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Eduardo Lukene Da Silva Amado Bachelor of Science Information Technology Angola |
João Zeferino Sebastião Bachelor of Science Telecomm unication Engineering Angola |
André T.F. Monteiro Bachelor of Business Administration Human Resources Angola |
Ricardo Gabriel Martinez Bachelor of Science Architecture Argentina |
Adriana Veronica Peralta Bachelor of Nutrition Nutrition and Disability Argentina |
Márquez, Samuel del Jesús Bachelor of Science Electrical Engineering Argentina |
Tatiana Cuéllar Antelo Bachelor of Business Administration Marketing Bolivia |
Sylvanus Nekenja Ngene Bachelor of Science Project Management Cameroon |
Lukong Jane - Francis Kijika Bachelor of Business Administration Business Administration Cameroon |
Azucena Sabina Garcia Tapia Doctor of Philosophy Accounting Canada |
Yamile Pinto Velandia Doctor of Education Education Colombia |
Franki Sigua Ortiz Bachelor of Science Civil Engineering Colombia |
Gladys Vallejos Delgado Master of Business Administration Public and Private Entities Colombia |
Gladys Vallejos Delgado Doctor of Finance Public and Private Finance Colombia |
Lukanu Ngwala Philippe Doctor of Philosophy Public Health Congo |
Sireesha Bala Arja Doctor of Philosophy Public Health Curaçao |
Rosa Elidee Santana Pérez Doctor of Physical Education Sports Science Dominican Republic |
Alfonso Amauris Bello Sánchez Bachelor of Science Electromechanical Engineering Dominican Republic |
Amauris Alfonso Bello Sánchez Bachelor of Science Electromechanical Engineering Dominican Republic |
Carlos Arroyo Ramos Doctor of Philosophy Comm unication Theory and Research Dominican Republic |
Joel Antonio Pinargote Jiménez Doctor of Philosophy Physics Ecuador |
Antonella Nasser G. Bachelor of Communications Mass Comm unication Ecuador |
Santiago Eseka Endje Bachelor of Legal Studies Legal Studies Equatorial Guinea |
Jose Manuel Esara Echube Doctor of Science Strategic Planning Equatorial Guinea |
Enriqueta Nse Mico Doctor of International Relations International Relations Equatorial Guinea |
Wayne Adrian Davis Doctor of Philosophy Psychology Ethiopia |
Comfort Araba Aryertey Bachelor of Accounting Strategic Management Ghana |
Eduin José García Godoy Bachelor of Science Industrial Engineering Honduras |
Rigoberto Antonio Cerrato Flores Bachelor of Science Sound Engineering Honduras |
Ernesto Zemel Doctor of Business and Economics Stock Market Trading Israel |
Delores E. Clarke Bachelor of Science Economics Jamaica |
Gerardo Pineda Betancourt Doctor of Science Information Systems Japan |
Ann Wairimu Mumina Doctor of Philosophy Public Health Kenya |
Julius Mutugi Gathogo Doctor of Philosophy Educational Leadership Kenya |
Tekabara Raurenti Bachelor of Science Sports Science Kiribati |
Yoselyn L. Galea Corales Bachelor of Literature Hispanic Literature Korea |
Ericson Di -faith Karwawhee Master of Science Petroleum Chemistry Liberia |
Ahmed Saleem Bachelor of Human Resources Human Resource Management Maldives |
Abdoul Karim Miharata Maiga Bachelor of Science Human Resources Management Mali |
Domingos Urbano Caetano José Master of Science Comp uter Science Mozambique |
Juan José Montoya Pérez Doctor of Business Administration Finance Nicaragua |
Aída Leticia Talavera Aráuz Master of Science Public Health Nicaragua |
Mobolaji Olutosin Adesoye Doctor of Education Educational Leadership and Management Nigeria |
Ogunjimi Samuel Olatunji Doctor of Philosophy Economics Nigeria |
Ngozi Angela Ogwo Doctor of Philosophy Finance Nigeria |
Mhd Anwar Karj Doctor of Arts Project Management Oman |
Orestedes Francisco Salazar Chavez Bachelor of Science Industrial Engineering Peru |
