“WE HAVE TO KEEP ON
IMPROVISING”
AN ETNOGRAPHIC FIELD STUDY ABOUT THE
CHALLENGES AND STRATEGIES OF NURSES IN
CENTRAL UGANDA
MADELEINE RAHMBERG
LINNEA STENLUND
”WE HAVE TO KEEP ON
IMPROVISING”
AN ETNOGRAPHIC FIELD STUDY ABOUT THE
CHALLENGES AND STRATEGIES OF NURSES IN
CENTRAL UGANDA
MADELEINE RAHMBERG
LINNEA STENLUND
Rahmberg, M & Stenlund, L. We have to keep on improvising. An ethnographic field study about the challenges and strategies of nurses in central Uganda. Degree project
in nursing 15 credit points. Malmö University: Faculty of health and society,
Department of care science, 2015.
Aim: To explore what kind of challenges nurses are facing in their work at a hospital in
central Uganda and what strategies they used due to these challenges.
Background: In Uganda, life expectancy is 53 years old and 50% of the population is
under 14 years. This means that the spectrum of diseases looks different in comparison from European countries. The most common causes of death are malaria, pneumonia and complications related to HIV and AIDS. State funding of health care is lower than in other sub-Saharan countries. The hospital in Entebbe should, as recommended by the Ugandan Ministry of Health, have 46 nurses and 11 doctors but in the present situation the number of nurses are 18 and 7 doctors.
Method: An ethnographic study based on observations of the nurses at the hospital in
Entebbe, Uganda and interviews with nurses at the same hospital. The study was done in four weeks from November to December 2014. The material was analysed using content analysis.
Findings: The nurses experienced that the biggest challenges in their work was the
shortage of staff, lack of equipment and dependence on relatives of patients. The strategies the nurses used were improvisation, faith in God, gathering every week and individually plan their shift.
Conclusion: The nurses at Entebbe hospital faces a range of challenges and applies
various kinds of strategies to deal with those. Due to the cultural and economic context both the challenges and strategies differs from the situation in Sweden. Further research should be done for a deeper understanding.
”VI MÅSTE FORTSÄTTA ATT
IMPROVISERA”
EN ETNOGRAFISK FÄLTSTUDIE OM
UTMANINGAR OCH STRATEGIER FÖR
SJUKSKÖTERSKOR I CENTRALA UGANDA
MADELEINE RAHMBERG
LINNEA STENLUND
Rahmberg, M & Stenlund, L. Vi måste fortsätta att improvisera. En etnografisk fältstudie om utmaningar och strategier för sjuksköterskor i centrala Uganda.
Examensarbete i omvårdnad 15 högskolepoäng. Malmö högskola: Fakulteten för hälsa
och samhälle, institutionen för vårdvetenskap, 2015.
Syfte: Att undersöka vilka utmaningar sjuksköterskor möter i arbetet på ett sjukhus i
centrala Uganda samt att undersöka vilka strategier de använder för att hantera dessa utmaningar.
Bakgrund: I Uganda är medellivslängden 53 år och 50% av befolkningen är under 14 år.
Det gör att sjukdomspanoramat ser annorlunda ut i jämförelse med europeiska länder. De vanligaste dödsorsakerna i Uganda är malaria, pneumoni och följdsjukdomar relaterat till HIV/AIDS. Den statliga finaniseringen av sjukvården är lägre än i andra subsahariska länder. Sjukhuset i Entebbe bör enligt rekommendationer från det Ugandiska Hälso Ministeriet ha 46 sjuksköterskor och 11 läkare men i dagsläget är antalet sjuksköterskor 17 och läkare 7 stycken.
Metod: En etnografisk studie baserad på observationer av sjuksköterskor på sjukhuset i
Entebbe i Uganda samt intervjuer med sjuksköterskor på samma sjukhus. Studien gjordes under fyra veckor, November – December 2014. Materialet analyserades med innehållsanalys.
Resultat: Sjuksköterskorna upplevde att de största utmaningarna i deras arbete låg i
brist på personal, otillräcklig utrustning och beroendet av anhöriga till patienter. De strategier som sjuksköterskorna använde var att improvisera, tron på Gud, att samlas varje vecka och att individuellt planera sina arbetspass.
Slutsats: Sjuksköterskorna på sjukhuset i Entebbe mötte många olika utmaningar och
använde olika strategier för att hantera dem. På grund av den kulturella och ekonomiska kontexten så skiljer sig både utmaningarna och strategierna från situationen i Sverige. Mer forskning är eftersträvansvärd för en fördjupad förståelse.
CONTENTS
INTRODUCTION 4
BACKGROUND 4
Uganda 4
The health care system in Uganda 5 Spectra of diseases 5 Entebbe Hospital 5 The study's theoretical approach 6 Concept of culture 6 Post colonialism and international placements 6 Symbolic interactionism 7 AIM 7 METHOD 7 Ethnography 7 Study population 8 Observations 8
The role of the researcher 9
Informal talks 9 Interviews 9 Analysis of data 9 Ethical considerations 10 RESULT 10 Organization of staff 11 Shortage of staff 11 Lack of motivation 12 Lack of equipment 12 Dependency upon attendants/relatives 12
Strategies 13 Improvisation 13 Faith 14 Support 14 Individual planning 14 DISCUSSION 15 Method discussion 15 Study population 16 Observations 16 Interviews 16 Result discussion 16 Organizations of staff 17 Lack of equipment 17 Dependency upon attendants/relatives 17 Strategies 18 CONCLUSION 19 FUTURE RECOMMENDATIONS 19 ACKNOWLEDGMENT 20 REFERENCES 21 APPENDIX 1 23 APPENDIX 2 24
4
INTRODUCTION
The idea of this study came in 2012 when we first heard about the Minor Field Study Program during our nursing education in Malmö, Sweden. We believe that we develop different strategies to deal with the challenges we are facing due to the context in which we live and work. As for the nurse, it also depends on what kind of patient you meet; the illness, the age etc. which all evoke feelings and thoughts in the nurse which has to be taken care of somehow. Since the spectra of illnesses and the life expectancy in Uganda differ greatly from Sweden, the challenges of the nurses are most likely different and one can expect that the strategies developed also differs. What kind of strategies does the nurse in Uganda use?
To explore that, we wanted to participate in the nurses' work at a hospital in Uganda. We wanted to see for ourselves what kind of challenges the nurses are facing to be able to understand it. That we decided on Uganda was because of the contacts we had made there which facilitated the project. We believe that learning about different cultures will help us as future nurses to deal with the challenges of a multicultural society.
