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1. 21st century nursing practice in Ghana:
challenges and opportunitiesinr_856 218..224
N.T. Donkor1
BSc (HONS), MSc, PhD & L.D. Andrews2
RN, BScN, MSc, PhD
1 Chair and Professor of Biology, Canadian University College, Alberta, Canada, 2 Director, Department of Nursing,Valley
View University, Accra, Ghana
DONKOR N.T. & ANDREWS L.D. (2011) 21st century nursing practice in Ghana: challenges and
opportunities. International Nursing Review 58, 218–224
Aim: This article is intended to stimulate critical thinking and generate fruitful discussion on nursing practice
in Ghana as experienced by the authors. Its rationale is to promote exchange of ideas and creative partnerships
to ensure that right decisions are made in preparing competent, adaptable and resourceful nurses who can
contribute to health for all in the 21st century.
The problem: The challenges of nursing education, practice and migration in Ghana seem grim. There is
inadequate capacity of training institutions, low staff morale, poor distribution and serious workforce
shortages.
Methods: Government reports and policy documents on nursing were sourced from official websites and
reviewed and discussed in the context of the international scholarly published literature.
Opportunities: The authors note that despite the severe crises, a number of opportunities such as improved
home-based training, international nursing education partnerships and welfare and human resource
development could foster effective nurse retention and managed migration.
Conclusions: To address the issues with nursing health service delivery and nursing shortages in Ghana
requires all stakeholders to move beyond the traditional stereotypes and be flexible and forward-looking.
Needed policy options include expansion of local nursing education and training capacity, collaborative
training opportunities, improving the welfare and retention rates of current staff and international exchange
of nurse resources that is mutually beneficial to both source and sink countries.
Keywords: Ghana, International Nursing Education, Nursing Migration, Nursing Practice, Primary Health Care
Introduction
Throughout the world, nurses play an integral role in the health
care delivery system by promoting health, preventing illness,
restoring health and alleviating suffering. However, globally,
nursing has and continues to face significant challenges to its
identity and sustainability. In particular, nurses in developing
countries face tremendous challenges in their practice. This
paper, an opinion piece of international interest, discusses the
challenges and opportunities of the 21st century nursing practice
in Ghana, West Africa. A range of local, national and interna-
tional issues are discussed from the perspectives of two authors
who have experience with nursing practice, nurse education,
research and administration in Ghana.
Methods
To describe and evaluate the challenges facing nursing practice in
Ghana, international health literature, official Ghana govern-
ment documents and press releases from the Ghana Health
Service were sourced from official websites and searched for any
reference to nursing issues and discussed in context.
Correspondence address: Noble Donkor, Canadian University College, 5415
College Avenue, Lacombe, Alberta, Canada T4L 2E5; Tel: 403-782-3381 Ext. 4186;
Fax: 866-928-9504; E-mail: ndonkor@cauc.ca.
Opinion Piece of International Interest
© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses 218

2. Background
The Republic of Ghana is divided into 10 regions, subdivided
into a total of 138 and increased to 170 districts since January
2008. The population of Ghana is 23 351 000. Infant mortality
(under 1 year old) is 64/1000. The under-5 mortality rate is
111/1000 [World Health Organization (WHO 2008)]. The life
expectancy at birth is 57 years (UNICEF 2007).Adult mortality is
328/1000. Maternal mortality is 451/100 000 live births (The
World Health Report 2006). Ghana is ranked 152 out of 182
countries according to the Human Development Index (HDI).
Ghana’s HDI of 0.568 places it at 69th position out of 75 ranked
as Medium Human Development Countries (United Nations
Development Programme 2009).
The Ministry of Health, represented by the Ghana Health
Service, owns half of the country’s health facilities; the private
sector owns approximately 21% and the Christian Health Asso-
ciation of Ghana owns the remainder (WHO 2008). The distri-
bution of health personnel is low, e.g. physicians (0.15/1000),
nurses (0.92/1000), dentists (0.02/1000) and pharmacists (0.06/
1000) (The World Health Report 2006). The total expenditure on
health as percentage of gross domestic product in 2003 was 4.5
compared with 15.2 in the USA. The general government expen-
diture on health as percentage of total expenditure on health is
31.8 (The World Health Report 2006). Wages of nurses in
Australia and Canada are 14 times those in Ghana (Vujicic et al.
