Linking Licensure Examinations to Nursing Practice …reprolineplus.org/system/files/resources/FINAL_Botswana...The use of task analysis ensures that education and training curricula

Linking Licensure Examinations to Nursing Practice through Task Analysis A Case for Botswana February 2014 Leah Hart Phelelo Marole Galina Stolarsky Peter Johnson Elizabeth Wagstaffe

Jhpiego is an international, nonprofit health organization affiliated with Johns Hopkins University. For more than 40 years, Jhpiego has empowered frontline health workers by designing and implementing effective, low-cost, hands-on solutions to strengthen the delivery of health care services for women and their families. By putting evidence-based health innovations into everyday practice, Jhpiego works to break down barriers to high-quality health care for the world’s most vulnerable populations. Published by: Jhpiego Brown’s Wharf 1615 Thames Street Baltimore, Maryland 21231-3492, USA www.jhpiego.org © Jhpiego Corporation, 2014. All rights reserved. This work has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Cooperative Agreement Number 3U2GPS001212-04W1 from the U.S. Centers for Disease Control and Prevention (CDC). The opinions expressed herein are those of the authors and do not necessarily reflect the views of PEPFAR, CDC or the United States Government.

Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana iii

TABLE OF CONTENTS LIST OF TABLES AND FIGURES ......................................................................................... v

ABBREVIATIONS ................................................................................................................. vi

ACKNOWLEDGMENTS ....................................................................................................... vii

EXECUTIVE SUMMARY ....................................................................................................... ix

BACKGROUND AND INTRODUCTION ................................................................................ 1

Nursing and Midwifery Council of Botswana .................................................................. 1

Task Analysis ..................................................................................................................... 1

OBJECTIVES ......................................................................................................................... 2

METHODS .............................................................................................................................. 2

Application to Conduct Research .................................................................................... 3

Development and Validation of the Task List ................................................................. 3

Study Sites ......................................................................................................................... 3

Sampling............................................................................................................................. 4

Participant Recruitment .................................................................................................... 6

Data Collector Training ..................................................................................................... 7

Pilot Study .......................................................................................................................... 7

DATA COLLECTION .............................................................................................................. 8

Data Entry ........................................................................................................................... 9

Data Cleaning ..................................................................................................................... 9

DATA ANALYSIS ................................................................................................................... 9

Combined Frequency and Importance ............................................................................ 9

Combined Frequency, Importance, and Performance Capability of Respondents ... 10

Likelihood of Being Trained In-Service/On-the-Job for Each Task ............................ 10

Variation According to Facility Level, When/Where Trained, and Length of Time As a Nurse ........................................................................................................................ 10

STUDY STRENGTHS AND LIMITATIONS .......................................................................... 11

RESULTS ............................................................................................................................. 11

Demographic Analysis .................................................................................................... 11

Task Characteristics ........................................................................................................ 13

Combined Task Variables ............................................................................................... 17

Notable Results and Recommendations by Task Category ........................................ 20

NEXT STEPS ........................................................................................................................ 31

Review Pre-Service Education Curriculum ................................................................... 31

Establish In-service Education Priorities ...................................................................... 32

Develop an Objective Structured Clinical Examination ............................................... 32

CONCLUSION ...................................................................................................................... 32

iv Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana

APPENDIX 1: TASK ANALYSIS SURVEY PARTICIPANT INFORMED CONSENT FORM ................................................................................................................................... 33

APPENDIX 2: DATA USE AND CONFIDENTIALITY AGREEMENT .................................. 34

APPENDIX 3: LIST OF SUBJECT MATTER EXPERTS ..................................................... 35

APPENDIX 4: TASK LIST FOR GENERAL NURSES ......................................................... 37

APPENDIX 5: DATA COLLECTION CARD GAME ............................................................. 41

APPENDIX 6: FACILITATOR SCRIPT ................................................................................ 42

APPENDIX 7: PARTICIPANT DEMOGRAPHICS................................................................ 44

APPENDIX 8: EXCERPT OF TASK ANALYSIS DATA COLLECTION TOOL ................... 46

APPENDIX 9: TASK ANALYSIS RESULTS ........................................................................ 47

APPENDIX 10: TASKS RATED “NEVER” PERFORMED BY A HIGH PERCENTAGE OF RESPONDENTS ............................................................................................................. 54

APPENDIX 11: ON-THE-JOB TASKS ................................................................................. 55

REFERENCES ..................................................................................................................... 56

Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana v

LIST OF TABLES AND FIGURES FIGURE 1. MAP OF STUDY WORKSHOP SITES ................................................................ 4

FIGURE 2. NUMBER OF LOCALLY TRAINED AND FOREIGN-TRAINED NURSES REGISTERED WITH NMCB FROM 2008 TO 2011 ............................................................... 5

FIGURE 3. NUMBER OF PARTICIPANTS BY FACILITY LEVEL ........................................ 5

FIGURE 4. NUMBER OF PARTICIPANTS BY FACILITY TYPE (GOVERNMENT, MISSION/PRIVATE) ............................................................................................................... 6

FIGURE 5. TASK FREQUENCY AS DEFINED BY THE RELATIVE MAJORITY OF RESPONDENTS ................................................................................................................... 14

FIGURE 6. TASK IMPORTANCE AS DEFINED BY THE RELATIVE MAJORITY OF RESPONDENTS ................................................................................................................... 15

FIGURE 7. TASK PERFORMANCE AS DEFINED BY THE RELATIVE MAJORITY OF RESPONDENTS ................................................................................................................... 16

FIGURE 8. TASK TRAINING TIME/LOCATION AS DEFINED BY THE RELATIVE MAJORITY OF RESPONDENTS ......................................................................................... 17

TABLE 1. PILOT STUDY PARTICIPANT CHARACTERISTICS ........................................... 7

TABLE 2. FREQUENCY-IMPORTANCE MATRIX FOR PRIORITIZATION OF KEY NURSING TASKS (DARKER RED = HIGHER PRIORITY) ................................................. 10

TABLE 3. DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS BY RESPONDENT GROUP ....................................................................................................... 12

TABLE 4. HIGH-PRIORITY TASKS FOR CURRICULUM AND LICENSURE EXAMINATION CONTENT .................................................................................................. 17

TABLE 5. TASKS WHICH MORE THAN 20% OF RESPONDENTS WERE UNABLE TO PERFORM, WITH PERCENTAGE WHO NEVER PERFORM THE TASK .................... 18

TABLE 6. TASKS WITH THE HIGHEST LIKELIHOOD OF IN-SERVICE/ON-THE-JOB TRAINING ............................................................................................................................. 19

TABLE 7. TASKS NEVER PERFORMED BY THE RELATIVE MAJORITY OF NURSES ............................................................................................................................... 54

TABLE 8. TASKS FOR WHICH THE RELATIVE MAJORITY OF NURSES WERE TRAINED ON-THE-JOB ....................................................................................................... 55

vi Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana

ABBREVIATIONS ARV Antiretroviral

CDC Centers for Disease Control and Prevention

DHMT District Health Management Team

MDR-TB Multidrug-resistant tuberculosis

MOH Ministry of Health

NMCB Nursing and Midwifery Council of Botswana

OSCE Objective structured clinical examination

PMTCT Prevention of mother-to-child transmission of HIV

SRH Sexual and reproductive health

TB Tuberculosis

Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana vii

ACKNOWLEDGMENTS The success of the task analysis study was due to the collaboration and support of many stakeholders. The Centers for Disease Control and Prevention (CDC) in Botswana and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) provided funding support for the study. The Health Research and Development Committee of Botswana, Johns Hopkins Bloomberg School of Public Health, and CDC Botswana provided ethical review of the study. The Nursing and Midwifery Council of Botswana (NMCB) committees provided input for the development of the study protocol and data collection tool. Khumo Modisaeman provided outstanding leadership during the task analysis process and kept the council updated. Special thanks is also given to Gabantshetse Mogorosi, the study’s coordinator, for initiating communication with each District Health Management Team (DHMT) to request permission for the use of data collection sites, for acting as study coordinator, and for facilitating data collection workshops, as well as for her expert input in the refinement of the data collection process. From the Jhpiego office, Botswana Country Director Galina Stolarsky provided staff guidance and assistance throughout the task analysis process. Peter Johnson provided technical input and advice in the development of the study protocol, led capacity-building efforts with NMCB, and provided expert guidance for the blueprinting of the nurse licensure examination. Phelelo Marole, pre-service advisor, provided oversight of the task analysis study, including training of data collectors and documentation of study-related activities. Leah Hart, the primary author of this report, also provided technical support and created the prototype of the data collection card game. Elizabeth Wagstaffe drafted the initial sections of the report and supported the data collection and entry processes. Kenanao Motlhoiwa assisted in preparing data collectors, developed the data analysis plan, and provided the outputs that were used in the “Results” section of the report. Thanks to the following data collectors: Punie Gongoro, Tebo Kelathile, Koketso Macala, Mapule Maema, Gabantshetse Mogorosi, Mosidi Mokotedi, Keamogetse Molake, Matlhogonono Molatlhiwa, Gofaone Mooketsa, Boitshoko Ntuanyane, Galaletsang Ramokgwana, Basutli Ramontshonyana, Opelo Rankopo, and More Tshupeng. The task analysis study team is grateful to heads of facilities for releasing staff nurses to participate in the study. We would also like to thank the study participants. To those nurses who provided feedback on the task list, you have given NMCB valuable information for the betterment of nursing regulation and education in Botswana. Thanks to Catherine Carr, Tracey Shissler, Stacie Stender, and Deborah Stein for copy editing as well as Courtney Weber for formatting the report.

viii Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana

Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana ix

EXECUTIVE SUMMARY BACKGROUND Task analysis provides information about the realities of practice for a particular health care cadre and can be used as a data-driven method of determining the content of licensure exams. The purpose of the Botswana nursing task analysis was to inform the development of a licensure examination for nurses entering practice in Botswana. The Nursing and Midwifery Council of Botswana (NMCB) is mandated to uphold public safety through the regulation of nursing education and practice. The council worked with Jhpiego in conducting the task analysis study. Task analysis has been used to systematically document the tasks that health care workers perform on-the-job. Rather than relying on obsolete curricula or out-of-date national documents to define tasks performed by a specific cadre of workers, task analyses collect data from those workers currently in practice. The use of task analysis ensures that education and training curricula and licensure exam content are based in the current, local practice reality (Oshio, Johnson, and Fullerton 2002).

METHODS AND OBJECTIVES The task analysis study in Botswana targeted those nurses who had graduated within the four years prior to the data collection period as the group that best reflected current curricula and training. Nurses relatively new to practice in Botswana gave their feedback on a list of tasks, creating a snapshot of the tasks they perform. For each task, nurses provided the following information:

Frequency—how often they performed the task

Location—when/where they were trained to perform the task

Performance—if they felt capable of performing the task

Criticality—how important the task is in terms of patient / public health outcomes A task list was developed based on the Essential Health Services Package for Botswana (MOH 2010) as well as treatment guidelines, nursing curricula, and job descriptions. A panel of experts validated the task list, which was then used as the basis for data collection from nurses who had between six months and four years of experience at the time of data collection. Study sites spanned all 10 political districts of the country and included Boteti, Chobe, Gaborone, Gantsi, Hukuntsi, Kanye, Kgalagadi South, Kgatleng, Lobatse, Maun, Serowe, and Tutume. Out of 1,836 eligible participants, 280 nurses from 67 health facilities in 12 health districts participated in data collection. The task analysis was conducted via district-level group-based workshops, during which participants provided systematic feedback on the task list. The workshop-based approach for data collection was suggested by NMCB members, based on the cultural appropriateness of a group forum for data collection. This approach also offered advantages compared to an individual, self-administered survey in terms of reducing participant fatigue and thereby improving the validity of responses.

x Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana

Responses were compiled into a data set that was analyzed in order to address the objectives of the study:

To describe new graduate nursing practice in Botswana 1.

To inform the content of a nurse licensure examination 2.

KEY FINDINGS Most nurses described most tasks as “high” frequency (meaning they were performed on a weekly or daily basis) and “high” importance (meaning they were essential to satisfactory patient / public health outcomes). For most tasks, nurses reported being trained during their pre-service education. Nurses considered themselves either “adequate” or “proficient” at task performance for almost all tasks. Based on a combination of frequency and importance, priority tasks for the nurse licensure examination were determined:

TASK # TASK DESCRIPTION %

OF

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% O

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% O

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31 Provides effective antenatal care 23.9 85.5 23.2

32 Prevents, recognizes, and refers pre-eclampsia and eclampsia

23.2 93.5 26.8

33 Provides effective intrapartum care 21.7 87.7 40.6

34 Provides effective postnatal care 22.5 84.8 29

35 Prevents, recognizes, and refers postpartum hemorrhage

25.6 92.7 29.2

38 Provides effective PMTCT [prevention of mother-to-child transmission of HIV]

26.1 92.8 19.6

42 Responds appropriately to gender-based violence (includes rape)

29.7 80.4 11.6

43 Provides effective postabortion care 24.6 85.5 16.7

44 Provides effective screening and care for clients with reproductive cancers

29 92.8 21.7

50 Provides care and treatment of children with HIV/AIDS

23.4 88.3 12.3

55 Recognizes, treats, and/or refers patients with opportunistic infections

20.3 88.4 4.4

59 Recognizes and refers patients with MDR-TB [multidrug-resistant tuberculosis]

48.6 96.4 16.7

61 Provides malaria preventive services 34.1 81.2 10.9

62 Provides care and treatment to clients infected with malaria

42.8 87 15.9

75 Provides care and treatment for patients with trauma

31.6 89.7 11.8

76 Provides diabetic preventative services 23.7 84.4 3.7

Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana xi

TASK # TASK DESCRIPTION

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80 Provides preventative services for cardiovascular disease

25.7 92.7 6.6

81 Provides care and treatment for patients with cardiovascular disease

30.4 97 8.2

85 Provides preventative services for chronic respiratory diseases such as asthma

21.3 91.2 4.4

87 Provides services to prevent conditions that can cause disabilities

24.3 82.4 13.2

Note: High-priority tasks for curriculum and licensure examination content are those which a significant proportion of respondents rated as “low” frequency, “high” importance, or “not capable of performing.” Shaded tasks are those where >20% of respondents reported being “unable to perform” the task.

NEXT STEPS The results of the task analysis study offer NMCB information regarding the current practice reality for nurses in Botswana. The results, especially the combination of importance and frequency, can be used to determine the content of a nurse licensure examination through a process of blueprinting, developing a test bank, and testing questions with experts and new graduates for the goal of a validated examination to determine whether those applying for licensure are suited to practice. Establishment of the licensure examination will ideally be preceded by changes in education that can be assessed by the exam. In order to achieve these and other global best practices for nursing education, the following steps are recommended:

Apply the results in the development of a written multiple-choice licensure examination. 1.

Review the pre-service education curriculum for nurses using the task analysis results. 2.

Review in-service education trainings, cross-referencing the areas where nurses feel least 3.capable in task performance.

