A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
A publication of the Southern African HIV Clinicians Society
Nursing occupational health
Infection control in HIV care
HIV post-exposure prophylaxis guideline update & self-testing
Overwork & nursing
June 2016 Volume 7 No. 2
SOUTHERN AFRICAN HIV CLINICIANS SOCIETY CONFERENCE 2018
JOHANNESBURG, SOUTH AFRICA | 24 - 27 OCTOBER 2018
ABOUT THE CONFERENCE
The Conference programme is being carefully designed to benefit all health
care practitioners. There will be a wealth of current and thought-provoking
academic presentations, fascinating ethics sessions as well as practical
sessions such as case studies and skills-building workshops.
CONFERENCE PROGRAMME FOCUS AREAS
ARVs • Women’s Health • Paediatric & Adolescent • Basic Science •
Monitoring & Evaluation • Prevention • Operations Research •
PHC & Nursing • TB • Opportunistic Infections • HIV Resistance
EARN CPD POINTS
The Conference will be fully CPD-accredited, providing delegates with an
opportunity to accumulate clinical and ethical points. Level One: 30 points
including ethics. Level Two: 45 points including ethics (subject to completion
of an online multiple choice test).
WHO SHOULD ATTEND?
Infectious diseases physicians, NIMART-trained (or interested) nurses, general
practitioners, HIV specialists, academics and other health care professionals.
JOIN US IN 2018 FOR THE SOUTHERN AFRICAN HIV
CLINICIANS SOCIETY 4TH BIENNIAL CONFERENCE!
Website: www.sahivsoc.org
Telephone: +27 (0)11 728 7365
2 18
Email: conference@sahivsoc.org
HIV Nursing
Matters
focuses on
inside the well-being
of a nurse
2 Guest editorial
Jennifer Cohen
37 C
ontinuous QI
Small deeds done are better
On the cover
than great deeds planned
• Nursing occupational health
3 Message from the president
• Infection control in HIV care
Francesca Conradie 40 Competition
• HIV post-exposure prophylaxis
A day in the life of a TB nurse
guideline update & self-testing
4 News
• Overwork & nursing
46 W
hat to do
Current issues Quiz questions
8 Nursing occupational health
12 Overwork and nursing 47 W
here to go
17 HIV self-testing Provincial nerve centre hotlines
20 Babies for bling and national AIDS helpline
Clinical updates 48 Dear clinician column
24 Infection control in HIV care Integrating HIV care into
27 Occupational exposure to HIV chronic care services
32 TB corner
TB infection prevention and
control in paediatric clinical settings
HIV Nursing Matters | June 2016 | page 1
Guest editorial
our interview-based study in Gauteng,
nurses felt ‘overworked’. This is also
explored in greater detail in this issue (p.
12).
earnings, and those who are ill or who Another cause of mental strain for
care for family members with mental nurses is moral distress – the sense
illnesses, HIV or physical disabilities. that one’s moral integrity is threatened
These were often the same nurses by a mismatch between one’s values
who thrive on the work itself; who love and perceptions or actions. Many of
helping patients get well and are often the nurses I interviewed believed that
pleased with the autonomy that income young girls are having ‘babies for
from nursing offers. bling’ and experienced frustration over
providing care that they perceive to be
Some of the nurses were emotionally contributing to a social problem. Hodes,
exhausted, having poured all of their Toska and Gittings (p. 20) look at the
work into caring for others, seemingly question of whether teenage girls are
Jennifer Cohen without being cared for themselves. As having children in order to access the
BSc Soc, MA (Pol), MA (Econ), PhD (Econ) one nurse put it in our interview: “Who Child Support Grant using data from
Society, Work & Development Institute, will care for the carers?” the Mzantsi Wakho study, and find that
University of the Witwatersrand, the grant may instead make girls less
Johannesburg This important question has a number vulnerable and less likely to engage in
of possible answers, some of these are risky behaviours.
Nursing is a profession unlike any other noted in Venter’s article in this issue (p.
in South Africa: female-dominated and 8). The article documents a wide range Each article contributes to a better
notoriously stressful, yet offering secure of interrelated occupational health understanding of the ways in which
employment, in contrast to many other hazards, from chronic and infectious nursing is a stressful profession, even
types of increasingly casualised work diseases, to risk of physical injury. though the work is secure. An answer to
in Africa and elsewhere. Nurses are the nurse’s question, ’Who will care for
securely employed in the sense that In terms of biological hazards, occu the carers?’ is complex. Some of these
the work is formal and contracted, they pational exposure to HIV and TB are challenges can simply be addressed
are unionised, and are in short supply key concerns. Crowley, Klopper and individually or institutionally, while
relative to the demand for health care. Moorhouse (p. 27) provide an update others require structural changes to the
Given these labour market conditions, on the post-exposure prophylaxis (PEP) profession. Still other challenges that
nurses should enjoy a measure of guidelines for HIV in the health sector. nurses confront in their work lives extend
bargaining power to secure good The piece clarifies the correct steps beyond the workplace, into nurses’ own
working conditions. The reality is that to take in case of exposure to HIV, households and into those of family
they continue to confront a number of and notes that PEP services need to and friends, and relate to child- and
challenges which are explored in this be scaled up in order for health care elder-care, financial dependency, and
issue of HIV Nursing Matters centred workers to care more effectively for complicated familial relationships.
on the theme of occupational health. themselves and each other. Mramba
and Garcia-Prats (p. 32) offer a rich One certainty is that nurses must care
During the past year, I conducted discussion of TB transmission from for themselves and for each other and
an infection prevention and control that nursing organisations and unions
in-depth interviews with about 70
perspective, specifically with respect to must advocate for improved working
professional, staff and auxiliary nurses
paediatric settings. environments. A conclusion drawn
in a public hospital in Gauteng. The
from the interviews that I conducted
interviews focused on challenges en
Sleep disorders, anxiety and depression in Gauteng is that other nurses are
countered in their daily lives, which are likely under-diagnosed among often a nurse’s best resource: each
often connect their work lives with nurses, in part because nursing is nurse has expertise and skills learned
their lives at home. I was struck by known to have a relatively high degree through experiences in their daily lives
the intensity of nurses’ emotions as of occupational stress. Occupational that are valuable to those they work
they described the strain that they are stress can enhance performance up to with. Actively trying to create a more
under on a daily basis. There were a point, but can contribute to excessive supportive and collaborative working
single mothers who struggle to pay strain beyond that. Many nurses are environment would facilitate sharing
for childcare, nurses who support under considerable stress from their expertise and could help enhance
more than 20 family members on their lives outside of paid work as well. In occupational health for nurses.
