Nursing education in Africa: South Africa, Nigeria, and Ethiopia experiences

This paper studies the development of nursing education in Africa and it is limited to three countries namely, South Africa, Nigeria and Ethiopia. Two cardinal periods are covered which are, colonial and post colonial. But Ethiopia is the only African country that has technically, never been colonised as it successfully repulsed Italy’s attempt at occupying it. The reason for this study is to assist modern states in Africa to learn from the past in order to make good decisions for the present as they build a future that will make nursing education a key and crucial partner in the management of health services, including attainment of some of the millennium development goals. Recommendations for the future of nursing education are made as well as important conclusions and findings.


INTRODUCTION
The development of nursing education in Africa has evolved through three cardinal periods, namely, precolonial, colonial and the post colonial periods except in Ethiopia. In the pre-colonial days in Nigeria and South Africa, not much is known about nursing. However, like in Europe and rest of the world, nursing care took the form of experimental practice arising from the sick and the wounded, especially in certain parts of the countries where inter and intra-tribal wars frequently occurs.
The training of nurses and midwives in Africa was then regulated by the Nursing and Midwives Board established by the ordinances which were inaugurated. The Nursing and Midwifery Council of the three countries took cognizance of the National Policy on Education in developing sound educational principles essential to the preparation of nurses to function independently and/or as members of interdisciplinary and intersectoral teams.
In compliance with its mandate, the respective councils have over the years, worked assiduously to ensure that *Corresponding author. E-mail: olubiyisimeon@yahoo.co.uk. policies, programmes and activities were developed and implemented with the goal of promoting and maintaining excellence in nursing education and practice as provided by the law and in conformity with local and international standards. In Ethiopia, however, the situation is different. Nursing education is controlled by the Health Professional Council of which Ethiopian Nursing Association is the member under the ministry of health.
University education is the key to the growth of the profession and nursing education programmes in many parts of the world are offered at universities and colleges affiliated to universities. The primary business of the university is "liberal education" which is neither to inculcate virtue nor to prepare for a vocation, but rather to train the mind; that the values served by such mental training are not absolute but are none the less good in themselves and that the inculcation of a philosophical temper is of great service to society.
The teaching/learning in the profession is a combination of theoretical, clinical and internship issues premised upon which any profession can build on for global acceptance. Other professionals in health industry have incorporated this concept into their curriculum and no one is registered and licensed to practice unless he/she has fulfilled the "Intern" period, which is also considered in the civil service placement.
For a country to meet human resource needs in nursing education that is required to attain Millennium Development Goals 4 and 5 (Reduction of child mortality and improving maternal health), there would be urgent need to scale up on nursing education in Africa in all nursing education institutions.

COLONIAL INFLUENCE IN AFRICA
Owing to the British colonial influence in the African region, the concept of regulating the health professions extended from South Africa throughout the continent. Nursing and midwifery professions were the first professions to be established on the African continent and to ensure statutorily recognised education and training centres, statutorily recognised curricula, statutory nursing examinations, and statutory certification of nurses (Searle et al., 2009).

Colonial influence in South Africa
South Africa has its own Florence Nightingale in Sister Henrietta Stockdale, who established a great nursing school in Kimberly in the 1880s. Not only was she the first to establish modern professional training standards, at least for white South African women, but she also provided the profession with its founding charter. Her influence was felt and appreciated from Cape Town in the South to Bulawayo in the North (Marks, 1994).
The independent states of Botswana, Lesotho, Swaziland, Zimbabwe, Zambia and Malawi have British colonial influence on the development of nursing and midwifery. The statutory provision of state registration for nurses and midwives which was enacted in the Cape Colony in 1891 was of a voluntary nature. The Cape Colony hospital boards entrenched the concept of requiring that all trained nurses and midwives appointed to posts under their control be registered, so that standards of education and training, and level of competence, responsibility and accountability, could be verified and disciplinary control exercised legally (Searle et al., 2009) (Searle et al., 2009). The change in the 1940s included gender, colour, class, and racial discrimination. Hospital was a profoundly gendered social institution. There was subordination of almost the entire female profession to nursing and medicine to their male counterparts. While discourses of gender were central to much colonial thinking, many middle class women successfully manipulated these discourses to their own advantage.
Not only the black nurses experienced the turmoil, but also the white sisters against their colonial bosses trained in Britain and Europe (Searle et al., 2009). The immigration of overseas trained nurses increased anxieties about white nurses in a colonial environment and new tensions between the local and the overseas nurse came to the fore. The Nursing Act 69 of 1957 provided for the distinction in respect of training and registration to be made on racial grounds (Searle et al., 2009). Such as the ousting of Mrs Margaret Ballinger from the council and being replaced by Charlotte Searle; the council maintaining separate registers for white and others; and membership to council shall be Europeans; and the Board of the South African Nursing Association was to be controlled by whites (Marks, 1994). The argument was about providing inferior training for black nurses. This impulse met with objections from certain colonies in South Africa.

