The contribution of leadership training for health workers in furthering palliative healthcare in Uganda.

Leadership is key in the ongoing development and integration of palliative care in Uganda. The importance of developing leaders in palliative care has been emphasised in the World Health Assembly Resolution in Palliative Care (2014), the Sustainable Development Goals (SDGs), Universal Health Coverage (UHC), the Lancet Commission Report on Pain and Palliative Care (2018) and the Global Nursing Now campaign. Developing and empowering leaders is essential for the ongoing sustainability of palliative care in Uganda and previous work had identified nurses as a core group for leadership development.

In Uganda, as in many low and middle income countries, nurses have a key role in shaping and guiding the development of palliative care. In 2015, the World Health Organisation (WHO) reported that  there were 1.2 doctors per 10,000 people in Uganda, and 6 nurses. Thus despite the low ratio, nurses are at the forefront of palliative care provision. The Uganda Palliative Care Leadership Programme was developed and implemented between 2015 and 2017. The aim of the programme was to develop nurse leaders within palliative care to support the ongoing leadership of palliative care within the country, and ultimately improve the quality of life of those needing palliative care.

20 Nurse Leadership Fellows were recruited from across Uganda, representing a range of organisations including the Ministry of Health, Non-Governmental Organisations, and Faith Based Organisations, along with providing care in hospitals, health centres and the community. All of the Nurse Fellows had been trained in palliative care, some of whom were working full time in palliative care, others carrying out palliative care on top of their main functions within the hospital. The leadership programme was delivered over a period of eighteen months and included three taught face-to face modules, interspersed with mentorship and supervision. Mentorship was provided by experienced palliative care nurse leaders from the UK as well as the team from Makerere/ Mulago Palliative Care Unit (MMPCU). Face-to-face mentoring was provided alongside remote mentoring via skype, WhatsApp etc. and mentors were matched with the Nurse Fellows according to the mentors experience and the fellows action plans.

Nurse Fellows developed Action Plans in three parts. The first part of their Action Plan focused on themselves as leaders – what areas of leadership did they need to work on e.g. conflict resolution, empowering others and self-care. The second part included the implementation of leadership activities within their work place – this included projects such as link-nurse training, instigating daily reporting about patients within the team, and providing supervision and mentorship, ensuring that palliative care provision continued in their absence.

Finally the Fellows were put into four groups to work on four National Level Projects: a) Review of competencies and curriculum for nurse prescribing b) Evaluation of nurse prescribing, c) Rapid appraisal of the system in which the nurses are working, and d)an evaluation of the Link-nurse programme implemented throughout the country.

An independent evaluation of the programme demonstrated the impact of the Leadership Programme on the Nurse Fellows, including improved knowledge and skills, increased aware of palliative care, increased training, mentorship and research capacity and building of confidence and self-efficacy. The UK mentors also reported skills improvement, learning that they can take back to the UK and a personal impact of mentoring the Nurse Fellows in Uganda. The programme was awarded the European Association for Palliative Care (EAPC)/ European Palliative Care Academy Award for Palliative Care Leadership programmes in May 2017. It has been recognized by THET and DFID as an exemplary programme.

Thus further funding was obtained through the Health Partnership Scheme to continue the programme and a second cohort of Leaders are part way through the programme. This second cohort includes nurses, midwives, counsellors and clinical officers from across Uganda.

The provision of leadership training can have a great impact on palliative care provision and development and is essential in the ongoing sustainability of palliative care in Uganda. Mentorship and supervision are key, along with modelling and self-reflection. The model of integrating leadership training with individual, local and national projects has maximized the impact and sustainability of the programme.

Nurse Fellow from Cohort 1

Lieutenant Edith Nandutu: ART Clinic Manager, Focal Person PC UPDF, Programmes Officer PMTCT, UPDF.

The impact of this course is great to me. Remember when we first started the course, I lacked so many things as far as leadership is concerned. Then, after the first module I went for another leadership training. Mhoira and Prof Julia allowed me to go because you said it is still leadership so you will gain. Actually, I gained something of the other leadership which is slightly different from this type of leadership. The other one is the boss type of leadership, where you just give orders, you command, no negotiation, but in this leadership there is negotiation, I have learnt how to delegate. Those days I could do all the work by myself, but these days I know how to delegate, like now I am here, but work is still continuing at my workplace because they know what to do, everybody knows what he or she is supposed to do and things are moving on smoothly. I have been away for a month and so, but things are still moving on. Um  I share, before I make decisions I sit down with my team members and we decide on what to do. Is what we are going to do good or bad, if its bad how best can we do it…..

That’s what I have learnt, I can delegate, I share with others, you know, I assign duties according to who will be able to finish it within the given time. I give opportunity to my different staff. If this one had an opportunity, then I should also empower the others so that they all learn, so that in case one is not around the other one can take over the responsibilities………

Actually, since I started this course I have achieved a lot. I came here when I was an ART clinic manager and programme officer for elimination of mother to child HIV transmission. Today, I am still holding that position as the ART clinic manager, focal person PC UPDF, I am also holding the position of the programmes officer PMTCT, I was given an added responsibility as a member of the research and ethics committee, and of course since I had the military training I am an officer of the UPDF – I’m a Lieutenant.

UK Mentor

Claire Lesley: Clinical Nurse Specialist, UK

So the impact of the programme, of this nurse leadership programme that I have been able to observe, I have been here for eight weeks observing some of these nurses and it has just been incredible.

The innovation from these nurses, their skills, and the development of their leadership skills has been really wonderful to watch and some of their negotiating and delegating techniques as well.

Also just learning a bit more about them, and how they work in their different settings which are very different to the settings which I work in in my role at home. It has been inspiring, the hard work and dedication that they have put into their work in PC and as nurse leaders means that other people will be able to see them as role models, now and in the future and I think that’s a really good sign of a good leader and so I have felt very inspired by these nurses  and I have learnt a huge amount from them as well and its been a wonderful experience to get to know them and to work with them.