SPECIAL EDITION 2016

 

An integrative review of Albertina Sisulu and ubuntu: Relevance to caring and nursing

 

 

Charlene Downing^{I, *}; Marie Hastings-Tolsma^II

^IDepartment of Nursing, Faculty of Health Sciences, University of Johannesburg, Johannesburg, Gauteng, South Africa
^IIInitiative for the Study of Normal Birth, Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA

 

 

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ABSTRACT

BACKGROUND: Caring forms the core component of nursing. The history of the nature of caring in South Africa is non-specific and is unknown. The impact of nurse and activist Albertina Sisulu - known as the Mother of the Nation - has the potential to offer unique insights into what could be the context of caring for nurses.
AIMS: The study aimed at 1) critically synthesising the available evidence of caring as portrayed by Albertina Sisulu within the South African context, and 2) interpreting Sisulu's work within the Ubuntu philosophy as a framework for nursing and caring.
METHOD: An integrative review was completed using Whittemore and Knafl's framework. Key electronic databases, selected references and web-based search engines were scoured for articles meeting the inclusion criteria. This systematic and iterative approach yielded 18 non-research reports related to Sisulu; eight reports (three research, five non-research) related to ubuntu and nursing. Data was extracted that related to relevant and conclusive new and innovative practices in caring.
RESULTS: The findings provided a context for practice guidelines of caring concerning knowledge and critical thinking about caring by nurses. Two primary factors emerged that demonstrated a culture of caring as seen through the prism of Sisulu's life: devoted dancer and creation of a healing environment. These factors also reflect African ubuntu principles, where the focus is on the relationships between people and how these relationships could be conducted.
CONCLUSIONS: Ubuntu and Sisulu's approach to caring have much to offer for the nursing profession in terms of developing of new directions for nursing pedagogy, curriculum, practice patterns, and policies that emphasise caring constructs.

Keywords: Albertina Sisulu; Caring; Ubuntu; South Africa; Integrative review; Nursing; Midwifery

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1. Introduction

Few women have left such a strong legacy like the South African Albertina Sisulu - nurse, midwife, mother, and activist (Anonymous, 2009 and Anonymous, 2011) (see .Fig 1). The struggles encountered by Sisulu were no doubt instrumental in shaping the values she stood for as she worked to create change for a nation. There are few other concepts that have as much relevance to Sisulu's life and work than that of caring, a core component of nursing and. midwifery.

The history of the nature of caring in South Africa is non-specific and is unknown. Sisulu's work, however, affords us the opportunity to gain a unique insight into caring from a South African historical perspective. Also, the philosophy of ubuntu plays a role in the history of caring. Roughly translated as "human kindness", ubuntu is often interpreted as "humanity toward others" (Brack et al., 2003, Haegert, 2000, Mulaudzi et al., 2009 and Murithi, 2009) and plays an important role in nursing.

1.1. Sisulu

The need to care for others began early in Albertina Sisulu's life. The impact of the 1918 Spanish flu left her mother weakened and in need of assistance (Albertina Nontsikelelo Sisulu, n.d). Her service-orientation was further fuelled by her conversion to Roman Catholicism in her teens and a desire to become a religious nun. These events strongly influenced her work, both as a professional nurse and as midwife, as well as her activism.

Initially thwarted by economic hardship in her efforts to finish school and become a nurse, Sisulu took to nursing "like a duck to water" (Sisulu, 2003). A lifetime of caring for others and self-discipline made her well-suited for work as a nurse. Completing her nursing education in 1944, she took a position as a midwife at Johannesburg General Hospital where she worked with Nelson Mandela's first wife, Evelyn, and her future husband's sister, Barbie (Albertina Nontsikelelo Sisulu, n.d). She received her midwifery qualification in 1954 and was subsequently employed by the Johannesburg Health Department as a midwife. In this position she visited township patients on foot.