HIV Nursing Matters | June 2016 | page 2
Message from the
The Team
president
Guest editorial
Prof Jennifer Cohen
President
Dr Francesca Conradie
Editorial Advisory Board
Dr Elizabeth Mokoka
Dr Natasha Davies
Dr Michelle Moorhouse
Dr Sindisiwe VanZyl
Ms Nelouise Geyer
Ms Zodwa Mthembu
Ms Talitha Crowley
Ms Maserame Mojapele
Mr Siphiwo Qila
Ms Rosemary Mukuka
Advertising Dr Francesca Conradie
Zodwa Mthembu President, Southern African HIV Clinicians Society
E-mail: zodwa@sahivsoc.org
Tel: +27 (0) 11 728 7365
When I became a doctor I was very young and naive. I wanted to make sick
Article/Letter submission people better and there were things I never thought about.
Zodwa Mthembu
E-mail: zodwa@sahivsoc.org The first was that I needed to look after my own mental health to be a good
Tel: +27 (0) 11 728 7365 doctor. I worked as an intern at Chris Hani Baragwanath Hospital in 1989. And
I saw, as in many emergency departments, terrible things: severe injuries, ill-
For more information
nesses and death. And this exposure made me hard. I had to leave this
SA HIV Clinicians Society
Suite 233 Post Net Killarney environment to gain perspective and to get my compassion back. I wish, looking
Private Bag X2600 back on that time, that I had been for debriefing more often, even if it was only
Houghton with my colleagues.
2041
www.sahivsoc.org The other thing is that we, as health care workers, can get infections from our
patients. I have seen a number of health care workers who have acquired TB
Tel: +27 (0) 11 728 7365 and even HIV at work. While it is the responsibility of the employers to provide
Fax: +27 (0) 11 728 1251 a safe environment for staff, we also need to take responsibility for our own
E-mail: sahivsoc@sahivsoc.org
health. With the high prevalence of TB, we are at real risk at work. And there
The opinions expressed are the are some very resistant TB bacilli out there. While I do not enjoy wearing an
opinions of the writers and do not N95 mask, I do not want to be infected with MDR- or XDR-TB. So, I put the
necessarily portray the opinion of the mask on, and carry on.
Editorial Staff of HIV Nursing Matters
or the Southern African HIV Clinicians My advice as you read this publication: remember that to be the best health
Society. The Society does not accept care workers, we need to keep ourselves well – mentally, emotionally and
any responsibility for claims made in physically.
advertisements.
All rights reserved. No part of this
publication may be reproduced in any
form without prior consent from the Editor.
HIV Nursing Matters | June 2016 | page 3
News
The full articles may be accessed via the ‘Read further’ links provided.
Gender differences and power with sexual-risk behaviours in New HIV treatment to
relationship power could be key adolescents. The researchers identified debut in June
in preventing HIV among South promising pathways to reduce IPV and
African adolescents help prevent HIV infection, including Published by Health-e News
on 19 April 2016
promotion of gender equity as a social
Published by Science in Action
norm. The findings are set for publication in
on 26 April 2016
an upcoming issue of Health Psychology. ViiV Healthcare is expected to introduce
the latest in antiretroviral treatment in
Millions of those infected with HIV South Africa’s private sector in June at
worldwide are young women, aged The research was conducted in South
Africa, where the prevalence of both HIV about R720 per month.
15 - 24, according to the World Health
Organization. Because the HIV epidemic and IPV is high and men often have more
power in relationships than women. The Although the brand name version of
overlaps with an epidemic of intimate
team assessed data from more than 700 dolutegravir is registered for use in South
partner violence (IPV) against women
and girls, researchers have suspected sexually experienced adolescents in the Africa, generic registrations may take up
a correlation between inequities Eastern Cape Province, South Africa, who to three years.
in relationship power and the risky had been followed up at regular intervals
sexual behavior that can lead to HIV for 54 months as part of a separate NIH- The new drug, dolutegravir, is also
transmission. funded trial ... marketed under the name Tivicay
and, like other ARVs, must be used in
A new research study from the University Read further: http://www.nursing.upenn. combination with other ARVs. The new
of Pennsylvania’s School of Nursing edu/research/Pages/Science-In-Action. drug has already made headlines due to
(Penn Nursing), Annenberg School for aspx?itemID=172 low side-effects and its ability to control
Communication, and Perelman School the virus better and sooner than South
of Medicine, investigated and confirmed Africa’s most common HIV treatment in
those associations of IPV and relationship some …
HIV Nursing Matters | June 2016 | page 4
news
Read further: https://www.health-e.org. Taking the HIV prevention pill is and Ethiopia. The federation estimates
za/2016/04/19/new-hiv-treatment-debut-june/ about recognising your risk that two-thirds of diabetes patients in
Africa are undiagnosed ...
Published by Bhekisisa
Treating mental health on 19 April 2016 Read further: https://www.health-e.org.
helps economy za/2016/04/19/one-nine-tb-patients-co-infected-
Elected state clinics will soon provide diabetes/
Published by Business Day Live a pill that can prevent HIV infection to
on 13 April 2016 people at high risk of contracting the
virus.
Every rand invested in treating depression ‘Not only are people with
and anxiety will yield a four-fold return Eight of the 10 sites where between
in better health and greater workplace 3 000 and 5 000 HIV-negative sex diabetes more likely to get
productivity, according to a global study workers will get an antiretroviral pill that
by the World Health Organization,
TB, they are also less likely
prevents HIV infection will be ready to
published in the Lancet Psychiatry journal do so in June, according to the health to respond to treatment.’
on Wednesday. department’s deputy director general of
HIV, Yogan Pillay.
The findings add weight to calls for
increased funding for mental health The 2013 - 2014 South African Health
programmes in low- and middle-income Monitoring Survey with Female Sex Quarter of surveyed health
countries, such as SA, where they receive Workers, which was conducted facilities report stock outs
a meagre slice of health-care budgets. among about 2 000 sex workers in
Domestic figures are sketchy, but Johannesburg, Cape Town and Durban, Published by Health-e News
experts agree that too few resources are found that about 72% of women on16 April 2016
allocated to mental healthcare ... surveyed were HIV-infected ...