Fernando Alex Ríos Ríos Master of Mine Engineering Industrial Occupational Health and Safety Peru |
Jorge Rafael Diaz Dumont Bachelor of Science Statistics Peru |
Luis A. Llanos Encarnación Doctor of Science Health Education Puerto Rico |
Melake Samuel Hadgu Master of Science Food Safety and Quality Management Russia |
Benedict, Olumide Henrie Doctor of Business Administration Business Management South Africa |
Fatai Adegbola Bachelor of Science Electrical Engineering Spain |
Randolph Franklin Bachelor of Science Agronomy St. Kitts |
Abdulrazak Alkhalaf Alhasan Master of Business and Economics Project Management Sweden |
Nuru Johnston Kilasa Bachelor of Science Information Systems Management Tanzania |
Newton Mjungu Master of Science Cyber Security Tanzania |
Angelino Dos Santos Master of Science Human Resources Timor-Leste |
Khemraj Nanhu Doctor of Philosophy Electronic Government Trinidad |
Trevor Joseph Bachelor of Science Project Management Trinidad and Tobago |
Kenneth Robert Daisley Master of Science Project Management Trinidad and Tobago |
Jane Biira Bachelor of Arts Guidance and Counseling Uganda |
Alan Alarashi Bachelor of Banking and Finance Financial Science UAE |
Angelo Massanga Cunfo Bachelor of Science Health Science UAE |
Johny Elvis Saucedo Curney Bachelor of Arts Music USA |
David Nakasala Muchemu Master of Science Chemical Engineering USA |
Rodríguez María Victoria Bachelor of Education Special Education USA |
Anita Tran Bachelor of Arts Fashion Design USA |
Antonio Aquino Mariñez Doctor of Philosophy Clinical Psychology USA |
Maria Eugenia Ruibal Pérez Bachelor of Architecture Architecture Venezuela |
Juan Carlos Puentes Mendoza Bachelor of Science Systems Engineering Venezuela |
Moses Zulu Doctor of Philosophy Sociology Zambia |
Grace Nomsa Kasoka Bachelor of Science Public Health Zambia |
Beatrice N. Musindo - Munodawafa Doctor of Philosophy Education Zimbabwe |
Maxwell Mutematsaka Bachelor of Science Project Management Zimbabwe |
Mjabuli Jamela Master of Science Public Health Zimbabwe |
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INTRODUCTION
This presentation is situated
within the context of the
theme for the 14th biennial
delegates meeting which is
‘Strengthening Nursing and
Midwifery Practice Autonomy
in Ghana’. For purposes
of dealing with the theme, the
topic ‘Addressing Barriers of
Nursing and Midwifery Practice
Autonomy’ is most appropriate.
Examining the issues
underpinning the topic, we
will define key words, identify
some barriers militating
against nursing and midwifery
practices with the framework
of empirical scenarios elsewhere
and attempt to draw
some similarities with the
Ghanaian circumstances and
eventually make a few recommendations
for policy makers
including Government, Ministry
of Health (MOH), Ghana
Health Service (GHS), Nursing
and Midwifery Council
of Ghana (NMCG) and Ghana
Registered Nursing and Midwifery
Association (GRNMA).
The preparation of this paper
is borne out of web-search and
my own opinions of some of
the consequences arising from
the barriers of nursing and
midwifery practice.
DEFINING KEY WORDS
A Barrier refers to something
immaterial that impedes
or separates as in behavioural barriers1. Synonyms of “Barrier”
include obstacle, handicap,
hurdle, limitation, hitch,
drawback, snag, obstruction,
stumbling block, impediment,
hindrance, check, difficulty,
restriction, hazard, stumbling
block2 .
Autonomy- "one who gives
oneself their own law". It is
the capacity of a rational
individual to make an informed,
un-coerced decision.
In moral and political philosophy,
autonomy is often
used as the basis for determining
moral responsibility
and accountability for one's
actions, choices, mistakes,
failures, etc.3.
