What nurses do by Lisa Kowalchuk

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This e-book is an important output of a research project funded by the Social Sciences and Humanities Research Council of Canada (SSHRC), through a grant attained in 2009. The larger project set out to examine how health-care policies in El Salvador and Nicaragua over the past 25 years have affected nurses’ well-being and their capacity to exercise nursing-specific knowledge and skills. A major aim was to compare nurses’ situation across the two countries, as well as between the major sectors of health-care provision within each country. Having conducted interviews and focus groups with dozens of nurses in El Salvador and Nicaragua during 2010 and 2011, I felt that the research project on nurses’ work conditions would not be complete without observing them at work in several different types of institutions and if possible throughout an entire shift. A great many nurses had told of the satisfaction they felt for making a difference in the life of another person, and had described the specific interventions and acts of understanding and compassion through which they did this. But pick up any print news story, or tune into any TV or radio news item on health-care themes, and you find that nurses’ knowledge and skills are rarely if ever consulted, nor their actions profiled. In other words there is a conspicuous silence about nurses in the news and entertainment media dealing with health-care. Arguably this reflects the general state of public understanding about the profession. A small exception in El Salvador and Nicaragua are the special inserts of the national newspapers devoted to National Nurses’ Day. 10

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Through conversations with other types of health-care professionals in El Salvador, I came to appreciate that nurses are not the only ones whose contributions to health remain largely unspoken and unseen. Perhaps this project could inspire similar efforts to generate awareness of the ways that workers in other health-care disciplines make a difference in the lives of patients. But one of the characteristics of nurses that makes their work distinctive is their roundthe-clock presence with patients. And, to quote one American nurse on this matter, “It’s not just that they’re there, it’s what they are doing when they are there” that merits greater recognition. The pages that follow are an effort to understand, document and relay, through narrative and visual information, what nurses’ responsibilities and skills consist of, and what difference they make to the health of Salvadoreans. In trying to make nurses’ contributions to health-care more visible to the general public in Central America, Canada, and elsewhere, my hope is to illuminate how they are affected by limitations of both physical and human resources in the public system, and also how they make due with these constraints. Faced with the need to limit the focus for this final phase of my study to only one of the two countries, I chose El Salvador.

1. Nancy Valentine, a nurse interviewed in Douglas, Kathy. 2012. Nurses: If Florence Could See us Now.

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UCSF SAN JACINTO

The Unidad Comunitaria de Salud Familiar (UCSF) San Jacinto The Unidad Comunitaria de Salud Familiar and El Salvador’s Health-Care Reform Our observation and photography of nurses began in the UCSF San Jacinto, in the San Jacinto district of San Salvador, the country’s capital city. UCSF stands for Community Clinic for Family Health (Unidad Comunitaria de Salud Familiar - UCSF). I will refer to these entities either by their acronym or by the English abbreviated term “Community Clinic”. We spent two consecutive weekday shifts observing and photographing nurses here. Outside of El Salvador, most readers will not be familiar with the “communal sector” of the public health system and how the UCSFs fit within it. Moreover, the role of this type of healthcare centre and how it fits within the MINSAL system have been substantially overhauled since 2009. So it is worth presenting some background information about this, extracted from Salvadorean government documents, my communications with the nurses in the Ministry who helped with the logistics of the project, the Pan American Health Organization (PAHO), and other sources. When the FMLN took office in 2009, nearly three decades of disruption and neglect in healthcare had taken a severe

toll on the quality and accessibility of care. Rebuilding health-care after a long and destructive civil war (1980 to 1992) was undermined by twenty years of neoliberal policy under the ARENA government (1989 to 2009). ARENA’s neoliberal orientation to social services, while stopping short of privatization of hospitals, manifested itself in various ways. Government spending in health-care declined to 3% of GDP by 2004, “one of the lowest rates of investment in health in the Americas”1. Public clinics kept sporadic and inconvenient hours of operation. Under MINSAL there were some Mobile Rural Teams that provided a set of basic services, but these did not cover the whole territory. Internationally funded NGO health programs targetted vulnerable populations but were not systematic, and

1.Murphy, Jill, 2006, “The impact of the Basic Integrated Health System (SIBASI) on participation in, access to, and quality of health-care among public health-care users in El Salvador.” Ottawa: International Development Research Centre, p. 21.

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were poorly integrated with the system. MINSAL institutions charged fees for a vast range of appointments, procedures and materials. The deterioration in services at the primary level, along with these ironically named “voluntary” fees, explain why approximately 40% of the population sought no form of care when they were ill or injured. Rural people who did seek state-funded services tended all too often to bypass the primary care facilities, turning to second level hospitals; these, in turn, had to transfer to many people to the third level hospitals2. One result was a backlog of about 10,000 surgeries by 2009. Inventories of needed medications were severely depleted; “many institutions [were] putting in emergency requests to the MINSAL for extra resources, having run out of medications and supplies before the end of the fiscal year”3. The objectives and mechanisms of the FMLN government’s health-care reforms are described in 2009 in a document authored by the Minister of Health Dr. Isabel Rodríguez, entitled Constructing Hope. Within an overarching plan of increased investment in health-care, a fundamental shift would be the revitalization of the primary level of care. One component of this is a new entity called the Community Health Team (Equipo Comunitario de Salud-ECOS). The ECOS are multi-disciplinary groups of healthcare personnel who act as “the entry gate to the health-care system” by going directly to the population in the barrios and cantons. As of June 2014 the government has created 520 ECOS, covering 63% of the country’s municipalities. Some of the ECOS are categorized as specialized (ECOS-E) based on the range of types of services they can provide and the diversity of professionals they have on staff. There are 38 of these specialized ECOS, or “ECOS-E”. Each ECOS is attached to, and managed by, a UCSF, and most UCSFs have several ECOS under their administration. Whereas the UCSFs are clinics in fixed locations where people seek primary care either by prior appointment or

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on an walk-in basis, each ECOS is a group of people who do a major part of the work of the UCSF out in the population. The ECOS maintain a physical location close to the population they attend, where they receive and attend patients. But these facilities are much smaller than the UCSFs and with a much more limited range of services and hours of operation. I will have more to say about the ECOS in chapter three. Another focus of primary care restructuring were the UCSFs. One transformation was an increase in the sheer number of these Community Clinics, from 377 before 2009 to 708 by mid-2014. Some of the new UCSFs were completely new constructions, while others were created out of the rehabilitation of existing “health houses”. This increase in the number of primary health-care entities – UCSFs and ECOS – has required a substantial number of new personnel, including nurses and auxiliares.4 Not only were the UCSFs more numerous but they were also recategorized as either basic, intermediate, or specialized according to the complexity of their functions. As of June 2014 there were 376 basic, 295 intermediate, and 38 specialized UCSFs. One of the FMLN administration’s main objectives for health-care was to bring greater coherence and integration to a public system that had grown increasingly fragmented over the previous 20 years. Toward this objective, it established geographically defined entities called “Integrated and Holistic Networks of Health Services” (Red Integral e Integradas de Servicios de Salud – RIISS), within which there would be an adequate number of health-care facilities of the various types, according to the size and characteristics of the population. These facilities would coordinate with each other to increase and rationalize people’s access to appropriate levels of care. This in turn would decongest the large hospitals and improve the health of the population through a greater investment in prevention, education, and early diagnosis. It is also important to mention that the abolition of

the so-called voluntary fees, an action the government took within the first 100 days of taking office, led to a 40% increase in patient demand in MINSAL facilities in some regions.5 There are 16 departmental networks or RIISS (one in each of the 14 departments and two additional), five regional RIISS, and 71 micro-RIISS at the municipal and intermunicipal level. The UCSF San Jacinto is one of two UCSFs that belong to the micro-RIISS San Jacinto; the other is a basic UCSF named after Los Planes de Rendero where it is located. One of the ECOS that is attached to the UCSF Los Planes became part of our focus in the study. Thus, observing the UCSF San Jacinto along with the ECOS de Quezalapa (which is the name of a cantón in Los Planes) enabled us to see two distinct aspects of primary care in one micro-network. Because San Jacinto is a specialized or “complex” UCSF, it oversees a specialized ECOS. Sixteen of the specialized UCSFs in El Salvador, including the UCSF San Jacinto, attend patients on weekends and holidays, and also provide 24-hour service through the Social Solidary Health Fund (Fondo Solidario para la Salud -- FOSALUD). FOSALUD was created in 2004 by the previous government to extend the hours of operation in a number of public sector clinics so that they offer services seven days a week, 24 hours a day. These expanded services are funded by taxes on activities considered harmful to health, principally smoking and alcohol consumption.6

2. Within the MINSAL system, the primary level consists of the UCSFs and a set of care-providing entities that fall under UCSF administration: the ECOS, rural Health Houses, Nutrition Centres, Maternity Homes, and Health Dispenaries. At the secondary level are the general hospitals found in each of the country’s 14 departments. The third level consists of the specialty hospitals, both regional and national. 3. Murphy, 2006: p. 21. 4. The “auxiliar” job title corresponds roughly with Licensed Practical Nurse (LPN) in most of Canada and the U.S., and with Registered Practical Nurse (RPN) in Ontario. 5. Koenig, Sybille and Liliana Marcos. 2011. EU Health ODA and Aid Effectiveness. Country Briefing 3. Health Spending in El Salvador: The Impact of Current Aid Structures and Aid Effectiveness. Action for Global Health Network, and German Foundation for World Population, p. 25. 6. Under the FMLN government the number of FOSALUD clinics increased to 161, covering all 14 departments. FOSALUD services have also been restructured to place greater emphasis on primary, preventive care. In 2012, the FMLN government incorporated FOSALUD into the MINSAL system. For more information about FOSALUD, see http://www.fosalud.gob. sv/index.php?option=com_ content&view=article&id=227&Itemid=260

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Our arrival at the UCSF San Jacinto We arranged ahead of our arrival to meet with Donald Ramos, one of the nurses at UCSF San Jacinto who had already volunteered to participate in the study. His shift started at 6:30 am. He brought us around with him while he inspected equipment and inventory in several of the Community Clinic’s consultation areas, together with the exiting night nurse. During the next few hours of his shift, Donald introduced us to his other colleagues who were on duty that day, and was our “go to” person for orientation to the nurses’ roles in the Community Clinic. In addition to Donald, the other nurses who agreed to be observed in their work were Cecilia Ramírez, Jose Ardón Rivera, Sandra Barraza, Julissa Zelaya, and Nora Marirene Najera.7 Over the course of the two days we were there, Donald shared an enormous amount of information about how the UCSF San Jacinto works and the services it offers. These include General Medicine, Pediatrics, Infant Care, Maternal Care, Respiratory Therapy, Family Planning, TB and HIV Counselling, Nutrition, Psychology, Vaccinations, Small Surgery, Wound Care, and Emergency Care. During the two days (approximately 16 hours) of our visit to the Community Clinic we observed six of these areas, and took photos in four of them. All of the six areas are ones in which nurses were working on their own (though in one case with a student), so we did not observe their interaction with other health-care professionals. The Community Clinic also has a pharmacy, a large archives department, and even a space

7. All of the nurses we observed and photographed signed informed consent forms. Patients gave verbal informed consent on the understanding that we would conceal their faces; our focus, we made clear, was the nurse’s actions as s/ he interacted with the patients.

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on the second floor where aerobic exercise classes are offered to both patients and staff. â&#x20AC;&#x192;The nurses at the UCSF San Jacinto have staggered start times, entering at 6:30, 11:00am, and 4:00 pm. These nurses work eight-hour shifts. Since this is a 24-hour Community Clinic, there are also nurses who work from 7:00 pm to 7:00 am. During the 6:30 to 3:30 period there are normally six nurses on duty in the Clinic. From 3:30 to 7:00 pm this contingent reduces to three, two of whom staff the Consulta Externa which is the patient intake area (described below) while

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one covers the specific services that the Community Clinic provides. After 7:00 pm there is just one nurse in Consulta Externa and one for the rest of the Clinic. During the days we were there, the staff were bolstered by four nursing students in the final â&#x20AC;&#x153;social serviceâ&#x20AC;? stage of their schooling, who were being trained in Consulta Externa and other areas. Under MINSAL regulations, nursing staff members in the communal sector are entitled to a 45-minute break during their shift. This UCSF allows an additional ten minutes but when patient demand is very

high and/or they are short-staffed, they do not always get to take this additional rest. It took me a couple of hours to realize that some of the personnel in the Community Clinic were wearing neither the all-white uniform of the auxiliares nor the dark blue of the nurses but rather, were dressed in skyblue, light-weight cotton. These were highschool students in the health-care studies stream who were doing their practicums. We would later see one of these youth at work in one of the areas of the Clinic, and we would see them in other MINSAL institutions. This

was a glimpse of a fascinating difference between the Canadian and Salvadorean education and health-care systems. Regarding the functions of auxiliares and the nurses in the UCSFs, there is both overlap and difference. Whereas the work of auxiliares consists of direct interaction with patients, including of course recording their data and charting their own interventions, the nurses’ work involves both direct care and administrative functions. During each shift one nurse is always designated to be in charge of the nursing staff.

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CONTROLES INFANTILES Cecilia Ramírez was the nurse assigned to Controles Infantiles, which translates to something like Infant and Child Check-up, on our first day at UCSF San Jacinto. After Donald introduced us, she explained that this is a unit staffed by nurses, and that they attend children ranging from newborn to nine years of age. They check their nutrition, vaccinations, their physical and psychomotor development. Most of the children seen here are “subsecuentes” which means they have already had their first visit with a doctor. The nurse here attends between eight to 20 babies and children (and of course their parent or guardian) during an average shift. Jim and I returned to this unit shortly after 11:00 am that day, partly because Donald informed us that Cecilia was about to do a thyroid screening. This routine procedure to test newborns for hyperthyroidism had been in use in El Salvador for three years, Cecilia explained. Introduced through a foreignfunded development project, it has now has been generalized through MINSAL services. The mother of the 11-day old infant was a young woman of about 20. Cecilia explained to her what the test was for, and that the baby would feel a little pinch on his wrist. She also obtained basic data from the mother, and counselled her about basic newborn care. Among other things, she told her that for his first six months the baby should only be breast-fed, with no store-bought nutritional supplements. She also advised her to remain well hydrated and to keep a balanced diet. While the young woman signed the consent form for the test, Cecilia explained to us that the baby must be kept warm for as long as possible before the test so that it will not require too many tries. The infant fulfilled Cecilia’s warning that he would cry, but she only needed four or five drops of blood. In one minute the exam was finished.

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Cecilia’s next patient was a two-month old baby boy brought by his mother for a routine check-up. When the baby was undressed she measured his weight and length, and listened to his chest with a stethoscope. As the young woman dressed her baby, Cecilia counselled her, as she had with the previous patient, regarding the importance of mother’s milk. Using a chart and a calculator, Cecilia compared the baby’s current weight with the average for that age. She then used a tape to measure his head

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circumference. Next she asked the mother about the baby’s responsiveness to voices and to objects, and instructed her how to do a simple auditory test. “It is important for you to sing and talk to the baby, and also to touch him often, because this transmits security,” she told her. The baby was due for his first oral vitamin-A supplement which Cecilia gave him. Finally, she told the young mother to return for a subsequent checkup in two months, and the appointment was finished.

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planificación familiar Early in our first day at the UCSF San Jacinto, Donald also brought us to Planificación Familiar — Family Planning — to introduce us to Sandra Barraza, the nurse assigned here for this shift. She described the main duties of the nurse in this unit: prenatal and post-natal care of mothers, conducting pap smear tests, counselling on contraception and related matters, prescribing contraceptives, and in many cases injecting those as well. According to Sandra this unit typically attends 24 to 28 patients per day. The five patients whom Sandra attended over the next hour or so were all women around the age of 20. Four of them had come for contraceptive prescriptions, and one had come additionally for a pap smear. For that patient, Jim and I exited the consultation room until she completed her appointment. Sandra greeted each patient, introduced herself, and asked her to step on a scale. After recording her weight, she invited the patient to be seated for some questions about the birth control regimen she was following. After measuring the patient’s blood pressure, Sandra described the different contraceptive drugs that she could choose from – how they are taken, the duration of their effectiveness, etc. One form of injectable contraception is effective for one month, and the other for three months;

they have differing effects on lactation and on the occurrence of menstruation. The nurse also ascertained the date of the patient’s last pap smear, whether she had had any miscarriages, etc. She took notes continuously during these interviews. For a patient who had recently had a pap smear, Sandra sent her to another area of the Community Clinic where a doctor would review the results. If the patient chose an injectable form of birth control, which several of them did, Sandra sent her to the on-site pharmacy to pick up the drug. When the patient returned she ushered her to the examination table. For the patients who chose the abdominal subcutaneous injection as opposed to the intramuscular form, we were able to observe and photograph this procedure with the patient’s permission8. In between patients, Sandra explained to us that this drug, medroxyprogesterone acetate, was a fairly new product and had only been available in El Salvador for about a month. It is packaged ready to use, with the syringe filled so that there was no need to draw it from a separate vial. She also told us when a patient is initially prescribed an oral contraceptive it is only for a month. If she is tolerating it well, the nurse writes her a six-month prescription.

8. On the second day of observations in the Family Planning unit, we exited the room when we realized the patient had chosen the intra-muscular injection, since this is administered in the hip.

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curaciones Our second shift at the UCSF began at Curaciones, or Wounds. Nurse Julissa Zelaya explained to us that the changing of basic wound dressings, an activity performed by nurses and/or auxiliares, takes place here in the mornings. More complex procedures such as the application or removal of stitches are done in the afternoon by doctors, with a nurse assisting. The logic of this sequencing of activities is to reduce infection risk by proceeding from the least to the most contaminating. When we arrived at the Curaciones unit at 7:40 am, Julissa was assisted by a high school student named Wendy Fernández in preparing the room for the morning round of patients. Julissa explained that, since Curaciones provides services during the night shift, the nurses who come in the morning must do a basic cleaning before they begin receiving patients. While they cleaned, working quickly but calmly, I explained my study. Before 8:30 they were ready to receive patients. They gave Jim and me face masks and hair nets, and of course put their own on as well. The mask became hot surprisingly quickly, which made me wonder how the nurses in a unit like this one, in an establishment which lacked air-conditioning, become accustomed to wearing it for hours at a time. Julissa’s first patient that morning was a woman who appeared to be in her late 60s, with an evident arm wound. Since this patient declined us permission to observe and photograph, we stepped out into the patient waiting area. With the next three patients we had better luck. The first of these was a man of about 60 with an abdominal wound. Wendy’s role was to hand Julissa the various instruments that had been carefully prepared beforehand. After Julissa cleaned and changed the dressing, the patient handed her a bottle of a substance he had brought in a brown paper bag, that he referred to as miel (syrup), for her to

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apply to the wound. Julissa’s next patient was a young man of about 20. Earlier in the hallway, he had smiled at us with what seemed a combination of bashfulness and curiosity, as though he wanted to chat with us. Perhaps he guessed, based on Jim’s camera, that we might be asking to photograph him. This young man’s wound was a rather cavernous gash on the side of his left shin. When Julissa removed the doressing, he leaned in to have a closer look at it. He could not mask a wince at several moments when she cleaned it, applied ointment, and rebandaged it.

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The third and final treatment we observed in Curaciones was of a man in his mid-50s who had cut his finger. Judging by how much the cleaning evidently stung, this must have been a fairly deep cut. Julissa asked how he had injured it, and he explained it had happened at work. He continued to evince pain after it was re-wrapped. Julissa instructed this patient to see the doctor that day in the UCSF for a tetanus shot. He responded that he had a fear of injections and preferred to put his faith in God. However, he was still at the Community Clinic a couple of hours later. Presumably this meant he had followed the nurse’s advice and had waited to see the doctor. In the course of the morning, we learned, Julissa treated 30 patients. Julissa made time for me to interview her later in the day regarding her professional trajectory. She had been working as a nurse for 14 years, all of that time in the UCSF San Jacinto. She graduated in the mid-1990s from the National Nursing School 9, and eventually decided to go for her degree. Studying part-time while working full-time, she obtained the B.Sc. in 2012. She was now doing a Master’s degree in teaching. She saw the teaching degree as extremely useful given that nursing in the public sector involves not just practise but also a great deal of instruction. Julissa had been hired into the position of auxiliar, and did not anticipate any sort of promotion based on her new educational credentials. This is a very common situation

in El Salvador: attaining a degree is no automatic pathway to the higher-paying job title of “enfermera”. I have spoken with many Salvadorean nurses who continue their education for the intrinsic reward of expanding their knowledge and abilities, much more than for instrumental expectations and pursuits. Until recently, it was very common for nurses with degrees to be hired as auxiliares, and paid as auxiliares, but still expected to perform all the functions of a degree nurse. The FMLN government recently put a stop to this practise. But this will not mean that nurses in auxiliar positions are promoted to the professional position. During our conversation, Julissa also told us of an incident that had happened just a few hours after we had been in Curaciones with her. While she was in the midst of a wound dressing, an apparently inebriated man barged through the closed door demanding to be attended. She called one of the security guards to the room, and asked him to remain present while she conducted the wound dressing on the intruder. I was struck by the vulnerability of the nurses and their patients in this situation, and I wondered whether such incidents are endemic to busy metropolitan hospitals and specialized clinics everywhere in the world, or whether they are more common in countries where public security is generally more imperiled. It is a question to which I do not know the answer, since I have not done comparative observation with, for example, North American public hospitals.

9. The state-run National Nursing School, which started training nurses in the 1950s, was closed down in the mid-1990s. Julissa was probably in one of the last graduating cohorts.

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Consejería TB-VIH Among the colleagues to whom Donald introduced us during our first morning in the UCSF was José Ardón Rivera, an auxiliar who was assigned to the unit called Consejería TB-VIH, or TB-HIV Counselling. We noticed that on the door of the consulting room was a poster promoting respect for gender diversity. This Health Ministry publicity material suggested that under the present government, members of the LGBTQ community can feel at ease seeking sexual and reproductive care in the public system. Nurses like Ardón are at the front lines of this transformation in the ethos and culture of the health system toward one of equality and respect. Although, unfortunately, we did not have an opportunity to request patients’ permission for observation and photography in this unit, Ardón took the time to describe the nurses’ functions and duties to us. Part of what he does in this unit is to provide HIV counselling to patients before and after HIV testing. The recipients of this counselling include pregnant women, adolescents, seniors, homosexuals, men who have sex with men, transgendered people, and people who are having intimate relations with prisoners. For HIV counselling, he always begins by asking the patient how much they know about HIV – what the acronym stands for and how it is transmitted. He reviews high-risk conduct, the role of condoms, questions about fidelity within couples (pointing out, for example, it is of little use to a woman to be faithful if her partner is not). He also talks about the risk of transmission from mother to fetus, and mother to infant through breast-feeding. As the name of the unit indicates, it also attends patients with respiratory symptoms of TB and their intimate partners. Part of Ardón’s responsibilities in attending those with TB is to administer Shortened Strictly Supervised Treatment (SSST). In this way of treating TB, the duration of the drug therapy

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is abbreviated, and healthcare personnel directly observe the patient taking their medicine. Both of these features of the treatment are aimed at increasing adherence. Over the course of an average shift, Ardón counsels about 30 patients. He spends a relatively long time with each one, and must also make thorough notes. TB was declared a re-emergent illness in Central America in 1983. Its eradication became a target of increased health-care investment by the FMLN government, and was incorporated into its health-care reform through greater efforts at prevention, early detection and more timely treatment. MINSAL recently began a remarkable program for tuberculosis diagnosis and treatment in prisons, funded by the Global Fund to Fight Aids, Tuberculosis, and Malaria. A mobile medical unit equipped for x-rays and laboratory exams goes to the institutions to attend to inmates pre-selected as suffering from possible symptoms. In each prison, volunteer inmates are trained by nurses and doctors to become health promoters specializing in TB detection. The program detected 227 cases of TB in the prisons by the end of its first year in 2012. El Salvador’s anti-TB program is an international role model, and has achieved the Millennium Development Goal (MDG) set by the United Nations of reducing the incidence by 50% relative to 1990, and has also reduced TBmortality by 50%10.

