Muriel Syacumpi. Printed August 2006

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1 Preservice and Pst-Basic Nursing Training Curricula fr Registered Nurses in Zambia: Curriculum Review and Expert Interviews t Assess Antimicrbial Use and Antimicrbial Resistance Cntent, March 2006 Muriel Syacumpi Printed August 2006 Advcacy Wrking Grup Ratinal Pharmaceutical Management Plus Center fr Pharmaceutical Management Management Sciences fr Health 4301 N. Fairfax Drive, Suite 400 Arlingtn, VA USA Phne: Fax: rpmplus@msh.rg Strategic Objective 5

2 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 This reprt was made pssible thrugh supprt prvided by the U.S. Agency fr Internatinal Develpment, under the terms f cperative agreement number HRN-A The pinins expressed herein are thse f the authr(s) and d nt necessarily reflect the views f the U.S. Agency fr Internatinal Develpment. Abut RPM Plus RPM Plus wrks in mre than 20 develping and transitinal cuntries t prvide technical assistance t strengthen drug and health cmmdity management systems. The prgram ffers technical guidance and assists in strategy develpment and prgram implementatin bth in imprving the availability f health cmmdities pharmaceuticals, vaccines, supplies, and basic medical equipment f assured quality fr maternal and child health, HIV/AIDS, infectius diseases, and family planning and in prmting the apprpriate use f health cmmdities in the public and private sectrs. Recmmended Citatin This reprt may be reprduced if credit is given t RPM Plus. Please use the fllwing citatin. Syacumpi, M Preservice and Pst-Basic Nursing Training Curricula fr Registered Nurses in Zambia: Curriculum Review and Expert Interviews t Assess Antimicrbial Use and Antimicrbial Resistance Cntent, March Submitted t the U.S. Agency fr Internatinal Develpment by the Ratinal Pharmaceutical Management Plus Prgram. Arlingtn, VA: Management Sciences fr Health. Ratinal Pharmaceutical Management Plus Center fr Pharmaceutical Management Management Sciences fr Health 4301 Nrth Fairfax Drive, Suite 400 Arlingtn, VA USA Telephne: Fax: rpmplus@msh.rg Web: ii

3 CONTENTS ACRONYMS... v EXECUTIVE SUMMARY... 1 Antimicrbial Use and Antimicrbial Resistance... 2 Ratinal Use f Medicines... 2 Infectin Preventin... 3 Antimicrbial Resistance... 3 Patient Educatin... 3 Recmmendatins... 4 BACKGROUND INFORMATION... 5 Cntext... 5 Scpe f Wrk fr the Cnsultancy... 7 Assessment Methdlgy... 7 FINDINGS... 9 Registered Nursing Curriculum (Preservice Nursing Prgram)... 9 Pst-Basic Nursing Curriculum (Graduate Nursing Prgram) Teaching and Learning Methds Respndents Views n AMU, AMR, and Cntainment f AMR DISCUSSION AND RECOMMENDATIONS Preservice Nursing Prgram Pst-Basic Prgram Patient Educatin Antimicrbial Use Ratinal Use f Medicines Infectin Preventin Recmmendatins REFERENCES ANNEX 1. INTERVIEW TRANSCRIPTS Heads f Institutins, Lecturers, Tutrs in Public and Private Schls, Guest Lecturers Graduate Interns, UTH Third-Year Student Nurses, UTH Schl f Nursing Regulatry Bdies and Senir Gvernment Officials ANNEX 2. CURRICULA FOR THE TWO NURSING PROGRAMS ANNEX 3. GAPS IDENTIFIED IN THE BSC NURSING PROGRAM ANNEX 4. KEY INFORMANTS ANNEX 5. STRATEGIES FOR CURRICULUM REVIEW AND INTERVIEWS iii

4 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 ANNEX 6. SCOPE OF WORK iv

5 ACRONYMS AIDS AMU AMR ARV BSc CBOH GNC HIV MH PBL PRA RN RUM STGs TB UNZA UTH WHO acquired immundeficiency syndrme antimicrbial use antimicrbial resistance antiretrviral bachelr f science Central Bard f Health General Nursing Cuncil [Zambia] human immundeficiency virus Ministry f Health prblem-based learning Pharmaceutical Regulatry Authrity Registered Nurse ratinal use f medicines standard treatment guidelines tuberculsis University f Zambia University teaching hspital Wrld Health Organizatin v

