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Helle Max Martin - Nursing contradictions
 
Nursing contradictions
Ideals and improvisation in Uganda
 
Helle Max Martin
 
AMB Diemen 2009
(isbn 97890 79700 12 7, 189 pp., bibliography, index, paperback, € 35,-)
 
Nurses in Uganda today are strongly criticized. Stories of their malpractice and cynicism are all too common in the public debate on government health care. But how do nurses see themselves? What is their perspective on their profession? What are the problems they face, their hopes and worries?
To address these questions, this book explores the relation between nursing education and professional life. It looks beyond common explanations of ‘bad character’ and ‘poor education’ to unpack the fundamental contradiction between nurses’ professional ideals and the realities of everyday nursing practice. The improvisation they must engage in at work, as well as their conceptions of (and sometimes, involvement in) corrupt practices illustrate how nurses struggle to balance and fulfill contradictory professional and domestic demands. All the while, they must position themselves in relation to public criticism, and at the same time maintain their faith in professional ideals.
The book shows what it means to be and work as a nurse in the resource-poor health service of Uganda, analyzing the concerns and motivations of the group of health workers that have the most profound impact on health care delivery. This analysis contributes to the growing field of hospital ethnography, which considers health facilities and health workers in their social and cultural context.
 
Helle Max Martin has a Ph.D. in Anthropology from the University of Copenhagen. She now works as a researcher and project manager at the Danish Institute for Health Services Research.
 
Table of contents
 
PART I -- INTRODUCTION
 
Chapter 1 Introduction
Health care and nurses in Uganda
Person and profession
Professions: sociological approaches
– A taxonomy of the professions
– Nursing as a profession
– The institutional anchoring
An anthropological approach
– Professions as culturally embedded
– Professional and domestic domains
– The whole person
Empirical themes: formation and survival
Formation of the nurse
Survival in a resource-poor system
– Eastern Uganda: the field sites
Locations and domains
Ugandan nurses: a homogenous group?
Mobility and stagnation
The importance of human resources
Structure of the book
 
Chapter 2 The Setting: Nursing in Uganda
A profession in the making
The lady with the lamp in black Africa
‘The time of regimes’
The nurse’s career
Cadres and courses
Decentralisation and employment
In-service training
Upgrading, promotions and professionalization
Earning a ‘living wage’
Salaries
Secondary work
Working conditions
Poor infrastructure
Lack of equipment and drugs
Attendants
Infection risk and hiv/aids
Institutional ad hocism
Conclusion
 
PART II -- FORMATION
 
Chapter 3 Learning to nurse: Knowledge and skills
A nursing school
Enrolment
The students
Types of learning
Classroom teaching
– Theory classes
– Demonstration Room classes
Practicum
Types of knowledge
Balancing formal and informal knowledge
A hierarchy of knowledge
From knowledge to skills
Acquiring skills
The social dimension of learning
‘Learning on your own’
Experience or academic merit?
Conclusion
 
Chapter 4 Becoming a nurse: The professional role
The image of the ideal nurse
Gender: woman, mother, nurse
Male nurses
The Christian heritage
The ‘commercialisation’ of nursing
Moulding ‘the right type of girl’
School rules
The school as parent
Disciplining the body
An example to the community
Challenges to professional authority
Difficult patients
The authority of male students
Differential treatment
The person in the profession
The ideal nurse at work
Conclusion
 
Chapter 5 Changing relations: the social person
‘Someone who is educated’
Modern lives
Domestic relations and professional practice
The nurse as a family resource
Nursing skills brought ‘home’
Home brought to the hospital
The social position of the nurse
Obligations
Respect
Relations with colleagues
Loyalty
Personal involvement
The imagined community of nursing
Conclusion
 
PART III -- SURVIVAL
 
Chapter 6 Improvisation: Dealing with deficiency
Tororo Hospital
Things and people
Authority in things
Blurred clinical boundaries
The meanings of improvisation
Improvisation as routine
Improvisation as defence
Time and place
Improvisation as nostalgia
Conclusion
 
