Research Article

The nurses'experience of possible HIV infection after injury and/or exposure on duty
L Roets, Ph.D School of Nursing, Faculty of Health Sciences, University of the Free State
LEZiady,M.Soc.Sc

School of Nursing, Faculty of Health Sciences, University of the Free State.

Keywords: Nurse, experience, HIV, infection, injury, exposure.

Abstract: Curationis 31 (4): 13-23
The purpose of the research was to describe the experience of nurses in the studied hospital who had been exposed to possible HIV infection during injury or exposure on duty. A qualitative phenomenological descriptive study was used to describe the emotions and non-verbal reactions of the twelve participants during two subsequent in-depth interviews. These were conducted post-exposure, and after counselling and prophylactic treatment took place. The nursing staffs from a selected private hospital Were included in the study after exposure of blood and/or human body fluid. After completion of the study, it was found that the exposed staff's experience had two main categories. Firstly, they were grieving for the loss of the concept of being healthy and invincible, blessed with nursing sldlls and definite goals in life. The bereavement process included phases of denial, anger, anxiety and fear, with recurring thoughts regarding the adverse events, as well as acceptance which developed with time. The bereavement process and shock of the exposure had wider consequences to the family, as well as an impact on the working environment. Most participants reported that they experienced genuine support and compassion from colleagues, at home and in the community. The second category of experience was the physical side effects which participant's developments developed due to the prophylactic antiretroviral therapy. Some participants experienced severe difficulties due to the treatment, wliile other had fewerproblenis. Some proposals to adjust and possibly improve the hospital's exposure surveillance system were developed from the research results, including that a 24-hour crisisimanagement system be implemented for exposed staff members; that support groups be started for staff, colleagues and family members; that all staff receive orientation and support during unfamiliar procedures or placement in unknown departments; that all exposures-on-duty be investigated and studied so that pro-active or preventive measures may be devised; and that problems with staffing and worldng climate be resolved. AU thefindingsand proposals were subsequently addressed to the relevant members of the Hospital Management. If healthcare services wish to retain nursing staff in future, more will need to be done to prevent all types of exposure-on-duty and, if they do occur, to anticipate, manage and shorten the subsequent period of the professional nurse or leamer 's bereavement.

Correspondence address: Dr L. Roets School of Nursing Faculty ofHealth Sciences University of the Free State BLOEMFONTEIN Tel: (051)4013536 Fax:(051)4019140 E-mail: gnvklr.md@ufe.ac.za

Introduction
The likelihood of being exposed to infection by the human immunodeficiency virus (HTV) while performing patient care in the health service increases every year. As medical technology develops, routine patient care, including the routine administration of injections and other intrusive procedures, becomes more complicated (Stoker, 2004: Online). Increasing numbers of the population of the Republic of South Afiica are diagnosed HIV positive every day (Department of Health RSA Ante-natal Surveillance Report 2004). These people are admitted to hospital as non-infected persons and are then found to be suffering from the acquired immuno-deficiency syndrome (AIDS). As a result there is inevitable increasing exposure of busy nursing staff to the presently incurable HIV infection (Department of Health Report National HIV and Syphilis Antenatal Seroprevalence Survey in South Africa 2003; Haiduven, 2004: Online). Anecdotal evidence of this was found during followup visits to the nursing staff who had been involved in injury or infection on duty incidents in tbe hospital used in the study (hereafter the hospital). Interviews immediately after the exposure incident showed that possible HIV infection was an overwhelmingly frightening thought to most of the participants.

staff members who were counselled and managed had a positive experience of the process, even though they were correctly managed according to protoéoF(Sftidied hospital. Records of Human Resources Department 2004). It appears as though the staff's experience of exposure can directly influence their work andjudgment If more information about this could be collected, coping mechanisms against the impact could be put in place early to ensure that service delivery to this special group of staff is not impeded.

your possible exposure to HTV after your injury or exposure on duty incident".