Develop an objective structured clinical examination to test those competencies that are 4.difficult to measure with a written exam, such as psychomotor skills and clinical decision-making

A licensure examination based on the study results will be the first examination to determine competency of new nurses in Botswana since 1984. The members and the Registrar of the council are to be commended for their efforts in pursuit of safer nursing practice in the country. With these and other continued efforts on the part of NMCB, the health of the Botswanan public will be protected through the regulation and education of nurses.

xii Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana

Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana 1

BACKGROUND AND INTRODUCTION NURSING AND MIDWIFERY COUNCIL OF BOTSWANA The task analysis study of general nurses was conducted by NMCB, with technical assistance from Jhpiego, as a means of determining the content of a nurse licensure examination. Entry into nursing practice in Botswana is regulated by NMCB, a statutory body established by the Government of Botswana that is responsible for the professional and ethical regulation of nurses and midwives in Botswana (Republic of Botswana 1995). NMCB’s primary function is to uphold public safety through the regulation of nursing education and practice. The council conducts various functions through its Education, Registration, Clinical Practice, Regulation, Professional, Ethics, and Disciplinary Committees (NMCB 2007). From 1964 to 1984, nurses in Botswana, Lesotho, and Swaziland were registered by the Nursing Examination Board of Botswana, Lesotho and Swaziland which conducted a licensure examination. Since the board’s 1984 disbanding, NMCB has utilized academic certificates and transcripts to register locally trained and foreign-trained nurses for practice. This mechanism has proven unreliable in terms of ensuring that nurses who register with NMCB are competent to practice, compromising the quality of nursing services in Botswana. From 2008–2011, NMCB recorded a concerning 28 cases of professional misconduct. Because the current method used for licensing nurses does not ensure the competency of general nurses entering practice, it does not uphold NMCB’s function of protecting the public (Republic of Botswana 2011). According to the Nurses and Midwives Act of 1995, NMCB is specifically mandated to establish a method of evaluating whether nurses and midwives are competent to enter practice. The development of a competency-based licensure examination to test all new registrants is one option for ensuring that this mandate from the Government of Botswana is fulfilled (NMCB 2007). To accomplish this, NMCB plans to reintroduce a written examination as a method of measuring the knowledge of applicants for nurse licensure. Measuring knowledge via written examination is helpful in terms of evaluating whether newly licensed nurses will be safe practitioners. However, skills and attitudes are also important components of competency. In order to evaluate nurses’ skills and attitudes, the council hopes to employ another method: an objective structured clinical examination (OSCE).

TASK ANALYSIS Task analysis has been used to systematically document the tasks that health care workers perform on-the-job. Rather than relying on obsolete curricula or out-of-date national documents to define tasks performed by a specific cadre of workers, task analyses collect data from those workers currently in practice. The use of task analysis ensures that education and training curricula and licensure exam content are based in the current, local practice reality (Oshio, Johnson, and Fullerton 2002). Originally used by industries and manufacturers to increase efficiency and productivity in their workforces (Copley 1923), task analysis has since been widely adapted in the developed world. It has been applied mainly in the context of the health professions and occupations—for example, as a basis for developing curricula of study for various health worker cadres and for defining the content areas of certification and licensing examinations (Reamy and Gedik 2001).

2 Linking Licensure Examinations to Nursing Practice through Task Analysis: A Case for Botswana

In Botswana’s case, a task analysis study was conducted in order to determine which tasks should receive emphasis on the licensure examination. NMCB used task analysis to determine examination content that is logically linked to current practice in Botswana. Using national documents that articulate key services that must be available within the Botswana health care system, Jhpiego staff developed a task list. A panel of experts systematically examined each task, providing edits and adding or deleting tasks as necessary to create a valid task list. Then, currently practicing new graduate nurses systematically reviewed the task list. The resulting data set was the basis of the task analysis study. The study targeted those nurses who had graduated within the four years prior to the data collection period as the group that best reflected current curricula and training. Nurses relatively new to practice in Botswana gave their feedback on a list of tasks, creating a snapshot of the tasks they perform. For each task, nurses provided the following information: how often they performed the task, when/where they were trained to perform the task, if they felt capable of performing the task, and how important the task is in terms of patient / public health outcomes. The analysis of the nurses’ responses was used to make informed decisions regarding examination content as well as education and training curricula.

OBJECTIVES Task analysis provides information about the realities of practice for a particular health care cadre and can be used as a data-driven method of determining the content of licensure exams. The purpose of the Botswana nursing task analysis was to inform the development of a licensure examination for nurses entering practice in Botswana. The study also supported ongoing efforts by NMCB to identify essential nursing competencies, in accordance with NMCB’s mandate to regulate nursing education and practice. The objectives of the study were to (i) describe the tasks undertaken by new graduate nurses licensed to practice in Botswana and (ii) determine the content of a nurse licensure exam based on the results.

METHODS The task analysis was conducted via district-level group-based workshops, during which participants provided systematic feedback on the task list. The workshop-based approach for data collection was suggested by NMCB members, based on the cultural appropriateness of a group forum for data collection. This approach also offered advantages compared to an individual, self-administered survey in terms of reducing participant fatigue and thereby improving the validity of responses. Responses were compiled into a data set that was analyzed in order to address the objectives stated above. Participants provided responses for each task in four key measurement areas: frequency of task performance; criticality (importance) of the task in terms of patient/public health outcomes; location (when/where the nurse was trained to perform the task); and the nurse’s self-perceived level of competence (or capability) in performance of the task.


APPLICATION TO CONDUCT RESEARCH Ethical review and permission to conduct the study was obtained from the Health Research and Development Committee of the Botswana Ministry of Health (MOH), CDC Botswana, and the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. The study was deemed “exempt,” meaning it posed no foreseeable risk to the nurses who participated. Protection of human subjects was assured by a process of informed consent (see Appendix 1 for the informed consent form), by maintaining the confidentiality of study information (see Appendix 2 for the confidentiality agreement signed by all study team members), and by data collector training (see Data Collector Training section for more information).

DEVELOPMENT AND VALIDATION OF THE TASK LIST

A. National documents reviewed The task list was based on a review of national documents relevant to nursing practice in Botswana, primarily the Essential Health Services Package for Botswana (MOH 2010). The following documents were also used:

Nursing job descriptions (Government of Botswana 1994)

Nurses and Midwives Act (Republic of Botswana 1995)

Curriculum for Higher Diploma in General Nursing (MOH 2009a)

Curriculum for Bachelor of Science Degree in Nursing (University of Botswana 2008)

Nurses and Midwives Regulations (Republic of Botswana 2011)

Botswana National HIV/AIDS Treatment Guidelines (MOH 2008)

Botswana TB/HIV Policy Guidelines (MOH 2011)

B. Validation of the task list by a panel of nursing experts Based on the above documents, the task list was drafted and reviewed by a small group of subject matter experts. To validate the list, an expanded panel of experts met on February 8–10, 2012, to further review and edit it. The expanded panel included members of NMCB, representatives from the Nurses Association of Botswana, nurses from the health facilities, and faculty members from schools of nursing and health training institutions. The panel of experts represented those who train, work with, or supervise newly registered nurses at various levels of health care service delivery. (See Appendix 3 for participants in the expert panel). The finalized, validated task list that resulted after the expert panel review can be found in Appendix 4.

STUDY SITES Obtaining a statistically representative sample of nurses based on various characteristics was not possible because of the lack of national data on the exact location and number of recently graduated nurses working in health care facilities at the time of the study. The study team did, however, make efforts to get feedback from as representative a sample of nurses as possible by conducting 12 workshops throughout Botswana.


Figure 1. Map of study workshop sites

Sites of study workshops: Boteti, Chobe, Gaborone, Gantsi, Hukuntsi, Kanye, Kgalagadi South, Kgatleng, Lobatse, Maun, Serowe, and Tutume.

SAMPLING The study targeted newly graduated nurses. New graduates were defined as having between six months and four years of experience. Foreign nurses who were registered with NMCB within the previous four years were also included in the study, regardless of the length of their previous nursing experience. Figure 2 shows the numbers of local new graduates and foreign nurses who registered with the council for the first time during the four years prior to data collection.


Figure 2. Number of locally trained and foreign-trained nurses registered with NMCB from 2008 to 2011

Sample selection was guided by an effort to ensure broad representation of entry level nurses, with varying roles and responsibilities at a range of health facility levels, by focusing sampling in the southeast part of the country (the most heavily populated area) while ensuring at least some representation from all 10 political districts in the country. From a comprehensive selection of health facilities, all nurses who met the criteria were invited to participate. Out of the 29 health districts listed in the facility list of 2009 (MOH 2009b), 12 (41%) were targeted. Districts with a large number of facilities that typically employed newly graduated nurses (according to local nursing experts) were targeted in order to reach a high number of eligible participants during the one-day data collection workshops. Out of approximately 1,836 total eligible participants, a total of 280 nurses (about 15%) participated in the study. Participating nurses came from 67 health facilities in 12 health districts. The facilities where participants were employed included health posts, private/mission and government clinics, referral hospitals, district hospitals, primary hospitals, and private/mission hospitals. Figure 3 shows participants by facility level. Figure 3. Number of participants by facility level

0

100

200

300

400

500

600

2008 2009 2010 2011

Local registered numbers

Foreign registered nurses

Total new nurse registrants

0

50

100

150

200

250

300

Health post(24)

Clinic (62) Primaryhospital (44)

Districthospital (98)

Referralhospital (52)

TOTAL (280)


There were 251 total participants from government facilities, where the majority of health care services in Botswana are delivered, and 29 nurses from private/mission facilities. Figure 4 shows participants by facility type. Figure 4. Number of participants by facility type (government, mission/private)

PARTICIPANT RECRUITMENT Prior to visiting the sites for the pilot and main study, the NMCB study coordinator contacted each DHMT via a formal letter requesting permission to access the facilities where the data collection activities would take place. A follow-up phone call was also placed to inform DHMT managers about the upcoming study, the sample criteria, and the dates of data collection. DHMT managers were asked to assist by informing selected health facilities, as well as by identifying and inviting eligible nurses to attend the data collection workshop. On the day of the data collection workshop, participants were oriented to the purpose, risks, and benefits of the study. No foreseeable risks were incurred by study participation and the study coordinator emphasized that all responses to the task list would remain confidential. No payment or remuneration was offered for participation. The informed consent form was read aloud (see Appendix 1). The participants were given the opportunity to ask clarifying questions and then to decide whether they wanted to join the data collection activity.

Inclusion criteria Registered nurses in active practice with experience ranging from six months to four years were included in the study. Foreign nurses who had registered with NMCB within the previous four years were also included, irrespective of their number of years of nursing experience.

Exclusion criteria Nurses who were registered and working for less than six months or more than four years were excluded from the study. Any nurse still in a probation period with his or her employer was excluded from the study, as was any nurse who was pending review by NMCB’s Disciplinary Committee.

0

10

20

30

40

50

60

70

80

Health post Clinic Primaryhospital

Districthospital

Referralhospital

Government facilities(251 participants)

Mission/private facilities(29 participants)


DATA COLLECTOR TRAINING To standardize the data collection process and to ensure proper data management and participant confidentiality, a two-day training workshop for data collectors was held at the Jhpiego Botswana office. During this workshop, 12 data collectors were trained by the Jhpiego pre-service education advisor. All data collectors, including two who were members of NMCB, had previous research experience. Training topics included an orientation to task analysis, ethical interaction with human subjects, informed consent, maintaining confidentiality, and handling sealed data, and a review of the data collection tools. On the second day of training, data collectors simulated the card game for data collection, switching roles between facilitator, recorder, and participant in order to appreciate all aspects of the data collection process (see Appendix 5 for images of the card game tool and the “Data Collection” section for further explanation of its use). In this simulation, facilitators were provided with a facilitator script in an effort to standardize workshop conduct (see Appendix 6). At the end of the training workshop, data collectors were able to explain the rationale and objectives of the task analysis study, describe the methodology, discuss ethical issues in data collection, and practice the skills required to use the data collection instruments effectively. The data collectors also signed a data confidentiality agreement (see Appendix 2) at the end of the training.

PILOT STUDY Prior to the actual task analysis study, a pilot study workshop was conducted for the purpose of validating the card game method of data collection and standardizing the approach the teams of data collectors would use for the study. The pilot study took place in the Southeast District over the course of two days, from October 22 to 23, 2012. The location was chosen for its array of facilities and proximity to Gaborone. Data were collected from one district hospital and two clinics. Twenty-nine nurses participated in the pilot study. Table 1. Pilot study participant characteristics

BACKGROUND GROUP 1 RESPONDED TO

TASKS 1–44

GROUP 2 RESPONDED TO TASKS 45–89

TOTAL (%)

Gender

Male 4 1 5 (17.2)

Female 10 14 24 (82.8)

Facility level

Health post 1 0 1 (3.5)

Clinic 3 4 7 (24.1)

Hospital 10 11 21 (72.4)

Facility type

Government 4 3 7 (24.1)

Private/mission 10 12 22 (75.9)

Designation

Registered nurse 9 9 18 (62)


BACKGROUND GROUP 1 RESPONDED TO

TASKS 1–44

GROUP 2 RESPONDED TO TASKS 45–89

TOTAL (%)

Assistant nursing officer 1 0 1 (3.5)

Senior registered nurse 4 5 9 (31)

Nursing officer II 0 1 1 (3.5)

Following the collection and analysis of the pilot study data, no changes were recommended for the data collection methodology or for the language used in the card game tool. The following changes were made to the Participant Demographics form (see Appendix 7):

Removed “home district” field 1.

Added “year first registered with NMCB” as a way to confirm eligibility 2.

Changed “year started current post” to “year started at current health facility” because 3.responses to the task list are supposed to be based on experience at current facility

Added the following designations: Assistant Nursing Officer, Nursing Officer II, Nursing 4.Officer I, and Senior Registered Nurse

DATA COLLECTION Data collection took place in two rounds, the first in December 2012 and the second in August 2013. The delay was related to a gap in funding for the study. The data from both collection periods were determined to be comparable (see “Demographic Analysis” section). The task analysis card game was used to collect data from workshop participants (see Appendix 5). The game was the precursor to the Jhpiego-developed data collection tool known as Task Master: Mining for Data™ (a fun and interactive game for workforce analysis). Workshop participants examined each of the four task areas: frequency, importance, capability, and when/where trained. Facilitators provided each participant with two sets of cards containing the possible responses to the task area being examined. Each task was read aloud four times and each participant indicated a response by choosing the appropriate card and laying it facedown. For example, when considering how frequently a task is performed, a participant could choose from “never,” “rarely,” “monthly,” “weekly,” or “daily.” A data collector would pick up the cards, keeping them facedown, and mark the responses on a data collection tool, out of view of the participants. (See Appendix 8 for an excerpt of the data collection tool). To maximize efficiency, while data collectors were recording responses, participants used the second set of cards to examine the next task. Respondents also completed a demographics form (see Appendix 7), covering variables such as current facility name, type of facility (government, mission, or private), level of facility (health post, clinic, primary hospital, district hospital, or referral hospital), age, gender, year graduated, institution of graduation, year started first job as nurse, year first registered with NMCB, year started at current health facility, and current designation. In order to match responses to the relevant demographic information, a nonidentifying code number marked each participant’s demographic form as well as the cards that were used to respond to the task list.


