Nurses are an integral component of the health care system in Africa, and it is important that we recognize over thousands of registered nurses for the significant work they do. We must  recognize their expertise and fully entrench it in law. We understand that nurses are not only the largest  healthcare professionals in Africa, but they are also responsible for the delivery of most healthcare, and are often in the best place to be able to see the whole pathway of care. We should therefore, lobby for major changes in laws that regulate nursing practice in Africa

For  too long nurses have been undervalued, restricted in what they can do with very few career opportunities in clinical practice .For far too long, nurses have endured a pay system that has held them back, both professionally and financially. Colleagues we must be ready to sail even during heavy storm and defend our profession by advocating for laws that favor nurses’ expertise and education in the field of healthcare.

Fellow nurses, we always complain that nurses do not practice fully what they learn in colleges and universities, but what most nurses do not know is that, the various laws regulating nursing practice in Africa are the causes of almost all nursing practice frustrations. Its known worldwide that Africa nurses are the best and most competent nurses in the world, their master of procedures and scientific based interventions always play to their advantage.

In Africa, various laws regulating the nursing profession  have always acted as our impediment in realization of our full potential in service delivery. The regulation laws guarding the profession  are shallow and do not fully recognize nurse’s expertise in clinical practice.  Colleagues, Majority of Africa trained nurses are registered nurses and whatever affect them in their diploma level also affect them in degree, masters and PhD level. There are no major change in our procedure manuals and what is expected of us at different stages. Many of us have never taken time to analyze the  various laws regulating our practice in our countries and it’s high time we started if we want nursing practice in Africa to change.

The Kenyan nurses started the journey of empowering the nursing profession through legal process that aimed at achieving nurses’ independence in healthcare practice. They have taken it upon themselves to lobby their members of parliament to amend various laws regulating nursing practice and the latest amendment of Kenya nurses act was done in 2011.It has not been an easy journey. The older generation of Kenyan nurses did justice to nursing practice in Kenya; they ensured all nurses are trained on leadership. Today the nursing profession in Kenya produces leaders throughout the healthcare system, from bedside to boardroom. this system  have produced a strong leadership that is critical in their vision of transforming nursing practice and it has become easier for them to advocate for favorable laws. Recently they started a forum that identified various clauses in their nurses’ act and if the clauses are amended and other clauses added, nursing practice in Kenya will be the best in Africa.

As African nurses we must follow Kenyan nurses’ example. Let us analyze our various laws that regulate nurses and nursing practice in our respective countries and identify the gaps and shortcomings if corrected, would improve nursing practice in Africa and make it a rewarding profession. We must propose fresh analysis and harmonization of the various laws regulating nursing practice in Africa to conform to nurses’ education and expertise in clinical practice and other fields. We should also think outside the box and come up with a humanitarian non governmental organization services  that will support nurses and communities in areas experiencing hardship in Africa with an aim of advocating for nurses practice independence.

At Kenyan nurses forum, we came up with the following clauses that we would like all nursing leaders in Africa to read and at least try to lobby in their respective countries for this proposals to be enacted as part of  the law regulating nursing profession.

Kindly take your time and read our proposals


Requirement for certification

In accordance with the provisions to be enacted , any nurse desiring to be certified as an advanced registered nurse practitioner shall apply to the Nursing regulatory body and submit proof that he or she holds a current license to the practice professional nursing and that he or she meets one or more of the following requirements as determined by the Nursing regulatory body


Samuel wainaina submitting Kenyan nurses memorandum in Kenya parliament.

Satisfactory completion of a formal post basic educational program of at least 1- 2 academic year ,the primary purpose of which is to prepare nurses for advanced or specialized practice.

Graduation from a program leading to a master’s degree in nursing clinical specialty area with preparation in specialized practitioner skills. For applicants graduating on or after this change have been effected, graduation from a master’s degree program shall be required for initial certification as a nurse practitioner as stated above.

The Nursing regulatory body in the respective country shall provide rule on the appropriate requirements for advanced registered nurse practitioners in the categories of certified registered nurse anesthetist, certified nurse midwife, and nurse practitioner etc

An advanced registered nurse practitioner shall perform those functions authorized in this section within the framework of an established protocol that SHALL BE filed with the Nursing regulatory body upon license renewal and within 30 days after entering into a supervisory relationship with a physician as shall be agreed between  Nursing regulatory body and MEDICAL BOARD in respective countries. The Nursing regulatory body shall review the protocol to ensure compliance with applicable regulatory standards. for protocols’ an advanced registered nurse practitioner may:

