WHO SDNM 2011- 2015) Despite the above global evidence of nurses and midwives contribution to the health outcomes of individuals, families and communities, literature review and consultation with a variety of stakeholders has given rise to the following categorization of the most critical challenges confronting nursing and midwifery services in Sierra Leone:

Weak health systems and services; Leadership and governance at different levels of health care system Education, training and career development

2 Van Lerberghe W, Matthews Z, Achadi E, et al. Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality. Lancet 2014; published online June 23. http://dx.doi.org/10.1016/S0140-6736(14)60919-3.

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Regulation of nursing and midwifery education and practice Nursing and Midwifery Workforce management; Partnership for nursing and midwifery services

If timely improvement of the performance of the health system has to be achieved in Sierra Leone, urgent action is needed to address the challenges that seriously undermine the potential contribution of the nursing and midwifery services to the vision of improving the quality of life of the Sierra Leonean people.

It is with this backdrop that the Nursing and Midwifery national Policy (2017 – 2021) has been developed. The Policy puts forth the:1. Background and the challenges which nurses and midwives are facing;2. Mission, Vision and values/principles of the Nursing and Midwifery Services;3. National Policy goal, objectives; 4. Policy Areas5. Nursing and Midwifery Strategic directions 2017–20216. Implementation, Monitoring and Evaluation Frameworks

1.2 Purpose of the Policy The Directorate of Nursing and Midwifery Services in the MOHS, for the first time, has developed a policy for Strengthening Nursing and Midwifery Services. The developed policy is designed to provide stakeholders with an overarching framework for the necessary collaborative action. This will guide the Directorate in addressing the identified nursing and midwifery challenges and in turn contribute effectively to improving the performance of the health system in the country.

This policy document has been developed with the following aims:

1. Create a positive environment for Nursing and Midwifery Governance, Leadership and Practice2. Promote education, training, regulation and career development for nurses and midwives.3. Contribute to the strengthening of the health system 4. Monitor the development of nursing and midwifery professions and ensure their quality5. Streamline Nursing and Midwifery Workforce Management6. Develop Partnerships for Nursing and Midwifery Services

1.3 The Policy Formulation Process

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Under the leadership of the Directorate of Nursing and Midwifery Services, the process in the formulation of this policy was participatory and consultative, involving key stakeholders from different sectors including nursing and midwifery leadership from training institutions, service sector, professional bodies, and regulatory bodies; other health professional groups, NGOs and community representatives. This involved a series of consultations, meetings, including a workshop for consensus building and prioritization of policy areas. In addition, various national, regional and global health and human resources policy documents were reviewed to ensure relevance and fit–for - purpose of the policy. The draft policy was widely circulated for additional comments and then validated at a national workshop.

1.4 Policy ContextThe overall goal of the health sector is to maintain and improve the health of all Sierra Leoneans (National Health Policy 2002). The Government of Sierra Leone (GoSL) is committed to pursuing such goals in an equitable manner. It will work towards ensuring that all citizens have access to basic quality health care. GoSL has special responsibility to ensure that the health of its citizens, who are particularly vulnerable, as a result of poverty, disease outbreaks, or specific health problems is maintained.Based on the National Health Policy orientation, the Ministry of Health & Sanitation (MOHS) in collaboration with stakeholders developed a National Health Sector Strategic Plan (NHSSP) 2010-2015. With the advent of the Ebola Viral Disease outbreak, the MoHS revised the Basic Package for Essential Health Services (BPEHS 2010 in 2015), reviewed the NHSSP 2010-2015 in February 2016, and developed a 2015-2020 Health Sector Recovery Plan being implemented in phases of 6 to 9 months and the 10 to 24 months Presidential Recovery Priority (PRP) Plan, as frameworks for guiding f a resilient healthcare system in Sierra Leone. The national HRH policy and strategy 2012 is also being revised. The above broader health and human resources for health policy orientations informed the nursing and midwifery policy development.

