Self-efficacy and Clinical Performance of Nurses Initiated and Management of Antiretroviral Therapy : Narrative Review

Self-efficacy is significant for attaining outcome or goals especially in the implementation of a learned skill [1]. Selfregulatory 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


INTRODUCTION
Self-efficacy is significant for attaining outcome or goals especially in the implementation of a learned skill [1].Selfregulatory 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 [7].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 selfefficacy 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.

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 [17].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).

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.

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.

RESULTS
The findings pertaining to self-efficacy, clinical performance and quality of care identified in various articles are presented in Table 2.

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 selfefficacy 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].

DISCUSSION
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 [17].Therefore, mentoring and support of the professional nurses after training is important for nurses to develop selfefficacy 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 [37].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 [10].Selfefficacy 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,   [25] Hiroshima, Japan Cross sectional 322 nurses Level of competency directly affects care provided to patients, therefore, nurses need to be competent [6] 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 [17] 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 [36] 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 [23].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.

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 [20].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 [8].Therefore, experience, clinical practice, motivation, supervision, support and knowledge are needed to develop the nurse's confidence and morale [7,42].

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 [27].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 [26].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.

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 [17].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 [42].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 [42].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 [44], 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.

CONCLUSION
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.

LIMITATIONS
Risk of biasness due to only two researchers viewed the literature for this study and only English written papers were included in the study.

Table 1 . Inclusion and exclusion criteria. Inclusion criteria Exclusion criteria
Articles published in EnglishArticles published in other languagesArticles 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

Table 2 . Selected papers for analysis.
(