Nurse/midwife Understanding
of Autonomy. According
to An Bord Altranais4
in articulating the responsibilities
of a nurse, World
Health Oraganization (WHO)
has stated that "the nurse is
an autonomous practitioner of
nursing, accountable for the
care he or she provides."
There are many reasons
why a nurse or midwife would
perceive a barrier to exercising
their autonomy. These reasons
are discussed into more detail
as highlighted below.
The power of autonomy
If nurses and midwives are
expected to be held accountable
for the areas of patient/
client care for which they hold
responsibility, they need to
have the necessary autonomy
to practice according to their
professional judgement. Autonomy
has been defined as
the: “freedom to make discretionary
and binding decisions
consistent with one’s scope of
practice and freedom to act
on those decisions”5. Thus, the
importance of defining the
scope of nursing and midwifery
is explicit in this definition.
If nurses and midwives are to
exercise their autonomy they
must first decide what the
parameters of their practice
are. The parameters of nursing
and midwifery practice in
Ghana are contained in their
duties emanating from the
syllabi for training.
Difficulties with autonomy
Nurses and midwives
have expressed a desire to be
autonomous in the practice
of nursing and midwifery 4.
While nurses have identified
that autonomy is an issue that
has been pursued by nurses,
unsuccessfully in most cases,
midwives have identified
that they have always been
entitled to practice autonomously
as midwives, but that
due to the medicalisation of
childbirth and the organisation
of the maternity services,
the practice of midwifery has
largely not been autonomous
in the recent past.
The fear factor
Although autonomy was
identified by a large number
of nurses and midwives as
desirable for the development
of patient care and the profession,
some have identified
that a fear of autonomy often
acts as a barrier to nurses and
midwives expanding their
practice4. A study carried out
by Batey and Lewis5 suggested
that the extent to which nurses
had autonomy to act varied;
directors of nursing reported
that even when they had
negotiated with other groups
for nurses to be autonomous
in their responsibility for a
particular charge, the nurses
tended to avoid doing so out
of fear. In Ghana no study has
been carried out to assess the
fear of autonomy of nurses
and midwives. However, a
similar phenomenon could not
be far-fetched.
If as a nurse/midwife you
are to exercise your autonomy,
then think for a few moment.
You may ponder over what the
boundaries of your practice
are. These would include the
level of experience, legal constraints
and knowledge.
I wish to suggest that we
define clearly the boundaries of
nursing and midwifery practice
and display these as protocol in
every health facility?
Task delegation
The United Kingdom Central
Council (UKCC) in their
Scope of Professional Practice
have, as the guiding principles,
the nurse's and midwife's
professional accountability
that reflect the belief that
practice is based on principles
and not tasks delegated from
doctors4. Nurses and midwives
should be concerned
with role expansion but not
role extension. Role Extension-
involves tasks borrowed
from other professionals while
role expansion deals with a
higher level of nursing/ midwifery
practice within the existing
boundaries of nursing.It is preferable to role extension
in relation to the development
of nursing/midwifery
practice. It is more consistent
with a holistic approach to
patient/client care. An Bord
Altranais recognises that both
nursing and midwifery roles
are evolving and recommends
that as a method of evolving,
the term expansion of practice
rather than extension of
practice be adopted.
Let us take cursory look at
what is contained in the practice
of nursing and midwifery.
Nursing practice
According to Kathleen A.
Russel6 one’s nursing care is
both directed and measured
by the Nursing Practice Act
(NPA) and rules. The standards
and scope of nursing practice
within an NPA are aligned
with the nursing process.
For example, comprehensive
nursing assessment based on
biologic, psychological, and
social aspects of the patient’s
condition; collaboration with
the health care team; patientcentered
health care plans,
including goals and nursing
interventions, can all be language
within the NPA. Further
standards include decision
making and critical thinking in
the execution of independent
nursing strategies, provision of
care as ordered or prescribed
by authorized health care providers,
evaluation of interventions,
development of teaching
plans, delegation of nursing
intervention, and advocacy for
the patient.
