Nursing in Nigeria, the journey so far and way forward. Dr. B.L. AJIBADE
A PAPER PRESENTED AT THE 6TH BIENNIAL AND 5TH QUADRENNIAL DELEGATE CONFERENCE ORGANISED BY
THE NATIONAL ASSOCIATION OF NIGERIA NURSES AND MIDWIVES (NANNM)
21ST NOVEMBER, 2012
GRAYLAND CULTURAL CENTRE, YENOGOA
B. L. AJIBADE (RN, Ph. D, FWACN)
LADOKE AKINTOLA UNIVERSITY OF TECHNOLOGY, OGBOMOSO
COLLEGE OF HEALTH SCIENCES,
DEPARTMENT OF NURSING, OSOGBO
NURSING IN NIGERIA THE JOURNEY SO FAR AND WAY FORWARD
The contemporary nurse constantly faces series of technological, managerial, administrative, political and economic changes involving new ideas, new values and new problems that may need on the spot decisions and solutions. It is therefore obvious that contemporary nurses need a new orientation, derived from the study of the past to help them successfully with developing changes in the health care industry.
The history of nursing in Nigeria includes many clinical, technological, scientific, social, cultural and educational aspects with critical implications for all properties required in modern decision making that could qualify nursing as a full fledged profession, sui-generis. Therefore, knowledge of past experience will definitely create a better understanding of the present and can cast some light on the pathway to planning the future without a knowledge of the past. Contemporary nurses therefore need to view their work against a multi-dimensional back-drop in order to be able to define, classify, appreciate and confront the multiple and complex problems they have to face constantly with confidence.
Nursing as a profession came into existence, rested, savoured and consolidated its position by developing its own language, rituals, ethics, arts and sciences from the physical needs of patients, the principles and concepts of prevention, its own body of traditions, attitudes, culture and values which were mainly drawn from the army and religious orders. High discipline with stern reprimands formed the foundations of the profession and developed with it.
The quiet evolution taking place in the nursing world today, the impact of which is being felt in developing countries of the world including our own country Nigeria, was largely influenced by internal and external developmental forces such as the influence of the world War II, impact of technological and industrial world and the society at large; tremendous advances in medical sciences and medical technology, changes and complex structure of hospital organization and management of health care industry; changing concept of patient care and early ambulation, perennial shortage of doctors and trained nurses; increased off-shoot of para-medical professions, the activities of the World Health Organization, a follow-up on the United Nations Universal Declaration of Human Rights of 1948 article 25(i) which states inter alia that “It is to be a fundamental human right for every person to have a standard of living adequate for the health and well being of himself and his family including food, clothing, housing medical care and necessary social services’’ (Adelowo, 1989, P.11). The resultant effect was for people to demand better health care services of different kinds including the developing role of nurse which was adopted by the Council of National Representative of the International Council of Nurses, Mexico City, Mexico in May, 1973.
Having perused over the introduction of the topical issue, it will be imperative on us to have phase by phases historical perspective of Nursing Growth in Nigeria.
Colonial Era:- Along with the administrative changes that took place with the establishment of the Colonial and protectorate of Nigeria came the need to establish hospitals and nursing homes in important towns in Nigeria. The first government hospital to be founded in Nigeria was St. Margret Hopsital, Calabar. It was established in 1894 with Miss. Margret Graham as the first Nursing Sister. Miss. Graham was joined by Miss Jane Mac Cofter who later established the famous Abeokuta Infant Welfare Centre for the training of Midwives. The Centre specialized in domiciliary services.
Growth of Scientific Nursing:- Modern scientific nursing started with the crusading efforts of the British War Secretary, Sidney Herbert, who organized a team of nurses led by Miss. Florence Nightingale to the Crimean War (1854 – 1856). Miss. Nightingale combined Christian ideals, strict discipline and a sense of mission to open the door for what is known today as the nursing profession.
By the end of the 19th Century, England and the Countries of continental Europe had started the apprenticeship of nurse training. The rapid changes brought about by the courageous lady, Miss. Florence Nightingale into British and North America nursing education system and practice had tremendous impact on the development of nursing education and practice in Nigeria.