Chapter 7 Corruption: Balancing concerns
Notions of corruption
Corruption in health care
Everyday corruption
Misuse of resources
Informal payments
‘Appreciation’ and kito kidogo
Favouritism and ‘technical know who’
Consequences: “We don’t like to fire people here”
Explaining corruption
From ‘bad seeds’ to ‘survival’
Conclusion
 
PART IV -- CONCLUSION
 
Chapter 8 Conclusion
Wide horizons and modern lives
Representations
Faces of the state
 
Notes
References
Index
 
Acknowledgements
 
I am indebted to a large number of people and institutions for their contributions to this work. First and foremost, I am most grateful to the students, nurses and other staff at the two main field sites in Uganda, Jinja School of Nursing and Midwifery, and Tororo Hospital, who put up with questions and visits during my fieldwork. In addition, I wish to acknowledge the friendly and enthusiastic reception I received from both health-workers and users in health facilities, ngos and at different levels of local council. It is my sincere hope that the results of the study will be beneficial to them. My research partner in Uganda, the Child Health and Development Centre (chdc) of Makerere University, provided logistical support and helped me through the formalities of doing research in Uganda through the Tororo Community Health project (torch). I am particularly grateful for the assistance and friendship of Augustine Mutumba and Jenipher Twebaze. The officials in various nursing bodies and the Ministry of Health and the Ministry of Sports and Education also deserve mention for their support. All the other friendly people of Jinja, Tororo and Kampala, who made our stay in Uganda decidedly pleasurable, are not forgotten. May we meet again!
 
In Denmark, I wish to thank the former Danish Council for Research in Developing Countries in the Danish International Development Agency (Danida) for providing the financial basis of the fieldwork with a research grant. For academic inspiration and constructive comments, I am particularly grateful to Sjaak van der Geest, Tomas Martin, Turf Böcker Jakobsen and Marianne Pedersen. Professor Susan Reynolds Whyte deserves credit not only for outstanding professional guidance, but also for her enthusiastic and empathic introduction to Uganda and East Africa. Finally, Tomas, Jakob, Aksel and Joakim – thank you for your encouragement and patience.
 
---
 
Chapter 1
Introduction
As a nurse, you want to see your patient recover and go away healthy. You have that spirit of nursing that she is almost your relative, and you want to her to be your friend. So when she walks out, you feel so proud. And when she gives you that recognition, says ‘thank you, nurse’, and maybe gives you something like a gift, the motivation is high. That’s when you really enjoy your work. But most times you just find yourself in this place without the proper equipment, you cannot use your skills, you are improvising, even doing some bad, bad things because the wages are small. Today, if the patient says ‘thank you’, you feel very surprised. We don’t expect it. People think ill of us today, and they have no respect even when we have struggled to save their lives. So you come home miserable, maybe there is no lunch, the children come from school hungry, you are not even sure of supper. You worry because you have a million problems and so you start misbehaving at work to find some solution, at least to make your children progress. That’s your responsibility as a mother. And maybe your parents also need something, so you start thinking of them first and your patients second. As a nurse you have so many responsibilities, but what can you do? Can you work miracles? You are also just a human being.
(Jessica, staff nurse, Tororo Hospital, Uganda)
 
At the last sentence Jessica(1) shrugged and laughed, indicating resignation in the face of overwhelming constraints. Jessica is a staff nurse at Tororo Hospital in eastern Uganda, and the interview from which this excerpt is taken was done outside her ramshackle house in one of the poorer areas of Tororo town. Sitting there in a shady corner of her courtyard, amongst chickens and bags of garden produce, occasionally interrupted by her sons, the carpenter she employed and the occasional patient from the neighbourhood, Jessica reflected on her work and her life. In many ways, her narrative epitomized the principal theme of this book – how government-employed nurses in Uganda struggle to handle the contradiction between professional ideals and everyday practice in the resourcedeficient health-care system, and to balance the diverse responsibilities and aspirations that relate to the professional and domestic domains respectively.
 
