Essay title - Nursing Profession Care
Nursing profession is the largest force in health care system holding the central role as health care providers. Our people’s health depends on competent and highly educated nurses. Nursing profession needs dynamic, visionary, educated and committed leaders who can protect the public health rights through productive input in national health policy. Effective nursing leaders also ensure the quality nursing education for safe nursing practice. In addition they advocate for the public and the professional’s rights. Effective nursing leadership supports the collaborative, innovative and evidence based work environment that helps nurses to feel respected and valued in their positions. According to Huber (2006) “leader use their power to bring teams together, spark innovation, create positive communication and drive forward toward group goals (p.4).” Nursing leadership must possess these characteristics. Especially nursing leaders who run professional organizations at national level have to acquire these characteristics. In our country health care system is decentralized at provincial level. So nursing leadership comprises provincial, federal and professional bodies at national level. “Director General Nursing” is the highest rank in each of the four provinces responsible for health and nursing matters in their particular area. Where as in federal “Nursing Advisor” is the top position directly working with ministry of health in close coordination with other nurse leaders. Likewise, professional bodies are the most important pillars of the nursing profession at national level in any of the country. These are comprised of nursing council, nursing association and nursing union. The role of these professional bodies slightly varies country to country depending on their scope of responsibilities and need of the time. In Pakistan we have two professional bodies; Pakistan Nursing Council (PNC) and Pakistan Nursing Federation (PNF). While addressing the issue related to “Challenges of nursing leadership” I will be focusing on professional bodies PNC & PNF only, being the national level leadership. The purpose of this paper is to describe the challenges related to leadership at national level, identify the key issues and recommend strategies to resolve the issues.
The role of nursing professional bodies in any country is vital as council regulates nursing education and practice and association advocates for trained nurses. PNC is an autonomous body that functions under the Pakistan Nursing Council Act, 1973. PNC Act 1973 authorized the Council fully to make the independent decisions related to public health rights, nursing education, nursing practice standards, licensing nursing professionals and recognizing or derecognizing educational institutions, monitoring of health and educational institutions, disciplining for mal practices, making new rules for betterment and addressing patients and professionals needs timely. PNC Act 1973 also gives the full authority to the council to establish and maintain its prescribed infrastructure with extensive range of functions. PNC office is located in Islamabad. Since the partition it was functioning in a small borrowed space in one of the government’s building. However, recently the office has been moved to a new permanent building fully allocated for council’s functions in Islamabad. The structure of the Council is President ( Director General Health) Vice President (one of the Senior Nurse) and Registrar along with Ex –Officio members. At present only one senior nurse in Registrar position with diploma qualification is working for the last 10 - 15 years. Recently one more BScN prepared nurse has been inducted as Assistant Registrar. For two nurses holding the extensive functions of the Council is humanly impossible.
Similarly, PNF Constitution and Bye-Laws 1949 authorized the federation to act independently in the light of full range of functions with it’s agreed infrastructure. According to PNF Constitution and Bye-laws 1949 spelled out functions and authority; federation is responsible to advocate the professionals and execute it’s duties in true spirit. For PNF functions we do not have separate office as the positions are held by the nurses who are already in government job. According to the PNF Constitution it’s structure comprises (1) National Executive Board of PNF is president, First Vice President, Second Vice President, Secretary General, Treasurer, Editor of the Professional Magazine, Representative from PNC and Chairmen of Standing Committees (2) Governing body of PNF is the National Executive Board, President of the Provincial Association, Secretaries of the Provincial Associations and Delegates from the Provincial Associations (3) Provincial Nurses Associations and (4) the Branch Nurses Associations as described in the Constitution and bye-laws 1949. As mention above the role of nursing professional bodies in any country is vital as council regulates nursing education and practice and association advocates for trained nurses. Unfortunately this is not the case in our country. American Nurses Association (ANA), Trained Nurses Association India (TNAI), Indian American Nursing Association (IANA) Indian Nursing Council (INC) Australian Nursing and Midwifery Council (ANMC) and Nursing Midwifery Council United Kingdom (NMCUK) are the few examples of its models who work commendable for the profession and the public.