Colonial influence in Nigeria
When Nigeria became a formal colony under the British Administration in 1914, nursing was among the first recognized and accepted professions in the British colony. The immediate benefit was the recognition of the overwhelming need of Nursing and Midwifery Services in all its colonies by the government of Britain. Nursing and midwifery practice was given its prime position, because of its relevance and direct impact on the lives, health and well being of the army, administrators, their families and the society in general.
The British government therefore made efforts to modernise nursing education and practice in the colony in line with the wind of change that was blowing across Britain due to the results of the post Crimean War reforms in nursing education embarked upon by Florence Nightingale.
During the colonial period, as Florence Nightingale evolutionary concept of nursing was gaining foothold in Europe, so was the effect in communities with European presence and Nigeria being a colony of the British at the material time was no exception. By the time the British Empire took over the administration of the territory of Nigeria as one of its colonies in the fall of 1861, the European style of nursing care had started to influence the practice of nursing.
In 1930, formal training of nurses and midwives started in Nigeria mostly in the mission hospitals and a few locations in the existing government hospitals (Adelowo, 1988).
The training of nurses and midwives in the country then was regulated by the Nursing and Midwives Board of Nigeria established by the Ordinance of 1930 and inaugurated in June 1931. In 1952, the University College Hospital, Ibadan established its School of Nursing with Mrs. Bell, a graduate of Florence Nightingale School of Nursing, St Thomas Hospital, London and a nurse tutor from Britain, as the first principal of the school. The minimum basic education entry was a full secondary education. However, for reasons unknown, the minimum acceptable educational qualifications were Standard VI and Government Class IV perhaps for other government nursing schools, due to limited number of qualified candidates.
At the end of the training, the graduates obtained the State Registered Nurse (SRN) Certificate of the Nursing Council of England and Wales. The training at the School of Nursing, University College Hospital, Ibadan was recognized for the British State Registered Nurse (SRN) Certificate, thus the tone for higher and better nursing education in the country started to have a facelift (Koyejo, 2008).

Italian occupation in Ethiopia
Long before the Italian occupation, a village called Hakims was known to be the first in caring and treating the sick. It is known that many of them had a very good knowledge of herbs, their effect, and how to use them for various illnesses. Some places had organised bodies that supplied a kind of medical service such as the Ethiopian Monks' Hospital in Debra Libanos, in which native methods and drugs were used for the treatment of sick people (Ivanka, 1961).
Although, this is not taken as colonisation, Italy occupied Ethiopia from 1934 to 1941. During this period, the hospital built by Presbyterian Mission was sold to the Italians. Italian invasion and occupation brought all the efforts of training health personnel to an end and young people trained disappeared. Upon the defeat of Italy and thus Ethiopian Liberation in 1941, the training of medical orderlies resumed at both government and mission hospitals (Ivanka, 1961).

