"To everyone we are just tools"
June 1, 2009 -- A number of recent press items from sub-Saharan African nations portray the nursing profession in positive terms. They stress how important and difficult the job is in those nations during the global nursing shortage, even though the articles sometimes fall prey to angel stereotyping or fail to convey much about the advanced skills nursing requires. A good example appeared on March 11 in the Kampala-based magazine The Independent: "Nurses -- Uganda's angels," by Mubatsi Asinja Habati. Then there are the stories about nursing in South Africa. A sadly typical example is Graeme Hosken's "Nurses 'drink tea while mom gives birth,'" which appeared today on page 1 of The Pretoria News. Another discouraging article with a drinking theme was Sipokazi Maposa's March 2 story in The Cape Argus, "Nurses drink on duty, say terrified patients." Pieces like this describe--as they should--the poor "care" that some patients report receiving from nurses in South Africa. Unfortunately, few of the pieces we've seen provide much context to explain why health care professionals might fail so miserably to discharge their duties to patients. One notable exception is Zara Nicholson's "Nurses also victims of poor health care," which ran on March 28 in The Cape Argus. Nicholson's article tells readers about the extreme challenges public sector South African nurses face, from critical shortages of staff and resources to widespread disrespect to the abuse by frustrated patients that is a natural result of the shortages. We commend those responsible for the above items--most of which focus on nurses working in obstetrics--for telling readers something of value about the troubled state of nursing.
The March 11 Independent article by Mubatsi Asinja Habati obviously begins with the angel stereotype, one which tends to suggest that nurses are unskilled spiritual beings who may not really need clinical or educational resources. But the actual article does convey some of the profession's stresses and dangers in a nation without many resources, and gives readers a general sense of what one Ugandan nurse does. That nurse is Irene Nabukeera, a veteran midwife who is "very good. If your wife was giving birth at Mulago Hospital in Kampala, you would want Irene to help her deliver."
The piece begins by describing a needlestick scare Nabukeera suffered in 2001 while drawing blood from an expecting mother--the HIV test was negative--but most of the article tells readers how Nabukeera spends a typical work day. Mulago features "unending queues and a sea of doctors, nurses and patients flowing in and out of the dilapidated hospital," along with "the yells and screams of the sick," and a "smell of pollution and decay [that] assaults the nostrils." But Nabukeera is undeterred: "By working abroad she could receive better pay and more pleasant working conditions, but she would not get the satisfaction that comes from treating fellow Ugandans." Much of the piece is simply Nabukeera describing her shift:
My shift usually starts with a little history. The nurse who supervised the patients during the previous shift briefs me. This is how I find out what to expect for the next eight hours. I have to learn each patient's diagnosis, what medications each needs, what special care each requires, and who might come or go during my shift. I will also go over the doctor's reports for each patient. I set up treatment sheets for my patients. I record the history the nurse has told me, and include any other important information picked up from the charts. This is a good time to look at the laboratory tests that have and will be run. You want to be prepared so when the unexpected happens, you won't get completely sidetracked. ...With people living longer than ever before and new technology and medications found every day to treat diseases, you have the opportunity to touch many lives. Once you learn how to balance the paperwork and schedules, as well as the emotions from patients, doctors and families, you can handle almost anything.
The article says that nursing "can be very stressful," the pay is not high, and there is a risk of contracting deadly diseases, pointing not only to Nabukeera's needlestick, but to the deaths of five nurses treating Ebola patients in the Bundibugyo district in 2007. Many Ugandan nurses have gone abroad to work. But those who stay "find that saving lives makes up for the stress."
On the whole, despite the headline and a lack of many concrete specifics--such as exactly what Nabukeera does for her patients as a skilled midwife--the piece does give readers a sense of how complex and difficult nursing work is. And of course, we're partial to any description of nursing that includes the phrase "saving lives."
The June 1 article by Graeme Hosken in South Africa's Pretoria News is a very different story. The lead is indicative:
Laughed at and then threatened with physical violence by a group of nurses, a Pretoria mother was forced to give birth unaided before she was chased from a clinic.
