Trends in Human Resource Development in Botswana Health Sector: The Case of Gaborone Private Hospital

This paper examines and analyses changes or evolution of human resource developments in nursing profession in Gaborone private hospital (GPH) and how they have impacted the nursing care delivery and how they will continue to affect the delivery of health care services.Gaborone private hospital is in the city of Gaborone. HRD in nursing goes beyond professional boundaries and has a strong connection to the organizational strategy. Healthcare organizations are highly knowledge-intensive foundations which need frequent learning for performance improvement. Creating learning environment is an important matter for the employees (Tsai,2014).Nurses around the world in different health care systems should be prepared such that they are able to function in different settings and still be productive to embrace the principle of universality and this can be achieved through learning and knowledge acquired by individuals themselves and/or through the organization programs. The human resource development model under the theory of human resource development will be used to explore the human resource development trends in Gaborone private hospital.


Background
Nursing in the second half of 20th century was marked by tremendous changes. Although the pace and outcomes of those changes varied throughout the world, the goal everywhere was to transform nursing from an occupation whose members struggled within a social context that devalued nurses' work as unskilled, to a profession comprising autonomous, well-educated, career orientated knowledge workers. [5] Learning and knowledge of nurses in Botswana can be traced back to the origins of nursing in our communities. Nursing in Botswana was started by uneducated women in the societies who informally organized themselves to help people with health problems. Sabone,traced nursing [6] education in Botswana back in the missionary era in the 1920s when there werefew mission hospitals and their expatriate nurses. These hospitals saw it fit to train local nurses to provide care to patients.As a result, after the 1966 independence, Botswana established health training institutions which offered certificate and diploma nursing programs trainings.
The trained nurses were further enrolled in diploma in midwifery. [7] Later on, a few faith-based hospitals in the country also established schools offering nursing certificates and diplomas.Following government THEOPHILUS TSHUKUDU (2021) ofBotswana`s aggressive development plan in the1970s, which was primarily towards Primary Health Care, additional diplomas for professional nurses were offered. The diplomas included family nurse practitioner, community health nursing, nurse anesthesia, and psychiatric-mental health nursing. [8] In response to concerns about the limitations of the certificate programs, the qualification was later phased out and its graduates were upgraded to professional nurses; a process that was completed in 2003. [9] In 1978, the University of Botswana started a nursing degree program with an aim to train nurse educators to teach in the diploma and certificate programs. Around 1985, the program started enrolling students from clinical services whose focus was leadership and management. The enrolled nurses were only exiting with a Bachelor of Education (Nursing) Degree. As such, a need for further education content was observed with concern. Regarding the management and leadership stream, the focus was on life-long learning. The graduates were expected to offer life-long education to nurses in the workplace, support students' clinical learning, and provide leadership in health education programs for communities. The first masters' degree students were enrolled in 1996; and in 2000, with its science foundation strengthened. Such was achieved through converting the Bachelor of Education (Nursing) Degree program to Bachelor of Nursing Science(BNS) and started enrolling pre-service students along with those upgrading their diploma to a degree. [10] Currently, nursing education in Botswana is provided by government`s six institutes of health sciences and two faith-based hospitals. The institutes of health sciences offer diploma in basic nursing and post basic diploma in community health nursing, psychiatric-mental health nursing, [11] midwifery, and family nurse practitioner. The faith-based hospitals also offer diploma programs .In addition to the undergraduate degree program, the University of Botswana offers masters' degrees in midwifery, community health nursing, psychiatric-mental health nursing, family nurse practitioner, pediatric nursing, and adult health nursing.
Botswana nurses also further their studies in countries such as South Africa, Canada, Australia, United Kingdom, and the USA. South Africa provides both undergraduate and postgraduate degrees while universities overseas mainly provide post-graduate degrees.

Literature Review
To understand the trends in HRD in nursing in Botswana`s Gaborone Private Hospital, the HRD model which is part of the theory of human resource development will be used. It is believed that HRD took a detour during the past fifty years and the clear vision and practice was lost during World War II in the 1950s and returned in 1980s. [12] The massive Training within Industry (TWI) project that culminated withthe ending of World War II is seen as the origin of contemporary HRD. [13] The actual fulfillment of the goods and/or services requirement is thought of in terms of units of performance and performance is a key goal of the organization that is viewed as the resultant of HRD. The larger frame in which HRD functions includes organizations and the milieu in which they function. Organizations are the host systems for most HRD activity . [14] The whole theory of HRD is proposed to be the integration of psychological, economic, and system theories within an ethical frame. This integrative state is central to securing HRD as a discipline, not in just knowing the elements and the whole of any integrated HRD theory will be larger than the sum of the parts and unique to HRD. [15] TThe faith-based hospitals also offer diploma programs .In addition to the undergraduate degree program, the University of Botswana offers masters' degrees in midwifery, community health nursing, psychiatric-mental health nursing, family nurse practitioner, pediatric nursing, and adult health nursing.

