Caring for patients with hepatitis B - experiences of Philippine nurses

(1)

Examensarbete i omvårdnad Malmö högskola

61-90 hp Hälsa och samhälle

Sjuksköterskeprogrammet 205 06 Malmö

CARING FOR PATIENTS WITH

HEPATITIS B

EXPERIENCES OF PHILIPPINE NURSES

EMMA KARLSTEDT

SOFIE LASSEN

(2)

CARING FOR PATIENTS WITH

HEPATITIS B

- EXPERIENCES OF PHILIPPINE NURSES

EMMA KARLSTEDT

SOFIE LASSÉN

Karlstedt, E & Lassén, S. Caring for patients with hepatitis B. Experiences of Philippine nurses. Degree Project in nursing 15 credit points, Malmö University: Faculty of Health and Society, Department of Care Science, 2015.

Background: Hepatitis B is a common disease in the Philippines. The disease

results in inflammation of the liver and is either an acute or chronic infection. Hepatitis B is spread through exposure to infected blood or other body fluids.

Aim: The aim of this study was to explore Philippine nurses' experience of caring

for patients with hepatitis B.

Method: A qualitative study with 11 semi-structured interviews. A qualitative

content analysis by Burnard (1991) was applied when the data was analyzed.

Results: The primary and most relevant experiences among nurses’ were to take

precautions while caring for patients with hepatitis B, to decrease the risk of transmission. The most common protective equipment used by the nurses was gloves. Proper disposal of used care material was also an important action to prevent transmission. Nurses need to be knowledgeable about the disease and use the knowledge to inform both patients and the community about hepatitis B. To care for patients diagnosed with hepatitis B caused different emotions among the nurses. Some nurses experienced fear while other nurses experienced the same emotions caring for a patient with hepatitis B as caring for a patient without an infectious disease. The nurses should support the patients and always treat all patients equally.

Conclusion: The study provides insights into Philippine nurses' experience of

caring for patients with hepatitis B. How the nurses protected themselves from getting infected with the disease varied, as did the feelings that the nurses had about caring for patients with hepatitis B.

(3)

ATT VÅRDA PATIENTER MED

HEPATIT B

- FILIPPINSKA SJUKSKÖTERSKORS

ERFARENHETER

EMMA KARLSTEDT

SOFIE LASSÉN

Karlstedt, E & Lassén, S. Att vårda patienter med hepatit B. Filippinska sjuksköterskors erfarenheter. Examensarbete i omvårdnad 15 högskolepoäng. Malmö högskola: Fakulteten för Hälsa och samhälle, Institutionen för

vårdvetenskap, 2015.

Bakgrund: Hepatit B är en vanlig sjukdom på Filippinerna. Sjukdomen är en

inflammation i levern som kan utvecklas till en akut eller kronisk infektion. Hepatit B sprids via infekterat blod eller andra kroppsvätskor.

Syfte: Syftet med studien var att undersöka filippinska sjuksköterskors erfarenhet

av omvårdnad av patienter med hepatit B.

Metod: En kvalitativ studie med 11 semistrukturerade intervjuer. En kvalitativ

innehållsanalys av Burnard (1991) användes för analysen utav data.

Resultat: Sjuksköterskorna upplevde att för att minska risken för smitta i vården

av patienter med hepatit B var det viktigt med skyddsåtgärder. Den vanligaste skyddsåtgärden som användes i vården av patienter med hepatit B var att använda handskar. Korrekt hantering av använt material ansågs också som en viktig åtgärd. Det ansågs viktigt att sjuksköterskorna skulle ha kunskap om sjukdomen och kunna använda kunskapen för att informera både patienter och samhället om hepatit B. Att vårda patienter med hepatit B orsakade olika känslor hos

sjuksköterskorna. Vissa upplevde rädsla medan andra hade samma känslor för att vårda patienter med hepatit B som patienter utan en smittsam sjukdom.

Sjuksköterskorna bör ge stöd till patienterna och behandla alla patienter på lika villkor.

Konklusion: Studien gav en inblick i filippinska sjuksköterskors erfarenhet av att

vårda patienter med hepatit B. Hur sjuksköterskorna skyddar sig från att blir smittade varierade, lika så vilka känslor sjuksköterskorna har inför att vårda patienter med sjukdomen.

(4)

INTRODUCTION

Hepatitis B is a common disease present throughout the world. The disease is prevalent in developing countries like the Philippines. This study is a Minor Field Study (MFS) and for relevance and insight had to be conducted in a developing country. The study also had to reflect a concerning area in the country that was chosen.

We selected the Philippines due to the desire to conduct our study in a country where the population spoke adequate English to make communication easier. A secondary reason for selecting this country was due to us having contact with a gatekeeper in the Philippines. Since the aim of the study had to be an area of concern to the country we chose, our selection and focus became hepatitis B. The disease is widely spread in the Philippines and both screening and treatment is too expensive for a big part of the population. The choice of focusing on hepatitis B is also relevant to us individually as future nurses in Sweden, were we are likely to encounter hepatitis B patients or patients diagnosed with other blood borne

diseases. Personal insights from this study and experiences gained interacting with different nursing cultures will also provide expanded knowledge for future use.

We wanted to conduct an MFS-study because we believe that we, in our future profession as nurses, will have great advantage of interacting with nurses from another culture and in different working conditions than those prevalent in Sweden. From the execution of this study we gained insights to the Philippines healthcare system and environment; this in turn will benefit us individually in our future profession as nurses in Malmö’s multi-cultural society.

BACKGROUND

Hepatitis B is a virus that causes inflammation of the liver (WHO, 2015a). The disease can either cause an acute or chronic infection (Melhus, 2013). Hepatitis B is a disease that is prevalent and present throughout the world (WHO, 2015a). According to Wong et al (2013) the hepatitis B virus, also called HBV, is a common infection in the Philippines (ibid).

The Philippines

The Philippines consists of more than 7000 islands in the West Pacific Region in Asia (WHO, 2011a). The official languages are Tagalog and English. There are 103 million people living in the country (ibid). Poverty is a problem in the Philippines (Worldbank, 2015). In 2009 37.8 % of the population were estimated to have an income of 2 dollars a day or less per day. The same year 16.6% had incomes of 1.25 dollars or less. The situation worsened by 2012 when 19% had incomes of 1.25 dollars or less (ibid).

Health care in the Philippines

The majority of the hospitals in the Philippines are privately owned (WHO, 2011b). Both the private and the public health sectors are regulated by the Department of Health (DOH). The DOH provides the healthcare industry with health guidelines and national plans (ibid).

(6)

The Philippines falls behind other countries in the Western Pacific region when it comes to health related spending (WHO, 2011b). The average health spending in the Western Pacific’s is 6.1% of GDP, where the Philippines spending rate is 3.9% of the GDP. People in need of care in the Philippines must most often finance the care by themselves, 48% of all health expenses in the country are paid privately by the patients (ibid).

