Future
challenges for
nurses
- Nursing student´s perception about caring for
patients with hepatitis B in Vietnam.
SUBJECT AREA: Nursing Science
AUTHORS: Anna Rådefjäll Forsberg & Linn Persson SUPERVISOR:Anna Abelsson
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Sammanfattning
Titel Framtida utmaningar för sjuksköterskor - Sjuksköterskestudenternas upplevelse
av att vårda patienter med hepatit B i Vietnam. Bakgrund Hepatit B är ett världshälsoproblem. Viruset är en blodpatogen som sprids genom blod- och kroppsvätskor. Hepatit B är vanligt i västra stillahavsområdet och i Vietnam har sjuksköterskor en större risk att bli infekterade av hepatit B. Syfte Syftet med studien är att beskriva vietnamesiska sjuksköterskestudenternas upplevelse av att vårda patienter med Hepatit B. Metod Det är en kvalitativ studie med semistrukturerade intervjuer. Resultat Det är brist på kunskap om hepatit B i samhället och egenvård är behövligt i vården. En rädsla av att bli infekterad bland sjuksköterskor och en misstro av vaccinet framkommer. Kunskap kring att bli smittad av nålstick och vassa instrument framkom också. Slutsats Okunskapen kring hepatit B är ett problem i samhället, inom sjukvården och något som även sjuksköterskestudenterna upplever. I framtiden vill sjuksköterskestudenterna utbilda patienter i hur de ska leva med viruset, men de upplever att det finns många utmaningar. Okunskapen leder till stigma som patienten blir utsatt för av både sjukvårdspersonal och samhället. Stigmatiseringen påverkar även sjuksköterskestudenternas syn på viruset och dess behandling.
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Summary
Background Hepatitis B is a world health problem. The virus is a blood pathogen that
transfers through blood and body fluids. Hepatitis B is common in the west pacific area and in Vietnam nurses are at higher risk to get infected by hepatitis B. Aim The aim with the study is to describe Vietnamese nursing student´s perception of caring for patients with hepatitis B. Method It is a qualitative study with semi-structured interviews. Result There is a lack of knowledge about hepatitis B in the community and self-education is needed in the care. Fear of getting infected among nurses and a mistrust for the vaccine were found. The awareness of getting infected by needles and sharp instrument were also found. Conclusion Lack of knowledge is a problem in the society, in the health care and also experienced by the nursing students. For the future the nursing students want to educate patients in how to live with the virus, but they see many challenges. Lack of knowledge leads to stigma that infected patients are exposed to by health care and the society, those actions of stigma affects the nursing students in how they see and treat the virus.
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Table of content
Background ... 5
Vietnam ... 5
The health care system in Vietnam ... 5
The Nursing program in Vietnam ... 6
Hepatitis B ... 6
Transmission ... 6
Symptoms and complications ... 6
Acute and Chronic HBV ... 7
Treatment ... 7
Hepatitis B in Vietnam ... 7
Prevention for hepatitis B in Vietnam ... 7
Theoretical framework - Stigmatization ... 8
The nurses work with Hepatitis B. ... 8
Problem formulation... 9 Aim ... 9 Method ... 9 Design ... 9 Sampling... 9 Data collection ... 10 Data analysis ... 11 Ethical considerations ... 12 Results ... 12
How to give the patient a better life ... 12
How to protect oneself as a nurse ... 14
Discussion ... 15 Method discussion ... 15 Result discussion ... 16 Conclusions ... 19 Clinical Implications ... 19 References ... 20 Appendix 1 Appendix 2 Appendix 3
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Background
Vietnam
Vietnam is located in southeastern Asia with borders to China, Laos and Cambodia. The country has a long coast with the city capital, Hanoi, located in the north. The majority of the country doesn’t have a winter season, instead Vietnam has rain seasons, called monsoon (Globalis, 2019). In 2018 the population reached 97 040 334 million people (Central intelligence agency, n.d.) with the life expectancy of 76 years (Globalis, 2017). There are 21 children of a population of 1000 that dies under the age of five in Vietnam (WHO, 2019).
Vietnam has a long history of war with the latest, the Vietnam War, that occurred between 1957 and 1975 with the north and communist side of Vietnam as the winning side. Since the Vietnam War, Vietnam has grown, both regarding the country’s economy and the people’s standard of life (Globalis, 2019).
Vietnam is a one partied state, were only the communist party is allowed. The freedom of speech is limited, and the government controls most of the media in Vietnam. The Vietnamese people aren´t allowed to criticize the government and critics of the government are threatened by imprisonment (Globalis, 2019). According to Regeringskansliet (2019) there are many flaws regarding the human rights in Vietnam. In the latest years the surveillance of the civilian population has increased and currently there are no conventions about human rights in the country (Regeringskansliet, 2019). Vietnam went from being one of the poorest countries in the world to a lower middle-income country in 2019 (The World Bank, 2019).
The health care system in Vietnam
The Vietnamese health care system is divided into several levels in the community, there are four levels in total. Level I is the central level, this includes central hospitals that are owned by the Ministry of Health and the general hospitals, that the municipalities owns. The other levels, level II-IV are also hospitals but there are owned by the government of each province. Depending on which level there´s a difference in how big population area the hospital is covering. There´s a mix of private and public hospitals in the country (Takashima,Wada, Tra, & Smith, 2017).