Participants were divided into two groups during data collection workshops. One group responded to the first half of the task list (Tasks 1–44) and the second group responded to the second half (Tasks 45–89). This was done to allow data collection workshops to take place in one day as well as to reduce responder fatigue, thereby increasing the validity of responses by nurse participants. The two groups’ demographic characteristics were compared and no statistical difference was found (see “Demographic Analysis” section).

DATA ENTRY Data were entered into an Excel worksheet from December 3 to 13, 2012, and from August 5 to 6, 2013.

DATA CLEANING Data were reviewed by Jhpiego Monitoring and Evaluation staff. Missing or inconsistent responses were given specific codes and were not included in the analysis or results.

DATA ANALYSIS Data analysis was done via simple descriptive statistics—including frequencies and cross tabulation with the use of Stata version 12 (StataCorp 2011). Data were analyzed by the Jhpiego Botswana Monitoring and Evaluation advisor. The four task areas (frequency, importance, performance, and when/where trained) as well as combinations of task areas were examined. Analyses included characterizing tasks according to the relative majority of participants for each task area. For example, in terms of frequency, for which tasks did the majority of nurses choose “high” (“daily” or “weekly”), “moderate” (“monthly”), “low” (“rarely”), and “never”? In terms of importance, for which tasks did the majority of nurses choose “high” (and so on)?

Note: The variable of “importance” in terms of a task analysis refers to the impact that task performance has on patient / public health outcomes. Therefore, importance is generally the most heavily weighted variable in a task analysis. When considering the application of task analysis results, those tasks rated “high” importance by the most participants should get additional attention in both pre- and in-service curricula and on licensure examinations.

Besides the frequency of responses within the four task areas, combinations of task areas were analyzed. The following combinations were most relevant to examine for the purpose of drafting the licensure examination blueprint.

COMBINED FREQUENCY AND IMPORTANCE The combination of frequency and importance variables is the most informative result of a task analysis study in terms of outlining tasks that require emphasis in curricula and licensing exams. As stated in the note above, high-importance tasks should receive attention because of their relation to patient / public health outcomes. In addition, low-frequency tasks need to be prioritized in education and training curricula and exams as they are least likely to be mastered or maintained in a normal working environment. In most settings, health care workers who perform


a task frequently (at least weekly) are observed by their co-workers and supervisor, providing the opportunity for correction if a task is not performed well. Capability is more likely to be achieved if a task is practiced more frequently. Thus, the most important tasks to prioritize in pre-service training, licensure exams, and in-service training are tasks that are performed with low frequency but that are of high importance. Note that “low frequency” in this case is defined as tasks that are performed rarely (Hart LJ, Carr CA, and Fullerton JT in press).1 Table 2 reflects prioritization of tasks according to the combination of their frequency and importance.

Table 2. Frequency-importance matrix for prioritization of key nursing tasks (darker red = higher priority)

IMPORTANCE FREQUENCY

Daily Weekly Monthly Rarely

High importance High importance + high frequency (3)

High importance + moderate frequency (2)

High importance + low frequency (1)

Moderate importance

Moderate importance + high frequency (6)

Moderate importance + moderate frequency (5)

Moderate importance + low frequency (4)

Low importance Low importance + high frequency (9)

Low importance + moderate frequency (8)

Low importance + low frequency (7)

COMBINED FREQUENCY, IMPORTANCE, AND PERFORMANCE CAPABILITY OF RESPONDENTS For tasks that respondents described as “high” importance and “low” frequency, tasks which more than 20% of respondents were not capable of performing were more strongly recommended for emphasis in curricula, training, and/or examination.

LIKELIHOOD OF BEING TRAINED IN-SERVICE/ON-THE-JOB FOR EACH TASK Tasks with a high likelihood of in-service/on-the-job training usually get a lower priority ranking for inclusion in the licensure examination compared to tasks for which opportunities for in-service/on-the-job training are limited or nonexistent.

VARIATION ACCORDING TO FACILITY LEVEL, WHEN/WHERE TRAINED, AND LENGTH OF TIME AS A NURSE Ordered logistic regression was used to describe the variation in frequency and performance capability of each task by facility level and facility type (for frequency and performance) as well as when/where the nurses were trained, including length of time as a nurse (for performance).

1 “Never” tasks should be examined carefully to determine why they are never done. If no nurses complete the task, it is likely irrelevant for nursing practice in Botswana; if some nurses complete the task, it may be important to maintain in education and training curricula and the licensure examination. (For example, malaria-related tasks may be performed only in certain geographic regions.)


STUDY STRENGTHS AND LIMITATIONS The task analysis study had several strengths, including a large sample of newly graduated nurses drawn from 41% of all health districts in the country. The data collection methodology ensured participant engagement and focus for the evaluation of each task. Coded numbers protected participants’ privacy while allowing responses to be linked to individuals’ demographic information for more in-depth analysis of task frequency and performance in relation to training history, work location, years as a nurse, or other variables of interest. The resulting data set is rich and can be mined in the future to answer questions not originally needed to achieve the study objectives (provided research approval for examining a secondary data set is sought). Limitations of the study method included a lack of ability to determine statistically representative sampling, due to missing national baseline data for work location of newly graduated nurses. There were also no available data for how many eligible nurses were in the districts where data collection workshops were held. In addition, there was a loss of some eligible participants on-site, due to night shift nurses needing to go home for adequate rest before the subsequent shift. There were also known eligible nurses in the districts who were attending other work-related duties, such as workshops. The task analysis results are based on self-reported responses by nurses about their own work, potentially contributing to bias. There was a delay between the two rounds of data collection due to a gap in funding. The timeline of the study was extended because of a lengthy wait for institutional review board approval of the study protocol, contributing to a lag between the development of the task list and its use for data collection. Although the national documents which the task list was based on were reasonably current, the task analysis data will soon become out of date, with the constant practice changes that are part of a dynamic health care environment. Ideally, a task analysis study will be conducted on a regular basis (every three to five years) to ensure tested competencies reflect the reality of the workplace.

RESULTS DEMOGRAPHIC ANALYSIS The characteristics of the nurses who participated in the task analysis study are detailed in Table 3. The group was relatively young, as expected for recent graduates, with 90% of them between 20 and 29 years old. The majority of participants were diploma nurses and about one-third worked in health posts or clinics the rest were employed by hospitals. Because of the length of the task list, the participants were divided in two groups, each focusing on one half of the task list during data collection workshops. The groups did not differ in any of the measured variables according to Fisher’s exact test (p>0.05). This confirms that the two groups are similar and represent the same population. As a result, they can be treated as one group for the purpose of analysis. There was also no statistical difference found between the groups of participants who responded to the task list in the two different rounds of data collection, in December 2012 and August 2013.


Table 3. Demographic characteristics of participants by respondent group

VARIABLE GROUP 1: TASKS 1-44

GROUP 2: TASKS 45-89

TOTAL % RESPONDENTS

P VALUE

Number of respondents

141 139 280

Gender 0.46

Male 53 54 107 38.2%

Female 88 85 173 61.8%

Age 0.7

20–24 47 37 84 30.0%

25–29 82 88 170 60.7%

30–34 5 8 13 4.6%

35–40 3 2 5 1.8%

>40 4 4 8 2.9%

Facility level 0.97

Health post 11 8 19 6.8%

Clinic 33 34 67 23.9%

Primary hospital 23 21 44 15.7%

District hospital 48 50 98 35.0%

Referral hospital 26 26 52 18.6%

Facility type 0.37

Government 129 122 251 89.6%

Mission 12 16 28 10.0%

Private 0 1 1 0.4%

Current designation

0.45

Registered Nurse

61 72 133 47.5%

Assistant Nursing Officer

58 43 101 36.1%

Senior Registered Nurse

5 5 10 3.6%

Principal Registered Nurse

9 8 17 6.1%

Nursing Officer II 8 11 19 6.8%

Year graduated 0.74

2008 14 17 31 11.1%

2009 37 34 71 25.4%

2010 38 33 71 25.4%

2011 23 29 52 18.6%

2012 16 18 34 12.1%

Other (for foreign nurses)

13 8 21 7.5%

Graduation institution

0.38

Local 122 123 245 87.5%

Foreign 19 16 35 12.5%


VARIABLE GROUP 1: TASKS 1-44

GROUP 2: TASKS 45-89

TOTAL % RESPONDENTS

P VALUE

Year first registered with NMCB*

0.55

2008 14 18 32 12.7%

2009 39 28 67 26.7%

2010 37 35 72 28.7%

2011 23 24 47 18.7%

2012 14 19 33 13.1%

Year started at current facility*

0.73

2008 8 12 20 8.0%

2009 29 21 50 19.9%

2010 36 33 69 27.5%

2011 30 34 64 25.5%

2012 16 18 34 13.5%

2013 8 6 14 5.6%

*Note: Numbers do not include participants in pilot study.

TASK CHARACTERISTICS To provide a succinct overview of study results, pie charts in this section summarize results according to the relative majority; that is, for a given variable, which of the responses participants chose most frequently to characterize the task. Keep in mind that the relative majority of nurses within a task category may be less than 50%. For example, in terms of frequency for Task 74, “Provides care and treatment for patients with oral diseases,” 39.7% of nurses responded “rarely.” Other possible responses of “never,” “monthly,” or “weekly”/“daily” (combined) were chosen by 21.3%, 12.5%, and 26.5%, respectively. Therefore, in terms of frequency for Task 74, the relative majority chose “rarely.” A summary of the relative majority of responses is as follows: Most tasks were considered “high” frequency and “high” importance by most nurses. For most tasks, nurses reported being trained during “pre-service.” Nurses considered themselves either “adequate” or “proficient” at task performance for almost all tasks. Given the descriptive nature of the study, it is necessary to examine results beyond the relative majority. Therefore, the “Notable Results and Recommendations by Task Category” section of this report considers more detailed results, as well as combinations of variables. Frequency Results

How often does the nurse perform the task?

Never—Lacks opportunity to perform task

Rarely—Completes task less than once per month

Monthly—Completes task less than once per week but at least once per month

Weekly—Completes task less than once per day but at least once per week

Daily—Completes task at least once per day


Participants provided feedback on how frequently a task was performed by choosing one of the following responses: (I perform the task) “daily,” “weekly,” “monthly,” “rarely,” or “never.” For analysis of results, “daily” and “weekly” were combined and defined as “high” frequency. “Monthly” was defined as “moderate” frequency.” “Rarely” was defined as “low” frequency. “Never” was categorized separately. Results showed variation in reported task frequency according to the type and level of the facility where the nurse was currently working. See Appendix 9 for complete frequency data. For 55 tasks, the relative majority of respondents categorized the task as “high” frequency, with a range of 48.3% to 98.6%. For two tasks (“Submits monthly reports as required” and “Ensures regular removal and safe disposal of medical waste”), 68.8% and 68.6% of respondents, respectively, categorized the task as “moderate” frequency. The relative majority of nurses (35.5%–48.6%) responded “low” frequency for eight tasks. For the remaining 24 tasks, a range of 30.9% to 82.5% of respondents indicated that they “never” perform the task. (See Appendix 10 for tasks never performed by the relative majority of nurses.) Figure 5. Task frequency as defined by the relative majority of respondents

Importance Results

How important is timely and effective performance of this task to the outcome for the patient or public health?

High—Failure to complete task correctly or in a timely manner will lead to client death, serious disability or major impact on public health

Moderate—Failure to complete task correctly or in a timely manner may lead to serious client impact or moderate impact on public health

Low—Failure to complete the task correctly or in a timely manner will have minimum impact on client or public health

Results show the majority of respondents, from 44.3% to 97%, labeled 85 of the tasks on the list as “high” importance. The remaining four tasks were considered by 37.7% to 50.7% of respondents to have “moderate” importance.” No tasks were considered “low” importance by the majority of respondents. These results are consistent with other task analysis results. There is a tendency for nurses to rate those tasks that are included on the task list as critically important for patient / public health outcomes (National Council of State Boards of Nursing 2006). For more detailed analysis, it is

55 tasks

2 tasks

8 tasks

24 tasks

High frequency (Daily orWeekly)

Moderate frequency (Monthly)

Low frequency (Rarely)

Never


helpful to consider the actual percentage of respondents that have rated the task “high” importance, rather than following the relative majority in defining the task as “high” importance. For example, when >80% of respondents considered a particular task “high” importance, then that task was categorized as “especially high importance.” Using this method, 34 tasks were categorized as “especially high importance.” When the results are interpreted, further partitioning of the importance variable in this way can assist with prioritizing curriculum and licensure examination content. Although there were no tasks that the majority of respondents considered “low” importance, there were a few tasks that a greater than usual portion of respondents (>20%) characterized as “low” importance:

Task 6: Wears uniform and insignia in accordance with MOH specifications

Task 27: Maintains active membership of the nursing association

Task 28: Participates in community activities

Task 51: Provides school health The vast majority of tasks were defined as “high” importance by a range of 44.3% to 97% of respondents. A range of 37.7% to 50.7% (the relative majority) of respondents rated four tasks as “moderately” important. Figure 6. Task importance as defined by the relative majority of respondents

* “Especially high importance” is used for tasks >80% of nurses rated “high” importance

Performance Results

What is the nurse’s self-reported level of competence in performance of the task?

Can perform proficiently—Nurse performs at expert level

Can perform safely and efficiently—Nurse adequately performs task

Not capable of performing

For self-reported task performance capability, the relative majority (49.3%–70.2%) of respondents rated themselves competent (“adequate”) at 77 tasks. For 11 tasks, more nurses rated themselves “proficient,” with a range of 48.9% to 60.3% of nurses. For only one task, the

44 tasks41 tasks

4 tasks 0 tasks

Especially high importance*

High importance

Moderate importance

Low importance


majority of nurses (53.7%) rated themselves “not capable of performing.” (Task 68: “Provides care and treatment to clients with leprosy.”) Although it is encouraging that only one task was defined by the majority as a task that they were “not able to perform,” there are other tasks where a significant number of nurses reported they were “not capable.” For example, 40.6% of nurses responded “not capable” to Task 33: “Provides effective intrapartum care.” Figure 7. Task performance as defined by the relative majority of respondents

When/Where Trained Results

When and where was the provider educated/trained to perform the task?