Population
For the purpose of this study the population was regarded as all members of the nursing staff on the establishment of the hospital who had been exposed to possible HIV on duty due to an injury and/or exposure incident.

Unit of analysis
All members of the nursing staff in all the wards and departments of the studied hospital, who had been exposed to possible infection with HIV while on duty, were, for convenience, automatically approached to take part in the study. The reason was the relatively small number of staff who was exposed daily to HTV infection on duty due to needle-stick or splash accidents. Every person who met the criteria in the period 1 March 2004 to 31 October 2004 was approached regarding inclusion in the study after complete counselling and treatment. Those who agreed were added as participants to ensure accuracy and avoid bias, until data saturation was achieved (Babbie, 2004:190-191); Bums and Grove, 2005:750). The following inclusion criteria applied: • Afrikaans-and Englishspeaking nursing staff of the hospital that had been exposed to possible HIV infection by exposure/injury on duty incidents. • The participants should all have been on the hospital's official surveillance list to ensure that the frame of reference, terms and standard exposure procedures that were used, wore known to them all. • Exposure must have talcen place during official duty hours on the hospital premises while performing patient care. • The exposed staff member must have been registered with the South African Nursmg Council and appeared on the hospital's establishment and have met all other staff criteria. Consequently both registered professional nurses and pupil nurses of the hospital's private training establishment were included in the study.

The aim of the study
The aim of the study was to describe the experience of the nursing staff of tbe studied hospital that was possibly exposed to HTV during the performance of their duties, and to recommend better management of such incidents.

Research design
A qualitative phenomenological descriptive study was undertaken, as the aim was to describe and study the individual experience of a person after exposure to possible HIV infection (Bums and Grove, 2005:55-56,232-233). Without preconceived ideas the emphasis was placed on the,participant's experience of events and circumstances rather than the researcher's interpretation thereof (Brink, 1996:13; Polit and Beck, 2004:253).

Problem Statement
Despite the enormous amount of available literature about the clinical process of counselling and management of post-injury/exposure on duty, little literature was to be found in scientific sources regarding the experience of South African nurses who had experienced the process (NISC DISCover Report, 2003). According to the hospital's monthly infection control reports, about 0.8% of the staff corps were exposed every month to possible HIV infection due to injury and/or exposure-on-duty (hereafter referred to only as exposure). (Studied hospital: Records of tbe Human Resources Department 2004). IntercoUeagial conversations during follow-up actions over a period of three years revealed that not all the exposed

Research technique
In-depth interviews were conducted that led to conversations that produced direct quotations, and that in their turn formed the basis of the study (Brink, 1996:119120); Polit and Beck, 2004:349-350). The experience of the nursing staff regarding exposure to HIV was described by conducting two unstructured in-depth interviews with each of the exposed members of the nursing staff and the gathered information was reproduced. The first interview was conducted as soon as possible after the exposure took place, while the second was completed three months later, at the end of the surveillance period. The research question of the study deals with the experience of a staff member who has been exposed to possible HIV infection and was formulated as follows: "Describe your experience regarding
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The first approximately twelve weelcs of the official six months surveillance period for each participant were included in the research period. The first interview took place as soon as possible after the exposure incident to ensure that the events were fresh.

interviews. Analysis of the results of the two in-depth interviews showed that the research question was undoubtedly clear tS both the participants. The collected data and the selected method of documentation functioned eflectively.

during the in-depth interviews (Okun, 1997:18-19,123).