Nursing is a female-dominated profession which status deserves to be raised. One of the methods to achieve that could be to highlight the different kind of strategies that nurses come up with every day in their daily work.
BACKGROUND
A short description of Uganda, its health care system and the countries spectrum of diseases are presented in this section. An overview of Entebbe Hospital is given in the end of this section as well as the theory that the study is based on.
Uganda
Uganda is located on the equator, south east in Africa. The country borders to Kenya, South Sudan, Democratic Republic of Congo, Rwanda and Tanzania. Uganda was a British colony from the 1860s until 1962 when the nation gained independence. After the independence, the country suffered from two military coups by Milton Obote and later Idi Amin. During Amins regime approximately 300.000 people died and he made the country‟s economy in total depravity. After eight years, Obote took the power once again and the Civil war and misgovernment continued until Youori Museveni took control 1986. He has been the president of Uganda ever since. The country has
stabilized and the standard of living for the population has risen (Nationsencyclopedia, 2014), but still approximately 25% lived under the poverty line 2010 (less than 1, 25 US per day). Uganda‟s population has grown quickly since the independence 1962 from about 7 million to 36 million in 2012 (World Bank, 2014).
The majority of the population lives in rural areas in the country. Population density is high but varies within the country depending on the fertility of land. The majority of the population lives in the fertile part along Lake Victoria's north shore, especially between the cities Kampala and Jinja. There are around 40 minorities in the country and they can be divided into four groups related to their languages; Westnilotic from the northern part, Eastnilotic from the eastern part, ethics groups that speaks Sudanese languages
5
from the north west and the bantupeople from the south and southwest of Uganda. The last mentioned group is the biggest in the country, approximately 2/3 of the population. There are about as many local languages as there are ethnic groups. English is the official language of Uganda but it is only spoken by 10-20 per cent of the population, mainly urban citizens (Utrikespolitiska institutet, 2014). In 2010, there were
approximately 100,000 refugees in the country and the largest group came from the Democratic Republic of Congo, DRC. After South Sudan's independence in 2013, a large group fled to Uganda from South Sudan. In the summer of 2014, the number of refugees has risen to about 300,000 (ibid.).
The health care system in Uganda
In Uganda US33 $ per capita is spent on health care. Of the country‟s total health expenditure 18, 95% are governmental funding‟s which is about half of that in other sub Saharan countries as well as in other low income countries (Ministry of health, 2012). Health governance in Uganda is led by Ministry of health, MoH, together with other ministries, health development partners, district leadership as well as representatives of civil society organizations. The public sector includes national and regional hospitals. At the higher levels there are regional referral hospitals, and above these are the national referral hospitals. Entebbe general hospital is a regional hospital. MoH is responsible for the regulation and supervision of the health sector performance, but the supervision in government hospitals has been shown to be very irregular. In 2007 no visits at all were carried out (MoH, 2008). As described by Chaudhury et al. (2006) one threat to the quality of MoH services is the spread of absenteeism and tardiness in the public sector.
Spectra of diseases
The life expectancy in Uganda has from 2003 increased from 45 years to 53 years in 2011, which is similar to the sub-Saharan Africa average of nearly 54 years (World Bank, 2011). Life expectancy could be seen as an indicator of the overall health status of a country´s population and of their quality of life (MoH, 2011). The infant mortality rate remains high and maternal and perinatal conditions contribute to the high mortality. The main cause of death in Uganda is Malaria, which in 2010 accounted for 21% of the country´s mortality (Health issues Uganda, 2011) those mainly affected are
communities in rural poor parts of the country (WHO, 2006). In line with this,
communicable diseases continue to remain those predominantly affecting the population of Uganda. Malaria is followed by HIV/AIDS and pneumonia according to facility-based reported death (MoH, 2011).
Entebbe Hospital
Entebbe hospital opened in 1904, for the British colonialists. In 1918 another wing of the hospitals was opened for the local population. In 1998 the two wings of the hospital merged together under one single administration. Since 2013 Entebbe hospital is undergoing major construction work which should be finished in August 2015. Originally the hospital consisted of three buildings but by the end of 2015 all of the hospital will be in the same building. The hospital is divided in one general and one private department. The services of the general side are free of charge, whereas in the private department the patients will have to pay for all services provided. The hospital does not provide any food, neither in the general nor in the private side. The private side of the hospital provides sheets if the patient wishes, but most times the patients prefer to
6
bring their own. In comparison with other private hospitals, Entebbe Hospital lacks a lot of facilities.
In the hospital there is one emergency room and one pediatric ward where the most common diseases are malaria, diarrhea and malnutrition. There is one delivery care unit, one maternity care unit and one post aborted care unit where women who have been undergoing failed home abortion are treated. The hospital also has one operation unit where the most common operation is caesarians. Entebbe hospital also provides screening for cervical cancer, circumcisions and a diabetes consultant.
Ministry of health in Uganda has decided that a general hospital should provide 100 beds, in Entebbe general hospital there are 193 beds due to a donation to the maternity side from a rotary club in USA. According to MoH (2011) the health care staff at Entebbe general hospital should consist of 46 nurses and 11 doctors. Due to insufficient funds the work posts are not covered. Today there are 17 nurses and 7 doctors at
Entebbe Hospital.
The study's theoretical approach
The study is relating to three different theoretical approaches in order to strengthen assumptions and have something to proceed from. The chosen approaches are; the concept of culture, post colonialism and symbolic interactionism
The concept of culture
Society can be defined as patterns of social relations that creates stabile and continues forms for everyday life, which makes it possible for individuals to coexist. A society could be said to consist of an extern reality (institutions, buildings, environment etc.) to which there are a corresponding inner realty among the individuals that make part of it. They know how things work and they know what meaning those things has been given. This inner reality could be said to correspond to what is called culture; which implies the sum total of the common concepts, values, norms and notions that its members acknowledge (Sachs, 1987).
In every society or culture, there are “rules” to which its inhabitants obey. The rules might consist in a notion of what is appropriate to do and not to do, what can be seen as normal and abnormal and also what is seen as health and sickness. These “rules” are often taken for granted and not outspoken, which most of the time makes them
unconscious. They can become visible either if someone question these “rules” or starts to infringe on them. One way of being able to get a grasp of the culture is to observe what is happening in given realty and to ask its members what is being done and why (Pilhammar, 1996).
Post colonialism and international placements
Postcolonial theories focuses on the politics of race, culture and ethnicity and in doing so uncover the politics that use certain features such as skin colour and the like to perpetuate dominant discourses of whiteness, difference and subordination. Despite the notion that nurses are more likely to view themselves as objects to be colonized rather than a colonizing force it is to be kept in mind that nurses too can participate in colonizing practices and thus contributing to what can be referred to as professional imperialism (Racine & Perron, 2012). Nursing cannot be isolated from the historical context and the dominant discourses that have marked its evolution.