Pre-Service—Received formal training as part of pre-service education

In-Service—Received formal training needed to complete task following graduation

On-the-job—Received informal training from co-workers or supervisor

Has not been trained—Has not received any formal or informal training

The relative majority of respondents reported having been trained on 77 of the tasks during “pre-service” education, with a range of 40.2% to 69.3%. “In-service” training was not reported by the majority for any task. “On-the-job” training was reported by the relative majority (40.4%–65.7%) for eight tasks (see Appendix 11). A range of 31.6% to 48.2% of nurses reported never having been trained on the remaining four tasks:

Task 40: Screens, advises, and refers infertility cases as per national guidelines

Task 52: Provides care to orphans and vulnerable children

Task 56: Provides ARV [antiretroviral] therapy

Task 68: Provides care and treatment to clients with leprosy

11 tasks

77 tasks

1 task

Proficient

Adequate

Not capable


Figure 8. Task training time/location as defined by the relative majority of respondents

COMBINED TASK VARIABLES

Frequency and Importance, plus Capability Tasks listed in Table 4 might be considered highest priority on the nurse licensure examination (see “Combined Frequency and Importance” section for rationale). They include tasks that were considered “especially high importance” (>80% of nurses rated the task “high” importance) and that also had a significant proportion (>20%) of respondents saying the task was “low” frequency. The shaded tasks are those where >20% also reported being “unable to perform” the task. Table 4. High-priority tasks for curriculum and licensure examination content


% O

F

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SP

ON

DE

NT

S

RA

TE

D “

LO

W”

FR

EQ

UE

NC

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% O

F

RE

SP

ON

DE

NT

S

RA

TE

D “

HIG

H”

IMP

OR

TA

NC

E

% O

F

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SP

ON

DE

NT

S

RA

TE

D “

UN

AB

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T

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FO

RM

”

31 Provides effective antenatal care 23.9 85.5 23.2

32 Prevents, recognizes, and refers pre-eclampsia and eclampsia

23.2 93.5 26.8

33 Provides effective intrapartum care 21.7 87.7 40.6

34 Provides effective postnatal care 22.5 84.8 29


25.6 92.7 29.2

38 Provides effective PMTCT [prevention of mother-to-child transmission of HIV]

26.1 92.8 19.6

42 Responds appropriately to gender-based violence (includes rape)

29.7 80.4 11.6

43 Provides effective postabortion care 24.6 85.5 16.7


29 92.8 21.7


23.4 88.3 12.3

77 tasks

0 tasks8 tasks

4 tasks

Pre-service

In-service

On-the-job

Never trained



% O

F

RE

SP

ON

DE

NT

S

RA

TE

D “

LO

W”

FR

EQ

UE

NC

Y

% O

F

RE

SP

ON

DE

NT

S

RA

TE

D “

HIG

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IMP

OR

TA

NC

E

% O

F

RE

SP

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DE

NT

S

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TE

D “

UN

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T

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FO

RM

”

55 Recognizes, treats, and/or refers patients with opportunistic infections

20.3 88.4 4.4

59 Recognizes and refers patients with MDR-TB [multidrug-resistant tuberculosis]

48.6 96.4 16.7

61 Provides malaria preventive services 34.1 81.2 10.9

62 Provides care and treatment to clients infected with malaria

42.8 87 15.9

75 Provides care and treatment for patients with trauma

31.6 89.7 11.8

76 Provides diabetic preventative services 23.7 84.4 3.7

80 Provides preventative services for cardiovascular disease

25.7 92.7 6.6

81 Provides care and treatment for patients with cardiovascular disease

30.4 97 8.2

85 Provides preventative services for chronic respiratory diseases such as asthma

21.3 91.2 4.4

87 Provides services to prevent conditions that can cause disabilities

24.3 82.4 13.2

Note: High-priority tasks for curriculum and licensure examination content are those which a significant proportion of respondents rated as “low” frequency, “high” importance, or “not capable of performing.” Shaded tasks are those where >20% of respondents reported being “unable to perform” the task.

Capability and Frequency, plus Importance There were 13 tasks which more than 20% of respondents were unable to perform. A relative majority of respondents also indicated that they “never” perform all but one of these tasks (Task 50). Those tasks that were rated “high” importance by >80% of respondents are shaded. Depending on their relevance, the shaded tasks may need in-service training focus. Table 5. Tasks which more than 20% of respondents were unable to perform, with percentage who never perform the task

TASK # TASK DEFINITION % UNABLE TO

PERFORM

% NEVER PERFORM

31 Provides effective antenatal care 23.2 48.6

32 Prevents, recognizes and refers pre-eclampsia and eclampsia

26.8 52.2

33 Provides effective intrapartum care 40.6 63.8

34 Provides effective postnatal care 29 54.4


29.2 58.4

38 Provides effective PMTCT 19.6 44.9

40 Screens, advises, and refers infertility cases as per national guidelines

32.6 63.8


TASK # TASK DEFINITION % UNABLE TO

PERFORM

% NEVER PERFORM


21.7 42

50 Provides care and treatment of children with HIV/AIDS 37.2 21.2

52 Provides care to orphans and vulnerable children 25.4 58

53 Provides care to children with disabilities 24.3 48.9

56 Provides ARV therapy 29.7 45.7

68 Provides care and treatment to clients with leprosy 53.7 82.5

Note: Shaded tasks are those determined to be “especially high importance” (>80% of respondents rated the task “high” importance).

Combined In-Service and On-the-Job Training Results of the likelihood of being trained in-service or on-the-job are presented as the proportion of respondents trained for the task in-service, the proportion of respondents trained for the task on-the-job, and the combination (sum) of both. More than 50% of respondents had been trained while in-service or on-the-job for nine tasks; 40% or more had received in-service/on-the-job training for 15 tasks. A number of these tasks may receive less emphasis on the nurse licensure examination, since the opportunity exists to receive training after graduation. Table 6. Tasks with the highest likelihood of in-service/on-the-job training

TASK #

TASK DEFINITION % NOT TRAINED

% TRAINED

IN-SERVICE

% TRAINED ON-THE-

JOB

% IN-SERVICE

+ ON-THE-JOB

11 Mobilizes health facility resources needed to care for the clients

5.7 19.9 33.3 53.2

15 Utilizes data from health information system

2.8 12.8 32.6 45.4

16 Reports notifiable medical conditions according to protocol

3.6 17.7 40.4 58.1

17 Keeps registers and monthly reports up-to-date

2.8 10.6 58.2 68.8

18 Submits monthly reports as required 5.7 12.9 65.7 78.6

21 Refers clients in accordance with policy and guidelines

4.3 7.8 31.9 39.7

22 Arranges transport for an emergency within one hour

11.4 7.9 51.4 59.3

23 Communicates effectively throughout the referral process

6.4 7.8 51.1 58.9

24 Records referrals appropriately 5 12.8 56.7 69.5

25 Participates in review of referred cases as part of continuing education and quality improvement

12.8 9.2 46.8 56

26 Participates in continuing education activities

7.2 13.7 30.9 44.6

29 Participates in quality improvement initiatives

10.9 13 40.6 53.6


TASK #

TASK DEFINITION % NOT TRAINED

% TRAINED

IN-SERVICE

% TRAINED ON-THE-

JOB

% IN-SERVICE

+ ON-THE-JOB

30 Contributes to the clinical education of students

15.4 8.1 34.6 42.7


17.4 28.3 12.3 40.6

59 Recognizes and refers patients with MDR-TB

15.9 24.6 23.2 47.8

NOTABLE RESULTS AND RECOMMENDATIONS BY TASK CATEGORY The following section provides guidance for NMCB in determining content of the nurse licensure examination, according to task category.

Basic Nursing Tasks

Caring for patients

Follows the disease management protocols and standard treatment guidelines 1.

Provides compassionate and individualized counseling that is sensitive to culture and the 2.social circumstances of patients

Provides care that is developmentally appropriate 3.

Treats patients with courtesy and in a client-oriented manner 4.

Observes the rights of patients and maintains confidentiality 5.

Wears uniform and insignia in accordance with MOH specifications 6. A large majority of respondents characterized all six tasks under caring for patients as “high” frequency, and also reported a high rate of training in “pre-service” education. A range of 0% to 1.4% of participants reported that they “never” performed these tasks, and a range of 0% to 6.4% reported that they were “unable to perform” them. Although the results showed the majority considered these tasks “high” importance, only one task, Task 1, was considered to be “high” importance by >80% of respondents. According to the prioritization matrix of importance-frequency (see Table 2), these tasks therefore do not require emphasis on the licensure examination. Another interesting finding in this category of tasks relates to the length of time a nurse has been practicing. The more years of practice, the less frequently the nurse is likely to perform Tasks 4 and 6. In other words, the longer a person is a nurse, the less likely he or she is to treat patients with courtesy and in a client-oriented manner and the less likely he or she is to wear the uniform with the proper insignia from the MOH.

Recommendation: For Tasks 1–6, no emphasis is required on the licensure examination. The results of this category reflect the need for continued professional development as well as a system of accountability that promotes respectful client care.


Management of health facility

Mobilizes community resources needed to care for the clients 7.

Ensures regular removal and safe disposal of medical waste 8.

Ensures patients safety 9.

Follows infection prevention guidelines 10.

Mobilizes health facility resources needed to care for the clients 11. Again, most nurses rated these tasks as “high” importance and “high” frequency, although less than 80% rated Tasks 7 and 11 as “high” importance. It is interesting to note that for Task 7, 15.1% of nurses reported they were “not capable” and 13% reported they had “never” been trained. A task from this area that is considered critical for patient / public health outcomes is Task 8, as it was rated “high” importance by 90% of participants and is also a less frequently performed task (rated “moderate” frequency by 68.6%). It is encouraging that 0% of respondents reported they were “incapable” of Task 8 and all respondents reported having been trained (mostly “pre-service”). Because they are performed with high frequency, the rest of the management tasks do require less emphasis on the licensure examination, as in-service exposure and practice will develop nurses’ competency.

Recommendation: Task 8 should appear on the licensure exam. Otherwise, tasks from this category should be given less emphasis in the licensure examination. However, attention to developing competency in the workforce may be promoted in other ways, such as worksite job training, continuing education classes focused on partnering with the community to mobilize resources for health, and workplace standards that ensure patient safety and infection prevention guidelines are upheld.

Patient education

Collaborates with the community to identify priority health education needs 12.

Utilizes culturally and linguistically appropriate educational materials when available 13. These tasks were rated less important, compared to other tasks, with 55.3% (Task 12) and 44.3% (Task 13) characterizing them as “high” importance. There was also a relatively high percentage who reported “never” doing the task: 27% and 17.9%, respectively. For Task 12, facility type affected the frequency of task performance, since nurses in higher-level facilities have less opportunity to work directly with the community. For Task 13, there is no difference by facility level. In Botswana, a Health Education Assistant cadre conducts community education, mostly in clinics, but performs home visits to conduct health education. This may explain why a large percentage of nurses reported “never” conducting patient education and rated the task as relatively less important than others. In hospitals, however, health education is considered the role of nurses.


Recommendation: Tasks 12 and 13 can receive less emphasis on the licensure examination compared to other tasks that are rated higher importance and lower frequency. However, patient education should receive attention in pre-service education, with sufficient credit hours devoted, in consideration of nurses’ role in providing patient education in hospitals as well as overseeing the health education assistants in communities. Continuing professional development courses should also include effective patient education and community health education strategies. Nursing supervisors should encourage nurses to spend sufficient time with clients for effective patient education to occur. This has implications for workforce deployment that takes into account appropriate nurse-patient ratios, allowing for holistic care that includes patient education.

Records

Collects data using the correct health information system tools 14.

Utilizes data from health information system 15.

Reports notifiable medical conditions according to protocol 16.

Keeps registers and monthly reports up to date 17.

Submits monthly reports as required 18. Task 16 was considered “especially high importance,” with >80% of respondents labeling the task “high” importance. The rest of the tasks are of moderate importance and performed frequently. These tasks appear in Table 6, with high combined likelihood of training occurring on-the-job or in-service. Therefore, these tasks will not need to be emphasized on the licensure examination.

Recommendation: Within this category, Task 16 would require more emphasis than the other tasks. Overall, Tasks 14–18 can receive less emphasis.

Community- and home-based care

Maintains links with the community health committee, civic organizations, schools, 19.workplaces, political leaders, and ward councilors

Conducts regular home visits 20. The frequency and performance of these tasks varied by nurses’ facility type: health post nurses are most likely, and also most competent, to make home visits and maintain links with the community, while hospital-based nurses are least likely to do so. For Tasks 19 and 20, 39% and 50.3%, respectively, reported they “never” perform the task, likely due to the work location. These tasks were not rated as “high” importance by more than 80% of respondents. Many nurses report they are “not capable of performing” these tasks (19.2% and 14.3%, respectively). About 14% reported they were “never trained” on Task 19. Although, according to the importance results, these tasks require less emphasis on the licensure examination, it appears that training for health post and clinic nurses may be helpful in developing their competencies for these tasks.


Recommendation: Facility level–specific training for Tasks 19 and 20 for community based nurses.

Referral

Refers clients in accordance with policy and guidelines 21.

Arranges transport for an emergency within one hour 22.

Communicates effectively throughout the referral process 23.

Records referrals appropriately 24.

Participates in review of referred cases as part of continuing education and quality 25.improvement

The first three tasks (21–23) are rated as “especially high importance” (>80% of nurses rate them high importance). For Task 25, 12.8% report they were “never trained” and 7.1% report they are “not capable of performing.” Compared to other task list areas, these tasks—with the exception of Task 21—are predominantly learned on-the-job, with a range of 46.8% to 56.7% of respondents reporting “on-the-job” training. For Tasks 21, 22, 24, and 25, there was no difference according to any of the measured demographic variables. For Task 23, however, nurses working in hospitals were less likely to report that they performed the task frequently or “proficiently.” Tasks 22–25 have high likelihoods of in-service/on-the-job training. For this reason, they can receive less emphasis on the licensure examination.

Recommendation: Tasks 24–25 can receive less emphasis on the licensure exam. Tasks 21–23 are of “especially high importance.” They should receive emphasis to ensure competency in new graduate nurses. However, the written exam may not be the best method of determining competency in communication techniques. An OSCE may be more effective.

Professional development

Participates in continuing education activities 26.

Maintains active membership of the nursing association 27.

Participates in community activities 28.

Participates in quality improvement initiatives 29.

Contributes to the clinical education of students 30. The frequency of Task 28 differs by facility type. Nurses at health posts or clinics are more likely to perform the task more frequently, consistent with responses to other community-related tasks. Training was associated with increased reported ability to perform Task 28. Only 39.9% of nurses rated the task as “high” importance. The range of “high” importance ratings for the rest of the tasks in this category was 57.8%–73.9%. According to the task analysis results, these are not the highest-priority items for the licensure examination. However, these tasks are crucial for the


maintenance of a competent nursing workforce and for the positive population-level health outcomes that a strong workforce can support (Campbell et al. 2013).

Recommendation: Tasks 26–30 can receive less emphasis on the nurse licensure examination. Professionalism within the nursing cadre is important and can be encouraged by providing incentives for those who maintain up-to-date registration and contact information with NMCB, as well as for those who complete continuing professional development courses. It is also recommended to encourage nurses to get higher education with further incentives. Guidance provided to facilities in order to have safe, effective preceptor programs in place will also allow clinical education of students to be prioritized. Note: The recommendations in this report focus on implications for the nurse licensure examination, with less frequent mention of general strengthening of the nursing cadre in Botswana through means other than the development of the nurse licensure examination. Although Tasks 26–30 are not to be heavily emphasized on the examination, this does not mean that the recommendation is for the tasks to also be removed from the curriculum. In fact, it is important that nurses are exposed to the principles of professionalism during pre-service education.

Clinical Nursing Tasks

Sexual and reproductive health (SRH)

Maternity care

Provides effective antenatal care 31.

Prevents, recognizes, and refers pre-eclampsia and eclampsia 32.

Provides effective intrapartum care 33.

Provides effective postnatal care 34.

