Wednesday, 25 September 1985
Seanad Eireann Debate
Mr. Ferris: In a short contribution on this very important piece of legislation, I wish to commend the Government, the Minister responsible and his Ministers of State for the interest they have shown in this Bill. I wish to thank them for the widespread consultation and debate they had with all the interested parties. This led in no small way to an excellent debate in the Dáil on this legislation and to some fundamental amendments being agreed by the Minister. He had wide-ranging discussions with members of the Irish Nurses Organisation, the Irish Transport and General Workers Union, the Federated Workers Union of Ireland and many other trade unions and associations representing nurses in various ways. It was because of that widespread discussion that there is now, generally speaking, a warm welcome for the terms of the Bill which has passed through the Dáil and is now before us.
The purpose of the Bill itself is that An Bord Altranais, who were established in 1950, will be abolished when this Bill becomes law and will be replaced by the Nursing Board. The composition of the Nursing Board has improved in regard to the representation of nurses on it. That was one of the areas that concerned nurses. They wanted to ensure that their profession would be adequately and majoritively represented on the board. Arising from amendments and various representations, not fewer than 18 and possibly up to 20 nurses out of a total board of about 29 will now be on the board.
I also welcome in the Minister's Second Stage speech the commitment to seriously consider, in making regulations, that the voting procedure to be adopted by nurses in electing their members would be proportional representation. If we draw a comparison between this legislation and the Dentists Act, which was put through this House after some considerable debate, discussion and amendment which produced very fine legislation at the end, a similar section was conceded by the Minister. I am glad that he has now given an assurance that, in making these orders setting down the procedure,  he is seriously considering the use of proportional representation. We welcome this because there are certain sections of the nursing profession who in the overall context might be in a minority situation but under the PR system of voting would have an opportunity of ensuring that their voice would be heard and represented on the board.
Regarding the functions of the board, most of us would welcome particularly the area of the registration of nurses, the whole area of the setting of standards of nursing and the minimum standard of educational requirements for nurses. I am sure that when we talk about the minimum standards of education required the incoming board will have regard to the recommendations of the working party on general nursing. Many of us, including yourself, a Leas-Chathaoirleach, I am sure, have views on the educational requirement of nurses. Nowadays we seem to be obsessed with academic achievements of people who are considered suitable to be even interviewed for nursing. We have many people who would achieve the minimum requirements and above the minimum but because of the numbers of applications from young girls for nurse training, training schools themselves have set a higher standard and that higher standard is usually based on academic qualifications. I admit that biology and chemistry are essential subjects for nurses but it is debatable whether mathematics or anything else should be that important.
Apart from being a very professional and dedicated body of people nurses also have a special qualification which has nothing to do with education. That is a vocational qualification: the ability to be kind to people who are sick or old or infirm. I would hope that when minimum standards for entrance to training are being set, that attitude would be considered as being a very important and necessary minimum educational requirement. We should ensure that instead of having hundreds of young people qualifying on the basis of seven or eight honours in the leaving certificate, those who  would have the minimum standards in the important subjects plus the ability to be able to deal with people would also be considered. That might need some change in the curriculum or otherwise in our second level schools. It is important that at least I put it on the record of the House that I consider that to be a very necessary part of any qualification to be a nurse. Apart from being a job nursing is a profession, a vocation and something that many girls we talk to in the country aspire to. A girl with an excellent leaving certificate might make a great banker but might not make a very good nurse.
The system of central application which has been talked about in the Bill and which has been the subject of some controversy is one that has to be welcomed. We have the problem at the moment of the same girls having to apply to five or six different locations, to different training schools or hospitals, seeking interviews that would result in their being placed on the panel for nurse training. If the system were centralised and some definition laid down by the board of what the requirements were, it is possible that interviews could be carried out at regional level and that the results could be sorted out at central level. Girls who may be successful in one area fail in others though the requirements may be the same. By rationalising this procedure in a central way girls could be spared some of the financial burden that is now placed on them by reason of their having to apply to the various health board areas.
Another very important function of the board which has led to some degree of debate — I will not say controversy — was the power of the board to remove nurses from the register. They could be removed for any of a whole list of reasons which are included in the Bill. One of these is professional misconduct. There was a reservation that any board would have that power. In speaking with nurses who raised this problem with me, I was glad to assure them that the members of any profession in this country, whether doctors, dentists, veterinary surgeons or otherwise, are expected by the public to  attain and adhere to a certain code of conduct.
I have no doubt that the vast majority of the nursing profession would welcome that provision. It is appropriate that they maintain a certain high standard which all of us accept and expect them to maintain. From our experience of dealing with nurses on health boards and in hospitals and so on they have this tremendous high standard of professional conduct, no provision in the Bill insinuates that there is widespread departure from this but it is appropriate that if their profession is to continue to have this high standing in the public mind, the safety valve would be included that the board have the power to remove from the register a nurse who was found to be guilty of misconduct.