2004). Like most African countries, several communicable dis-
eases, vaccine-preventable diseases and malaria continue to
present health and economic burdens for Ghana (WHO 2005).
Challenges for the 21st century
Some authors argue that today’s disease patterns show little
change from previous years (Akiwumi 1994), yet the emerging
signs with regard to morbidity and mortality present new chal-
lenges that must be confronted with new approaches for
improved outcomes. Moreover, for any country to meet these
challenges, it has to have knowledgeable and resourceful nurses.
The main objective of this paper therefore is to outline the chal-
lenges facing the 21st century nursing practice in Ghana. These
challenges often are symptomatic of broader issues of social,
economic, political and cultural environment of the people. We
argue that no matter how difficult the challenges, with the col-
lective will of the people and the political will of the government,
these challenges can be turned into opportunities for solutions.
Solutions are not always simple. Therefore, suggestions on
possible approaches to address these challenges are presented.
We know of no universal solutions that exist to solve all the
problems of health care delivery in all jurisdictions of the world.
First, health approaches must be country-specific, site-specific
and context-specific, based on a detailed knowledge of the health
needs and lifestyle patterns of the population, tailored to local
cultural, socio-economic and political conditions.
Second, countries should also recognize the impact of global-
ization and technology on nursing and health care delivery.
Third, the world has become a global village and health con-
cerns are usually similar among nations making collaborative
efforts essential.
A brief historical overview of nursing practice
in Ghana
Development of nursing practice in Ghana has been character-
ized by dynamic change and growth. To fully appreciate the
current and future challenges of nursing practice in Ghana, it is
necessary to briefly review the history of nursing education and
practice in the country, and reflect on how historical issues have
affected health affairs in Ghana today.
Nursing in Ghana prior to independence (1874–1956)
Nursing practice in Ghana (then Gold Coast) prior to indepen-
dence must be understood in the context of colonial administra-
tion and organization of health services. At first, the main
recipients of the health care system were the colonists, local
soldiers and civil servants (Patterson 1981). In 1880, the Gold
Coast Medical Department focused on preventive services such
as vaccinations and sanitation, and emphasis on urban, hospital-
based and curative services (Anyinam 1989).
In later years male orderlies were recruited to assist in the
provision of care to native Ghanaians, because local customs of
the day did not permit young women to provide nursing care to
non-relatives (Twumasi 1979). By 1899, the influx of British
nursing sisters enabled a few Ghanaian women to be trained as
nurses, although most nurses continued to be men. Until 1945,
all senior nurses in Ghana, including nurse tutors, were white
colonial sisters. The nursing curriculum at that time followed the
syllabus set out by the General Nursing Council of England and
Wales. This was to ensure that locally trained nurses could be
accepted for registration in Britain, to undergo post-basic
courses there and eventually return to practice in Ghana.
Nursing in Ghana in the post-independent period (1957–1980)
On March 6, 1957, Ghana became the first of the colonies in
sub-Saharan Africa to gain independence. Shortly after indepen-
dence, the government of Ghana implemented a policy of
Africanization that encouraged the replacement of expatriate
workers with Ghanaians (Rose 1987).
In 1960, the Ghana Registered Nurses Association was formed
to provide a central organization for all registered nurses in the
country (Kisseih 1968). In the period between 1957 and 1980, the
emphasis on training nurses to work in hospital-based curative
Ghana nursing challenges and opportunities 219
© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

3. health system, which had been a legacy of colonialism, gradually
shifted to broad-based education that prepared nurses to work in
a variety of settings. With time, the Ministry of Health adopted
the Primary Health Care (PHC) approach, which was initiated by
the WHO in 1978, to provide promotional and preventive ser-
vices to improve the health status of the people.
Nursing in Ghana after the structural adjustment period
(1980 onwards)
In the early 1980s Ghana launched an economic recovery pro-
gramme (Structural Adjustment Program, SAP), a standard pre-
scription of the International Monetary Fund (IMF) and the
World Bank to help nations recover from economic crisis. The
implementation of the SAP in Ghana led to cutbacks in health
expenditure resulting in large staff lay-offs, significant salary
reductions (due to inflation) and closure of many facilities. In the
1990s, in support of its application to the IMF for additional
loans, the Ghana government wrote:‘The quality of health care is
suspect, resulting in low utilization of services, particularly by the
poor. . . . Drug shortages are still common, medical equipment
often does not work, personnel are not effectively deployed and
staff morale suffers . . . Health services and management is par-
ticularly weak at the community, sub-district and district level,
where people should be making first contact with the health
system’ (Ghana Ministry of Health 1995).