Adopted from Hillton and Swanson(2008)
The human resource development model, which is from the theory of human resource development, is the one that will be particularly used to explore trends in human resource development in nursing in Botswana at Gaborone Private Hospital. The model is intended to be a way of making sense of the relationships between various organizational factors that both influence and are influenced by HRD. [16] This model of HRD illustrates HRD as a five-phase process working in concert with other core organizational processes, all functioning in the organizational context and the larger environmental context . [17] Human Resource Development Model

Adapted from Mankin(2001)
The overlaps should be viewed as set of the multidimensional, interrelated factors. [17] The relationship between strategy and structure and HRM is predicated on the argument that human resource policies should be integrated with strategic business planning. [18] The dynamics of these overlaps can also be used to illustrate the need to THEOPHILUS TSHUKUDU (2021) break down boundaries and barriers to facilitate the exchange of information and develop shared learning and collaborative processes. Boundaries inhibit the flow of information; they keep individuals and groups isolated and re-inforce preconceptions. Human resource model components affect one another and managing them well helps the organization to achieve its goals. Human resource management and HRD will be explored to understand learning and knowledge at Gaborone private hospital within the nursing profession and this is mainly due to the closeness and the linkage of the two concepts.

Human Resource Management
Gaborone Private Hospital, as a profit making entity, is more concerned with making a lot of money with little expenses and as such it is not interested in sending nurses to school to enhance their skills. The little it can do is to organize short courses or in house programms for the nurses if there is a need especially if there is a new condition or crisis to try to overcome the situation. For example, they had organized a short training for the whole staff when the COVID-19 pandemic started. Gaborone Private Hospital prefers to hire the nurses who already have higher qualifications and at the time of hiring the nurse may be relevant to the present time.As time goes on, the nurse gets overtaken by the events and as such this may affect the service delivery of such personnel.
The importance of HRM in health care performance has not been recognized and systematically analyzed until recently. The interest and financial support of senior managers are most important componentsnecessary for the effective management of people in health care organizations. Managing people for high performance requires a significant investment in time and money to have positive employee relations, competent employees, competitive compensation, continuous training and development, thorough performance appraisal, and a safe workplace. An executive team that considers employees to be long-term competitive assets is more likely to allocate financial resources to enhance the value of individuals in the organization and hold managers accountable for earning a rate of return on the investment. [19] There is a good public perception about Gaborone private hospital as compared to the government owned facilities and this is mainly attributed to the quality time that the clients are given not necessarily the skills that the nurses there posses and this is attributed to by the reasonable nurse patient ratio which reflect a sign of good human resource management practice.
Human resources and their development are crucial elements in today's health care and its future reforms. [20] In fact, clients today, living in the information age, have a high expectation that health professionals are intelligent and competent to provide the highest quality of care available. The other factor that contributes to highly ranked service in Gaborone private hospital is the high moral of the nurses which is high as compared to the other nurses at the government facilities and this is due to high salaries in GPH as compared to government facilities. Even though the salaries are high there is no job security and most nurses do not like that. Tyson (1995) opined that HRM is one crucial strategic component in the health care field. This issue also has economic implications, as two-thirds of all costs of the health care organization consist of the salaries of personnel (directly and indirectly). [20]

