eCommons@AKU

School of Nursing & Midwifery, East Africa Faculty of Health Sciences, East Africa

January 2014

Exploring the potential for advanced nursingpractice role development in Kenya: a qualitativestudyLinda Anne EastThe University of Nottingham

John ArudoMasinde Muliro University of Science and Technology

Martha LoeflerAga Khan University, martha.loefler@aku.edu

Catrin Mai EvansThe University of Nottingham

Follow this and additional works at: http://ecommons.aku.edu/eastafrica_fhs_sonam

Part of the Nursing Commons

Recommended CitationEast, L. A., Arudo, J., Loefler, M., Evans, C. M. (2014). Exploring the potential for advanced nursing practice role development inKenya: a qualitative study. BMC Nursing, 13(33).Available at: http://ecommons.aku.edu/eastafrica_fhs_sonam/56

RESEARCH ARTICLE Open Access

Exploring the potential for advanced nursingpractice role development in Kenya: a qualitativestudyLinda Anne East1*, John Arudo2, Martha Loefler3 and Catrin Mai Evans1

Abstract

Background: Definitions of advanced nursing practice abound, yet little has been published concerning the contextfor advanced nursing in sub-Saharan Africa. This study set out to explore the existence of, and potential for, advancednursing practice in Kenya.

Methods: Ten nurses were invited to participate in semi-structured qualitative interviews. Participants were purposivelyselected to provide insight into the practice of experienced nurses in urban, rural, community, hospital, public andprivate health care settings. Interview narratives were recorded, transcribed and subsequently analysed using athematic approach.

Results: All participants reported that they were engaged in the delivery of expert, evidence-based care. The majorityalso undertook administrative activities, teaching in the practice area and policy and practice advocacy. However, onlythe two private practice nurses interviewed during the study were working with the level of autonomy that might beexpected of advanced nurse practitioners.

Conclusions: While participants were undertaking many of the activities associated with advanced nursing roles,advanced nursing practice as widely understood in the (largely western derived) international literature was not identified.The nurses practicing with the greatest autonomy were generally those with the lowest educational qualifications ratherthan the highest. Highly qualified nurses and midwives tend to move into management and education, and seelittle opportunity for advancement while remaining in clinical practice. It is notable that, although a growingnumber of universities offer master’s level education, no African countries have yet regulated an advanced levelof practice. The existence of the physician substitute ‘clinical officer’ cadre in Kenya, as in other Sub-SaharanAfrican countries, suggests that the development of the advanced nurse practitioner role is unlikely at present.However, there is a pressing need for advanced nurses and midwives who can implement evidence-basedpractice and exercise clinical leadership in the drive to attain the Millennium Development Goals and theirpost-2015 successors.

Keywords: Advanced nursing practice, Sub-Saharan Africa, Task-shifting, Nursing workforce, Qualitative research

* Correspondence: Linda.east@nottingham.ac.uk1School of Health Sciences, South Block Link, Queens Medical Centre,The University of Nottingham, Nottingham NG7 2HA, UKFull list of author information is available at the end of the article

© 2014 East et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0) which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.

East et al. BMC Nursing 2014, 13:33http://www.biomedcentral.com/1472-6955/13/33

IntroductionThis paper presents the findings from a small-scalescoping project that aimed to explore the nature of, andpotential for, advanced nursing practice in Kenya. Theproject was carried out as part of an existing, EuropeanUnion-funded collaboration between the Aga KhanUniversity, East Africa and the University of Nottingham,United Kingdom entitled ‘Improving Nursing Educationand Practice in East Africa’ (INEPEA). INEPEA workedwith universities in Kenya, Uganda and Tanzania to de-velop a shared framework for a master’s level curriculumdesigned to support advanced and specialist nursing prac-tice in the region. The study reported here was conductedas a follow up to an INEPEA situation analysis survey thatidentified the need for more detailed examination of exist-ing senior nursing roles in Kenya, with reference to inter-nationally recognised frameworks for advanced practice.Further details of the INEPEA project and its outcomescan be found online in its final report [1].

BackgroundAccording to the International Council of Nurses (ICN),an Advanced Practice Nurse (APN) is:

A registered nurse who has acquired the expertknowledge base, complex decision-making skills andclinical competencies for advanced practice, the char-acteristics of which are shaped by the context and/orcountry in which s/he is credentialed. A masters de-gree is recommended for entry level [2].

The ICN’s definition emphasises the knowledge andexpertise of the APN, which is derived from both theoryand experience. Contextual variation in APN roles is ac-knowledged, but a master’s degree is recommended foreducational preparation. In general, the APN title em-braces the roles of both nurse practitioner and clinicalnurse specialist, hence ‘APN’ will be used as the um-brella term throughout this paper.APN roles have their roots in healthcare developments

in the United States [3]. The key drivers for APN roledevelopment in many countries has been medical substi-tution alongside a strong professionalising impetus inwhich enhanced status, recognition and remuneration isaccorded to nursing roles through a formalised processof regulation and educational preparation [4]. In manycases, the substitution agenda is clear, but the nursingprofession has had only mixed success in creating recog-nition for an enhanced nursing role through formalisedregulation, education and the development of new careerpathways [5].In a survey of international developments in advanced

nursing practice, Schober and Affara [6] note there is littleevidence documenting the development of recognized