In 1993 the Vietnamese government introduced a health insurance for the Vietnamese people, the government is currently working to reach all the Vietnamese citizens. By 2015 the government established that 77% of the population was included in the insurance. The goal is that, by 2020 to have reached 90 % of the population (Takashima et al., 2017). Even though there´s an insurance, the Vietnamese people needs to pay for their healthcare. There´s a big difference in how much and it depends on where the person lives. If the person lives in the same area as a hospital in Level I, that person pays less money than a person who lives outside that district, the access to healthcare is therefore unequal (Nguyen, 2017).
Resources in Vietnam are low, and the physicians are too few to meet the number of patients that´s in the need care. In remoted areas there´s a lack of medical equipment and training, therefore the health care quality when diagnosing and treating patients can be lower. A common problem in the higher levels (Level I) is that there are too many patients that need hospital care, leading to that patients sometimes need to share bed with one or two other patients (Takashima et al., 2017).
6 The Nursing program in Vietnam
The nursing program runs over the course of four years. In the education, the nursing students have both theoretical and practical experience. As a part of the nursing student's education they´re studying how to give patients good care and how to apply traditional medicine when giving care and health treatment. The education includes that student´s get knowledge on how to give counseling and how to educate patients. At their first year the student´s learn about Vietnam in general and in the end of that year they start their first medical course, anatomy and physiology. During their second year they study medical microbiology and how to work practical with infectious diseases. The final year the students get practical experience and also read a course about medical care for infectious patients (University of Da Nang, 2019; Hue University of Medical & Pharmacy, 2015).
Hepatitis B
According to WHO (2019) hepatitis B is a disease that has become a global health problem in a huge part of the world. It´s a viral infection that´s caused by the hepatitis B virus (HBV). The virus attacks the persons liver. Worldwide the burden of this disease is extremely high and is posing as a great threat for the world (Schilsky, 2013). WHO (2019) established 2015 that around 257 million people in the world suffers from chronic HBV. The virus is a blood pathogen, this means that the virus transfers through blood and body fluids from an infected person (Shepard, Simard, Finelli, Fiore & Bell, 2006; WHO, 2019). HBV can be both an acute and a chronic condition. The risk for the virus to evolve into a chronic condition is as high as 95 % when the person is infected during infancy. HBV increases the risk for people dying of liver associated diseases. (WHO, 2019).
Transmission
In areas were the prevalence of HBV is higher, the most common way of transmission is through mother to child during childbirth (Shepard et al., 2006; WHO, 2019). Another way for transmission in these epidemic areas are through horizontal transmission, exposure to an infected persons blood. Therefore, the virus can spread among drug users when they reuse needles or in the health care area when nurses are exposed to needles and sharp instruments. In average the incubation time for the virus can be from 30 to 180 days. The virus survives for a week outside the human body, in some cases longer. During this time HBV can cause infection to an unvaccinated person (WHO, 2019).
Symptoms and complications
It´s common not to experience any symptoms as a newly infected person, this makes it difficult to notice if a person is infected. In some cases, an acute illness occurs with symptoms that can last for weeks (Osei, Niyilapah & Kofi Amenuvegbe, 2019). HBV gives symptoms such as icterus, this is a condition where the skin and eyes yellows, extreme fatigue, fever, nausea and vomiting, abdominal pain and darkened urine. A small group of persons that get infected with acute HBV can develop liver failure which is life threatening (WHO, 2019; Wilkins, Sams & Carpenter, 2019). Liver cirrhosis is a complication due to a chronic HBV infection were the liver get damaged and the liver function doesn´t work properly (Kim, Oh & Lee, 2006). Another complication is hepatocellular carcinoma which is a common primary cancer disease (Kim et al., 2006; Mules, Gane, Lithgow, Bartlett & McCall, 2018).
7 Acute and Chronic HBV
There is a difference between an acute HBV infection and an HBV infection that has developed to a chronic state. The acute state can be described as discrete onset of symptoms such as fatigue, darkened urine, nausea and diarrhea. These symptoms start to develop slowly, often without the person noticing. Acute HBV is defined with these kinds of symptoms, the presence of ikterus and test results that shows Hepatitis B surface antigen (HBsAg) and Hepatitis B core antigen (HBcAg) (Wilkins, Sams & Carpenter, 2019).
The chronic state of HBV is defined with the same symptoms as the acute state although if the infection has become chronic, the level of HBsAg is elevated for more than six months. To get the diagnose of chronic HBV a full history is needed, with metabolic risk factors, alcohol intake and vaccination history, as well as a full examination looking for signs and symptoms of cirrhosis (Wilkins, Sams & Carpenter, 2019).
Treatment
The acute HBV cannot be treated, the focus is on the patient's comfort and good nutritional balance. The chronic state of the virus can be treated with the right medicine (WHO, 2019). The recommended treatment for chronic HBV patients is an antiviral treatment. The most used medicine is Tenofovir or Entecavir, this is an oral treatment and simple to follow with the patient taking one pill every day. In this way the treatment can slow down the development of the virus and it´s complications such as cirrhosis and improve a longer life for the patient. It is not common that the treatment cures the infection, so it is a rest of life treatment. It is not the virus itself that can be deadly, it´s the complicated diseases that the virus develops in the body during a long time(WHO, 2019; Ozaras et al., 2014).