Prevents, recognizes, and refers postpartum hemorrhage 35. Although maternity care–related tasks are included in the diploma nursing curriculum for level II students in the course “Parent and Child Health Nursing” (MOH 2009a), these tasks are considered by NMCB to be primarily the responsibility of midwives in Botswana. During the development of the task list and expert panel review, there was extensive discussion regarding whether these maternity care–related tasks should remain on the nursing task list for this analysis. NMCB has not established these competencies for the diploma nurse. However, according to the task analysis results, these tasks are performed by nurses, albeit on a low-frequency basis. More than 80% of participants rated all of these tasks “high” importance. For Tasks 32–35, >50% of nurses reported “never” performing the task; for Task 31, >40% reported “never” doing the task. For all five of these tasks, >20% reported performing the task on a “low”-frequency basis, a significant number when considering the criticality of the tasks to maternal- and child-health outcomes. A range of 23.2% to 40.6% of nurses reported they were “not capable of performing” the tasks. When analyzed according to whether the nurse had received training, and


whether this influenced performance, results showed that training in any location resulted in nurses being more capable of performing the tasks. Based on the task analysis results, it is incumbent upon NMCB to review whether maternity care tasks should be addressed in the pre-service nursing curriculum, in-service training, and, potentially, the licensure examination. The results also have implications for deployment; nurses in clinics and health posts should not be placed without some preparation for these high importance–low frequency maternal- and child-health related tasks.

Recommendation: Tasks 31–35 should receive emphasis on the licensure examination. Furthermore, NMCB may consider review of the general nursing curriculum to determine whether increased content and clinical practice is needed for mastery of these tasks. Otherwise, there is a pervasive risk to the public in general nurses performing maternity care–related tasks without first being expected to demonstrate maternity care competencies.

Sexually transmitted infections and reproductive health

Provides effective family planning 36.

Provides effective care to clients with sexually transmitted infections 37.

Provides effective PMTCT 38.

Provides effective youth-friendly adolescent SRH services 39.

Screens, advises, and refers infertility cases as per national guidelines 40.

Promotes male involvement in SRH 41.

Responds appropriately to gender-based violence (includes rape) 42.

Provides effective postabortion care 43.

Provides effective screening and care for clients with reproductive cancers 44. Tasks 37, 38, and 42–44 were all rated by >80% of participants as “high” importance. For the same five tasks, more than 24% of participants rated them as being “low” frequency. The others tasks (36 and 39–41) were also rated “high” importance by a range of 58% to 66.7% of participants. The most frequently performed of the group is Task 37, with 66.9% of nurses reporting they perform the task “daily” or “weekly.” This is to be expected, considering that in 2009 alone, 153,688 health care visits were due to sexually transmitted infections (MOH 2012). Task 40 was the least frequently performed (63.8% said “never”); in addition, 32.6% responded they were “not capable of performing” it and 40.6% reported they had “never” been trained.

Recommendation: Tasks 37, 38, and 42–44 should receive emphasis on the examination.


Child health

Provides services leading to immunization according to protocol 45.

Provides care and treatment of children with diarrhea 46.

Provides care and treatment of children with respiratory infections 47.

Provides care and treatment of children with malnutrition 48.

Provides micronutrient supplementation to children 49.

Provides care and treatment of children with HIV/AIDS 50.

Provides school health 51.

Provides care to orphans and vulnerable children 52.

Provides care to children with disabilities 53. All of the above tasks are more likely to be performed by nurses at lower-level health facilities. Tasks 51 and 52 were two of the tasks labeled “moderate” importance by the majority of participants. Almost 70% reported “never” providing school health and 58% reported “never” providing care to orphans and vulnerable children. Therefore, these tasks are moderate importance–low frequency and would be lower on the list of priority task areas for the licensure examination. Tasks 46, 47, and 50 were rated by >80% as “high” importance. Although Task 50 appears in Table 6 as having a high likelihood of either in-service or on-the-job training (tasks that would normally receive less attention on the licensure exam), it may be an exception. The task has been the topic of much in-service training by the MOH, and yet 17.4% of nurses report they were “never trained” in the task. Furthermore, 37.2% responded that they were “not capable of performing” the task. Considering the high burden of HIV in Botswana—23% prevalence among 15- to 49-year-olds according to the latest UNAIDS estimates (2012)—this task may therefore be considered for emphasis on the licensure examination.

Recommendation: Tasks 46, 47, and 50 should receive emphasis on the licensure examination. Review of in-service training recipients may also reveal the need to reach more nurses with currently existing in-service training topics related to HIV/AIDS.

Communicable diseases

HIV/AIDS and TB

Provides HIV/AIDS preventive services 54.

Recognizes, treats, and/or refers patients with opportunistic infections 55.

Provides ARV therapy 56.

Provides care and treatment to people living with HIV/AIDS 57.

Provides TB preventive services 58.

Recognizes and refers patients with MDR-TB 59.

Provides care and treatment to clients infected with TB 60.


For Tasks 54, 57, and 58, more than 70% of nurses reported performing the task on a “high”-frequency basis. For Task 60, 68.8% of nurses reported “high” frequency of performance, but 16.7% reported they performed the task with “low” frequency. Notably, 45.7% reported they “never” perform Task 56, and 34.8% reported they “never” perform Task 59. According to World Health Organization surveillance data (2012), the prevalence of MDR-TB out of previously treated cases was 6.6%; in newly diagnosed cases, the prevalence was 2.5%. Still, almost 50% of nurses reported “low” frequency for Task 59. This is likely related to the system of MDR-TB treatment in Botswana: treatment was managed in two referral hospitals in Francistown and Gaborone beginning in 2002, with three more centers treating MDR-TB since 2011. For Task 58, 13.8% reported performing the task with “low” frequency. Task 55 was reported to be “high” frequency by almost 60% of respondents. However, >20% also reported it as a “low”-frequency task. All of these tasks were rated “high” importance by more than 80% of the respondents. This means that Tasks 55 and 59 should receive emphasis on the licensure exam as high importance–low frequency tasks, followed by Tasks 60 and 58 as high importance–moderate frequency. Characterization of Tasks 54, 57, and 59 did not differ according to the facility level where the participants were working. Task 56 was more likely to be performed by nurses at higher-level facilities. This is likely resulting from the nurse prescriber program begun in 2004, which prepares nurses to deliver ARV drugs to clinically stable patients (MOH 2012). For Tasks 55 and 60, nurses at lower-level facilities performed the tasks more frequently. For Task 60, nurses at lower-level facilities were also more likely to report “proficient” or “adequate” capability. However, although Task 55 was performed more frequently by nurses in health posts or clinics, those nurses were not more likely to report that they were capable of performing the task. Task 56 should be further examined to determine why so many nurses report “never” doing the task: whether another cadre is performing the task instead, whether there are supply issues, whether patients are not seeking services, and whether there is need for increased training.

Recommendation: Tasks 55 and 59 should receive emphasis on the exam, followed by Tasks 58 and 60.

Malaria and other infectious diseases

Provides malaria preventive services 61.

Provides care and treatment to clients infected with malaria 62.

Provides preventive services for diarrheal diseases 63.

Provides care and treatment to clients with diarrheal diseases 64.

Provides care and treatment to clients with communicable respiratory infection including 65.influenza

Provides care and treatment to clients with meningitis 66.

Provides care and treatment to clients with dermatological diseases 67.

Provides care and treatment to clients with leprosy 68.

Provides preventive services for nosocomial infection 69.

Provides services related to the prevention and management of emerging infectious diseases 70.


Task 68 stood out with anomalous responses by nurses. Less than 80% of nurses considered the task “high” importance, almost 50% reported “never” having been trained, and 82.5% reported they “never” did the task. If leprosy cases were nonexistent, the task could be removed from the curricula and licensure exam. There were less than five new cases of leprosy in Botswana in 2011. The condition appears to be on the path to eradication, with increasing decline in Botswana and the region (World Health Organization 2014). The task should therefore receive less emphasis on the licensure exam, until the condition is eradicated in the country, when it should be removed entirely. Tasks 61 and 62, related to prevention and care of malaria, were both considered “high” importance by more than 80% of nurses. The frequency of task performance was split between “never” (40.6% and 42%, respectively) and “low” (34.1% and 42.8%, respectively). Although the results were not analyzed according to geographic location, it is reasonable to assume these responses reflect the areas of Botswana where malaria is not endemic and the areas where it is (the northwest). Given that graduating nurses are meant to be prepared to be deployed to any area of the country, and that these tasks were rated “high” importance and “low” frequency, these tasks should receive emphasis on the licensure examination. In addition, in-service training for the malaria-endemic areas of the northwest might also be necessary. For Tasks 63 and 64, >80% of nurses considered the tasks “high” importance and about 65% reported “high” frequency of performance. These high frequency–high importance tasks should appear on the exam, but with less emphasis than those high-importance tasks that are performed with low or moderate frequency. Greater than 90% rated Task 66 “high” importance, although 57.5% reported “never” performing the task. However, 21.3% of respondents also said they performed the task with “high” frequency and 21.3% with “moderate” frequency. Also, 16.1% of nurses reported they were “not capable of performing” the task. The responses did not differ according to facility level, meaning the occurrence of meningitis care is not predictable. By averaging the responses, this task may be considered high importance–low frequency and should receive attention on the licensure exam, although less attention than those tasks which more nurses reported as “high” importance and “low” frequency. Task 67 was rated “moderate” importance by 45.3% of nurses (only 40% rated the task “high” importance). “Low” was the most common frequency category, chosen by 36.5% of nurses. About 22% reported they “never” did the task and 28.5% reported “high” frequency. Compared to other tasks, this should receive relatively less emphasis on the licensure examination since it is moderate importance–low frequency. Similarly, Task 69 should receive relatively less emphasis, since it was rated “high” frequency by the vast majority (81.2%) and “high” importance by less than 70% of respondents. Almost no nurses reported not being capable or not having been trained on either task. For Task 70, slightly less than 80% reported the task was “high” importance; 43.5% reported “high” frequency while almost 30% reported “low” frequency. Using 80% as a cutoff for “especially high importance” and 20% for low frequency, this task can be characterized as moderate importance–low frequency. Although the task will receive relatively little emphasis on


the licensure exam, it is important to note that several nurses reported they were “never trained” (21.7%), correlated to the high number that reported they were “not capable” (18.8%).

Recommendation: Tasks 61, 62, and 66 should receive emphasis on the exam. Tasks 63 and 64 should receive some emphasis on the exam. Task 67, 69, and 70 will receive some emphasis, but less than others in this category. Task 68 may also be emphasized, depending on epidemiological data regarding leprosy in Botswana.

Noncommunicable diseases and conditions

Provides services to optimize patient mental health 71.

Provides care and treatment for patients with mental health conditions 72. About 49% reported Task 71 and 65% reported Task 72 as “high” importance. About 30% of nurses reported “low” frequency for both tasks, while 40.3% and 35.6% reported “high” frequency for Task 71 and 72, respectively. Lobatse, the location of the only mental health specialty hospital in Botswana, was one of the locations of data collection, although the task analysis results show that there is no variation in mental health-related task performance according to facility level or location. In other words, a variety of nurses across the country, outside of Lobatse, perform these tasks. Therefore, some emphasis on mental health tasks should appear in the curriculum and on the licensure examination, as they were considered moderately important and relatively low-frequency tasks.

Provides services to optimize patient oral health 73.

Provides care and treatment for patients with oral diseases 74. Tasks 73 and 74 were considered to be of “moderate” importance by 50.7% and 44.1% of respondents, respectively. About 13% reported they were “never trained” in these tasks and a similar number reported they were “not capable.” Nurses reported a range of frequency data, but many reported “low” frequency: 35.3% for Task 73 and 39.7% for Task 74. These tasks can therefore be considered for emphasis in the licensure examination along with other moderate importance–low frequency tasks.

Recommendation: Tasks 71–74 should receive similar levels of emphasis (less than high-importance and “especially high importance” tasks, but greater than moderate- or low-importance tasks that are also high frequency).

Provides care and treatment for patients with trauma 75. Almost 90% of nurses rated Task 75 “high” importance. It was also rated “low” frequency by 31.6% of nurses and should therefore be emphasized on the licensure examination. Interestingly, task performance did not vary by any of the demographic variables, including facility level.


Recommendation: Task 75 should receive high emphasis on the licensure examination, as an “especially high importance”–low frequency task.

Provides diabetic preventative services 76.

Provides care and treatment for patients with diabetes 77.

Provides hypertension preventative services 78.

Provides care and treatment for patients with hypertension 79.

Provides preventative services for cardiovascular disease 80.

Provides care and treatment for patients with cardiovascular disease 81.

Provides cancer preventative services 82.

Provides care and treatment for patients with cancer 83.

Provides screening, care, and treatment for patients with eye conditions 84.

Provides preventative services for chronic respiratory diseases such as asthma 85.

Provides care and treatment for patients with respiratory diseases 86. All of the above tasks were rated “high” importance by >80% of respondents, except Task 84 (63.7% responded “high” importance). Over two-thirds of nurses noted they were “adequate” or “proficient” at diabetes-related Tasks 76 and 77; 55.6% and 65.4% (respectively) reported they perform these tasks with “high” frequency. Almost 24% reported “low” frequency for Task 76. Over 76% of nurses reported “high” frequency for Tasks 78 and 79. For Task 80 and 81, >25% and 30%, respectively, reported “low” frequency. Most of the above tasks showed few nurses being “not capable.” The exceptions are Tasks 82–84, with a range of 14% to 19.3% who responded “not capable.” For Tasks 83 and 84, a large portion of nurses (38.5% and 28.9%, respectively) reported “low” frequency. Task 86 was rated “high” frequency by over 90% of the nurses, and almost no one responded “not capable” or “never trained” for the task.

Recommendation: Tasks 80–83 should receive emphasis on the licensure examination, followed by Task 84. Tasks 76–79 should receive slightly less focus on the exam, given the high frequency of task performance. Task 84 should receive less emphasis on the exam compared to other tasks in this category because it is considered relatively less important.

Provides services to prevent conditions that can cause disabilities 87.

Provides care to patients with disabilities 88. More than 80% of nurses reported that Task 87 was “high” importance, while Task 88 was considered “high” importance by 60%. About 15% and 17% reported “never” performing Tasks 87 and 88. For Task 88, 21.3% reported they were “never trained,” while only 11% reported they were “never trained” on Task 87. Most nurses (45.6%) reported “high” frequency for Task 87 while most nurses (40.6%) reported “low” frequency for Task 88. Task 88 is considered


moderate importance–low frequency, and will therefore receive less emphasis on the exam compared to Task 87, a high importance–moderate frequency task.

Recommendation: Task 87 should receive attention on the exam as an “especially high importance” task, although its high frequency of performance means it should receive less attention than “especially high importance”–low frequency tasks. Task 88 should also appear on the examination with slightly less emphasis than Task 87, as it is high importance (though relatively lower importance than Task 87) and low frequency.

Provides effective pre- and postoperative care 89. Task 89 was considered “high” importance by >80% of respondents. About one-third of nurses reported they “never” performed the task, 19.1% reported “low” frequency, and about 40% reported “high” frequency. Nurses in higher-level facilities were more likely to perform the task. This task should be addressed on the licensure examination as a high-importance task, with a range of responses averaging as “moderate” frequency.

Recommendation: Task 89 is specific to a job site where surgery is performed, and therefore should involve job-specific training. However, since it is an “especially high importance” task and is in some cases done with low frequency, it should also receive emphasis on the exam.

