PRESENTATION AND ANALYSIS OF THE MAIN FINDINGS
4.3 THE RESULTS OF THE STUDY
4.3.2 Antecedents for establishing a CoP
4.3.2.2 The Internal Domain: The Emotive Challenges
Within this category, it was apparent that the challenges experienced within the participants work environment also created emotional challenges for them. These challenges were classified as the internal domain, and described causal conditions that related to the emotive or intrinsic dimensions that the participants experienced. It emerged from a variety of data sources that the emotional challenges of dealing with HIV/Aids and the complexities that embodied it, created dimensions of distress for the participants. These were described as two subcategories, namely (a) workplace distress and emotional exhaustion and (b) a loss of professional identity.
123 Workplace Distress and emotional exhaustion
Emerging from the data, lack of training, shortage of staff, increased patient care and lack of resources were some of the contributors to distress experienced by the participants. Further analysis of this subcategory showed that coupled with workplace distress, participants also experienced emotional exhaustion. This subcategory illuminated the lack of space or forum where emotional issues experienced by the HIV nurse practitioners could -be discussed and supported, and further showed the relevance of CoPs to fill this gap.
The nature of HIV counseling and acceptance of the HIV diagnosis by the patient was a source of emotional exhaustion and ethical dilemma for participants. Revealed from the data, participants shared that patients were reluctant to disclose their HIV status to partners and deliberately engaged in risky behaviour, which made them feel demoralized in their nursing practice. Despite their best efforts of trying to provide optimum care in a climate where they felt overwhelmed due to the lack of training, participants were of the opinion that they were always coming out on the short side on account of the patients’ attitudes and unwillingness to adhere to HIV interventions and care. The selected extracts below reflect this.
Participant 8: “I find it is difficult to get through with the counseling with some of our patients…they just tell you such things like…I know I am going to die…so why should I save the others…so you end up feeling so low in your spirit to keep working….Participant 4: Ja’ it is also emotionally tiring when you hear such things…because these women…err they will just end up infecting many….because of them not being ready to accept this HIV…” (Urban FGD)
“…one patient said to me…when I spoke to her about partner disclosure and bring in the boyfriend for testing as well…she just said…why should I…it is for him to discover it like me…I will take as many with me… they are purposively spreading this HIV…and we are trying to stop it…it is a losing battle this HIV” (Rural FGD participant 3)
Participants spoke of having to see a younger profile of patients, who perceived having HIV as a social and fashion symbol. This compounded their challenge of trying to succeed with mandated
124 HIV intervention programmes from the management, and left them feeling that they were not achieving their goal in preventing harm. Participants further noted that there was no avenue they currently had where they could deliberate in these issues and find possible solutions. The extracts hereunder illustrate this.
“…we are seeing younger patients coming for in…when they hear they are HIV positive…some are so excited with this…it is like a new fashion or craze with them...some will even say to you…
“oh I am happy now…because now my boyfriend will be happy to sleep with me...”you feel deflated to hear these things…what are we doing as nurses…when our children are happy to have this” (Rural FGD, participant 5)
“…our job as nurses is to prevent illnesses…not to step back because it is the patients right because of confidentiality…and in the process we are causing death….we are seeing a culture in our patients where this HIV is not taken seriously…they take it so lightly…like it is some fashion to have this thing…” (Urban FGD, participant 3)
“…everyday it is the same thing…the same type of patients and you know most are sick with HIV…they don’t want to take the treatment…some are in denial…others are just happy to have it…we are feeling deflated with this… there is no place…no one who we can take this forward to…maybe to look at what we can do in our hospital to find some solutions…” (Rural FGD, participant 6)
Apart from the physical strain of sometimes having to work extra shifts to fill the gaps, shortage of staff and lack of adequately trained nursing staff put more pressure on the participants to cope with the increased workload.. There were also emotional consequences to the lack of resources as in some circumstances; death or malpractice could have been avoided. The emotional burden of having to deal with grave outcomes of care due to under-resourced health facilities caused a great amount of guilt within the participants. Participants also noted that they had no support in such circumstances, which resulted in feelings of isolation in their emotional challenge. The following excerpt illustrates this.
“…sometime I am the only Advanced Midwife in the ward…and I have to end up working in a extra shift…we are so short staffed in the labour ward…and you know that because there are so
125 many patients, and there are so few hands to do the job…you end up cutting corners…and you feel bad to do this…but you have no choice…” (Rural FGD participant 3)
“….I was the only advanced midwife in labour ward over the weekend, and we had a maternal death…it just makes you feel bad…we should not be losing mothers…but sometimes you are not skilled…or you are too few nurses on duty…so one is not sure why this mother had to die…whether it was us as nurses…or something just went wrong…but you sometimes want to just talk about such things…instead of keeping it in you…but where does one go?” (Urban FGD, participant 5)
Workplace distress was also translated into moral dilemmas experienced by the participants.