  • Monitor and alter drug therapies.
  • Initiate appropriate therapies for certain conditions
  • Perform additional functions as may be determined by rule in accordance with proposed protocol
  • Order diagnostic tests, physical and occupational therapy.
  • Determine the health status of the patient as it relates to the risk factors and to the anesthetic management of the patient through the performance of the general functions.
  • Based on history, physical assessment, and supplemental laboratory results, determine with the consent of the responsible physician, the appropriate anesthesia within the framework of the protocol.(for nurse and certified nurse  anesthetist)and Order under the protocol pre-anesthetic medication.
  • Perform under the protocol, procedures commonly used to render the patient insensible to pain during the performance of surgical, obstetrical, and general anesthesia ,inhalation agents and techniques ; intravenous agents and techniques ; and techniques of hypnosis.
  • Order or perform monitoring procedures indicated as pertinent to the anesthetic health care management of the patient.
  • Support life functions during anesthesia health care, including induction and intubation procedures, the use appropriate mechanical supportive devices, and the management of fluid, electrolyte, and blood component balances.
  • Recognize and take appropriate corrective action for abnormal patient responses to anesthesia, adjunctive medication, or other forms of therapy.
  • Recognize and treat a cardiac arrhythmia while the patient is under anesthetic care.
  • Participate in management of the patient while in the post anesthesia recovery area, including ordering the administration of fluids and drugs.
  • Place special peripheral and central venous and arterial lines for blood sampling and monitoring as appropriate.

The certified nurse midwife shall, to the extent authorized by proposed protocol perform any or all of the following

  • Perform superficial minor surgical procedures.
  • Manage the patient during labor and delivery to include amniotomy, episiotomy, and repair.
  • Order ,initiate and perform appropriate anesthetic procedure
  • Perform postpartum examination
  • Order appropriate medication
  • Provide family planning services and well woman care
  • Manage the medical care of the normal obstetrical patient and the initial care of a newborn patient

Applicant shall submit proof of national advanced practice certification from an approved nursing specialty committee

Those proposed nursing specialties committee seeking recognition by the Nursing regulatory body in respective countries shall meet the following standards;

  1. Attest to the competency of nurses in a clinical specialty area;
  2. Requires a written examination prior to certification
  • Completion of a formal program prior to eligibility of examination
  1. Maintains a program according or review mechanism that adheres to criteria which are equivalent to requirements in Kenya
  2. Identification standards or scope of practice statements as appropriate for the specialty.
  3. Pursuant to proposal changes in law governing nurses in respective countries, we may propose all ARNPs to carry malpractice insurance or demonstrate proof of financial responsibility.


 Acceptable coverage shall include:

Certification Provisional

Prior to certification by the appropriate professional or national nursing specialty committee, applicants for certification as certified registered nurse anesthetists or certified nurse midwives may apply for provisional certification

Each applicant for provisional certification SHALL be a graduard of an appropriate educational program pursuant to proposed changes in law governing nursing practice

The provisional ARNP certification will expire if no specialty certification is submitted within 12 months of the date granting provisional ARNP certification.

Proposed Program Guidelines

  1. The nurse practitioner certificate program which shall prepare the registered nurse for advanced or specialized levels of nursing practice in the expanded nursing role.
  2. The philosophy, purpose, and objective s of the program shall be clearly defined and available in written form
  • The objectives reflecting the philosophy shall be stated in behavioral terms and describe the competencies of the graduate

The program shall be conducted by one of the following;

  1. An accredited school of nursing that offers a degree or higher degree in nursing
  2. An accredited school of medicine
  3. An institution or a health care agency approved by the Nursing regulatory body and shall have;
  • Practicing advanced registered nurse practitioners AND their equivalent
  • Adequate number of qualified faculty in the specialty area available to develop and implement the program and achieve the stated  objectives
  • ARNP shall participate in teaching ,supervising and evaluating students.



proposal on Curriculum of the advanced nursing program shall reflect the following

  1. The course content, methods of instruction and learning experiences shall be in written form
  2. The program shall be at least 2 academic year in length and shall include theory in the biological, behavioral nursing and medical sciences relevant to the area of advanced practice ,in addition to clinical experience with a qualified lecturer
  3. The program shall include ,but not be limited to the following areas
  • Theory and directed clinical experience in comprehensive physical and bio-psychosocial assessment
  • Interviewing and communication skills
  • Eliciting ,recording and maintaining a health history
  • Interpretation of laboratory findings
  • Pharmacotherapeutics,to include the initiation ,selection and modification of selected medications
  • Initiation and modification of selected therapies
  • Nutrition including modification of diet
  • Providing emergency treatment
  • Assessment of community resources and referrals to appropriate professionals or agencies
  • Role realignment
  • Legal implications of advanced nursing practice nurse practitioner role
  • Health care delivery systems
  • Management of selected diseases and illnesses
  • Differential diagnosis related to specially problems
  1. The program shall provide a minimum of 500 hours or that Nursing regulatory body may propose of supervised clinical experience in the performance of the specialized systematically and be retrievable
  2. Provision shall be made for periodical evaluation by the faculty and students

proposals on Graduation from a program leading to a masters ,a post masters ,a doctoral or post doctoral degree ,which prepares the nurse for advanced or specialized nursing practices as an advanced registered  nurse practitioner shall meet the following criteria;

