The

Chi

ldren’s Hospital Trust

Red Cross Children’s Hospital

Healing is in Your Hands

In support of

Child Nurse Practice Development InitiativeDepartment of Paediatrics & Child Health

Progress ReportJanuary – December 2018

How to build children’s nursing:

‘Begin before you’re readyStart where you are Use what you have

Share what you know’

That’s how we do it - The CNPDI team

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2018 HIGHLIGHTS

About the CNPDI: The Child Nurse Practice Development Initiative (CNPDI) was established in 2008. 10 years later, and the CNPDI team has grown to become a leading partner, building the children’s nursing workforce in Africa. As part of this, we offer three postgraduate (PG) programmes at UCT School of Nursing:

• PG Diploma in Child Nursing.

• PG Diploma in Critical Care Child Nursing.

• Master of Nursing in Child Nursing (MNCN).

In addition to the direct training of children’s nursing professionals, our team is committed to building children’s nursing throughout Africa. To do this, we support partners across the continent in the development of both new and existing Child nurse training programmes. Together we are building children’s nursing for Africa, in Africa – and are proud to present our progress report for 2018.

31 PG Diploma nurses enrolled

5 first year Masters nurses enrolled

29 graduates across all three postgraduate programmes

83% in-year graduation rate

100% of nurses returning home to practice

4th Child Nurse Educator Forum delivered

6 new nurse training programmes established (Malawi: 4, Zambia: 1, Kenya: 1) to date

Winner: Burdett Nurse Global Health Impact Award

Best Presentation at the THET Annual Conference (UK)

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OUR GOALS

To deliver post-graduate training in child and paediatric critical care nursing.

91% achieved160 child nurses trained.

175 child nurses trained as Postgraduate Diploma between 2014-18.

To establish a Clinical Masters programme.

84% achieved11 graduates to date.Nine students currently enrolled.

13 child nurse specialists trained at Masters level between 2014-18.

To retain specialist nurse graduates in health services.

100% achieved100% of APFP nurses retained.

90% retention rate of APFP nursing fellows at their home institution one year post training.

Practice improvement. AchievedJournal Club engaging 200 nurses per month.

Documented changes where graduates work towards improved nursing practices and child health outcomes.

Research to observe and document best nursing practice in caring for hospitalised children in Africa.

In progress Three papers written and undergoing peer review, with publication expected in 2019.

Multi-centre study introducing a ‘Care-by-Family’ model published by 2017.

Building children’s nursing training and specialist training.

100% achievedNew training programmes established in:… Malawi: 4… Zambia: 1… Kenya: 1

Six new training programmes at African institutions established by 2018.

Target StatusActivity

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This year has seen 29 nurses graduate as children’s nurses from UCT, 25 with PG Diplomas and four with a Masters qualification that equips registered nurses with the skills to become Advanced Paediatric Nurse Practitioners (APNs). This brings the total number of graduates since 2008 to 319, with trainees coming to us from eight African countries. Our work in 2018 has helped us build a new understanding of why we work in the way that we do, and how our programme comes together to align with principles of effective educational practice and healthcare development. It is an exciting time for nursing, and we are proud to have gained the endorsement of the Burdett Trust for Nursing’s first Global Health Impact Award, and also for the story of the way we work to have been recognised by THET as the ‘Best Abstract Presentation’ delivered at their Annual Conference in London in September.

As the role of this important profession gains increasing profile and strength, the work of the CNPDI team becomes ever-more relevant. Having started with a mission to train children’s nurses, we increasingly understand what it takes to build a workforce. The climate of austerity within health services and higher education makes the conditions to achieve this more challenging than ever. Guided by our new Five Year Strategic Plan, we draw strength from the new profile given to nursing through global health agendas and initiatives, and welcome new relationships with collaborators including the Clinton Health Access Initiative, and the launch of new global initiatives such as the NursingNow campaign. We are not alone, and will continue to tackle the challenge of building children’s nursing in Africa through the work that we do best - education, workforce strengthening, clinical practice development and better evidence. More than ever, Africa needs the solutions – and the hope - that CNPDI can offer. We look forward to building on this in 2019 and beyond.