Data analysis and interpretation
Data analysis encompassed the conceptualisation, contrasting and equalisation of the final highly detailed data of a small group of participants, to identify common patterns, themes or trends. Information was repeatedly sifted, arranged and described to create a clear and understandable construct that could later be of use to the nursing profession and other researchers (Tesch, 1990:91-93; Brink, 1996:120; Labuschagne, 2003: Online). Tesch's model of data analysis was used as a guide-line. Words and phrases were categorised and not only counted (Tesch, 1990:37-38,92; Pope, 2000: Online; Ryan and Weisner [s.a.]: Online). In the course of time all the observed meanings were placed in categories according to appropriate criteria such as certain word choices or meanings. Conceptual categories were not determined beforehand, but developed out of the systematic process. In the study both the emotional and physical experiences of the participants were identified as categories. This in turn led to the development of the subcategories. By repeatedly sifting and arranging data, analytical and theoretical ideas were developed which were ñirther refined, adapted and grouped together. Broad themes were created where new data was found (Pope, 2000: Online; Bums and Grove, 2005:547-548,596). In the end an understandable framework (figure 1) could be created that summarised and set out the totality of the unique experience of the participants (Tesch, 1990:91-93; Labuschagne, 2003: Online). Data analysis actually began during interviewing. This process was found to flow parallel with data collection and was even integrated with it. According to Tesch (1990:04-73) and Pope (2000: Online) this method ofwork is acceptable.

Data collection
After exposure the researcher conveyed each participant's first blood results verbally to him/her. She explained that a study was being conducted and enquired whether they would be interested in taking part in it. All the exposed staff members who were approached to participate agreed in writing to do so. Participants were anonymously included in the study and a verbal appointment for the first in-depth interview in the hospital was made with each one as soon as possible. The researcher personally interviewed each participant as all of them knew her and a relationship of trust already existed. Thefirst45-60 minute in-depth interview 'with each participant was conducted in the hospital in the infection control office or in a quiet office in the participant's ward, where privacy could be ensured. An appointment for the second interview was made at the end of the first one. Field notes about the participants' nonverbal communication patterns or other observed mannerisms were added after each interview and later transcribed with the interviews. In order to ensure confidentiality for the participants, the two transcriptions of the interviews were filed under a successive reference number as (a) and (b) and the data processed as soon as possible. In view of the warnings of Brink (1996:153) and Polit and Beck (2004:347) about the possibly inhibiting effect of the tape recorder on the participants, it was kept in a drawer, with their consent, and only the microphone was placed on the desk near the participant's chair. The participant was encouraged to relate the incident in her/his own words and sequence. The researcher used communication skills to obtain information: eye contact, nonverbal behaviour, listening sldlls, silences ^ d references back to statements were used to facilitate theflowof information 15

Exclusion
• Staffmembers, who tested HIV positive at the time of the injury/ exposure on duty incident, were excludedfr'omthe study as the risk of being infected with the virus on duty no longer existed. These staffmembers were referred directly for counselling.

Data saturation was used as the measure for the size of the unit of analysis in the study. Saturation of data is achieved when themes and descriptions start repeating without any new data being collected (Polit and Beck, 2004:57). Data collection was continued until saturation of information was achieved after eight months with a total of twelve participants

Exploratory interview
An exploratory interview was conducted with two exposed staffmembers to ensure that the required information could be collected and to try and determine any unexpected factors beforehand (Brink, 1996:213;BumsandGove, 2005:42,396; Polit andBeck, 2004:196). There was a three-fold advantage in conducting the exploratory interview: Firstly, the researcher could test whether the central research question would ensure the desired response. Secondly, there was the possibility of ironing out potential problems regarding the interview technique, inadequate time for the in-depth interview, and ambiguity in the way questions were worded. Lastly there was the opportunity to practice the process and to analyse the small amount of data quickly to ensure that the envisaged procedures progressed effectively (Brinlc 1996:60,174). Both in-depth interviews with the participants in the exploratory interview elicited the desired responses. The information was saved on audiotape and transcribed directly after the in-depth

Trustworthiness of the study
Trustworthiness affects the measuring instruments used in research - in this case therefore, the researcher herself. The