APN roles in Sub-Saharan African countries. However,many African countries are increasingly embracing pol-icies of ‘task-shifting’, or the delegating of tasks upwardsor downwards through the perceived hierarchies of thehealth professions in order to address health workforceshortages [7]. There is a burgeoning literature on taskshifting and, indeed, a growing evidence base demonstrat-ing comparable health outcomes for doctor or nurse ledcare in Sub-Saharan Africa [8]. It is interesting to note,however, that task shifting/medical substitution debates inAfrica appear to be developing quite independently of de-bates and discourses on advanced nursing practice despitethe potential overlaps between the two agendas [3,9]. Arecent survey of nursing and midwifery regulatory reformin east, central and southern Africa concluded that thereis a lack of alignment between the regulatory environmentand the expanding role of nurses and midwives [10].Indeed, to date, it seems that no African countries

have regulated an advanced level of practice and/or de-veloped an acknowledged advanced nursing practice roleunderpinned by graduate education [6]. In the absenceof APN competencies specific to Kenya, therefore, theinternational competency framework developed by theInternational Council of Nurses [2] offered a useful ref-erence point for the INEPEA initiative. In this frame-work, APN competencies are categorised within thethree domains of (a) professional, ethical and legal prac-tice; (b) care provision and management and (c) profes-sional, personal and quality development. In the interestof public protection and workforce planning, the ICNoffer member countries guidance on the scope of prac-tice of an APN, as outlined in Table 1.The ICN’s account of advanced practice nursing shares

much in common with other frameworks and models tobe found in the international literature. For example,

Table 1 APN Scope of Practice [2], p.13

APN practice requires:

• Cognitive, integrative and technical abilities of the qualified nurse toput into practice ethical and culturally safe acts, procedures, protocolsand practice guidelines;

• The nurse to deliver evidence based care in primary, secondary andtertiary settings in urban and rural communities;

• Practice of a high level of autonomy in direct patient care andmanagement of health problems including case managementcompetencies;

• Accountability for providing health promotion, patient and peereducation, mentorship, leadership and management of the practiceenvironment;

• Maintenance of currency and improving nursing practice achievedthrough the translation, utilisation and implementation of meaningfulresearch;

• The nurse to engage in partnerships with patients and health teammembers for determining resources needed for continuous care aswell as partnering with stakeholders in influencing the policy thatdirects the health care environment.

East et al. BMC Nursing 2014, 13:33 Page 2 of 11http://www.biomedcentral.com/1472-6955/13/33

Mantzoukas and Watkinson’s review [11] identified sevengeneric features of advanced nursing practice: the use ofknowledge in practice; critical thinking and analyticalskills; clinical judgement and decision-making skills; pro-fessional leadership and clinical inquiry; coaching andmentoring skills; research skills and the skills for changingpractice. This list does not tie advanced level practice toany particular role or job title, supporting the ICN’s con-tention that APN knowledge and competence is shapedby the needs of the particular context. However, it is not-able that Mantzoukas and Watkinson’s review [11] con-cludes that the common goal of advanced nursing practiceis ‘the attainment of practice autonomy and professionalintegrity within the nursing discipline so as to improve theprovision of care’ (p.35). Their conclusion reflects the em-phasis the ICN guidance places on a high level of auton-omy in direct patient care, including the practical skillsassociated with the management of a clinical caseload.While often treated uncritically, the significance of ‘au-

tonomy’ in delineating the scope of APN practice can bequestioned. For example, one reason for considering au-tonomy to be the hallmark of advanced nursing practicemay be its origins in primary care. The primary careAPN role, in particular, expands nursing into the trad-itional medical domains of examination, diagnosis andthe management of discrete episodes of care, includingprescribing rights. This is often considered to be a defin-ing feature of the APN role within western countries,but may or may not be of significance in the Africancontext. It is therefore important, as stated within theICN definition, to consider the social and economic con-text for advanced nursing; it is to the Kenyan contextthat this paper now turns.

The Kenyan contextKenya is a low-income country situated on the east coastof Africa. Almost 80% of its 40 million people live in ruralareas. With a Gross Domestic Product (GDP) per capitaof $1800, Kenya ranks as the 198th poorest of the 228countries of the world according to 2012 estimates [12].Given Kenya’s proportional spend of GDP on health care

of 4.8% [12], service delivery represents a challenge, par-ticularly in the arid northern areas. Kenya has a pluralistichealth sector consisting of private and non-governmentalproviders operating alongside the public sector in whichservice delivery is organised according to 6 levels from pri-mary to tertiary care (see Figure 1) [13].Kenya has an acute shortage of doctors and nurses

(0.14 doctors and 1.2 nursing/midwifery personnel per1000 population [14]), as compared to a World HealthOrganisation (WHO) recommendation of a minimum of2.5 nurses per 1000 population [15]. The shortage of healthcare personnel has been attributed to a number of factors,including a lack of workforce planning; high attrition of the

health workforce; international and internal migration; theimpact of HIV/AIDS and chronic under-investment inhuman resources for health [15]. As in many sub-SaharanAfrican countries, Kenya has attempted to address theshortage of physicians by developing a mid-level cadre ofnon-physician clinicians known as ‘clinical officers’. Theyreceive three years training and are able to diagnose, pre-scribe and generally manage the care of patients [16].Nurses and midwives in Kenya can be found working

in the enrolled or registered grades. Enrolled nurseswork at the level of dispensaries and above, registerednurses in health centres and above. Registered nursesmay hold either a diploma or a bachelor’s degree, withdegree-qualified nurses generally found in the provincialand referral hospitals. A general registered nurse maytrain for a further year to become a registered midwifeand community health nurse, or can undertake a furtheryear of training in a range of clinical specialities. Enrollednurses, who form 85% of the total nursing work force[17], can follow an education programme to convert toregistered nurse status. There are also opportunities fordiploma-qualified registered nurses to study for a post-registration degree. Enrolled and registered nurses with 5or more years of experience can set up in private practiceas independent health care providers [18]. Within theoverall workforce, the distribution of nurses is skewed to-wards secondary care services: 71.6% work in hospitals,13.2% in health centres and 15.2% in dispensaries [15].Bearing in mind that the ICN consider a master’s degreethe appropriate preparation for an APN, three Kenyan uni-versities currently offer a masters degree in nursing [19].At the time of the INEPEA project there was great en-

thusiasm expressed for advanced nursing practice byKenyan nurse leaders and educators. However, within thecontext described above, it was unclear as to whether and

Figure 1 The six levels of health care service delivery in Kenya.

