The Impact of Caring for Persons Living with Hiv and Aids on the Mental Health of Nurses in the Limpopo Province

Curationis 31 (2): 67-73 This study assessed the impact of caring for AIDS sufferers on the mental health of nurses. This assessment was measured against the level of burnout, stress and depression among 174 nurses caring for people living with HIV and AIDS in Limpopo Province, South Africa. A structured questionnaire was used for data collection. The questionnaire incorporated the AIDS Impact Scale (AIS), Maslach Burnout Inventory (MBI), Beck Depression Inventory (BDI) and the participants' demographic and professional profiles. Participants were conveniently selected from five selected hospitals in Limpopo Province. The study participants' valuation using the AIS showed that nurses tended to develop strong bonds and relationships with the patients; felt frustrated by their inability to help the terminally ill AIDS sufferers and were subsequently affected by the death of their patients. Personal accomplishments of the nurses remained high and the levels of emotional exhaustion and depersonalization levels were low. The BDI showed that over 3 out of 4 nurses were experiencing between mild mood disturbance and extreme depression. Higher average scores were noted for items of the depression scale like sadness, dissatisfaction, fatigue and low level of energy. The findings highlight the need to develop psychological support programmes for nurses caring for AIDS patients and promote the provision of social incentives and recognition of the role of nurses in AIDS care.


Background
The growing demand for health services as a re su lt o f the A ID S epidem ic exacerbates the strain on Africa's limited h ealth w orkforce (W H O , 2006: 5;Marchal, 2005: 301).Caring for AIDS sufferers and their evolving health needs come with occupational risks of infection and the need for m ore training and support.E ffo rts to ad d ress these concerns have often been inadequate.This is despite the fact that these factors lead to increased emotional and physical stress for nurses caring for HIV-infected persons (Marchal, 2005: 301).Research studies in other places have shown that caring for persons living with HIV and AIDS (PLWHA) results in burnout and high level of stress among nurses.This occurrence is known to be situation and consequent on the time spent in caring for PLWHAs, level of institutional support and the intensity of related care in developed countries (Li, Lin, Wu, Wu, Rotheram-Borus, Detels & Jia, 2007:262).In spite of this knowledge, there is limited information on the impact of caring for PLWHA on the w ellbeing o f South African nurses and this is despite of the country's high HIV and AIDS burden which averages about 18.3% among persons aged 15-49 years (UNAIDS, 2006: 17).
It is also known that more than 50% of hospital beds in the sub-Saharan Africa are occupied by people with HIV-related conditions (UNAIDS, 2006: 95).).In addition, PLWHAs generally stay in hospital four times longer than other patients.South Africa accounts for a su b stan tial p ro p o rtio n o f PLWHA worldwide (+14%), with its estimated 5.5 million PLWHA in 2005 (UNAIDS, 2006: 17).It was also reported that 346 000 people died of AIDS-related illnesses in South Africa in 2005 alone, translating to about 900 deaths daily (Dorrington, Johnson, Bradshaw & Daniel, 2006:11).Statistics revealed that Limpopo Province a total of 397 000 PLWHAs (Dorrington, et al 2006:67).Nurses are a critical part of these events either in term s of the workload of providing care, preparing PLWHA for a p eacefu l death or com m unicating with and consoling grieving family members.
This study looked at the interplay of the above experiences on the mental health of nurses in the Limpopo Province of South Africa.Limpopo is one of the most rural provinces in South Africa and this is a major cause of attrition of health workers due to urban-rural migration w hich fu rth e r strain s the lim ited workforce (WHO, 2006: 5) Bennett, Ross & Sunderland 1996: 145;Visintini, Campanini, Fossati, Bagnato, Novella & Maffei, 1996:185).These individuals have relied on the AIDS Im pact Scale (A IS) developed by Bennett, Kelaher andRoss, (1991,1994) and Bennett et al. (1996:145) as well as the Maslach Burnout Inventory (MBI, Maslach & Jackson, 1981) in their efforts to measure the impact of HIV and AIDS on the mental health o f health care workers.These instruments have been validated and found reliable in various cultural settings (Visintini et al., 1996:188;Ergin 1992: 150).The MBI measures the endurance to work perform ance and exhaustion in service delivery in relation to level of stress in the workplace while the AIS assess the various implications of HIV and AIDS care for health care workers.Using these instruments, this study assessed the impact of caring for PLWHA on the mental health of nurses in public health facilities in the Limpopo Province.

