Sleeping in Safety: A Study of Nurse Anesthetists in Ghana
—Lauren Kasparian (Edited by Brigid C. Casellini)
Smells have the unique ability to instantly transport us into the past. Yet, for me, despite a search, the distinctly rich, earthy scent that defined the summer of 2010 can only be found in the bag containing a smuggled piece of rock that’s hidden in my drawer. Almost a year later, memories linked to this distinct scent still linger in my heart and follow me in my day-to-day life.
I traveled to Africa with funding from the International Research Opportunities Program (IROP) to complete research that would become the basis of my senior nursing thesis. The whole experience was to be very Lion-King-esque—those gorgeous savannas and baboons everywhere. But four hours after I arrived in Ghana and was introduced to my first toilet, effectively a swinging door hiding an enclosed space and a hole in the corner, I realized I might have been just a little unprepared for what the next nine weeks would bring. It wasn’t until four days after I arrived that I finally felt a vague sense of ease because I was back in a somewhat familiar element, at a clinic in the village that would become my home.
The author inserting her first IV in a post-delivery patient.
The smell of antiseptic was the first familiar thing I had encountered since arriving in Ghana. From my personal and clinical experiences, I had come to assume that operating rooms would be pretty standard worldwide—immaculate and orderly. I had connected the smell of that antiseptic with this ideal, and was shocked when my first surgery experience was a scene that depicted a naked patient, flies crawling on his cheeks, his stomach opened on a rusty table overseen by a nurse anesthetist who was wearing flip-flops. With this experience I began my research on the anesthesia providers currently practicing in Ghana. What I found was that their work satisfaction levels vary greatly from urban to rural settings, emigration is heavily tied to poor remuneration and lack of educational opportunities, and, most prominently, that the anesthesia field in this country is an extremely selfless profession.
The Issue
I became interested in anesthesia after an extremely positive experience I had with my own surgery and anesthesia provider. While researching anesthesia practices in Ghana in preparation for going abroad, I learned about the healthcare crisis in the nation, and that a startling number of nurse anesthetists, who are the anesthesia providers on over 90% of the anesthesia cases in Ghana, emigrate out of the country (Nurse Vacancies, 2002). Dr. Boakye, the Head of the Anesthesia Program at the Komfo Anokye Teaching Hospital in Kumasi, told me that his school teaches 95% of the nurse anesthetists in his country and that the majority of those who graduate leave. Over 400 nurse anesthetists have been taught in the last five years alone at his hospital, yet only a total of 201 now practice across the country, with the help of a scant dozen anesthesiologists (providers who received extensive anesthesia education out of the country and earned their doctorate). I became obsessed with the why—why do these anesthetists leave, why do they stay, and what makes the difference. I chose to conduct a qualitative study on the experience of nurse anesthetists, focusing on what they perceive as the reasons for emigration or retention.
With a goal to get as comprehensive a picture as possible concerning the nurse anesthetist experience in Ghana, I traveled to rural clinics serving villages outside of major cities and to hospitals located within the major city of Kumasi. I observed the nurse anesthetists in their practice and then sat with them through a series of interviews. Interviewees were nurse anesthetists whose experience ranged from newly graduated to those who had practiced over twenty-five years. In total, I interviewed seventeen nurse anesthetists, two female and fifteen male, from six different clinical sites and ten different operating rooms. I divided the information that I acquired through my interviews and observations into factors that played into emigration and that encouraged retention. A preliminary analysis of the data collected showed that several common themes emerged from the interviews.
Education and Employment
A major grievance cited by all the nurse anesthetists was the education system. Nurse anesthetists in Ghana have comparable requirements and education standards as the master’s program in nurse anesthesia offered in the United States (Lohert, 2002). However, all three of the programs offered in Ghana only furnish certificates, rather than advanced degrees. The reasons why these certificates are so heavily opposed by the nurse anesthetists are multifaceted. Since it is not a degree program, their education is only relevant in Ghana and does not transfer to other countries if they decide to pursue work elsewhere. Although continuing education and refresher courses are mandated by different establishments, they have no chance to further their education. They have no option to specialize and decide whether they want to concentrate their learning expertise and practice in a particular subgroup. All nurse anesthetists have to be flexible enough to work every anesthesia case, which poses an additional challenge.
In accordance with the nation’s healthcare system, nursing salaries are primarily based on a graded scale set by degree and experience (Bennet, 2009). Nurses who get their certificate in anesthesia are still regarded as nurses and make comparable pay, despite working additional hours with additional responsibilities. As nurses, most anesthetists interviewed made between 400-800 Ghana Cedi a month ($280-$565). The majority of interviewees found this allotment insufficient to raise their families, as raising a family in Ghana usually involves supporting not only the immediate family but also a large extended one. Typical shifts are from 7 a.m. to 5 p.m., and nurse anesthetists stated that they are constantly on call, with the average interviewee working between 60 and 80 hours a week. There is no overtime, benefits, or travel-cost compensation. These depressing factors played into a negative experience in their work environment.