Hood and Leddy (2003) discussed that political situation in the country move so fast that polices changes with in no time. So ANA prepares “an annual legislative agenda” (p.338) to update its polices congruent with circumstances. ANMC was established in 1992 to function as regulatory body for nursing and midwifery in Autralia. ANMC develops standards and protocols according to it’s peoples need and plays a key role as professional regulatory body at national level http://www.anmc.org.au/ . Silmilarly, NMC ensures safe and quality care for public health by maintaining it’s professional standards. NMC develops standards for professional conduct and guides nurses and midwifes on regular bases http://www.nmc-uk.org/. India being our neighbor country; INC has planed to commence the Nursing Ph.D program to promote research activates. Six institutions has been approved by the Indian national association for Ph.D program all over the country. Student will pay Rs. 5000 fee per annum to the respective study centerhttp://www.indiannursingcouncil.org/Nation_Consortium_PhD_Nursing.asp. Being a Muslim country with the support of King Abdullah nursing profession in Jordan plays a central role in health care system. Over the decades nursing profession proved it’s importance. Nursing regulatory body has the full authority to develop national standards and activate resources to uphold transformation of nursing education. Jordan is top one country in Muslim world to recognize nursing as an self-governing profession through the clear vision of King Abdullah; who believes that nursing is the vital partner in health care system of the country http://www.jnc.gov.jo/english/home.htm.
Dormant role of professional bodies and slow development in nursing profession is alarming situation in Pakistan on way forward to meet the demands of 21st century. Nursing leadership at national level and their input in health policy, succession planning, educational opportunities for nurses, professional recognition, true recognition of BScN & Masters prepared nurses, forum to address the public health rights and professional’s rights, mal practices, implementation of PNC Act 1973 and PNF Constitution 1949 in its true spirit and absence of true professional projection remains a high concern to all Pakistani nurses. According to Ladhani (2002) “issues in nursing are very complex and are like web of causes interlinked and interconnected. It is therefore very crucial to link up policies, trainings and commitment of all concerned parties together (p.9)”. Similarly, Hemani (2003) explained “India where independence was gained at the same time, and the level of nursing education in India has had far more recognition internationally than Pakistan” (p. 122).
Impacts of present scenario
Lack of true commitment and clear vision of the professional bodies leads to violation of public and professional’s rights, no control over mal practices and sub standard educational institutions. patients safety is also at risk due to absence of professional accountability. Furthermore, it creates poor nursing image nationally and internationally.
Following are few examples of piling up of work at professional organizational level that was planned but never turned in to actions: Consultancy PNC & PNF (John knapp 1997 & 1998), Report of Visioning workshop: (2000), Minutes of Senior Nursing Advisory committee meeting July 4-6 (2000), PNC Act Revision ( 5th session 2004) and Nursing Organizations workshop (2000) are just kept in the shelves with out any follow-up work. As the present leadership lack the capacity to take the lead in progressing the actions further.
Root causes of present scenario
There are political, cultural, educational and personal reasons hindering the nursing development in the country.
Analysis of the situation
According to PNC Act (1973), nurses have the responsibility to their patients to provide safe, competent and ethical nursing care. But most of the time nurses are unable to provide safe care to the patients due to lack of back support from the professional bodies. One of the reason is compromised quality of nursing education and lack of opportunities in higher education as nursing faculty is not adequately equipped with required knowledge and skills but they are teaching all nursing programs. Due to this compromised education level nurses are unable to play the effective role in health care system. This damages the image of nursing profession in our society despite of nurses working so hard. It gives great impact on nurse’s job satisfaction and self esteem. Though nurse’s role is limited to the tertiary care only; nurses working in hospital setting face numerous challenges related to safe provision of care; shortage of nurses at bed side, lack of resources to provide safe care, compromised nursing education, no involvement in decision making at institutional level and absence of professional autonomy. Nurses have no professional platform to unite and address the health related issues. It is evident that nursing professional bodies in Pakistan are far behind to address the future health care demands of the society. There is no projection of the profession at all, even we do not have any publication and web site developed for our professional bodies yet.
