Students too poorly trained
By CAROL MATROO Sunday, July 15 2012
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Nursing Council members Russel Salcedo and Karin Pierre engaged in discussion during a press conference they staged to express their opposition to Hea...
Former Planning Economic Social Restructuring and Gender Affairs Minister Mary King is agreeing the nursing registration examination should not be scrapped, saying the training institutions for nurses in this country are not adequately outfitted for such a task and therefore nursing students must sit the examination.
King is one of several persons in the public sphere who have come out against Health Minister Dr Fuad Khan’s planned proposal to scrap the examination. Khan says he wants to abolish the exam, essentially because its failure rate is too high, but this move is not being supported by the Nursing Council of Trinidad and Tobago.
Speaking with Sunday Newsday on the issue, King said one of the major questions being asked was whether the institutions charged with training nurses were in fact capable of carrying out this mandate.
“This is the question that people are asking. Some people who have been talking to me are indicating that we do not have the kind of in-depth training and experience that is needed during their training at COSTATT and Niherst, and therefore that is why they must have the Council Exam,” King said. Nursing hopefuls are currently being trained at COSTATT, Niherst and the University of the Southern Caribbean and the University of the West Indies, St Augustine.
King said had the nursing trainees been trained as was she, King– who is registered nurse, state registered midwife and also has UK paediatric certificate in specialist nursing– they would have been trained both in classrooms and in the wards.
“This training went over the period of three years and I am talking about the first degree, the first aid registered nurse of Bsc ...You are at a teaching hospital which is accredited by the nearest university. You are trained in the classroom, you then have experience on the wards and you actually must go through different kinds of experiences, which include general medical nursing, children ward nursing and casualty, which is emergency,” King said.
The former minister said nurses must have surgical ward experience, pre-natal experience and some floor sessions in the maternity unit and even in the laboratory.
“We were trained to do a lot of things that the classroom type or the university only type don’t get doing, and that is why, therefore, our local nurses must sit the exam. If they don’t sit the exam, then why are we then putting them through training when we are finally telling you you’re not graduating,” she said.
“They’ll always be in training as far as the Nursing Council and the expertise in the field, unless properly qualified, unless they sit that final examination which tests on details which they would never get in the classroom.”
King said nurses in her time were trained in the hospital environment on setting trays for operating theatres, had experience in the operating theatre and in casualty.
“We were taught how to set up, how to sterilise, how to stitch, how to take blood, how to test urine, all these things we were able to do and not like some nurses who were trained only in the classroom and they come out and they are assistants to the properly trained nurses,” she said, adding many of the current institutions charged with training nurses do not offer these practical components.
“Once the doctor leaves the ward that nurse is the one responsible ... she has to be aware of what is the next step if anything happens. If she gets an emergency in casualty she must know exactly what to do in that emergency and not wait for a doctor. These are the things I think are lacking in the current training, and therefore, I think we have to insist that they have a medical or nursing council examination.”
She added, “It’s like telling Dr Fuad Khan when he came out of university, ‘don’t worry to do your internship, we’ll take you as they are’. That will never happen because you are not a trained doctor, and without that final exam, you are not a trained nurse.”
King said there had been many complaints about the environment where nurses were being trained, saying it was not conducive to good teaching, training or learning, and did not have the same kind of ward training that the nurses should have.
Nursing Council member, David Murphy, meanwhile said Khan needed to have serious discussions with the council before going ahead with any plan to scrap the exam, which the council remains opposed to.
“What the minister has been doing was simply going to the media and making these public pronouncements. I do not know that these things could be done by ministerial decree,” he said.
Murphy said while the minister had his legitimate reasons to have concerns about the nursing exams, he felt Khan was being ill-advised.
“They are really setting him up. He needs to check and double check the source of his information,” he told Sunday Newsday.
Murphy said if there were students at an institution who failed certain exams, naturally there would be subjective biases
“He or she would know exactly what they have done in terms of how they would have failed an exam, but not because you have failed an exam you would come out to accuse somebody of perhaps victimising you, when you know fully well you were not up to the standard that was required to pass these exams,” Murphy said.
“You never applied yourself as a student and because of that you paid the ultimate price. The council can only operate in so far as the law allowed them to operate. The act says there are three chances to these exams, and we cannot go outside of what the act recommends. If we were to do that we would become very lawless and the very same people who are now making statements are going to be the same ones to crucify us for breaking the law, and for doing our own thing.”
