Nurses and Tuberculosis- Education for life

(1)

Hälsa och samhälle

NURSES AND

TUBERCULOSIS-

EDUCATION FOR LIFE

CHARLOTTE LUNDIN

LINA NORMAN

Examensarbete i omvårdnad Malmö högskola

Nivå 61-90 p Hälsa och samhälle

Sjuksköterskeprogrammet 205 06 Malmö

(2)

SJUKSKÖTERSKOR OCH

TUBERKULOS -

UNDERVISNING FÖR LIVET

CHARLOTTE LUNDIN

LINA NORMAN

Lundin, C & Norman, L. Sjuksköterskor och Tuberkulos. Undervisning för livet.

Examensarbete i omvårdnad 15 högskolepoäng. Malmö högskola: Hälsa och Samhälle, Utbildningsområde omvårdnad, 2009.

Syfte: I denna kvantitativa och kvalitativa studie var syftet att inhämta förståelse för sjuksköterskor som arbetar med att undervisa tuberkulospatienter och deras kunskap om tuberkulos. Syftet var även att undersöka sjuksköterskestudenters kunskap om tuberkulos.

Metod: Studien utfördes i Sydafrika i provinsen KwaZulu-Natal på ett sjukhus, en klinik samt ett universitet. Kvantitativ metod med frågeformulär användes för att undersöka kunskapen hos sjuksköterskor och sjuksköterskestudenter. För att undersöka hur sjuksköterskor undervisar tuberkulospatienter användes en kvalitativ metod med intervjuer. Svaren från frågeformulären sammanställdes separat så att mönster i materialet kunde upptäckas och så att resultatet från sjuksköterskor och sjuksköterskestudenter kunde jämföras. Intervjumaterialet analyserades med hjälp av innehållsanalys.

Resultat: Resultatet från frågeformuläret visade att det eventuellt finns en brist i sjuksköterskor och sjuksköterskestudenters kunskap om tuberkulos. I intervjuresultatet framkom det var och när patientundervisning ägde rum. Vidare framkom det att sjuksköterskorna ansåg det vara viktigt att kommunicera med patienten på ett respektfullt sätt, att lyssna på patienten, ställa frågor och ta reda på om patienten förstått. Sjuksköterskorna uttryckte också att det fanns ett behov av att anställa mer personal, ha tillgång till mer undervisningsmaterial, ha fler mottagningsrum samt bättre väntrum.

Slutsats: Det gick inte med säkerhet att fastslå att resultatet från frågeformulären visar på kunskapsbrist hos sjuksköterskor och sjuksköterskestudenter, vad gäller tuberkulos. Om det finns en kunskapsbrist riskerar tuberkulospatienter att bli felinformerade. Intervjuresultatet visade att den patientundervisning som bedrivs på sjukhuset och kliniken i stora drag liknar den patientundervisning som

förespråkas i litteraturen. Dock finns det utrymme för förbättringar i form av utökad sjukvårdspersonal, undervisningsmaterial och bättre faciliteter.

Nyckelord: Frågeformulär, Intervjuer, Patientundervisning, Sjuksköterskestudenter, Sjuksköterskor, Sydafrika, Tuberkulos.

(3)

NURSES AND

TUBERCULOSIS-

EDUCATION FOR LIFE

CHARLOTTE LUNDIN

LINA NORMAN

Lundin, C & Norman, L. Nurses and Tuberculosis. Education for life. Degree

project, 15 credit points. Nursing programme, Malmö University: Health and Society, Department of Nursing, 2009.

Aim: In this quantitative and qualitative study the aim was to gain understanding of nurses working with educating tuberculosis-patients and their knowledge of tuberculosis. The aim was also to investigate nursing students´ knowledge of tuberculosis.

Method: The study was conducted in South Africa in the province of KwaZulu-Natal, at a hospital, a clinic and a university. A quantitative method with

questionnaires was used to investigate the nurses and nursing students´ knowledge of tuberculosis. In order to investigate how nurses educate the

tuberculosis-patients, a qualitative method with interviews was used. The replies from the questionnaires were separately compiled so that a pattern in the material could be discovered and so that the replies from the nurses and the nursing students could be compared. The interview-material was analyzed through content analysis.

Results: The result from the questionnaires showed that there might be a gap in the nurses and nursing students´ knowledge of tuberculosis. The interview results showed where and when patient education took place. It also showed that nurses thought it was important to communicate with the patients in a respectful way, to listen, ask questions and to find out if the patient has understood. The nurses also expressed a need for hiring more personnel, more educating equipment, more counseling rooms and better waiting rooms.

Conclusions: It could not be established for certain that the results from the questionnaires show that the nurses and nursing students have a lack of knowledge of tuberculosis. If however there is a lack of knowledge, the tuberculosis-patients are at risk of being misinformed. The interview results showed that the patient education done at the hospital and the clinic had many aspects in common with the patient education recommended in literature. However, there is room for improvements through hiring more healthcare personnel, access to more educating material and through better facilities.

Keywords: Interviews, Nurses, Nursing students, Patient education, Questionnaires,The Republic ofSouth Africa, Tuberculosis.

(4)

TERMINOLOGY

DOTS – Directly Observed Treatments Shortcourse HIV – Human Immunodeficiency Virus

HDI – Human Development Index

MDR-TB- Multi Drug Resistant Tuberculosis MFS- Minor Field Study

Pmb - Pietermaritzburg

RSA – Republic of South Africa SAHR – South African Health Review

SIDA – Swedish International Development Agency TB - Tuberculosis

WHO – World Health Organization

(6)

INTRODUCTION

The term Nursing can, as by the Swedish Medical Research Council, be defined as:

“/…/satisfying the basic human needs and through that safeguard the individuals’ own resources to preserve or retain optimal health, and to satisfy the need for care in the terminal stage of life. Nursing coincides partly with and constitutes a complement to the medical care, when it comes to psychological, social and cultural aspects” (authors translation) (Nunstedt, 1994: 32).

Registered nurses involved in Nursing in Sweden are obliged to work in accordance with the guiding principles for registered nurses from the Swedish National Board of Health and Welfare (2005). The guiding principles state that, the registered nurse should have the ability to inform and educate patients

individually and in group taking in to consideration the appropriate time, form and content. It rests on the registered nurse to make sure that the patient has

understood the given information and that those patients who do not themselves express their need for information also get their need for information satisfied. The registered nurse should also be able to communicate with patients, relatives, personnel and others in a respectful, considerate and empathetic way (ibid). In that it is incumbent on the nurse to educate patients, of amongst other things their disease, it is important for nurses and nursing students to acquire good educating and communicating skills. Doing research on the subject is one way of acquiring these skills.