In 2003, I got the opportunity to work in Women health project under Ministry of Health. During that period I conducted a survey in 3 provinces; Punjab, Frontier and Sindh in major hospitals. The mid level nursing leaders (chief nursing superintendents, supervisors, principals and nursing teacher) were interviewed to explore their job satisfaction level. The mid level nursing leaders from all 3 provinces verbalized the issues they were facing during their nursing practice. Quality of nursing education, image of nursing in our society, job satisfaction, career path, promotion and benefits, succession planning, opportunities for continue education and higher education, involvement in decision making at institution level, shortage of nurses on bed side, poor nursing regulatory and advocacy mechanisms were the 10 emerging themes of the high area of concern among all mid level nursing leaders. These mid level nursing leaders exhibited helplessness and hopelessness working in the existing system. They wanted to see the positive change that could provide them the better work environment, safe patient care, job satisfaction, higher education opportunities and better career structure.
Lack of visionary nursing leadership and infrastructure at PNC & PNF level affects quality care, job satisfaction of nurse’s, nursing image and public health. During my professional journey, I have worked as an intensive care nurse, team leader manager and acting chief of nursing. In every role I have experienced different challenges and problems. After working more than 20 years in nursing I realize that nursing profession in Pakistan could not earn the respect and the recognition it deserved. Because nursing professional bodies fall short to respond to the call of society and the nursing professionals. Infrastructure of PNC is equal to none. We can imagine it’s affects on health system, nurses and society as a whole. I would like to share my own work experience. I faced many issues related to provision of safe care and professional autonomy. I faced high expectation and high work load without adequate preparation in every assigned role. Managing high turn over /shortage of nurses, and ensuring safe care remained questionable throughout my work life due to unfavorable work environment that affected me right from the bed side nursing to leadership role. In addition to that I could not get any educational opportunity for advance nursing education on time as it was hardly available. Being a nursing leader in my institution it was difficult for me to advocate nurses and patients rights effectively due to absence of nursing standards and regulatory mechanism in the country in term of professional autonomy, professional growth, salary and benefits and professional conduct. In my personal experience I have seen nurses working with fake diploma (even working abroad) but there is no regulatory mechanism to control such practices. I can share another example that nurses working in public sector even senior nurses having more than 25 years experience are not registered with PNC yet. Similarly, there is mushrooming of nursing schools for male nursing in the country just to earn the money . But again there is no effective check and control for such a major offence. In addition to that Health Care Institutions are hiring untrained personals and giving them the name of nurses and they are wearing the nurse’s uniform creating bad impression of the profession and putting patient’s safety at risk.
In short, nursing leadership at national level whose mandate is to hold up and advocate the public and professional rights, regulate quality care, professional conduct and quality nursing education by implementing PNC Act 1973 and PNF Constitution 1949 in its true spirit; lacks the qualified visionary leadership and adequate infrastructure that causes serious health care affects through out the country. These short comings at top level are truly reflected right down the level in hospitals and nursing educational institutions. All practicing nurses and faculty are diploma prepared. Even senior nurses having more than twenty five years and plus experience holding leadership positions have no access to continue education and preparation for their leadership role at institution level. Existing scenario presents that both professional bodies that are pivotal in health care system are severely deficient in their professional commitment and competence that lead to dearth of visionary nursing leadership at national, institutional and unit level. In result the whole society is at high risk along with nursing professional. This drawback is a major threat to public health as well as country’s economics.
To look for the solution of prevailing situation many questions arise in my mind that, How can we establish adequate infrastructure at PNC level. What can we do to have visionary and qualified leadership at national level. How can we take the example of nursing regulatory bodies in other developed countries? How can we ensure effective leadership at institutional and unit level that gives direct impact in quality patient care? What we can do to improve staff satisfaction and productivity? How can we address the issue of compromised nursing education? What measures we can take to protect the public and professional’s rights? How can we change the nursing image in society? How professional autonomy could be possible? How can research based nursing practice be introduced?
