Where flowers bloom, so does hope!
Lady Bird Johnson
I have a close friend who is qualified as a midwife in the states, but no longer works as one. She is naturally assertive and curious, and she left the profession after she had a baby. I think parenthood holds the tension for all of us, creating cracks in our beautifully compartmentalised lifestyles. Creativity born of necessity forces us to reimagine our lives lived in a way that traditional structures might not allow. The result may be a wonderful eruption of difficult but valuable stories and journeys, as it was in her case.
Her parents had moved to rural Mexico – her parents are also wonderful eruptions. Her mom had an accident and had surgical care in a setting that, when described would probably translate to a district setting in the South African landscape. Some of her remarks – as a former nurse – made me reflect on some very powerful similarities. She described a place where the “profession” was a source of immense pride – she was astounded at how amazingly the nurses could keep their uniforms so lily-white but where nurses seemed to have very little agency and power in their interaction with doctors and in the management of patients. Given the language barriers – her observations might have a very strong bias, but it made me think about the nursing profession in my own country, South Africa.
One more example of my perception of nursing in America – and I say perception – because I have never worked there, is the interaction with the nurse practitioners from Nationwide Hospital in Columbus, Ohio, who have a kind of partnership with paediatric colorectal services in South Africa. Granted that these women did not represent all of America and given that there is probably a dynamic of nurse vs nurse practitioner that I don’t really get. The impression created by these women was that they were organizational and relational powerhouses who had redefined the so-called support services to doctors as the MAIN THING. They elevated the important work of nursing to being much more than doctor’s assistants.
And the last American example has to be the character of Penelope Alvarez from the sitcom, “One day at a time”. She is a nurse who sees her own booked patients and who essentially runs Dr Berkowitz’s practice. She is fictional, yes, but oh so awesome! She is knowledgeable, assured, decisive and wears the coolest scrubs.
Having set the scene, my question is why does nursing look so different in the developing world?
An Interesting Exploration
And because I am not a nurse – I actually think that I don’t have the capacity for such intense work – I surveyed my nursing friends. They answered earnestly and I am grateful. At this point, I might add a disclaimer that there might be a strong selection bias here. Because these are my friends, there might have been a magnetism (situational or as individuals), that has bonded us.
In total honesty, there was probably a very positive professional experience, and this cohort represents very motivated and passionate nursing staff. It might not be the views of the profession but it’s a much better place to start telling the story. Also, these are women with their noses to the grindstone, and some might have been promoted for a while but have essentially been on the ground for decades. Some are brand new to the profession in terms of donning their epaulettes but because so much of nurses’ training is “in-service” – they have already had ample exposure to the system.
Unfortunately, there are no male nurses in my sample – and I think this was an oversight and will be corrected if this conversation continues or deepens. It would be interesting to hear the angle of the male nurse.
Having made all of these disclaimers, storytelling is a concept that is not celebrated in our world of quantitative research. This is not a randomized clinical control trial.
I asked a series of questions and asked them all to send replies.
The questions were:
1) Is this what you signed up for?
2) Are you optimistic about your profession?
3) Do you have dreams about your career path?
4) Would you recommend studying nursing to other people?
5) Do you feel that the compensation is fair?
To the first question – “Is this what you signed up for?” – there were mixed responses explaining a state of having been trained in state hospitals and therefore being familiar with the milieu but being shocked by other aspects of the profession.
“Unprepared for a toxic uncaring environment where empaths don’t survive.”
“Becoming ill, suffering fatigue and burnout due to staff shortages”
“Yes, because I volunteered in the field before I studied, but I was not prepared for the staff shortages and disrespect from the public and our government”
“I was idealistic in the beginning but did not realise that due to the lack of resources – I would be doing everyone’s job including the porter, the doctor, the cleaner”
The emphatic No!
“Things have changed tremendously. The standards have dropped”
The optimistic Yes!
“I still get to live out my passion for working with the sick and vulnerable”
“I knew what I signed up for – my passion is really for working with the sick and their families”
The second question assesses the level of optimism about the profession and seems to speak to a love for the work, but hopelessness about the country. There seems to be a feeling of being in the equivalent of an abusive relationship.
“I would like to leave SA – I feel unappreciated, and that the profession is abusive”
“Unfortunately, the love and passion for my profession, keeps me holding on”
“I am optimistic about the profession but not about the department of health. There are too many people without experience or leadership skills occupying high ranking posts and messing up the profession”
“I am disappointed and feel like my voice is being silenced. I have heard that in Dubai – the opinion of the nurse is considered”
For some, the hopelessness about the situation in leadership seems to be diluting any optimism left.