There is no doubt that the standard of nursing training during the pre-colonial era in the various mission posts which later formed the nucleus of the various training schools for professional nurses and midwives was lower than apprenticeship type of training. People recruited had no formal education other than being loyal housemaid, servants, cooks or stewards to the missionaries. In short, apart from the nursing or reverend sisters, all others could at best be regarded as aides.
During the Colonial days, the pervading British influence had marked the beginning of modern nursing as well as formal nursing training in Nursing. The crusading efforts of Florence Nightingale had gained ground, graduates of Florence Nightingale School had taken over the campaign for organized and formal training for nurses all over the world, especially to the British Colonies and protectorates such as Nigeria. By the end of the 19th Century and early 20th Century, training of nurses and midwives had started in Nigeria. In 1930 formal nursing and midwifery training had started mostly in mission hospital, and a few African government hospital.
Initially, when formal training of nurses started in Nigeria, the profession was predominantly a male profession: The reason behind this is that Nigerian culture gives man superior social status which was reflected in the fact that a very small percentage of girls were given formal education. Most fathers believed that it was a waste of money to invest on the education of girls.
Immediately after the end of World War II, there was an increase in the number of male nurses because of an influx of many soldiers that were discharged from the West African. Army Medical Corps of the British Army. The profession remained predominantly male to such extent that male nurses were made to take change of female wards and work on the ward as pupil nurses, student nurses and staff nurses.
The year 1952 saw the beginning of the taking over of the nursing profession by female nurses when the University College Hospital, Ibadan established it’s Nursing School (the premier teaching hospital nursing school in Nigeria). Miss Bell, a graduate of Lady Florence Nightingale School of Nursing from St. Thomas Hospital, London, was the first Principal of the School. The School authority made it a very strong rule not to accept male nurses into training. This Minimm basic education for entry into the school was fixed as full secondary school education whereas in Government nursing training schools the minimum acceptable educational qualification was standard VI and Government Class IV in some regions. The UCH training was generally accepted as superior and equivalent to SRN (State Registered Nurse) in England and Wales. Many more Teaching Hospitals Schools of Nursing were later established by the same Principal and with the same Principles and objectives. Lagos University, Ahmadu Bello University, University of Benin, University of Nigeria, Nsukka and the Obafemi Awolowo University all have nursing schools. Today, the nursing profession in Nigeria is predominantly a female one as female nurses have taken over population-wise and are in position of leadership.
Nursing Legislation: The continuous inflow of new Knowledge in health care, Science and Technology as well as the rapid socio-economic, educational and political changes all over the World made it necessary to regulate the training of nurses and midwives in the Country. For example, the midwives Board of Nigeria came into existence by the Midwives Ordinance of 1930. The first meeting of the Board was held in June, 1931. Later the Midwives Decree of 1966 put greater emphasis on the education of Midwives and the Practice of Scientific Midwifery in the nation. The Board has the duty of determining the standard and skill to be attained by people seeking to become members of the Midwifery profession in Nigeria as well as to formulate policies on registration of midwives, and maintenance of discipline among members of the profession. Later on, the Board acted as examining body with its own approved syllabus for Grade II and Grade I Midwifery Certificate. It is pertinent to mention that most mission hospitals Schools of Midwifery trained Grade II Midwives, while Grade I midwives were trained by government approved schools of midwifery.
The entry qualification and period of training for Midwifery Grade II were standard VI and one year respectively. Among the most popular training schools for this cadre of midwives were - Egba Native Authority School of midwifery under Miss. Jane Mc Cotter, whose name was almost synonyms with the training center, and Wesley Guild Hospital, Ilesha, Mercy Street Hospital, now Lagos Island Children Hospital, was popularly Known for Grade 1 mid-wifery training.
With the midwives Board Degree 1966, the training of Grade II midwives was phased out and a better syllabus for training of midwives was provided.
Nursing Council of Nigeria:- The Nursing Council of Nigeria Came into existence officially by the Nurses ordinances of August 1947. Though in the Lagos Colony, legislation had been made for nurses but not until 1946 did the first Nursing ordinances came out, and this came into operation in August, 1947. This ordinance for the first time laid down requirements for the education, examination, registration and discipline of nurses. The practice of organized nursing service and training at the period was characterized by what we now refer to as phase one of nursing development, a time when training of nurses was purely apprenticeship type of training and when emphasis was upon physical aspects of nursing and medical care of hospital patients.