Hepatitis B in Vietnam
According to WHO (2019) the highest prevalence of cases with HBV is in the west pacific area. The burden in these countries are higher than in other parts of the world. In this area, Vietnam is one of the countries with the most infected persons and in comparison, with other countries the prevalence of HBV is higher in Vietnam. HBV classifies as a health problem in the country (Nuygen et al., 2019). A global goal according to the United Nation development program is that by 2030 the epidemic of hepatitis should have ended. This is one of the goals in agenda 2030 (UNDP, 2019). The main transmission route in Vietnam is through perinatal transmission (Nuygen et al., 2019) HBV is the main cause to liver cirrhosis and liver cancer in Vietnam. About 8 % of the women and 12 % of the men in the country are infected with the virus, meaning that about 20% of Vietnams population are infected. Since 1982 there has been a safe and effective vaccine against HBV that should cover up 94-98 % (WHO, 2019).
Prevention for hepatitis B in Vietnam
A lot of the transmissions happen through childbirth (perinatal transmission). It is recommended to pregnant women to get the right treatment before birth. Using maternal treatment and giving the vaccine soon after birth, gives the newborn a good chance to not get infected (Thomas, 2019).
In 2016 the Vietnamese government followed the world health organization recommendation that all babies within 24 hours after birth should receive the first dose of the hepatitis B vaccine (Nguyen Si Anh et al., 2019). Although according to Giao,
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Quang Vinh, Huynh Tam Lang, and Le An (2019) there are only 45,2 % of the babies that receive their first dose within 24 hours and only 33,9 % that fulfills the full vaccine program.
WHO (2019) describes the vaccine to be very effective and safe. There are two different schedules of vaccination for infants, children and young adults against HBV in the world. A three dose and a four-dose schedule. If these schedules are completed, the protective rate is more than 95%, the protection lasts 20 years or longer and probably a lifelong protection. Around 90% of the infected people with chronic HBV gets infected in infancy (Thomas, 2019).
Theoretical framework - Stigmatization
Good health care is recognized by given the best possible care for any patient, but to be able to do so health care workers needs to be aware of, stigmatization (stigma). Within the health care area stigma includes when health workers undermine or stereotypes the patient in any way, by diagnosis or treatment. The result of this can lead to that the patient experience discrimination or feel the loss of power in their already exposed situation. This can also lead to that the patient's wellbeing gets affected and that the patient hides information about their health condition due to fear of undermining. Stigma can be related to a specific disease or health condition, such as blood borne transmissions (Nyblade et al., 2019). The social stigma that affects chronic HBV patients is a multidimensional issue that concerns four different parts of the person's life. The infected person can feel isolated from the society (social isolation) and experience rejection by family members and friends (social rejection). Their economic can be affected by that their work get jeopardized (economic stigma) and the person often feel an embarrassment and fear (fear for disease disclosure) that others might find about the virus. This can lead to feelings for the infected person that it´s better to pretend to be asymptomatic and live a life by not telling others that they have a HBV diagnose. The infected person with HBV has to live with both mental and physical discomfort (Valizadeh, Zamanzadeh, Bayani, Zabihi, 2017).
A big part of the patients with HBV tend to not include their partners in their health status because of the virus and they believe that their partners and relatives will mistreat them because of it (Le et al., 2018). There´s a lack of knowledge in how the virus can spread in Vietnam, with people thinking that the virus can be transmitted through food and by hugging and kissing. With this, the risk of stigma in the community also increases (Dam et al., 2016).
The nurses work with Hepatitis B.
In general nurses in development countries are at higher risk to be exposed to the virus (WHO, 2019). In development countries the risk of exposure to blood pathogens is higher than in other countries and one reason could be that nurses aren´t aware about the risk (Konlan, Aarah-Bapuah, Kombat & Wuffele, 2017). A common injury that nurses are exposed to in hospital environment is needlestick and sharp instruments which means that the risk to get infected is higher. In general, there is a risk for nurses to be exposed to these kind of injuries (Kasatpibal et al., 2016; Chakravarthy, Singh, Arora, Sengupta & Munshi, 2010). The risk of getting a needlestick increases when nurses must work in a bad working environment and when there is a lack of staff and resources (Cho et al., 2013). The high prevalence of HBV in Vietnam increases the risk of exposure even more for nurses (WHO, 2019).
To be able to give a good healthcare there are six core competencies that nurses should work by when giving care. One of these are safety which means that nurses should
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work in a way that decrease the risk of harm to the patient and themselves. To be able to adapt a safe care, nurses needs to use evidence-based practice, which is another core competence. Nurses should always be updated to the latest science to ensure safe care, this includes new scientific discoveries regarding HBV and the vaccine (Quality and Safety Education for Nurses, 2020).
There is much research about HBV, but there is limited research in what future nurse’s perception is about caring for patients with the virus. WHO (2019) describes that there is a high-risk factor to get in contact with the virus when working in hospitals and that it is a health hazard for the people that work with these patients. The nurse's education and knowledge about HBV affect his/her opportunity to work in a way that is safe for the patient and to not contract the virus or transfer the virus to another patient (WHO, 2019).