Murphy said if Khan found that a student should be given more than an unprecedented third chance at the exam, then the minister had the authority to take his request to Cabinet, get the Cabinet’s approval, then go to the Parliament and effect the necessary changes.
“If somebody cannot pass the registration licensing exam each time, would you want that person to take care of you? I would not want to trust that person with my life. That cannot happen in medicine, it cannot happen in law, it cannot happen in any of the other professions.
“It really pains to know that instead of the minister coming and sitting with us, letting us know what the challenges are, telling us what the complaints you have been receiving are ...We can validate them, but truth be told not even one of them has been a correct statement, and the yet our minister unwittingly goes out there, and one of our greatest fears is that at the end of the day he is going to embarrass himself when he discovers otherwise.”
Murphy pleaded, “Let us sit down and talk through the issues before we make public utterances. You don’t put your problems out there in the public, you work on the issues, because the more you ventilate in the national public, the more difficult it is to arrive at a consensus.”
Murphy said King was correct with her statement, adding that the problem could not be blamed on the exam. He said the focus should be on the training institutions and where they may be falling short.
“Mary King is absolutely correct in that before you begin to look at the removal of an exam, you need to look to see what happens at the level of the institutions. Do you know why Wall Street crashed? It crashed because they removed all the regulations that governed their financial practices and it almost crippled the world.
Regulations are important, standards are important. Let us wait and see what is going to happen if they remove these standards, and then you realise that we have no quality out there any more,” Murphy said.
“Remove the standards and we will cry out there. I myself would be afraid to go to the ward to have any of these nurses who have not met the minimum competencies that we require. Give them a licence and I myself, with fear and trepidation, would lie in fear in a hospital to have these people coming to take care of me. This is not coming to change a sheet or to give a bedpan. We are talking about higher level skills that are required by a professional, skills that if a mistake is made can result in my death.”
Murphy said as an educator, and a principal of one of the schools for nursing, he could tell first hand what he had to start with.
“Some of the people who come to be nurses start at the lowest end of the academic ladder. Nursing is not the preferred occupation for many people who have very good passes and very good O’Levels. They would choose medicine, law, engineering and when they can’t get anything else to do then okay, ‘you know what, let me try nursing,’” he said.
“We want people in our profession who care, but people also who can think outside of the box, people who have a good brain in their head. Many of the students that we get are the academic dregs. When you have taken 15 and 20 years to get five O‘Level subjects, it is like pulling wood out of the forest to bring you up to speed in an academic programme at a tertiary level.”
Murphy said not all people had the brain power to be nurses.
“Everybody who started out in medical school, they are not all doctors out here, and some of them who are doctors, I wish they went back to medical school. If the nurses begin to talk stories we shall read verse, book and chapter,” he revealed.
Murphy also suggested that because the Nursing Council exams were relatively cheap – $400 per exam – students did not seem to take it seriously.
“If they had to pay $5,000, people would value that $5,000. They would have made ultimate sacrifices to discipline themselves with a view toward passing the exam. It is easy to lose $400. People gamble that during Play Whe,” he said
The nursing programme is funded by the State and students are paid a stipend, but apart from that Government covers the programme through GATE (Government Assistance for Tuition Expenses).
“The Ministry of Science and Technology has been speaking ad nauseam about our colossal failure rate that now exists at our premier institutions, which were UWI and UTT, because when people get things for free they do not make the sacrifices to apply themselves.
“Those institutions have been failing course, after course, after course, because they know they do not have to produce the money to redo the exam. We have to look again whether in fact the so-called freeness that now exists has been giving us the best quality that we deserve,” Murphy said unapologetically. He said members of the council are not paid, given stipends or receive any subvention from Government. He said he believed this has always been so since, with each government, it has always been “whoever pays the piper, plays the tune.”
The Nursing Council Exam was signed off by Caricom ministers of health in 1990 because, across the Caribbean, it was discovered that the standards of patient care and the nursing profession had fallen so badly there was need to standardise it across the region. Students were marked by three examiners and if they received a failing mark, they could then pay a fourth independent examiner to review their marks. If that examiner recommended that the student should receive marks that would give them a passing mark, the council accepted the recommendation of the fourth examiner.
“We bend over backward, we even show the students their paper. If you read some of those scripts you would cry,” Murphy said.
“You would not trust a nurse to even bring a cup of water for you because you would be shocked to know that at the end of four or five years, if this is what the student is writing, then what are we producing? Something has gone wrong in education system. The quality that comes to us is very suspect.”