6 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 vi

7 EXECUTIVE SUMMARY Despite the significant strides in fighting disease and infectin brught abut by the discvery f antibitics, sme bacteria have develped ways in which t utwit the effects f antibitics. Widespread use f antibitics is thught t have spurred evlutinary changes in bacteria that allw them t survive these pwerful drugs. Antibitic resistance presents tw big prblems: it makes it mre difficult fr the bdy t purge itself f infectins, and it heightens the risk f acquiring infectins in a hspital. It is in this vein that antimicrbial resistance (AMR) becmes f utmst imprtance in the medical field. Zambia is ne f the cuntries cncerned with the high levels f AMR, ratinal use f antimicrbials, and the issue f cntainment f AMR. With the emergence f newer medicines n the market and easy unregulated access t sme f these medicines by varius individuals in the cmmunities, the need fr the educatin f health prviders t help with the cntainment f the prblem cannt be veremphasized. The cmmissining f this study t assess the status f AMR/antimicrbial use (AMU) training in schls is therefre imprtant as a starting pint. A review f the curricula fr the graduate nursing prgram at the University f Zambia, Department f Pst-Basic Nursing, and the curricula fr Registered Nurse (RN) training prgrams in Zambia was undertaken t assess hw tpics n AMU and AMR were addressed in thse curricula. The review prcess was als aimed at identifying gaps in the curricula based n the cverage and prgramming f the AMR/AMU tpics in the training plans. The first phase f the study cnsisted f a desk review f the curricula, identifying curses within which antimicrbial tpics are integrated, the perids when the tpics are taught, the amunt f time allcated, and whether students are examined n the tpics. The secnd phase invlved cnducting in-depth interviews with key fficials with links t the teaching prgrams in the nursing schls. That grup included thse persns invlved in training, thse respnsible fr the regulatin f training institutins, and thse respnsible fr plicy frmulatin. The persns interviewed were fficials frm the General Nursing Cuncil (GNC), which regulates training, certificatin, and registratin f all nurses t practice and had recently guided the review and revisin f curricula fr all nurse training prgrams in Zambia; the Chief Nurse in the Ministry f Health (MH) in rder t btain the gvernment s stand n the issue f AMR/AMU; tutrs in gvernmental nurse training institutins; tutrs frm the newly pened private nurse training schls; guest lecturers in micrbilgy and pharmaclgy; three recent nursing graduates; and three senir student nurses. These in-depth interviews were a vital surce f infrmatin relevant t this study. The interviews further slicited infrmatin n hw the subjects wanted related training t be dne better r imprved. Annexes 1 and 2 shw the curriculum curse cntent fr the three-year training fr the preservice and pst-basic graduate prgrams. Sme key literature was als reviewed t help put the issues f AMR and AMU int the cntext f this study (References). The Pst-Basic curriculum was reviewed t prvide insight n hw well prepared the graduates frm the prgram were t be able t teach in the nursing schls, especially teaching AMR/AMU, infectin preventin, and ther related tpics. The findings shw that very little 1