MISSION HOSPITALS AND TRAINING OF BLACK NURSES
From 1866, Swedish missionaries, teachers, doctors and nurses started to come to Eritrea whilst it was still part of Ethiopia. In one group around 1909, there was a nurse named Roza Holmer and her daughter Karin who was educated in Sweden and then returned to Ethiopia as a nurse. The first clinic was established at a place called Eilet near Massawa where sick people used to bath in the hot springs. In 1928, elderly women were recruited and were given short term training to serve as midwives and nurses (Ali, 2011) and a midwifery textbook was translated from Swedish to Tigrina. The Swedish evangelical mission came to Addis Ababa in 1904. And in 1909 the first hospital was built in Ethiopia and was named Menelik II Hospital. The hospital was equipped and staffed by Russian medical personnel. And some Ethiopians were sent to Russia for medical training (Ivanka, 1961). The government later engaged French doctors who were assisted by nuns from the Catholic Mission. At that time there was no trained nurse in the whole of Ethiopia.
It was the missionaries who trained the first professional African nurses at the beginning of the twentieth century in South Africa. Miss Mary Balmer in February 1903 started training two black women as professional nurses: Cecilia Makiwane and Mina Colani at Victoria hospital (Marks, 1994). Not only nursing has undergone change in education, but other health professions as well. Before 1970 as some may recall, radiographer and laboratory technician were trained in hospitals (Mission) under the supervision of a qualified professional, and had to further their studies thereafter.
In Nigeria, there was no formal training for the treatment of the sick as missionaries in the 19th century who settled in Abeokuta (South West Nigeria) and Calabar (South East Nigeria), and engineered the establishment of dispensaries and mission posts, and helped in the treatment of the sick and carrying out relief work amongst the citizens in addition to the care of those in the convents. It later progressed to other towns including, Lagos, Ibadan, Ijaiye, Onitsha, Bonny, Calabar, Itu, Unwana, Lokoja, Wusasa and Zaria. Each of these mission posts had a doctor and nurses resident therein and the structures later formed the nucleus for the early training schools of nursing and midwifery in Nigeria. The training of nurses and midwives during this period was informal being an apprenticeship-type of training of "do as you are told" approach.

POST COLONIAL EXPERIENCES
Nursing education in South Africa has undergone dramatic changes from colonial training of white nurses, on-the-job training for black males and later women, to hospital based training and later higher education institutions.

The role of the South African Nursing Council in nursing education
General education system reforms have effected unprecedented changes in health professional education. Nursing education was initially controlled by each province under the South African Medical and Dental Council. Standardised guidelines and norms for the training of nurses were followed in all the provinces. When all the provinces were united (Union of South Africa), the South African Nursing Council (SANC) came into existence in 1944 in terms of the Nursing Act 45 1944. This was 300 years after the first licensing of midwives in South Africa and 53 years after nurses were first included in the professional register (Searle et al., 2009).
The Act was passed to provide for the statutory control of the nursing and midwifery professions by nurses. SANC was given powers similar to those exercised by the South African Medical Council under the Medical Dental and Pharmacy Act 13 of 1928. Only in 1978 were blacks, coloureds and Indians represented in the council. There were also self-imposed exclusions in Republics of Venda (1971), Transkei (1978), Ciskei (1984), and Bophuthatswana (1985. The following trends followed (Searle et al., 2009). In 1819 began the first formal professional training of midwives. For the first time in 1891, qualified nurses could be admitted to a register maintained under the provision of a law under the Pharmacy Act 34 of 1891.
Nurses for the mentally ill were for the first time in 1899 included in the registration concept and male attendants received statutory recognition under the Act 21 of 1899.
Ordinance No. 1 of 1904 empowered the council to prescribe the course of study and provision for registration and professional practice for the various categories of nurses. The introduction of post-basic nursing courses in 1922 was followed by the postregistration course at university level in 1935. The first Baccalaureate degree in nursing was introduced in 1955. Post-Baccalaureate degrees in nursing were introduced in 1967. Affiliation of nursing colleges with universities was introduced in 1985 to enhance quality of care to Dolamo and Olubiyi 17 patients through improving education and skills.

