A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...

 
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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
A publication of the Southern African HIV Clinicians Society - Nursing occupational health Infection control in HIV care HIV post-exposure ...
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 8
current 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 9
accountable 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 10
current 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 11
Overwork 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 12
current 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 13
than 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 14
current 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 15
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