East et al. BMC Nursing 2014, 13:33 Page 3 of 11http://www.biomedcentral.com/1472-6955/13/33

how APN roles could be developed and implemented inthe East African context, and the extent to which existingsenior nursing roles could be considered ‘advanced’. Thestudy reported here was therefore designed to explore theexisting situation in Kenya, with reference to internation-ally recognised frameworks for advanced practice.

MethodsThis study adopted an exploratory qualitative designbased on semi-structured interviews with ten nurses.The interviews began with an initial generative question -Can you tell me about your first job as a nurse, andthe subsequent development of your career? This ques-tion was designed to elicit a wide-ranging narrative,followed by more focused questions related to advancednursing [20]. Participants were asked to reflect upon(a) their professional and educational backgrounds and(b) the scope, responsibilities and challenges of theircurrent role. A 12 item check-list of typical APN activ-ities was developed based on the domains of practice de-scribed by the ICN [2] and other international literature(Table 2). The check-list was used as a prompt to encour-age participants to reflect upon their day-to-day practice.Study participants were recruited by faculty of the Aga

Khan University, Nairobi (the lead institution for theINEPEA project), and were purposively selected on thebasis that they were working clinically at a level thatmight be considered advanced in the Kenyan context.They were selected to represent a range of clinicalbackgrounds, levels of service provision and rural andurban practice locations (Table 3). Government, privateand not-for-profit (NFP) institutions were also repre-sented. The majority of participants were graduates of

the Aga Khan University’s post-registration Bachelor ofScience in Nursing (BScN), the ‘Advanced Nursing Studies’programme. In addition, and as further discussion aboutthe nature of advanced practice took place between theUK and Kenyan faculty, it became clear that it was alsoimportant to speak with nurses practicing independ-ently as private practice nurses (PPNs). Their scope ofpractice appeared to embrace many of the activities gener-ally held to indicate advanced practice in the internationalcontext, although higher level nursing education for thePPN role is limited and their role would not generally beconsidered ‘senior’.Ethical approval for the study was secured from the

Aga Khan University as a follow-up to a situational ana-lysis conducted as part of the INEPEA project [1]. Allnurses were contacted in advance and invited to partici-pate in the study by a member of the administrative staffof the Aga Khan University. Interviews were conductedin the participant’s own workplace, with the UK facultyas the main interviewer and the AKU faculty as liaisonand support. Each participant was given an informationsheet and asked to sign a consent form. With permis-sion, interviews were recorded using a digital recorderand later transcribed in full.

Data analysisA thematic analysis of the interview transcripts was con-ducted using the steps advocated by Charmaz [21]:

1. initial coding, where the transcripts are read closely,line-by-line, and the researcher asks questions suchas ‘what is happening here?’

2. selective (focused) coding, where the researcher usesfrequently reappearing initial codes to sort andsynthesise the data;

3. the development of categories (themes) and analyticframeworks from the focussed codes.

The initial coding stage was undertaken by the firstauthor and produced 18 codes, generally reflecting thetopics in the interview schedule but also revealing new,unanticipated topics of concern to the participants. Fol-lowing selective coding, the number of codes was re-duced to 12. In order to enhance rigour of the analysisand the credibility of the findings [22], the codes werereviewed and agreed by all four authors. The team col-lectively identified three key themes of significance inthe debate concerning the context for advancing nursingpractice in the Kenyan context:

� scope and activities of daily practice;� contexts that constrain nurses from acting

autonomously;� contexts that facilitate autonomous practice.

Table 2 Check-list of typical APN activities [2,11,24]

1. Direct delivery of expert care to patients, families and/orcommunities as part of a health care team (assessing, planningimplementing and evaluating nursing care; health promotion)

2. Managing own, independent case load of patients: autonomouspractice (assessing, diagnosing, planning and implementingtreatment programmes, evaluating outcomes)

3. Advising other health workers on direct care (acting as a consultant)

4. Advocating for policy and practice improvement with managersand/or MoH

5. Teaching colleagues and students in the practice area

6. Formal teaching in the classroom setting

7. Spending time in the library or online to identify evidence forpractice

8. Collecting data on service outcomes for audit and evaluation

9. Formulating protocols and guidelines for the service

10. Carrying out primary research as lead investigator

11. Carrying out primary research as team member

12. Administration (managing staff and resources, maintaining records)

East et al. BMC Nursing 2014, 13:33 Page 4 of 11http://www.biomedcentral.com/1472-6955/13/33

ResultsAll interview participants were female, senior, experi-enced nurses with an average of 20 years experience(ranging from 9 to 34 years). Five of the 10 participantswere dual qualified as both nurse and midwife, and 8were graduates of the Aga Khan Advanced NursingStudies programme. Of the private practice nurses, oneheld a bachelor’s degree in community development anda master’s degree in public health (not mandatory for herpractice); the other held a diploma-level qualification.