7
Symbolic interactionism
As described by Blumer (1969) symbolic interactionism rests on three premises. The first two premises consists in the presupposition that humans are acting towards things on basis of the meanings they ascribe to those things, and that the meaning of such things is derived from, or arises out of, the social interaction that one has with others and the society. This also includes the process of learning how to see the world through other people‟s perspective. The third premise describes how these meanings are handled in, and modified through, an interpretative process used by the person in dealing with the things she encounters. Individuals in a given culture learn that a social activity has a certain meaning; how the individual interprets something depends on the interpreting alternatives available, those alternatives in turn depends on the culture and the social context to which the person belongs.
AIM
The aim of this study was to discover the main challenges that Ugandan nurses are facing in their daily work at Entebbe Hospital and explore what kind of strategies they apply in order to deal with those challenges.
In order to find out the aim of this study following questions were explored:
What are the challenges of the nurses working at Entebbe Hospital?
What kind of strategies are they using to deal with those challenges?
METHOD
A qualitative approach was used with an ethnographic design since it is a good way to describe subcultures, such as a hospital or a group that works at a hospital. The data was based on observations, interviews and informal talks.
Ethnography
The ethnographic research approach has since 1920 been used to study subcultures within their own society. In the 1960s, the interest in qualitative studies started to grow and relate to symbolic interactionism. Today ethnographic research is a way to describe subcultures within the society and also a way to try prejudices against actual behaviour (Pilhammar, 1996).
According to Crang and Cook (2007), the basic purpose of ethnographic studies is to try to understand the world by understanding how it is perceived and understood by the people themselves, living in it. That can only be done by the researchers participating in people‟s daily lives for a period of time, watching what happens, listening to what is said and asking questions about it in informal and formal interviews. Data collection is basically a range of sources, but participant observation and informal interviews are the main ones.
Pilhammar (1996) argues that the researcher should not look at the chosen world
8
will no longer be able to describe what happened to others, outside the examined world. Does the researcher take over the individual‟s perspective, it will also not be possible to see what is hidden behind the taken for granted. The complexity of being ethnographer is therefore in being both "here" and "there" at the same time. Being "here" may also be known as the researcher see through an "emic" perspective. In that case the researcher considers and explains the world from the inside and use the individual‟s way of explaining the surroundings. When instead the researcher uses scientific terms and explanations to describe the selected world the perspective is known as "etic". Both of these perspectives are needed when an ethnographic study is conducted. "Emic" perspective is required when the researcher collects data, the "etic" –perspective is needed when the data is interpreted and described. Because the data collection and data analysis is done in parallel when an ethnographic method is used, the researcher needs to be able to handle both perspectives simultaneously (ibid). According to Sachs (1987) it is impossible to understand how people in a society looks at diseases without first trying to understand the citizen‟s culture – and social fabric.
Study participants
The study population in this study included eight nurses who all worked at different wards at Entebbe Hospital in Entebbe, Uganda. One of them where male. Five of them worked in the general side of the hospital, two nurses worked in the private side and one worked in the operation theatre. The five nurses that were interviewed were also
observed. Three nurses was observed but not interviewed. The nurses had different kinds of training. In Uganda there are three kinds of nursing training. The first “level” is called “diploma” and consists in two years of training, the next one is “certificate” and to obtain that level another one year and a half of training is added on top of the diploma. Then there is also a university degree in nursing which consists of five years of training. One of the nurses had a diploma, five a certificate and two with a university degree. The nurse with the longest experience of working as a nurse had been working for 19 years while the two nurses with shortest experience had been working for less than one year.
Observations
The observations took place at the hospital wards, nurse office, board room and right outside the hospital ward in the period of November and December 2014. Three to four days per week, two to three hours per day was spent at the hospital. During participant observation there are different ways to keep field notes, so called “memos” to remember what had happened and was said during the observation as well as where and when the observation took place, according to Pilhammar (1996). It would not been appropriate to stand and take notes during the observations in the wards. Instead, notes were made immediately after the observation. These “memos” contain information about where, when and how the activity was made. Notes were also made for what was said and done. After the observations feelings about the atmosphere, pace and how we experienced the atmosphere during the observation and the way we felt that our presence influenced the room were written down. Those latter notes were called “our reflections” and it became a more subjective data material. During the observations at the meeting between nurses and doctors it was suitable to take field notes since the rest of the staff made notes of things said during the meeting, all according to Pilhammar (ibid.).
9
The role of the researcher
Making an ethnographic study involves trying to find yourself in different worlds simultaneously. As a researcher, you must maintain the requirements contained at you from the scientific community. You also view the world from a personal perspective. Both these perspectives will you bring in the "world" you have chosen to study. The challenge will be to try to understand the world through the individuals who live in it, without becoming so-called "native" (Pilhammar, 1996). It was a conscious choice to not participate actively in the activities that took place on the wards. Instead, we choose mostly to stand in the entrance to the hospital ward where we were not in the way of the patients or nurse. During the observations at the nursing expedition, we sat together with the nurses around the table. Some days were spent some outside the wards trying to catch the atmosphere and for people to get used to us since we obviously did not belong at the hospital.
Informal talks
According to Pilhammar (1996), informal talks are a complementary part of the
observation. It provides an opportunity for participants to reflect on their experiences. In this study the informal talks took place mostly at the nursing expedition after the
observed activity performed. Then it was an opportunity to clarify the observed parts that was unclear, often related to that the conversation between nurse and patient was carried out in a local language. Sometimes the nurse self took initiative to informal talks to talk about her/his profession or about the patient‟s situations.
Interviews
Five formal interviews were conducted in English and all are reported in this study. All interviews were tape-recorded and transcribed. Participants choose were the interview would take place and it ended up in various places around the hospital. Two open questions were used; “What kind of challenges are you facing in your daily work as a nurse at Entebbe hospital?” and “What kind of strategies are you using in order to deal with those mentioned challenges?” Both of us were active during the interviews. All interviews took approximately 20-45 minutes and were conducted our two last weeks at the hospital during December 2014. Three of the respondents had been observed in their work during approximately one week before the interviews were conducted. Of these three nurses, two worked at the general side and one worked in the private wing of the hospital. Through the administer of the hospital we got in contact with two other nurses, one worked in the private wing and the other one in the operational theatre. Those two nurses were not observed during their work.