Current structure of the nursing education in South Africa
The nursing education is being offered at Universities and University Technologies which provide a Generic

Post colonial experience in Nigeria
The post colonial period (1960)  There was a tremendous leap in nursing education in Nigeria with the establishment of the Department of Nursing at the University of Ibadan in 1965 based on the need in Africa to produce teachers and administrators in the region. The successes of the programme led to the transformation of nursing education and practice in Nigeria with the establishment of Department of Nursing in the 17th conventional (face to face) universities in the country (private and public) of a Baccalaureate/Generic Bachelor of Nursing Science (BNSc) degree in line with the accepted minimum academic standard and curriculum of the National Universities Commission (NUC) for university based nursing programme (National Universities Commission, 1989).

The role of Nursing and Midwifery Council of Nigeria in nursing education
The It is the statutory body responsible for the regulation and control of nursing and midwifery training and practice in Nigeria. The council is the only regulatory body for all cadres of nurses and midwives in Nigeria. It is the only legal, administrative, corporate and statutory body charged with the performance of specific functions on behalf of the Federal Government of Nigeria, in order to ensure the delivery of safe and effective nursing and midwifery services to the public through quality education and best practices. The statutory roles and aims of the council are stated in the 1992 Nursing and Midwifery Council of Nigeria Act, Section 1, Subsection (2) a, b, c, d, e, f, and Section 12, Subsections (1), (2), (3), (4) and (5).
In accordance with the provision of section 1 subsection 2 (a), (b), the council observed that majority of Nigerian-trained nurses are products of procedure and diagnostic centred nursing educational system, geared only to the need of hospital services. Premium was placed upon training in the recognition of the need for changes in nursing education in Nigeria and this led to the revision of the old syllabus and producing a new one that will be acceptable nationally and internationally. The new standard of training in nursing education was conceived. Upon graduation, the nurses were awarded Registered Nurse (RN) Certificate. This new standard of general nurse training had duration of three and a half years, while the midwifery education and other post basic nursing education programme had 18 months (National Universities Commission Curriculum for General and Post Basic Nursing Education, 2009).