Almost 25% of health facilities surveyed
Read further: http://www.bdlive.co.za/ Read further: http://bhekisisa.org/ nationally have gone without HIV or
national/health/2016/04/13/treating-mental- article/2016-04-19-prep-is-about-recognising-
health-helps-economy tuberculosis (TB) medicines at least once
your-risk
in the last year, according to preliminary
survey results released this week.
Home HIV testing gets the One in nine TB patients co-infected
green light with diabetes As part of its third annual survey, the civil
society coalition Stop Stock Outs Project
Published by Health-e News Published by Health-e News telephoned about 60% of the country’s
on 8 February 2016 on 19 April 2016 public health facilities in late 2015. As
part of the survey, facility staff were asked
Pharmacists can sell take-home HIV About one in nine South African whether their facility had experienced a
testing kits, according to Pharmacy tuberculosis (TB) patients are also living shortage of HIV, TB or other essential
Council of South Africa Registrar and with type 2 diabetes, according to medicines and vaccines in the preceding
CEO Amos Masango. According to Stellenbosch University medical biologist three months ...
Masango, a May 2015 decision by the Dr Katharina Ronacher. Ronacher warns
council effectively quietly removed the Read further: https://www.health-e.org.
rising rates of co-infection could have
ban on pharmacist sales of HIV self-testing za/2016/04/16/quarter-surveyed-health-
consequences for treatment outcomes. facilities-report-stock-outs/
kits. The decision comes almost one year
after the council gazetted a draft plan to About 2.3 million South Africans may be
remove the ban. The proposed lifting of living with diabetes and many of these Delamanid clinical access
the ban was warmly received publicly, people may not even know it, according programme expected
Masango told Health-e News ... to the International Diabetes Federation.
Published by Health-e News
Read further: https://www.health-e.org.
According to the federation’s 2015 atlas, on 29 March 2016
za/2016/02/08/home-hiv-testing-gets-the-
green-light/ nearly half Africa’s diabetes patients are
found in just four countries – South Africa, The South African National Department
Democratic Republic of Congo, Nigeria of Health is expected to roll out a clinical
HIV Nursing Matters | June 2016 | page 5
access programme to allow drug-resistant South Africa rolls out ‘test and ARV-infused vaginal ring
tuberculosis (DR-TB) patients access to treat’ to sex workers significantly lowers HIV infections
the new drug delamanid.
Published by Health-e News Published by Bhekisisa
on 4 March 2016 on 3 February 2016
According to Director of the Department
of Health’s DR-TB, TB and HIV division
South Africa has become one of the Trials have found that vaginal rings
Dr Norbert Ndjeka, the Department
world’s first countries to begin rolling out containing an antiretroviral drug could
is currently in talks with Japanese
pre-exposure prophylaxis as well as ‘test more than halve women’s chances of
drug maker Otsuka Pharmaceutical
and treat’ to sex workers as it launches contracting HIV if used consistently.
to negotiate access to Otsuka’s DR-TB
drug delamanid for what will initially be Africa’s first plan to prevent and treat HIV
among sex workers. A vaginal ring infused with anti-HIV
a small number of patients as part of a
medication can reduce women’s chances
clinical access programme ...
South Africa will soon begin providing of contracting the virus by almost a third
Read further: https://www.health-e.org. HIV treatment to HIV-positive sex workers – and by up to 56% in women older
za/2016/03/29/south-africa-to-roll-out- upon diagnosis as part of a new national than 21 – according to the results of
delamanid/ plan announced late Friday. Currently, two clinical trials announced at the
most people living with HIV must wait annual Conference on Retroviruses and
until their CD4 counts – a measure of the Opportunistic Infections in Boston in the
‘South Africa treats about immune system’s strength – fall to 500 United States on Tuesday.
12 000 MDR-TB patients before they can start treatment ...
The trials required over 4 000 HIV-
each year and only Read further: https://www.health-e.org. negative women aged between 18 and
40% are ever cured ... za/2016/03/14/south-africa-rolls-out-test-and- 45 in South Africa, Uganda, Zimbabwe
treat-to-sex-workers/
and Malawi to insert a flexible silicone
Delamanid could help the ring containing the antiretroviral
country improve these cure dapavirine into their vaginas. They had
Occupational health into to replace the ring every month over a
rates.’ mainstream healthcare (planning
period of two years ...
the future: implications for
occupational health; delivery and Read further: http://bhekisisa.org/
training) article/2016-02-23-drug-laced-vaginal-ring-could-
New clinical trial may shorten TB lower-hiv-infections
Published by UK Council for Work & Health
treatment for kids
in March 2016
Published by Health-e News Promising new HIV prevention
on 24 March 2016 The number one recommendation from a tool gives women greater control
recently released report from the Council
About a million children develop tuber for Work and Health, based in the UK, is Published by Business Day Live
culosis (TB) annually around the world the integration of occupational health into on 23 February 2016
and when they do, they are often forced mainstream healthcare provision. ‘Return
to try to take tiny handfuls of adult-sized to work should be a clinical outcome for A new tool for women to protect
tablets for months. Now, local researchers care pathways formulated for adults who themselves against HIV is a step closer,
are looking at ways to make TB treatment need or wish to work. Clinical health care with the announcement on Monday that
for kids shorter and easier. teams in hospital and general practice a vaginal ring containing the antiretroviral
settings should have access to, and be drug dapivirine is safe and reduces the
When the world’s tiniest patients develop able to refer to, competent advice to risk of infection by up to 56%.
active TB, everyone from mom to the facilitate appropriate return to ‘good’
local clinic nurse is left trying to crush work’ ... The results of two phase 3 studies — the
adult-sized tablets into bitter-tasting, kid- Ring Study and ASPIRE — were released
Read further: http://www. on Monday at the annual Conference
sized portions ...
councilforworkandhealth.org.uk/images/uploads/ on Retroviruses and Opportunistic
library/Final%20Report%20-%20Planning%20
Read further: https://www.health-e.org. the%20Future%20-%20Implications%20for%20 Infections in Boston, paving the way for
za/2016/03/24/new-clinical-trial-may-shorten- OH%20-%20Proof%202.pdf the developers of the ring to apply for
tb-treatment-for-kids/ regulatory approval.
