Role analysis of the nurse/midwives in the health services in Sub-Saharan Africa
Leana Uys  (DSoc Sc RN RM Professor Emeritus)
Jennifer Chipps (MPH RN RM lecturer)
Thekla Kohi (PHD RN Associate Professor)
Dickson Mokoka (M Nursing RN lecturer)
Miriam Libetwa (PHD RN Nursing Officer)
Abstract Aim
The aim of this paper is to describe the actual current roles and tasks of nurses in Sub- Saharan African health services.
Background
The current roles of nurses and midwives in the African region of the World Health Organization have not been empirically established, with only two country studies found (South Africa and Mozambique). This makes it difficult to establish whether current nursing education programmes and nursing regulations adequately address the needs in the health services.
Methods
This was a descriptive quantitative study using two survey questionnaires, a 120 task Hospital Questionnaire and a 153 Primary Health Care task questionnaire. Nurses from nine African countries (five Anglophone and four Francophone) completed a hospital or Primary Health Care task questionnaire - a total of 927 respondents from both hospital and Primary Health Care settings. Data was collected between June and December 2010.

Results
The highest role functioning in both settings was found in the role "General Care". The lowest role functioning in both settings was found in the role "Maternal and Child Health" and in "The Provision of Mental Health Care". The role performance in Anglophone countries was significantly higher than in Francophone countries and this was also reflected in regional comparisons.
Conclusion

The development of competency in nursing roles other than medical surgical roles (general assessment and care) should receive more attention in curricula. Special attention needs to be given to Francophone countries, where the professions of nursing and midwifery are poorly developed.
Summary statement
What is already known about this topic:
•	The curricula used to prepare nurses should be based on the current roles of       nurses and the health needs of the communities they serve.
•	The roles of professionals are dynamic and changes over time.
•	Tasks and roles of nurses have been empirically studied in only three African countries.
What this paper adds:
•	The role functioning of nurses in Sub-Saharan Africa varies significantly between    countries, regions and language groups.
•	The greatest role functioning was found in general care and general assessment, and the lowest role fulfilment was found in the role of maternal and child care (midwifery), which directly influences the attainment of Millennium Development Goals 3 and 4.
•	The role functioning was significantly lower in Francophone countries, and in regions where these countries dominate.
Implications for practice and/or policy:
•	The low role functioning in areas outside of general medical and surgical nursing indicates a need for curriculum development that ensures a better balance between physical and mental health, treatment and rehabilitation and a greater focus on midwifery content.
•	There is a need for a special effort in Francophone countries to develop postgraduate educational programmes that can prepare nurse leaders, researchers and educators in order to develop the profession.
•	The detailed task analysis studies should be done on larger samples in each country, in order to inform curriculum and continuing education   
decisions.