Patients in the Philippines have freedom of choice of where to receive health care (WHO, 2011b). In reality many patients’ choices are limited to financial

limitations. Much effort has been put in to providing health care to poor families. PhilHealth is an organization that enables poor families to get the health care needed (ibid).

Hepatitis

Virus is the most common cause of hepatitis but can also be caused by for example toxins or pharmaceuticals (WHO, 2015b). Viral hepatitis is a generic name of hepatitis caused by hepatitis viruses A through E. These types of infections can cause severe illness and can be fatal (ibid). Hepatitis is an

infectious disease where the different types are variously contagious with hepatitis B as the most infectious of the types (Melhus, 2013).

Hepatitis B is a significant health problem in the world (WHO, 2015a). Annually the disease causes approximately 780 000 fatalities (ibid). The hepatitis B virus is an aggressive virus that can cause severe liver damage and life-threatening

infections (Melhus, 2013). If the acute hepatitis B infection heals or develops to a chronic infection depends on the infected patients’ immune system. If a chronic infection is developed, the infection damages the liver and will often over time lead to liver cirrhosis and liver cancer (ibid).

The virus is spread from person to person through infected blood and other bodily fluids (Murray, 2013). HBV can be detected in most body fluids like saliva, semen and vaginal secretion. The most contagious way of HBV transmission is from infected blood being directly introduced into a person’s bloodstream (ibid), for example through reusing needles or syringes in health care settings (WHO, 2015a). The HBV can survive for at least 7 days outside the body, during which time the virus can cause an infection through exposure to a person lacking protection from the HBV vaccine (ibid).

For acute hepatitis B, symptoms usually last from weeks to several months (CDC, 2015) Usually the symptoms begin approximately 90 days after point of

transmission (ibid). Some infected patients of acute hepatitis B show symptoms including fatigue and loss of appetite, though symptoms do not occur in all cases (Public Health Agency of Sweden, 2013). Some patients will experience icterus, dark urine, abdominal pain, nausea and vomiting (WHO, 2015a). Symptoms of a chronic hepatitis B infection does not occur in most cases until the end stage of the disease or though the progress of cirrhosis (CDC, 2015).

To be diagnosed with hepatitis B, the virus or antibodies against the virus has to be detected in the patient’s blood sample (Public Health Agency of Sweden, 2013). The virus can be detected in the patient’s blood from 30 to 60 days post infection and can then remain and become a chronic hepatitis B infection (WHO, 2015a). Vaccine is available to prevent transmission and infection of HBV (Public

(7)

health agency of Sweden, 2013).

Treatment for an acute hepatitis B diagnosed patient focuses on the disease

symptoms and maintaining comfort for the patient, since there is no cure available (WHO, 2015a). There are medications available for treating chronic hepatitis B (CDC, 2015). The medical treatment does not eliminate the infection, but reduce the virus ability to replicate (WHO, 2015a). The medical treatment for chronic hepatitis B is lifelong (ibid).

The possibility for infected people to be diagnosed and treated is limited in some developing low-income countries (WHO, 2015a). In those countries it is common to be diagnosed after prolonged hepatitis B infection where the virus already has caused advanced liver disease (ibid).

Nursing

Nursing is based on the relationship between the nurse and the patient

(Edvardsson et al, 2010). According to International Council of Nurses (2012) the main responsibility of nurses is to care for people in need of nursing care. In nursing care it is important to follow the declaration of human rights where everyone should be treated equally and with respect (ibid).

Nursing should be evidence-based, meaning nursing needs to be scientifically grounded (Willman, 2011). Nursing should also be person-centered, where the patient is treated as an individual, and the patient’s experiences and feelings are confirmed (Edvardsson et al, 2010). In person-centered care patients should be engaged in all aspects of the care and focus should be kept on the personality of the individual. Person-centered care is based on good ethical values and on a humanistic perspective, and needs to be applied in proper nursing (ibid). A study by Olsson et al (2006) indicates that person-centered care shortens a patient’s required length of hospital admittance significantly (ibid).

Nursing and hepatitis

Practicing nurses are at risk of exposure to blood borne viruses (Castro, 2009). It is important for health care providers to prevent hepatitis infection from spreading from one patient to the next and from getting infected themselves (Murray et at, 2013). Proper hand hygiene, plastic disposable gloves and apron should always be used when there is a possibility of getting in contact with contaminated blood or bodily fluids (ibid). Blood spatter from a patient with hepatitis B should be removed while wearing gloves due to blood, including dried blood, is infectious (CDC, 2015). Daily work in health care settings should be organized and

performed in a way so that accidents and transmission of diseases are avoided. (AFS 2012:7 6§)

Higher frequency of screening and vaccination is required to reduce the prevalence of HBV in the Philippines, according to Gish et al (2015). Also transmission in health care settings needs to be prevented. Reusing of needles occurs in some healthcare settings in the Philippines, a practice that must end in order to prevent transmission in health care. Also used medical equipment that lack proper sterilization leads to transmission. Therefore, such equipment requires proper sterilization before being use with another patient. Another important issue leading to transmission of hepatitis B is inadequate education, both among health care workers and the general population (ibid). According to the International

(8)

Council of Nurses (2012) nurses should provide care that is safe for the patients. Nurses should also keep their knowledge updated to maintain competence. The knowledge that the nurses have should be shared with others with the purpose to further educate (ibid).

Patients with hepatitis B need emotional support from healthcare workers (Ng et al, 2013). The patients also need information about for example prevention, complications and ways of transmission (ibid).

Area of concern

Hepatitis is a common infection in the Philippines (Wong et al, 2013). The population chronically infected by hepatitis B alone is at 16.7 %. Hepatitis B is considered an endemic disease in the Philippines (ibid). About 50% of hepatitis B related deaths in the world occur in the Western Pacific Region and approximately 900 people die every day (WHO, 2014). According to Bacasen et al (2006), hepatitis B infections are a public health problem, yet there are few studies available on the prevalence of hepatitis B in the Philippines (ibid).

Many people in the Philippines get infected by hepatitis B, but few recover from the disease. Since few recover, many of the infected people will sooner or later need nursing care. The authors searched for articles related to nursing and hepatitis B in PubMed and Cinahl but discovered very few on the subject. No study done in the Philippines related to the subject was found. Therefore the researchers believed that it was of importance to investigate the chosen subject and chose to do an empirical study.

Aim

The aim of this study was to explore Philippine nurses' experiences of caring for patients with hepatitis B.

METHOD

A qualitative design was chosen for the research study with data collection through in-person interviews. Malterud (2009) defined qualitative methods as an appropriate research strategy when the objective is to understand human

experiences, attitudes or emotions (ibid).

Sample

To be included in the study the respondents had to meet all the inclusion criteria which included three parts: the ability to speak English, being a registered nurse or specialist, and having experience of caring for patients with hepatitis B. Using a gatekeeper is, according to Polit and Beck (2013), a way to obtain access to a research site (ibid). The authors had access to a gatekeeper who provided participants for the study. The gatekeeper had a broad network, including nurses. The nurses were working at four different medical centers in Boracay, where the gatekeeper had contact with nurses’ at all four centers. The gatekeeper also assisted the authors with scheduling the interviews. According to Polit and Beck (2013) snowball sampling is a method where early respondents are asked to spread information about the study to other possible informants (ibid). After

(9)

interviews were completed with the gatekeepers’ contacts, snowball sampling was used to find additional respondents.

