The Role of the Nurse : A Comparison of the Canadian and Ghanaian Health Care Systems as Experienced by Undergraduate Nursing Students

Undergraduate nursing students were placed for three weeks in three small communities in Ghana as part of an international cross-cultural nursing elective.  The main objectives of the placement were to learn about the country’s culture and health care system, and to participate in community nursing placements in both community clinic and school settings.  As nursing students participating in this cross-cultural experience, we had the opportunity to work in Ghana’s health care system, where we were able to learn about the nursing role. It became evident that the nursing values, scope of practice, roles and responsibilities had some similarities, but also demonstrated several differences compared to nursing in Canada. A literature review was performed to contrast the cultural differences compared to nursing practice in Canada. Literature was also applied to our personal experiences to facilitate our understanding of the importance of providing culturally sensitive care. Overall, this valuable cross-cultural experience influenced our personal growth, allowing us to thoughtfully integrate our experience through further reflection and review of literature after the course was completed.


Introduction
Eleven students from a Canadian nursing program participated in various community nursing placements that occurred in Ghana as part of a cross-cultural nursing elective during the spring of 2017.This paper discusses the experiences and perspectives of three of those nursing students.The international cross-cultural course provided us as nursing students with clinical practice experiences in global health in an international setting, and also explored the influence of culture and geography on people's health.Over 100 clinical hours were completed for this course in community health clinics and schools serving the surrounding communities in rural areas of Ghana.
The clinical placement settings in Ghana were situated in three small communities, two of which were in rural areas.The primary learning objectives of the community placement experience were to be immersed in the culture and communities, to learn about the country's health care system, and to participate in community nursing placements in both clinics and schools.Before the placement, all nursing students spent one week in class learning about community nursing theory and the geographic and demographic characteristics of Ghana including its culture.All of the nursing students had an opportunity to work in a small rural clinic, a polyclinic on the outskirts of a larger city which included several different wards, and in two different schools where health teaching was provided to students of various ages.This was achieved through partnership with a non-government organization called Building for the Future Generation.This article will compare the scope of practice, nursing values, and roles and responsibilities between Canada and Ghana with respect to the practice of nursing.The role of cultural competence in providing culturally sensitive care is also examined related to our experience as nursing students.Finally, the influence of this overall experience on our personal growth as future health care providers is discussed.

Literature Review
Themes explored in the literature included cross-cultural learning, the context of Ghanaian nursing, the nursing scopes of practice in Ghana and Canada, and the nursing values between both countries.These themes were included as search terms while researching the CINAHL and EBSCO databases from Laurentian University, and also online resources of the professional nursing organizations from Ghana and Canada were utilized.The formation of an in-depth understanding of the concepts and their influence in the context of nursing is established and reflected upon within the scope of our experiences as nursing students.

Cross-Cultural Learning
Cross-cultural experiences contribute to the provision of holistic client care, the development of cultural competency, as well as personal and professional development.According to Allen (2010), cross-cultural learning is focused on the development of cultural competence in health care professionals.Nurse educators often encounter challenges when seeking opportunities for nursing students to increase their cultural competency and adapt care to diverse populations without discrimination or stigmatization (Allen, 2010).As stated in Repo, Vahlberg, Salminen, Papadopoulos, and Leino-Kilpi (2017), cultural competency is a lifelong learning practice and is an essential component in providing effective culturally appropriate care.In the previous study, it was determined that at graduation, most student nurses were culturally aware or culturally safe, and no students were entirely culturally incompetent or fully competent, with many factors involved in contributing to this competency (Repo, Salminen, Papadopoulos, & Leino-Kilpi, 2017).Thus, cross-cultural learning opportunities have been found to affect the personal and professional development of nursing students positively.

Context of Ghanaian Nursing
The Ghanaian health care system exists in its own specific context, which affects how it is administered and utilized.Generally, the Ghanaian health care system has been impacted by the migration of their health care professionals, which include registered nurses (Bell, Rominski, Bam, Donkor, & Lori, 2013).According to the Ghana Health Services (GHS) (2017), for their population of approximately 28 million people, there are only 3,365 doctors, whereas Canada has a population of approximately 26 million people in 2016 with 84,063 physicians (Canadian Institute for Health Information, 2017).In Ghana, staffing shortages and accessibility issues impede the provision of adequate health care (Bell et al., 2013).The country cannot supply enough registered nurses to meet the health needs of the population.Their education system provides adequate education, but its volume of teaching faculty is not large enough (Bell et al., 2013).In addition, Donkor and Andrews (2011a) found that registered nurses in Ghana often provide care without equipment and resources that are in optimal condition.These issues that influence the Ghanaian health care system also affect the nurses while providing care, which further impacts their roles.These nurses attempt to work within their scope of practice to provide appropriate care for individuals, families, and communities despite these limitations.