Generous to a fault, her work as a nurse allowed her to be the breadwinner and carer for three sons, two daughters, and two adopted children, as well as other extended family and grandchildren. She appreciated education and this value was reflected in the sacrifices she made to further the education of those she loved. Her Soweto home had a garden that has been described as immaculate and supported a determination and generosity to feed every visitor - no matter how little was to be had (Sisulu, 2003).

Later professional work would find Sisulu working in Soweto beside Dr Abu Baker Asvat, a physician and leading anti-apartheid activist who was murdered in 1989 (Layman). They were described as kindred spirits who sought to eliminate apartheid and improve the plight of those suffering under the apartheid state. The relationship between Asvat and Sisulu has been described as that of mother and son (Sisulu, 2003).

Sisulu's adult life was dominated by poverty, sacrifice, self-discipline, racism, relentless persecution, detention, and worry about the health and wellbeing of those she loved (Sisulu, 2003). She quietly but fervently worked for justice and equality and she did so with a belief that women play a clear role in creating social and political change; she called this a "petticoat layer" of women leaders (Albertina Nontsikelelo Sisulu, n.d.). Her abiding concern over the plight of women and children (McGregor, 2011) reflected the ideals of nursing and midwifery.

1.2. Ubuntu

Ubuntu is both a world view and a moral philosophy that historically binds together African communities (Taylor, 2014). The concept of ubuntu is found in diverse forms in many societies throughout Africa (Murithi, 2009). Several different definitions, some of which are contradictory, make it difficult to extract one central definition of ubuntu that would be universally accepted (West, 2014). Irrespective of definition, Taylor (2014) suggests there are two basic aspects to Ubuntu: relationships between people and how those relationships could be conducted.

Critics have suggested that the ubuntu philosophy served as an effective framework which promoted standards for moral behaviour until eroded by Western values such as individualism (Nyaumwe & Mkabela, 2007). At a time when the caring compass of professional nursing is being strained (Scott, 2014), Ubuntu values woven together with the ideals of Sisulu offer a clear lens through which professional expectations may be re-evaluated.

The objective of this study is 1) to bring to the fore the work, life and way of living of Albertina Sisulu in order to create a theoretical basis for further development and application of caring within the discipline of nursing; 2) to compare care from a Sisulu perspective with that of the traditional South African philosophy of ubuntu; and 3) to provide the South African nursing community with greater knowledge for direct application of caring for nursing pedagogy, curriculum practice.

 

2. Methods

A systematic search of articles written by and about Albertina Sisulu and which related to caring and the impact on the work she undertook was conducted, as well as a search of the literature related to nursing and the philosophy of ubuntu.

2.1. Data sources

2.1.1. Sisulu

A comprehensive search of the literature was conducted using the databases of Ebsco, Cinahl, SABINET, SAepublications, ScienceDirect, Medline, Web of Science, ProQuest Dissertations and Theses, WorldCat, and web-based search engines. The search terms included the following: Sisulu, caring, ubuntu, United Democratic Front, apartheid, politics, policy, nursing practice, and health. In the final analysis, however, only "Albertina Sisulu" was used as it was distinctive and captured known key works; the search of other terms yielded citations of little or no relevance. Only sources published in English between 1960 and 2015 were included. Table 2 identifies the 18 relevant sources used in the final review.

2.1.2. Ubuntu

A literature search was conducted using Ebsco, Cinahl, SABINET. Africa-Wide Information, AMED - The Allied and Complementary Medicine Database, Business Source Complete, CINAHL, Education Full Text (H.W. Wilson), Family & Society Studies Worldwide, Health Source - Consumer Edition, Health Source: Nursing/Academic Edition, Humanities Source, MEDLINE, Political Science Complete and Women's Studies. The search terms used were "nursing" and "ubuntu". An initial search with the keyword "ubuntu" was performed. A further, more refined, search was conducted using the following key phrases: principles of ubuntu, and relation to nursing. Seven sources published in English between 2000 and 2014 were included. The relevant sources are included in Table 2.