All recorded material was stored in two computers, both with personal password. The recorded material was deleted right after the transcription. The names of the nurses were never mentioned in the transcriptions and instead numbers were used.
Analysis of data
According to Burnard (1991) the data analysis should starts immediately after the data collection. The categories in this study came out during several steps. The interviews was tape-recorded and transcribed after each interview. One of us transcribed three interviews and the other transcribed two. However, both of us listened and read the interviews to guarantee that it was correct transcribed. Headings and general themes were written in the margins and dross excluded. After the transcriptions, coloured
10
highlighting pens were used to identify categories. In order to reduce the themes, the ones that were similar with others were placed together, all according to Burnard (ibid.). Individual field notes were made directly after observations or during the observations. Field notes from the informal talks were always made after the conversation. The notes were then compared with each other and then summoned into narrative text from which units of meaning were collected. These units of meaning were then organized into a coloured category system. As with the data from the interviews, the categories that was similar with each other were placed together to moderate the numbers of categories. The categories from the observations were then matched with the categories from the
interviews in order to get a coherent category system. The data were analysed in this way simultaneously as the data collecting process, all according to Pilhammar (1996). This resulted in four main categories. Two of the categories also got subheadings.
Ethical considerations
The study was guided by the Ethical Principles for Medical Research Involving Human Subjects which are adopted by the declaration of Helsinki (World Medical Association, 2013). The declaration is a statement of ethical principles for medical research and was settled in 1964. It was amended last time in 2013. Some of the principles of the
declaration are that it is voluntary and the participant can always call of the participation and also give the researcher informed consent. The study was also guided by the
International Council of Nurses (ICN, 2012), a federation represented by 16 million nurses worldwide. The federation published a guide for code of ethics for nurses in 1953 and it was last revisited in 2012. It basically has four fundamental responsibilities of the nurse; “To promote health, to prevent illness, to restore health and to alleviate suffering. The need of nursing is universal” (ICN, 2012, page 1).
Ethical approval was given from Malmö University which was sent to our contact person in field Olive Ayebala. Through her we got in contact with the head of nurses at Entebbe hospital and got her oral approval for the study.
All respondents got written and oral information about the study before the observations and the interviews. They got information about their ethical rights such as
confidentiality and voluntary. The nurses gave written approval to participate in the study and to be tape-recorded during the interviews. All the participants‟ names were deleted during the study process to respect confidentiality. Instead, numbers were given for each nurse. The nurses had the responsibility to inform the patients about the study, since the patients did not always speak English. The nurses were also told to tell us if there was a situation when it was inappropriate for us to do observations.
RESULT
In this section the findings from the observations, informal chats and the interviews will be presented. The result has been divided into four main categories, which are;
organization of staff, lack of equipment, the dependence upon attendants/relatives and strategies. These four categories were the main findings regarding challenges and strategies of the nurses at Entebbe hospital.
11
Entebbe hospital is, as mentioned, divided into two sections; grade A and grade B. The first weeks of the observation period we spent most of the time with the nurses working in the general wards of grade A. The morning shift started at 8:30 but the nurses often came a bit later for various reasons, which gave us the chance to observe the
surroundings and “breathe the atmosphere”. It is a white building situated on a slope. The general wards are sited on the back of the building from the main road and its doors opens to a courtyard with a big tree in the middle. On the other side of the courtyard from the hospital is a small kiosk with a veranda, where attendants can get drinks and snacks for their sick relative. There are hens and chickens pecking grains, sometimes accidently entering the wards. There is a constant movement of people and at a first glance, for us, it is difficult to distinguish patients from attendants. On the roof there are monkeys playing with empty medication bottles snatched from the overflowed bins outside the nursing expedition.
Organization of staff
From the first category in the result of this study two subheadings has emerged; shortage of staff and lack of motivation. At Entebbe Hospital 17 nurses work. They all have received different kind of training. At the general side of the hospital are two wards, one for female and one for male patients. Each ward has possibilities for six patients. The private side of the hospital has possibilities for 17 patients.
Shortage of staff
All nurses in our study expressed the challenge to almost every day work with a shortage of staff. As mentioned, Entebbe general hospital should consist of 46 nurses and 11 doctors. Due to insufficient funds the work posts are not covered. Instead there are 17 nurses and 7 doctors at Entebbe Hospital. During the observations it was obvious that the hospital sometimes lacked staff. Occasionally we saw assistant nurses perform work that nurses were supposed to do. So was the case we got confirmed afterwards in informal conversations with the nurses. We were told that was the “only way to make things work” when there was just one nurse working some shifts.
During our observations we occasionally came to the hospital and there were no staff at all who had the responsibility of the wards. In those cases the nurses explained
afterwards that the nurse who worked the dayshift had gone home before the evening nurse arrived. There was no staff available to fill the gaps between the shifts. In those cases the patients had to wait for their treatment or with their questions they had. Another consequences of the shortage of staff expressed by one of the nurses was that the patients, while waiting to be examined, starts advising each other in matters of treatment alternatives, often diverting each other to “traditional healers”.
“/…/the staff is a challenge. You are supposed to be at least two nurses per shift or more. I don‟t know back in Sweden, but here the patient/nurse ratio is quit
alarming. We have, the bed capacity here is about 17 beds, and so if it‟s full, now if I am duty I should supposed to cover all beds. So it comes to be a challenge”
Another concern due to lack of nurses, was that the nurse who was on duty has to ask attendants to help her/him with the patient work. In our observations we saw this happened several times. There was often a continued activity in the ward, sometimes it was up to fifteen people, and since all were wearing private clothes it was not always easy to say who the patient was. The attendants could sometimes get scared while helping the nurse with her work. The nurses knew it was not ideal, but it was another way to make things done.
12
Lack of motivation
The nurses who were on duty did not always show up. During a meeting between the head nurses, one of the nurses brought up the issue with a nurse who had not shown up in three weeks. No one knew where she was. Some of the nurses in this study
mentioned the problems in the interviews and some of them explained it as a lack of motivation.
“We are all humans and we need motivation, without it we get demoralized. People might choose not to come to work, or if you come at all you might just sit and do nothing”
The same nurse expressed another of her thoughts for the nurses lacking in motivation. Two nurses in our study mentioned that the lack of motivation came from lack of supervision. The nurses end up doing nothing due to lack of control over the staff. In other private hospitals it can be very strict and the nurse‟s work will be followed up. One nurse thought the reason due to lack of motivation may come from the lack of promotion possibilities.