The First Phase: received impetus as a result of the Goldmark Report of 1923 which had as its objectives a study of general nursing education with a view to developing a programme for further study and recommendation of procedure. This study led to a shift in focus of nursing practice from a primary emphasis on physical aspects of nursing patients in clinical units of hospitals to the inclusion of general nursing of patients and families in homes and health agencies.
The Second Phase: began with the completion of the Brown Report in 1948 which had as one of its major objectives to receive nursing service and education in terms of what is best for society. This eventually led to the extension of the concept of professional nursing practice to include comprehensive nursing that is nursing the body and the mind, with all other social needs of patients. In a nutshell, this means effective planning and implementing nursing care for each individual person according to his particular needs.
The Third phase: Nursing today is characterized by a sharp shift to scientific nursing by principles and concepts rather than by rigid rules of procedures.
THE INDEPENDENT NIGERIA: Nigeria as a political entity came into formal existence in 1914 with the amalgamation of the Northern and Southern British protectorates. The imposition of British rule culminated in the birth of a nation. The nation achieved independence on October 1, 1960. On October 1, 1963 Nigeria became a republic. As I have elucidated in the introductory aspect of this discourse, the history of nursing as a profession has a lot in common with the political and socio-economic history of the Country. After independence, there was an increase in the level of education, increase awareness of the quiet evolution taking place in the nursing world as a result of the impact of World-wide technological and industrial development. There were also changes in the structure of hospital organization, the management of health care industry, the concept of patient, care plus the activities of the World Health Organization. All these influenced the nation’s health care planners to develop a new philosophy of health care different from the Colonial heritage.
Nigeria as a young nation has about 80% of her population living in rural areas and a perennial shortage of doctors and trained nurses. Mindful of the fact that the type of nursing training provided determines the type of quality of nursing care the society gets, and mindful of their statutory obligation and responsibility for the nursing education and training in the Country, the Nursing Council of Nigeria decided to set up a committee to revise the system of nursing education in the Country. The committee submitted the new standard of Nursing Education Syllabus which was approved in 1965.
The Committee was to look into the existing working situation in the Country with regards to the performance of certain traditional functions of doctors by nurses. They were to examine the possibility of including some of these functions in the basic programme without conflicting with the international responsibility of nursing. Professor F. O. Okedeji of the University of Ibadan was unanimously elected as the Chairman of the Committee, while Mrs. S. O. Savage, Deputy Chief Nursing Officer, Federal Ministry of Health was appointed Secretary to the Committee. After the untimely death of professor Okedeji, Professor (Mrs.) E. O. Adebo, Head, Department of Nursing University of Ibadan took over the Chairmanship of the committee. Other members of the committee included –
§ Miss. O. O. Kujore – Head, Dept of Nursing and Medical Rehab, O.A.U. Ife.
§ Mrs. O. O. Alade – Principal School of Nursing, UCH, Ibadan. Alhaji D. A. Adamu, Principal Nursing Officer, Ministry of Health Kano.
§ Mr. P. O. Odeh, Chief Nursing Officer, General Hospital Makurdi, Benue State.
§ Mrs. N. N. I. Nwangwu, Matrim, University Teaching Hospital, Enugu, Anambra State.
§ Prof. O. Ransome Kuti, Head, Dept. of Paediatrics Lagos University Teaching Hospital, Lagos and Director Primary Health Service Scheme.
§ Mr. J. A. Akinsanya, Deputy Secretary/Registrar (Education), Nursing Council of Nigeria.
§ Dr. A. B. Sulaiman, Director Health Planning Directorate, Federal Ministry of Health, Lagos.
§ Mrs. Akpofure, Chief Education Officer, Federal Ministry.
§ Mrs. R. O. Sosanya, Principal School of Midwifery, Ijebu-Ode.
The Committee believed that sound educational principles are essential ingredients to prepare nurse for their functions, that the basic nursing education programme should be geared both to the learning needs of the students and health needs of the community to be served. This way, the students’ critical faculties and skills in problem solving will improve greatly. Based upon the above information, the committee adopted philosophy of nursing to be based on nature of nursing care and the nature of nursing.
The pioneering Nurses ordinance of August, 1947 was replaced by the Nurses Act of 1957 and the Nurses ordinance of 1959, a new ordinance enacted to reflect the new political structure in the Country following the introduction of the MacPherson constitution in 1954.