Health care and nurses in Uganda
The government health-care system(2) in Uganda is struggling with serious problems. Historically, the political and economic instability in post-independence Uganda caused a decline in the provision and quality of public health services, particularly during the 1970s and 1980s. Despite improvements brought about by government and donor initiatives since the mid 1980s, continuing economic and political problems and the onslaught of the aids pandemic in the 1990s have made it difficult to achieve targeted levels of health care (Lyons 1998: 201), and this continues to be the case according to local health-care administrators. Today, government health facilities at all levels lack the necessary resources, equipment and staff to fulfil health policy goals. As an indication of the crisis, the Uganda Health Sector Strategic Plan 2000/01-2004/05 mentioned a mere 75% fulfilment of the minimum staffing norms as a key objective (MoH 2000a: 60-62). At the end of the period, a level of 68% human resource coverage had been reached (MoH 2006a: 51).
Nurses make up the largest group of biomedically trained health workers and often have the primary contact with patients, particularly in the rural areas. As the foremost representatives of health care, they play a crucial role in the delivery of government health services. Their job situation is characterized by poor working conditions, low salaries and dismal career opportunities. In order to perform even basic tasks, the nurses must devise creative strategies to overcome the unavailability of material and human resources. In addition, to obtain a ‘living wage’, they must supplement their pay through a variety of income-generating activities. Some set up business enterprises, others take on additional work in the private health-care sector or in business, and many engage in a range of informal activities, such as demanding fees from patients(3) or supplying their own private drug shops with medicines taken from government facilities (Asiimwe et al. 1997: 142). At the same time, nurses’ relatives have high expectations about the medical capabilities, financial means and social influence of the nurse in their family, obliging her to treat, provide for and find jobs for less fortunate family members.
Representations of nurses and nursing practice relate to these problems in two ways. First, a highly critical public discourse about malpractice in the health-care system is common among users, in the media and in politico-administrative circles. There is an outcry from the public about the poor services they receive in government health facilities, and in local communities health workers are held personally responsible for the malfunctioning of the health-care system. Although health workers are often grouped together in this respect, the number and visibility of nurses make them particularly vulnerable to this criticism, and accounts of their corruption, negligence and rudeness abound, first-hand, second-hand or without identifiable origins. There are shocking stories about the extortion of large sums of money from destitute patients, children who died because they were not given drugs in time, moribund patients scolded for disobedience and so on. Such stories, and many less dramatic ones, are an integral part of the general discourse about the failure of government health care, and, sadly, can be heard all over the country in different versions.
Secondly, and in contrast, a historically founded discourse celebrating the particular moral character of nurses provides an ideological pivot for the nursing profession, not only in Uganda but worldwide. This discourse defines and highlights the ‘true nature’ of nursing and nurses, and is communicated and shared among nurses in both education and service. Students and qualified(4) nurses alike come to understand the profession and their work and roles through such discursive representations (cf. Gupta and Sharma 2006: 18). Like users, they engage with these representations to make sense of practices and clinical encounters, to validate choices of action and evaluate successes and failures, and to carve out positions from which one may criticize or support nursing practice.
Many nurses talk about being ‘demoralised’ and working without commitment because they feel that their efforts are not appreciated and because they have to struggle to make ends meet both at work and at home. Thus, working in a faulty health-care system puts nurses under pressure in both professional and domestic domains. Despite this gloomy context nurses manage to maintain an enduring confidence in the professional ideals of the nurse’s role, ideals which refer to both nursing practice and the nurse as a person. It is with this puzzling contradiction in mind that this book explores nursing education and service, focussing on the interface between the person and the nursing profession in Uganda today.
Person and profession
This is a study of Ugandan nurses and their perceptions of who they are, what they do and why. It is based on ten months of ethnographic fieldwork from 2002 to 2003 in Jinja and Tororo Districts.(5)
Being a nurse in Uganda today is difficult and demanding. She must perform in a highly resource-deficient setting and is exposed to severe public criticism. She must come to terms with the contradictions between professional ideals and everyday practice. Throughout the book everyday practice refers to the performance of nursing work, reflected in concrete, observable activities and professional encounters between the nurses and other actors in professional and domestic domains. The professional ideals concern both these activities and the characteristics of the nurse as a person.
The contradictions between professional ideals and everyday practice, which to an extent are a condition of all professional work, are further complicated by the values of kinship and education that inform the local, social context in which the Ugandan nurses are situated. In the coming chapters I will argue that this complex of conditions sets the stage for the formation of nurses during their education and will describe how qualified nurses employed in the government health service seek to act in a way that maintains professional ideals and legitimises everyday practice, while striving to fulfil the responsibilities and aspirations related to professional and domestic domains.
The analysis foregrounds the emic perspective of the nurses and will reflect the situations and relations in which they consider their profession to have a particular impact on their lives – during their education, in their relationships with members of their families, or in the struggle to provide nursing care under very constrained circumstances. In order to ensure the broader relevance of this grounded, intimate perspective, I will relate their perspective to the wider historical, systemic and discursive context of the nursing profession and health care in Uganda.
An analysis of this kind demands a theoretical approach which is more holistic than those most studies of the professions have traditionally employed.
I will present an anthropological approach to the study of professions and professionals that explicitly acknowledges the localized nature of institutions and actors.
 
