I should like to indicate the following printing errors in the list of amendments — on page 2 in amendment No. 4, "(iv)" should read "(v)". In page 7, before amendment No. 42, "section 51 — continued" should read "section 54 — continued."
Nurses Bill, 1984: Committee Stage.
On the question of the establishment day and the setting up of the new board, will the Minister give some indication when the board will be set up following passage of the legislation through both Houses of the Oireachtas? My understanding is that with regard to legislation of this nature there has been a long delay in the past in setting up boards. Will the Minister give some indication when he intends the board will come into operation?
I can assure the Deputy that following the elections I will contact immediately the other interested bodies. For example, in relation to section 9 I will have to contact the professional bodies concerned. There will be no delay on my part. I was reluctant to put in an establishment day after, say, 30 days because a number of these bodies might not meet between June and September and the whole process of setting up the board could be nullified. I can assure the Deputy I will not delay in getting the earliest possible establishment day. The quicker the elections are held, the better.
I move amendment No. 1:
In page 6, subsection (1), line 29, to delete "to fulfil the functions assigned to it by this Act", and substitute "the general concern of which shall be to promote high standards of professional education and training and professional conduct among nurses, and which shall, in particular, fulfil the functions assigned to it by this Act".
The amendment is designed to spell out in general terms the objectives of the board. It will improve substantially the overall perception of the functions of the new board.
While I accept the Minister's amendment and consider it appropriate that it should go into section 6 of the Bill, nevertheless running through the Bill, particularly in the later sections, there is a provision where An Bord Altranais will have a function to give guidance to the nursing profession on matters relating to ethical conduct. I notice that is not included in the amendment. We will oppose with all the powers at our command the section relating to guidance on matters of ethical conduct because we do not think that is a function of the board. It is worth noting that the amendment in the name of the Minister makes no reference to it.
This section sets out the functions of the board but the question must be asked why is the Bill drafted in such a way that some of the functions are put in higgledy-piggledy. Why is one of the more important sections put in as one of the last sections of the Bill? Is the Minister trying to hide something since he has separated the functions in this way? Normally the functions of a board are listed comprehensively in legislation. In this case one of the most controversial sections is section 39. Perhaps the Minister will answer those points.
This is a quite comprehensive Bill; in many ways it is a very elaborate Bill. I want to ensure, particularly in section 6, that the general functions of the board shall be incorporated into the section, and be seen to be incorporated, specifying the specific functions of the board. The specific functions were not clearly delineated in the section and I considered it essential that they should be clearly set out. There is no purpose other than producing an effective measure. The standard form of the functions of An Bord Altranais are incorporated.
While I accept the Minister's amendment I do not understand what has happened with regard to this matter. In part VI — the miscellaneous section — it is stated clearly that it shall be a function of the board to give guidance to the nursing profession generally in all matters relating to ethical conduct and behaviour. We are opposed to that. When the Minister spelled out the functions of the board in section 6, why did he not make any reference to what I would consider to be of fundamental importance in terms of the functions of the board?
The Minister appears to have said that the functions set out in section 6 are the normal functions of An Bord Altranais. However, in section 52 (2) we deal with the general advisory functions of the board. Why is this inserted in section 52? Is it to wear down the Members of this House in that by the time we come to section 52 no one will have any real interest in discussing the matter? In all other legislation functions are listed in the section of a Bill that talks about functions and not in an omnibus, non-controversial section. In this case we are talking about a major section dealing with ethical conduct and behaviour of the nursing profession but it is dealt with under the heading of "Miscellaneous". Perhaps we are a little naive and a little green on this side of the House but there seems to be something highly unusual in this case. I should like some Member to quote me a precedent where a major controversial function was listed on page 25 of a Bill under the term "Miscellaneous". The functions of this Bill are set out in great detail section by section and we deal also with the establishment of the new board and the dissolution of the former board but the major function is put into page 25. It seems incredible. Before we go any further the Minister should make absolutely clear why this has been done.
