Footnote #1
The Ewes are the people of the Volta Region
Footnote #2
Charge nurses are registered nurses who are in charge of a particular shift. Charge nurses change frequently to allow all registered nurses the opportunity to learn how to run shifts.
Footnote #3
A registered nurse (all registered nurses have a bachelor's degree in nursing) is known as a nursing sister in Ghana, and thus has the prefix "Sister" as a title to indicate her position.
Footnote #4
Glaser, B. and Strauss, A. "The Social Loss of Dying Patients", American Journal of Nursing, Volume 64, Number 6, June 1964: 110-121
Footnote #5
The Brong Ahafo Region is one of the ten regions in Ghana. It is situated in the northern portion of the country, and shares a border with the Volta Region.
Footnote #6
Brong is the language of the Brong people from the Brong Ahafo Region.

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Subjectivity in Public Health Nursing

By Nana Koram
January 15, 2002

Overview 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 Click to open footnote 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 Click to open footnote 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." Sister Ella Click to open footnote 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 Unit

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 dried blood.

"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 week.

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." Click to open footnote 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 Click to open footnote 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 Click to open footnote 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. Conclusion

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 of English.


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