Scope and activities of daily practiceAs was a precondition for inclusion in this study, allinterview participants were engaged in the direct deliv-ery of expert care to patients, families and/or communi-ties as part of a health care team. We also found that all10 participants were engaged in collecting service datafor audit and evaluation and a variety of other adminis-trative duties including resource management, recordkeeping, rostering and bed allocation (Figure 2).As might be expected of a group of degree-level senior

nurses, the majority of BScN qualified participants wereinvolved in teaching in the practice area, advising otherhealth workers and advocating for policy and practiceimprovement. However, only one of the nurses inter-viewed contributed to formulating protocols and guide-lines for their service area, or to classroom teaching intheir specialist field.All participants reported that they were able to access

the internet and/or local libraries to obtain evidence forpractice, thus utilising research findings in practice.However, none of those interviewed were leading researchprojects (including Participant 2, who was involved in theimplementation rather than leadership of research).During the interviews, we asked participants to de-

scribe their typical day. For the provincial and referralhospital nurses, a typical day was instantly recognisable

to the UK researchers and is arguably typical for hos-pital nurses the world over. The day began with takingreport from the night nurses, allocating staff to the ap-propriate areas, reviewing bed availability, overseeingadmissions and discharges and accompanying doctorson their rounds. Depending on whether the participantwas leading the shift, they would take on the clinicalcare of a group of patients and organise that care ac-cording to the principles of the nursing process. As se-nior nurses, they also reported having to attend manymeetings.Participants working in rural and primary care settings

described a large public health element to their roles as aresult of the poor living conditions of their populations:

Just down here, this is a slum area, so the kind ofclients we will have are those coming from lowsocio economic background, with conditions like TB.We have a lot of malaria. Recently we had acholera outbreak, which is already under control.Children with respiratory tract infections, which isprobably because of the dust and the kind ofenvironment. There is no proper drainage or sewer.(Participant 1)

In the rural areas, an APN activity such as advocatingfor policy and practice improvement could take on adifferent guise to that which might be expected in moreaffluent countries. Participant 5, for example, was aDistrict Public Health Nurse working in a remote vil-lage about four hours from Nairobi. As a BScN Ad-vanced Nursing Studies graduate, she was keen to keepher own knowledge and expertise up to date, and alsoto enable local people to connect to the wider world.She therefore lobbied one of the national mobile phonenetworks to erect a telecoms mast, thus enabling localpeople to make phone calls and equipping the rural

Table 3 Characteristics of interview participants

Role & nursing qualification Setting: community Setting: hospital Setting:urban

Setting:rural

1. Nursing officer (BScN) District hospital (Level 4) x

2. Head nurse/ research nurse (BScN) Research-funded primary care clinic (Level 2) x

3. Nursing officer (BScN) National referral hospital (Level 6) x

4. Shift leader (BScN) Private/NFP hospital (Level 6) x

5. District public health nurse (BScN) District hospital (Level 4) x

6. Shift leader (BScN) Private/NFP hospital (Level 5) x

7. Sister-in-charge (BScN) NFP/mission hospital (Level 4) x

8. Head nurse (BScN) Outreach clinic (Level 3) x

9. Private practice nurse (Dip Nursing) Independent private practice (Level 3) x

10. Private practice nurse (Dip Nursing) Independent private practice (Level 3) x

East et al. BMC Nursing 2014, 13:33 Page 5 of 11http://www.biomedcentral.com/1472-6955/13/33

district hospital with access to the internet: ‘we reallyhave to be proactive’.On the whole, and despite the challenging conditions,

the BScN nurses we spoke to enjoyed their jobs. Despitetheir seniority, they drew the greatest satisfaction fromhands-on care and making a difference in their patients’lives:

Personally, as an individual, I like being there. Whena patient comes, particularly, a complicated case, or avery ill child, I want to work with that childthroughout their stay here. The junior nurse may dothe vital signs, the nurse may do this and that, but I’llbe there. So you find that at one point, I also dosomething. My role does not mandate that I do that, butthere’s no way I can stay away from it. (Participant 8)

To summarise, the participants in this study wereundertaking many of the activities associated with the ad-vanced practice role as outlined in Table 2. However, wefound that none of the BScN nurses were acting with thedegree of autonomy required to manage their own case-loads, often considered a hallmark of advanced nursingpractice [11]. The factors constraining the degree-qualifiednurses’ autonomy will be considered in the next section.

Contexts that constrain nurses from acting autonomouslyAs noted above, the role of the senior nurses in hospitalcould be recognised as the role of the acute care nursethe world over. To some respondents, this role offered aconsiderable degree of autonomy in the management oftheir department:

I have a lot of autonomy - with the patients who comehere, I have a lot of say. In this trauma theatre, we de-cided we can only see trauma patients - gun shots, stab

wounds, fractures, clean cases. Anything infectious, wedon’t do. (Participant 3)

However, in relation to clinical decision-making, thehospital nurses reported that their practice was limitedby the traditional doctor-nurse role hierarchy. An inter-esting account was given by Participant 4, whose rolewas that of shift leader (senior staff nurse). She washighly experienced, having worked on the neonatal unitfor 18 years and having completed a six week neonatalintensive care course overseas. However, in the absenceof an advanced practitioner role, even experiencednurses had to defer to, or cover for, doctors. Participant4 described her frustration thus:

I cannot take a pen and prescribe a fluid, for example,but I know how to do it. So I can assist him to do it,but he’s the one to write it down.

Participant 4 explained that the regulatory context inKenya allows qualified nurses to prescribe from a limitedrange of medicines in particular circumstances, but thiswould not generally extend to an acute care hospitalenvironment.Other hospital nurses expressed their frustration at the

slow pace of change and the power of the medical pro-fession. For example, Participant 7 was a senior nurseworking in the maternity unit of a mission hospital onthe outskirts of Nairobi. She had worked in several otherAfrican countries, often with limited medical back up,and completed the BScN Advanced Nursing Studies in2008. She was keen to base practice on evidence, for ex-ample, arguing against the need for pubic shaving whenwomen are in labour. She described the process of tryingto change practice as frustrating, with resistance fromboth medical and nursing colleagues:

0 1 2 3 4 5 6 7 8 9 10

Research, lead investigator

Formulating protocols

Formal classroom teaching

Research, team member

Managing own caseload

Policy and practice advocacy

Advising other workers

Teaching in the practice area

Administration

Collecting outcomes data

Gathering evidence

Direct delivery of expert care

Figure 2 Typical APN activities as demonstrated in nursing roles.

