Self-efficacy and Clinical Performance of Nurses Initiated and Management of Antiretroviral Therapy: Narrative Review
Nozuko Glenrose Mangi1, *, Daniel Ter Goon1, Elizabeth Matsidiso Yako2
Identifiers and Pagination:Year: 2019
First Page: 86
Last Page: 93
Publisher Id: TOPHJ-12-86
Article History:Received Date: 10/10/2018
Revision Received Date: 30/01/2019
Acceptance Date: 12/02/2019
Electronic publication date: 19/03/2019
Collection year: 2019
open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Self-efficacy plays a major role in the behaviour of a human being by how he/she approaches a goal, task or a challenge so that a desired level of performance is produced. The objective of this paper is to review and analyse literature on self-efficacy and clinical performance among professional nurses regarding quality of care in implementation of NIMART programme.
A literature review was conducted using online resources. Search engines included EBSCO, Google Scholar, Medline, PubMed, Psych info and BIOMED Central articles and journals published between 2007 and 2017. Relevant papers on self-efficacy and clinical performance regarding the implementation of NIMART programme in South Africa were analysed.
278 papers were identified and 22 eligible papers were selected for analysis. Reviewed literature exhibited that self-efficacy is very crucial in the clinical performance of nurses in the implementation of NIMART. Self-efficacy helps to predict motivation and performance of individuals. Lack of mentoring, support and exposure to clinical practice had negative effect on nurse’s self-efficacy.
Given the paucity of information on self-efficacy and clinical performance of NIMART in the South African context, future studies are warranted to gain more understanding of self-efficacy in the clinical performance of professional nurses.
Self-efficacy is significant for attaining outcome or goals especially in the implementation of a learned skill . Self-regulatory abilities are central importance for attaining personal goals of the individual [2, 3]. Self-efficacy plays a major role in the behaviour of a human being by how he/she approaches a goal, task or a challenge so that the desired level of performance is attained [4-6]. Self-efficacy is also crucial to obtain quality care of client especially those suffering from HIV/IADS. The basic principle behind Self-Efficacy Theory is that individuals are more likely to engage in activities for which they have high self-efficacy and are competent on those activities; and less likely to engage in activities they are not competent . Therefore, self-efficacy can be improved by accomplishing small tasks and gaining confidence in one’s ability and support from the experienced person or colleague [8-12]. Individual’s sense of self-efficacy has an impact on performing a skill which can result in good or poor quality of care for clients [13-16]. Therefore, sound decision making in clinical performance is affected by one’s self-efficacy, support and motivation.
There is limited literature in South Africa regarding self-efficacy in implementing Nurse initiated and management of Antiretroviral Therapy (NIMART) programme with a quality outcome. Therefore, this narrative review was conducted to analyse literature on self-efficacy and clinical performance for quality of care among nurses regarding the implementation of NIMART programme.
1.1. Nimart Practise
South African Department of Health identified a need to implement strategies to upskill nurses in the clinical management of HIV and AIDS, for effective and efficient management of people living with HIV/AIDS . One of the strategies identified was the nurse-initiated management of antiretroviral therapy (NIMART) course. NIMART practise covers the following activities: (i) clinical aspects of HIV infection and AIDS i.e. staging; (ii) HIV management in adults and children, which includes opportunistic infections and their presentation and management; (iii) Initiation ART in adults and children, which includes classes of drugs and their modes of action; (iv) reading and implementation latest SA guidelines; (v) management of drug-related toxicities and including treatment failure; (vi) HIV in women; (vii) HIV and Tuberculosis (TB) comorbidity; (viii) ethics related to HIV and AIDS; and (ix) palliative care for People Living with Human Immune Virus (PLHIV).
2. MATERIAL AND METHODS
2.1. Search Strategy
A search was conducted using electronic database EBSCO, Google Scholar, Medline, PubMed, Psych info, BIOMED Central articles and journals published between 2007 and 2017 were selected for analysis. Studies were limited to self-efficacy and clinical performance, written in English language and published between 2007 and 2017.
2.2. Criteria for Selection of Articles
The retrieved articles were scanned for relevancy by reading their abstracts. The articles were relevant if these two key search words, ‘self-efficacy’ and ‘clinical performance’ were appearing in the article. Articles were also included if they have information on a relationship about self-efficacy and clinical performance. Only English written articles were reviewed and analysed. Table 1 shows the inclusion and exclusion criteria of articles for analysis.