10. CONASIDA, 2013, “Hablemos de VIHDA – Tuberculosis en la Mira” http://www.youtube.com/watch?v=CoiBhGWGM3I

Inhaloterapia Late in the morning of our second day at the UCSF we paid a visit to the Inhaloterapia unit. Like the Wounds Unit and several others in the Community Clinic, Inhaloterapia services are available to the public 24 hours a day. Nurse Nora Najera explained that some of the patients who come at night are emergency cases, while for others, work schedules make a nocturnal appointment necessary. Apart from inhalotherapy, another common service that nurses in this unit provide is nebulization of patients who have pneumonia, bronchitis, or asthma. They also administer anti-rabies vaccinations and injections of other medications prescribed by a doctor. Nurses here also interview patients and record and tabulate patient data. During an average shift, Nora said, she attends 30 to 40 nebulizations and gives 15 to 20 injections. The patients range in age from five years to senior citizen. The first patients who arrived while we were here were a very restless toddler and her mother, who was having a difficult time getting the child to accept the nebulizer. This is a device that converts liquid medications (for example to control asthma) into a mist that can be inhaled11. Because all of the mother’s attention and energy was needed to keep the nebulizer face mask over the child’s nose and mouth, we did not approach her for permission to photograph. Eventually the child fell asleep in her mother’s arms. Next was a girl about eight years old and her mother, who brought with her an apparatus called a spacer, still in its package. Nora explained to us later that this apparatus is designed for very efficient delivery of the medication and allows patients to treat themselves at home. For patients who need to receive the medication frequently throughout the day, as with this young girl diagnosed with bronchitis, home treatment is not just convenient but is a crucial health matter. Nora showed the mother and daughter how to use the spacer, then

instructed them to return to the doctor for further consultation. A short while later, a young man in his early 20s came to the unit, also with a spacer he had evidently just obtained. Nora explained to him how and why the device is used, showed him how to use it, and answered his questions. Nora has been working at the UCSF San Jacinto for 11 years, and has been a nurse for 15 years. Her initial training was as a técnico12, and hence she was hired as an auxiliar. But like Julissa, she also returned to school and obtained her degree in nursing within the past year. Like Julissa and many others, she continues to work as an auxiliar.

11. http://kidshealth.org/parent/medical/ asthma/nebulizer_inhaler.html# 12. Prior to major educational reforms of the mid-1990s in El Salvador there were two educational titles that nurses could attain: enfermera graduada (the highest level one could attain in nursing) and auxiliar. In the mid-1990s, these were replaced by técnico and tecnólogo, the latter roughly equivalent of what used to be the enfermera graduada. The nursing degree or licenciatura, which corresponds with the B.Sc in Nursing in the U.S. and Canada, was first launched in 1985. So while there are three educational titles in nursing (técnico, tecnólogo, and licenciatura), there are two job titles: (i) “enfermera” which can only be held by someone with the tecnólogo diploma or the licenciatura, and (ii) “auxiliar”, which requires only the técnico diploma or the auxiliar diploma which is no longer granted.

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Nora explains how the spacer is used to administer a drug, in this case salbutamol

Consulta Externa The area we spent the greatest amount of time observing was Consulta Externa, the patient intake area, since this was where we usually returned in between observations of the direct care areas. We saw several main kinds of actions performed by nurses in this area. It is the first point of contact with the Community Clinic for people who come for an appointment (pre-scheduled or not) with a doctor, or who need to see a nurse. Located in a large room by the main entrance of the Clinic, it has seating for about 60 people. At many times during our two days we noticed that every seat was full and there were people standing, while at other times it was much less busy. Outside the entrance of the Clinic, which was under the watch of an armed security guard, there were always patients lined up 44

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waiting to be sorted and ushered into the interior waiting area. After his inspection of inventory for the shift hand-over, Donald was at Consulta Externa at 7:00 am. This is where he was assigned for the day. He began by summoning groups of waiting patients according to the doctors they had come to see. Groups of six to ten at a time lined up at the nurses’ station. Donald weighed each patient, measured their height, thobtained some basic verbal information, and asked them to return to their seats. These first patients were all adult women, most of whom looked to be in their mid-50s. We noticed later that for small children brought to Consulta Externa, nursing staff also take their temperature. At about 7:30 am Donald was joined at Consulta Externa by his colleague Sandra

Barraza. Her first task was to address those who had come for appointments with personnel of the specialized ECOS that was attached to the UCSF San Jacinto – doctors, nurses, nutritionists, physiotherapists, and other types of professionals. She took their basic data and prepared their paperwork for their appointments. Later that morning she would move to the Family Planning Unit, her main assignment for that day. I knew that education was a fundamental aspect of the nurses’ role in the primary health sector of MINSAL. But it was interesting and surprising to find that even in Consulta Externa, the nurses take advantage of

their captive audience to do impromptu presentations. At around noon of our first day, Donald stepped away from the nurses’ station and approached the seated members of the public to ask them how many of them knew about infant diarrhea. A few people nodded that they did. Using a pictogram chart, he spoke for about ten minutes about how to recognize four main signs that an infant needs medical attention for diarrhea, other than frequent defecation which is normal in babies who are breast-feeding. He also talked about prevention measures, with a special emphasis on hand-washing.

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We observed how Consulta Externa nurses received patients who arrived looking particularly unwell. In the mid-afternoon of our second day, while Cecilia Ramírez was weighing patients in the waiting area, a man entered the Community Clinic carrying a young girl of about ten years of age over his shoulder. Cecilia brought them immediately to Máxima Urgencia, the Emergency care unit of the Clinic. A minute later a teenage girl entered, partly leaning on and partly carried by a young man. Another nurse ushered these two to a small room beside the Archives department, and a few minutes later the girl was also taken in a wheelchair to Máxima Urgencia. Over the next half hour Cecilia made several trips back and forth between that unit and Consulta Externa. Of course, not all urgent health-care needs are visibly detectable to a lay person. From time to time, one nurse told us, they give brief educational chats in the waiting area about their occasional need to triage incoming patients. The objective of these chats is to sensitize the public to the fact that people who arrive with an urgent problem, even if it is not visible, may be seen by a doctor ahead of others who arrived earlier. This nurse explained that this can help people not to feel mistreated. It is important for the nurses to explain this in general terms because they are prohibited from revealing any patient’s information to another patient. Patients who arrive at the USCF needing emergency attention are sometimes referred by a doctor to a higher level facility. Shortly after 1:00 pm on our first day we had a glimpse of the nurses’ role in transferring patients. Donald whisked past us alongside a young pregnant woman being wheeled in a stretcher. In his hand was this patient’s IV bag. He entered the ambulance beside her and they were driven away. The patient, he later told us, had pre-eclampsia, and he had to accompany her to the hospital. Cecilia later explained that nurses in Consulta Externa often do this, especially if there is

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an intravenous drip to maintain in place. The patients at this UCSF ranged in age from a few days old to very elderly seniors, and seemed to represent a range of occupations. It is a safe guess that the patient population of the UCSFs is made up blargely of people from lower income backengrounds, perhaps informally employed or unemployed. Health-care provided at MINSAL institutions is free of charge, and people with formal sector jobs are entitled to use the clinics and hospitals of the Salvadorean Social Security Institute (ISSS). Meanwhile, most people with economic means turn to private care providers. Among the patients who receive care in the UCSFs and other MINSAL entities are those in police custody. Being already familiar with El Salvador’s problem with crime and youth gangs, I was only mildly surprised to see, on our second afternoon at the UCSF San Jacinto, two young men brought inside by police, shackled together at their hands and feet. Nurses told us that it was common to see five at a time being escorted in this manner13. We had already witnessed similar scenes in one of the large hospitals. Not only did we see handcuffed patients in the corridors, but also balaclava-masked police, rifles in hand, standing guard in recovery wards. We guessed they were there to prevent particular patients from being attacked by rival gang members. Nurses at the UCSF San Jacinto said they are accustomed to these sights, and to treating patients injured through physical violence. Nevertheless, they are ill at ease when police leave staff alone with the presumed gang members for their treatment or procedure. Some patients have been known to harass and threaten staff, pressing doctors, for example, to loan them their cell phone. Several nurses also consider criminal violence a hazard when their shifts end after dark.

Sandra Barraza records information on the care she provided to patients during a morning in the Family Planning unit. Charting is enormously important in nursesâ&#x20AC;&#x2122; duties

13. Members of El Salvadorâ&#x20AC;&#x2122;s incarcerated population have access to health care within the penal institutions, and therefore would generally not need to be brought to an Unidad or an ECOS for primary care.

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SUMMING UP With its renewed investment in health and its substantial reorganization of the national health-care system, the Salvadorean government is betting on a revitalized primary sector as a crucial means of ensuring continuous, accessible care for all Salvadoreans. By directing more human and material resources to this level, the FMLN government is shifting from an excessively curative model of care to one with more emphasis on prevention, education, and early diagnosis. The brevity of our presence at San Jacinto afforded only a small glimpse of what takes place at a complex-level UCSF, how it fits within the reorganized health-care network, and the nurses’ role in fulfilling the UCSF’s function. Nurses’ counselling and educative function is larger in the UCSFs than in the hospitals but they also need to know their science across a broad array of areas, since every two months they rotate through all of the services that the Community Clinic provides. They are called on to be compassionate and non-judgemental, and they certainly seemed to live up to that calling. It was impressive to see that they were all cheerful and pleasant with patients and with each other by the end of their shift. At around 3:00 during our second day at the Community Clinic, as I sat observing activities, an elderly woman making her way through the hallway with a walker approached me and struck up a conversation. I told her I was doing a study of nurses. She had been a nurse for a few years before having her first child, she said, and then quit because she did not like the long hours. A couple of hours later I encountered this woman again in Consulta Externa. She was coming from her appointment. “They give me good care here” she added, before moving off.

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hospital nacional salda単a

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Encountering a Century-Old Hospital The selection of each of the five locations for participant observation and photography of Salvadorean nurses reflected the assistance and collaboration of personnel at the Nurses’ Unit of the Ministry of Health. The specific Ministry hospitals and clinics we chose to focus on reflected criteria that we agreed were important. In the case of Hospital Nacional Dr. José Antonio Saldaña, (i) it was part of the Metropolitan Area of San Salvador and therefore minimized our travel time; (ii) its location in Los Planes de Rendero enabled us to observe two distinct types of clinical settings in the same micronetwork of the Health Ministry (the other one being a Community Health Team); (iii) being a second level institution, it enhanced the representativeness of the hospital focus of the study, since later on we would be looking at a first level hospital (see chapter X). The Ministry facilitated our authorization to observe and photograph here and in the other institutions that we would focus on for this phase of my research project. Hospital Nacional Saldaña has an intriguing history. Founded in 1909, it was built on the grounds of an 11.5 hectare coffee estate purchased by a governmental entity called the Sanitorio Nacional de Tuberculosis.

The funding of the buildings that would house the treatment wards came partly from private donations, and partly from a 1-colón tax raised on the sale of every bottle of aguardiente. The hospital has undergone several transformations in its chief purpose and the type of services it has offered. In 1972 it expanded from the treatment and isolation of TB-sufferers to treat a broader array of respiratory ailments, and was renamed Hospital de Neumología. In 1995 its services expanded again to encompass general medicine. The following year it was renamed to reflect this change and to honour a Salvadorean doctor renowned for his dedication to respiratory medicine; hence it now bears the name Hospital Nacional Dr. José Antonio Saldaña, Neumología y Medicina Familiar. According to the Ministry of Health, the hospital attends an average of 20,000 patients per month1.

1.http://hospitalneumologico.site90.net/ historia.htm

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Within Hospital Saldaña we had to choose a particular unit or ward as the focus for our observation and photography during one day shift (7:00 am to 5:00 pm) and one night shift (5:00 pm to 7:00 am). The Director of nursing for the whole hospital, Licenciada Marta Alicia de Elías2 helped us to decide on Internal Medicine as an appropriate unit for us to focus on. Lic. de Elías graciously connected us with Lic. de Silvestre, the unit’s head of nursing; Lic. de Silvestre in turn introduced us to the nurses whom we would approach to request their voluntary participation in the project. During the first afternoon of our visit to Internal Medicine, the Director of the Hospital, Dr. Roberto Castillo, took a few minutes to drop by the unit, where he warmly greeted us. The fact that our work was welcomed by these hospital authorities boosted my confidence and sense of ease in conducting this phase of my research. 54

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What is Internal Medicine? Also known as general medicine, internal medicine involves the treatment of “complex, multi-system diseases”3 in adults, such as high blood pressure, diabetes, dengue, organic brain syndrome, and some liver illnesses such as Hepatitis A. In Hospital Saldaña where there is no Intensive Care Unit (ICU), Internal Medicine is typically where the most critical adult patients in the hospital are treated. 2. Nurses with the licenciatura degree, which is the equivalent of the Bachelor of Science in Nursing in English speaking countries, have the title “licenciada” or “Lic.” for short. In this document I use the “Lic” in reference to nurses who have managerial positions – the jefas -- since this is how the ordinary, non-managerial nurses address them; conversely, the nonmanagerial nurses address each other by first name. 3. http://www.csim.ca

Physical Layout of the Internal Medicine Unit Hospital Saldaña’s Internal Medicine unit has 20 beds that include two beds in isolation rooms. These are normally reserved for patients with dengue but are sometimes occupied by sufferers of TB. The unit is roughly divided between a men’s and women’s section with the nurses’ station in the centre; I say “roughly” divided because during the shifts that we observed, an elderly man occupied a bed on the women’s side. The Internal Medicine unit is connected

by a corridor to Bienestar Magisterial, a unit that provides care to retired teachers. Though Bienestar Magisterial has its own nursing staff during the day, at night it is the nurses from Internal Medicine who attend any in-patients who are there. During the day-shift, they have to move back and forth between the two wards to retrieve certain kinds of equipment. Downstairs from Internal Medicine in the same building are the Gynecology and Surgery units.

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The Day Shift Observed There were four nurses of the Internal Medicine unit who generously allowed us to observe and photograph them during an entire shift4. They were: Mónica Vanesa Torres, Griselda Martínez (who works as an auxiliar), Karen Elizabeth Oliva de Reimundo, and Carmen Lorena Vásquez. Mónica, Griselda and Karen Elizabeth were the three nurses on duty during the day shift, while Griselda and Carmen Lorena were our night shift participants. Lic. Antonia Murga de Silvestre as the head nurse of the unit (the jefa of nursing in this ward) was also extremely patient and helpful with us, taking time to explain and describe innumerable aspects of the nurses’ work, and to answer specific questions that I had. Several specialist doctors also took a few minutes out of their hectic schedules to chat with us; one even gave us his contact information in case I had any factual questions. The doctors shared intriguing information about matters such as the history and characteristics of the hospital, the health profile of Salvadoreans, and how the staff manage stress in this unit. After all, this is a ward in which patients regularly die. In regards to coping with stress, we saw for ourselves that several doctors have a gift for generating laughter among the various staff, students, and patients. In general, the doctors, nurses and medical students appeared very cheerful and mutually supportive throughout the two shifts that we observed here. 4. These and other nurses who agreed to participate in this phase of the study signed informed consent forms as per the University of Guelph’s research ethics protocol.

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After our introductions to the nurses and to Dr. Eduardo Guatemala, who oversaw several hospital units during that shift, Jim and I positioned ourselves centrally to begin observations and to get our bearings in the flurry of activity around us. It became obvious that on the day shift are many different kinds of actors who are involved in patient care. There were, of course, numerous medical students, as this is a teaching hospital. And as in the UCSF San Jacinto, there were a dozen or so high-school students doing their practicums. These students who were present throughout the 10-hour day shift and also came on weekends, assisted the nurses in changing bed clothes, bathing patients, helping those who could eat with their meals, and other basic activities. Patients have more visitors during the day shift, which is part of what adds to the bustle of activity in the unit. These are mainly relatives but also the occasional religious clergy; that morning it was impossible not to overhear a fairly exuberant Evangelical pastor ministering to one of the male patients. About a half hour after we began our observation that first morning, a young male patient a few feet away from us, whom I will call Tomás5, turned and vomited substantially over the side of his bed – our side of his bed – and onto the floor. This was one of several moments that I would have during the ethnographic observation when I would become acutely aware of my status as an outsider to health-care who is woefully inexperienced in the sights and sounds of routine hospital life. Two simultaneous thoughts occurred to me: “if the whole shift is like this, this will be a real test for us”, and “this is just a tiny glimpse of everyday life for the nurses and doctors in Internal Medicine”. But there was little opportunity to ruminate further on my own psychological adjustment process, as the nurses’ duties presented new opportunities for observation and photography.

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5. I use pseudonyms for all of the patients who are named in this study. 6. We did not observe or photograph the bathing or changing of any patients.

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â&#x20AC;&#x192;The nurses began their day shift at 7:00 am holding hands in a brief prayer circle, followed by the hand-over of the nursing duties by the exiting night-shift crew. The latter is a process that takes about 15 minutes with two or three nurses from both shifts moving from patient to patient. Even with the assistance of the high-school students, the next 90 minutes of the morning appeared the most physically demanding of the day shift. This is the result of the confluence of so many different types of basic care needs in the morning, and the fact that the two nurses and one auxiliary were responsible for all 20 patients.

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Among the nursesâ&#x20AC;&#x2122; activities in this period were bed-baths6 using a portable privacy curtain, retrieving and returning the portable curtain, taking patients by wheelchair to the shower room and bathing them there, changing diapers, assisting patients in and out of bed (sometimes with a family member of the patient also helping), reviewing patient charts together with doctors, sorting bed linens, preparing and administering the oral medications, and making phone calls to the laboratory to inquire about a drug or an exam result. â&#x20AC;&#x192;

窶ィy mid-morning (around 10:00 am) we noticed that Tomﾃ｡s, the patient who had vomited earlier, now had clean bed linens, and there was a sheet on the floor to absorb any subsequent material. At this time the nurses began to work on intravenous (IV) medications, an activity that would last until 12:30 pm (though, I was told, they often do not finish until 1:00 pm). The preparation of intravenous medications requires protective gloves, a gown that covers their entire uniform, and a mask, as seen in these photos of Griselda.

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Before these drugs could be administered, some of the patients required prior insertion of an intravenous catheter. As MĂłnica explained, the two nurses and the auxiliar worked in tandem, with one performing the IV insertions (a duty that fell to Griselda on this shift) and the other two following behind with their carefully prepared syringes and IV fluid bags.

The following eight photos document several steps in the insertion of an IV catheter for a female patient performed by Griselda7. This patient needed to have one catheter removed and another inserted in a different location. This is called changing IV sites. The woman looked comfortable throughout the procedure. 7. All photos of nursesâ&#x20AC;&#x2122; direct attention to patients were taken with patientsâ&#x20AC;&#x2122; verbal informed consent, and do not reveal their faces.

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In the photo above (right), Griselda writes on the medical tape that she will apply over the inserted catheter to hold it in place, indicating who did the procedure, the date and time, and the size of the catheter. With her next patient, Griselda remarked that her vein was harder to access and that she would require a smaller catheter; the patient flinched in some pain with this second attempt but Griselda was successful.

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Lic. De Silvestre, the head nurse in this unit, explained why the nurses often need to perform many IV insertions per day. One problem is that patients who are restless sometimes end up pulling out their IVs. Secondly, the medical tape is often too weak to hold up in the shower; this is an example of an inadequacy in medical supplies that other staff would also mention to us, as will be described below. Thirdly, the patient’s blood sometimes coagulates, which occludes the cannula and prevents serum or medications from passing through; therefore, a new IV needs to be inserted at a different site. While Griselda inserted the IVs, Karen Elizabeth and Mónica worked behind the

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nurses’ station preparing the injectable medications. These included antibiotics, ranitidine, heparin, and dramavol. Insulin is another common drug administered in this unit but must be timed carefully with the patients’ meals. Some of the drugs are highly concentrated and need to be diluted (with normal saline —0.9% sodium chloride solution— or 5% dextrose solution, so that they do not cause discomfort) before they can be injected into a patient’s catheter. Some drugs like the antibiotic ciprofloxacin are administered as a slow drip, rather than injected. For each drug, of course, the nurses carefully read the instruction for each patient. We would learn more about these medications later in the day.

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Karen Elizabeth and MĂłnica moved back and forth between the meds preparation area and their next patient. Once she finished inserting the IVs, Griselda would also take part in administering the intravenous meds. Meanwhile, Lic. de Silvestre started working on the files that record each detail of the patientsâ&#x20AC;&#x2122; treatment and condition. She would be joined in this task by MĂłnica just after 12:00 noon while Griselda and Karen Elisabeth continued injections for another 20 minutes. And of course, before almost every activity and certainly prior to giving direct attention to a patient, there was hand-washing, making this a constant action throughout the shift.