Because of the wage and salary freeze and high inflation asso-
ciated with SAP, many health workers were compelled to take
second jobs to make ends meet, resulting in absenteeism and
poorer health care (Oppong 2000). Many of the already inad-
equate nurses left the country to seek better economic fortunes
in Europe and North America. The imposition of user fees locally
called ‘Cash and Carry’, drastically reduced access to biomedical
health care (Anyinam 1989) compelling clients to forgo or delay
treatment and seek cheaper alternatives to biomedical services.
The impact was more drastic in rural areas. While the user fees
led to an immediate decline of 25–50% in hospital and clinic
visits in the national capital, Accra, in some rural areas it was as
high as 45–80% (Enyimayew 1988).
During the SAP period private hospitals – a deliberate goal of
SAP – received a new boost, providing health care for the afflu-
ent, particularly, urban populations. The combined contraction
of government biomedical services and the increase in costly
private biomedical services drove many people away from the
formal biomedical system (Oppong 2000). For example, in
1991–1992, 74% of ill persons in the rural savannah regions of
Ghana consulted practitioners other than doctors (Ghana Statis-
tical Service 1992). Self-treatment became the leading source of
health care for most residents particularly in the rural areas.
Consequently, a proliferation of new groups of providers (vari-
ously termed drug peddlers, fringe practitioners and bus-stop
dispensers) emerged to fill the void created by reduced access to
biomedical care (Oppong & Williamson 1996).
The challenges, opportunities and
possible solutions
Worldwide, nurses’ education and practice in the 21st century
face many challenges. These challenges affect nursing care, the
nursing profession and the professional development of the indi-
vidual nurse. With a clear understanding of the multiple factors
causing these challenges, nurse leaders and educators can work to
meet the challenges and embrace the opportunities afforded by
global nursing. In the following sections, we discuss some of the
challenges faced by nursing practice and education in general,
with particular reference to Ghana.
Nursing education
Before we can discuss the challenges facing the nursing practice,
we have to begin with where the nurses receive their training.
Talley (2006) described some of the nursing institutions she
visited in Ghana as follows: ‘Educational resources are limited.
Faculty members do not have ready access to online information;
libraries are virtually empty and the few books on the shelves are
old and outdated and only a few journals are available; clinical
laboratories are poorly supplied and equipment is very old; dis-
posable nursing supplies are simply not available for teaching.’
It has been realized that international learning experience can
provide excellent opportunity for nursing students to practice
nursing in a cultural systems different from their own, gain an
increased global perspective and enhance their cultural compe-
tency (Kollar & Ailinger 2002). An international educational
programme that engages students in health care in another
culture is a wonderful way to immerse students in diversity
issues. Ogilvie et al. (2003) suggest two foundations necessary to
build capacity in international nursing educational partnerships:
capital (physical, human, organizational and cultural) and
mutual empowerment (mutual trust, tolerating ambiguity and
taking risks into the unknown). Therefore, Ghana needs an
expansion of local nursing education and training capacity as
well as well coordinated international nursing education
partnerships.
A sterling example of this type of mutual partnership is the
graduate education in nursing between the University of Ghana
(UG) and the University of Alberta (UA) (Edmonton, Canada)
sponsored by the Canadian International Development Agency.
Through this respectful collaboration, UG and UA faculty are
engaging in mutually empowering interactions while facilitating
such encounters for their students (Ogilvie et al. 2003).
220 N.T. Donkor & L. D.Andrews
© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

4. Profile of health problems
The total expenditure on health care per capita in Ghana is $100
(World Health Statistics Annual 2006). Malaria continues to be a
major threat to the health of both children and adults. Despite
aggressive immunization programmes, infectious diseases like
measles are among the leading cause of death in children in
Ghana (WHO 2001). Furthermore, infants are especially suscep-
tible to enteric illnesses since water supply in most communities
in Ghana is not safe. Facilities and equipment are either dated or
non-existent in health facilities. In most places, the common use
of gloves is a luxury. Other factors that put pressure on the health
care system include rudimentary and uncoordinated record
keeping, and senseless and preventable carnage on the roads
which increase daily caseloads for nurses.
