By Nana Koram
January 15, 2002
of Ho District Hospital - Volta Region, Ghana
The Volta Region, once the center of political controversy between
Ghana and neighboring Togo because of the large expanse of water
(Lake Volta) that runs through it, is now one of the most deprived
regions in Ghana. Although the
region remains important because of hydroelectric power, which would
be impossible without Lake Volta, many Ewes have accused the government
of neglecting them.
Ho, although it is its regional capital,
hardly qualifies as a city and instead bears a strong resemblance
to a large town. The Ho District Hospital is a government-run hospital
situated right in the middle of the town and is meant primarily
for the district of Ho. Patients with complex problems that cannot
be treated at the District Hospital are transferred to the Volta
Regional Hospital, which is much larger, better equipped and caters
for the entire Volta Region.
The Ho District Hospital is made up of several units: the Maternity
Unit, Children's Ward, Diabetes Center, HIV/AIDS Unit, etc. The
daily running of the hospital is not done by the hospital director,
but rather by the matron of the hospital. A matron is a registered
nurse with a bachelor's and master's degree in nursing. He/she usually
has a work experience of at least ten years. The charge nurses
of each unit report to her at the end of both day and night shifts.
Doctors in the hospital come and go and it is the nurses who see
to all the patients' needs.
I spent three months last summer working at the Ho District Hospital
as a public health intern. Being interested in women's health, I
concentrated my efforts at the Women's Health Division, which is
made up of three different sections: the Family Planning Unit, Postnatal
Care Unit and the Antenatal Care Unit. The unique characteristic
of the Women's Health Division is that it is run entirely by women.
This is to ensure that women do not feel discouraged about coming
to the clinic for fear that a male doctor or nurse might examine
them. However, the women who most needed the services of the clinic
were often noticeably absent
Ho District Hospital, Women's Health
Division - Family Planning Unit
"Madam, please come in and sit down."
smiles broadly, revealing her sparkling white, but uneven teeth.
She ushers the nervous woman into the consultation room of the Family
Planning Clinic. The young woman shuffles into the room and lowers
herself slowly into the cushioned chair that Sister Ella points
to. Her left hand comes up to push a lose curl away from her face
and her gold wedding ring gleams in the yellow sunlight streaming
into the room.
"How can I help you today?" Sister Ella sits in the adjoining chair.
In halting speech, the young woman explains that she's recently
married and would like some advice on family planning as she
and her husband have decided to wait five years before having
children. Sister Ella nods approvingly. Patiently, she goes through
all types of birth control available at the clinic and suggests
several types that would be suitable for the young woman's
lifestyle. Then she explains that there will be a physical exam
and a pregnancy test ("…because some women show up when
the mistake has already been made...") before any family
planning program is begun. The young woman listens intently,
the initial tension gone from her face. She's sitting back in her
chair, her chin propped up on her well-manicured hands. At the
end of the session, she lets Sister Ella know that she is not ready
to make a firm decision yet since she would like to discuss the
options with her husband first. She leaves, but not before
setting up an appointment for the following week.
Ho District Hospital, Women's Health Division - Postnatal Care
The Daily Graphic, one of Ghana's
national newspapers has a multipurpose. Not only is it a good source
of current events, but, as new mothers in the Postnatal Care Unit
demonstrate, it can be rolled up and used as a make-shift fan to
combat the already intense 11 a.m. heat - 280C and rising.
A thin film of sweat on collects on
Sister Ella's forehead, but otherwise, she doesn't seem to be affected
by the tropical sun. She's talking to a young girl who looked like
she couldn't have been more than fifteen or sixteen years of age.
On the girl's lap lies a small fragile-looking newborn. You can
still see its thin blue veins through the transparency of its delicate
skin. Sister Ella's brilliant smile is missing and her eyebrows
are furrowed into deep trenches of disapproval. "How old are you?"
"I - I - I just turned 18." The poor girl chews nervously on a fingernail.
Most of her fingernails have already been chewed down to the nub,
and a couple which have gone down too low are crusted over with
"Are you sure? You look 14. Remember that I'm a nurse. If you lie
to me I can easily find out how old you are through other means."
The threat hangs in the air for a couple of minutes.
"I'm 15," the child confesses. Her eyes are already clouding over
with tears. But Sister Ella's tenderness is missing today. She always
said she didn't have time for "children of today who want to do
the same things their elders do". Almost mechanically, she goes
through the nutrition talk for mother and child, thrusting dozens
of colorful pamphlets at them.
"Any questions?" She practically grunts out the words.
Quickly, the child shakes her head, gathers her precious bundle
into her arms and hurries away, half of the pamphlets she was given
still lying on the tabletop. She makes no appointment for the following
Analysis of Effects of Attitudes
on Quality of Healthcare
"Healthcare is objective. Doctors,
nurses and hospital staff are objective and treat patients to the
best of their ability."