Scope of Practice
The scopes of practice of registered nurses are regulated by professional bodies which demonstrate some similarities and a few differences in the nursing role.When compared, the scopes of practice of the two regulatory bodies in Ghana and in Ontario (Nursing and Midwifery Council of Ghana [NMCG] and College of Nurses of Ontario [CNO]) share many similarities (see Table 1).However, as shown in Table 1, the NMCG lists regulations that are different compared to the CNO's scope of practice.These include sterilizing equipment, preparing and serving food, making blood films for diagnosing malaria, arresting hemorrhage, giving first aid in labour if no other health care professionals are available, treating snake bites and insect stings, and performing minor operations such as inserting stitches or sutures (NMCG, 2017).Typically, physicians in Canada would perform tasks such as providing first aid treatment of snake bites or insect stings or performing minor operations such as incisions or insertion of sutures.However, as observed in the rural communities in Ghana, it is often the registered nurse.Also, in Canada, based on our experiences as students, there are services within health care settings such as sterile processing departments and dietary departments responsible for tasks such as sterilizing equipment and cooking meals for patients.However, in Ghana, we noticed that registered nurses are mainly involved in performing these tasks.
As the observations made by the students were limited to rural nursing in Ghana, a conclusion of the nurses' involvement in these tasks in urban facilities is not possible at this time.In addition, these conclusions of Canadian nursing do not take into considerations the large rural population that require nurses to work independently without physicians, and where standing orders are often in place so that nurses can perform certain procedures.As determined in the 2011 Statistics Canada Census, a rural population of 18.9 percent was noted (Statistics Canada, 2018).As stated in Jackman, Myrick, and Yonge (2010), in many Canadian rural communities, access to physicians was often not possible; therefore, nurses often took on their responsibilities.The rural nurse has the responsibility of providing complete care and treatment as well as many advanced roles such as the delivery of babies (Jackman et al., 2010).Given this further examination, it can be concluded that there may be more similarities between Canada and Ghana with respect to the nurse's role in rural areas.However, the rural population in Ghana is 45 percent, therefore contributing to an increased percentage of rural nursing practice (The World Bank, 2017).As evident in Table 1, the NMCG took into consideration the rural nurses' responsibilities whereas the CNO did not take into consideration the advanced practices of the rural nurse.This could be due to limiting the scope of the nurses' role in this depiction to registered nurses, which does not include the scope of practice of nurse practitioners, who are advanced care nurses often working within rural communities in Canada practicing in an expanded role.A complete and accurate comparison of the nursing scope of practice, which would include nurse practitioners, was not completed, as the focus was on the role of the registered nurse in the rural areas of both countries

Regulations from NMCG that are different than CNO's scope of practice
• Sterilization of all nursing equipment.• Cooking and serving patient's food.
• Make blood films for the diagnosis of malaria.
• Arrest hemorrhage by use of pad and bandage, digital pressure or tourniquet.
• Giving of first aid in labour if no midwife or doctor is available.
• Giving of first aid treatment for snake bites or insect stings.
• Performance of minor operations such as incision or insertion of sutures in wounds.(NMCG, 2017)

Nursing Values
The Ontarian and Ghanaian regulatory bodies have similar nursing values.The mission of the CNO is, "to protect the public's right to quality nursing services by providing leadership to the nursing profession in self-regulation" (CNO, 2002, p. 2).Similarly, the mandate of the GHS (2017) is, "to provide and prudently manage comprehensive and accessible health services with special emphasis on primary health care at regional, district, and sub-district levels in accordance with approved national policies." We discovered the Ghanaian code of professional conduct posted on a wall in the Salvation Army Polyclinic in Agona Duakwa during the clinical placement.Once we arrived back in Canada, we compared it to the professional standards of practice issued by the CNO (2002) as indicated in Table 2. Ultimately, both professional standards reflect similar core nursing values such as accountability, knowledge, and relationships.The only significant difference was that the CNO named their sixth standard as leadership, whereas the Ghanaian code identified it as trustworthiness.