SUMMARY

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As our flagship programme, we are proud to have maintained an overall average of 35 student enrolments a year. 2018 saw 31 students enrolled, and 25 student graduates (to date). This brings the total number of graduands to 308 (160 since 2014) – of which 239 came to us from South Africa (128 since 2014) and 69 (32 since 2014) from across the continent. Where last year saw a number of students struggle to complete their studies, we are pleased to report that most of those who deferred their course have now successfully graduated. The student intake for 2018 was stronger and we were pleased to see students coping well with the demands of the programme and demonstrating encouraging levels of professional ability.

GOAL 1To deliver post-graduate training in child and paediatric critical care nursing.

175 child nurses trained as Postgraduate Diploma level between 2014-2018.

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The two-year Master of Nursing in Child Nursing Programme (MNCN) began in 2016. Now having completed its third year, this new venture feels increasingly well established. To date, 11 students have completed their studies with us (4 in 2018) with 7 of these coming to us from South Africa and another 4 from Malawi (1), Namibia (1) and Kenya (2). Whilst this falls marginally short of our 2018 target, we are proud to report a 100% graduation rate once again – with this year seeing one student awarded her full degree with distinction. A valuable asset, the APN role is now well described in South African National Department of Health policy. However, despite this recognition, an interesting paradox exists. When it comes to employment, delays in career pathway development and budgetary restrictions at national level are limiting job opportunities for graduating APN nurses. To counter this, our team have developed a pilot project to deploy a small number of APNs as part of a study to evaluate the impact of this new nursing cadre. We are delighted to report that in November 2018 the Children’s Hospital Trust awarded R7.8m to support this work over the next three years, with work due to begin in 2019.

The difference an APN nurse can make…As part of her second year study, Sister Evelyne Mvungu (2018 MNCN graduate) returned to Kenya for a six week placement at a busy referral hospital, with a brief to undertake a review of patient flow. The neonatal unit had space for 68 babies. But there were always more – sometimes up to 20 babies in seven incubators. With one nurse looking after 20 babies, staff-patient ratios were extremely low. The layout of the unit made it hard to keep track of individual patient needs, to separate medical from surgical patients, or to monitor high-priority patients. The risk of cross-infection was also high. Sister Mvungu worked to understand the situation, and identified a number of ways to improve patient flow. A member of the nursing team was given responsibility for ward coordination, and a stock-room was cleared so that she had space to work. A business case was to put to the CEO to reorganise the ward and Sister Mvungu negotiated permission to knock down a wall, an important step that created new space for more beds, as well as space to care for abandoned children and a proposed isolation room. With the Chairman and CEO behind the project, a new system for ‘internal locums’ was introduced and ward staffing capacity increased. The unit has achieved a ratio of one nurse to ten babies and is working towards a target of 1:5. After three months the unit reported that mortality had fallen by 30%.

GOAL 2To establish a Clinical Masters programme

13 child nurse specialists trained at Masters level between 2014-2018

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GOAL 3 To retain specialist nurse graduates in health services.

90% retention rate of African nursing fellows in their home institution one year post training.

Every year, the African continent loses qualified health workers to the ‘brain drain’ – with registered professionals leaving their home country to practice overseas. Countering this trend, we are pleased to report that 2018 saw 100% of CNPDI graduates return to practice in their home countries.

The value of specialist paediatric nurses

Sister Virginia Ngugi (2018 MNCN graduate) reflects on her clinical placement experiences: ‘We found a baby that was really sick. We were able to start a baby on CPAP [to help with breathing] and by the time we left the baby was on the mother’s chest. She had never held her baby, for the two weeks or the three weeks since it had been born. This was the first time that she had held her baby. She just sat there, and she kept coming back for more. The one nurse said ‘I can see the difference, because I gave her the reason to come back. The other mothers that have their baby in an incubator, they are sitting there next to the incubator and they don’t know what to do. They feel like they are wasting time, they feel like useless. This mother, because she is bonding with her child, she even comes earlier than she needs to.’ Those words stuck with me, ‘I gave her a reason to come back.’ That’s what changes the outcome, and for that nurse, it is what changes the outcome for everyone… I asked, how does it make you feel, she says ‘it gives me a sense of achievement’ – and that is what will drive her to continue’.