In providing care to the
patients, nurses implement
a nursing care plan which is
based on initial condition of
the patient. It is based on a
specific nursing theory. The
scope of nursing practice
includes the sets of duty that a
nurse needs to perform in her
job which can vary from place
to place and state to state. It is
necessary for the nurses to familiarize
with new changes. In
Ghana, it is unclear if there are
new changes in the practice
of nursing and midwifery. In
the United States of America,
the Nursing Practice Act (NPA)
sets out the scope of practice
and responsibilities for Registered
Nurses (RN) and formulates
the rules and regulations
which specify the implementation
of the law.
Midwifery and scope
of practice
Midwifery as practiced
by certified nurse-midwives
and certified midwives
encompasses a full range of
primary health care services
for women from adolescence
beyond menopause7. These
services include primary care,
gynaecologic and family planning
services, preconception
care, care during pregnancy,
childbirth and the postpartum
period, care of the normal
newborn during the first 28
days of life, and treatment
of male partners for sexually
transmitted infections.
Midwives provide initial and
ongoing comprehensive assessment,
diagnosis and treatment.
They conduct physical
examinations; prescribe medications
including controlled
substances and contraceptive
methods; admit, manage
and discharge patients; order
and interpret laboratory and
diagnostic tests and order
the use of medical devices
Midwifery care also includes
health promotion, disease
prevention, and individualized
wellness education and
counselling. These services are
provided in partnership with
women and families in diverse
settings such as ambulatory
care clinics, private offices,
community and public health
systems, homes, hospitals and
birth centres. Certified Nurse
Midwives (CNMs) are educated
in two disciplines: midwifery
and nursing. They earn graduate
degrees, complete a midwifery
education programme
and pass a national certification
examination to receive
the professional designation
of CNM. Certified Midwives
(CMs) are educated in the discipline
of midwifery and pass
the same national certification
examination as CNMs
to receive the professional
designation of CM. CNMs and
CMs must demonstrate that
they meet the Core Competencies
for Basic Midwifery
Practice upon completion of
their midwifery education
programs and must practice in
accordance with Standards for
the Practice of Midwifery.
For the purposes of the
discussion it is prudent to
identify some the functions
of the Nursing and Midwifery
Council of Ghana (NMCG) as regulatory body of nurse
and midwives.
Functions of
the Nursing and Midwifery
Council in Ghana include the
following:8
It shall be concerned with
the Nursing and Midwifery
Professions and in particular
with the Organization of training
and education of Nurses
and Midwives and the maintenance
and promotion of standards
of professional conduct
and efficiency. It issues Professional
Identification Numbers
(PINs) / Auxiliary Identification
Numbers (AINs) Certificates
and Badges to those who have
attained the required standard
of proficiency in Nursing or
Midwifery. The Council regulates
the following programmes
among others:
1. Registered General Nursing
2. Registered Midwifery
3. Registered Mental Health
Nursing
4. Registered Community
Nursing
5. Public Health Nursing
6. Ophthalmic Nursing
7. Critical Care Nursing
8. Peri Operative Nursing
9. Ear Nose & Throat Nursing
10. Paediatric Nursing
11. Community Psychiatric
Nursing
12. Post EN / CHN / HAC
Midwifery
13. Enrolled Community
Health Nursing
14. Health Assistant (Clinical)
It makes regulations governing
nursing and midwifery
practices9. Its Legislative Instrument10
codifies the Practice
of Nurses. However, it seems
the same L.I. does not make
provision for the practice of
Midwifery. Regulatory bodies
exercise a regulatory function,
that is: imposing requirements,
restrictions and conditions,
setting standards in relation
to any activity, and securing
compliance, or enforcement.
These functions should stress
in no uncertain terms if the
autonomy of nurses and midwives
is to achieved.
SOME BARRIERS
IN NURSING AND
MIDWIFERY PRACTICE
Lack of Teamwork
Acceptance of each profession’s
contribution to patient
care as essential fosters good
team spirit, cohesion and
trustworthiness. Let me add
that in New York a Nurse
Practitioner was once elected
Medical Staff President.11
He was the clinical director
of emergency medicine. He
was elected to this influential
position by his physician
colleagues and enjoyed great
support from the hospital’s
medical staff. Lack of teamwork
among professionals is
an disincentive for another’s
autonomy while the converse
motivates.
