Garantías Otorgadas

During all the focus groups and even during individual interviews it was often stated ‘well, that is Malta’. It was felt that certain things were accepted just because things have been ‘like that’ for so many years and that there were ‘hidden’ rules that occurred that were just known and not challenged. This cultural element was thought to further provide context to the findings described in this section of the chapter.

“Undisciplined …We accept everything.” (FG4 .N,4) or

“This is another thing about culture. You learn through your experience, through your own experience.” (FG4 .N,4).

4.12.1 Promotional Systems in Malta

Only one group of stakeholders mentioned the grading of nursing and that of specialist nurses. The Multidisciplinary Group recognised that in nursing there was an anomaly with the grades (salary scales) and that specialist nurses needed to be upgraded. They stated that they should be paid in the same salary band as Senior Nursing Managers, although they had completely different roles. This was supported by the specialist nurses who stated that they deserved a salary scale increase that would not demand them to leave their specialist role and go into administration.

“in the previous structure you had a Departmental Nursing manager, responsible for a number of wards and areas within a speciality. They are on par, there; they are part of that directorate. (FG1. MDP,2)

“I wish that our grades were improved because I find it unfair that for me to get a promotion and an increase in grade and wage I would have to leave this unit and my specialisation...” SN 2

Specialist nurses and most stakeholders also felt that there needed to be a change in the way nurses are promoted, or chosen for positions within the health service. It was noticeable that the Directorate of Nursing group did not discuss issues that were discussed by all other participants, such as the promotional system of nursing in Malta, the paucity of career structure to progress and the loss of expertise due to these factors. It emerged that in this system, a nurse who worked in an area all her career could be sent as a nurse manager in a completely alien working environment to that which s/he was expert in, and was expected to lead a group of nurses. Consultants were once again very critical of this situation in the nursing profession and emphasised that this needed to be changed and that calls for application should be issued for the specific area to attract the right people for the job and keep experts in their area. An example was given of one Theatre Nurse who was promoted to Charge Nurse and sent to the Mental Health Hospital. There was also agreement that a nurse might be brilliant in practice but not in management and thus you will be losing very valuable expertise.

“Well I think there is a big problem with nursing grading in that to get a promotion, and to get paid more money, you have to become a manager. So you might have a very experienced theatre nurse, who enjoys her work, and her only way of getting seniority is to become a manager, and she might be a very bad manager, but a very good theatre nurse…”(FG3. Cons,6)

Most stressed that the whole system of Nursing needed to be changed to aid the national development of these nurses. The career structure should start from the first day of

employment and nurses should be encouraged to work in an area of their choice and not just sent anywhere in the hospital. This was particularly emphasised by the consultants:

“So the first step is that when nurses come into work, when they are employed, they go to the area where they are best suited for and where they are most likely to give their best output. (FG3. Cons,5)

4.12.2 Politics in Malta with the big ‘P’

It was also evident that the system of promotions or ‘choosing’ professionals was not always transparent and in fact one nurse stated that these posts should not be for ‘blue eyed’ boys. Another consultant stated that there should be a system that cannot be bent to ‘fit’ individuals and yet another explained that sometimes calls for application are not even issued and people are handpicked. In these instances they seemed to be inferring that the system was nepotistic. There was an element, both during the groups and individual interviews, that this lack of meritocracy could be another effect on the professional recognition of nursing posts, both past and present, which could stall progress.

“Well. Criteria should be well defined and written and agreed upon by all stakeholders… Yes, and not some blue eyed boy or whatever, he should be academically well trained, experience is extremely important...” (FG4. N,1)

“There should not be a system that fits individuals, so we can bend it. There should be one system for all, like we have a specialist register for specialists in medicine and to become a specialist you have to follow the full training.” (FG3. Cons,1)

“Or else even worst is if there will be no interview and somebody is put in that role.” SN 3

In the Nurses’ Focus group the strong political situation in Malta was also referenced as a situation that did not help nursing in general to develop. According to the participants there were too many changes in such a short period of time to build relationships and make the necessary changes. As one nurse expressed, this system destroys everything:

….and there is not enough time to rebuild relationships, when it happens that fast. When you have three directors in one year, for me it destroys everything. (FG4. N,4)

Due to these factors and especially due to the recent changes in Directors at the general hospital, one participant in the MDT focus group stated that the strategy should encompass a vision shared by all stakeholders, and not be attached to a particular person or individual group because if those individuals moved on there would be a problem to sustain it.

