Nursing: Problems and Prospects in Nigeria
Nurses, according to the International Council of Nurses (ICN) Code of Ethics as reviewed in 2005, have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups.
The detailed history of a profession that combines scientific principles, technical skills and personal comparison can’t be precisely relayed but records hold that Nursing came to limelight in 1854 when the Mother of Professional Nursing, Florence Nightingale started the battlefield with other 38 nurses and cared for the sick and injured men during the Crimean war in England. Her persistence dedicated service, day & night, experiences paid off by making her famous and recognized by lady with the lamp. Her metric service resulted in complete change in Nursing profession and lead to the beginning of professional nursing.
Though, Nursing in the early days was primarily a family matter with mothers caring for their own families or neighbors assisting each other.
In 1880, the status of Nursing was greatly improved and many women including religious orders were now involved in patient care. During the era, there are many school of nursing for trained nurses throughout Europe with the first school established in 1836 by Parker Theoder Fliedner in his parish in Kavesworth Germany through the influence of Florence Nightingale the kareworth school.
In 1882, came the first movement for the recognition and registration of nurses. International body were formed emigrate Royal British Nurses Council of Nurses established in 1893 and international council of nurses was established with headquarters in Geneva, Switzerland and branches all over the world. Also, in 1926, the British College of Nurses was founded. The first African-American graduate nurse, Mary E. Mahoney, who promoted integration & better working condition, for black patients and healthcare workers.
Though, nursing came to Nigeria through the British Colonial masters. They provided services and medical care for wounded soldiers at the furtherworth Hospital. Later the first nursing home in Nigeria in Jericho, Ibadan by the government of the British Colonial masters.
Later on missionaries and their wives came to supplement government effort by setting up Mission homes, Dispensaries e.t.c. and commence the training of Nurses in Nigeria, though language barrier there was no formal training but on the Job acquisition skills and practical aspect are been rendered by nursing surgery.
The regional government in Nigeria began the training of Nurses by settings individual regional standard. In 1949, the School of Nursing, Eleyele was established to facilitate the training of nurses, later in 1952, the University College Hospital Ibadan started the training of nurses in a higher standard. In 1949, the Nursing Council of Nigeria was established to complement the efforts of the various training bodies and creating standards for Nurses.
By 1965, a department of Nursing was established in the University of Ibadan to commence a degree programme in Nigeria. Later on, University of Ife and University of Nigeria, Enugu also started degree in 1973. At present all the states on Nigeria has one or more School of Nursing, Midwifery and kinds of Post Basic schools. More degree awarding institutions has been granted the license to produce degree holder in Nursing. Among them are Ahmadu Bello University, Zaria; University of Calabar, Calabar; Ladoke Akintola University (LAUTECH), Ogbomoso. Also private University, Babcock University, disan Remo; Leadcity University; Madonna University among others started degree in Nursing.
Before 1981, nursing was adjudged a vocation in Nigeria, but by virtue of the Industrial Arbitration Panel (IAP) award of 1981, nursing got the recognition of a full-fledged profession.
“To stand still is to move backwards”. This statement is true of life’s existence where man aspires to grow, develop progress, invent, and initiate actions that would bring about changes. For without changes, there would be no progress. Nursing has over the decades, gone through changes. As time and situations change so has nursing, thereby bringing about challenges facing the practice of nursing even in Nigeria.
The greatest challenge to nursing practice in Nigeria is the nurse herself. Nurses in contemporary Nigeria are less caring, committed and dedicated to meeting the needs of clients. Most nurses are resistant to change, professional development and advancement. In nursing practice and education, some nurses tend to hold onto previous knowledge and skills without making efforts to improve and maintain new skills. Many nurses are not willing to accept the challenges of staying abreast with education and development of new skills in their areas and levels of nursing practice. Similarly, the natural qualities expected to be found in nurses (punctuality, selfless service, among others) is virtually absent these days. This has serious implication for nursing practice. Many nurses just practice for practicing sake, they do not see the intricacies of nursing as a care from nurse professionals, rather they are committed to other issues of life than nursing care practice. Many practice only for financial benefit not because nursing is a calling for them. Student nurses are also victims of this situation.
Related to this is education; an essential element in all treatment activities and a means of keeping current or progressing aimed at developing individuals who are open to change. Regrettably, a large percentage of nurses are not open to change. This can be stretched into the training of both student nurses and professional nurses creating an environment where there are no checks and control, i.e. failure to abide by rules and regulations, leading to a crop of poorly trained nurses. Undue favour to some nurses in training by trainers of nurses which is commonplace in the society is an additional challenge. This has direct implication for the nursing care provided by such half-baked nurses. In fact, they become dangerous to patients, society and themselves. The hitherto unqualified educational standard of the basic nursing certificate is also a challenge. Nurses continue to practice in most hospitals without re-orientation to the needs of patients in the 21st century. Non attendance of clinical care workshops by nurses and non organization of seminar/workshop on clinical nursing issues are all inherent problems in many Nigerian hospitals. This in turn affects nurses’ remuneration which is another obvious concern for nursing practice.
