A row has erupted between the Health ministry and Uganda’s nursing and midwives professional body over the former’s decision to waive off medical internship training for nurses and midwives upgrading from Diploma to Bachelor of Science in Nursing (BSN) and Bachelor of Science in Midwifery (BSM) early this year.
On Tuesday, the Association of Graduate Nurses and Midwives of Uganda (AGNMU) labelled the decision a disgrace to the profession. Assoc Prof Edward Komakech, the President of AGNMU, said the decision was taken without proper assessment, research and consultation with other professional bodies.
What’s the background?
In June, the Health ministry rolled out the operationalisation of the medical internship waiver policy. On May 29, 2024, an Inter-ministerial Standing Coordination Committee on Education and Health (IMSCCEH) sat and agreed to phase out internship training for nurses and midwives (Diploma levels) upgrading to bachelor’s level across the country. It was resolved to phase out the internship for the diploma extensor nurses and to review the curriculum of the BSN course to include more hands-on training with a view to phasing out internship training for the same course once the beneficiaries of the reviewed curriculum start graduating.
Proponents of the policy reasoned that whilst the diploma extensor nurses had extensive hands-on training during their course and also through their work, the direct entrants to the BSN trainees had very limited hands-on experience in their curriculum.
On June 20, the Health ministry’s Permanent Secretary, in a letter, directed the registrar of Uganda Nursing and Midwives Council (UNMC) to submit the prospective medical intern nurses/midwives disaggregated by their status of admission as direct entrants or extensors. The directive, Dr Diana Atwine said, followed the Human Capital Development Programme Inter-ministerial Committee on Education and Health resolution of July 2024 to waive medical internship for nurses and midwives who upgrade from Diploma to BSN and BSM.
What objections have been raised?
Prof Komakech says the extensors undergo varied durations of BSN or BSM training programmes. For example, in some universities, the extension training is a two-week-day of classes for 2.5 years, whereas for others, it is weekend training for three years. In other universities it is established to last three years, with full-time lectures plus supervised clinical rotations at the university teaching hospital. Elsewhere, they are trained alongside the direct entrants for four years full-time with both lectures and supervised clinical rotations at the university teaching hospital.
Prof Komakech says the post-BSN/BSM internship training provides these interns with non-uniform backgrounds with a standardised or uniform supervised hands-on clinical training at accredited internship training centres. The extension curricula design recognises the prior learnings and skills of the extensor BSN/ BSM by exempting them from some of the basic course units and reducing the duration of their extension training programmes from four years to two and a half or three years.
‘Many universities that offer the extension training programmes for nurses and midwives have already recognised the prior learnings and skills of the extensors by exempting them from some of the basic course units that the direct entrants study such as anatomy, physiology, first aid, fundamentals of nursing, basic clinical nursing procedures and skills, among others,’ he said. According to AGNMU, some of the old nursing and midwifery care models, approaches and systems of the extensors from their diploma level training are obsolete.
During the BSN/BSM internship, the extensors are taught new nursing and midwifery care models, approaches and systems such as interpreting clinical assessment findings, taking appropriate first-line interventions such as triage, resuscitation, etc., rather than the obvious nursing procedures.
‘Waiving medical internship training for the extensor BSN/BSM is a threat to patient safety and public health since patients will not receive competent and safe nursing and midwifery care from the extensors BSN/BSM without the medical internship training, particularly the ones with diploma backgrounds in psychiatric nursing, public health nursing, palliative care, medical education, leadership or management,’ Prof Komakech noted.
So has a petition been filed?
Yes. The association, in a July 29 letter addressed to the chairperson of the IMSCCEH and the registrar of the UNMC, objected and appealed the decision, reasoning that sporadic meetings that birthed the resolution were conducted subjectively. ‘An internship training exemption policy like this requires a formal assessment and evaluation of whether the clinical knowledge and skills of the extensors are non-inferior or equivalent to the post-BSN/BSM internship training clinical knowledge and skills, which was not done,’ it stated.