Problem formulation
Since the risk of being exposed to HBV is higher for Vietnamese nurses than in other countries it is crucial to highlight the issues for the individual nurse and therefore also the country. Future nurses in the country needs to have knowledge about how to care for patients with HBV in a proper way. Since the knowledge about the virus is low in Vietnam the nurse’s knowledge could help people with the virus to trust the health care and feel less discriminated if the society get more awareness about HBV. This could lead to stigmatization of HBV patients could decrease in the future. Through more knowledge, hopefully the risk of infection will decrease, and fewer people will get infected. This might lead to that future nurses will be aware of how they will work in a safer way both with the patients and for their own safety.
Aim
The aim with this study was to describe Vietnamese nursing student´s perception of caring for patients with hepatitis B.
Method
Design
A qualitative interview study was adapted to get a deeper understanding about the phenomena (Henricson & Billhult, 2017a). To reach the aim, a semi-structured interview method was used to describe the nursing student's perceptions of caring for patients with HBV (Danielsson, 2017).
Sampling
The researchers took contact by email with the chosen school to get information about potential participants. An information letter was sent to the responsible teacher at the chosen school. The information letter was then translated into Vietnamese by the same teacher, who then gave the letter to students in their last semester (Appendix 2). The letter described the aim with the study and informed the participants about their rights as participants. Nursing students, (n=63) from the last semester (semester eight) of a nursing program in Vietnam were asked to participate by the teacher. To participate in the study the participants had to sign the letter given to them by the teacher, by signing the information letter they confirmed their participation.
When arriving in Vietnam, the researches got a list of the students accepting to participate in the study by the teacher. Eight students participated in this study, seven women and one man which is representing the gender distribution in the nursing program in Vietnam. The age of the participants was between 22 to 23 years old (mean
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22,6). The participants didn´t have any previous experience in caring for patients with hepatitis B before their nursing education. The researchers had a week to collect the data. Inclusion criteria for this study was nursing student in the last semester in nursing education.
Data collection
The data collection was carried out in January 2020, at the nursing faculty of a school in Vietnam, through student interviews. To be able to get a deeper understanding about the phenomena and to get a wide content the interviews were semi-structured (Henricson & Billhult, 2017a).
The researchers performed two pilot interviews to be prepared for the upcoming interviews. The purpose was to see if the prepared questions gave those answers that the study aimed to get and to get familiar with the recording functions (Polit & Beck, 2017). The two pilot interviews were not included in the result and did not change the prepared interview guide.
The data was collected from eight semi-structured interviews. Individual interviews were chosen to be able to focus on the participant.
Before the first question the researchers did a short presentation about themselves and the subject of the study were presented. The participant was given information about that they participated by free will and that they could decline at any time without any further questions. Before the interview started the participant had the opportunity to ask about any uncertainties.
The interviews were all initiated with the question “Would you like to describe your perception about caring for patients with hepatitis B?”. Supplementary questions like “Will you work in a specific way in the future when you treat patients with hepatitis B?” and “Which patient groups are you going to meet in the future that has hepatitis B”?, were asked during the interview to gain a wider understanding and more information about the phenomenon. See appendix 1.
Throughout the eight interviews both researchers were present with one caring out the interview and taking notes and the other focusing on audio taping the interview. To take notes pen and paper was used by the interviewer. To audio tape the interviews an iPhone was used. All the participants agreed before the interview started to be audio taped.
The interviews were carried out during 15-25 minutes (mean 17,12 minutes), with the question being asked in English and an interpreter translated the questions to the student in Vietnamese. The student answered in Vietnamese and the interpreter translated the answer to English so the researcher could ask a supplementary question. The participant spooked freely about the main question and depending on what the participant answered the researcher asked supplementary questions to get a deeper content (Danielsson, 2017).
The time and place were chosen by the nursing faculty of the school and the interviews were carried out at the school in a separate room where the interview could not be disturbed. The interviews were carried out for four days during four different occasions. During the interviews the participant, the interpreter and the researchers were the only one present in the room (Polit & Beck, 2017).
11 Data analysis
The audio taped interviews were all transcribed directly after the interviews had been carried out. The transcribed material was written into a text document on a computer. Sounds like silent pauses and laughter was not included in the transcription. To process the data collection, a manifest content analysis by Elo and Kyngäs (2008) was used. Graneheim and Lundman (2004) describes that when using a manifest content analysis, the researches focus is on the obvious and visible aspects of the material. An interpretation can be made but the interpretation isn´t as deep when adapting a latent content analysis. Through the analysis process the content from the interviews were analyzed in three steps (Elo & Kyngäs, 2008).
The first step was the preparationphase, in this phase the transcribed data, was read through several times to make sense of the data and to understand the whole. This was done one interview at a time (Elo & Kyngäs, 2008).
The second step was the organization phase. In this step meaning units were identified from the transcribed material and were connected to the aim of the study. The meaning units were coded into words and short phrases. This was done in a table to be able to see the whole. The codes were then sorted into categories. The categories were sorted by identifying different groups by similarities and differences. The meaning units were colored into different colors, this helped to see which codes belonged to each other. By dividing the material into categories, the phenomena was described, and a deeper understanding gave knowledge about the connection to the aim “to describe the nursing student's perception about caring for patients with hepatitis B (Elo & Kyngäs, 2008). See table 1.