Work Environment and Work Satisfaction
Concerns about the work environment were noted by nurse anesthetists in both the urban and rural settings. Even in the teaching hospital, which sets the standard for anesthesia care, there are occasional shortages in equipment and staffing. For those clinics that were more rural, problems ran from a lack of equipment to a lack of power. Surgery and anesthesia are often performed by intuition rather than science, as monitors and equipment are either scarce or nonfunctional. Proper sanitation techniques are also hard to adhere to, and although there are few deaths caused directly by anesthesia, many patients suffer complications related to prolonged surgery times and infection.
From what I witnessed, Ghanians have a more flexible sense of time than Americans. Although this more lax attitude was refreshing, when that cultural practice transfers to the medical field, it has the potential to contribute to dire effects resulting from delays and rushed practice. Communication breakdown was often seen in the systems. For those who worked in the rural setting, there was little to no communication with anesthesiologists when facing a difficult case. Those who worked at the teaching hospital had almost constant interaction with anesthesiologists when necessary. Although in both areas surgery was primarily based around the time the surgeon arrived, it was only in rural areas where nurse anesthetists had to work on multiple cases at once on a regular basis. During my interviews, I asked these nurse anesthetists to share their personal stories of times that were particularly rewarding or frustrating. Many of these stories related to communication breakdown and the need to wait for surgeons to be ready, which prolonged cases and negatively impacted patient outcomes.
An innovative way of transporting IV fluid for a patient in transit.
Another source of dissatisfaction in the work environment was gender inequality. Although, as in America, females comprise the majority of the nurses in the region, they form less than half of the nurse-anesthetist workforce (Hamilton & Yu, 2004). Most females felt that they had to work harder to be recognized in this field. About half of the men interviewed (seven) felt that women did not belong in this line of work—that they let emotion get in the way of decisions and were missing days due to maternity or sick children. The rest either abstained from answering this question or said that there were no problems. This barrier factored into decreased work satisfaction for the females of this field and, according to several interviews, played into the emigration epidemic.
Although my interviewees cited many of the same challenges in their work environment, I observed a glaring difference in their level of work satisfaction. Nurse anesthetists from the urban area reported a much higher rate of retention and satisfaction than those who worked in isolated clinics. Work satisfaction was heavily tied into perception of self as a member of interdisciplinary team, so I tried to assess how each interviewee felt as a member of her or his healthcare team and whether that perception influenced their decision to stay working in Ghana.
Witnessing my first surgery in Ghana at the clinic in my home town of Asamang.
Nurse anesthetists make up a pivotal role in the team during surgery; they are the sole trained professional who has an education that revolves around anesthesia. Those who worked in the teaching hospital felt that they were an integral member of their team, well respected by their colleagues, and that feeling contributed to their desire to remain working in Ghana. Those in the suburban and rural areas however, reported lower work satisfaction and felt that they were not respected as part of the healthcare team. This feeling tended to influence their desire to leave; all of the interviewees who wished to emigrate from Ghana felt they were disrespected or not appreciated by their coworkers.
Finding Fulfillment
Three of the nurse anesthetists I interviewed in the rural setting were actively trying to leave their country. However, they could not, due to financial, familial and governmental barriers. The other fourteen interviewees reported that although there were difficulties, they do get satisfaction from working in their field, and that is a major reason why they choose to stay.
I wondered why so many people went into this field without obvious incentive. Most of the interviewees alluded to the following: (1) they felt the pull of this field because of the shortage of workers; (2) they were aware that stable jobs were available; (3) and that their services could be used throughout the region. Another aspect of the field that appealed was the fact that it presented a challenge; this was a field in which they were the expert on hand. It is an extremely autonomous job where decisions often have to be made unassisted and without the opportunity to solicit another professional’s advice if needed. A common theme throughout the interviews was that these healthcare workers acknowledged a need for them and knew that by staying they could make a real contribution.
Embedded in these Ghanians, not only the healthcare workers but something I also gleaned from spending time with the people as a whole, is a deep sense of pride in their country. These people couldn’t leave their homes, not when they felt they could bring about positive change. The concept of the family is so powerful that familial reasons also influence them to stay. There is an innate obligation to support and be around their family unit, to stay and support their countrymen. In the words of one interviewee, “there is no praise, no thank you, no principal reward, but we can get thanks from our patients for doing work, and that makes it worth it.”