NEXT STEPS The results of the task analysis study offer NMCB information regarding the current practice reality for nurses in Botswana. This data set can be used for establishing a licensure examination with relevant, validated content. Establishment of the licensure examination will ideally be preceded by changes in education that can be assessed by the exam. In order to achieve these and other global best practices for nursing education, the following three steps are recommended.

REVIEW PRE-SERVICE EDUCATION CURRICULUM Besides their use in developing the nurse licensure examination, the task analysis results are also useful for updating the nursing curriculum. A thorough comparison of the results of the task analysis and the current curriculum is recommended. Relevant updates, deletions, and revisions may be made as a result. For example, for Task 68—caring for a patient with leprosy—information related to the task can hopefully be removed from the curriculum in the next five years, if supported by continued review of country-level epidemiology to verify that there are no more new cases of leprosy in Botswana. For those maternity care tasks that nurses reported were “high” importance–“low” frequency (such as Tasks 31–35), determine whether these tasks should be incorporated in the basic nursing curriculum, or examine the systems in place to ensure that midwives (who are trained in these skills) will be present whenever these tasks arise in the workplace.


ESTABLISH IN-SERVICE EDUCATION PRIORITIES The task analysis results, especially the combination of importance, frequency, and capability, may also inform in-service training priorities, based on results where capability is low for highly important tasks (see shaded tasks in Table 4). An on-site approach to in-service training is recommended to avoid the burden of nurses leaving their work sites for training purposes, as well as to take advantage of the improved knowledge retention that occurs when new skills are learned in the same environment where they will be applied (Bluestone et al. 2013).

DEVELOP AN OBJECTIVE STRUCTURED CLINICAL EXAMINATION A written nurse licensure examination is a widely accepted practice as one component of determining the competency of nurses entering practice (Kak, Burkhalter, and Cooper 2001). An OSCE is another method of testing not only knowledge of new graduates but also attitudes and skills (Epstein and Hundert 2002). Therefore, the interest that NMCB has expressed in creating an OSCE to determine competency of new graduate nurses is well-founded. The results of the task analysis study can be used to structure the content of a series of supplemental OSCEs for licensure purposes, focused on tasks that are particularly difficult to measure solely with written, multiple-choice questions.

CONCLUSION The nursing task analysis study was successfully conducted in order to describe the tasks undertaken by newly graduated nurses licensed to practice in Botswana and to determine the content of a nurse licensure exam. The results, especially the combination of importance and frequency, can be used to determine the content of a nurse licensure examination through a process of blueprinting, developing a test bank, and testing questions with experts and new graduates for the goal of a validated examination to determine whether those applying for licensure are suited to practice. Beyond applying the task analysis study results for a written nurse licensure examination, it is recommended that NMCB pursue development of an OSCE for a more comprehensive assessment of newly graduated nurses seeking licensure. A licensure examination based on the study results will be the first examination to determine competency of new nurses in Botswana since 1984. The members and the Registrar of the council are to be commended for their efforts in pursuit of safer nursing practice in the country. With these and other continued efforts on the part of NMCB, the health of the Botswanan public will be protected through the regulation and education of nurses.


APPENDIX 1: TASK ANALYSIS SURVEY PARTICIPANT INFORMED CONSENT FORM INTRODUCTION On behalf of the Ministry of Health, CDC Botswana and Jhpiego Corporation, we are conducting a task analysis survey to learn about the tasks being performed by new graduate nurses in the health facilities. Your responses to the survey will be used to inform the development of the blueprint for licensure examinations. This survey will take about 45 – 60 minutes of your time. Your participation in this survey is entirely voluntary. Your decision whether or not to participate will not affect your status as a nurse in the health facilities. Your responses will remain completely anonymous and no names or personal identifiers will be recorded or reported. We would like you to answer all of the questions as completely and honestly as you can. However, you may wish to skip questions or decide not to complete the survey at any time. If you have any questions about the survey, please contact Mr. Pilate Khulumani at Ministry of Health, Health Research Unit +267 363 2018 or let the Survey Administrator Khumo Modisaeman at phone number + 267 363 2565 know. Please check the box below to indicate your consent for participation in this review. Tick to indicate consent:

If you are ready, you may begin the survey now. Date of survey dd mm yyyy

For office use only: Survey I.D. Facility Code.


APPENDIX 2: DATA USE AND CONFIDENTIALITY AGREEMENT

(NAME IN BLOCK LETTERS) I understand that I am obliged to abide by ethical considerations guiding the dispensation of my work in the study entitled “Linking licensure examinations to nursing practice through Task Analysis- A case for Botswana”. These considerations include, but are not limited to, the following:

I am required to fully explain the study to participants and give them an opportunity to ask 1.questions prior to signing informed consent forms.

I shall not use any coercion to solicit information from participants, and I will respect 2.participant’s right to withdraw from the study or to withhold any information at any given time.

I undertake to treat all information collected for the study with utmost confidentiality, and 3.shall not disclose any of the information collected to any other party or for any other reason other than that for which the information was collected.

I will ensure that all data under my care are collected, stored and used in accordance with 4.data handling guidelines for the study.

I will not fabricate any information, and shall undertake to report any data losses and/or 5.misrepresentations as soon as I become aware of them.

I undertake to seek clarity from the Data Collection Supervisor(s) should I face any 6.uncertainties regarding protection of participants in this study

I shall adhere to the study protocol throughout the survey. ____________________ _____________________ Signature Date

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cont

inui

ng p

rofe

ssio

nal d

evel

opm

ent

activ

ities

for

nurs

es

Sou

thea

st

Mos

idi M

okot

edi

Uni

vers

ity o

f Bot

swan

a G

abor

one

Nur

se L

ectu

rer

Tea

ches

nur

sing

stu

dent

s

Sou

thea

st

Han

na K

au-K

igo

NM

CB

mem

ber

Gab

oron

e D

isci

plin

ary

Offi

cer

Doc

umen

ts d

isci

plin

ary

issu

es o

f pra

ctic

ing

nurs

es

Sou

thea

st

Rin

ah R

apul

a N

MC

B m

embe

r M

ogod

itsha

ne

Reg

istr

atio

n O

ffice

r R

egis

ters

new

ly g

radu

ated

nur

ses

Sou

thea

st

Khu

mo

Mod

isae

man

N

MC

B m

embe

r G

abor

one

Reg

istr

ar

Ove

rsee

s N

MC

B a

nd r

egis

trat

ion

of n

ew

grad

uate

s

Nor

thea

st

Fan

ny M

atim

ba

NM

CB

cha

ir F

ranc

isto

wn

Ret

ired

Nur

se

Cha

irs N

MC

B m

eetin

gs a

nd a

ctiv

ities

Sou

thea

st

Oga

r R

aphi

nyan

a U

nive

rsity

of B

otsw

ana

Mog

odits

hane

N

urse

Lec

ture

r T

each

es n

ursi

ng s

tude

nts

Sou

thea

st

Phe

lelo

Mar

ole

Jhpi

ego

Gab

oron

e N

urse

/Mid

wife

, T

rain

ing

Exp

ert

Cap

acity

-bui

ldin

g w

ork

with

NM

CB

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

36

SU

BJE

CT

MA

TT

ER

EX

PE

RT

PA

NE

L

Dis

tric

t N

ame

Des

ign

atio

n

Pra

ctic

e S

etti

ng

S

pec

ialt

y R

ole

wit

h N

ew G

ener

al N

urs

es

US

A

Pet

er J

ohns

on

Jhpi

ego

Mar

ylan

d G

ener

al

Hos

pita

l, B

altim

ore

Mid

wife

ry, E

duca

tion

Cap

acity

-bui

ldin

g w

ork

with

NM

CB

, exp

ert i

n nu

rsin

g re

gula

tion

and

licen

sure

exa

min

atio

n de

velo

pmen

t

US

A

Leah

Har

t Jh

pieg

o M

ercy

Med

ical

Cen

ter,

B

altim

ore

Nur

se

Cap

acity

-bui

ldin

g w

ork

with

NM

CB


APPENDIX 4: TASK LIST FOR GENERAL NURSES BASIC NURSING TASKS

Caring for Patients

Follows the disease management protocols and standard treatment guidelines 1.

Provides compassionate and individualized counseling that is sensitive to culture and the 2.social circumstances of patients

Provides care that is developmentally appropriate 3.

Treats patients with courtesy and in a client-oriented manner 4.

Observes the rights of patients and maintains confidentiality 5.

Wears uniform and insignia in accordance with MOH specifications 6.

Management of Health Facility

Mobilizes community resources needed to care for the clients 7.

Ensures regular removal and safe disposal of medical waste 8.

Ensures patients safety 9.

Follows infection prevention guidelines 10.

Mobilizes health facility resources needed to care for the clients 11.

Patient Education

Collaborates with the community to identify priority health education needs 12.

Utilizes culturally and linguistically appropriate educational materials when available 13.

Records

Collects data using the correct health information system tools 14.

Utilizes data from health information system 15.

Reports notifiable medical conditions according to protocol 16.

Keeps registers and monthly reports up to date 17.

Submits monthly reports as required 18.

Community- and Home-Based Care

Maintains links with the community health committee, civic organizations, schools, 19.workplaces, political leaders, and ward councilors

Conducts regular home visits 20.


Referral

Refers clients in accordance with policy and guidelines 21.

Arranges transport for an emergency within one hour 22.

Communicates effectively throughout the referral process 23.

Records referrals appropriately 24.

Participates in review of referred cases as part of continuing education and quality 25.improvement

Professional Development

Participates in continuing education activities 26.

Maintains active membership of the nursing association 27.

Participates in community activities 28.

Participates in quality improvement initiatives 29.

Contributes to the clinical education of students 30.

CLINICAL NURSING TASKS

Sexual and Reproductive Health (SRH)

Provides effective antenatal care 31.

Prevents, recognizes, and refers pre-eclampsia and eclampsia 32.

Provides effective intrapartum care 33.

Provides effective postnatal care 34.

Prevents, recognizes, and refers postpartum hemorrhage 35.

Provides effective family planning 36.

Provides effective care to clients with sexually transmitted infections 37.

Provides effective PMTCT 38.

Provides effective youth-friendly adolescent SRH services 39.

Screens, advises, and refers infertility cases as per national guidelines 40.

Promotes male involvement in SRH 41.

Responds appropriately to gender-based violence (includes rape) 42.

Provides effective postabortion care 43.

Provides effective screening and care for clients with reproductive cancers 44.

Child Health

Provides services leading to immunization according to protocol 45.

Provides care and treatment of children with diarrhea 46.

Provides care and treatment of children with respiratory infections 47.


Provides care and treatment of children with malnutrition 48.

Provides micronutrient supplementation to children 49.

Provides care and treatment of children with HIV/AIDS 50.

Provides school health 51.

Provides care to orphans and vulnerable children 52.

Provides care to children with disabilities 53.

Communicable Diseases

Provides HIV/AIDS preventive services 54.

Recognizes, treats, and/or refers patients with opportunistic infections 55.

Provides ARV therapy 56.

Provides care and treatment to people living with HIV/AIDS 57.

Provides TB preventive services 58.

Recognizes and refers patients with MDR-TB 59.

Provides care and treatment to clients infected with TB 60.

Provides malaria preventive services 61.

Provides care and treatment to clients infected with malaria 62.

Provides preventive services for diarrheal diseases 63.

Provides care and treatment to clients with diarrheal diseases 64.

Provides care and treatment to clients with communicable respiratory infection including 65.influenza

Provides care and treatment to clients with meningitis 66.

Provides care and treatment to clients with dermatological diseases 67.

Provides care and treatment to clients with leprosy 68.

Provides preventive services for nosocomial infection 69.

Provides services related to the prevention and management of emerging infectious diseases 70.

Noncommunicable Diseases and Conditions

Provides services to optimize patient mental health 71.

Provides care and treatment for patients with mental health conditions 72.

Provides services to optimize patient oral health 73.

Provides care and treatment for patients with oral diseases 74.

Provides care and treatment for patients with trauma 75.

Provides diabetic preventative services 76.

Provides care and treatment for patients with diabetes 77.


Provides hypertension preventative services 78.

Provides care and treatment for patients with hypertension 79.

Provides preventative services for cardiovascular disease 80.

Provides care and treatment for patients with cardiovascular disease 81.

Provides cancer preventative services 82.

Provides care and treatment for patients with cancer 83.

Provides screening, care, and treatment for patients with eye conditions 84.

Provides preventative services for chronic respiratory diseases such as asthma 85.

Provides care and treatment for patients with respiratory diseases 86.

Provides services to prevent conditions that can cause disabilities 87.

Provides care to patients with disabilities 88.

Provides pre- and postoperative care 89.


APPENDIX 5: DATA COLLECTION CARD GAME DATA COLLECTION CARDS FOR TASK ANALYSIS

Task Areas

Response Cards for Frequency

Response Cards for Criticality (Importance)

Response Cards for Location (When/Where Trained)

Response Cards for Performance (Capability)


APPENDIX 6: FACILITATOR SCRIPT Greet the participants. 1.

Ask someone to pray. 2.

Welcome the participants. 3.

Explain the purpose of the meeting. 4.

Agree on the norms such as: 5.

a. Silence phones.

b. Do not discuss anything with neighbors while playing the game.

c. Raise your hand every time you need clarification.

d. No side meetings.

Read the consent form to the participants. 6.

Give the participants three minutes to read the consent. 7.

Ask the participants to tick in the consent box to indicate consent and write in today’s date. 8.

DEMOGRAPHIC INFORMATION Read aloud to participants:

Page 2 of your survey tool gathers demographic information about the participants of the 1.survey.

Do not write your name anywhere in the form. 2.

This form will remain completely anonymous. 3.

Check if all the pages have identifying numbers at the corner of each page. 4.

At the “Facility name” space, write in the name of the facility you currently work at. 5.

Tick the type of facility and level of facility you work at. 6.

Write the date you are completing this form in the space provided. 7.

Tick the age range that corresponds to your age. 8.

Tick your gender. 9.

Tick the year you graduated in and the most recent institution you graduated from. 10.

Tick the year you started our first job as a nurse. 11.

Tick the year you first registered with Nursing and Midwifery Council of Botswana 12.

Tick the year you started your current job. 13.

Tick your current designation. 14.

If you have any questions, feel free to ask. 15.

Thank you for completing the demographic data. 16.


GAME FACILITATION

Divide the group into two. 1.

Distribute cards, pencils, pens and tool. 2.

Ask group one to respond to Tasks 1–44 and group two to respond to Tasks 45–89. 3.

Refer to the cards. 4.

Take out one set of cards and explain the colors of the cards. 5.

Explain the number of cards per each card color category. 6.

Explain the levels of the cards 7.

Explain the directions on how to play the game. 8.

Read each task four times. 9.

Ask how frequently they perform the task. 10.

Ask how important the task is. 11.

Ask how well the task is performed. 12.

Ask when and where the nurse was trained to perform the task. 13.

Ask participants to choose the appropriate card with appropriate answer based on personal 14.experience at their current health facility.

Participants should place their cards with the appropriate responses facedown on the table. 15.

Ask the participants to not discuss their answers with the other participants in the group. 16.

Note total time taken to complete the survey tool. 17.


