By Dr Andrew Silumesii
In an article I read recently, entitled: ‘Why do nurses abuse patients? Reflections from South African obstetric services’, Jewkes et al (1) put forward a very pertinent question which, in the Zambian context, not only remains unanswered but perhaps has not even been systematically asked in the first place. Like the pioneer of modern nursing, Florence Nightingale, once remarked, ‘it may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm’ (2). But verbal, and sometimes physical, abuse is not an uncommon phenomenon in health facilities in Zambia. The media is replete with stories of patients and their relatives suffering abuse at the hands of nurses. Yet, despite this being a topical issue in the public domain, abuse of patients by nurses features nowhere near the top of the agenda in discourses within the Ministry of Health, the General Nursing Council or the Zambia Union of Nurses Organisation (ZUNO). It is imperative to open this debate so as to gain insight into the nature of and the underlying reasons for patient abuse, analyse its impact on health-seeking behaviour and seek avenues to address the problem.
The abuse of patients takes various forms. 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. Jewkes et al provide sociological perspectives to explain why nurses abuse patients. They point to 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.
Tracing the career path of the average Zambian nurse may shade some light on the issue. His or her completion of high school entailed being 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. The struggle to get a place in a nursing college is an extremely competitive one with only about 20% of the eligible applicants being admitted. For the fortunate few that are selected and trained, 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. The resultant power differential tends to exert a significant negative influence on the nurse-patient relationship. Jewkes et al suggest that nurses deploy violence against patients as a means of creating social distance and maintaining fantasies of identity and power.
The impact of patient abuse by nurses on health-seeking behaviour is not difficult to elucidate. The impolite nurse places a psychological barrier to access to health care by rendering the services unacceptable by the population. 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.
It is high time the nursing profession regained its image of “caring”. A number of actors have an important stake in addressing this issue. The schools of nursing are well placed to initiate the young nursing student in his or her formative years into a value system of respect and care for patients. The nursing professional body is implored to fulfil its role in positively re-enforcing behaviour that it espouses as reflecting its ideals. The General Nursing Council, as a regulatory body, needs to ‘revisit the formulation, interpretation, dissemination and enforcement of professional ethics and consider to what extent they provide adequate protection for patients against abuse’. Nurse Managers must stand out as role models, and explicitly demonstrate that unbecoming behaviour among nurses is punishable. In health facilities, it is important that complaints-handling mechanisms are streamlined and reported cases of abuse thoroughly investigated and effectively acted upon. And the onus also remains on the Ministry of Health and Government in general to 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.
In this reflection, we have acknowledged abuse of patients by nurses as a prevalent problem in health facilities in Zambia, with a plethora of manifestations and underlying sociological factors. Its role in reducing access to health care is highlighted, while emphasis is placed on the fact that with concerted efforts by all relevant stakeholders, the problem is amenable to change.
[The author is a Master of Public Health (MPH) candidate at the Institute of Tropical Medicine, Belgium]