I go along with what Deputy Ahern says. I was totally at a loss in relation to that aspect of the Bill. Section 6 deals with the functions and then suddenly we find this. Section 52 on ethical policy is a critical part of the Bill, yet it is tucked away at the back of the Bill. I would expect also some satisfactory explanation.
With profound respect to my colleagues, there is a slight touch of paranoia in relation to this Bill which I have detected both in representations and in some of the comments made. For example, Deputy Bertie Ahern said in a recent newspaper report that this Bill was devolving authority on the Minister for Health to determine ethical practices among nurses. That is nonsense. It is devolving on An Bord Altranais. Various bodies have read this Bill and then rushed in and jumped to mad conclusions about it. A classic example is in relation to the incorporation of ethical powers. I am absolutely shocked that this House would refuse to devolve to An Bord Altranais where the nursing profession have an overwhelming majority on the board, the running of their own professional body.
Deputies and some hospitals as well as other organisations do not consider that the board should be empowered to give guidance to the nursing profession on matters relating to ethical conduct and behaviour. I think it is essential. I would refer Deputy O'Hanlon to the fact that the Medical Council have enshrined in very definite terms the ethical conduct of members of the medical profession.
It is our job to raise the general level of professional standards and above all to give protection to members of the nursing profession. That is why I have specifically put in the broad functions of the board. Section 6 (1) is no more than a general statement of the functions of the board. There has to be a general statement in some part of the Bill and it is not introduced on the basis of being exhaustive. Right through the Bill we are dealing with education and training, fitness to practise and registration. Section 6 (1) simply states the general import and thrust of the board. Part of their task in relation to professional conduct among nurses will be to give guidance to the nursing profession on matters relating to ethical conduct. I will deal in greater detail with this point when we come to amendment No. 39 (a). There is a difficulty in dealing with the Bill in that we may be hopping ahead of ourselves. My amendment is purely germane to section 6.
The Minister does not understand the fundamental importance of this section. We accept the Minister's amendment but section 52 (2) is of fundamental importance in terms of the new nursing board. To my knowledge no similar section exists in the miscellaneous section of the Medical Practitioners Act to which the Minister referred. If the Minister has it in mind that the nursing profession should be given guidance on matters of ethical conduct, it should be brought to the forefront. I cannot understand why the Minister brought forward an amendment and did not include an issue which is of such fundamental importance.
It is absolutely essential that early in the Bill there should be no ambiguity as to the general functions of An Bord Altranais. I have attempted with the help of the parliamentary draftsman to capture the broad functions of An Bord Altranais and to insert them at an early stage in the Bill. We can get down to the specific functions subsequently, including the question of ethical practices, on the interpretation of section 6. At the moment I am simply stating the general functions and this is very appropriate.
I fully agree with the Minister that there should be no ambiguity about the functions of the board and it is for that reason that I am highlighting this point. I believe we are creating an ambiguity by putting in an amendment which does not spell out a fundamental departure from similar legislation governing other professional bodies, namely, that the board should give directions on the ethical conduct of the nursing profession.
My version of this amendment is that it is a general reference to the establishment of An Bord Altranais and there will be amendments later on going into the details.
Amendments Nos. 2, 3 and 4 are related and may be discussed together.
I move amendment No. 2:
In page 8, subsection (1), to delete lines 34 to 41 and in page 9, to delete lines 1 to 5 and substitute the following:
"(c) ten nurses resident in the State who are engaged in clinical nursing practice of whom—
(i) two shall represent nurses who are engaged in clinical nursing practice in general nursing,
(ii) two shall represent nurses who are engaged in clinical practice in psyciatric nursing,
(iii) two shall represent nurses who are engaged in clinical practice in midwifery,
(iv) two shall represent nurses who are engaged in clinical practice in public health nursing, and
(v) two shall represent nurses who are engaged in clinical practice in the nursing of mentally handicapped persons,".