The findings pertaining to self-efficacy, clinical performance and quality of care identified in various articles are presented in Table 2.
4.1. Quality Appraisal of the Included Papers
The literature searched on self-efficacy and clinical performance produced 278 published papers (Fig. 1). Forty-one duplicate papers were removed and 211 papers do not have information on self-efficacy, clinical performance, and quality of care, HIV/AIDS, antiretroviral therapy and literature review. Ultimately, 22 published papers were identified which meet the criteria for inclusion.
The findings of the published papers were highlighted in a narrative text (self-efficacy, clinical performance and quality of care) (Table 1). From included reviewed papers, 12 of the papers used quantitative approach [3, 6, 8, 17, 25] and 10 papers used qualitative approach [26-36] These papers examined and narrated self-efficacy and clinical performance in different countries. The qualitative studies in this study had a common factor there is a relationship between self-efficacy and clinical performance. Self-efficacy plays a protective role when the person is experiencing emotional exhaustion and high stress conditions [27, 33, 34] Therefore, a person who is emotionally exhausted has difficulty in performing the usual duties. Several studies [20, 28-31] indicated that shortage of personnel to perform specific duties at work place negatively affect self- efficacy of the nurses, and thus, can lead to poor performance due to demotivation. Other studies had evidence that mentoring, exposure to clinical skills, practise and support of personnel improves self-efficacy [3, 6, 8, 18, 21, 26, 32-34]. There is also empirical evidence that quality of care for the clients is affected if the nurses have low self- efficacy [19, 34, 36].
This narrative review of literature revealed that nurses do not have confidence to initiate clients on ART after NIMART training course. A need for on-the-job mentorship and support in order to maximise clinical outcomes related to HIV and improve self-efficacy of the professional nurses was suggested . Therefore, mentoring and support of the professional nurses after training is important for nurses to develop self-efficacy in the initiation and management of clients on ART for better clinical outcomes. Nurses as the largest group within the multidisciplinary team, have a vital role to play if success is to be achieved . Professional nurses are ideally committed to the broad aims of quality care; and their main concern to provide high standard services and to meet the needs of individual service users, their families, and communities [38-40]. Self-efficacy influences the task employees choose to perform and the goals they set for themselves [20, 21, 30, 31, 41]. Self-efficacy can affect people’s behaviour positively or negatively, and this behaviour, may have an impact on one’s performance and clinical outcome for the clients . Self-efficacy and clinical performance have relevancy in health care practices. These practices are gained through knowledge and skills, therefore, the expectation is to have good clinical outcomes [7, 32]. Professional nurses need to be well trained, knowledgeable, confident and have clear job description for better clinical management of clients. Self-efficacy is not only needed on rational decision making, but also to build trust with clients in clinical management of HIV/AIDS affected clients . Trust is important, especially in this era of HIV/AIDS prevalence because trust can influence a client to behaviour change. People with positive self-efficacy display mastery of their environment and more confident in acting safe and competent in challenging situations. Mastery experience is the most influential source of self-efficacy because it provides the most authentic evidence of whether one can master a skill and what it takes to succeed or reach a goal [22, 42]. Therefore, nurses who are the backbone of the Department of Health, need to be upskilled, motivated and supported to have confidence in implementing NIMART.