East et al. BMC Nursing 2014, 13:33 Page 6 of 11http://www.biomedcentral.com/1472-6955/13/33

My biggest struggle, or experience of resistance, will beif you come up with an idea - dealing with the trad-itional way of doing things is always hard. You knowthe doctors, they have their own mindset and theyhave what they have learnt. OK, it’s also in us, it’s notonly the doctors - we also prefer to do things the waywe’ve always done them.

Thus, the interviews suggested that there were someareas of conflict at the interface between nursing andthe medical profession. Within a hospital context, it ap-peared that nurses were expected to defer to the expert-ise of doctors and had limited autonomy in clinicaldecision-making. Even in the two rural district hospitals,the BScN qualified nurses were not managing caseloadswith the degree of autonomy that might be expected ofan APN. In the cases of Participants 1 and 5, the clinicalofficers were making the initial contact with patients,examining, diagnosing and prescribing treatment. Thedual qualified nurse/midwives, on the other hand, ranthe maternity services. Participant 1 described the div-ision of labour between nurses and clinical officers inher district hospital as follows:

Mostly they (clinical officers) do the clerking of thepatients. The nurses handle the midwifery, from theantenatal clinic all the way to the deliveries, thereferrals and everything else. But the clinical officershandle the outpatients, clerking, seeing the sick adultsand also seeing the sick under fives. (Participant 1)

Participant 5 expressed a sense of frustration thatnurses were not considered appropriate personnel tomanage the rural hospitals – a role generally allocated tothe clinical officer:

It’s been a contentious issue, especially now that thenurses have got an opportunity to go and do a degree.But then again, there are policies. Maybe the policywill need to be changed to give an opportunity tonurses to become in-charges. Because in many casesthe nurses do a marvellous job, they really run thefacilities very well. You’d find that the clinical officerwill come back to you again for consultation, ‘What dowe do? What can we do here?’ (Participant 5)

Given the hierarchical nature of health care profes-sional roles in the Kenyan context, and the lack of a clin-ical career pathway, it is perhaps not surprising that fewof the BScN nurses expressed a desire for further educa-tion in specialist or advanced nursing practice. Partici-pant 4 was a notable exception, explaining that shewould love to undertake further training in neonatalnursing. However, she noted the lack of opportunities

for specialist nurses such as herself: ‘with nursing, I havecome now to know that, when you are clinical, you mightremain there for a long time, and your talents are notreally noticed’. Although the BScN nurses spoke verypositively about the knowledge and confidence they hadgained through studying for their Advanced NursingStudies degree, only two wanted to undertake a master’sdegree in nursing, as compared to four who aspired to amaster’s in public health, one in research methods andone in international development.

Contexts that facilitate autonomous practiceAs noted earlier, with reference to Figure 1, degree-qualified nurses in Kenya are generally found in the pro-vincial and referral hospitals (although our study includedtwo BScN nurses working at Level 4 district hospitals).Given the emphasis of the International Council ofNurses’ and other international frameworks for APN ongraduate education, the UK faculty expected to find theAdvanced Nursing Studies BScN graduates to be workingwith higher levels of clinical autonomy. However, as datacollection progressed and further discussion took place, itemerged that the cadre of nurses known as Private Prac-tice Nurses (PPNs) in Kenya were practising with a degreeof independence and autonomy that is often associatedwith APN in western countries.Only two PPNs were interviewed during the course of

this study due to its exploratory nature and time and re-source constraints. However, the PPNs’ views and experi-ences are represented here as relevant to the considerationof contexts for advanced practice in Kenya. Both nursesmaintained independent practices located in Nairobi. Par-ticipant 10 worked in an affluent suburb, serving mainly theemployees of the richer households, and Participant 9 oper-ated in a poorer area of the city. To gain a license to prac-tice independently, nurses in Kenya must have at least fiveyears’ experience and undergo regular inspection by theMinistry of Health. It is often enrolled nurses who set up inbusiness; private practice is not considered appropriate fordegree-educated nurses, who are expected to be in posi-tions of leadership in secondary and tertiary care services.However, the two PPNs we spoke to operated with a

high level of independence and autonomy. In the case ofthe first clinic, the PPN (Participant 10) had a suite ofrooms including a consulting room and a treatment roomwhere minor surgical operations can be performed. Sheemployed a technician and had a laboratory equipped toundertake simple tests, plus basic X Ray facilities. ThisPPN described a network of doctors she could call uponwhen a client needed a surgical or medical intervention,with gynaecology being the clinic’s specialism:

In our minor theatre we do kind of a day surgery,where patients come for minor operations and are able

East et al. BMC Nursing 2014, 13:33 Page 7 of 11http://www.biomedcentral.com/1472-6955/13/33

to go home same day. We do dilatation and curettage,post abortion care for missed abortions or incompleteabortions. We do circumcisions for those who are to becircumcised, especially school/college children. We alsodo biopsies from the breast, from any other parts ofthe body, and we send the samples to Nairobi Hospitalfor histopathology, to detect whether it was cancer orjust a benign growth. We also do minor skin operations,and stitching of wounds and cuts, and dressings, andburns management.

It should be noted that the client’s initial appointmentat the clinic was always with the PPN, who took a his-tory and carried out a clinical examination, with the out-come being treatment in the clinic by the nurse or aphysician/surgeon she employed, or referral on to thehospital if necessary. Participant 10 also ran a home careservice, employing health care assistants to deliver careto clients in their home. A true entrepreneur, she wasseeking the capital to establish a residential facility forolder people, as Kenyan families are becoming increas-ingly fragmented, with adult children often workingoverseas. However, she was also committed to running afree clinic on an outreach basis in the local slum areaand facilitating community development.In contrast to the facilities of Participant 10’s clinic,

Participant 9 had a very small consulting room in amuch poorer area. Her practice was mainly based on thecare of children, and she reported taking a holistic ap-proach to disease management:

So when the patient comes in, of course I’ll sit themdown, usually we laugh and we have very goodrelationship, cordial relationships. I take the wholehistory about their sickness, whether there’s the sameasthma in the family, and so on and so forth. I comeup with a tentative diagnosis, then I take theobservations, take their temperature, and check theirblood, I check their chest, I auscultate the chest, andlook at even general conditions of the child, and askquestions as I go along. And of lately I’ve had a lot ofrickets, children have been having a lot of rickets.Malaria is rampant and it is so resistant.

