Matter entangled with power

Joyner, Shefer & Smit 2014:45) state that “the discourses and practices shaping institutionalised nursing internationally, coupled with local historical legacies of gender, class, racial and socio-cultural inequalities, diminish the possibility of democratic, socially responsive and humane care in South African healthcare institutions”.

Matter is entangled in the power relations that play out in the health system and are particularly evident in Obstetrics. Our students, in their being and becoming doctors, get caught in these intra-actions. Materiality matters in maintaining the status quo of a system that is strongly influenced by surveillance and fear.

This hierarchical division of labour is entrenched in the South African health system in (Joyner, Shefer & Smit 2014:40). It is represented by symbolic emblems that mark the rank and status of each actor, and subsequent power. The white coats and stethoscopes indicate those with an MBChB qualification and beyond, while the nursing profession wear epaulette bars of different colours to show the categories of nursing in which they are registered and enrolled. These distinguishing devices, (as named by the South African Nursing Council) make visible their rank and responsibility. For instance a green bar signifies midwifery expertise.

Our students enter and exit from this system during their clinical block rotations. Their student cards give them access to the facilities where they learn the skills to become competent as indicated by the curriculum requirements. In Obstetrics, the sign-off of deliveries becomes the pot-of-gold that determines students’ agency. At times they feel helpless when caught in the entanglement of the web of relationships within the health team. When uncaring behaviours are witnessed, there is evidence that they emanate from all ranks within the hierarchy. While disciplinary processes are in place with complaints procedures through various mechanisms, the power relations do not encourage responsible responses to promote accountability.

This image (created on Adobe ideas) represents the entangled nature of the relationships present in the learning environment of Obstetrics. I was imagining a flattened relationship between all the actors in the Maternal Obstetrics Units. How different would it be if these markers of rank were removed?

Joyner, K., Shefe, T. & Smit ,E.  2014. Discourses and practices in institutionalised nursing in South Africa: Challenges for care, South African Review of Sociology, 45:3, 34-5.

Glow glimmers

The design and arrangement of public birthing facilities has emerged as a key theme in my research. Much of this reflects a hierarchical and biomedical approach whereby efficiency for the medical team appears to override patient comfort. For instance, curtains that separate cubicles tend to offer little privacy, contributing to the prevalent disrespect. When a woman screams or a midwife shouts, everyone hears it.

Last week I was invited to walk around the labour ward in a local hospital after interviewing one of the educators there. I took a photo of the recently decorated room for mothers experiencing neonatal deaths. What struck me was the difference between this room and the starkness of the other spaces. It had curtains with colour, pictures on the walls, with a large lamp and clock as prominent features.

In the image above, using iPastels on the iPad, I added colour and patterns to demonstrate the entangled relationships. The pastels enabled me to blur the colours to depict the complex intra-actions that manifest in this space.

Drawing on the significance of the materiality of the labour wards, I recognize the glow that emerges from this visit – a sense of pulling in. This feeling is affirmed by MacLure who recommends that we take a novel stance with data collection by suggesting that “in the research relation with data, we must be invited in” (2013:662). 

MacLure, M. 2013. Researching without representation? Language and materiality in post-qualitative methodology, International Journal of Qualitative Studies in Education, 26:6, 658-667.

Speaking Silence

The invisibility of disrespect in Obstetrics can be viewed as “desiring silence”. Such “silent discourses serve to maintain a status quo … [and are] produced by a longing for maintaining a normative and unchallenged (even unrecognized) belonging (status) that is important” (Jackson & Mazzei, 2012:100).

Recently I was surprised by two students who insisted that their reflective commentaries should remain private without any sharing with colleagues, even anonymously. While the reflection on a challenging incident was troublesome, the other was complimentary of a clinical educator displaying great skill and empathy.

While reading, Thinking with theory in qualitative research (Jackson & Mazzei, 2012), I realized the value of exploring what is producing the silence in medical education, and what the silence is producing. The forces and actions of the silences provide channels to unpack the many issues that are emerging from my interviews such as the medical hierarchy, professional silos, status and power. The institutional teaching machine is embedded in these silencing desires. Students learn to be strategic to work with and among the silences - not to compete with their desires for success. Deleuze and Guattari's work becomes more important to me as I investigate these silences and desires.

Jonathan Jansen, the Vice Chancellor of the University of the Free State has challenged the silences in South African society and Higher Education Institutions. He has transformed racial practices and cultures through engagement and dialogue. By developing an authentic learning intervention that promotes dialogue, there is a chance for the opening up of silences to explore the desires.

The image above was created using Notability on the iPad. I see my research as the blue arrow entering this vast space of intra-actions related to “desiring silences”. I will seek “to understand the confluence of interests that both produce desire, and that desire seeks to produce and/or protect" (Jackson & Mazzei, 2012:96).