|Fig. (1). Papers reviewed for analysis.|
|Inclusion criteria||Exclusion criteria|
|Articles published in English||Articles published in other languages|
|Articles that have information on self-efficacy clinical performance and quality of care, HIV/AIDS, antiretroviral therapy, literature review,||Articles that have no information on self-efficacy, clinical performance and quality of care, HIV/AIDS, antiretroviral therapy, literature review|
|Published articles on peer reviewed journals||Articles that were not published|
|Self-efficacy||Clinical performance||Quality of care|
|Vhembe, South Africa||Quantitative Descriptive,cross-sectional||233 nurses||-||Knowledge is the key for quality care of clients||-|||
|Shiraz, Iran||Quantitative, cross-sectional||264 nurses||General Self-Efficacy is associated with the willingness to work in the nursing unit and interest in the nursing field and beliefs affect
how people think, feel, motivate and act
|12 students nurse||-||Clinical practise requires skilled personnel for quality care of clients, active involvement in practise makes a nurse more proficient, flexible and resourceful||-|||
|79 participants||High self-efficacy seems to play a protective role from experiencing more emotional exhaustion when in high stress condition,||-||-|||
|Tennessee, USA||Qualitative, descriptive||State agencies, advocate and attorneys, nursing facility representatives||-||-||Quality of care and quality of life have a long-standing concern nation-wide, in Tennessee home litigations negatively impact the quality and access of care|||
|Halifax, Nova Scotia||Quantitative,||253 nursing students||Nursing Competence Self-Efficacy Scale (NCSES) The influence of well-prepared registered nurses who willingly embrace a challenge will likely to exert a positive influence in the entire health care system||-||-|||
|Oshikati, Namibia||Qualitative Descriptive design||24 nurses||-||Shortage of nurses for clinical performance affect quality management of clients and outcomes||Nurses are vulnerable to emotional distress due to care of HIV people. Quality of for HIV client depends on the quality of care they receive from emotional nurses|||
|Shiraz, Iran||Qualitative, content analysis||17 student nurses||Deficient in clinical practice skill affects the quality of care for the HIV affected client|||
|Mwanza, Malawi||Qualitative, descriptive||6 focus groups||-||Clinical performance is greatly affected by poor supervision, poor access to training, workload and extensive job description||-|||
|Bonafide Benquet, State University, Philippines||Qualitative, descriptive design||I focus group and 9 interviewed student nurses||-||Exposure to clinical practice is crucial for nurses, it enriches the nurse for better performance for client care, experience, knowledge and practice, these aspects develop the nurses’ competency and confidence||-|||
|Al-Quds University, Palestine||quantitative descriptive, explorative||185 professional nurses||Adequate number of qualified nurses according to work is essential in each shift for the quality of care for the clients||Shortage of nurses due to all types of leave negatively affects the quality of care and performance of nurses|||
|Limpopo Province, South Africa||Quantitative descriptive, cross-sectional||85 nurses||-||Evidence of poor performance of nurses was due to the absence of support, motivation and good working environment.||-|||
|Hospital, United States||Quantitative,
|77 registered nurses||-||-||Ongoing learning and development of nurses is essential for quality of care because of continual advances in treatment and management of diseases|||
|Australia and New Zealand||Qualitative, secondary analysis of interview||11 professional nurses||Nurses with high levels of self-efficacy demonstrate responsibility for their acts and omissions||Experienced professional nurses apply their skills to both novel and familiar situations. When they are competent, they are capable to adapt and flexible in response to any challenge|||
|Quantitative, Descriptive design||900 student nurses||Mastery of clinical skills is the key to clinical performance and confidence.||High level of stress, anxiety, shortage of equipment and staff may result in poor quality of care for clients|||
|Namibia||Quantitative descriptive survey||180 professional nurses||Building knowledge and expertise will improve clinical performance, quality performance improves efficiency and confidence.||lack of recognition and support of the employee will affect the quality of care rendered|||
|Nine European countries, Cyprus, Belgium, Finland, England, Ireland, Italy, Netherlands, Spain, Sweden||Quantitative design||1903 participants||Nursing requires both significant time spent with clients and supportive supervising relationship for the quality of care.|||
|Iran||Qualitative||28 semi structured interview||Self-efficacy in clinical practice improves performance of health workers and quality of care for clients,|||
|Zimbabwe||Qualitative||25 nurses and 40 guardians||Adherence is mostly to succeed if there quality of care for clients and compassionate nurses|||
|South Africa 7 provinces, Limpopo, Mpumalanga, Gauteng, North west, Free state, Kwazulu Natal, Northern Cape||Telephonic interviews||126 nimart trained nurses||Nurse management of ART had good accomplishment and retained more clients and had improved self-esteem of the nurses in initiation of ART.|||
|Hiroshima, Japan||Cross sectional||322 nurses||Level of competency directly affects care provided to patients, therefore, nurses need to be competent|||
|South Africa University of KwaZulu-Natal||Quantitative approach||1 369 nurse trainees||Despite the observed increase in knowledge, however, participants were not confident to initiate ART which suggests a need for an ‘on-the job’ mentorship programme for positive health outcomes|||
|South Africa||Qualitative||Phase scale up design for doctors, nurses and clerks||Quality improvement technique can be used to assist to address system failure and quality care for clients|||
5.1. Negative Effects of Self-efficacy
Lack of social support, knowledge, practice, shortage of staff and work-load can affect self-efficacy negatively. These challenges can affect the quality of care delivered by the nurses for the clients [29, 33]. Lack of motivation and absence of hygiene factors were also identified as aspects that can lower self-efficacy of nurses consequential to poor clinical performance . Lack of confidence in professional nurses in implementing NIMART can also lead to poor management of clients. People with lack of confidence exhibit low self-efficacy which interfere with initiation and pursue of intentions of NIMART programme . Therefore, experience, clinical practice, motivation, supervision, support and knowledge are needed to develop the nurse’s confidence and morale [7, 42].
