Treating a sick hospital
If you and your family use government hospitals, then experiences of shoddy treatment, of long queues, of no bedding, no food for sick patients, of clothes being stolen from dying patients, are probably familiar to you. But sometimes it is the hospital that is more sick than its patients. For the last four years, Cosatu’s research body, Naledi, working with trade unions and management has been trying to diagnose Chris Hani Baragwanath Hospital ‘s (CHB) illness and prescribe some medicine for it. Jenny Grice reports.
Soweto ‘s Chris Hani Baragwanath Hospital (CHB) has 2800 beds serving 3,5m people in Soweto . It ranks as the largest hospital of its kind in the world. But that is where its world class status ends.
Inside the sprawling mass of 429 buildings, spread across 173 acres (the size of a small farm), a massively understaffed hospital battles to give quality service to 150 000 patients a year and almost 1500 outpatients a day.
But it is a struggle. CHB should have 3000 nurses. It only has 2000. It doesn’t have the money to employ an extra 1000 nurses. Nor does it have the resources to fill the 30% shortage of support staff. Nurses find themselves doing the work of both. And quality service suffers.
“I have to rush time – I must stop washing and serve tea,” a nursing assistant explains. “If there are no ward attendants I must make tea myself. There’s no point in washing the patient and giving medications, but failing to feed him. Again, how can you leave a sick person in a wet bed and go for lunch?”
The reasons for the shortage of staff are complex.
One is the apartheid legacy. Black hospitals like CHB received less money than white hospitals like Johannesburg General. With national health spending remaining more or less the same since 1994, the gap in spending has not closed.
Another is post apartheid health policy. This shifted health spending from big hospitals to primary health care and to less resourced provinces and rural areas.
Aids too, is taking its toll. Dr Martin Smith, chief clinician in the surgical Department at CHB estimates that 70% of the patients in the medical and paediatric wards of the hospital are there because of Aids related illnesses. This was not so ten years ago.
Recently newspapers have made much of nurses going overseas to better paid jobs. The Department of Health claims that nurses are leaving because “they wanted to improve themselves”. Nurses dispute this.
“The reason for us leaving is that we can’t work comfortably, we have to nurse 66 patients. Service provision has collapsed. A toilet breaks, you report it, it doesn’t get fixed. You can kick and scream for 25 months… but nothing happens,” says a chief professional nurse.
“Nurses at CHB are saying that they are being pushed out because of conditions,” says another chief professional nurse and Denosa representative. “They are capable, but they are made to be incapable. They want to go to an environment where they can nurse.”
Others complained of the lack of career pathing for nurses. The massive shortage of staff at all levels means that overtime for night shift workers has increased. But shortage of money means that overtime is not paid. Workers can take the equivalent time off when they work day shift. But shortages of staff mean that they rarely get given the time off.
If CHB’s illness was confined to a lack of resources, shortage of staff, and pressure from Aids, the prescription would be simple – give it a massive injection of staff and money.
But researchers found when they pried open the sick body that it needed more than just an injection of funds. There was a cancer that had spread deep within.
…Weak management – unable to discipline
Workers – both nursing staff and support workers – complained of weak management that seemed unable to discipline the “rotten potatoes”.
“Someone comes on duty drunk but will never be disciplined,” a nursing auxiliary explained. “A known habitual loafer is never disciplined. Someone steals a patient’s clothes. They know exactly who is responsible, but there will be no disciplinary action. They call a meeting of everyone and give a lecture on how to conduct ourselves.”
…Dysfunctional work organisation
In each ward there were three parallel structures – nursing staff, doctors, support staff (cleaners, clerks and others). Nurses complained about doctors, doctors complained about nurses, both complained about cleaners and other support workers. But there was no structure at a ward level to bring together all three parties to see how they could work together with their limited resources to improve things.
And far removed from the action, management sat in its nine-floor administration block circulating memos announcing new methods of work for the wards that were unworkable.
“When we meet with management we complain about the shortage of staff, the linen, and cleaners – they tell us to try our best! It’s a joke! They come with no solutions. Who do we cry to?” asked a desperate Chief Professional Nurse.
A year ago the Department of Health sent in a new management team which has made some improvements. However, with inadequate resources it is an uphill battle.
Plans to transform CHB
Working with trade unions and management and with support from the Gauteng province, Naledi and the parties have prescribed medicine that will start to treat the ailing surgical department. It involves:
regular doses of meetings with representatives of nurses, support staff and doctors meeting together in one meeting and ongoing teamworking
a new diet and regime that will include negotiating a new code of conduct with an effective grievance process and the power to issue verbal and written warnings at ward level. This must be followed by effective communication and training for supervisors and shop stewards and training and career pathing for all workers.
new blood in the form of more ward assistants (WAs) and nursing assistants (NAs), the widening of their work tasks and ward clerks’ (WCs) jobs with the promise of career pathing
stress relief for professional nurses because of the broadening of work tasks of the WAs, WCs and NAs
ongoing monitoring of the shortage of staff and the development of a plan to address this
regular check ups by a quality audit officer to measure how patients are being treated, the bedsore rate and wound sepsis rate.
Prospects for success
Those taking part in the project are positive. “We are the starting group for the whole hospital. So let us hold our heads high and go forward,” says a chief professional nurse.
And according to Naledi researcher, Karl von Holdt, the Gauteng MEC for health recently instructed the hospital to develop a strategic plan for the whole institution based on the thinking of the transformation project in the surgical department. “So there is a real prospect for change — if the necessary resources are provided.”
(The quotes are taken from reports by Naledi researchers on their project and from nurses and a doctor who spoke about the exercise at a talk given by Karl von Holdt at Wits University on November 5 2004 )