Sunday, 6 November 2016

IN RETROSPECT: FROM 2015 NATIONAL PROFESSIONAL CONFERENCE, ABAKALIKI



NURSING AND MIDWIFERY COUNCIL ESTABLISHMENT ACT: THE NEED FOR URGENT REFORMATION -By UGONSA.

A critical analysis of the NURSING AND MIDWIFERY (REGISTRATION, ETC.) ACT revealed that the current established legal framework for Nursing education and practice is riddled with myriad of flawed sections that fall short of current trends and international best practices.
The Act titled ‘An Act to establish the Nursing and Midwifery Council of Nigeria for the registration of nurses and midwives in Nigeria and State Nursing and Midwifery Committees and to provide for the discipline of nurses and midwives and other ancillary matters [1979 No. 89. 1992 No. 83.]’ is now obsolete in scope, nature, content and timing. Some flawed sections of the Act (attached herein as Annexure A) are presented below:

Offences and Punishments
 The provisions of the Act is laughable on what constituted punishment to offences such as unauthorized practice without registration, employment of an unregistered person to practice as nurse or midwife and forgery of the council’s documents such as practicing license. For clarity sake Section 20 that borders on punishment for quackery, employment of quacks and forgery of Council’s document is reproduced verbatim below:
 (1) Any person not being a person duly registered under this Act who- [1988 No.4.]
 (a) for or in expectation of reward practises or holds himself out to practise as such; or
 (b) without reasonable excuse takes or uses any name, title, addition or description implying   that he is authorised by law to practise as a nurse or midwife, is guilty of an offence under this section.
 (2) Any person who employs any unregistered person as a nurse or midwife is guilty of an offence under this section and liable on conviction to be punished as provided in this section.
(3) It shall be an offence under this section for any registered nurse or midwife to establish a private nursing or maternity home without complying with the provisions of this Act.
(4) If any person for the purpose of procuring the registration of any time, qualification or other matter-
(a) makes a statement which is false in a material particular; or
(b) recklessly makes a statement which is false in a material particular, he is guilty of an offence under this section.
 (5) If the registrar or any other person employed by the Council willfully makes any falsification in any matter relating to the register he is guilty of an offence under this section.
The above sections that sound good at a blush are however over diluted and ridiculed by subsection 6 below:
(6) A person guilty of an offence under this section shall be liable-
(a) on conviction in a court lower than the High Court to a fine not exceeding N1,000 and where the offence is a continuing one, to a further fine not exceeding N50 for each day during which the offence continues;
(b) on conviction in a High Court, to a fine not exceeding N2,000 or imprisonment for a term not exceeding two years or to both such fine and imprisonment and where the offence is a continuing one, to a further fine not exceeding N50 for each day during which the offence continues.
Note that in 6(a) above, no mention was made of imprisonment upon conviction and after putting enormous resources to prosecute offenders at the level of high court, 6(b), the outcome is a fine of N2000 on the offender. This compared with prosecuting charges is demoralizing and discouraging. The prison term of “not exceeding more than two years” is also ambiguous, amorphous, misleading, and non-definite because “not exceeding more than two years” can be interpreted to be an hour or a day depending on the presiding judge and the connection of the offender. There is a need to specifically define the prison term by stating its definite duration, e.g. two years, than leaving it at the discretion of the judge with the attendant loop holes being exploited by well-to-do offenders. Also cunning is “a fine not exceeding N50”. It is not only funny, based on today’s economy, but also not definite as “not exceeding N50” can be 50 kobo or 1 naira. If the makers of the Act were sincere enough, they should have inculcated the term “not less than” rather than “not exceeding”.
    (7) Where an offence under this section which has been committed by a body corporate is proved to have been committed with the consent or connivance of, or to be attributable to any neglect on the part of, any director, manager, secretary or other similar officer of the body corporate, or any person purporting to act in any such capacity, he, as well as the body corporate, shall be deemed to be guilty of that offence and shall be liable to be proceeded against and punished as provided under paragraph (b) of subsection (6) of this section.
       Section 21 that borders on unauthorized training is no less repugnant as what we have above. It is           also   reproduced verbatim here for ease of appreciation of the subject matter:

It shall be an offence for any person without the approval of the Minister, given on the recommendation of the Council, to train or purport to train any person as a nurse or mid wife or to provide any course of training or establish any school for such purpose or as one of its purposes; and any such person shall be liable-
 (a) on conviction otherwise than in a High Court, to a fine of N1,000 or to imprisonment for a term of six months, or to both such fine and imprisonment;
 (b) on conviction in a High Court, to a fine of N2,000 or to imprisonment for a term of two years or to both such fine and imprisonment.
From the foregoing it is evident that the Act does not fight quackery but rather encourages it. The ‘slap-on-the wrist’ punishments prescribed by the Act has emboldened defaulters to keep defaulting. No wonder most Private Hospitals had continued to constitute themselves into quack breeding centres with unbridled impunity.
When punishment that is meant to serve as a deterrent lacks weighty penalty, its essence is abysmally lost. A fine “not exceeding” N1000 or N2000 in today’s economy is a heightened mockery on the fight against quackery in Nursing, a profession that foresees health promotion, health protection, health restoration, illness prevention and alleviation of sufferings of the healthy, sick and disabled citizens. Quackery is a crime against humanity whose punishment must be commensurate and hefty. There is an urgent need for amendment of these sections to reflect adequate penalty for the afore-mentioned crimes.

Power of the Minister of Health
The minister was mentioned 22 times in the Act and has so much power vested on his office that no business of the council is executed without his permission or interference. Even the training and education of Nurses cannot be done without the Ministers approval as is seen in the following declaration of section 21-“It shall be an offence for any person without the approval of the Minister, given on the recommendation of the Council, to train or purport to train any person as a nurse or midwife or to provide any course of training or establish any school for such purpose or as one of its purposes”. What then has the council right to regulate as the power to approve or disapprove Nursing education and training is solely vested on the Minister? The power of the Minister to give directive to the council was summarized in Section 4 as follow, “The Minister may give to the Council directions of a general character or relating generally to particular matters (but not to any individual person or case) with regard to the exercise by the Council of its functions and it shall be the duty of the Council to comply with the directions”. All Nursing activities, including education were therefore blankly placed under the Minister with repeated use of the clause-‘Subject to subsection (4) of this section and to any direction of the Minister under this Act’.
In a nutshell, as the NMCN is a statutory regulatory body for Nursing education and practice so is the office of the Minister of Health a statutory regulatory body to the council based on the powers vested on the Minister by the Act. In other word the Minister of Health is the regulator of the regulator of Nursing education without consideration to the Ministry of Education that regulate educational activities in the country. The emphasis here is not that the Minister should not have a say in the affairs of the council but that such should not be in a way as to erode the professional autonomy of Nursing which was defined and granted by industrial Arbitration Panel (IAP) Award 1980 (herein attached as Annexure B).The tribunal observed and granted that ‘Nursing is a profession sui generis subject to no directions or control whatsoever by any profession. The enormous power vested on the office of the Minister of Health to control every inch of Nurses’ professional affair, in a country like ours where the position of the Minister of health has been skewed as the birth right of Medical Doctors, smacks of interference with professional autonomy of Nursing and therefore at variance with the provision of the IAP award.  Few examples of the excesses of the Minister’s power are pointed below
v 
   Nursing Education: The Act for example vested Nursing education on the ministry of health rather than ministry of education, without any consideration to or consultation with the Ministry of education that handles all education related issues. Designing and redesigning of Nursing and Midwifery curriculum of training is vested on the Minister of Health so is the accreditation of Nursing and Midwifery programmes and selection of committees to lead accreditation and establishment of schools without recourse to consultation with the Ministry of Education that foresees issues pertaining to curriculum development and accreditation of educational programmes. Section 12 subsection 2 reproduced here reads “Where the Council is of the opinion that a trial should, in the public interest, be made on a scheme of training and examinations to be undergone and passed by persons as a condition prior to registration under this Act (being training and examinations which differ from prescribed training and examinations but appear to the Council to be no less efficient), the Council may adopt the scheme for such period and in relation to such institutions as may be specified in the resolution; but any such resolution shall be subject to confirmation by the Minister”.
v  
   Appointment of Membership of the Council and State Nursing and Midwifery Committees:  Section 2 subsection 1 of the Act, apart from vesting the sole power of appointing the Chairman of the Council on the Minister, went further in Sub-section 3 to elaborate that appointment of other members of the council is the prerogative of the Minister (All appointments under paragraphs (d) to (i) of subsection (1) of this section shall be made by the Minister). Section 13 on State Nursing and Midwifery Committees appointment in sub-section 2 ended with the declaration that “Nothing in this section shall be construed so as to authorize the appointment to a State Nursing and Midwifery Committee of any person not registered under this Act, without the approval of the Minister”. Therefore, the minister is the summary of what nursing is or is not, what it shall become and what it shall never be in Nigeria.