FIGURE 1 : Framework for data analysis
CATEGORY SUB-CATEGORY

THEME "/ didn 't want to know... " "/ 'm not readyfor this". "It's over. We Just carry on..." "The thought of a repetition of everything was just too much ". "/ delayed and delayed, until a nurse told me to go " "I was so frightened... " "Ijust could not go through it again " "It's a nightmare. I want to get married... " "/ wanted to stop nursing. I'm always frightened" "I'm angry all over again " "It makes me furious to think... " "I know I'm exposed" "I now have so much more empathy with the HIV positive patients. There is satisfaction in nursing these patients ". "It's part of the work" "It was very good...I'm satisfied with the support". "/ have no complaints " "I think a full-time person should be appointed for this " "I was well supported at work" "My husband understands what I had to go through " "We were so busy, there was no time to think about yourself "It was only when the note about the follow-up blood test came that I thought about it again " "I had forgotten all about it until now" "I'm always far more careful now" "I'm always conscious of the risk'". "Iremain afraid" "I didn't want to take the pills again. Those pills kill you " "I was so afraid I would get sicker from the medication " "Everyone speaks about the effect of the pills on you, and it's true - they make you feel ill" "The medication was my greatestfear " "The side-effects...!" "Oh no, I was slightly nauseous, but that was all". "I was not nauseous ". ability to collect that information consistently, document it accurately and to express it repeatable (Silverman, 1997:202). Theti-ustworthinessof the information was ensured, among others, by the creation of the central research question to keep the in-depth interviews focused and to avoid straying from the subject, as well as by taking complete notes, transcribing the interviews as soon as possible and then studying them repeatedly (Okun, 1997:154,242-243).

Emotional experience

Grieving response: 1. Denial

2. Anxiety and fear

3. Anger

4.Accep tance

Experience of support

Thoughts about the events

Physical experience

Side-effects due to pro-pbylactic treatment

skills the researcher evinced eventually contributed to the scientific acceptability of the study (Brink, 1996:124; Polit and Beek, 2004:434). The researcher possesses the necessary counselling sldlls and abilities demanded by a Rogerian client-centred approach to interviewing and, in effect, acted only as a sincerely accepting and reflecting person and listener and not as someone giving direction (Olcun, 1997:122-123; Burns and Grove, 2005:637-640). Clinically speaking the researcher, as a

registered professional nurse and infection control consultant, possesses the necessary interviewing skills. credibüify, transferabilify, dependabilify and confirmability were accepted as criteria for trustworthiness (Polit and Becli, 2004:430431,437; Bums and Grove, 2005:383-385,627-632).

Credibility
The eore of credibility in qualitative research is the content of the participants' accounts, as well as the researcher's
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AU knowledge garnered during the study was dedueed and developed only from the participants' own experience. Audiotape transcriptions and field notes were strictly adhered to in data analysis and any possible bias on the part of the researcher was limited (Brink, 1996:120). The study process that was followed was cai-ried out as consistently as possible to enable a following researeher to repeat the study over a period of time and to obtain similar results.

recommendations are supported by literature and that there is similarity between the researcher's interpretation and the evidence. Confirmation may be obtained by doing an audit of the data or by obtaining the participants' response to the findings (Polit and Beck, 2004:434435; Speziale and Carpenter, 2003:38). Due to the fact that there was such a limited amount of evidence-based literature available about the experience of exposure of South African nurses to HIV infection on duty, international literature that included similar exposure of health care workers, doetors and medical students was used. The reason was that these "health care workers" woxild have included nurses and that the information and conclusions of other studies would probably be transferable to this profession too.

generally accepted as a traumatic situation with a high probability of direct or indirect harm to health and even loss of life (Balachandran, 2002: Online; Bandolier Extra, 2003: Online; Stoker, 2004: Online). Participants in the study showed that any occupation-related exposure to a patient's blood or body fiuid was very traumatically experienced.

Transferability
Transferability has to do with the stability of a research design and the possibility of generalising the information of the participants from one study to another group or broader population (Polit and Beck, 2004:435 ; de Vos, Strydom, Fouche andDelport, 2007:346). The detail data of this study is not transferable because the individual experiences of nursing staff regarding their exposure to possible HIV infection after an injury and/or exposure on duty is unique to every individual in the hospital. Nevertheless the findings and deductions are useful to demonstrate the experience of exposed staff members so that the effectiveness and/or deficiencies of surveillance proeedures may be evaluated and corrections affeeted.

