Nursing Leaders in Afghanistan: Competency and Challenges

Wais Mohammad Qarani

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Significance

The objective of this topic is in line with the Afghanistan Ministry of Public Health (MoPH) priority program on human resource development as indicated that MoPH supports “research at all levels…and capacity building of nursing and midwifery department” (MoPH-National Priority Program, 2012, p. 95). Moreover, understanding of the competency of nursing leaders in Afghanistan would provide evidence to maintain equity in the provision of learning opportunities, serve as an advocate for allocation of resources through the MoPH for the capacity development, and facilitate donor attraction for the development of nursing profession to create carrier development opportunities. Subsequently, this would be a foundation to increase awareness, build on knowledge, facilitate advocacy, improve professional image, improve quality, and enhance patient outcome. Therefore, it is important to explore that what is the competency level of nursing leaders who are working in the public hospitals in Kabul, Afghanistan and what challenges they face that hinder their practice and subsequently affect patient care.

Search Strategy

This literature review consists of the data from the CINAHL, PubMed databases and Google Scholar. The data about nursing in Afghanistan were limited to the opinion articles and were searched as an entire through the term “Nursing AND Afghanistan” without filtering and only six relevant articles were found. Other search terms were conducted in combination of the keywords including; leadership, nursing, capacity, competency, development, building, challenges, and assessment. Afghanistan national strategic plans and reports were also taken into consideration through the search from Google Scholar and web pages. The searches were filtered to recent data according to the number of available articles accordingly. Majority of the search terms were searched without any filter as the total number of articles were limited. (Refer annexure A for more detail).

Introduction

Attention to the nursing in Afghanistan peaked in the mid to late 1970s through the establishment of nursing schools for both male and female (Furnia, 1978, p. 94). Likewise other systems of the country, nursing education and practice started to deteriorate after the initiation of war which continued for decades. From the invasion of Afghanistan by the Soviet Union and the fall of Taliban, the Afghan education and health systems have drastically damaged. Since the late 2001 the flow of international agencies and contributions to participate in the reconstruction of health sector have increased which have positively contributed in the health of Afghan population (Ministry of Public Health-National Strategy on Healthcare financing and Sustainability, 2009-2013, Forward section, para. 1). International agencies have made to contribute in majority of the health branches and brought remarkable improvements in the health system both at the knowledge and skills level. The nursing education has improved during the past decade. There are some improvements in the curriculum, learning resource package, teaching methodologies, capacity of the instructors, and supervision skills since 2002 and a lot more is needed (Herberg, 2005, p.132). The first four year Bachelor of Science in Nursing (BScN) program was established and launched just in 2007 at the Kabul Medical University (KMU) under the Ministry of Higher Education (MoHE). Despite improvements in nursing education, nursing services/practice and leadership at the point of practice have not been addressed through any mechanism to improve patient outcome, which needs to be explored and design programs for improvements.

The purpose of this literature review is to explore available data and researches conducted on the competency of nursing leaders in Afghanistan. The review also covers literature from the neighboring and other developed countries. The review includes both theoretical and empirical literature focusing on the concepts of competency and leadership.

Critical Review and Analysis

Robbins et al. (2001) defined competent person as “one who has the knowledge, skills, and abilities to perform a job adequately” (p. 192). Robbins et al. have also concluded that competency is divided into four main domains which include “technical skills, industry knowledge, analytic and conceptual reasoning, and interpersonal and emotional intelligence” (p. 193). Furthermore, 25 participants of a conference attendees in Texas who were leaders reported competency as “the ability to think in action, have confidence and clarity in decision making, and retrieve information throughout the career trajectory” (Allen et al., 2008, p. 81). In addition, political skill to understand and manage every stakeholder’s conflicting behaviors and external awareness of laws, policies, and decisions are the two important characteristics of effective leadership and management (Blaney, 2012, p. 44) which all together outline competency based leadership and management. Indeed, these domains and components of competency and leadership are distinct from individual to individual, hence have diverse outcomes.

Kang et al. (2012) have compared managerial competencies among nursing administrators (n=330) from 16 hospitals in Taiwan through a cross-sectional survey and found that more than 50% of the Head Nurses (HNs) and more than 35% of the high level management had never received any administrative training (p.942). The findings also revealed that HNs and Nurse Executives (NEs) both rated themselves highest in integrity and lowest in financial management followed by clinical skills and knowledge, and interpersonal relationship skills for HNs, whereas; collaboration and team skills and human resource and labor relations were rated by NEs (pp. 942-943). Although organizational outcome is relied on effective leadership and management, it has been given less importance to fulfill capacity development needs of the nursing leaders. Furthermore, considering diverse technological and resources accessibility, competency also differs from person to person in different contexts. Therefore, it is reasonable to explore nursing leaders’ competencies on the context of Afghanistan to enable us in planning programs for the capacity development of nursing leaders accordingly.

