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Nurses: Recovering The Health System Image By Chief Ignatius T Ahula FWACN , FCAI, FTPD
Date Posted: 10/Jan/2017
It gives me great pleasure to be in your midst today to discuss a topic that has no doubt been agitating your minds and indeed the minds of all practitioners in the health industry and beyond.
When I was given the invitation to come and present this keynote address to this distinguished gathering made up of eminent personalities that are assembled here today, I had no hesitation accepting this invitation in honour of my beloved brother, Comrade and mentor, Late Comrade Moses Ahura Matu who passed on to the eternal glory in August, 2015 but whose ideas and contributions continue to shape the course of Nursing and Nurses in Nigeria. I thank the organizers for finding me worthy among notably competent professionals to come and deliver this keynote address.
Today, we are discussing “Nurses: Recovering the Health System Image” as theme for our health week. I believe there is a presumption in the minds of the organizers of this forum that all is not well with our health system whether we agree or not. There is also no doubt an image problem which we shall be looking at but with a specific focus on Nurses vital roles in the transformation of our health system. It is a truism and as correctly noted and opined by Trant, Kate and Usher Susan (2010) that millions of Nurses who care for our population’s come from different background and work in every imaginable setting. Education, social standing and specific skills differ from place to place and over time. But Nurses everywhere share an underlying drive to help people through difficult periods in life and it is this drive that truly defines Nursing.
When asked what is a Nurse? Most people will give varying definitions but my concept of what a Nurse is, is fluid. But again who are Nurses? From my conceptualization and varied experience as a professional Nurse cum trade unionist, I have come to the conclusion that Nurses are trained group of autonomous and polyvalent health care professionals. ‘Sui Generis’ who perform work or render recognized practical and special service to the society on the basis of organized body of knowledge and for the benefit of mankind.
Infact Nurses are the mirror of the health system anywhere in the world. This is because their services reflect the quality of the health system we have in a given society. If Nursing Services are becoming increasingly inadequate in quantity and quality then the health system is heading towards chaos.
How our health system is organized.
According to NOUN Publication in NSS410 titled Management in Nursing on page 46 “there are three hierarchical levels in the organization of health services in Nigeria. In such arrangement a village aid, aid post, dispensary and health centre, will become the point where a patient makes the first contact with a health care system (Primary Health Centre). Hospitals will represent the second level (advisory) and teaching hospitals the third tier (specialized treatment). The relationship amongst these levels is ideally that of referral. A village aide or worker at the rendezvous aid camp is expected to refer cases that cannot be handled to a dispensary of health centres. Similarly health centres are to refer difficult cases to hospitals and only cases that will require specialized treatment and/or use of very sophisticated equipment will be referred to a teaching hospital. This means that as one moves from Primary Health Centre (PHC) to the third tier, health workers encountered get more specialized. The assumption underlying a referral system is that all units are available in all localities and that patients actually move from one to the other”. 
In practice, there is no clear pattern of utilization. A patient who began a course of treatment at the teaching hospital may later be moved to the house of a traditional healer or may decide that to cut down on cost, it will be better to ask an auxiliary health worker in his vicinity to complete the course of treatment. 
In the care protocol that is established above, Nurses are very central to the delivery of care at all the three levels. Infact Nurses concern go beyond care and involve care, cure and coordination. These three Cs are very crucial to ensure effective delivery of health care services and Nurses are visible and participate in all the three tiers of our health system management. As good as the above picture appears, there are still some assumptions which need to be worked on and these include:-
Almost all healthcare professions are practice disciplines with their various theoretical underpinnings and what has brought all of them to the healthcare system is the patient.
But instead of engaging in team based education that leads to better patient outcomes some are busy defining the supremacy of one profession over the other.
This to my mind has resulted in the needless acrimony in our health care system thereby creating the image problem we want to recover. Our health care system has been operated over the years and is skewed in favour of one dominant health care profession. In the past, there was natural inclination to caring and management of the patients on the part of most health care professionals but this seems to be different today.
But how did we get to where we are today? We must look at our history because our country is a by-product of British colonialism. This may perhaps explain why we copied everything from our British colonial masters including Nursing education and practice. But unfortunately we were introduced to those aspects of Nursing education and practice which were effective in the management of subjugation. This again explains why our colonialists introduced their own kind of health system which had no roots in our society. Thus from the colonial times, the system of Nursing education and practice was based on apprenticeship model and those trained, created and maintained a master-servant relationship with their medical colleagues who had more formal and longer training. But incidentally while this was the status quo in our environment the British Government back home organized their Nursing and medical training and practice on the basis of objective professional complimentarity. 