The sample size included 11 registered nurses who all met the inclusion criteria. The respondents were between the ages of 22 through 34 years old and had professional experience of working as a registered nurse from 10 months to 11 years. The respondents consisted of 3 males and 8 females.

Data collection

According to Trost (2010) a successful pilot study could be included in the data material (ibid). The interview questions (appendix 1) were tested on one subject in a pilot interview. The pilot interview was deemed successful and was included in the final data collection sample.

Data collection initiated November 20th, 2015 and concluded November 30th, , 2015. According to Maltby et al (2010), interviews are suitable when the objective is to collect in-depth qualitative data (ibid). Individual interviews were conducted to collect data for the study. Semi-structured interviews are suitable when the researchers have some broad questions that must be included during every interview (Polit & Beck, 2013). Therefore the interviews were semi-structured. According to Polit and Beck (2013) a topic guide will ensure that all the questions are asked (ibid). A topic guide (appendix 1) was made by the authors, which made sure all interview questions were discussed. The interview guide started with the open question: Can you tell us about a situation when you were caring for a

patient with hepatitis B? Since English is one of the official languages in the

Philippines (WHO, 2011a), the interviews were conducted in the English

language. Each interview lasted approximately 15 minutes. During the interviews focus was kept on the interviewees’ experiences dealing with hepatitis B.

The gatekeeper was informed about the study before the researchers arrived in Boracay, Philippines. Upon arrival a meeting was held with the gatekeeper and further information about the study was shared. The gatekeeper then informed the potential respondents. According to Trost (2010) it is important for the respondent to feel comfortable during the interview. One option to ensure the respondent’s comfort is to allow the respondent to choose the location of the interview (ibid). Therefore all interviews were carried out at a location chosen by the respondents. Both oral and written information was provided to the respondents. The

gatekeeper informed the potential respondents about the aim of the study and that the interview would take approximately 20 minutes. The researchers provided the respondents with additional information, both oral and written (appendix 2), before starting the interviews. The respondents were also asked to sign an informed consent form (appendix 3) before starting the interviews.

During the interviews both authors were present and conducted the interviews together. The first author was responsible for the oral information before the audio recording started, and additionally for comments and further questions that arose during the interview. The second author asked the respondents the primary questions from the interview guide.

According to Trost (2010), when using audio recording the interviewer can focus on the questions and answers instead of taking notes (ibid). The interviews were

(10)

audio recorded using a cellphone. On the same day when interviews were

concluded the recorded material was transferred from the cellphone to both of the researchers’ computers and to a flash drive for secondary backup.

In close adherence to each interview the researchers transcribed the data. The researchers transcribed the first interview together so that the following interviews were transcribes in the same manner. The researchers listened to the recorded material several times and transcribed five interviews each. After transcribing the material individually the researchers listened to the audio-recordings together while reading the transcribed material to ensure the responses were covered in full in the transcripts.

Analysis of data

The data consisted of 11 audio-recorded interviews. Upon conclusion of interview the material was transcribed. Qualitative content analysis was used to analyze the collected data material, an approach inspired by Burnard (1991). The content analysis included 14 stages. The stages most suitable for the study were included. Two stages, number 10 and 11, were excluded. Stage 10 consisted of pasting cut out sections from the transcribed material on to a piece of paper. Instead the authors used a Word-document to copy and paste the sections. Stage 11 involved asking the respondents to confirm that what has been said during the interviews was relevant and suitable to the categories. One stage was adjusted, the 6th_stage,

where the authors chose to view the transcribed material and finding categories individually and then discussed together, instead of inviting two colleagues. Burnard (1991) described the importance of reading the transcripts several times (ibid). The authors read the transcribed data repeatedly, both individually and together. The transcribed data was then coded individually. Burnard (1991) stated that after the material was coded, categories should be grouped together (ibid). The authors worked through the material and created categories first individually and then compared and discussed the codes and categories together. A final list of categories and subcategories was created. The list consisted of three categories and seven subcategories. During the analyzing process the names of the categories and subcategories were changed several times to ensure the most suitable names. A word document was created for each category. Appropriate parts of the

transcribed material were transferred from the transcribed interview and inserted into the document under the most appropriate category. When all the coded material was placed under a suitable category the results were typed in to a final report. According to Burnard (1991) copies of the transcribed material should be saved to make sure that the context of the material would not be lost (ibid). The authors saved a copy of the original transcribed material so that it would be possible to review the original transcribed interview if there were any questions that arose regarding what the respondents were talking about.

Ethical considerations

Before beginning the interviews, ethical approval was given from the Ethical Council of Health and Society at Malmö University (HS 2015/Löp nr 1). Key considerations for the authors were the security of respondents’ anonymity and confidentiality, the handling and storing of the material during the study and when the confidential material should be destroyed.

(11)

According to Malterud (2009) information about the study and how the data would be collected had to be given to the respondents, also that participation was voluntary (ibid). The given information consisted of the aim of the study,

description that an interview would be held and audio recorded, about confidentiality and anonymity and how the material would be handled. The information also made clear that participating in the study was voluntary and that the respondents had the right to withdraw participation at any time, without any consequences. All respondents were asked to sign a consent form (appendix 3) confirming to have been informed about the study and understanding that withdrawal of participation was possible at any given time without any explanation required.

During the interviews the respondent’s name was not written down. Instead each interview was given a code number. To make the respondents comfortable, the interviews took place at a location of the subject’s choosing. The material from the interviews, the audio recordings and transcriptions, were during the study secured on two computers and one flash drive. The computers, flash drive and the printed transcripts were kept in a security box in a locked room, to which only the authors had access.

RESULTS

The results consist of three main categories with seven sub categories (Table 1). The categories are presented below together with quotes from the respondents to clarify what the nurses discussed during the interviews.

Table 1. Categories and sub-categories.

Category Sub-category

Importance of precaution - Using protective measures and equipment - How to handle used materials

Knowledge as prevention - The importance of nurses’ knowledge - Reducing transmission through education Caring for patients with hepatitis B - Nurses’ feelings

- Treating patients equally - Supporting the patient

Importance of precaution

Experienced nurses’ noted the importance of taking precautions when caring for a patient diagnosed with hepatitis B, to avoid transmission of the disease to the nurses. One precaution was to wear protective gear while interacting with the patient to avoid exposure. Another precaution was to handle and dispose used

(12)

materials properly.

Using protective measures and equipment

Most of the respondents noted the importance of being careful while caring for patients with hepatitis B to avoid personal exposure and possible transmission, and discussed different ways to protect themselves. The most common protective equipment described was wearing gloves while in contact with patients with hepatitis B. Some of the nurses also spoke of wearing two pairs of gloves as further protection.