I pointed out on Second Stage the major deficiency of this Bill, the lack of representation on the board for nurses in the general nursing area and psychiatric nursing, the two major areas in which 80 per cent of nurses are involved. Although it may appear from the Bill that nurses are well represented on the board, they are told whom they must elect. They must elect five from the general training area, five from the administration area — in other words, nurse managers — and only five from those engaged in clinical practice, that is, ordinary ward sisters and nurses. The Minister should accept this in order to redress the imbalance of representation on the board.
The amendment is designed to alter the balance. It is in line with what the National Nursing Council of the ITGWU, the largest union involved in nursing — the Irish Nurses Organisation do not claim to be a union and are not affiliated to Congress — have recommended. Therefore, the largest nursing union in the country, particularly representing psychiatric nurses, have asked for stronger representation on the new board.
The purpose of the Bill is to get away from the archaic idea, which was hard line and paternalistic, that nurses had to be protected and looked after by the board, all of whose members would know what was good for the nurses. The board primarily should be for the protection and benefit of the nurses and should be run by the nurses themselves, at least those engaged in practice. That is the perception of nursing of the general public, the nurses they meet in hospital wards throughout the country. This Bill is supposed to be designed for them.
The proposed representation on the board is a major step backwards because it would further grind down nurses in an administrative system which does not include them. They should have a majority representation on the board. We are not asking for representation in proportion to their numbers because they would have all the membership on the board if the election were open to all nurses. All our amendment is asking for is fair representation. That would be much more in line with what the nurses are seeking and much more democratic. It should have been what the Minister was thinking when he designed the Bill. He should have looked at the demands of the nurses over the years. This would ensure that the nurses doing the work on the ground would have fair representation on the board.
The membership of the board has been increased from 23 to 27. A working party made recommendations in regard to the new board and I wonder why the Minister did not accept them. I agree that there is only slight variation between the working party's recommendation on the elected membership and the provision in the Bill, in section 9. The working party recommended six elected members who are engaged in training and three or four who are engaged in nursing administration. They recommend that there should be a training paediatric nurse.
I should like a definition from the Minister of "nursing administration". Deputy Mac Giolla asked about the number of nurses in active practice who will be among the 15 elected members. Nurses will have a majority of the elected members, unlike the medical profession and the dentists who do not have a majority of their members elected to their respective councils. However, it appears that nurses in active practice will not have representation proportionate to their strength. The same can be said of psychiatric nurses of whom there are 6,000 as against 25,000 in practice.
Amendment No. 3 in my name seeks to delete "nurses" and substitute "midwives" in subsection (1) (c) (iii). The purpose of that is to guard against the possibility of having a nurse who is not a midwife eligible for membership under the subsection. As I said earlier, it is important that we should have a definition of "nursing administration" because we should know at what level or grade a nurse is recognised as being involved in administration. I suppose public health and district nurses are so engaged, as are ward sisters.
Amendment No. 5 in my name deals with the 12 nominees of the Minister for Health on the nursing board.
We are not dealing with amendment No. 5 at the moment. We are dealing with amendments Nos. 2, 3 and 4.
I should like to hear the Minister on the definition of nursing administration. Will he accept changing the word "nurses" to "midwives" in subsection (1) (c) (iii)?
I accept that it is not possible to satisfy all groups who feel they should be represented on this board. Many groups of nurses could make legitimate claims to be represented but, if we were to cater for them all, we would make the board totally unwieldy. The representation for the 20,000 nurses on the wards is inadequate — five out of a total board of 27. They comprise 90 per cent of the nurses. They deserve greater representation. I ask the Minister to have another look at this section and to note my request.