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Karen Elisabeth is carefully reading the pink slip instructions

On the men’s side of the unit, an amiable, chatty, tattooed man in his early 30s named Giovani, required an antibiotic to be administered through an existing IV site. Mónica asked him if the injection hurt at all. “No,” he said. Giovani struck up a conversation with Jim and me, telling us that he was going to be moved to Hospital Nacional Rosales, a first-level institution in the heart of San Salvador. He said this was because he needed a blood transfusion and that this was a procedure that could not be done in Hospital Saldaña. Later, we learned that in fact, the nurses in this unit do administer and carefully monitor blood transfusions. The real reason Giovani was being moved to the other hospital was to discover the source of some internal bleeding that this hospital was not equipped to diagnose. Just after 12:30 Jorge’s ambulance arrived; before he left the grounds he looked up and waved at Jim and me. One of the patients on the women’s side was a 14-year old girl who was about to be discharged. Accompanied by her mother, she listened as Lic. de Silvestre explained the use of insulin and diet to control her diabetes. Lic. de Silvestre showed me the written material for diabetic self-care that she had shown the patient. Nurses provide this informational chat, she said, not only to newly diagnosed patients, but also as a refresher with diabetics who may have forgotten some aspect of the instructions. This was the first of several times throughout the study that we would see nurses’ educational functions. I did not attempt to shadow Lic. de Silvestre, since our focus was not on head nurses. But I noticed that in addition to her managerial duties, she carried out several direct care actions with patients, including changing them as needed throughout the shift. This was also the case in the other hospital units and community clinics that we would visit. By 12:45 the nurses had been working steadily since 9:20 am, most of that time gowned and masked, and on their feet (with

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the exception of a few minutes working on files). They admitted they were thirsty and had not had a drink of water all morning. As they took their second break, the last they would have for the duration of the shift, Lic. de Silvestre as the only nurse in the unit continued working on files. This was the main visiting period and there was a slight lull in the activity level. During this period, shortly after Jim and I came back from lunch, a man and a woman who had been visiting Tomás approached us as they were about to leave. Tomás, we could see, was not conversant and seemed to be asleep most of the time. The couple, who seemed to be of rural or small town origins, thanked us, and said that what we were doing was very important. This was one of several particularly surprising and humbling experiences that I would have during these ethnographic observations. Shortly after visiting hours, one of the nurses needed to assist two specialist doctors and another health-care staff member who arrived to perform procedures with one of the male patients. They were examining a wound and a urinary catheter. The doctors asked a visiting relative to step out, and the curtains were drawn around the patient. Since these were relatively invasive procedures, and ones in which the patient needed utmost privacy, it would not have been appropriate for us to observe or photograph. The next main nurses’ activity we observed was the drawing of blood for various types of laboratory analysis requisitioned by doctors. At the bottom left, we see Mónica preparing for a round of samples, labeling test tubes. The bottom right photo shows the gloved hands of Griselda drawing a sample, and in the next frame she transfers it from the syringe to a tube. Some of the samples are for monitoring the progress of patients who have recently had transfusions. Monitoring glucose levels (for many patients something that needs to be done every 12 hours) is another common reason for blood work.

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Karen Elizabeth prepares a venous medication with an IV drip chamber

M贸nica adjusts an IV drip chamber for Giovani

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Throughout the shift, the nurses who had volunteered to be our participants often took a moment to explain what they were doing or to answer specific questions that I had. In the early afternoon I asked Mónica a few more questions about the intravenous medications. She explained that some of these drugs, such as dopamine, nitroglycerine, and dobutamine, must be administered by drip at a specific rate— over a certain period of time. Ideally these should be administered via a special IV pump, which—after being programmed by a nurse—regulates the drip rate automatically. But because there is only one pump for the whole unit, medication is often infused by gravity through a drip chamber, regulated by a clamp in the IV tubing. Dr. Guatemala, a specialist in charge of several units that afternoon, approached us and joined in the conversation. He added that the pump for the Internal Medicine unit is used for the most critical patients and is sometimes not around. He lamented that a limit was imposed on the number of pumps provided to hospital wards depending on the number of drip chambers they use. As he was about to elaborate, he was called away to an urgent patient matter, ending the conversation. Shortly after 3:00, a doctor who had performed the procedures within the unit approached us to chat. This doctor, whose name we did not get, told us about the hospital’s historical specialization in respiratory medicine, about interactions between TB as a respiratory ailment, and diabetes and HIV. He too raised the topic of material resource deficiencies. He felt embarrassed, he said, that even though the hospital is renowned for respiratory care, they have never had a mechanical ventilator. This means some patients must be sent to the Intensive Care Unit of Hospital Rosales. The ventilator, he explained, would entail more additional expense than authorities were willing to cover, since there would need to be an intensivist on staff at the hospital.

At around the same time as our impromptu chat with this doctor, Mónica and Karen Elizabeth dedicated themselves to working on files at the nurses’ station. They sometimes went to patients’ beds to ask or check for specific information, and they communicated often with each other and with doctors. The files would occupy them both for more than an hour, work that they interrupted to attend to various patient needs. For example, Tomás needed to be wheeled to the washroom. (He was able to vocalize this need and to get himself into the chair). A set of blood samples had to be taken to the lab. There were doctor’s instructions for Tomás to be given oxygen. And at 4:35, another oral medication round. There was also inventory usage to be documented in detail. For example at the end of every shift the nurses need to extract the wrappers from the used needles and chart the number of each size that they used. Patients needed to be turned in their beds. The third and last meal of the day arrived at 4:45. At 5:00 Karen Elizabeth and Mónica did the 15-minute shift “handover” to the newly arrived night-shift nurses, and were able to leave at 5:20. I would later observe that hospital nurses here and elsewhere tend to stay considerably longer than 20 minutes past the official end of their shift, which confirmed my findings from the focus groups and interviews. Several nurses from other hospitals explained to me in interviews and focus groups that in all of the MINSAL establishments, the employees’ time is counted when they enter but not when they leave. The reason that health-care staff are made to punch the clock when they leave is to ensure they are not doing so before the official end of their shift. Only on rare occasions do nurses receive compensation for an hour or two of overtime, and that is when the jefa of nursing in a department or unit authorizes this after the fact. There are some common reasons why nurses may end up working an additional hour or two without

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recognition. It sometimes happens that a doctor adds a prescription to the patient’s file but does not inform the nurse. Or a patient’s condition can shift rapidly, and this may happen to several at once; this is especially likely in more critical care areas of hospitals. Shortly before she left for the day (about an hour ahead of the ordinary nurses, since the managerial schedule is different), Lic. de Silvestre brought me to see the nurses’ “mural of values” on the outside wall of the unit. It was decorated with photos, cartoons, and other images, some of them comical and some very sentimental. Every month a different value is featured, and this month’s value was integrity. I would like to have had the opportunity to interview the nurses of the Internal Medicine unit regarding the meaning that this mural held for them in their daily and nightly practice. It seemed to me that nurses’ values in the hospitals of El Salvador are linked to an overarching faith in God. In Hospital Saldaña this was evident in

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the ritual morning prayer and also in the Christian (and mainly Catholic) iconography in the work place, as seen as seen on p. 86. Regardless of whether it had religious moorings, an ethos of caring for others, on the part of the nurses, showed itself in some surprising and touching ways. One of these was that the nurses on each shift generally all leave together; if one finishes her assigned duties she helps the others until they are all finished. This showed collaboration and care for one another. During the night shift that we observed a short time later, the two nurses on duty were very concerned about our physical comfort – where we could take a nap during the night, and how we were faring in the chilly air; Los Planes de Rendero is particularly cool given the high-altitude and the fact it was in the middle of the rainy season. I now turn to describing nurses’ night shift activities in the Internal Medicine unit.

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night shift observed It was a Saturday evening at 5:00 when we came back to the unit, 24 hours after finishing our day shift observation. Griselda and Carmen Lorena had already arrived for their shift. We had met Carmen Lorena very briefly at the start of our study when she was finishing her night shift. There would just be these two nurses on duty, a typical night on the Internal Medicine ward. The shift hand-over finished at 5:30, but one of the day-shift nurses continued working until almost 6:00 pm, almost a full hour beyond the official end of the shift. Through interviews with nurses in other public sector hospitals, I learned that overtime is expected, and nurses feel ethically compelled to stay until their duties are completed, but overtime is usually not official recognized. When it is recognized, it is supposed to be repaid in time rather than in salary. In theory this would mean that eventually they could have a paid day off. But in practice this tends to remain an outstanding debt of the institution to the nurses. In one of my focus groups, one nurse manager who had examined this phenomenon in her hospital found that most nurses were working an average of 32 hours of unpaid overtime per month. Soon after the shift hand-over, Griselda and Carmen Lorena began preparing medications for injections. There were three rounds of these during the night shift in this unit, at 6:00 pm, 10:00 pm, and 4:00 am. As in the day shift, there were some intravenous catheters to be inserted, and again this duty fell to Griselda. For one of the patients, a talkative and cheerful man probably in his early 40s, she had to make more than one attempt, first on one arm and then the other. The patient explained to Jim and me that some of his veins were “quemadas” (literally burned); by this he meant that he had been treated in hospital many times for bullet

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injuries (he showed us the visible scars on his wrist and abdomen) that some of the veins could not be accessed with an IV catheter. Flinching a bit in pain when Griselda made a final successful attempt on his left hand, the man speculated that the catheter probably touched a bone. By 6:30 it was already dark outside. A surprisingly cold breeze entered through the open windows; it had thundered and rained a bit earlier. Several patients in the main men’s part of the ward were listening to a football game on a transistor radio. They were talking and laughing and would continue to socialize well into the night. During the first seven hours or so of the shift, a few doctors visited the unit briefly to inquire with the nurses about patients, medications or supplies. Though there were not nearly as many medical students as during the day, a few maintained a constant presence until about 2:00. At that point, most of them seemed to retire to the couches in the Bienestar Magisterial lounge area – not lying down but somewhat reclined -- for a meager three hours of sleep. Patients received very few visitors; a man who had come to see Tomás left around 7:30. There were two elderly patients with a relative at their bedside during the whole night. Griselda and Carmen Lorena took separate meal breaks starting around 7:00. I could not help but notice how small and modestly appointed the nurses’ break room was. There were tiny lockers for personal belongings, three chairs, a plastic table, a microwave, a sink with several mops, a fridge, a filing cabinet. The room looked like it had not been painted in many years. The nurses had no further breaks after their dinners, in other words between 8:00 pm and 7:00 am. From about midnight to 3:30 they were mostly able to be off their feet while they worked on files at the nurses’ station. But unlike the other types of personnel in the unit, the nurses were not relieved for a brief nap. As one of them told me, they would never finish their work

if they stepped out to sleep; this made sense considering that there were only two of them for 20 patients and no one to fill in for them. During the nurses’ second round of preparing injections, from about 8:00 to 8:30, we were able to ask questions and converse. One thing I was curious about was how the day and night shift duties are assigned to them, and how this compared with shift work in some Canadian industries where employees work a long string of consecutive nights, alternating with a set of days. But in the hospitals it is not like that. Their dayand night-shift assignments are intermixed. One of them, for example, was scheduled that week for Friday day, Saturday night, and Monday day. They also talked about nurses’ acquisition of knowledge and experience in the different areas of hospital nursing as they rotate through the different types of units. Nurses are supposed to do two-year rotations through each unit. But their own careers at Saldaña illustrate exceptions to this norm: Carmen Lorena worked eight years in the Emergency unit before coming to Internal Medicine, and Griselda worked three years in the respiratory unit, and has now been in Internal Medicine for four years. Different areas of the hospital have distinctive rhythms and forms of intrinsic reward for the staff. In Hospital Saldaña, the biggest contrast with Internal Medicine is the Emergency unit. Carmen Lorena described this contrast: because it is inherently an area of urgent care “Everything is ‘right now’. You get the satisfaction of quickly making a huge difference, and then the patient is moved. Here it is rare to see a crisis. The emotion is seeing someone able to go home. Often, they thank you.”

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Carmen Lorena shakes a vial of Ceftriaxona, an injectable anti-biotic

Here she draws the precise amount ordered for a patient

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Having heard stories from other Salvadorean nurses about hospital hauntings which invariably occurred at night, I could not resist asking whether this hospital had any similar lore. It turned out that there is a ghost nurse here as well, and she also makes her appearance to some people in the middle of the night. I made a mental note to find out whether anthropological research has ever been done on hospital ghost stories in any country; it would be interesting to find patterns in these stories and to interpret how they might reflect the beliefs about health-care workers’ roles, and about hospitals as places of birth, death, suffering, and spirituality. Admittedly this remains a project I have not yet pursued. The two nurses did the second round of injections from about 9:45 to 10:30 pm. They used an empty 1-gallon water jug (below, right) to dispose of sharps waste. This exemplifies improvisation with limited resources to get biohazardous materials out of harm’s way. Just before 11:00 pm, a nurse supervisor making nightly rounds through the hospital arrived at Internal Medicine. After checking on several patients, she joined Carmen Lorena and Griselda at the nurses’ station

where they worked steadily on charting. Upon receiving a call on her cell phone that was obviously work-related, the supervisor relayed information about an elderly man with abdominal pain who had been getting out of his bed periodically to kneel and pray, and another patient who complained of headache. Just before midnight, a young male doctor passed quickly through the unit, looking like he was not dressed for work and did not plan to stay long. The nurses made sure he did not leave before dealing with both of these patients’ concerns. Shortly after midnight the supervisor left the unit. Carmen Lorena turned off most of the ceiling lights over the patients, and then replaced a blanket over a mentally and physically handicapped young man, protecting him against the chilly air. The three men who had been socializing all night were now finally silent, as was the whole ward. Every now and then a newborn baby’s cry seemed to fill the hospital grounds. Through the open windows we heard and saw a gurney being wheeled between buildings, bearing a covered cadaver. Though I had initially been confident that I would not need to nap during this 14-hour shift (my attitude was that if the nurses

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could stay alert all night, then so must I), by 1:00 am I found it virtually impossible to keep my eyes open. After a one-hour nap I returned to the unit at 2:00 to find the two nurses still working through their charting, occasionally rising to check on a patient. It was now Jim’s turn to grab some sleep. The next hour and a half remained quiet in the unit. Griselda told me that this calm was unusual; typically there were at least a few patients calling out for something they needed, or some wanting to rise from their beds who are not supposed to, etc. At 3:30 an elderly woman awoke and asked the young man who had been at her bedside since the beginning of the shift, who I assumed was her grandson, what time it was. The young man, who had been slumped over sleeping in a chair, answered her. Overhearing them, Carmen Lorena at the nurses’ station said quietly, with a laugh, “Dios mío! Can you believe it’s only 3:30!” A few minutes later she sprang into action. She emptied several patients’ urine drainage bags into a bedpan and brought this to the washroom to dispose of. She took away

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the remains of several patients’ uneaten suppers. Soon after that she changed the diaper and bed linens of an elderly patient. She also instructed him on how to maneuver himself within the bed using his arms. At 4:15, Carmen Lorena put all the lights back on. Gowned and masked, Griselda began drawing blood samples on the women’s side of the unit. Soon after that Carmen Lorena began taking vital signs. For most patients this meant waking them up, and she spoke to each one in a kind voice. In this pre-dawn hour, Tomás, the young man who had been quite ill and non-conversant less than 48 hours earlier, now appeared enormously recovered and able to reveal something of his personality. Since his bed was one of the closest to the nurses’ station, he was amicable and playfully demanding with Carmen Lorena. “When are they going to stab me?” he asked her. “Right now!” she replied. “Why did I ask!” he said, eliciting a chuckle. A bit later he reminded both Carmen Lorena and Griselda that it was time for his oral medication. “We forgot, Tomás. We’ll get to it right away,” Carmen Lorena

told him. Distracted by another matter, Carmen Lorena arose and came back, and for a fraction of second she dozed, chin resting on her hand. Tomás made the “Ssssssk ssssssssk” noise to wake her up, in much the same way that one calls a waitress, servant, or a store clerk. “You got sleepy,” he said to her. “That’s right, Tomás,” Carmen Lorena said with a smile, “I wasn’t reacting.” “It’s because you don’t help me, you only stab me.” Again she laughed, taking it in good humour. After she gave him his prescribed syrup, he proclaimed, “It’s awful”. “You were asking for it,” she retorted cheerfully. Her voice was kind. Between 5:20 and 5:30, about six medical students were back in the ward. One of them took over the vital signs duty from Carmen Lorena, who handed over the files to him. At 5:40 Griselda finished doing blood samples, almost running at the end to complete the task. It had taken her more than an hour and a half. Daylight had now returned and the ward was swinging back into its usual bustle.

CONCLUSION As we neared the end of our second (and last) visit here, I realized that Tomás was not the only patient who had made enormous strides to recovery over the course of our presence. The woman who had allowed us to photograph her IV insertion on the Friday morning now had so much energy that she rose unassisted, went to shower, and made her own bed when she came back. It was not surprising to hear a doctor tell her she was going to be discharged. I was pleased to have had the chance to hear this before we left, and in general, gratified to have witnessed in some way the difference that the nurses (and of course the doctors, med students and others) made to these two people. These had to be the kinds of cases that Carmen Lorena and Griselda referred to when she spoke of the satisfaction that nurses feel when patients who arrive seriously unwell are eventually able to leave.

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“ecos” de quezalapa

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Community Health Team (ECOS) Quezalapa Background Before turning our attention to what nurses do in the Community Health Teams (ECOS), some further clarification is in order about the purpose and role of the ECOS in the restructured health-care system. In the previous chapter I outlined the serious deficiencies in the system that the FMLN health reform aimed to ameliorate. The FMLN government introduced the ECOS as a new feature of a system in which institutional roles are more sharply defined and there is greater inter-institutional coordination. This is aimed not only at increasing access to health-care for the majority of Salvadoreans but also encouraging a shift in people’s use of the system to take greater advantage of the primary level services. The ECOS are multi-disciplinary teams that are attached to, and administered by, Community Clinics for Family Health (UCSF). There are slight differences between the rural and urban ECOS in the size of the population they attend and the diversity of health-care personnel they have on staff. In the rural

areas, the basic-level ECOS (designated by the acronym ECOS-F in which “f” stands for “family”) is staffed by a doctor, a nurse, an auxiliar, three health promoters, and a multi-functional worker (for example a driver or office clerk), and attends about 600 families. In urban centres, the ECOS-F is responsible for about 1800 families, and has three additional health promoters as well as a dentist on staff. Each specialized ECOS, or ECOS-E, has one doctor in pediatrics, one in obstetrics and gynecology, and one in internal medicine. Each ECOS-E also has three dentists, a health educator, a health statistics analyst, a respiratory therapist, and two lab technicians. For every two ECOS-E there is a psychologist and a nutritionist. Rural and urban ECOS-E cover populations of about 6000 and 8400 families, respectively. As of June 2014, there were a total of 520 ECOS (of which 38 were specialized) in 164 municipalities, covering just under two million people.

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The ECOS intervene in primary health-care through documenting individual, household, and community health statuses, making follow-up house calls to individuals and families whose health categorization places them at risk, and attending patients on specific days of the week at the ECOS clinic. Two nurses volunteered to let us watch and photograph their work at the ECOS Quezalapa (named after the cantón whose population it serves), giving us a glimpse of these activities, and of the nurses’ role within them. They were Lic. Angela Ostorga de Bernal, head of nursing at the UCSF Los Planes which oversees this ECOS, and Lic. Reina Elizabeth Ramírez. Lic. Angela Ostorga has been working in the communal health sector since 1999. Early in her career she worked in the Bajo Lempa area of San Vicente where she sometimes had to intervene to save patients in the absence of a physician. This fact, which she relayed simply in order to describe conditions in those years, resonated with stories shared in focus groups by other nurses who had worked for years in rural areas. In 2008, the year before the health-care reform, Lic. Ostorga was hired on as head nurse in the UCSF Los Planes. A doctor who works with her, with whom I had a chance to chat informally, commented that she is highly adept in a broad range of areas, including responding to emergencies. For Lic. Ramírez, being a nurse was a recent career change. While teaching high-school health she decided to do a degree in nursing. She graduated in 2008, in the midst of the H1N1 outbreak. Her first nursing jobs were short-term contracts, until she was hired on a full time basis in 2010 at the UCSF Los Planes to be part of this ECOs. Our conversations with these two nurses provided a wealth of information that I have not seen documented elsewhere in regards to El Salvador’s re-organized primary care system1.

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Lic. Angela Ostorga

Lic Reina Elizabeth Ramírez

1. Under neoliberal reforms to health-care in the early 2000s, temporary contracts had become more common for nurses than fulltime positions. Under the FMLN health-care reforms, most forms of temporary hirings were phased out, and many temporary positions were converted to full-time.

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The UCSF Los Planes is an intermediate UCSF located in a two-story, repurposed factory on the busy road to the area’s main tourist destinations. The UCSF Los Planes administers the ECOS Quezalapa. Created in 2010, ECOS Quezalapa is a basic or “familial” level ECOS that attends 3767 people, or 846 families. For the first months of the ECOS’s existence, the staff had no fixed location for patients to make clinic visits, so they worked out of different residents’ homes. Finally a rental space was found in a building that houses the local Community Development Association (ADESCO). Through gradual renovations, the clinical space has come a long way since its inauguration. There used to be only curtains instead of walls between the different areas of attention. Initially there was no electricity or running water. It took two years and numerous meetings with the ADESCO to get hooked up to the water system, and they now have the service for one hour, twice a week.

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Map of cantón Quezalapa showing the sectors where the ECOS works

Despite the limitations that the ECOS Quezalapa has had to grapple with, the clinic has distinct areas for specific forms of nursing and medical care, such as wound treatments, respiratory therapy, family planning, and dentistry. It is open to the public three days a week, and typically receives 20 to 30 patients each time. This ECOS coordinates with the specialized ECOS (ECOS-E) that is attached to the UCSF San Jacinto, through a mechanism called “interconsulta”. In this process, specialist staff from the ECOS-E, such as the psychologist, physiotherapist, and others, come to the ECOS Quezalapa clinic on a monthly basis, and patients are referred to them by either the doctor or the nurse from the ECOS-F. ECOS Quezalapa patients also get referred to the UCSF Los Planes, or to the UCSF San Jacinto, where there are specialist doctors. Within the ECOS clinic there is a separate area for patients’ files. As Lic. Ramírez pointed out, the ECOS are the only entity in the healthcare system that monitors and intervenes at the level of families, not just individuals.