The health care situation in Ghana is much the same as in
other African countries. For example, the healthy life expectancy
at birth in South Africa for males and females is 43 and 45 years,
respectively (World Health Statistics Annual 2006). The AIDS
epidemic affects mostly the younger age groups (15–35 years),
and tuberculosis infection rates are also high. The tuberculosis
and HIV co-infection rate is 2540 per 100 000 people.
Traditional healers
In the search for a more effective, appropriate and efficient
means of meeting the health care needs of a country’s growing
population in the 21st century, the burden should not be on
nurses and other health professionals alone. Health care delivery
system in Ghana for example, has always been pluralistic consist-
ing of traditional/herbal and modern medicine.
In Ghana, the ratio of traditional practitioners to the popula-
tion (1:200) is higher than that of medical doctors to the popu-
lation (0.15/1000) (WHO 2006). Arguably, some 70% of Africa’s
population see traditional health practitioners but these indig-
enous health service providers are often not well organized and
integrated into a country’s health system and have not been
studied and analyzed in much detail (Africa Working Group of
the Joint Learning Initiative 2006). The challenge for nurses and
nurse-midwives and policy makers is to have a good understand-
ing of preventive and sometimes curative aspects of traditional
medicines. With this knowledge they can in turn help people
identify and use the positive elements of traditional health
resources. Health care challenges demand input from all people.
Everyone has a part to play including all citizens in the diaspora
whose families remain at home and use the health care system.
Negative nursing affectivity
Affectivity reflects a predisposition to perceive and experience
events in a negative or positive way (McCrae & Costa 1991). In
many developing countries, nursing has suffered from negative
affectivity, manifested by the growing concern about nurses’
ethical competence in dealing with clients.
The inscription in front of the Komfo Anokye Teaching Hos-
pital Nurses Training College in Kumasi, Ghana, reads ‘Enter to
learn and go out to serve.’ Unfortunately, as nurses leave the walls
of their academic institutions, somehow many of them come out
with the unwritten notion that ‘the patient is expected to be
ignorant about his or her health problem and the cure needed;
the patient should be submissive to the health provider; and the
patient should always be cooperative.’ Nurses cannot carry such
stereotyped ideas into the 21st century. The 21st century also
comes with a rise in living standards, knowledge about patient
rights, a highly educated population and easy access to quality
health information online. Therefore, as countries explore new
and innovative approaches to nursing practice in the 21st
century, nurses should see all clients, both literate and illiterate,
as partners in health care delivery and not as passive and sub-
servient consumers.
Urban–rural distribution
In 1960, the urban population in Ghana totalled 1 551 174
persons or 23.1% of the total population. By 1970, this had
increased to 28% and in 1984, to 32%. In 1992 the urban popu-
lation was estimated at 33% (Berry 1994). High rates of urban-
ization occurred in the south. While the Greater Accra Region
showed an 83%-urban residency, the Ashanti Region matched
the national average of 32% in 1984 (Berry 1994). Arguably, the
structural adjustments in the 1980s ‘pushed’ subsistence farmers
who have lost their land to cash crops and the unemployed youth
from the rural areas to the cities. The impact of the structural
adjust policy was more drastic in rural communities and on the
poor living in urban areas.
The WHO has always intimated that Health for All should be
the primary objective of all countries. This is captured in the
PHC concept, which is: essential health care made universally
accessible to individuals and families in the community by
means acceptable to them, through their full participation and at
a cost that the community and country can afford. However, like
most developing countries, one observable feature of health care
delivery in Ghana is spatial disparity and unequal access. For
example, more than half of the physicians and midwives in
Senegal are concentrated in the Dakar region, where only one-
third of the country’s population lives (WHO 2009). In Niger,
only 20% of the population lives in the capital city (Niamey),
where more than 35% of the doctors and nurses are based
(WHO 2009).
The rural areas in Ghana do not receive a fair share of the
health care budget and one’s place of residence determines to a
great extent one’s access to available health care services
Ghana nursing challenges and opportunities 221
© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

5. (Oppong 2000). Although 36% of Ghanaians reside in urban
areas, they account for 49% of total government health budget
and 55% of total outpatient spending. Regional disparities are
also apparent in the distribution of and access to health services.