The new ordinance reconstituted the defunct Nursing Council of Nigeria. It provided for the inclusion of members representing their regions membership of the Council was increased to 21, all of whom, except two were nurses. It has representatives from all the states of the federation. The Nurses Amendment Act, 1974 No 30 (20th July, 1974) provided for inclusion of three registered, nurses appointed by the minister from nursing organizations.
EVOLUTION OF PSYCHIATRIC NURSING IN NIGERIA
The first formal training centre for psychiatric nursing in Nigeria was established at Lantoro Hospital, Abeokuta in 1950. The centre offered “Selection Course” for inspectors and clerical officers who were interested and sufficiently motivated to study psychiatric Nursing. Government scholarships were made available for those found suitable for training. Many lunatic attendants from Yaba Asylum (now Psychiatric Hospital) Yaba, Lagos and from Calabar took advantage of selection course.
The course was run by Mr. Osita Aduba, the first male Nigerian male Nursing council registrar. It paid good dividend as great improvement was observed in the system of nursing in Lantoro. Chaining and locking up of patients disappeared. The year 1954 witnessed the arrivall of professor Lambo, the first Nigerian Psychiatrist from England to Lantoro Asylum and Aro Mental Hospital Abeokuta. He improved on the “Selection Course” and established the premiere school of psychiatric nursing, Aro Hospital Abeokuta in 1954 with 27 male and female student nurses under the tutorship of Mr. Maxwel, an expatriate nursing superintendent.
The Nursing Council of Nigeria gave the school recognition in 1958. The first qualified nurse tutor of the school was Mr. D.A. Babayode who was also the first Nigerian psychiatric nurse tutor.
Psychiatric nursing education has gone through different phases of development. Schools of nursing throughout the States of Nigeria now operate the new syllabus. This new syllabus includes 8 weeks of introduction to the principles and concepts of psychiatric nursing, thereby improving tremendously the quality of nursing education.
GROWTH OF PUBLIC HEALTH NURSING IN NIGERIA
Qualified health visitors were recruited from United Kingdom by the government to start the training of public health nursing in Nigeria. Locally trained mid-wives grade II were also recruited by government as student health visitors in training. Period of training for this cadre was 3½ years. At present, Nigeria has schools scattered throughout the federation for the training of public health nurses and University matters’ degree programme for the award of MPH.
POST – BASIC NURSING EDUCATION IN NIGERIA
Post – basic nursing education is a formal structured post registration nursing course of not less than one academic year.
Nurse Tutors Programme: The nurse tutors training programme was started at the National Technical Teachers College, Lagos by the Federal Ministry of Health in 1969. The programme was started due to acute shortage of nurse tutors which became glaring after the creation of states – and opening of new schools of nursing and midwifery. The programme started as a crash programme of one academic year duration and was supposed to fold up after a few years. However, due to the creation of more states which gave rise to the need for opening more schools of nursing, midwifery, psychiatry, public Health and the establishment of Schools of health technology, the Ministry had no choice than to carry on the programme and even established similar programmes at the institute of Management and Technology, Enugu (1976), the Polytechnic Kaduna (1977) and UCH, Ibadan (1977/78): An evaluation of this programme after five years of existence showed that one year was not sufficient to prepare students for the diverse functions they were supposed to perform at the end of the course. The two year programme was started in 1975.
UNIVERSITY OF IBADAN POST – BASIC (BSC) NURSING PROGRAMME
The post-basic nursing degree programme at the University of Ibadan was established in 1965 as a joint effort of the Federal Government of Nigeria, World Health Organization (WHO), and the United Nations Children’s Fund (UNICEF). The purpose of the programme was to prepare registered as nurse tutors and nurse administrators to meet the needs of the rapidly expanding health services in Nigeria and Africa as a whole. This programme has metamorphosed into training generic nurses as it happens now in many of Universities offering nursing courses.