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2. Situation Analysis of Health, Nursing and Midwifery Services

Globally, Sierra Leone is amongst the countries with the highest maternal and infant mortality rates in the world. According to the 2013 Demographic Health Survey (DHS), the maternal mortality ratio is estimated at 1,165 per 100,000 live births and overall under- five mortality rate is estimated at 156 per 1,000 live births.The poor maternal and neonatal health outcomes despite increases in Maternal and Newborn Health (MNH) services utilisation require reflection on the quality of the provision of Emergency Obstetric and Newborn Care (EmONC) services. A key recurring challenge preventing facilities from attaining and maintaining compliance is related to staffing, characterized by uneven distribution, inadequate numbers in many facilities, lack of required skills and motivation to carry out their functions. Availability of appropriately trained human resources is also an important pre-requisite for the delivery of quality services including those of the Basic Package of Essential Health Services (BPEHS) in Sierra Leone.

The following are some of the factors which contribute towards poor quality of nursing and midwifery services in the country as expressed during the consultative meetings, interviews and evidence from existing literature on nursing and midwifery and delivery of health services.

2.1 Governance and Leadership of nursing and midwifery

Governance is the process of decision making and the process by which decisions are implemented or not implemented. Leadership is the ability to influence decisions and course of action towards the desired goals of the organization or team. It is a critical skill for influencing change and getting things done. Some of the challenges facing nursing and midwifery in this regard include:

• Nursing is regarded as a low status occupation and has a poor image not only with respect to society in general, but also within the health care system. • Image and status problems are accentuated by the powerlessness of nurses and midwives to make decisions about their profession; communicate

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articulately with confidence in the planning and decision making areas that are of relevance to their profession in contributing to health care delivery

• The lack of good role models and opportunities for mentoring at all levels – in the clinical field, education, management, planning, policy development and leadership – is a major obstacle to developing a competent and confident nursing and midwifery workforce. • Leadership and good managerial skills are inadequate in all sectors of nursing and midwifery–education, service, regulation and the development of the professional organizations.

Few opportunities have been available for nurses and midwives to develop and exercise leadership skills, and the value of having well prepared senior nurses functioning in a collegial and collaborative fashion in the different sectors.

2.2 Provision of Nursing and Midwifery Services The country has organized delivery of health services around a three tier system of Primary, Secondary and Tertiary levels utilizing the primary health care approach which the country has adopted. At the primary level, there are Peripheral Health Units (PHUs) at different sub levels: Maternal and Child Health Post (MCHP), Community Health Posts (CHP) and Community Health Centres (CHC). At secondary level, are regional and district hospitals. There are also two specialized hospitals; Sierra Leone Psychiatric and Lakka infectious hospitals. There are three tertiary hospitals based in the Western Area. All these levels provide defined package of health services by defined categories of service providers based on the organization of BPEHS.

Overall, the nursing and midwifery workforce including cadres carrying out assistive nursing roles constitute the largest group of direct health service providers in the country with a high proportion of lower-skilled nurses, called State Enrolled Community Health Nurses (SECHNs). There is also a large number of Maternal and Child Health Assistant (MCH Assistant), who are trained to provide basic safe motherhood and under-five services at the community level. In contrast, Sierra Leone has a low proportion of higher-skilled nurses, midwives and doctors. The shortage of medical officers is even more critical when taking into account that 14% of all medical officers and 27% of medical specialists are serving in administrative roles rather than practicing as clinicians. Sierra Leone also has a higher-skilled clinical cadre called Community Health Officers, which are equivalent to physician assistants in other countries.