Nursing Roles and Responsibilities -Canada
The following is a brief discussion regarding the roles and responsibilities of Canadian nurses.
Our academic clinical experience influences this discussion; however, it is primarily supported by recent and relevant literature.This information will then be compared with our experience in the Ghanaian health care systems and our understanding of the nurses' roles and responsibilities in Ghana.

Registered Nurse Role
The Canadian Nurses Association (CNA) defines registered nurses (RNs) as, "self-regulated health care professionals who work autonomously and in collaboration with others to enable individuals, families, groups, communities, and populations to achieve their optimal levels of health," (CNA, 2015, p. 5).In Canada, the role of the RN is diverse.RNs work in areas such as clinical practice, education, administration, research, and policy (CNA, 2015).The variety of clinical settings makes it necessary for the RN to possess a knowledge base that can be applied in all settings.RNs in Canada are responsible for being able to facilitate therapeutic conversations and develop positive nurse-patient relationships.Potter, Perry, Stockert, and Hall (2014) propose that the development of therapeutic relationships is the cornerstone of effective nursing care.When the RN is caring for a patient, the patient is in a vulnerable position and therefore requires a trusting relationship in being able to communicate with the RN.The ability to establish a trusting relationship ensures that the RN can provide effective care.In addition, providing care for a patient in Canada is demonstrated by the administration of nursing procedures such as dressings, medication, and the provision of the basic needs of hygiene and nutrition.
As nursing students in Canada, we learn to practice according to the regulations and scope of practice of the RN (Potter et al., 2014).In addition, we are encouraged to work one-on-one with patients and to develop trusting relationships with them.It is our responsibility to care for the patient within the context of their individual needs.For instance, if a patient requires assistance with eating or bathing, it is our duty to assist them and to provide this care.In Canada, there is a strong emphasis on health promotion and wellness.Nursing is not solely based on the delivery of medication and health-related procedures, but also on the provision of health education (Potter et al., 2014).Health education as part of the nursing role in Canada is learned throughout the nursing program.There is a strong focus on learning how to teach patients skills that are required for selfcare and to provide follow-up care to ensure that the teaching was effective.Nursing education in Canada is focused on constant planning and evaluation to meet patient goals in order for them to achieve optimal well-being (Potter et al., 2014).This area of emphasis on the role of the RN in Canada differs from the role of the RN in Ghana.

Nursing Roles and Responsibilities -Ghana
This section will discuss information based on our observations while in Ghana.We were immersed in clinical settings that were mostly located in rural and remote communities.These settings included a small clinic in a rural town, an elementary school, a junior high school, as well as a larger polyclinic located approximately 20 minutes from a city with a larger population.Overall, observations of the nursing roles, nurse-client relationships, nursing shortages, as well as public health nursing and community outreach will be discussed, as these were all perceived to impact the roles and responsibilities of nurses in Ghana.

Registered Nurse Role
As students, we made some general observations of the nurse's role in the limited time we had in the clinical settings in Ghana.In comparison to the role of the RN in Canada, as student nurses working in the Ghanaian health care system, we performed similar nursing skills with similar responsibilities.We administered vaccinations, provided health teaching, and participated in local community outreach programs alongside the nursing staff in the clinics.However, in our roles as student nurses, we did not have the opportunity to provide one-on-one patient care since we worked more as members of a healthcare team.We were solely responsible for administering medications and ensuring that the patients had the necessary information regarding their medical care.We were not responsible for ensuring that the patients had food, clothes, briefs if needed, or any other supplies necessary for the maintenance of health and well-being during care at the clinic.This responsibility was imposed on the family members of those requiring medical attention.This was a significant observable difference in the delivery of care that was noticed by the students.However, the reason for the lack of care could not be explained merely and could be due to a variety of reasons, often related to cost and availability of resources.