Professions: sociological approaches
The study of professions is found mainly within sociology, and I will briefly outline some central questions that have marked debates in this field since they have important implications for an analysis of nursing and the interface between person and profession.
 
A taxonomy of the professions
Conceptual battles have been waged over how to theorize the nature of professions, and to this day there is little academic consensus about a viable definition (Freidson 1994: 14-15; 2001: 12-13; cf. Siegrist 1990). The most significant approach was the ‘taxonomic approach’ (or attribution theory), which flourished until the late 1960s and argued for the identification of a number of essential traits that occupations must have to qualify as professions, and through which they may be empirically distinguished from other occupations and assessed by degrees of professionalism (Macdonald 1995: 3). Suggestions as to the specific traits (and hence the occupations that may be labelled professions) varied, but usually included an independent knowledge base made available to students in institutions of higher learning, a monopoly of and autonomy in practice, high ethical standards, a service orientation and an ideology of altruism (cf. Saks 1995). This approach implied an emphasis on the positive functions of the professions in society as the stable elements which ‘inherit, preserve and hand on a tradition’ and as ‘centres of resistance to crude forces which threaten steady and peaceful evolution’ (Carr-Saunders and Wilson 1964: 497). Classic examples of professions are medicine, the law and the clergy.
In the 1970s academic interest turned away from this functionalist approach, which in addition regarded professions as essential for the coherence of society and proposed a rigid model of them that conveyed very little about how occupations falling under this label actually work and organise themselves (Abbott and Wallace 1990). Alternative approaches turned towards a more critical examination of the professions as political agencies, the relationship between the professions and political and economic elites, the maintenance of professional monopolies at the expense of alternative forms of knowledge and practice, and the relationship between autonomy and privilege on the one hand and ideological claims to altruism on the other (Freidson 1986: 29).(6)
An interactionist approach focused on the actions and interactions of professionals and groups of professionals in order to understand the construction of the professions themselves, and it also pointed out the ideological quality of professional traits such as altruism and high ethical standards (MacDonald 1995: 4). While the shift away from functionalism implied an increased focus on the professional as a social actor, most studies undertaken in this tradition nevertheless had the overall purpose of describing the role and nature of the professions in modern society, not of understanding the situation and activities of professionals as such.
Even though the taxonomic approach came under serious criticism in the early 1970s and the foci of research into the professions have changed, the approach has proved difficult to escape from and has continued to inform studies of the professions in sociology and other disciplines in more or less concealed forms. For example, the debates and analysis of the ‘semi-professions’, including nursing, and their struggle to achieve full professional status imply a particular vision of the characteristics of this status.(7)
The effort to isolate the specific traits that set the professions apart from other occupations was also an effort to develop a generic and unified concept that would remain stable over time and place and hence make comparative studies possible (Freidson 1986: 28). While this explicit ambition was largely left behind in the sociology of the professions decades ago (see, e.g., Freidson 2001), it has nonetheless been reproduced in studies or popular accounts that compare professional practice in different countries. In the case of nursing, such comparisons have brought out conflicting definitions of nursing and of the cultural values relating to care, thus implying predefined (and often normative) notions regarding the nature of professional practice in general and nursing in particular along the lines of ‘Western’ and ‘non-Western’ (see, for instance, Schuster 1981; Sciortino 1996).
 