Research design and method
The study was a cross-sectional study.
A structured questionnaire was used for data co llectio n .The questionnaire in co rp o rated the M B I, A IS, Beck Depression Inventory (BDI), participants' demographic and professional profiles in the m easurem ent.AIS is a self administered scale which is composed of 28 items and used a five point Likert scale (strongly agree to strongly disagree); grouped in five scales, namely: Stigma and discrimination, Peer relationship, Identification with patients, Social reward, Grief and loss (Visintini, et al. 1996).This study polarized the responses to the AIS items into 'never' and 'agree' in an attem pt to categ o rize the respondents into the tw o broad categories instead of using a 5 point Likert scale.
The MBI has 20 items divided into three scales, namely personal accomplishment, em otional ex h au stio n and depersonalisation to explore burnout levels.The BDI is a 21 item tool that m easures the level o f depressio n .Participants' aggregate scores on the BDI are rated from norm al to extrem e depression.
The p artic ip a tin g nurses w ere conveniently selected from five referral hospitals in Limpopo Province.The choice o f convenient sam pling was necessitated by the difficulty of co opting random ly selected nurses to participate in the study amidst their heavy patient workloads.One referral hospital was randomly selected from each of the five districts of Limpopo Province.The study targeted all nursin g cad res (including professional, enrolled and auxiliary nurses) in the Limpopo Province.A total of 174 nurses participated in the study out of the 1687 nurses employed in the Limpopo Province.To allow for comparison, efforts were made to obtain similar number of professional, auxiliary and enrolled nurses.Ethical clearance was obtained from the

Demographic characteristics of participants
The sample comprised of 174 nurses, with sim ilar p ro p o rtio n s o f q u alified professional nurses (51% ) and the auxiliary and enrolled nurses (49%) without professional nursing training (Table 1).The participants were mostly females (92%) and the average age of the participants was 37 years (SD = 9.2, Table 1).One out of the three participants had been working as a nurse for 2 to 4 years and over 10 years respectively (Table 1).
The average years of experience was 7 years (SD = 7) and ranged from less than 1 year to 32 years of experience.

The impact of working with HIV and AIDS patients on nurses
The 28 items of the AIS had a Cronbach's alpha of 0.78 (this a m easure of the re lia b ility o f the in stru m en t and instruments with a reliability of 0.70 and over are considered to be reliable).Onethird of the participants reported that they were being stigmatised and discriminated against by their friends and other health care workers because they worked in units that care for HIV and AIDS patients (Table 2).However, half of the participants rep o rted receiv in g som e form of normative support, encouragement and recognition from their friends for their involvement in HIV and AIDS care.
A higher proportion of qualified nurses agreed that they had trouble coping with the number of deaths (p = 0.045; X2 = 4.031).
More qualified nurses agreed that their friends recognized that the work they are doing in the More nurses without professional nursing training agreed that they suffered sigma/discrimination from other staff at the hospital due to the unit in which they work (p = 0.039; A2=4.242).
Two-thirds (63%) of the nurses felt that they would end up like their patients and that they had a lot in common with the patients (70%) and that many aspects of the patients' lives reminded them of their own (68%) (Table 2).The majority of the nurses (>80%) reported that they formed good friendships with their patients with HIV and felt a responsibility to help deal with the impact o f AIDS on society respectively.Similar proportions noted that they w ere d istressed by the difficulties faced by PLWHA in their care.
A high proportion (89%) of nurses agreed that seeing patients suffer and die was very difficult for them and that they had difficulty coping with the number of deaths in their units and this made them feel powerless because no matter what kind of care they offered, the patients would still die (Table 2).

Measure of depression among nurses
Using the 21-item Beck Depression Inventory with a scale o f 0 to 3, a Cronbach's Alpha of 0.96 was obtained and the mean total score was 26.70 (SD = 20.25).The scores ranged from 0 to 63. Sadness had the highest mean score (1.61) followed by fatigability (1.58), low level of energy (1.56) and insomnia (1.52).E xpectation of punishm en t (0.78), pessimism (0.88) and ideation of suicide (0.89) had the lowest mean scores (Table 3).There was no significant difference between mean scores of professional

Burnout among nurses
The 20 MBI items were categorised under 71 Curationis June 2008 personal accomplishment (Cronbach's Alpha = 0.84), emotional exhaustion (C ro n b a c h 's A lpha = 0.86) and depersonalisation (Cronbach's Alpha = 0.78).W ith regards to personal accomplishment, about one-third of the study participants felt they dealt with emotional problems calmly, positively influencing other people with their work and could create a relaxed atmosphere with their recipients on a daily basis.On the other hand, over one-quarter of participants noted that they never felt exhilarated after working closely with patients and never felt that they had accomplished any worthwhile journeys in their jobs (Table 5).
It can also be observed from Table 5, that the majority of the participants reported very low frequencies of measures of emotional exhaustion except for the item on how often they felt they were working too hard.Of the participants, 28% (n= 49) felt they were working too hard on a daily basis (Table 5).
High p ro p o rtio n s o f the study participants never experienced feelings of depersonalization feelings, such as not caring about what happened to patients (62%), feeling that patients blamed them for their problems (51%) and feeling that they treated some patients like impersonal objects (48%) (Table 5).On the other hand, 1 in 10 nurses reported that on a daily basis, they felt as if they treated patients as impersonal objects, felt as if they had become more callous towards people since they took the jo b and  5).The m ean values expressed as a percentage for personal accomplishment, em o tio n al ex h austion and depersonalisation were 52%, 33% and 29% respectively.According to Figure I, 75% of the participants scored below 72% , 50% and 42% in personal accomplishment, emotional exhaustion and depersonalisation respectively.