Nurse led models of care
have been tried in some general
practices with promising
results. In an Australian
study12, it was found that a
nurse led model of chronic
disease management in a
general practice environment
was acceptable and feasible.
Similarly, another Australian
study found that a nurse led
immunization clinic saved
general practitioners time
and improved immunization
rates13. To ensure that
other professionals recognize
the worth of nurses and
midwives and by extension
their autonomy, we should
demonstrate competence by
designing models of patient
care and be assertive. One is
not too sure if the Nursing
Process (NP) model taught in
the classroom to professional
nursing students without
putting theory into concrete
out of school practice is
worth taunting. An informal
complaint is that managements
are not supportive of
the implementation of the NP;
they are not willing to commit
resources. Nurses also find
the process so cumbersome to
work with. Perhaps we need
to make the Nursing Care
Plan (NCP) user-friendly and
convince our financiers that it
is an effective tool to guaranteeing
quality client care.
Opportunities to empower
nurses and midwives through
training are dwindling. The
consequential effect is knowledge
deficit and lowering of
self-esteem and independent
functionality. We cannot
talk of autonomy in the
circumstances.
To be continued
Talking about a university,
talking about schools
means studying, it means
researching. For students it
is the least beautiful because
they always think about the
facilities, the colleagues and
those who follow their programs
at distance universities
their thinking is: if I will be
able to use the Platform and if
I will be able to do what they
ask me.
Enrolling in a university is
always the excitement of I’m
already a university student,
I’m already a student, I will
have a degree and in the end I
will achieve a good salary.
When they send me the
first activity that I have to do,
the following questions arise:
what do I have to do, I don’t
understand how to do what
they ask me, what happens to
me, what happens with what
is now learned. (See image 01)
They begin a series of emotions
and feelings something
special: I can ask and see if
I understand what I have to
do or I can fill myself with
frustration and say: this is not
for me anymore, I’m old and
this will not be possible and
the best It will be to ask to
leave the university.
It happens that I enroll in a
university and I am thinking
about the works I did years
ago and I haven’t think in
the way things are changing
and what they are asking me
doesn’t fit into the scheme I
had of what it is to study.
I begin to see that in this author
the citations or references
appear in one way, in this
other the bibliography is different
and I’m very confused.
In my previous article of
Campus Mundi, June and #
55, I presented the different
forms that exist to make citations
or references and even
the Latin model of making
the bibliography where the
works appear in the order in
which the document presents
them; In addition, the model
changes so much that it is no
longer used.
“All you had to do to discover
a Law or a Principle was
to observe and collect data
in an appropriate way and
from them the scientific truth
would inevitably arise”. (Pozo
and Gómez Crespo, 2001, p. 23). Science in this way doesn’t
solve the social and human
situation that culture is
building.
They tell us at the university
that this will be our Curriculum
or they tell us that we can
do whatever we want.
The interesting thing is that
the curriculum has changed
little and the student feels it is
something strange.
The current society is growing
in all aspects very fast and
what the university asks us
seems very difficult because
we forget, or rather we didn’t
realize all the changes, in all
aspects, that occurred in that
time that we didn’t study.
Researchers in education and
within them Pozo and Gómez
Crespo, say the following
about the Curriculum and the
students:
“…the problem is precisely
that the science curriculum
has barely changed, while the
society to which this teaching
of science and the formative
demands of the students are
directed has changed”. (Pozo
and Gómez Crespo, 2001, p. 23).
They ask us for a job that
seems complicated and in
reality it is not because the
change of society has been
greater than that of the school.
The university as an organization
of knowledge must
give us more than we know
because otherwise we can’t
insert ourselves in the way
in which resources are being
produced.
“The new culture of learning
that opens in this horizon of
the 21st century is hardly compatible
with school formats
and educational goals that have hardly changed since the
constitution of school institutions
as such in the nineteenth
century.” (Pozo and Gómez
Crespo, 2001, p. 23).
