The study observed that medical doctors and nurses had different relations with clients. This had an impact on the way and manner they interacted with clients and related to them during encounters in the centres and clinics. It also influenced the perceptions of clients of different categories of health workers and how they interacted with them outside clinical encounters. During participation in counselling and testing sessions, consultations and other activities in the facilities, it was observed that medical doctors had brief interactions with clients. Discussions in the encounters were limited to clients’ medical concerns or problems related to treatment. Nurses, on the other hand, had more interactions with clients and showed concerns for their welfare beyond care and treatment. They were also interested in the social well-being of clients and were attuned to their individual needs. Nurses had a cordial relationship with clients, especially in the clinic. Clients as a result adopted nurses as ‘parents’ or ‘siblings’ in the clinic and took decisions on treatment and other related matters with them. It also encouraged clients to continue accessing services. In this regard, the good practices of nurses towards clients facilitated their use of services at the facilities.
Similarly, Campbell-Heider & Pollock (1987: 422) describe the striking contrast between the physician’s contacts with hospitalised patients, which are characterised by brief, highly structured, almost ceremonial interactions, and those of the nurse, who may spend hours in direct, spontaneous contact with patients, from casual conversations to the most intimate bodily functions. The authors, who studied barriers to physician-nurse collegiality in the United States of America, attribute the nurse’s closeness to patients and physician’s remoteness to features of ideologies of social relations within hospitals, in which status is proportional to separation from patients. That is, the physicians’ top position in hierarchical relationship in the hospital explains the limited social interactions they have with clients who are at the bottom of this relationship. Robertson (1996) for his part contends that the parallel difference between doctors and nurses in their approaches to patient care is due to their different professional goals. The study which was carried out in a British psychiatry ward notes that nurses’ prime professional goals are daily care and helping patients as normally and independently as possible, goals which are pursued through ongoing relationships. The most important goals of doctors, on the other hand, are systematic problem solving that is technical in nature, improving organic function and research. Unlike nurses, doctors have brief contacts with clients, negatively affecting communication between them and clients. This, Robinson (2001) notes, deprives the physician of adequate time to identify and fully discuss patients’ additional concerns. The same can be said in Ghana about doctors and nurses.
Clients in this study were of the view that medical doctors distanced themselves from them because “they are not friendly” (Wcnnte wcn anim). Clients often found it
difficult to ask doctors questions for clarification on issues they did not understand during consultations. On many occasions clients refused to go back to doctors and asked questions related to treatment after they left the consulting room. Clients sometimes worried that the concerns they expressed in such brief clinical encounters might appear irrelevant to the technical interventions of doctor and other care providers. They feared they would be labelled as non-compliant, uncooperative, troublesome or irritating. Clients therefore hesitated to discuss their personal problems with medical doctors during the brief consultations they had with them. It also led to the perception among clients that medical doctors lacked sensitivity. Throughout this study, clients did not talk much about doctors in their narratives as they did about nurses.
The generally good relationship between nurses and clients in the present study was also characterised by challenges that led to the perception that in some cases they did not treat clients professionally. Their closeness to clients for instance led to frustrations with some of the clients who were non-compliant, uncooperative or troublesome. They reacted harshly or angrily towards such clients by using abusive language on them or condemned them. Others were punished with denial of services. These observations fit into Robertson’s (1996) assertion about nurses in Britain that engaging in close relationships with patients, however, was not always a matter simply of compassion and affection. It sometimes also involved tension and negative or mixed feelings about difficult patients (1996:295). In this study, since nurses had daily contacts with clients, they were identified as the group of health workers who often showed compassion towards clients and supported them in various ways whenever they were in difficulties. On the other hand, nurses were mentioned as the category of care providers who showed the most negative practices towards clients during interactions in the facilities. In some cases, the unfavourable treatment they gave to some clients discouraged them from accessing care and treatment. This way, their negative behaviours were a constraining factor on the use of services by clients.
