ABSTRACT Emergency Trauma Nursing in Sub-Saharan Africa

ABSTRACT

Emergency Trauma Nursing in Sub-Saharan Africa

Jennifer Reimer

Director: Kathryn Osteen, PhD, RN, CMSRN, CNE

Trauma is a major cause of death and disability across the globe and there is a disparity in trauma care, made evident by comparing trauma care systems worldwide. Trauma is overwhelming in low and middle-income countries due to the lack of resources, pre-hospital care and nurse training. Sub-Saharan African countries experience the highest rates of every kind of traumatic injury and bear the brunt of the global burden. The disparity demonstrates the need to evaluate and create changes in trauma care worldwide. Changes need to be implemented concerning resources, organization of pre- hospital care, and personnel training. Global effort is needed to facilitate the requisite changes. The purpose of this article is to examine emergency trauma nursing in Sub- Saharan Africa and explore ways to increase nurse competency and proficiency in Sub- Saharan Africa emergency trauma care.

APPROVED BY DIRECTOR OF HONORS THESIS:

______

Dr. Kathryn Osteen, Louise Herrington School of Nursing

APPROVED BY THE HONORS PROGRAM:

______

Dr. Elizabeth Corey, Director

DATE:______

EMERGENCY TRAUMA NURSING IN SUB-SAHARAN AFRICA

A Thesis Manuscript Submitted to the Faculty of

Baylor University

In Partial Fulfillment of the Requirements for the

Honors Program

Jennifer Reimer

Waco, Texas

May 2019

TABLE OF CONTENTS

Acknowledgments iii

Emergency Trauma Nursing in Sub-Saharan Africa 1

Appendices

Figure 1: Africa Affairs: Countries and Other Areas 15

Appendix A: Table 1: Challenges Facing Emergency Nursing in Africa 16

Appendix B: Table 2: Self-Rated Competency in Skills 17

Appendix C: Table 3: Educational Needs 18

Appendix D: Medical Conference Recommendations 19

References 22

ACKNOWLEDGMENTS

Dr. Kathryn Osteen has been a wonderful support throughout this process. She believed in me when I did not believe in myself. It was she who saw the potential in me to begin the Honor’s Program. She has demanded the best that I could give, more than I thought I could do at many times. I am so blessed to have a teacher and a mentor who has pushed me to be the best that I can be.

To my Honors council, Dr. Cheryl Riley and Dr. April Walker, thank you for your time and commitment to both me and this project. I truly appreciate the help that you have given to me.

Thank you, Dr. Beck and Ms. Diane Haun, for also believing in me. There were times when the prospect of completing the Honor’s work was too much to bear and you both set me back on the path of believing in myself and in what I can accomplish.

iii

Introduction

Worldwide, trauma is a major cause of mortality and disability with 5.8 million deaths each year attributable to trauma and 90% of traumas taking place in low and middle-income countries (Nielsen et al., 2012; Wesson et al., 2013). Worldwide, trauma is the leading cause of death for people 1 to 34 years of age (Brysiewicz & Bruce, 2008;

Sasser, Varghese, Kellermann, & Lormand, 2005; Tutton, Seers, & Langstaff, 2008). In

Sub-Saharan Africa, trauma is the leading cause of unnatural death (Hardcastle et al.,

2011). Sub-Saharan African countries experience the highest rates of every kind of injury, and therefore, bear the brunt of the global burden (Calvello, et al., 2013).

According to Disease and Mortality in Sub‐Saharan Africa, Sub‐Saharan Africa has the highest level of mortality from trauma (Jamison et al., 2006). The Global Burden of

Disease Project predicted that the global burden of injury will increase by 28% between

2004 and 2030, while major communicable illnesses such as AIDS and malaria will decrease in that same time frame (World Health Organization, n.d.). Access to health care resources in Sub-Saharan Africa is a significant factor impacting morbidity and mortality from traumatic injuries, however, to discuss differences in health care resources is beyond the scope of this paper. According to the United States Department of State

African affairs: Countries and other areas (n.d.), Sub-Saharan African countries include

46 of Africa’s 54 countries. See Figure 1. Countries that are not included in Sub-Saharan

Africa are more affluent countries such as Egypt and Morocco.