8 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 time was devted t AMR and AMU, with the Pst-Basic training prgram allcating nly 13 hurs in a semester t teach micrbilgy, within which tpics f AMR/AMU and ther related tpics are taught. Althugh the curriculum indicates 6 hurs f lecture cntact per week as an ideal situatin, that is nt the case. The tw brad areas that were reviewed at bth pst-basic and preservice levels in this study were AMU and AMR and related tpics, such as infectin preventin, patient educatin, and ratinal use f medicines (RUM). Antimicrbial Use and Antimicrbial Resistance The tw curricula reviewed and the ensuing interviews shw that antimicrbials have been adequately cvered in different curses and applicatin f such knwledge is guaranteed because students are nrmally examined as is the case in the preservice prgrams where examinatins are cncerned with applicatin f all knwledge acquired during the three-year perid. The student is therefre expected t have knwledge n antimicrbials and an understanding f when, hw, and why these apply in patient care. Hwever, their indiscriminate prescriptin has had an adverse effect n use because f the many resistant strains being seen tday. The curricula talk abut drugs f chice but d nt adequately teach the prcess f prescribing effectively. Students are taught prescribing principles, drug interactins, and adverse drug reactins and effects. Antimicrbial resistance is mentined, but the teaching prgrams have nt been clear in ensuring the subject adequately addresses hw t find further ways f cntaining the prblem. Ratinal Use f Medicines Respndents als expressed cncerns n the variatins in the levels f detail being taught t students in schls. The University Teaching Hspital (UTH) has specialists that participate in teaching in the nurse training, and their understanding is at a different level. In ther hspitals, hwever, thse experts are nt available, thus resulting in the nurse tutrs having t cver the tpics. RUM is being cmprmised because nurse tutrs may nly discuss issues pertaining t AMU superficially, especially thse cming frm hspitals where interactin with specialists is minimal. Mst respndents bserved that the situatin has resulted in nurses nt challenging sme f the dctrs prescriptins. The GNC initiative in develping a guide t prescribing fr the nurse is an effrt that will need t be supprted. Having said this, the curricula fr bth prgrams talked abut RUM, but the tpic des nt stand ut separately and is nt adequately cvered. The discussins n different disease cnditins d talk abut the drugs f chice (althugh nnavailability r pr supply f medicines des affect what the drug f chice may be), the mechanism f actin, side effects, and length f use. 2

9 Executive Summary Infectin Preventin The preservice nursing curriculum is strng in the area f infectins and infectin preventin. The tpics are discussed in such curses as medicine, surgery, pediatrics, bstetrics and gyneclgy, public health, and the related nursing interventins. The tpic is discussed at different levels f training, and the daily practices in patient care always emphasize hand washing befre and after every prcedure. This als emphasizes in many prcedures the imprtance f aseptic techniques, and prmtes them as ways t prevent the spread f infectins. Students are cmprehensively expsed t related clinical practice; hwever, the practice f infectin preventin is crippled by lack f essential supplies. Tpics n immunizatin are als a strng cmpnent f the curriculum. Fr bth prgrams, students are prvided with pprtunities t wrk in the cmmunities where they reinfrce what has been taught in class. The pst-basic prgram is very weak in the teaching f infectin preventin. The level f effrt in teaching the tpic varies and is mstly dependent n the lecturer s interest and prir rientatin. Antimicrbial Resistance This area had been identified during the assessment as an area f greater cncern. The curriculum review and in-depth discussins revealed that the schls d appreciate the dangers f such resistance and expressed the need fr schls t urgently address the resistance prblems, but n clear strategy existed n hw the issue culd be addressed. The tpic is cvered when teaching related subjects but nt in greater detail. It is mentined as ne f the negative effects f antimicrbial treatment. The tw prgrams are very weak in the area f AMR. Patient Educatin Respndents were als in agreement n the imprtance f teaching patients abut the need fr adherence t prescribed medicines. The curriculum emphasizes the imprtance f patient educatin as a cmmunity apprach t reducing AMR. Patients need t knw the imprtance f cmpleting treatment, f taking medicines as instructed by the health prviders, f nt sharing medicines, f string medicines safely, and f discuraging self-medicatin. Frm the freging, the review has been able t establish the emphatic need t refcus effrt in addressing AMR issues in bth the preservice and pst-basic nursing prgrams. The study has further established the need t address ther factrs dictating the current situatin, such as lack f labratry facilities and inadequately trained tutrs. All stakehlders shuld agree n ways and means f dealing with AMU and AMR. 3

10 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 Recmmendatins The curriculum fr nurses in bth prgrams shuld be reviewed, including tpics n AMR. Related cmpnents f the tw curricula shuld be revised t clearly state what needs t be taught s that anyne teaching the subject prvides the same infrmatin. Funding shuld be made available fr the GNC t initiate training f nurses in prescribing skills and t take the pprtunity t teach tpics n AMU, AMR, and AMR cntainment. The lecturers wh teach and supervise student nurses in the clinical areas need t be riented t AMU and AMR, injectin safety, and infectin preventin s that they can prepare the learners better. Practical classes shuld be prvided during training. Standard treatment guidelines (STGs) and the Essential Drug List shuld be made available t all student nurses, qualified nurses, and ther cncerned health prviders. Essential medicine security shuld be imprved and safeguarded against stck-ut f medicines. Mre labratry assistants shuld be trained and made available t cnduct investigative tests, and the required labratry resurces shuld be made available. 4