Description of the unit of analysis
The unit of analysis consisted of twelve participants from the nursing staff of the hospital who were exposed to possible HIV infection due to an injury and/or exposure on duty.

Age and qualifications
The participants were between 18 and 57 years old (average age: 33 years), while their clinical experience rangedfromfour weeks to 39 years (average: 15 years). Eight participants were registered professional nurses, one a registered professional enrolled nurse, while three learners were busy with their basie training for the rank of registered professional enrolled nurse. Two leamers were in theirfirstyear and one in her third year of study.

Ethical aspects

In order to protect the rights of all the participants in the research proeess, consent to undertake the study was obtainedfromboth the Ethics Committee of the Faculty of Health Seiences of the University of the Free State and the hospital. Written permission obtained from the partieipants was available in Afrikaans and English, although all the partieipants in the study used Afrikaans as their language of preference. The inType of exposure depth interviews were recorded on Dependability Of the twelve partieipants seven had audiotape after consent was obtained The accuracy and authenticity of sharps injuries and five had been from the participants (Babbie, 2004:72,80- splashed in the face with human blood scientific findings in qualitative research 81). are important for the determination of or body fluid. It was interesting to note dependability. The degree of that it was the leamers who had splash The four basic ethical principles for dependability can be determined if the accidents while the older, trained and researchers who do qualitative research, following can be determined: (1) to what qualified registered professional nurses i.e. autonomy and respect for others, had mainly sharps injuries. A possible extent the conclusions of the researcher benevolence, equity and fairness, were explanation is the fact that the leamers represent the observed reality, and (2) universally applied (Terre Blanche, were all performing basic physical patient whether the research constructs measure care during exposure, while most of the Durrheim andPainter, 2007:67-68). or represent the true range of human qualified staff was busy with experience. If there is agreement between administering medication or with more All data was handled eonfidentially and the observations of the partieipants and specialised tasks. depersonalised, audiotapes were the reader regarding the study, its destroyed after completion, no dependability is largely ensured (Polit rem\ineration was paid but partieipants and Beck, 2004:434-435; Speziale and Emotional and physical have access to the final researeh results, Carpenter, 2003:38). aspects privacy was ensured at all times and Theti-anscriptionsof the twenty-four in participants were referred for further Data triangulation and tracing negative depth interviews were repeatedly studied counselling if necessary and if they cases or incidents that could provide and the data divided into two main agreed. contradictory information, were used to categories of experience, that is, emotional check dependability. experience of the exposure and the Data interpretation and physical experienee of side-effects after Confirmability prophylaetic anti-retroviral treatment. literature check Confirmability is the guarantee that the Sub-categories with themes were Oecupation-related exposure to HTV is data findings, conclusions and
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identified under each category. The sub'categories under emotional experience included: "Grieving response ", "The experience of support", and "Thoughts about the event". The sub-category "Experience of side-effects due to prophylactic treatment" was identified under the' category "Physical experience ". Themes obtained from the transcriptions were identified under each sub-category (See Figure 1).