 

3. Analysis

The analysis was guided by Whittemore and Knafl's (2005) updated integrative review method. The revised method, as derived from the expanding work of Ganong, is rigorous and widely used for summarising and analysing data from diverse methodologies. This approach provides a comprehensive understanding of a phenomenon (Pfaff, Baxter, Jack, & Ploeg, 2013).

Key electronic databases, selected references, and web-based search engines were scoured for articles that met the inclusion criteria. This systematic and iterative approach yielded 18 non-research reports related to Sisulu from which data was extracted with relevant and conclusive new and innovative practice evidence detailed, and then this data was compared to findings from the ubuntu search. All 18 Sisulu sources and seven ubuntu sources were included in the review. A systematic and iterative approach was used to extract and reduce the data in order to be able to draw conclusions (Pfaff et al., 2013).

 

4. Quality scores

All reports were coded for methodological rigour prior to the data reduction. A 3-point scale was used based on the qualitative and quantitative criteria of Letts et al. (2007) and Polit and Beck (2012) respectively. A score out of three was allocated for methodological quality and the topic relevance of the article. An overall final score was allocated to each article (Pfaff et al., 2013). Table 1 and Table 2 detail report scores, sub-concepts and final concepts.

4.1. Data abstractions

This involved an iterative process of reading the sources and embracing the constant focus of the review aim. Examples of essential features of caring from a Sisulu perspective and the relationship to ubuntu were sourced (Pfaff et al., 2013).

4.2. Synthesis

A data matrix was applied to facilitate the synthesis phase. Categorisation was done by source, key sub-concepts, main concepts and metaphors, and ubuntu principles to identify patterns and relationships among the data. The researcher enhanced further analysis strategies, noting relations between and among variables, looking for extremes of variant cases and finding intervening factors (Miles, Huberman, & Saldanha, 2012).

4.2.1. Description of caring

Caring forms the core in nursing and comprises the fundamental building blocks of the philosophy and science of caring. Caring of the human weaves together the essence and fibre of the tapestry of human-to-human caring in our profession. Watson (1988:58) describes an event in caring to be the occasion where the nurse and patient encounter and come together in a human care transaction. The enactment of deeper caring in a caring occasion promotes self-actualisation in the person.

The essence of being there for the individual and sharing the moment of enlightenment and movement to a deeper connection with self takes place during the caring moment. Life and living comprise many encounters during which there is a connectedness between people, sharing of a common space, an exchange of energies that can bring about change, regardless of how miniscule or deep these changes are. Caring affects the life of all people and a shared space for the authentic meaning-making and unveiling of the inner purpose and vision of the caring moment is central to the critical caring moment (Hills & Watson, 2011).

 

5. Findings

5.1. Sisulu

A review of sources reveals Sisulu's deep commitment to creating a culture of caring. This culture was based on a way of being in a healing environment (see Table 3).

5.2. Way of being in a healing environment

5.2.1. The devoted dancer

During her lifetime Albertina demonstrated a presence of engagement in all aspects of community which can be compared to the synergy between dance, music and dancer. Her intuitive awareness of the needs of her community and the wider population placed her in a unique position to provide the caring and help exactly where it was required. Sisulu had a heightened awareness of the vulnerability of the people in a variety of situations and applied extreme care in her decisions and actions. She listened to the inner music of her heart and the vulnerability of the people led her to care, nurture, and proceed with patience and caution. Elinor Sisulu noted the following:

I never failed to be amazed by the way Albertina coped with a workload that would exhaust most people half her age. After a full day at the surgery, she would return home to find local activists waiting to see her. Most days of the week, she would face another three to four hours of meetings before going to bed. Her weekends were also mostly taken up with meetings and frequent interviews with local and overseas journalists, many of whom were interested in the mobilisation of women under apartheid.

"Ma Sisulu" as Albertina was affectionately known, infused her life with the beauty of caring of people - a gift that nurtured and guided healing to nourish humanity and to be part of the greater civilization, living together harmoniously (Watson, 2012).