Key words

Task analysis, nursing, Africa, roles

NTRODUCTION
In the World Health Report 2006 one of the major constraints facing Human Resource for Health (HRH) in the delivery of interventions aimed at achieving the health-related Millennium Development Goals (MDGs), was the inappropriate or inadequate training, with curricula which is not needs-based (WHO, 2008). Reaching the MDGs is a challenge in the face of limited resources and inappropriate training. The WHO African Region completed as survey of pre-service nursing programmes and found that "Since the educational programmes have not been evaluated for some time, it is difficult to tell whether the programmes are responding to national and community health needs and the emerging role of the practitioner" (WHO, 2008:15).
As health technology changes and illness patterns change, so nurses and midwives adapt their practice. In the USA the National Council of State Boards of Nursing (NCSBN) does a periodic practice analysis or job analysis in order to ensure that the licensure examinations are valid in terms of the actual current practice of nurses in the country (Wendt & Eich, 2007). This is seen as essential in the situation in which a national examination has to test the competence of nurses for current practice. Such regular and systematic role studies are not common in Africa and other areas in the world.
The current roles of nurses and midwives in the African region of the WHO have not been empirically established. Current documents outlining the roles of nurses and midwives for instance, the Nursing and Midwifery professional framework of The East, Central and Southern African College of Nursing (ECSACON) ( 2001) are based on expert panels of nurses. They are also about ten years old. Very few countries in Africa have post-graduate programmes which prepare nurse-researchers and most of these programmes are in Anglophone countries. The lack of nurses prepared with the necessary research skills leaves countries without the ability to scientifically establish the current roles and health needs in their countries. It is significant that two of the three African studies mentioned above were led by international researchers (Democratic Republic of the Congo and Mozambique).
Background
The study is based on the technology of job or task analysis, and also uses some concepts from the role theory, which was developed in the 1950-60's and formed the basis of many studies well into the 1990's. The theory describes how people are socialized into roles and how they deal with these roles. Biddle and Thomas (1966) identified seven ways of describing roles. In this study we used overt descriptive roles (tasks that are overtly enacted by the group of people. The study deals with aggregate roles of nurses as a group, and not with the roles taken by any individual nurse. All covert aspects of roles, such as motives and values, were not directly addressed.
A task is a meaningful unit of work activity generally performed on the job by one worker within some limited time period. It is a discrete unit, which represents a composite of methods, procedures and techniques (Uys, Groenewald & Mbambo, 2003:34). A role is performed when a group of people puts the rights and duties which constitute the status of a specific occupation into effect. Every group "has a series of roles deriving from the various patterns in which (they) participate, and at the same time a role, general, which represents the sum total of these roles and determines what (they) do for society" (Biddle & Thomas, 1966:7). A role is made up of tasks. Role functioning is the level at which a group of nurses perform the tasks within every role frequently and deems these tasks to be important.
The process of task analysis the National Council of State Boards of Nursing (NCSBN) follows is to develop a questionnaire based on the input of a panel of subject matter experts, who are representative of the regions and nursing specialties (Wendt & Eich, 2007). Since the total of 153 activity statements would be too much for one respondent, these statements are divided into four forms, and sent to four different randomly selected samples of nurse respondents, with some items being asked in all four instruments. Nurses were asked to rate each activity in terms of frequency on the last day they have and importance. The data was analysed taking into account the setting of the nurse and the months of experience. The included over 19,898 nurses in the web-based survey. This is a well-developed methodology, which provides a valid description of the generalizable nursing practice in the USA.
Few African studies on this topic were found. Similar methodology was used in a study in South Africa doing a job analysis of health workers in a district health system (Uys el al. 2003, Groenewald et al. 2003; Mbambo et al. 2003). The PHC instrument was developed based on the Primary Health Care Package of South Africa and included 141 tasks. Two samples was used and a mail survey included 42 nurses working in district hospitals and 61 nurses working in Primary Health Care clinics, representing 19% and 22% of the randomly sampled nurses respectively.
A team in Mozambique did a comparable study of nurses in that country (Dgedge et al. 2009). They wanted to identify the knowledge and skill necessary for nurses of all categories. They developed a tool based on the ICN Framework of Competencies, and a number of WHO AFRO documents. The final instrument contained 233 items organized into 9 domains and addressed both frequency and importance. Data was collected through interviews with 1295 individuals representing all regions of the country. Based on their results they have made recommendations about the curricula of different categories of nurses, identifying both the unique and common roles. A similar study was done in the Democratic Republic of the Congo (Parent, Lemenu, Lejeune et al. 2006).
THE STUDY 