When doing a literature study on Tuberculosis (TB), in our second year of nursing school, we discovered that there was a connection between TB-patients’ non-adherence and the quality of the interaction with healthcare personnel (Kaona et al 2004; Mishra et al 2006). There was also a connection between the patients’ knowledge of TB and non-adherence (Peltzer et al, 2003).

To further investigate this connection we performed a study in KwaZulu-Natal in the Republic of South Africa (RSA). RSA is a high endemic country when it comes to TB. It is one of the ten most TB-burdened countries in the world, and therefore served as an excellent location to gain deeper understanding of the widespread problem of TB (WHO, 2007a).

We chose to write the undergraduate thesis in Nursing science, at Malmö

University, about TB knowledge and the education of TB patients. The aim of the study was to gain an understanding of nurses working with educating TB-patients, how they perceive TB-patients should be educated and how they actually educate their patients. The study also sought to find out what knowledge nurses and nursing students have of TB.

The results were found using both quantitative and qualitative methods i.e. questionnaires and interviews.

(7)

BACKGROUND

This chapter includes background information about TB being A global health

problem, TB, the Republic of South Africa, Health care in South Africa, TB in

South Africa and the connection between Nursing and TB. A global health problem

According to the World Health Report (WHO, 2008a) trends show that people are getting “/…/healthier, wealthier and live longer than 30 years ago”. The trends however also show that the progress made in the health sector is deeply unequal. As health care has been improved in large parts of the world, yet many other countries are falling behind even showing extensive inequalities between people living within the same country. Health policies on both global and national levels have focused on single issues needing immediate priority, whilst little attention has been aimed at anticipating new challenges and changing the underlying reasons for the slow development and bettering of the health care. The money is simply not spent on health systems set to even out inequalities and create social justice (ibid).

The recent year’s massive increase of people infected by TB and its drug-resistant forms was only to some extent expected along with the increase of other

communicable diseases and the worldwide transmission of those (WHO, 2008a). Reasons for the growth are above all poorly-managed urbanization and also globalization. Thirty years ago 38 percent of the world’s population was living in cities, compared to now when more than 50 percent do so. Most of the rapidly growing cities are in developing countries. The urban populations increasing so quickly results in that one third of the urban population are living in slums. Slums often lack durable housing, access to clean water and sanitation and are therefore an environment unfavorable for health (WHO, 2008a).

Tuberculosis

TB is a widely spread infectious disease causing about 1,6 million deaths each year, and more than eight million people become sick with TB around the world yearly (WHO, 2007a). The infectious disease is caused by Mycobacterium Tuberculosis, which is spread by people infected with pulmonary TB, exhaling and coughing aerosols through the air. TB can also exist in other parts of the human body, but it is only the pulmonary kind that is transmittable. Inhaling the bacteria does not necessarily mean that you will become sick, since the bacteria can become encapsulated by the immune response system and lie dormant for years.Those who develop the disease are foremost people with low immune response, caused by old age, poor nutrition, medication, diabetes or Human Immuno- deficiency Virus (HIV). People falling ill with TB get symptoms like long lasting cough, mucus cough ups, weight loss, fatigue, fever, nightly sweats and swollen lymphoid glands (Ericson & Ericson, 2002).

If contact with the healthcare is made, and the disease diagnosed, the infected person will be treated with a combination of antibiotics lasting between six to twelve months (SMI, 2008). The treatment regime recommended by WHO (2007a), and that is practiced in large parts of the world, is by Directly Observed Treatment Short-course (DOTS). In using DOTS the patient regularly visits a hospital or clinic where he or she is observed, by health care personnel, while

(8)

taking his or her medication (ibid). Drug- resistant bacteria are developed when patients do not follow the treatment regime, sometimes due to feeling better before finishing their treatment-course, when health care personnel prescribe the wrong antibiotics or if the drug supply is unreliable (Kaona et al 2004; WHO 2007a). Drug-resistant strains of the bacteria are resistant to one or several antibiotics making the treatment regime more complicated. Multi Drug Resistant-TB (MDR-Resistant-TB) is resistant to at least Isonazid and Rifampicin, the two most powerful anti-TB drugs available, and Extensively Drug Resistant-TB (XDR-TB) is resistant to Isonazid, Rifampicin and three or more of the second-line TB-drugs (WHO, 2007a).

The Republic of South Africa

RSA has a population of over 47-million people, living in nine provinces. With a gross national income (GNI) per capita of 5390 US dollar, RSA is classified as an upper-middle-income-economy (The World Bank, 2008). RSA is however one of the world’s most unequal countries with only a minority of the people benefiting from being an upper-middle-income-country (Sida, 2008). About 40 percent of the population lives on less than two US dollars per day and 10 percent live on less than one US dollar per day (Swedish Embassy, 2008). There is a large ethnic diversity in the country, because of the history of enslavement and colonization of its inhabitants. The colonization started in 1652 with the Dutch seafarers arriving and more or less ended in 1994 when the first free elections were held and the apartheid regime ended (South Africa info, 2008a). The population consist of 79,6 percent Africans, 9,1 percent white, 8,9 percent colored and 2,5 percent of Indian and Asian descent. There are 11 official languages spoken, IsiZulu, IsiXhosa and Afrikaans are the three largest. English is the fifth most commonly spoken language but it is the main language when it comes to business, politics and the media. The largest religions are Christianity, traditional African religions, Islam and Hinduism (South Africa Info, 2008c). RSA has a subtropical climate and about 82 percent of the land area is agricultural. The largest exports are

agricultural products, minerals, machinery and other equipment (Swedish Trade Council, 2008).

Facts on South Africa 2006/2007

Human Development Index (ranking): 121 Human Poverty Index (ranking): 55 Gross National Income, per capita: 5390 US dollar Percent of population living in urban areas: 60

Adult literacy rate, both sexes: 87 %

Life expectancy at birth (years): 51 Infant mortality rate (per 1000 live births): 56 Number of HIV/AIDS-infected in the age of 15-49: 18,1 % Source: WHO, 2008b

Health care in RSA

With a large percent of the population living in poverty and with an

unemployment rate of 38 percent, the South African health care is under great economical pressure (South Africa info, 2008b). After the ending of the apartheid regime the health system started to change from a race-based system, not

attempting to deliver health care to the whole population, into a system more available to everyone. However, having to cope with the poverty-related diseases like cholera, HIV and TB first, does not give a lot of room to improve the general health of the population. Furthermore the clinics have a shortage in drugs, basic

(9)

equipment, piped water, sufficient electricity and telephone access. Health care in RSA consists of both a large public sector, offering basic primary health care, free of charge, and a small private sector that offers everything from basic to

specialized, advanced health care at the patient’s own expense. Poor resources, difficulties attracting health care personnel and a large workload are problems the public sector is facing. The public sector also stands under the pressure of

delivering health care to about 80 percent of the population, although the money the South African state spends on the public sector only constitutes 40 percent of all money spent on health care in the country. The private sector on the other hand have no problem meeting their patients’ demands, nor recruiting health care personnel or finding resources, amongst the 20 percent of the population that seek private health care (South Africa info, 2008b).