Nurse-Client Relationships
In addition, most encounters with patients in Ghana were brief.There was very little communication observed between healthcare providers and patients.The patients did not communicate more than what the nurses asked of them, and no 'small talk' was made.A qualitative study by Yakong, Rush, Bassett-Smith, Bottorff, and Robinson (2010) revealed that women seeking reproductive healthcare in Ghana had negative experiences with forming relationships with RNs.This study confirmed that therapeutic communication should be emphasized in nursing education in Ghana since it lacks in the clinical setting.We observed that the RNs only asked questions that were directly related to the initial complaints.The patients did not ask questions, even though at times it was clear that they did not understand the circumstances surrounding the health issue.We also observed an unspoken hierarchy between nurses and patients.As stated in Donkor and Andrews (2011bb), nurses often leave their academic institute with the preconception that patients are expected to be ignorant about their health and the treatment needed, that the patient should be submissive to the healthcare provider, and that the patient should always cooperate with the health care provider.However, it is maintained that nurses and other health care providers should not carry this type of mentality into the 21st century, which would aid in providing overall better care for their patients (Donkor & Andrews, 2011b).
Nursing Shortages Oulton (2006) stated that Ghana has 4,000 nurses, but requires 10,000 to meet the care demands of the population.It has been discovered that nurses have been migrating to other countries due to a lack of continuing education opportunities, the lack of professional development and career advancement, stress, workplace violence, as well as feeling unvalued (Naicker, Plange-Rhule, Tutt, & Eastwood, 2009).Because of the wage and salary freeze as well as high inflation associated with the Structural Adjustment Program established in the early 1980s in Ghana, many healthcare workers were obligated to take second jobs to make ends meet (Donkor & Andrews, 2011b).This resulted in absenteeism and more indigent health care.The nursing shortage impedes client care because it negatively influences patient outcomes, reduces job satisfaction, results in high staff turnover rates due to stress and burnout, and increases associated health care costs (Hughes, 2008).The shortage of nurses in Ghana is a current and relevant issue; it results in health care needs not being met in a health care system that is underdeveloped (Bell et al., 2013).

Public Health Nurse and Community Outreach
The practice of community outreach maintains the NMCG (2017) practice standard for public health nurses, which states that public health nurses are responsible for organizing and providing nursing services to the sick, disabled, and those requiring care in their own homes.This standard falls in line with the GHS (2017) objective of increasing access to good quality health care services.The Ghanaian Ministry of Health (GMH) (2018) created the Community Health Screening Outreach Program in 2015.The purpose of this program was to collaborate with the GHS and increase accessibility of health care services in Ghana through the use of public health screening and community outreach (GMH, 2018).During the community outreach program in the clinical setting, students were responsible for taking blood pressure readings and pulses of young to older adults, and results were recorded in a notebook.If the findings were abnormal, the student was responsible for further assessing the patient and their surroundings to provide relevant health teaching that would enable the community member to obtain optimal health benefits.By providing the community outreach program to individuals in the community, RNs are ensuring access to health services for individuals who may not be able to access the clinic due to decreased mobility or lack of income.This example coincides with the objectives established by the GHS and the GMH.

Nursing Roles and Responsibilities -Comparison Between Ghana and Canada
As stated previously, the role of the RN in Ghana varies from that of the Canadian nurse since nurses that work in clinics in rural communities often do not provide care such as feeding and bathing to patients, even though they may educate patients on nutrition and hygiene.Another factor we observed that differentiates the role of the nurse is the method in which patient assignments are designed and how plans of care are carried out.Nurses in Ghana work more as a team: A group of four to six RNs work together to deliver care in the various wards.In Agona Duakwa, there were four clinic wards that each contained four to eight people where the nurses were mainly responsible for administering medication and recording assessment information on patient charts.There was little evidence of the use of the nursing process beyond assessment.Agyeman-Yeboah, Ameyah Korsah, and Okrah (2017) determined that the nursing process is not utilized efficiently in the clinical setting in Ghana.Factors influencing this include a lack of understanding by the nurses of the nursing process as a tool, a lack of access to nursing care plans, and limited time to have the opportunity to implement a care plan (Agyeman-Yeboah, Ameyah Korsah, & Okrah, 2017).
In Canada, the nursing program emphasizes the nursing process and students are to apply this process throughout the programin class and the clinical setting.Bell et al. (2013) explain how in Ghana, most nursing education follows the hospital-based diploma model in teaching.This is a model that Canadian nursing universities have moved away from using.However, it has been noticed within the country of Ghana that there is a movement to increase the number of degree-holding nurses and community health nurses (Bell et al., 2013).With the increase in nurses holding a degree, the difference between practices could potentially become less noticeable, as more emphasis is placed on the process of nursing as compared to solely on how to nurse.Overall, the experience of working as student nurses and observing the role of the RN in Ghana provided us with a valuable learning opportunity in exploring the various similarities and differences in comparison to Canadian nurses.