1     .The program shall prepare nurses as nurse practitioners, certified registered nurse   anesthetist or nurse midwife

  1. The philosophy, purpose and objectives of the program shall be clearly defined and available in written form
  2. The curriculum shall include, but not be limited to, the following practitioner’s skills.
  • Theory and directed clinical experience in physical and bio-psychosocial assessment
  • Interviewing and communication skills relevant to obtaining and maintaining a health history
  • Phamacotheropeutics, including selecting, prescribing, initiating, and modifying medications in the management of health/illness.
  • Selecting ,Initiating and modifying diet and therapies in the management of health /illness
  • Performance of specialized diagnosis tests that are essential to the area of advanced practice
  • Differential diagnosis pertinent to the specialty area
  • Interpretation of laboratory findings
  • Management of selected diseased and illnesses
  • Professional socialialization /role realignment
  • Legal implications of the advanced nursing practice/nurse practitioner role
  • Health delivery systems ,including assessment of community resources and referrals to appropriate professionals or agencies
  • Providing emergency treatments
  • A minimum of hours of preceptor ship/supervised clinical experience in the performance of the specialized diagnostic procedures that are essential to practice in that specialty area as shall be prescribed by Nursing regulatory body.
  • Faculty shall include currently practicing ARNPs
  1. Records of the program, philososophy objectives,administration,faculty,curriculum,students and graduates shall be maintained systematically and be retrievable



A registered nurse applying for initial certification of an advanced registered nurse practitioner shall file with the Nursing regulatory body an initial application for certification as an advanced registered nurse practitioner, and provide the Nursing regulatory body with the following

  • Documentation acceptable to the Nursing regulatory body that the education program attended meets the program guidelines stipulated in  nurses governing laws.
  • An official registrars copy of the applicant s transcript shall be sent directly to the Nursing regulatory body from the school and shall INDICATE successful completion of the formal post basic program or awarding of the masters degree in a nursing clinical specialty
  • A verification form prescribed by the Nursing regulatory body submitted by the director of the advanced nursing program indicating successful completion with the official school seal
  • Such other documentary proof which evidences certification by an appropriate specialty COMMITTEE
  • Verification from the specialty committee of certification

A registered nurse applying for certification as an advanced registered nurse practitioner in the category of certified nurse midwife, shall file the appropriate application form with the Nursing regulatory body and provide the Nursing regulatory body with the following:

  • Documentation that the specialty meets requirements to be stipulated in nurses governing laws proof of certification by an appropriate specialty committee recognized by the Nursing regulatory body


  • The original specialty certificate
  • A true and correct copy of the current specialty certificate
  • other documentary proof specialty which evidences certification by an appropriate specialty committee
  • Verification from the specialty Nursing regulatory body of certification
  • Documentation acceptable to the Nursing regulatory body as which shall be set in sections of nurses governing laws.


Application shall be made on a form prescribed by the Nursing regulatory body and submitted together with the appropriate fee. Applications shall be valid for one year from the original date of submission failure to provide all required documentation shall result in the application becoming null and void and requiring the applicant to submit a new application and a new application fee.


An applicant who wishes to be certified in more than one ARNP category shall be required to submit separate application in accordance with new change that shall be effected in nurses governing laws and these rules for each category which certification is desired

An applicant who shall wish to be certified in a second category must be able to document eligibility for certification in that category. Such eligibility may be determined by meeting at least one of the following criteria;

  • Content appropriate to the second category was addressed in the initial ARNP educational program and the completion of initial ARNP education and the applicant has passed a national certification examination in the second category if required


An advanced registered nurse practitioner may perform additional acts of medical diagnosis, treatment and operation in accordance with rules to be agreed by nursing regulatory body sets minimum standards for protocols pursuant to which an ARNP performs medical acts identified and approved.


All categories of advanced Registered nurse practitioner may perform functions stated in this section. The scope of practice for all categories of ARNPs shall include those functions which the ARNP has been educated to perform including the monitoring and altering of drug therapies, and initiation of appropriate therapies, according to the established protocol to be established and consistent with the practice setting.