Evident from the data, participants spoke of institutional or policy restrictions that put boundaries to the nature of nursing care they could afford the patient. Participants related how such restrictions made them feel guilty of not providing optimum care that they would ordinarily provide. A common discussion thread that illustrated this was the issue of providing treatment for the patient. Policy and institutional restrictions meant that nurse participants had to turn away some patients who wanted assistance knowing, however, the grave consequence it would have.
Another aspect was because of the lack of skilled and trained staff and heavy workload, certain tasks were sometimes delegated to an inexperienced or ill-prepared staff member. This caused participants the ethical dilemma of deciding which patient to delegate to them, being mindful of the inexperienced care that the patient would be likely to receive. The following extracts illustrate various such moral dilemmas.
“…some patients come to us for the repeat of milk formula…maybe this patient was not counseled properly about breastfeeding and feeding choices…now she is crying in your clinic…wanting this…but our hands are tied…we cannot just issue this formula…so you know that this mother when she leaves….she is just going to mix feed…so how are we going to win with this HIV transmission…” (Urban FGD participant 3)
“…you find that there are many patients that need to be attended to… you end up delegating to the students from the colleges that come for their training…they are very much inexperienced...they are only learning about midwifery…some never had HIV training before…but what do you do…you just need the patients to be seen…knowing that the care is not going to be what they must get….” (Rural FGD participant 7)
126 Another dimension to the workplace distress experienced by the participants was that of emotional exhaustion. Participants experienced fatigue and emotional exhaustion as a result of work overload, which was compounded by continually working within an emotionally charged environment. A sense of hopelessness resonated due to poor patient outcomes when dealing with a condition such as HIV. Participants shared that they no longer felt any personal accomplishment in their jobs, and this was characterized by decreased motivation and commitment in their job, having a negative perception of their work and duties and feelings of failure and inadequacy. Emerging from the reflective sessions, however, it was noted that despite feeling demoralized and de-motivated; participants felt an intrinsic pressure to continue to function in their professional role.
“…sometimes I find that even when my patient is sharing their problems with me, I start to think about how many more patients I got to see and how this person is holding me up, you get so tired or hearing the same things from the patients, and there is no cure for this, so it makes you feel so heavy…I sometimes switch off and wait to finish with them…because we still are expected to finish all the patients…”(Urban FGD participant 7)
“After spending the whole day hearing the same thing, and we know that our patients will not get well, or that the baby will not survive…because even they share with you how they are not adhering because of disclosure…so you feel like you are nursing the dead…and what is the use… this job is draining you emotionally …” (Rural FGD participant 3)
From the various sources of data, participants noted that they experienced diminished work
related self esteem. The nature of the patient’s problems often left them feeling emotionally and mentally exhausted. Some participants drew parallels between some the clinical incidents they encountered and their own personal lives, making it difficult for them to separate their personal life from their professional life. Caring for people who were close to them also added to the emotional strain as some of the participants spoke of the strain of nursing members of their own
127 families who had HIV related illnesses. They shared what an impact this had on their work life, especially in terms of not having a break, thus making them feel “emptied” to go any further.
“We also have our family and relatives that are having this thing (referring to HIV/Aids) and you find that there is just no escape…you come to work and it is here… you go home and find it there as well… it can be very tiring. For me, I find that this is draining me because I have no outlet for this thing” (Urban FGD participant 1)
“…when you see how young the patients are that are testing positive…you just think about what might be happening in your own home…I have a younger daughter too…so it takes over your whole life…and how you see everything like it is HIV…”(Rural FGD participant 2)
“…even now as we are talking, my son is dying in his bed at home...hai (long silence)…this monster is everywhere, even in my home…and I am so tired of seeing this, it is like we cannot get a break…sometimes when I see these young children coming and getting their results…and being so happy…I just want to scream (Urban FGD participant 7)
Loss of Professional Identity: Low staff morale due to high work demands, increase in patient
rate and less time to cover everything were the core properties that described how the participants felt about their work. An entry in one of the participant’s reflective journal entry indicated that she had lost her meaning of being a nurse. The external demands placed on her in terms of nursing an ever increasing number of patients, who all have very emotionally distressing stories to share, made her no longer feel like a nurse, but rather a “porter of death” .