Secondly, the advancement in science and technology will continue to affect the nursing profession. In the past, nurses relied on their experiences, observation and intuition but today, nursing has a defined body of knowledge specific to the profession and continues to develop this knowledge through research and practice as they relate to new drugs, methods of delivery, disease control and prevention through sterilization and disinfection of equipment, and models in nursing, among others. For instance, the knowledge and implementation of the nursing process as a scientific and systematic approach to nursing care has been seen by many nurses as problematic. Some nurses have found it difficult to implement it because some professionals in the health system do not quite understand what it is about. In addition, some nurses have attached a lot of constraints such as shortage of staff and lack of stationery as reasons hindering the implementation of the nursing process which is a tool for improved nursing care. The changing role of the nurse requires continued competence. Many nurses are unable to maintain a high level of individual competence in nursing practice, skill and knowledge, recognizing and accepting responsibilities for individual action and judgment.
Thirdly, a major challenge to nursing practice is policy making on health issues. Most nurses are women and therefore the position of nurses in Nigeria and the value given to nurses’ work are aligned with their position in the society. The nurses of the past were grossly handicapped because of the type of training they received. They were maids and took this feminine submissive roles without questioning, after all, the “Husband is the Head of the Home”. Nurses have traditionally been subordinate to physicians and these have perhaps affected their leadership roles in policy making on health issues. Nursing today is practiced in the midst of other health needs competing for the scarce resources allotted to health. The poor representation and participation of nurses in decision making on health matters will not move nursing forward. This situation must change if our wonderful dreams about the future of nursing must be fulfilled.
According to WHO at the World Health Assembly in May 2004 (ICN, 2004), some advanced countries have approximately 1000 nurses per 100,000 population while many developing countries, including Nigeria, have 10 nurses per 100,000 population or even less. Registered nurses are leaving Nigeria either for family reasons or for greener pastures giving the advanced countries chances to gain while Nigeria stands to loss through this brain drain. The shortage of nurses in rural areas is particularly another constraint. In Nigeria, nurses posted to rural areas feel that they have been forgotten. Many a time, such nurses perform far below expectation. Furthermore, the nursing profession aims at providing quality nursing care by providing a scientific base for the practice of nursing. Thus the need for research has become necessary. Unfortunately, only very few nurses are interested in research even though it is the responsibility of all nurses to do research to improve nursing care. The introduction of Research Methodology as a course in Schools of Nursing has done little for now to make students attach much importance to research projects as most students believe that research ends after school.
It must also be pointed out that some work environment are un-conducive and non –supportive for nursing practice as they lack sufficient facilities and equipment to work with. They also lack sufficient motivational input such as housing, transportation, incompetent supervision, poor working relationship, general moral laxity in the society, undue familiarity with the subordinates with a weakness in disciplining erring staff, among others. Nurses are no longer in control of the immediate environment in which patients are nursed. If quality health care must be provided, then we have to look critically into some of these problems of the physical, social and mental environments.
We must not forget that despite the increasing number of infections, many Nigerians still very much patronize traditional healers and traditional birth attendants especially now that they have to pay for the health service they receive. Even if they come to the hospital acutely ill, they leave much sooner than they did in the past there by increasing the demand on nurses to ensure high quality, comprehensive care before discharge. These challenges indeed have a lot of effects, among which are relapses and complications which are they further challenges to nursing. These have affected nursing care to clients, families and the community at large; many nurses are unable to set priorities for care and assist client in meeting their needs in the most time- and cost-effective manner possible, while ensuring excellence in client care.
Additionally, most government policies do not focus on meeting the needs of the profession because nurses do not fully participate in policy making. Nevertheless, nurses occupy a central position in the health care delivery system. The shortage of nurses in Nigeria and lack of sufficient facilities and equipment to work with are not just a “problem of nursing” but a health system problem which undermines health system effectiveness. Also, unavailability or lack of proper planning and budgeting due to non involvement of nurses and many nurse leaders in management’s budgetary meetings. Poor knowledge of nurse leaders’ knowledge about politics and the influence of nursing administration on general hospital administration/management.
Often, Nigerian nurses, instead of asking for the right equipment and materials for nursing care services, they seldom go on industrial action because of lack of equipment for nursing clinical works rather they continue to improvise to the detriment of their professional practice.