There is another section which gives the board power to bring in ancillary grades of nurses. This has created some concern particularly when we have regard to the large numbers of nurses who are unable to obtain employment in hospitals, nursing homes, health boards or otherwise. They find it difficult to perceive that we are now possibly going to create a category of people who are not nurses but who are allied to nursing. In some professions this is to be welcomed and is necessary because we do not have sufficient qualified people to carry out all the functions they would normally carry out. In the Dentists Act we created certain groups who with proper training could do a lot of very important work that dentists do not have time to do. In the area of nurses and ancillary grades of nursing I would have reservations about the urgency factor in view of the fact that there are so many unemployed nurses available for work. I am personally aware of such people and most Members of this House would be aware of them also. I should like to think that they would be employed before anyone else would come in as a second tier or lower tier to be provided with a certain status which would be included in the functions of the board.
In saying that I know there are some girls who because of the educational requirements or for some other reason  will never be able to qualify as nurses but who will spend their lives caring for the sick or the infirm or the mentally handicapped. Perhaps in the area of mental handicap there is a place and a need for this ancillary type of nursing. I would have certain reservations about ancillary nursing grades in general hospitals, geriatric hospitals and so on, but in the area of mental handicap there probably would be a need for this ancillary type of person who would be very good and extremely kind with these types of patients. In that regard I hope the board will take into account that type of person if they decide to have a second tier of nursing type personnel with a certain type of registration in this new board.
The other area is one that is really controversial and that is the area of the right of nurses to object to carrying out particular medical functions which could in fact contravene their own conscience or moral judgment. All of us accept that in any walk of life, in any profession, people should have the right to opt out of particular medical operations or otherwise that could create a conscience problem for them. The discussions we have had with nurses organisations in this regard indicate that they are satisfied that this was not the area which was included in the section that gave the Minister certain powers of direction. It did not impinge on their moral and conscientious right to object as a profession, as indeed the professional ethics they acquire on the day of their graduation would have given them in any case. I want to put it on the record that that principle should be enshrined in any legislation. We are living in a democracy in which people would have the right to opt out of any procedure that would be in conflict with their conscience.
Generally speaking the provisions of the Bill are ones that I welcome. They are long overdue. The nurses themselves are anxious that we as a House would complete this legislation as soon as possible so that the board may be set up. I welcome all the efforts that have been made to tidy up all the anomalies that  apparently had been there in the past and hope that with this new surge forward in the importance of the profession the nurses will respond magnificently, as they always have done in the past. I commend the Minister and his Ministers of State for the interest they have shown in trying to ensure that the legislation reflected their views because they are the people who will be involved in the carrying through of this legislation by way of the setting up of this new Nursing Council.
Mrs. McGuinness: I join with other Senators in welcoming this Bill in its regulation of the nursing profession and in its bringing up to date legislation covering the nursing profession. All of us, either through ourselves or through our friends or relatives have cause to appreciate the care and the high standards which obtain in the nursing profession in Ireland. It is quite obvious that this is true because in so many countries one finds Irish nurses working and Irish nurses appreciated for their high standards and their high qualifications.
This is an essential piece of legislation in terms of widening the horizons of nursing and, as was said by the Minister of State in introducing the Bill in this House on the 18 July, in taking in the fact that nurses nowadays go ahead to further qualifications, to third level education of different kinds and to dealing with this kind of situation. Therefore I think the Bill is necessary and it is to be welcomed. I would certainly support the flexibility that has been built into the Bill to allow for changing situations with regard to the nursing profession. It is practically impossible for us as legislators to foresee exactly what may happen in future years and we should try to enact legislation which will be flexible and which will be adaptable to changes that happen in the future.
I accept that the Bill has had long debate in another place and that it has been improved by various amendments. Generally speaking the idea of a central applications board is a good one for the reasons which have been mentioned by other Senators. It is very cumbersome  and difficult for a girl who wishes to become a nurse, or indeed for a man who wishes to become a nurse, to apply to all sorts of different hospitals and different health board areas. Therefore the central handling of applications is probably, as it has turned out to be in the university situation, a reasonable way of dealing with this.
There is, however, one area that I wish to draw to the attention of the House in this Second Stage debate, and indeed possibly also on the Committee Stage but certainly now, and it is one which was mentioned at the close of his speech by Senator Ferris when he referred to the wish of certain nurses to include what is usually described as a conscience clause in the Bill. I, in common with other Senators no doubt, have received correspondence about this from various nursing and matrons associations. I have quite carefully replied in at least two long letters to what has been said to me. This refers to section 51 (2) of the Bill which states that it should be the function of the board to give guidance to the nursing profession generally on all matters relating to ethical conduct and behaviour. As was pointed out by the Minister of State in his contribution on 18 July last, a code for nurses has been brought out by the present board. This provides in section 1 (11) of the code that a nurse shall be entitled to make known at the earliest possible opportunity to an appropriate person or authority any conscientious objection which may be relevant to professional practice and that the board shall be the final arbiter at to whether any such objection falls within the scope of this clause.