Nursing as a profession
In academic writings about nursing in the social sciences and in nursing itself, the discussion about whether it qualifies as a profession is a recurring theme. The debate over the professional status of nursing reached its height in the 1960s, but it continues to be an object of controversy (Abbott and Meerabeau 1998). It has, of course, been complicated by the lack of agreement over how to define a profession and how to distinguish it from other occupations. If we consider the basic characteristics proposed by the taxonomic approach – an independent knowledge base, monopoly over education, professional autonomy, altruism etc. – nursing fails in two respects: it has no independent knowledge base, but is grounded in medical knowledge; and nurses do not have full autonomy over the content of their professional practice, but are subject to more administrative control than their colleagues in medicine. On the other hand, the nursing community partially organises and regulates nursing education, supervises the service and lays claims to altruism. In this tradition, therefore, nursing was labelled a ‘semi-profession’ (Abbott and Wallace 1990: 7-8).(8)
It is not my intention to discuss or determine what a profession formally is and whether nursing fits into one or other analytical category. Nonetheless it is relevant to draw attention to the professional status of nursing because the theoretical debate over the definition of the term ‘profession’ has had quite an impact on the way nursing has developed over the last forty years, not only in Uganda but also around the world. Although the taxonomic approach has been largely discarded in academic discourse, it continues to inform reflections and discussions within nursing itself about what is required to achieve professional status. In this way it has contributed to the development within nursing of an increasing academism, further fuelled by technological advances in medicine. One strategy in this quest to establish a knowledge base and a range of competences independent of medicine has been to launch nursing education at university level. This trend has resulted in greater specialisation, rigorous admission criteria and an emphasis on examination results and advanced administrative competences rather than practical experience and expertise.
Despite academic disagreements over the term profession, I have chosen to refer to nursing as a profession throughout this book. Freidson (1994: 20-21) argues that, instead of focussing on characteristics, we must approach the concept of professions from a more phenomenological perspective and ask how people in different positions define and make use of the concept of a profession and how its meanings affect their work practices and self-perceptions. Ugandan nurses refer to themselves as professionals, and ‘the profession’ provides an important framework for perceptions of their role in health care and the construction of professional identities. Thus, my retaining the term ‘nursing profession’(9) here is part of my effort to present the perspectives of the nurses in the analysis, rather than imposing a designation based on a strictly theoretical argument.
 
