Strengthening the Preparation of Student Nurses to Participate in the Provision of Nurse Initiated and Monitored Antiretroviral in South Africa

Background

As the worldwide fight against Human Immunodeficiency Virus (HIV) continues, incidence and mortality rates are being reduced, with an increase in the number of people living with HIV infection and needing care. This increase is partly attributed to advances that have been made with regard to the management of HIV and Acquired immunodeficiency syndrome (AIDS). The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set the 90-90-90-target, striving to ensure that, by the year 2020, 90% of those who are infected with HIV know their HIV status; 90% of those with HIV diagnosis are receiving continued antiretroviral therapy (ART); and viral suppression is attained for 90% of those receiving ART (UNAIDS, 2014). The South African Government has made the fight against HIV one of its priorities, and developed strategies and policies targeting the HIV epidemic, with the aim of reducing infections and providing the best treatment as promptly as possible, all in line with global efforts to deal with the HIV epidemic (South African Department of Health, 2010; Johnson, 2012; Motsoaledi, 2014).  In South Africa, the current policy related to the management of HIV and AIDS recommends ART initiation at a CD4 count of 500, providing opportunity to increase the number of people who are initiated and monitored on ART. Nurses’ role in the initiation and management of ART is crucial, and has been documented to be effective. However, literature notes that in Sub-Saharan Africa, it’s not clear how this aspect is covered in the pre-service training of nurses (Zuber et al 2014). Furthermore, Relf et al. (2011) stress that it is important to prepare new nurse graduates in a holistic manner so that they can acquire the essential competencies that relate to HIV and AIDS. In the 2013 South African’s United Nations General Assembly Special Session on AIDS mid-term report, one of the programmatic actions that are reported to be necessary for achieving the target related to reaching 15 million people living with HIV on ART by the year 2015, is strengthening the capacity of nurses to initiate and monitor people living with HIV on ART. The report notes that the ability of new nurse graduates to manage adults and children living with HIV will be enhanced by inclusion of nurse initiated and monitored ART (NIMART) in the pre-service training (Republic of South Africa, 2013). This paper presents attempts to strengthen South African student nurses’ preparation for NIMART, by integrating such aspect in the pre-service nursing curriculum at one university in South Africa.

Methods:

Working within a constructivist paradigm and applying a qualitative approach, 8 group discussions using the nominal group technique and 7 individual interviews were conducted with 52 nurse educators in seven provinces in South Africa, and 2 members of the Nursing governing body. Using volunteer and purposeful sampling techniques, a total of 54 participants contributed to the study until data saturation was achieved. During the data collection, there was a discussion of competencies related to HIV and AIDS for nurses including NIMART and how NIMART can be integrated in the pre-service training for nurses in South Africa. Workshops were conducted to discuss how the competencies can be integrated into the four year nursing program, and a verification process provided the final list of competencies and how they can be integrated. The collected data were transcribed verbatim and analysed using the steps of multiple group data analysis for nominal group technique, and content analysis. The study received ethical clearance and permissions from the institutions where participants were recruited. The study was conducted in English, all participants signed informed consent and ethical considerations were adhered to. Member checks, prolonged engagement and data audit are some of the strategies applied to ensure trustworthiness.

Results

Of the 52 participants in the group discussions and interviews, 59% were aged 50 years and less, with about 6% who were over 60 years of age, and 89% were female. Up to 69% of the participants reported being involved in the teaching of HIV in the pre-service program. 48% of the participants held a master’s degree, while 20% were PhD holders. The participants agreed that NIMART is an important aspect in the fight against HIV, and literature supports that nurses’ care in NIMART is on par with the care provided by doctors. However, there seemed to be two different views, with some nurse educators preferring to have NIMART in the post-graduate programme, while another group noted that it can be done at a pre-service level as the current legal framework is enabling. Participants raised concerns related to knowledge related to pharmacology, and gaining experience to be able to provide NIMART upon graduation. Aspects related to knowledge of ART, side effects and interpretation of results were noted as weaknesses in practicing nurses, and these will need special attention in the curriculum. This study developed outcomes that relate to participation in initiation and monitoring of ART, which will require the student nurse to have the opportunity to participate in ART initiation and monitoring during the training. This inclusion of NIMART in the pre-service training of nurses will facilitate the new nurse graduate to improve the competency after graduation. Furthermore, prior exposure to NIMART during pre-service training will enhance reduction of reliance on in-service training, while speeding up provision of ART to people living with HIV by nurses. Various outcomes were developed, and these outcomes can be integrated into the four year nursing undergraduate program. The outcomes related to the development of required competencies for NIMART include understanding the various medication used in the treatment of HIV, how they work and their side effects. The outcomes also include interpretation of results and enhancing adherence.

Conclusion

The study developed competencies that will enable student nurses to participate in the NIMART program during their training, facilitating quicker functioning upon graduation. Such competencies could be integrated vertically and horizontally throughout the four year programme, facilitating thorough preparation of nurses. Furthermore, the developed outcomes can be transferred in other pre-service nursing programs in various settings, as the fight against HIV continues worldwide. Considering the shortage of nurses in many countries, efforts such as this in other nursing programs will improve nurses’ ability to participate in the provision of ART, hence the opportunity to reach 90-90-90 target set by the UNAIDS.