  1. An advanced registered nurse practitioner shall only perform medical acts of diagnosis, treatment, and operation pursuant to a protocol between the Nursing regulatory body AND MEDICAL BOARD .The degree and method of supervision, determined by the Nursing regulatory body and MEDICAL BOARD, shall be specifically identified in the written protocol and shall be appropriate for prudent health care providers under similar circumstances. General supervision by the physician or dentist shall be required unless these rules set a different level of supervision for a particular act.

The number of persons to be supervised shall be limited to ensure that an acceptable standard of medical care is rendered in consideration of the following factors:


  • Risk to patient
  • Educational preparation, specialty and experience of the parties to the protocol
  • Complexity and risk of the procedures
  • Practice setting and
  • Availability of the physician or dentist

A written protocol signed by all parties, representing the mutual agreement of the physician or dentist and the ARNP, shall include the following, at a minimum

  1. General Data
  2. Signatures of individual parties to the protocol;
  3. Nature of practice, practice location, including primary and satellite sites and
  4. Data developed and dates amended with signature of all parties
  5. Collaborative practice agreement
  6. A description of the duties of the ARNP
  7. A description of the duties of the physician or dentist (which shall include consultant and supervisory arrangements in case the physician or dentist is unavailable
  8. The management areas for which the ARNP, IS RESPONSIBLE, including;


  • The conditions for which therapies may be initiated
  • The treatments that may be initiated by the ARNP depending on patient condition and judgment of the ARNP
  • The drug therapies that the ARNP may prescribe, initiation monitor, alter or order
  • A provision for annual review by the arties

Specific conditions and a procedure for identifying conditions that require direct evaluation or specific consultation by the physician or dentist. The parties to the protocol, to ensure an acceptable standard of supervision and medical care shall decide the detail and scope needed in the description of conditions and treatments and in doing so shall consider the factors listed above

The original of the protocol and the original of the notice shall be filled with the Nursing regulatory bodies in their respective countries yearly and a copy of the protocol and a copy of the notice to be prescribed shall be kept at the site of practice. Any alteration to the protocol or amendment SHALL be signed by the ARNP and medical board or dentist and filed in the Nursing regulatory body within 30 days of the alteration to be kept I the Department for filing purposes only

After the TERMINATION OF THE relationship between the ARNP and the supervising proffessional, each party is responsible for ensuring that a copy of the protocol is maintained for future reference for a period of four years.




Upon initial certification, an ARNP shall be issued with a certificate in the appropriate category. At the first and subsequent recertification thereafter, the license shall, upon payment of the renewal fee to be provided in respective nursing regulatory body rules

ARNP shall submit all of the following to the nursing regulatory body;

  1. Protocols or exemption
  2. Proof of current national certification if required

Failure to recertify as an advanced registered nurse practitioner within the time period prescribed by the Nursing regulatory body result in the certificate shall be placed on delicate status.

An ARNP may apply to place his certificate on inactive status .The application shall be made on forms provided by the Nursing regulatory body and shall be accompanied by an application fee for inactive status as will be specified in Nursing regulatory body rules


No inactive certificate may be reactivated unless the applicant holds a current active license to practice as a RN/Registered Nurse in their respective country and meets the requirements of proposed rules

Reactivation of an inactive ARNP certificate or dual RN/ARNP license /certificate shall be in the manner as provided in rules to be formulated

Documentation of active practice as a nurse practitioner within the past 5 years or documentation of an ARNP refresher course to include both theoretical and clinical components must be submitted .A current registered nurse license SHALL be required for the clinical component of a refresher course.






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Lead Nurse Africa is a Pan-African nursing organization dedicated to public health promotion and professional development.


  1. Wow Mr. Samwel, av always liked ua mindset. I love this. U r one of the leaders we need in our nursing profession. God bless you.

  2. you av demonstrated clear understanding of the profession and its demands for higher practice.we now need champions lyk yu to push for commencement of masters in anesthesia for nurses especially by the Kenyan public universities

  3. Does Kenya need advanced nurse practitioners?

    September 20, 2017 by Compleat Nurse

    Does Kenya need advanced nurse practitioners in view of shortage of primary care physicians? That is a mega dollar question considering that someone somewhere will oppose the entry of nurses into ‘their docket’. This article explores a Kenyan perspective.