The petition also pointed to a lack of representation of the professional associations of graduate nurses and midwives, former lecturers of extensors at universities that run Diploma to BSN/BSM extension programmes, among others, at the committee meeting that voted for the waiver. For 17 years now, they have argued that all BSN or BSM graduates are required by UNMC to undergo mandatory one-year internship training before they can acquire a permanent registration status and a licensure to practice as graduate nurses or midwives.
The petitioners also argued that since some extensors joined diploma in nursing and midwifery training after A-Level, while others upgraded from certificate level, both categories of upgraders were not uniformly grounded in Biology, Chemistry and the other relevant subjects for nursing and midwifery training. It is at the BSN/BSM training that they get exposed to the new concepts in Biochemistry, pathophysiology, and many more that they need to appreciate, apply and get proficient in through the post-BSN/BSM internship training, not to risk the lives of patients under their care, it stated.
It added: ‘Today, extensors join the BSN/ BSM training with non-uniform fields of diploma. While others extend from the diploma in psychiatric nursing, some extend from diploma in Medical Education, general nursing, midwifery, public health nursing and palliative care, among others.’ Such non-uniform pre-BSN/BSM diplomas, according to experts, imply that some of the upgraders get exposed to new concepts and clinical skills during their BSN/BSM training that they need to appreciate, apply and get proficient in through the post-BSN/BSM internship training.
Whereas it is argued that there is no standard national university entry clinical examination for the extensors to exempt them from the post-BSN/BSM internship training, with others joining universities through examinations and others submitting CVs, the extensors are said to possess varied pre-BSN/BSM clinical experiences.
‘Just imagine the health risks posed to the patients from internship exemption for the extensors who extended from the diploma in psychiatric nursing and mental health, public health or medical education and got exposed to the new concepts, and clinical skills of surgical nursing, medical nursing,’ Mr Christus Atukwase, the AGNMU general secretary, said.
He added: ‘There is a rush implementation of the medical internship training waiver policy for the extensor graduate nurses and midwives without giving the universities sufficient time to phase out already admitted students, re-organise and retool their extension training programmes for a training that will not need post-graduation medical internship training.’
A waiver policy like that should have been given at least five years for the universities that run extension training programmes to phase out the students already admitted into the training programmes and readjust their curricula, tools and other resources required to train and graduate a new batch of nurses and midwives,’ he noted.
Per Mr Atukwase, it’s during the BSN/BSM training that they get exposed to new concepts and clinical knowledge that they need to appreciate, apply and get proficient in during the internship training, not to risk the lives of patients under their care. These recognitions of the prior learnings and skills of the extensors allowed the universities to pack the extension training programmes with medical science details and highly specialised course units that were not in the scope of the diploma-level training and practice.
What does the future look like?
Assoc Prof Peter Waiswa, a Health Policy and Health Systems expert (Makerere University College of Health Sciences), said a waiver of medical internship spells doom for the future of health service delivery quality. The internship in question, he said, ‘is meant to be different and it is not the experience they’ve been having.’ Since internship allows them to ‘appreciate the new field they are joining,’ removing it would be,’ reasoned Prof Waiswa, ‘a missed opportunity.’ Why? Because ‘they will have to be forced to depend more on small training and practice during the training.’
As such, Prof Waiswa advises the government (Health ministry) to deliberately invest in the health sector. In October, the association sued the Health Ministry (Attorney General) in a civil suit filed before the High Court Kampala seeking a judicial review and injunction to halt the Health Ministry’s directive that waived off the mandatory one-year internship for nurses and midwives upgrading from a diploma to a degree. It argued that the decision is deemed procedurally flawed, irrational, and a significant threat to public health and professional integrity.
According to the petitioners, the internship waiver decision was made without consulting key nursing and midwifery professional bodies and also ignoring the appeal against the waiver from the statutory regulator, UNMC. The association asked the court to issue a temporary injunction halting the directive, nullify the waiver permanently, order comprehensive stakeholder consultations.