HIV Nursing Matters | June 2016 | page 6
news news
More than 4 500 women were enrolled Africans from ever contracting the virus.
in the two studies, which each included The MCC has officially registered the
volunteers from SA ... use of a combination pill of two anti-
retroviral drugs as a form of pre-exposure
Read further: http://www.bdlive.co.za/ prophylaxis (PrEP) medication; a pill
national/health/2016/02/23/promising-new- taken once a day that massively reduces
hiv-prevention-tool-gives-women-greater-control the chances of contracting HIV ...
Read further: http://bhekisisa.org/
article/2015-12-09-sa-registers-a-two-in-one-pill-
Policy: Managing patient safety
that-can-prevent-hiv-infection
incidents in South Africa
Published by Health-e News
on 8 January 2016
Released in December, this 56-page
policy outlines the management of
patient safety incidents, including the
provision of feedback to patients, families
and clinicians, as well as the sharing of
lessons learned.
This policy describes a national stan
dardised system for managing patient
safety incidents to ensure that health
facilities, district offices, provincial
offices and the national office respond
effectively to patient safety incidents.
According to the document, all health
facilities must have a system in place
to manage patient safety incidents
according to the following principles …
Read further: https://www.health-e.org.
za/2016/01/08/policy-managing-patient-safety-
incidents-in-south-africa/
SA registers a two-in-one pill that
can prevent HIV infection
Published by Bhekisisa
on 9 December 2015
South Africa has become only the second
country in the world to allow widespread
access to groundbreaking HIV pre-
exposure prophylaxis medication.
On Tuesday, the Medicines Control
Council (MCC) helped secure South
Africa’s leading position on the continent
in the fight against AIDS. In one press
release they have allowed a new,
extremely easy-to-use and powerful
weapon to stop HIV-negative South
HIV Nursing Matters | June 2016 | page 7
Nursing occupational health
Francois Venter, MB BCh, FCP (SA), MMed, Dip HIV Med, DTM&H
Wits Reproductive Health & HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
A challenge for governments, public health,
trade unions and nurses themselves
Nurses are a unique occupational that occupational health receives very high incidence of these disorders. High
group, when one looks at the myriad little attention does not make sense, workloads, especially in the context of
of health challenges they may face especially as some interventions can nurse shortages, which are common
in an average career. A nurse may easily be accommodated in health across Africa as noted above, affect
transition from a frontline shift-work facility planning and management. many of these disorders, and may
job in a hospital, to working days in also affect sleep and stress, even in
a primary care clinic and occasional Occupational health for nurses can the absence of shift work. In addition,
nights in casualty, to a management broadly be broken down into several nurses often earn more than women
role requiring substantial desk work, categories. The majority of nurses are from surrounding communities, and
to a pharmaceutical representative women, so this article will focus on are often expected to shoulder added
required to undertake frequent travel. issues directly affecting them, although support burdens for their families, which
This article focuses on occupational most areas also apply to men. can create significant stress. Finally,
health challenges that nurses face unpaid reproductive work still falls
doing conventional clinical practice, Shift work, overwork and predominantly on women. Childcare
rather than managerial or other roles in chronic diseases facilities for unsociable shift work times
which they may find themselves. may not be available, meaning that
These are discussed together, as issues home life creates additional stress.
Nurses’ health matters, especially in such as hypertension, obesity, diabetes
Africa, where nurses are a precious and mental disorders themselves It is important to realise that many
commodity. There are far too few interact in complex ways, and are consequences of chronic diseases are
of them to meet the health needs of exacerbated by shift work and sleep extrapolated to Africa from health data
the population and training takes disturbances. Shift work is only one taken from developed countries; it is
substantial time and resources. In many aspect that may contribute to this important to have a healthy scepticism
areas in Africa, nurses are the only complex interplay, and nurses who about some of the so-called ‘chronic
health care resource available; the fact do not do shift work may still have a diseases’ that are commonly cited as
HIV Nursing Matters | June 2016 | page 8current issue
‘epidemics’ in African communities, activity. Associations with elevated Hypertension: This chronic condition
as we lack data on the extent of the cholesterol, high blood pressure and appears to be associated with cardio
consequences of these disorders, as abnormal sugars have been raised. vascular and renal outcomes, although
well as on their causality. That said, However, there is a substantial amount its manifestation in Africa appears
certain issues such as sleep problems of research to demonstrate that inactivity to be different from heavily studied
and diabetes clearly impact on health may be a far more serious risk factor populations in richer countries. As with
and quality of life, with interventions that than weight gain, which is notoriously diabetes, treatment revolves around life
can help people with these disorders. difficult to reverse. style modification and medication.
HIV is now regarded as a chronic dis
ease, but is covered elsewhere in the Mental illness: There are few data on
article. ‘[n]urse complaints the prevalence of mental illness among
around patient care nurses; however, it is unlikely to be lower
Sleep: Shift work is strongly correlated than the general population, where
with sleep problems, for obvious reasons.
and other issues may undiagnosed anxiety and depression
Tiredness, insomnia, and poor quality not be taken seriously, is very high. Women in particular have
sleep all impact heavily on quality of leading to a feeling of high rates of these disorders, and again,
life in multiple studies, and interventions disempowerment, as the fact that nurses are overwhelm
are often inadequate. Sleep disorders ingly female, suggests that prevalence
have been associated with weight well as poor peer would be high. Mental illness remains
gain and hypertension. Sleep is often support ...’ highly stigmatised, even among health
further disrupted by exposure to light, care staff. Referral mechanisms for
interruptions by children and family, treatment are notoriously inadequate,
and daytime noise. Medication that Recent dietary advice has veered despite availability of some effective
induces sleep artificially can assist, but towards cutting down on refined interventions. Shift work has been asso
is rarely an option for the long term, due carbohydrates, especially sugar, and ciated with depression.
to increased tolerance, dependence away from recommending low-fat diets;
(especially with the older medications) the diet field, however, is notoriously Substance abuse: Again, there are
and cost. Typical ‘sleep hygiene’ advice faddish, with few evidence-based few data to suggest that levels of
may help (comfortable bed, light and recommendations beyond those around use of substances such as tobacco,
noise control, etc.), but the temporal refined carbohydrates, as a mechanism alcohol and illegal recreational drugs,
nature of shift work may prove to be to reverse weight gain. Exercise is all but interact with chronic disease
very difficult in lessening impact of poor similarly controversial as a mechanism presentation. Opiate and other addict
sleep. Recently, cognitive behavioural to reverse weight gain; however, in ions to drugs available through the
therapy interventions have been used activity (the ‘couch potato’) is firmly workplace would be more prevalent
successfully for insomnia, and may help linked to poor health outcomes, even in among health care workers (HCWs),
address other areas that may be useful skinny people, and trying to stay active due to easier access, but almost no
in nursing, such as stress and burnout. seems prudent advice. data are available on this issue.