Currently the following numbers of nursing and midwifery cadres are on the payroll: 2447 SECHNs; 1729 MCH Assistant ; 830 Nursing assistants; 349 higher cadre nurses/specialists 272 Midwives; .(HRH draft Strategic Plan

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2016-2020). These numbers severely constrain delivery of quality nursing and midwifery services at all levels of service delivery. In addition, the following factors have also affected delivery of quality services:

• The delivery of nursing and midwifery care has quality control problems. Service providers lack clear job descriptions, role definitions and criteria for evaluating their performance; • Inadequate role models in most nursing and midwifery practice areas;• Few opportunities for professional development such as specialty nursing and midwifery to upskill critical skill areas;• Predominance of unskilled health workers conducting deliveries (fewer professional midwives) in the maternity units;• Poor motivation to do their jobs with commitment in most nursing and midwifery personnel due to poor conditions of service including housing and lower salaries.• The role of nurses and midwives at the primary health care level is yet to be clearly defined. The majority of nursing and midwifery personnel working at this level are auxiliary personnel.• Inadequate preparation of certain categories of nursing and midwifery staff, a severe shortage of equipment and other resources to carry out nursing and midwifery care makes it difficult to provide care of acceptable standards.

2.3 Education and Training of Nursing and Midwifery Workforce

2.3.1Pre service:Currently educational preparation of nurses and midwives and Assistant Nursing personnel in the country is as follows:Nursing: Three (3) levels of educational preparation:

- BSc in Nursing: 4 years after 13 years of general schooling- Diploma in Nursing: 3 years after 13 years of general schooling- Certificate in Enrolled Community Health Nursing: 2.5 years after 13 years of general schooling- Auxiliary (Maternal and Child Health Assistant): 2 years after 13 years of general schooling

Midwifery - 2 levels of preparation:- Certificate in Midwifery (SCM): 18 months after completion of an RN programme and 2years working experience;- Certificate in Midwifery (SCM): 24 months after completion of an SECHN programme with 3 to 5 years working experience

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The identified challenges related to education and accreditation includes:

•Reinforcement of Standards for initial nursing and midwifery education and accreditation which are now in place;Small number of professional nurses and midwives are prepared at the higher educational level• Limited educational resources for nursing and midwifery in terms of faculty, materials and the physical setting• Many nursing and midwifery educators/instructors do not have higher level educational preparation (Masters or PhDs)• Traditional teaching methodologies are used in both didactic and clinical areas and there is obvious inadequate clinical experience and clinical supervision for both nursing and midwifery students;• There is limited coordination and collaboration between the Ministry of Health and the Ministry of Higher Education in the development and management of nursing and midwifery education programs;• Post-basic programs in nursing and midwifery specialization are very limited.• Teachers and practicing nurses and midwives have limited access to new technology, new information skills• There is a severe shortage of the educational resources: teaching resources, training materials, learning materials, textbooks and educational supplies• The quality of the educational programs is poor, and a large gap exists between education and service requirements.• Some Heads and Deans of nursing schools especially at University level are non-nurses. They may come from other health professions groups thereby compromising the understanding and appreciation of nursing and midwifery education issues and challenges;

2.3.2 In-service training and continuous professional development Lack of an established framework and system for continuing

professional competence. Limited long term educational opportunities locally and internationally

for professional development of nurses and midwives

2.4 Regulation and AccreditationThe purpose of regulation is to control the education, practice and professional behaviours of its members in order to protect the public from malpractice. The challenges affecting regulation and accreditation for nursing and midwifery education and practice in Sierra Leone include:

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The term nurse has no singular meaning and is used to cover a whole range of nursing personnel from the nearly illiterate auxiliary to the university degree prepared nurse.

The Nurses and Midwives Board has just submitted its revised Act to the Ministry Of Health and Sanitation for further submission to Parliament. Hence the Board is still using its old Act of 1956 until its repealed.

