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Why do nurses abuse patients?

Zambian patient 
April 22, 2012 -- Today the Zambian Watchdog website posted an opinion piece by Andrew Silumesli entitled "Why do Zambian nurses abuse patients?" The piece says that such abuse is a serious problem in Zambia, and it discusses possible causes and solutions. Silumesii relies in part on research about abuse by nurses in the South African obstetric context and in part, we assume, on his own experience in Zambian clinical settings. The piece includes a note that Silumesii is a "Master of Public Health (MPH) candidate at the Institute of Tropical Medicine, Belgium," but does not make clear that he is a physician. The South African research on which he relies was led by a physician and a nurse, though he does not say so. Nor does he note that the research was from 1998, before the current global nursing crisis really took hold. Silumesii does deserve credit for asking the "why" question, which is rarely asked, despite the many media accounts about this kind of abuse in the region. These articles typically focus on horrific examples, but then stop at highlighting the abuse, offering no comment from the nurses involved and no ideas about why the abuse occurs; a notable exception is a March 2009 piece by Zara Nicholson in The Cape Argus, which told readers about the extreme challenges South African nurses face. Silumesii's analysis of the problem is fairly persuasive as far as it goes. He points to a complex array of factors, including inferiority and superiority complexes that may develop after a new nurse has managed to find one of the few escape routes from the generally bleak job prospects for Zambian youth. Silumesii might have looked more closely at potential factors that can't be addressed simply through changes in nurses' values and attitudes, like understaffing, resource shortages, and relations with physicians, which research has shown to be a problem in South Africa and around the world. Most of his proposed solutions are pretty vague. And there is no indication that he has asked any Zambian nurses what they think. Even so, the piece is a positive step, and we thank Silumesii and the Zambian Watchdog site.

Zambian patientSilumesii starts by citing the article "Why do nurses abuse patients? Reflections from South African obstetric services," by "Jewkes et al." He observes that in Zambia this "very pertinent question" "not only remains unanswered but perhaps has not even been systematically asked in the first place." Silumesii says such abuse is not uncommon in Zambia, where the "media is replete with stories of patients and their relatives suffering abuse at the hands of nurses." Silumesii does not dwell on the problem, but he notes that it "may range from a sheer ignoring of an in-patient who calls out to the nurse for a cup of water to drink, to a thorough public scolding of a mother whose child's weight is below the lower line during an under-five clinic, or the physical 'manhandling' of an 'uncooperative' teenager in labour trying to come to terms with her novel experience of giving birth." Such conduct, he rightly notes, can block access to care, since "a mother would choose to delay seeking treatment for her sick child for fear of being reprimanded by the nurse, while an adolescent would altogether shun accessing sexual and reproductive health services for the same reason."

Florence NightingaleBut, Silumesii says, the issue does not seem to be a high priority for the nation's Ministry of Health, the General Nursing Council, or the Zambia Union of Nurses Organisation (ZUNO). Silumesii argues that it should be, citing no less an authority than "the pioneer of modern nursing," Florence Nightingale, who once said that "it may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm."

Turning to the "why" question, Silumesii says that Jewkes and her colleagues "provide sociological perspectives," namely "a complex interplay of factors including organisational issues, professional insecurities, the perceived need to assert control over the environment and sanctioning of coercive and punitive measures to do so, and an underpinning ideology of patient inferiority." The piece might have benefited from a little more detail about the South African research, including its methodology, which involved individual interviews and group discussions. And while Silumesii's descriptions of the main findings are accurate, he might have noted that the research appeared in the journal Social Science & Medicine in 1998, before the global nursing shortage had really taken effect, and so the research might not fully reflect the role of current factors like resource shortages. He might have also noted that the authors are physician Rachel Jewkes MD, nurse Naeemah Abrahams, RN, PhD, MPH, and Zodumo Mvo, MPhil. Zambian nurses(It appears that Abrahams got her PhD after the 1998 research was published.) Had Silumesii noted that one of the researchers was a nurse, it would have shown readers that nurses themselves are serious health professionals who conduct scholarly research--and who are willing to study their own profession's shortcomings.

Silumesii then makes some observations about the Zambian situation, though he does not explain what his source is, leaving readers to guess that he is drawing on his own experience or some unspecified reading. He says Zambians who graduate from high school are typically "offloaded onto the streets to join ranks with several hundred thousand other disillusioned youths who are stranded with lack of opportunities for training or employment." Nursing college admission is "extremely competitive" and for the "fortunate few" who make it, "it is not hard to notice the sudden leap in their sense of self-esteem, and often you hear the affirmation of their feeling of having climbed to a superior socio-economic stratum relative to the majority of their patients." He suggests that that "power differential" tends to greatly impair nurse-patient relations, and he correctly observes that Jewkes et al. "suggest that nurses deploy violence against patients as a means of creating social distance and maintaining fantasies of identity and power."

Silumesii wants nursing to "regain . . .its image of 'caring'" and he has several ideas, most of which are pretty vague. He proposes that nursing schools initiate students "into a value system of respect and care for patients," and that nursing professional bodies "positively re-enforc[e]" conduct that reflects nursing's high ideals. In particular, the General Nursing Council should "revisit the formulation, interpretation, dissemination and enforcement of professional ethics and consider to what extent they provide adequate protection for patients against abuse." Zambian nursesNurse managers should act as "role models" and make clear that poor conduct among nurses is "punishable." In perhaps the most specific recommendation, Silumesii says that health facilities should ensure that "complaints-handling mechanisms are streamlined and reported cases of abuse thoroughly investigated and effectively acted upon." Finally, he says that the government should "address the thorny issue of improving working conditions for nurses to ensure that they are adequately motivated and that they operate in environments that are conducive to quality patient care."

Of course, only so much can be said in a short opinion piece. And this one does at least try to explore some of the reasons for nursing abuse as well as offer some ideas for improvement. Silumesii does not pretend that the problem is all in nurses' heads, or that all they need is a change in attitude. But that does seem to be his main focus. He mentions improving working conditions, but does not say what's wrong with them. Are the nurses overwhelmed with more patients than they can care for, leading to stress and burnout? Are they asked to provide care without adequate equipment or other resources? Are they underpaid? Have their numbers been decimated by emigration to wealthier nations? And there is no mention of relations with physicians, which has been shown to be a key factor in nurses' workplace experience in Africa and around the world, with other studies from South Africa suggesting that physician abuse of nurses is a key factor in nurse burnout and turnover. All of these factors could play roles in nursing abuse, and none of them could be addressed simply by emphasizing ethics and modeling good behavior, measures that tend to fade in the face of great stresses on the ground, in the clinical setting. Perhaps the most glaring omission in the piece is input from nurses themselves, except to the extent nurse Abrahams' undisclosed role in the 1998 South African research could be seen as nursing input. Did Silumesii consult any current Zambian nurses? Do they have any ideas about why this abuse may be happening now?

Despite the piece's shortcomings, it does at least ask the right questions and point to some possible solutions. We thank Dr. Silumesii and the Zambian Watchdog.

See Andrew Silumesii's piece "Why do Zambian nurses abuse patients?", posted on April 22, 2012, on the Zambian Watchdog site.