Table 1, sorting the interviews into meaning units, codes and categories.
In the third step, reporting, the result was described. The connection between the aim of this study and the categories showed the relevance of the result. By procession the text in a systematic way, the validity of the result became more truthful (Elo & Kyngäs, 2008).
12 Ethical considerations
The World Medical Association (2019) writes that when humans are the object of a study the researches need to follow principles such as integrity, autonomy, dignity, health and the private life of the participant. Sandman and Kjellström (2013) describes the importance of protecting the participants thorough four aspects. Not harm which includes emotional and physical aspects, do good to maintain wellbeing and not cause any physical harm, autonomy which means that every person has their own freedom of choice and justice includes the equality of the participant. These basic principles have been adapted throughout the study.
To ensure an ethical approach the principles from the Helsinki protocol have also been adapted. The participants got information about the aim of the study and was asked to confirm their understanding, this according to the Helsinki protocol. The participants had the opportunity to ask questions about the study, the aim and the procedure of data (WMA, 2019).
To participate in the study the participants had to sign a consent form where information about their rights was given. In the consent form the participants got information about that if wanted to, they could decline anytime during the interview. If so, this would not affect them in any negative way. Before the interview this information was given again and confirmed verbally (WMA, 2019).
All eight interviews started with information about the participants rights to be confidential and that no information could be connected to a specific person or location. Information about the storage of the data collection was given and the participant had the right to decline how the data collection was storage. The data was storage in a locked safety deposit box (WMA, 2019).
The participants were informed that the data collection would be deleted after the study was completed. During this stage the researchers informed the participants that this study will not be published (WMA, 2019).
An ethical audit following the school of Health and Welfare was carried out together with the researcher's supervisor (See appendix 3). A signed approval of the study was given by the chosen school.
Results
The aim with this study was to describe the nursing student’s perception of caring for patients with HBV in Vietnam. The data collection created two categories: How to give the patient a better life and How to protect oneself as a nurse. These two are presented below:
How to give the patient a better life
The participants felt that self-education is an important aspect when caring for HBV patients. They mean that the knowledge about self-education helps the patient and the family to experience well-being. To self-educate patients it´s required that the patient have compliance, without compliance the care gets difficult for the nurse. To get compliance from the patient it’s important to explain why and how self-education can help.
“The patient should follow the medical advice of the hospital, but they don’t have the right compliance”.
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The participants felt that the patient should have compliance regarding the information they get about diet, exercise, alcohol and smoking. But the patients doesn´t always listen to the nurse's advice and even though they got information they continued to live on as before. The participants felt that this part is difficult, it´s hard to help patients that doesn’t listen, and they felt that they´re powerless in this dilemma.
“After they get the HBV diagnose, they still drink a lot of alcohol and they still have a bad diet”
The participants talked about transmission ways and that how important it is to educate the patient in this. The patient needs to have knowledge to not spread the virus to others. They mentioned that the patient and the family of the infected person needs to know how to handle bleeding in case of an accident and that they need to know how to care for injuries in a safe way. Within the families the participants thought it´s important to educate not to use the same toothbrush as an infected family member as the virus can spread from that as well.
“The first prevention is that the patients must have knowledge about HBV. The second thing is that they must know how to treat their bleeding and fluids to protect their relatives”
Another thing that was mentioned was the importance of educating the infected person about safe sex, how to protect themselves and others from the virus. They mentioned that a big part of the community doesn´t have an education which leads to information about the virus or what they can do to prevent is unclear. The participants mentioned perinatal transmission, they said that it´s unknown to many patients although it’s a common transmission way. They felt that the reason for this, is the lack of knowledge in the community. Even though Vietnam have a vaccination programme for pregnant women to not transfer the disease through childbirth. But the lack of knowledge leads to many not using the programme.
“There´s a lot of patients in the community that don´t know how to prevent the virus to another person.”
The participants mentioned that the most common group of people that have a HBV diagnosis are drug users. They mean that drug users are at higher risk to become infected because of all the unsafe and reused needles. The participants describe that the people that use drugs doesn´t have a proper education and their economy is bad. The participants describe low education and bad economy as an obstacle for these people to receive and understand information about HBV. They mean that this patient group are more inclined to listen to the health care staff and does not take their advice in the treatment.
“People with low income and low education can´t follow the medical advice. “
The participants have experienced that the patients with HBV are afraid of being isolated from the society and from their families when getting diagnosed. This because of the lack of knowledge about HBV in general but also in how it transfers. Prejudice from society worries the patients and they’re afraid to talk about the diagnose which affects the patient’s wellbeing in a negative way. The participants mean that the virus affects both the physical and the psychological part of the infected person, with common complications such as depression and isolation. Therefore, they emphasize the importance of providing care from both aspects.
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“The patient that gets this disease will be sad and feel afraid, they don´t want everyone to avoid them.”
The participants describe HBV as a challenge since many patients do not react to early symptoms such as extreme fatigue. If the patients would recognize the symptoms they could know when the virus has developed and contact the hospital to get care in time. The participants think that the reason for this is because a big part of the community has a lower education which makes their perception low. The participants think that the patient only reacts to visible symptoms like yellow skin, eyes and stomach pain. In many cases the participants felt that the patients seek hospital care in a late state.