The nursing staff in RSA is composed of registered nurses, staff nurses and nursing assistants. To become a registered nurse one has to go through four years of studying at the university. The staff nurse studies for two years and the nursing assistant for one.

Tuberculosis in RSA

According to the South African Health Review (SAHR, 2006) RSA is one of the top ten countries in the world when it comes to newly diagnosed TB-cases per year, with 722,4 cases per 100 000 inhabitants in 2006. The high incidence of TB in South Africa is related to the extensive HIV- prevalence, since HIV weakens the immune response and TB breaks out when the immune response is weak. In the 1990’s the number of people infected with HIV started to rapidly increase (ibid). In 2007 about 18,1 percent of the South African population were infected with HIV and TB followed the same trend (WHO, 2008b).

As previously mentioned South Africa is burdened with a high level of antibiotics-resistant TB, varying in number of cases between the provinces (SAHR, 2006). In 2006 a study performed at a hospital in a rural area in KwaZulu-Natal showed that the antibiotics resistance was more common than previously known (Gandhi et al, 2006). KwaZulu-Natal, with 843 new TB-cases per 100 000 inhabitants/year (Health KwaZulu-Natal, 2008) has a higher level of incidence then South Africa in total (SAHR, 2006). The problematic situation with antibiotics resistance in South Africa is complicating patient-treatment and challenges the already strained health care (South Africa info, 2008b).

Patient education

The following chapter describes the connection between treatment adherence and communication style of health professionals and also the essence of patient education.

A literature search on the connection between the communication style of health professionals and treatment adherence revealed significant results concerning hypertensive patients and patients on anti-depressants (Aanand et al; 2008, Brus et al, 2000). The same connection has been found in studies concerning TB. Mishra et al (2006) state that better communication between health professionals and patients is important if wanting to improve treatment adherence in TB-treatment. The conclusion made is that TB drug-dispensers should train and develop their communication skills and respect the patients’ autonomy and integrity in order to achieve compliance to treatment regimes from the patients (ibid).

(10)

In the book Patient Education in Health and Illness, by professor and registered nurse Sally H Rankin et al (2005), patient education is described as a process which starts with the nurse finding out the patient’s needs and concerns. This includes formulating a list of nursing diagnoses, for example the patients´ learning needs.

Thereafter, together with the patient, the nurse sets goals for the patient’s health. This includes a plan of how the care should be given, when education should be done and about what etc. The nurse then provides the patient with essential information. This information is not only to be taught by the nurse but also to be understood and applied by the patient. Finally, an evaluation is done on what the patient has learned and how well the newly learned skills are being used (ibid). Patient education can be both individual, as described above, and in a group (Rankin et al, 2005). The advantage of individual education is that the nurse can give information individually adapted to the patient’s needs and level of

understanding. When doing health education in large groups of 30 or more learners, the most effective way to educate is by giving shorter lectures and combine with showing videos and smaller group exercises (ibid).

For patient education to be successful, the patient needs to feel that he/she is taken seriously and that he/she can trust the nurse to be confidential (Rankin et al, 2005). The nurse must therefore create an environment where the patient feels comfortable and safe. Showing interest in the patient, adapting to the level of the patients language, clarifying the purpose of the education, speaking slowly and clearly and taking time, are strategies used to create a trusting environment (ibid). According to Rankin et al (2005), equipment can be useful when educating

patients. A poster, flip-charts etcetera, helps to attract and maintain the interest of the patient. These kinds of equipment require little time to prepare, are

inexpensive and clarify information (ibid).

In order to further investigate the relationship between educating and

communicating skills, and TB, we applied for a Minor Field Studies Scholarship (MFS). The scholarship was granted by the Swedish International Development Agency (SIDA) and made it possible for us to travel to KwaZulu-Natal in RSA to gather data for our undergraduate thesis.

AIM

The purpose of this study was to gain understanding of nurses working with educating TB-patients and their knowledge of TB. The purpose was also to investigate nursing students’ knowledge of TB. In order to gain this understanding the following objectives were investigated:

- What knowledge do nurses and nursing students have of TB?

-How do nurses perceive patients should be educated on the facts of TB? -How are TB-patients educated, according to the nurses?

(11)

METHOD

This chapter explains the chosen methods for the study. Both quantitative and qualitative approaches are used and presented under the headlines Questionnaires and Interviews. Also Ethical aspects with conducting the study are considered. But first an introduction to the study sites under the headline Field work. Fieldwork

The study was inspired by the ethnographic method, which is suitable when trying to gain greater understanding of the patterns and experiences of a cultural group (Polit & Beck, 2006). Through fieldwork we learned about the study sites and also tried to gain some understanding of the participants of the study. According to Polit & Beck (2006) researchers often spend months and years amongst those he/she wants to learn from. In our case two months were spent at the study sites getting to know the environment.

The study took place in Durban and in Pietermaritzburg (Pmb), the largest and the second largest cities in the province of KwaZulu-Natal. Our supervisor first introduced us to the Edendale Hospital where we familiarized ourselves with the South African health care system. Through talking to doctors and nurses working with TB-patients we widened our understanding of TB care in RSA. After

spending valuable time at the Edendale Hospital, our investigator introduced us to the actual study sites.

The University of KwaZulu-Natal

At the University in Durban 40-60 nursing students at the Faculty of Health Sciences graduate every year. The four year long nursing program includes anatomy, nursing, physics, chemistry, physiology, community health nursing, nursing research, pharmacology, midwifery, psychiatric mental health nursing and primary health care. Clinical work is compulsory at all school holidays and this gives the students about 4000 hours of clinical training. The students graduate as registered nurses.

The Doris Goodwin Hospital

In the outskirts of Pmb is a public, district TB hospital, receiving patients from an uptake area with approximately one million inhabitants. The patients are

transferred to the hospital from other hospitals or clinics in the district. They are sensitive-, MDR-or XDR- TB-patients. There are 72 beds divided on five wards, two for females and three for male patients. An average length of stay for a patient is two to three months and the criterion for being discharged is three negative sputum tests. Once the patient is discharged the treatment will be managed by the patient’s local clinic. One doctor is responsible for all patients but the daily care is carried out by the nursing staff consisting of 14 registered nurses and 30 staff nurses and nursing assistants.

