I just couldn’t let little Brian lie dying

IT promises to be a day of fun. Stacey-Anne Penny has been in Uganda for about three weeks, working at a private hospital. This weekend there’s the chance to do something slightly different: joining other volunteers to paint murals in the children’s ward of another hospital. This one is a public institution – such units, Stacey reflects later, often proving “beyond grim” to a western eye. It’s common in Uganda for patients’ families to take care of basic needs, such as washing and feeding, with nurses dealing with medical matters. But if you haven’t got any relatives who can pitch in, you’re in difficulties.

The children have been put up one end of the ward so the volunteer decorators can work their magic. Very quickly, though, Stacey’s focus shifts away from cartoon-like characters.

“There was an 18-month-old little boy in a cardboard box, on the floor, covered in excrement and vomit – the weight of a three-month-old. Skeletal,” she recalls of that day. “His mother had died of HIV a week or two before. He had HIV, TB and chest infections. Really, really sick. And he was just left in the corner, in a cardboard box . . . no-one to care for him.

“This is when I suddenly thought ‘I don’t understand this culture. I cannot begin to expect to understand this. It was utterly shocking – a slap round the face, effectively.”

Walking away wasn’t an option. “I started visiting Brian each day: 20 minutes on my way home. I’d take him food and nappies – and make sure he was clean.

“I thought he was going to die – well, he was dying. I thought ‘If he dies, that’s “OK” – kids here die; it’s one of those things – but I can’t have him dying on the floor, forgotten. Can’t he die with a cuddle – at least some sort of humanity (shown) towards him?

“He would just cry, a whine, and when you held him he would be quiet. All he wanted was to be cuddled.

“One night I had to leave him at the hospital and I thought he was going to die overnight, and that was my darkest hour.

“I phoned a VSO doctor and said ‘I don’t know what to do . . .’ He got some things moving.” Stacey also spoke to a VSO nurse, an Irish lady who had been there a year, who got Brian cleaned and fed, and a feeding tube inserted. She also got a doctor involved and managed to get the lad moved to a different unit.

A five-strong group organised a rota, with someone going into the hospital for half a day or so to look after the sick boy.

Stacey also got in touch with a local orphanage, which sent Ugandan carers, and a social worker managed to trace a grandmother.

“And, a month later, Brian’s back on his ARV drugs (anti-retrovirals), his chest infection had cleared up, he’d put on weight, his grandmother had come, and he was waiting for discharge to go home with her.

“We didn’t do anything amazing; we didn’t do anything they couldn’t have done themselves. We didn’t have lots of money; we didn’t have special drugs; we didn’t have lots of equipment. And that made me think ‘Actually, it’s only small things that need to change here. And I can help that.’”

Stacey realised her core belief that a nurse is a nurse is a nurse – sharing the same essential values and characteristics whether in Chicago or Cafunfo, Canberra or Calcutta, Coventry or Campbellpore – probably didn’t stand up to scrutiny.

“It became my . . . quest is too strong a word . . . but I wanted to find out what made a Ugandan nurse tick. Why could a Ugandan nurse leave a child to die, in the corner, while she sat at a desk; whereas I as an English nurse could not?

“I wasn’t being judgemental; I was really trying to understand what made it OK for her and not OK for me. Was it education; my culture? Was it apathy; lack of power?”

It prompted the Suffolk volunteer to conduct a research project, partly in conjunction with an Australian lady, and extend her stay by about four months. She managed to get some funding from England, and the forward-thinking Ugandan private hospital where she worked allowed her two days a fortnight to gather data.

It took her across Uganda as she interviewed dozens of nurses – male and female, from both the public and private sectors, rural and urban. Her VSO experience “became more than just my placement at the hospital”.

“I visited nurses in rural areas who had no water, had no light, had no telephone, had no equipment, had no gloves . . . had delivered babies at night by the glow from their mobile phone.

“That made me begin to realise why Brian was left in the corner: because they were just powerless to do anything else; and to accept that is easier than continually battling against it.”

Stacey learned that nursing is not the first choice of career for many. “They wanted to be lawyers or accountants or architects. If you don’t get into one of the ‘higher’ professions you’re offered nursing, even if you didn’t apply for it – and a job is a job. Many of them, in their own words, they don’t have the heart.” Some nurses were, of course, “truly amazing, and for them it was a vocation. Others, it’s a way of earning a living.

“I don’t know any nurses here who don’t want to be nurses, because it’s quite tough sometimes and, if you don’t want to do it, there are other options. But there aren’t always, there” – in Africa.

Stacey also found the wider medical profession in Uganda was traditionally very hierarchical. Many nurses had been treated unprofessionally by colleagues in other branches of medicine. “They didn’t have a voice. They weren’t listened to. ‘Disempowered’ is the only word I can think of.”

Her essential conclusion was that nurses knew what they should do, “but there were barriers to them doing it. Some of those barriers were environmental things – like light, heat, equipment – and some were more engrained things, like self-worth and not wanting to rock the boat or be seen to be difficult. There’s no protection for nurses; if someone doesn’t like you, you’re out”.

She was invited to present her findings to 500 people at a conference in Zambia last August. Stacey also wrote an article that went via VSO to the World Health Organisation. She’s currently waiting for a last batch of material before compiling her final report.

“My dream, and it is a dream, is to see if I can replicate it in other developing countries.

