Nurse-patient relations in the context of ART treatment

1. Nurse-patient relations in the context of ART treatment Lecture 2 Photo credit: Joseph Malinga

2. Aim of lecture • To equip nurses with the knowledge and understandings to foster supportive and positive healthcare environments for both patients and healthcare workers. To do so this lecture will: • Sensitize nurses to some patient perspectives on ART care • Help nurses understand how and why nurse-patient conflict or friction occurs • Discuss ways to minimize such conflict and build positive healthcare environments

3. Lecture overview • Background on ART nursing (5 minutes) • How to facilitate positive nurse-patient interactions (70 minutes) • Resource limitations • Power relations • Different knowledge and priorities • Institutional and professional norms • Self care for nurses • Topic-driven discussion (45 minutes)

4. 1. Background on ART nursing • ART availability has rapidly changed HIV nursing • Previously palliative • Now long-term care • Current HIV nursing involves: regular check ups for ARVs, co-trimoxazole prophylaxis, counselling, the management of opportunistic infections and comorbidities, and nutritional support. • Patients may live in relatively good health for over 10 years with good care, including ARVs.

5. 1. Background on ART nursing • What are some characteristics of good patient care provided by a nurse? Photo credit: MSI Missions 2007

6. A nursing philosophy Photo credit: Kerry Scott 2009 • What does this statement mean to you? • Can you think of a specific nurse you know of who truly displays this approach to nursing? • Can you think of a time when living up to this ethic would be difficult?

7. 2. How to foster positive nurse-patient interactions • Resources limitations • Power relations • Different knowledge and priorities • Institutional and professional norms • Self care for nurses Photo credit: Astrid Walker/HelpAge International 2005

8. A) Resource limitations • Resource limitations can be contribute to friction between nurses and patients • Salaries and financial rewards Because the salary is low, when I come to work I think that I have no school fees for children or that I didn't get even a cup of tea at home. My efficiency at work becomes low and therefore there is not good service to patients. (Nurse, Manongi et al 2009)

9. A) Resource limitations • The salary is low. I am not satisfied when I get to work. I only think of how to get money. I ask patients to give me some money so that I give them quality service or I bring things to sell around what I get will help boost my life. So instead of helping the sick I just think of a business to give me income" (Nurse, Manongi et al 2009). • There are no easy solutions. • The issue is governmental, political, organizational • However, studies have found many nurses working with dedication and compassion despite resource limitations

10. A) Resource limitations • When we look inside our clinic, April [envisaged date for provision] is too soon. But when we look outside our clinics, it cannot be soon enough (Nurse, Stein, Lewin and Fairall 2006) • In fact, many nurses were remarkable in their ability to remain positive towards their work while being critical of the management and payment structures • Positive nurse-patient interactions can actually lessen the strain of nursing in resource-poor environments and be a source of inspiration when salaries and staff resources were low

11. A) Resource limitations ii. Drug and equipment availability: Patient versus staff perspectives People might hate the pharm tech, say if they are told the drugs they have been prescribed are out of stock. To them maybe they think I will be hiding these drugs somewhere. (Pharmacist) iii. Personnel and workload • Fewer resources mean health centres have higher work-to-staff ratios • One study in America found that each additional patient per nurse was associated with a 23% increase in the odds of burnout and a 15% increase in the odds of job dissatisfaction (Aiken et al 2002)

12. B) Power relations: controlling the environment Power can be thought of as the ability of an entity to control its environment. Everyone has the right to control important elements of their environment Patients and nurses both feel the need to have some control over the clinical interaction Nurses can make both themselves and their patients feel in control, secure and empowered Photo credit: L. Lartigue 2006

13. B) Power relations: Symbols of power and notions of the ‘good patient’ There are many symbols of power in clinics and hospitals • Uniforms, insignia • Arrangement and use of furniture (size of chairs, who sits at the desk, who sits on the ground) • Greetings and names (first name, formal name) There are commonly held understandings of what a good patient is like Patients may sometimes not act as ‘good patients’ and may been seen by nurses as challenging the accepted clinical power relations • They may be unable to perform as ‘good patients’ • They may not want to perform as ‘good patients’ • It may be better for their clinical care to move away from traditional understandings of how ‘good patients’ act

14. Suppose a patient has missed the review date. The reasons that they give for missing it makes you reverse your initial decision to feel frustrated or angry with them. One will tell you they couldn‘t get transport, or they could not get the money to come, and maybe today they have borrowed money to be able to attend. For me to be dissatisfied with such a patient would mean that I was not doing justice to them. It‘s often their life situations that cause their behaviour. (Nurse, Campbell et al 2010)

15. B) Power relations: identity and status • Identity and status • Formal education • Language differences • Urban living • Middle-class • Different clothes • Different knowledge • In the hospital or clinic, nurses have significant status and power Photo credit: Agra-alliance 2010

16. B) Power relations: identity and status • Jewkes et al (1998) Why do nurses abuse patients? • Nursing as a middle-class, professional, respectable identity and status in South Africa • But nurses found their status was fragile: • Difficult working conditions • Patients did not always give them the respect they wanted, did not always value their biomedical care • Discussion: • What are examples of advice or treatment patients might resist? • How would this make nurses feel?