The ‘core’ regions like Greater Accra have more health care per-
sonnel per capita than the ‘peripheral’ regions such as Northern,
Upper West and Upper East regions. In 1999, while the entire
population of the Accra Metropolitan Area had access to health
facilities, only 11% of the population in the Northern regions
had access compared with 77% in the Central Region and 26% in
the Western Region (Batse et al. 1999). Access to basic health care
and service utilization are constraints to health care service deliv-
ery in hard-to-reach areas in many countries. For example, about
40% of the population in Ghana lives more than 15 km from a
health facility (WHO 2005).
How should these challenges be addressed in developing coun-
tries, for example? Seers (1969) captured the essence of this
question succinctly, when he wrote:‘The questions to ask about a
country’sdevelopmentaretherefore:Whathasbeenhappeningto
poverty? What has been happening to unemployment? What has
been happening to inequality? If all three of these have declined
from higher levels, then beyond doubt this has been a period of
development. If one or two of these central problems have been
growing less, especially if all three have, then it will be strange to
call the result development, even if per capita income doubled.’
Possible solutions to these inequality problems therefore may
include (1) addressing the poverty situation of rural people not
only during years of national elections; (2) addressing unemploy-
ment,especially in rural areas;(3) addressing infrastructure prob-
lems (e.g.road network,housing,potable water,electricity,health
facilities) in rural areas; (4) encouraging nurses to accept postings
to rural areas, not just with verbal promises of rural allowances,
but with handsome and tangible rural living allowances – as a
matterof socialjusticenursesshoulddemandthis;and(5)sharing
the national ‘cake’ equally by paying particular attention to hard-
to-reach, vulnerable and neglected areas.
Nurses as responsible citizens
Throughout the world,hospitals and nurses are being called upon
to treat increasing numbers of sick people and seriously injured
patients. In developing countries, treatment must often be ren-
dered without optimal equipment and resources. In such cases,
nurses and doctors have the right to lament over the distressful
working environment. Patients are also worried about whether
they will receive the needed treatment, can afford the fees and be
able to purchase the prescribed medication. Therefore, any
unethical attitude on the part of nurses towards patients would
erode patients’ confidence and create unnecessary tensions
between nurses and clients. The International Council of Nurses’
(ICN) Code for Nurses (2006) states: ‘The nurse’s primary pro-
fessional responsibility is to people requiring nursing care’.Nurses
in developing countries work under very difficult circumstances
but receive very little remuneration from their work; but some of
them trample upon patients’ rights and treat them with such
indignity as verbal abuse,use of foul language,violent and aggres-
sive behaviour, unfriendly attitudes and showing no empathy for
the sick and vulnerable people.We believe some nurses go too far
out of frustration with the entire health care system, or from the
abuse they also receive from unruly clients. Nevertheless, such
behaviours are totally against the international code of ethics for
nursesandshouldstop.Nursesareurgedtoberesponsiblecitizens
and be their brothers’ and sisters’ keepers to help maintain the
good name of this noble profession.
The following points if taken into consideration will hopefully
bring sanity to the working environment of the nurse.
1 First and foremost, people in charge of hospitals and other
health facilities should protect nurses and hospital staff from
abuse.
2 Nursing education programmes should cover professional
ethics more comprehensively. Instructors should stress respect
for all classes of people in society and zero tolerance for abuse.
3 Abusers (be it nurses, doctors or clients) should be educated
and repeat offenders sanctioned.
4 All nurses in practice should benefit from continuing profes-
sional education to keep them abreast with changes and develop-
ments in the nursing profession. Nurses should increase their
individual professional and social skills to enhance the efficiency
of health care services and effect advancement in health care
delivery.