Obesity: Many countries in Africa have Diabetes: Raised blood sugar is asso ‘Burnout’ and compassion fatigue:
documented rapid rises in weight as ciated with obesity (although weight Some work has been done on ‘burnout’
people become wealthier and eating and diabetes may be more related and compassion fatigue, two distinct
patterns change. South African women to intake of refined carbohydrates, but related entities that have had
have recently been said to have the than a causative association; many substantial media attention. The advent
highest rate of obesity in the world cases of diabetes are now being of video capture has highlighted
(South African men came in seventh), noted in people with normal weight); public and very distressing instances
and it is likely that nurses are similarly diabetes-related mortality is significant of nurses behaving callously or even
affected. Shift work is associated with in countries that have accurate data. abusing patients. The reasons for this
weight gain, presumably because of Diabetes complications are complex are very complex, but seem largely
unsocial eating times, time pressures, and myriad, with impact on kidneys, related to an unsupportive workplace
and lack of access to healthier food. eyesight, circulation to feet and environment, where nurse complaints
The definition of obesity has recently hands, and on cardiovascular health. around patient care and other issues
been challenged, but there definitely are Diabetes outcomes can be modified may not be taken seriously, leading to a
associated disorders at extreme weight with a range of lifestyle modifications, feeling of disempowerment, as well as
gain, including joint and back problems, which include medication, but require a poor peer support, where fellow nurses
that may affect other areas of nursing comprehensive approach. do not hold their work colleagues
HIV Nursing Matters | June 2016 | page 9accountable to commonly held ethical valence of HIV and hepatitis B, and infection symptoms are not permitted to
and professional standards. often inadequate access to timely come to clinical work.
prophylaxis.
Occupational interventions to address Blood-borne infectious diseases: HIV is
chronic diseases: Occupational support Tuberculosis: TB deserves special men the most feared blood-borne virus in
to address these chronic diseases is tion, as a major occupational hazard. the Southern African region, although
complex; shift work is required for Both drug-sensitive and -resistant TB it is now readily treatable with safe
patient care, so this aspect of nursing affect HCWs disproportionately, espe medication, with a return to near-normal
care will remain as part of the work cially those with HIV, and drug-resistant life expectancy. HIV occupational
landscape requirements. Workplace- TB carries substantial mortality, and exposure is common, although actual
based screening programmes that treatment is very toxic. TB prevention transmission appears to be very unusual;
screen for obesity, diabetes, hyper requires facilities that encourage nurses are far more likely to acquire
tension, renal disease and mental venti
lation and exposure to sunlight, HIV sexually than through blood or
illness can be implemented relatively patient isolation, as well as personal
other exposure at work. Hepatitis B is
simply. Practical advice on issues protection devices such as N95 masks.
far easier to transmit via needle sticks
surrounding sleep could easily be Unfortunately, little attention has been
than HIV, and is very common, but
provided. Better management support given to facility design with ventilation in
with a very effective vaccine available,
may have an impact on burnout and mind – many clinics and hospitals were
compassion fatigue. Further research built decades ago, and renovations are which is compulsory in some countries
can help identify effective interventions expensive or impossible. Even newer for HCWs. Hepatitis C is common in
for addressing complex issues of facilities rarely seem to be built with certain pockets in Africa, and, while
occupational health and chronic occupational exposure to TB in mind, a now curable, requires drugs that are
diseases. huge problem when one considers that extremely expensive and generally not
TB can live for months in droplet form, yet available in the places where the
Infectious diseases if not exposed to sunlight. Isolation virus exists. Organisms such as malaria,
of patients with sputum-positive TB is syphilis and others are very rarely
Nurses are a critical part of the triage rarely undertaken, often due to over- spread through blood exposure.
process, and are often the first to have crowding of health facilities. Finally,
contact with people with infectious N95 masks are somewhat effective in Dread diseases: Ebola outbreaks have
diseases. Personal protection devices stopping inhalation of TB bacilli, but focused urgent attention on the risks
are often expensive, uncomfortable are expensive and uncomfortable; in that HCWs face. The areas where these
and unwieldy, and often disliked by addition, they are often confined to use outbreaks have occurred have some of
patients, as they can create perceived in TB or infectious diseases wards, and the most fragile health care systems;
barriers to human interactions. Gloves, not in many other places in which TB is Ebola deaths among trained nurses
masks and aprons may provide some commonly found, including admission decimated maternal health services in
protection from bodily fluid exposure, areas. Liberia in a very short time, with catas
but the nature of clinical care is that trophic consequences for maternal
they may not be used at the point of Influenza: Flu carries substantial mor and infant health. The very complex
contact. Occupational exposures, such bidity for HCWs, who are more likely to community engagement seen with the
as needle stick injuries, cause significant be exposed to the virus than the general Ebola outbreaks, with attacks on health
anxiety due to high background pre population. A partially effective vaccine
care staff wearing protective gear, has
is available, and may be obtained
also focused attention on education,
through some workplace programmes,
‘Occupational exposures, and the impact of protective gear on
although is not mandatory. Flu also
patient perceptions of staff. Health
such as needle stick injuries, carries substantial morbidity and mor
care staff, especially those involved
cause significant anxiety tality risks for hospitalised patients,
where it can have devastating conse with initial contact with ill people at
due to high background quences in already ill patients. Calls for facilities, as well as those undertaking
prevalence of HIV and the mandatory vaccination of HCWs intense nursing, in environments such as
have been tempered recently by data hospitals and high care environments,
hepatitis B, and often are likely to be canaries in the mine for
questioning how effective routine HCW
inadequate access to timely flu vaccines are in preventing hospital many similar infectious diseases.