11 BACKGROUND INFORMATION Cntext The Wrld Health Organizatin (WHO) fact sheet Use f Antimicrbials Outside Human Medicine and Resultant Antimicrbial Resistance in Humans (WHO 2002) describes antimicrbials as natural r synthetic medicines that inhibit r kill bacteria. This capability makes antimicrbials unique fr the cntrl f deadly infectius diseases caused by a large variety f pathgenic bacteria. The discvery f antibitics r antimicrbials fr human medicine in the 1940s prvided a psitive develpment and change t management and treatment f different cnditins and infectius diseases [antibitics] transfrmed medical care and dramatically reduced illness and death frm infectius diseases. 1 Tday, hwever, this picture has changed because mst bacterial infectins are becming resistant t antimicrbials, a factr that is nw psing a danger t the lives f thse having a need fr the antimicrbials. Mst f the rising AMR prblem in human medicine is caused by the veruse and misuse f antimicrbials by dctrs, ther health persnnel, and patients. It is a fact that the cntinued use f antibitics withut apprpriate mnitring will result in the develpment f antibitic-resistant strains f bacteria. Apprpriate mnitring includes accurate diagnsis and crrect use f apprpriate antimicrbials. Thse are sme f the psitive factrs that will cntribute t the reductin f AMR. Hwever, t reduce AMR, the envirnment within which clients/patients are being managed needs t be carefully reviewed. The emergence f resistance strains f micrrganisms like the human immundeficiency virus (HIV), Mycbacterium tuberculsis (TB), and Streptcccus pneumnia has created challenges t antimicrbial use in hspitals and cmmunities. Bacterial resistance means that the antimicrbials have n effect n the bacterium r it is resistant t the antibitic. When AMR ccurs in the cmmunity it becmes a public health cncern, because the illness and resulting suffering are prlnged. Accrding t the Natinal Institute f Allergy and Infectius Diseases fact sheet, The Prblem f Antibitic Resistance (NIAID 2004), Tuberculsis, malaria, gnrrhea and childhd ear infectins are mre difficult t treat tday than they were a decade ag. Drug resistance is an especially difficult prblem fr hspitals because they harbr critically ill patients wh are vulnerable t nscmial infectins. Heavy use f antibitics in these patients hastens the mutatins in the bacteria that bring abut drug resistance. The issues in AMR that urgently need t be addressed tday include training f health prviders, patient educatin, availability f resurces fr labratry analyses, cnstant and sustained availability f medicines, and prescribing patterns. T strengthen interventins aimed at patients and the general cmmunity and thse that are t be carried ut by the prescribers, the WHO Glbal Strategy fr Cntainment f Antimicrbial Resistance (2001, 6) recmmends the fllwing interventins 1 Centers fr Disease Cntrl and Preventin (CDC) Abut Antibitic Resistance. < (accessed Aug. 25, 2006). 5

12 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 Patients and the General Cmmunity Educatin Educate patients and the general cmmunity n apprpriate use f antimicrbials. Educate patients n the imprtance f measures t prevent infectins, such as immunizatin, vectr cntrl, use f bednets, etc. Educate patients n simple measures that may reduce transmissin f infectin in the husehld and cmmunity, such as handwashing and fd hygiene, etc. Encurage apprpriate and infrmed health care seeking behavir. Educate patients n suitable alternatives t antimicrbials fr relief f symptms and discurage patient self-initiatin f treatment, except in specific circumstances. Prescribers and Dispensers Educatin Educate all grups f prescribers and dispensers (including drug sellers) n the imprtance f apprpriate antimicrbial use and cntainment f antimicrbial resistance. Educate all grups f prescribers n disease preventin (including immunizatin) and infectin cntrl issues. Prmte targeted undergraduate and pstgraduate educatinal prgrams n the accurate diagnsis and management f cmmn infectins fr all health care wrkers, veterinarians, prescribers and dispensers. Encurage prescribers and dispensers t educate patients n antimicrbial use and the imprtance f adherence t prescribed treatments. Educate all grups f prescribers and dispensers n factrs that may strngly influence their prescribing habits, such as ecnmic incentives, prmtinal activities, and inducements by the pharmaceutical industry. Zambia tday faces a critical shrtage f prescribers f medicines. Health facilities are being manned by varius categries f staff with n r inadequate knwledge and skills t prescribe and dispense medicines simply because they are fund in that health facility. T cmpund the situatin, mst f these health facilities d nt have adequate equipment, reagents, and ther resurces t carry ut labratry tests t determine the apprpriate antimicrbials t use. The Natinal Drug Plicy (MH 1999) states its bjective as being t eradicate unnecessary and inapprpriate drug use at all levels f sciety, and as such, prescribing and dispensing were t be aggressively cntrlled. It further adds that drugs n the Natinal Essential Drug List were t be allcated t certain levels f use, such as primary health care, first-level referral, and s n. This plicy wuld further encurage practitiners t handle nly a small number f medicines in whse use they culd gain a lt f knwledge and expertise. Furthermre, The reslutin by the Wrld Health Assembly fr member cuntries t encurage apprpriate and effective use f antimicrbials, t prhibit the dispensing f antimicrbials withut the prescriptin f a qualified 6