“/…/ You need to take some precautions for example you have to wear gloves /…/” X3

The respondents mentioned certain patient interactions where wearing gloves was of additional importance. The most common situation where the nurses believed gloves were extra important was when drawing blood or handling wounds of a patient with hepatitis B.

During the interviews some of the nurses mentioned situations where using gloves was considered difficult and therefore chose not to use gloves. The nurses

described situations when wearing gloves would upset the patient and make the patient feel belittled. Wearing gloves could also interfere with the nurse-patient relationship. A few of the nurses described an approach of explaining to the patient the reason for wearing gloves and asking for the patient’s permission to wear gloves first, so that the patient would not be offended.

“/…/ I ask the patient if I could use gloves, and he’s aware of it and yeah, it’s okay with him /…/” X6

In addition to wearing gloves, some of the nurses spoke about wearing other protective equipment, such as gowns, goggles and masks when exposed to blood and other bodily fluids. The type of protective equipment that the nurses used depended on the situation. The more blood and bodily fluids that the nurses were exposed to from a patient with hepatitis B, the more protective equipment would be used.

“/…/ And there is a lot of blood coming out we use gowns or aprons, nurse tools, and we use double gloves and double mask /…/” X10

To protect themselves from getting infected with hepatitis B, a few nurses stated the importance of having a healthy lifestyle as a nurse since the ability to give the patients proper care decreased when having a disease. Some respondents also mentioned the importance of not having wounds or cuts while caring for patients with hepatitis B. Nurses who suffered from wounds or cuts needed to take extra precautions to avoid exposure of the wounds to infected blood or bodily fluids, since having wounds increased the risk of getting infected with hepatitis B.

“/…/ like healthy lifestyle, good nutrition, like exercise, good diet and at the same time you are precautionary about the fluids. /…/” X2

(13)

How to handle used materials

The nurses noted the importance of proper disposal of used material. Proper disposal of syringes was the most frequent subject when disposals was discussed. The nurses needed to always be careful while handling used syringes. Also the syringes should never be reused after initial use with a patient with hepatitis B, according to the respondents. The used syringes should not be disposed in

common trash bins, but instead in special containers for disposal of used syringes and other sharp objects. One of the reasons why proper disposal was important was to avoid accidental pricking of the nurse by the syringe needle. Another reason was to prevent that the needles would not harm other patients or co-workers.

“/…/ When you withdraw or extract blood you have to be very careful about the needle and the syringe. It’s single use so you need to place it in the proper placement, so it won’t harm other employees or co-worker.” X9

Material like dressings, gaze and other material that had been in contact with blood and body fluids from a patient with hepatitis B should be disposed in a proper way, according to the nurses. The reason why the used material should be handled and disposed of properly was, according to the nurses, the same reason as why proper disposal of syringes was important. Which was to avoid health care workers or other patients’ exposure to the potentially infected material. One example of how the used material was disposed properly was to put the material in the correct trash bin. There were four different colors for used materials that were graded from “low” to “high” infectious waste.

“/…/ If I make a dressing the gaze that I use just throw it in the infectious garbage can. Because it’s fluids from the patient, you know, it is

infectious/…/” X11

Knowledge as prevention

Knowledge and education were considered similarly important in the prevention of transmission of hepatitis B. The nurses’ spoke about the importance of being knowledgeable about hepatitis B and that information about the disease should be shared to others.

The importance of nurses’ knowledge

During the interviews many of the nurses talked about the importance of knowledge while caring for patients with hepatitis B. It was a requirement that nurses had the correct information about hepatitis B with ongoing updates so that the correct information could be shared with the patient.

“/…/ You must have knowledge on hepatitis B. Always update! /…/ Information is very important. Correct information rather.” X2

Additionally, knowledge about the disease enabled the nurses to protect them selves appropriately to avoid infection. Therefore knowing the mode of

transmission was important, according to the nurses. Knowledge also made the nurses feel more safe while caring for patients with hepatitis B.

Reducing transmission through education

(14)

hepatitis B. The respondents that discussed education highlighted the requirement to educate the affected patient about the hepatitis B disease. When the nurses educated and informed the patients about hepatitis B, some of the nurses had experienced that patients sometimes found it hard to talk about the disease and had difficulty with accepting the hepatitis B diagnose.

Some respondents said that not only should the patient be given information about hepatitis B, but family and relatives of the patient needed to be informed as well.

“/…/ You have to educate them, also not only them, but also the ones who are not yet infected but possible to be the one who will be getting the disease /.../” X1

The community and people who were not yet infected also needed to be given information and education about hepatitis B. Through educating people who were not infected, further transmission could be avoided. Educating the patient,

relatives and the community should consist of the process of the disease, the ways of transmission and how transmission can be avoided, according to the

respondents.

“/…/You can also for the patients having the hepatitis B, advice their friends or relatives that always be careful so that they will not be given the hepatitis B.” X8

Caring for patients with hepatitis B

While caring for patients with hepatitis B the nurses experienced different emotions. Despite the emotions that the nurses had, all patients should be treated equally. Being supportive was experienced as a part of the nursing care of a patient with hepatitis B.

Nurses’ feelings

Some of the nurses found that caring for patients without hepatitis B was easier than caring for patients with the disease, both when it came to meeting with the patient and caring for the patient. Once the nurse found out that a patient had hepatitis B a common first reaction was feeling fear and anxiety. The nurses also felt that they had to be extra cautious when caring for the patient. The fear and anxiety was based on the fear of possibly getting infected of the disease. The fear was not only based on the physical consequences of the disease but also due to the impact on the family life. One way of possible infection that the nurses feared was being pricked by syringe needles that had been used on a patient with hepatitis B. The nurses’ were also anxious about the situation itself, that while caring for a patient with the disease, a single mistake made could not be undone.

“/…/I was very afraid, it scares me a lot. Because a little mistake, you know, you cannot change, you cannot change it, you cannot undo things/…/” X6

A few of the nurses discussed empathy for the patient. The nurses should have empathy and be sensitive when interacting with the patient in order to give the patients better care. Another emotion described was feeling sad for the patients with hepatitis B because the nurses felt inadequate. The feeling of inadequacy was due to that the nurses felt they could only provide good nursing care but being concerned that was not enough, since there was no treatment available to cure

(15)

hepatitis B.

“/…/ I feel a bit sad as well /…/ I cannot help him or her from anything except for just making sure they´re feeling okay /…/” X4

Some of the nurses’ described no difference in emotions regardless of caring for a patient with or without hepatitis B. Since caring for a patient with hepatitis B was common in the Philippines, the nurses felt safe as long as the proper protective equipment was used.

“/…/ Actually same with the other patients feel normal reaction, normal treatment /…/” X5

Despite the individual nurse’s feelings, the feelings must not affect the nursing care. The respondents felt that it was important to show professionalism at all times and under all conditions. If the feelings the nurses had about hepatitis B were projected against the patient, the care of the patient could be affected. Some of the nurses explained that if the nurses’ feelings about caring for patients with hepatitis B were expressed, the patient could be affected in different ways. The patient could experience unequal treatment as compared to other patients and also experience feeling belittled by the nurses.