Emergency trauma nurses are nurses who administer care to patients during the critical stage of their injury (Wolf et al., 2012). When reviewing emergency trauma

nursing care literature, disparities are noted in the delivery of emergency trauma nursingcare given in Sub-Saharan Africa versus developed countries (Brysiewicz &

Bruce, 2008; Calvello et al., 2013; Dulandas & Brysiewicz, 2018; Hardcastle et al., 2011;

Klopper, Coetzee, Pretorius, & Bester, 2012; Mould-Millman et al., 2017; Neilsen et al.,

2012; Scott & Brysiewicz, 2015; Stein, Wallis, & Adetunji, 2015; Wesson et al., 2013).

For example, there is a plethora of research on emergency trauma nursing care in developed countries, such as the United States (U.S.), however, there is little research in developing countries such as those included in Sub-Saharan Africa. The purpose of this article is to compare the role of the emergency trauma nurse in Sub-Saharan Africa to the nurse’s role in developed countries in an effort to examine similarities and identify areas for expansion of the emergency trauma nurse’s role globally.

Emergency Trauma Nursing

In Sub-Saharan Africa, emergency trauma nurses work in the Accident and

Emergency Department which is similar to the emergency department in the U.S. and other developed countries (Adoga & Ozoilo, 2014). This manuscript will include a discussion about pre-hospital care, the role of the emergency trauma nurse, emergency trauma nurse training, and the impact of compassion fatigue, burnout, and workplace violence. Much of the research literature included here was completed in South Africa, one of the more developed countries within Sub-Saharan Africa.

Pre-Hospital Care

Pre-hospital care providers, such as Emergency Medical Services (EMS), are the first line of treatment for the trauma patient. However, the longer it takes for a patient to arrive to the emergency department, the worse the condition of the patient due to the delay of specialized trauma care (Calvello et al., 2013; Stein et al., 2015). Evaluating pre- hospital trauma care is important to nursing as this element of care determines the severity of the patients’ conditions when they arrive to the hospital.

Trauma patients in Sub-Saharan Africa have a disproportionate amount of pre- hospital deaths compared to other countries due to delay in EMS treatment and transport to hospital care (Mould-Millman et al., 2017). Comparing other low and middle-income countries’ rate of deaths among pre-hospital traumas to those in Sub-Saharan Africa,

Sub-Saharan Africa has a higher rate of pre-hospital injury deaths (Mould-Millman et al.,

2017). According to existing data in Ghana, a country in Sub-Saharan Africa, 80% of trauma deaths occur outside the hospital (Jayaraman et al., 2010; London, Mock,

Abantanga, Quansah & Boateng, 2002).

Very little information can be found about the organization of pre-hospital care in

Sub-Saharan African countries. However, The African Federation of Emergency

Medicine is working to bring community, pre-hospital, and hospital practitioners together to improve emergency trauma care and is organizing efforts to distribute resources

(Calvello et al., 2013). Specifically, the African Federation for Emergency Medicine is working to develop training materials for emergency trauma workers, to create guidelines, and to improve organization. (Calvello et al., 2013). Trauma care organizations globally have the opportunity to partner with this federation to share

knowledge and skills to help provide culturally appropriate resources to increase provider’s capacity in caring for trauma patients. Ten years ago, in 2008, South Africa was the only country on the African continent with an organized pre-hospital EMS system, and as of 2013, this system was still in the early stages of organization and implementation (Hardcastle & Brysiewicz, 2013).

The Role of the Emergency Trauma Nurse

The role of the emergency trauma nurse in Sub-Saharan Africa continues to be in the developmental stages and is still evolving. Literature on the role of the emergency trauma nurse and the skills and education necessary to optimally function in this role is scarce (Dulandas & Brysiewicz, 2018; Uys, Chipps, Kohi, Makoka, & Libetewa, 2012).

The Emergency Nurses Society of South Africa is “leading the way in defining the scope of practice and the core skills for emergency nurses” (p. 85) and along with the African

Federation for Emergency Medicine, has developed an African Emergency Nursing

Curriculum (Dulandas & Brysiewicz, 2018). Prior to the development of the African

Emergency Nursing curriculum, “consensus on a standardized approach to emergency nursing” (p. 85) was difficult to find in South Africa (Dulandas & Brysiewicz, 2018). The

African Emergency Nursing curriculum is the first step in providing a defined role for the emergency trauma nurse and in providing homogenous standards for emergency trauma nursing practice throughout Sub-Saharan Africa (Scott & Brysiewicz, 2015).

