Book published

Article published

Graduate appointed as Chief Executive Officer in Lamu County

Student Testimonials

Addressing barriers of nursing and midwifery practice autonomy in Ghana

George Yaw Segnitome | Doctor of Community Public Health | Part 1/2

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

Publications by Students: aiu.edu/StudentPublication.html

Researching

By Dr. Rosa Hilda Lora M. Advisor at AIU | rosa@aiu.edu

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.

Disease detectives

Why are they in a cave crawling with snakes?

New fundamental particle

It is called the Sterile Neutrino.

AIU makes a huge contribution to the world by giving new scient ifics the space for original investigations and research. Visit MyAIU Evolution

Women of power

Find support for your own unique art and design projects, or support other creative projects at MyAIU Research

Walk faster

It could help you live longer.

Empathetic people

They interact with music as if it were a person.

Live a better life learning how to keep your body, mind and soul balanced. Visit regularly MyAIU Body / MyAIU Mind / MyAIU Spirit and MyAIU Energy.

Eco Tip: Simplify your life as much as possible. Only keep belongings that you use/enjoy. Change your life, get sustainable, visit MyAIU Knowledge

Get a better knowledge about our rights and the way we can use them on a daily basis to prevent any abuse or limitations of them. Visit MyAIU Human Rights.