This seems to me to be a very fairly reasonable way of dealing with the matter. But what is being sought is probably something that goes a good deal further than this, something which will allow a nurse — or perhaps nurses gathering together — through conscientious objection to prevent a patient from having some form of medical treatment  which is within the conscience of the patient and very possibly within the conscience of the patient's doctor. This would seriously concern me.
It is very easy for us to say that in a democratic society, as Senator Ferris said, one should have a right of conscience but this can be an area where there is a right of conflicting conscience. There is the conscience of the nurse and also the conscience of the patient and possibly the conscience of the doctor. It seems to me that sometimes in these discussions we lose sight of the fact that all medical care is really about patients and not about nurses or doctors. Nurses and doctors exist to care for the patient. In a sense where the patient needs treatment and accepts that that treatment is within his own conscience, it seems to me to be going rather far to suggest that by concerted action or even by individual action nurses could prevent the patient from getting that treatment. I know this may seem to be a far-fetched idea, but it is not really.
The Minister of State says regarding the common contract for consultants, that consultants must accept the ethical position of the hospital they work for. This can give rise to difficulties. During the summer while this House has not been meeting there has been considerable discussion and debate, particularly in the west of Ireland, about the question of female sterilisation being provided in the Galway Regional Hospital by a certain gynaecologist. Statements have been issued on the matter by the Bishop of Galway. There have been threats — if I may put it that way — to bring in an ethics committee which will put a stop to this kind of thing. In addition it has been revealed that when gynaecologists wished to purchase a hospital from diocesan authorities they were only allowed to purchase it on condition that they obeyed the ethical standards set out by the diocese, not the ethical standards of the doctors or the ethical standards of the patients but of the Roman Catholic diocese. I am inclined to think that when we talk about ethics and conscience in this situation we are very often talking  about the ethics and conscience of the majority Church and perhaps of a rather right wing group within the majority Church. Therefore, I am worried about the idea of it being put forward that there should be either an overt conscience clause in this Bill which would allow total freedom of conscience to the nurse at the expense of the freedom of conscience to the patient, or alternatively, that even if we do not put this in, it should be as Senator Ferris said, accepted that it is in the nature of things that this is the position that should prevail.
It is easy to talk about freedom of conscience, about the necessity for each person to be able to exercise his private conscience. It is perhaps a lot harder to work out an acceptable balance between what are the needs of the patient, the recommendations of the doctor, the conscience of the nurse or whatever. That is not easy. I quite accept that it is not easy and that it can create difficulties for nurses just as it creates difficulties for doctors and patients. But I would say that the task that the new board have to apply themselves to, and a task they can well apply themselves to under this section 1 (11) of the code for nurses, is to develop what the correct balance is as between the rights of the patient, the rights of conscience of the nurse, the view of the doctor and perhaps the view of those who run the hospitals.
In this situation whatever may be said about the rights of private hospitals, which of course though private hospitals are largely run on public money, the rights of health authority hospitals are a very different matter because they exist for the whole community, not just for, say, a private nursing order or whatever. Therefore, we must be extremely careful that these types of consicence clauses cannot be used in the framework of health authority hospitals to prevent certain kinds of treatment to patients who wish and desire a certain treatment, whose conscience allows them to have that treatment and whose doctors are willing to carry out those procedures.
I am rather afraid that the Minister  of State in his attitude, as shown in his contribution at column 1989 of the Official Report of 18 July last, may be too weak-kneed in this situation, that he is leaning over backwards to reassure that nothing that will offend anyone will be done. This is a nettle that we have to grasp as legislators, as health boards, as the new nursing board and so on. It is something that we have to think out quite carefully. I would ask that in this debate we do not make assumptions that the new board will be totally bound by this type of conscience clause or by this type of view of ethics that has been virtually accepted by the Minister of State in his contribution.
This is a crucially important area in medical and social ethics. It is something which arises on this Bill and which I feel strongly about. I would ask that the powers of the board and the powers of the Minister in this situation should not be curtailed by a particular view of what are or are not medical ethics. Having said that, I would repeat that I welcome the Bill and that in general its clauses are very suitable and that it will provide a framework for the progress of the nursing profession.
Mr. Durcan: I. too, join with other Senators in welcoming this Bill. In doing so I would like to compliment the Minister for Health on bringing this legislation before the House. The Minister is one member of this Government who has been criticised by many people across the broad, political and quasi-political spectrum for many diverse and different reasons. But we as legislators and certainly those involved in the medical profession in its broadest sense have to be thankful to the Minister for at least bringing various aspects of the medical profession into the eighties in the legislative sense. I say that because the Bill we are discussing this afternoon is in many ways similar to the Dentists Bill we discussed in this House some months ago. My only regret is that the Minister did not introduce this Bill in this House also. If he had done so he would have followed the  precedent set by his illustrious predecessor, Dr. Noel Browne, who introduced the 1950 Act in this House as the 1949 Nurses Bill. When we are discussing this Bill we have the opportunity of recollecting briefly the whole history of nursing in this country. It is only appropriate that we pay tribute to all of those over the centuries who played a role in developing the nursing profession to what it is today.