29 graduates in 2018.

100% of nurses returned home to practice

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GOAL 4 Practice improvementDocumented changes where graduates work towards improved nursing practices and child health outcomes.

Each and every graduating fellow takes back an invaluable set of knowledge, skills and experience to their home working environment – a toolkit that both enables the delivery of direct care, whilst also supporting broader service developments. In addition to the case studies featured in this report, the CNPDI team has launched a number of initiatives to support our graduates as they work to put their training to practical use. These include:

• A regular Journal Club: Facilitated by CNPDI research team members, the Journal Club is designed to build nurses’ abilities to access and apply evidence and research to their clinical practice. Up to 200 nurses joined Journal Club sessions each month throughout 2018.

• Protocol development: As part of the second year Master’s curriculum, CNPDI students are asked to develop evidence-based practice protocols for children’s nurses in low-income settings. Ranging from high-flow oxygen therapy in general paediatric wards to the ethics of social media use by healthcare professionals, we continue to support our students as they work to publish these valuable resources.

• Exchange visits: Led by Minette Coetzee and Jane Vos in May 2018, MNCN students spent two weeks on invitation to Zimbabwe’s Mpilo Children’s Hospital to assist with clinical governance and practice support. In addition, 2018 saw CNPDI team member Jonathan Muller-Stuurman join APFP alumni in Namibia for the first in-country paediatric cardiac surgery outreach visit.

‘One of the big things my experience of working in Africa has taught me is that it doesn't help to look at situations as being resource-poor. The philosophy of this team is that people, especially nurses, are resource-full. If you keep that in mind, you can usually find a way to get things done.’ Clare Davis, Programme Convenor, Critical Care Child Nursing

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GOAL 5 Implementation of science to add rigour to practice change and measuring outcomes and impact of health services.

Multi-centre study introducing a ‘Care-by-Family’ model published by 2017.

The CNPDI ‘Care-by-Family’ study launched in 2016 in order to observe, document and articulate children’s nursing practices relating to family involvement in the care of hospitalised children. The accompanying literature review has revealed a well-established evidence base in support of continuous maternal presence and family involvement in the care of hospitalised infants and newborns. This is an important foundation for the CNPDI’s clinical practice development and education work, but there is little evidence of direct research beyond neonatal/infancy stages. As such, this project is contributing to the rigorous foundations on which to further develop research and education workstreams to support children’s nurses. With field work and data analysis now complete, we are looking ahead to implementing this knowledge through the Best Practice Units outlined in our new Five Year Strategy. Two papers describing the study design and emerging findings have been written and submitted for peer review. These join two additional reports on the children’s nursing workforce more generally, both of which will be published in 2019.

The children’s nursing workforce

In 2018 original research by CNPDI has established the first ever data on the size of the specialist children’s nursing workforce in South Africa and four of the countries we work with: Kenya, Malawi, Uganda and Zambia. Based on this data, we estimate that at the end of 2018 there will be 4,000 children’s nurses across these five countries. South Africa accounts for around 8/10 of nurses in this workforce. We are delighted to report that the children’s nursing workforce in southern and eastern Africa is growing and gaining in strength, through new training programmes and the dedicated efforts of many nurse leaders and colleagues. Of course, the need for more children’s nurses remains great: children aged 0-15 make up between a third and half of the total population in the five countries studied. Training output across the five countries adds 260 children’s nurses to the workforce on average each year. Our research programme will continue to build the capacity of partner countries to collect and share accurate workforce information as we work together to build children’s nursing in Africa.

Original research

4,000 children’s nurses across Kenya, Malawi, Uganda,Zambia and South Africa.

Training output adds 260 nurses to the workforce each year.

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GOAL 6 Building children’s nursing training and specialist training

Six new training programmes at African institutions supported to commence student intake by 2018.

To date, six new programmes have been established in Kenya, Malawi and Zambia. The development of three more programmes is currently in progress in Botswana, Namibia and Zimbabwe, with two more in discussion in Ghana and Kenya (Eldoret).