Learning and Knowledge (HRD)
It is the responsibility of an individual and organization to make sure that employees have got the needed and reasonable skills for the work they do. HRD transcends professional boundaries and has a strong connection to the organizations strategy. [21] Gaborone Private Hospital does not recognize any qualifications that an employee may attain while in service. That is, there is no remuneration or rewards for individual development. Extra qualification may be considered at the point of hiring but after that the organization does not deem it beneficial to them while in an actual fact organization will benefit from the skills that an employee has gained. The new roles, training and development needs can be identified with sufficient lead time to implement appropriate programs for enhancing performance. Effective training can significantly improve productivity, lower costs, and play a major role in improving patient care. [22] The employees who are frequently refreshed and sent for training turn to have trust in the organization as they realize that the organization values and appreciate their importance. The more the employees stay long in the organization they turn to adopt the organizational culture of performance and as such the nurses in Gaborone private hospital feel abounded and as such they do not feel that attachment between them and the organization hence this affect their service delivery. Arnold (2010) argued that employee training and development needs must be analyzed when formulating and implementing new strategies for restructuring, lowering costs, improving quality, or providing better patient service. To implement and sustain a higher quality patient service strategy, employees who are providing excellent service to patients should be rewarded accordingly. Learning paths must be taken into consideration as a strategy to help with this process, considered as multiple alternatives offered to individuals, followed according to individual, group and organization expectations, based on the competences they already have and those they still need to develop. [23] Learning must be seen as a voluntary act, when individuals need to have a reason to be committed to the educational process. The act of being qualified through Learning Paths is like moving across a network of opportunities and not becoming entangled with a preestablished qualification curriculum or program. The Learning Paths enable professionals to build up their learning from their needs and choices, integrating personal planning with health organization expectations, including their ambitions, expected performance, the competences they already have and those they need to add to their knowledge. For the development of coherent competences that meet the expected results, the work environment must promote learning and professionals have to be interested and encouraged to learn and teach. [24] Training takes into consideration both the organizational and professional needs because it assumes shared responsibility for development of competencies, and as such acts as a contract between the two. Training and development in healthcare is based on continuous knowledge development in which by generating new information from clinical research and translate it into practice to improve patient care. [25] Human resource management emphasizes a top management's responsibility for managing culture. [26] THEOPHILUS TSHUKUDU (2021) Managers as individual human beings hold varying beliefs and values about themselves, their work, and other people in the abstract and particular, and about organizations in the abstract and particular which influence how they approach their work and how they interact with those they manage. [27] For a human resource development program to be implemented and to prosper in an organization, the human resource personnel or managers have to understand it and be more than willing to support it because they are the ones who are responsible for the staff welfare and development. HRD is to ensure that employee'sknowledge and skills are fully utilized, which requires effective HRM practices. [28] The nature of HRD as a concept comprises of a variety of activities and processes rather than viewing it purely as a function or department within an organization. If human resource development does not take place, then neither learning or improvement or change can take place, for all these both require and result in a shift in mindset or behaviour or skills. To develop the knowledge organization, it is necessary to create an appropriate learning environment. Walton (1999) noted that with years that there was a shift from training and development to learning and a lot of organizations acknowledged the pervasive nature of informal learning in the workplace. Regardless of the status of nursing's position or the stage of its development in any one country, individual nurses require support in their practice and in their professional development. [30] Continuing education in health is a possibility of innovation and re-organization of the work process through in-service education, aimed at strengthening the development of competences of nursing professionals. [31]

Recommendations
It is critical for the nurses to have a wealth of knowledge and skills for better service delivery.
• Gaborone Private Hospital and other employers of nurses must create a nurturing environment to develop nurses and allow nurses to develop themselves for the benefit of the clients and for professional and personal development. • Nurses should be recognized and rewarded for the learning that they undergo while on duty. • There is an acute need for right policies to be developed and implemented to allow for the nurses growth just like other professionals in the health sector such as medical doctors who are allowed to go to school after 2 years in service and they can be given a study leave on full pay for the entire training in the government sector. [31]

Conclusion
Trends in human resource development in the field of nursing fraternity are important in any health sector of a community or country because they determine the health outcome of that particular community or country mainly because nurses form the backbone of the health sector of most countries. Nationally, the density of health nurses per 10,000 populations has been persistently low by international standards (World Health Organization [WHO], 2010, 2014). The WHO views nursing personnel as the most critical of all health system resources. The training and development of nurses in a health sector is crucial and has to be evolving in order to be able to face the ever-changing challenges in the health sector. The growth and improvement of the nursing care is more dependent on the human resource management, how it values the staff development in order for that staff to be able to contribute to achieving organizational goals.
There is extensive evidence that HRM practices have an impact on organizational and employee performance in many sectors (Bowen &Ostroff, 2004;Guest, 1997). Public health sector HRM in Botswana has experienced inadequate planning, poor deployment and underutilization of staff. Lack of comprehensive retention strategies and poor working conditions contributed to the failure to attract and retain skilled personnel (Seitio-Kgokgwe, Gauld, Hill, & Barnett, 2016). This in turn contributed to the stagnation in the development of nurse's profession and knowledge in order to be able to provide quality nursing care that is relevant to the current changing times.