In the U.S., there is a rich history regarding the nurse’s role in the emergency department. Emergency departments in the U.S. became an established standard in hospitals in the early twentieth century, where emergency trauma nurses played an

essential part of the operations of the department, often working as informal department leaders (Schriver, Talmadge, Chuong, & Hedges, 2008). Changes to emergency department policies and procedures in the U.S. were often nurse-initiated (Schriver et al.,

2008). For example, the modern crash cart used for cardiac arrests or severe respiratory distress, first known as a crisis cart, was developed in 1967 by Anita Dorr, a registered nurse (Schriver et al., 2008). In 1970, Dorr and another nurse, Judy Kelleher, founded the

Emergency Department Nurses Association, now known as the Emergency Nurses

Association (ENA), which accelerated the professional development of the emergency trauma nurse (Schriver et al., 2008). As of 2019, the ENA has more than 43,000 members

(Emergency Nurse Association, n.d.). The creation of the ENA was followed by the development of the Journal of Emergency Nursing, the Trauma Nurse Core Course

(TNCC), the Emergency Nurse Pediatric Course (ENPC), the ENA Foundation, and the standards of emergency nursing practice (Schriver et al., 2008). A partnership between the ENA and the Emergency Nurses Society of South Africa would be a valuable collaboration to address increasing nurse capacity and common issues experiences by all trauma nurses globally.

In many countries, emergency trauma nurses are specifically trained in life saving techniques and skills that are used during emergency situations (Uhlenbrock, 2019). An example of the scope of practice for emergency trauma nurses in U.S. emergency departments is defined as “the assessment, analysis, nursing diagnosis, outcome identification, planning, implementation of interventions, and evaluation of human responses to perceived, actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or acute, and which occur in a variety of settings”

(Emergency Nurses Association, 1999, p. 3-4). The role and the scope of practice for the emergency trauma nurse in the U.S. is clearly defined while the role and scope of practice for the emergency trauma nurse in Sub-Saharan Africa is still in its developing stages.

Emergency Trauma Nurse Training

Emergency trauma nurses, wherever they practice, interact with trauma patients in the hospital setting, therefore, emergency and trauma training is important. Even though

South Africa is a more developed country, in a survey of 128 emergency trauma nurses in

South Africa, 48% of the nurses rated themselves as not competent in advanced skills such as EKG interpretation and defibrillation (Dulandas & Brysiewicz, 2018). These ratings reflect a common trend that these nurses do not think they have the necessary knowledge or training to adequately treat patients (Dulandas & Brysiewicz, 2018).

Dulandas & Brysiewicz (2018) explored how emergency trauma nurses in Sub-Saharan

Africa rated themselves on basic, intermediate, and advanced skills (see Appendix B). Of the surveyed nurses, 72% stated that more emergency nursing education is needed in many areas (see Appendix C). The majority of nurses in the study indicated experiencing no formal emergency trauma nursing training (Dulandas & Brysiewicz, 2018). Another finding of Dulandas and Brysiewicz’s study (2018), is the emergency trauma nurses surveyed reported they do not have confidence in their ability to perform CPR or administer rescue drugs during a cardiac arrest. Extensive education is needed for Sub-

Saharan African emergency trauma nurses to feel competent and safe in delivery of patient care (Dulandas & Brysiewicz, 2018).

In comparison, in many developed countries, hospital management encourages additional training for emergency trauma nurses. Multiple courses are available to the nurse to expand trauma and emergency knowledge, such as Advanced Cardiac Life

Support (ACLS), Pediatric Advanced Life Support (PALS), the TNCC, Advanced

Trauma Care for Nurses (ATCN), and the ENPC (Uhlenbrock, 2019).

Efforts are in place to improve Sub-Saharan African emergency trauma nursing care, as evidenced by the 2014 Botswana Emergency Medical Conference attended by local, regional, and international delegates. At this conference, 23 recommendations were set forth for emergency care in the future, many of which can be read as goals for the future of trauma care in Sub-Saharan Africa. See Appendix D for the recommendations published at the 2014 conference in Botswana (Christopher et al., 2014).