prophylaxis.’ infections. In some developed world
countries, HCWs with upper respiratory
HIV Nursing Matters | June 2016 | page 10current issue
Occupational interventions to address Occupational health and others, though, are systemic workplace
infectious diseases: There should be patient care deficiencies that require advocacy and
clear protocols for things such as focus. Employers (including govern—
exposure to infectious fluids, and the Mechanical assistance for the move ments) have traditionally not paid
handling of patients with potentially ment of patients is very limited, as it is much attention to issues beyond what is
transmittable diseases. Protocols for a complex task; nurses are often res required of them legally, and it seems
dealing with known exposures and ponsible for the lifting and moving unlikely that this will change until nursing
access to prevention interventions (such of patients, in and out of beds, into representatives start challenging the
as post-exposure prophylaxis for HIV wheelchairs and stretchers, and onto status quo.
and hepatitis B), should be readily diagnostic equipment.
available and monitored. One of the most trumpeted clichés
Backache and joint problem: These beloved of public health policy makers,
Some infectious diseases are easily are almost invariable, especially in in- politicians and managers is that ‘nurses
dealt with through vaccinations – all patient care, or where poorly designed are the backbone of our health care
HCWs should ensure they have access furniture exists. Nursing care of patients system.’ Sadly, when it comes to occu
to the hepatitis B vaccine, which is involves examinations that may involve pational health, much more needs to
very effective. Those who have had lifting, rolling and moving patients. be done if nurses are going to get the
the vaccine should have titres checked Some studies have shown high levels interventions they need to function at
periodically. The flu vaccine should be of backache and knee and hip pain their best.
offered annually, due to the high-risk among nurses, enough to have an
nature of contact with flu patients. impact on quality of life. Useful resources
For practical advice on Post-exposure pro
New vaccines against Ebola look very Violence: Studies have shown sub phylaxis: Moorhouse M, et al. Guideline
promising, and should be made avail stantial risk for HCWs to be exposed on the management of occupational and
able to frontline workers as soon as to violence at work, largely through non-occupational exposure to the human
they are shown to be safe and effective. exposure to mentally ill, intoxicated or immunodeficiency virus and recommendations
upset patients or their families. Immo for post-exposure prophylaxis: 2015 Update.
HIV-positive nurses should consider their bilisation of violent patients is complex S Afr J HIV Med 2015;16(1). http://dx.doi.
options carefully, as they are at very from a practical perspective, as well as org/10.4102/sajhivmed.v16i1.39
high risk of acquiring TB. At the very from legal and ethical perspectives. For an overview of the challenges facing nursing
least, they should be on suppressive health (American): Gooloo S, et al. Nursing
antiretrovirals, appreciating that TB risk Occupational interventions to address Staff in Hospitals and Nursing Homes: Is It
still is significant. Additional prophylaxis patient care issues: Thoughtful design Adequate?, National Academy Press, 1996.
with isoniazid should be considered. of facilities and equipment that makes http://www.nap.edu/read/5151/chapter/1
Ideally, HIV-positive nurses should movement of patients easier has A website with multiple links to legal and policy
avoid working in high-TB burden areas, been implemented in many richer workplace resources: http://www.mywage.
such as casualties, medicine wards countries, and should be assessed co.za/main/decent-work/health-and-safety-at-
or TB hospitals, when making career for implementation in local scenarios, work/health-and-safety
choices. according to budgets. Clear guidance An overview of nursing in South Africa: Rispel
on dealing with violent patients that L, Bruce J. A profession in peril? Revitalising
The role of unions and other professional permits safe restraint within legal limits nursing in South Africa. In: Padarath A, King
bodies needs mentioning. There has is usually available, and needs to J, English R, eds. South African Health Review
been precious little advocacy around be easily accessible in areas where 2014/15. Durban: Health Systems Trust; 2015.
ensuring a safe environment for patient violence is most likely, such as in casualty http://www.hst.org.za/sites/default/files/
care. Needle stick injuries are widely or in-patient psychiatric facilities. KWIKSKWIZ_SAHR_Ch9.pdf
recognised as management failures, but Website for Democratic Nursing Organisation of
workplaces rarely investigate them as Conclusions South Africa (DENOSA): http://www.denosa.
such. Facility safety is unlikely to change, org.za/index.php
based on current experience, without Nursing occupational health is exceed
advocacy around HCW health. These ingly complex; some aspects are easily
issues are easily monitored, and should met, such as vaccinations, access to
be a major focus of groups tasked with prophylaxis, and provision of bare
looking after the well-being of nurses. minimum protective clothing. Many
HIV Nursing Matters | June 2016 | page 11Overwork and nursing
Jennifer Cohen, BSc Soc, MA (Pol), MA (Econ), PhD (Econ)
Society, Work & Development Institute, University of the Witwatersrand, Johannesburg, South Africa
Stress and overwork are top health stress, both physical and mental, than impact the worker at home or ‘home-
and safety concerns for nurses, who male workers due to unpaid household work conflict’ in which home-based
also report that such concerns influence work and care work.[4] Care work stresses impact the person at work.[4-6]
their decisions to remain in the nursing entails unique physical, emotional and According to this research, individuals
profession.[1] Nursing is known to be an psychological demands, whether or have experiences that connect their
extraordinarily stressful occupation.[2,3] not it is performed for pay. For women workplaces and their homes even
Unlike in other professions, stress in in paid care work such as nursing, the though they may not perceive a conflict
nursing is assumed to be present. focus of this piece, stress from overwork between the demands of paid work
can come from the workload in the and unpaid work.