The institutional anchoring
The implicit marriage between professions and institutions constitutes another important premise in studies of the former. Professional work in the field of health care, for instance, is formally enacted in medical institutions – the facilities offering medical services to the public. These institutions are organised according to bureaucratic principles, which prescribe accountable and impartial service and a hierarchy of functions and authority. At the same time, the management and monitoring of medical practice in these facilities are entrusted to members of the profession, thus permitting the professional autonomy mentioned above (Freidson 2001: 105).
The majority of studies on the professions are strictly concerned with the profession as an institutionally bounded phenomenon (the writings, except the most recent ones, of Eliot Freidson, who has been a driving force in this field for decades, are a good example). It is as entities anchored in the institutional setting that the professions play their role in the organisation and development of society.(10) Less sweeping analyses of specific procedures, ways of communicating, professional hierarchies, relations etc. have also explored their topics strictly within the institutional setting. This approach has produced insightful and informative results about the way professional interactions and practices unfold within institutional walls.
While functionalist and critical ‘macro-level’ studies have situated the profession within the larger societal landscape, the institutional anchoring of the professions has severed the bonds between the professionals and their lifeworlds. The socio-cultural, economic and political circumstances in which they are embedded are considered external to their professional roles. This is the echo of a Weberian ideal-type bureaucracy that promoted the complete separation of public functions and private lives and perceived bureaucratic practice as the performance of impartial and authorless procedures. Even studies concerned specifically with professional socialisation and accompanying transformations of identity have had little to say about the way such processes interact with personal biographies and non-professional relations (Olesen and Whittaker 1968; Bucher and Stelling 1977; Melia 1987; Good 1995).
We may discern here three premises that have guided the study of the professions: 1) professions are comprised of universally comparable units; 2) professions are conflated with the institutions in which professional practice is authorised, and these institutions and professions may be analysed as isolated from the society around them; 3) the professional is an institutional figure rather than a whole person.
This sociological approach, which has set the agenda for studies of the professions, has also influenced studies of nursing and medicine in other disciplines. While the growth of medical anthropology as a research field in the 1970s introduced the notion of culture into studies of health and illness and included the life-worlds of patients as significant for understanding health systems and practices (cf. Janzen 1978; Kleinman 1980; Baer et al. 1997: 28), this insight has rarely been applied to health providers working in the field of biomedicine. Ethnographic studies of nurses have been undertaken mostly in a Western context, and the analyses have focused exclusively on the professional learning, practice and relations found within medical institutions (see, for instance, Wolf 1988; Samuelsen 1991; Littlewood 1991; Hansen 1997). Historical accounts concerned with the establishment or role of the medical professions present interesting and comprehensive accounts of the professions as embedded in societal change (Marks 1994; Iliffe 1998; Hunt 1999; Takahashi 2004), but lack the intimacy of detailed ethnographic writing. The few ethnographic studies on health care professionals in the South have often employed the institutional point of departure, but have also acknowledged the significance for health workers of the interaction between the professional and institutional spheres and the sociocultural, economic and political spheres of life (Holden 1991; Sciortino 1995; Andersen 2004; Zaman 2005).
 
An anthropological approach
 
Professions as culturally embedded
The taxonomic approach and the overall exclusion of non-institutional and non-professional factors in the sociological approach to the study of the professions may well have promoted the assumption that the elements comprising a profession are universal and essentially similar. But from an anthropological perspective concerned with a contextual understanding of the object of research, we cannot take universalism for granted, not even when focusing on a single profession like nursing. Certainly there are structural similarities, some of which have already been mentioned – the institutional settings of hospitals and clinics, the theoretical knowledge, the specific skills and tasks involved, the position of nursing in the medical hierarchy etc. These similarities constitute the backbone in the nursing profession as a global phenomenon. Yet, from the initial description, the reader may already have guessed that nursing in Uganda is in many respects very different from nursing in Denmark or the uk, for instance.
If we want to understand the Ugandan nursing profession, we must give up the inherent bias that we may read in the fundamental premises that have informed both popular perceptions and studies of the professions and institutions, and which assume an essential similarity between similarly classified phenomena. As Gupta and Sharma point out in relation to the state, the anthropological perspective questions ‘the assumption that cultural difference is epiphenomenal to the functional and structural characteristics of states’ (2006: 10). Gupta and Sharma argue that states are culturally embedded and discursively constructed, and that they come into being through everyday institutional practices and different public representations of the state. We must not, they say, assume that a structural similarity between state institutions in different cultural settings reflects a more pervasive similarity in terms of the local meanings attached to these institutions.
This argument applies well to the professions from both an academic and a structural perspective: they have been studied as largely separate from social and cultural contexts because of the universalism implied in the taxonomic approaches, and they are closely connected to the state. The very existence of the profession hinges on state authorisation, the state funds and regulates professional education and service through policy and administrative bodies, professional practice is moored in state institutions, and employment is regulated by laws and guidelines relating to the public service. Thus, we must not look at the nursing profession simply as a universal phenomenon based on structural similarities, but also as a cultural phenomenon that takes on different meanings in different contexts. Also, we must shift the focus from the failures of health-care provision as evidence of deviance from an objective universal standard towards the local ways of understanding and dealing with those failures and the particular ways in which the global, structural characteristics of the profession articulate local practices and perceptions.
 