against the expected change it will cause in their lives. Expected sorrow may therefore develop (O'Neill^^and McKinney, 2003: Online). '• -^--- ' I got a fright when I pricked myself. You wonder what will happen. But then you think of the patient lying there - she is only nine years old. One of the XXXX's children. Then I went to Sister LR and she said I must nil in everything. At first I wanted to leave it, but then I thought one can't just leave it these days. One never knows. One doesn 't have to be thin, does one? " The practical effect of sadness was noticed in the participants as adj ustments to professional methods and in the family context needed to be made, for instance condoms suddenly had to be used in a stable marriage. "We didn't use condoms. I should have told my husband but I was not ready to tell him ". A grieving person experiences sadness, anxiety and depression before the loss and change can be assimilated and accepted (Cross Creek, [s.a]: Online). Statements such as "/ always thought... " and "How will I...?" are often used, as the participants did. "/ never thought I would come upon .such a situation ". "How do I tell my husband? He is sometimes so hostile towards my job ". The idea that the exposure could possibly have been avoided often complicates the person's grieving process, such as the experience of side-effects due to prophylactic treatment (HIVAN, 2003: Online; Medical Library, 2004: Online). From the responses of the participants it was clear that the elements of the model of Kübler-Ross (Bowers, [s.a]: Online) best correspond with the emotions that the study participants experienced. Denial, anger (that includes fear and anxiety) and acceptance were clearly demonstrated in the study. The narratives of some of the participants revealed elements of depression and sadness in their interviews, while negotiation, where the person, according to Kübler-Ross, pleads with a "higher power" to undo the loss, was never directly verbalised by the participants (Gode, 2002: Online; MentalHelp.net, 2005:Online).
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Déniai
Denial is the inabihty or unwillingness to accept or admit the shock or expected loss (exposure), and often occurs shortly after the incident. The incident may be experienced as a bad dream where everything will retum to normal when the dreamer awakens. People often go through periods of disregarding or standing aloof from the reality. Their attention is so thoroughly diverted by other activities and thoughts that they do not think of the exposure or expected loss (Macnair, 2005; Online; Kessler, 2005: Online; Leaver, 2006: Online). The latter phenomenon was clearly obsciTcd, where a number ofparticipants often remarked spontaneously that they still could not believe that the exposure hadtalcen place, or could not believe that they had forgotten about it. "Generally speaking I'm always very careful - / still can't understand how it happened". Others evidently had a more pragmatic attitude, but still hesitated to seek treatment or help immediately, did not disclose their exposure or spealc openly about it, which may indicate denial of the impact of the incident (Brahm, 2004:Online; Callahan, Jaffe, Segal and Segal, 2005 :Online). "...and I had things to do here. I still don't grapple with the idea that I'm going to get AIDS". According to experts such as KüblerRoss and Horowitz denial is a normal coping mechanism with the aim of making the acute pain of the loss or shock more bearable and less overwhelming (Psychosocial impact of HIV/AIDS, [s.a.]:Online). "And the main thing is one is in denial a little, and one does not really want to talk about it, one doesn't want to deal with it" [laughs furtively]. A person in denial often feels cold and may appear to be without feeling or apathetic (Macnair, 2005: Online; Leaver, 2006: Online). "You know, I do not fed like it now! [Vehemently, waves her hand]. A'of again...If the staff had not insisted so, I would have been at home now". [Staff member comes across as cold and clinical when telling of her experience, but becomes heated when speaking about

Emotional experience of the exposure on duty
The emotional experience of the exposure was, without exception, emphasized most by all the participants, and had, according to them, a long term impact on their emotion^s and even their method of worldng. It affects one emotionally andphysically, especially as I've now got these [side] effects [of the prophylaxis]. These feelings varied between anxiety, resignation and acceptance, and more negative emotions such as fear, anger and loss.

t

The grieving response as part of the grieving process
A study of the experiences expressed by the participants shows that their descriptions correspond to the typical grieving process described in the literature (O 'Neill and McKinney, 2003 : Online). The grieving process includes a

grieving response, as was clearly indicated by the participants in the study. The grieving response consists of the experience of various emotions such as anger, fear, denial, depression, resignation and acceptance (Pecorino, 2002: Online; Kessler, 2005: Online; Leaver, 2006: Online). Behavioural and emotional variations are undoubtedly part of the active giieving response (O'Neill and McKinney, 2003 : Online). The participants therefore grieve over the loss of their basic beliefs about life and their own concept of personal health and inviolability (GP-Training.net, 2006a: Online), although a number of external manifestations of these were observed. This experience is one aspect of post traumatic stress disorder (GPTraining.net, 2006a: Online). The participants may unconsciously have measured the shock of the moment

