Scrutinizing care in nursing practice. An ethnographic study of nurse-mother interaction in programmes to prevent HIV transmission from mother to child in Tanzania
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Background: Care lies at the core of professional nursing practice worldwide, however, the content of the concept and what care implies in actual practice have been debated for decades. The constructions and essence of care as particularly connected to nursing practice have attracted limited attention in research from sub-Saharan Africa. The major aim of the present study has been to scrutinize nursing care in nurses’ every day practice in low-income settings. The study seeks to explore the caring behaviours found in nurses’ interaction through the examination of nursing practice in a context of HIV-positive women enrolled in Prevention of mother-to-child transmission of HIV (PMTCT) programmes in rural and semi-urban areas of Tanzania.
Methods: The study is based in ethnographic tradition. Fieldwork took place from November 2008 to August 2009 in a rural and a semi-urban area in Tanzania. The study settings were PMTCT programmes in two hospitals, one church-run and one government-run, and their outreach areas. Participant observation in clinical settings and during home visits combined with in-depth interviews, informal conversations and group discussions produced the bulk of the data material. The main categories of informants were nurses employed in the two PMTCT programmes and HIV-positive women enrolled in these programmes. Two female research assistants were trained to help with translation during the interviews, and worked closely with the researcher throughout the fieldwork period. Two additional research assistants transcribed and translated the interviews and counselling sessions that were audio recorded. The observations and transcriptions were discussed and clarified with the research assistants, the nurses and the HIV-positive women on a daily basis in efforts to enhance the understanding and the emerging meaning of the findings. After leaving the field, a thorough reading of the material was followed by manual coding of the data set, a process that identified key categories and themes. All supervisors and co-authors have extensive research experience from Tanzania, have proficiency in Swahili and took part in discussions of the emerging themes and their meanings during the diverse stages of the analysis.
Findings: The three papers present the major findings. Paper I focuses on care, Paper II on counselling and choice, and Paper III on confidentiality. The findings provide a scenario characterized by stark diversity between the two programmes in terms of how the nurses perceive and practically handle and relate to the national guidelines on PMTCT and infant feeding while the nurse-mother interaction did not, overall, vary to the same degree. All nurses enrolled in the study were found to ‘care about’ their patients, while their opportunities to ‘care for’ their patients varied due to the differing terms and conditions of the two programmes. How the nurses in the two programmes were observed to ‘care about’ was expressed through examples of a genuine concern for the HIV-positive women enrolled in the programmes. HIV- positive women were seen to adhere to, and trust, the nurses in situations where the mothers’ experiences of care were expressed and observed to be appreciated and to coincide with their expectations of the nurses, who were impacted by authoritative knowledge and a combination of instructive communication and personal involvement in the women’s lives. Such behaviours were observed to make the HIV-positive women feel safe and secure, which led them to trust the nurses and follow their advice in infant feeding practice. In situations where the expectations of the HIV-positive women were not met by the nurses, the mothers felt that they had provided unclear and diverging advice as well as not being able to ‘care for’ them. In such situations the HIV-positive women expressed being frustrated and lacking confidence in how to relate to the PMTCT programme and were often found not to follow the advice on infant feeding practices given to them by the hospital nurses. The key findings are the manner in which caring conduct emerges through a communication characterized by the clear and direct education (‘giving instructions’) and by broader and less strictly defined borders between private and professional lives (Paper I). Nursing care is scrutinized as it emerges at the intersection between health- related ethics and nurse-patient interaction, and is exemplified through a concrete focus of contexts calling for ‘informed choice and patient participation’ (Paper II) and ‘confidentiality’ (Paper III).
Conclusion: The study has added to the understanding of nursing care as culturally- and socially constructed and as produced, re-enforced and changed not only through policy, socio- economic structures and training but also in the interaction between the nurse and the client. The way nursing care is constructed in the example provided in this work is an important comment to the dominant discourse on nursing care which emanates from nursing in Europe and North-America where the socio-cultural, professional and health system context is very different. As illustrated here, this does not imply that patients in the PMTCT programme in Tanzania feel less cared for. On the contrary, the care given to them resonates with their desires and strengthens their trust in the nurses. The implications drawn from the study are that although nurses globally aim to relieve pain and suffering, their approach should be allowed to evolve in local contexts of authority, knowledge and legitimacy.
Paper I: Våga, B. B., Moland, K. M., Evjen-Olsen, B., Leshabari, S. C. & Blystad, A. (2013) Rethinking nursing care: An ethnographic approach to nurse-patient interaction in the context of a HIV prevention programme in rural Tanzania. International Journal of Nursing Studies Aug;50(8):1045-53. This article is not available in BORA. The published version is available at: 10.1016/j.ijnurstu.2012.11.025
Paper II: Våga, B.B., Moland, K.M., Evjen-Olsen, B. & Blystad, A. (2014) Reflections on informed choice in resource-poor settings: The case of infant feeding counselling in PMTCT programmes in Tanzania. Social Science & Medicine. Mar;105:22-9. This article is not available in BORA. The published version is available at: 10.1016/j.socscimed.2014.01.005
Paper III: Våga, B.B., Moland, K.M. & Blystad, A. (2015) Boundaries of confidentiality in nursing care for mother and child in HIV programmes. Nursing Ethics. May 8. [Epub ahead of print]. This article is not available in BORA. The published version is available at: 10.1177/0969733015576358