In addition to attending people in its clinical headquarters, the ECOS also reaches them in their communities through a process called “dispensarización”, defined by Lic Ramirez as: “a dynamic, continual process of classification of people assigned to an ECOS.” This entails registering, diagnosing, and following up with specific interventions and further monitoring of the patients. The initial dispensarización is done by doctors who categorize people into one of four risk levels or groups: (1) apparently healthy; (2) at risk of becoming ill; (3) ill; (4) incapacitated. Doctors, nurses and health promoters perform subsequent dispensarizaciones, with the promoters authorized for risk groups 1 and 2 only. When doctors and nurses go into the communities they are generally attending higher risk individuals and families. The decision as to which people the ECOS staff will visit on any given day is based on the level of risk in which the patients have been initially classified, and on the outcomes of the patients’ most recent dispensarización with the doctor. L I SA KOWA LC H U K

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On the morning of our observation on July 25, we met up with Lic. Ostorga at the UCSF Los Planes, and got a lift with several other ECOS members to the ECOS headquarters where we met Lic. Ramírez. These other ECOS personnel were on their way to a different sector of the cantón Quezalapa. During the ride, a doctor on the team told us that bringing down the maternal and infant mortality rates is among the main goals of the ECOS. The two nurses who were our guides for the day echoed this observation. Lic. Ramírez stated that the dispensarizaciones target even those pregnant mothers who are already entitled to care through the Salvadorean Social Security Institute (ISSS)2. That morning, they had scheduled dispensarización visits to two pregnant women. For MINSAL, reducing the number of inhome births for women in rural areas is crucial to tackling maternal mortality in El Salvador. Lic. Ramírez told us that the Health Ministry had recently opened an Expectant Mothers’ Home for patients in the UCSF Los Planes coverage area. By housing these women close to a hospital when they are nearing their delivery date, these homes are aimed at helping those with complicated pregnancies, and/or those who face a journey over difficult terrain from remote areas. The inauguration of the Expectant Mother’s Home in Los Planes, within easy access of Hospital Saldaña, was reported in one of the national newspapers. According to the article, as of May 2013 there were now 14 of these Homes throughout the country, with funding from FOSALUD (described in previous chapter)3. The same news article quotes the Director of FOSALUD, Dra. Villalta, observing that remnants of indigenous culture in the rural areas of Los Planes contribute to higher than average numbers of at-home births. But even without this cultural factor, convincing women to deliver in hospital sometimes requires an extraordinary effort on the part of the primary care doctors, nurses and

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health promoters. An example of this was relayed to us by a doctor who works in the Los Planes area: a woman in her late 40s, in a very poor household, was pregnant with her 13th child. To persuade her to go to the hospital, the staff at UCSF Los Planes had to arrange for a neighbour to come and make tortillas for her family in her absence; that task fell to one of the health promoters. The ECOS involve themselves in the health of their communities in additional ways. ECOS Quezalapa has mounted a Senior Citizen’s Club that meets in the ECOs clinic, and that has been quite popular. So popular, in fact, that even though the Ministry has not had the resources to provide snacks for the club gatherings, the participants raise the money on their own. Nurses who organize and facilitate the club’s activities donate funds as well. Many seniors travel from remote areas of the cantón to attend the club activities, which include educational sessions imparted by doctors, nurses and others who are specialists in health-themes for seniors. Lic. Ostorga noted that the gender ratio in the clubs is quite balanced, in contrast to those who visit the ECOS for health consultation, who are about 90% female. There is also a Senior Citizen’s Club run by the ADESCO in the same building as the ECOS, and some seniors belong to both clubs.

2. The ISSS is a set of hospitals and clinics within the National Health System for those insured through formal sector jobs, and is better resourced than the MINSAL system since it is funded by both employers’ and employees’ contributions. 3. Bernal, Laura. 2013. “Inauguran hogar de espera materna en Planes de Rendero”. Diario CoLatino. May. h t t p : / / w w w. d i a r i o c o l a t i n o . c o m / es/20130522/nacionales/116027/Inauguran-hogar%C2%A0de-espera-materna-en-Planes-de-Renderos.htm

The Planes de Rendero is both a zone, and a cantón belonging to the municipality of Panchimalco, bordering the San Salvador and San Marcos municipalities. A main reason that it is highly visited by local and foreign tourists is its high altitude (971 m above sea level) and the stunning vistas this offers. The topography of the area is such that the communities attended by this ECOS are situated mostly downhill from the ECOS clinic. This means a long, steep journey to and from the communities for both staff and residents of the area. The ECOS personnel only occasionally enjoy use of a Ministry vehicle and a driver to transport them on these visits, as we had on this particular day. Even when they are dropped off at the roadside, much of their journey is on foot. As we saw for ourselves later that morning, this is often through areas in which vegetation conceals one home from another, and where few other people are in sight. I asked Lic. Ramírez if they feel these visits place them at risk given the scourge of violent crime in the country; what I had in mind, but did not state explicitly, was that this terrain appeared to yield opportunities for assault. “This uniform gets us a lot of respect,” she replied. “I wouldn’t go around without it. Thank God nothing has happened.” Reflecting on what I had heard in my previous interviews and focus groups with nurses who worked in the primary care sector, I asked her also whether dog attacks were a hazard. “In sector two, I had an experience!” she recounted, referring to one of the sectors of the cantón where the ECOS works. “I had had the opportunity to see someone demonstrate a technique of defense. I was in the sector about to enter someone’s property when a dog suddenly lunged at me, barking. I grabbed my [nurses’] bag and put it in front of me. I am sure that saved me from being bitten.” These kinds of hazards, she said, are partly why ECOS nurses never make dispensarización visits without being accompanied by the promoters, who live in the communities. If

no promoters are available, a community leader fills in for them. The two nurses further explained that the promoters are crucial to the ECOS’ mission. They are the nurses’ “door to the community”. When there is an emergency they are the first responders; they bring the patient either to police or to a community member who has a vehicle. The promoter who accompanied the two nurses on this morning’s work was Marina. Lic. Ramírez recalled an example -- a recent day when Marina was making a house-call to a couple with a newborn baby. Coincidentally during her visit, the baby began having difficulty breathing. Due to Marina’s understanding of the situation and her quick action, they were able to get the baby to hospital. It helped that the promoters and the nurses are all equipped with cell phones, and that on that day, there happened to be a MINSAL vehicle at the ECOS clinic, after a week without it.

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An expectant mother steps on the scale that the ECOs members brought to her home; Lic. Elizabeth Ramírez records her weight

The ECOS home visits Home visit #1 At 9:45 am, with Lic. Ostorga and Ramirez in the Ministry truck, we picked up Marina and headed to the first of two home visits the team had scheduled for that day. We did not have far to walk from where the truck dropped us off. A man who appeared to be in his 60s greeted us. He was the father of the patient whom the team had come to attend, a 21-year old woman named Delia4 who was due to deliver in three months time. Lic. Ramírez introduced Jim and me to the young woman, and I explained why I was requesting her permission to observe and photograph her appointment. She consented, and Lic. Ramírez began her consultation on the front porch of the home, while Marina engaged the father in a conversation that lasted for some time. Later Marina sat near the nurse and patient, and made some written notes. Lic. Ramírez conducted the whole consultation, with

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Lic. Ostorga, her supervisor, observing. Lic Ramirez began by weighing the patient, and then taking her blood pressure. She told her that she had tried to reach her by cell phone recently but had not been able to, and asked her if the number she had given her was correct. Apologizing, Delia gave her a correct current number. It became clear in their exchange that Delia had recently been concerned that the baby was not moving. It was also clear that she had missed a recent appointment that Lic. Ramirez had given her with the gynecologist at the UCSF San Jacinto. “I saw you on Tuesday regarding your situation,” the nurse said. “Doctora Rivera was waiting for you on Wednesday. You need to look for her. We need to know if the baby is doing okay.” 4. Not her real name. All patients’ names in this study are pseudonyms.

“The baby is moving normally now,” Delia replied, adding that she had recently had an ultrasound. Lic. Ramírez asked to see the image. After looking at it, she pointed out that the positioning of the fetus might be a cause for concern, and gave her an appointment at the ECOS clinic for the following day with all of her paperwork. She also told her the date of the monthly inter-consulta at the clinic a few weeks later and instructed her to attend then as well. “Have you been having any of the signs of alarm?” the nurse asked her. “Just some pain,” Delia said. “But not the pushing feeling? Do you remember the signs of alarm? Can you remind me of them because sometimes I forget them, so can you tell me?”

Health promoter Marina charts information from Lic.Ramírez’s interview with the patient

Delia listed a few of the signs. Lic. Ramírez unfolded a visual chart of the pregnancy alarm signs and quickly reviewed each one in plain language. These included strong headache, pain in the “mouth” of the stomach (this is a common expression in El Salvador in reference to stomach pain), convulsions, fever, pain or burning when urinating, the baby not moving, pains with a “pushing” feeling. “Actually I did have pain when urinating,” Delia said. “How much water are you drinking?” “About three glasses a day.” “You should be drinking more than that,” Lic. Ramírez said, and told her the recommended amount. As the interview went on, Delia reported that she had been found to be anemic, and that she was taking an iron supplement. “How about what you’re eating?” Lic. Ramírez asked her. The nurse then listed common locally available, natural sources of dietary iron, including hojas verdes or green leaves (which in El Salvador

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typically refers to the leaves of the chipilín and mora plants), bean soup made extra thick and with added drops of lime, and a beverage made from a fruit called carao. She also explained the seriousness of iron deficiency in pregnancy: “With anemia you lose blood during the delivery, so the anemia can get worse and complications can develop.” Next, Lic. Ramírez reiterated the importance of taking action when there is an alarm sign, and of having a logistical plan in place. “For example if the baby is not moving, it could be dying, so if that happens, you need to go immediately to the Hospital. Here, Don Evelino5 is very approachable and can take you. So you need to get his number. The police can also be contacted as a form of transportation6. Is everything clear?” Delia nodded. “Have there been any problems with your weight?” the nurse asked. “Yes and the doctor told me it’s not high enough for this stage of pregnancy.” “Did they give you harinas7?” Delia nodded. “We’ll give you an instruction sheet on the different ways to prepare it.”

Lic. Ramírez asked the Delia to sign a form when the consultation ended. This visit had taken about an hour. The young woman and her father thanked the ECOS members. Jim showed Delia the photos he had taken, which, as he had promised, kept her face concealed. We wished the patient good luck and headed off to the next home visit. Much of nurses’ work is concerned with education and prevention, but this is particularly true in the primary care sector. It occurred to me that throughout this dispensarización interview, Lic. Ramírez demonstrated a style of education that invited the patient, who was expecting her first baby, to state what she knew about key questions and issues. Only then did the nurse bring in new or reinforcing facts. Many of the nurse’s questions were ones to which she herself already knew the answers, for example, regarding the patient’s weight and blood test results, and of course the pregnancy warning signs. Undoubtedly this method of interaction made the patient an active participant in her own health, increasing the likelihood of better outcomes for her and her baby.

Delia did have a couple of questions. “Tomorrow it’s just one vaccination?” she asked regarding her appointment at the ECOS. “Yes, the second of three annual ones.” “Have I gained weight?” Delia asked, “and is it where it should be?” “You’re up five pounds,” she told her. “Keep eating enough and with the right elements. Three meals and two snacks. Avoid fried junk food, and soda pop. You need all the food groups. The water here is not potable. It has microbes, so it’s best to boil it and drink it when it has cooled off.”

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5. In El Salvador, “Don” is a prefix of respect added to the first name of a man. For women, the equivalent term is usually “niña”, as in “Niña Gloribel”. 6. The ECOS and UCSF keep a birth plan index card for expectant mothers which needs to indicate the name of a person whom the patient can contact when she must get to hospital. 7. This is wheat flour supplemented with micro-nutrients.

Lic. Ostorga communicates with her staff back at the UCSF

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Home visit #2 Getting to the next home required a 15-minute walk through a ravine, over very uneven terrain that featured some steep climbs. Jim and I noticed that there were enough fallen leaves and rotting mangos on the ground that if one did not look carefully or could not see, one could very easily slip. Lic. Ramírez and Lic. Ostorga commented that this was not really all that bad, and that it was much more slippery after a rain. I asked Lic. Ostorga how a resident who could not walk and was having a health emergency would be transported to the road. “Generally, the people helping would use a hammock as a stretcher” she said. We arrived at the second home at about 11:45, for a visit that would also take about an hour. This home looked poorer than the one we had just come from; it was built with adobe walls, one of which had an immense crack, and a corrugated metal roof. Nevertheless the three children, all under the age of 11, looked energetic and on route to the second home visit

on route to the second home visit. Marina, who is more familiar with the area, walks ahead of the nurses 112

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a typical home we passed while walking in cantón Quezalapa, with adobe walls and clay tile roof

happy. Ranchera music was playing on a radio in the yard, and there were laundered clothes hanging on a line. Iris, a woman of about 30 years of age, thanked the three ECOS members for coming. After giving her consent for the observation and photos, she motioned us to sit under a tree that the children were climbing. She was about five months pregnant. Once again, Lic. Ramírez conducted the appointment while Lic. Ostorga observed. As with Delia, Lic. Ramírez made frequent written notes during her interaction with the patient. She began by measuring the blood pressure. “Tomorrow without fail you must go to the ECOS,” she told her. Marina passed her the weigh scale and she asked the patient to step on. “But whenever I’ve gone there” Iris said. Lic. Ramírez interjected with a smile, “Yes, I know, I’m never there! Correct. Remember the clinic is only open on Monday, Wednesday and Friday. Your weight and blood pressure are about the same. Did you have any pain?”

“Yes,” Iris replied, “and it was quite strong. But it stopped.” The three children had come out of the tree and were now seated around us in rapt attention, no doubt fascinated by the camera and the strangers. “Now the kids are not interested in playing,” Lic. Ramírez observed with a smile. “No tienen remedio,” Iris replied, laughing, which means something like “there is no cure for them.” Lic. Ramírez asked Marina to take the kids into the house, and then proceeded with the interview. “Is the baby moving?” she asked Iris. “Yes, the baby has been moving a lot recently. I’m having trouble finding a position to sleep in.” Lic. Ramírez gave her several ideas, including placing a pillow between the knees. “At five months, you need to watch that it’s moving about every hour,” she said. “If you feel it’s not moving, that’s a sign of alarm. And are you eating adequately? And getting foods with iron?” “Yes.” L I SA KOWA LC H U K

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“And you need to have confirmed who will go with you for the delivery.” “I don’t know yet. My husband might not get permission from work. But yes, we have close relatives who could do that.” “And you also need to have some money saved for things that you will need when the baby arrives. And transportation – can I put Don Evelino’s name here? And do you know his number?” She also asked her whether she would leave the children with her mother. After she worked out these details with Iris, Lic. Ramírez asked her if she had delivered any of her three children in hospital. The ensuing conversation was suggestive of a cultural shift underway in rural El Salvador in regards to childbirth, a shift that MINSAL has certainly been promoting. Iris answered no, all of her children had been born at home. “What will it be like with our follow-ups?” Lic. Ramírez said, smiling. “I guess I’m going to find out!” “We had a similar patient. She figured she’d have her baby at home, again. But her husband insisted on the hospital. She ended up having a lot of bleeding. If she hadn’t been in hospital, she would have died. Sometimes you’ll hear people say, why bother going to the hospital.” “But now most people are saying they do go, that it’s safer,” Iris said, “Even my in-laws.” “The local midwives are helping us a lot in this regard,” Lic. Ramírez said. “With my last baby, my mother and my father-in-law were the only ones with me. [laughing] Now they’ll be ‘with me’ but taking me to the hospital.”

“What else did the doctor talk to you about that I haven’t mentioned yet?” the nurse asked. “She talked about bleeding.” “Right, and what would you do if it was just a little stain? Would you just stay at home? And what if it was white or watery?” Iris answered to the nurse’s satisfaction. Next, Lic. Ramírez unfolded the pictogram of the alarm signs and reviewed each one. “And we also emphasize keeping up with your check-ups,” she concluded. As Lic. Ramírez, Lic. Ostorga, and Marina packed up their materials, Jim showed Iris the photos he had taken. As we were leaving, Iris again expressed her appreciation to the ECOS personnel. Lic Ostorga replied, with a smile, “And we would also appreciate your collaboration in going to the hospital for the birth, and doing all the follow-ups.” Later, Lic. Ostorga commented that this woman would be a good candidate for the newly opened Expectant Mothers Home, given that the terrain between her home and the main road would make a quick exit very difficult. During our walk to the road, Lic Ramírez told us that she wanted to stop in at a home we were soon going to pass, of an elderly resident who had been sick. The man, who was in his yard, greeted her warmly. She chatted with him for a few minutes while we waited outside the fence. Though I could not hear much of their conversation, I heard him say that he was feeling better, so much so that he had walked the whole way from the ravine to the road. When we left, he boisterously said goodbye to all of us. He had had a stomach ailment, Lic. Ramírez told us as we continued walking, and had been incapacitated for a few days.

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Marina organizes the patientsâ&#x20AC;&#x2122; records, while Lic. Ostorga takes a call from the UCSF Los Planes

All in a day’s work It was now about 1:00 pm. After these two visits, Lic. Ostorga had work to do back at the UCSF Los Planes, and Lic. Ramírez would be attending a training session in the UCSF San Jacinto. Since it was a Thursday, there was nothing for us to observe in the ECOS clinic. During the hour or so that we waited for our ride, the nurses filled us in on additional aspects of their work as ECOS and UCSF personnel. After the community visits for the day are finished, Lic. Ramirez said, she still has paperwork to complete at the ECOS headquarters to document her interventions and what she has found out about each patient. As well, the nurse, auxiliar and promoters on the team stay in touch with each other by phone after hours regarding what has happened with various patients. For communication during and after their workdays, each ECOS team member has been given a cell phone and can make as many calls as they need at MINSAL expense. Lic. Ramírez tells her colleagues that they can call her at any time up to 11:00 pm. It struck me that this was a down-side of this technological bonus – it tied the nurses to a potentially extended workday, one in which there could be unpaid overtime. As it is, UCSF and ECOS nurses are already faced with occasional six-day work weeks, particularly during vaccination campaign in the first weeks of the rainy season, and when there are special training sessions on a Saturday. But Lic. Ramírez spoke about the use of team-work to resolve the health concerns of the community members as an enjoyable, stimulating and motivating aspect of her work; for her, the cell phones simply facilitate this. In the several hours of my conversation with her that day, Lic Ramírez evinced enormous pride in the ECOS’ work and her role in it. She seemed to have a sense of mission and purpose in being part of the government’s program to meet its MDG commitments in maternal and infant health,

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and its health reform goals overall. Another characteristic of the ECOS and the UCSF that facilitates team work is that, according to Lic. Ramirez and Lic. Ostorga, the relations between doctors and nurses in the UCSF and ECOS are a highly collaborative; the doctors enthusiastically accept, and rely on, the nurses’ knowledge. The nurses did not complain about extended hours or other demanding aspects of the work, some of which I was able to see for myself. In regards to the physical demands, I found the mid-day walk rather grueling, partly because I needed to constantly watch where I put my feet, but also because of the heat. The temperature surprised me somewhat given that the Los Planes zone is generally a cooler one, but it does contain lower-lying areas. And that short walk was but a small part of what the ECOS team members cover on a typical shift with morning and afternoon visits, the nurses wearing their thick, polyester, dark blue uniforms. I noticed that by 1:00 they had not given themselves time to sit down to eat or drink anything. Often, they said, they must eat while in transit (usually by foot), and it has to be something portable that does not require reheating. Indeed, while we waited for the MINSAL vehicle, the two nurses produced fruit, nuts and typical pan dulce (cookies) similar to what Jim and I had brought for our own lunch. In the few minutes we had back at the ECOS headquarters, before heading back to the UCSF, Marina and a young auxiliar very quickly gulped down some chicken and rice purchased from a nearby diner; they only had about five minutes to eat before heading to their other activities. Clearly, these few hours observing the work routines of ECOS nurses yields only a small glimpse of the contributions they are making to primary health-care. They were disappointed, as were we, that our schedule did not permit a return to the

ECOS headquarters on a clinic day. What we saw and heard, however, gave us a sense of highly motivated nurses who love their work, and who are collaborating to provide integral attention to a population previously marginalized by state health institutions. In the three years of their existence as a team,

the nurses and their colleagues in the ECOS Quezalapa appear to have already developed a deep familiarity with the communitiesâ&#x20AC;&#x2122; health profile, and the plights and triumphs of individual residents.

quenching thirst after a morningâ&#x20AC;&#x2122;s work

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hnbb oncology

THE BENJAMIN BLOOM NATIONAL CHILDREN’S HOSPITAL: ONCOLOGY The Benjamin Bloom National Children’s Hospital The Benjamín Bloom National Children’s Hospital is one of three specialized or “third level” institutions in El Salvador’s public health-care system. The other two institutions at this level are Hospital Rosales, which is a general Specialist hospital for adults, and the Maternity Hospital, which in May 2014 was renamed the Women’s Hospital and moved to a newly built, enlarged facility. Benjamin Bloom Hospital opened in 1928, founded through a donation by a U.S.born bank executive turned philanthropist after whom the hospital was named. Despite initiating out of a private funding source, and the fact that the benefactor Mr. Bloom was the hospital’s director until his death in 1951, Benjamin Bloom Hospital has always been a state institution. Over its 86-year history, the hospital has been moved across the city, evacuated to makeshift facilities after a devastating earthquake, and reconstructed mostly with international assistance. The Hospital has historically received considerable support in various forms from international and national NGOs. This is as much due to the high calibre, seriousness, and dedication

of its personnel, as it is to absolute need of resources that comes with being a Third World, state-funded institution. Children from all over the country, and even beyond El Salvador’s borders, receive referrals to Benjamin Bloom Hospital; hence it is considered as a hospital “de referencia nacional”. The pediatric specializations that the hospital offers have gradually expanded in number over the years. Most recently, under the FMLN-Funes administration (2009 to 2014), a burns unit was added in 2010, and in May 2014, the Outpatients department was expanded. Currently, for hospitalizations, the institution has 12 departments and three units, the latter being the designation for the hospital’s most critical care specialties –Intensive Care, Intermediate Care, and Neonatal Intensive Care. For day patients, the expanded Outpatients department provides attention in 37 specializations– 17 in pediatric medicine, 10 in pediatric surgery, and 10 in other areas such as psychology and nutrition. The hospital also has a Centre of Excellence for Children with Immunodeficiency (CENID),

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and a Day Hospital for patients who need beds for less than 24 hours for treatments such as hemodialysis and surgery1. In May 2013, two months before embarking on this ethnographic and photographic project, I was able to meet with the Director of Benjamin Bloom Hospital, Dr. Alvaro Salgado. He expressed enthusiastic support for the e-book idea. He also stated that the hospital administration is extremely grateful toward the nurses for their dedication to, and identification with, the institution, adding that they are a role model to all nurses everywhere.

The Oncology Department at a Glance The Oncology department is on the 8th floor of the hospital. From the ground level one can count on a long wait for the sluggish elevator. The department is divided into an east and west wing, each with a Nurses’ station, bathing area for the patients, washroom, and a staff hand-washing sink which is frequented by the nurses multiple times per hour. Jim and I would spend most of our time that day (and the next day as it turned out) in the west wing of the ward. On the outside of the west wing door, an obsolete sign indicated this was the adolescents’ side of the ward. In reality the two wings are roughly divided by type of cancer, with more leukemia patients in the west wing, and patients with tumours in the east wing. The west wing is a large rectangle, with three patient care rooms, a procedures room, and a play room that everyone calls the Escuelita or Little School, all with exterior

1. Information for this section comes from the following government documents: http://www.hospitalbloom.gob.sv/index. php/principal/historia http://www.hospitalbloom.gob.sv

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walls and ample windows. Each of these rooms has a doorway to a large central area where one finds the nursesâ&#x20AC;&#x2122; station, a TV that is always on, a few chairs, a tall cabinet full of bed sheets and hospital pyjamas from which both nurses and parents of patients take fresh linens throughout the day (but particularly in the morning). Because the interior walls of the patient rooms are partly glass, they allow the whole wing natural illumination during the day, and also allow a sight-line to the patient areas from the

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middle of the ward. Each patient room contains four beds (or cribs, depending on the age of the patient), and beside each of these is a lounge-chair that reclines enough to lie down. â&#x20AC;&#x192;The procedures room is where doctors, assisted by nurses, perform treatments on patients who are sedated but not under anaesthetic. The most common ones performed are lumbar punctures, bone marrow aspirations, and the insertion of central catheters (usually just below the

clavicle). Nurses also use this room for the preparation of injectable medicines. I learned later that renovations to create the Escuelita and other areas displaced what used to be a staff kitchen. â&#x20AC;&#x192;As we had seen in Hospital SaldaĂąa, here the nurses are outnumbered during the day by an array of other actors. This is one of the hospitalization areas where the presence of parents (usually mothers) is a constant. Most of the patients have one parent or guardian with them practically around the

clock. They might step out briefly to run an errand or get a meal. Often one parent or guardian of a child arrives to relieve the other. Throughout the nursesâ&#x20AC;&#x2122; day shift there were always young medical residents and interns present, sometimes in the central area doing desk work, and other times attending to patients. Since it is a teaching hospital, several times during the day one sees the cluster of a dozen or so medical students following their teacher, in rapt attention, from patient to patient.