13 Backgrund Infrmatin health prfessinal, t imprve practices t prevent the spread f infectin and thereby the spread f resistant pathgens, t strengthen legislatin t prevent the manufacture, sale and distributin f cunterfeit antimicrbials and the sale f antimicrbials n the infrmal market, and t reduce the use f antimicrbials in fd-animal prductin (WHO 2002, 24) is a very imprtant develpment in guiding medical practice t address issues relating t AMR/AMU and AMR cntainment. The findings and recmmendatins f this curriculum review will prvide the avenue by which the gvernment f Zambia thrugh the MH can address the prblems f AMR. Scpe f Wrk fr the Cnsultancy Antimicrbial resistance has been and cntinues t be a majr area f cncern in the medical field. Gvernments and their cperating partners have been wrking n ways t cntain this prblem. Varius appraches are being taken t cntain AMR. In Zambia, the U.S. Agency fr Internatinal Develpment is supprting the develpment and implementatin f a cuntry-level apprach tward building lcal advcacy, a calitin, and a package f activities t cmbat the grwing prblem f AMR. Althugh advcacy is the main thrust f the Zambian prgram, educatin, regulatin, surveillance, and research are the fur majr interventin areas identified t supprt cntainment f AMR. As part f the verall AMR cntainment initiative in Zambia, this cnsultancy reviewed the undergraduate curriculum fr nurses at the preservice and pst-basic levels. The inclusin f the pst-basic prgram in the review prcess was aimed at prviding infrmatin n the preparatin f nurses wh are invlved in the nurse training prgrams at the preservice levels. The review f training curricula fr undergraduate/preservice health prfessinals will generate infrmatin n what and hw much f AMR-related tpics are being addressed in the preservice training. Such an assessment will identify any gaps that need t be filled and assist in the subsequent prcess f develping recmmendatins n suitable mdificatins and additins required in the Zambian cntext t ensure adequate cverage f these tpics during the training. Assessment Methdlgy The assessment was cnducted in tw phases, first a review f the curricula fr bth the pstbasic nursing prgram f the University f Zambia (UNZA) and the preservice curricula fr registered nurses. Other relevant dcuments that have bearing n the training f nurses in the preservice prgram were als reviewed. The dcuments included the RN curriculum and schl f medicine reference bk, the Nurses and Midwives Act, the scpe f practice fr nurses, and the training learning guides. Secnd, in-depth interviews were cnducted with heads f institutins, lecturers, tutrs in public and private schls, guest lecturers, regulatry bdies, and senir gvernment fficials. Fcus grup discussins with recent graduates (interns) and senir students in the preservice prgram were als held in tw separate sessins. The entry levels f the preservice and pst-basic prgrams differ, and the AMR-related cntent f the curricula must reflect the differences. 7