ir

of grieving, as is clearly demonstrated in the following quotation from the interview with one of the learner Although some participants hesitated to participants: report their exposure immediately due to "...I got a very big fright. One ofthe denial, this response did not prevent them from actually doing so and all the sisters said it was nothing, but when I staff received treatment. phoned Sister O [lecturer] and she said I "I decided to take the pills for my own must go to Emergencies I was very safety. If there could be something, they frightened. I thought now I'm going to could have prevented it or taken it diel" [Youngest, wide-eyed, away ". inexperienced learner]. All four participants who had previously been injured on duty felt that the process of completing all the documents took a great deal of time, resulting in a loss of productivity. This phenomenon was also found in the literature (Balachandran, 2002: Online). ".../ was in Emergencies for about two hours. In the meantime the work stood still". Tbe literature review for the study revealed that 40-70% of exposed staff world-wide fail to report the incident at all. Denial of exposure can lead to underreporting and is a great source of concern to health services (Wilburn, 2004: Online). The participants differed, for personal reasons, about what they told about the exposure incident: "/ did not tell my child -1 did not want to expose him... I did not tell myfather. I did tell my sister and we decided that we would cope with it and see what happens. I don't want my father to be worried-he is so protective of his little girl". "Anxiety" is defined as a vague, uncomfortable emotional condition, dxiring whicb feelings of uncertainty, discomfort, uneasiness and dismay occur without a specific reason. "Fear" is similar to anxiety, but has a specific reason or cause (Loughborough University, 2005: Online). During sudden intense emotion anxiety and fear are often similarly experienced. Theparticipants' self-reporting in the first interviews of fatigue, forgetfulness, loss of concentration and purposeful performance, were attributed to anxiety disorder if the participant indicated that she felt better. Haiken and Herscher (2004:Online) state that when the temporary tension has been relieved and tbe anxiety is past, the body and brain recover and the person will gradually begin to function optimally until full capacity is reached. "Iread the information leafiet again and saw: Why, they did tell me that, and I did read it, but I was so shocked [at that moment] that I couldn 't remember it". Fear and guilt feelings may combine to prevent the exposed person from seeking help, talking about the incident or even trusting others. "/ told the people at home, but this sort of thing happens [with one at work] and you don't want to talk about it. Jt feels too ridiculous... " [Did not want too many colleagues or others at work to laiow]. The unpredictable nature of HTV infection after exposure-on-duty leads to feelings of hopelessness, frustration and being overwhelmed, as well as fear that friends and family members will withdraw from one (Goldblum, [s.a]:Online). "Look, I tell my husband nothing. I'm too afraid of telling him ...he will. ..not worry with me or anything. He knows now, but I didn't tell him when it happened". [Second in depth interview. 19

the incident].

three months later]. Research has shown that health workers often experience traumatic anxiety after exposure, in spite of the availability of effective anti-retroviral prophylaxis (Wnuk, 2003 : Online), but that evidencebased research about this is scarce (Meienberg et al; 2002: Online). Anxiety was expressed as follows by one of the participants: "That's what frightened me. Accidents happen so suddenly and I'm exposed to them eveiy day. I was in such a state when it happened". [Staff member working as a surgical scrub nurse in a general theatie, where the surgeon accidentally pricked her with a used scalpel]. After anxiety and fear anger was the next prominent emotion described by the participants.