This is an ideal that Ghana's Ministry
of Health would like everyone to believe. Indeed, healthcare can
be and is very subjective because doctors, nurses and hospital staff
are not immortals. They respond to patients emotionally and this
can affect the quality of care they give. As Glaser and Strauss
point out in their study of the effects of the social characteristics
of a patient on nurses, "…a social value is placed on a patient,
and that value has much to do with the impact on the nurse…and frequently
on the care he [patient] receives."
The quality of care a patient receives is influenced by the impact
of their social characteristics on the nurse. If a nurse approves
of a patient's lifestyle, the quality of care is significantly better
than if she disapproves.
Let's examine Sister Ella reaction to the two different patients
she received at the Women's Health Division. Sister Ella is an elderly
public health nurse. Married for over thirty years with two grandchildren,
she is always in good spirits and takes her job seriously. But,
Sister Ella does not leave her values and prejudices at home when
she comes to work. She firmly believes in no sex before marriage.
As a result, the treatment that single, young women receive at her
hands differs significantly from that which married women receive.
Married patients are warmly received into her office and put at
ease. Sister Ella is patient in her explanation of the kind of care
available at the clinic and encourages the women to ask questions.
With single, young women, she is often curt, her attitude almost
accusatory. Although she does make sure that they are aware of their
options, her judgmental attitude discourages the patients from opening
up, and most leave after a short consultation, too frightened to
return to the clinic.
According to Glaser and Strauss, nurses tend to judge patients on
the basis of several social characteristics: age, sex, race/ethnicity,
socioeconomic status, family status, education, occupation, beauty,
personality, talent and accomplishments. Sister Ella places value
on her patients according to their family status. Those with the
highest value are married women, while those with the lowest value
are teenage girls. Ironically, teenage girls are the ones who need
the most care because they lack the social support that many married
women have. Married women seek emotional support from their husbands
and families. Teenage girls often don't even have the support of
their boyfriends. In a country where women's health is strongly
emphasized and family planning is a well-developed practice, the
teenage pregnancy rate is unusually high. This may be because the
accessibility of birth control advice for young women is limited
because of the attitudes of some public health nurses and the value
the nurses place on these girls.
Sister Ella is not alone in her
prejudices. Some nurses are more open and friendly with women
from the same region or ethnic group as they were or spoke the same
language as they did. Sister Vick, a young nurse in her thirties originally
from the Brong Ahafo Region
of Ghana who was transferred to the Volta Region as a result of shortages
being experienced in that area, is an example of such a nurse. She
was often more friendly with women who spoke Brong
than with any others. Others identified more with women who worked
for the Ministry of Health than with women in other professions. Sister
Lydia, for example, developed closer relationships with other nurses
who were patients at the clinic than with other women. She said it was
easier for her to identify with them because they understood her
problems with her job. Although every patient technically received the
care they were supposed to receive, the impact of their social
characteristics on the nurses affected variables such as how long
they spent talking to the nurses, how well the different medical
processes they were going through were explained to them,
how comfortable they were made to feel, etc.
Possible Solutions to Subjective Care
Medical care is not objective, although
it is supposed to be. The question is can it ever be objective? Perhaps
the Ministry of Health can reduce subjective care by placing nurses
in regions in which they can work with people they identify with and
perhaps placing younger nurses in Family Planning Units to reduce
/eliminate prejudice against teenage girls. But these are temporary
solutions and do not necessarily solve the problem. There is the
need for long-lasting solutions to this problem.
What is needed most is first of all, an acknowledgement from
the Ministry that nurses have certain prejudices which can affect
the quality of care patients receive. Because the Ministry of Health
tends to ignore the fact that healthcare workers are not necessarily
objective in their dealings with patients, pressure is put on these
nurses to be perfect. Pretending that the problem does not exist
only puts pressure on nurses to act like nothing is wrong, and
ultimately this affects their ability to give their all to a patient.
Secondly, an education program for nurses and hospital staff
on how to handle these prejudices. I would recommend
workshops for nurses in which they can discuss how they react
to "difficult" patients, with the word "difficult" referring to patients
whose social ideals are very different from those of the nurses.
During these workshops, nurses will also be able to exchange
ideas on how to handle such patients to ensure that all patients
receive the best possible care.
Healthcare professions are perceived to be the "caring" professions.
People expect to be treated with respect and to be made to feel
comfortable when they go into hospitals. With the high cost of healthcare
these days, people also expect to receive the best possible care
available. However, many people forget that hospital staff are also
human. Thus the quality of care they receive is sometimes dependent
on the attitudes of hospital staff, particularly nurses who spend the
greatest amount of time with patients. At the Ho District Hospital, the
attitudes of some nurses negatively affect the care that some patients
receive. Thus there is the need for this problem to be addressed to
ensure that there is equity in the quality of healthcare given to patients.
This story was written by Communication
of Science, Engineering and Technology Major Nana Koram for English
200, Advanced Composition, taught by Carol Burke, associate professor