Lack of equipment
All nurses but one talked about lack of equipment in the interviews. They expressed that they did not have what they needed to be able to do their work properly. Instead they had to improvise with what they had or only use the material available. This was a challenge for both the general and private side of the hospital. In the operation unit one nurse showed us a broken bed and explained how they had to put a cushion underneath it to make it function.
“…since it is a governmental hospital, there are so many things you lack, we have to keep on improvising, but you reach a certain limit where you cannot, some of the patients are very poor, they don‟t have money. And you really want to perform something but you cannot because there is no money. So that‟s a very big challenge”
Several nurses mentioned that sometimes the equipment was there, but a lot of nurses do not know how to use it and they end up not using the equipment at all. During the observations the lack of certain equipment was obvious, for example mosquito nets were often lacking or the ones there was not functional. The wards were often very dark due to recurrent power cuts or broken lamps. The supply of medical equipment was often low, which meant that some of the instruments had to be reused several times.
Dependency upon attendants/relatives
The final category in the result of this study we found that the attendants i.e. relatives and friends of a patient, play a major role when it comes to the basic care of the sick. This means that the attendant will be responsible for all basic components of the treatment. A great challenge expressed by a number of nurses in interviews and seen in the observations emerged when the patient did not have any attendant. In those cases the treatment of the patient failed.
When a patient does not have attendants they will end up with no food, no clean clothes or sheets. One nurse told us that even if they have medicine that can treat a patient, no one can be cured without food in the stomach.
13
”You need to bath the patient, change their linen, make their bed comfortable, but sometimes you find we don‟t have that and you fail. So we end up leaving some of those very practical things to the attendants. So here, every patient must have an attendant.”
The nurses can ask relatives to other patient to share their food or maybe the nurse will buy the patient some food for her own money. The consequence of the patient not having any attendants can also sometimes lead to failure of the treatment. One nurse talked during the interview about her patient she was treating at the moment:
”They come, they don‟t have a blanket, the ones you have are finished, and the patient is there very cold, so you keep on improvising. You keep on begging the other ones, please help. Yeah, cause if the attendant is there, and they have what they need, it wouldn‟t be a problem. I can bathe them, but if a patient come with nothing? For example there is a patient I am having now; I really try to sort out what I can do for him. He doesn‟t have anything, no attendants. They don‟t have bed sheets, no clothes, those he has are dirty, you want to bathe him, but there is nothing you can give him to put on. He doesn‟t have anything to eat, so he is just there and I am trying to see how I can help him.”
Strategies
Further down the strategies of the nurses are presented. The findings has been witnessed in observations and confirmed or mentioned in interviews. The strategies have been divided into four subcategories improvising, faith, support and individual organization.
Improvising
During our time at Entebbe hospital we often saw how the nurses improvised solutions to the challenges they encountered. The method of improvise required, particularly in relation to the challenge "lack of equipment". When the electricity went off and it became very dark in the wards a nurse once chose to bring a patient out into the daylight to be able give an injection. This happened without further notice so it seems as a
common solution. When the electricity went off during a caesarean a nurse solved the problem by get some flashlights for herself and her colleagues. These flashlights were easily available so even then it felt like the solution was familiar. In the absence of tourniqueta nurse chose to use a glove instead during one of our observations. One of the respondents said in one interview that she sometimes bought food for her own money to the patients when they did not have any relative who could to it for them. Although it was not a long term solution, it was a way to solve the problem right then:
”Because for example if you are to give a patient a medicine and the person has an empty stomach you cannot give the medicine, so you end up buying for them” Faith
In all of the interviews the respondents described their faith in God as a strategy in order to deal with their challenges. It seems like believing in God was a strategy that could apply on any challenge. One of the respondents said that the feeling of „serving God‟ gave her the motivation that she needed when it was difficult at work.
”It gives me the motivation to move on and help them in the right way. Cause when I do that I feel, I am not serving that person, I am serving God. So that helps me so much”
14
Another nurse described how she always wanted to do the right thing because she saw herself as one of God's servants. This was something that all of the respondents explained in various ways, that their profession was a religious vocation and the knowledge of that gave them strength.
“I think nursing is based on God, they have that saying that „we are chosen by God to love and serve, to love the patients and serve them‟ so that‟s the first thing, God is first, you can do everything but if God doesn‟t want, the patient will be dead”
Believing in God was seen almost as a matter of course. The quote that the nurses mentioned above is written on all of the midwifes uniforms at the hospital. At the Friday meeting all of the nurses prayed together.
Support
There was one organized strategy to face the challenges at Entebbe hospital. Every Friday the head nurse of the departments gathered with the chief medical officer to discuss the challenges of the week at the different departments. The meeting lasted about two hours. The purpose was that they together could discuss solutions to problems relating to specific departments or problems that applied generally to the hospital. We observed one of those meetings. In the end of the meeting the chief medical officer gave a speech to motivate the nurses and encourage them in their work. Three of the respondents in this study mentioned that the Friday meeting was a strategy for them to deal with the challenges.
”We have meetings on Fridays where they ask us what challenges we have. We tell them and the administration looks into it”
Individual planning
Finally two of the respondents mentioned in the interviews that they in different ways tries to organize their shift to complete their work. This seemed like a solution to the shortage of staff and the issue with staff coming late. Both of them wrote a “to do list” in the beginning of their shift. They wrote which patients needed their medication or treatment first depending on who was most ill or needed a medication at a specific time. One respondent described that even thought it was a lot to do she must allow herself to sit down and organize her work.
Another respondent explained that she must “work by example”. She always tried to be in time and do the right thing because in that case other nurses will follow her example. She said that she cannot tell other what to do if she does not do the right thing herself.
”I need to work by example, i need to come early. Even if they are coming late I need to come early /.../”
DISCUSSION
In this section a methodological discussion about the ethnographical design, study population, the observations and the interviews will be presented. Further down the result of the study will be discussed.
Method discussion
15
understand the world by understanding how the people living in it perceive it
(Pilhammar, 1996). To achieve this aim the researchers has to spend physical time in the given environment. It has also been argued that the researchers should not become so called “native” as this position would impede them to describe certain aspects that would then be taken for granted (ibid.). As in being white Europeans in a foreign culture a humble approach towards the fact that we might not understand customs, behaviours etc. has been essential. This means that what we have looked upon as challenges may in fact not have been experienced as such by the nurses. That we have used interviews partly to confirm what we have seen in our observations has been one way to strengthen our assumptions.
Study participants
Eight nurses were included in the study, which can be argued too small in order to draw any conclusion. We did however experience satiation of data in spite of the limited number. This conclusion was made after five interviews were made and nothing new came up during the last two interviews. Another strengthening feature includes the fact that even though the nurses were stationed in different wards they expressed similar challenges.