How to protect oneself as a nurse
The participants felt that HBV can affect their job as a nurse because it can be a danger to care for people with the virus. As future nurses they sometimes will be unaware of that the patient that they´re caring for has HBV. They mean that this leads to them not being as careful as they should be when doing different nursing procedures as for example injections. This increase the risk of getting infected but also the risk of transfer the virus to another person. This makes the participants feel that it´s hard to know how to act when they don’t know if the person has HBV.
The second thing that can make it dangerous for the participants is the lack of time. They feel that it is hard to be careful when they are in a hurry. They describe that they´re stressed and the lack of time increase the risk for mistakes and injuries for the nurse but also for the patients. In this way the risk of needlestick and exposure for blood and fluids increases. The participants mean that they choose not to wear gloves to save time and help more patients even though they know that gloves are their protection. The gloves are the thing that protects the nurse and other patients from transmission.
“One nurse is taking care of many patients, they don´t have the time to work in a patient safe way because the lack of time. They often don’t wear gloves and they recap the needle by hand because they want to save time to take care for another patient.”
Another thing the participants mentioned was the lack of guidelines regarding blood pathogens which can be dangerous for them. They have no specific guidelines to use when caring for patients with blood borne viruses. They can only follow the guidelines that´s aimed for patients at the hospital.
“We don´t have a checklist for taking care of HBV patients or for patients with blood borne viruses, we just follow the procedure as normal”
The participants felt that they´re afraid to care for patients with HBV, because of the fear of being infected by the virus. If they get infected this could affect their job as a nurse and how the colleagues look at them. They mean that if one nurse would get infected the other nurses could be frightened because of the increased risk of getting infected themselves. The participants have a fear of getting infected through patient contact, but they mean that they can’t avoid the patient, they must take care of them. The fear of getting isolated by their colleagues and family appears when they think about the consequences of getting HBV. The participants mean that the society’s prejudice of the virus has an impact on how they see the virus. The society believes that a HBV infected persons should be avoided, and this makes the participants worried. If the participants get infected, they´re the person who gets avoided.
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“I know that this patient has the disease, but I can´t avoid caring for him/her.”
The participants explained that they don’t trust the vaccine for HBV. They feel that it doesn’t have a high protection from the virus or the right antibodies which makes it unsafe. Due to mistrust of the vaccine there´s a concern when caring for patients with HBV, they´re afraid that they will contract the virus even though they are vaccinated.
Discussion
Method discussion
The trustworthiness of a qualitative study is built on three criteria’s, credibility, dependability and transferability. Credibility means that the chosen method for content analysis is suitable for the purpose of the study. Dependability means how stabile the data is over time. Transferability means how the data is represented and if the study can be remade in other settings (Elo et al., 2014; Graneheim & Lundman, 2004; Polit & Beck, 2017).
The researchers e-mailed an information letter in English about the study to the teacher. The information letter was translated into Vietnamese by the teacher so that the participants would understand the aim and their rights. The teacher had the condition to translate the letter herself in order to give it to the students. By letting the teacher translate the information letter, the researchers lost control over the content. The teacher gave the information letter to the students and those who wanted to participate had to sign to confirm participation (WMA,2019). This approach meant the researchers did not have control over the participants willingness to participate in the study. This can affect the dependability of the study (Polit & Beck, 2017). To be able to conduct the data collection during the short time in Vietnam the teacher had to provide the participants before the researchers arrived.
When the researchers introduced the subject at the interviews it was confirmed that the participants understood the purpose of the study. The eight students that participated in the study were introduced to the researchers by the teacher, this can be ethical questionable. The researchers do not know if the teachers had chosen the ones who would answer most properly at the questions. This can affect the dependability of the study (Polit & Beck, 2017).
The interviews were carried out with seven women and one man which represents the distribution in terms of gender in the nursing program at the chosen school, this increases the credibility. Since the age of the participants was narrow it could have helped with various ages of the participants. The researchers asked the teachers to get a wider range of age, although in the nursing program of the chosen school the age of the students in semester eight was between 22 and 23 years. This could affect the credibility of the study. To be able to get a wider age variation the researchers could have asked students from other semesters to participate. Although these students could have had limited knowledge about the phenomena. To get various perspectives at a phenomenon there must be a variation of the participants, this gives the study credibility (Graneheim & Lundman, 2004).
The interview method that was used helped the researchers to get a deeper understanding about the phenomena and the researcher felt that the number of participants was enough to answer the aim. Although the researchers felt that focus interviews, could have widened the content and more students participating could have
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helped. Since the subject of the study can be sensitive for the participants, focus groups could have helped the participants to feel less vulnerable and could have created a safer environment. With this method the researchers could have saved time (Henricson & Billhult, 2017b). The study can be remade in other settings. Since HBV is a global health problem the research is adaptable in other countries, but also in other professions such as nurses and physicians. This increases the transferability of the study (Elo et al., 2014).
The interviews were carried out with the teachers as interpreter. This can question the trustworthiness in the study because the researchers did not have any control over the interpreting of the questions or the supplementary questions. An authorized interpreter was not an option. The teacher had the condition to be present in the room as the translator. If possible, an authorized interpreter would have been the researchers first choice to ensure the integrity of the participants (Polit & Beck, 2017). One thing that also is worth mentioning is that none of the participants were talking about their own knowledge about the phenomena. The students are dependent on the teacher, this can be one reason why they did not talk anything about their own knowledge. On the other hand, the students talked about sensitive subjects and flaws in the healthcare which suggests that the students had the opportunity to speak freely regarding the health care system in the country.