ADVENT OF NATIONAL ASSOCIATION OF NIGERIAN NURSES AND MIDWIFES (NANNM)
The first nurses organization was the defunct Nigerian Nurses Association (NNA) registered in 1943. It had as foundation members a very high percentage of nurses trained locally in Nigeria who represented a majority of nurses serving in Nigeria. The association was officially registered as a trade union in 1943 by Mr. Kuti. Late Mr. N. A. Cole, the first full time general secretary was the president of the Trade Union Congress of Nigeria between 1945 and 1948. Although not a nurse by profession, Mr. Cole (Late) fought bravely and deligently to promote the growth and development of nursing in Nigeria until his retirement in 1973 and death in 1975. Mr. Cole was succeeded by Mr. S. S. Okezie who was assisted by Chief Adeleke as Deputy General Secretary, Headquarters. Hon. Yinusa Kaltungo was assistant Secretary in charge of Northern Zone while Mr. Moses Olabode (now Kabiyesi) was assistant general Secretary in charge of Western Zone.
The Association headquarters was No.13, Broad Street, Lagos, Nigeria while the zonal offices were at Ibadan, Kaduna and Enugu, with branches spread all over the country. Every unit hospital had a branch. Among the first pioneering associations that contributed immensely to the growth and development of nursing were nurses associations of various cadres that had evolved for themselves new philosophy, objectives and constitution quite different from the Nigeria Nurses Association. They include:-
Ø Professional Association of Trained Nurses of Nigeria (PATNON)
Ø Professional Association of Midwives of Nigeria (PAMON)
Ø Nigeria Association of Nurse Tutors
Ø The University Graduate Nurse Association
Ø The Professional Health Visitors Association of Nigeria
Ø Nigeria Industrial Nurses Association
Ø Guild of Registered Nurses of Nigeria.
Toward the end of 1970 and early seventies, there was fusing of activities between NNA and PATNON. Resolution for unity between the two associations were passed at the N.N.A. national conferences in 1972 and 1974 in Benin and Ilorin respectively. PATNON passed similar resolution at its own conferences at Benin in 1973 and Ibadan, 1974. These were followed with series of exchanges of correspondences, joint meetings of the executives of both associations.
NIGERIAN NURSES AND THE INTERNATIONAL COUNCIL OF NURSES (I.C.N.)
In 1957 representatives of Nigerian Nurses were sent to the eleventh Quadrennial Congress of the International Council of Nurses held in Rome as observers. In 1961 PATNON was given full admission into the ICN at the 12th Quadrennial Congress held in Melbonrne, Australia. On that occasion six nurses from Nigeria represented PATNON. Dr (Chief) (Mrs.) K.A. Pratt at the thirteen Quadrennial Congress was elected the first Coloured and African 3rd Vice-President of ICN. As one of the prices PATNON had to pay in order to promote one united nurses association for Nigeria, the association transferred its membership in ICN to the newly organized all-embracing National Association of Nigeria Nurses and Midwives (NANNM). Nigerian nurses have since continued and shall continue to play major and effective role in all the activities of ICN.
Nigeria As A Member of the West African College of Nursing
The idea of establishing a West African College of Nursing was first mooted during the deliberations of the Assembly of Health Ministries in Lagos, Nigeria in November, 1973, by Alhaji Aminu Kano, Federal Commissioner for Health, Nigeria. During her first meeting held in Tema, Ghana in 1976, a resolution was passed that a special committee on Nursing Education in West Africa should be set up by the West African Health Community to examine existing facilities for nursing education in the Sub-region. Nigeria as a foundation member of West African College of Nursing has remained an active member of the organization.
TRADE DISPUTE BETWEEN NANNM AND FEDERAL MINISTRY OF HEALTH: By the first week of April 1979, NANNM had come out with a comprehensive memorandum, which was submitted to the Federal Ministry of health on the 18th April, 1979. This could be described as the beginning of a long stretch of historical events, which eventually ushered in professional recognition for Nursing in Nigeria. On 14th May, 1979, the Federal Ministry of health acknowledged receipt of the memorandum, stating that the Ministry was studying the recommendations and concluded that the association would be contacted if necessary before decision was taken on the issues raised.
On the 27th August 1979, the Ministry of Health’s letter was received by the Secretariat. Unfortunately, the letter, which was a long awaited reply to the Association’s memorandum, brought Nursing profession down to the very pedestal of professional ladder. While the Ministry accepted Nursing as profession on its own right, it disagreed that Nursing should have equal remunerations and privileges with other professions. Based on that new development, an emergency meeting of NEC was convened to deliberate on the Ministry’s letter. The outcome was a letter to the Ministry informing it the decision of the association to embark on industrial action effective from September 6, 1979.