Migration of nurses
Few countries are untouched by what has been described as the
‘crisis in nursing’, a critical shortage of professional nurses to
deliver care (Barnett et al. 2010). Some highly educated and
skilled nurses have been leaving the developing countries in large
numbers to work in Great Britain or the USA. The general
human emigration rate in Ghana is 4.5% (United Nations Devel-
opment Programme 2009). Trends of availability of nurses in
Ghana declined from 119/100 000 in the 1970s to 36.4/100 000 in
the 1980s and 1990s (WHO 2006). From 1995 to 2002, 20% of
nurses/midwives trained in Ghana each year migrated overseas
(Institute of Statistical, Social and Economic Research at the
University of Ghana 2003). Talley (2006) quoted the Ghanaian
Minister of Health that Ghana has lost nearly half of its nurses in
the last 5 years, and the Minister estimated that Ghana has only
10 000 nurses available to provide care to a population of about
20 million. It is not difficult to imagine why some nurses leave
the country. Pay and working conditions for nurses are very poor
222 N.T. Donkor & L. D.Andrews
© 2011 The Authors. International Nursing Review © 2011 International Council of Nurses

6. in Ghana and there is limited chance for advancement (Health
Sector Support Office of Ghana 2001). Many nurses are assigned
to positions by the government with little opportunity for choice
in location or the nature of the work. Some nurses take leave
from work and do not return and others are leaving the country
to practise nursing elsewhere. The deficit in those available to
provide nursing care is indeed critical.
Nursing emigration is not restricted to Ghana; it is happening
to most developing countries, resulting in unbearable caseloads,
decreased job satisfaction and emotional fatigue on the part of
the remaining nurses. The migration of nursing professionals
and the consequent impact on poor countries has been identified
as a global concern. For example, Zimbabwe loses, on average,
20% of its health care professionals each year (Chikanda 2005).
Vietnam and Sri Lanka reportedly have lost half their nursing
workforce in just a few years, while Ghana lost more than double
the number of its new graduates in 2001 (Sparacio 2005).
Opportunities for change
In our opinion, countries can turn some of the challenges
described into opportunities for solutions. We propose institu-
tional, national and international policies and programmes to
facilitate effective nurse retention and managed migration. Here
are a few examples:
1 Considering global pay differentials, Ghana cannot compete in
the global health labour market to retain higher-level profes-
sional staff (WHO 2008). A formal policy is needed to train for
export. It may be possible to attract private investment in nursing
schools or investment from beneficiary Western countries and
embark upon some form of ‘controlled migration.’ This is what
we call ‘compensatory brain drain’: if resources will allow,
‘source’ countries should increase enrolment in nursing institu-
tions more than the current levels. The reason is simple: if the
‘source’ nation trains more nurses and some leave to the ‘sink’
countries, some will remain. However, we are not advocating
watered-down nursing programmes; far from it, it is the duty of
each country to maintain international nursing education stan-
dards. Even though nurses’ migration affects the health care
system in the short and probably medium term, in the long run
the migrants will benefit the ‘source’ country through the remit-
tances they send home to help their families cope with the con-
ditions at home.
2 Also, not all migrants remain abroad forever; some do come
back home with experience and resources to help the health care
system. If the ‘source’ country stops labelling migrant nurses as
‘unpatriotic’ it could use some of them as ladder to forge part-
nerships and collaborations between local institutions and hos-
pital and overseas ones.
3 Nursing migration should not be tackled by increasing the
supply of new nurses alone. The creation of a safe and supportive
work environment is important to the long-term success of
nursing practice. The conditions of service for nurses who
remain behind to serve should be improved. Governments
should extend calls for help to non-governmental organizations,
philanthropists, Ghanaians in the diaspora to come to their aid.
4 Nurses must be encouraged to become active in their commu-
nities, serve in local communities and pressure groups and by
example and education, influence their friends and neighbours
to lead healthier lifestyles, and together make their cases known
to policy makers. Nurses should take the lead to dialogue with
the public and each other about the real pressures nurses face.
Nobody else will do this for nurses.
Conclusion
Like many developing countries, the challenges facing the 21st
century nursing practice in Ghana are many. So are the oppor-
tunities to look at these challenges with optimism. Together all
stakeholders can help fashion out solutions that will improve the
education and working conditions of the hardworking nurses
and improve health care delivery to all people living in all parts of
the country. We conclude with the following quote: ‘More than
ever, it is essential to clarify and agree on fundamental issues: the
who, the what, the why and how of nursing. Nurses, other health
workers and communities must move beyond the traditional
stereotype and be flexible and forward-looking. This may some-
times be painful and difficult, but it will enable us to create
nursing and midwifery services that are appropriate for the 21st
century’ – Dr Hiroshi Nakajima, World Health (1992).
Author contributions
Both authors designed the original paper, presented at the Ghana
conference (‘Nursing in the 21st Century: New Approaches for
Improved Outcomes’, 3–9 August 2009) and made revisions after
input from presentation. Both authors drafted the manuscript.
ND carried out critical revisions for important intellectual
content.
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