I too would argue for an increase, if possible in the nursing representation on the board. There is a fair amount of concern about what might in some cases be perceived to be a degree of imbalance. This board is designed to regulate and improve the standard of performance and organisation in the nursing area. Analogous boards in other professions would be much more likely to have a higher preponderance of people from the profession than that proposed in the Bill. In this section there is provision for the Minister to vary subsection (1) by regulation. Subsection (3) provides that the Minister may, by regulations made with the consent of the board, vary the provisions of subsection (1) of this section. Subsection (1) has to be seen in that context. I wonder why that provision is there and to what extent it is envisaged that it would change the ratio of nursing skills represented on the board.
I would argue for an increase in the number of nurses on the board. Perhaps the Minister could increase the psychiatric representation by one person and the general nursing area by at least one. There is a strong view on the need to include midwives by naming them in the section. I support that proposal. There is concern about the imbalance in the 27 proposed members. Perhaps the Minister would be good enough to have a look at that.
I want to draw the Minister's attention to the fact that there appears to be an unsatisfactory imbalance here. I note that it is intended to have three members of the medical profession on the board. When they were setting up their own structures they did not include members of the nursing profession. While I accept that it is necessary to have an input from them, I argue that three are in excess of what is required.
It is desirable also to have representation from the midwifery section of the nursing profession. Sixteen out of 27 is not a satisfactory representation from the nurses' point of view. Perhaps when the Minister is appointing members of the board, he could appoint two people from the Department of Health. He has expert people from the nursing profession in that Department. If he appointed two members of the nursing profession this would help to redress the imbalance. I ask the Minister to take note of that.
I argue the case for increased practising nursing participation on the board. The setting up of this board is a very important step. This is the first chance nurses will have to have a real input into their affairs. In debates concerning nurses we pay tribute to them, and rightly so. We could give practical effect to those tributes by increasing to 18 the number of nurses on the board.
I concur with my colleagues. I appeal to the Minister to increase the nurses' representation on the board. There are many merits in the Bill and in the composition of the board. The medical service in hospitals includes doctors, nurses and management staff. Nurses have given dedicated service and they are constantly in a working capacity within the hospitals. This is their Bill. This is their board. I appeal to the Minister to increase the nurses' representation. As another speaker said, the two people to be nominated from the Department of Health could be reduced to one and the other substituted by a nurse. There could be one representative of the educational field involved in nurses' training and a substitute to allow nurses to have a minimum of 18 members on the board. This Bill gives absolute power to the Minister. It is very important that the Bill, which will have such powerful effects on the nursing profession, and on the regulation of the nursing profession, should provide that two thirds of the board will be people who will be affected by the Bill. I appeal to the Minister to increase the nurses' representation from 16 as proposed to a minimum of 18.
Amendment No. 4 proposes to reduce the number of people appointed by the Minister from 12 to seven. Amendment No. 2 proposes to increase the nurses' representation while leaving the first two areas of training and administration intact as the Minister proposed. Amendment No. 2 doubles the representation of nurses in clinical practice. If we are to retain the membership at 27, we have to alter the Minister's representation. There is no reason why the figure of 27 must be maintained. I do not propose to alter the figure of 27 but, having increased the number of nurses to 20, five from the training area, five from the administration and ten from the clinical practice area, representing all fields, amendment No. 4 seeks to reduce the number appointed by the Minister from 12 to seven.
Why must the Minister appoint three doctors to the Nurses Council? If it were a medical council, would he appoint three nurses? We dealt with the Dental Council yesterday and there was no question of appointing three dental nurses to the Dental Council. The Dental Council is for dentists, the Medical Council is for doctors and the board that we are setting up now is for nurses. There is an attitude of paternalism, that you have to have doctors to see that the nurses do their job right. That is what we should get away from. The nurses are quite capable and totally competent to run their council. They can get advice from any doctor they wish on any medical matter. The appointment of the three doctors is a negation of the nurses'independence and right to run their own board.
We continue, in our amendment, that one person is to be representative of management, of health boards, and one representative of management of hospitals — they can be doctors, if necessary. There should be one person representing the Department of Health, one to be a person experienced in the field of education and three to be persons representative of the interests of the general public. That makes a total of seven. The interests of the general public are very important on the Nurses' Council. The nurses would be able to avail of the advice of such representatives in the interests of consumers and the general public.
