The registration and regulation of nurses in this country is at present governed by the Nurses Act, 1950, as amended by the Nurses Act, 1961. An Bord Altranais, as they now exist, were established under the 1950 Act to replace the former General Nursing Council. The Central Midwives Board established under the Midwives Act, 1944, were also dissolved under the 1950 Act and their functions were taken over by the Midwives Committee established under Bord Altranais.
Thirty-five years on, it is obvious that the present legislation is not sufficiently comprehensive to keep pace with the developments in nursing that began in the sixties and which have been growing constantly ever since. Nurses have clearly demonstrated over these years that they will not relax and content themselves with routine nursing skills once they have obtained their basic qualifications. They are, as professionals, eager to improve their knowledge and skills on an on-going basis. We might expect to find an eagerness among our nurses to keep abreast of developments in their particular areas of practice — be it in the clinical, teaching or administrative fields. We do not necessarily expect to find that eagerness channelled into, for example, a desire for further education at university level. Yet, increasingly, Irish nurses are taking time away from the practice of their profession to pursue third level degree courses — many of them at their own expense. The most popular areas of study are education, sociology and psychology. These highly-motivated nurses, together with their colleagues among the leaders of the profession, are aiming to prepare nurses for the challenges that face them in this modern age of high-powered medical and technological science. They will not be hidebound by outmoded concepts about education, training and practice limitations deemed appropriate in the past for nurses. They see that nurses need a broader approach to nursing and a deeper appreciation of the contribution potential of their profession in contemporary society. There is a new era for nursing opening up and today's nurses want to ensure that their profession is ready to play a full part in its shaping.
We can support these laudable ideals by creating the framework most conducive to the future development of nursing, both as a profession and as an essential component of an efficient health service. I believe that the enactment of this Bill will be the greatest service we, as legislators, can give to Irish nurses. Through enactment of the Bill, we will pave the way for the establishment of a nursing board with the composition, the powers and the authority they will need to give effective leadership to the profession.
It is impossible, of course, to foresee every eventuality; every new development; every ideological or practical change that may come about. But it is possible to plan for change and I am satisfied that this Bill has sufficient provision for flexibility built into it to allow for adjustment to suit changing needs and circumstances in nursing as they may develop. To give one example of flexibility, I have provided in section 9 (3) for the power to vary by regulations the composition of the membership of Bord Altranais. Senators will appreciate that this is not a power that would be used lightly or frequently but it is, I believe, an essential power to have in view of the rapid rate of development we may expect to see in nursing as we come in sight of the twenty-first century. This board must be in a position to lead, to guide and to respond, as appropriate and as the profession requires. This provision, then, will help to ensure that the board will always be composed of members whose particular skills and expertise will be in keeping with the needs of the day.
The Bill before the House is essentially the same Bill that came before the Dáil in June 1984. The Bill generated great interest and was the subject of lengthy debate in that House. There were quite a few amendments made to it on Committee and Report Stages in the Dáil. In making my own amendments to the Bill, I was guided by those which were made to the Dentists Bill on its passage through Seanad Éireann. The constructive and lively debate which the Dentists Bill engendered in this House was most helpful to me on this Bill which resembles the Dentists Bill very closely. The outcome, therefore, of a thorough debate, and the inclusion of a number of constructive amendments in the Dáil, is a Bill which, I believe, is much stronger and better than the original and is, indeed, a very solid piece of legislation.
I will now give the House a brief outline of the provisions of the Bill.
Part I contains the normal preliminary and general provisions.
Part II provides for the dissolution of the present Bord Altranais and its replacement by the new board. The new board in numbers and composition will differ greatly from the present board. Section 9 provides for a membership of 17 elected nurses representing the areas of nurse teaching, nursing administration and clinical practice. There will also be at least one nurse and, conceivably, three among the appointed members. This means that of the total membership of 29, up to 20 (and at least 18) members will be nurses. I might add that in deference to the wishes of many nurses I am currently considering the possibility of providing in the regulations, which I must make for the election of members of the first board, that the election will be conducted on a system of proportional representation by means of the single transferable vote.
Part III deals with registration — the primary function of the board. Section 30 is an enabling provision for the registration of persons in a profession or calling ancillary to nursing. There was a similar provision in the 1950 Act but the section in its present form is much improved on the original in that it makes it absolutely clear that a register entirely separate to the register of nurses is to be established if this power is invoked.
Part IV sets out the functions of the board in relation to the education and training of nurses. The functions are for the most part similar to those that apply at present under the 1950 Act. There are, however, some noteworthy additions that I would like to comment on.
Section 35 is completely new and contains two important provisions. The first is the power given to the board to determine minimum educational requirements for entry to nurse training. I would expect that in exercising this function, the board would be guided by the recommendations of the Working Party on General Nursing. The working party recommended a standard of pass level leaving certificate with honours in two subjects as a basic educational requirement. Traditionally, a pass leaving certificate is required but subjects and grades vary from one nurse training school to another, making for considerable lack of uniformity in selection procedures. The board will have the task of structuring entry levels and procedures so as to achieve the right balance between the educational and vocational requirements necessary for caring, effective nurses.