The Church Street Clinic

Is located in the city of Pmb and specializes on TB and receives about 1200 patients, suspected to have TB, every month. The patients enter the clinic and are seated in a crowded waiting room with other patients waiting to see a TB-nurse or the doctor. The staff consists of one doctor, three registered nurses, one staff

(12)

nurse, one TB-tracer and one HIV-counselor. The registered nurses all have their own rooms where they receive patients.

Patients that come to the clinic have either been sent there from other clinics that don´t specialize in TB, or they come in for screening because someone in the family has TB or they just suspect themselves to have TB. The nurse examines and takes the anamnesis from the patient and sputum tests and chest X-rays are done. If TB is diagnosed treatment is initiated. The patients are educated on their disease and come to the clinic for follow-up and sputum-testing. Most patients are in the DOTS program and hence observed while taking medication by health care personnel, a family member, or a colleague etc. Since many of the TB-patients are co-infected with HIV the clinic also offers HIV-testing and counseling.

Questionnaires

In order to investigate the nurses and nursing students’ knowledge of TB a questionnaire of TB was chosen. Using questionnaires is a quantitative way of conducting research when gathering information on the knowledge, actions, intentions, opinions and attitudes of people (Polit & Beck, 2006). A

cross-sectional study is the most appropriate design when trying to describe the status of a phenomenon at a certain point in time. In this case the knowledge of TB in a group of nurses and nursing students at the time of our study in RSA.

Participants

According to Polit and Beck (2006) it is beneficial to have a sampling plan specifying who and how many is to be included in the study so the individual’s together should be representative of the group under study. However, due to lack of knowledge of the groups under investigation a set sampling plan was not possible before arriving to the actual study sites in RSA.

The inclusion criteria for participants to answer the questionnaire were that they should be nursing students in their last semester or nurses working with educating TB-patients in a hospital or a clinic. One class of nursing students, approximately 25 students, attending a class when we visited the university, was asked to

participate and 15 participated (See table 1). All nursing staff at the hospital and at the clinic was asked to participate in the quantitative part of the study through convenience sampling. This is by Polite & Beck (2006) described as using the most conveniently available people as participants. In total 48 nurses were asked to participate and 13 ended up answering the questionnaire.

The length of the study-period and the distances between the hospitals forced us to limit the study to be conducted in one nursing school, one TB-hospital and at one TB-clinic, all situated in the province of KwaZulu-Natal, RSA.

Data collection

To secure reliability, the questionnaire used is a modified version of the,

“Knowledge Assessment for TB”, used in studies performed by a nurse affiliated with the Center for TB Research at Johns Hopkins University. The original questionnaire consists of questions concerning knowledge, attitudes and practice of TB and was too extensive for our purpose. The questions concerning

knowledge of TB were extracted and used in our modified version (appendix 1). According to Polit and Beck (2006) it is advisable to test the study design and questionnaire before using it in an actual study. Therefore, before we started

(13)

collecting data from the participants, a nurse involved in the Swedish TB-care and also a doctor working with TB-patients in RSA were consulted on the contents of the questionnaire and some questions were altered. All questions were closed-ended questions.

The nursing students had just finished class when we informed them of our study and the questionnaires were handed out to those who wanted to participate. The questionnaire was handed out together with an information sheet (appendix 2) of the study and also a consent form (appendix 3). The participants left the

questionnaire in a special questionnaire-box before leaving the classroom; this was then collected by the authors.

All nursing staff at the hospital willing to participate was gathered in a separate room where they all filled out the questionnaire at one time. Oral and written information was given of the study before filling in the questionnaire. The questionnaires were then put in the questionnaire-box together with the signed consent form.

At the clinic the questionnaires were placed in the nurses’ tearoom and collected together with the signed consent form after a week.

Data analysis

The replies from the nurses and the nursing students, given in the questionnaires, were separately compiled so that patterns in the material could be discovered. According to Polit and Beck (2006) statistical analysis of quantitative data is a technique used to finding patterns in a material. By doing this it was possible to compare the results of the two groups. As previously noted, the questions in the questionnaire were closed-ended which makes it easier to compare and analyze the results.

Table 1. Study population questionnaires and interviews Questionnaire nurses Questionnaire nursing students Interviews nurses Participated 13 15 7 Asked to participate 48 25 10 Interviews

In trying to gain understanding of how nurses perceive patients should be educated on the facts of TB and of how they actually are educated according to the nurses, a qualitative study design was chosen. A qualitative study design is a research design that evolves as the project proceeds, as suitable when performing a study without knowing the study site in advance (Polit & Beck, 2006).

Decisions concerning how to best attain the sought after information, are made with consideration to what has been learned up until then. As with our study this method was applied so that the format of the study could change as it proceeded (ibid). Interviews are preferably used when the researcher is looking to gather a rich and multifaceted material, and hence that is the form we have chosen (Trost, 2005). It is an efficient method when trying to understand people’s different or similar ways of reasoning, acting and reacting (ibid).

(14)

Participants

To find and ensure permission to enter a research site a qualitative researcher often uses a gatekeeper that already possesses access to the site and can supply the researcher with suitable informants (Polit & Beck, 2006). We found a suitable gatekeeper, involved in the South African health care, before leaving for RSA, who could introduce us to the research-sites and assist in finding the appropriate informants. Appropriate informants in the qualitative part of this study are nurses working with educating TB patients.

The nurses at the hospital and the clinic were asked to participate in the study on an ad hoc basis, meaning we asked the nurses we met during our visits if they wanted to be interviewed. Ten nurses were asked to participate out of which seven agreed.

Since the nursing students were in their last semester of nursing school and did not yet work with TB-patients, they were not interviewed of how TB-patients are educated or should be educated.

Data collection

At both the Doris Goodwin and at the Church Street Clinic the Head of Clinic gave us permission to conduct the interviews during working-hours. Before starting the interviews oral information of the study was given and the nurses gave oral consent to participate.

At the hospital the interviews were held in a secluded room, in a separate administrative building. The interviews at the clinic were held in the nurses own counseling rooms. When choosing a location for an interview Trost (2005) states that it is important that the interview takes place in an environment with no disturbing elements and where the participant can feel as comfortable as possible. With this in mind we found an interview-friendly room, when performing the interviews. It is also recommended that the participant in advance is informed of what the interview is about and roughly of how long it will take. The informants therefore received information of the study beforehand (ibid).