Today we have to learn
to insert ourselves into the
society in which we live or we
will become strangers in our
own world.
Everything was done with
taking notes and going to
treat the test tubes to a small
laboratory. Everything was
composed of a positivist science
in most cases.
The previous positivist conception
has been overcome
between the historians of the
sciences and the philosophers
but it continues to prevail
in the classrooms. Scientific
knowledge arises from the
theories and models with
which scientists try to explain
reality.
Science today has to give
answers and solve.
Scientific theories are social
constructions that show
everything we understand by
our world.
Students have to understand
that science is a process
that relates the development
of it, the technological production
and social organization
and being this dynamic
process science is not a
finished product.
Science is the search for
answers instead of a process of repeating knowledge
“In a society where knowledge
and training demands
change so quickly, it is essential
that future citizens be
effective and flexible learners,
who have procedures and
capabilities that allow them to
adapt to these new demands.”
(Pozo and Gómez Crespo,
2001, p. 52).
The above is what universities
have to do.
If you go to study at a
university the question of I
don’t know what to do, I don’t
know how I have to do it is the
mental contrast between what
you knew and the new thing
to learn with a different model
for learning.
The problem is that we have
images for everything and in
the situation we describe as
students we look for an image
of what we have to do and that
image doesn’t appear.
The world that the student
needs is what Popper says:
“In this way, as Popper
pointed out, between
the physical world and the
psychic world, thanks to the
union and the pertinent mixture
between the two, a new
world appears, the world of
culture. (Neira, 2000, p. 8).
The culture, the civilization
in which we live is from
images, so to think abstractly
in the knowledge becomes
very difficult. “Culture is a product of
man, and man, in turn, is a
product of culture.” (Neira
2000, p. 8).
What do we have to do to
see the image of our work?
The easiest thing is to graph
what the description of my
work says.
The changes are and will
continue.
“No one doubts that we are
in a state of radical change,
which covers all areas of existence.
It’s a planetary change”.
(Neira 2000, p. 24).
From the world of images,
of color, of flavors, of information,
we will not leave.
“The new generations are
confused by the successive
waves of information and contemplate,
every day, the school
as an archaic precinct, unalterable
against the noise of the
present.” (Neira 2000, p. 62).
We have to transform what
the school gives us in texts in
images because there is a difference
between the world of
marketing and that of scientific
thought in which everything
can’t be taken to images
because they are products
of reasoning and deducing,
inferring, inducing, we make
them in the mind where an
image of the objects can be but
everything can’t be taken to
the object.
“The school will have
to teach how to organize information, to give it meaning
and significance, as it
has already been pointed out
repeatedly, it will have to
teach to know and know how
to continue knowing, that this
is what it means, among other
things, to learn and learn to
learn”. (Neira 2000, p. 62).
What you have to do?
Make as many graphs as
you can to form the mental
image of the new knowledge.
You like the images, the
colors; you can make a graph
for the essay like the following
(See Image 02).
“Each human life is a dynamic,
living, broad and plural
trajectory. We can say that human
life is like a problem that
must be solved successively,
at the rhythm of its development.
And like any problem,
the important thing is to raise
it well “. (Rojas, 1999, p. 129).
What you as student have to
do when you have new knowledge
is to think how I can see
it and make the graph that I
enjoy more instead of thinking
it is that I can’t, this is very
different from how I thought
and leave what I started with
such pleasure with so much
motivation. In the new world,
in the new society things
change every day and we have
to have a quick adaptation
power or we don’t do anything
and we are left out of what we
do have the capacity to do.
BIBLIOGRAPHY. Neira, T. R. (2000). La cultura contra la escuela. (Primera
reimpresión) México: Ariel. | Pozo Municio, J. I. y Gómez Crespo,
M. A. (2001). Aprender y enseñar ciencia. Del conocimiento cotidiano al
conocimiento científico. (Tercera reimpresión). España: Morata. | Rojas,
E. (1999). El hombre light. Una vida sin valores. México: Planeta.