“/…/ You have to separate your feelings from professional work because it will affect your care /…/” X1

Treating patients equally

Many of the nurses talked about treating all patients the same and not treat them differently because of the disease. During the interviews the nurses also

highlighted the importance of not judging patients infected with hepatitis B. Instead all patients should be treated with respect. The respondents explained that it was just a matter of what protective measures and equipment that should be used.

“Regardless if there is a laboratory result you have to be precautious when handling, especially when there is a blood contact so you secure your safety all the time /…/” X7

The nurses should always be cautious when caring for patients, not only when the patients were diagnosed with hepatitis B. Patients who were not diagnosed with hepatitis B may still be infected without the patients’ or health care providers’ knowledge.

Some of the nurses said that in most cases it was not possible to tell whether a patient was infected by hepatitis B or not simply by meeting them. If the patient did not inform the health care provider about having hepatitis B, the health care providers would most often be unaware of the patient’s condition, according to the respondents. Without the knowledge of that some of the patients may have been suffering from hepatitis B, it was critical that the nurses always used the right protective equipment. Therefore same protective equipment should be used while treating any patient, not only the patients known to suffer from hepatitis B. Even with the knowledge that a patient was infected with hepatitis B the nursing care must not be affected. All patients should be treated equally.

(16)

“The first thing is we should not judge the person with the positive hepatitis B. Second is we need to be safe all the time, whether if it is a positive or negative. Because we don’t know if the patient is reactive by seeing it physically /…/” X5

Supporting the patient

A few of the nurses talked about that while caring for patients with hepatitis B, it was important to be supportive and be considerate of the patients’ feelings. Some patients had difficulties accepting the hepatitis B diagnose and therefore needed some support and encouragement. The nurses described different ways of being supportive such as talking to the patients and letting the patients know that the nurses care and want to help. Even if the nurses’ job in itself is to provide nursing care, the nurses wanted the patients to know that the care was being given because the nurses cared about the patients.

“/…/ I don’t want them to think that just because I have this job, it’s my responsibility to take care of them /…/” X4

DISCUSSION

The discussion is divided into discussion of methods and discussion of results. The discussion of methods consists of how the chosen method and the authors’ pre-understanding can have affected the results. Credibility, dependability and transferability are also included. The discussion of results consists of a discussion of the results of the study together with previous scientific studies and relevant literature.

Discussion of methods

A qualitative method was chosen for the study. Semi structured interviews were conducted to collect the data. The chosen method enabled the authors to

investigate the aim of the study. According to Malterud (2009) a qualitative method is suitable when wanting to explore experiences (ibid). Therefore the authors applied a qualitative method for the study.

Sample

A gatekeeper assisted the authors in reaching potential respondents. The gatekeeper did not work at any of the four medical centers where the subjects worked, but knew the respondents privately which was seen as a strength because the authors believed it was easier for the respondents to decline participation when asked by a friend than by a supervisor. Convenience sampling and snowball sampling was used. The authors consider the chosen method appropriate for the study since the authors were conducting the study in a foreign country with a limited network and time. The authors chose to interview 11 nurses since the interviews conducted lasted less time than first assumed. The higher interview count ensured that a rich material was collected for the study. Before the sample was final the authors hoped for a variation in age, working experience and gender. Despite this, the age between the respondents, working experience and gender did not vary as much as the authors had hoped for, which could be seen as a potential weakness of the study. A greater variation could have resulted in a different result, which the authors were aware of.

(17)

Data collection

When data was collected, semi structured interviews with open-ended questions were used so that the respondents were able to talk freely about the subject. According to Polit and Beck (2013) the researchers cannot know for sure that the respondents are telling the truth when using a qualitative design. Therefore there is no other option than to believe in the respondent’s responses (ibid). Though the researchers could not be certain, the authors believed that the respondents

answered truthfully during the interviews.

Trost (2010) described the importance of that the respondents felt comfortable during the interviews (ibid). To increase the credibility of the study the

researchers let the respondents chose the time and location of the interviews, to make the respondents feel more comfortable. The interviews were conducted in a more public setting. A more private setting would have been desirable for

conducting the interviews. However the authors let the respondents’ chose the location and the respondents did not seem to be affected by a more public setting. Before the interview the researchers introduced themselves and the study and made sure that participation was voluntary and anonymous, also to increase credibility. The information shared with the respondents should be both oral and written, and should be easy to comprehend (The Research Committee of

Medicine, 2000). When both oral and written information was provided, the respondents would always have the option to go back to the written information to avoid any uncertainties (ibid).

The interview guide started with the open question: Can you tell us about a

situation when you were caring for a patient with hepatitis B? The question was

asked to let the respondent talk freely about an experienced situation and so that the respondent kept the situation in mind while answering the following questions. Some of the respondents had a difficult time to recollect a specific situation. However, the authors chose to continue to include the question, even with some respondents’ difficulty recollecting, since the authors believed that the question made the respondents reflect about the topic. If the respondents had no experience with an acute or stressful situation, then the following question would not be asked: “Can you tell us about your feelings and thoughts regarding hepatitis B in

acute or stressful situation?”

The interviews were held in English. Both authors and respondents spoke adequate English but since English was not the native language of neither the authors nor respondents there was a possibility that the understanding could have been affected.

The interviews were audio recorded using a cellphone so that the authors were able to listen to the responses several times. According to Polit and Beck (2013) using an audio recorder would not distract the respondents during the interviews (ibid). The authors still had in mind that the recording could have affected the respondents’ answers. After each interview the authors transcribed the material first individually and then together to ensure full data inclusion. According to Burnard (1991) validity increases when colleagues who are not involved in the study are invited to read the transcripts and establish categories (ibid). Instead the authors selected categories individually and then discussed and combined a final list of categories together.

(18)

The limitation of time for the study was considered as a weakness. The authors had ten weeks to collect the material, analyze and complete the study. The limited time frame may have affected the results. If more time was given to conduct the study, interviews could have been held in different parts of the Philippines. A broader geographical span would then be covered, which would have increased the study’s credibility.

Data analysis

According to Graneheim and Lundman (2008) a content analysis is appropriate when the researchers have a rich set of data that has to be analyzed. Using qualitative content analysis was common in the field of nursing research (ibid). Burnard (1991) had developed a content analysis consisting of 14 stages (ibid). The researchers were inspired by Burnard’s (1991) approach when analyzing the material. The stage process was followed to establish relevant categories and subcategories. To make the analysis more suitable for the study, two of the 14 stages were excluded. Since the authors were novices in research, Burnard’s (1991) qualitative content analysis was further helpful. The analyze method presented stages that were easy to follow and understand. During the first part of the analysis phase the authors worked individually to increase the credibility of the study.