The remainder of section 35 is concerned with giving the power to Bord Altranais to establish, if they so decide, a central applications system to process applications from people who wish to undertake nurse training. This is another provision in the Bill that stems directly from a recommendation made by the working party on general nursing. Senators will be aware that this is one of the two areas in the Bill which has given rise to concern and some opposition.
The other area concerns function of the board in relation to matters of ethical conduct and behaviour and I will come to that later.
In relation to the central applications bureau, I have found total commitment to and acceptance of the concept of a central depot for the receipt of applications from candidates. This is as might be expected. There could be no opposition to a system which would relieve young people of the tedium and expense of making numerous applications to the different training schools. However, the system envisaged by the working party and clearly spelled out in their report is more than a simple sorting office procedure. It is a comprehensive selection process in which the training schools would be heavily involved. The factor that gives rise to concern is that, at the end of the day, the individual training schools would no longer personally select their own candidates for nurse training. I can understand that any progressive step, in whatever field, is always accompanied by some misgivings about the effect of change. However, I cannot accept, in this instance, that those misgivings should lead to unwillingness even to consider change. To include this provision in the Bill is to give the board the opportunity and the authority they need to pursue the feasibility of establishing a central applications bureau. It leaves the way open for the training schools to give their views on the operation of such a bureau. To exclude this provision from the Bill, or to limit it in any way, would be to close the door firmly on any possibility of change in selection procedures for the foreseeable future. That, I submit, would be an unfortunate and retrograde step. I must stress that the working party in recommending the introduction of a central applications bureau considered the following stipulations "most important":
that training schools should be involved in a meaningful way in the selection of students through the CAB which would act as an agency on behalf of all participating schools; that the CAB should be as representative as possible of all nurse training schools and of other bodies interested in recruitment and training of nurses. The committee of the CAB should have approximately twenty members appointed by An Bord Altranais, fifteen of whom should be appointed by the Board on the nomination of the Schools.
The working party also envisaged a specific role for hospital authorities to pursue the question of character and health references and to conduct their own assessments/interviews with a view to determining suitability for employment.
It would indeed be a pity if this dynamic concept were to fail because of any reluctance on the part of the training schools to modify the selection process. It would be an even greater pity if the opportunity to test the system were to be denied by the exclusion or dilution of this provision in the Bill.
Part V of the Bill is concerned with fitness to practise. I am providing in this part for considerable improvements on the existing, inadequate controls. The present board are empowered only to remove a nurse's name from the register as a disciplinary measure. The grounds for removal are prescribed by the board under their rules. They are: infamous or professional misconduct; conviction of treason, felony or misdemeanour; or, conviction of an offence under the 1950 Act.
In my view, neither these grounds for sanction nor the sanction itself — removal from the register — are appropriate for every case of unfitness to practise. I decided, accordingly, to provide comprehensive statutory controls in the areas of discipline and fitness to practise. The board will be obliged under section 13 (2) to establish a fitness to practise committee. The committee will have functions of investigation and of recommending sanctions similar to those that already obtain for the medical and dental professions.
An important feature, in the interests both of public safety and professional integrity, is the inclusion of a provision for erasure or suspension from the register for unfitness to practise due to physical or mental disability as well as for professional misconduct.
Part VI of the Bill contains a number of miscellaneous provisions which, albeit important in themselves, would not be expected to engender much comment. However, section 51 (2) has proved to be one of the most contentious provisions in the Bill. The subsection provides that:
it shall be a function of the Board to give guidance to the nursing profession generally on all matters relating to ethical conduct and behaviour.
The provision is exactly the same as that contained in the legislation governing the medical and dental professions. I was genuinely surprised to find that there could be any objection to the proposal that the board should be empowered to give guidance to nurses on matters of ethical conduct and behaviour. If the board can penalise nurses for professional misconduct, they must also have the power to set guidelines generally for the practice of nursing. The main cause of concern expressed in relation to this provision is that it would interfere with the rights of hospitals to establish and enforce their own ethical codes for their employees. I gave assurances to the Members of the Dáil and to the nurse representatives who approached me on this issue that there is no reason to fear on that account. A precedent already established in relation to the common contract for medical consultants provides a practical and relevant example of how any potential conflict can be overcome. In accepting the common contract, consultants acknowledge that the ethical code of contract-holding body will take precedence over their own ethical principles.
In April this year, the present board published a "Code for Nurses". Their purpose is "to provide a framework to assist the nurse to make professional decisions, to carry out his/her responsibilities and to promote high standards of professional conduct"— The board stress that the code provides guidelines. Specific issues will be considered as they may arise. I am satisfied that there is absolutely nothing in the code likely to cause confusion for nurses or their employing authorities. On the contrary, I believe it will prove to be a very useful document for everyone concerned.
The nursing profession is anxiously awaiting the enactment of this Bill. Since it was first published in May 1984 there has been a consistently high level of interest in all aspects of it among the profession generally. The Minister for Health met personally with representatives of all the main nurse representative bodies and he received and considered innumerable written submissions — many of them from individual nurses. The Bill as it now appears before you is the product of co-operation and, indeed, compromise following widespread consultation and lengthy debate in Dáil Éireann. I would remind the House that it is now well over a year since it first appeared and I would appreciate your co-operation in facilitating its speedy passage through this House.
