Uganda and the entire world today celebrate the International Nurses Day (12th May) which also happens to be Florence Nightingale’s Birthday which was on May 12, 1820, in Florence, Italy. Although her parents were from England, she was born in Italy while they were travelling.
Nightingale OM RRC DStJ was an English social reformer, statistician and the founder of modern nursing. She came to prominence while serving as a manager and trainer of nurses during the Crimean War, in which she organised care for wounded soldiers at Constantinople.
Nursing has kept on evolving according to the generational healthcare demands and system checks, especially after the last Pandemic of COVID-19. It’s very clear and undoubted that nurses are the backbone of the health care system in the world. Modern Nursing has adopted the North American Nursing Diagnosis Association (NANDA) to generate its independent Holistic Patient Care aimed at;
- Writing a Problem-Focused Nursing Diagnosis.
- Writing a Risk-Focused Diagnosis.
- Writing a Health Promotion-Based Diagnosis.
- Writing a Syndrome Diagnosis.
These are completely different from Normal Clinical Clerkships and ancient Patient care.
This NANDA is facing system challenges of implementation, especially in public health facilities due to low staffing levels, high Patient to Nurse Ratio, Nursing Training changes and lack of professional Multidisciplinary Team Collaboration where other Medical officers and allied health Professionals don’t understand this holistic care Approach.
Nursing in Uganda has also evolved in recent years positively and negatively. The scraping off of Nursing Aids / Assistants was pretty good to standardize and equip the least cadre with all basic knowledge for 2.5 years rather than a rush of 9 months.
Negatively, the failure to incorporate the Registered Comprehensive Nurses who were trained by the system but not employed by the government yet licensed to a level of scrapping them off last year claiming that they are incompetent in the Midwifery field.
Diploma Registered Comprehensive Nursing (DCN) and Certificate Enrolled Comprehensive Nursing (ECN) training programs started in Uganda in 1994 & 2003 respectively running for Four years and three years but since then there has been no clear recruitment policy for the graduates.
The diploma Registered Comprehensive Nursing direct entry requirements are not different from a fresh A-Level graduate for entry of Bachelor of Medicine and Surgery, Bachelor of Dental Surgery, Bachelors of Nursing(Direct), Bachelor in Medical Laboratory Technology, BSc. In Orthopaedic medicine, physiotherapy, BSc. Speech and language therapy, Diploma in Clinical Medicine and Community Health and most allied health training of two Principal Passes at A Level in Biology & Chemistry.
Government until now still sponsors students for this training upon selection from Jab form filling during UCE & UACE sitting every year with only Soroti & Masaka Schools of Registered Comprehensive Nursing government-owned training institutes which admit, train and qualify both direct students from A level and certificate cadres for Upgrading as Extension and eLearning midwifery programs affiliated to government-owned Regional Referral Hospitals with a varsity of specialized departments which enable them receive adequate mentorship from well-positioned Seniors who also in most times are their clinical instructors for all their practicum.
The trained Comprehensive nurses, who have been unemployed since graduating when the government introduced the program in 1994,may never have reasons to smile following a move by government to phase them out even without been Integrated into public service. Regrettably, society, hospitals, healthcare settings are deteriorating in nursing care partly due to lack of multi skilled Licensed nurses the Comprehensers.
This should be noted the even before comprehensive Nursing training, Double trained Nurses Studying Two diplomas in Nursing & Midwifery for 1.5 years each aimed at having management positions in health facilities; so comprehensive nursing training had sorted out all this since its paper weight has both Nursing & midwifery incorporated in one with even specialized nursing training like mental health, Orthopeadic Nursing, Nursing Research, Community health,Dental health practicum, Peadriatics ,palliative care , Health management, HIV/AIDs care, ophthalmology, Nutrition & dietetics and basic Laboratory at practice centers up to date.
Up to now the midwifery associations still dis-own Comprehensive nurses while even the General nurses do so especially the Double trained Nurses and preference goes to General nurse and general Midwife trained candidates during recruitment when comprehensive Nurses apply as for Jobs as Nurses or as Midwives.
A comprehensive nurse is expected to provide preventive, promotive, curative and rehabilitative services to the community as well as extend primary health care to all sections of the community among other duties.
These changes have not left the Nursing sector the same. There is need to reframe the agenda from “phasing out” to a less scary concept of ‘transitioning’. This would encourage buy-in from other stakeholders especially government.
Not only that, a common trend in several health facilities in the country are served by registered nurses who upgraded but are still recruited as enrolled due to limited scheme of service and temporary ban on recruitment. In that case, if quality has remained low at the facilities managed by registered cadres, will phasing out comprehensive nursing cadre guarantee quality improvement? Thus, there is need to focus on other determinants of health workforce and health system performance. The fact that many registered nurses are still employed as enrolled nurses defeats the essence of upgrading and is a big de-motivator for retraining.
Relatedly, there is need to extend the discussion of implications of phasing out these nursing cadres which is training multi-skilled nurse-midwives from Universal Health Coverage(UHC) to the broader question of achieving the sustained Development Goals (SDG) agenda. Then, there will be a need to examine the potential influence of this decision on achieving the new development goals.
The burden to the system arises from; the costs for upgrading the enrolled, registered nurse cadres that must be borne by either the individuals, their sponsors or government. Secondly, there are costs due to disruptions in service delivery when nurses start rushing to upgrade. Thirdly, there are costs due to increased wage bill as diploma level nurses are paid higher than what certificate level nurses receive.
Lastly, there are envisaged costs to the country due to efflux of nurses to other countries if they are not absorbed into the system and/or if the remuneration packages in the region are not harmonized as well especially Comprehensive Nurses.
What needs to be done?
The nursing profession needs to develop a justification for upgrading. However, these efforts need to be cognizant of the realities of the barriers created by the current entry eligibility criteria and the many related costs such as training costs.
Introduce Specialized nursing like other countries in addition to Nurse Tutors, Psychiatric Nurses, Peadiatric Nurses, Hospice& Palliative care Nurses, Community Health Nurses, Nurse anesthetist and Critical Care Nursing with cardiac nursing, dental nursing , neuro-nursing , diabetic nursing , Emergency Care Nurse, Nurse Midwife Training, Dermatology Nursing, Ambulatory care Nursing, Nurse researchers, Developmental and disability Nursing, Nursing Leaders, Burn care nursing, Ambulatory, oncology Nursing transitioning them to advanced Practioner Registered Nurse.
Scholarships should be negotiated for these out bursting unemployed Comprehensive nurses with the development partners to support those who will not be able to fund their studies.
Happy Nurses Day “Our Nurses. Our Future” To love and Serve, For God and my country.
About the Writer:
Brian Nambale is a Specializing Student Palliative Care Medicine, Makerere University| IHPCA, Clinical Case Manager at Medicure Trauma Centre-Nabumali, Palliative Care Advocate, Independent Medical Writer, RCN, LCV Councilor Mbale District & Member of the Health & Education Committee.
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