The authors experienced gathering the coded material into categories easier than to name the categories due to some themes being consistent throughout the interviews. Subcategories were harder to generate, according to the authors, since some of the subcategories were similar in content. The researchers worked through the subcategories resulting in a reduced number of subcategories. The authors believe the reduced amount of subcategories impacted the study positively due to the coded material became easier to link to the correct subcategory.

Credibility, dependability and transferability

Credibility, dependability and transferability are three important criteria in nursing research (Polit & Beck, 2013). Graneheim and Lundman (2003) describe

credibility as how well the collected data material and analysis work together to support the aim of the study. The researchers must choose an appropriate method for data collection and enough data must be gathered to achieve credibility (ibid). According to Maltby et al (2010) interviews are suitable for data collection when conducting a qualitative study (ibid). To reach credibility the researchers chose interviews as the method for collecting data. To ensure enough data was collected the authors originally planned to conduct 6 to 8 interviews. After conducting a few initial interviews, the authors realized that the interviews lasted for a shorter time than assumed. Therefore the authors decided to conduct at least 10

interviews. Eleven interviews were completed to ensure an adequate amount of data was collected.

According to Polit and Beck (2013) dependability refers to the trustworthiness of the collected material and the analysis of the material (ibid). Trost (2010)

prescribes that to increase a study’s dependability follow-up questions should be included during the interviews (ibid). Therefore the authors asked follow-up questions during the interviews. To increase the research dependability and to get a deeper understanding of the nurses’ experiences the authors believed that additional follow-up questions should have been asked. Due to inexperience the

(19)

authors found it difficult to conduct additional questions outside the established interview guide. If the authors were to redo the interviews, more follow up questions would have been asked.

Graneheim and Lundman (2003) describe transferability to what extent the results can be applied in a different group or setting (ibid). Since a qualitative design was used for the study, achieving the same results from a repeated study would be unlikely. The results were based on the specific nurses’ individual experiences. To try to achieve a level of transferability, the authors described the entire process of the study.

Pre-understanding

According to Malterud (2009) the researchers pre-understanding can affect the study and must therefor be considered (ibid). Neither of the authors had any deeper knowledge or experience of the chosen subject prior to the study. Dahlberg and Nyström (2001) state that the results can be affected if the

researchers are not aware of the understanding and the consequences of understanding (ibid). In the beginning of the study the researchers had a pre-understanding that the nurses experienced fear of being infected when taking care of a patient with hepatitis B. During the study the researchers tried to set aside the pre-understandings. Although, it was difficult to know if the results were affected or not.

Discussion of results

The discussion of results is presented together with previous scientific studies and literature.

Importance of precaution

Taking precautionary measures were important to the respondents and an issue that was repeatedly highlighted. According Lymer et al (2004) wearing gloves is considered to be the most important protective equipment when being exposed to blood or bodily fluids from a patient. Even if gloves are considered important, nurses do not always use them (ibid). The results of this study confirm that wearing gloves was the most important protective equipment when caring for patients with hepatitis B and despite this gloves were not always worn.

Lymer et al (2004) states that protective eye-cover is not commonly worn when being in contact with blood or bodily fluids. The use of protective eye-cover is often an overreaction of fear of being infected by blood borne diseases (ibid). Some of the nurses spoke about wearing goggles as protection, which could be translated as an action taken based on fear by the nurses.

There was a risk of getting pricked when handling needles. The results of a study by Lymer et al (2004) indicate that almost all the respondents had been pricked by needles themselves or knew someone who had been pricked (ibid). Therefore it was important for safety that nurses handled used needles and syringes with care. The nurses in this study talked about how to handle used needles and syringes properly and thought it was an important factor to think about to avoid

transmission of hepatitis B.

(20)

the nurses in a study by Lymer et al (2004) talked about recapping syringe needles manually before throwing them in a container for sharp objects. Even though the practice increased the risk of needle pricking the nurses chose to recap the needles to protect co-workers and patients (ibid). The safety of co-workers and patients was also a concern to the nurses in this study, the nurses had in mind to protect others when handling used needles and syringes.

A study by Rajasekaran et al (2003) showed that approximately half of the

respondents had designated containers for sharp materials. The other half disposed of the sharp material in common use trash bins together with other waste (ibid). Similar results were found in this study. The results of this study revealed that the nurses had special containers for disposal of used needles and syringes.

According to a study by Enwere and Diwe (2013) approximately half of the respondents knew of color-coded bins (ibid). Some of the nurses described throwing material that had been in contact with infected blood or bodily fluids in separate colored containers. The colors represented different levels of infectious waste.

Knowledge as prevention

The results of a study by Lymer et al (2004) indicate that knowledge is important to maintain a high safety culture. A knowledgeable person should continuously be updated about the disease (ibid). Similar results were found in this study. The results show that knowledge was an important factor in preventing transmission of hepatitis B. Knowledge made the nurses aware of how to protect them selves and others in situations where there was a risk of transmission. A study by Selvin and Wilkin (2004) show that knowledge together with working experience can help the nurse to feel safe and confident when providing care to a patient

(ibid). Similar results were found in this study. The nurses talked about feeling less worried when having knowledge about hepatitis B. According to International Council of Nurses (2012) nurses are responsible for maintaining updated

knowledge and should keep updated during their professional career (ibid). The nurses in this study talked about that the knowledge should be updated.

Education was a part of the nurses’ professional duties to prevent transmission of hepatitis B. A study by Larsson et al (2005) indicates that exchange of knowledge and information between the nurse and the patient is important. The nurse should provide the patient with knowledge for caring for their disease. It is important to find out what the patients already know so the education is put at a suitable level (ibid). The nurses highlighted the importance of education to prevent hepatitis B from being transmitted. The nurses should educate the patients how hepatitis B is transmitted so further transmission could be avoided.

Caring for patients with hepatitis B

The nurses experience different emotions when caring for patients with hepatitis B. According to Lymer et al (2004) some nurses may experience fear of becoming infected with a blood borne disease. The fear was not only of the personal

physical impact of the disease but also of the impact on the family and

professional life (ibid). A study by Batty et al (2012) also reveal that fear was experienced among health care workers. The respondents feared acquiring a blood borne infection while at work (ibid). Fear was one of the emotions that the nurses in this study felt while caring for patients with hepatitis B. The most common fear

(21)

was being pricked by needles that had been used with a patient with hepatitis B and thereby becoming infected. The results in this study also showed that the nurses experienced fear for the disease itself and also for how any exposure resulting in infection could affect them privately, with concern on their families and their ability to work as a nurse.

A study by Cekin et al (2012) shows that most of the respondents have the same feelings while caring for patients with hepatitis B as when caring for patients without any infectious disease (ibid). Even though some of the nurses experienced fear when caring for patients with hepatitis B, other nurses experienced the same emotions as when caring for patients with any other condition.

Empathy is an important feeling to have when working as a nurse (Selvin & Wilkin, 2004). Empathy is described as trying to understand the patients’ situation (ibid). The nurses talked about feeling empathy towards the patients since it could enable better care for the patient.