Taping interviews is useful because the interviewers can use the recordings to transcribe the interview onto paper (Trost, 2005). An Mp3-player, lying on the table, was used to record the interviews. Besides interviews, observations are helpful in collecting a broad and reliable material (Polit & Beck, 2006). In observing the areas in which the actual patient-education took place the authors tried to gain a deeper understanding of the educational environment

Semi-structured interviews are interviews where the researcher has a written interview-guide (appendix 4) to ensure that all topics are covered (Polit & Beck, 2006). As long as all topics are covered, the order in which they are brought up is irrelevant (Trost, 2005). The authors created an interview-guide but were open to making changes in the order in which the questions appeared and also to adding new questions if needed. The interview-guide was pretested in Sweden when the authors held an interview with a Swedish TB-nurse. This interview was not included in the result, but merely served as an exercise and evaluation of the interview-guide. After the first interview held in RSA, the interview-guide was partly changed, in order to clarify some questions.

(15)

An interviewer should follow the participant and encourage him/her to speak freely and follow-up questions should depend on the answers of the participant, as recommended by Trost (2005). Also part of a semi-structured interview-technique is that the interviewer adapts his/her language to that of the participant. As we were aware of the benefits of simplifying the language, we tried to do so in our interviews with the nurses, when needed. We worked as a team doing the interviews, which according to Trost (2005) can be an advantage and generate a greater amount of information and understanding, if the interviewers are

collaborative (ibid). One of us was conducting the interview, in English. The co-interviewer was sitting slightly in the background, not actually participating unless something needed clarification or was forgotten. Each interview took roughly 35 minutes and in the end the participant was given time to ask questions of the study and express his/her thoughts about the interview.

Data analysis

A qualitative content analysis is according to Graneheim and Lundman (2008) preferable when analyzing transcribed texts from taped interviews, especially within the nursing Sciences. We have therefore chosen to use content analysis on our material. We used an inductive approach which means to study a phenomenon without making theories in advance and simply try to put together pieces of information and to find patterns. The heart of a content analysis is to identify similarities and differences and by doing that the researcher describes variations in the text (ibid).

The recorded material was transcribed word for word directly after each interview with the advantage that emotions, impressions and gestures were fresh to us. These thoughts and impressions were then written down to facilitate in the analyzing process. Inspired by Graneheim and Lundman (2008) and their content analysis we read the interviews through individually. Thereafter we discussed the material and then extracted meaning units from the texts. The meaning units were then analyzed in several steps from condensed meaning units, to code,

subcategory and finally category. The categories and subcategories are used when presenting the results.

The final results were then compared to the quotations from the transcripts to see if it matched the informants’ original statements.

Ethical aspects

Prior to leaving for RSA the Ethics Trial Board at Malmö University approved this study Dnr HS 60-08/212:42. The Heads of Clinics and the ethical board at University of KwaZulu-Natal also gave their approval.

Ethical aspects to consider when performing studies with humans are those of beneficence, respect for human dignity, and justice (Belmont Report, 1979). The ethical principle of beneficence is followed in that the authors were aware of in their wording to minimize the harm to the informants and maximize the benefits for the informant and also society as a whole. No interviews needed to be interrupted due to stress or discomfort for the nurses. We also tried not to make the participants in the quantitative part of the study feel stressed when filling in the questionnaire.

(16)

In interviewing the nurses during working hours, we however felt that we stole valuable time from the nurses and their patients. Asking them to be interviewed after working hours was however not considered an option.

The principle of respect for human dignity was observed in that the informants participating in the quantitative part of the study were given an information sheet, in that they signed a written form of consent and in that their participation was voluntary. They, as well as the nurses being interviewed could at any time

withdraw their consent to participate in the study, without any further explanation. To follow the principle of justice the authors showed respect for and sensitivity towards the participants’ beliefs, lifestyles and culture. We also made sure that the privacy of the participant was preserved throughout the whole study (ibid). No rewards were either demanded by or given to the participants in order for them to take part in the study.

Confidentiality (Polit & Beck, 2006) is preserved in this case as only the authors have access to and analyze the collected material. The material is analyzed and presented at group level, therefore no individuals can be identified. After

examination of this undergraduate thesis at Malmö University, the collected data will be destroyed.

We will send this undergraduate thesis to a contact person on each of the study sites in order to share the results of the study. The study will also be published on Malmö University Electronic Publishing (MUEP) and as a MFS-report.

RESULTS

The results from the questionnaires and the interviews are presented in this chapter, giving answers to the questions posed in the onset of the study. Namely:

What knowledge do nurses and nursing students have of TB? How do nurses

perceive patients should be educated on the facts of TB? and How are TB-patients

educated, according to the nurses?

Questionnaire results

The nurses and nursing students’ replies to the fact questionnaire of TB is visible in Table 2. In total 13 nurses and 15 nursing students answered the questionnaire. The correct reply is marked as bold in the table. The number of nurses and

(17)

Table 2. TB questionnaire reply by Registered nurses (RN) vs Students (St)

RN St RN St RN St

Disagree Agree Uncertain

1 Tuberculosis can affect other parts of the body

besides the lungs. 1

13 14

2 Tuberculosis infection and Tuberculosis disease are the same.

5 7 7 3 1 5

3 Tuberculosis can be inherited from your parents.

10 11 3 4

4 Tuberculosis bacteria have a hard time living in

fresh air and sunlight. 2 2 11 10 3

5 Tuberculosis can be given to people by: a) Sharing utensils

7 10 3 5 3

b) Coughing 13 15

c) Physical touching 13 12 2 1

d) Sharing cigarettes, food or drink 6 7 5 6 2 2

6 Tuberculosis treatment usually lasts for approximately 1-2 months 3-4 months 6-8 months 2 13 13 7 If a tuberculosis-infected person follows the

treatment-regime, how long does it usually take until he/she can no longer transmit the disease to others

2 weeks 2 months 6 months

7 7 2 3 4 5

8 If a person misses doses of the medication for tuberculosis

Disagree Agree Uncertain

a) He/she may become sick with tuberculosis 1 13 12 2

b) He/she may give tuberculosis to others 13 14 1

c) The tuberculosis medication may no longer work

3 4 10 10 1

d) Drug resistant strains of tuberculosis may evolve

(18)

All participants but one nursing student knew that TB can affect other parts of the body besides the lungs. Three nurses and five nursing students mistakenly thought that TB can be transferred to others by sharing utensils. All nurses and nursing students knew that TB is transmitted through coughing. Five nurses and six nursing students falsely believed TB can be transmitted through sharing

cigarettes, food or drinks. Two nurses and two nursing students were uncertain. All participants but two nursing students knew that TB-treatment usually lasts for 6-8 months. Seven nurses and seven nursing students knew that TB-patients that follow their treatment regimes usually no longer can transmit the disease after two weeks. All nurses that participated in the study knew that a person that misses doses of the TB medication may become sick with TB, may give TB to others and that drug-resistant strains of TB may evolve if a person misses doses.

The total number of questions in the questionnaire was 14. Presented in Table 3 is the number of nurses and students that circled 9 or fewer correct answers, 10-11 correct answers, and also each group that circled 12 to 14 correct answers. What can be noted is that the nurses circled a larger amount of correct answers, then the students.