Unavailability of definitions of national scopes of nursing and midwifery practice, with clear definitions of Nurse, Midwife and their roles, functions and responsibilities

Weak institutional capacity and regulatory mechanisms to reinforce established regulatory provisions for the education and practice of nurses and midwives country wide;

2.5 Management of Nursing and Midwifery WorkforceTo promote improvement of nursing and midwifery workforce management at all levels of national health system, the following challenges need to be addressed:

Weak recruitment and deployment systems at national and district levels should be strengthened and improved and harmonized to ensure an equitable distribution of nursing and midwifery workforce for the health sector;

Poor reinforcement mechanisms in utilizing guidelines for deployment to ensure an equitable distribution of well-trained nursing and midwifery workforce in all health facilities in the rural and urban settings;

Lack of Job descriptions, and scopes of work to ensure accountability and responsibility for job assignments;

Lack of mechanisms to facilitate career progression, promotions and mobility of the nursing and midwifery workforce across the entire health sector;

Lack of Evidence – based staff retention mechanisms/strategies for the nursing and midwifery workforce and other health workers;

Individual objective performance assessment methods for all health professions to improve performance is only limited to staff working at national level;

Adequate safety measures shall be provided for nursing and midwifery and other health workers in the workplace at all times

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2.6 Partnership and advocacy for resource mobilization

Collective action and building of synergies is a key to success. Challenges identified which need to be addressed include:

Limited collaboration and coordination mechanisms between Nursing/Midwifery Directorate and other different stakeholders

Hospital Nursing/Midwifery matrons or management teams have little authority over staff, especially regarding staff discipline and promotions. This makes it difficult to bring changes/innovations according to the standards of nursing and midwifery care;

Lack of clearly defined mechanisms for advocacy and resource mobilization for nursing and midwifery services;

2.7 Information and Research for Nursing and Midwifery Workforce

Challenges related to information and research in nursing and midwifery include:

Lack of a nursing and midwifery personnel database for the entire country which needs to be established ;

Limited application of research results to improve practice and quality of care

Lack of communication strategy

2.8 The challengesWeak health system and services; Leadership and governance at different levels of health care system; Education, training and career development; Nursing and Midwifery Workforce management and Partnership for nursing and midwifery services are some of the key challenges that are contributing to poor quality of nursing and midwifery services in the country.

3. NURSING AND MIDWIFERY SERVICES POLICY DIRECTION

The main rationale for this policy is to ensure quality, equitable, accessible and non-discriminating nursing and midwifery services to save lives, public safety, prevent illness and alleviate suffering and promote health for the entire population of Sierra Leone.

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3.1 Vision A functional and dynamic Nursing and Midwifery workforce capable of delivering quality, safe, evidence-based and comprehensive nursing and midwifery services to all the people of Sierra Leone

3.2 Mission The mission of the Nursing and Midwifery Service Directorate is to contribute effectively to the health goals of the Ministry of Health and Sanitation and the nation as a whole.

3.3 Guiding Principles The provision of Nursing and Midwifery Services must adhere to the guiding principles inherent in the core principles of PHC and the national health agenda.

3.3.1Ownership and Accountability Adopting a flexible approach to be implemented with local involvement that is designed to guide action at every level of service delivery;

3.3.2Ethical Considerations Planning and providing nursing and midwifery services will be based on equity, integrity, fairness and respect for gender and human rights. The rights of both the providers and recipients of health care shall be respected and protected;

3.3.3Relevance Developing health services and systems that are guided by health needs, evidence and strategic priorities;

3.3.4PartnershipWorking together on common objectives, acting collaboratively and supporting each other’s effort;

3.3.5Evidence-Based Approach Through evidence-based approach, utilize nursing and midwifery process to assess, diagnose, plan and implement nursing and midwifery care for positive health outcomes.

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3.4 GoalTo ensure the existence of a safe, disciplined and competent nursing and midwifery workforce that is capable of delivering safe, patient- centred quality care to the people of Sierra Leone.

3.5 ObjectivesThe objectives of the Nursing and Midwifery Policy are to ensure, within the context of the national macro- health policies, that:

1. Supportive Policy Environment exists for effective decision-making of nurses and midwives, towards improvement of nursing and midwifery services in the country.

2. Regulatory and Accreditation systems are developed for controlling the education, practice and behaviour of all cadres of nursing and midwifery to ensure that the public safety is protected through the highest standards of education and practice of nurses and midwives in Sierra Leone.

