Why Bangladeshi nurses avoid ‘nursing’: Social and structural factors on hospital wards in Bangladesh
Introduction
Direct patient care is a central responsibility of nurses operating within Bangladesh as elsewhere (Bangladesh Nursing Council, 1993; Uys, Groenewald, & Mbambo, 2003). It entails nurses going to the patients’ beds and having physical contact or talking to the patients directly (Eastabrooks & Morse, 2003). An observational study of nurses (Hadley & Roques, in press) raised disturbing questions about the care provided by nurses in Bangladesh. Only 5.3% of nurses’ time was spent in direct contact with patients. In this paper, we sought explanations for their behaviour. While the nursing curriculum follows the British model of 1947, after taking up their duties nurses enact their role in a cultural context, interacting with members of the society at large (Zaman, 2004). It is therefore important to examine both how nurses perceive their role and how those interacting with nurses, such as hospital staff and patients, view nursing within the broader context of Bangladeshi culture. Because most nurses are also women, daughters and wives, gender and family roles may pose conflicts.
A great deal has been written about occupational role conflicts experienced by women (Klumb & Lampert, 2004). While nurses are no exception, their role conflicts may be experienced differently depending on the culture and the demands placed by others on nurses (Lambert et al., 2004). The nursing profession prescribes certain behaviours that may be proscribed by the culture to which nurses belong, particularly behaviours considered inappropriate for women (Bryant, 2003; Kim & Motsei, 2002; Marks, 1997). The study of stigmatised roles has frequently used the framework offered by Goffman (1961) (see also Garfunkel, 1956; Pilgrim & Rogers, 2005) who employs the concept of negative labelling to understand role enactment and social acceptance. However, for nurses there is both value and stigma attached to their role. Positive recognition is linked to their comparatively higher educational level and professional status. On the other hand, their dual role as Bangladeshi women means that certain behaviours are disapproved of. This conflict between professional and social roles will be examined as it affects nurses’ work, particularly direct patient care.
The companion paper (Hadley & Roques, in press) reported on the amount of time nurses in government hospital were observed to spend in different activities. Nurses spent only 5.3% of their working time in direct contact with patients. Paperwork and indirect patient care occupied nurses for 32.4% of their time while unproductive time, for example away from the wards and chatting with other nurses, took up 50.1%. These figures diverged considerably from the activities reported by these same nurses which fit the training curriculum they were taught but not what they were observed to do. By contrast nurses in the hospitals outside the government system were found to spend 22.7% directly with patients.
The British nursing model was introduced into Bangladesh, then West Bengal, in 1947 (Harun & Banu, 1996). Historically, the nursing profession was unacceptable to Muslim families in Bangladesh (World Health Organisation, 1994). Recruitment was, therefore mainly of women from low caste Hindu and Anglo Indian families. Additional efforts to increase the workforce encouraged those considered unfortunate in society, for example widows and spinsters, to apply for nurse training. This reinforced the notion that a career in nursing should be pursued as a last resort. Simultaneously, a campaign targeted high school girls, emphasising the benefits of a high salary including a stipend during training, secure accommodation, a vocation suitable for girls with lower academic achievements and the opportunity to earn a living abroad. This campaign was successful in attracting young girls (Harun & Banu, 1996). Because Bangladesh nursing did not move into primary care community settings as in other countries (e.g. Isely, 1980), it remains an inpatient hospital-based profession.
If international nurse:patient ratios are used to evaluate workloads Bangladeshi hospitals are short of nurses. However, observations of daily nursing activities (Hadley & Roques, in press) indicated that conflicts experienced by nurses are not due to an over taxing workload, as elsewhere (Klumb & Lampert, 2004). Yet, the demands of their professional training do create socially derived conflicts.
In Bangladeshi society hierarchical designations govern behaviour between individuals and groups (Kotalova, 1993). A person's place in the social hierarchy is largely determined by family connections or family reputation. Women in particular are identified in terms of their father's and husband's position. As a result, social life revolves around maintaining the family structure and protecting the family reputation (Rozario, 2001). This necessitates strict adherence to cultural expectations and societal norms. The importance attached to family economic status and family connections is most critical when choosing marriage partners. Parents take the lead role in identifying a partner from a range of eligible persons dictated primarily by educational and family status (Rozario, 2001; White, 1992). As nurses are not permitted to marry before training is completed (20 years of age) by the time they become registered, they are over the average age for marriage which is 16, thus reducing their prospects (Bangladesh Demographic & Health Survey, 2004).
Therefore, it will be important to determine if and how the nursing role comes into conflict with a young woman's obligation to protect her family's reputation. Sharp distinctions are also made between family and non-family roles and relationships. Women play a caregiver role within the family ministering to sick kin. This does not, however, render them appropriate candidates for care-giving towards sick people in general. The Bangladeshi Islamic culture prohibits physical touch between non-family females and males. This could conceivably interfere with the nurse–patient interaction.
In order to explain the lack of hands-on nursing care (see Hadley & Roques, in press) we examined three themes: the impact of cultural and societal factors on nurses’ behaviour; strategies used to manage the conflict, and aspects of the broader hospital structure that influence nursing. Nurses themselves and others in the hospital system who have direct experience with nurses were interviewed to understand nurses’ professional and social roles.
Section snippets
Methods
The study used a cross-sectional, descriptive design. Data were collected over a 9-month period in 2002 and 2003. The research strategy entailed semi-structured interviews with hospital staff (nurses, doctors, support workers), patients and patient carers from six hospitals to explore influences on nurses’ activities. Independently contacted key informants from the same broad categories provided information to help create interview questions and interpret the findings. Finally, group
Results
Themes were identified and grouped in line with the three study objectives designed to explain nurses’ behaviour. The impact of a career in nursing on marriage prospects was the principal theme that emerged to describe professional and social role conflicts. Explanations are best elucidated through three sub-themes including: the requirement to work during evening and night hours, the need for close contact with members of the public especially with males, and involvement in work considered
Discussion
Our findings indicate that critical elements of basic nursing fall outside the parameters of cultural norms shaped by beliefs associated with religion and gender. Night duty, physical contact with strangers and males, and certain tasks regarded as low status were singled out as creating a conflict. The resultant polarization of nursing guidelines and societal norms fosters a widespread and profound conviction among Bangladeshis that nursing is an offensive practice. These findings may help
Conclusion
The findings suggest that nursing in the public sector in Bangladesh has diverged from the original British model introduced during the colonial period, which involved direct contact with patients from all walks of life. In contrast, results from this study suggest that providing care for patients is an unwelcome feature of the profession that, if possible, one should avoid. This state of nursing is linked to the fact that basic nursing practices are antithetical to many fundamental aspects of
Acknowledgements
This research was funded by the Department for International Development (DFID) Bangladesh, through the Strengthening the Role of Nursing Project (SRN), grant number GR-00161. ICDDR,B acknowledges with gratitude the commitment of DFID to the Centre's research efforts. Angie Roques was responsible for the conception of the research, the initial study design, interpretation of data and contributed to the intellectual content of the paper at an earlier stage. Support and advice in developing and
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