Cultural Competence and Culturally Sensitive Care
Cultural competence refers to a continual process where nurses exhibit practices, behaviours, and policies that allow the delivery of high-quality services in a variety of cross-cultural contexts (Albougami, Pounds, & Alotaibi, 2016).Some of the most significant influences on a student's cultural competency include working abroad, studying abroad, participating in an exchange program, or completing a clinical placement abroad (Repo et al., 2017).
Providing culturally sensitive care involves careful preparation prior to the immersion experience, which entails knowledge of the culture and community.In-class theory on cultural competence and sensitivity preceded the experience and included discussion on the cultural differences between Canada and Ghana.The knowledge that was gained prior to the trip abroad helped the students during their clinical rotations, especially when providing health promotion and health prevention activities, which were the main nursing roles undertaken by all the nursing students in Ghana.The knowledge that was gained prior to the trip abroad helped us as students during our clinical rotations, especially when providing health promotion and health prevention activities, which were the main nursing roles undertaken by us in Ghana.Our experience is supported by the work of Seear (2012).The preparation allowed us to explore our thoughts on culture and to help reduce culture shock.Seear (2012) indicated that culture shock often presents upon immersion in surroundings that are very different to what one is habituated.Learning about the culture, social structures, customs, and geography of Ghana increased our knowledge of the community, which facilitated our integration into the clinical settings.Ruddock and Turner (2010) found that the immersion experience furthers this knowledge by enabling students to incorporate the culture's values and beliefs, especially about health and illness, which did occur to some extent in the three weeks we worked with the communities.Overall, nursing education including global experiences proves to be beneficial in increasing student cultural competence and sensitivity, which contribute to personal and professional development (Kent-Wilkinson, Dietrich Leurer, Luimes, Ferguson, & Murray, 2015).