Aim
The aim of this study was to describe the actual current roles and tasks of nurses in SS African health services in order to inform policy and curriculum development.
Design
This was a descriptive quantitative study using two survey questionnaires, a 120 task Hospital Questionnaire and a 153 Primary Health Care (PHC) task questionnaire. Nine African countries participated and both hospital and PHC settings were targeted. The surveys were administered by each country researcher.
Sample/participants
Countries from the same language group, and therefore sharing a similar historical nursing history, were assumed to have similar health care systems with nurses playing similar roles. The purposive sample therefore included countries from each of the major language group (Francophone and Anglophone). Since differences within language groups are possible, we included five countries from the Anglophone group and four from the Francophone group. It might also be possible that health services and health/illness patterns differ by region, and therefore all four regions of Africa were included in the sample.
The sample of nurses for the task analysis survey was a stratified convenient sample of nurses. A total of 100 nurses were to be the target sample in each country (total 900). The samples in each country were stratified for levels of health setting, with at least three levels, including primary health care and tertiary hospital level, included. All nurses from the categories of nurses recognized and used in each country were included.
Data collection
Two survey instruments were used. The first, for use in the Primary Health Care settings, was based on that developed by Mbambo, et al. (2003). The instrument they used, with the tasks they found missing during their study, was compared with the current NCSBN list and a final instrument developed by the team. It has 174 items. Section one has four demographic questions (gender, age, professional rank and work setting). Section two consists of a list of 153 tasks that describes the nursing practice in a setting.
The second instrument was based on the NCSBN instrument used for the 2006-2007 practice analysis, and is more the hospital-focused (Wendt & Eich, 2007). It has 120 items. In both instruments, for each activity three questions are asked: whether the task applies to the setting; how frequently it is performed (less than 1 per week, 1-5 times per week, 6-10 times per week; more than 10 per week); and lastly how important the task is (whether it can sometimes be omitted or never be omitted).
The survey instruments were distributed to nurses on duty on a specific day at health settings of the target type (urban/rural and hospital/PHC), and collected the same day. Data collection was done in the second half of 2010.
Ethical considerations
The total study was approved by the Ethics Committee of the lead university and permission was also sought from the health authorities of all participating countries and services. Nurse-respondents were assured of anonymity and completion of the instrument was taken as agreement to participate in the study.
Data Analysis
The items of both instruments were classified into seven role categories with the number of items in the two instruments in brackets:
1.	General care and treatment (51/43), which includes all common tasks of activities of daily living and administering or assisting with treatment e.g. correctly identifying a patient, applying principles of infection control, administering medication.
1.	General assessment (22/31), which includes all assessment tasks except for those specific to Maternal and Child health or Mental Health, e.g. taking vital signs, taking a history.
2.	Health education (11/11), which includes all patient, family and community teaching activities, e.g. educate a patient and family about treatment and procedures,
3.	Planning and management (20/32), which includes all the tasks necessary for managing a unit or planning services, e.g. participate in maintaining the institution's security plan, plan to incorporate alternative therapies in a patient's care.
4.	Maternal and child health (MCH) (6/10), which includes maternity service tasks, e.g. provide intra-partum care, do foetal heart monitoring.

5.	Mental health (9/17), which includes the assessment and intervention to promote mental health, e.g. assess for the need for suicide precautions, lead a group therapy session.

6.	Rehabilitation (1/9), which deals with the rehabilitation of a patient after an illness, e.g. teach a client to do activities of daily living, counsel a client with urinary or bowel incontinence.
This classification was used to identify the roles most commonly filled by nurses in the sample.
The methodology used to calculate the frequency-importance index is based on that described in the article "Certified Occupational Health Nursing - Job Analysis in the United States of America" (Burgel et al. 1997:45). This methodology enables one to compare the both the frequency and the importance of a task, giving more weight to the latter. As highlighted by the abovementioned article, this methodology is common in job analysis studies for the health professions, as the less frequent tasks are often the most important tasks, e.g. administering cardio-pulmonary resuscitation (CPR). A task index for each task was calculated (Task Index=Frequency + Importancex2). A mean index was calculated by dividing the sum of ratings by all respondents. Roles we defined using the Hospital and PHC observation task list.
Due to an administration error, some hospitals completed the 153 Task Questionnaires instead of the 120 Task Questionnaires. Due to this, four data sets were created: HOS 120 - Hospitals which completed the 120 task list; HOS 153 - Hospitals which completed the 153 task list and PHC - PHC services with completed the 153 task list form. Roles from HOS 120 and HOS 153 were then combined to get a definitive Hospital Role set. PHC roles were based on PHC form tasks. A standard Role variable was created for comparison.
Comparisons were done by country, by language group (Franco and Anglophone countries), by region, by nurse category, and by service type, using SPSS version. Significant testing was done with 95% Confidence Intervals (alpha < 0.05) and Kruskall Wallis Tests for Independent samples.