Table 3. Interval of amount of correct answers

Number of correct answers ≤ 9 10-11 12-14

Nurses (n=13) 2 4 7

Students (n=15) 5 7 3

In total (n=28) 7 11 10

Interview results

By analyzing the interviews with the help of content analysis the questions: “How

do nurses perceive patients should be educated on the facts of TB?” and “How are

TB-patients educated according to the nurses?” were answered. Under the categories and subcategories presented below, are the compiled answers from the nurses. To give an overview of the interview results, the categories and

subcategories are illustrated in figure 1. The statements from the nurses are exemplified by one or several quotations. The quotations have not been

grammatically corrected, but pauses are indicated by a comma and participants quoting others are marked with quotation marks. Informants are stated as Informant 1 = (Inf. 1), Informant 2 = (Inf. 2) etc.

Figure 1. Overview of interview results

Category Subcategory

Patient education Equipment Time Stress

Communication Respect and individuality

Trust and confidentiality

Non-verbal and verbal communication and distractions What the nurses would change

(19)

Patient education

At the hospital education takes place in the wards and in private rooms. It can be both individual and in groups. Usually the education is led by one nurse and he/she is assisted by other nurses. Education is done on admittance and then every day during the patient’s stay. The patients are educated of TB-treatment, cough-etiquette, cleanliness, the importance of ventilation in the wards and other major health issues like HIV and Sexually Transmitted Infections (STI). Patients and relatives are also educated of TB and of the necessity of wearing masks when inside MDR-TB wards.

“When the patient is being admitted, he is being admitted and then we give them the health education at the same time so that she knows what she is not supposed to do and what she is supposed to do. On admission she must know everything.”(Inf. 2)

“ /…/when we have the education so we/…/ and there is one person that talks and then the others just remind her about what she has forgotten and even some will add things they have read in the paper.” (Inf. 1)

“At times we do it in a group form, in small groups, maybe groups of six or one to one, when it is you and that patient.” (Inf. 3)

At the clinic health education is done by the nurses, the DOTS-supporter or the TB-tracer, in the waiting room. The nurses do the individual health education in their private counseling rooms. Relatives are sometimes also educated together with the patient. The relatives can support the patient and help him/her to

remember what the nurse said. They do health education to relatives and patients on a special information day, called World TB Day. Where the patients do role plays about TB.

“In this clinic, /…/ in this room here, in a private room basically.” (Inf. 5) “Sometimes the relatives come with them and yes we do let them, but obviously if there is anything that’s confidential we do ask the relatives to go out.” (Inf. 5)

“/…/ also there are these special days /…/ there is this TB day where we, sometimes we ask them questions and sometimes we ask them to have I mean little role plays, where they would demonstrate how they treat TB and how it affects them."(Inf. 1)

Listening to the patient is a vital thing. It is also important that the nurse doesn’t talk to much. Communication is a two-way process; one has to both listen and talk. Through listening and asking questions the nurses get information about the patient and his/her knowledge of TB. This makes it easier to educate the patient. Education is adapted to fit the patients’ level of knowledge.

“/…/ communication is a two-way process, you should tell a person and you should also listen. Don’t expect the person to listen to you. You know everybody has something very important to tell.” ( Inf. 3)

“What I found interesting and which makes your job easy/…/ when you are teaching a person you must identify first what does that patient know. Because you may find that you are boring the person and dwelling on

(20)

knows anything about this, how far does he know and then you encourage him to ask you the questions and then you can, I mean, start elaborating on whatever you want.” (Inf. 1)

The nurses start with educating the patients about the basics, important things, like the treatment-regime. He/she gets the patient to open up by asking open-ended questions. To make the patient understand the nurse takes the time needed to explain to the patient, he/she also gives the patient time to ask questions. The first time the nurses meet the patients, the patients are anxious, they usually have more questions the second time they meet. At the clinic the nurse and patient decide together how often the patient should return for follow-up, the patient’s money-situation is considered by the nurse. Patients tend to default treatment if made to come too often. It´s important to repeat the information given to the patient, however a nurse should not overload patients with information. If the nurse doesn’t know the answer to a question, he/she should not make an answer up; he/she should go and find out the real answer instead.

"You give patients the chance to ask questions and then you also have to ask questions, and see if he has grasped it. If you see that he did not understand that well, then you have to repeat again, but also you must be careful, you must not overload the patient with too much information, because then they may forget.” (Inf.6)

The nurses said its important to observe if the patient looks as if they have

understood. The patient shows that he/she has understood by asking questions and by changing his/her behavior. It can also be seen in how the patients interact with relatives. While doing education the nurses reflect on whether the education has been good enough, if the patient has understood. They check the patients

understanding by asking them if they have understood. They also ask the patients to explain what they have been taught. If patients don’t understand, then they might not take their medication.

“Any health education you do you give them time for questions or YOU direct the questions to them and say, now when you go home what you gonna do? Or who do you think has got TB? And if they just sit there and look at you, you must know they haven’t heard a thing.” (Inf.4)

“Because the way they act and, they also change from what they have been doing, then you know you have done something for them.” (Inf. 2)

“They must understand, because if they are not understanding then you have a big problem, then they go home with the problems and it can be patients not taking medication and not taking the right advice and telling others the wrong thing.” (Inf. 5)

Equipment

Equipment used when educating the patients are flip-charts and posters. Some nurses hand out pamphlets for the patient to take home and read. The written text on the equipment is in English or isiZulu. Some nurses only use a pen and paper. The equipment is an asset both when educating groups and individuals, but there is not enough material available. The nurses said that equipment with pictures makes it easier for the patient to understand and remember. They often show equipment while they educate the patient of it´s contents.

(21)

“/.../you need visuals because it sticks better. Because I tell you even if how much you absorb, only 20 percent whereas when you see what comes to mind. So its better for the client. They are sick they are tired and they are listening to the talk automatically, your voice, but if there are pictures they are “-Oh ok, I have this symptom, but I don’t have that symptom.”.” (Inf. 4)

“Those posters got information about etiquette, what to do when you are coughing. How do you get TB. How do you know the signs and symptoms of TB.” (Inf. 3)

Time

At the hospital, the group education generally starts at eleven- or two-o’clock, either before or after lunch. The length of the education depends on the interest and participation of the patients, but it usually lasts for one hour. If the patients have a lot of questions, it may last longer. Individual education shouldn’t take more than 30 minutes, its better with several short sessions than one long. The patients tend to not listen if long sessions.