Personal Growth and Learning
Our experience as nursing students in Ghana allowed us to expand our knowledge and to grow on a personal level.We were able to work through many of our cultural perceptions during our class sessions before departing, which assisted us while in Ghana.As part of our preparation, we learned community assessment skills, cultural considerations in relation to the Ghanaian culture, and some key phrases in the native dialect of the area in which we were going to be working.In addition, living with Ghanaians and asking questions when we were unsure of procedures enabled us to work through the new experiences presented to us.
Our clinical experience allowed us to learn about the incorporation of cultural and religious beliefs into perceptions about health and illness.In fact, Ghanaians hold cultural beliefs that if an individual is aware of their illness or current serious state of health, they may die sooner (Donkor & Andrews, 2011a).Also, client autonomy is also an ethical quality that could be compromised due to cultural beliefs.Typically, health decisions are made by a family rather than an individual (Donkor & Andrews, 2011a).Donkor and Andrews (2011a) found that cultural beliefs might render clients susceptible to stigmatization from communities and families if they suffer from certain types of communicable diseases.For instance, in Ghana, the perception of health is influenced by religious beliefs, which leads individuals and families to believe that lack of prayer or sin causes illness.It is believed that to get well again, one needs to pray and ask for forgiveness for their sins.For example, while doing a small rotation in the psychiatric center, many patients came into the polyclinic that suffered from alcoholism.When these individuals came in, it was observed that the nurses at the clinic attributed to the patient's alcoholism as a sign of weak faith; the nurse would state that the cause of their alcoholism could be remedied merely if the individual prayed more.This prevailing belief in faith being able to cure illness is a significant cultural difference that we observed.Furthermore, Osafo, Knizek, Akotia, and Hjelmeland (2012) found that religion is a significant contributor to the health beliefs that nurses hold towards those who have mental illnesses in Ghana.Many individuals who seek health care in Ghana for mental illness have negative experiences as a result of the stigma that is created through underlying religious beliefs.Since many nurses hold the religious belief that an attempted or successful suicide is a sin, individuals who are suffering through this experience have reinforced feelings of worthlessness and hopelessness as well as feelings of judgment and rejection (Osafo et al., 2012).
In addition, we learned that nurses have authority over clients because they are perceived to have a higher position in society, and so are perceived as superior.This was observed numerous times in the clinical setting.Clients obeyed orders from nurses and did not dare to question them their knowledge was fully respected.This was difficult because it did not allow patients to feel that they could ask questions if they did not fully understand the interventions, and there appeared to be a lack of emphasis on the development of a therapeutic relationship.The development of trusting and respecting relationships in Ghana differs from those in Canada because of the inherent trust in the nurse.In Ghana, patients believed and trusted the nurse and the information they received.This inherent trust can be due to a lack of health education and resources.This trust in the nurse's knowledge combined with the set respect of the hierarchy in society is an example of one of the main differences in nurse-patient relationship development as compared to Canada.
Overall, being exposed to the clinical setting in Ghana allowed us to be more appreciative of the plentiful resources that we have in Canada.For instance, we have more accessibility to equipment, towels for washing, potable water, bed sheets, and personal protective equipment for isolation purposes.We also have access to pharmacies that dispense medications, other healthcare providers such as physicians to report changes in health status or to receive medication orders, as well as online resources for client support.Our experience in Ghana allowed us to gain a better understanding of necessary equipment versus non-essential equipment.Highly mechanized technological, medical equipment is not necessary to treat all patients.It is possible to use older technology and skills to determine the same information.For example, the midwives use wooden or plastic horns to detect and record heart rates.This proves that the use of fetal dopplers are not necessary, even though they are easier and quicker to use.Also, our living arrangements made us more appreciative of our resources in Canada as civilians, such as access to water, air conditioning, heat, and even little items such as mirrors and pillows were not readily available.Based on our experience in the central region of Ghana, we observed a lifestyle that is much less materialistic than in Canada.Many communities we visited lacked running water, adequate infrastructure, access to food to achieve well-balanced diets, and homes that were big enough to accommodate large families.The majority of individuals we saw while in Ghana would be classified as living in poverty; 37.9 percent of individuals in rural areas of Ghana in 2013 were living in poverty (Cooke & Hague, 2016).We were fortunate to have access to running, clean water, a roof over our heads, and an abundance of food while staying in rural Ghana.We are aware that there are individuals in Canada who live in circumstances that we describe seeing in Ghana.Many individuals in Canada experience homelessness, low-income, and food insecurity.However, the poverty rate in Canada in 2013 was 12.6 percent (Government of Canada, 2017).While we are aware of the poverty issue in Canada, the rate of poverty is significantly higher in Ghana and was, therefore, more easily observed.
In relation to cultural competency, we believe that this cross-cultural opportunity positively influenced us.The immersion into a foreign culture allowed us to adapt our nursing practice to meet client needs and to learn about the culture of the community and the healthcare workers.We learned that it is essential to be sensitive to different cultures and appreciative of the knowledge they have to offer.Our experience in Ghana allowed us to increase our cultural competency and provide culturally sensitive care.Due to Canada's increasing cultural diversity, these interpersonal skills will be beneficial in our future practice.The Kent-Wilkinson et al. (2015) study confirmed the positive contributions that cross-cultural nursing experiences can evoke on student's future nursing practice, particularly considering growing diversity and complex global health issues.As previously mentioned, these opportunities contribute to cultural competence, sensitivity, as well as personal and professional development among students (Kent-Wilkinson et al., 2015).

Conclusion
The international cross-cultural nursing elective placement in Ghana proved to be a positive and beneficial learning opportunity.As students, we accomplished the objectives of the course, which were to learn about the country's health care system and to participate in community nursing Diversity of Research in Health Journal /Revue de la Diverstité de la Recherche en Santé Vol 2, September 2018-ISSN 2561-1666 DOI 10.28984/drhj.v2i0.138115 placements in community clinics and schools.The application of the cultural knowledge we acquired in classes assisted us to complete the clinical hours in these settings successfully.We learned about the similarities and differences between the Canadian and Ghanaian health care systems and the culture during our immersion in the communities.We were able to compare nursing scopes of practice, values, and roles and responsibilities with those in Canada.This learning experience allowed us to grow as nursing students, increasing our knowledge and appreciation of community health nursing and the importance of demonstrating cultural sensitivity in nursing care.

Table 1 .
Nursing Regulations in Ontario Compared to Ghana

Table 2
Standards of Nursing Practice in Ontario Compared to Ghana