3. Education and training of the nursing and midwifery workforce responds to national health needs and meets the nursing and midwifery personnel requirements of Sierra Leone for effective and quality health service delivery.

4. Management of nursing and midwifery workforce is improved

with capacitated structure, clear job descriptions, role definitions and responsibilities.

5. Partnership and collaboration is promoted with different

stakeholders and development partners through clear coordination and collaborative mechanisms for strengthening the contribution of nursing and midwifery services to general service delivery in the country;

Health & Safety at Work 6. Advocacy and resource mobilization to support implementation of

the nursing and midwifery policy and plan is pursued.

7. Quality Assurance and Continuous Quality Improvement is promoted to support the Patient and staff Safety pillar of the health reform.

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4. NURSING AND MIDWIFERY SERVICES POLICY AREAS

4.1 Appropriate Leadership and governance for Nursing and Midwifery Services

Contribution of nursing and midwifery workforce to health system performance, service delivery, universal coverage and health outcomes through the active engagement and leadership of nurses and midwives at every level of health policy/programme development and decision-making will be the key focus.

Structural and technical capacities shall be strengthened for nursing and midwifery leadership and governance at all levels of service delivery;Key leaders (e.g. Chief Nursing and Midwifery Officer;, nurse and midwifery leaders in both the education and service sectors) will be strengthened by:

i. Implementing mentorship programs, twinning arrangements inside and outside of the country and providing appropriate fellowships;

ii. Establishing mechanisms to collaboratively implement policy decisions in relation to education and nursing and midwifery services;

iii. Improving access to health policy and health planning decision-making areas by nurses and midwives;

iv. Advocating for nursing and midwifery structures that are supportive of effective and efficient contribution of nurses and midwives to the national health agenda;

4.2 Nursing and Midwifery Service DeliveryMOHS is committed to increasing access to quality nursing and midwifery services at all levels through:

1. Creation of a visible nursing and midwifery service administration at institutional levels that is responsible for:• Managing, developing and implementing quality nursing and midwifery services• Clearly delineating the nursing and midwifery functional structure• Developing job descriptions and nursing and midwifery service standards• Creating safe, quality workplaces.2. Strengthening and improving the capabilities of nurses and midwives through structured, sustainable continuing education programmes.3. Establishment of community health nursing and midwifery within the primary health care system.

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4. Addressing the issue of production, deployment and retention of appropriately trained nursing and midwifery workforce to deliver affordable and equitable packages of health services; 5. Improved planning and utilization of nurses and midwives based on service delivery requirement;6. Working with the HR Directorate, and using updated data sources which will improve planning, management, development and utilization of nursing and midwifery workforce in order to deliver quality nursing and midwifery services to the population.

4.3 Training and Continuing Education of Nursing and Midwifery workforce

4.3.1Pre-service training

The MOHS is committed to improving the quality and relevance of nursing and midwifery education at pre and in-service levels. It will improve the quality and relevance by:

1. Establishing only 2 levels of nursing educational programs (technician and professional), and create bridging programs to upgrade intermediate and technical nurses over a designated period of time2. Improving quality of nursing and midwifery education at all levels through:- Strengthening tutors’ preparation and increase the numbers- Providing access to updated teaching and learning materials- Upgrading the physical setting of teaching- Improving quality of clinical placements and the effectiveness of clinical teaching- Strengthening, enlarging and increasing access to university education (B.Sc.,Master and Ph.D.)3. Developing post-basic nursing specialty programs based on the country’s needs and according to Regional standards.4. Reducing the education-service gap by better liaison and collaborative mechanisms and alliances (between education and service, and Ministry of Health and Ministry of Education Science and Technology).5. Supporting the creation of standardized bridging pathways for nurses and midwives to upgrade their skills and qualifications without having to start from the beginning.6. Include midwifery programs that allow skilled or unskilled midwives to upgrade their skills and obtain a technical or university degree.