“It depends on the interest and the participation of the patient. If patients ask questions we have to answer them, but usually we allocate an hour if we start the health education talk at eleven. Twelve o’ clock is their lunch, so it should be over. “ (Inf. 1)

“Because once you talk for a long time they will get bored and they will not listen to you.” (Inf. 2)

“If the patient have more questions to ask, then you will find that it will take 30 minutes or more, but usually it is less than an hour. /…/. /…/when you counsel a person you shouldn’t exceed 30 minutes because that person tends to wander and just think something else, then it is better that you rather have more sessions than have one long session. ” (Inf. 3) The individual patient-education at the clinic takes from 25–60 minutes, depending on the patients’ level of understanding.

“/…/if you’re gonna do it thoroughly with the patients understanding, demonstrating and everything then 45. But there is no way that we can do it in this situation with so many clients. So 20-25 minutes /…/.” (Inf. 4)

“When the patient is in your room, it can take say about 45 minutes to one hour, because it will also depend on the patient, the patients’ level of understanding.” (Inf. 6)

Furthermore, it is not only the patient’s level of understanding that determines the length of the patient-education done at the clinic. If it is a new patient there are many things to go through about TB and also a lot of paper work. If the patient comes from far away or has other health problems that also takes extra long time, doing tests and finding out what is wrong.

“/…/it is supposed to be 45 minutes for a new patient because you have got so much to explain, starting them on TB-treatment and you have got a lot of paper job to do as well.” (Inf. 5)

(22)

It is important to give the patients the time they need:

“ /…/you will release the patient when you feel you are happy he’s understood and he is happy he knows what he is going to do at home, or if he is going to a hospital why he is going to the hospital.” (Inf. 4)

“As I said to you it could take longer. But you don’t stop and say, please get out of my office. No.“ (Inf. 4)

Stress

At the hospital it was stressful but the nurses did have time to educate the patients and they usually have time to answer questions.

“Yes, we do have the time to educate the patients”. (Inf. 3) “/…/ this is a small hospital so our staff is not that big. We are understaffed compared to how many patients.” (Inf. 1)

At the clinic the nurses did not feel they had enough time to educate the patients as much as they wanted to. It was because of the lack of staff and the too large amount of patients. The nurses should educate the patients for 45 minutes to cover all topics, but there is just not enough time.

“For me that’s an issue, time. I battle with that cause I know that I should be spending more time with the patient, but when you’ve got 50 people sitting outside, that needs to be seen, so you don’t have that time.” (Inf. 5) “Well, with the time it is always allocated as one of the major problems we are facing/…/you can not spend as much time as you want with the patient. Because now there are lots of patients we have to see in a day/…/ let’s say for an argument that you take two hours with one patient, which means you will end up seeing only four patients in a whole day, because you are only here for eight hours to work and the number of staff is, well now, and that is the problem because there are a lot of people who are suffering from this disease and it is very hard for us to do as much as we want to because of the time.” (Inf. 6)

“/…/as much as you want to finish the crowd that you aim now, because they come from far and wide and get here six o clock in the morning and they are still sitting here eleven o clock. You know all these things goes through your mind. You know they have been waiting so long, they are hungry. You know I try not to be long with them, but on the other hand I want to be long with them.” (Inf. 7)

Communication

The subcategories Respect and individuality, Trust and confidentiality and

Non-verbal and Non-verbal communication and distractions are gathered under the category Communication.

Respect and individuality. The nurses said it´s important to see the patient as being a person apart from just a patient. Patients are individuals. They are people like everyone else. Respect the patient and his/her culture and beliefs. Different

(23)

patients have different problems, the education should be individual. Allow the patient to express feelings.

“You should know that they are human beings like yourself, they have families at home, he may be a manager where he is working. So, when you address them you should know that he is not just a patient, he is somebody apart from that.” (Inf. 3)

Patients should be treated as if he/she is someone in your family or someone you know. Treat everybody the same way with respect and concern, regardless of who they are. Try to imagine and understand what it is like to be in the patient’s situation. The atmosphere must be friendly because the patients are very sick. Attitude and approach is important.

“/…/ treat everybody the same way/…/./…/ Not because I’ve come in with a suit and tie and you must now be able to give me all the information. And somebody that comes in with tattered clothes is just rushed through and get him out. Everybody should be treated alike, with respect and concern/…/. (Inf. 4)

“For me, I mean I always put myself in someone else's shoes, I don’t have a problem much with it. I always imagine what it is like to be the person on the other side and so then I try to see from their perspective, how I would be feeling if I were in there shoes. So this comes quite natural to me, its not a very difficult thing for me.”(Inf.5)

Trust and confidentiality. The nurses said that what the patients tell them is strictly confidential. To protect the patients’ confidentiality they talk quietly and use the consulting rooms for education. This is important because patients might experience stigma towards their disease. The patients must feel that they can open up to the nurse. It’s the patient who decides if the patients´ family can be educated together with the patient. The nurse has do respect his/her decision.

“In the consulting room, we encourage privacy because TB people start feel that is a stigma and each nurse has got a consulting room /…/” (Inf. 4)

“If the patient says no, I want to be alone, this person can excuse him and be outside, it’s their right." (Inf. 6)

Non-verbal and verbal communication and distractions. A non-verbal

communication factor mentioned by the nurses was that the nurse should focus on the patient and don´t do other things during the education. Other people coming into the room, interrupting the education might upset and distract the patient. During education the patient should sit forward and to the left of the nurse so that the table does not function as a barrier between nurse and patient. Also, obstacles on the table, things on the walls and the nurse wearing fancy clothes or jewellery can cause distraction. Make-up might give an artificial impression. Furthermore, facial expressions can scare patients to not asking questions that they need to ask.

“I like to have a patient sitting here (points at the chair forward and to the left of the table) because I feel that it´s more, not like a barrier. “ (Inf. 5)

(24)

“/…/ also you mustn’t be to fancy. You know the way you dress, golden chains and the like, it makes them think oh this one has got money looking at the chains now trying to think how many carats on this chain, yeah, you know that makes the person to concentrate more on you than to what you are saying. /…/And make-up, women they put on the red things on their mouth so that now the patient is looking more on the things, and also the patient can loose trust in you if you are to artificial and so he can see that you are trying to be somebody that you are not”(Inf. 6).

By having eye contact with the patient, the nurse shows that he/she is listening and can see if the patient understands. However, when informing Zulu-patients this can be inappropriate because they might find it disrespectful to look someone in the eyes. It is part of some Zulu-patients culture. The nurse can then just look up at the patient occasionally and also observe the patients’ body language to see if he/she has understood.