Compassion Fatigue and Burnout

Compassion fatigue and burnout in emergency and trauma-related professions is a reality for healthcare professionals across the globe (Berg, Harshbarger, Ahlers-Schmidt,

& Lippoldt, 2016). Compassion fatigue is the condition of becoming desensitized to the suffering of others, often feeling numb or disconnected (Berg et al., 2016; Wentzel &

Brysiewicz, 2014). Burnout is physical or mental stress caused by overwork or overexertion, often resulting in physical or mental collapse (Berg et al., 2016; Munnangi,

Dupiton, Boutin, & Angus, 2018). Emergency trauma nurses are at risk for compassion fatigue and burnout, caused by excess stress in the workplace, regardless of their country

of origin or where they practice (Berg, et al., 2016; Freeman, Fothergill-Bourbonnais,

Rashotte, 2013; Klopper, et al., 2012; Munnangi et al., 2018).

Stressors that can lead to compassion fatigue and burnout include senseless deaths and perceived inefficiencies in the healthcare system or processes (Berg et al., 2016). A senseless death is a death that occurs from an avoidable situation or when inadequate or inappropriate care is given and contributes to the death of a patient (Berg et al., 2016).

Often, Sub-Saharan hospitals are “a setting where health demands continue to exceed limited resources” (Wesson et al., 2017, p. S4). The lack of resources can lead to a high degree of burnout in nurses in Sub-Saharan Africa associated with “limited opportunities for advancement and a practice environment with inadequate stafﬁng and resources”

(Klopper et al., 2012, p. 685). According to Berg et al. (2016), emergency trauma nurses state working with children in emergency situations, as well as and situations that reminded them of personal traumatic experiences are the most stressful situational occurrences. Often, emergency trauma nurses must provide care to very critically ill patients, which can lead to a more intense and stressful work environment (Munnangi et al., 2018). Berg et al. (2016) also noted that emergency trauma nurses reported working with patients’ family members, cases of pediatric and geriatric abuse, and any case involving a child are triggers of additional stress to the nurse.

Compassion fatigue and burnout caused by excess stress can cause physical and psychological symptoms in emergency trauma nurses (Berg et al., 2016; Klopper et al.,

2012; Munnangi et al., 2018). Commonly reported physical and psychological symptoms of burnout include fatigue, headaches, eating disorders, insomnia, emotional instability, and excessive rigidity in social settings (Berg et al., 2016). Munnangi et al. (2018) state

higher than average stress reported by emergency trauma nurses may also lead to stress- induced illness, potentially increasing absenteeism.

Reported psychological symptoms of the stress that causes compassion fatigue and burnout among nurses include nightmares, flashbulb memories regarding disturbing cases, and second-guessing clinical decisions (Berg et al., 2016). Emergency trauma nurses also report feeling increasingly anxious about possible serious injury occurring to their own children or family members, but also feeling desensitized to injury if and when it does occur to those close to the nurses (Berg et al., 2016). They also report feelings of burnout as extreme emotional exhaustion, depersonalization, and no sense of personal accomplishment (Munnangi et al., 2018). Nurses with compassion fatigue often present with emotional exhaustion, sadness, depression, sleeplessness, and generalized anxiety

(Berg et al., 2016). Emergency trauma nurses can develop compassion fatigue by becoming so closely connected with their patients that they become absorbed by their pain and trauma (Wentzel & Brysiewicz, 2014). Compassion fatigue can often make nurses feel as though they have failed at nursing, and as a result of this, they no longer feel that they have the ability to nurture and emotionally care for their patients (Berg et al., 2016; Coetzee & Klopper, 2010).

Compassion fatigue and burnout in emergency trauma nurses can negatively affect patient care (Munnangi et al. 2018). Berg et al. (2016) found that stress in the workplace is linked with decreased personal productivity, impaired concentration, inability to pay attention to detail, absenteeism, decreased morale, high turnover, diminished work engagement, and medical errors, which decrease the quality of patient care. As quality patient care is the focus of nursing, nurse burnout and compassion

fatigue are an important area of research that requires more study in order to prevent and treat the conditions globally.

Nurses and management across the globe need to be aware of the possibility of emergency trauma nurses suffering from compassion fatigue or burnout. Increased job satisfaction and a positive practice environment are ways to decrease risk for burnout or compassion fatigue (Klopper et al., 2012). Klopper et al. (2012) found that environments with healthy practice settings, more effective managers, and higher nurse-to-patient stafﬁng ratios are signiﬁcantly associated with lower levels of nurse burnout. A positive and healthy practice environment is important to have positive and healthy nurses. This is a significant problem in low to middle income countries where access to knowledge, skills, and resources are not available.