In the report of the working party on general nursing, published some years ago, there is an interesting history of the development of nursing in this country. We note from that report that the idea of nursing as such was known as far back as the Brehon Laws and was recognised as such. Indeed reference is made to the role which monastic settlements played in the time of early Christianity in providing a nursing service. There is also interesting reference, interesting in the historic sense, to the development of some of the terms which we now associate with nursing. I was particularly amused to note the way the concept of “matron” has developed — I quote from page 18 of the report of the working party where they refer to a definition of “matron” as follows:
The function of the matron in Dr. Steevens' Hospital in the early Nineteenth Century is described as follows: to take care of all the functions belonging to the house, to keep all stores and deliver them to the nurses as the occasion requires, to see that the several nurses keep their wards clean, to lay up carefully the old linen and blankets and to deliver them to the surgeon as often as he should call for them.
When one realises that was a description in the early 19th century it is interesting to realise how the role of matron in a hospital has developed up to the present time. If we note the development of the role of the State in providing nursing services it is also interesting that the nursing services which were available until the beginning of this century were provided by charitable organisations and largely provided by private resources.
 I welcome the fact that this Bill updates the 1950 Act and also has the effect of repealing the Midwives Act, of 1944, and the amending Act of 1961. I hope at the outset that in considering and in preparing the Bill the Minister and his Department took account of the various excellent reports which were published over the past ten or 15 years dealing with nursing, such as the survey of the workload of public health nurses published in the early seventies, the 1973 report on the psychiatric nursing services board and, more importantly, the report I referred to earlier, namely, that of the working party on general nursing. I hope that the effect of this Bill will allow An Bord Altranais to give effect to the recommendations of these working parties in so far as they govern the nursing profession.
I would like to refer to certain sections of the Bill, in particular to Part II of the Bill which re-establishes the board, because the board are already in existence by virtue of the 1950 legislation. I welcome in particular section 9 of the Bill which deals with the composition of the new board, a board of 29 members which constitutes nurses involved in various types of training and in various aspects of nursing administration, nurses engaged in various aspects of clinical nursing practice and the 12 other members whom the Minister, after consultation with various bodies, may appoint. The Minister has chosen wisely with regard to persons who were suitable for appointment to the board. Subparagraph (x) of section 9 (1) (d) states that “two shall be persons representative of the interest of the general public.” I hope that those two will play a wise role in bringing in outside expertise and the views of the public to ensure that the new An Bord Altranais operate in an objective way.
It is extremely unfortunate that the Bill provides that one committee, namely, the Fitness to Practise Committee, will not have on it any member of the public. Section 13 deals with the establishment of committees. Section 13 (3) states:
 A committee established under this section, other than the committee referred to in subsection (2) of this section may, if the Board thinks fit, include in its membership persons who were not members of the Board.
The committee referred to in subsection (1) is, of course, the Fitness to Practise Committee. I think it is a very good idea that all professional committees should have people who are not members of the professions. It brings to the committees the views of outsiders. It gives them the opportunity of seeing things objectively, it certainly brings to committees a sense of openness and it allows the public to look at statutory committees in a way that is fair.
The most important committee which this Bill establishes is the Fitness to Practise Committee. It is wrong that that committee should not have outside members. If one bears in mind that at the moment we are debating in this country — although we are not yet debating it in the Houses of the Oireachtas — establishment of a Garda complaints procedure the question arises as to whether or not we should have outside participation within that procedure. There is a broad spectrum of opinion which says we should have outside opinion. I know that the Incorporated Law Society have been in consultation with the Department of Justice regarding the committee of that body which deals with solicitors who have been out of order. I understand that legislation is in the pipeline which will provide for lay participation on such a committee. The very same thing applies in relation to the nursing profession.
It is extremely important that the Fitness to Practise Committee of the nursing profession should have outside, lay participation. I say that not in any way to try to worry the nursing profession. I do not say this to try in any way to make the nursing profession feel that they are coming under a microscope but I say it for the reason that by having lay participation they are protecting themselves against the public. The Fitness to Practise Committee is a statutory committee  with quasi-judicial powers. It is an extremely important committee and if nurses are subject to review by a committee composed entirely of their own peers then I think a worry may emerge. I ask the Minister to reconsider his attitude to that section and to that committee.
I know in the preparation of legislation Ministers have consultations with outside bodies. I am quite sure that the Minister had consultations with representatives of the existing board and with representatives of the various nursing organisations and possibly they said that there should not be outside participation. I say that without any pre-knowledge. It would be very wise, not merely from the point of view of the public but also from the point of view of the nursing profession, that there should be outside participation on this committee.