14 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March

15 FINDINGS Registered Nursing Curriculum (Preservice Nursing Prgram) Students entering the preservice nursing prgram have a minimum f five O-level qualificatins, and the prgram runs fr three years. The training prgram allws students t be expsed t bth thery and practical experiences in a phased manner. It is arranged in a blck system that ensures that at every stage f training, the student is given an pprtunity t practice in the clinical areas and in the cmmunity, where knwledge gained frm the thery classes and practical sessins is put int practice. The student frm this prgram qualifies as an RN with key skills t prvide health care and als manage health facilities. In accrdance with the RN curriculum, the aim f the prgram is t train a nurse wh will be self-directed, analytical, knwledgeable, skillful, and able t respnd t changing and emerging diseases and cntribute tward imprving the quality f care. The prgram bjectives state that the graduate nurse shall be able t Assess health needs f individuals, families, grups, and cmmunities, using varius nursing mdels Apply knwledge frm basic sciences (behaviral and bilgical) in the management f patients and clients Initiate and cnduct peratinal research Develp a multidisciplinary and team apprach in his r her wrk Wrk in partnership with grups and cmmunities in the assessment, planning, and implementatin f and evaluatin f health care Recgnize and accept the needs fr self-directin, prfessinal awareness, and cntinued prfessinal grwth Apply varius innvative methds f learning and educatin in rder t be self-directed in addressing different health care issues Apply knwledge n infrmatin technlgy in day-t-day wrk Serve as a rle mdel in the nursing prfessin The three-year prgram f study is arranged in a blck system where the student systematically builds n the knwledge previusly gained. There are tw lecture perids in each f the first tw years, and ne in the third year. Students attend thery classes and are then expsed t clinical practice in the apprpriate hspital departments r health facilities r in the cmmunity fr applicatin f thery t practice (Table 1). 9

16 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 During the fundatin perid, students learn abut infectin preventin and related tpics. These tpics are taught in different curses like Fundamentals f Nursing and Public Health Nursing I and II. In micrbilgy, tpics n types f micrrganisms, micrscpic examinatin, cultivatin and identificatin f micrrganisms, antimicrbial susceptibility, nscmial infectins and pprtunistic infectins, sterilizatin, and disinfectin are taught. In Pharmaclgy I and II, Surgery and Surgical Nursing, and Pediatrics and Pediatric Nursing, AMR/AMU-related tpics are clearly stated; hwever, in ther curses such as Medicine and Medical Nursing and Integrated Reprductive Health, the tpics relating t AMR and AMU are nt categrically mentined r stated in the curriculum, but it is assumed the tutr r lecturer will make reference t r discuss thse issues. Infectin preventin-related tpics appear t be mentined frequently in the different curses. Determining the actual number f hurs spent n these tpics was difficult. The curriculum states the ttal number f hurs fr each subject and the cntact hurs per curse per week (Table 2); hwever, the actual r minimum amunt f time allcated t each cmpnent is nt stated because tpics are part f the ttal number f hurs allcated t the curse. In additin, the tpics are gruped and taught as a whle. As the student prgresses thrugh the training, the time allcated t clinical practice increases while that allcated t thery classes decreases. Determinatin f the actual time spent n AMR/AMU-related tpics in each lecture blck was nt pssible. Discussins during the lectures always make reference t AMR/AMU because infrmatin n AMU is applied when discussing management f different cnditins. Table 1. Three-Year RN Prgramming Perid Prgram Length f Time Year 1 First lecture blck 13 weeks Clinical practice* 13 weeks Secnd lecture blck 10 weeks Clinical practice 12 weeks Year 2 First lecture blck 8 weeks Clinical practice 21 weeks Secnd lecture blck 8 weeks Clinical practice 12 weeks Year 3 First lecture blck 8 weeks Clinical practice 38 weeks Revisin blck 2 weeks Surce: GNC Nte: Examinatin and vacatin perids are nt included. * The clinical practice is dne n rtatin basis t all medical, surgical, and specialized departments, including fieldwrk in urban and rural cmmunities. 10

17 Findings Table 2. Actual Hurs n AMR/AMU-Related Tpics Year Perid Weeks Number f Days/Week Hurs/Day Ttal Hurs 1 First lecture perid Secnd lecture perid Clinical practice ,280 Ttal 2,200 Ttal curses taught 12 Curses with AMR/AMU-related tpics Medicine/medical nursing Related tpics Fundamentals f nursing 4 Public health nursing 4 Micrbilgy 4 Surgery/surgical nursing Related tpics Pharmaclgy 6 Actual time spent n AMR/AMU-related tpics 18 2 First lecture perid Secnd lecture perid Clinical practice ,560 Ttal 2,200 Ttal curses taught 8 Curses with AMR/AMU-related tpics Medicine/medical nursing Related tpics Public health nursing Related tpics 4 Surgery/surgical nursing Related tpics Pharmaclgy 4 Pediatrics/pediatric nursing Related tpics Integrated reprductive health Related tpics Actual time spent n AMR/AMU-related tpics 8 3 First lecture perid Clinical practice ,520 Ttal 1,920 Ttal curses taught 3 Clinical practice 11

