Practice Training Needs Analysis of Nurses in the Implementation of TB and HIV Policy Guidelines

Abstract

Background: South Africa has the highest burden of TB and HIV incidence in the world, which can be attributed to poor infection control at primary health sectors, particularly in the rural areas (Engelbrecht & Van Rensburg, 2013). Several measures have been devised to ensure the provision of health care services that takes cognisance of the health profile of the population. Such measures include the development of policy guidelines that facilitate appropriate and effective care for both TB and HIV patients. However, the policy guidelines for TB and HIV services at primary health care facilities were poorly implemented (Churchyard, et, al., 2014). Moreover, the introduction of policy guideline for nurses to initiate management of antiretroviral treatment (NIMART) in the public health sectors (NDOH, 2011) was challenged due to nurses have insufficient knowledge and skills on the implementation of such policy guidelines. Swart, Cohen, Workman, Cameron & Blockman, (2013) identified nurses’ knowledge gaps in the following aspects: initiating antiretroviral therapy (ART), adverse drug reaction and the ability to interpret laboratory results before initiation ART (Swart, et al., 2013).The study recommended the need to improve the knowledge and skills of nurses, most importantly nurses in the rural area for successful implementation of such policy guidelines.

 Aim: The aim of the study was to assess the practices training needs of nurses in the implementation of TB and HIV policy guidelines.

Objectives:

• To assess the training given to nurses  in the implementation of TB and HIV policy guidelines
• To identify gaps in knowledge and skills of nurses in the aspects of TB and HIV policy guidelines implementation

Method: Mixed methods approach with concurrent design as developed by (Creswell, 2013) was employed to conduct the study. The study was conducted in the rural sub-district of the Overberg region in the Western Cape. Survey data was collected using self-reported questionnaire from a sample size of (N=60). Data was analysed using SPSS programme version 23.  Descriptive statistics with graphs and percentages were presented. The qualitative interview data was collected from 14 participants who were purposefully selected based on their experiences with TB and HIV services. The qualitative interviews were focused on barriers of TB and HIV policy implementation. Ethical clearance for the study was obtained from the University Senate Ethics Committee and the Provincial Department of Health. All participants singed the consent form before the data collection process.

Survey results: Out of the 60 questionnaires distributed 44 questionnaires were returned, with the response rate of 73%. Among the respondents, (77%) attended training on HIV policy and (64%) TB policy, (46%) on STIs and 32% attended on integrated TB and HIV policy. With regard to TB infection control measures, 64.1% responded  to keep window open, 61.5% see patients with cough first, 88.1% washing hands after handling sputum, 83.3% do sputum collection away from others, 8.7% keep waiting area outside, 69% fast tracking system to reduce contact time, 73% don’t notify neighbours about TB infection, 16% do notify neighbours. Related to TB treatment for pregnant women, 52.3% responded that INH to be given, 56.8% no streptomycin to be given to pregnant women, 43.2% were unsure how TB is treated in pregnant women. On the aspect of sputum storage system until the transport comes to collect the sputum to the laboratory, 62% of them indicated that they store sputum at room temperature, 25% store sputum in fridge, and 3% were unsure where it should be stored. Management of TB patient with less than 100 CD4 count, 60.5% initiate ART when TB stable, 9% delays ART initiation, and 27.9% were unsure when to initiate ART. Conditions that INH TB prophylaxis could not to be given, 44% responded if patient has liver disease, 28.9% if patient abuse alcohol, and 44.7% were unsure when INH prophylaxis could not be given. Reasons for  Co-trimoxazole prophylaxis to be given, 54.8%  said to prevent pneumonia and other infection, 14.3% to prevent rashes and other side effects, and one-third (33%) were unsure why co-trimoxazole to be given. Aspects of counselling information that need to be given to patients related TB & HIV treatment, 61.9% responded that information on large number of tablets to be given, 45.2% information on IRIS, and 28.6% were unsure what type of counselling information to be given. Reasons for transferring patient to TB hospital, 88.1% responded when patient too ill, 42.9% when care cannot be achieved, 35.7% for re-treatment and streptomycin cannot be managed at clinic level, and 33.3% when patients are uncooperative.

 Qualitative results: Three major themes originated from the interview on the barriers of TB and HIV policy implementation: patient driven, personal related, and systems driven. The patient driven barriers were social challenges and behaviour of the patient. Medication side effects also linked to patient behaviour and poverty impact on patient adherence to treatment. Personal related barriers were nurses’ lack of training affected implementation and self-confidence in terms of performance and perpetuate personal resistance attitudes and stigma. Systems driven barriers were frequent changes of policies and protocols, fragmented services, lack of consultation with health workers, and lack of knowledge transfer.

 Conclusion: The study revealed a number of knowledge and skills gaps in the implementation of policies. Nurses have insufficient knowledge and skills on the aspects of TB and HIV policy guidelines implementation; therefore, it is recommended that a continuous staff capacity development programme, which includes suitable pre-service and in-service training in TB and HIV/AIDS management, has the potential to address the current knowledge and skills gaps in the implementation of TB and HIV policy.