Section 10 imposes on the Minister the duty to take all steps to secure the appointment of the members to the first board and, of course, consequent on that we come into the election of the president and vice-president of the board. Those elections are provided for in the Second Schedule to the Bill. I must compliment the Minister on ensuring that the president and vice-president can be elected by the members of An Bord Altranais. One of the legislative controversies of the past 25 years was when the 1961 Bill was introduced by the then Minister for Health, Mr. MacEntee. If one reads the debates dealing with that measure one will see that the principal provision was to ensure that the president of the board could be appointed by the Minister for Health. If one reads Mr. MacEntee's speech on Second Stage in the Dáil one can see very little good reason but if one reads speeches by Opposition speakers one certainly gets the impression that there was a very able president on the board at that time who had obviously come into conflict with the then Minister. I must compliment the Minister for being open in this regard in allowing the new board to elect their own president. It is a very welcome development.
On the question of education and training of nurses, I hope the board will  comply with the recommendations contained in the report which I have mentioned. The report of the psychiatric nursing services board lays down very clear recommendations as to student training. I will just mention a few of them. One is that there should be a nurse education committee in each hospital, another is that clinical teachers should be appointed in all hospitals and there should be one fixed time of student intake each year, followed by a proper induction course. It is possible that all of these things are already in existence in so far as psychiatric nurses are concerned. I understand there has been a revolution in their training but I hope that the recommendations of the 1972 working party are complied with and I hope that the Minister, in exercise of his statutory powers under the new legislation, ensures that is done.
In relation to the report of the working party on the workload of public health nurses, I think there are recommendations there to the effect that public health nurses should have as much practical training as possible. There are also recommendations to the effect that public health nurses should be spared the workload of clerical work which they were certainly subjected to until recently. I am not altogether au fait with how public health nurses operate but I hope this is already in existence and if it is not in existence I would like the Minister, under the section of this Bill dealing with education and training, to ensure that the board carry out their functions to see that the recommendations of the working party are carried out. Likewise, with regard to the report of the working party on general nursing, there are recommendations there dealing with education. Again, I hope that those recommendations are carried out because certainly they make impressive reading.
I have expressed my views on the Fitness to Practise Committee. I would just like to say in a general way that the powers which that part of the Bill confers on the board are extensive and will be exercised with caution and properly. There is one particular power that is a  very important one. It is one that I would like to see being used frequently and my nursing friends may not like my making reference to it. It is the power contained in section 41 that refers to the power of the board, following an inquiry and report by the Fitness to Practise Committee, pursuant to section 38 of this Act to advise or admonish without taking any further steps.
There are certainly bodies who have similar powers and who do not use them. I refer to the Garda Síochána who under the Garda Síochána discipline regulations have powers under section 7 of those regulations to deal in a very informal way with a member against whom an allegation is made. For some peculiar reason Garda officers have failed to use that power in a regular way. There may be fears of various kinds behind that reluctance but I hope that no fears of that kind will arise in relation to the exercise of the power conferred by section 41 of this Bill. If An Bord do not exercise that power, then I ask the Minister, in exercise of his very substantial powers, to ensure that they use that power and use it frequently.
Finally, I would like to refer to one issue which Senator McGuinness referred to and it is one which I think many Members of this House have been approached on namely, the question of the inclusion in this Bill of a conscientious objection clause. I do not agree with all the remarks of Senator McGuinness. I agree with her when she says we must get the balance right. There is a duty on legislators to consider the rights of a specific group for whom we are legislating and also those of the public whom that group serve and to try to get the balance right between the two of them. Having said that, I do not think that the balance is right if you remove absolutely from nurses the right of conscientious objection. I do not agree with the point made by Senator McGuinness that one must take into account absolutely the right of conscientious requirement on the part of the patient. If a patient requires the administration of drugs which would have the effect of allowing euthanasia, should  that right in an absolute and unfettered way be given to the patient, should that right of conscience be given to the patient in an absolute way and should that right of conscience under those circumstances be removed from the nurse who would be required by law to exercise the administration of such drugs? I just cannot see that that stands to reason.
Having said that, I do not want to get involved in the sterilisation controversy. I do not altogether disagree with the views the Senator expressed on that subject but I do not altogether agree with the facts as she outlined them here today. I do not think it is relevant to get involved in that argument in relation to the question of conscientious objection by a nurse. If a nurse is required to do something which she or he believes to be morally wrong, then I think that nurse should have the right to opt out. I certainly do not accept that the inclusion in the code of conduct of nurses covers the point. The code of conduct provides in paragraph 1.11 as follows:
a nurse shall be entitled to make known at the earliest possible opportunity to an appropriate person or authority any conscientious objection which may be relevant to profession practice. An Bord shall be the final arbiter as to whether any such objection falls within the scope of this clause.