Conclusions and recommendations
This study highlights the resilience of nurses in the fight against the AIDS epidemic.This is evident despite the high HIV and AIDS burden in South Africa, staff shortages, heavy workload and hum an and m aterial resource inadequacies (Maluleke et al, 2006: 33, Mavhandu-Mudzusi et al, 2007:254).
This study revealed that one out of three nurses experienced extreme depression w hile tw o out o f three nurses had between borderline clinical depression and extreme depression.Higher measures of sadness, fatigue and low energy was noted among the nurses.Chandra et al (2004: 48) remarked that psychological d istu rb an ces am ong health care providers may lead to suboptimal quality of care.This situation could compromise the quality of survival of HIV-infected persons and may exacerbate the risk of work-related injuries including the risk of HIV infection among health workers (Li etal, 2007:258).The study showed that high proportions of nurses formed good friendships with their patients, and felt responsible for dealing with the impact of AIDS in the society.In addition most of the nurses reported that watching patients suffer and die and being unable to help was very difficult for them.Visintini et al. (1996: 185) added that this scenario presents a complexity of feelings could lead to a high risk o f burnout am ong nurses and discourage future relationship with other patients.Visintini et al. (1996:192) added that em pathetic re la tio n sh ip s with patients could be protective against burnout and this study showed the high levels of empathy reportedly shown by nurses to AIDS patients (Table 2).
Despite the widely reported high level of depression among the study participants, personal accomplishment remained high w hile em otional exhaustion, depersonalization and burnout were notably lower (Figure I).Contrary to this finding, Chandra et al (2004: 52) noted high levels o f burnout, em otional exhaustion and depersonalization among Indian nurses caring for AIDS suffers.These differences may be explained by suggestions that burnout among health care workers is situational and driven the balance between stressors and rewards (Bennett et al, 1996: 148;Visintini et al, 1996: 191).In this regard, this study reported high levels of markers of social rewards, recognition and positive peer relationships (Table 2).This interplay may explain the significantly higher level of burnout noted among nurses without professional training who were also receiv in g lesser social and organisational rewards and with higher reports of stigmatization by peers when compared to the level of depression, rewards and stigmatization reported by professionally trained nurses caring for AIDS patients.
Against the findings of this study Li et al (2007:258)

Figure 1 :
Figure 1: Scores on Maslach Burnout Inventory scales in percentage AM A, VO & DAVHANA-M A S E L E S E L E , M 2007: N u rse s' experiences o f delivering voluntary counseling and testing services for people with HIV/AIDS in the Vhembe district, Limpopo Province, South Africa.Nursing and Health Sciences 9(issue no): 254-262.N E S B IT T , W H ; R O S S , M W ; SUNDERLAND, RH & SHELP, E 1996: Prediction of grief and HIV/AIDS-related burnout in volunteers.AIDS Care 8: 137 -143.UNAIDS 2006: Report on the Global AIDS Epidemic.Geneva: UNAIDS.V IS IN T IN I, R ; C A M P A N IN I, E; F O S S A T I, A; B A G N A T O , M ; NOVELLA, L & M AFFEI, C 1996: P sy ch o lo g ical stress in n u rse s ' relationship with HIV-infected patients: the risk of burnout syndrome.AIDS Care.8(2): 183-194.W A LLA C K , J 1989: AIDS anxiety am ong health care p ro fessio n als.Hospital and Community Psychiatry.40: 507-510.W ORLD HEALTH ORGANIZATION 2006: World Health Report.Geneva: WHO

Table 1 : Demographic characteristics Variable Attributes Frequency Percent
the variables being considered.Chisquare and t tests were performed to compare the frequency of respondents to and average scores of the variables.

Table 2 : Measures of the impact of AIDS Question Seeing
my patients suffer and die is very difficult When I look at my patients I think I'll end up like that I feel the distress that my patients are going through I am highly regarded by my friends due to my work in the AIDS unit I am working in this area due to my involvement in Home-Based Care I identify strongly with my patients I have trouble coping with the number of deaths on the unit I have had to deal with my losses due to AIDS I feel helpless watching a patient suffer in the final stages of his illness I think it is important for the community to help combat problems associated with AIDS I have a lot in common with my patients My friends recognise that my work in the area of AIDS is a valuable contribution to society People move away from me at social functions if they hear that I work in the area of AIDS I become friends with many of my patients and suffer when they die I am rewarded by my patients' gratitude for the work I do I feel a responsibility to help deal with the impact of AIDS in our society Some friends have had less contact with me since I started working with AIDS patients I receive status and recognition due to my involvement in the area of AIDS I am grieving for the loss of patients' lives due to AIDS My friends encouraged me to apply for this job in the area of AIDS I suffer stigma/discrimination from other staff at the hospital due to the unit in which I work I feel guilty when I have to say 'no' to a person who has AIDS and needs help I feel powerless because no matter what I do my patients with AIDS will die

Table 4 : Level of depression
when compared to the Extreme depression (Over 40) M 34.0%proportion of qualified nurses