Private practice nurses are allowed to prescribe anddispense medicines, and Participant 9 kept a limitedstock of common medicines, including antibiotics, whichshe sold on to her clients at a reasonable price. She didnot make a great deal of money, as often clients couldnot afford to pay the full fee, but stated ‘if I have medi-cine in my cupboard I will always give it’. As well as aprescription, the client’s treatment programme may in-clude a home visit for health promotion purposes, forexample to advise a young mother on how to manage

cooking with a kerosene stove so as not to further ex-acerbate her child’s respiratory illness.Neither of the PPNs had a degree in nursing, although

Participant 9 had a first degree in community develop-ment and a master’s degree in public health. In additionto running her practice, she lectured on communitynursing at a local university. Participant 10, on the otherhand, felt well prepared for private practice throughnearly 20 years of experience with the flying doctor ser-vice (AMREF), working in remote areas and establishingclinics where there was no other health care provision.Both of the PPNs expressed great satisfaction with theirwork, which required them to keep up to date withregular continuing professional education and undergobiannual re-registration. Although both had good rela-tionships with medical colleagues to whom they referredpatients or whose services they engaged, both felt the over-all relationship between doctors and nurses in Kenya couldbe improved, and that nurses need to gain confidence:

Nurses have been so lax. They’ve just been waiting tobe given instructions by doctors. And doctors have notbeen very kindly to nurses. They have made the nurseswork even until they feel like they… they are secondclass. (Participant 9)

My colleagues who are just working in hospitals, theysay, “You’re so bold that you can work alone.” Butgiven my background at AMREF, I’ve never relied onsomebody to give me direction. (Participant 10)

It seems poignant that the two interview participantswhose daily activities came closest to the ICN’s charac-terisation of the scope of practice for APNs in terms of a‘high level of autonomy’ (Table 1) had the least require-ment in terms of education and training in the Kenyancontext. This is, perhaps, because PPNs are consideredto operate at Level 1 or 2 of the Kenyan hierarchy ofhealth care service delivery (Figure 1). However, weaccept that our sample of only two PPNs may be atypicalin terms of experience, expertise and (in the case ofParticipant 9), educational preparation. While PPN prac-tice is closely regulated by the Ministry of Health, bothPPNs interviewed for this study considered themselvesunusually well qualified, with some other PPNs report-edly being of ‘very low level’ (Participant 9).

DiscussionAs noted earlier in relation to conceptual frameworksfor advanced nursing practice, the ICN definition em-phasises the importance of APNs practising with auton-omy in clinical decision-making and patient management.In the list of activities explored during the interviews, thisarea of APN practice was described as ‘Managing own,

East et al. BMC Nursing 2014, 13:33 Page 8 of 11http://www.biomedcentral.com/1472-6955/13/33

independent case load of patients: autonomous practice(assessing, diagnosing, planning and implementing treat-ment programmes, evaluating outcomes)’ (see Table 2). Wefound that only four of our respondents undertook thiskind of autonomous practice. Two of the four were refer-ring to their practice within maternity services as dual-qualified nurse/midwives, roles somewhat outside thescope of this discussion (Participants 1 and 7).The two nurses who came closest to the international

understanding of autonomous advanced practice nursingwere the two private practice nurses (Participants 9 and10). Ironically, therefore, we observed what appeared tobe an inverse relationship between higher levels of nurs-ing education and the degree of autonomy that charac-terises nursing practice in the Kenyan health caresystem. In this study, the nurses practising with the mostautonomy were those working in the lower tiers of theprimary care services. As noted earlier, nearly 72% ofnurses in Kenya work in hospitals [15], with the betterqualified graduate nurses to be found in the teachingand referral hospitals. Indeed, the majority of nurses aregiven their posts by the Ministry of Health: primary careand independent private practice is generally consideredthe province of enrolled and diploma-level registerednurses.The shortfall of doctors in Kenya in the rural areas

and district hospitals has been addressed (as in otherAfrican countries) by the development of the ‘clinical of-ficer’ cadre. Although a shortage of doctors has been adriver for the emergence of the advanced nurse practi-tioner role in western countries, it seems this driver hasnot produced a similar outcome in Kenya. In part, this isbecause the potential for nurse-doctor substitution isundermined by an extreme shortage of qualified nursesas well as qualified doctors [14]. In addition, and unlikequalified doctors and nurses, clinical officers are rela-tively cheap to train and are not able to emigrate insearch of better pay and working conditions as theirqualification is not internationally recognised [23]. How-ever, there has been a curious silence in the internationalliterature on advanced practice about how this mid-levelrole potentially interfaces with the nursing profession. InKenya, our data suggests that role tension can exist be-tween experienced nurses and clinical officers within thedistrict hospitals. Indeed, one might conclude that theexistence of this cadre of health care workers rendersthe development of the APN role in primary care inKenya unlikely. In Kenya, clinical officers undergo inde-pendent training and their role is not seen as alignedwith, or developed from, the nursing profession. This isa professional boundary that requires further investiga-tion if the development of APN roles is to proceed.The private practice nurses, on the other hand, do

