Nurses show insufficient ability for autonomous practice:
“You cannot just sit there and wait for the doctor to come and order a nasogastric tube you should be able to assess and see that the patient needs a nasogastric tube yes! And when the doctor comes and ask you, you will stand your ground and say I needed to put this up immediately because of this, that, that” (Int10:1)
Nurses fail to manage patient care as expected of them and depend on physician’s instructions. The ability to perform expected nursing roles provides a means of establishing the autonomy of their practice.
Nurses in leadership positions are seen to demonstrate unprofessional behaviours:
“I asked N, that why you are here just watching your profession being trampled upon and you are just watching quietly, what is your own role? She said when she goes on retirement that’s when she will stand up and speak.” (Int8:8)
Some nurse leaders fear advocating for proper nurse education policies because they might lose their positions. Advocacy is reserved for retirement when there is nothing to lose in the process.
Some nurses are not ready to learn and don’t get involved in scientific activities
“And they are not willing to learn, they are not willing to learn (Int8:2)…What do nurses do? Once you are through and are given a little job, when they close either they go to the
drinking joint, meeting houses or farms (Int8:3)…You cannot find them in academic forums to discuss something” (Int8:4)
Continuous learning, organising and participating in scientific/academic events is an aspect of professionalism that is not strongly emphasised by some nurses. Failing to organise and take part in such forums misses opportunities for continuing learning and capacity building.
Some nurses have linked shortcomings in professionalism to nurse education:
“If you ask a nurse who has passed through our nursing education process, can you detail the activities you will carry out on a vaserectomy post-operation patient for the first three hours. Will she tell you?” (Int3:6)
The educational system doesn’t adequately prepare nurses to perform their roles in the different clinical scenarios they could find themselves in. Inability to meet those expectations diminishes professionalism.
Nurses should become more assertive of their role and change the way nurse education is implemented:
“I mean…in class we said we should go out of this “the doctor has said” and create our own abilities, our own technicalities, our own professionalism wherein you can proudly say that as a professional nurse I decided to put a nasogastric tube because for two days this patient has not eaten since I admitted the patient” (Int3:12)
Training has to move from emphasising carrying out orders to defining the autonomous role of the nurse in patient care. This also reflects defining the identity of the nurse as an autonomous practitioner.
Education is perceived as the key to addressing lack of professionalism in practice:
“If in nursing education we can succeed in getting nurses perceive [emphasis] their role in patient care, perceive their role in what they are doing and taking doctors instruction ooooh!
We would have gone miles and miles! But when shall that come? When shall that come?” (Int3:2)
The belief then is that nurses have to be trained to master their role as autonomous professionals who can function independently of the physician. However, such a scenario seems a long way off implying the quality of training taking place now can’t achieve this outcome.
Inferiority complex
Some nurses lack the confidence to operate as professionals and take decisions
“We are the ones to take our decisions and because people of – our level is too low, they are afraid to take decision and they are still hanging on doctors to be deciding for them.” (Int8:4)
The lack of confidence is due to low levels of education which cause the nurse to rely on the more educated physician for guidance and decision making.
Lack of confidence and deference to physician is directly linked to educational levels:
“because these nurses are having low qualifications, some of them are nursing assistants that will not be considered as nurses in this country, and then the ones who are nurses had diplomas and should I say they don’t know their left from their right, they don’t know their
rights as professionals so they tend succumb to that subordination and think that okay the doctor is higher than them, they don’t see them as colleagues or team members.” (Int9:1)
Nurses with low levels of education are not academically prepared to apply critical thinking and make care decisions. This leads to an increase dependence on physician’s instructions because they trust the physician’s knowledge base better than their own.
Demonstrating knowledge and competence will earn nurses respect:
“If you talk intelligently, if you talk squarely on your profession they cannot do anything without calling you. And when they do it without calling you, you too will nullify it” (int8:1)
Education promotes confidence and makes the nurse more convincing in professional debates. These will cause policy makers to defer to the nurse when it comes to nurse education issues.
Disregard for the nursing profession
Nurses perceive that their profession is disregarded by other stakeholders. At the level of the political administration the profession is not given the respect it deserves.