The item explains that the mother's own mother "alerted her employer," apparently named Van der Merwe, who then visited the clinic to question its staff about the incident. When the woman who had given birth brought her baby back to the clinic for a check-up, she was reportedly "threatened" by nurses because of the employer's visit. Van der Merwe comments: "How can nurses, who are there to help, be allowed to do this? If they don't want to work as nurses then they should not be in the profession." One of the nurses reportedly told the employer that "the reason the incident happened was that the clinic was understaffed and had 'too many patients.'" But Van der Merwe notes that at the time her employee's daughter needed help, the nurses were "apparently not busy, but sitting around and having tea." The daughter herself says she is "terrified of returning to the clinic."
I am afraid that the nurses will hurt my baby. ... When I asked one of them why they were not helping the mothers at the clinic, one of the nurses grabbed me, saying she would slap me. She told me to never come back and said I must find another clinic. When I told her that was the closest clinic to my house, she said she would "get me" if I came back. When I was in labour and asked for help, three of the nurses laughed at me and told me to do it myself. They said I had got myself into the situation, and must get out of it. I was crying and begging them to help, but they would not (help), and when I started yelling from the pain, one of the nurses said that if I did not shut up, she would hit me and make sure I kept quiet.
Van der Merwe says she will be filing a complaint about the care her employee's daughter received. Spokesman John Louw of the Gauteng Health Department promises that a district manager will follow up with the mother, ask her to file a complaint so they can investigate, and offer counseling. Louw also noted that "a shortage of skills in the health sector across the whole country was a publicly known fact and had been communicated as such by various leaders."
The mother who is the main subject of the story says she was one of three who gave birth "without assistance" that day at Soshanguve Clinic. Another mother, "bleeding from complications," had to unwrap her newborn son's umbilical cord from his neck while the nurses "sat back, watched and 'drank tea.'" This woman "screamed for help," but "[t]he nurses told her to shut up and sort out the 'little' problem because they were busy, but they were not. They were sitting on chairs laughing and drinking tea. They did not care whether we lived or died."
The article says that the newspaper recently reported that a cancer patient who had had his colon removed last year "lay in his own faeces for nearly three days in Steve Biko Academic Hospital last week after follow-up operations allegedly went awry, with nurses ignoring his pleas for help."
The piece does at least provide suggestions of the difficult conditions health workers face, though probably not enough to explain why anyone would behave as reported. The piece notes that this "latest disclosure on the shocking state of government hospitals in Tshwane comes as the Department of Health is beset by a lack of resources and cash to procure food and medical supplies needed for patients." Does that lack of resources include short-staffing, as one of the clinic nurses apparently suggested to the employer? What about the tea drinking? Louw's comment about the "shortage of skills" suggests that some nurses are simply not well-trained, and that may be the case. But the piece might have sought input from some nursing expert to provide better context, or reaction from the clinic nurses themselves. Or were those nurses too fearsome to confront?
The March 2 article by Sipokazi Maposa in South Africa's Cape Argus also describes nursing care that is very poor, to say the least. The report includes allegations that nurses at the Gugulethu Community Health Centre are so scary that some patients "would rather die on hospital benches than approach the nurses to discuss the seriousness of their illnesses." Patient Nomhle Bandla points to poor service, long queues, and frequent confrontations as a result of abusive nurses. One factor is reportedly that nurses drink alcohol while on duty. Patient Anezwa Umbali says that this exacerbates nurses' rude conduct, noting that "a number of times I've seen nurses and cleaners drunk and swearing at people." The piece quotes two union officials, Solidarity spokesman Jaco Kleynhans and Democratic Nursing Organisation provincial secretary Bongani Lose, both of whom say they are aware that some nurses drink on duty. Kleynhans is at least able to offer this explanation:
We are not saying that drinking on duty is acceptable, but it is a reality that nurses work under extreme pressure, having to work long hours under difficult conditions. Many of our public hospitals are understaffed and nurses often find it difficult to cope with the work and trauma. Nurses go through emotional trauma because they work with human lives.
He says that better working conditions and counseling are needed.
Kleynhans's comments provide some context for the allegations that dominate the rest of the article, which are of course very troubling. Drunk and abusive may have been qualities associated with nursing since Sairey Gamp in Charles Dickens's time, but it's not exactly what modern nursing is aiming for. Some of the working conditions Kleynhans describes would apply to most nursing jobs today, and the piece might have included more specifics to explain just how bad understaffing and other working conditions are at the hospital in question. And once again, the piece might have sought comment from the nurses who actually work at the hospital.