That quotation comes from the code for nurses issued by the nursing board but that phrase and that right do not have any statutory force. It is only right that there should be included in our legislation a statutory provision giving our nurses the right of conscientious objection to opt out of something which they do not wish to participate in by virtue of the terms of their employment. I stress “by virtue of the terms of their employment” because the majority of our nurses, 95 per cent at least, are employed either by the health boards or by the voluntary hospitals and as employees there are certain restrictions on what they can do and what they cannot do. As an employee a nurse may be compelled to do certain things and  rather than create a situation where a clash may arise within employment we should now legislate and provide in this legislation for that right which our nurses seek.
I have had the opportunity of speaking with many nurses who are involved particularly in the maternity and gynaeco-logical side of things and they are extremely worried about this matter. I do not envisage a situation arising whereby a mass of nurses will, as it were, gang up and come together to prevent an individual having a right to certain types of surgery. I do not see that situation arising and to suggest that, as has been suggested in this House today, is a totally unrealistic response to the call by nurses and matrons for this right.
I call upon the Minister to include such a right. I do not know how he will respond but I hope he will respond as openly to this Bill in this House as he responded to the Dentists' Bill in this House some months ago. This is an issue on which I will certainly have to consider my own position when it comes to dealing with this Bill. Having said that, I think it is important to realise that in relation to this type of issue some months ago the Cortes in Spain enacted legislation providing for the legislation of abortion under certain circumstances in that country. The Irish Times of 3 August 1985 carried the news of the introduction of that legislation. I qoute from that newspaper one paragraph from the article dealing with it where it says:
I sought a copy of that legislation from Spain. The Spanish Ambassador kindly sent me a copy of it in Spanish but I did not have the knowledge to translate it and I could not find somebody else who could do so for me. I ask the Minister to look at the legislation which the Socialist Government in Spain have introduced in relation to a matter very similar to this. I ask our Minister who is a member of the Government which I support and who  is also supported by many people who describe themselves as socialists to look at that legislation and see if at this stage we could introduce such an amendment here.
I conclude by saying that this is essentially a Committee Stage Bill and it certainly is a Bill which I will be following with interest in Committee, as I know will many Senators. I also say to the Minister that we were very happy in this House at his attitude in relation to the Dentists' Bill. We learned much about the organisation of the medical and allied professions when he accepted, dealt with and debated with us the various amendments which we, on the Government side, principally, put forward in relation to that Bill. I hope the Minister will be equally open when it comes to Committee Stage of this Bill in this House.
Mr. Lynch: My contribution to this Bill will be short. We must remember we are dealing with a profession which has given a tremendous service to the nation over the years, in many cases far beyond the call of duty. I listened to some of the speakers, both in this House and in the Dáil, and I ask the Minister to take seriously the views expressed by the nursing profession. We are dealing with a service that is over-burdened. How much longer can the nursing profession withstand the strain? Members of health boards are fully aware that while the embargo on recruitment continues there is an extra heavy burden put on this profession. When we are dealing with geriatric hospitals there is a limit in so far as one can act in this area.
When this Bill was published and was discussed in my health board I waited for a reaction. I got a very very mixed reception from medical practitioners on the board and indeed from the nursing profession. Some went so far as to say the Bill was ambiguous. Representations have been made to all Members of both Houses of the Oireachtas with regard to the matter of conscientious objection referred to by Senator Durcan. This House should not let the Bill go through without making proper amendments.
 The Bill is to provide for a new nursing board to deal with the registration, control and education of nurses and other matters relating to nursing. With a total of 29 members, 17 elected by the nurses and one nominated by the Minister, it appears that the nursing staff will have control in nearly all matters related to in this Bill. However, I am not satisfied with the conscientious objection clause in this Bill because if a nurse objected to carrying out a specific duty because it was against her conscience, there would have to be a ruling by the board in order to decide whether she was entitled to object or not. This would neutralise her objection. If a nurse has a conscientious objection she could not feel assured that the Bill has adequate in-built protection for her.
The board as envisaged at present seems to be capable of dealing with any such problem but there is no guarantee whatever what will be the constitution of this board in future years. It is proposed to have a central applications board. I consider each hospital should be allowed to interview and choose their own trainee nursing staff and that the amendment tabled in the Dáil regarding this matter should have been accepted by the Minister. Each hospital should also be allowed its own ethical committee in order to make decisions on a moral question for the hospital in general. The overall result of the Bill is that it vests too much power in the Minister. He will have the final decision on questions of alleged misconduct or behaviour. The question of misconduct is very much open to misinterpretation and for that reason I hope the Minister will take seriously the views expressed by Senators and, indeed, take more cognisance of the views expressed by the nursing staff who made representation because it is their future that will be affected by the Bill.
