“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. Keywords: Challenges, nurses, relatives, strategies, Uganda ”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. Nyckelord: Anhöriga, strategier, sjuksköterskor, Uganda, utmaningar. 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 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 4 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).