Birthing of newness and for others by "the mother of the nation" lead to transformation within her community. Sisulu was an activist and a professional nurse, who led a selfless and courageous life during which she showed an unwavering commitment to a non-racial philosophy of human equality and dignity for all.

5.2.2. Caring through softness and gentleness

Connectedness and being part of a wider community played a critical role in Sisulu's life. The mothering role was fittingly bestowed upon her. She was affectionately known as Ma Sisulu throughout her lifetime. In the world of caring and nursing it would be Sisulu who provided the connectedness to the persons in need of care and hope. She instilled hope, trust and provided the most excellent and competent care possible in those critical moments of engagement with her family and extended community. Caring involved a compassionate sharing of love, heartfelt empathy and dignity.

Ma Sisulu extended her caring to her community, cultivating a culture of interpersonal sensitivity in which each individual was valued and respected (Smith, Turkel & Wolf, 2013). The continuation of caring existed in being present with a smile, an act of kindness, and showing an openness to the pain or joy of the other person. The acts of caring from the heart of Ma Sisulu happened in an enabling environment of caring and respect of the individual (body). Such care was also reflected in her passion and belief in the importance of growing things - "gardening" being an apt metaphor for her approach to life. The caring environment enabled the person with whom Ma Sisulu came in contact with to grow and actualise themselves so as to maintain and grow within themselves (Smith, Turkel & Wolf, 2013).

Nursing and caring was lived by Sisulu and formed an important societal part of her being in the enhancement of human dignity and the preservation of humanity (Watson, 2012). Her passion and sense of responsibility for the sacred duty of caring for others was a defining feature of her life.

5.3. Creation of a healing environment

5.3.1. Seize the day

Sisulu's life reflected extraordinary strength of character, discipline, and self-sacrifice - all requisite behaviours needed to seize the day if the shackles of apartheid were to be removed and desperately needed during the delivery of nursing services. Those engaged in the creation of change couldered the burden for those for whom they cared, standing in a united silence as they worked for justice and equality. Perhaps the best example of this was Sisulu's work in Soweto with Dr Asvat where the needs of all - regardless of political stance or personal characteristic - were served. Effectively creating change required order and organisation, a clear work ethic, and a quiet resolve to "stand in silence" -- but like a rock -- for needed change despite the hazard in pushing against prevailing beliefs ( Motshekga, 2011).

5.3.2. Winds of change

The need for education provided the foundation for creating the framework for effective change. Education provided the foundation whereby knowledge and skills could be taught in order to weave the fabric of the much needed societal change. Effective change required movement, acute awareness and astute observation to ensure that things were improving. During all the years during which her husband was imprisoned, Sisulu kept vigil "until the lights of South Africa shine again" (Sisulu, 2003:281). She was part of the "winds of change" that swept across the subcontinent during a period where little pride could be found in the system.

5.3.3. Riding out the darkness

In times of enormous burden, sorrow, and suffering, Sisulu was tireless in her efforts to do the right thing to improve the health, education and welfare of others. She possessed perseverance and an enormous sense of responsibility and obligation to eliminate the injustices she faced during her life. Believing that behaviour matters, Sisulu sent a strong message that "behaviour is the best teacher…more powerful than anything you say" (Sisulu, 2003:27). Her behaviour demonstrated her faith and conviction that things could be different. In working to create change, she was committed to honouring tradition as well as honouring her word, having been raised with and strongly believing in ritual. Sisulu was both principled and competent and determined to ride out the darkness - those defining moments of history.

5.3.4. Playing with fire

Perhaps the most powerful and influential effort by Sisulu focused on the need to risk oneself for justice and to act as an honoured leader, i.e. to play with fire in order to achieve equality. Risk involved liaising with others who could help to create change and who had the fortitude to see it through. She had a strong sense of revulsion and distain for deliberate injustices and she believed in resistance against the opposition. At the core of Sisulu's work to create change was her belief in those who were "highly principled and competent" ( Sisulu, 2003, p. 203). She believed in justice, even if it inconvenienced her own family - it was the price she was willing to pay at all times (Sisulu, 2003, p. 76).

