Lecture 2
Photo credit: Joseph Malinga
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To equip nurses with the knowledge and
understandings to foster supportive and positive
healthcare environments for both patients and
healthcare workers. To do so this lecture will:
◦ Sensitize nurses to some patient perspectives on ART care
◦ Help nurses understand how and why nurse-patient conflict or
friction occurs
◦ Discuss ways to minimize such conflict and build positive
healthcare environments
Background on ART nursing (5 minutes)
How to facilitate positive nurse-patient interactions
(70 minutes)
1.
2.
a)
b)
c)
d)
e)
3.
Resource limitations
Power relations
Different knowledge and priorities
Institutional and professional norms
Self care for nurses
Topic-driven discussion (45 minutes)
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ART availability has rapidly changed HIV nursing
Previously palliative
Now long-term care
Current HIV nursing involves: regular check ups for
ARVs, co-trimoxazole prophylaxis, counselling, the
management of opportunistic infections and
comorbidities, and nutritional support.
Patients may live in relatively good health for over 10
years with good care, including ARVs.
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What are some characteristics of good patient
care provided by a nurse?
Photo credit: MSI Missions 2007
Photo credit: Kerry Scott 2009
What does this statement mean to you?
Can you think of a specific nurse you know of who truly
displays this approach to nursing?
Can you think of a time when living up to this ethic would be
difficult?
B.
C.
D.
E.
Resources limitations
Power relations
Different knowledge and
priorities
Institutional and
professional norms
Self care for nurses
Photo credit: Astrid Walker/HelpAge International 2005
A.
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Resource limitations can be contribute to friction
between nurses and patients
i.
Salaries and financial rewards
Because the salary is low, when I come to work I think
that I have no school fees for children or that I didn't
get even a cup of tea at home. My efficiency at work
becomes low and therefore there is not good service
to patients. (Nurse, Manongi et al 2009)
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The salary is low. I am not satisfied when I get to work.
I only think of how to get money. I ask patients to give
me some money so that I give them quality service or I
bring things to sell around what I get will help boost
my life. So instead of helping the sick I just think of a
business to give me income" (Nurse, Manongi et al
2009).
There are no easy solutions.
The issue is governmental, political, organizational
However, studies have found many nurses working
with dedication and compassion despite resource
limitations
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When we look inside our clinic, April [envisaged date
for provision] is too soon. But when we look outside
our clinics, it cannot be soon enough (Nurse, Stein,
Lewin and Fairall 2006)
In fact, many nurses were remarkable in their ability to
remain positive towards their work while being critical
of the management and payment structures
Positive nurse-patient interactions can actually lessen
the strain of nursing in resource-poor environments
and be a source of inspiration when salaries and staff
resources were low
ii. Drug and equipment availability: Patient versus staff
perspectives
People might hate the pharm tech, say if they are told the drugs
they have been prescribed are out of stock. To them maybe
they think I will be hiding these drugs somewhere.
(Pharmacist)
iii. Personnel and workload
 Fewer resources mean health centres have higher work-to-staff
ratios
 One study in America found that each additional patient per nurse
was associated with a 23% increase in the odds of burnout and a
15% increase in the odds of job dissatisfaction (Aiken et al 2002)
Power can be thought of as
the ability of an entity to
control its environment.
Everyone has the right to
control important elements
of their environment
Patients and nurses both feel
the need to have some
control over the clinical
interaction
Nurses can make both
themselves and their
patients feel in control,
secure and empowered
Photo credit: L. Lartigue 2006
There are many symbols of power in clinics and hospitals
 Uniforms, insignia
 Arrangement and use of furniture (size of chairs, who sits
at the desk, who sits on the ground)
 Greetings and names (first name, formal name)
There are commonly held understandings of what a good
patient is like
Patients may sometimes not act as ‘good patients’ and may
been seen by nurses as challenging the accepted clinical
power relations
- They may be unable to perform as ‘good patients’
- They may not want to perform as ‘good patients’
- It may be better for their clinical care to move away from
traditional understandings of how ‘good patients’ act
Suppose a patient has missed the review date. The
reasons that they give for missing it makes you reverse
your initial decision to feel frustrated or angry with
them. One will tell you they couldn‘t get transport, or
they could not get the money to come, and maybe
today they have borrowed money to be able to attend.
For me to be dissatisfied with such a patient would
mean that I was not doing justice to them. It‘s often
their life situations that cause their behaviour. (Nurse,
Campbell et al 2010)
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Identity and status
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Formal education
Language differences
Urban living
Middle-class
Different clothes
Different knowledge
In the hospital or clinic,
nurses have significant
status and power
Photo credit: Agra-alliance 2010
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Jewkes et al (1998) Why do nurses abuse patients?