Validity and reliability
Mbambo, et al. (2003) pilot tested the Primary Health Care instrument for test-retest reliability on a small sample and argues for content validity based on the fact that the items reflect the Primary Health Care package of services. The fact that the additional tasks listed by their 84 nurses in a health district in South Africa have been added to the instrument makes it more valid for this study. The hospital questionnaire has also been tested in the USA (Wendt & Eich, 2007) and in South Africa (Uys et al, 2003) for test- retest reliability.
The instruments were translated into French by two independent translators, and a third independent linguist then compare the two translations and in discussion with the French- speaking country investigators decide on the most appropriate translation.
RESULTS Sample description
Nurses from nine countries completed a hospital or PHC task questionnaire - a total of 927 respondents (Table 1). Five Anglophone (56.5% of respondents) and four Francophone countries (43.5% of respondents) participated.
                                                             Table 1: Sample realization and description
Anglophone Country	Francophone country	PHC	Hospital	Total	
Botswana		4	118	122	
	Cameroon	9	110	119	
	DRC	34	67	101	
Kenya		6	94	100	
	Niger	15	64*	79	
Nigeria			102*	102	
	Senegal	43	61	104	
Tanzania			100	100	
Zambia		35	65	100	
Total	4	146	781	927	

Hospital Roles
Nurses from hospitals in nine countries completed a hospital questionnaire - a total of 781 respondents (Table 1). In most countries both tertiary and district hospitals were included. Five Anglophone (479, 61.3% of respondents) and four Francophone countries (302, 38.7% of respondents) participated. The hospital respondents included 231 (29.6%) respondents who completed the 120 task questionnaire and 550 (70.4%) who completed
the 153 task questionnaire. One hundred and thirty one (131, 56.7%) of the respondents who completed the 120 Task questionnaires were from Francophone countries.
The average age of the respondents was 38.1 (SD 9.3) with 494 Females and 165 Males. Only 96 (12.3%) were nurse assistants or enrolled nurses with 579 being professional or registered nurses, 16 midwives and 77 who classified themselves as specialist nurses.
Task frequency:
According to the '120 hospital tasks' respondents, only one task was very frequently performed (6 or more times a week by >70% of respondents), namely vital signs assessment. However, administering medication and infection control was performed by 69% of respondents >6 times a week. Similarly, although the '153 hospital tasks' respondents did not identify one task as very frequently performed (6 or more times a week by >70% of respondents), taking a blood pressure (BP) and administering medication scored the highest with 68.5% and 66.7% respectively.
If one looks at tasks performed frequently, that is 6 or more times a week by 50% of respondents, this figure increases to 19 tasks for the '120 hospital tasks' respondents, most of them from the General Care and Treatment (11 items). Similarly, the '153 hospital tasks' respondents also identified 16 tasks, again with most of these from General Care and Treatment (10 items).
While the tasks performed infrequently in the General Care and Treatment and Assessment roles were ones perhaps less widely used (e.g. performing an peritoneal dialysis or doing an ECG), the tasks reported as infrequent in MCH included essential tasks such as foetal heart monitoring and intra-partum care. Similarly, a very necessary mental health tasks such as providing a patient and family with information about mental illness and treatment, was reported to be done very infrequently.
Roles:
On average, the highest mean role functioning were reported for General Care (58.8, SD17.2), followed by General Assessment (56.3, SD17.9), Management (53.7, DD16.8) and Health Education (52.8, SD19.2), and then by Rehabilitation (51.4, SD23.5), Mental Health (48.1, SD19.2) and Maternal and Child Health (MCH) (39.4, SD21.6). MCH was significantly lower than all the roles and General Care was significantly higher than all the other roles except General Assessment (Figure 1).