“when I think of why I started nursing and now..I can see a lot had changed, every day I feel challenged to be here…I mean there is death all around and some of patients are going through such trying time...what is the sense of nursing like this, there is no good I am doing...it is like we are porters not nurses...just transporting them to their death…” (Rural nurse journal entry-April 2010).
This phenomenon of meaningless nursing was a theme that resonated with many of the participants. Further to this, it also emerged from the data that the participants felt a way coping with the despair and hopelessness of nursing was to look at avenues of getting out of the current
128 health care system or looking towards migrating from their current institution, as illustrated in the following extracts:
“I am looking all the time for another job...at least in private you don’t have to see so much of this...because there the doctor sees to the antenatal care”(Urban-Individual interview)
“…I have even gone back to school (laughing) but now to learn about business, so that I can get out of nursing...because what is the sense of nursing…you put your life at risk for these patients that don’t think about what they are doing”(Urban FGD participant 2)
It also emerged that participants perceived that they had lost some of the core nursing values.
The nurses described their lack of emotion and altruism to go beyond the minimum requirements to assist the patients. This was primarily in response to the heavy work load and to the apathy of the patients in response to their own status. Many participants also spoke of having prejudicial attitudes towards the patients, due to the familiarity and predictable nature of their patients presenting with the same problems. The participants justified their negative attitudes by explaining that they become frustrated when dealing with patients who don’t take their illness seriously, and thus perpetuate poor outcomes. This is depicted in the following extracts:
“at times you have no choice but to judge these women. I know it is not right to ask them why are they keep coming to the clinic pregnant when they know their status…so such things makes you not to have a choice and to ask them such things, because even they are not taking it seriously…” (Rural FGD, participant 2)
Sometimes I get angry with some of the patients that come, because some of them are so sick and then they just keep coming to us pregnant, yet you can see even the previous baby died with this HIV, but when you try and make them understand, they just say no, they know they are not sick…so it is a real challenge and depressing for us to keep seeing this type of patients(Rural FGD participant 1)
I mean what do these women expect, and then they come pregnant for the 5th time…I mean are they looking for marriage or to trap this boyfriend, and yet they can see how thin they are..what are they wanting to get?..maybe marriage? (Urban FGD participant 3)
129 Continuous contact with HIV/Aids also created an attitude of disregard for their patients. The participants related that they tended to generalize all patients as the same, with a prejudicial outlook of their illness, and therefore did not waste time on comforting them or fostering an interpersonal relationship with them. As one participant describes below, the work demand of seeing an increased load of patients, also exacerbates this attitude:
“… when they come to the hospital they think that they are going to be treated differently…like s HIV is now a privilege…because there is so much attention on them… and we must have sympathy towards them…then they see there is no room for that…we are very busy and got no time to listen to their stories about why they got this disease…CHA-No we got no time for this…” (Urban FGD participant 5)
Patients’ beliefs and attitudes concerning the existence of HIV was also another determining factor that contributed towards the nurses’ experiences of powerlessness and fatigue.. The participants expressed how difficult it is to motivate the patients to comply with the recommended treatment. The midwives reported feeling lost with this aspect, especially as many of their patients were in denial about their illness and often sought counsel from traditional doctors. Participants found this challenging and explained that as trained midwives, they felt patients should value their expert knowledge. They acknowledged that the era of HIV has led to a fragmentation of this role in society, as patients resort to other avenues of care.
“so you think what is the point in even telling them any advice because they will just end up coming back pregnant…they just tell you that they went to the traditional healer and they know they are bewitched or something…” (Rural FGD participant 7)
“….sometimes things happen out of work...like we are having relatives that are ill. They are denying, saying this things calling it in Zulu “uGobongo” some are even becoming amaSangoma (i.e. traditional healers) to run away from this, they come to you or the neighbours come to you because they know you are a nurse, when they are very ill, but only wanting medication, so these things challenge you as a person” (Urban FGD participant 3)
130 4.3.3 The context of establishing communities of practice
Defined by Strauss and Corbin (1990), the context refers to a particular set of conditions within which the researcher constructs action and interactional strategies to manage, carry out and respond to the specific phenomenon. In the context of this study a set of conditions which emerged included (i) the national health priorities; and (ii) national frameworks and policy documents. These emerged due to the dynamic and changing nature of HIV/Aids care and management which stemmed from this set of conditions and grounded the need for the development of Communities of Practice to support users (namely nurse practitioners) to cope with the dynamic nature of these clinical guidelines which underpin HIV/Aids care, and to create a platform wherein the objective of the national health priorities and policy documents can be achieved.