A competent nursing workforce is a critical building block for an effective health system [1]. Nurses form the backbone of the health system and are a universal access point for almost 90% of healthcare users in Sub Saharan Africa [2-4]. However, literature reports severe shortage of nurses in the region. Malawi has a nurse based health system but still has a vacancy rate of 65% for nursing and midwifery positions in public sector [5]; and a geographic mal-distribution of 74% of providers in urban serving 19% of the population [6]. Malawi requires 20% more nurses to meet healthcare needs [6].

The World Health Organization through a resolution at the World Health Assembly 59.27 urged member states to strengthen nursing and midwifery by establishing comprehensive programs to train nurses and midwives [7]. The Plan of Action for Scaling up Quality Nursing and Midwifery Education and Practice for the African Region 2012 – 2022, Transforming and scale up heath professionals’ education and training guidelines, the Regional Professional Regulatory Framework for Nursing and Midwifery, the Four Year integrated nursing and midwifery competency- based prototype curriculum for the African Region provide adequate framework for improving quantity, quality and relevance of nurses and midwives at region level. The National Nurse Scale up Operational Plan highlighted need to double nursing intake to solve the human resource for health crisis in Malawi [8].

Between 2004 – 2010, Malawi greatly increased the number of nurses through the Emergency Human Resource for Health Program [5]. However, quantity of health workforce alone is not adequate to strengthen the health system. Malawi still reports skill mix imbalance [9] and geographical mal-distribution of the workforce [10]. To accelerate gains in health outcomes, health systems must continuously adapt and evolve according to the health care needs. The changing health care landscape should inform changes in the health care professionals’ education system. However, health professionals’ education has generally not coped up with health care needs and demands [11] and competencies of health workers do not match health needs. There is poor collaboration among professionals. Professional education is still hospital based care at the expense of community based care.

The purpose of this study was to describe strategies being implemented in Malawi to improve nursing education. Specifically, the objectives of the study were to explore strategies being implemented, identify stakeholders and their targets in order to share practices with countries experiencing similar nursing education challenges.

The purpose of this study was to describe strategies that are being implemented in Malawi to improve quality and relevance of nursing education. The Lancet Commission reported a gap between health needs and educational outcomes [15]. Many educational programs do not adequately address the needs of health care system [16]. While previous clinical teaching has traditionally focused on how and where clinical learning should take place, which clinical activities are required, how many hours should be acquired, improvements in clinical teaching and learning have focused on producing intended students learning outcomes [17]. Learning objectives often focus on what the leaner should know. Curriculum reform is central to transform the quality and relevance of nursing education. The recent focus on competency based curriculum call for identification of critical nursing activities and general competencies [18]. Competency based learning strengthens individual-based outcomes for each student. Transformative education demands that curricula be responsive to the needs of the society especially the neglected and marginalize poor populations [19].

As nursing education transformation is taking shape, findings indicated that inter-professional education is not well established in nursing education. However, inter-professional education is becoming a tool to add relevance to health professionals’ education worldwide [20]. Inter-professional education encourages members of more than one health profession to learn interactively together for the explicit purpose of improving inter-professional collaboration and overall health of the populations. Inter-professional collaboration has been linked to a range of outcomes, including improvements in patient safety and case management, the optimal use of skills of each team member and provisions of better health services [21]. With growing task shifting within the health care system [22], inter-professional education will enhance collaboration among healthcare teams [23].

Improving educational capacity through nursing faculty development has been pursued as one of the several strategies to address a complex human resource problem [24]. Steinert [25] described faculty development as “scholarly activities critical for promoting educational leadership, innovation, excellence and they are key to academic vitality”. Nursing education has witnessed a paradigm shift from traditional to emerging active, student- centered, transformative approaches to learning. Strategies to foster faculty development are significant because nurse educators are expected to do much more. Faculty development activities need to include opportunities for nurse educators to address and reshape norms to facilitate a successful transformation to a new educational paradigm [26].

NMCM reinforces mandatory continuous professional development for all nurses including faculty as a criteria to renew professional license. This is necessary considering that nursing faulty lose their practice competence over time. Nurse educators execute nursing curriculums that are aligned to the practice setting. It is vital that nurse educators should keep themselves at par with the dynamic clinical setting [27]. The mentorship program fits very well to provide nursing faculty with an opportunity to update their clinical skills [28]. Faculty development is helpful to equip faculty staff to recognize students’ needs and develop strategies to support these needs [29].

Findings have reported strategies to build capacity of clinical staff through preceptorship and mentorship. There is evidence of adequate learning gains by students when clinical staff take charge of student learning [30]. Nurses could be experts in their clinical field but might not be able to transfer such expertise to students. Most clinical nurses might feel unprepared and disconnected when handling students. Lack of proper capacity building causes a feeling of lack of support in their role and inadequate preparation for clinical staff. Building capacity of clinical staff through mentorship facilitates appropriate communication and interaction between clinical staff and students, incorporation of both theory and practice. Preceptors facilitate development of students’ practical skills and facilitate professional socialization [31]. Students who are being supported by preceptors have a widened knowledge base and clinical skills [32]. Preceptors develop self-confidence and there is better communication [33]. Maintaining a positive clinical placement that promotes learning through effective role modelling and clinical teaching where students are given the appropriate attention, nurtured and supported ensures adequately prepared graduates.

Msiska, Smith [34] reported that in many clinical settings in Malawi, the clinical learning environment was hostile and oppressive due to negative attitudes of staff towards students. Findings of this study show a considerable effort to improve clinical learning environment. Introduction of ideal teaching model wards was necessary to provide students with positive clinical learning environment. A good clinical learning environment is crucial to develop learning skills, clinical reasoning and develop students as professional nurses. A positive clinical learning environment facilitates acquisition of competencies. Studies have shown that a positive clinical environment is one in which students feel confident, motivated to learn, are respected and recognised [35]. The strategies been implemented are fostering a sense of cooperation and willingness for staff to teach students. Students are given appropriate guide to provide quality care [36, 37].

The Regional Professional Regulatory Framework for Nursing and Midwifery reported that efforts to improve nursing and midwifery tend to ignore regulation [38]. Building capacity of regulatory bodies is paramount to quality check and maintenance of standards in nursing education [24]. Educational institutions and professional nursing organizations need to actively contribute to the development of health policy on regulation [14].

In a poor resource setting like Malawi, simulation with high- fidelity technology is an innovative and effective clinical teaching strategy. Simulation addresses the challenge of increased student enrolment, faculty shortage and limited clinical sites. Weaver [39] and Parker and Myrick [40] have documented multiple benefits of simulation in nursing education. These are an increased learner satisfaction, teamwork, increased self- confidence and promotion of clinical judgement and critical thinking. Richardson, Goldsamt [41] observed that substituting simulation for traditional clinical hours can be a sustainable and educationally sound option to increase faculty capacity. Students tend to have more time for clinical practice when using simulation [42].

Nursing education remains critical to building a strong health system. Transforming and scaling up of nursing and midwifery improves the quality, quantity and relevance of nursing education. Considering that the healthcare environment is increasingly becoming complex, dynamic with changing demands, transformation of nursing education is needed than before. Improvement in nursing education needs to match these changes if the nurses are to effectively perform and positively impact on patient and care outcomes. Findings of this study have shown that the strategies being implemented to improve nursing education are relevant to closing the gap that exists between health care needs and nursing education. Building capacity of nursing faculty, clinical nurses will ensure that nursing student acquire the necessary knowledge, skills and competencies to provide quality and safe care. Provision of adequate resources and a conducive learning environment strengthens teaching and learning for students.