Figure 1: Mean role percentages by combined hospital roles

Figure 2: Mean role percentages by combined hospital roles by language group

The mean role scores in Anglophone countries were significantly higher on all roles than the scores in Francophone countries (p=.000). The highest role function (General Care) was 65.8, SD 13.8 in Anglophone countries compared with 44.6, SD 16.3 in Francophone countries (Figure 2). This was also seen in the regional analysis with significant differences in all roles (p=.000) except for MCH (p=.238). Specifically, higher mean roles in the South & East African Regions (with exclusively Anglophone countries) than the Central& West African Regions (mixed Anglophone and Francophone countries) were reported for all roles except Planning and Management. For this role the Central Region's mean role score was significantly lower than all the regions and the West Region's mean role score was significantly lower than the Eastern Region. For MCH, only the Eastern Region's mean role was significantly higher than the Central Region
Mean Role score differences by Country varied according to different roles.
•	In the Planning and Management role, Cameroon and Senegal had significantly lower mean scores, while Niger had a very mean high score (not significant).
•	The mean score for MCH for Tanzania was significantly higher than all countries except Nigeria and Zambia.
•	Botswana, Kenya and Tanzania had significantly higher scores for Rehabilitation
•	Botswana Tanzania and Zambia had significantly higher scores for Mental Health, with Senegal having significantly lower mean scores for this role.
•	Botswana, Tanzania and Zambia had significantly higher scores for General Care and General Assessment, with Cameroon having significantly lower mean scores
There were significant differences between nurse types with enrolled and assistant nurses having lower mean scores for Assessment, General Care, MCH and Planning and Management. Midwives had mean role score for MCH care which was significantly higher than all other nurse types.
Primary Health Care (PHC) Roles
Sample description
Nurses from seven countries completed the PHC form - a total of 146 respondents. Three Anglophone (45, 30.8% of respondents) and four Francophone countries (101, 69.2% of respondents) participated in the survey.
The average age of the respondents was 39.4 (±9.1) with 99 Females and 35 Males. Only 52 (35.6%) were nurse assistants or enrolled nurses with 87 being professional nurses and 5 midwives. Most of the respondents were from peri- urban areas (53.8%), with only 3.8% from rural settings and the rest (42.3%) from urban areas.
Tasks:
According to the respondents, no tasks was very frequently performed (6 or more times a week by >70% of respondents). If one look at tasks performed frequently, (6 or more times a week by 50% of respondents), seven such tasks were identified. Five of the seven tasks frequently performed can be classified as General Care and Treatment (e.g. giving oral medication and giving injections) while two are General Assessment tasks (e.g. assessing health status and assessing respiratory status).
According to the respondents 23 tasks were very rarely performed (<1 times a week by >80% of respondents) The 23 tasks very rarely performed falls into six of the roles, with General Care and Treatment (7 items) and Planning and Management (7 items) most frequent. If one look at tasks performed a task performed rarely that is < 1 times a week by 50%, of respondents this figure increases to 120 tasks. There are some tasks generally associated with PHC such as participating in community projects and providing antenatal teaching that falls into this category of tasks.
Roles:
On average, the highest mean role were reported for General Care (53.2 , SD 18.1), General Assessment (51.3, SD18.1) and Health Education (50.9, SD20.5), followed by Rehabilitation (48.1, SD20.4), Management (44.6, SD18.0), Mental Health (42.6, SD18.1) and Maternal and Child Health (MCH) (39.9, SD18.1). The MCH mean role was significantly lower than the means for General Care, General Assessment Health Education and Rehabilitation roles (Figure 3).

Anglophone countries had significantly higher means in all the roles (p=.000) except for the Maternal and Child Health Roles (p=.446), where there were no significant differences. The highest overall role function (General Care) was 65.3, SD 13.1 in Anglophone countries compared with 45.0, SD 15.4 in Francophone countries (Figure 4).This was also seen in the regional analysis with significant differences between all the regions in all roles (p=.000), specifically the Central and West African Regions (lower) and the Southern and Eastern Regions (higher) for all roles except Planning and Management where the Eastern and Southern regions were higher than Central & Western regions. In the MCH role, only the East African Region's mean was significantly higher than in the other regions. These differences were driven by country differences which were significant for all roles (p=.000) with Kenya, Botswana and Zambia having generally higher mean roles (significant) except for MCH where only Kenya scored significantly higher
Figure 4: Mean role percentages by PHC roles by language group