Professional and domestic domains
The distinction between institution and society that has informed the study of professions makes perfect sense as a physical and structural divide. Institutions do have walls and rules and objectives and ways of functioning that set them apart from other localities in society. As an analytical distinction, however, referring to separate, even isolated, spheres of action and being, it is too rigid for the purposes of the present analysis. The local context of nursing calls for a different perspective. In an article on bureaucratic practice in India, Akhil Gupta has argued that the distinction between state and non-state domains becomes blurred in everyday practice and that it is ‘descriptively inadequate to the lived realities that they purport to represent’ (1995: 384). Similarly with the nursing profession,(11) we may think of the boundaries between the profession and the surrounding society as blurred, and the domains these boundaries are considered to separate as mutually constitutive. We may do so at both the macro level, concerning the interaction between the profession and the surrounding society, and at the micro level, which focuses on the actors who embody and enact professional and cultural ideals and practices.
Therefore, I will argue that we need to uncouple the nursing profession from its analytical fit with the health facility in order to draw attention to the empirical confluence of professional and domestic domains that is so common in Uganda. I am not arguing that there are no boundaries between institutional and non-institutional settings, rather I am promoting an alternative way of conceptualising the relations between the nursing profession and the society in which it is embedded, which releases professional practice and identity from their institutional isolation.
Throughout the book, I will focus mainly on the micro level and distinguish between the professional and domesticdomains (12), while bearing in mind that the two domains overlap in multiple ways. Long (2001: 59) uses the concept of a domain to ‘identify areas of social life that are organised by reference to a central core or cluster of values which, even if they are not perceived in exactly the same way by all those involved, are nevertheless recognised as a locus of certain rules, norms and values implying a degree of social commitment’. Long’s definition describes very precisely the conceptual status of domains. In this case, however, it is important to realize that the domain may refer not only to norms and values but also to more manifest features. Hence, in this work the professional domain concerns both the training and the practice of nurses – what nurses learn, do, say and think in the name of nursing. It comprises the particular professional ideals, relations and activities related to nursing, certain types of knowledge and skills, and may include different institutions (such as schools and health facilities), types of facility (hospitals, health centres, clinics etc.), and formal positions (matron, staff nurse, student and various officials) within the profession. The domestic domain refers to values, relations and activities involving the family, the home and livelihood. It comprises a variety of social roles that a person may be assigned (such as mother, wife, daughter, businesswoman, farmer etc.) and concerns issues like financial status, life-styles, the expectations of kin etc. ‘Domains’ do not correspond to any local term, but rely on the way nurses categorise practices, events, relations, and circumstances. Their distinctions reflect how the domains interact and overlap with one another. Indeed, the characteristics of each domain stand out particularly clearly when the domains impinge on each other or come into conflict (ibid.).
Of course, the problem with conceptualising such distinctions is that the domains must be capacious yet precise. They must designate without constricting and differentiate without disconnecting. Admittedly, those domains introduced here do not immediately cover issues such as politics and religion, which also play an important part in people’s lives in Uganda. They do, however, reflect the main concerns of the nurses in my study and, as we shall see in the coming chapters, illustrate the interface between person and profession that I am exploring. It is essential to conceptualise both domains on a par – rather than primary and secondary or foreground and background – if we want to understand the way professional ideals of practice and of person interact with working and living conditions to shape the difficult situation of nurses today. The distinction between the professional and domestic domains reflects both an anthropological preference for inductive analysis and grounded theory which grows out of the empirical data, and an anthropological concern with the relationships between people and the complex social contexts in which they are embedded, taking the activities and emic perceptions of everyday life as the main point of departure (Hastrup 2003: 9). The anthropological approach offers important insights into the local construction and meaning of professions and professionals that more conventional approaches have missed. It makes possible an analysis of the factors that at once unite and separate the professional and domestic domains, seen from the perspectives of tho
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