Another major problem in the nursing sector is the fact that most nurse leaders lack experience and they retire away quickly as soon as they enter into nursing administrative arena because of age on entry and number of years in service. The experienced nurses are not also available in the clinical settings to render service rather they are kept in offices away from their patients and fellow nurses that need to learn from their past clinical experiences. They seek office allocation, good chair to seat on as soon as they have been promoted to higher ranks; this they claim is to show the level of their status instead of good clinical practice to be shown for the status. And this has brought the idea of nurses migrating at alarming rate out of the country to seek greener pastures. Some experienced nurses also hide under the canopy of poor health not to render service yet they remain as leaders. All these are copied by the junior nurses and nurses in training and subsequently as soon as nurses become registered they form the association of nurses that seat round the table or in offices in different wards with their bags full of items that are on sale and latest materials in town (cloth and jewelries).
Inter/intra professional rivalry is a major contributing factor hindering the ‘successes’ of the career. Nurses not seeing themselves as the strongest pillar in health field, rather they practice other professions that are none nursing in order to seek personal/societal recognition. Most times many nursing independent activities are left undone the interdependent activities are done with much commitment. Bed bath, Bed pan round, monitoring of vital signs and patient care reporting are fast leaving hospital setting. The relatives are made to carry Bed pans, Doctors to see patient alone on wards/clinics, and do patients’ vital signs themselves while in clinics, caterers also have to book meals for the patients themselves without the nurses’ participation. Nurses claiming to be too busy to perform these activities and making them to be less important activities of nurses.
SOLUTIONS TO THE PROBLEMS OF NURSES
The solutions to these challenges lie in nurses’ hands and in those of policy makers. It is the responsibility of all to join hands to provide adequate funds for regular in-service training and seminars to update nurses knowledge and skills, provide funds to improve existing health institutions and modern equipment, continually focus on delivery of care that is safe, comprehensive and effective, appropriation of funds by the government to Departments/Schools of Nursing for scholarship for nursing students in order to attract more people into the nursing profession, as well as help those already in the profession to have higher education without much financial burden. A blueprint targeted at quickly situating all nursing education programmes in higher institutions will greatly enhance the educational image of the profession and consequently improve remunerations. Nurse researchers should continue to develop and refine nursing knowledge and practice through the investigation of nursing problems. Mentorship in nursing should as well be encouraged.
Continuous training and development that leads to good leadership and better skills in nursing care services should be encouraged; and this will in turn promote the image of the nurse in the society. The status of nursing in our society has not promoted good professional image, for the nurses largely because of poor facilities in the training institutions and lack of commitment to practical teaching on the ward by all cadres of nurses. Nurses leaving professional care to student nurses or pupil midwives Nurses must practice to show the learners how to do it, nursing professional training is hospital based. All cadres of nurses must be committed to this apart from clinical instructors.
The nurses need to learn to regulate their own services not leaving it for others to decide upon, by extension, there is a need to professionalized the career, nurses in Nigeria should fully operates within the ambit of a code of professional conduct for Nurses as put together by the Nursing and Midwifery Council of Nigeria like making it possible for nurses with first degree to practice along with those with Diploma trainings. This is supposed to be strength for nursing care in Nigeria. If intra professional rivalry is removed nurses would learn from each other and subsequently nursing care would be improved in this century. Nurses at leadership position should consult their learned and experienced fellows nationally and internationally to be able to acquire both theoretical experience and practical skill needed for improved services. Consultation now made easy with computerization. E-mailing each other on ideas about care in hospital settings that are more advanced than ours. Use of internet facilities to improve nursing care in Nigeria. Nurses need to read newspapers, journals and internet articles to be more informed about current issues in Nursing Services.
As nurse leaders we must not confine ourselves to nursing alone we must read wide, socialize well and work as assertive individuals to promote our image and the image of nursing profession in Nigeria. We must be seen to be here and there in health services and must contribute maximally in our areas of interest or specialization in care apart from administrative skill used in office as Nurse Administrators. Nursing informatics are essential for application of computer into nursing care, lack of knowledge in this area can cause declining care as nurses will fail to utilize computer technology to the advantages of clinical nursing care recipients.
Nurses should also imbibe the following simple steps as part of their profession;
· Show other persons that you listen and understand the situation/problem.
· Say what you think or feel
· Suggest what you want to happen
· Ensure that you do not manipulate unnecessarily
· Say things honestly and be self confident.
And they should put-off and shun common types of behavior among theirselves that can be contributory to declining services; such behavior includes passive or lazee fair attitude, aggressive or autocratic behavior, assertive behavior etc. By assertiveness, over confidence should be avoided.