5.4. Ubuntu

When examining the sources related to ubuntu and nursing, several key concepts were identified in the literature (see Table 2). These relate to a primary emphasis on humanity, the importance of kindness and a sharing that connects humans. Ubuntu embodies a clear value for humanity, respect, and dignity with demonstration of openness and availability to others while recognising the uniqueness and differences of others. Mulaudzi et al. (2009) has commented that, "Ubuntu is a way of living that allows our goodness to come forth."

In the philosophy of ubuntu, caring that is compassionate serves as the foundation for connecting with individuals who are protected where vulnerable.

I am humiliated when others are humiliated or diminished….and my belonging is diminished when others are not treated well. ( Murithi, 2009)

Care emphasises sharing, understanding, reciprocity, kindness, solidarity, and sensitivity (Whitworth & Wilkinson, 2013).

Ubuntu is a guide for living and offers a framework for right action. Taylor (2014) states, "An action is right insofar as it promotes cohesion and reciprocal value amongst people. An action is wrong insofar as it damages relationships and devalues any individual or group" (p. 338). Ubuntu is a framework to understand culture (Boon, 1997) and can serve to shape social conduct (Brack et al., 2003). There is an obligation to care about because I must ( Beets, 2012).

5.5. Sisulu's caring & ubuntu principles

The two basic aspects of ubuntu philosophy, i.e. relationships between people and how those relationships are conducted (Taylor, 2014), are requisite to both ways of being and creating a healing environment. Ubuntu emphasises humanness, connectedness, cohesion, and conscience - all characteristics embraced by Sisulu, as well as respect, empathy, cooperation, harmony, sharing, and warmth. In ubuntu, an action is right if it promotes cohesion and reciprocal value; thus emphasising "the right way of living". And, connection with ancestors and those who are wise, as well as understanding and caring for the quality of life of others are central to both ubuntu and Sisulu's work. There is thus a mutual obligation to "do good".

Combining Sisulu's values and beliefs with those of ubuntu provides a useful framework for guiding nursing practice. Such a framework focuses on caring as a central construct within the discipline of nursing. The values, knowledge, and implications for practice are directed toward the life world of the experiencing person; the framework is thus anchored in an existential-phenomenological field (Ranheim, Kärner & Berterö, 2012:80). This ties in with the idea that nursing could teach one that the best way to understand another human being is to subjectively appreciate the inner world of the experiencing person (Watson, 1979:207).

Nightingale (in Hills & Watson, 2011) describes nursing as the "finest of fine arts". Where caring is threaded between nursing as an art and science, human caring science emerges (Hills & Watson, 2011). The nurse is viewed as a co-partner in the practice of nursing. The co-existence of the nurse and the person sharing the caring moment is of utmost importance. The focus for the nurse is on health, healing, and caring in the patient's experience. Sisulu thus stands at the centre of the caring moment and co-partners nurse and patient for healing. Her focus provides a foundation for nurses to create an epicentre of caring for professional practice with patients, sharing human experiences, happenings, and encounters in a conscious interaction of now. Incorporating Sisulu's principles within the context of ubuntu moves the "good" to the wider practice field of caring. The philosophy of human freedom, living the choice of caring in a mindfulness in everyday living is thus important.

 

6. Limitations

This study was limited to the written works about Albertina Sisulu. All were secondary accounts, and no efforts were made to verify the accuracy of writings. Oral history sources were not available but would have enriched the study with a deeper understanding of the struggles, values, and beliefs of Sisulu. More research is thus required in this area.

Similarly, there is no definitive work regarding the philosophy of ubuntu. While widely embraced in southern Africa (Taylor, 2014), there are variations in interpretation which, over time, may have created a drifting away from the original cultural intent. This study precluded the verification of the practical implementation of ubuntu within the context of South African culture.