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In contrast, nursing students do not do their practicums here. But nursing students from the National University (UES) occasionally do the “social service” component of their training here; this is the six-month period of full-time, intensive training that degreenurses do in one area of specialization after completing their five years of course work and practicums.

Mirna Esmeralda de Girón

Nursing Care in the Oncology Department In mid-July, I met with Lic. Dinora Barrera de Recino, the head of nursing (jefa in Spanish) in the Oncology department, to describe my project and to ask for her support in this ethnographic and photographic part of it. She facilitated our work by telling her nurses ahead of time that we were coming, although we did not know exactly which day that would be. She did not seem surprised to see us on the morning of July 22, and in fact greeted us warmly, and introduced us to the nurses on duty that day. I explained my project to them. The two who volunteered to participate were Mirna Esmeralda de Girón and Ofelia del Carmen Benavides Polío. Since they were working that day in different sides of the ward, we decided to focus mainly on Ofelia’s work during the first day, and Mirna’s work the next day. During the day shift there are normally two nurses in each wing, in addition to the head nurse Lic. Barrera. When the beds are at full capacity, which they usually are, there are 24 patients, for a ratio of 6: 1. Soon after we arrived, Lic. Barrera informed us that because one of their colleagues had suffered a back injury, they were one nurse short that day. She would be filling in for the absent staff member. I noticed that throughout the shift that she was just as often engaged in direct care as she was in administrative desk work. As it turned out, with three children being discharged that day (though one new

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Ofelia del Carmen Benavides Polío

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patient was also admitted), it was fortunately not as hectic for the nurses as it might have been. At the start of each shift, Lic. Barrera assigns one nurse to be in charge of each wing. When a nurse works two consecutive days, their jefa insures they do not have the same assignation they had the previous day. On our first day in the ward, Ofelia’s role in the west wing was oral meds while Mirna held the “in charge” role in the east wing. The following day it was Mirna on oral meds. It did not take long to notice that this role encompassed far more than its name would imply. There were many other activities that both Ofelia and Mirna carried out in response to patients’ situations and needs, such as drawing blood samples, prepping and administering intravenous meds, administering chemotherapy, etc. Ofelia explained to me that in some in-patient areas of the hospital, nursing is organized according to what is known in North America as a primary care model; this means that one nurse attends to all the needs of a set of specific patients assigned to him or her. But this is not the case in Oncology, mainly because they do not have enough nurses on staff. Instead, the nurses work as a team to meet the various care needs of all the patients. Even if one of the two nurses is assigned to injectable medications, her colleague helps her out. In what follows, I will provide a more or less chronological description of the nurses’ activities during their respective shifts. This will be a window on the ways they attend to the bio-psycho-social needs of the patients, and to a great extent, those of the parents. Documenting several other events and interactions that I managed to observe here will also be a window on the characteristics of the Oncology ward itself, and of Hospital Bloom. Even though it was the same nursing role we were looking at and photographing over two days (because Mirna was assigned the same role that Ofelia had had the previous day), there was an

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interesting variability in their activities owing to the different kinds of patient needs that arose (eg. admissions, discharges, etc).

DAY ONE OBSERVATIONS The nurses’ day shift in Benjamin Bloom Hospital, similar to most MINSAL hospitals, starts at 6:30 a.m., but according to hospital norms, the incoming nurses must arrive at 6:15 in order to conduct the shift “handover”. I learned later that the shift change is also when medicines, books and other nurses’ materials are handed over and become the responsibility of those starting their shift. On both days, we arrived too late to observe this process. By the time we got started on day one, most of the patients had already taken their baths. We started observing Ofelia in some tasks she had between patient bathing and administering the oral medications. In one of the rooms where all four children seemed to be under seven years of age, she comforted a crying five-year old. She checked on whether the children had all been bathed, replaced a bandage tape for one of the kids, and changed the bedding and diaper of another child. As she did so, she chatted briefly with the boy’s father. After checking and adjusting the pump that delivered the baby’s IV fluid, she approached Alex, a toddler who was sitting up in his small bed. This was a boy who was often unaccompanied by any adult; both parents were working, I learned later, and the uncle who filled in for them was not always available. Not surprisingly, the boy looked extremely sad most of the time, and was sometimes crying. Ofelia told him that he could have the day off from bathing today but that tomorrow he could not skip it. “Okay?” she said. This was my first glimpse of an ethos that guides the nurses’ interactions with the children in this ward: respect for their autonomy and wishes. Oral medications encompass oral hygiene, a crucial aspect of the care of children being

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treated for cancer. Since these children’s immunity is suppressed, and the mucous membrane of the mouth is quite sensitive, Ofelia explained to me, it is important to prevent the build-up of bacteria. Behind the nurses’ station she mixed two pitchers of mouthwash made of bicarbonate and a product that looked like IV fluid. Ofelia wore a mask for this task; even though it is not a sterile area, she explained, it is better to protect the materials if she is talking over them (which of course, she was doing in order to explain things to me). One pitcher was for the children under three, and the other, more highly concentrated, for those older than three. For some of the older children the mouth rinse supplements toothbrushing but for younger kids it substitutes it, since their mouths are too delicate for a brush. Most children (or their parent) would be given the rinse in a small plastic bag, for them to gargle on their own. Infants needed a different delivery method. One

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improvisation that the nurses have for this, Ofelia pointed out, is a small tongue depressor with a strip of gauze wrapped around the wide end; this substitutes for a toothbrush for the younger children. The nurses also need to educate the parents on how to use this tool. I observed Ofelia explaining and demonstrating this to a mother of an infant girl who was less than a month old, the youngest patient in the ward as far as I could see. As she gently cleaned the inside of the baby’s mouth, the little patient seemed perfectly at ease. “This is something that you will need to do after every breast-feeding,” she told the baby’s mother. There were other oral medications to prepare and deliver according to doctors’ indications. One child needed liquid ranitidine. “We seem to be out of that one,” Ofelia said, and asked Doris, the secretary to bring some from the east wing. She poured the medicine in a small paper flask

and gave it to the child’s mother. In the midst of distributing the medications, Ofelia turned to me with an observation: “You probably noticed the difference between the treatment of adult patients and the treatment of kids. Kids are much more dependent, even though there are some who are fairly independent, for example they don’t allow us to do their mouthwashes. And there is a constant education of the parents, by the nurses, to prevent infection. Most parents learn and implement this very well.” Before she took her morning break at around 9:30, Ofelia attended to several other patient and parent needs. She responded to a father who asked her for help with his son’s IV pump so that he could walk him to the play room. She chatted with the parents of a child who was using an improvised toothbrush. At the nurses’ station she spoke with the mother of a child who was being discharged that day, asking questions and making notes. The mother looked cheerful.

Jim and I took went out for a break when Ofelia did. Not wanting to intrude on her rest time, we decided not to follow her. The hospital staff are entitled by law to a 40 minute break during their shift (which is, for nurses, a 10.5 hour shift during the day, and a 13.5 hour shift at night). Several people explained to me that Benjamin Bloom Hospital and other MINSAL hospitals have internal rules whereby the staff can split these 40 minutes into two 20-minute segments; this allows daytime staff who start very early to eat breakfast at a normal time, as opposed to eating at 5:00 am. When we came back half an hour later, Ofelia was seated with the parents of three children – a couple and two mothers– giving a pre-discharge education session. Later on, she told me that it was rare for three patients to be discharged on the same shift. This was one of the only times I saw Ofelia sitting during her shift; even when she worked on files she usually did this standing

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up. When a brief pause opened in her chat with the group of parents, I approached and asked them for their permission to photograph the interaction. They readily consented. During the 45-minute session, Ofelia gave them information about followup care, including the medications the children would continue to need, and also the warning signs they should watch for, such as headache, diarrhea, or stomach pain. If those were to occur, the child should be taken to the closest health-care centre. There would be certain situations where the child should wear a filter mask. The children’s defenses were low, they would need to avoid blows, falls, getting the flu or cold, and non-nutritional food like churros and candies. The two mothers returned to their children while the couple stayed for some counselling that was specific to them, regarding measuring and administering the child’s medications (prednisone and an antibiotic). Ofelia reviewed a set of hand-written notes on a green index card that she would leave with them. Did they have any questions? she asked them. One parent asked if they could bring their child around animals. “Leukemia changes a child’s life,” she told them, “So your lifestyle will also have to change. And have faith in God that the treatment will work.” The couple returned to their child, and the other mothers came back. One inquired about a prescription. Ofelia relayed the inquiry to a doctor who was in the ward, then returned with an answer, “That medicine is expensive. The doctor says she will try to find a cheaper one.” When the parents had no more questions, Ofelia completed the paperwork for their release. I watched as she removed the intravenous catheter from the hand of one of these patients, and then cut his hospital bracelet off. It was during this education session that I noticed Ofelia addressed the patients’ mothers as “mamá”. This term conveyed respect but also warmth and familiarity.

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I found it an interesting contrast to the way some nurses I had interviewed earlier in the project, who worked in private hospitals in Nicaragua, were instructed to address their patients. They had to leave all colloquial and commonly used expressions of the masses out of their discourse, using only “Doña” or “Señora So and So”. Connoting formality and distance, this reminded me of the way servants in starched uniforms spoke with their employers in the Mexican soap operas. In between working on charts Ofelia left the desk for various direct care activities. She gave an injectable medicine to a baby via an pre-existing central catheter. A cherubicfaced boy of about nine, named Joel, asked her to tape over his central catheter so that he could watch a movie in the Escuelita; he had already gotten a doctor to detach it from the IV drip. In the procedures room, she prepared an IV bag for the five-year old who had been quietly sobbing when we started our observation. While she replaced the old bag with the new, she made him laugh and smile with a comment about how amazing he would look at 15 when he has all his hair back. The boy’s mother smiled, looking pleased. At about 12:15 we observed Ofelia attending to a 9-year old boy named Ariel, giving him an oral medication. Ariel, whose hair had fallen out due to chemotherapy, was sitting up in his bed, with his mother sitting nearby. Ofelia told us later that his face was swollen from the treatments. At his bedside, she told us, with her hand on his shoulder, “Ariel is very courageous, one of the most courageous we’ve ever had.” She announced to the boy and his mother that she would be drawing blood in order to test for bacteria that could be causing his fever. It was important to take the sample now, she said, while he was running a fever. Finding a vein that worked, though, would be challenging, she added. I asked Ariel’s mother for permission to observe and photograph. (Later, a comment that Ofelia would make about asking permission of

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Ofelia tries to obtain a second blood sample from Ariel

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the parent, something that my University’s Research Ethics Committee demanded, would reinforce the lesson about prioritizing the children’s preferences.) First, Ofelia had to insert a new intravenous catheter. While she began, attempting on the left arm, Ariel’s mother stood several feet away from the boy. I realized suddenly that she must have thought this necessary to facilitate the photography. I told her to please feel free to be close to her child, and she did. This was a humbling and tense experience for me; I felt mortified that she was keeping a distance during this difficult moment for her son, on our account.

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Ariel was remarkably calm, showing no expression. His mother held the arm that Ofelia had selected. “Easy now,” Ofelia said while she rubbed the surface of his hand in search of a vein. She was successful on the first attempt. She later told me that she tries to visualize where she will find a vein, and she usually starts from the most peripheral areas first (like the hand, in this case) and work upward only when necessary. Ariel had had a forearm IV catheter inserted earlier, which was another reason to try on the hand. Ofelia tied off the tourniquet, obtained the sample fairly quickly, and took it away.

But this was only one of the samples that was needed. Five minutes later she tried to get a second sample, but the vial would not fill. “I’m not getting enough,” she stated. Though this must have been very uncomfortable, the boy did not cry. “I would have to do a new puncture in the same arm to get enough blood,” she said. (His other arm had an IV attached to it). “Ariel, do you want me to do a second puncture?” “No,” he said shaking his head. Ofelia told Ariel’s mother, “When the doctor comes, you can tell him that we tried. If he wants an additional sample, they can try with a smaller butterfly catheter.” Ofelia stepped out and I chatted briefly

with Ariel’s mother. They were from San Miguel, one of the eastern-most provinces in El Salvador. A few minutes later, Ofelia summarized the situation to Lic. Barrera, adding that the catheter she had applied was still in place, and sealed. Lic. Barrera affirmed her decision. Just after 1:00, the jefa told Ofelia and her colleague to go on their lunch break. Ofelia demurred; she had some things to finish first, and told her colleague to go without her. She finally took her break at about 1:30, and was back before 2:00. When Jim and I returned, she took ten minutes to talk with us about various aspects of the work.

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At about 2:15, Lic. Barrera summoned Ofelia and her colleague for the daily review of all the activities the nurses had completed for the patients so far that day. This was something that she does each day before leaving. (As I pointed out in chapter one, the work schedule for administrative nurses is different than for the others). The three went from bed to bed, visiting all the patients in the wing. The children in the playroom had all been called back to their beds or cribs for this process. A short while later, a group of youth in their late teens or early 20s arrived, wearing vests and other wardrobe that clearly marked them as the entertainment. Mirna told me later that these volunteers were sponsored by an NGO called Ayúdame a Vivir (Help Me to Live). That afternoon also saw the arrival of a 10-year old patient named Sabrina. It was evident that Ofelia had a rapport with this girl already. This was because she was not new, but rather, had been re-admitted that day. As Ofelia exited her room after checking on another of the patients there, she said in a friendly tease, “I’m going to stick you soon!” the girl grinned, and Ofelia added, “Pretty princess.” At 3:40, Ofelia donned a mask, washed her hands, and began preparing IV medications in the procedures room. These were ordinary hydration fluids to which she and her colleague were adding specific medications according to written instructions by doctors. Normally, Ofelia told us, the door to this room was closed not just for procedures but even for medication preparation. “But this is a kind of an unusual situation,” she added, in reference to the fact that Jim and I were in the room observing. “No one has ever wanted to observe up close what nurses here are doing. So we make this exception.” After watching Ofelia deliver several of the injectable medications, followed by several oral medications, to various patients, our observations took us once again to the room where Sabrina was. After introducing us, Ofelia commented to me that the girl is

“very easy to talk to, and a real fighter.” She added that she was about to receive hydration fluids today to prepare her for the following day’s chemotherapy. Next came an interesting lesson on the regard that the Oncology nurses have for the children as autonomous actors whose wants and thoughts matter. Sabrina’s mother was a tall, thin, quiet, humble looking woman, young, with a pleasant expression. Like all the families I had seen in the hospital so far, she and her daugther were almost certainly people of scarce means. Ofelia needed to insert an IV in Sabrina’s arm for the IV fluid. She asked the girl’s permission for us to photograph this. I turned to the mother to ask her consent. Both mother and daughter said yes. With a smile, Ofelia said that the most important thing is the child’s permission. At that moment I remembered that I had done the same thing with Ariel a few hours earlier; I had not taken the child’s perspective into account, but had only asked permission of his mother. Ofelia asked Sabrina to lie down while she looked for a vein, first in one arm and then the other. She had enormous rapport with the girl, and was able to make her laugh and smile. She tied off above the insertion point to create pressure, informing the girl of what she was doing. For about ten seconds the girl cried. The insertion was successful on the first attempt. Ofelia started the IV drip and held up her wrist-watch to the bag to check the flow rate. Sabrina was looking cheerful once again. At 4:45 the night nurses began coming in. In preparation for the shift hand-over, Ofelia told a few kids who were in the Escuelita to return to their rooms; “If not, they’re going to say ‘where are these kids?’” Ofelia and her colleague alternated in leading the rounds. It seemed this was because Ofelia was still giving oral medications when the hand-over started. When the children’s dinners arrived just after 5:00 pm, we were treated to a few minutes of entertainment. The kitchen staff

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person was something of a comedian. She called out in a haunting, semi-howling voice that the wolf was here. She joked around with the interns and cracked up most of the adults in the ward. And as she delivered the meals to each child or parent, it was obvious that she knew most of the children by name. Ofelia worked on files until 5:20 at the nurse’s station. At 5:30 she finished, then gave us an additional half hour of her time in a walk through the other side of the Oncology Department, describing and explaining things as we went along. As in Hospital Saldaña, here there was also a “values mural”. The nursing staff incorporate this into continuing education, Ofelia said, and they talk as a group about the values. She pointed out that two of the 12 beds in the east wing are in isolation units. She also showed us a room where the diapers of small children are weighed as a means of monitoring the quantity of fluids being eliminated. That the parents often assume this task is another manifestation of the Hospital’s reliance on them to support the nurses’ work; the Hospital makes them active participants’ in the children’s care. This reinforces the importance of the nurse-parent interaction in Oncology, since it is primarily the nurses who work with the parents to ensure they know how to contribute effectively to their children’s care during and after hospitalization. Ofelia also pointed out that none of the patients in the ward that day were in a critical state. Often, however, they do attend children whose condition has much in common with patients in an ICU, and who need more frequent monitoring than the average Oncology in-patient. The ICU has several advantages particularly in certain kinds of medical equipment such as mechanical ventilators and vital signs monitors, as well as a higher nurse-patient ratio. Yet that is a unit that is practically always filled to capacity.

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Knowing that Ofelia faced an hour-long bus ride across the city, I did not want to detain her any further after her long shift. Yet because there were aspects of her work and her career that I wanted to follow up on, and she was so accessible, I asked if I could interview her on another day. As it turned out, the time slot we scheduled was after her next night shift, which is even longer than the day shift. But we did the interview over breakfast. I present highlights of that recorded conversation with Ofelia in the following section and the final section of this chapter.

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An interview with an Oncology Nurse I began by asking Ofelia about her nursing career. She had completed the four-year “tecnólogo en enfermería” program in nursing at the Instituto Especializado de Educación Superior de Profesionales de la Salud de El Salvador (IEPROES) in 2000. This included a full year of social service in the Oncology department2. After graduating, she stayed on in an unpaid capacity in the department, in hopes of obtaining a full time position. “I liked the hospital. As a student I liked the specialization. When I was studying nursing, my dream was to treat sick people. I didn’t have a clear idea of which type of patients. My first experience [with clinical practicums] was in Hospital Rosales. It’s a hospital that has a lot of science, a lot of great human resources. But they are greatly limited in the physical space and the materials. There are so many shortages that should not exist because it’s the hospital that receives the most critical patients. It’s a shame and a loss. So my first experience was there. Then I was assigned to do social service in Bloom, and specifically Oncology. I liked it a lot. I was very interested in the pathologies. And perhaps I made a connection with the type of patients. And I liked the hospital. And this was one reason why I stayed there waiting for an opportunity in Hospital Bloom.” Ofelia was able to earn some income during these six additional months of working “ad honorem”, by covering shifts of colleagues on vacation or sick leave 2. In 2002, her perseverance paid off when she was hired on a full-time basis. Although the tecnólogo title she attained qualifies one to be hired as a nurse, the position that was open in Oncology when Ofelia was seeking employment was that of auxiliar. I had learned through my previous research that this position pays about $100 less per month than the enfermera position. Though Ofelia’s 148

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job title is that of auxiliar, her assigned duties are commensurate with her training. This means they are very similar to those of a degree-nurse, with the exception of administrative functions. I remembered something I had been told by one of the highest ranking nurses in Hospital Bloom: in the Oncology department, as well as in several other departments and the three critical care Units, no nursing staff are hired with less than a tecnólogo title; all have completed the tecnólogo diploma, or the degree. It is striking, then, that there are any auxiliar positions in these areas of the hospital, since these staff do the work of regular nurses. Soon after coming to power, the FMLN government made a commitment to cease hiring nurses into positions that were below their level of training. But because this is not a retroactive measure, it does not reclassify those previously hired into the lower-level positions. I asked Ofelia what sorts of functions distinguish the degree nurses and tecnólogos from auxiliares and técnicos (the educational

2. Ofelia expained that for IEPROES students, the social service component is a full year long, whereas students completing a degree program at a university do only six months. 3. The “ad honorem” contract is one in which the employee works without pay or benefits, but assumes the same responsibilities as a regular staff member. This type of contract became common for nurses in the public sector starting in the early 2000s when the ARENA government closed many full-time positions. Unfortunately the ad honorem contract has not been abolished under the FMLN government but rather, became formalized in law. Newly graduated nurses accept ad honorem contracts for several reasons: jobs are extremely scarce in relation to the supply of new graduates; they hope that working in an institution may enhance their prospects of attaining regular employment there when a position opens; they want to keep up their skills.

title that replaced the auxiliar diploma under modernization reforms of the 1990s). Her answer was that anything having to do with care of the critical patient is for the nurse. In Oncology, the hospital authorities recognize that a cancer patient is “clinically compromised, and that the interventions have to be done by specialized staff, familiarized and with knowledge of this kind of patient. That’s why we don’t have auxiliares there. …We have so many responsibilities that correspond to us. For example the specific procedures that we have, like accessing (inserting a needle into) an implanted port catheter. That [port] is a special apparatus that the cancer patient may have inserted in their body as a central line to be able to administer medical treatments, take blood samples, and provide care at any moment. It’s so specialized that not just anyone can do it, because they’re not trained. That’s one of the important

functions. Also, administering injectable medications and chemotherapy, they are specific medications for treatment of cancer that… only nurses must give.” She also mentioned psychological and educational interventions with patients and parents that an auxiliar might be able to do, but without the depth of understanding that a nurse attains through his/her training.