There were no significant differences between nurse types except for MCH where midwives roles scored significantly higher (p=.009) and health education where enrolled and assisted nurses had higher means (p=0.048).
Where rural and urban comparisons were done, significant differences were found in the MCH role (p=.001), the mental health role (p=.014) and the health education role (p=.003) with rural areas having higher mean scores.
Comparison Hospital and PHC
There were significant differences between hospital and PHC planning and management, general assessment, general care roles and mental health with hospital roles being much higher. There were no significant differences between PHC and hospital roles for health education, rehabilitation and MCH roles.
DISCUSSION Study limitations
The study has certain limitations. The fact that only 193 nurses from PHC settings completed the questionnaires as opposed to 927 from hospitals points to inadequate representation of this kind of setting. Furthermore, only 3.8% of the PHC nurses were from rural settings, where the roles might be significantly different from urban settings. Further studies are therefore necessary focusing on PHC settings in rural areas. While an effort was made to make the countries chosen for the sample representative of the countries in the WHO African region, the significant country differences indicate a need for country level studies of this kind.
Discussion of results
The samples from both hospitals and PHC settings indicate that nursing/midwifery in African is still a predominantly female profession, with the female to male ratios in hospitals being about 5:2 and in PHC settings 3:1. The samples were also predominantly from the professional nurse group, so that the roles identified can be ascribed to professional/nurse-midwives.
The highest role functioning in both settings was found in the role "General Care", but in hospitals this was only at the 58.8% level and in PHC settings at 53.2% level. In comparing the difference between Anglophone and Francophone countries, the low overall levels are due to the low mean scores for Francophone countries. The South African study which used the same methodology indicated the highest performance in Assessment in hospitals settings (76%), while the highest performance in PHC settings was in Counselling and Teaching (87%). The higher performance levels in the General Care and General Assessment roles in this study may indicate that nurses are better prepared for these two roles than for the others. When one looks at the content of pre- service nursing curricula outlined in the WHO review of these programmes done in 2008, the predominance of "general nursing" content, such as surgical nursing, anaesthetics, medical nursing is clear, with about 80% of modules dealing with this component of care. It may also indicate that many of the fundamental competencies needed by nurses in all areas of nursing is located in these two roles, such as taking vital signs or preparing a patient for transfer.
The lowest role functioning in both settings was found in the role "Maternal and Child Health". In hospital settings it could be argued that this is related to the fact that midwifery services are generally offered in specialized units, which might not be well- represented in the sample. However, this cannot be said about PHC settings, where such services are generally integrated. This finding probably relates to the less than adequate progress the region has made in achieving Millennium Development Goals 3 and 4. The 2010 progress report indicates that progress on indicators such as the Under Five Mortality Rate (U5MR) and the Maternal Mortality Rate (MMR) is too slow to reach the 2015 goals. It also seems that in some countries midwifery content is limited to Midwifery curricula, with nurses having little or no preparation in this field, for instance in the "licence" curriculum of Mali (a qualification considered on par with the B Nursing degree in Francophone countries), midwifery content is only represented by a module on Obstetrics and Gynaecology (WHO, 2008, p. 11).
The provision of Mental Health Care is the second lowest in both settings. This is of concerns if one considers that Neuropsychiatric Illness has the second largest impact on DALYs in adults in the African region and is number ten in children (WHO, 2004). Intentional injuries, which includes violence against women and children and suicide, are number four in adults and these conditions may also relate to mental health.
The relatively low score of Rehabilitation might be related to the low number of items relating to this role in the case of the hospital settings, but not in the PHC settings. In a region where alternative health providers, such as Occupational Therapists and Physiotherapists are very scarce (WHO, 2009) the limited role functioning of nurses in terms of rehabilitation may lead to poor rehabilitation and an increase in disability.
The low role functioning in areas outside of general medical and surgical nursing indicates a need for curriculum development that ensures a better balance between physical and mental health, treatment and rehabilitation and a greater focus on midwifery content. These roles need to also be attended to through in-service training for nurses currently in practice.
The significantly higher role performance in Anglophone countries than in Francophone countries is a robust finding that also emerges in regional comparisons. It may relate to the generally better development of nursing and midwifery in Anglophone countries with regard to the presence of nursing and midwifery in Universities, the presence of regulatory bodies for nursing and midwifery and the preparation of nurses and midwives with higher educational qualifications. For example, amongst the four Francophone countries in this study, only in two of the countries a Masters' degree is currently offered: in the DRC a Masters is being development through the CHENMA project and Cameroon has one Masters in Nursing Education offered in the English language University of Buea. Also, in the four Francophone countries in this study only one (Cameroon) has a legislated regulatory bodies for nurses. However, in Cameroon the regulatory body, set up by a presidential decree and deals with nurses, midwives and all other health technicians, making regulation extremely difficult or non-existent. This general development of the profession might influence the quality of education and practice. For instance, with a regulatory body present, the roles of nurses and midwives might be more clearly regulated, and the preparation for such roles better prescribed and monitored. There is therefore a need for a special effort in Francophone countries to develop post-graduate educational programmes that can prepare nurse leaders, researchers and educators. The development of regulatory bodies for nurses which is supported by legislation is essential to develop the education and practice of nurses.
Significant differences in role fulfilment were found between countries. The detailed study of which tasks are being under-performed can only be addressed nationally and not internationally. It is therefore essential that such task analysis studies be done on larger samples in each country, in order to inform curriculum and continuing education decisions.
CONCLUSION
The importance of nurses and midwives for the health care systems of Africa is difficult to over-estimate. They are also the most widely distributed health care professionals and the most generally available health professionals in the region. The adequate development of these professions, their education and their practice should therefore be a priority for the governments of all countries in the WHO African region. The limited role functioning in some nursing and midwifery roles found in this study indicates a need for targeted interventions to improve service delivery.