18 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 Pst-Basic Nursing Curriculum (Graduate Nursing Prgram) Students wh enter int this prgram are qualified RNs wh pssess O-level qualificatins. Because they are already qualified nurses, they are exempted frm the first year and enter the university in the secnd year, ging n t study fr three years. Upn cmpletin, the nurse graduates with a Bachelr f Science in nursing degree and is ready t wrk in any health care setting. The majrity f such graduates, hwever, have gne t teach in the nursing schls. A review f the UNZA Schl f Medicine Reference Bk (2000) shws that 32 curses are ffered t students in the secnd (12 curses), third (13 curses), and furth (8 curses) years. The training perids d nt indicate the number f hurs spent n each f the tpics; hwever, it des state the fllwing cntact hurs per week f each semester (6 lectures, 1 tutrial, and 2 practicals), and a semester is abut 13 weeks. Fr each curse listed in the Reference Bk, the aim, bjectives, curse cntent, teaching methds, cntact hurs, curse assessments and examinatins, lists f prescribed textbks, and recmmended textbks are indicated. The review f the curriculum shws that in the third year, students are taught tpics in Bacterilgy, which is a cmpnent f Systemic Pathlgy fr nurses. Tpics cvered in Bacterilgy include Intrductin t Medical Micrbilgy, Classificatins f Micrrganisms, Grwth and Nutritin f Micrrganisms, Antimicrbial Agents, Resistance, Sterilizatin and Disinfectin, Cmmn Infectins, Nscmial Infectins and their cntrl. Students are expsed t lectures in this curse nce per week in a semester. Hwever, as expressed by the lecturers and graduates frm the prgram, the cntent and length f expsure t practical teaching in the labratry is nt adequate fr nurses wh are expected upn graduatin t teach in the nursing schls. The curriculum als revealed that during Cmmunity Health Nursing, students are taught preventin and cntrl f cmmunicable diseases, including universal child immunizatin, imprtance f health educatin in preventin and cntrl f diseases, and the rle f essential medicines prgram in preventin and cntrl f diseases. The lecturer teaching Cmmunity Health Nursing has t use his r her wn initiative t include tpics related t infectin preventin practices because this subject is nt categrically expressed in the curriculum. Therefre, the strength f this teaching will depend n the rientatin f the lecturer. Teaching and Learning Methds The nursing department f the university uses lecture presentatins, tutrials, clinical practices, and case studies. Students are given pprtunities t wrk in the clinical areas f the different branches f medicine fr practical experiences. During the time in the clinical areas, the student is expsed t different cnditins and als given the pprtunity t wrk n case studies in the areas f practical allcatin. The preservice prgram als uses teaching/learning situatins, including demnstratins and tutrials by the lecturer, fllwed by return demnstratins by students. The teaching schls 12