    Availability of skilled and motivated physicians and nurses in sufficient numbers is critical in attaining better primary healthcare outcomes. Primary care is the foundation of an evolving health care system. There is need for more focus on primary care and realigning the health system to meet our country’s basic care and equality through redistribution ( if this were possible). It had been variously argued that to meet future demand for primary care in US, NPs could be increasingly utilized to meet the needs. Nicole Fishers (2013) was reluctant that NPs were the panacea to PCP shortage http://thehealthcareblog.com/blog/2013/09/04/why-nurse-practitioners-will-not-solve-the-primary-care-crisis/ (Links to an external site.

    I start by looking at the situation of physicians (it is a luxury in Kenya context to begin talking about primary care physicians but for the purpose of this discussion let’s call them so).

    It has emerged that the doctor-patient ratio in Kenya has widened in the past four years, an indication that the number of doctors entering and staying in the public health sector has been outpaced by population growth. By end of 2011, Kenya had a doctor-population ratio of one doctor to 17,000, for a population of 40million dhsprogram.com/pubs/pdf/spa8/02chapter2.pdf.

    A report by the Ministry of Health report suggested that the country had one medical officer for every 20,000 people. According to: Kenya Service Availability and Readiness Assessment Mapping (SARAM, 2013) also showed that there was only one registered clinical officer (physician Assistant) for every 10,000 people and a nurse for every 3,333 people http://www.who.int/healthinfo/systems/sara…/en/

    According to chairman Kenya Medical Practioners, Pharmacists and Dentists union (KMPPDU) Dr Samuel Oroko, in 2014 alone 1800 doctors left public service to join private practice. The main reason cited during this season was the bumpy take of the revolutionized health care services; there was reported harassment of health care providers by local leaders including Members of County Assemblies (MCAs) who forcefully wanted to run facilities in their various county wards. The Union also attributed the low retention of doctors in the public sector to poor remunerations and poor working conditions. The Kenya government itself in 2011 admitted that up to three quarters of doctors joining public hospitals after graduation would have left these hospitals in three years’ time.

    The commitment of a few pioneer private nurse midwives in Kenya had increased access to community-level reproductive health /family planning services and child welfare activities but they generally provided curative health services and very few preventive services. If anything Advanced Nursing Practice (ANP) or Nurse practitioners (NP) as defined in the US are most likely to be in nursing education than as practitioners. Doctorate of Nursing Practice (DNP) degree is not available in Kenya yet. Personally I only know one DNP and she trained at Indiana US.

    So in my approach NP is the same as nurse in private practice, in other words self- employed, and likely to be operating a standalone clinic as opposed to one who is employed. Nurses in this category do not work under physicians. Private maternity homes fall under the governance of the Kenya Registered Midwives Association (KRMA). Some maternity and nursing homes are run by other health care professionals, such as doctors and clinical officers.

    According to Private Nurse Practitioners’ (PNP) Chapter, the association ‘encompasses nursing experts with at least 5 years post registration certificates who have advanced to operate their own facilities countrywide thereby contributing remarkably to increasing access to quality healthcare’. Sources from National Nurses association of Kenya (NNAK, 2014) indicate that there wre over 1600 registered nurses who were in private practice http://www.nnak.or.ke/privatenur.php. Therewere high chances a good number do not have degrees or advanced nursing education for that matter and these are not a requirement to practice but they must be licensed by Nursing Council of Kenya. The clinic or the outfit they run must comply with the (multidisciplinary) statutory checklist nckenya.com/wp-content/…/Guidelines-for-Private-Practice-Nurses.pdf.

    As much as it took sometime (late 90s) for nurses to be allowed a license to practice privately, nurses are not essentially in competition with doctors in this aspect though one cannot rule out that from a business point of view. Nurses in Kenya usually opt for rurals, the estates while physicians practice in plazas in large towns. Every doctor looks forward to specialization and they have incentives to do them. A few general practitioners (those with one degree MBChB) perhaps may be referred to as primary care physicians (PCP), but certainly I am not too sure if there is any PCP’s as such in our context. Medicine and disciplined forces are about the only careers that guarantees one a job in the government after graduation in Kenya. Nurses have to hassle for placements, in recent years they have managed to secure stipends during internship after BSN but after that they have to look for a job.

    I agree that in Kenya too nurse practitioners will not solve the primary care crisis. But again we also have clinical officers. But expanding this discussion that way would bring in many other issues that are beyond the scope of this article. But my reader is free to add a voice in that direction. But do we have nurse practitioners (NPs) in Kenya? Yes to some extent as explained above.

    [Dimon Kamau alias Compleat Nurse has a MS in Nursing Leadership and Health Systems Administration from University of Colorado Denver].
    Post available: http://www.compleathealthsystems.com/advocacy/kenya-need-nurse-practitioners/

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