Constructing Category Five

The data revealed that there was significant tension over the control of nurse education.

“These are health personnel, in some settings there can be no health personnel who will not train within the…ministry of health context…But now they just diffuse the whole thing, in the

final analysis all those who are being trained be trained so the patients will not suffer. Because we imagine what type of certificates ministry of professional training gives them. So those things…there’s really a mix up somewhere needing synthesis” (Int13:1)

Training being given by ministries of vocational training and higher education are ‘out’ of the health context and so may not meet the required standards for patient safety. This is influenced by opinion that the other ministries have less stringent rules for programme accreditation:

“when we were in the ministry of health, there were many applications from people who wanted to open schools, economic operators, but when you look at their profile, they were not qualified so they now went them into vocational education…and opened schools, got

their authorisation from there” (Int1:1)

Some nurses are not comfortable that the law allows entrepreneurs to open schools but other nurses argue against such resistance. The position is seen as territorialism:

“Of course there is no rationale, there is no rationale. Again it has to do with what we call protecting your turf” (Int7:1)

Rejecting other ministries is perceived as an effort by health to return to the old era where they monopolised training:

“The ministry of health who is the employer feels that they should follow its ideology, unfortunately times have changed. We cannot be following your ideology when you are

ending at the diploma level and some of us are ending at the bachelor’s level. Something, somebody, something has to give.” (Int7:3)

The contrary view is that nursing education has evolved and qualifications are going beyond the diploma to university degrees. The implication is that the ministry of health has to rise and accommodate these changing trends in nurse education rather than opposing them.

Employment controversy

The data also revealed tensions also arise from the area of employment. Nurses who hold certain diplomas are discriminated against:

“When we train these people there are some people they call higher nursing diplomas and there are others they call state registered nurses, in a country like our own which is not determined, in the public service okay, during recruitment they take both higher nursing diploma with state registered nurses. But if the ministry of health has to organise its recruitment it doesn’t take into consideration the higher nursing diploma, you see!” (Int12:1)

National recruitment recognises the HND only when the recruitment is organised by the ministry of public service. When ministry of health recruits it considers only its SRN holders. This creates tension and puts pressure on higher education by forcing students to choose ministry of health programmes for employment reasons. However, the data also suggests that some other nurses from higher education are recruited by the ministry of public health

“They are not willing to let go at the basic training level, they are not even willing to let go even when people have been trained now in terms of even how you hire. But you are hiring their products with mixed feelings, and there are many out there who have not been hired because of the same reason” (Int7:4)

When hiring takes place it is done grudgingly and the policy leads to a situation where many nurses are not employed because of where they are trained. This policy is perceived to be contributing to a nursing shortage:

“The nursing shortage still continues, it has not been resolved and this one is deliberate and policy driven because I think the nurses have been trained whether in the private or public sector, they have been trained they just need to be hired. But you see because of these conflicting ideologies and protecting turfs and so on, there is no harmonized policy to say fine let’s take theses nurses at this entry level and then they will continue with their careers, it is simple. It’s still the problem.” (Int7:5)

Conflicting ideologies around training is increasing the nursing shortage even when nurses are available to be employed. The lack of a harmonised education policy perpetuates the turf wars and ensures that trained nurses will not always be employed to meet the nursing shortage by virtue of their higher education training.

Personal prejudices

Data revealed conflicts which arise not from policy but rather from personal prejudices.

“you always find those people who are in charge and who had to take decisions that when they look at themselves they are not at the level or unit, they may be seeing you as a stumbling block on their way and they will not want you to advance” (Int10:1)

Nurses at the ministry of health with advanced diplomas blocked the recognition of those with higher qualifications in order to protect their status and positions.

“They somehow feel threatened that if they allow this young people to go into universities or they allow training to move into the universities, what that means is that young people will come out with higher qualification and that may jeopardize their job and their position.” (Int9:1)

Personal insecurity is a hindrance to advancing nurse education. Some nurses already in service see advancing education opportunities as a direct threat to their careers especially because they have lower qualifications than the new ones that are now available.

“I think that people are protecting their diplomas, they are not protecting the profession. They are protecting the kind of training they got, because I am a state registered nurse, I have to make sure that state registered nursing stays on the market, because I did HND let me protect HND, no! ” (Int9:3)

There seems to be little objectivity in addressing nurse education issues. The observed tendency is for nurses to back their form of training perpetuating a perception of ‘us against them’. This subjectivity is revealed in the data as follows:

“I have not been able to look at their programme [higher education programmes] but I think that it is really, it does not have that flesh” (Int8:4)

Strong arguments are made against other models without an objective assessment of the content of those programmes. There is more passion than reason in arguments and nurse leaders are failing to assess each programme model on its merits before taking a position for or against it. This demonstrates the strong influence of personal prejudices on nurse education.

Professional membership tensions

Another area of tension emerging from the data has to do with membership to professional nursing associations.