APPENDIX 7: PARTICIPANT DEMOGRAPHICS Participant code:

District code:

Facility name:

Type of facility:

Government

Mission

Private

Level of facility:

Health Post

Clinic

Primary hospital

District hospital

Referral hospital

Date:

Age: 20–24

25–29

30–34

35–40

Over 40

Gender: Male

Female

Year graduated:

2008

2009

2010

2011

2012

Other

Institution of graduation:

Institute of Health Sciences

Gaborone

Kanye SDASON

Molepolole

Lobatse

Serowe

Francistown

Deborah Retief Memorial

University of Botswana

Foreign Institution Please Specify_______________________


Year started first job as nurse:

2008

2009

2010

2011

2012

Other

Year first registered with NMCB:

2008

2009

2010

2011

2012

Year started at current health facility:

2008

2009

2010

2011

2012

2013

Current designation:

Post Basic Student

Registered Nurse

Principal Registered Nurse

Senior Registered Nurse

Assistant Nursing Officer

Nursing Officer II

Nursing Officer I

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

46

AP

PE

ND

IX 8

: E

XC

ER

PT

OF

TA

SK

AN

AL

YS

IS D

AT

A C

OL

LE

CT

ION

TO

OL

FR

EQ

UE

NC

Y

CR

ITIC

AL

ITY

(I

MP

OR

TA

NC

E)

PE

RF

OR

MA

NC

E

(CA

PA

BIL

ITY

) L

OC

AT

ION

(W

HE

N/W

HE

RE

TR

AIN

ED

)

Never

Low (Rarely)

Moderate (Monthly

High (Daily/ Weekly)

Low

Moderate

High

Not capable

Efficient (Adequate)

Proficient

Not trained

On-the-job

In-service

Pre-service

Bas

ic N

urs

ing

Tas

ks

Car

ing

fo

r p

atie

nts

1 F

ollo

ws

the

dise

ase

man

agem

ent p

roto

cols

and

st

anda

rd tr

eatm

ent g

uide

lines

0.

7 2.

8 6.

4 90

.1

7.8

5.7

86.5

0

70.2

29

.8

0.7

17.7

6.

4 75

.2

2 P

rovi

des

com

pass

iona

te a

nd in

divi

dual

ized

co

unse

ling

that

is s

ensi

tive

to c

ultu

re a

nd th

e so

cial

ci

rcum

stan

ces

ofpa

tient

s

0 14

.9

4.3

80.9

10

36

.4

53.6

2.

1 67

.4

30.5

3.

6 12

.8

7.8

75.9

3 P

rovi

des

care

that

is d

evel

opm

enta

lly a

ppro

pria

te

1.4

2.1

2.8

93.6

10

.6

23.4

66

0.

7 64

.3

35

2.8

19.3

10

.7

67.1

4 T

reat

s pa

tient

s w

ith c

ourt

esy

and

in a

clie

nt-o

rient

ed

man

ner

0 0.

7 0.

7 98

.6

8.5

25.4

68

.1

0 55

.3

44.7

0.

7 4.

3 7.

1 87

.9

5 O

bser

ves

the

right

s of

pat

ient

s an

d m

aint

ains

co

nfid

entia

lity

0.7

0 0.

7 98

.6

3.6

22.7

73

.8

0.7

39

60.3

0.

7 3.

6 4.

3 91

.5

6 W

ears

uni

form

and

insi

gnia

in a

ccor

danc

e w

ith

MO

H s

peci

ficat

ions

1.4

7.8

2.8

87.9

32

.6

27.7

39

.7

6.4

44.7

48

.9

1.4

9.2

5 84

.4

Man

agem

ent

of

hea

lth

faci

lity

7 M

obili

zes

com

mun

ity r

esou

rces

nee

ded

to c

are

for

the

clie

nts

10.4

24

.1

14.9

42

.6

7.8

32.6

59

.6

15.1

59

.7

25.2

13

23

10

.8

53.2

8 E

nsur

es r

egul

ar r

emov

al a

nd s

afe

disp

osal

of

med

ical

was

te0.

7 0.

7 68

.6

30

2.9

7.1

90

0 40

60

0

6.4

12.1

81

.4

9 E

nsur

es p

atie

nts

safe

ty

0 0.

7 0.

7 98

.6

1.4

5 93

.6

1.4

46.1

52

.5

1.4

5.7

8.5

84.4

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

47

AP

PE

ND

IX 9

: T

AS

K A

NA

LY

SIS

RE

SU

LT

S

F

RE

QU

EN

CY

C

RIT

ICA

LIT

Y

(IM

PO

RT

AN

CE

) P

ER

FO

RM

AN

CE

(C

AP

AB

ILIT

Y)

LO

CA

TIO

N

(WH

EN

/WH

ER

E T

RA

INE

D)

Never

Low (Rarely)

Moderate (Monthly)

High (Daily /Weekly)

Low

Moderate

High

Not capable


Proficient

Not trained

On-the-job

In-service

Pre-service

Bas

ic N

urs

ing

Tas

ks

Car

ing

fo

r p

atie

nts

1 F

ollo

ws

the

dise

ase

man

agem

ent p

roto

cols

and

st

anda

rd tr

eatm

ent g

uide

lines

0.

7 2.

8 6.

4 90

.1

7.8

5.7

86.5

0

70.2

29

.8

0.7

17.7

6.

4 75

.2

2 P

rovi

des

com

pass

iona

te a

nd in

divi

dual

ized

co

unse

ling

that

is s

ensi

tive

to c

ultu

re a

nd th

e so

cial

ci

rcum

stan

ces

ofpa

tient

s

0 14

.9

4.3

80.9

10

36

.4

53.6

2.

1 67

.4

30.5

3.

6 12

.8

7.8

75.9

3 P

rovi

des

care

that

is d

evel

opm

enta

lly a

ppro

pria

te

1.4

2.1

2.8

93.6

10

.6

23.4

66

0.

7 64

.3

35

2.8

19.3

10

.7

67.1

4 T

reat

s pa

tient

s w

ith c

ourt

esy

and

in a

clie

nt-o

rient

ed

man

ner

0 0.

7 0.

7 98

.6

8.5

25.4

68

.1

0 55

.3

44.7

0.

7 4.

3 7.

1 87

.9

5 O

bser

ves

the

right

s of

pat

ient

s an

d m

aint

ains

co

nfid

entia

lity

0.7

0 0.

7 98

.6

3.6

22.7

73

.8

0.7

39

60.3

0.

7 3.

6 4.

3 91

.5

6 W

ears

uni

form

and

insi

gnia

in a

ccor

danc

e w

ith M

OH

s p

ecifi

catio

ns1.

4 7.

8 2.

8 87

.9

32.6

27

.7

39.7

6.

4 44

.7

48.9

1.

4 9.

2 5

84.4

Man

agem

ent

of

hea

lth

faci

lity

7 M

obili

zes

com

mun

ity r

esou

rces

nee

ded

to c

are

for

the

clie

nts

10.4

24

.1

14.9

42

.6

7.8

32.6

59

.6

15.1

59

.7

25.2

13

23

10

.8

53.2

8 E

nsur

es r

egul

ar r

emov

al a

nd s

afe

disp

osal

of

med

ical

was

te0.

7 0.

7 68

.6

30

2.9

7.1

90

0 40

60

0

6.4

12.1

81

.4

9 E

nsur

es p

atie

nts

safe

ty

0 0.

7 0.

7 98

.6

1.4

5 93

.6

1.4

46.1

52

.5

1.4

5.7

8.5

84.4

10

Fol

low

s in

fect

ion

prev

entio

n gu

idel

ines

0.

7 1.

4 3.

6 94

.3

1.4

12.1

86

.5

1.4

46.4

52

.1

0.7

4.3

17.9

77

.1

11

Mob

ilize

s he

alth

faci

lity

reso

urce

s ne

eded

to c

are

for

the

clie

nts

6.4

9.2

8.5

75.9

2.

8 17

.7

79.4

0.

7 66

.7

32.6

5.

7 33

.3

19.9

41

.1

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

48

F

RE

QU

EN

CY

C

RIT

ICA

LIT

Y

(IM

PO

RT

AN

CE

) P

ER

FO

RM

AN

CE

(C

AP

AB

ILIT

Y)

LO

CA

TIO

N

(WH

EN

/WH

ER

E T

RA

INE

D)

Never

Low (Rarely)

Moderate (Monthly)


Low

Moderate

High

Not capable


Proficient

Not trained

On-the-job

In-service

Pre-service

Pat

ien

t ed

uca

tio

n

12

Col

labo

rate

s w

ith th

e co

mm

unity

to id

entif

y pr

iorit

y he

alth

edu

catio

nne

eds

27

23.4

17

.7

31.9

10

.6

34

55.3

12

.1

61

27

7.1

15.6

7.

1 70

.2

13

Util

izes

cul

tura

lly a

nd li

ngui

stic

ally

app

ropr

iate

ed

ucat

iona

lmat

eria

ls w

hen

avai

labl

e17

.9

31.4

8.

6 42

.1

15

40.7

44

.3

9.3

64.3

26

.4

11.4

19

.2

6.4

63.1

Rec

ord

s

14

Col

lect

s da

ta u

sing

the

corr

ect h

ealth

info

rmat

ion

s yst

em to

ols

2.1

5 4.

3 88

.7

7.1

14.9

78

1.

4 53

.2

45.4

4.

3 20

.6

8.5

66.7

15

Util

izes

dat

a fr

om h

ealth

info

rmat

ion

syst

em

3.6

7.2

9.4

80

6.5

22.3

71

.2

2.9

65.7

31

.4

2.8

32.6

12

.8

51.8

16

Rep

orts

not

ifiab

le m

edic

al c

ondi

tions

acc

ordi

ng to

pr

otoc

ol7.

9 5.

7 10

.7

75.7

5.

7 7.

9 86

.4

2.1

46.1

51

.8

3.6

40.4

17

.7

38.3

17

Kee

ps r

egis

ters

and

mon

thly

rep

orts

up-

to-d

ate

3.6

7.1

21.3

68

.1

11.4

24

.8

63.8

3.

6 38

.9

37.6

2.

8 58

.2

10.6

28

.4

18

Sub

mits

mon

thly

rep

orts

as

requ

ired

8.5

13.5

68

.8

9.2

14.9

19

.9

65.2

5.

7 56

.4

37.9

5.

7 65

.7

12.9

15

.7

Co

mm

un

ity-

an

d h

om

e-b

ased

car

e

19

Mai

ntai

ns li

nks

with

the

com

mun

ity h

ealth

co

mm

ittee

, civ

ic o

rgan

izat

ions

, sch

ools

, wor

kpla

ces,

po

litic

al le

ader

s, a

nd w

ard

coun

cilo

rs

39

33.3

14

.2

13.5

18

.4

36.9

44

.7

19.2

63

.1

17.7

14

.3

22.9

5.

7 57

.1

20

Con

duct

s re

gula

r ho

me

visi

ts

50.3

24

.1

5.7

19.9

10

.6

31.2

58

.2

14.3

52

.9

32.9

5

6.4

5.7

82.9

Ref

erra

l

21

Ref

ers

clie

nts

in a

ccor

danc

e w

ith p

olic

y an

d gu

idel

ines

7.

9 5.

7 5.

7 80

.7

5 11

.4

83.6

1.

4 52

.9

45.7

4.

3 31

.9

7.8

56

22

Arr

ange

s tr

ansp

ort f

or a

n em

erge

ncy

with

in o

ne h

our

12.9

15

.7

7.9

63.6

0.

7 5.

7 93

.6

5 44

.3

50.7

11

.4

51.4

7.

9 29

.3

23

Com

mun

icat

es e

ffect

ivel

y th

roug

hout

the

refe

rral

pr

oces

s2.

1 12

.8

5 80

.1

2.1

14.9

83

2.

8 52

.5

44.7

6.

4 51

.1

7.8

34.8

24

Rec

ords

refe

rral

s ap

prop

riate

ly

2.1

7.8

10.6

79

.4

10.6

24

.1

65.3

0.

7 48

.9

50.4

5

56.7

12

.8

25.5

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

49

F

RE

QU

EN

CY

C

RIT

ICA

LIT

Y

(IM

PO

RT

AN

CE

) P

ER

FO

RM

AN

CE

(C

AP

AB

ILIT

Y)

LO

CA

TIO

N

(WH

EN

/WH

ER

E T

RA

INE

D)

Never

Low (Rarely)

Moderate (Monthly)


Low

Moderate

High

Not capable


Proficient

Not trained

On-the-job

In-service

Pre-service

25

Par

ticip

ates

in r

evie

w o

f ref

erre

d ca

ses

as p

art o

f co

ntin

uin g

educ

atio

n an

d qu

ality

impr

ovem

ent

7.8

31.2

10

.6

50.4

7.

1 32

.6

60.2

7.

1 61

.7

31.2

12

.8

46.8

9.

2 31

.2

Pro

fess

ion

al d

evel

op

men

t

26

Par

ticip

ates

in c

ontin

uing

edu

catio

n ac

tiviti

es

9.3

25.7

12

.1

52.9

10

25

.7

64.3

6.

4 58

.6

35

7.2

30.9

13

.7

48.2

27

Mai

ntai

ns a

ctiv

e m

embe

rshi

p of

the

nurs

ing

asso

ciat

ion

5.9

22.2

20

51

.9

20

22.2

57

.8

8.8

46.7

44

.5

11

22.1

12

.5

54.4

28

Par

ticip

ates

in c

omm

unity

act

iviti

es

18.8

43

.5

18.1

19

.6

21

39.1

39

.9

11.7

53

.3

35

9.5

20.4

8

62

29

Par

ticip

ates

in q

ualit

y im

prov

emen

t ini

tiativ

es

4.4

21.2

16

.8

57.7

7.

3 31

.4

61.3

5.

1 67

.9

27

10.9

40

.6

13

35.5

30

Con

trib

utes

to th

e cl

inic

al e

duca

tion

of s

tude

nts

15.9

25

.4

11.6

47

.1

2.9

23.2

73

.9

5.8

53.6

40

.6

15.4

34

.6

8.1

41.9

Clin

ical

Nu

rsin

g T

asks

Sex

ual

an

d r

epro

du

ctiv

e h

ealt

h (

SR

H)

31

Pro

vide

s ef

fect

ive

ante

nata

l car

e 48

.6

23.9

2.

9 24

.6

3.6

10.9

85

.5

23.2

52

.9

23.9

17

.4

7.3

5.1

70.3

32

Pre

vent

s, r

ecog

nize

s, a

nd r

efer

s pr

e-ec

lam

psia

and

ec

lam

psia

52.2

23

.2

1.5

23.2

0.

7 5.

8 93

.5

26.8

52

.2

21

21.7

8.

7 3.

6 65

.9

33

Pro

vide

s ef

fect

ive

intr

apar

tum

car

e 63

.8

21.7

1.

5 13

2.

2 10

.1

87.7

40

.6

41.3

18

.1

29

8 5.

8 57

.3

34

Pro

vide

s ef

fect

ive

post

nata

l car

e 54

.4

22.5

4.

4 18

.8

4.4

10.9

84

.8

29

50.7

20

.3

20.3

5.

8 5.

1 68

.8

35

Pre

vent

s, re

cogn

izes

, and

ref

ers

post

part

um

hem

orrh

a ge

58.4

25

.6

1.5

14.6

2.