Nursing as a middle-class, professional, respectable
identity and status in South Africa
But nurses found their status was fragile:
◦ Difficult working conditions
◦ Patients did not always give them the respect they wanted,
did not always value their biomedical care
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Discussion:
◦ What are examples of advice or treatment patients might
resist?
◦ How would this make nurses feel?
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Jewkes et al (1998) continued
Nurses struggled to retain their middle-class identities
by emphasizing how different they were from their
patients
◦ Symbols of difference
◦ Controlling patients
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At its extreme, this effort to sustain their identity as
better and different from patients resulted in severe
abuse of patients
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Power can be visibly displayed in hospitals and clinics by
observing the control of space for example:
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who moves freely and who is restricted,
who sits and who stands,
who is told where and how to move their body
who waits for whom
He will be shouting different kind of instructions for
example “make sure you are in line” and “may everyone
sit down, I won‘t serve anyone standing up”. The benches
will be full so some will sit on the floor...if you try to
complain he might even shout at you (Patient, Campbell
et al 2010)
From
“Man kicks child; child kicks dog” (Atwood, 1994)
to
Collaboration and addressing root problems
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Nurse knowledge: biomedical, scientifically tested,
curative, pharmaceutical, linked to Christianity
Patient knowledge: sometimes patients see health and
illness differently, perhaps more mystically or
spiritually
Some patients will not value and share the same
knowledge as nurses
Some patients will be very interested in accessing
certain elements of knowledge held by nurses
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Campbell et al (2010) found:
With ART, nurses focused on checking patient
adherence and anticipated negative side effects
Nurses wanted to see patients frequently and closely
control quotas of ARV pills
Patients were often proud of their good adherence and
wanted to come in as rarely as possible
Patients prioritized getting several months supply of
pills at once and not waiting too long
Nurses prioritized checking in monthly and failed to
realize the strain of long line ups.
Everyone is an expert
in his or her own life
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When people enter new organizations they take
behavioural clues from experienced staff
Organizations develop normal ways of being and doing
things
Building positive environments for workers and
patients requires ongoing effort involving
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Accountability
Self reflection
Openness to change
Governing bodies
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Listening to patients is a major facilitator of positive nursepatient interactions
We listen to people‘s personal problems because HIV is more
than a medical condition (Nurse, Campbell et al 2010)
When they come here apart from getting their treatments
they also want to be listened to, so we try to give them a
chance to say what they want (Nurse, Campbell et al 2010)
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Likewise, communicating honestly with patients can go a
long way to mitigate possible sources of friction
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You are most able to
help others if you
yourself are mentally
and emotionally well
Health care staff face
many pressures
Self care is personal
health maintenance
In nursing, it is an
ongoing process of
reflecting on your
mental health and
doing what you can to
stay well
 Discussion:
what are some of the
emotional challenges of nursing?
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Self care cannot solve macro problems but it can help
in some very important ways
Self care involves
◦ Recognizing that there emotional challenges with this type of
work
◦ Reflecting upon your mental state
◦ Giving yourself permission to feel the way you feel
◦ Making time for yourself: Talk about emotions and/or do
actives that make you feel well
 What activity do you do to de-stress and feel well?
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What would a good hospital be like:
a. For patients?
b. For their families?
c. For nurses, doctors and other healthcare staff?
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Does your
understanding of
‘a good hospital’
differ depending on
whether you are a
patient or
healthcare worker?
Photo: Curt Carnemark /World Bank
What factors in a clinic or hospital can contribute to a
norm of positive or negative nurse-patient
interactions?
What can new nurses entering the profession do to
foster positive nurse-patient interactions?
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Campbell, C., Scott, K., Madanhire, C., Nyamukapa, C., & Gregson, S. (in press).
A ‘good hospital’: Nurse and patient perceptions of good clinical care for HIV
positive people on antiretroviral treatment in rural Zimbabwe. Int J Nursing
Studs.
Campbell, C., Scott, K., Skovdal, M., Chirwa, C., Mupambireyi, Z., & Gregson, S.
(submitted) “How do notions of ‘a good patient’ impact on patient/nurse
relationships and ART adherence in Zimbabwe.” Journal for the Association of
Nurses in AIDS Care.
Jewkes, R., Abrahams, N., Mvo, Z., 1998. Why do nurses abuse patients?
Reflections from South African obstetric services. Social Science and Medicine
47(11), 1781-1795.
Manongi, R., Nasuwa, F., Mwangi, R., Reyburn, H., Poulsen, A., Chandler, C.,
2009. Conflicting priorities: evaluation of an intervention to improve nurseparent relationships on a Tanzanian paediatric ward. Human Resources for
Health, 7(50). doi:10.1186/1478-4491-7-50.
Atwood, M. (1994). Victim Positions. In Francis, D. ‘Imagining Ourselves’.
Arsenal Pulp Press: Vancouver, Canada.