Blanket Restriction on the roles of Nurses and Midwives
Section 22 under this Act placed a blanket restriction on the professional roles of Nurses and Midwives as evidenced by its provision that Registration under this Act shall not confer the right to assume any name, title or designation suggesting or implying that the person registered is by law entitled to take charge of cases of abnormality or disease in or relating to any pregnancy requiring medical attention”.
This hold back reins is a limiting constraints that keep Nurses and Midwives from performing with the full set of competencies for which they were educated, trained, and licensed. This regulation had often prevented nurses from exercising their full knowledge and skills.
Contribution of Nurses and Midwives to primary healthcare can be strengthened and enhanced based on a reorientation of the Act through legislation to allow Nurses and Midwives to practice to the full extent of their education and training. Until this regulatory and institutional obstacle is removed, our healthcare system, especially the primary healthcare, will never reap the full benefit of Nurses and Midwives training, skills and knowledge.
In a country facing a shortage of primary care physicians like ours, one way to fill the gap is to permit nurses with advanced degrees and experience to practice with minimal or no doctor’s oversight, order and interpret diagnostic tests, prescribe medicines, and administer treatment. Unfortunately, this obvious solution that now constitute international standard and best practices faces stiff opposition from the Nigerian Medical Association (NMA) in our country.
NMA had continued to believe that expanding the scope of nursing practice in Nigeria will have an adverse effect on the quality of patient care but had refused to look at the evidence. Mounting evidence shows that this opposition is more about competition than competence.
It has been evidenced that Hospitals with a higher ratio of nurses to patient have lower mortality rates. Studies also underscored the quality of care provided by nurses, including preventing medical errors and medication mistakes, reducing or eliminating infections, shortening hospital stays, and easing the transition of patients from hospital to home. Nurses using new technologies to care for patients, including the elderly, in their homes have been shown to reduce the number of hospital readmissions and visits to emergency wards. All of this cuts costs, of course, but it also improves the quality of life for patients. What is needed at this material time is therefore a less rigid dichotomy between the autonomy of nurses and doctors, and more collaborative teamwork. Hence, there is an urgent need to review and lift of this blanket restriction.

Composition of Membership of the Council
Among the membership of the council as defined by Section 2 subsection 1 of the Act  included in subsection 1 (f ) one person who is adviser on secondary education; and subsection 1 (i) one registered medical practitioner who shall be a qualified gynaecologist and obstetrician.
Since all Nursing Programmes, whether diploma or baccalaureate, are done at post-secondary school level the adviser should rather be one on tertiary education instead of secondary education. Gone are the days when admission into schools of Nursing and Midwifery was done without O’level. The current trend is not only that a candidate for admission must possess O’level but that the O’level must bear at least credit pass in English, Mathematics, Biology, Chemistry and Physics. The Act goofed by portraying Nursing and Midwifery education and training as secondary rather than the tertiary, that it is, and should be urgently amended to reflect the current trend.
For an autonomous profession, the inclusion of a Medical Doctor, who is not a member of Nursing/Midwifery profession, as a compulsory membership of the Nursing and Midwifery council does not only smack of hegemonic interference by Medical practitioners but highly repugnant and contempt of the IAP award 1980. No nurse or midwife is a compulsory member of the Medical and Dental Council of Nigeria. Why then should Nursing and Midwifery Council of Nigeria be invaded by Medical Practitioners whose past and present demeanor towards the Nursing profession and her members are more or less at variance with having her interest at heart?

Citation
 This work should be cited as follow:
University Graduates of Nursing Science Association [UGONSA]. (2015). Nursing and Midwifery Council Establishment Act: The Need for Urgent Reformation. Abakaliki. National Professional Conference.

REFERENCES
An Act to establish the Nursing and Midwifery Council of Nigeria for the registration of nurses and midwives in Nigeria and State Nursing and Midwifery Committees and to provide for the discipline of nurses and midwives and other ancillary matters [1979 No. 89. 1992 No. 83.]
WHO (2015). WHO Director’s address at ICN conference. Seoul, South Korea.


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