Fournier B, Kipp W, Mill J, Walusimbi M. Nursing care of AIDS patients in Uganda. J Transcult Nurs 2007 Jul;18(3):257-64.
To explore the experience and perspective of hospital-based nurses in Kampala, Uganda, who care for HIV seropositive individuals in order to identify the challenges and opportunities in their practice.
This paper describes a qualitative research study that was guided by participatory action research (PAR) methodology and took place from September 2003 to August 2004. The research employed three data collection strategies: in-depth interviews, focus groups, and photovoice, which entrusts cameras to the hands of local individuals, to enable them to act as researchers of their communities. The research took place in two stages. The first stage took place over four months, during which in-depth interviews and focus groups were conducted. The focus groups met every two weeks for a total of six meetings: two photovoice and four research process meetings. The nurses continued to meet without the researchers for group discussions once a month for next five months. The second stage then took place, and featured two additional focus group meetings.
Data were collected at a national referral public teaching hospital in Kampala, Uganda with 1,500 beds, 757 full-time nurses, and a weekly HIV/AIDS outpatient clinic.
Six key informants (four nurses, one lay health worker, and one government nurse official) from governmental and non-governmental agencies working in the area of HIV/AIDS participated in an interview and were recruited using purposeful sampling. Inclusion criteria for the key informants were the ability to speak English, affiliation with an HIV/AIDS organization, and age older than 18 years.
Six nurses from a large national referral hospital participated in the focus groups. The inclusion criteria for the nurses were the ability to speak English, provision of care on a regular basis for people living with AIDS (at least one patient every shift or every day), age older than 18 years, and work in a hospital setting. The investigators recruited the nurses by attending a nurse manager meeting, where they requested managers to nominate a nurse who fit the criteria. The nurses came from in-patient departments, including medical, cancer, tuberculosis, and pediatric units. Five of the nurses were female and one was male.
There was no intervention in this study. The key informants were interviewed once at their work setting using a semi-structured format. The interviews were used for two purposes: a) to develop an understanding of the local context and issues surrounding nursing care of persons with AIDS (PWAs) and b) to initiate discussion and generate broad themes for the photovoice technique within the focus groups. For the focus groups, the photovoice meetings served as means for group discussion using participatory analysis, which allowed for nurses to identify themes, through photography, that impact their work.
Data were collected through key informant interviews and focus group discussions. The interviews and focus groups were audiotaped and transcribed verbatim. Data analysis occurred simultaneously with data collection and was guided by general methods for data management and analysis. Themes that emerged from the individual statements of participants were summarized. Summaries were written immediately after each focus group and were reviewed with participants for validation. The researchers also took field notes after each meeting to record their thoughts and feelings about the process, as well as to document the process.
Two major themes emerged from the key informant interviews and the photovoice focus groups: 1) challenges to caring, and 2) coping with challenges. Sub-themes related to challenges to caring included ward congestion, patients' poverty, inadequate resources, and fear of contagion. For example, most of the patients seen in the hospital cannot afford to buy their own food or medications or provide their own bed linens when they stay in the hospital. The nurses provide whatever services they can, but they feel helpless with regard to these patients. The hospital does not turn away patients, but an inadequate number of nurses are available to care for them. Typical nurse-to-patient ratios are 1:50 during the day and 1:100 at night. Additionally, there are inadequate supplies and equipment, which amplifies nurses' fears of treating HIV-positive patients without the proper supplies, such as gloves, gowns, and masks. Sub-themes related to coping with challenges included transferring care to relatives and caregivers and improvising. The nurses all indicated themes that pertain to moral distress, which is the inability to act on one's moral choices due to constraints interfering in what one believes to be right.
The authors conclude that nurses faced many challenges in their daily care, including poverty, insufficient resources, fear of contagion, and lack of ongoing education. Nurses experienced moral distress due to the many challenges they faced during the care of their patients. Moral distress may lead nurses to "burnout" and result in quitting their jobs, which would exacerbate the acute shortage of nurses in Uganda.
No standard grading system is available for qualitative studies. However, this study has a few limitations. This qualitative study is based on the experiences of a very small group of Ugandan nurses, which may not be representative of Ugandan nurses in general. The nurses were recruited from only one facility, which may have produced results specific to issues at the national public referral hospital and not more generalizable to other facilities.
Many of the issues that were raised during the focus group discussions have been documented in other studies. The issue of inadequate supply of materials and equipment for nurses has been reported in many sub-Saharan African countries.(1,2,3,4) Other studies have also documented a reluctance to treat PWAs due to a shortage of supplies and equipment in health facilities in resource-limited countries,(5,6) which suggests that fear of contagion could be largely due to lack of appropriate resources rather than ignorance or negative attitudes. Moral distress has been widely documented in the developed world,(7,8) but little is known about it in developing countries.
This study identifies several key issues that nurses face in treating HIV-infected patients in resource-limited settings. Although very small in size, it identifies many themes that resonate with findings from other studies conducted in developing countries. Most of these countries have critical shortages of healthcare personnel. Nurses are being charged to take on increasing responsibility and often do not receive adequate training or resources. The challenges facing nurses are frequently underappreciated and the potential for "burnout" must be addressed. After identifying their needs, the nurses in this study sought funding for training in the administration, monitoring, and evaluation of the use of antiretroviral drugs. Such empowerment of nurses will be vital in maximizing their efficacy in the care of HIV/AIDS patients. Nurses should be included in the planning and delivery of care programs for HIV/AIDS patients at the individual, institutional, community, and government levels. The challenge for policymakers is to maximize support for nurses when allocating limited resources across all aspects of the epidemic.
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