Vice-president of the Nursing Council, Karin Pierre, said once a student fails the Nursing Council Exam in three tries, he/she could not do it again.
“If you fail your licence you can’t be registered as a registered nurse (RN), because the word RN is a legal title that you get, which is given by a licensing authority (Nursing Council of TT). The Nurses and Mid-wives Act 29:53 stated before anything could be passed, it had to be approved by the Parliament,” she said.
Pierre acknowledged that while there was a nursing shortage, the council could not be blamed.
“The council is not the training agency. The council does not employ ...Council issues a regional exam, agreed upon by Caribbean ministers of health in 1990, and all Caribbean countries from Belize to TT do this exam the same day twice a year, in April and October.
“There is a first marker, a second marker and final marker, which is an external examiner, and that is the person who decides if the person has passed or failed. We have to understand the exam is a regional one, like CXC. When you do your exam everybody on the island does it at the same time.”
Pierre said the council’s main function was to protect the public. She too, questioned whether there were shortcomings in the training institutions now operating.
“If there are failures like (what we are having), we would have to go into the schools to see what is making them fail the exams. Is it the teaching component or the infrastructure and the clinical area? There are many factors which can cause a person to fail an exam,” she said.
Pierre said, however, that she believed students were failing because they did not have the competence.
“I am not saying that nursing is easy, it is difficult. You have to do many sciences, work in a practice environment. You have to understand how to take care of the patient, it’s a life and death situation. Today I am tired, I am hurting for my profession,” Pierre admitted.
Pierre claimed that while Khan stated he had consulted with all professional bodies involved in nursing, they had not met.
“We have a professional association and none of us have been called in for discussion and this is what we have been trying to tell people. We are professionals and we need to be respected. None of the professionals have been consulted. You just hand out policies and we have to accept policies without question,” she said.
Nursing student Shirlan Gomez told Sunday Newsday she failed the exam, but said she believed she had passed. She described her failing her exam as “horrifying.”
“Most of us left our jobs. I started straight out of school and I never failed any exam before, not even the first exam, because you have your fundamental exam, your preliminary exam and the final exam to be registered,” Gomez said.
“It was the clinical one paper they said I failed, which they had no proof of that I actually failed.
I know to myself that I did not fail ... to know that through everything as a nurse on the ward, giving medication, controlling taking over the ward, working night shifts, getting the support of your family and then telling them I failed the course, I did not pass the exam. It was horrifying to me mentally and physically. I cried for weeks after that after those results.”
Gomez also claimed there was no system in place for students to see the exam scripts, contradicting Murphy’s statement that students could access their files. She said after she paid an independent marker to access her paper, she was still given a failure mark.
“There is no transparency at all,” Gomez claimed. However, Gomez believes the final exam should not be a qualifier as to whether one should be registered as a nurse.
“Some people are academically inclined and some are not. There are some people who would literally freeze during an exam. They can function perfectly on the ward, do everything ... they know their stuff, but when they sit in front of a paper to express it in words for someone else to understand, that could be difficult for them. But this does not say that they are not qualified or capable to take care of a ward and to function properly as a nurse,” Gomez said.
Gomez now works with the judiciary, but intends to try again to secure her nursing licence.
“It is my passion, it is what I want to do,” she said.
But a “public spat” over the proposal is unnecessary, since the Health Minister and the Nursing Council both want what is best for the public, according to Public Services Association general secretary, Oral Saunders.
“However we believe the manner in which the minister is going about to make those changes are not really wise, because at the end of the day, the Nursing Council will guard its turf jealously and rightfully so,” Saunders said. The PSA is the representative union for over 1000 nurses.
Saunders warned that if the minister did not understand this, he would “get a war the likes he would have seen in 2000 when he was a junior minister of health, when nurses came out and protested across the country and the only person who really suffered during that time was John Public.” He advised the minister to engage in genuine discussions behind closed doors.
“I don’t know if he is being advised, but what his proposals would really lead to is all nurses closing rank and supporting the nursing council. It would cause disharmony among the work force. The nursing profession is really about team work to provide quality service to our patients,” Saunders said
He also cautioned the minister about legislating behavioural change.
“In other words, you cannot use a big stick on the backs of the council, they will respond appropriately. You must listen to all sides before engaging in finding a solution. Good governance is not because you have the might of the say, not because you have a majority in Parliament, the change is because of how you feel.
“Good governance dictates that because you have that might, that you choose not to use that might, but to use dialogue because you must always convince persons of the strength of your argument instead of the big stick approach,” Saunders said.