Mr. Harte: I welcome the Bill. The aspect of it that I wish to concentrate on is the question of educational training because it is very important indeed particularly in view of the rate and pace of change which has taken place over the  years in the nursing profession. I see educational training as being possibly the most important aspect of the Bill from the point of view of the question of dealing with the patient's health. Many other provisions relate to the questions of discipline, procedures for recruitment and so on, but emphasis must be placed on the actual training. This is very important because particular types of patients are more dependent on good nursing than they are on the attention of a doctor. For this reason it is very important that educational training be given very serious thought and I believe that the appointed board will take that road.
I am satisfied also that where a multi-discipline team is involved and where good nursing turns out to be the major aspect so far as the needs of the patient is concerned, there is no reason why a nurse should not lead that clinical team. It does not have to be led by a doctor. Given developments in training and education this can be very much more a reality than it is at the moment. It is no harm to put on record that nurses spend the longest time with the patients and they are the people who really get to know them. If they have been in training with a multi-discipline team and they have a good grasp of the other aspects of the care of the patient the nurse is, in that sense, the leader. Therefore, her time and talents can be made greater use of and I think this board will possibly pay attention to that aspect.
There is no reason why there should not be a development of the nurses training service and ultimately taking a greater share of clinical responsibility. At present in psychiatric nursing nurses are actually going into the community from the hospital base and in this respect nurses are acting as therapists. Of course, in giving care and treatment inside the hospital base, they act as therapists as well but not in the accepted recognised sense. If there was more recognition through education and training and an examination of the discipline involved we would find that the talents and time of the nurses could be better utilised. In the psychiatric  field nurses are called on to give more care and attention to patients because of the limited number of psychiatrists. Some doctors and psychiatrists are remote and nurses are the best people to give leadership when it comes to considering the question of taking general nursing into consideration, which would include community and psychiatric nursing.
There have been remarkable developments since the beginning of the century. The nursing profession has undergone great changes but it needs to be developed. We should harp on the fact that the profession is on the threshold of further development in training and education. The new board may supplement that. They have to give the nursing profession greater recognition through their education and training so that they will be more self-confident and be recognised not as an auxiliary to medicine but as members of a different profession. The potential for that exists. The board, as at present constituted, should be able to bring about initiatives in that direction and changes in the training programme. If that occurs we can look forward to our nurses playing a more central role in the care of the mentally handicapped and the elderly.
I should like to see the board developing the area of training. At present a nurse when psychiatric training is completed moves on to community care. That training programme should include all aspects of nursing. Nurses will not let anybody down and they have proved that over the years. They are a unique group and are separate from medicine or any other profession. The quality of our nurses is well recognised and overseas the Irish are well established in many hospitals.
There have been improvements in the recruitment of nurses as a result of developments in education and I trust that any new educational programmes will lead to a continuation of that. We will always have many people applying to enter the nursing profession and, for economic reasons, they may have to pursue their careers elsewhere. It is a pity that that is  happening. I hope the board will have a look at that. It is sad to see such talented people having to look elsewhere for a job when they have set their sights on securing a position at home. Nursing is a vocation and it is sad that some people have to leave it at a certain stage. While great work has been done about the quality of the candidates and the standard required before training there is the problem in regard to numbers. I hope that will be looked at in an objective way.
As a result of further education and training some nurses get promotion in the caring grades or in the direct patient service but because there are not sufficient posts in the patient care area some nurses opt for administrative jobs. I am not saying that people should not opt for administrative jobs but many nurses who have given most of their lives to nursing would prefer an opportunity to advance to more senior positions, if they were available, rather than taking on administrative posts. We should try to cater for nurses who want to stay in nursing. The structure will have to be changed and talents directed towards patient care, particularly where a nurse wants a career in nursing as distinct from administration. There will be practical problems in this respect but there are ways of dealing with them.
The training of specialist geriatric nurses might be a way of providing promotional outlets. That brings in the question of working alongside other health visitors who work with children. There may be problems in regard to overlapping. I trust the board will help with training and development in this area so that nurses will have another avenue for promotion open to them.
It is easy to stand up and wish the nursing profession well because most of us have a high regard for them but I also wish the board well because they will have a difficult task. I can see them having all sorts of difficulties. The onerous task of looking after nurses' education and training is only one aspect of their work. There is also the whole question of discipline. The possibility of somebody taking a case to the High Court  is another problem that must be dealt with. They have many areas to cover. However, education and training will be the key area.
I have one area of concern and the Minister might ease my mind on it, the question of rehabilitation. There is not a lot about rehabilitation in the education and training of nurses. I hope the development of the area of training will have regard to rehabilitation because nurses have a substantial contribution to make in that area. They can teach people, through their own approach, psychological and otherwise, to become more independent and self-reliant. District nurses can encourage relatives and friends to teach people to use aids. Some people through fear have failed to use aids and subsequently there has been a deterioration in their health. Nurses have much to offer in that respect.