“The last time we had a nursing society programme in Buea, we were there more than 500 or 700 nurses were there. I was very surprised that the minister did not bother to come and open or close the session.” (Int6:2)
The presence of public administrators during professional events is a key indicator of the importance of that profession to public life. Nurses see the absence of the minister during their own event as indication that they are not a valuable group within the health system.
Disregard of the profession is also perceived when doctors are given power over nursing:
“It was hard for them to understand that a nurse was somebody who had also gone through adequate academic training before going in into professional training they looked on them as though they were subordinates. And that is why even in the ministry we hear anything concerning nurses they were the doctors that were put in charge, even on the nursing training.” (Int12:1)
Physicians don’t recognise the education that nurses undergo as sufficient to earn equality and respect. In addition to this policy makers assume that physicians can make decisions on nurse education and so place them in positions to do so.
The members of the public don’t see nursing as an autonomous profession:
“I think that people in this country don’t yet consider nurses [sic] as a profession (Int9:1)…A lot of people still think that we are a doctor’s handmaid” (Int9:2)
Public perception of nursing is as a supporting profession to medicine and not an autonomous one as nurses will love to be seen. The situation some nurses say is again linked to education:
“one of the reasons that made nursing not to be regarded was that the entry qualification were not well defined as compared to medicine” (Int1:2)
Entry into medical schools is clearly defined and highly competitive as opposed to nursing programmes. People with little general education have access to nursing education thus reducing the status of the profession in the eyes of the public.
Conceptualising nursing
Nurses link deficiencies in professionalism to the lack of conceptualisation of nurse education:
“Conceptualising nursing is a way of nursing education that says that when you are giving that injection what does it mean for the patient?...When you were doing that dressing, you have done it so well but then what does it mean for the patient? What have you done for that patient? How has that patient conceptualised your practice during the dressing? This is where there is a big problem.” (Int3:5)
Conceptualisation goes beyond the psychomotor intervention in practice. It includes critical thinking, involving the patient actively in care decisions and transmitting the value of nursing care to the patient. The focus on technical skills is insufficient:
“…we need to develop a policy of conceptual practice. As observed the policy is technical practice and that is what the doctors know” (Int3:14)
The skill-focused model that characterises hospital-based training is what physicians recognise as it fits their perception of nursing as a supporting role. Introducing conceptual practice sets nursing apart and deviates from the handmaid-perception of the nurse.
“Teach others that the patient is not just suffering from pain and then we are saying “ashia” “ashia yah” “E go cold yah” But then that pain is more than the ‘ashia’ we are saying.
Whether it will be to study the psychoanalysis of that pain, tell me the emotional content of that pain then you can well appreciate the physical factor of it that is showing up. Just seeing like that is not only psycho-emotional…What is behind the pain, the causative factor of that pain? We know that it is emotional for that patient and the “ashia ashia very soon e go cold,” it will not be cold because the psycho emotional content has not moderated.” (Int3:11)
Nurse education should prepare nurses to be able to bring together knowledge, skills and affect into the assessment, care of, and interaction with the patient. Without this kind of model, care is substandard and the patient can’t really be satisfied with nursing services and nurses don’t get fulfilment.
“That is where we can lift, have an uplift in nursing practice. That is even where the nurse can obtain her own satisfaction” (Int3:12)
Conceptualisation will improve practice in a way that patients will be able to identify the autonomous nursing role and better appreciate the services of nurses. That recognition will bring fulfilment to the nurse.
Conceptualisation has not been fully achieved even at higher levels of education:
“…we begin to see a change in mentality, in conceptualising nursing, this is at the level of education, university, conceptualising nursing.” (Int3:1)
University level programmes are being seen to be gradually conceptualising nursing practice. This thus is making the case for nurse education to move to the university.
Professional independence
Data also revealed a desire by nurses for full professional autonomy. Nurses perceive that absence of autonomy will continue to slow down professional advancement
“That’s where we have had some problems in trying to advance the nursing profession when the nurses are not given the opportunity to speak on behalf of their own profession.” (Int12:1)
Nurses think they have not had the opportunity to represent their own profession and so articulate forcefully the case of professional advancement.
The nurses want to be the main players in decision making when it comes to their profession:
“We need to be main actors; nurses need to be the main actors driving their profession. They are not! They are not in the driving seat! Somebody else is in the driving seat and somebody who does not have a listening ear, so the question is who is going to do it? That’s the big
issue right now.” (Int7:1)
Non-nurses lead and make decisions on nurse education without listening to nurses’ views. Nurses seem to feel helpless as they seek their own nurse-led leadership. Thus the awareness of the need is felt, the solution is known and the nurses desire to get there.