The most common language in central Uganda is Luganda (Utrikespolitiska institutet, 2014b). Since the researchers does not master the language a choice was made that respondents for the interviews could speak English well. Being able to speak English in Uganda may indicate that one belongs to a privileged group in the society. This argues that the study may miss a group whose opinions and experiences could have been of interest. It is also to notice that English is none of the researchers‟ mother tongue and even though we speak English well it can have affected the outcome. However, using an interpreter can be problematic in different ways.
Since the study has taken place exclusively at Entebbe hospital the transferability can be argued, even though the challenges that we have been focusing on are likely to appear also in other similar settings in Uganda.
Observations
The most apparent concern risible when discussing the observations is whether or not the nurses were affected by our presence. Since we were two white women in a
predominantly black environment our being there was evident. Coming from a western context to Uganda can be seen as problematic from a postcolonial point of view. As to not fall in to “professional imperialism” as mentioned in the article by Racine & Perron (2012), it was important to always keep a humble approach and openness for the context we found ourselves in. The fact that we were there did not however seem to influence the nurses significantly in terms of them pursuing their daily work tasks. On the other hand the patients sometimes seemed to not know what we were doing there and this might have influenced the nurses. The responsibility to inform the patients was from the very beginning given the nurses and they were also told to tell us when our presence seemed unsuitable.
The observations were made during four weeks and we tried to capture as many aspects of the nurse‟s daily work as possible. With this aim, four weeks is a short period of time, we did though experience a satiation of data after some times observing the same activity. That data saturation was reached when it did no longer appeared anything new after observing the same activity several times (Pilhammar, 1996).
16
Interviews
Five formal interviews were conducted in this study during December 2014. Three out of the five respondents had been observed in their daily work by the researchers. This can be seen as strength since the respondents supposedly felt more comfortable in our presents (Pilhammar, 1996). The first interview was intended as a pilot interview but since it came out interesting opinions, it was decided to use it in the study. The
interviews revolved around two open questions about challenges in nurse‟s daily work and gave the respondents opportunity to speak freely about the topic. However it is unclear if the respondents really spoke open about the topic, and according to Polit and Beck (2014) the researchers has no other opportunity than trust that the respondent speak truthfully when a quality design is used.
The respondents chose where and when the interviews would take place to make them feel comfortable to make the data more truthful, all though it is never possible to tell if the respondents are telling “the truth” (Polit & Beck). Four out of five interviews were held in rooms where the respondent and researchers were the only ones present. One of the nurses chose a spot right outside the hospital, where patients and nurses were passing. This could have effect the respondent answers to the questions but since it was the nurse's choice, the researchers do not think it affected the replies. All interviews were tape-recorded after asking the respondents for permission; this to ensure that everything said would be remembered and to be able to focus on the respondent during the interview.
Result discussion
The discussion of the result is divided into four section where the findings from this study is discussed.
Organization of staff
The majority of the nurses in this study did express concerns regarding their situation at the hospital. The concerns involved the shortage of staff, lack of motivation among nurses and an insufficient supervision. It is hard to tell which the cause is and what are the effects, since all factors seem so intertwined and all presumably affect one another. One apparent effect of those factors, mentioned by the nurses in the study, was that a growing number of nurses leave the governmental settings and chose to go into the private sector with a more satisfying payment, a more adequate supervision and a nurse - patient ratio not as alarming. The motivational factor can be seen to depend on all these aspects and is also, needless to say, individual to a large extent. When the motivation is lacking though, its consequences can be far reaching. Like in any health care system those most likely to suffer from the lack of motivation and stress among the nurses will be the patients who will not receive proper care (Hallin & Danielsson, 2006). Our point here is not to blame any nurse in whichever system she finds herself in, but to question the system that fail to deliver the essential requisites that would promote motivation. We believe that the health care system on the other hand cannot and should not be seen as an isolated entity but part of a greater context. As Schaepe (2011) writes, it is easy from an western context to demand a higher engagement of The Ministry of Health, but we believe that the questioning of the health care system and its priorities become a difficult task, since the Ugandan society has suffered from
colonialism leading to subsequent internal conflicts (Utrikespolitiska institutet, 2015), a fact that cannot be ignored when talking about Uganda as a country. From this point of view, we think that the concern on motivation goes beyond the individual nurse and the health care system in which she works.
17
In Sweden the same tendencies to switch from governmental to private settings are taking place, not so much for the lack of supervision in the governmental settings but for the better payment and a less stressful and more manageable work situation. There are also a growing number of Swedish nurses that chose to leave Sweden for Norway where the payment is better (Berge et.al, 2011, Vårdförbundet, 2010). In a thesis about how Swedish nurses are working in Norway it is said that the payment can be seen as a motivational factor, not only because of the money per se but also as it can be seen to symbolize the value of the work performed by a certain workforce in a given society (Kohlström & Lidbeck, 2012).
Lack of equipment
As mentioned in the result, the lack of equipment was experienced as a challenge by many of the nurses in this study. We have referred to the word “equipment” all the things needed in the nursing process from bed sheets, clean clothes and syringes to all types of machines for diagnosing diseases. Some of the nurses expressed that while in training they did learn about various kinds of nursing procedures and the correct way to perform them, but in practice the correctness could not be upheld due to this lack. In Atefi et.al (2014) lack of equipment can be seen as a key issue for nurses and cause a lot of pressure for them. In our study it became obvious that some of the nurses knew what do to, but was not able to perform the work correct, due to lack of equipment.
Some nurses in this study expressed for example that, while knowing that some drugs are not supposed to be given on an empty stomach, this fact had to be ignored in those cases where no attendant was accessible and thus not enough food could be given the patient. Schaepe et.al (2011) is writing in her study that in western countries, moral distress for nurses often comes from lack of time, instead of lack of equipment. Not that these two shortcomings need to be weighed against each other, but Schaepe et.al (ibid.) argues that we have a lot to learn from Uganda in this issue. Spending time with the patients and build a relationship with her and the family is a starting point of delivering care.
Another example to be mentioned is the importance of nutrition and hygiene as basic key factors for recovery. These aspects too could not always be met, were there no attendants. The nurses however were not ignorant on the matter but could simply not do anything else but to compromise this knowledge. In the operational theatre the bed had broken down which the nurses was aware of but could do nothing about, more than trying their best to come up with a solution that could work for some time. The nurses in the study expressed that they did know the correct way to perform the tasks given but for several reasons, both these mentioned above and others, they could not perform them. As the Canadian nurses association puts it “When values and commitments are
compromised in this way, nurses‟ identity and integrity as moral agents
are affected and they feel moral distress” (Canadian Nurses Association, 2008). With
such an incongruity between knowledge and possibilities the emergence of moral distress, if we are to believe the Canadian nurse association, is inevitable. It can be argued however that the concept of moral distress is of western origin but according to Harrowing & Mill (2009), moral distress is a phenomenon which exists also in an Ugandan context, however appearing slightly different, caused mostly by the lack of resources.