“Because for us it is eye contact but for a lot of the older cultures, Zulu people, they find it disrespectful to look into someone's face when they are talking. (…) it can be very difficult because you can´t make someone look at you, especially if they believe that it is wrong, its their culture.”(Inf. 5) Most patients that come to the clinic and the hospital speak English or isiZulu and hence the education is in those languages. There are also patients that are Sutu-speaking and some that speak sign-language. Furthermore, it is important to talk to the patient in the language he/she understands and to use a simple language. The nurses said its important to be polite, warm and talk gently to the patient. Never to shout at a patient or use abusive language.

“I will talk to them in the language they understand. And most of the clients are actually good at English but they are very free to say: “–Look I don’t understand”. But we try and talk in their language. “

(Inf. 4)

“Most of the patients that are here, they talk Zulu so you talk Zulu. You have to be as simple as possible so that they understand what you are saying/…/. “ (Inf. 6)

What the nurses would change

When asked about what the nurses would change if they could change anything they’d like, there replies were: TB should be taken seriously and more effort should be put in it because it’s a global crisis. At the hospital the DVD-players are not working so the nurses wanted them up and running again. They said they have educational DVD:s to play and that they thought it would be a nice way of

educating patients to show those. They said it showed the difficulties about the treatment and complications that can arise because of treatment failure. Small private rooms for all patients with TV:s in would be good. There should be more theme days, like World TB-day with patients doing role play and opportunities to ask the patients questions. They also wanted more training on communication skills for the staff.

“There is room for improvement./…/ You know private hospitals they have cubicles, a small room, for them selves. And each person is having a TV which you can use as you like /…/ and they can be given films that can tell them more about their illness. They can even have headphones for them to

(25)

listen /…/./…/ even the nurses if they can be send for more training on communication skills.” (Inf. 3)

At the clinic one nurse said he/she wanted there to be one section with the elderly, one with the middle age and one with the young ones. This is because when giving education to a group the young people don´t want to ask questions. They are afraid that their parents will find out what they are asking about because there may be someone here that knows the patients family.

“/…/ have a section with the elderly, the middle age and the young once. Because sometimes if you are giving a general talk and you have the adolescent they wanna ask questions but they’re afraid “-oh there is my mother’s friend sitting there.” (Inf. 4)

Another clinic nurse wanted enough staff to be able to give group education to the patients in the waiting room every day. They also wanted to educate in smaller groups because of the difficulties to get every ones attention in a big group. One nurse wanted there to be big open spaces where patients could sit in the fresh air instead of in the crowded the clinic. A parking lot and a beautiful garden where the patients could sit and eat lunch was another suggestion. This was thought to make the patients feel more at ease. They wanted the air condition to work. All nurses wanted more and bigger counseling rooms. All nurses wanted more staff to make the workload lighter, to be able to see more patients in a day and to be able to spend more time with each and every one of the patients. One nurse wanted to serve the patients a hot meal, knowing that they did not have much money and that they needed nutritional meals to get well. Another nurse said it would be a good idea to build a nice big clinic where both HIV and TB is treated because the patients are often co-infected and have to visit different clinics for the diseases.

“I would be happy if they would actually build a nice big clinic/.../ where we’d combine HIV and TB because the two can not be parted . And instead of the clients moving from here going down the road to another clinic they are on the same floor and the same building."(Inf. 4)

“When they thought of this clinic they obviously did not think of the future when there would actually be an increase and they did not realize that is was going to increase to such a point that it is, it very congested and people are coughing and infecting each other. More spacious and

obviously have your air conditioning working all the time/.../. And a bigger ground were there is parking for the patients. And we would love to have some garden for the patients to sit, to have a beautiful garden were the patients could sit and go out and have their lunch and then come back to the clinic. Cause sometimes they are sitting here all day and eating in here is not healthy. So, that would be really nice. Where the patient will feel more at ease as well.”(Inf. 5)

Nurses education on communication

This category cannot be connected to the aim of the study, but it is an interesting finding and is therefore also presented in the result.

Nurses from both the hospital and the clinic had some education on

communication in nursing school. They practiced by doing education in groups and also patient-to-nurse education. A few nurses did psychiatry-courses in nursing school that included learning how to educate and communicate with patients. Most of them could remember one thing that they had learnt and still

(26)

used in the daily work with the TB-patients. Other then that they said they did what felt right in the educating situation. They all thought it would be good to have more education on how to educate patients.

“/…/ each year we used to have to give a health education talk maybe in the wards /…/ or in a clinic. /…/ as a first year student you do a person to person talk/…/. It is a nurse to patient education and the patient is able to ask you questions. And then the group talk we used to do it on a certain day when we are doing the clinics second and third year /…/."(Inf. 1) At the hospital the infection nurse educates the staff on communication. The nurses at the clinic said that they get education on customer service which is explained as putting the patient first, how to handle the patient and to be polite. The clinic has also sent some of the nurses to counseling courses about learning techniques. One nurse said it was very important to acquire new skills, to up-date herself. Another nurse said he/she learnt new things about communication in the daily work with the patients.

“You know, things keep on changing. It is very important to acquire new skills, I mean to update yourself, so, it is.” (Inf. 3)

DISCUSSION

The discussion is divided into two parts, a method discussion and a result discussion.

Method Discussion

Included in the method discussion are reflections of setting and participants, data collection and data analysis.

Setting and participants

Not knowing the setting in advance forced us to trust the gatekeeper in choosing locations for the study. The gatekeeper is employed by WHO and had no interests in choosing those particular sites. Our only request was that the sites inhabited nurses working with TB-patients. All but one nurse being interviewed were registered nurses. The exception was a nursing assistant, who informed the patients just like the registered ones.

Inclusion criteria for the questionnaires were that they were nursing students in their last semester or nurses working with TB-patients. We had anticipated a greater amount of both nurses and nursing students to participate, but because of smaller nursing staff than expected and since participation was voluntary, there was nothing we could do about it.

The nurses at the hospital and the clinic had been informed of our presence before we arrived and were then asked on an ad hoc basis to participate. A convenience sampling, as we noticed, does not always result in informants with easiness to talk and lots of things to say (Polit & Beck, 2006). One of our informants did not provide us with a great amount of useful information and is hence only quoted once or twice in the results. Also, informants with other views on education might have been missed through the convenience sampling.

Nurses and Tuberculosis- Education for life

NURSES AND

TUBERCULOSIS-

EDUCATION FOR LIFE

CHARLOTTE LUNDIN

LINA NORMAN

SJUKSKÖTERSKOR OCH

TUBERKULOS -

UNDERVISNING FÖR LIVET

CHARLOTTE LUNDIN

LINA NORMAN

NURSES AND

TUBERCULOSIS-

EDUCATION FOR LIFE

CHARLOTTE LUNDIN

LINA NORMAN

CONTENTS

TERMINOLOGY

INTRODUCTION

BACKGROUND

AIM

METHOD

RESULTS

DISCUSSION