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4.3.2 In-service training /Continuing Professional Education7. Oversee a national program for Continuing Professional Development to ensure continued quality of services, as well as provide opportunities for professional development and more focused knowledge in critical clinical areas. 8. Support the creation of opportunities for educational collaboration and exchange programs between Nursing/Midwifery institutions and hospitals, regionally, nationally and internationally.

4.4 Regulation and Accreditation Systems for Nursing and Midwifery Workforce and Services

To ensure that public safety is safeguarded, regulatory and accreditation systems will be supported in partnership with professional associations and development partners by:

i. Defining national scopes of nursing and midwifery practice, with clear definitions of Nurse, Midwife and their roles, functions and responsibilities;

ii. Supporting institutional capacity building of the regulatory body in order to effectively control the education, practice and professional behaviours of its members.

iii. Developing clear mechanisms to regulate education and practice, including a system of registration and maintenance of a live register of nurses and midwives.

iv. Creating a framework and system for continuing competence.v. Strengthening one professional regulatory body for nursing and

midwifery to develop and implement regulatory policies and practices.vi. Creating clear quality assurance mechanisms that will ensure quality

and relevance of nursing and midwifery education and practice in the country.

4.5 Management of Nursing and Midwifery WorkforceTo promote improvement of nursing and midwifery workforce management at all levels of national health system, the following policy directions are provided:

i. Recruitment and deployment systems at national and district levels should be strengthened and harmonized to ensure an equitable distribution of nursing and midwifery workforce for the health sector;

ii. Deployment guidelines should be utilized and reinforced to ensure an equitable distribution of well-trained nursing and midwifery workforce in all health facilities in the rural and urban settings;

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iii. Job descriptions and scopes of work shall be made available to ensure accountability and responsibility for job assignments;

iv. Mechanisms to facilitate career progression, promotions and mobility of the nursing and midwifery workforce across the entire health sector must be developed;

v. Evidence – based staff retention mechanisms/strategies shall be in place for the nursing and midwifery workforce;

vi. Individual objective performance assessment methods shall be introduced and used in all staff appraisal process to improve performance;

vii. Adequate safety measures shall be provided for nursing and midwifery and other health workers in the workplace at all times.

4.6 Partnership for Nursing and Midwifery Servic esTo ensure effective implementation of the nursing and midwifery services intervention, the following policy orientations are provided:

i. Appropriate coordination mechanisms for relevant stakeholders shall be established or/and strengthened to ensure effective planning and implementation of the nursing and midwifery policy and strategies.

ii. Formal collaborative and partnership mechanisms shall be established between the directorate of nursing and midwifery, professional bodies, development partners, training institutions in government, private and Faith Based Organizations to ensure that training outputs match the health sector requirements.

iii. MOHS shall ensure that Nursing and Midwifery Directorate, in collaboration with the public and private sectors and professional associations promote evidence based practices and holistic nursing and midwifery services at all levels of public and private health care system.

4.7 Advocacy and Resource Mobilization

The MOHS with the support of its partners will need to make sustained efforts to advocate for and mobilize resources (human, financial and materials) for the implementation of the Nursing and Midwifery Policy and its Stratetic plan for improved nursing and midwifery services delivery. Within this context, the MOHS shall ensure:

i. The Directorate of Nursing and Midwifery is supported by government in its advocay and resource mobilization effort.

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ii. Capacity building of the directorate and its supporting structures in advocay and resource mobilization strategies including proposal writing.

iii. Resource mobilization strategies are clearly defined in the strategic plan.