Workplace Violence

Violence and aggression towards nurses in the workplace is not limited to Sub-

Saharan African countries but is widespread throughout the world (Gurney, Bush,

Gillespie, Patrizzi, & Walsh, 2014; Kennedy & Julie, 2013). The level of workplace violence for all nurses in general remains high (Gurney et al., 2014; Kennedy & Julie,

2013). According to the ENA, “the incidence rate of workplace violence in the healthcare industry is 3.8 times higher than all private industry, with the Emergency Department being a highly vulnerable area” (Gurney et al., 2014, p. 1). The Nurses’ Early Exit

(NEXT) study, which is endeavoring to call attention to the widespread presence of violence towards nurses in the healthcare environment within ten European countries, reported that 22% of emergency trauma nurses often experience violent incidents at work

(Kennedy & Julie, 2013). In the U.S., Gates, Ross, and McQueen (2006) found that 67% of nurses in an emergency department have been physically assaulted by patients, while

78% have been verbally threatened, and 44% have been harassed sexually.

On the African continent, the Western Cape Province of South Africa has the highest rates of homicide and assault in all of Africa (Kennedy & Julie, 2013). Kennedy and Julie (2013) found that 61.1% of emergency trauma nurses in South Africa reported frequently dealing with crime and violence, while 76.1% reported never receiving training for defusing threatening situations (Kennedy & Julie, 2013). In fact, violence in the healthcare environment tends to be unreported by nurses as some hospital cultures can frame violence as an accepted and commonplace part of the job for nurses (Kennedy

& Julie, 2013).

Kennedy and Julie (2013) found that in the trauma and emergency department of a large hospital in the Western Cape of South Africa, all participants reported experiencing verbal abuse by patients. In fact, patients and their families are the most common perpetrators of violence against nurses in the emergency healthcare environment in both the U.S. and Sub-Saharan Africa (Gacki-Smith et al., 2009; Gates et al., 2006;

Kennedy & Julie, 2013). The participants in the study did not report any occurrences of physical violence, although they do admit to being physically threatened (Kennedy &

Julie, 2013). The nurses in the study also reported a constant expectation of imminent violence, often feeling unsafe, and expecting to be assaulted at any time (Kennedy &

Julie, 2013). One participant reported normalizing patients’ inappropriate behavior as a coping strategy to the assault stating, “Many of them are a little drunk, so we rather let it pass ... like the head injuries ... you know he is confused, and you realize he does not

really want to be like that, then one tends to ignore it” (Kennedy & Julie, 2013, p. 5).

Another participant admitted that: “Well, I’m used to it ... you work here every day with these kinds of patients, so I don’t stress myself ... the swearing comes with the territory”

(Kennedy & Julie, 2013, p. 5). An association exists between work-related violence and decreased job satisfaction, increased absenteeism, and increased nurse burnout (Kennedy

& Julie, 2013).

Discussion

Trauma is a major cause of death and disability worldwide (Nielsen et al., 2012;

Wesson et al., 2013). There are many issues related to emergency trauma care that directly affect the death and disability rate. The Sub-Saharan African emergency trauma nurse’s role in trauma care needs to be evaluated and solutions implemented to decrease death and disability from trauma. Specifically, research needs to be conducted regarding the role of the Sub-Saharan African emergency trauma nurse. While the role of the emergency trauma nurse is more advanced in developed countries, the role is still developing in Sub-Saharan Africa (Dulandas & Brysiewicz, 2018; Uys et al., 2013).

Emergency trauma nurses in Sub-Saharan Africa state that they feel they do not have the necessary knowledge or training to adequately treat patients (Dulandas &

Brysiewicz, 2018). Trauma patients arrive to the hospital in conditions that are more difficult to treat due to the delay in accessing care (Calvello et al., 2013; Mould-Millman et al., 2017; Stein et al., 2015). Nurses in Sub-Saharan Africa are in need of emergency and trauma education (Wesson et al., 2013). Perhaps, nurse organizations around the

world could collaborate and develop education materials to increase the professional capacity of emergency trauma nurses’ in low to middle income countries.

Compassion fatigue and burnout in trauma-related professions is a reality for healthcare professionals across the globe (Berg et al., 2016). Nurses in Sub-Saharan

Africa are suffering from the stress of lack of resources, lack of personnel, workplace violence, and disorganization (Kennedy & Julie, 2013; Stein, Mould-Millman, Vries, &

Wallis, 2016). As quality patient care is the focus of nursing, nurse burnout and compassion fatigue are an important area of research that requires more study in order to prevent and treat the conditions.