seem to have been granted a license to address the

shortfall of doctors in primary care within the Kenyancontext. Their practice is regulated by the Ministry ofHealth, and a basic level of in-service training is pro-vided. However, the PPNs do not fulfil the criteria setout by the ICN [2] in terms of the educational prepar-ation for their role, and do not appear to exercise theAPN sub-roles of educator, researcher and consultantand expert in practice development [24]. Indeed, auton-omy in clinical practice is only one dimension of theAPN role as described by the ICN [2], albeit a funda-mental element of the nurse practitioner role [11]. Fur-ther research is needed into how private practice nursesare working in Kenya and other African countries andtheir levels of expertise, not least to attempt to quantifytheir impact on health outcomes.It was encouraging to see the importance all nurses

interviewed during the course of this study placed onevidence-based practice, and to find that the majorityhad internet and library access that allowed them tokeep up to date. The nurses in the rural hospitals wereable to exercise some control over their practice, par-ticularly when working as midwives or delivering publichealth programmes. However, the senior nurses andmidwives working in hospitals were to a large extentdependent on the support of medical colleagues andhospital managers to advance their practice. This reflectsManley’s observation [25] that advancing nursing practicedepends not only on the individual nurse but also on theorganisational context in which he or she practises.According to Manley [25], the contextual pre-requisites

for advancing practice include shared beliefs and values;open non-hierarchical management and sufficient organ-isational authority attributed to post. Hospital nurses inthis study seemed to suffer from a hierarchical manage-ment structure and a lack of organisational authority,where deference to the doctor was expected. In addition,there was little opportunity to progress in a clinical orclinical-academic career as it seemed that specialist nurs-ing expertise was not generally recognised and valued, andopportunities for nurses to engage in research were few.This may explain why few of our respondents were look-ing to undertake a nursing master’s degree as there was noobvious career pathway as a result other than becoming anurse teacher. Undertaking a master’s degree in publichealth appeared a more attractive option, not least becauseit could lead to work with a higher paying and more pres-tigious non-governmental organisation. Alternatively, out-migration to countries with greater opportunities for pro-fessional development is an attractive option for Kenya’syounger, and most highly-educated, nurses [26].

ConclusionsAnalysis of the interviews suggests that, although pur-posefully selected because they were considered to be

East et al. BMC Nursing 2014, 13:33 Page 9 of 11http://www.biomedcentral.com/1472-6955/13/33

working at an advanced level, the BScN Advanced Nurs-ing Studies graduates were not working as advancedpractice nurses as defined by the ICN [2]. In Kenya, itseems that highly qualified nurses tend to move intomanagement and education, and see little opportunityfor advancement while remaining in clinical practice.We conclude, therefore, that the potential for the devel-opment of advanced nursing practice is constrained inpart by structural health system factors congruent withKenya’s low-income status, i.e. the shortage of well-qualified nurses and doctors, and the presence of anestablished clinical officer cadre. In addition, bachelorsor masters level education seems to offer a route to ‘ad-vanced’ expertise in management, leadership, educationor advocacy roles but has limited potential to developautonomous clinical practice in a context characterisedby traditional, hierarchical doctor-nurse relationships.However, in a region where the overall number of reg-

istered nurses is so low, it may be that the management,leadership, advocacy and educational functions of theadvanced practice role are of greater importance, notleast because senior nurses supervise others. There is apressing need for advanced nurses who can implementevidence-based practice and exercise clinical leadershipin the drive to attain improvements in quality of careand better patient outcomes [15]. Indeed, as part of anextensive consultation with regulatory bodies, ministriesof health and other stakeholders, the INEPEA projectconcluded that competencies for APNs in the EastAfrica region should include domains such as ‘beingknowledgeable and competent in gender mainstreamingand cultural awareness’ and ‘ethical decision-making andanti corruption’ [1], amongst other competencies morefamiliar to a western audience.The potential contribution of advanced practice nurses

to Kenyan health care goes beyond policies of task-shifting as advocated by the WHO [7], in this case wherenurses substitute for doctors. Increased recognition, andsupport for, the practice development and leadershipfunctions of advanced practice nurses, in addition to astrengthening of expertise in clinical practice, could reapdividends at all levels of the health care system de-scribed in Figure 1. In addition, a clinical career path-way leading to recognised APN roles could enhancejob-satisfaction and retention among qualified nurses.As noted by McCarthy et al. [10], such a clinical careerpathway would need to be supported by updated regula-tory arrangements, requiring capacity building amongnursing and midwifery regulators.In their recent systematic review of advanced nursing

roles, Jokiniemi et al. [24] conclude that a more balancedinternational description and framework for advancednursing practice will be achieved when more countriestake part in the discussion. While this study has

limitations in terms of sample selection and size, it ishoped that it will contribute a much-needed African per-spective to the international literature on advancednursing.

AbbreviationsAPN: Advanced practice nurse; AKU: Aga Khan University; AMREF: AfricanMedical and Research Foundation; BScN: Bachelor of Science in Nursing;CIA: Central Intelligence Agency; Dip: Diploma; GDP: Gross Domestic Product;INEPEA: Improving Nursing Education and Practice in East Africa; ICN: InternationalCouncil of Nurses; MOH: Ministry of Health; MPH: Master of Public Health;NCAPD: National Coordinating Agency for Population and Development;NFP: Not for profit; PPN: Private practice nurse; UK: United Kingdom; WHO: WorldHealth Organisation.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsLE designed the study with substantial contributions from JA, ML and CE. LE,JA and ML carried out data collection and analysis. LE and CE drafted themanuscript, which was subject to critical revision by JA and ML. All authorsread and approved the final manuscript.

AcknowledgementsThe authors wish to acknowledge the ACP-EU Cooperation Programme inHigher Education (EDULINK), which supported the INEPEA project fromwhich this study arose. We are then grateful to the University of Nottingham,School of Health Sciences, for providing the funding to complete this study(LE flights and subsistence; transcribing costs), and to the Aga Khan University,East Africa for hosting the study. The findings and conclusions of this study arethose of the authors, not the wider INEPEA project.