17. B) Power relations: identity and status • Jewkes et al (1998) continued • Nurses struggled to retain their middle-class identities by emphasizing how different they were from their patients • Symbols of difference • Controlling patients • At its extreme, this effort to sustain their identity as better and different from patients resulted in severe abuse of patients

18. B) Power relations: Control of space and waiting • Power can be visibly displayed in hospitals and clinics by observing the control of space for example: • who moves freely and who is restricted, • who sits and who stands, • who is told where and how to move their body • who waits for whom • He will be shouting different kind of instructions for example “make sure you are in line” and “may everyone sit down, I won‘t serve anyone standing up”. The benches will be full so some will sit on the floor...if you try to complain he might even shout at you (Patient, Campbell et al 2010)

19. B) Power relations: within staff From “Man kicks child; child kicks dog” (Atwood, 1994) to Collaboration and addressing root problems

20. C) Different knowledge and priorities • Nurse knowledge: biomedical, scientifically tested, curative, pharmaceutical, linked to Christianity • Patient knowledge: sometimes patients see health and illness differently, perhaps more mystically or spiritually • Some patients will not value and share the same knowledge as nurses • Some patients will be very interested in accessing certain elements of knowledge held by nurses

21. C) Different knowledge and priorities • Campbell et al (2010) found: • With ART, nurses focused on checking patient adherence and anticipated negative side effects • Nurses wanted to see patients frequently and closely control quotas of ARV pills • Patients were often proud of their good adherence and wanted to come in as rarely as possible • Patients prioritized getting several months supply of pills at once and not waiting too long • Nurses prioritized checking in monthly and failed to realize the strain of long line ups.

22. C) Different knowledge and priorities Everyone is an expert in his or her own life

23. D) Institutional and professional norms • When people enter new organizations they take behavioural clues from experienced staff • Organizations develop normal ways of being and doing things • Building positive environments for workers and patients requires ongoing effort involving • Accountability • Self reflection • Openness to change • Governing bodies

24. E) Communication • Listening to patients is a major facilitator of positive nurse-patient interactions We listen to people‘s personal problems because HIV is more than a medical condition (Nurse, Campbell et al 2010) When they come here apart from getting their treatments they also want to be listened to, so we try to give them a chance to say what they want (Nurse, Campbell et al 2010) • Likewise, communicating honestly with patients can go a long way to mitigate possible sources of friction

25. F) Self care for nurses • You are most able to help others if you yourself are mentally and emotionally well • Health care staff face many pressures • Self care is personal health maintenance • In nursing, it is an ongoing process of reflecting on your mental health and doing what you can to stay well

26. F) Self care for nurses • Discussion: what are some of the emotional challenges of nursing?

27. F) Self care for nurses • Self care cannot solve macro problems but it can help in some very important ways • Self care involves • Recognizing that there emotional challenges with this type of work • Reflecting upon your mental state • Giving yourself permission to feel the way you feel • Making time for yourself: Talk about emotions and/or do actives that make you feel well • What activity do you do to de-stress and feel well?

28. 3. Group discussion • What would a good hospital be like: • For patients? • For their families? • For nurses, doctors and other healthcare staff? • Does your understanding of ‘a good hospital’ differ depending on whether you are a patient or healthcare worker? Photo: Curt Carnemark /World Bank

29. 3. Group discussion What factors in a clinic or hospital can contribute to a norm of positive or negative nurse-patient interactions? What can new nurses entering the profession do to foster positive nurse-patient interactions?

30. References • Campbell, C., Scott, K., Madanhire, C., Nyamukapa, C., & Gregson, S. (in press). A ‘good hospital’: Nurse and patient perceptions of good clinical care for HIV positive people on antiretroviral treatment in rural Zimbabwe. Int J Nursing Studs. • Campbell, C., Scott, K., Skovdal, M., Chirwa, C., Mupambireyi, Z., & Gregson, S. (submitted) “How do notions of ‘a good patient’ impact on patient/nurse relationships and ART adherence in Zimbabwe.” Journal for the Association of Nurses in AIDS Care. • Jewkes, R., Abrahams, N., Mvo, Z., 1998. Why do nurses abuse patients? Reflections from South African obstetric services. Social Science and Medicine 47(11), 1781-1795. • Manongi, R., Nasuwa, F., Mwangi, R., Reyburn, H., Poulsen, A., Chandler, C., 2009. Conflicting priorities: evaluation of an intervention to improve nurse-parent relationships on a Tanzanian paediatric ward. Human Resources for Health, 7(50). doi:10.1186/1478-4491-7-50. • Atwood, M. (1994). Victim Positions. In Francis, D. ‘Imagining Ourselves’. Arsenal Pulp Press: Vancouver, Canada.