5.2. Positive Effects of Self-efficacy
Learning has a positive effect on self-efficacy in clinical performance of nurses as it increases their self-efficacy [8, 43]. Self- efficacy has been associated with enhanced motivation, strong self-direction and goal orientated. Therefore, positive self-efficacy will enhance clinical performance. Self-efficacy is also gained by modelling achievements from other people thus gaining self-efficacy in performing a task. Peer education, mentoring and working with patients also play a significant role in building self-efficacy in professional development [13, 44]. This explains that learning from peers in clinical practice is an important aspect in building self-efficacy. Therefore, sufficient skill and ability to perform a task are very important to enhance one’s self-efficacy. High level of self-efficacy will result in high level of work performance; and there is a relationship between self-efficacy and work performance [19, 27]. High self-efficacy also plays a protective role from experiencing more emotional exhaustion when in stressful condition . Therefore, self-efficacy is very crucial in clinical performance of health workers. Self-efficacy and resilience at workplace is a positive aspect in clinical practice and can enhance confidence . Employees that are motivated, well skilled, involved in practice are likely to perform to their best level, proficient and resourceful than those with low self-efficacy.
5.3. Comparison of South African NIMART with Other Countries
HIV/AIDS continues to be a global public-health problem, therefore NIMART is the best strategy identified to improve access to ART care. The Johns Hopkins University School of Nursing embarked on a transformative curriculum overhaul to integrate HIV prevention, treatment, and care into the Adult /Geriatric Nurse Practitioner Program. There is a need to implement strategies to upskill nurses in the clinical management of HIV and AIDS, for effective and efficient management of people living with HIV, in the South African context . Therefore, a training on NIMART was conducted for nurses at the University of KwaZulu Natal. Upskilling nurses by training was conducted to ensure that they have the required knowledge to implement NIMART for access of care by clients . However, there is a gap in implementing NIMART. The nurses indicated they need mentoring, support and practice to build confidence in order to manage those affected with HIV/AIDS.
Notwithstanding the implementation of NIMART in Kenya, nurses have gaps in training, competency, and practice in HIV care and treatment. It was recommended that further investment in nurse capacity building is needed to bridge the gaps and prepare nurses to provide high-quality, comprehensive HIV care and treatment . Therefore, if the nurses are not well trained, their self-efficacy will be compromised by incompetency, resulting in poor management of the clients.
In a multi-country study conducted from 2007 to 2011 in five countries (Angola, Burundi, Lesotho, Mozambique and South Africa), successful ARV roll-out was observed, despite HRH shortages, skill scale up , which suggest that these countries have adapted a similar model of upskilling and mentoring as an antidote in speeding up the implementation of NIMART for the purpose of building self-efficacy in nurses.
This narrative review has shown that there are gaps in nurses’ skills and self-efficacy regarding the implementation of NIMART. Experiential learning, support, supervision, skills update, mentoring and peer education are fundamental aspects to enhance self-efficacy and quality improvement in the management of clients by professional nurses. Several studies have alluded to the fact that self-efficacy is the motivation that a person needs to accomplish a task or a goal. Therefore, there is a need to motivate and build self-efficacy among professional nurses, especially in South Africa.
Risk of biasness due to only two researchers viewed the literature for this study and only English written papers were included in the study.