19 Findings have a cach, r a clinical instructr wh has the respnsibility f reinfrcing whatever thery is taught in class and further intrduces students t practical applicatins f prcedures n patients. Sme schls (preservice) are using a prblem-based learning (PBL) apprach, allwing students t cnduct their wn search fr infrmatin, write case studies based n the assigned tpics, and make presentatins t the class with guidance frm the tutrs (GNC 2004a, 39). When discussing micrbilgy and pharmaclgy, students in the preservice nursing prgrams were fund t have little cntact with the labratry the labratry visit was intended t intrduce students t sme f the equipment, ccasinally allw them t view micrscpic presentatins f red bld cells r sme parasites, and the like. Thse in the undergraduate prgram, hwever, were expected t have sme practical experience in the labratry, a prcess that has nt been happening adequately. The hurs spent in teaching the related tpics r curses that deal with AMR r cntainment f AMR are nt clearly stated and the time spent n the tpics depends n the interest f the persn teaching and the level f understanding. Respndents Views n AMU, AMR, and Cntainment f AMR The majrity f key respndents in this review were generally f the view that AMR, cntainment f AMR, and AMU were critical issues that needed t be addressed by the Gvernment f Zambia. Mst respndents indicated that AMU was nt being adequately addressed. In Zambia, different categries f unrecgnized and unlicensed prescribers and dispensers exist. Fr example, a qualified RN r even an Enrlled Nurse smetimes has t screen a patient and prescribe medicatins because n dctr r clinical fficer is available. In mst cases, the cmmunity expects that whever is wrking at the health facility is adequately trained t prescribe. Furthermre, the lack f adequate equipment, pr labratry infrastructure, lack f reagents, and staff shrtages have cntributed t inadequacy f AMR cntainment prgrams in the cuntry. Where dctrs are available t prescribe, a nurse will in mst cases carry ut the dctr s rders withut questin because she r he is nt adequately prepared t understand medicine use, especially antimicrbials. Members f the cmmunity believe that treatment is adequate when they are given antimicrbials and thus d nt accept ther medicines and smetimes will even ask fr antimicrbials. The bserved practice f prescribing relates t past experiences where certain antimicrbials were used and prvided psitive results in patient health. Respndents cited examples f health prviders prescribing specific antimicrbials fr patients wh shwed similar symptms t anther wh may have respnded t treatment withut carrying ut any labratry tests t determine the causative rganism(s) and the antimicrbial f chice. The practice f sharing medicines is quite cmmn in cmmunities, as is self-prescribing f antimicrbials withut seeking medical attentin. Respndents expressed lack f clear understanding f the subject f AMR and cntainment f AMR; hence, the subject has nt received prnunced attentin in the preservice prgrams and the pst-basic curricula. The MH has made effrts t develp treatment guidelines and prtcls, but the reality is that thse dcuments rarely reach thse they are intended fr and end up n the shelves in higher ffices. 13

20 Preservice and Pst-Basic Nursing Training Curricula in Zambia: Curriculum Review and Expert Interviews t Assess AMU and AMR Cntent, March 2006 The GNC recently revised the scpe f practice fr nurses. The Nurses and Midwives Act, N. 31 (1997) has, amng ther prvisins, a new prescribing rle fr the nurse. The act states Part VI: Nursing and midwifery scpe f practice Prfessinal Practice f Nurses and Midwives 2) A nurse, midwife r specialist referred t in subsectin (1) shall in administering nursing care Prescribe relevant drugs and ther pharmaceutical preparatins frm a list defined by the natinal drug Frmulary Cmmittee cnstituted under the Pharmacy and Pisns Act The GNC develped the Drugs and Prescriptins fr Nurses and Midwives Guideline in July This natinal dcument was well intended. Amng ther gals, it was t cntribute t making prescribers available as clse t the family as pssible and t reducing indiscriminate prescribing by nurses and midwives. The guidelines clearly state that nurses will prescribe medicines based n clinical symptms, labratry findings, r prtcls. Hwever, since the dcument was develped, the GNC has had n resurces t cnduct training fr nurses, and nurses in practice cntinue t prescribe. During training, nurses are taught pharmaclgy during years ne and tw. Pharmaclgy, which is a full curse, is allcated nly 45 hurs fr each year, cmpared t a curse like Medicine and Medical Nursing, which is als a full curse and is allcated 310 and 315 hurs in years ne and tw, respectively. Mst respndents were f the view that tutrs shuld teach the details n medicine use during discussins n management f related cnditins. This time was felt t be when issues pertaining t AMR culd be explained and strategies t cntain AMR culd be discussed. The academic staff believe that if AMR and AMU are t be addressed adequately, pharmaclgy and micrbilgy curses need t be reviewed and a system f retraining tutrs and lecturers in the tw areas f specialty has t be instituted. Because thse teaching pharmaclgy are guest lecturers, the depth f the cntent t be taught shuld be discussed fully with the schl management and agreed n fr critical areas like AMR and AMU. The current situatin is pen t sme kind f neglect because different peple teach at different times, and the identity f the persn teaching always will depend n availability. The curriculum des cntain tpics in prescribing antibitics under classificatin f medicines and issues f antimicrbial use, antimicrbial resistance, and cntainment f AMR culd be adequately addressed under thse tpics. 14