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A Parent’s perspective Two informal encounters with the parents of children hospitalized in this Department led to unprompted opinions on the quality of care here. The first occurred before we began our observations. It was before 7:00 am, and Jim and I were waiting in the austere lounge between the two wings to ask Lic. Barrera if we could begin our work that morning. Three or four women who also looked like they were waiting for someone struck up a conversation with us. They appeared to be from working class or small farmer households. Without our asking, two of them voiced very positive views of all the Oncology staff for their attitudes and treatment of the patients. They were waiting for the social worker to give them their “tickets” for breakfast and lunch; this is something the hospital provides to parents who spend all day, day after day, with their hospitalized child. The second instance occurred shortly before noon that day. Jim and I had entered the east wing hoping to briefly observe Mirna. A woman emerged from one of the patient rooms and stood looking into the hallway where I was standing. We smiled and said hello, and I told her what we were doing. Her 14-year old daughter, she said, had been treated here over a two-month period and she was very happy with the care. “The nurses especially are great. They’re always there. They’re caring. And it’s not like at other hospitals where the visiting hours are very limited, even for parents of children.”

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Day Two Observations Jim and I arrived a little earlier for our second day of observation and photography while the patients were having baths or showers. Mirna greeted us from behind her mask; she was about to begin the preparation of oral medications. Parents are quite involved with the patients’ showering, but they need certain kinds of help from nurses. For example Mirna transported a child’s IV pump as the child walked to the shower room, the mom following behind. FFor two other patients she taped plastic over their IV ports as they waited in line – in one case over the arm and in the other, a boy with a central line, over the shoulder so it would cover the clavicle. A non-nursing staff person talked amicably with Ariel who was also in line for a shower, and hugged him affectionately. We observed Mirna in tasks involved in the oral medications. While she prepared the pitchers of mouth rinse she explained that only older kids use real tooth-brushes, because brushing can cause bleeding in the mouth which must be avoided. In between distributing the mouth washes she received a delivery of thermometers, counted the items, and signed a form for the delivery person. This is something that is done by whoever is on hand when supplies arrive. A doctor asked her for an examination lamp, which she found in the procedures room. Observing Mirna took us to little Alex, the toddler who was being minded by an uncle. The uncle had stepped out. Gently, Mirna asked Alex if he wanted to have a bath. Whenever she entered this room throughout the shift, she would check in on him, adjusting his IV or simply to see how he was. In the same room was an eight-year old named Miguel. Mirna changed this boy’s IV bag and straightened out the tubes that had become somewhat tangled. She checked the IV pump and re-set it. What she was doing, she said, was an actualización de líquidos (monitoring and resetting the IV fluids).

I had gotten permission from Miguel’s parent the previous day to observe and photograph. At that moment the parent was not in the room, and I asked Miguel again if we could photograph what Mirna was going to do next. Mirna disinfected and then gloved her hands, then started to work on removing the catheter that was in Miguel’s hand, followed by one that was higher on his arm. The medical tape seemed very firmly stuck. Affectionately, she told him that he had a lot of little hairs, and told him to take a big breath. “Okay done!”, she said. She gave him a wad of cotton and told him to press it where the catheter had been. Finally she wrote indications on the IV bag. Miguel asked Mirna to change the television channel and she complied, finding the one that he liked. Mirna had left the room, as did Jim, and before I could follow, Miguel beckoned me over to him. He asked me what were Jim and I doing here. I explained it to him in terms that I thought he would understand. I was intrigued that he was curious about the “why” of our work. The next thing he said bowled me over: why had I not asked his name yesterday? I grasped that he was trying to understand why had I only introduced myself properly to him now, and not the day before? I thought back to the previous morning, when I had asked all three parents who were in the room at the time if it would be okay to observe and photograph the nurse with their child. We had not focused on Miguel that day. I did not know what to answer, and indeed I do not remember what I answered, but felt I was getting the most important ethics lesson that I had gotten so far during the study. Miguel then asked me whether the licenciada who comes to play with the children and brings toys would be coming in today, and when she would be coming. “I don’t know,” I said, “but I’ll find out.” I asked Mirna, and then reported back to the boy that she would be coming very soon.

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rna prepares an injectable medication in the procedures room

While Mirna’s colleague took a 20-minute morning break, Mirna continued through the patient rooms delivering mouth washes and addressing other needs. For patients who were at the shower, she took advantage of their absence to make their beds. In the bottom right photo above, she is making Sabrina’s bed. Watching her do this, I realized that it is a physically demanding task. She also communicated with one of the doctors about several patients, including Ariel and a blood sample that he needed. Shortly after 8:00 am the children’s breakfasts were delivered. This kitchen staff person had a few characteristics strikingly in common with the woman we had encountered the previous afternoon. She came in the door boisterously joking, making all the adults within earshot laugh. She was also very interactive with the children, and clearly knew them. To one of the boys who was waiting for the bathroom, she asked, “How are you?” “Well,” he answered. “Well what? ¿Bien bien? ¿Bien mal? (Because the word bien can mean “quite”, this translates as “quite well, or quite bad?”) “Well showered,” he said. “Well showered? I don’t believe you... You don’t look wet. Let me see,” and she put her hands on his head to see if his hair was wet. When Mirna took her 20-minute morning break Jim and I went as well. This time we decided to eat in the nurses’ break room, accepting Lic. Barrera’s suggestion. Chatting with Mirna and her colleagues, I told them about my interaction with Miguel. Mirna seemed intrigued but not surprised. We learned that Mirna makes a rather lengthy commute to work from Sonsonate, a department to the west of San Salvador. On her weekday day-shifts she gets a ride with her husband who also works in San Salvador. But for her weekend and night shifts, she comes by bus which takes longer. After a weekday shift she gets home at 7:30 pm and still has to attend to her children’s dinner and homework. I asked the group what kind of other space the nurses had for resting

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and changing; for example where were their lockers? Laughing, one nurse replied that their lockers were in their bathroom, and that there was no separate area for them to change their clothes. It struck me that there are not a lot of spaces that are just for the nurses. Even Lic. Barrera’s office was labelled “bodega” and was filled with general supplies. Back in the ward I observed Mirna drawing a blood sample from a patient in the same room where Miguel was. Before obtaining the sample from the boy, she chatted for a few minutes with him. She then charted the intervention and made a phone call from the nurses’ station to say that some blood samples urgently needed to be taken to the lab. A staff person arrived only a few minutes later to take the samples. While I was standing in the main area, within sight of Miguel’s room and also where I could watch Mirna, Miguel beckoned me over. He had been playing with a bubble mix that had presumably been given him by the licenciada he had been asking about earlier. “Hola,” I said. “When can I go to the Escuelita?” “I don’t know, Miguel, but let me ask and let you know. Do you go every day?” “No, because sometimes I’m too tired”. I exited the room to find Mirna so as to relay Miguel’s inquiry, but as it turned out she was on her way to talk to him. Chart in hand, she asked him what he had eaten and drank, and recorded the information. Next she asked him if he wanted her to take him to the Escuelita. “Si!” he replied. She walked alongside him to the playroom, bringing his IV pump. A minute later I looked in and saw him waving his arms in front of the television screen, absorbed in a video game that follows the player’s motions. A non-nursing staff person was teaching him how it worked. At 10:15, staff arrived to do a general cleaning in one of the rooms. One patient room in the department is cleaned every day, Mirna told me. Ariel and the three others in his room, and their parents, had to move

to the main area along with their beds until the process was finished; it took about 50 minutes. In the meantime, Mirna, who was now wearing a head cover, called Miguel back to his bed from the washroom where he had stepped out from the Escuelita. “I want to go back,” he said. “You can go back later.” Miguel looked unhappy, and what Mirna said next explained why: she was about to administer his chemotherapy treatment. He received it via an IV catheter that was already in his arm. We watched as Mirna disinfected the port of the small IV bag containing the drug, and flushed Miguel’s IV line with fluid to ensure patency of the cannula. Then she connected the medication bag to the IV cannula via a plastic tube that is supplied with the chemotherapy. Regulated by pump, the bag would take about 20 minutes to deliver its contents. Just before 11:00 am, the nurse supervisor on duty that day, Alejandra Castillo, dropped by the Oncology Department. The supervisors make rounds of all the in-patient departments and units in the Hospital during the day and night shifts. A few minutes later, Mirna began preparing oral medications, reading indications from small sheets of paper. She worked with syrups, drops, and pills. A few of the children were in the Escuelita, and she administered their medicines to them there. When she got to Ariel’s room she took his temperature, and then continued her rounds to the room where Sabrina was. She spent some time chatting with the girl, and then reported Ariel’s temperature to one of the doctors, which was now a bit lower. She then gave Ariel his oral medication. He said something to her that made her laugh.

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I was able to ask Mirna a few questions at this point. One was about the insertion of intravenous catheters in children. Typically they had to apply six or eight of these in an average shift, she told me. And yes, children are generally more difficult than adults for this procedure. With two attempts that do not succeed, she does not try any further because it becomes a trauma. I asked her why I had not observed her or Ofelia doing basic vital signs readings. It was because that was the role of the other nurse on duty in this side of the ward. Mirna called Joel from the Escuelita back to his bed, where she gave him oxygen therapy. At about that moment we noticed that a doctor and several nurses entered the procedures room with a child on a stretcher. Mirna had told me earlier that several procedures would be done that day. This first one was a patient from the other wing of the ward. Meanwhile, in the same room where Joel reclined with his oxygen mask, Mirna attended to Alex, changing his diaper and giving him a bed bath; this was the bath that he had declined the day before. While he sat in one of the reclining chairs she also changed his bed linens. Afterwards she removed her gown and mask and began working on files at the nurses’ station. Jim and I alternately sat or stood in the central area, observing the activity of the ward. Just after 12:00, a doctor and nurse supporting Sabrina, one on either side of her, walked her from her room to the procedures room. She looked weakened. Was this from a chemotherapy treatment she had received, or was it simply the dread of the procedure? I had no way of knowing. About 15 minutes later the girl was brought back out on a stretcher, lying face down. Mirna got up to help the doctor and two other nurses move her to the bed, using a bed sheet. She was conscious and soon began to move a bit more. When the lunches arrived at 12:30, she was not able to eat, and was too weak to get up for the washroom. Her mother emptied her bedpan.

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Jim and I took about a half hour break at 1:00, stepping out when Mirna did. This time we decided to go outside of the hospital grounds, choosing one of the nearby diners. When we returned Mirna was already back and working on files. Sabrina’s mother approached her and asked if her daughter could have her lunch now. “Yes of course,” Mirna replied. She brought the girl’s meal to her room. Sabrina, who was now sitting up in her bed and smiling, said something that made Mirna laugh uproariously. Jim and I had to leave at 3:00 that day, two hours before the end of the nurses’ shift. During the last hour or so that we were there, we observed Mirna charting data (often in communication with a doctor whom she asked for details and indications), preparing injectable medications, preparing oral medications, accompanying Lic. Barrera on her final rounds of her shift, and making phone calls related to patients (for example to the hospital pharmacy). During that hour, the youngest patient in the ward, an infant girl less than a month old, was taken to the procedures room in her mother’s arms. The mother entered with her, and the door closed behind them. We also saw the youth volunteers arrive for their afternoon visit. The troop of five made their way through the patients’ rooms, interacting with every child. That day they were distributing bags with paper symbols for some sort of game. Observing their interactions in Sabrina’s room, I saw that she was laughing at their antics. One of the volunteers told the kids to imagine their names if they replaced all the vowels, for example Magal instead of Miguel. The children looked engaged and entertained.

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Humanismo: An Institutional Quality These last scenes we witnessed in the Oncology Department encapsulated, for me, a dual reality of this area of the hospital. On an hourly basis there are heart-wrenching moments of society’s most innocent members dealing courageously with the pain, debilitation, life disruption, and uncertainty thrust on them by one form or another of cancer. And there are just as many moments of “humanismo” in the treatment of these patients by the nurses, doctors, and the broader gamut of staff in Hospital Bloom. Humanismo is a term that many nurses in El Salvador and Nicaragua use in reference to a character trait or orientation that motivates people to become nurses. In English it connotes something like genuine caring for, empathy with, and love of one’s fellow beings. Obviously this trait can be found in many other kinds of professionals and workers in organizations that serve the public; certainly this was evident in the Oncology Department. Nurses here are part of a fabric of staff and administrators in Hospital Bloom; the care they provide reflects an institutional ethos. But nurses also stand apart from other health-care personnel by the roles, responsibilities, and orientations in which they are trained. This distinctiveness resides partly in their constant presence with patients. This spatial and temporal proximity, which is seen particularly in hospitals, enables them to notice small changes in a patient’s evolution, to be a “voice of alarm” to doctors and the wider health-care team (to quote a Nicaraguan nurse I interviewed), and if necessary to intervene directly in emergencies. During my research since 2011 I had heard several accounts of urgent actions by nurses who had to think and act swiftly when no doctors were available. Another example

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of this emerged in my interview with Ofelia when I asked her to recall any instance in which she made an important positive difference in a patient’s well-being: “During a night shift, in the hospital there are residents who are on call who look over the whole hospital. We have interns who are students, not yet specialized, doing their internship. They generally substitute the doctor – the pediatric or cancer resident -- but not in all the decisions. During the night the staff is more limited. At about 1:00 or 2:00 am [one night], a patient developed complications, acquiring bacteremia. In Oncology that’s an emergency. A patient can die because it’s an active infectious process. The interventions have to be timely and effective to get the patient out of danger. In that moment I feel that my actions were effective. The patient was an adolescent. The mother expressed herself very well at the end of the shift. She called me her angel several times when she saw me….and she said that she felt safe which is very good for a nurse, not just in Oncology, but all nurses, that we know we are trustworthy for a patient or their relative.” Nurses are also trained in the inter-linkage of biological, psychological and social needs of patients. In this framework, empathy and understanding are not feminine graces, but a dimension of care that maximizes recovery and well-being. In observing Ofelia and Mirna, I saw numerous instances of empathy and compassion – humanismo – as they attended to their patients. In my conversation with her, Ofelia talked about the importance of taking the time to listen:

“They need that, the child as much as the parent. They have so much need for us to first, listen to them and attend to them. There are so many people inside and outside the hospital who need to be listened to, that need for us to look them in the eye when they ask us something, and that we give them importance as human beings and demonstrate with your gaze, that’s important to me…There are so many things that I can identify and keep in my mind, of one person, by simply looking in their eyes and responding to their psychological demands, not just fulfilling [tasks].” When she said this, I recalled that both she and Mirna demonstrated this direct acknowledgement of the children and the parents. They connected with them as persons, not as tasks that had to be completed. A second anecdote that Ofelia told in our interview reinforced the specific and crucial ways that nurses are present for their patients, addressing emotional needs that are linked to physical health. This story concerned an adolescent patient whose mother had to step out of the ward for a short time.

It is something very beautiful to feel that we are capable of helping someone in such an important moment.” To be fully realized, of course, these aspects of nurses’ training depend on adequate levels of staffing, as well as the availability and accessibility of medication, equipment, and medical supplies. Both staffing, and material resources, are structural features of health-care organizations and systems which influence the competing claims on nurses’ time. Humanismo in nursing care flows from individual character and motivation, and gets reinforced in high-quality training. But it also depends on the extent to which policy-makers recognize the role of nurses in attaining health outcomes.

“And when [the mother] left, the girl called me and took my hand and said ‘don’t leave, stay here with me.’ Because she felt fear and apart from that, I feel that an adolescent patient who is [old enough to be] conscious of what they are doing, if they take the hand of a nurse because they feel she’ll keep her company, and they feel safe when you’re present, and they know that if something happens you’ll know what to do to help, that is something that is so important. And it’s a role that no one other than the nurse can fulfill. At that time I had activities on the ward I had to do, but I stayed with her, because a human being is the most important thing.

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Post-Script: Recognition for Prevention of Nosocomial Infections Earlier I mentioned that nurses in the Oncology Department visit the hand-sink multiple times per hour. Undoubtedly if I shadowed any of the doctors I would have found a similar tendency. What matters is the frequency of hand-washing before and after each intervention with a patient. Preventing nosocomial infections, in other words, infections associated with health care, is a high priority for the Ministry of Health. This is seen in numerous MINSAL posters that we saw in the Oncology Department and in other MINSAL establishments, and in the fact that MINSAL Hospitals like Benjamin Bloom, and individual departments and units, have nosocomial infections committees with both nurses and doctors as members. Ofelia Benavides is one of the committee members for her Department.

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In April 2014, the Oncology Department won a diploma of recognition from the Hospital for having the highest frequency of hand-washing by doctors and nurses in the institution (though it must be said that the latter came out considerably ahead of their doctor colleagues). In a personal communication, Ofelia commented that this has been an important new area of doctor-nurse collaboration, and that hand hygeine, both with washing and with the use of anti-bacterial gel, has an enormous impact on patient health.

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Chapter Five: Benjamín Bloom National Children’s Hospital: The Intensive Care Unit The ICU at a Glance The ICU is on the second floor of Benjamin Bloom Hospital. During the daytime, it seemed, no non-staff member approaches the entrance of the Unit without stating one’s business to, or being okayed by, the security guard who patrols this part of the hallway. This contrast with the Oncology Department, I later surmised, had to do with the store-room of drugs and medical supplies in the ICU. As one enters the unit, one of the first things one sees is a tiny room with laundered hospital shirts for visitors to cover their street clothes, and beside this, the unmarked doors of a staff meeting room, a nurses’ kitchen and dining area, a lockerroom, a doctors’ lounge, and (in interesting contrast with the Oncology Department) a change room that is just for the nurses. At the end of this hallway and around the corner are four glass-walled single-patient rooms, two of which are air-lock cubicles for burns patients, and two cubicles marked as isolation units. Across the corridor from them is a room frequented mainly by nurses and

assistants, for disinfecting certain kinds of equipment and for measuring and discarding discharged fluids. This long corridor gives way to a more open rectangular room with the other 12 beds, the nurses’ station, a medication supply room, and an area for preparing injectable medications. The Unit’s 16 patient capacity, we were told, is practically always full. As we were able to observe, many of the ICU patients at any given time are likely to be very young infants, some in incubators. A steady whirring and beeping of monitors and other machines around many of the beds distinguishes this as a critical care area where patients need constant monitoring and in many cases also mechanical assistance for breathing, for drainage of fluids, etc.

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INTERNATIONAL ASSISTANCE The ICU is one of the units that has seen the benefits of international cooperation initiatives toward the Hospital. It has received donations not only of material equipment but also of time and expertise of foreign specialists. Our visit to the Unit coincided with a period in which this was very visible; a session of cardiovascular surgeries performed with crucial assistance and guidance of U.S. specialist doctors was underway all that week. Three nongovernmental charities collaborate to fund this program which started in 2012: the Los Angeles-based Gift of Life (founded by Rotary Clubs of the US); the Salvadorean and U.S. Rotary Clubs, and a Salvadorean charity created by Gift of Life, called Látidos de Esperanza (Heartbeats of Hope). The program provides Salvadorean specialists (both surgeons and nurses) with preparation and training for the surgery that corrects lifethreatening heart defects, while U.S. doctors and nurses donate their services for the operations and follow-up. The program has also provided state of the art equipment to the ICU and surgery units1. There had been several of these surgery sessions prior to the one in July 2014; in each instance, about a dozen Salvadorean children ranging in age from newborn to 13 years were selected as beneficiaries from among dozens of families that apply. Jim and I would spend a fair amount of time around two of these recently operated patients, and would take an inevitable interest in their progress, because they had been assigned to one of our nurse participants.

1. Orellana, Gloria Silvia. 2010. “Cirugías cardiovasculares en el Hospital Nacional Benjamín Bloom.” Diario CoLatino. June 10. h t t p : / / w w w. d i a r i o c o l a t i n o . c o m / es/20120726/nacionales/106000/Cirug%C3%ADas-cardiovasculares-en-el-Hospital-Nacional-Benjam%C3%ADn-Bloom. htm

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THE Nurses of the ICU As I had done with the Oncology Department, I approached Lic. Marta Luz Martínez, the jefa of nursing in the ICU, early in July to sound out her support for the ethnography and photography of the nurses. She responded enthusiastically and gave us a quick tour of the unit. The morning that we arrived to request participants and in hopes of beginning the work, Lic. Martínez summoned the day-shift nurses

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after the shift hand-over so that I could pitch the fundamentals of the study to them. Jim and I waited out of earshot while they conferred with each other as to who, if any, would volunteer to be shadowed and photographed. The two who stepped forward were Hilda Karina Martínez and Mirna Vásquez, who had 10 and 14 years of experience in the unit, respectively.

Ordinarily five nurses staff the day shift in the ICU – four regular nurses and the jefa. But for the duration of the heart surgery program they would need two extra nurses in each shift to accommodate the additional care demands. The organization of the nurses’ work in the ICU can be described as following the “primary” model of nursing care: each patient has one nurse who attends to all of his/her care needs during the shift.

This was the first unit in which I saw this model in action. Normally, each nurse in the Unit is assigned three patients. Because the heart surgery patients require more care, nurses to whom they are assigned take on only two patients during the shift. The day that we were observing, Karina was responsible for 18-month old Sebastián and 10-year old Jaime —both beneficiaries of the special program. As patients who had come quite recently out of the complex surgery (Jaime was 48 hours post-operative and Sebastián’s operation was more recent), they were immunocompromised and were therefore placed in the isolation units. Mirna was assigned three patients, all infants in adjacent beds in the main section of the ward. The fact that hers were “ordinary” ICU patients, not part of the special heart surgery program, gave us the opportunity to observe very different sets of activities. In alternating back and forth between Karina and Mirna during the shift, we ended up taking a bit more time observing Karina. This was largely because her interventions required more effort on my part to understand the purposes of the medical equipment these patients relied on, and the roles of the different care providers who were often interacting with her. Though the two nurses’ patient assignments were quite different from each other, I would learn equally from each one about what nurses do in the ICU, such as their use of various technologies, how they chart patient data, and the purposes of some common nurse interventions in this unit.