“What I think happens is western nurses like me, with western values and western ideals, are sent out to these countries with no real concept of what that country needs. If we actually had a collective idea of what makes a nurse tick in Uganda, and somebody like me going again, they’d know the problems.

“Maybe it could be tackled at a strategic level by the Government or aid agencies. ‘Leadership’s poor, so let’s send leaders’, or ‘clinical skills are poor; let’s send clinicians’. Let’s have more of an idea.

“If nothing comes of it, at least I’ve raised awareness in Zambia, and there were people who listened who were from South Africa, Zimbabwe, Malawi – countries all over Africa sent delegates, and they asked questions.

“Even if only a few people go back and think ‘Well, actually, that resonated; maybe we can tackle that in some way’, then I’m happy.”

Winning-over the doubters

VOLUNTARY work far from home always requires a step in the dark, however well prepared one is. For Stacey-Anne Penny, early days in Uganda tested her mettle.

Upon arrival at the private hospital, she learned the nursing director was about to leave. “So I said to the management ‘So who’s going to be the nursing director now?’ ‘Well, you are . . .’”

Stacey needed a good think about that revelation . . .

“They wanted me to do things like be on call, and take charge of the hospital overnight, and I thought ‘I can’t do this, because I’m putting my own registration at risk, because I don’t have the skills to do that in a country I don’t understand. Here, I could probably do it, but I don’t understand your issues well enough.’

“So I went back in and said ‘I’m sorry, I can’t do that.’ They were quite disappointed.

“The point of me being there was to mentor and adapt and set up systems they could carry on with when I’d gone.

“One of the things I said very quickly was ‘You have to employ another Ugandan nursing director and I will work with her. It’s not that I’m not engaged here, but when I leave she can run the nursing department.’ They did come round, and that was wonderful – lovely, lovely girl called Juliet, who was outstanding. We worked the nursing department together.”

The great thing was that the hospital owner had travelled widely and realised changes were needed on the nursing side. Stacey was effectively given autonomy to make them happen.

That was a exciting prospect . . . but of course it’s never easy altering established practices.

She was given a beautiful air-conditioned office, with internet connection and a lovely big window, but remembers sitting there early on and no-one coming near for a whole day.

Colleagues weren’t being hostile; “they just didn’t know what I was there for! I spent the time emailing a friend in tears. At the end of the day, I thought ‘I’m never going to have another day like this. I’m either going to go home or I’m going to do something about it. If I go home now, nothing’s going to change; if I put one tiny thing in place, at least I might have a little bit of self-worth when I do go home.’ But it was really hard.”

The department had no database of qualifications and no proper disciplinary procedure. “Some nurses were amazing, but some were less than amazing.”

Some sub-let their shifts to other people. Some on duty at night would settle down in spare beds, she says – disconnecting the call-bell so they weren’t disturbed. Some didn’t do proper drugs rounds – they would instead give medicine to the patients and rely on them to take it at the right times.

First priority was to establish proper rotas and stop shifts being sub-contracted. “A lot of the things I did weren’t popular!” she smiles.

There was one big hold-your-breath moment six weeks in when a senior member of the hospital hierarchy issued an “either she goes or I do” ultimatum. It was Stacey who stayed.

The lengths of shifts were equalised and nurses had more time off. In came detailed job descriptions, appraisals, a formalised disciplinary system, regular management meetings and nurses’ meetings. Minutes were kept and points for action were followed through.

Minimum staffing levels were set for each ward and the number of nurses and midwives rose from 43 to 82.

Stacey won the trust of the staff by demonstrating that if they supported the reforms, she would fight their cause in the boardroom.

A performance-based innovation gave nurses an extra 25% on top of their salary if they consistently wore the correct uniform, arrived promptly, worked efficiently, attracted no complaints, supported colleagues and were flexible and willing.

“If I’d done it here, with my nurses, they’d have hanged me for insulting them!” she laughs. “You have to take a step back and think ‘What’s going to work here that I wouldn’t necessarily do at home?’”

Not everyone kept to the rules, though.

“I did sack nurses, which was quite difficult; but you had to. I sacked a nurse because she stole and I sacked another person because there was a difficult delivery and the midwife refused to get up from the couch and help until the television programme she was watching had finished!”

As nursing care improved, more patients came to the hospital. So the owner was happy with his investment and strategy.

“Things I did weren’t rocket science. They were about organisation,” says Stacey, now back managing the community nursing team in the Woodbridge area and hugely grateful to Suffolk Community Healthcare for granting her a sabbatical.

“We did things like a flow chart for a patient being admitted: what a nurse should do, what a nurse shouldn’t do, whose responsibility it was.”

Those who worked the hardest were the hospital staff, she insists.

Did she ever feel uncomfortable about being a foreigner and telling the locals how she thought it ought to be done?

“I’d go to my desk sometimes in the morning and think ‘What right have I got to be here? How do my values as a white British nurse fit in here?’ But people tended to see you as the answer to everything. ‘Because you’re white, you’re right.’ Which is not always the way!

“I knew very early on that if I was going to do anything worthwhile or sustainable I had to learn more than I was teaching, and I had to work with the Ugandans, rather than them working for me.”

Web links:

• The charity that supported Francis on the night of the bombings and paid for his care over the next few months was www.suubitrust.org.uk

• The charity that Stacey’s boyfriend is involved with, to give orphans an education, is www.lessons4life.co.uk

• Anyone wanting to investigate volunteering with VSO or giving support: www.vso.org.uk