 

7. Recommendations

There is much overlap between caring and ubuntu. Basically, ubuntu espouses that a person can only be a person through others and stresses two aspects: relationships between people, and how those relationships are conducted (Taylor, 2014). Sisulu most certainly embraced ubuntu and these beliefs are central in developing a culture of caring for nursing in South Africa. The raison d'être of nursing is the care of patients, and the implications for nursing education, practice, research, and public policy are clear.

7.1. Recommendations for nursing education

Nursing curricula provide important guidelines in terms of developing professional nursing and midwifery. It is thus important to restructure these curricula in terms of how we educate nurses, emphasising the strong need for morality and ethics in nursing. Students need clear guidelines on what to expect and they need to be guided by examples of caring behaviour so that they imbibe a sense of the importance of relating to others and how to go about relating to others. Nurses need to learn to give attention to patient needs (Scott, 2014). Strategies must be developed for nurturing the sense of moral compassion in neophyte professionals. One such strategy could be to provide strong mentoring from more advanced students (Mulaudzi et al., 2009).

7.2. Recommendations for nursing practice

Perceptions, ideas, and beliefs determine the way we act toward others, and beliefs show themselves in action (Haegert, 2000). The current crisis in nursing (Scott, 2014) requires a reassessment of services with clear guidelines with regard to expectations and execution of care in terms of ubuntu and the principles followed by Sisulu. Professional staff need support and nurturing (Haegert, 2000) to maintain virtue and character while delivering quality and compassionate care that is based on core caring competencies (Watson, 2012). Such care needs to reflect a partnership with the patient through shared decision-making (Friesen-Storms, Bours, van der Weijden, & Beurskens, 2015).

7.3. Recommendations for nursing research

While widely referenced, little is known about the empirical referents for caring. More research is needed to ascertain how nurses behave in a caring manner (Mulaudzi et al., 2009). This research could be taken further by funding agencies who appreciate the need for caring models with a demonstration of the outcomes confirming the enactment of caring principles. Compassionate care could be prioritised and patients could be recognised as key stakeholders in further research studies.

7.4. Recommendations for health policy

A health policy is needed for restructuring healthcare delivery systems to ensure adequate staff and resources. Such restructuring needs to focus on systems where nursing services consistent with caring principles are prioritised. Nurses could be included as equal partners when health policy decisions are made to ensure caring is at the forefront of healthcare. Healthcare that is organised, coordinated, and emphasises shared decision-making for patient care preferences requires nurse participation in order to ensure a meaningful policy that improves quality (Lee & Emmanuel, 2013). Caring, inspired by Sisulu and ubuntu, could form the cornerstone for change in healthcare delivery and evaluation of nursing services.

 

8. Summary

Albertina Sisulu worked to address the racial injustices in South Africa (Earl, 2011). She helped to grow a "whole new generation of women leaders" (Sisulu, 2003); her leadership in terms of ubuntu has provided a blueprint for helping to give birth to a whole new generation of nurse carers. Just as Sisulu felt deep distain for deliberate injustices, today's nurse could also feel deep distain for the deliberate failure to give clear and compassionate care.

Commitment to caring as seen from Sisulu's perspective affords nurses the opportunity to engage in a new way of being, of being transformed into a devoted dancer with a soft and gentle presence which is essential if nursing is to assume its rightful place as leaders in care. The time has come for nurses and midwives to seize the day, and play with fire and move with the winds of change. It is only by embracing the principles espoused by Sisulu and ubuntu that nurses will ride out the darkness that is so apparent in nursing today.

 

Acknowledgements

The authors would like to thank Susan Bader, MLS, Director of the Learning Resource Center at Baylor University Louise Herrington School of Nursing; Ivy Segoe, Faculty Librarian: Health Sciences and Mlungisi Dlamini, Information Librarian: Health Sciences, Library & Information Centre, Doornfontein Campus, University of Johannesburg, for their assistance in the literature review for this paper.

 

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Received 12 November 2015
Accepted 7 April 2016
Available online 11 June 2016

 

 

* Corresponding author. Tel.: +27 011 559 9063.
E-mail address: charlened@uj.ac.za (C. Downing).
Peer review under responsibility of Johannesburg University.