Workload and stress workplace, at home, or a combination
of the two. Consider the case of overwork as a
For nurses, the word ‘stress’ describes cause of stress. Nurses tend to feel
a mix of unpleasant situations and Research on occupational stress often overworked, but ‘overwork’ is not merely
unpleasant inner personal experi focuses on workplace stress alone, a workplace-based phenomenon,
ences.[3] Stress may come from as if the workplace and home are parti
cularly for women. Nurses have
high workloads; staff shortages, distinct and unrelated.[5] Implicit in this a heavy workload, consisting both of
which contribute to overwork; and approach is an understanding of the paid and unpaid work, and often feel
a perceived lack of support from workplace and home as ‘separate fatigued, overwhelmed and stressed
colleagues, management and hospital spheres,’ dividing the economy into out as a result. Paid work includes
administration. But workload-related a public sphere and a private sphere the hours of activity for which nurses
stress may also come from outside of the and the life of the worker into a work- receive pay. Unpaid work consists of
workplace, namely from the household. life and a home-life. However, some the hands-on work of child-, self- and
This often differs for women and men: research emphasises ‘work-home con eldercare, in addition to household
women workers tend to have more flict’ in which work-based stresses work like cooking and cleaning. The
HIV Nursing Matters | June 2016 | page 12current issue
unpaid work that women do can be workloads are not separable: the work Because a nurse’s caring work may
considered a ‘second shift’ of work.[7] is connected through the worker and the be paid (located in the workplace) or
care that she provides. The substance of unpaid (located at home), ‘the job’ here
Nurses do this unpaid work on top of the work that nurses do, and the hands- may refer to either, or both, of the jobs. In
the 9 or 12 hours of paid work that they on nature of that work, connects nurses’ other words, the demands of care never
do in wards and clinics. An interview- lives inside their ward or clinic to their end, which can contribute to a feeling
based study of 24 female professional world outside. Nurses care for patients of time pressure, stress, frustration and
nurses in a public hospital in Gauteng and for members of their own and other even anxiety or depression.
Province that divided nurses’ time households. One nurse summarises the
into sleep, paid work, unpaid work, relationship: Caring work is a shared
commuting and leisure found that, on an challenge for nurses
average workday, nurses who do shift ‘I think its a continuation actually, the
work do nearly three hours of unpaid home-life and my work-life. To me, it’s a The most obvious form of unpaid care
work in the home and professional continuation. I’m here in the hospital work done by the nurses who were
nurses in clinics who work from 7 am dealing with the life of human beings. interviewed in the Gauteng-based study
- 4 pm do over four hours of unpaid And at home I also care for human is childcare. This form of care work is
work.[8] On average, the nurses spent beings. I continue to look after the life not limited to those nurses with young
about two hours commuting to and but indirectly. It’s not direct like here in children or to single mothers; it affects
from the hospital per day. Therefore, the hospital. There is a connection to nurses in a wide range of circumstances.
on workdays, leisure time amounts to me, with the hospital and home.’[9] For example, one nurse in her early 60s
under two hours for nurses in clinics is supporting two children, ages 4 and
and averaged just 24 minutes for nurses Caring work, paid and unpaid, can be 6, who belong to her daughter who
on 12-hour shifts (Figure 1). It is no especially strenuous in part because passed on four years ago. The nurse is
surprise, then, that many nurses feel that it places extraordinary physical, emo also supporting her husband, another
they are under constant time pressure tional and mental demands on the daughter, and another grandchild. She
both at work and at home, which can carer.[6] But more fundamentally, caring said:
contribute to feelings of distress. work is uniquely demanding because
while the legally or socially recognised ‘You know, when we grow up, you
Time-use in hours per day[8] claim on care for a particular person or have got plans. “Ok, this is what I’m
Interpreting overwork as the result of patient may be fulfilled, the desire for going to do, if I work I’m going to do
separate, if heavy, workloads at home care is by its nature without limit. This this or that.” I had a daughter who was
and in paid work paints an incomplete limitlessness may leave the carer feeling working, who was helping me here and
picture. It suggests independent work that she can never provide the quantity there financially, now, she’s gone. And
loads for the same worker. Yet the and quality of care that the job requires. I’m left with her two kids. And [my other
daughter] is not working. I have to look
after her, I have to look after her son, I
have to look after myself, I have to look
Leisure time per day after my husband … it becomes a lot too
Unpaid work time per day much.’ [10]
Commute time per day workday
Paid work time (workday) including lunch/breaks Beyond child care, and among other
Sleep challenges, the demands of care work
may be particularly challenging for
24 nurses in South Africa due to HIV. Studies
of health professionals have found that
18 caring for HIV-positive patients can
contribute to overwork and burnout.[2,11]
12
Caring for patients with HIV can place
Hours
6 social burdens on caregivers and may
take a psychological toll. Several of
0 the nurses who were interviewed in
Shift nurses Clinic nurses the Gauteng-based study talked about
HIV as a source of stress and overwork.
However, that stress typically came
Figure 1: Time-use in hours per day. from outside of the workplace, rather
HIV Nursing Matters | June 2016 | page 13than from patient care, but had impacts allowed the nurse to ‘escape into a stress on burnout and satisfaction at work. J
both at home and at work. different world, where I did not have Organiz Behav 1991,12(1):39-53.
to give out or help anybody …’[11] But 6. Ten Brummelhuis LL, Bakker AB. A resource
Some nurses are HIV-positive themselves for many nurses, finding the time to perspective on the work–home interface:
and other nurses are caregivers for replenish exhausted mental, physical The work-home resources model. Am
HIV-positive family members. Still more and emotional resources outside of Psychol 2012,67(7):545-556.
nurses are the caregivers for elderly paid work may prove difficult, if not 7. Hochschild A. The Second Shift. Viking.
relatives or for their own grandchildren impossible. As a shared challenge for 1989.
because other relatives or children nurses that cuts across generations 8. Research protocol approved by the Whitman
passed on due to HIV-related illnesses. and the professional hierarchy, care- College Institutional Review Board on 6
HIV has meant a rising demand for care based overwork may provide a basis April 2015 and issued approval number: IRB
inside and outside of the paid work for organisational consideration of 14/15-61. The qualitative study used in-depth
environment for nurses. Not only can responses that would reduce overwork interview techniques to collect time-use data.
The broader study includes 71 professional
HIV contribute to overwork in terms of in the workplace.
nurses, staff nurses, and auxiliary nurses and
intensity of demand for care in daily life, was approved by hospital administration. The
it can have life-long consequences and References/Footnotes
time-use categories are discrete; meaning
has left some nurses unable to retire, 1. Worthington K. Health & safety: Stress and that they add up to 24 hours per nurse per
with frustrated hopes for their own overwork top nurses’ concerns. Am J Nurs day. The reality of time-use is more complex,
futures.[8] The demands of care work, 2001,101(12):96. however, as activities do not divide so neatly
therefore, present a multi-generational into discrete categories. The time-use data
2. Van der Colff JJ, Rothmann S. Occupational
cited here covers 12 professional nurses who
challenge for nurses. stress of professional nurses in South
work in shifts and 12 professional nurses who
Africa. Journal of Psychology in Africa
work in clinics with hours of 7 am - 4 pm
Nurses’ heavy load of caring work in 2014,24(4):375-384.