Clients however looked for other avenues to talk about their non-medical con- cerns. Some of them found it appropriate to discuss such concerns with the researcher who they considered as an outsider. I was seen as a neutral and safe audience for many clients to discuss their non-medical concerns or personal issues with. I was an outsider in the field because I am neither a health care provider nor an employee of the hospital, which made clients to assume that I would empathise with them. This suggests that clients were careful in choosing the audience to make their complaints in the hospital setting. In a few cases, some personal complaints of clients were discussed with health workers for attention before I left the field. A
client, for instance, complained that a nurse had refused to transfer him to another clinic so he could reduce the high transportation cost to and from the facility for treatment. The nurse was reluctant to do so on the assumption that the client might not continue with the treatment at a different facility. I discussed this with the nurse and she agreed to transfer the client to the other clinic where he continued to access treatment.
This study shows that the way health workers related to clients in some cases did not adequately address their non-medical and personal concerns during clinical encounters. Clients may suffer from the same disease but their experiences of it may differ and they have to be assessed in their own right. Hospital ethnography studies give health authorities and care providers a unique opportunity to understand the clients’ point of view. As the ultimate beneficiaries of health care services, clients’ appraisal of quality of services deserves consideration, too. According to Stein (1985), data collected in the hospital through ethnography can help health practitioners become better observers in medical encounters. These can be used to formulate appropriate interventions to improve upon client-centred care and the quality of services provided.
Another relationship is that between health workers and peer educators who are also clients, which was not always good. The peer educators are selected clients who have successfully undergone the treatment and have been trained as peer educators to work in the clinic as volunteers. Their training and work in the clinic was necessitated by the increase in the number of clients accessing services in the face of limited health staff. The main role of the peer educators in the clinic is to comple- ment the work of health workers, particularly in the area of adherence counselling. However, these peer educators were not given due recognition by the hospital authorities and some health workers. The peer educators were not rewarded financially or in kind for their contribution to the provision of services. They were also sidelined from giving or attending adherence counselling sessions and confined to certain peripheral duties in the clinic which they were not trained to do. This led to tensions between health workers and the peer educators in the clinic.
According to health workers, peer educators were excluded from formal counsel- ling sessions because some of them were not following the procedures laid down for conducting adherence counselling. They allowed some clients to go through the three weeks of adherence counselling without adequate knowledge on treatment and the commitment to adhere to antiretroviral drugs. Peer educators on the other hand explained that the decision of the health workers was motivated by the fear that they were becoming too popular with clients who often consulted them first with their problems for advice instead of health workers. It was, however, observed that the tension between the two was mainly due to lack of clearly defined roles for the peer educators (see Shiner 1999). The training and work of the peer educators in the
clinic was at the instance of a non-governmental organization. Their skills as experience experts in adherence counselling were under-utilized in the clinic. Nevertheless, they continued to work in the clinic in spite of the lack of recognition and employed various strategies to change their misfortune of HIV infection into a relatively lucrative venture.
A close analysis of the relationships between health workers and clients in the facilities point to one important thing: nurses were dominant and powerful. The role of nurses in the centres and clinics was crucial for the provision and use of services. Doctors might be taking all the important decisions on care and treatment, but their limited interactions with clients in the facilities created a distance. It also reduced their control over clients who only saw them briefly during consultations. The nurses had daily contacts with clients. They implement the decisions of doctors on care and treatment, sometimes with some level of discretionary powers. In one of the clinics, nurses decided when a patient who had tested positive would be registered as a new client and start the processes leading to treatment. Besides, they often decided whether a client had understood adherence to treatment after three weeks of adherence counselling to be initiated onto antiretroviral drugs. On clinic days, they sometimes determined which client could see the doctor first, depending on who they considered to be in need of immediate or preferential treatment. They are also the intermediaries between doctors and clients. Clients feel reluctant to approach the doctors with questions about their treatment and other personal issues, so they pass such questions through the nurses to the doctors for clarification. Unlike the doctors, the nurses in the clinics know clients by name and not merely as clients of the facility. Nurses are therefore the most powerful category of health workers in the clinics, although hierarchically doctors are on top and wield power in decision-making process in the hospital. The strong position of nurses in the clinics derives mainly from their close relationship with clients and the intermediary role they play between doctors and clients.