Dependence upon attendants
18
feature in as much as the system would not function without relatives. If a patient is admitted and no relatives are to be found, the basic care of the patient including feeding, clothing and washing will not be taken care of. This is not due to a lack of
understanding on behalf of the nurses but the way the health care system is constructed. The organization of the health care system can be seen to depend on the cultural context in which its features have taken place and different phenomena are experienced and interpreted differently depending on the cultural and religious context in which they are experienced. The “sunrise model” (Leininger & McFarlan, 2006) shows factors such as; technological, religious and philosophical, kinship and social, cultural values and life ways, political and legal, economic and educational. All these factors forming sunrays that influence individuals, families and groups in health and illness. When it comes to a Ugandan context the fact that the relatives plays a major part in the caring for the patient might not be seen as anything peculiar. Rather it could be looked upon as a comforting and reassuring element for the patient in a health care context where the extended family is of outmost importance. This in contrast to the individualism in western societies, and its implications in the health care system were the individual does not have to rely on any member of the family in order to receive proper care. When a patient is admitted in a health care institution in a western country, relatives can even be looked upon as “intruders” or at least as a disturbing element if they wish to be a part of the caring for the patient, especially if their points of view differ from that of the health care staff. Those two views could be problematic since their compatibility is not given. A patient from a more family oriented context can experience an exclusion of the family in the western health care system, which may lead to feelings of institutionalizing, isolation and loneliness. As Pilhammar (1996) argues there are rules in every society and culture to which its inhabitants obey, and that those often are not outspoken or even conscious. They do however, become visible if someone starts to question the “rules”. If nurses can use this idea to deepen their cultural understanding, it could probably be very fruitful. Another interesting aspect is what a person is basing her sense of identity. In individualized western countries, the “normal” way to perceive oneself is as an
individual, as a single person with wants and needs of her own. We believe that in other more family oriented countries, the sense of identity is more often based on the fact that you belong to a certain family or a group. The efforts of the health care staff in an individualized western society to address only the individual in order to respect the person/patient integrity can be perceived as an infraction on that sense of identity. To include the family to a greater extent is a challenge for any health care system that has been focusing almost solely on the individual. This can be seen as a flagrant contrast to the challenges expressed by the nurses in this study, where the lack of relatives made it almost impossible for the nurses to perform their daily tasks satisfactorily.
Strategies
Most of the respondents in this study talked about improvising as a strategy when facing difficulties. Improvising can be looked upon as a strategy applied when no satisfactorily system of organization is accessible. It can be seen as a very creative aspect of the nursing profession and it is an important feature for nurses in any health care system. However, it can become problematic when the system, i.e. the features defining the work tasks is not worked out properly. This makes the nurses work situation more risky in that they cannot justify their actions referring to a certain rule established by the organization but have to “trust their instincts” that they are performing the right action, which can be seen as a great responsibility. When there are no worked out systems the nurses performances will also become less predictable and the care the patient receives will depend much more on the nurse personal ability to come up with good solutions.
19
As in the case of the nurses in this study, is not so much about the nursing tasks not being properly defined as a lack of certain necessities such as equipment, attendants etc. which force the nurses to improvise when caring for the patient.
Some of the nurses in this study expressed a need for organizing ones work before starting their shift. This can be seen as a means to have something to relate to during the shift and also make the working hours more foreseeable. This is favourable both from a personal point of view but also for the patients that can expect a more coherent care, especially when the general system of organization gives little to relate to. We believe this is a common strategy applied by nurses in different contexts.
Faith seen as a strategy in a country like Uganda is interesting from different
perspectives. Since we come from Sweden, one of the most secularized countries in the world, to Uganda, where religion plays a major role in the lives of many people the fact may be that seeing believing in God as a strategy is our concept. However in western countries it is common to treat patients from other cultures and Schaepe et.al (2011) argues that religion in Uganda is a way for nurses to give hope to the patients and a way to create deep relationship with them. This is why it is important to remember the big part that religion might plays when treating patients from other countries, such as Uganda.
That believing in God cannot be described as a conscious strategy as it is the culturally accepted way to perceive reality. This position can be confirmed by adding that no nurse in this study mentioned faith as a strategy by themselves, but all answered affirmatively when asked if they used religion as a strategy in their work as nurses.
CONCLUSION
Nurses at Entebbe general hospital are facing a spectrum of challenges in their daily work. Those include dependency upon relatives/attendants, lack of equipment and lack of motivation. Reliance upon relatives might be seen not only as a challenge but also as a culturally accepted and normalized way of caring for family members. Challenges arises when nursing staff are to care for patients without any relatives and thus forced to improvise to be able to provide for the basic care that the relatives should have been responsible for. Many nurses at the hospital experienced a lack of motivation. This could be explained by low pay, insufficient supervision and the difficulty to get promoted. Yet another challenge was lack of funds, which made it difficult for the nurses to practice their knowledge. The nurses applied various strategies to deal with the challenges faced, most of which had to do with improvising. From this study no general conclusions can be drawn due to the size of the study, either cannot Entebbe hospital represent all hospitals of Uganda, but since all the governmental health care services are led by the MoH, the challenges describes in this study are likely to be found elsewhere in the country.
FUTURE RECOMMENDATIONS
To be able to make the challenges that the nurses are facing fewer at Entebbe Hospital the hospital is in need of more funds. The hospital would in that case be able to provide
20
basic equipment for the patients and that would lift some of the burden off the nurses. In general the state funding‟s of health care in Uganda should be more generous.
Since knowledge about the challenges and strategies of sub-Saharan nurses are limited it would be valuable of more research about this study‟s topic. Learning about different nursing conditions (due to different economic, social, cultural, religious, health
conditions) and the strategies the nurses adopt in specific conditions will always contribute to the development of the nurse profession.
The findings in this study can hopefully be used in order to understand how people from other cultures experience hospital care and therefore facilitate caring for the people in a Swedish context. It can also be useful to Swedish nurses to know that the family of a patient can play a different role depending on culture.
ACKNOWLEDGEMENT
We wish to thank the head nurse and the staff at Entebbe Hospital for letting us collect the data for our study at the hospital. We are also very grateful to the nurses who let us observe them in their daily work and let us interview them. We often had a lot of questions after the observations, especially the first weeks of our time at the hospital, and the nurses offered their time and kindly explained to us what we did not understand. Without them this study would not have been possible to finish.