LIST OF ABBREVIATIONS
|AIDS||= Acquired Immune Deficiency Syndrome|
|ART||= Anti-Retro Viral therapy|
|ARV||= Anti-Retro Viral|
|HIV||= Human Immune Virus|
|NIMART||= Nurse Initiated and Management of antiretroviral therapy|
|NCSES||= Nursing Competence Self-Efficacy Scale|
|PLHIV||= People Living with Human Immune Virus|
CONSENT FOR PUBLICATION
CONFLICT OF INTEREST
The authors declare that they have no competing interest, financial or otherwise.
|||Saeed R, Mussawar S, Lodhi RN, Iqbal A, Nayab HH, Yaseen S. Factors affecting the performance of employees at work place in the banking sector of Pakistan. Middle East J Sci Res 2013; 17(9): 1200-8.
|||Newark PE. Self-beliefs, resources, and self-regulation in adult ADHD psychotherapeutical relevance and implications (Doctoral dissertation, University_of_Basel) 2014.|
|||Warne T, Johansson UB, Papastavrou E, et al. An exploration of the clinical learning experience of nursing students in nine European countries. Nurse Educ Today 2010; 30(8): 809-15.
|||Cherian J, Jacob J. Impact of self-efficacy on motivation and performance of employees. Int J Bus Manage 2013; 8(14): 80.
|||Stein J, Lewin S, Fairall L, et al. Building capacity for antiretroviral delivery in South Africa: a qualitative evaluation of the PALSA PLUS nurse training programme. BMC Health Serv Res 2008; 8(1): 240.
|||Takase M. The relationship between the levels of nurses’ competence and the length of their clinical experience: a tentative model for nursing competence development. J Clin Nurs 2013; 22(9-10): 1400-10.
|||Bandura A. On the functional properties of perceived self-efficacy revisited 2012.
|||Kennedy E. The nursing competence self-efficacy scale (NCSES): An instrument development and psychometric assessment study 2013.|
|||Mpondo F, Ruiter RA, van den Borne B, Reddy PS. Self-determination and gender-power relations as predictors of condom use self-efficacy among South African women. Health Psychol Open 2015; 2(2): 2055102915598676.
|||Dieleman M, Gerretsen B, van der Wilt GJ. Human resource management interventions to improve health workers’ performance in low and middle income countries: a realist review. Health Res Policy Syst 2009; 7(1): 7.
|||Twigg D, Duffield C, Thompson PL, Rapley P. The impact of nurses on patient morbidity and mortality - the need for a policy change in response to the nursing shortage. Aust Health Rev 2010; 34(3): 312-6.
|||Van Damme W, Kober W, Laga K, Letsoalo M. HIV Nursing Matters. HIV Paediatrics Issues 2011; 2(3): 12.|
|||Mensah AO, Lebbaeus A. The influence of employees’ self-efficacy on their quality of work life: The case of Cape Coast, Ghana. Int J Bus Soc Sci 2013; 4(2)|
|||Workneh G, Scherzer L, Kirk B, et al. Evaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana. AIDS Care 2013; 25(1): 11-9.
|||Bekker L G, Venter F, Cohen K, et al. 2014.Provision of antiretroviral therapy in South Africa: the nuts and bolts Antiviral therapy
|||Azia IN, Mukumbang FC, van Wyk B. Barriers to adherence to antiretroviral treatment in a regional hospital in Vredenburg, Western Cape, South Africa. South Afr J HIV Med 2016; 17(1): 476.
|||Mngqibisa R, Muzigaba M, Ncama BP, Pillay S, Nadesan-Reddy N. Upskilling nursing students and nurse practitioners to initiate and manage patients on ART: An outcome evaluation of the UKZN NIMART course. Afr J Health Prof Educ 2017; 9(3): 153-8.
|||Makhado L, Davhana-Maselesele M. Knowledge and psychosocial wellbeing of nurses caring for people living with HIV/AIDS (PLWH). Health SA Gesondheid 2016; 21(1)
|||Soudagar S, Rambod M, Beheshtipour N. Factors associated with nurses’ self-efficacy in clinical setting in Iran, 2013. Iran J Nurs Midwifery Res 2015; 20(2): 226-31.
|||Thulth AS, Sayej S. Selected Organizational Factors Affecting Performance of Professional Nurses in North West Bank Governmental Hospitals. J Educ Pract 2015; 6(7): 100-10. http://iiste.org/Journals/index.php/JEP|
|||Makunyane CM. Factors influencing performance of nurses in the Makhuduthamaga Sub-District, Sekhukhune District, Limpopo Province, South Africa (Doctoral dissertation) 2012.|
|||Crannell BA, Witte MM. Clinical practice of registered nurses and learning styles preferences. Institute for Learning Styles Journal 2012; 1(1): 1-7.|
|||Reeve J. Why teachers adopt a controlling motivating style toward students and how they can become more autonomy supportive. Educ Psychol 2009; 44(3): 159-75.