What we are asking, in the combined amendments, is to increase the representation of nurses and remove the three doctors appointed by the Minister. By all means, doctors may represent health boards, the field of education or hospitals, but to have them just as doctors on the council is an insult to the nurses. Amendment No. 4 calls for seven members to be appointed by the Minister and amendment No. 2 calls for 20 nurses to be appointed.
I commend the Minister on the mix which he has achieved in the proposals on this section. The general proposals show very clearly the number of areas in which nurses are involved. While many representations have been made to all of us by the nurses, the present representation of 15 nurses out of a total board of 27 is not unfair. You could compare it with the 1950 Act. resulting in only 12 nurses out of a total membership of 23. It certainly represents the required broad spectrum to be represented on the board. Doctors would be an essential part of the work of this new board although perhaps fewer than three members would serve the purpose. You cannot have a board dealing with the professional needs of nurses and exclude doctors from it. They are an essential and very important aspect of the medical profession. That the nurses on the wards, in clinical practice, perceive that they are under-represented is not a fair comment because the whole board will be working for the good of nurses in all areas. If they perceive that they are under-represented, I would ask the Minister, in conjunction with the other Deputies who suggested it, to reconsider in his own appointment possibly increasing the number somewhat in order to give the nurses a sense of fair representation. However, I believe that it is fair.
I support the other speakers who requested greater representation for nurses on the board. It is obvious that the nursing profession should be very strongly represented but not to the point of monopolisation. They are the people best versed in the problems which already exist and are likely to occur in the future. Perhaps at some stage an amendment could be considered adding after "where two shall be persons representative of the Department of Health""one of whom should be a member of the nursing profession". That would slant the bias more in favour of greater representation for the nursing profession, as we are requesting. It will be recognising that nurses are well qualified to point out the necessity for strong representation of their profession on the board. It would not be overdoing the representation, but merely giving to the nursing profession the recognition it deserves.
I thank the Deputies for their views on this section of the Bill. Taking the question of medical representation which is the only matter that I can deal with now we must remember that on the existing board there are six members of the medical profession. The working party recommended four members and we are now proposing in the Bill three members of that profession. The existing Bord Altranais has a master or an assistant master of a maternity hospital, two medical practitioners engaged in the training of nurses in teaching hospitals, a psychiatrist, a general medical practitioner and a medical officer of health — six in all. The working party is heavily representative of the nursing profession, having a large number, including all the trade unions. That party recommended one medical practitioner in a general hospital, one from a psychiatric hospital, one from the community services and one from the obstetric side.
In section 9 I have decided to recommend to the House that the representation be reduced to three. It most certainly would not go below that. In effect, I am proposing that there will be one registered medical practitioner engaged in the practice of medicine in a hospital approved by the board for the training of general nurses — a training hospital in other words. There should be one registered medical practitioner in a hospital approved for the training of psychiatric nurses and one engaged in the training of midwives on the obstetric side.
It is about time that we here stopped this excessive inter-professional paranoia. The health services are riddled, overwrought, overstrung and massively dominated by professionalism, with the enormous tensions, rivalries and preoccupations which relate to individual professions. We should have an integrated health service, with people working with one another, training with one another and, above all, delivering a service to the public. It is people that matter, not professionalism. People will not have the services if they are not delivered by the professions on an integrated team basis.
I propose to retain the provision regarding three medical practitioners. I suggest, to Deputy Mac Giolla in particular, regarding the trade unions which now propose to remove the doctors, that Mr. Eddie Brown, National Group Secretary of the Transport Union in the working party signed the recommendation. The Deputy's erstwhile colleague Philip Flynn, now General Secretary of the Local Government and Public Services' Union also signed it.
He is not a colleague of mine.
He was. I said erstwhile. He signed the working party report recommending four doctors.