“The profession has changed. Due to the high levels of unemployment (in the country), many people sign up to become a nurse because they don’t find employment, which results in a lack of passion for the work. They are disloyal job-hoppers, and this contributes to low staff morale and a very stressful environment”.
“I am not optimistic. One is not taken seriously unless you threaten to go on strike”.
The career trajectory envisioned is often scattered with obstacles, for which there is no support to overcome. The feeling that the selection process for promotion is not a fair one, has led to mistrust of leadership structures.
“My dreams have been killed by politics and inadequate policies”
“I no longer apply for senior positions – there’s too much corruption”
“I wanted to be a matron. I studied for a total of six years, including specialization and was never placed in a specialist post. I was acting as the operational manager for 5 years and was never placed in a post”
“Growth is stunted by corruption. The government used to assist with funding for studies but now one has to self-fund, and this is difficult, given what we are paid”
Yet, hope persists.
“I want people to call me because I am the best. There is very little room for growth, I feel, here in SA and maybe it’s time to spread my wings and broaden my horizons”
‘I did have goals about my career path, and I’ve achieved it. I’ve studied further and I am now an experienced paediatric ICU nurse. There are many career paths to choose from after studying nursing. I know a few nurses who run private clinics”
There is an awareness of the tremendous need that exists in terms of staff numbers, but a cautionary air when asked whether they would encourage entry into the field.
“Only if they are passionate about working with people in their most vulnerable state”
“I would not recommend this except if there was passion”
“I would recommend nursing as a profession as there is a need for nurses, but only if you have the passion, love and feel the calling to be a nurse”
“Yes, but I’d be honest about all the pros and (especially the) cons of the nursing profession”
“I could never recommend nursing – it’s a lot of work, you lose a lot of energy with no compensation and I cannot recommend this to anyone that I love”
There is a unanimous and emphatic NO when it comes to the fairness of compensation. Period.
As doctors, we could’ve speculated with fair accuracy that these would be the responses. The overarching theme is one of disappointment. It should really add depth to our interactions and expectations of nurses working in the public sector. We have been taught to speak about “The System” as this vague, complex quandary that we defer to when the questions cannot be answered – but we actually cannot separate any facet of our work from the system.
In an impossible multi-dimensional maze of organograms and flow diagrams, the best point to intervene is concealed, except to those who have taken up the act of taming the beast so that it serves the people as a lifelong cause.
As a young doctor, I had inherited a paternalistic and downright disrespectful value system from the institutions that I grew up in. I saw doctors swearing at nurses, throwing instruments and even chairs in behavioural displays that would get them “cancelled” in today’s atmosphere. In my final year of medical school, I felt that nurses were trying to cut me down to size because there was a power dynamic that allowed them to avenge the wrongs that I had witnessed from these people who were supposed to be my mentors. I felt that I was being treated unjustly, and never considered that the workplace might be unsafe for these healthcare workers.
Given all the ingredients it has taken to bake this disastrous cake that is state healthcare, and sprinkle some racial and socio-economic disparity – one realises that the environment that we have fostered is one where one can only expect to survive, never mind thrive or live out the ideals of service and care that are expected, or that one has dreamed of living out in one’s work.
Charlotte Maxeke – one of the founding mothers of the nursing profession in South Africa said – “This work is not for ourselves, kill that spirit of self and do not live above your people but live with them, and if you can rise, bring someone with you”.
Many of our hospitals have been renamed after these founding mothers for the very sacred work of patient and community advocacy. Remarkable brave women. These women changed the course of history. I am of the opinion that the nurses in my story are made from the same kind of grit.
Our collective history as South Africans bears a mostly painful narrative, but hope was a kindling and uniting force. During the struggle, there was hope that the pressure for liberation from within and internationally was inching open a door, in increments. The gathering momentum made freedom feel like an inevitability. The energy of the struggle fueled and mobilized our communities into a frenzy of creativity and excellence that has since been dampened by the multitude of disappointments referred to earlier in this piece.
There’s a provocative quote by Alexander Den Heijer that encapsulates the problem.
It reads, “When a flower doesn’t bloom, you fix the environment in which it grows, not the flower”, and I would like to propose that the resilience, fortitude and dedication that our nurses have shown, are much more than we deserve.