4.8 Information and research for Nursing and Midwifery Workforce and Services

Strategic information is critical for informed decision making. In order that information and research results in health and human resources for health contribute to appropriate evidence for decision making to improve nursing and midwifery services, the following are the policy directions:

i. Nursing and midwifery data systems should be established ii. Resources should be invested in the utilization of research findings to

inform and influence nursing and midwifery policymaking, education and practice;

iii. Mechanisms shall be established and maintained for effective monitoring and dissemination of information related to recruitment, deployment, retention and attrition to assess and monitor equity and access to nursing and midwifery services;

iv. Capacity building initiatives in research development and use of information shall be promoted and supported

4.9 Quality Assurance and Quality ImprovementAn institutionalized national quality improvement structures and system with clear standards is critical for sustained quality improvement interventions. This policy will focus on ensuring that such systems and structures are established and operationalized across all the levels of health service delivery from national, to district and facility levels. The following are the policy directions:

i. Establish Quality improvement (QI) systems ii. Sensitize and convene coordination fora at national and district levels

to accelerate quality of care initiatives iii. Development, adoption and implementation of quality improvement

standards, approaches, tools and indicators iv. Establish and ensure functionality of quality improvement teams at all

levels of service delivery

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v. Development and implementation of a national quality technical working group

vi. Development and implementation of clinical mentorship and supervision guidelines

vii. Support development of and implementation of district and facility quality improvement plans.

viii. Development of a national quality improvement mentorship program for health workers

ix. Integrate quality improvement as part of incentive based motivation schemes such as performance based financing

5. NURSING AND MIDWIFERY POLICY IMPLEMENTATION FRAMEWORK

5.1 Nursing and Midwifery Services LeadershipSuccessful implementation of the Nursing and Midwifery Services policy calls for multi-sectoral, inter-professional teamwork among all stakeholders at country level. The Directorate of Nursing and Midwifery Services will coordinate implementation effort, with policy advice from MOHS top management and the support of key partners sharing a commitment to – and interest in – the strengthening of national health systems with emphasis on PHC approach.

5.2 Nursing and Midwifery Services Partnership and institutional mechanisms

Nursing and midwifery services are a subsystem of the general health delivery system for the country. Nursing and midwifery functions are spread over many programmes, departments, sectors, districts, institutions and organizations. The MOHS is mindful of the need for external financial and technical support and for productive partnerships with committed stakeholders and development partners. The MOHS through the Directorate of Nursing and Midwifery services leadership team shall partner with other branches of government, development partners, autonomous health and social welfare organizations and institutions including professional boards and associations.

The Directorate shall continue participating in global, regional and sub-regional organizations and forums that promote good nursing and midwifery education and practice, professionalism and innovative actions to solve nursing and midwifery challenges.

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5.3 Nursing and Midwifery Services Strategic and Operational Plans

To facilitate the implementation, financing and monitoring of this Nursing and Midwifery Policy, the Directorate of Nursing and Midwifery, with the technical support of key partners, shall collaborate and facilitate the development of the national Nursing and Midwifery Strategic Plan. The Strategic Plan shall be costed and based on the Nursing and Midwifery Policy strategic orientations.

The costed Nursing and Midwifery Strategic Plan shall be developed using participatory approach similar to those used in the preparation of the policy, and shall be disseminated to all relevant institutions, organizations, programs and partners

5.4 Monitoring and Evaluation FrameworkMonitoring and evaluating implementation of the policy will be done as part of the governance and management function and will serve to ensure that the government and partners are implementing and aligning to the nursing and midwifery policy orientations.

Measuring the performance of the Directorate of Nursing and Midwifery Services is crucial for ensuring that the processes and expected outcomes are objectively contributing to addressing the challenges faced by the nursing and midwifery workforce in delivering the services. The monitoring will improve the efficiency and effectiveness of the directorate.

All partners and stakeholders shall collaborate and participate in the monitoring of the costed national Nursing and Midwifery Strategic Plan and annual operational plans through a unified monitoring framework, based on agreed baseline, indicators and targets.

6. Assumptions

The Nursing and Midwifery Policy has been developed under the assumptions that the country will continue to enjoy political stability and progressive economic growth. The government will continue to raise the visibility of human resources for health crisis at forums where health is an agenda and development partners will continue to provide sustained financial and technical support to implement the policy and its startegic plan.

Policy Review:This policy will be reviewed after 5 years or earlier, as required

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