Programme StatusCentre

Bamalete Lutheran School of Nursing

Development in progressAdvanced diploma: Child & Newborn Nursing

Gertrude’s Children’s Hospital School of Nursing

Launched 2013Diploma: Child Critical Care

International University of Management

Due to start 2019

University of Malawi & UCT

Launched 2011 (interim course)

Dual registration Masters:Child Health Nursing

University of Malawi Launched 2016Masters degree:Child Health Nursing

University of Malawi Launched 2018Bachelor of Nursing:Child Health

Country

Botswana

Kenya

Namibia

Malawi

Malawi

Malawi

Lusaka School of Nursing Launched 2013Advanced diploma: Paediatric Nursing

Zambia

National University of Science & Technology

Development in progressPostgraduate diploma: Children’s Nursing

Zimbabwe

Postgraduate diploma: Children’s Nursing

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Working towards long-term change

‘We were asked who is willing to go and study. I chose to come. I am here for a purpose. When I go back, I will start with my colleague to train children’s nurses in Namibia. This is my passion.’ Sister Fredrika Hamutoko, Nurse Lecturer, International University of Management, Namibia (2018 PGDip student).

Building a Community of Practice

Established in 2014, the ‘Children’s Nursing Educator Forum’ is an increasingly important part of the CNPDI’s mission to build a community of practice among child nurse educators in Africa. Held in July 2018, this year’s annual forum was attended by Nurse Educators from across all eight South African schools of nursing that offer children’s nursing training, as well as educators from Namibia where a programme is due to start in 2019. This year’s programme was designed to support the re-curriculation of training programmes as schools of nursing work to meet new requirements set by the Council for Higher Education. A number of nursing colleges are part-way through this process, but the outcomes are uncertain. This makes the uniting and supportive role of the ‘Children’s Nursing Educator Forum’ more important than ever before.

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CHALLENGES UCT continues to be the only South African institution offering children’s nursing training to nurses from other African countries. As pioneers in our field, operations are not without their challenges, with key issues from 2018 highlighted below.

• APPOINTMENT OF MNCN GRADUATES: When the MNCN launched in 2016, no APN practitioners had been trained in South Africa for a generation. Whilst this role is both described in South African National Department of Health policy and recognised by SANC, the implementation of this important role has stalled. Employers lack guidance about how to appoint APNs, and have questions about the contribution and value of this ‘new’ professional cadre. This situation needs to be resolved so that South Africa’s children can benefit from the input of Advanced Practice Nurses. The evaluation described on page 6 sets the way for employment of APNs at the Red Cross Children’s Hospital and provides important opportunity to measure and advocate need for this role.

• STAFF RECRUITMENT: As with many African health education facilities, the CNPDI can struggle to find suitably qualified staff to fill its teaching posts. The position of Senior Lecturer for our Masters Programme is one such example. We are yet to appoint someone in this role, meaning we will scale back development plans – including the development of proposed Best Practice Units - whilst the post remains vacant. At this time, it is important that we do not over-stretch our resources, and that we prioritise workload to ensure the best-possible outcome and deliverables for everyone involved.

• SANC REGISTRATION: One of the greatest challenges we face is the delay in obtaining temporary SANC registration for visiting nurses – with a number of our foreign students having no option but to defer their studies. This uncertainty is disruptive and causes a great deal of anxiety and emotional distress for students, as well as additional cost. We continue to work intensively to expedite the registration process where possible.

‘It is incredibly rewarding to work with a team that shares such a passion for paediatric nursing. I have such respect for our students, who make so many improvements to their places of work. The challenges of providing quality care in our continent are huge, and I love that this team aren’t afraid to tackle them. Together we are building children’s nursing for Africa: one nurse at a time.’ Jonathan Muller-Stuurman, Critical Care Child Nursing

WITH THANKSThe Burdett Trust for NursingThe Children’s Hospital Trust FoundationHarry Crossley FoundationThe ELMA FoundationSleepNetThe Vitol FoundationPhatisa Foundation

In Memoria: With this report we would like to remember Dean Professor Bongani Mayosi Emeritus Professor David Beattie. Both have given more to the CNPDI that we can say. You may have gone from our lives, but in the Child Nurse Practice Development Initiative your legacy will always be remembered.