Monday to Thursday and 7 am - 1 pm on
the workplace and at home interact in 3. Bond M. Stress and Self-awareness: A Guide Fridays.
ways that are particularly stressful given for Nurses. London: Aspen Pub, 1986.
9. Anonymous professional nurse. Author’s
the unique demands of care work and 4. Galanakis M, Stalikas A, Kallia H, interview, 13 May 2015. Study protocol
the limitless nature of the desire for care. Karagianni C, Karela C. Gender differences approval: IRB 14/15-61.
For healthcare workers, life outside of in experiencing occupational stress: The role
10. Anonymous professional nurse. Author’s
work is critically important for avoiding of age, education and marital status. Stress
interview, 12 May 2015. Study protocol
stress-related burnout. One clinical and Health 2009,25:397-404.
approval: IRB 14/15-61.
care nurse described the importance 5. Bacharach SB, Bamberger P, Conley S.
11. Lempp H. Burnout associated with caring for
of other interests and hobbies outside Work-home conflict among nurses and
people living with HIV/AIDS. Nursing Times
of nursing and other engagements that engineers: Mediating the impact of role
1995;19(18):34-35.
Do you have too much stress?
Some stress is beneficial because it Identifying stress anger, self-doubt, indecisiveness, pro
stimulates engagement with work. crastination, or suppression of feelings.
Without it, we would be bored and may Stress may be difficult to notice be
become frustrated. It is the stress that cause it may increase gradually. Per Behavioural impacts: withdrawing
builds beyond this that is experienced sonal reflection can help you identify into the self, verbal aggression, grip
as unpleasant and can provoke anxiety symptoms and sources of distress, a key ping objects tightly, losing interest in
or have other negative impacts on first step in coping with it. things you liked, insensitivity toward
others, or destructive behaviours such
well-being. Nurses may be hesitant to
Physical impacts: headaches, nau as excessive drinking.
acknowledge distress because they feel
sea, heart palpitations, high blood pres
that it is simply part of their lives at work
sure, tense muscles, stomach cramps,
and at home, and therefore they should constipation and diarrhoea.
‘Nurses may be hesitant to
put on a brave face. But internalisation acknowledge distress because
of this can lead to feelings of isolation Emotional impacts: anxiety, de they feel that it is simply part of
from others, both at work and at home. pression, fear, feeling trapped, hope their lives at work.’
lessness, despair, loneliness, defeated,
HIV Nursing Matters | June 2016 | page 14current issue
Coping with stress and experience of their colleagues. can provide you with information
Peer mentoring is valuable because and help you make a plan.
1. Distractions: distractions such as it can help establish the supportive
hobbies, exercise, interactions with relationships that are sorely needed in What can management do?
friends, and helping others can many wards and clinics. Mentoring can
provide temporary relief from stress. help with work-based concerns but it 1. Make mental health resources
2. Self-care: meditation, relaxation can also help with financial difficulties, available and easy to access:
exercises, breathing exercises and family problems including divorce, and The extraordinary stress that nurses
eating well may help you prepare health-related concerns. are under can lead to anxiety and
for, and respond to stress. Further, depression as well as burnout.
some evidence suggests that the How to help stressed out Social workers who are available
ways we think about stress can colleagues: to nurses and who actively engage
predict whether stress will impact 1. Offer to help with work if you see with nurses in their clinics and
us negatively. Rethinking stress as someone struggling with their work wards could help nurses talk about
an opportunity to give and receive load. the challenges that they confront.
support may help strengthen 2. Be approachable so that people feel They could also refer nurses to
support networks. able to ask for help if they need it. mental health professionals located
3. Emoting and externalising: crying, 3. Communicate with your colleagues in the hospital, which could make
talking about stress with supportive about challenges so that you can seeking help easier.
people, or writing down feelings work together for things to function 2. Be supportive of peer mentoring:
can help you release stress instead more smoothly in the future. Peer mentoring can improve the
of keeping it inside. working environment. Management
4. Confronting causes of stress: How not to help stressed out could put together a list of nurses
• Reflect: instead of avoiding colleagues: who are willing to be contacted by
thinking about sources of stress, 1. Tease them for requiring assistance. peers who are in need of support
try to figure out what causes 2. Tell them to ‘cheer up’ without and mentoring, and distribute the
stress at work and at home. working with them to address list with contact details to all nurses.
• Communicate: communicate sources of stress. 3. Provide channels for receiving
with others at work and at home 3. Have a row rather than waiting and responding to feedback:
about sources of stress and ask to communicate with colleagues The hierarchical organisation of
for help. The things that cause about challenges once an urg the profession can make it difficult
stress can be difficult to talk ent matter has been resolved. for nurses to provide feedback to
about, but sometimes simply management and administration.
talking about them helps ease Do you have financial stress? Solicited feedback could help
stress. Nurses have many shared management identify needed inter
challenges and can benefit from 1. Make a budget: Putting together ventions.
learning about each other’s a budget can change how you feel 4. Schedule meetings in advance:
experiences. about your finances. Being organ Last-minute meetings are experi
• Make a stress-relief plan: ised can improve your sense of enced as a disruption in a busy
consider seeking out peer men financial well-being. day. Schedule meetings ahead of
tors or counsellors to help you 2. Keep track of expenses: time so that clinics and wards can
reduce stress. Keeping a notebook where you plan their shift when they arrive.
record your income and your 5. Increase transparency when
Who will care for the carers? spending every day can help you work processes change: If
stay on top of your expenses. This nurses are required to take new
Do you have a good working relation can ease payday stress because notes or fill in a new form, take
ship with your colleagues? Or do you you will know exactly what is in your care to make the reasoning clear.
or do others who you work with feel bank account and where it is going. Otherwise, already overworked
bullied? 3. See a financial counsellor: nurses may interpret changes as
If you need assistance with your ‘make work’ policies.
One of the best resources that nurses finances or have questions about
have available to them is the expertise debt, then a financial counsellor
HIV Nursing Matters | June 2016 | page 15You can also read