“…the prerequisite to register in the association is a diploma in your profession of three years consecutive training, academic training” (Int8:1)

Membership is only for those who have a three-year professional diploma implying that only SRN holders can be admitted as the HND is not seen as professional enough.

Some associations still reject even those nurses with bachelor degree qualifications:

“…you’re A-levels and you go and start doing a degree course when you have not yet been a professional. There is a jump, and that is why shows in the field. And that is why we are not registering them” (Int8:2)

Bachelor degree holders must begin first with the three-year SRN programme before they can be registered into the association. So going directly from high school into the degree programme disqualifies nursing graduates from registering with some professional associations within the country.

Resistance to higher qualifications

Elements in nursing have always resisted colleagues coming in with higher qualifications. From the early days of formal training, the first group of nurses were rejected by the dressers:

“Those who grew from the dresser profession claimed that there were more practical than the new nurses. They could do things in a more practical way and claimed nursing professionalism.” (Int3:4)

The dressers had better dexterity in technical skills than the incoming trained nurses and saw this as evidence of their superior abilities. Professionalism here is linked to dexterity in technical procedures. The resistance and misrepresentation of professionalism slowed down the growth of the profession:

The resistance emerged again when the university started training nurses. The existing SRN holders who took over from the dressers now argued that university trained nurses were not ‘professional’

“…they went studying theory and not the practical part of nursing and so problems between the two contesting factions –the factions that [had] people who were not university trained and…who were still at the level of SRN and the faculty nurses” (Int3:9)

So just like back in early years it is again about skills. The more experienced nurses who over time became very skilled resist the new highly qualified nurses because they are not as skilled:

“I think that it’s this tension ‘this child, why is this child trying to…have a bachelor’s degree while I am here I have worked for 10, 15, 20years and I don’t have a bachelor’s degree. When she comes here with a bachelor’s degree can she inject?...can she deliver a baby? I am here I can deliver 100 babies, I can do this but I don’t have a bachelor’s degree’” (Int9:2)

The perception seems to be that a higher qualification is not necessary as long as you are skilful in performing nursing tasks. Some nurses argue that every novice nurse needs time to perfect their skills:

Tension is also increased by the fact that the older nurses hold lower qualifications:

“This…war…exists…because those who are in the hospital-based schools, the trainers there are not having higher qualifications in nursing like bachelor degree or master’s degree.” (Int9:2b)

Having lower qualifications poses risk of potential loss to incoming highly qualified nurses and thus perpetuates resistance and conflict from the less qualified nurses. Making available advance education opportunities for this group may reduce these insecurities and promote collaboration.

Tension over title

The data revealed that nurses are not satisfied with the rampant use of the title ‘nurse’:

“You see that you will train as an auxiliary for six (6) months or nine (9) months - I am a nurse, for what? Eighteen (18) months I am a nurse; this this this- I am a nurse.” (Int3:3)

‘Nurse’ should not be applied to auxiliary care staff to facilitate recognition of the nurse. By presenting themselves as nurses, auxiliaries’ shortcomings affect professional status because stakeholders can’t make the out the difference.

Another area of tension is the use of the word ‘infirmiére’ for nurse by the Francophones

“For them ‘infirmiére’ means nurse. But then, the duties of the infirmiére were simply dispensing medication and doing minor treatment. It never from the primary stage ever meant…a conceptual framework wherein people can enrol, get trained and become

Anglophones translate ‘infirmiére’ as ‘infirmarian’, a role they perceive as auxiliary. Use of the francophone appellation is seen as representing the perception of the nurse as a skilled care assistant rather than a professional.

For some nurses there has to be redefinition of who a ‘nurse’ is.

“You need to redefine a nurse in this country. If we redefine a nurse in this country we need to now ask ourselves what a nurse should do in this country, with what training, then we need to go into the curriculum documents and look at them and ask ourselves whether it is going to give us that nurse that we want in this country.” (Int9:2c)

There is a search for a new identity for the nurse at this point in the evolution of the profession. This identity should be defined in curricular and education should aim at establishing and consolidating that identity. The emphasis on what the ‘country wants’ can be seen as indication for a national identity in addition to internationally accepted nurse identities.

Category Five: Turf Wars and Intra-Professional Conflicts

The category started from initial codes like ‘protecting your turf’, ‘continuing conflicts within nursing’, ‘resisting more qualified nurses’ and ‘using the title nurse’. Data was studied to refine these into focused codes that generated the subcategories reflecting the kinds and areas of tension in nurse education. The conflicts over control of nursing, employment controversies, professional membership tensions, resisting more qualified nurses, personal prejudices infringing on the profession as well as conflict over appellation revealed the tensions that affect the profession. It all boils down to a conflict between two major ideologies or models with nurses taking sides against each other. The category thus elaborates evidence of turf wars and intra-professional conflict.