Violence and aggression towards emergency trauma nurses in the workplace is widespread globally and tends to go unreported by nurses (Kennedy & Julie, 2013). One solution to this problem of increased aggression and fear of violence would be to provide aggression or violence de-escalation training for nurses. The ENA recommends workplaces across the globe create or adopt a Workplace Violence Prevention strategy

(Gurney et al., 2014). Further research needs to be conducted on how to increase nurse satisfaction in an environment where it may not be possible to increase nurse-to-patient staffing ratios or other resources.

Conclusion

This paper compared and contrasted emergency trauma nursing in Sub-Saharan

Africa to emergency trauma nursing in developed countries. In particular, this paper examined the role of the nurse in an emergency environment, emergency trauma nurse training, the impact of compassion fatigue and burnout on emergency trauma nurses, and

workplace violence. Further research needs to be conducted regarding the increased demand on nurse capacity and the role and training of emergency trauma nurses.

Additionally, research on the impact of compassion fatigue, burnout, and workplace violence on the ability of the nurse to reach their full capacity is necessary. Further research needs to be conducted on how to increase nurse satisfaction in an environment where it may not be possible to increase nurse-to-patient staffing ratios or other resources. It is important for nurses to be aware of the global issue of emergency trauma to educate and assist the community in injury prevention and first aid (Neilsen et al.,

2012).

Figure 1 African Affairs: Countries and other areas

United States Department of State, n.d

Appendix A

Challenges and Issues Facing Emergency Nursing in Africa

Calvello, et al., 2013, p. 46

Appendix B

Self-Rated Competency in Skills

Dulandas & Brysiewicz, 2018

Appendix C

Educational Needs

Dulandas & Brysiewicz, 2018

Appendix D

2014 Botswana Emergency Medical Conference Recommendations

1) “Emergency care is a right that promotes public safety and crisis intervention.

2) The use of health economic and epidemiological lenses to ‘view’ emergency

medicine implementation must be implemented.

3) The conference values the ethical implementations of the ‘market-failure

principle’ of emergency medicine as a theoretical tool to avert perversity and

undue corporatization in Emergency Medicine endeavors. The health value

proposition of Emergency Medicine must not be undermined by undue fiscal risk.

4) In implementing Emergency Medicine, the country specific influences on health

needs and the reciprocal value proposition of emergency medical care must be

considered.

5) The conference elected to professionalize the Emergency Medicine response in

the region, with international comparability but with regional relevance, with

regard to service delivery, education and research.

6) The conference adopted the enhancement of evidence-informed guidelines across

the spectrum of Emergency Medicine theory, praxis, practice and policy.

7) To avoid therapeutic and economic misconceptions, both health economic and

epidemiologic measures of health must determine Emergency Medicine

effectiveness.

8) Emergency Medicine design must be sustainable to promote population

confidence and public safety.

9) Micro-economic evaluations at the treatment level are likely to identify cost

drivers.

10) The development of an evidence-informed policy landscape for Emergency

Medicine is paramount to guide sustainable and ethical implementation, relevant

to country need and resource availability.

11) Positive feedback mechanisms after Emergency Medicine evaluations are likely

to enhance quality.

12) Community education and agency building are recommended as central to the

emergency care system resilience.

13) The psychosocial welfare of emergency care staff must be promoted.

14) Policy development on Emergency Medicine training, remuneration, retention,

selection and particularly rural human resource supply and sustainable systems is

recommended.

15) A stakeholder inclusivity approach must be adopted where pre-hospital and in-

hospital emergency care personnel work towards a continuity of care for the

critically ill and injured.

16) A Botswana Emergency Medicine Society should be formed.

17) Inter-university collaboration should be promoted.

18) Other county experiences of implementing emergency medicine should be

considered by stakeholders.

19) Country specific endeavors must include a decision on the most appropriate

terminology that describes the continuum of emergency care and acknowledges

all stakeholders and participants.

20) The quantification of demand for Emergency Medicine must precede country

implementation.

21) Individual, organizational and country membership and/or representation of the

African Federation of Emergency Medicine were recommended.

22) Regional collaboration at the regulatory level, such as collaborative agreements

between health regulatory entities is recommended as necessary to promote

Emergency Medicine in the region.

23) A Southern African movement and country specific professional emergency

medicine societies should be formed to galvanize growth around emergency

medicine endeavors.”

Christopher et al., 2014, p. 155-156

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