Author details1School of Health Sciences, South Block Link, Queens Medical Centre,The University of Nottingham, Nottingham NG7 2HA, UK. 2Masinde MuliroUniversity of Science and Technology, Kakamega, Kenya. 3Aga KhanUniversity, Nairobi, Kenya.

Received: 2 August 2013 Accepted: 22 October 2014

References1. Improving Nursing Education and Practice in East Africa (INEPEA): Final

Report. [http://www.acp-edulink.eu/sites/all/files/documents/docs/INEPEA%20Final%20Report.pdf]

2. International Council of Nurses (ICN): The Scope of Practice, Standards andCompetencies of the Advanced Practice Nurse. Geneva: International Councilof Nurses; 2008.

3. Duffield C, Gardner G, Chang A, Catling-Paull C: Advanced nursing practice:a global perspective. Collegian 2009, 16(2):55–62.

4. Ketefian S, Redman R, Hanucharurnkul S, Masterson A, Neves E: Thedevelopment of advanced practice roles: implications in theinternational nursing community. Int Nurs Rev 2001, 48(3):152–163.

5. Sheer B, Wong F: The development of advanced nursing practiceglobally. J Nurs Scholarsh 2008, 403(3):204–211.

6. Schober M, Affara F: Advanced Nursing Practice. Oxford: Blackwell; 2006.7. World Health Organisation (WHO): Task shifting to tackle health worker

shortages. [http://www.who.int/healthsystems/task_shifting_booklet.pdf]8. Shumbusho F, van Griensven J, Lowrance D, Turate I, Weaver M, Price J,

Binagwaho A: Task shifting for scale-up of HIV care: evaluation ofnurse-centered antiretroviral treatment at rural health centers in Rwanda.PLoS Med 2009, 6(10):e1000163. doi:10.1371/journal.pmed.1000163.

9. Holzemer B: Building a qualified global workforce. Int Nurs Rev 2008,55(3):241–242.

10. McCarthy C, Voss J, Salmon M, Gross J, Kelley M, Riley P: Nursing andmidwifery regulatory reform in east, central and southern Africa: asurvey of key stakeholders. Hum Resour Health 2013, 11(29). doi:10.1186/1478-4491-11-29

East et al. BMC Nursing 2014, 13:33 Page 10 of 11http://www.biomedcentral.com/1472-6955/13/33

11. Mantzoukas S, Watkinson S: Review of advanced nursing practice: theinternational literature and developing the generic features. J Clin Nurs2007, 16(1):28–37.

12. Central Intelligence Agency (CIA): The World Factbook 2013. Accessedonline 02.08.13 at [https://www.cia.gov/library/publications/the-world-factbook/geos/ke.html]

13. National Coordinating Agency for Population and Development (NCAPD)[Kenya], Ministry of Health (MOH), Central Bureau of Statistics (CBS), ORCMacro: Kenya Service Provision Assessment Survey 2004 [http://www.measuredhs.com/pubs/pdf/SPA8/00FrontMatter.pdf]

14. World Health Organisation (WHO): Global Health Observatory DataRepository. [http://apps.who.int/gho/data/view.main.92100]

15. Rakoum C: Nursing Human Resources in Kenya. Case study. Geneva:International Centre for Human Resources in Nursing; 2010.

16. Mullan F, Frehywot S: Non-physician clinicians in 47 sub-Saharan Africancountries. Lancet 2007, 370:2158–2163.

17. AMREF USA: Upgrading 20,000 nurses in Kenya [http://www.amrefusa.org/what-we-do/train-health-workers]

18. Nursing Council of Kenya: Private Practice Information 2011. Accessed online14.11.11 at [http://nckenya.com/wp-content/uploads/2013/09/Guidelines-for-Private-Practice-Nurses.pdf]

19. Mutea N, Cullen D: Kenya and distance education: a model to advancegraduate nursing. Int J Nurs Pract 2012, 18:417–422.

20. Flick U: An Introduction to Qualitative Research. London: Sage; 2002.21. Charmaz K: Qualitative interviewing and grounded theory analysis. In

Handbook of Interview Research: Context and Method. Edited by Gubrium J,Holstein J. London: Sage; 2002:675–694.

22. Tobin G, Begley C: Methodological rigour within a qualitative framework.J Adv Nurs 2004, 48(4):388–396.

23. Dovlo D: Using mid-level cadres as substitutes for internationally mobilehealth professionals in Africa: a desk review. Hum Resour Health 2004,2(7):1–12.

24. Jokiniemi K, Pietila A-M, Kylma J, Haatainen K: Advanced nursing roles: asystematic review. Nurs Health Sci 2012, 14:421–431.

25. Manley K: A conceptual framework for advanced practice: an actionresearch project operationalizing an advanced practitioner/consultantnurse role. J Clin Nurs 1997, 6(3):179–190.

26. Gross J, Rogers M, Teplinskiy I, Oywer E, Wambua D, Kamenju A, Arudo J,Riley P, Higgins M, Rakuom C, Kiriinya R, Waudo A: The impact ofout-migration on the nursing workforce in Kenya. Health Serv Res 2011,46(4):1300–1318.

doi:10.1186/s12912-014-0033-yCite this article as: East et al.: Exploring the potential for advancednursing practice role development in Kenya: a qualitative study. BMCNursing 2014 13:33.

Submit your next manuscript to BioMed Centraland take full advantage of:

• Convenient online submission

• Thorough peer review

• No space constraints or color figure charges

• Immediate publication on acceptance

• Inclusion in PubMed, CAS, Scopus and Google Scholar

• Research which is freely available for redistribution

Submit your manuscript at www.biomedcentral.com/submit

East et al. BMC Nursing 2014, 13:33 Page 11 of 11http://www.biomedcentral.com/1472-6955/13/33