I do not know what the position with regard to undergraduates is but there should be an element of common training for social workers, radiographers and so on. In other words, nurses should see themselves that, while they are a profession in their own right they are not elite and that there are other problems with which they must deal. On the question of common training I suggest that a study be undertaken to see if a more effective method is needed. The whole question of drug abuse, for example, has to be dealt with. It is not just a question of rehabilitation but one of common training with social workers and so on. That would be of great assistance to nurses. There is great potential if the education and training are handled and developed properly.
Accidental injury is another area to which we do not pay much attention. Nurses should be trained with other groups and get the experience they require from the other professionals. Psychology, occupational health, sociology, health economics and social administration are all part of the social preventive medicine area. I hope the new board pay attention to some of the points that have been made in the Seanad, not only by myself but by other Members.
 I will conclude by referring briefly to the powers given to the board to inquire into alleged unfitness to practise, professional misconduct and so on, where they have the power to suspend registration. The power to suspend registration is an additional power. This is a very serious step. I do not rate it in the context of people being pilloried or anything like that but often lapses occur. With a board of 20 or 30 people it is possible to lose sight of how a problem should be tackled and, at the end of the day, for an error to occur. Since the majority of nurses are in trade unions I would have thought that it would have been appropriate for the Minister to have appointed a member of the Irish Congress of Trade Unions. One could say that 90 per cent of the nurses are members of the two major unions — the Workers' Union of Ireland and the Irish Transport and General Workers' Union — and some are members of nurses' organisations. As we have to deal with this question of misconduct it might not be a bad idea to have somebody on the board who could look at a case from the point of view of the person being investigated. I am not saying that the board will not be impartial but this advice might be necessary. I have no hang-up about this but such a move would be wise because some difficulties could be avoided.
Mrs. Honan: When we decide to take the Second Stage of any piece of legislation we should ask ourselves how vital to the nation are the people referred to in the legislation. This evening we have an extraordinary situation. I would welcome anything that would help our nurses but we must bear in mind the conditions in our hospitals with which we are all familiar. The Nurses' Bill is dated 1984 and it is now September 1985 and it is a much amended Bill to that introduced in the Dáil last year. Members of all parties, and the INO, at a very early stage did not realise the implications of some of the provisions. It was at that early stage that I decided to oppose the Bill no  matter what the eventual consequences for me would be. Nobody in this House would have made me vote for the Bill in its original form. It has been greatly amended since due to the commonsense of my colleagues in the other House and the Minister who used his commonsense before a vote was taken on it in the Dáil.
We seem to have arrived at a stage of not giving enough time and interest to legislation that affects people like our nurses. We have gone off on flights of fancy and wasted time on things that affect people who are not as important as nurses. The Minister of State in his Second Stage speech said:
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.
That was much different from the Second Stage speech in the Dáil. Some of the things he said then when considered in relation to conditions under which nurses in general hospitals, such as the general hospital in Clare, work under do not add up at all. I do not want to be unruly, but I want to quote what the Minister of State said. He went on:
That sentence should be re-read because, even though he did not mean it, it would be wrong to talk about a new era for nurses because they have played an enormous role in Ireland since we got our freedom. We are all very quick at times, when it suits us, to pay tribute to them. Many Members here referred to a new era of nurses but I want to put on record a tribute to the nurses who have gone and those who are serving. It is fine if the Minister wants to be prepared for the era that seems to be ahead of him.
But it is possible to plan for change  and I am satisfied that this Bill has sufficient provisions for flexibility built into it to allow for adjustment to suit changing needs and circumstances in nursing as they may develop.
Mrs. Honan: I am quoting the Minister's speech. It was shown earlier on another Bill today, introduced by the Taoiseach, that some Members do not read the Minister's speech over and over as I have done.
I would say that it is thanks to the commonsense of Members in the Dáil — and, indeed, to the Minister — that a decision was made on the composition of the board. A lot of people were sore until it was decided to have 18 nurses on the board. In fact some people thought there should be 20.
. . . I am currently considering the possibility of providing 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.
I welcome that system of election because it will give a chance to the people with the lesser numbers to have a voice. Here I must state that people who care for the mentally handicapped seem to get a lesser voice in the nursing world. I make the difference between mentally handicapped and mental illness. Nurses in that area will get a voice on the board.
We have a much amended Bill before us and that is a good thing. I am glad it has been corrected. I understand there will be 17 elected nurses and one appointed by the Minister, a total of 18. That makes much more sense than what was proposed earlier.
Mrs. Honan: What worries me is the amount of power the Minister, for whatever length of time he survives, and Ministers who will succeed him, will have. It is extraordinary. The Minister seems to give himself a lot of power and I do not think that is a good thing. I do not think there have been too many comments in speeches today on whether he should have that amount of power or not.
With regard to sub-committees referred to in section 13, I asked: why exclude the chairman of the board from being chairman of any of the committees? That is a little different from legislation dealing with other boards.
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