An Idea

So I have this idea. I want to somehow help improve nursing practice here. Okay, I'm not any kind of expert on organizational change… I don't even have enough experience to justifiably make judgments and suggestions on practice improvement in a hospital I've only been in 3 months, in a country and continent I've been in for less than 6. However, … I do think I have to start somewhere and I do think things can change for the better, regardless of whether I'm in Canada or Katete. I've talked about some of the issues happening here, some nursing-specific issues among others, and I've heard the same complaints over and over again from the physicians and other staff. And I've always thought that complaining is absolutely pointless unless someone decides to do something about it. So that's where I am. I've talked to people, done some informal mini-surveys to get a feel of the situation and what could be helpful, and here's my idea: create a series of educational sessions for nursing staff. The goal is twofold: 1) provide a process that supports quality nursing care to the public and 2) support nurses in a commitment to lifelong learning. An example: Topic - cardiovascular system. We would discuss this system, go over a nursing assessment (demo), talk about common conditions, and go through case studies (Mr. Banda is 1 day post-op, here are his vitals and complaints, what would you do in this situation?). The hope is that this kind of interaction will get nurses thinking, get them talking, maybe get them excited to learn more, perhaps even on their own time. Maybe eventually there can be a more formal continuing competence program, but since there's nothing of the sort at the moment and nurses don't do anything work-related outside work time…I think we need to take baby steps.
Talking about this with nurses on the wards was exciting - people were interested, telling me this is definitely needed, gave me suggestions, told me they'd come to these meetings, blah blah blah. I learned that sometimes you have to offer an incentive to get people to come (money, snacks), and most people don't like 'work stuff' unless it's part of work…but still, I felt fairly confident and excited about the whole thing.

So, I had the first meeting today. The agenda was basic - talk about the idea, get some feedback, make a timeline. I had spoken to some nurses before to remind them of the meeting, and distributed a memo to each of the wards in advance. Again, I got a good response, the memos were taped neatly to the desks by the charge nurses for everyone to read. Even this morning nurses talked to me about it, said they'd be there. You can see where this is going, right? Yep, nobody came. Not one. Okay, there were three of us, but not one Zambian nurse. What the heck?! Honestly, I'm not super surprised, and it did turn out to be a productive meeting with the three of us, so I'm not that disappointed, but still. Why didn't anyone come? How can I get people interested in their work? Am I looking at things the wrong way? Maybe I'm making too many assumptions, and my thoughts on nursing just don't fit in this setting, and continuing education isn't something that's wanted. Or maybe it just needs to happen in a different way. Thoughts??

I Love Grandmas

Grandmothers are amazing. I say this from my own experience with my own grandma, and from watching grandmothers work tirelessly to make sure their children and grandchildren have a place to sleep and food to eat. I look at an older woman here and can only imagine what she's been through. How many children has she lost, how many grandchildren? How many orphans is she looking after right now, and how is she able to find enough food to feed them all? And yet these grandmothers always seem to be smiling. I met an old woman in a village, all but one of her children had died, and she was looking after her 8 orphaned grandchildren, on her own, with no income at all, and their food coming from the plot of maize a short walk away. The unfortunate part is that her story is not unique, or even the worst one I've heard. However, she's doing the best she can with what she has, and she is showing those kids love that they may not have known otherwise. And she greets us with a huge smile and proudly shows us around her home, even offering us some fruits or groundnuts if she has any handy. She is quite inspirational in many ways, and I learn a lot from her, things I never could have learned in my comfy developed country. I look at the grandchildren she's raising, wearing tattered clothing and walking barefoot. An older girl greets me in English, and I learn that she has just completed grade 7. She won't be going to school this year, there's not enough money for that. She's 18 now, it won't be much longer until she is married and a mother herself. Her options are limited. Does she even have options? I remember being her age; worrying over what clothes to wear to school that day, finishing applications to university, driving home from basketball practice in my very own car. How different our worlds are…

Culture of Jealousy

Status is everything. There is a definite culture of rank here. People occupying positions of power or prestige know it, and they make sure everyone else knows it too. If as much effort was spent on maximizing efficiency as is spent on maintaining authority, a lot more things would get done. A lot. There is no emphasis placed on teamwork, and a very absolute hierarchy exists in any organization or group. Villages have headmans (chiefs), tribes have Supreme Chiefs, everyone knows who’s superior to them, and who’s below them. It does have a purpose, and for all I know, the system may not run as well without them, but it seems to limit certain things. Gender equality is one of those things. Sure, behind every headman or chief is a great woman…or two or three, but her job is to produce children, cook, and work in the fields. Not involve herself in politics or money.

People in positions of power tend to create rules that limit competition and diversity, and eventually I think this kind of structure leads to an imbalance of opportunity, widening the gap between haves and have-nots. Lower-level employees focus on their responsibilities and tasks, rarely (if ever) offering suggestions to the higher-ups, as this would be disrespectful. The flow of information is not very fluid, one must follow the correct protocol. I’m realizing that it is perhaps unrealistic to think that change can happen from the bottom-up.

Interestingly though, this hierarchy is based more on social status than income. In fact, good businessmen who have made quite a good living are often accused of being “Satanists”, and people blame all sorts of misfortune on them. My neighbour was telling me about a woman in town who went into labour, had complications and lost the baby, and died two days later. I sympathized with her and said childbirth can be dangerous if there are complications and no midwife or doctor, and she told me that it was because of one of the wealthy “Satanists” that the woman and baby died – he had placed a curse on her. This is not unlike the Salem witch trials. Where does this come from? Perhaps a myriad of factors; poverty, jealousy, ignorance, deep-rooted traditional beliefs, isolation. The bigger question is, will such accusations ever stop? Can you stop jealousy?

This culture is everywhere. It doesn’t take long to figure out who’s in charge, who’s a bwana. They have an arrogance about them, and are able to look down at you with noses in the air despite being nearly a foot shorter than you. I attend weekly clinical meetings, not often attended by nursing staff as they are busy on the wards. Often, the only other nursing representative is two or three nursing directors or tutors, all of whom regularly arrive 10 minutes late, disrupting the presenters as they shuffle about and move chairs, then sit smugly through the remainder of the meeting with an all-knowing look on their face. I caught up with one of these women to ask if the information from these meetings makes it to the general nursing staff. I explained that many of the issues brought up concern nurses directly, and improving care and outcomes begins with them. She mumbled a vague answer, not meeting my eyes, about how someone is supposed to attend these meetings and pass the information on to the morning staff, who then should pass it on to the evening staff, and so on. She admitted the information gets lost along the way, and stated very matter-of-factly that the staff need to do a better job of this. I hesitated asking her what exactly her purpose of attending the meeting was, and what exactly her role was, as “Director of Nursing”. Perhaps something to do with directing the nursing staff, but I may be out on a limb there.

So…why? Why is it like this? Why do people care so much about status, even when it knowingly gets in the way of efficiency? Is it because getting to that level is difficult, and once you’re there, you feel that you’ve earned the right to be treated a certain way, and to treat everyone else a certain way? You deserve the best seat, the first and biggest plate of food, and there’s never any question about this? The current President of Zambia has travelled more in his first 8 months than the first President did in his 27 years of office. Zambians say he’s been out of the country more than in it. His mode of transport while in Zambia? Helicopter, of course.

Stay keenly aware,
Of the Culture Of Jealousy,
It tears humans apart,
The Culture Of Jealousy…
How much will it hurt us,
And where can it lead?
No one has the answer,
On the Culture Of Jealousy …
(T. Martin)