What is required
Immediate and effective action is needed to respond the existing situation. There is intense and immediate need to improve the productivity of professional bodies in the light of other countries. We can learn the lesson from Nursing Midwifery Council in United Kingdom, Canadian Nursing Council, Australian Nursing Council, Indian Nursing Council. In addition to that Pakistan Medical Dental Council infra structure could be studied that may be replicated straight away at PNC level. Beside that university based education must be ensured to raise the professional standard. To take all these positive steps a strong commitment and clear vision of policy maker and nursing professional bodies is required. My suggestion to BScN and Masters nurses is that they must prefer to work with donor agencies like World Health Organization (WHO) UNICEF and other significant. This is how change will take place. I hope that new nursing generation who are getting better opportunities for education; one day will be holding key positions in health sector as well as political representation. I am sure that time is not far; change is inevitable.
The present nursing leadership at national level is ineffective and unproductive due to lack of team work and coordination. These characteristics are similar to laissez –faire leadership style as described by Tomy (2000). To bring about the positive change we need to adopt leadership style that is role modeling leadership inspiring people focusing the processes, net working, sharing, Intellectual and source of motivation that is transformational theory support by Tomy.
Ministry of health to show the commitment by immediate action to correct the situation as follow: Revise criteria for key positions, ensure right person at the right place and create 4 MScN and 2 Ph.D nursing positions at national level in initial phase. So they could work to improve the existing situation of nursing profession in Pakistan. Suggested plan is to advertise the new positions 2nd quarter 2008 and ensure hiring in the beginning of the 3rd quarter 2008.
We all know that nursing professional bodies in any country breath oxygen to professional’s and the public. Having infrastructure improved at national level will be the first step towards the success and to address and engage in health care system, public policy issues and collaboration with government. Existing nursing leadership at national level must take immediate action to resolve the situation. Otherwise, Tichy, (1993) warns that “Control your Destiny or Someone Else Will as three act play: (1) the awakening (2) the vision (3) revolution as a way of life” cited in Tomy.
Australian Nursing Midwifery Council (2008). Welcome to the australian nursing and midwifery council incorporated (ANMC). Retrieved from: http://www.anmc.org.au/. Retrieved on 26/03/2008.
Huber, D. L. (2006). Leadership and nursing care management (3rd ed.). Philadephia: W.B. Saunders. Hood, L. J. & Leddy, S. K. (2003). Conceptual base of professional nursing. (5th ed.). Lippincott: Williams & Wilkins.
Hemani, H. (2003). History of nursing in Pakistan. (1st ed.). Peshawar: N.W.F.P.
Indian Nursing Council (2006-2007). National Consortium for Ph.D Nursing. Retrieved from: http://www.indian nursingcouncil.org/Nation Consortium_PhD_Nursing.asp. Retrieved on 25/03/2008
Jordanian Nursing Council, ( 2007) HRH Princess Mona’s Address. Retrieved from: http://www.jnc.gov.jo/english/home.htm. Retrieved on 26/03/2008.
Knapp, J. (1997). A strategic plan for Pakistan Nursing Council. Islamabad, DWHP.
Knapp, J. (1998). A strategic plan for Pakistan Nurses Federation. Islamabad, DWHP.
Ladhani, Z. (2002). Training needs assessment of Ist, 2nd and mid –level nursing leaders. WHP.
Minutes, (2000). Senior Nursing Advisory Committee Meeting.
Nursing Organizations, (2000). Workshop. Islamabad, Nursing Organizations.
Nursing and Midwifery Council, (2008). About us. Retrieved from: http://www.nmc-uk.org/aSection.aspx?SectionID=5. Retrieved on 21/03/2008.
Pakistan Nurses Federation (1949). Constitution and Bye-laws. Author.
Pakistan Nursing Council Act, 1973 Revised (5th session 2004). Proposed amendments in the Pakistan Nursing Council Act, 1973. PNC.
Pakistan Nursing Council (1996). The Pakistan Nursing Council Act, 1973. Islamabad: Author.
Pakistan Nursing Council (2000). Report of visioning workshop: A preferred future for nursing
in Pakistan. Islamabad, DWHP.
Tomy, A. M. (2000). Nursing management and leadership. (6th,ed.). Philadephia: Mosby.