The present situation of nursing education in Nigeria
The National Policy on Education of 1981 states inter-alia that "Education is the most important instrument of change in any society". And that "any fundamental change in the intellectual and social outlook of any society has to proceed by an educational revolution". It further emphasized that "Federal Government shall undertake to make life-long education the basis for the nation's education policy and that at any stage of the educational process after primary education, an individual will be able to choose between continuing his full-time studies, combining work with studies, or embarking on full-time employment without excluding the prospect of resuming studies later on Federal Ministry of Education Blueprint and Implementation Plan for National Open and Distance Learning Programme (2002)" The Nursing and Midwifery Council of Nigeria takes cognizance of the National Policy on Education in developing sound educational principles essential to the preparation of nurses to function independently and/or as members of interdisciplinary and intersectoral teams.
In compliance with its mandate, the council has over the years worked assiduously to ensure that policies, programmes and activities are developed and implemented with the goal of promoting and maintaining excellence in nursing education and practice as provided by the law and in conformity with local and international standards. The following activities were executed by "the council". 1) In 1978, a new curriculum was produced by the Committee for Basic Nursing in Nigeria for implementation by all Schools of Nursing in the country. This curriculum differed from that of 1965 in three major aspects, namely: it was community oriented, there was expanded role for nurses and more emphasis was placed on liberal education leading to the reduction in the duration of the basic nursing programme from three and a half years to three years with increase in the content and learning experiences. This was made possible through the use of planned clinical experience system instead of the block system of clinical experience which was more of a service oriented than a learning oriented approach. 2) In the 1990s, the Polytechnic option was adopted as a short term approach and Nursing and Midwifery Council of Nigeria worked with National Board for Technical Education (NBTE) to upgrade the Schools of Nursing into Monotechnics for the award of Higher National Diploma in Nursing. This decision was taken at that time since less than 10% of the Schools of Nursing existing then could meet up with the criteria for affiliation with the universities. The option could not be implemented because it was rejected by Nigerian nurses who were still of the conviction that the future of nursing education in Nigeria lies in the university.
3) In 1993, a further review of the curriculum was done and the trends in health care were incorporated. The entry requirement was further reviewed and upgraded to five 5 credit passes in subjects to include English Language and a science subject at WASC or GCE Ordinary level. 4) In 2001, the nursing education curriculum was reviewed to reflect emerging trends and new diseases.
In 2006, the entry requirements for general nursing education programme of the Nursing and Midwifery Council of Nigeria is five 5 credit passes in Physics, Chemistry, Biology, Mathematics and English Language at not more than two sittings.
The entry requirements for the Bachelors degree programme requires that a student must have satisfied the prescribed minimum conditions of the University for Admission to the degree course, and fulfill the requirement of direct or concession entry. The direct entry (4 years) requires the candidate to be a registered nurse in addition to the five credit passes in English, Biology, Chemistry, Physics and Mathematics at not more than two sittings. Candidates holding the Senior Secondary School Certificate with credit passes in English, Biology, Chemistry, Physics and Mathematics at not more than two sittings plus an appropriate pass in the University Matriculation Examination (UME) is admitted for the indirect degree programme for five years.
Trainings are done at the 76 approved schools of nursing that have received accreditation by the Nursing and Midwifery Council of Nigeria. There are twenty-seven post basic nursing education programmes in Nigeria. These include mental health-psychiatry, midwifery, and peri-operative nursing education programme among others.
All of these reflect the efforts of the Nursing and Midwifery Council of Nigeria aimed at improving nursing education. The general nursing education is therefore geared towards the student's learning needs, societal needs, philosophy of nursing, learning theories and professional standards. The programme forms the basis for the practice of nursing and continuing education in the discipline of nursing. It further develops students' affective, cognitive and psychomotor skills in problem solving (Olanipekun, 2007).
The National Advisory Council on Nurse Education Practice in I996 recommended that a Federal Policy be adopted to achieve a basic nurse workforce in which at least two-thirds holds Baccalaureate or higher degrees in nursing by the year 2010 (American Association of Colleges of Nursing Bulletin, 1998). This decision has resulted in reforms in nursing education and practices in Nigeria. In Princess Tsehai Memorial Hospital, a post-basic course in midwifery commenced in 1959 with four students by Catherine Hamlin (Catherine Hamlin a degree of Doctor of Medical Sciences, 2010) and husband Reg from Australia. In 1960, the four students were successful in completing the National Midwifery Examination.

SCHOOLS FOR NURSES IN ETHIOPIA
Other schools include Tafari Makonnen Hospital in Lekempte which was started by Swedish missionaries in 1951 for both males and females; and Asmara which was established in 1955 with the assistance of the United States Technical Assistance Programme.
Entry requirements in the past have been the minimum of 16 years in age for both men and women and a minimum of 8th grade education. All candidates were to pass an entrance examination and a physical examination was given by the nursing school.

The Nursing Council in Ethiopia
The Nursing Council in Ethiopia was established in 1954 as a permanent sub-committee of the General Advisory Board of Health. The Nursing Council composed of 11 to 15 members appointed by the Minister of Public Health for a period of two years (Ivanka, 1961).
The Nursing Council in Ethiopia was concerned with all nursing activities. The Nursing Council's responsibilities included licensing of nurses, midwives, and dressers 1 and recommending withdrawal of such licences for malpractices and other reasons to the General Advisory Board and final recommendation to the minister. The Nursing Council acted as the official liaison body between the Ministry of Public Health and the Ethiopian Nurses Association.
The functions of the Nursing Council included amongst others: 1) The development and recommendation of policies for accreditation of nursing, midwifery and auxiliary nursing.
2) The development and recommendation of the minimum curriculum and entry requirements for schools 3) The recommendation for disciplinary action when necessary 4) To advise on ethical and medico-legal problems concerning nurses and nursing practice 5) To promote the training of nursing personnel No literature mentioned what happened to Nursing Council in Ethiopia. In 1974, there was downfall of the Emperor regime. In 1977, three years after the downfall, the nurse training was revised at a national level to training of one category of a 'comprehensive nurse' who can function at all levels of health institutions. Training of other nurse categories was discontinued. The entry requirement was raised to grade 12 and duration reduced to two and half years. After the downfall of the Derge regime in 1991, the training duration was reduced to 2 years and training changed to specialised form of training. And again the two years training of different types of nurses in most training institutions began to train clinical nurses, public health nurses and midwives (Ali, 2011).
In 1994, a post basic Baccalaureate program was launched in Ethiopia, in the former Jimma Institute of Health Science (now known as Jimma University). The baccalaureate program trainees on completion were deployed in schools of nursing and management positions (Ali, 2011).