We would also like to thank our supervisor in field Olive Ayebale. She was a great help with the preparations for our stay in Uganda and also gave us the contacts to the staff at Entebbe Hospital. During our time in Uganda she was very supporting and made our visit wonderful.
Finally we would like to thank our supervisor at Malmö Högskola, Ann-Mari Campbell, for her guidance and good advices throughout the whole process of this thesis.
21
REFERENCES
Atefi, N, Abdullah K.L., Wond L-P, Mazlom R (2014) Factors influencing registered
nurses perception of their overall job satisfaction: a qualitative study. International
Nursing Review 61, 352–360
Berge, Ö. M., Falkum, E., Trygstad, S. C. & Ödegård, A. M. (2011) Skaff oss dem vi
trenger: Om arbeidskraftstrategier og forebyggning av sosial dumping i helse og omsorg. Oslo: Fafo.
Burnard, P, (1991) A method of analyzing interview transcripts in qualitative research Nurse Education today 11, 461-466
Blumer, H, (1969) Symbolic interactionism: perspective and method. Prentice-Hall: New jersey
Canadian Nurses Association, (2008) Code of Ethics For Registered Nurses, Ottawa, ON
Chaudhury, N & Halsey, R, (2006) Missing in Action: Teacher and Health Worker
Absence in Developing Countries. Journal of Economic Perspectives 20, 91–116
Crang, M & Cook, I. (2007) Doing Ethnographies. SAGE Publications: London ICN (2012) The ICN Code of Ehtic‟s for Nurses
>http://www.icn.ch/images/stories/documents/about/icncode_english.pdf < (2014-03-15)
Hallin, K. & Danielson, E. (2006). Registered nurses‟ experiences of daily work, a balance between strain and stimulation: A qualitative study. International Journal of Nursing Studies, 44(7), 1221-30. doi:10.1016/j.ijnurstu.2006.05.011
Harrowing, J & Mill, J, 2009 Moral distress among Ugandan nurses providing HIV
care: A critical ethnography International journal of nursing studies 723-731
Kohlström, D & Lidbeck S, (2012) Svenska sjuksköterskors upplevelser av att arbeta
inom den norska sjukvården Examensarbete. Uppsala
Leininger, M, McFarlan, M. (2006). Culture care diversity and universality:
A worldwide nursing theory. Boston, MA: Jones & Bartlett
Ministry of Health. 2011e. Annual Health Sector Performance Report Financial Year
2010/2011. Kampala: Ministry of Health
Ministry of Health, Health Systems 20/20, and Makerere University School of Public Health, 2012. Uganda Health System Assessment 2011. Kampala, Uganda and Bethesda, MD: Health Systems 20/20 project, Abt Associates Inc.
22 Nationsencyclopedia (2014)
>http://www.nationsencyclopedia.com/Africa/Uganda-HISTORY.html< 2014-10-30 Pilhammar Andersson, E (1996) Etnografi i det vårdpedagogiska fältet- en jakt efter
ledtråder. Studentliteratur: Lund.
Polit D F, Beck C H, (2014) Essentials of Nursing Research: Appraising Evidence for
Nursing Practise. Philadelphia: Lippincott Williams & Wilkins.
Sachs, L (1987) Medicinsk antropologi. Stockholm: Liber.
Schaepe, C & Campbell, A-M &Bolmsjö, I, (2011) A spider in the web American Journal of Hospice & Palliative Medicine 28(6) 403-411
Utrikespolitiska Institutet (2014) Landguiden Uganda
> https://www.landguiden.se/Lander/Afrika/Uganda/Befolkning-Sprak < 2014-10-30. Utrikespolitiska Institutet (2015) Landguiden Uganda
http://www.landguiden.se/Lander/Afrika/Uganda/Aldre-Historia <2015-02-12 Vårdförbundet, Vårdfokus. (2010). Fler svenska sjuksköterskor väljer Norge och
Danmark. Stockholm: Vårdförbundet.
>https://www.vardforbundet.se/Vardfokus/Webbnyheter/2010/6/Fler-svenska-sjukskoterskorvaljer-Norge-och-Danmark/< 12-02-2015
World Bank. (2011) World Development Indicators. Washington, DC: World Bank World Medical Association (2013)
23
Inin
Project title:
Challenges and strategies of Ugandan nurses
Datum: 17/11-5/12 2014 Study manager: Madeleine Rahmberg Linnea Stenlund Our E-mail madeleine.rahmberg@gmail.com linnea337@hotmail.com
Studying at Malmö University, Faculty of Health and Society, S-205 06 Malmö
Phone +46 40 665 70 00
Education: Bachelor of science in nursing
Level: Bachelor program
The aim of this study is to investigate what kind of challenges Ugandan nurses are facing and what kind of strategies they apply, in order to deal with those challenges. We would like to conduct this study since different phenomena are experienced and
interpreted differently depending on the cultural and religious context in which they are experienced.
With this information you are being asked to participate in the study.
This study is our bachelor thesis in nursing science at Malmö University in Sweden. We will use an ethnographic design for our study which means we will interview and observe nurses in their daily work in a hospital ward. The interviews will be audio recorded and take approximately 30-60 minutes. The observations will take place at the hospital ward where you are working, during 2-3 days for three weeks.
The participation is fully voluntary and as an informant you have the right to withdraw at any time without further questions. The data will be handled with confidentiality and the data will be presented anonymously. When the study is finished you have the right to take part of the results.
If you would like to participate in the study, please fill in the form of consent as provided to you. In case you have any further questions, do not hesitate to contact us. Madeleine Rahmberg & Linnea Stenlund
Number: +46722821774
E-mail: madeleine.rahmberg@gmail.com Form
24 Form
Informed consent Appendix 2
(submitted along with Appendix 1 to the participant joining the project for signature)
Project title:
Challenges and strategies of Ugandan nurses
Datum: (ifylles av student)
17/11-5/12 2014 Study manager: Madeleine Rahmberg Linnea Stenlund Our E-mail madeleine.rahmberg@gmail.com linnea337@hotmail.com
Studying at Malmö University, Faculty of Health and Society, S-205 06 Malmö
Phone +46 40 665 70 00
Education: Bachelor of science in nursing
Level: Bachelor program
I have been verbally informed about the study and read the accompanying written information. I am aware that my participation is voluntary and that I, at any time and without explanation, can withdraw my participation.
I hereby submit my consent to participate in the above survey:
Date: ………..