2 5.

1 92

.7

29.2

50

.4

20.4

23

.9

5.1

5.1

65.9

36

Pro

vide

s ef

fect

ive

fam

ily p

lann

ing

29

23.2

5.

8 42

6.

5 26

.8

66.7

5.

8 58

36

.2

2.2

2.9

5.1

89.9

37

Pro

vide

s ef

fect

ive

care

to c

lient

s w

ith s

exua

lly

tran

smitt

ed in

fect

ions

11

.8

16.9

4.

4 66

.9

2.2

13.2

84

.6

3.7

46

50.3

1.

5 5.

8 10

.9

81.9

38

Pro

vide

s ef

fect

ive

PM

TC

T

44.9

26

.1

2.9

26.1

2.

2 5.

1 92

.8

19.6

52

.2

28.3

18

.8

7.3

13.8

60

.1

39

Pro

vide

s ef

fect

ive

yout

h-fr

iend

ly a

dole

scen

t SR

H

serv

ices

43.5

16

.7

3.6

36.2

5.

1 29

65

.9

10.2

56

.2

33.6

8.

8 16

.1

9.5

65.7

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

50

F

RE

QU

EN

CY

C

RIT

ICA

LIT

Y

(IM

PO

RT

AN

CE

) P

ER

FO

RM

AN

CE

(C

AP

AB

ILIT

Y)

LO

CA

TIO

N

(WH

EN

/WH

ER

E T

RA

INE

D)

Never

Low (Rarely)

Moderate (Monthly)


Low

Moderate

High

Not capable


Proficient

Not trained

On-the-job

In-service

Pre-service

40

Scr

eens

, adv

ises

, and

ref

ers

infe

rtili

ty c

ases

as

per

natio

nal g

uide

lines

63.8

27

.5

1.5

7.3

11.6

30

.4

58

32.6

50

.7

16.7

40

.6

13

2.9

42.8

41

Pro

mot

es m

ale

invo

lvem

ent i

n S

RH

38

24

.8

8 29

.2

14.6

22

.6

62.8

12

.5

58.1

29

.4

15.4

19

.9

11.8

52

.9

42

Res

pond

s ap

prop

riate

ly to

gen

der-

base

d vi

olen

ce

(inc

lude

sra

pe)

30.4

29

.7

6.5

33.3

4.

6 15

.2

80.4

11

.6

63

25.4

18

.1

23.9

8.

7 49

.3

43

Pro

vide

s ef

fect

ive

post

abor

tion

care

39

.1

24.6

8.

7 27

.5

3.6

10.9

85

.5

16.7

52

.9

30.4

14

.5

21

4.4

60.1

44

Pro

vide

s ef

fect

ive

scre

enin

g an

d ca

re fo

r cl

ient

s w

ith

repr

oduc

tive

canc

ers

42

29

2.9

26.1

2.

2 5.

1 92

.8

21.7

53

.6

24.6

23

.4

21.2

6.

6 48

.9

Ch

ild h

ealt

h

45

Pro

vide

s se

rvic

es le

adin

g to

imm

uniz

atio

n ac

cord

ing

to p

roto

col

41

13.7

5

40.3

11

.5

12.2

76

.3

3.6

56.8

39

.6

0 0

7.2

92.8

46

Pro

vide

s ca

re a

nd tr

eatm

ent o

f chi

ldre

n w

ith d

iarr

hea

26.1

7.

3 2.

9 63

.8

2.9

5.1

92

2.2

51.5

46

.4

0.7

7.2

14.4

77

.7

47

Pro

vide

s ca

re a

nd tr

eatm

ent o

f chi

ldre

n w

ith

res p

irato

ryin

fect

ions

27

.3

10.1

6.

5 56

.1

2.9

3.6

93.5

4.

3 63

.3

32.4

2.

2 12

.2

12.2

73

.4

48

Pro

vide

s ca

re a

nd tr

eatm

ent o

f chi

ldre

n w

ith

mal

nutr

ition

30.9

28

.8

11.5

28

.8

2.9

20.1

77

5.

8 58

.3

36

3.6

13

12.2

71

.2

49

Pro

vide

s m

icro

nutr

ient

sup

plem

enta

tion

to c

hild

ren

47.1

17

.4

13.8

21

.7

8 34

.1

58

18.8

58

23

.2

15.9

18

.8

15.2

50

50

Pro

vide

s ca

re a

nd tr

eatm

ent o

f chi

ldre

n w

ith

HIV

/AID

S37

.2

23.4

11

28

.5

2.9

8.8

88.3

12

.3

59.4

28

.3

17.4

12

.3

28.3

42

51

Pro

vide

s sc

hool

hea

lth

66.7

18

.8

10.1

4.

4 26

.8

37.7

35

.5

13.8

55

.8

30.4

6.

6 4.

4 9.

5 79

.6

52

Pro

vide

s ca

re to

orp

hans

and

vul

nera

ble

child

ren

58

30.4

7.

3 4.

4 15

.2

44.2

40

.6

25.4

59

.4

15.2

39

.9

16.7

5.

8 37

.7

53

Pro

vide

s ca

re to

chi

ldre

n w

ith d

isab

ilitie

s 48

.9

32.1

10

.2

8.8

11

32.1

56

.9

24.8

57

.7

17.5

31

.4

13.1

8

47.5

Co

mm

un

icab

le d

isea

ses

54

Pro

vide

s H

IV/A

IDS

pre

vent

ive

serv

ices

5.

1 15

.9

8 71

2.

9 13

84

.1

2.9

53.6

43

.5

2.9

8.7

22.5

65

.9

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

51

F

RE

QU

EN

CY

C

RIT

ICA

LIT

Y

(IM

PO

RT

AN

CE

) P

ER

FO

RM

AN

CE

(C

AP

AB

ILIT

Y)

LO

CA

TIO

N

(WH

EN

/WH

ER

E T

RA

INE

D)

Never

Low (Rarely)

Moderate (Monthly)


Low

Moderate

High

Not capable


Proficient

Not trained

On-the-job

In-service

Pre-service

55

Rec

ogni

zes,

trea

ts, a

nd/o

r re

fers

pat

ient

s w

ith

o ppo

rtun

istic

infe

ctio

ns

6.5

20.3

13

.8

59.4

0.

7 10

.9

88.4

4.

4 57

.3

38.4

2.

2 12

.4

21.2

64

.2

56

Pro

vide

s A

RV

ther

apy

45.7

10

.9

6.5

37

1.5

7.3

91.3

29

.7

42

28.3

31

.6

15.4

22

.1

30.9

57

Pro

vide

s ca

re a

nd tr

eatm

ent t

o pe

ople

livi

ng w

ith

HIV

/AID

S8.

7 12

.3

5.1

73.9

1.

5 9.

4 89

.1

5.8

62.3

31

.9

4.4

11.7

21

.9

62

58

Pro

vide

s T

B p

reve

ntiv

e se

rvic

es

8 13

.8

6.5

71.7

1.

5 4.

4 94

.2

2.2

47.1

50

.7

0.7

9.5

25.6

64

.2

59

Rec

ogni

zes

and

refe

rs p

atie

nts

with

MD

R-T

B

34.8

48

.6

7.3

9.4

0.7

2.9

96.4

16

.7

58

25.4

15

.9

23.2

24

.6

36.2

60

Pro

vide

s ca

re a

nd tr

eatm

ent t

o cl

ient

s in

fect

ed w

ith

TB

7.

3 16

.7

7.3

68.8

0.

7 8.

7 90

.6

2.2

49.3

48

.6

3.6

8.7

23.9

63

.8

61

Pro

vide

s m

alar

ia p

reve

ntiv

e se

rvic

es

40.6

34

.1

10.1

15

.2

2.2

16.7

81

.2

10.9

63

.8

25.4

8.

7 11

.6

14.5

65

.2

62

Pro

vide

s ca

re a

nd tr

eatm

ent t

o cl

ient

s in

fect

ed w

ith

mal

aria

42

42

.8

8 7.

3 0.

7 12

.3

87

15.9

62

.3

21.7

10

.1

9.4

20.3

60

.1

63

Pro

vide

s pr

even

tive

serv

ices

for

diar

rhea

l dis

ease

s 13

.8

10.9

10

.9

64.5

2.

9 12

.3

84.8

1.

5 53

.6

44.9

0

11.6

10

.1

78.3

64

Pro

vide

s ca

re a

nd tr

eatm

ent t

o cl

ient

s w

ith d

iarr

heal

di

seas

es10

.2

13.1

8

68.6

0.

7 12

.4

86.9

2.

2 56

.9

40.9

0.

7 10

.2

7.3

81.8

65

Pro

vide

s ca

re a

nd tr

eatm

ent t

o cl

ient

s w

ith

com

mun

icab

le re

spira

tory

infe

ctio

n in

clud

ing

influ

enza

8 13

.8

8 70

.3

4.4

19.6

76

.1

1.5

62.8

35

.8

0.7

11.7

5.

8 81

.8

66

Pro

vide

s ca

re a

nd tr

eatm

ent t

o cl

ient

s w

ith

men

ingi

tis

57.5

0

21.3

21

.3

1.3

5 93

.8

16.1

59

.1

24.8

9.

5 11

.7

5.1

73.7

67

Pro

vide

s ca

re a

nd tr

eatm

ent t

o cl

ient

s w

ith

derm

atol

ogic

al d

isea

ses

21.9

36

.5

13.1

28

.5

14.6

45

.3

40.2

13

.9

67.2

19

9.

5 13

.9

2.2

74.5

68

Pro

vide

s ca

re a

nd tr

eatm

ent t

o cl

ient

s w

ith le

pros

y 82

.5

13.1

0.

7 3.

7 5.

1 18

.3

76.6

53

.7

37.5

8.

8 48

.2

2.2

9.5

40.2

69

Pro

vide

s pr

even

tive

serv

ices

for

noso

com

ial i

nfec

tion

6.5

9.4

2.9

81.2

7.

3 25

.4

67.4

2.

9 41

.3

55.8

2.

2 6.

5 6.

5 84

.8

Lin

kin

g L

icen

sure

Exa

min

atio

ns

to N

urs

ing

Pra

ctic

e th

rou

gh

Tas

k A

nal

ysis

: A

Cas

e fo

r B

ots

wan

a

52

F

RE

QU

EN

CY

C

RIT

ICA

LIT

Y

(IM

PO

RT

AN

CE

) P

ER

FO

RM

AN

CE

(C

AP

AB

ILIT

Y)

LO

CA

TIO

N

(WH

EN

/WH

ER

E T

RA

INE

D)

Never

Low (Rarely)

Moderate (Monthly)


Low

Moderate

High

Not capable


Proficient

Not trained

On-the-job

In-service

Pre-service

70

Pro

vide

s se

rvic

es r

elat

ed to

the

prev

entio

n an

d m

ana g

emen

tofe

mer

ging

infe

ctio

us d

isea

ses

17.4

29

.7

9.4

43.5

2.

2 19

.6

78.3

18

.8

63

18.1

21

.7

15.9

8.

7 53

.6

No

nco

mm

un

icab

le d

isea

ses

and

co

nd

itio

ns

71

Pro

vide

s se

rvic

es to

opt

imiz

e pa

tient

men

tal h

ealth

19

.4

29.9

10

.5

40.3

6

4.8

49.3

11

.1

65.9

23

7.

5 5.

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APPENDIX 10: TASKS RATED “NEVER” PERFORMED BY A HIGH PERCENTAGE OF RESPONDENTS Table 7. Tasks never performed by the relative majority of nurses


% OF NURSES RESPONDED

“NEVER—LACKS OPPORTUNITY TO PERFORM

TASK”

19 Maintains links with the community health committee, civic organizations, schools, workplaces, political leaders, and ward councilors

39

20 Conducts regular home visits 50.3

31 Provides effective antenatal care 48.6

32 Prevents, recognizes, and refers pre-eclampsia and eclampsia 52.2

33 Provides effective intrapartum care 63.8

34 Provides effective postnatal care 54.4

35 Prevents, recognizes and refers postpartum hemorrhage 58.4

38 Provides effective PMTCT 44.9

39 Provides effective youth-friendly adolescent SRH 43.5

40 Screens, advises, and refers infertility cases as per national guidelines

63.8

41 Promotes male involvement in SRH 38

43 Provides effective postabortion care 39.1


42

45 Provides services leading to immunization according to protocol 41

49 Provides micronutrient supplementation to children 47.1

50 Provides care and treatment of children with HIV/AIDS 37.2

51 Provides school health 66.7

52 Provides care to orphans and vulnerable children 58

53 Provides care to children with disabilities 48.9

56 Provides ARV therapy 45.7

61 Provides malaria preventive services 40.6

62 Provides care and treatment to clients infected with malaria 42

66 Provides care and treatment to clients with meningitis 57.5

68 Provides care and treatment to clients with leprosy 82.5


APPENDIX 11: ON-THE-JOB TASKS Table 8. Tasks for which the relative majority of nurses were trained on-the-job

TASK #

TASK DESCRIPTION % OF NURSES REPORTING

TRAINING “ON-THE-JOB”

16 Reports notifiable medical conditions according to protocol 40.4%

17 Keeps registers and monthly reports up-to-date 58.2%

18 Submits monthly reports as required 65.7%

22 Arranges transport for an emergency within one hour 51.4%

23 Communicates effectively throughout the referral process 51.1%

24 Records referrals appropriately 56.7%

25 Participates in review of referred cases as part of continuing education and quality improvement

46.8%

29 Participates in quality improvement initiatives 40.6%


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Oshio S, Johnson P, and Fullerton J. 2002. The 1999–2000 task analysis of American nurse-midwifery/midwifery practice. Journal of Midwifery & Women’s Health 47(1): 35–41. doi:101.1016/S1526-9523(01)00218-5. Reamy J and Gedik G. 2001. Health human resource reform in Tajikistan: Part of a masterplan for change. Cahiers de Sociologie et de Démographie Médicales 41(3–4): 327–345. Republic of Botswana. 2011. Nurses and Midwives Regulations. Botswana Government Gazette. Republic of Botswana. 1995. Nurses and midwives act. In: Botswana Statute Law, 1995. Government Printers: Gaborone. StataCorp. 2011. Stata Statistical Software: Release 12. StataCorp LP: College Station, TX. UNAIDS. 2012. HIV and AIDS Estimates. http://www.unaids.org/en/regionscountries/countries/botswana/ (Accessed February 11, 2014). University of Botswana. 2008. Curriculum for Bachelor of Science Degree in Nursing. University of Botswana: Gaborone. World Health Organization. 2014. Atlas of African Health Statistics 2014: Health Situation Analysis of the African Region. WHO Regional Office for Africa: Brazzaville. http://www.aho.afro.who.int/sites/default/files/publications/921/AFRO-Statistical_Factsheet.pdf (Accessed February 18, 2014). World Health Organization. 2012. Surveillance of anti-tuberculosis drug resistance in the world: An updated analysis, 2007–2010. Bulletin of the World Health Organization 90(2): 111–119D. doi:10.2471/BLT.11.092585 (Accessed February 12, 2013).


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Linking Licensure Examinations to Nursing Practice …reprolineplus.org/system/files/resources/FINAL_Botswana...The use of task analysis ensures that education and training curricula