Mirna and Karina read the consent forms for the study

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ICU Observation: Day Shift We began observing Karina at 7:20 am, at a moment when she was conferring briefly with Lic. Martínez over the bed of 18-month old Sebastián. Karina explained to me that this child had been operated on to correct a congenital defect called “anomalous venous return”. Karina read and recorded the boy’s vital signs from a monitor above the bed. Because of the delicate state of these heart surgery patients, she told me, their vital signs were noted every hour; with more stable patients the readings are every two hours. “We note everything,” she said. In addition to the indicators on the electronic monitor, the amounts of urine and other fluids being drained are also recorded. As was standard for all the cardiac patients, both Sebastián and Jaime had urinary catheters which permitted measurement of urine output. At the foot of Sebastián’s bed (as at Jaime’s) there were two white rectangular “Pleurevacs” suspended close to the floor. This is a chest tube drainage device that removes fluids from the chest, collects it, and displays and measures the volume. To the American nurse, Johanna, who had recently entered Sebastián’s cubicle, Karina commented “It’s draining a lot!” The two conversed for a moment to the best of their ability; they both seemed to understand each other although Johanna spoke little Spanish and Karina spoke little English. The patients also receive intravenous fluids. Karina adjusted the electric-powered pumps that controlled the flow of several substances that Sebastián received, and read information from them. This was a new kind of IV device, she pointed out, that combined four pumps stacked vertically, thereby economizing floor space. Karina and her colleagues had recently been trained to use it. Karina spoke briefly with a doctor who came in to check on Sebastián, then emptied the patient’s urine, removed her gloves, washed her hands and moved over to

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Karina records the data from the Pleur-evac unit of a patient recently operated on for a heart defect

Jaime who was two cubicles away. Jaime’s surgery had corrected a condition called “tetrology of Fallot”, which is actually a combination of four structural abnormalities in the heart. The boy, who was conscious and demonstrating discomfort, moved the oxygen mask that was over his nose and mouth. “I’m thirsty,” he told Karina. She told him he needed to wait a little, and asked him if he wanted the head of the bed raised. “¿Te subo el respaldo?” “Sí”. Once she had gotten him from laying flat to a more reclined position, she continued recording information from his monitor and Pleur-evacs. Karina then put on gloves, emptied the urine, and washed her hands. Lic. Martínez had come into Jaime’s cubicle. The boy said that something hurt. She told him they would get him something for the pain. “Easy now, dear,” Karina said, caressing him. She left for a minute and came back with two large syringes to flush the IV line through which the medicine would be infused. She told me that Jaime had been given pain medication not long ago. The boy now looked a little more comfortable, perhaps because that analgesic was taking effect. Karina read data from his monitor, and reminded him gently not to pull on the cables or drainage tubes. Then she went back to Sebastián. It was 8:25 am. In Sebastián’s cubicle Karina squeezed the drainage tubes near the point where they exited his body. This would cause him a bit of pain, she told him. She explained to me that this was necessary so that the fluids would not coagulate. I found it interesting that although the patient was so young, and did not seem to be very conscious, she wanted to let him know what was going on. At that moment, a group of about 12 English-speaking foreigners entered the ICU, accompanied by several hospital officials. They clustered around the first four beds (the two airlocks and two isolation units), talking happily and excitedly. Several of them had cameras and began to take photos of

the cardiac patients. These were Americans linked to the NGO called Gift of Life which had provided the funds for the surgery sessions; no doubt these were people who had personally contributed. We overheard one say, “Come over here! This one is really cute!” When the visiting crowd had moved on, Karina and Johanna were communicating in Jaime’s room. They understood one another enough to collaborate in moving him from his bed to a chair, carefully keeping the cables and tubes in place. Karina gave the boy a drink of water and adjusted the IV pumps. When Karina left the room momentarily, I asked Johanna in English if this was the first time Jaime had sat up since his surgery. She responded that it was, and that this was important for the patient’s progress. Karina returned with a machine whose function I did not find out. She dashed back to the nurses’ desk to look at paperwork, looking somewhat harried. Yes, she told me later, the pace was definitely more hectic than usual with the surgery sessions. At this point we turned our attention to Mirna. When we approached her she was at the bed of one of her patients, a three-month old baby named Gabriela. The patient’s diagnosis was “cardiopathy”, as indicated on a small sheet taped to her bed, along with her age and name. Mirna told us that her parents had applied for the special heart surgery program but the nature of her condition made it too risky to operate. We watched as Mirna attempted to take a blood sample from this patient’s arm. Something that I found heart-wrenching and hard to watch was that the baby appeared to be crying, but emitted no sound; she seemed to have no voice. Mirna said out loud, perhaps to us or to herself, that she could not obtain the blood sample. Then she repeated the observation to a young medical resident who was working over another patient in an adjacent incubator. “¡Dios santo!” he replied quietly. Mirna told me that she would warm

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the baby up in hopes of facilitating a later attempt; her temperature was 35.5. She wrapped her in additional bed linens and placed a mint-green knit cap over her head. (The ICU is quite cool compared to other areas of the hospital; the air conditioning, I was told, was essential for the functioning of the electronic equipment). The next patient Mirna attended, one of her assigned three,

was a toddler who had been diagnosed with septic shock, who was now on the road to recovery. Mirna read and recorded his vital signs. At 9:45 am we returned to Karina who was conversing with Johanna by Jaime’s bed. Something about one of the new pumps was not working properly. “You did everything right,” Johanna was saying to her in English,

Measuring and emptying the uri

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ine output

“it’s the machine.” A moment later, one of her U.S. colleagues brought some sort of device that corrected the problem so that they could obtain readings from the pumps. Over the next half hour Karina checked the monitors, pumps, and fluids output of Sebastián and Jaime again at least once. During this time Johanna, together with a young American doctor, did some sort of intervention with Jaime. Meanwhile, Karina attended to a patient of a colleague who was taking her break, charting readings and draining the urine. While she worked at Sebastián’s bed, she took a moment to fill me in quickly on some aspects of the medical technology that is deployed for these patients. For example, the two tubes that are part of the Pleur-evac boxes have different names and each one drains a different part of the chest. The vital signs monitors capture two types of blood pressure: external (which is what is measured with an ordinary blood pressure cuff) and “invasive” which requires a catheter inside an artery; this is crucial when there may be rapid fluctuations in the pressure. Not long after this exchange, the U.S. specialist in charge of the surgery program, Dr. Alejo, approached Jim and me for friendly introductions. When I explained what we were doing he praised the Salvadorean ICU nurses for their skills. Karina took her morning break at about 10:15; she had been on her feet for four solid hours. At one point she said to Jim and me, “You’ll have sore feet today.” Her prediction proved to be accurate, since in the ICU I had less opportunity to sit while watching and taking notes than I had had in the other observation sites. Her comment was also quite thoughtful and considerate, since it was just a small taste of what the nurses themselves endure in this unit. Returning to Mirna, we found her attending to an infant for a colleague on break. The patient had been having difficulties breathing. Mirna and a couple of other nurses moved the patient’s bed to a different station. I heard someone, not

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Mirna, say that they were going to intubate her. For the next half hour I stood about six feet away to observe Mirna’s role and the multiple interactions in this procedure involving four doctors, a nursing assistant, and Mirna as the only nurse. The team moved the patient’s crib into a more open space where they could work, with Mirna keeping cables and tubing in place as they did so. She then wrapped the patient in bedding, and prepared and brought the intubation kit. One of the doctors began manual bag valve mask (BVM) ventilation. Mirna took a metal apparatus (a laryngoscope) from the kit and gave it to the doctor, who then removed the manual BVM and applied the device. He then inserted the endotracheal tube into the trachea. But this first attempt did not work; the light-bulb within the laryngoscope was not working properly. The doctor put the manual ventilation mask back over the patient, and one of the assistants resumed pumping. Mirna went to the supplies room to obtain a different apparatus, and gave this to one of the doctors. To the group she gave an instruction about the need to sustain the patient’s head, and she herself moved to do that. A second attempt by the doctor was again unsuccessful, and they reverted to manual ventilation. Mirna rushed to bring yet another new device, unwrapped it and brought it to the doctor. The two doctors who took more of a supervisory role did not look alarmed. Although the team members’ actions were swift and nononsense, signalling a definite urgency of the situation, they were smiling, calm, and amicable with each other. An outsider could only surmise that all of them had performed or assisted in intubations numerous times before. “The baby’s head!” Mirna reminded the team again. Finally, on the third attempt, success. Mirna went to get a roll of medical tape. A doctor attired in a suit had been teaching a group of med students in another part of the ward. When his lecture concluded he

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stood close to the procedure and observed the last five minutes. He offered some sort of advice, and then cracked a joke. Mirna placed tape over the baby’s nose to hold the apparatus in place. She recommended something to one of the doctors regarding the fluids that the patient would need. A short while later she brought a new IV pump to the infant’s bed, which was now back in its place. She prepared and administered a bag of hydration fluid with an added sedative. This was to ensure that the ventilation apparatus, which is quite uncomfortable, would remain in place. Shortly before 11:00 am it was time for me to seek out the parents of patients to obtain their consent for photography. Some 20 meters down the hallway from the ICU entrance, a dozen attached plastic chairs against a wall designated a waiting lounge. There always seemed to be at least a few people here during the day, with more as visiting hours approached. I would see relative strangers trading experiences and information with each other, others leaning against a wall, a few trying to keep an infant entertained. Earlier that month when I waited to speak to Lic. Martínez, I heard one parent telling another that he had been there for three days, and did not want to sit down because he did not want to fall asleep. “I’m looking for the parents of Jaime,” I said to the little crowd that had collected there already. I felt self-conscious about the impression I must have made with my hospital shirt over my clothes; did people think I was a foreign nurse or doctor, or that I simply had some kind of insider knowledge or authority? Did Jaime’s mother think that, as she approached me with a somewhat anxious expression? I explained to her who I was and why I wanted her consent to take photographs of the nurse attending to her son. She agreed without hesitation. Back inside the ICU I returned to observing Mirna. She was wheeling a machine that resembled a vacume cleaner from Gabriela’s bed to another one of the patients. The

purpose of this machine, which was called the oso (which means bear), is to warm up hypothermic patients. Mirna was replacing a lamp that was being used as an improvisational heater for this patient. The lamp, she said, can only be a temporary measure and in fact can be hazardous in the long term. She dusted it off before hooking it up and placing the end of the hose under the patientâ&#x20AC;&#x2122;s blanket. From the use of this machine, Gabrielaâ&#x20AC;&#x2122;s temperature had risen from 35.5 to 37, Mirna said, so a blood sample could be attempted again.

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When we rejoined Karina she was taking readings of Jaime’s vital signs and fluids. Next she went to Sebastián’s cubicle where three American doctors were working around him, speaking to each other in English. Karina detached the Pleur-evac and took it across the hall to the sinks area, then returned to the patient. For the next 10 minutes or so she took part in a procedure called a central line dressing change. The cubicle filled up briefly, with Dr. Alejo and at least one other U.S. doctor joining, along with Johanna the American nurse. Just before they started, one of the U.S. doctors said that they were going to teach this procedure to the nurses here. But in watching the team, it appeared to me that Karina did the work without instruction, changing her gloves a couple of times throughout. Afterwards she told me that she was showing the Americans how

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the Salvadorean nurses do this quite routine procedure. This was an interesting contrast in perspectives about what was going, one that I could probably have reconciled through deeper inquiry with both the Americans and the Salvadoreans regarding the way skills are shared or transferred. At 11:35, Mirna was preparing injectable medications with another nurse. One of these was an antibiotic for baby Gabriela. She shook the medicine in the syringe before administering it. This was to prevent it from sedimenting, she explained. While she injected the drug, the baby cried, again soundlessly. Karina meanwhile was having a discussion with Johanna about Jaime’s Pleur-evac tubes and morphine dosage. They were about to do a procedure in which they would change and separate the drainage tubes.

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This required administering a sedative to the patient first. Before they began, Karina replaced Sebastián’s nearly empty hydration fluid with a new one that was set to be administered over 24 hours. A conversation with someone I knew in the Unit distracted me for a few minutes. When I returned to observing Karina, the procedure with Jaime had already begun. Karina was assisting Johanna and a young American doctor, while two other U.S. doctors came by to observe and provide translation when needed. Karina took away part of the tube that had been cut and discarded it, then clamped the tubes near the drainage site. When they were nearly done, Johanna said several times to her colleagues that Karina was very good at what she was doing, and to Karina said, “You should come and work in the US.” Karina understood this testament to her competence, and smiled modestly.

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At 12:20 I went back to observing Mirna as she attended to one of her patients. We chatted about what she was doing at that moment, the pace and nature of the nurses’ work in the ICU, and her career. She showed me the standard chart that she was using to record patient information throughout the day. In this registro de enfermería, the nurses record details on, for example, the amounts, types and timing of medications they administer, the position the patient is lying in, whether their feeding is enteral (oral) or parenteral (intravenous). On the back of the sheet is a space to record any unusual events. The patient she was attending at that moment, she said, was receiving a medication that tends to increase blood pressure. Mirna was making note of the fact that her pressure was somewhat elevated.

Karina replaces hydration fluid for a heart surgery patient and resets the IV pumps

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Hand-washing. In the foreground, prepared infant formulas for the Unitâ&#x20AC;&#x2122;s youngest patients

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Some of the busiest times for nurses in the ICU, Mirna said, are weekends and holidays. It is particularly hectic for the nurse who is assigned the “in charge” role because he or she must oversee the work of their colleagues in addition to fulfilling their own patient assignments. She talked about a few kinds of responsibilities that fall to nurses but that are not really nursing-related. For example, they sometimes have to look for beds, cribs and IV pumps from other departments. Conversely, other units and departments sometimes call the ICU for medicines because it is so well supplied. Nurses are often on the phone trying to borrow, or loan, materials. It is rare that they leave less than 45 minutes after the official end of the shift. Despite these interruptions of nurses’ direct care and administrative duties, Mirna expressed immense enjoyment of her work. “God knows how one ends up in a place. Hospital Bloom was my first choice, Rosales my second choice. Our job is beautiful. And the kids often come back to see us.” I asked her about the fact that during and after the intubation, she gave instructions to the medical personnel, which intrigued me. She said that yes, she does sometimes tell doctors what needs to be done, and the doctors, residents and interns generally respect the nurses’ knowledge. Furthermore, the staff in this unit get along very well. “You saw how we were during the procedure. We all work in harmony for the sake of the kids. Any personal conflicts we leave outside.” At approximately 1:00 pm I went to see what Karina was doing. She was in Jaime’s cubicle, handling the small cables of one of the monitors. She then lifted this monitor (which looked rather heavy) from above the bed to a cart, explaining that a more recently operated patient needed it. This monitor, which could track two vital signs, would be replaced by one that captured only a single indicator. Yes, she said, this was an example of a shortage of materials. She installed the

less sophisticated monitor and reset it. I asked her when and how she had learned to work with these complex technologies. “The use of these machines is learned here in the Unit,” she said, “not something we study in school. How to set them, and read them. We have our training and practise on the job.” A few minutes later, the American nurse Johanna initiated a conversation with me. We had introduced ourselves some time earlier, and I had told her what Jim and I were doing here. She wondered what the Salvadorean ICU nurses thought of the American team, given that so many American ICU personnel had come through here. I said that I could only guess they greatly appreciated them, and I asked her if the Americans learn from the Salvadoreans. Her reply was emphatic: yes, they learned a great deal. For example, the U.S. approach in the ICU is to run a huge number of tests, some of which are probably not necessary. Here the patients do well without so many tests. Visiting hours that day began at 2:00 pm, an hour later than usual. Jaime’s mother noticed me on her way in, and stopped to talk with me. She looked very happy. The doctor had just told her that her son was progressing so well that most likely they would be able to take the drainage tubes out the next day. I congratulated her on this encouraging news. I then took advantage of the visiting period to approach Sebastián’s father for his consent for the photography. For the rest of the afternoon Karina’s and Mirna’s activities appeared to be standard ICU nursing duties similar to routines we had observed in the morning. In addition, there were diaper changes, injections to prepare and administer, and a new patient admission. After changing Sebastián, Karina wrapped him, and put his cloth arm restraints and oxygen mask back in place. She prepared and administered an IV of isotonic sodium chloride solution. I had another extended chat with Mirna late that afternoon, in which she told me more about her own career. She teaches nursing students here in this

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hospital, as an employee of the National University of El Salvador (UES). Recently she had completed a three month stint teaching in the Ophthamology Department and in a few months time would be teaching here in the ICU. The fact that this work is additional to her regular ICU shifts means that she sometimes has to work seven days a week. One way that she prevents fatigue from affecting her work is by making sure that her teaching shifts come after her regular shifts, so that she is not tired while attending to patients. She is supported in this by her jefa in the ICU, Lic. Martínez, who schedules the nurses’ shifts. “You get used to these [intense] schedules,” Mirna said. “It’s very satisfying work. You feel very fulfilled.” She also pointed out that when nursing students do practicums in the ICU, their teacher has to be a nurse in this unit, not from some other department or unit in the hospital. And although there are nursing practicums in the ICU, one does not find students in the social service component of their training here. At 4:15, Mirna and another nurse worked on the admission of a new patient who had just come out of heart surgery. Initially there were four or five doctors, along with the two nurses, inside one of the airlock cubicles where the patient was placed. A few more packed into the room to receive information, making it too crowded to listen or approach. Before Jim and I left the ICU just after 5:00 (before any of the day-shift nurses had left), I made arrangements with one of the other nurses who was on duty that day, Vicente Sánchez, to observe him during his next shift. I was pleased and grateful to have his collaboration since it enabled a glimpse of what the unit was like during a night shift. I would stay for about half the shift.

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L I Sheart A K O Wsurgery A L C H U K patient 199 Karina adjusts IV and monitor cables for

Karina administers medicine to Sebastiรกn. The cloth arm restraint can be seen here.

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ICU Observation: Night shift For this second observation period in the ICU I came without Jim. Unfortunately then, we have no photographs of Vicente at work. When I arrived at 5:15, Vicente was taking part in the shift handover. He stepped out of these rounds at the fifth patient and headed for the nurses’ station. Since he was assigned medicines inventory, he said, he had to complete the list of drugs that were used during the day shift. He rejoined the rounds about 10 minutes later. Vicente had three patients assigned that evening. There were six nurses on duty, two more than usual because of the heart surgeries. In contrast to my previous day’s visit, there were no U.S. doctors in the unit now. The only member of the U.S. heart surgery team who was here was Johanna, the nurse. Another contrast with the day shift is that now nurses outnumbered doctors. Shortly after visiting hours began at 5:30, I spoke with Joanna for about 10 minutes. She voiced high praise for the ICU nurses. She was also struck by the difference in their scope of practice compared to the U.S.. By this she meant that U.S. nurses are permitted to carry out more direct care responsibilities that in El Salvador are entrusted only to doctors. She speculated that one reason for this was the difference in the nursepatient ratio (3:1 one here, compared to 1:1 for pediatric ICU in the U.S.). Having more patients undoubtedly limited what the nurses can do. She had been at Benjamin Bloom Hospital since Monday and would be leaving on Sunday. Though she observed the first couple of cardiac surgeries, her principle role was in post-operative recovery. A few minutes after our conversation, she asked Vicente to take a photo of her together with one of the heart surgery patients – a boy of about two years of age -- and his mother, using her own cell phone. I noticed that Vicente and the other nurses occasionally asked one another, “who has the key?” in reference to the medications

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supply room. At 5:50 pm Vicente pointed out to me that one of the day-shift nurses was still working; she was still completing the shift-handover, not receiving patients but rather, supplies. This is an important function, and nurses are responsible for any missing thermometers or other items. Just after 6:00 pm Vicente left the ICU to get the nurses’ dinners from the hospital kitchen. When he returned he prepared some injectable medications, then charted some information on a nine-year old girl, Laura, who was one of his patients. He did this at her bedside, and spoke with the girl’s father for about ten minutes. He explained what he knew about the girl’s condition, answered questions, and assured him that she would receive the necessary treatments. The visitors had to leave at 6:40. I watched as parents said good-bye to their children, lingering as long as they could. Laura’s father was one of several who left with tears in his eyes. For me, this one of the more difficult moments to witness in the ICU, leaving me with a lump in my throat. I observed Vicente attending to his other two patients, both infants diagnosed with pneumonia. One of them was two months old. He was in an incubator, Vicente said, because he was underweight and needed to be kept warm. The other child was on a mechanical ventilator. He read and recorded their vital signs. I asked him whether the temperature is one of the vital signs that is automatically monitored. He said yes, this machine does do an axillary reading. To demonstrate, he took a sensor from the monitor and put it under the baby’s arm, and we watched the device register the temperature. A few minutes later I pointed out that the sensor had fallen out of place. This is one reason why they do not really use it very much, he said. Nine-year old Laura seemed to be asleep when Vicente checked her IV pump and cables, but awoke when he approached. She asked him something that he had to get her to repeat a couple of times. Did she want

to be moved up in her bed?, he asked her. “No”, she said. Stepping away from her bed, Vicente asked the doctor who was seated at the nurses’ station whether it had been confirmed that Laura had Hepatitis. Yes, she replied, but the origin was not known, and arthritis was also possible. “What kind?” Vicente asks. “They don’t know.” Vicente told me that a specialist would have to come and assess her; he added that it might be auto-immune arthritis which would explain her breathing difficulty, and that she would probably need to be intubated. At around that time, we noticed that Johanna was talking to the toddler whose photo she had taken a bit earlier, with his mother. The boy had been crying after his mother left. Johanna was showing him something on her cell phone, which she also showed Vicente and me. It was a photo of a pug dog (hers) with a ridiculously long tongue hanging out. The boy seemed mesmerised by the photo, no longer crying though there were still tears on his cheeks. At 7:20 Vicente obtained a bag of type O+ blood, hung it over Laura’s bed, and connected it to the IV port on her arm. He then told me a little more about this patient. She had been admitted that day with a fever that was probably the result of the infection caused by the Hepatitis. She needed the transfusion because she was losing blood where the IV connected to her arm, because her blood was not coagulating. He looked at her chart and read me her ferritin level, which was well below the anemia borderline. One cause of anemia, he said, can be loss of blood. When Vicente took his dinner break at 7:45 I went along with him. Although the nurses are allowed two 20-minute breaks, he said, there are times when the demands of the unit leave them without time to sit down and eat. Benjamin Bloom Hospital provides food for the staff (doctors as well as nurses) on the night shifts; hence his trip to the kitchen earlier. Several other people had told me that this benefit used to be provided

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to both day and night shift staff. The logic of retaining it for those working at night, I surmised, must be the lack of any place to buy a meal near the hospital during those hours. In the nurses’ break room, Vicente showed me what the food for him and his five colleagues on duty that night consisted of: six deep-fried tortillas soaked in honey; a bag of pureed beans, and six buns. It did not look like enough food for six dinners; snacks, maybe. Two of Vicente’s colleagues were in the nurses’ dining room at that time, and I noticed they, like Vicente, had brought their own food from home. They concurred that what the hospital provides could only be regarded as a supplement to their own food, but that it was better than nothing. I asked whether the doctors receive the same thing. The doctors get these same items but usually with something additional, they said, and it is served in meal containers rather than in clear plastic bags. Another difference is that the doctors’ meals are brought to them, so that they do not have to delegate one of their own to get them. For staff working on the higher level floors this is a considerable time savings, given how long one waits for elevators. When he returned from his break, Vicente attended first to Laura. She expressed the need to urinate, and he brought a bedpan and helped her to use it. I realized this was the first time I had seen the bedpan being used in the ICU. The other children I had observed with the nurses here either had bladder catheters or diapers. After helping the girl with this necessity, Vicente removed his gloves, moved her up in her bed, and made a note in her chart. Next, he attended to one of his other two patients. Reaching into the incubator, it took him about a minute to connect a new bag of yellowish-orange IV fluid that the infant was to receive. He explained that this IV substance was plasma: a blood product without the red blood cells. He was also administering a diuretic so that the plasma would not overwhelm the baby’s lungs.