The development of nursing in China is associated with one of the key factor which is medical orientation of the health system (Wong, 2010, p. 526), while the most troubleshooting challenge of the American nurses is distinct to “absence of adequate pipeline for nursing leaders” (Thompson, 2008, p. 914). A descriptive qualitative study on the perception of the Community Health Nursing (CHN) Assistant Manager role in Pakistan indicated confusion of the role which needed role clarity (Gulzar, Mistry, & Upvall, 2011, p. 389). The same study reported existence of tension between CHN assistant manager and Lady Health Visitors (LHVs) and expected to be the result of the lack of understanding of their roles and expectations (p. 390). This conflict is further exaggerated where the role of one discipline (nursing) is taken by the other discipline (medical) and vice versa particularly in Afghanistan.

A quantitative exploratory study by Essani and Ali (2011) conducted at a tertiary care hospital in Karachi Pakistan about knowledge and practice gaps among pediatric nurses revealed that incompetency of the participants had a great impact on the level of care provided to the patients. The gaps were categorized in five areas where knowledge and skills were ranked second and third highest respectively (p.1). The competency of low level staff is dependent on the managerial skills and leadership competencies of high level staff of a particular entity which in turn has its impact on patient outcome. Therefore, capacity development of nursing leaders must be a priority which plays a vital role in organizational outcome.

Scarcity of research in Afghanistan hinders any step forward; and due to decades of conflicts, Afghanistan faces greater challenges in terms of leadership than any other country. The issues and practices of nursing in Afghanistan have not been published to guide nursing practice in the country or plan for improvements. Majority of the published articles are on the missions and personal experiences of the international armed forces nursing personnel who worked in Afghanistan. Cameron (2008) described Afghans as “extremely intelligent and bright” but, decades of war have destroyed the health system of the country and the emotional wellbeing of the population (p. 30). Cameron claimed that despite the role of supervision in maintaining standard of care, majority of the managers do not turn to the wards and do not know about the patient’s condition (p. 30). This claim is needed to be explored through the nursing research to discover leadership incompetence as a contributing factor. It appears that nursing leaders could best identify and describe their need for capacity development to design programs which would enable them to avail international knowledge and technology.

The Ministry of Public Health (MoPH) has valued to develop evidence based public health programs (MoPH, Strategic Plan, 2011-2015, p. 20). Besides, the MoPH strategic plan has determined the human resources management and development (pp. 24-25) which is in line with the Afghanistan National Development Strategy (ANDS, 2008-2013, p. 62). Although evidence based programs and human resource development are the focus of MoPH, nursing profession has disadvantaged in this regard. This fact is supported by Forsyth (2013) that “Health Services professionals shifted their focus from caring for sick and injured coalition personnel to mentoring and capacity building with the Afghan National Security Forces (ANSF)” (p. 32). Although international nurses are posted within ANSF for mentorship and training, this opportunity is much limited within the public hospitals. The MoPH strategic direction on increasing equitable access to quality health services (strategic objective -5) to improve patient safety (MoPH, Strategic Plan, 2011-2015, p. 30) is purely dependent on effective nursing care through effective leadership and management. Strategic direction on governance in the health sector (MoPH, Strategic Plan, 2011-2015, pp. 31-32) is an important consideration for fulfilling the objectives. Therefore, identification of the nursing governance competency limitations and evidences which hinder effective nursing leadership require an in-depth research.

Conclusion

Competency of the nursing leader plays a vital role in the organizational outcome. Global Nursing Leadership Institute (GNLI) under the International Confederation of Nurses (ICN), designs annual leadership development programs for nurses at the executive level. The objectives of the institute focused to develop capacity of the nursing leadership and build international network at the global level (Blaney, 2012, p. 47). On the other hand, Afghan nurses have disadvantaged from such opportunities. Efficiency of a health industry is associated with the better workplace and workforce management and also connected with clinical supervision and effective leadership and management which is compromised component in diverse settings. Therefore, it is vital to develop the capacity of the nursing leaders on the bases of evidence to enhance productivity. Administrators play a central role in the provision of high quality health services to the patients. They are the one who train his/her designee what to do, when to do and how to do and above all why to do which is more significant for patient outcome. Thus, the finding of this literature review indicates a need to explore the capacity of nursing leaders to plan developmental programs accordingly. The purpose of the research would be to explore competency level of the nursing leaders in public hospitals in Kabul, Afghanistan and also identify challenges they face in the workplace.