This was made possible because of the development of health team approach in the administration of healthcare system which also entailed the learning and application of ways to manage interdependence. They believed that all health professionals depend on colleagues and others from time to time in order for their services to be complete. But that, this does not place them in subordinate positions that compromise their independence.
At independence in 1960 the Nigerian Medical Colleagues inherited power from their departing British colleagues in an environment that was grossly under doctored compared to the Nurses and other health care practitioners who were more in number. The working relationship appeared to be cordial because there was interdisciplinary dialogue, trust, cooperation and collaboration on the part of all the other health professionals. However, gradual changes in the working relationship started appearing after the Udoji Salary review of 1974 and reach their peak after the IAP Award of 1981 to Nurses by the Federal Government. Even before then, the going was not rosy as presumed. Ahula (1995) is of the view that Nurses kept silent and this was interpreted as accommodating to the issue. He concluded by saying that Nurses probably kept quiet because the type of education and orientation they had in the past did not stimulate them to be self assertive on their rights but were rather submitting to instructions and passivity.
How can our Health System Image be recovered or improved?
Black (2005) points out that the Nursing contributions to the transformation of health care can only be achieved if doctors, managers, and politicians recognize and respect the contributions that Nurses can make and there are enhanced opportunities and improved leadership opportunities available. 
Mutual respect brings improvement in care. Health care practitioners must therefore consider themselves as a group who are interdependent with one another for the accomplishment of a purpose and who communicate and interact with one another on a more or less continuous basis. There should also be recognition of power on the side of all groups in the health industry and a relationship of equality and respect for each other.
Nurses must continue to explore critical issues in the health care system that if changed, could allow Nurses to practice to the full extent of their education across the country. To that extent Nurses must learn to work together with other stakeholders, patients, physicians and other care givers in improving quality of care while reducing cost of care for patients and their families.
The legislative arm of Government together with our regulatory agency should ensure that barriers to practice are removed by maximizing the use of Nurses and removing outdated laws, regulations and policies that prevent Nurses from practicing to the full extent of their education and training.
Our policy makers should promote a team–based approach to education and practice to improve the quality and coordination of health care. This is becoming increasingly evident nowadays because our Nurses are also increasingly earning advanced degrees and serving as primary care providers. They practice in rural or urban areas, in hospitals, communities and homes. In short, Nurses are considered scientists and innovators and are looked upon as change agents in the world of health care today.
All health care professionals must be adequately trained and equipped to cope with serious rising health care challenges occasioned by chronic disease burden, HIV/AIDS, TB, other emerging health challenges, rising costs and shortage of care providers.
Government should organize and establish broad – based training for our doctors but the over – sophisticated training with emphasis on specialized hospital – based services for the few rather than promotive services for everyone should be discouraged. Government should equally prepare and train our Nursing workforce for the future by strengthening education and training. Remember a more highly educated Nursing workforce can lead to health system improvements.
In conclusion, ladies and gentlemen, it must be emphasized that the health system is a function of the political process and the health problems of our country are also interrelated with problems of economics, politics and culture. It is in this regard that I wish to call on all organs of government to continue to provide a supportive political climate in which health is viewed as part of human development and the right of each individual. To that extent I wish to commend the laudable initiatives of the Governor Samuel Ortom led administration in the provision of modern primary health centers in strategic locations across the state and for the upgrading and making sure that the schools of Nursing Makurdi and Mkar, and the programme of the college of Health Sciences Benue State University (BSU) were given accreditation.
Distinguished participants, ladies and gentlemen, I celebrate you all today for the role your profession has played over the years in strengthening health care delicery to the people and I wish that you continue to do more. 
I thank you for listening and may God bless you all.
1. Ahula (2015) Dimensions in Nursing Practice and Society Health. A Collection of Papers on the Nursing Profession and Humanity, 1st Edition. Mikroticha & Associates Publishers, Makurdi.
2. Black, N. (2005) Rise and Demise of the Hospital: A reappraisal of Nursing. British Medical Journal 331 (10) 1394–96.
3. Berman, A. and Synder, S. T. (2012) Kozier and Erd’s Fundamentals of Nursing: Concepts, Process and practice. 9th Edition. Pearson Publication, New York, USA.
4. NSS 410 (2011) Management in Nursing NOUN Publication 1st Edition, Lagos.
5. Porter and Perry (2001) Fundamentals of Nursing. 5th Edition, Mosby Publication. A Harcourt Health Sciences Company. St. Louis USA.
6. Trank, K. and Usher, S. (2010) Nurse: Past Present and the Future. The Making of Modern Nursing. 1st Edition, Blackdog publishing. London UK.

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