In response, the Ministry arranged for an emergency meeting with NANNM to resolve the looming crisis. The meeting took place on 5th September, 1979, a day prior the industrial action of NANNM.
The Federal Commissioner for Labour by an instrument, dated 6th September, 1979, referred to the industrial Arbitration. Panel the dispute ousting between NANNM herein after referred to as the 1st party and the Federal Ministry of Health herein after called the 2nd party. When the case was first mentioned on Tuesday 11th September, 1979, both parties were ordered to file their memorandum and exchange same with each other on or before the 24th September, 1979.
After very careful and anxious consideration of the evidence adduced on behalf of the NANNM, the Federal Ministry of health and Department of Establishments in the office of the Head of service of the Federal Republic of Nigeria, and the final submission in the case, the Tribunal: (i) agrees with the hereby confirms the needs of Agreements reached between the two parties.
(ii) reject the classification of nursing as system maintenance.
The history of Nursing is very inexhaustible that cannot be curtailed by this write-up, unless one is making a textbook. Therefore, having chronicled the journey so far, let us elucidate on the Way forward.
Sponsorship of Nurses by NANNM: NANNM has magnanimously sponsored some willing nurses for Masters and Ph.D Programme in Nursing and equally some nurses have benefited from NANNM in terms of tuition apart from those that were sponsored fully.
Harmonization of Salary Structures and Nomenclature: NANNM has been meeting with government to ensure that there must be a unified nomenclature for all nurses and the salary package should be commensurate with the qualifications.
THE WAY FORWARD:-
1. The public image/perception of nurses is currently low in Nigeria vis-à-vis other professions particularly among health care professionals. As a professional association, NANNM should have a “watch dog” within its organization in each unit of its umbrella to watch nurses in providing quality care with positive attitude and behaviour in nursing care delivery. This will serve as tool to modify the image positively.
2. Involvement of Academics at any meeting of NANNM with stake holders and in any sensitive discourse.
3. The minimum entry requirement into clinical area should be BNSc.
4. Whenever the ideal of HND becomes implementation, there must be a true post HND programme for the holder of HND that will make the holders to be at per with the BNSc holders so that the two graduates can enter the University for their post graduates without discrimination.
5. All the current post basic programmes should be named by competent lecturers with the at least MSC (Nursing) in order to serve as the bridge the gap between the BNSC and HND holders.
6. NANNM should have its umbrella to accommodate other professional groups but any of these groups should not feel superior or at par with NANNM.
7. All Academics in the departments of Nursing should be made financial members of NANNM in such a way that whatever contribution that comes to GNAN a part of it should be paid to NANNM.
8. NANNM should encouraged as a matter of urgency all the department of Nursing to commence a part-time BNSC programme, and by extension assist the Open University to commence the true Nursing programme the way, it should be.
9. NANNM as a professional association that should be a pressure group should be more aggressive in enforcing disciplines in all our health care institutions and I am suggesting that, each branch should have inspectorate division that will interact with directorate of Nursing services periodically. The members should be given stipens to serve as morale booster.
10. National Committee on Evidence based Nursing practice – In order to maintain suis generic, the NANNM should establish and maintain a national committee on evidenced based nursing practice. This committee if established, should ensure that ritualistic behaviour of carrying out our nursing care is dropped and accept current practice based on evidence.
11. Internship – NANNM should put more weight on the operationalization of internship for graduate nurses as this will assist the placement of nurses in the carrier structure.
SUMMARY AND CONCLUSION: This discourse was divided into introduction, pre-colonial era, Colonial era, independence Nigeria, Era of NANNM, advent of WACN, partnership with PCN, trade dispute with Federal Ministry of Health, amalgamation of all nurses professional association into NANNM and the way forward conclusively, NANNM should be commended for sustaining nursing as a professional and for its ability to sponsor academically inclined nurses for further education at MSC up to Ph. D irrespective of tribes and religion affiliation.
I hope, with this discourse, I have been able to add to our knowledge on the historical perspective of nursing profession and I have equally preferred way forward to the best of my ability.
I wish us all a good deliberation at this biennial and quadrennial conference.
Long live Nigeria, Long live Nursing and Long live NANNM.
Thanks for listening and God bless.
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