“So, I ask is that vision embedded in our values, because if it were it would be no problem to continue with that strategy and we could move on in the person’s absence. But if we had to restart every time then we have to question the strategy.” (FG1. MDP,6)

Finally, it was emphasised that when introducing new systems or innovative roles Malta needed to be intelligent, cautious and ready to learn from other countries. A participant emphasised the need to take the Maltese local situation into consideration when adopting foreign models of healthcare. It was imperative, as she stressed, that whatever was imported would fit into the culture and also ascertain that the resources are available to sustain the changes implemented. The lack of planning was once again discussed in the MDT focus group.

“…we have to be intelligent enough that we adopt what models are in keeping with our culture, and I am talking about culture in the bio-medical culture, that we are part of because sometimes unfortunately we tend to follow and we don’t learn from their mistakes.” (FG2. D,2)

“I think we need a strategy because we suffer a lot in this country because we tend to get this and this and this without a plan. It is sometimes who shouts the loudest who gets it. There is no plan…But without a strategy we will suffer.” (FG1. MDP,7)

4.12.3 Recruitment and engagement of Specialist nurses

The engagement of specialist nurses was another topic discussed by both the specialist nurses and their stakeholders. According to most participants a ‘simple’ interview giving the right to work as a practice (specialist) nurse should be improved by developing these nurses before they actually start their new career. It was suggested that further work was needed to choose the right people during the recruitment phase and that one of the criteria to become a specialist nurse should be a passion for the area they work in and the willingness to further their studies both in the field and also on a continuous level of professional development. Experience in general and in the specialist area was also mentioned as a pre-requisite. A director strongly stated:

“My opinion after ten years is that it is not an experiment anymore, and I think that one needs to consider how for example, these practice nurses are being engaged. It is a simple interview, and from this the next day you will be appointed a practice nurse, and an interview makes you a practice nurse?...I think we need to try and find a way how these practice nurses need to develop themselves before they start their new professional job.” (FG2. D,7)

Another Director went a step further and stated that prior to engagement, the job descriptions should also be changed to allow for the expansion of their role since in her

experience they were restricting the development of these specialist nurses. Some specialist nurses, were not embracing the notion of their role evolving other than what was stated in their original contract that could be anything up to a decade old.

“…also within these job descriptions or structures, one has also to add that people who take them, have also to be open and able to change…we need an evolving job description but I don’t know how one could go about it. So we won’t get stopped if all of a sudden, a specialist nurse needs to carry out some clinical skills that have now become assigned to us; that we are not stopped by a rigid job description. (FG2. D,2)

Having a system similar to that of the medical profession that will allow professionals to specialise after the call for applications was also mentioned by the specialist nurses themselves. This was thought important since Malta is a small country with limited opportunities and the investment by the professional will be useless if they were not chosen for the post or if the vacancy never materialised.

“You cannot really expect people to invest their time and energy in a Masters in a speciality and then the call never comes out. …I mean this is the same as the doctors; nobody specialises in, Jien Naf [trans. I don’t know] surgery, unless they have a post as an HST or BST in surgery. It is not worth investing in that field since the call may not be issued or in the interview you are not chosen and somebody else is chosen.” SN3

A couple of specialist nurses distinctively stated that when they recruit a nurse they would wish to know her before joining the team:

“I think I would want to know that person beforehand, before having her on my team, not somebody who is just given to me.” SN 4

This was an unexpected request, however they explained that one might be working with this person for life in the current situation in Malta. It was also considered necessary to know how capable she is to work alone, with patients and within a team. Thus they felt it necessary that they would be part of the selection group and not be just given ‘a nurse’ to join because this could affect the whole team and service if chosen incorrectly. This was also considered important by the Consultants who further explained that as experts in their field and running their clinics they should be involved in who, and how many specialist nurses were recruited. They referred to another criticized system in Malta that ‘no one is ever fired’ thus if you get an unlucky draw of a nurse you are stuck with her/him for the rest of your career.

“Here you cannot do it even from the legal point of view … God knows I had proof and I had everything and I had to pass through a lot of hell and this one wasn’t even fired, he was placed somewhere else.” (FG4 .N,5)

The ‘silo’ situation of the hospital was referred to and most insisted that this did not bode well for the specialist nurse right from the very beginning of her engagement.

“Over here there are these silo effects…So if we have a unit, we have no say at all on how these nurses apply, are selected, chosen, how many they are, there is none of that…” (FG3. Cons,6)