The March 28 article by Zara Nicholson in the Cape Argus admits that South African nurses do sometimes abuse patients, but it also explains why the horrific conditions in which the nurses work may help to explain such conduct. The piece begins by acknowledging that patients in government clinical settings may face bad conditions and "less than optimal treatment," and that "nurses' apparent callousness has hit the headlines in recent weeks, but a closer look reveals the stresses they have to deal with, such as lack of staff, insufficient and inefficient equipment, and low wages."
The story is based almost entirely on the tell-all account of a "retired registered nurse and midwife, who spoke on condition of anonymity" and "painted a gloomy picture" of nurses' working conditions. This woman had reportedly been a nurse for more than 40 years, working in OB and trauma. She describes the very small Hanover Park Obstetric Unit where she had worked, which had just three labor beds and six post-natal beds. It was common not to have the right equipment, the pay was low, and short-staffing was a major problem. In a 12-hour-shift, she says, there were usually two midwives, one staff nurse, and two "assistant nurses" "to deliver as many as 14 babies, several of the births taking place simultaneously."
We like to keep them in the post-natal ward for six hours but sometimes we had to send people home two hours after giving birth because we had other mothers waiting. Sometimes we just have to wait until the mother is stable and not bleeding heavily and see that she and baby have bonded and send them home earlier because the turnover is so big and there are too many patients. It's really hectic because the assistant nurses don't do deliveries and as one of two midwives you often have more than you can handle, and you can't see to everyone at the same time. There are so many times when both midwives are busy with a delivery and another baby wants to come out. The working environment is very tense and stressful, but it depends on the team you are working with. If it's a good team you are tired but not as frustrated and stressed as you would be in a team that doesn't work as well together. It drains you mentally because you want to do justice to each patient.
The nurse explains how this situation can lead to conflicts between the nurses and the patients.
Some patients become rude and abusive and threaten nurses. Some patients have no respect for what we do yet they expect you to respect them. They don't realise what you are doing for them and so many other people at the same time.
This is a blunt statement of how the undervaluation of nursing can affect health care at ground level. On the other hand, the nurse concedes that (in the report's words) "some nurses did not handle pressure well and verbally abused patients," with nurses "regularly" telling patients: "Don't shout now, you knew what you were getting into when you opened your legs." The nurse says her stressed colleagues often refused the available counseling because "they were in denial and would only go once they had a breakdown...Nurses who act out often come in late and leave early and they don't report irregularities with patients or the babies, and that's dangerous."
Turning to her work at the Mitchell Plains "day hospital," the nurse again stresses the effects on patients and nurses when health workers have to work without adequate staffing or equipment.
It's a 24-hour facility and they are short-staffed especially with doctors. Often recruited foreign doctors are used because our doctors stay there for two years and then they go off to start their own practices. The experience there is terrible from the time you come on duty till you leave. The equipment is better now but it was terrible, we had to work with broken instruments, sometimes we had no scissors and would have to use a blade, which is dangerous for the patient and the nurse. A lot of the equipment is outdated and instruments are old and rusty and you can't use those on a wound. Our sterilising equipment would often be delivered late. ... You seldom hear the words 'Thank you' from management or patients. To everyone we are just tools, and sometimes we wonder why we put up with this, but it's the nurse in you that carries on. Some of the things we see are heartbreaking, like people being negligent with their children.
This piece does not pretend that the reports of abusive and incompetent nurses are wrong, but it does provide valuable context to help the public understand how things can become that way. When nurses and other health workers are regularly faced with trying to care for patients without the help or materials they need, over time the result is tremendous stress and burnout, and good care becomes more and more difficult to provide. It also sounds like the nurses do not receive much respect from colleagues or patients. The comparison to "tools" is actually not so surprising; nurses have been compared to inanimate health care technology, like robots, in a range of global media. Such attitudes are another critical impediment to good care. Nurses can be disciplined and counseled for the kind of misconduct and poor care reported in South Africa, but the long-term solution to situations like these is better working conditions. Of course, that requires more resources and better understanding of nursing.
Press pieces like these are a start.
We are looking for nurses to start chapters of the Truth in their home towns. We need chapters especially in South Africa to help respond to some of the media there. Please contact us at firstname.lastname@example.org to inquire about starting a chapter. Also please see our chapters mission and activities page and a list of Truth chapters. Thank you for getting involved in our grassroots activities!