The interviews were carried out at the nursing school, a safe environment for the participants and carried out one by one. According to Polit and Beck (2017) this maintains the integrity and privacy of the participants. An atmosphere that is safe and an undisturbed environment leads to interviews with better opportunity to rich content and a deeper relationship to the aim of the study (Danielsson, 2017).
A preunderstanding about the subject is needed for the researchers to ask suitable questions and for understanding the material. When analyzing the data there is an advantage of being two researchers. It helps the researchers to be true to the content. During the pilot interviews the researchers tested the prepared interview guide to see if the question was suitable and if the question answered the aim. In this way the researchers got knowledge about if the interview guide got rich and deep answers that were connected to the aim. By doing the pilot interviews, it was confirmed that the questions were suitable for getting answers about the phenomena. The researchers were self-aware of how the questions can be perceived, this increases the credibility of the outcome of the interviews (Elo et al., 2014).
The researchers applied a content analysis using Elo and Kyngäs (2008) method, this includes three steps. Since there were only three steps the researchers experienced a challenge in analyzing the data, this is because of, in the second step of Elo and Kyngäs (2008) there are many tasks that are included. To make it easier to analyze, the researchers could have chosen another method. Nonetheless when using Elo and Kyngäs (2008) the researchers used various literature to understand the chosen method and specially to understand the second step, organization. The researchers have put a lot of time into understanding the chosen analysis method and any unclarities have been straightened out, this increases the transferability (Polit & Beck, 2017).
Result discussion
This study found that the nursing students believe that patients have limited knowledge about the HBV virus. They describe that the patients don´t listen to their
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advice and are unaware of how the virus transfers. Hwang, Roundtree and Suarez-Almazor (2012) found that there´s a lack of knowledge among the Vietnamese population about HBV. People believe that HBV transfers through food or by drinking alcohol and some people believe that the virus will disappear if they stress less. Similar topics can be found in an article made in Vietnam by Hang et al. (2019), where the result showed that Vietnamese people believe that HBV can be transferred through sneezing, contaminated water or when sharing food with someone that´s infected with HBV. This can be the reason why people avoid people that are infected with the virus. According to Shepard et al. (2006) and WHO (2019) HBV is a blood pathogen that merely spreads through blood and fluids from an infected person, such as through injections, sexual relationships, surgery, saliva and through perinatal transmission. The nursing students in the present study also believe that patients with no education don´t have a good compliance or understand information regarding following medical advice when having HBV. In a previous research, Polis, Zablotska-Manos, Zekry and Maher (2017) found that the reason why patients don´t have better compliance is because they don’t get information in a suitable way by the health care staff leading to misunderstandings. Although Thuy (2012) means that the level of education does matter in the patient compliance. The higher level of education the easier it gets to understand given information. With today’s research there´s still question marks about how these misunderstandings appear, is it because of the patient’s low education or is it about information given in the wrong way? It´s of high importance that the patient gets the right information about the virus since the right information can give the patient a longer and better quality of life.
The perception that nurses should use self-education as a help for the patient was found in this study. The nursing students want to focus on a suitable diet, good exercise and information and prevention about transmission. A study made by Kong, Zhu, He, Whang and Guo (2018) shows that to be able to conduct self-education for the patient, the nurse needs to implement self-care to the patient's daily life, this makes it more understandable and realistic. Kong et al. (2018) also found that aspects such as good diet, exercise, medication and psychological symptoms are important to self-educate about. Since the nursing students in the current study want to conduct self-education it´s even more important to offer information in a proper way to eliminate misunderstandings.
In the current study the participants said that a common patient group with the virus are drug users. Other literature shows that the most common patient group with HBV in Vietnam are newborns that contract the virus through perinatal transmission (Nguyen, 2012; WHO, 2019). The participants in the present study mean that the people who use drugs are known to be difficult to care for and to help since they do not always listen to or understand information. This can be a sign of the stigma that drug users are exposed to both by health care workers and the society. A study made in Japan (Ishimaru, Wada, Arphorn & Smith, 2016) describes that drug users are a challenging patient group, that they do not always have the ability to listen, can be less truthful and doesn´t always understand information. Which can confirm the nursing student’s perception about drug users. In a study by Perlman et al. (2014), the participants were people who use drugs by injection and the result showed that 1 % of the participants had chronic HBV. The study shows that people who use drugs are at higher risk of getting HBV but that it´s a low percent that does get infected. The current study shows that the participants think that drug users are at high risk of getting infected. This can also be a sign of stigma from the nursing students. According to an article made in Vietnam, people that are drug users or people with a history of drug
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addiction are a vulnerable group in the society that are often exposed to discrimination and stigma because of their way of life (Tomori et al., 2014). This can explain the nursing student´s perception about that drug users are the most common group with the virus even though that perinatal transmission and therefore newborns are the biggest patient group. Assumptions like this increase’s stigma both in health care and in the society.
