Transformative Education
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Case Study: Primary Healthcare Clinical Placements during Nursing and Midwifery Education in Lesotho

Alice Christensen, Semakaleng Phafoli, Johanna Butler, Isabel Nyangu, Laura Skolnik, Stacie C. Stender

In Lesotho, primary healthcare is the main access point for health services. While nurses and midwives provide most of the care at this level, assessments of the clinical education programs have highlighted gaps in primary healthcare experiences for nursing and midwifery students. This case study examines placement of nursing and midwifery students in primary health clinics alongside preceptors. The placements provide students with varied clinical experience, better preparing them to practice in primary healthcare clinics. To date, more than 700 nursing and midwifery students have been placed in 40 rural health centers and 228 preceptors have been trained. 

Full project description: 

The full project report can be downloaded, see file  WH_vol16_no2-v3-clr_Christensen.pdf 


The Kingdom of Lesotho is a small, land- locked, mountainous country in Southern Africa. The majority of the population of 1.8 million subsists on farming (World Bank 2015) and three-quarters live in rural areas (United Nations 2015). Despite its small size, the country faces extraordinary health challenges.



The country’s health workforce is challenged to meet the needs of its population. The nursing and midwifery workforce is six per 10,000 compared to neighboring South Africa’s 41 per 10,000 and 11 per 10,000 for the Africa region (WHO 2009). In Lesotho, over half (54%) of nurse and midwife posts remain vacant in rural areas (Ntlale and Duma 2012). 




Pre-service primary healthcare clinical experiences can serve as the link between community health theory and practice and are crucial for clinical skills development and professional socialization (Lofmark et al. 2008).

The United States Agency for International Development’s (USAID’s) Maternal Child Health Integrated Program (MCHIP), implemented through Jhpiego, began work in Lesotho in 2011 with a specific focus on strengthening pre-service nursing and midwifery education.


 Students were placed in cohorts of 4–8 per clinical site


To address the absence of a primary healthcare emphasis in pre- service education, MCHIP supported clinical placements in primary care settings for certificate-level nursing assistant and diploma-level registered nursing and midwifery students.


Methodology / change process


Lesotho has six schools of nursing education; five of which also provide midwifery education. Initial pre-service education assessments of nursing and midwifery programs conducted in 2009/2010 highlighted gaps in student education and clinical experiences and indicated that most students were placed in hospital sites without trained preceptors and where the nursing staff had little time to serve as preceptors.


Willingness for Deployment in primary health clinics following graduation 


The majority of questionnaire responses (68%) indicated that students would like to work in a similar setting after graduation (134 yes; 46 maybe; 19 no). Six themes were identified as reasons students were willing to work in rural clinics: independence, challenging and diverse clinical care, supportive staff and community, the need for staff and having had a good learning experience. For example, one student wrote on independence, I was able to do everything in a hospital, we expect the doctor to do everything.



Suggestions for improvement of clincial placements 


Overall, the areas students identified for improving clinical placements are also common reasons rural nurses give for leaving their jobs, including inadequate staffing and lack of electricity, water and supplies.


 Some of the students and, their preceptors and tutors during PHC clinical placements

Discussion / conclusion


Student nurses and student midwives need pre-service clinical experiences that are relevant to their deployment post-graduation and that are responsive to national health priorities. 


If the majority of nurses work in primary healthcare but only have clinical experiences at tertiary hospitals, then there is a mismatch of clinical education with skills required in the workplace. The evaluation of participants’ experience during this clinical placement documented that students felt they improved their skills in diagnosis and treatment of primary health conditions, providing maternal and child health and HIV/AIDS care, which corresponds closely with national health needs.


In addition, many of these students will be deployed upon graduation to health facilities with few or no doctors, which essentially requires these nurses to have diagnosis and treatment skills that were strengthened during their clinical placements.








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