REFERENCES
Biddle, B.J. and Thomas, E.J. (eds.) (1966) Role Theory: Concepts and Research. New York: John Wiley & Sons, Inc.
Burgel, B.J., Wallace, E.M., Kemerer, S.D. & Garbin, M. (1997) Certified Occupational Health Nursing job analysis in the United States, AAOHN Journal 45(11): 581-591.
Dgedge M., Inusso M. and Augusto G. et al (2009) Situation analysis of nursing career
in Mozambique. (Draft report) Maputo: Department of Health, Jhpiego and CDC
ECSACON (2001). Nursing and midwifery professional regulatory framework. Arusha, Tanzania: Commonwealth Regional Health Secretariat.
Hardy, M.E. and Conway, M.E. (1978) Role Theory. Perspectives for health
professionals. Norwalk: Appleton-Centry-Crofts.
Mbambo, S., Uys, L.R., and Groenewald, B. (2003) A job analysis of selected health workers in a district health system in KwaZulu-Natal. Part two: Job analysis of nurses in primary health care settings. Curationis 26(3): 42-52.
NEPAD (2010) Annual Report: Education and Training. Halfway House: NEPAD.
Parent, F., Lemenu, D., Lejuene, C., Baulana, R., Komba, D., Kahombo, K. and Coppieters, Y. (2006) Presentation du referential de competences infirmier en Republique Democratique du Congo dans le cadre du renforcement des ressources humaines en Sante. Sante Publique 1-12
Wendt, A. and Eich, M. (2007) 2006-2007 RN Continuous Practice Analysis. NCSBN Research Brief 34: May 2007. www.ncsbn.org/08-2006-
2007 RN Continuous Practice Analysis Vol34 FINAL.pdf Accessed 15/07/2009.
WHO AFRO (2007) An Action Framework for the WHO African Region 2008-2017 for Strengthening Nursing and Midwifery Development for Scaling up of Health Service Development. Brazzaville: WHO Regional Office
WHO AFRO (2008) Evaluation of Nursing and Midwifery Education Programmes in Selected Francophone Countries in the WHO African Region. Brazzaville: WHO Regional Office
WHO (2009) WHO Statistical Information System (WHOSIS).
www.who.int/whosis/en/index.html.) Accessed 16/07/2009.
WHO (2004) Global Burden of Disease (GBD)
(www.who.int/healthinfo/global burden iseases/2004 report update/). Accessed 16/07/2009.
Uys, L.R., Groenewald, B. and Mbambo, S. (2003) A job analysis of selected health workers in a district health system in KwaZulu-Natal. Part one: Job analysis of nurses in hospital settings. Curationis 26(3): 32-41.