References

Allen, P., Lauchner, K., Bridges, R., Francis-Johnson, P., McBride, S., & Olivarez, A. (2008). Evaluating continuing competency: a challenge for nursing.Journal Of Continuing Education In Nursing,39(2), 81-85. doi:10.3928/00220124-20080201-02

ANDS – Afghanistan National Development Strategy (2008-2013). Retrieved from http://www.diplomatie.gouv.fr/en/IMG/pdf/Afghanistan_National_Development_Strateg y_eng.pdf

Blaney, P. P. (2012). Senior nursing leadership – capacity building at the global level. International Nursing Review, 59(1), 40-47. doi:10.1111/j.1466-7657.2011.00953.x

Cameron, A. (2008). Planting seeds of hope — nursing in Afghanistan. Australian Nursing Journal, 16(5), 30. Retrieved from http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=83dab417-8198-4e8d-b006- ca398eb9f9b9%40sessionmgr113&vid=1&hid=113

Essani, R., & Ali, T. (2011). Knowledge and Practice Gaps among Pediatric Nurses at a Tertiary Care Hospital Karachi Pakistan. ISRN Pediatrics, doi:10.5402/2011/460818

Forsyth, J. (2013). Building capacity in Afghanistan. Canadian Nurse, 109(9), 32-33. Retrieved from http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=5af86ac0-ed52-42e7- b821-aef93fea8df3%40sessionmgr114&vid=1&hid=113

Furnia, A. H. (1978). Syncrisis: The dynamics of health. XXIV: Afghanistan. Washington, D.C.: US Department of Health, Education and Welfare Public Health Service (DHEW 78-50056). Retrieved from http://pdf.usaid.gov/pdf_docs/PNAAH120.pdf

Gulzar, S. A., Mistry, R. R., & Upvall, M. J. (2011). Capacity development for Community Health Nurses in Pakistan: the assistant manager role. International Nursing Review, 58(3), 386-391. doi:10.1111/j.1466-7657.2011.00896.x

Herberg, P. (2005). Nursing, midwifery, and allied health education programmes in Afghanistan. International Nursing Review, 52(2), 123-133. Retrieved from http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=a63c682f-0b1b-410f-a19e-4d991fd96aa5%40sessionmgr114&vid=1&hid=113

Kang, C., Chiu, H., Hu, Y., Chen, H., Lee, P., & Chang, W. (2012). Comparisons of self-ratings on managerial competencies, research capability, time management, executive power, workload and work stress among nurse administrators. Journal of Nursing Management, 20(7), 938-947. doi:10.1111/j.1365-2834.2012.01383.x

Ministry of Public Health (MoPH) – National Strategy on Healthcare financing and Sustainability (2009- 2013). Retrieved from http://moph.gov.af/Content/Media/Documents/NationalStrategyonHealthFinancingandSu stainability20092013English1742013132843116553325325.pdf

MoPH, National Priority Program, (2012). Health for All Afghans. Retrieved from http://moph.gov.af/Content/Media/Documents/NPPEnglishVersionNarrative29July20122 752013125750126553325325.pdf

MoPH, Strategic Plan, 2011-2015. Retrieved from http://www.google.com.pk/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad =rja&ved=0CCcQFjAA&url=http%3A%2F%2Fmoph.gov.af%2FContent%2FMedia%2F Documents%2FMoPHStrategicPlan2011Final2882011115859177553325325.doc&ei=6r 8IU7yqDIir0gWSloDoBw&usg=AFQjCNHy730DBrvhFbHBqDFOd7UtpTS- 1g&sig2=JJnlggylJ5mHxP2DlfKRSw&bvm=bv.61725948,d.Yms

Robbins, C., Bradley, E., & Spicer, M. (2001). Developing leadership in healthcare administration: a competency assessment tool. Journal of Healthcare Management, 46(3), 188. Retrieved from http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=ad517ba7-0311-433a-bd10- 40f4819cf245%40sessionmgr198&vid=1&hid=126

Thompson, P. (2008). Key challenges facing American nurse leaders.Journal of Nursing Management,16(8), 912-914. doi:10.1111/j.1365-2834.2008.00951.x

Wong, F. (2010). Challenges for nurse managers in China.Journal of Nursing Management,18(5), 526-530. doi:10.1111/j.1365-2834.2010.01115.x

Annexure – A: (detail of search strategies)

Search Engine

Key Words

Year

Results

Full text

Remarks

CINAHL

Nursing AND Afghanistan

Open

266

Majority of the articles were opinion

Nursing leadership AND Pakistan

1996-2014

229