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    The risks in perioperative care are well known. However, for patients having surgery in some African countries, the dangers are far more apparent. Staff are few and far between and many have not been able to access rationale for their practice or receive adequate training over the years. Friends of African Nursing (FoAN) is a small UK-based charity that has been providing education in several African countries to address this issue. More than 3,000 nurses and other healthcare workers have been trained face to face—and many more on-line—in patient safety, staff safety and infection prevention. FoAN's Chair of Trustees Kate Woodhead describes the challenges facing nurses working in perioperative care in many African countries.


    Perioperative learning in Africa

    Operating theatres are a high-risk area in every country but in parts of Africa where infrastructure, equipment and staff are in short supply, they are particularly risky. Information on the risks is rarely available as there are scarce opportunities for training. Since 2002, Friends of African Nursing (FoAN) has been delivering training on patient and staff safety to perioperative nurses in various countries. We find that participants in our training are often surprised and alarmed at what we share with them. 

    Through face-to-face education, and more recently webinars, we deliver training on infection prevention, patient safety and how staff can keep themselves safe. Group work on the same topics enables participants to put their own stamp on future practice back at their individual hospitals, as well as learning from fellow participants. 

    How Friends of African Nursing was established

    FoAN was conceived by two nurses working in the NHS who had visited hospitals in different African countries and wanted to share their knowledge of how to keep patients safe. The team made its first visit to Uganda in 2002, where one delegate taking part in the training had worked in the operating theatre for 38 years and had never had any ongoing professional education. That first course is memorable as we had asked for a maximum of 50 students and 77 turned up! It was a very crowded teaching room with complicated logistics into the bargain! After that, many other countries asked us to help them with the same update to basic perioperative information. Working through the Ministries of Health or national nursing organisations, we have now worked in 11 African countries. 

    The charity is run on a voluntary basis, so there is a limited amount of time we can take away from our paid roles. However, because we still work in clinical settings, the training we deliver is up to date and in line with international best practice. Each visit usually lasts a week and we spend each day delivering education to eager students. Since the Covid-19 lockdowns, we have run webinars on a regular basis. Although these are better than nothing, they are unsatisfactory as we cannot check understanding. However, recently we have found that the chat button is a helpful way to get feedback and find answers to questions.  

    Perioperative teams in Africa

    We usually visit capital cities where we are hosted by teaching hospitals and visit their operating theatres at some time during the week. In the early days of FoAN, we made it our business to also visit and teach at rural hospitals, so we could understand the different issues that occur at theatres away from the capital. It has certainly been eye-opening, and we still ensure that the training we do includes delegates from rural areas. 

    The country we visited most recently has invited us to specifically train district theatre nurses on our next visit. One issue they face is that some nurses do not undertake much surgery and have hours of inaction. Supplies and equipment are scarce and qualified team members even fewer. The literature shows that sometimes surgery is not available in some district hospitals at weekends and during the night due to lack of staff. Training is unavailable and as the use of surgery increases, as it is doing all over the developing world, these are the teams that need the most input.

    Focus on safety

    The training programme we deliver focuses on many aspects of patient safety. It is a relatively new academic topic and many theatre nurses have not been educated in initiatives such as WHO’s Safe Surgery Saves Lives. Some hospitals are using the checklist for every surgery if they have a champion clinician, but many are not. When we introduce the topic, citing the data, many of our participants are visibly shocked.  

    In 2015, the Lancet Commission on Global Surgery outlined five necessary components to ensure the delivery of safe surgery. These are infrastructure, surgical workforce, service delivery, financing and information management. Capacity building through improved infrastructure and trained surgical workforce expansion has proven to be challenging to sustain on a global scale. (1) One reliable study which is frequently cited is perioperative patient outcomes in the African Surgical Outcomes Study undertaken in 25 different African countries in 2018. Their findings showed that one in five surgical patients in Africa developed a perioperative complication, following which, one in ten patients died. The findings also show that despite the profile of the surgical patients being younger with a low-risk value and lower occurrences of complications, patients in Africa were twice as likely to die after surgery when compared with outcomes at a global level. They reported that most surgical procedures were done on an urgent or emergency basis and one third were caesarean sections. Importantly, ninety five percent of the deaths occurred after surgery, indicating the need to improve the safety of perioperative care. (2) It is critical in the light of this data that surgical care becomes safer and more effective. 

    Barriers to patients accessing surgery

    There are many barriers to overcome for patients in countries that are upscaling their surgical services. They include fear of surgery, fear of anaesthetic and fear of poor outcomes. It is therefore essential that perioperative staff are able to show confidence in the safety of their service when they meet their patients. 

    There are also financial barriers which may prevent patients accessing healthcare. The costs of drugs, dressings, laboratory tests and X-rays are all paid for in many African countries by the patient or their relatives. Hospital stays must also be paid for, as well as food and drink. In addition, the cost of the accompanying caregiver who stays alongside the patient, looking after them when there are too few nurses to do so, must also be covered.  

    An understanding of the challenges that patients have in accessing the care they need, helps to make the teaching we deliver a two-way process, so we all learn from each other. It also serves to underline how fortunate we are in the NHS where costs are taken by the taxpayer and all professional healthcare staff can access learning in so many specialities. 


    1. Meara J, Leather A, Hagander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic developmentLancet, 27 April 2015

    2. Bicard B, Madiba T, Kluyts L et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort studyLancet, 3 January 2018

    About the Author

    Kate Woodhead has been Chair of Trustees since Friends of African Nursing was founded in 2002. She was previously Chairman of the National Association of Theatre Nurses and President of the International Federation of Perioperative Nurses and was an Advisor to WHO on Safe Surgery Saves Lives. 

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