According to Kagan et al (2009) nurses should treat all patients as potential carriers of an infectious disease (ibid). Some of the respondents talked about the importance of treating all patients similarly. The possibility of a patient being a hepatitis B carrier without the nurses’ knowledge was highlighted. Therefore the nurses must treat all patients the same when it comes to both protection and the care given.

The results of a study by Kagan et al (2009) show that many of the nurses included in the study avoided caring for patients with blood borne diseases. Although some of the nurses did not avoid contact. The results also indicated that the degree of nurses’ knowledge did not affect the avoiding behavior (ibid). The results of this study showed that the nurses did not avoid contact with patients with hepatitis B. Since the disease was common in the Philippines the nurses were used to caring for patients with hepatitis B.

According to a study by Haeok et al (2010) patients with hepatitis B may feel fear and sadness because of their disease (ibid). Selvin and Wilkin (2004) described the importance of listening to the patient and letting the patient talk about the feelings and thoughts the patient may have (ibid). The nurses highlighted the importance of supporting the patients since the hepatitis B diagnoses could affect the patients in different ways. Support was described as a process when the nurse gave the patient hope and assisted the patient in both an emotional and a practical way (Selving & Wilkin, 2004). The nurses should use professional knowledge to give the patient the support that the patient may need (ibid).

CONCLUSION

Key findings of the study describe the importance of proper precautions taken by nurses caring for patients with hepatitis B. Taking proper precautions include the use of protective equipment and proper disposal of used material. It was important that the nurses have knowledge of hepatitis B so that transmission can be avoided. Knowledge is also important so that the nurses can educate both patients infected with hepatitis B and the general population.

(22)

The nurses experience different emotions when caring for patients with hepatitis B, with the most prevalent emotion being fear of transmission while caring for the patient. Despite the nurses’ feelings, it is important that the nurses are professional and provide the patients the care they require.

When caring for a patient with hepatitis B, providing support is important. The results also show that the nurses believe it is important to treat all patients equally. The patients should never feel like the nurses is treating them differently because of the hepatitis B diagnoses. The nurses should be mindful of that all patients are potential carriers of hepatitis B without the patients’ or health care providers’ knowledge. Therefore it is always important that the nurses use appropriate protective equipment.

FUTURE RESEARCH

RECOMMENDATIONS

The study has increased the authors’ knowledge of nursing approaches in caring for patients with hepatitis B and what nurses who provide such care believe to be important regarding the subject. Hepatitis B is a prevalent disease in the

Philippines. In order to decrees transmission of the disease understanding of the disease needs to be expanded and more prevalent, about the disease itself and how transmissions can occur. Increasing vaccination and screening of the general public are also important measures that will decrease transmission of the disease. Currently, the possibility of screening is limited due to socioeconomic realities since the test is not affordable to a large part of the population. Even when screening is preformed and the result is positive, the treatment is many times too expensive for a large section of Filipinos.

Further investigation of nurses’ approach to care for patients with hepatitis B using a larger sample size of subjects would be helpful to understand if approaches differ between different parts of the country. The researchers

recommend additional research about nursing and hepatitis B in the Philippines. The authors have noticed a lack of research studies about hepatitis B in the Philippines. With the prevalence of hepatitis B in the country the researchers believe additional research will be useful in improving prevention of the disease and care of the patients with the disease. General studies of Philippine nursing practices would also provide helpful insights to assist with improvements of the practice. Lastly, further research about caring for patients with hepatitis B is also recommended.

The results of the study will hopefully increase the awareness of hepatitis B. The findings may highlight how nurses in the Philippines approach caring for patients with hepatitis B and possibly contribute to giving Swedish nurses an

understanding of the similarities and differences from caring for patients with hepatitis B in Sweden.

(23)

REFERENCES

Arbetsmiljöverkets författningssamling, 2012:7

Bacasen LC, Rodenas JG, Que E (2006) The prevalence of HBsAg (+) and anti-HCV (+) among healthy blood donors at east avenue medical center, Quezon city.

Philippine Journal of Gastroenterology 2:64:70, 64-70.  

Batty L, Cliffe S, Ncube F, Tomkins S, Winchester S.A, Zuckerman M (2012) Healthcare workers' perceptions of occupational exposure to blood-borne viruses and reporting barriers: a questionare-based study. Journal of Hospital Infection

82, 36-39.    

Burnard P (1991) A method of analysing interview transcripts in qualitative research. Nurse education today 11, 461-466

Castro AB, Cabrera SL, Gee GC, Fujishiro K, Tagalog EA (2009) Occupational health and safety issues among nurses in the Philippines. AAOHN Journal, 57(4), 149-157.

Cekin AH, Cekin Y, Ozdemir A (2012) The level of knowledge of, attitude toward and emphasis given to HBV and HCV infections among healthcare professionals: data from a tertiary hospital in Turyeky. International Journal of

Occupational Medicine and Environmental Health, 26(1), 122-131.

CDC, (2015) Hepatitis B FAQs for Health Professionals

>http://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#overview< (2015-11-25)

Dahlberg K, Nyström M (2001) Pre-understanding and openness – a relationship without hope? Scandinavian Journal of Caring Sciences, 15, 339-346

Edvardsson D, (2010) Personcentrerad omvårdnad – definition, mätskalor och

hälsoeffekter. I: Edvardsson D, Personcentrerad omvårdnad i teori och praktik (1:2). Lund: Studentlitteratur. s. 29-35.  

Enwere OO, Diwe KC (2013) Knowledge, perception and practice of injection safety and healthcare waste management among teaching hospital staff in south east Nigeria: and intervention study. PanAfrican Medical Journal, 17:218, 1-5.    

Gish RG, Lapasaran A, Ong JP, Sollano JD (2015) Chronic Hepatitis B Virus in the Philippines. Journal of gastroenterology and hepatology DOI:

10.1111/jgh.13258

Graneheim U H, Lundman B (2003). Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse

education today, 24, 105-112.

Graneheim U H, Lundman B (2008) Kvalitativ innehållsanalys. I: Granskär, M & Höglund-Nielsen, B (Eds) Tillämpad kvalitativ forskning inom hälso- och

(24)

Haeok L, Yang JH, Cho MO, Fawcett J (2010) Complexity and Uncertainty of Living with an Invisible Virus of Hepatitis B in Korea. Journal of Cancer

Education. 25, 337-342.

International Council of Nurses, (2012) The ICN code of ethics for nurses.       Kagan I, Ovadia KL, Kaneti T (2009) Perceived knowledge of blood-borne pathogens and avoidance of contact with infected patients. Journal of Nursing

Scholarship, 41:1, 13-19.

Larsson IE, Lindencrona CSC, Plos KAE, Sahlsten MJM (2005) Patient participation in nursing care: an interpreation by Swedish Registered Nurses.

Journal of Clinical Nursing, 14, 35-42.

Ng CJ, Low WY, Wong LP, Sudin MR, Mohamed R (2013) Uncovering the experiences and needs of patients with chronic hepatitis B infection at diagnosis: a qualitative study. Asia Pac Journal of Public Health, 25:1, 32-40.