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FINANCIAL REPORT

Budget by Line Item vs Actuals Approved Budget FY2018

ACTUAL SPENDFY2018

(1 Jan- 31 Dec 2018)Variance % Variance

PersonnelStaffing costsUCT Staff Overhead Charge

Postgraduate Diploma in Child Nursing APFP PGDip Student Costs: SADC StudentsAPFP PGDip Student Costs: non-SADC StudentsAPFP PGDip Student Allowance (SADC and non SADC) SA PGDip ScholarshipsPG Dip Student Study Support - all students

Masters in Child NursingAPFP MNCN Student Costs: SADC StudentsAPFP MNCN Student Costs: non-SADC StudentsAPFP MNCN Student AllowanceSA MNCN CNPDI FellowshipsOther MNCN ScholarshipsHarry Crossley ScholarshipsResMed SleepNet ScholarshipsMcIntosh ScholarshipsCNPDI Fellow International Conference PresentationCNPDI Fellow National Conference PresentationMNCN Study Support

R 6 316 414 5 479 196

837 218

R 640 253 66 559

105 751 251 943 150 000

66 000

R 1 977 048 96 726

431 959 898 363

- - -

300 000 150 000

- 30 000 70 000

5 530 817 4 839 625

691 192

R 645 879 66 065

135 622 230 874 150 000

63 318

R 1 847 306 101 908 337 641 833 510

- - -

300 000 150 000

- -

124 247

785 597 639 571 146 026

R -5 626 493

-29 870 21 069

- 2 682

R 129 742 -5 182 94 318 64 853

-

- - - -

30 000 -54 247

12%12%17%

-1%1%

-28%8%0%4%

7%-5%22%

7%

0%0%

100%-77%

Expenditure Report, January – December 2018

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Budget by Line Item vs Actuals Approved Budget FY2018

ACTUAL SPENDFY2018

(1 Jan- 31 Dec 2018)Variance % Variance

Clinical Practice Development with FacilitiesClinical Practice Development Facilitators:Team building support at Practice Development Sites Practice Development Support of facilities and new programmes Training materials and refreshments

ResearchPostgraduate Research Lead Initiative Staff Conference Attendance - InternationalInitiative Staff Conference Attendance - DomesticPost Doc Grant

Building Child Nurse training programs in AfricaCurriculum Development Visit Lecturer Exchange Visits between programmes Internships for African educatorsSupport of South African child nurse training programmes

Operational ExpenditureStaff Recruitment/AdvertisingTelephone/FaxPhotocopy/PrintingSalesforce DevelopmentsStationery & Contingencies

7 Office Equipment

Program DevelopmentStaff Capacity buildingNational Forums (includes Fundisa & SANC)Western Cape & National DOH meetingsInternship 1 week training programmeAPFP annual report assistance and productionTechnical Support - MalawiOn Line Learning Course DevelopmentCommunication Officer

Total Program Budget

R 770 264 700 737

6 193 26 174 37 159

R 1 182 416 899 215

57 560 25 641

200 000

R 265 266 36 740

111 241 12 000

105 286

R 93 214 - -

42 000 20 000 31 214

R 63 000

R 123 432 28 000

7 432 15 000

- - -

25 000 48 000

R 11 431 307

R 765 262 741 562

881 3 024

19 795

R 1 053 730 771 754

54 495 27 481

200 000

R 208 734 29 060 99 285

8 886 71 502

105 893 - -

47 099 22 438 36 355

R 75 737

R 105 659 41 250

5 443 8 566

- - -

25 000 25 400

10 339 017

R 5 002 -40 824

5 312 23 150 17 364

R 128 686 127 461

3 065 -1 840

-

R 56 533 7 680

11 956 3 114

33 783

-12 679 0%

- 5 099 2 438 5 141

-12 738

R 17 773 -13 250

1 989 6 434

- - - -

22 600

1 092 290

1%-6%86%88%47%

11%14%

5%-7%0%

21%21%11%26%32%

-14%

12%12%16%

-20%

14%-47%27%43%

0%47%

10%