|||Helminen K, Coco K, Johnson M, Turunen H, Tossavainen K. Summative assessment of clinical practice of student nurses: A review of the literature. International Journal of Nursing Studies 2016; 53: 308-19.
|||Cameron D, Gerber A, Mbatha M, Mutyabule J, Swart H. Nurse-initiation and maintenance of patients on antiretroviral therapy: are nurses in primary care clinics initiating ART after attending NIMART training? S Afr Med J 2012; 102(2): 98-100.
|||Shirazi F, Sharif F, Molazem Z, Alborzi M. Dynamics of self-directed learning in M. Sc. nursing students: A qualitative research. Journal of advances in medical education & professionalism 2017; 5(1): 33.|
|||Smolen-Hetzel A. Geropsychiatric nursing staff: The role of empowerment, geriatric caregiving self-efficacy, and emotional labour at work 2010.|
|||The Lewin Group. Quality of Care and litigation in Tennessee Nursing Home 2009; 1-40.|
|||Shipanga VM. The perception of the care and support services for nurses caring for patients with HIV/AIDS in the Intermediate Hospital Oshikati (IHO) Doctoral dissertation 2011.|
|||Jamshidi N, Molazem Z, Sharif F, Torabizadeh C, Najafi Kalyani M. The challenges of nursing students in the clinical learning environment: A qualitative study. Sci World J 2016; 2016: 1846178.
|||Kok MC, Muula AS. Motivation and job satisfaction of health surveillance assistants in Mwanza, Malawi: an explorative study. Malawi Med J 2013; 25(1): 5-11.
|||Tiwaken SU, Caranto LC, David JJT. The real world: lived experiences of student nurses during clinical practice. International Journal of Nursing Science 2015; 5(2): 66-75.
|||Awases M H, Bezuidenhout M C, Roos J H. Factors affecting the performance of professional nurses in Namibia. Curationis 2013; 36(1): 1-8.
|||Cheraghi F, Hassani P, Yaghmaei F, Alavi-Majed H. Developing a valid and reliable Self-Efficacy in Clinical Performance scale. Int Nurs Rev 2009; 56(2): 214-21.
|||Campbell C, Skovdal M, Mupambireyi Z, Madanhire C, Nyamukapa C, Gregson S. Building adherence-competent communities: factors promoting children’s adherence to anti-retroviral HIV/AIDS treatment in rural Zimbabwe. Health Place 2012; 18(2): 123-31.
|||Webster PD, Sibanyoni M, Malekutu D, et al. Using quality improvement to accelerate highly active antiretroviral treatment coverage in South Africa. BMJ Qual Saf 2012; 21(4): 315-24.
|||Dennill K, King L, Van Blerk L. Nurses respond to South Africa's HIV and AIDS and STI National Strategic Plan (2007-2011): infection control. Professional Nursing Today 2009; 13(3): 12-5. https://hdl.handle.net/10520/EJC79308|
|||Polit DF, Beck CT. Essentials of nursing research: Appraising evidence for nursing practice. Lippincott Williams & Wilkins 2010.|
|||Okereke E, Tukur J, Oginni AB, Obonyo B. Evaluating Health Workers’ Knowledge Following the Introduction of Clinical Mentoring in Jigawa State, Northern Nigeria. Afr J Reprod Health 2015; 19(3): 118-25.
|||World Health Organization. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. 2007. ISBN 978 92 4 159631 2|
|||Buhat-Mendoza DG, Mendoza JNB, Tianela CT, Fabella EL. Correlation of the academic and clinical performance of Libyan nursing students. J Nurs Educ Pract 2014; 4(11): 82.
|||Smith J, Odera DN, Chege D, et al. Identifying the gaps: An assessment of nurses’ training, competency, and practice in HIV care and treatment in Kenya. J Assoc Nurses AIDS Care 2016; 27(3): 322-30.
|||Farley JE, Stewart J, Kub J, Cumpsty-Fowler C, Lowensen K, Becker K. Development of The Johns Hopkins University School of Nursing Adult/Geriatric Primary Care Nurse Practitioner Program in HIV Prevention, Treatment, and Care. J Assoc Nurses AIDS Care 2016; 27(3): 223-33.
|||Fournier B, Kipp W, Mill J, Walusimbi M. Nursing care of AIDS patients in Uganda. J Transcult Nurs 2007; 18(3): 257-64.
|||Cailhol J, Craveiro I, Madede T, et al. Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities. Global Health 2013; 9(1): 52.