Lymer UB, Richt B, Isaksson B (2004) Blood exposure: factors promoting health care workers’ compliance with guidelines in connection with risk. Journal of

Clinical Nursing, 13, 547-554.

Maltby J, Williams G, McGarry J, Day L, (2010) Research Methods for Nursing

and Healthcare. Harlow: Pearson Education Limited.

Malterud, K (2009) Kvalitativa metoder i medicinsk forskning: en introduktion. Lund: Studentlitteratur AB

Melhus Å, (2013) Klinisk mikrobiologi för sjuksköterskor. (2nd edition). Lund: Studentlitteratur AB.  

Murray P, Rosenthal K, Pfaller M, (2013) Medical microbiology. (7th edition). Philadelphia: Elsevier Saunders.  

Olsson L-E, Karlsson J, Ekman I (2006) The integrated care pathway reduced the number of hospital days by half: a prospective comparative study of patients with acute hip fracture Journal of Orthopaedic Surgery and Research , 1:3, 1-7.    

Polit, DF & Beck, CT (2013) Essentials of nursing research: Appraising evidence for nursing practice (8th edition) Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins.

Public health agency of Sweden - Folkhälsomyndigheten, (2013)

Sjukdomsinformation om hepatit B

>http://www.folkhalsomyndigheten.se/amnesomraden/smittskydd-och-sjukdomar/smittsamma-sjukdomar/hepatit-b/< (2015-12-05)  

Rajasekaran M, Sivagnanam G, Thirumalaikolundusubramainan P, Namasivayam K, Ravindranath C (2003) Injection practices in Southern part of India. Public

health, 117, 208-213.

(25)

the nature of caring work in an intensive care unit. Journal of Clinical Nursing,

13, 50-59

The Research Committee of Medicine - Medicinska Forskningsrådet (2000)

Riktlinjer för etisk värdering och medicinsk humanforskning - Forskningsetisk policy och organisation Sverige. Stockholm: MFR-rapport 2.

The World Bank, 2015, Poverty & Equity        

>http://povertydata.worldbank.org/poverty/country/PHL<   (2015-12-05)    

Trost, J (2010) Kvalitativa intervjuer. 4:1 edition. Lund: Studentlitteratur. Willman A, (2011) Evidensbaserad omvårdnad – En bro mellan forskning &

klinisk verksamhet. (3:d edition) Lund: Studentlitteratur AB.    

Wong SN, Ong JP, Labio ED, Cabahug OT, Daez MLO, Valdellon EV, Sollano JD, Arguillas MO (2013) Hepatitis B infection among adults in the Philippines: A national seroprevalence study. World Journal of Hepatology 5(4), 214-219. World Health Organisation, (2011a). Country Cooperation Strategy at a glance >http://www.wpro.who.int/countries/phl/ccsbrief_phl_en.pdf?ua=1< (2015-12-01) World Health Organization (2011b) The Philippines health system review. World Health Organization (2014) Viral hepatitis in the Western Pacific  

>http://www.wpro.who.int/hepatitis/hepatitis_hepatitiscp_viral_hepatitiswpr/en/< (2015-11-15)    

Word health organization, (2015a). Hepatitis B

>http://www.who.int/mediacentre/factsheets/fs204/en/< (2015-12-01)    

World Health Organisation, (2015b) What is hepatitis? >http://www.who.int/features/qa/76/en/< (2015-12-07)    

   

(26)

Appendix 1

INTERVIEW GUIDE

Code number______________________ Demographic questions Year of birth?______________________ Male or female?____________________

Level of nursing education? Registered nurse or specialist education?_________________________

Number of years working as a nurse:__________________ Workplace:___________________

Introducing questions

Can you tell us about a situation when you were caring for a patient with hepatitis B?

Can you tell us about what precautions you take when you are caring for a patient with hepatitis B?

Can you tell us about what feelings and thoughts you have when you are caring for a patient with hepatitis B?

Can you tell us if you think that your feelings and thoughts about hepatitis b can affect the care of an infected patient?

Can you tell us if caring for a patient with hepatitis B differs from caring for a patient without an infectious disease?

Can you tell us about the precautions you take when drawing blood from a patient with hepatitis b?

Can you tell us about how you handle wounds of a patient with hepatitis B? Can you tell us about your feelings and thoughts when you are handling wounds or drawing blood from a patient with hepatitis B?

Can you tell us if you have been in an acute or stressful situation with a patient with hepatitis B?

Can you tell us about your feelings and thoughts regarding hepatitis b in an acute or stressful situation?

(27)

Can you tell us about what you think is the most important thing to think about while caring for a patient with hepatitis b?

Clarifying questions

Can you tell us more about that?

Can you tell us about another situation?

Close-up question

Thank you for letting us do this interview. Do you have any questions or would you like to add something?

(28)

Project title:

Caring for patients with hepatitis B – an empirical interview study of nurses experiences in the Philippines

Date: 19th of November – 11th of December Study manager: Emma Karlstedt Sofie Lassén Your e-mail Emma_karlstedt@hotmail.com Sofie.lassen90@hotmail.com

Studying at Malmö University, Faculty of Health and Society, S-205 06 Malmö,

Phone +46 40 665 70 00 Education: Nursing program Level: Bachelor degree Information on the project (clear information, aims and objectives and targeting information to the appropriate person):

You have been asked to participate in a study about nurses’ experience of caring for patients with hepatitis B. The study is for a bachelor thesis within the nursing program at Malmö University in Sweden.

The aim of the study is to explore nurses’ experience of caring for patients with hepatitis B. To collect data for the study, interviews will be held. The interview will be audio recorded, with your permission. The researchers will handle the data confidentially and no names will be portrayed in the study. The material from the interviews and the study will be kept in a locked space when it is not being used and the data will after the bachelor thesis is finished, be deleted.

The participation of this study is voluntary and you have the right to withdraw your participation at any time. If you participate in this study you will be asked to sign a consent form. Participation of the study means answering questions about the subject in an interview that will take approximately 15 minutes. If you have any questions regarding the study, feel free to contact us.

Form

Caring for patients with hepatitis B - experiences of Philippine nurses

CARING FOR PATIENTS WITH

HEPATITIS B

EXPERIENCES OF PHILIPPINE NURSES

EMMA KARLSTEDT

SOFIE LASSEN

CARING FOR PATIENTS WITH

HEPATITIS B

- EXPERIENCES OF PHILIPPINE NURSES

EMMA KARLSTEDT

SOFIE LASSÉN

ATT VÅRDA PATIENTER MED

HEPATIT B

- FILIPPINSKA SJUKSKÖTERSKORS

ERFARENHETER

EMMA KARLSTEDT

SOFIE LASSÉN

CONTENTS

INTRODUCTION

BACKGROUND

METHOD

RESULTS

DISCUSSION

CONCLUSION

FUTURE RESEARCH

RECOMMENDATIONS

REFERENCES

INTERVIEW GUIDE