Entry level into nursing permits aspiration to top level in the career structure, not running from clinical setting to school of nursing to teach. Clinical setting requires nurse clinicians for appropriate rivalry inter professionally in the health care setting. Nurses are to teach themselves as well, as the public, these days the public is well informed, they need informed nurses too. In all these areas senior nurses or nurse leaders may be copied positively or negatively by the junior ones or nurses in training. It is necessary for nurse leaders to serve as good example by practicing appropriately having appropriate, education and ensuring same by others. Adequate dressing promotes the image of nursing so also is the professional rivalry
There is also a need to review procedure manual nationally and steps in the procedures should be implemented appropriately in all hospitals. This would always improve the quality of care rendered by nurses. Quality assurance units must be established to ensure auditing of nursing services. Nurses need to be closely monitored to ensure quality care and accountability.
Nurses should most times give room for negotiation to press home their demands. It has been discovered that embarking on industrial strike paralyze a lots of activities in the sector, and this bring about the death of many in the society.
Finally, I must stress that the nursing profession must remain dynamic in its attempt to meet health care needs of the society. In an address by His Excellency, Chief Olusegun Obasanjo, ex- president of the Federal Republic of Nigeria at the West African College of Nursing Conference on the Theme: Reforms in Nursing Practice in the 21st center Abuja, March 2005, stated that “the 21st century nurse should be one that is equipped not only with the basic requisite knowledge and skill to function in the clinical aspect of health care provision, but must also possess the requisite knowledge and skill to function as a team leader, manager of resources, counselors and advocate to patients”. With this in mind, let us strive to make nursing practice in Nigeria, a supportive profession that is interested in meeting the health care needs of its people. There is also a need for nursing to fashion out its own philosophy in the light of this present challenges to quality nursing practice and high level of professionalism. This includes all nurses, irrespective of their qualifications, to come out and speak with one voice. There should also be proper periodic education to sensitize them on the changes in the socio-cultural environment, the increase and growing sense of their responsibilities to recipients of care, the new clientele in the health industry/new concept of man and her relationship to the world around him, the rise in literacy level/ advances in medical science and technology, the complexity of knowledge and skills required to give safe and hazard free nursing care to consumers of healthcare services, the greater awareness of individual’s rights and obligations of human worth of dignity among other things
SUMMARY AND CONCLUSION
Nursing clinical services in Nigeria is a challenge to all nursing leaders. The problem causing the declining clinical practice is enormous but all are challenging. Some are as identified in this paper solution to them all, are removal of all professional rivalries, continuous education, good adaptation to ones profession, commitment of all leaders to good professional image and practical nursing services in hospital settings. Politics and administration also are instrument for use by leaders to move nursing care forward not for personal gain only. Self-centeredness should be replaced with adage such as nursing profession is our own. Nursing is a noble profession.
Nursing profession keeps growing in the 21st century ours as leaders is to ensure the growth in our own country by promoting good education of our subordinates, making ourselves good examples and ambassadors of the noble profession “nursing”. Nursing is in the hand of nurses, lack of basic equipment and appropriate technology is a problem in our hands. Solution will be appropriate budgeting, planning and implementation of our plan. Loyalty and commitment are also essential.
The paper has been able to just make a brief discussion on the issue of declining nursing care in Nigeria and proffer some solution just to keep nurse leaders abreast of the issue and to challenge nurse leaders to move ahead with the instrument of administration in their hand. Professional regulation and individual clinical judgment in practice could add beauty to nursing professional practice in Nigeria. The nursing care recipients are our people, they deserve the best (SERVICOM).
It is also necessary to do research, so as to give evidence base practice. Utilization of the research findings by nurse leaders are also essential. Betty Ackley et al are working hard to ensure evidence based practice in USA, Nurses in Nigeria can be part of their work to ensure evidence based practice in Nigeria.
Nurse leaders must all be available to study and to service. Declining nursing services as a language must be removed from Nigerian nurses dictionary when Nigerian nurses are internationally acclaimed nurse professionals.
· Leadership trainings that would benefit nursing clinical services improvement centre round. Advanced nursing training course, at Post Basic and Masters Degree level (Joyce 2001).
· Specialized education of family nurse practitioners who will function at all levels of care also is a desirable goal to provide holistic health care for Nigeria family. (Irionoye, Ogunfowokan and Olaogun 2006).
· International literature identified that any change to the nurses role in health assessment skills, requires strategies that involve the regulatory, educational and practice components of nursing. Teaching physical assessment skills to nurses within a holistic health model would improve nursing care services. (Lesa and Dixon 2007)
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