This study, as prior research showed that nurses are afraid of patients that have HBV and that they would if possible, avoid these patients. In a Vietnamese article Ishimaru et al. (2017) found that nurses with a discriminative and stigma associated attitude against HBV patients are less willing to care for these patients. The current study found that future nurses are afraid of caring for HBV patients even though they feel that they must care for these patients. Fears such as jobs getting affected, isolation and the society's feelings and attitudes towards HBV, affects the nurses due to fear of avoidance if they get infected. According to Maglalang et al. (2015) there are many people in the society that are aware of stigma concerning HBV patients. Many people choose not to tell friends and family about their disease because of societies prejudice, the infected person doesn’t want to burden the family and wants to protect their and the family's social life. Since society has a view of the virus that´s associated with stigma it´s understandable that the nursing students have been affected by this and perceive it in the same way. To see the situation in this perceptive can affect the patient with HBV that´s in the need of care.
According to the present study the participants do not believe that the vaccine has a high protection or the right antibodies against HBV which makes the vaccine unsafe. An article by Reinert et al. (2010) shows that a full dose vaccination that is given in infancy has a high protection, not just during childhood but also in longer terms. Aspinall, Hawkins, Fraser, Hutchinson & Goldberg (2011), mean that after the age of 40 the protection of a full dose vaccination given during infancy begins to decrease. Another study made by Garzillo (2020) shows that if health care workers are given a full-dose vaccination in adulthood the protection is 80 %. In the current study the participants mean that it doesn´t matter if the nurses are vaccinated or not, there´s still a concern when caring for HBV patients. The science shows that the vaccine is high protective, and the nursing students concern is not justified. If future nurses don´t trust the vaccine, how will they motivate the patient to conclude the full vaccination program? This can lead to or strengthen the already existing mistrust for the vaccine in the society. The result of this is that the population are less willing to use the vaccination program and that Vietnam can have difficulties in decreasing the transmission. In the Agenda for sustainable development goals, goal number three, Good health and wellbeing, contains that before 2030 the epidemic of HBV should be fought (UNDP, 2020). This means that there must be more research in the vaccine for HBV to be able to enlighten all the people in Vietnam. WHO can be a good information source for this and with this, Vietnam may reach the goal of 2030.
The current study shows that the participants are afraid of needle sticks in the workplace and that the fear of getting infected by HBV increase because of this. They´re aware of that safety precautions, such as gloves protects them from transmission in blood and fluids, but the lack of time makes it hard to use these precautions. Similar topics were found in an article by Cho et al. (2013) were the result shows that 70,4 % of the nurses had been exposed to needle sticks and sharp injuries. The same result showed that to prevent these injuries, guidelines and strategies needs to be developed at the workplace. In the current study the participants also mentioned
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that there´s a lack of guidelines regarding procedures when caring for patients with blood pathogens. The result of Joukar, Mansour-Ghanaei, Reza Naghipour and Asgharnezhad (2018) article shows that nurses don´t use gloves during nursing procedure even though they know that the gloves protects them from transmissions and is an important safety precaution which also correspond with the current study. This can mean that the nursing student´s choose to care for more patients rather than working with fewer in a safe way. In the long run this may lead to difficult complications. To be able to secure a care that´s safe, both for the patient and for the nurses, it may be important to prioritize the safety for the nurses even though the work is stressful. Quality education is the fourth goal of Agenda 2030, the goal illustrates that every student should have the right knowledge and acquirements. With the right education the nursing student´s wouldn´t choose to work in an unsafe way and think more about the consequences.
Conclusions
The current study found that there´s a lack of knowledge about HBV in the society, by the nursing students and the health care. Future nurses want to educate the patient in how to live with HBV but there are several challenges such as adjusting and use information that´s suitable for patients with low education and bad economy. The participants experience a lot of fear due to the risk of getting infected by HBV. The fear creates stigma towards the patients and the virus itself. The fear is based on lack of knowledge about the virus in the society and in the health care, this affects the nurses in how they see the virus. Stigma is also found in how future nurses perceive the typical HBV patient, in this case people who use drugs and not what the reality shows which is through perinatal transmission. A mistrust for the vaccine were also found with fear concerning both nurses and patients. In conclusion, the future nurses in Vietnam have many challenges to face regarding HBV.
Clinical Implications
This study aimed to get at wider understanding in how nursing student´s in Vietnam perceives what it´s like to care for patients with HBV. An understanding in how the nursing students in Vietnam feel about caring for HBV patients can be useful by identifying gaps in their nursing education and in their profession as a nurse. Further research needs to be conducted in several areas regarding HBV, areas such as self-education, how information is perceived and the trustworthiness in the vaccine. Stigma is a problem in Vietnamese health care and this study can enlighten this issue and hopefully, help health care workers to be aware of the present stigma. By increasing their own awareness and put their perception into words, this might help them to get a deeper understanding to care for vulnerable patient groups. Through increasing the awareness about a global health problem this can lead to that agenda 2030 being reached and saving lives in the future.
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Question:
• Would you like to describe your perception about caring for patients with hepatitis B?
Supplementary questions
• What do you think about that...?
• How do you feel about that...?
• Why do you think is like that...?
• How do you mean...?
• Tell us more...?
• Will you work in a specific way in the future when you treat patients with hepatitis B?”
• Which patient groups are you going to meet in the future that has hepatitis B”?