The teaching role
Teaching nurses is one of the key facts that emerged from the data. The first issue is that there is significant presence of non-nurses among nurse teachers:
“…you get to a nurse training programme and find few nurses teaching. The greater part of the teachers are medical laboratory scientists and medical doctors who are not nurses and don’t understand the philosophy of nursing…it’s true that they need to come in for inter-
professional learning because in medicine, we have to have all those people but what they do matters.” (Int9:3)
The significant involvement of non-nurses dilutes the transmission of the nursing philosophy to students. The role of non-nurses is acknowledged for inter-professional education but their influence should be limited to that role.
In other scenarios, nurses involved in teaching roles are not adequately qualified:
“The issue with teachers is that a good number of them are not qualified to teach nurses at the level where they teach” (Int9:1)
Some nurses teach at levels where their qualification is inadequate. This poses a risk to the quality of education the students receive. Qualified teachers should be academically prepared for their role:
“I think that a good teacher first, is that person who has a nursing background, who understands philosophy, the scope of nursing in this country, that person has a teaching certificate, who has been trained to be a teacher, it could be at whatever level, certificate level, but that person must have been trained, undertaken a teaching programme to become a teacher.” (Int9:7)
A good nurse is therefore not necessarily a good educator. Nurse educators must master the philosophy and scope of nursing practice and should have an academic qualification backing them.
Inter-professional collaboration
Nurses recognise the role of other professionals in nurse education as evident in the data.
“As nurses we have skills, there are certain skills that we need that cuts across other disciplines, for example as a nurse in this country you may be expected to collect specimen. Normally that specimen collection is the work of the laboratory scientist but in Cameroon given the limited resources, lack of nurses and all of that we have to do such things. So we need the laboratory person to come to the classroom and tell us how to do it better because they are better in doing it, but they cannot come and take over the profession.” (Int9:2)
Skills which are not primarily nursing but are being borrowed from other professions are best taught by such professionals to enhance their effective transmission to students. So when other health professionals are invited into nurse education it should not be to teach nursing or take over the profession but to teach nurses that particular content that is taken from his field.
Nurses expect key elements of training to remain in the hands of nurses:
“The nurses should play that role, they should teach, they should evaluate. They have the competence; they know any activity can be evaluated based on the primary objectives set by the nurses themselves not the doctors.” (Int7:1)
Teaching and evaluation of nursing and nursing programmes should primarily be the prerogative of nurses because they understand the goal of training and can best evaluate its outcome.
Professional recognition
There is a desire among nurses to see the recognition of their profession.
Participants believe that nurses are still to win the confidence of the patients:
“The perception of the patient about your practice: what language – can that patient also say “thank you nurse, I thank you nurse, I appreciate” as they say to the doctor… Have we seen a patient who has ever said that? That “that drug that you prescribed and given by the nurse” – meaning that it was given at the correct time and the correct dose and given to the
correct patient, all those five things, can a patient say that?”
Patients can’t see the input of nurses in their care. Their perception is that nurses only carry out the instructions of the doctor and so when they recover from their illness they give all credit to the doctor. Nurses should practice autonomously to earn recognition from patients.
Participants recount the value of proper nursing input to the health care service:
“We know that research has shown that where nursing care is very, very good, the rest of the public health indices improve automatically. For one thing their numbers matter, their skills matter, their intellectual know-how matters, then the care that they give matter. That is not considered, that is a big problem.” (Int7:1)
Nurses are vital to improving public health indicators if they are carrying out their duties as professionals. Improvement of such indices strengthens and improves the profession’s status among all other stakeholders.
Category Eight: Professionalising Nursing
The category covers key issues related to professionalism in nursing as emerging from the data. Subcategories like: deficiencies in professionalism; inferiority complex; disregarding nursing; conceptualising nursing; professional independence; the teaching role; inter-professional collaboration; and professional recognition weave together the picture of how nurses grapple with professionalising their practice. The category reflects clearly the self-criticism, realisation of shortcomings, and a desire to gain patients’ recognition among nurses. These indicate that professionalism is a tool to secure the profession’s status by earning the respect and confidence of the public.