The current structure of nursing education in Ethiopia
Nursing education in Ethiopia is offered at governmental, non-governmental and private institutions. There are seven schools that offer Bachelors of Science in Nursing. At the end of the training period, Ministry of Health of Ethiopia register and license them to practice the profession in the country through the Health Professionals' Council. Addis Ababa University offers a regular BSc Nursing and diploma-to-BSc Nursing upgrading program. There are six Government Diploma Schools, and two Ethiopia Nursing Association approved private nursing colleges (Ali, 2011). Addis Ababa University also offers a two year post graduate Masters program.

The role of the Ethiopia Health Professional Council in nursing education
The Health Professional Council was established in 2002 by the Ministers' Act No 72/2002, as a regulatory and advisory body and accountable directly to the Minister-Ministry of Health of Ethiopia (Ali, 2011). The council has established different committees with a specified function for each committee. Ethiopian Nursing Association (ENA) as a member is involved in the registration and licensing of health professionals and nurses in particular in Ethiopia. The Ethiopian Nursing Association is a legalised professional organisation in Ethiopia, striving to improve nursing services to the benefit of the society: 1) Develop a standardized nursing service appropriate to Ethiopia 2) Organize nurses under the umbrella ENA so as to provide standardized nursing service to the community 3) Stand for the rights for nurses and clients through working in harmony with concerned health policy makers.

LESSONS LEARNED, CHALLENGES AND RECOMMENDATIONS
Domination of the profession by medical doctors should be the thing of the past; nursing education for and in Africa should be the responsibility of the nurses. Nursing Councils should involve all nurses and those at grassroots in (re)structuring nursing education programmes regardless of gender, race, class, and colour. Nursing education should be structured in such a way that knowledge, skills, and attitude (moulding behaviour) are inculcated in the health professionals.
Africa seem to be a baseless bucket, as there is less and less generic programme student output from learning institutions, and those who qualify leave the continent for other countries. This paper recommends that institutions of higher learning should review teaching/learning in relation to output.
In this era of globalisation, nursing education in Africa has to strengthen collaboration and utilisation of student/ teacher exchange programmes available at universities. They should form linkages and partnerships with other countries as these would improve quality in teaching, learning, and research.

CONCLUSION AND RELEVANCE
For a country to meet the human resource needs in nursing education that is required to attain the Millennium Development Goals 4 and 5 (Reduction of child mortality and improving maternal health), there would be urgent need to scale up on nursing education in African countries in all nursing education institutions. South Africa, Nigeria, and Ethiopia have a large number of willing and readily available nurses who can benefit from higher education in nursing to cater for the training needs of the continent. While the conventional universities are limited by their admission policies and the inability of nurses willing to pursue further studies on full time, the University of South Africa (an open distant learning) and the National Open University of Nigeria provides an open and flexible mode of instruction to accommodate large number of nurses for their post basic nursing degree programmes. This will definitely help to address the acute shortage of human resources in the schools of nursing and university nursing departments.
The South African Nursing Council, Nursing and Midwifery Council of Nigeria and the Ethiopian Nursing Association have identified certain strategies to overcome this problem through collaboration with and financial support from organizations such as World Health Organization, Canadian Nurses Association, Royal College of Nursing, United States Agency for International Development (USAID), United Nations International Children Emergency Fund (UNICEF) and World Trade Organization (WTO) for funds for those willing to pursue higher degrees in nursing education. Available funding should be widely advertised to nursing and midwifery fraternities through their respective professional organisations.