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Laura’s transfusion was almost finished, and she now looked more alert. Vicente told her that they were soon going to give her a sondita (sonda being the word for urinary catheter). She said that she needed to pee again. A few minutes later a doctor drew a blood sample, and asked a nurses’ assistant to get the bedpan. The assistant reported the output to Vicente as 500 cc. After ten minutes of gathering materials, Vicente, wearing a mask, brought a cart to Laura’s bed with equipment for the procedure. Checking her arm, he reported to the doctors who were doing desk work at the nurses’ station that the bleeding still had not stopped. While he searched for another ten minutes in the supplies area for the right-sized catheter, the assistant spoke kindly to Laura about what they were going to do. Vicente showed two catheters of different sizes to the more senior doctor, who selected one. While the doctor conducted Laura’s procedure with Vicente and the assistant helping, I moved a few meters away where I could not visually observe them. This was more out of squeamishness on my part than anything else; I could have observed from a distance without seeing anything of the procedure itself. The doctor’s work was done within ten minutes, leaving Vicente and the aide to do the rest. They adjusted bed linens to improvise a pillow to sustain the girl’s knees, turned her so that she lay on her side, and placed several bed sheets behind her. Vicente took her temperature; it was 37.5, lower than the last reading. A little while later, he replaced the patients’ empty blood bag with a plasma drip. When I asked him why this patient needed the urinary catheter, he explained that the doctor wanted a more precise reading of her urine output because she has been so unstable. Alejandra Castillo, the nurse supervisor on duty that night, came into the ICU on her rounds at about 9:45. I noticed that her approach was literally “hands on”: she looked closely at all the patients, touching each one, and listening intently as each

nurse gave her report. After filling Alejandra in on his patients, Vicente carried out several routine activities. He did some charting of information at the nurses’ station (and, noticing that he did this standing up, I realized that I had hardly ever seen him sit down during the shift); read and recorded his patients’ vital signs from the monitor, and changed the diapers of the two infants. Some time after 10:00 pm the lights over the patients were dimmed. Nurses placed small cloths over the children’s eyes to provide them with some additional darkness. During my last hour in the ICU, at one point Vicente spent about 15 minutes preparing intravenous medications. Several of the other nurses were doing the same in this room behind the nurses’ station. The interaction among them was jovial, with Vicente clearly the one coming up with comments that made his colleagues and even the two female doctors crack up. Overall the atmosphere seemed somewhat more relaxed than during the day shift. If laughter is crucial to health-care givers’ ability to deal with stress, as one doctor had commented to us in Hospital Saldaña, then this was certainly a valid and very human way to work, in what must surely be one of the most stressful areas for nurses in a children’s hospital.

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conclusion As is the case for hospitals everywhere, the nurses in the ICU at Benjamin Bloom need to have a considerable amount of pediatric hospital experience behind them before they can begin to work in critical care. Even with prior experience, their initial learning curve in this unit is steep. The knowledge they need to develop is highly specialized, not only for mastering the use of complex medical equipment, but also for dealing with the breadth of different life-threatening pathologies with which their patients present. That is another distinguishing feature of an ICU. As well, it is safe to say that more than in most other divisions of the hospital, ICU nurses must know how to recognize and deal with sudden, serious complications. To quote a nurse from this ICU whom I interviewed in 2010, “this is an area in which we’re alert for the entire twelve hours because the patients can present something at any time. They’re unpredictable, even when they seem to have come out [of crisis].” Facilitating their ability to closely monitor patients’ conditions in the ICU is a more favorable nurse-patient ratio than in the non-critical care areas of the hospital (and other MINSAL establishments). This may be one reason why, as Mirna observed in an informal conversation we had with her later, the ICU in this hospital has an unusually low rate of nurse absenteeism. And this was fortunate, she added, because it is very hard to get someone from another unit to substitute someone in ICU. I did not inquire of anyone at Benjamin Bloom about the comparative incidence of absenteeism across the hospital. But something that my prior interviews and focus groups in El Salvador and Nicaragua made clear is that nurse absenteeism is generally a serious problem in the state-run hospitals in these two countries. This information from my broader study, along with international literature on nurses’ working conditions,

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point to overwork, injury and illness produced by short-staffing as a fundamental cause. While the over-work related health problems of nurses lead to absenteeism, they are also a result of it; It is a vicious circuit. The day after my observations in the ICU, I received disturbing news from a friend who worked elsewhere in the hospital in a different health-care profession: two of the special heart surgery patients did not make it. She did not know their names, but I found out later that one of them was 10-year old Jaime. I felt shocked and incredulous as I thought back to his mother’s joy when she relayed the doctor’s hopeful news. This was of course a grim confirmation of the unpredictability and variability of the patients’ condition, spoken of my by interviewee. It also reflected the inevitable and indeed routine emotional challenges that come with ICU nursing, challenges which are perhaps magnified when the patients are children. And yet nurses like Mirna feel fulfilled working in this unit. To understand what sustains them, one has to consider the inherent rewards of the work. I have heard nurses and nursing students in El Salvador say that they simply thrive on the stimulation and pace of the “área de choque”, in other words an area of crisis and emergency. It must also be remembered that the ICU personnel save many children as well. Again, many nurses in my broader study spoke about the sense of pride and purpose they feel in seeing their patients evolve from a critical condition to full recovery. The satisfaction this brings is not contingent on being thanked by the parents, though many times they are thanked. But even when patients do not survive, nurses speak of feeling a deep satisfaction in knowing they have done everything within their grasp to ease the suffering of child and parent alike. In this regard, when I asked another nurse from this ICU in an earlier interview to talk

about what she found rewarding in her work, she recalled the following anecdote: “One satisfaction that I once had, that I will always remember, was a mother who arrived and looked for me, and said “Señorita Elisa2, I want to thank you.” “Ahhhhh!”, but I didn’t remember her, and then when she approached me and says “I’m the mother of Rafaelito.” “Ah yes,” I said, “How is he?” “He died already,” she said, “But I want to thank you, because I believe that my son has taken you with him in his heart, and that in heaven he must be remembering you, because no one treated us better than you in the ICU.” In spite of the fact that we did not save her son’s life, but she remained grateful…It’s very different when your child, or the child of that person ends up recovered, then it’s easier to go and thank people. But to go and express gratitude knowing your child died, usually you don’t want anything to do with the hospital. That was the greatest satisfaction I have experienced…Because it fulfills you, because you say to yourself I did my work well. I did what I needed to do.”

2. Not her real name

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The selection of the clinical sites for this ethnographic and photographic study enabled a glimpse of nurses’ hour by hour activities across the three levels of care in El Salvador’s public health system: primary, secondary and tertiary. In the primary sector, we observed a nurse who forms part of a multi-disciplinary team of providers that has daily contact with people in their communities of residence, often in their homes. This was the Community Health Team (Equipo Comunitario de Salud or ECOS) of Quezalapa, in the cantón Planes de Rendero, on the edge of the capital city. A different type of primary sector setting was the UCSF San Jacinto, a large, urban, specialized clinic whose main function consists of out-patient consultations, many of which are carried out by nurses and auxiliares. And we observed nurses in two in-patient units in a second and third level hospital, the former institution being a generalized family hospital and the latter a specialized children’s hospital with an international reputation. Broadly speaking, the most obvious dividing line in the types of roles that nurses assume in the establishments we visited is that between the primary sector entities on the one hand, and the hospitals on the other. In the former, education, prevention, and the facilitation of early diagnosis are at the forefront of nurses’ responsibilities. Conversely, nurses whose patients are hospitalized exercise their skills within the curative mission of those institutions. But this division is blurrier than it might seem. Across all three levels, nurses contribute crucially to health-care goals involving the prevention of illness. Of course,

it is in the primary sector that the main focus is on reducing or eliminating a broad array of pathologies and illnesses, contagious or otherwise, and within that, it is nurses who have the decisive educational role. For example, toward the aim of reducing maternal and infant mortality, they educate pregnant women on nutrition and on the early signs of possible problems. They also assist these women (and as we saw, gently cajole them) in devising a plan for emergency transportation to a health-care facility, availing themselves of the health promoters and community leaders. Also in the primary sector, nurses help women to plan and prevent pregnancy; they counsel people of all ages in the prevention of HIV transmission. But in the hospitals as well, among all the staff who have direct contact with patients, nurses are probably the most active in preventing nosocomial infections and teaching this practise to patients’ relatives. It is nurses who form the majority of the nosocomial infections committee members. Secondly, nurses have the main responsibility for educating parents to participate in the care of their seriously ill children during and after hospitalization. These are just a couple of examples of nurses’ preventive and educational roles within hospitals. Across all three levels of health-care in the MINSAL system, nurses help to heal and cure, and are technically, scientifically trained. In regard to these functions and characteristics of nurses, the hospitals come more readily to mind because of the greater sophistication of the material technologies they use, and because there are a greater number of L I SA KOWA LC H U K

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physically invasive interventions. As well, hospital nurses must exercise enormous care and precision in administering prescribed intravenous treatments including antibiotics, chemotherapy and blood transfusions. Though it is commonly thought that they simply follow physicians’ indications, they have the pharmacological knowledge to question a dosage when necessary; there were several examples of this from the interviews and focus groups in the broader study. In the typical hospitalization unit, nurses insert venous catheters numerous times per day. Some deal with multiple types of complex equipment, as seen in the complicated-looking nest of tubes and cables connecting patients to machines in the ICU. But notwithstanding the material resources of Benjamin Bloom Hospital’s ICU, bolstered as they are by international cooperation, high-tech medical equipment is scarce in the public sector hospitals. Furthermore, to be deployed properly these machines require the expertise of nurses who have years of schooling and on-the-job experience. An interesting characteristic of nurses who do their clinical training in public sector facilities and continue to work there, is that they become experts in improvising; they learn how to deliver care with minimal modern technologies. For those who study nursing in El Salvador’s only public University, improvisation is part of their training. Though the University of El Salvador (UES) is a high-calibre institution, students do not have the very best or latest laboratory equipment. My focus groups revealed that this was a source of pride for nursing students in the public universities in El Salvador and Nicaragua, precisely because it prepared them to deal with the realities most of them would encounter in their work. What should not be overlooked is that nurses also perform various kinds of curative roles in the primary sector. They intervene in the recovery of tuberculosis sufferers when they administer the Shortened Strictly Supervised Treatment (SSST). They tend to

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a variety of types of wounds on their own or assisting a physician; they deal daily with emergencies (like the woman with preeclampsia in the UCSF San Jacinto) which may entail accompanying a patient to the nearest hospital. And although we did not witness it, I heard several accounts by nurses in Nicaragua and El Salvador of life-saving interventions in remote regions when no doctors were present. Common to nurses and all health-care professionals across the entire public health-care system is that the majority of their patients are from the lower income sectors of the population. Most are people who, because they do not have jobs in the formal sector of the economy, do not have access to the Social Security Institute (ISSS) clinics and hospitals where staff to patient ratios and material resources have traditionally been superior to MINSAL. In all countries, the social determinants of health include the employment rate, the quality of jobs (for example, whether or not they are secure, full-time, and unionized), the extent of inequality in income and wealth, inequalities in access to public infrastructure like potable water, the spatial distribution of environmental hazards, etc. These are largely stacked against the working poor, the informally employed, and the unemployed in a less developed country like El Salvador, and can only be fully improved by an array of policies and programs, some of which are not determined solely at a domestic level. But the way the formal health-care system is funded and organized is undeniably one piece of the solution; equality of access to health services is, in itself, one of the social determinants of health. In 2009, El Salvador embarked on a re-organization of its healthcare system with a goal of bringing care to those sectors of the population neglected and marginalized through neoliberal policies. Underpinning the reform is the tenet that health is a human right, not a commodity that depends on one’s income. The FMLN government increased the National Health

Expenditure by 26.7% during its first five year mandate . Within this greater overall investment in health, the emphasis on the primary sector has been an extremely wellconceived, well-informed strategy toward reversing the damage of two decades of neoliberal health policies. This has been attained largely through the creation of the ECOS and a greatly increased number and enhanced quality of UCSFs. The government has made strides toward additional objectives laid out in the healthcare reform blueprint, Constructing Hope, including the modernization and expansion of several hospitals; increased numbers of doctors, nurses and other health-care workers; enhanced health-care training programs; improved access to medicines, reduced wait times for essential services, improved capacity to respond to healthcare emergencies such as dengue, etc2. But in relation to nurses’ role within the government’s ultimate objectives for health, at least one key deficiency in the MINSAL establishments remains unaddressed. In this regard, the Pan-American Health Organization (PAHO) makes the following observation about the kind of expansive reforms that have been carried out in El Salvador and several other Latin American countries: “The revitalization of individuals as agents in their own health involves the capacity to claim their rights and to exercise assertive demands in regards to the medical act. This potentially creates spaces of conflict between health professionals and healthcare users, instead of a shared vision of the objectives of the health-care system – closing the gaps in access and guaranteeing the quality and humanization of the treatment.” In other words, while the goal of bringing more of the population into contact with health-care services is indispensible for upholding the human right to health, and ultimately improving national health indicators, an increase in demand on the

system in the absence of other policies to improve workers’ conditions is a recipe for strain and conflict. To protect the interests of both the recipients and providers of care in the process of health services expansion, the PAHO recommends complementary policies to improve nurses’ work conditions and safeguard their labour rights. It calls on governments to ratify International Labour Organization (ILO) Nursing Personnel Convention 149, and ILO Nursing Personnel Recommendation 157, documents that are quite general and therefore adaptable to many different countries’ circumstances. At the same time, the articles in Recommendation 157 pertaining to Working Time and Rest Periods are compatible with the FMLN government’s commitment to increase the number of permanent nurses’ positions throughout the MINSAL system, a commitment that is still unrealized. Nurses are at the front lines of the services that the FMLN administration has been striving to expand, but thus far they have seen no improvement in the nurse-patient ratios in the MINSAL institutions. This has negative implications for both nurses’ and patients’ well-being. One need look no further than Nicaragua to see the effects of a failure to match increased patient demand with any relief for a grossly overworked, understaffed nursing work force.

1 MINSAL 2014. Informe de Labores 2013 a 2014. The FMLN won a second mandate in the March 2014 Presidential election. 2. Readers can learn more about the advances in the MINSAL’s annual reports, available online at: http://www.salud.gob.sv/servicios/ descargas/documentos/DocumentaciónInstitucional/Memorias-de-Labores 3. Pan-American Health Organization (PAHO). 2011. Regulación de Enfermería en América Latina. Serie Recursos Humanos para la Salud No. 56. Washington: OPS: Area de Fortalecimiento de Sistemas de Salud: Unidad de Recursos Humanos para la Salud, p. 1. My translation from Spanish to English.

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The additional problem in Nicaragua is that patients have been encouraged to formally denounce perceived inadequacies in the treatment they receive in the public system. Rising incidence of threats, denunciations and legal actions by patients have added enormous psychological stress to Nicaraguan nurses’ work lives, in effect, fulfilling the PAHO’s warning, while generating what has been named elsewhere a culture of “defensive care”4. Furthermore, patients also suffer. “Failure to rescue” is a term used in studies about medical errors, with “rescue” understood as an intervention that “prevents a clinically important deterioration, such as death or permanent disability, from a complication of an underlying illness.” 5 It has been demonstrated in quantitative studies that failure to rescue on the part of nurses is due largely to short-staffing. When the nursepatient ratio is reduced, patient mortality increases. It is time for the government of El Salvador to aim for a greater balancing of two goals: that of expanding services to cover geographic zones and sectors of the population previously excluded, and improving the quality of services in the existing institutions. This depends vitally on better staffing, and specifically, more permanent positions for nurses. While completing the draft of this book I watched two visual media representations of health-care workers. One was an episode of the PBS TV series, “Pioneers of Television”. The episode called “Doctors and Nurses”, from the 2014 season, is supposed to be an overview of the way U.S. television dramas since the 1950s have portrayed these two types of health-care professionals. In reality the show focused overwhelmingly on the portrayal of doctors. Perhaps two or three minutes of the hour-long broadcast focused on one nurse from the 1980s show St. Elsewhere, played by Christina Pickles. The PBS show replays a 30-second segment of a St. Elsewhere episode in which the nurse

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walks briskly down a hospital corridor trying to keep up with the Chief physician, played by Normal Lloyd, wringing her hands and voicing anxiety about some patient. The other media representation I watched was Barbara, a 2012 German movie set in the Soviet Union of the 1980s, about physicians in a small town hospital. Remarkably, in this otherwise excellent film, the doctors’ hour to hour work resembled pretty much what I had observed nurses doing in the Salvadorean hospitals. They even sat watch at the bedsides of their sleeping patients for hours at a time. Nurses were entirely absent from the film except as blurry, white-attired women folding linens in the background. In both of these media works, the doctors are variously eccentric, cold, clever, kind, hugely compassionate, but always heroic. In neither case do we get any sense whatsoever about nurses’ activities or their role in people’s recovery from, or prevention of, illness. Nurses were forgotten. I stated in the introduction to this document that I wanted to look for, and convey, the ways Salvadorean nurses contribute to the well-being of their patients despite physical and human resource limitations. Material resource constraints, which are lamented as much by doctors as by nurses, as we saw in Hospital Saldaña, lead to interruptions of nurse-specific activities by tasks such as searching for supplies, medicines or equipment.

4. Guevera, Edilma B. and Elnora P. Mendias. 2002. “A Comparative Analysis of the Changes in Nursing Practice Related to Health Sector Reform in Five Countries of the Americas.” Pan American Journal of Public Health 12(5): 347-353. 5.http:// psnet.ahrq.gov/popup_glossary.aspx?name=failuretorescue

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With short-staffing, there is higher risk of injury and illness. The absentee in the Oncology Department on our first day of observation there was certainly suggestive of this kind of problem. The vicious circuit of absenteeism with overwork, injury and illness was not something I asked people about during my observations of the nurses’ work, nor did I inquire how staffing levels affected their physical state. But this was something nurses spoke about in the wider project, and is also reinforced in other scholarly studies. Furthermore, overwork is compounded by unpaid overtime, which in addition, is effectively a salary reduction. Nurses bring together scientific knowledge and technical skills, with a vocation for “humanismo”. They feel fulfilled in their work by the fact of helping others. This came across in many of the conversations I had with the nurses who participated in this phase of my study: in accounts of intervening to “rescue” a patient from a sudden crisis; being the main support for a patient fearful of being alone with their illness; doing everything possible for the

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recovery of the critically ill or injured, and making them as comfortable as possible; staying in touch with colleagues after hours to communicate about at-risk patients. Observing the nurses who volunteered for this e-book, I got the strong sense that to enter and stay in this profession requires a certain kind of character and personality: one needs to be incredibly unruffled, easygoing, capable of smiling through exhaustion and being treated by some patients (however affably) as a servant. Good cheer and humanismo are individual traits that can be reinforced through training. But they can only be fully deployed when the value of nurses’ contributions is fully recognized. The same is true of the knowledge and skills that that nurses accumulate through years of training and work experience. The invisibility or distortion of nurses in news and entertainment media undoubtedly both reflects and reinforces perceptions and real social relations in society. What is needed therefore are changes in the way health-care employers, but particularly governments, value nurses’ contribution.

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This e-book would not have been possible without the logistical and intellectual support of the nurses in El Salvador’s Ministry of Health (MINSAL), particularly Concepción Castaneda, Director of the MINSAL Nurses’ Unit, and Sofía Viana de Abrego and her colleagues of the Research Nucleus within the Nurses’ Unit. Special thanks also to Ana Miriam de Landos of the Dirección Regional Metropolitana de Salud, and Blanca Gutierrez of SIBASI-Sur. I am also deeply grateful to the nurses who facilitated my access to their workplaces by pitching the idea to their colleagues and helping me to recruit volunteers: Elizabeth Elías, Antonia Murga de Silvestre, Marta Luz Martínez, Angela Ostorga, Donald Ramos, and Dinora de Recinos. And to those volunteers, the nurses who so graciously agreed to be observed and photographed during their daily and nightly work routines, I cannot thank-you enough for your patience and generosity of spirit: Cecilia Ramírez, Donald Ramos, Sandra Barraza, Julissa Zelaya, Nora Najera, Mónica Vanessa Torres, Karen Elizabeth Oliva de Reimundo, Carmen Lorena Vásquez, Angela Ostorga, Reina Elizabeth Ramírez, Ofelia del Carmen Benavides de Polío, Mirna Esmeralda de Girón, Vicente Sánchez, Hilda Karina Martínez, and Mirna Vásquez. A very special thanks to Alejandra Castillo who facilitated countless connections, and gave crucial advice, encouragement and support over the three and a half years from the initiation of the field research to the final phase. Enormous thanks as well to Mary Angela Elías Marroquín for her invaluable help and support. Also crucial to the e-book endeavour were a group of highly competent, diligent and energetic assistants in Toronto, San Salvador, and Mexico City who gave of their skills and creativity to various aspects of the project: Sara González, Irma Molina, Aleks Phoenix Correa and Hernán Sicilia. Aleks’ deep understanding of, and enthusiasm for the project, combined with an expert eye for beauty and logic in visual composition, made the document come to life as a book. Hernán is one of the best English to Spanish translators anyone could ask for. What a blessing to have found the two of you (thanks Irma!) I would be remiss if I did not mention Sandy Auld, Director of the University of Guelph’s Research Ethics Board, who read and processed my lengthy research ethics “change request” application in a remarkably expedited time period during the summer break of 2013 so that we could conduct the ethnography and photography. Finally, the e-book would have remained a purely narrative product were it not for the handiwork volunteered by Jim Gronau. The images in these pages evince the keen eye and humanist sensitivity that he brings to all his “social landscape” photography. Thank-you, Jim, for your meticulousness, patience and perseverance, and your dedication to the goals of this project.

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With a Ph.D. from York University (2000), Lisa Kowalchuk has been with the University of Guelph’s Department of Sociology and Anthropology since 2004. Prior to that, she worked for four years in the Department of Sociology and Criminology at St. Mary’s University. One of Kowalchuk’s main research interests is social movements and collective action. She has done research on small and landless farmers’ efforts to deepen and defend land reform, and maintains an interest in the fate of existing land reforms under state efforts to unravel them. She has also studied collective resistance to neoliberal globalization in Central America, with a specific focus on healthcare services. Issues of gender justice in the developing country context are another area of interest, and have been a theme of several courses she has taught. She has recently turned her attention toward the area of work and occupations, combining this with her ongoing interest in health-care policy and gender issues.

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The design and edition of this e-book concluded on November, 2014. Its release will be determined by its editors. The intellectual property of the work, as well as the graphic elements and the photographs, belong to the authors. Any unauthorized reproduction is prohibited.

PHOTOGRAPHER WEB SITE

www.jim gron a u.com

What nurses do: a glimpse of their work in El Salvadorâ&#x20AC;&#x2122;s public health-care system Lisa Kowalchuk, 2014 photography by Jim Gronau graphic design by Aleks Phoenix funded by The Social Sciences and Humanities Research Council of Canada ISBN 978-0-88955-623-2 (ebook)

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