The author rounding up escaped runaway chickens with the locals.
Implications
The nursing shortage in Ghana is severe; as more people attempt to access healthcare, they will be faced by a waiting list of momentous proportions. The information I gathered in this research leads to very serious concerns for the future. Although more nurse anesthetists are enrolled in courses in Ghana than ever, according to Dr. Boakye more are leaving upon graduation to seek what they term as “greener pastures.” Although I could not obtain information about whether they leave knowing that their degrees from Ghana won’t transfer, several interviewees indicated that these providers simply wanted to continue furthering their anesthesia practice in environments more conducive or were willing to repeat their education for better remuneration for their services. Steps need to be taken to ensure that more nurse anesthetists choose to stay in Ghana. For both patient safety and work satisfaction, conditions need to change to facilitate the process of administering anesthesia.
One of the most vital processes in work is the development of a degree program at the Komfo Anokye Teaching Hospital. They are hoping to make anesthesia an advanced degree which would allow nurse anesthetists to specialize, receive additional training, be recognized in other countries for their degree and put them on a salary scale more reflective of their responsibility. In my final interview, when asked about what he sees for the future, the nurse anesthetist replied “I do not know how it will change, but it will—if we stay, and we talk, and we try, I can only see great things for us.”
This study has helped to identify areas that nurse anesthetists perceive as challenging or problematic in their field, as well as to single out the positive aspects of their practice. If such information is introduced to organizations interested in furthering anesthesia practice in Ghana, it is possible that long-term implications of this study can eventually work to better the anesthesia industry and the healthcare system as a whole in this West African nation. I do have hopes that as their international bonds strengthen and their degree programs further develop, the nurse anesthetist population in Ghana will become one that is more satisfied and respected in their field.
Coming Home
One of the questions I was told to ask myself on my return is what I took back with me. This experience was amazing, and I had a much harder time acclimating myself to home than I expected. Pictures did not prepare me for what I was able to witness and experience in Africa; the notion of living in a developing world was not one I could truly conceptualize until I did it. I came into a country that was beautiful in a way that I did not initially understand, with its red earth and packed cities, but by the end of the summer it had become a part of me. I now wish that I had not been so timid those first few weeks and had put myself out there more. However, I’m walking away having learned to care for patients without all of the technology we find so necessary here, having discovered how to live without running water, having experienced the feeling of closeness to wild animals on a safari, and with the comfort of knowing that I had the opportunity while there to make choices that directly affected other’s lives in a positive way. I have come back with a sense of fulfillment that will forever leave me indebted to the IROP program, nursing, my sponsor, and the people I’ve met in Ghana. I will go back one day, hopefully with more knowledge than now, and try again to make a true difference. I can only hope that as Ghana moves into the modern world, the people take with them the sense of fulfillment and happiness that they seem to embody.
This trip would not have been possible without the help of many amazing people in my life: Mr. Ellis Woodward, for his generosity and support of expanding knowledge; Dr. Georgeann Murphy and the rest of the Hamel Center for Undergraduate Research, who have been so supportive throughout this entire practice; Dr. Gene Harkless, whose mentorship has been invaluable throughout this experience; Dr. Boakye, my foreign mentor who provided me his countless contacts and experience; and Dr. Carol Williams-Barnard, my honors mentor who has guided me through this endeavor with grace. A special thanks to both my old and new-found friends and family—thank you for all of your support along the way.
References
Bennet, C. (2009, March 5). Ghana’s National Health Insurance Scheme to be restructured : Ghana Business News. Retrieved October 13, 2009, from http://ghanabusinessnews.com/2009/03/05/ghanas-national-health-insurance-scheme-to-be-restructured/
Bump, M. (2004.). Ghana: Searching for Opportunities at Home and Abroad.Migration Information Source. Retrieved October 13, 2009, from http://www.migrationinformation.org/USFocus/display.cfm?ID=381
Fain, J. (2004). Reading, Understanding, and Applying Nursing Research. Pennsylvania: F.A. Davis Company
Hamilton, K., & Yu, J. (2004.). Migration Information Source - The Global Tug-of-War for Health Care Workers. Retrieved October 13, 2009, from http://www.migrationinformation.org/Feature/display.cfm?ID=271
Löhnert, H. (2000). Health care and regional anesthesia education for nurse anesthetists in Ghana.CRNA: Clinical Forum For Nurse Anesthetists, 11(3), 99-102. Retrieved October 7, 2009, from http://www.ncbi.nlm.nih.gov/pubmed
Nurse Vacancies-2000. (2002.). Ministry of Health-Ghana. Retrieved October 7, 2009, from www.moh-ghana.org/moh/default.asp.
Copyright 2011, Lauren Kasparian