Anger
Anger is the experience of strong feelings that vary from slight unhappiness, embarrassment, irritation or hostility to extreme antagonism, and is caused by actual or supposed harm, injustice or damage (Brahm, 2004: Online). Ten of the twelve participants reported anger, irritation, frustration or distress at tbe first in-depth interview, although these emotions were expressed in a variety of ways such as impatience, irritation or tearfulness. "At the beginning I was angry with the patient and didn 't want to go into the room again. But I did go in again later". Some of the participants indicated that they were angry, unhappy or annoyed with themselves about the role they felt they had played in their own exposure. "/ was so angry with myself-1 said I would never again show anyone how to inject insulin ... it's not worth it". Some ofthe participants reported anger towards the patient in question, their employer or a surgeon, for the circumstances under which exposure took place. "In the first place I was annoyed with the doctor [who pricked her with the used scalpel in tbe theatre]. The doctors are actually very naïve about this thing. They laugh at you when you put on your goggles ... and they mustn't huny us. It's about hurry. They ask for three things

Anxiety and fear
Anxiety and fear were two strong emotions reported by most of the participants in the in-depth interviews. The two exposed learner nurses experienced overwhelming anxiety about the splashes of body fiuid in their faces, while the needle-stick and sharps injuries were experienced with gi^eater equanimity by the older, qualified participants. "I was in Emergencies for less than two hours and of course I said in the first hour already "Give me mypilll Give me my pill" [laughs a little]. According to Meienberg et al. (2002: Online) and O'Neill (2003: Online) factors such as the level of training of the exposed person without a doubt contribute to differences in the experience

at once and you try and give them all three at once ". At the second in-depth interview the emotion Üiat emerged strongly was one of greater acceptance of what had happened.

Acceptance
"I understand that it's part of my job - a risk we take". "I want the [surveillance]/»enoß? to pass now. I want to donate bone marrow". As can be gathered from the quotations, acceptanee is a stage in the grieving process in which the exposed person makes peace with the traumatic event, develops a ftiture-orientated outlook to plan for the future with more energy and re-establishes contact with other people (Brahm, 2004:Online; Leaver, 2006:Online). Often the acceptance of reality is an indication that the person has regained emotional balance and that recovery is taking place (Interdenominational Church, 2005: Online). "/ think it helped that I didn't sit and brood and that I wasn 't too worried. I think that contributed to the fact that I accepted it ...I accepted that I had done what I could, and had exercised a little control ". When someone who has experienced a grieving response is ready to speak openly about the events without experiencing excessive sadness or guilt, the process has been [almost] completed (GP-Training.net, 2006b: Online). "In the meantime I've forgiven myselfit was my ownfault, and since then things have looked much better. It was an eyeopener, really an eye-opener. Now I see well. It could have been much worse ". During the ti'auma of exposure and the experience of the personal grieving process thereafter, all the participants in -the study told of the importance of the support they received. Although depression is one ofthe phases of the grieving response (Callahan et al, 2005 : Online) it is not discussed as it was not one of the responses emphasized by the respondents.

family and next of kin of the exposed staff members were affected by the exposure. There are always inevitable and I increasing consequences, such as the side-effects of prophylactics and measures to prevent further transmission of infection between spouses (HASA, 2003:11-14). Eleven of the participants (N=12) related that they were emotionally supported in the surveillanee period by their spouses, family members and colleagues. 'Wo, / told them [family]. One of my daughters, L ... you know, I'm a grandmother of two little ones ...teased and said she wouldn't come near me, but they didn't mean it. They did.support me. My husband told me to drink the stuff [anti-retroviral prophylactics]. When I said there are so many disadvantages in the pamphlet, he said but that won't malee any difference ".

indicated that they personally thought that their complaints were directly related to their treatment with anti-retroviral.

Experience of side-effects after treatment with anti-retrovirai therapy
All the participants were treated prophylaetie ally for between three and 28 days, and eleven of them completed their therapy as planned. Only one participant was forced to discontinue treatment early for medical reasons. Prophylactic anti-retroviral therapy was the aspect of the surveillance process negatively experienced by all the participants. Without exception all of them feared the effects of this treatment "...No, I can't come back to the treatment every time! But the treatment was the nail in my coffin, really Sister! I was in my coffin. Sister!" [Second interview, during which she repeatedly refen-ed to the effect of the medication]. The treated participants experienced side-effects such as malaise, nausea, vomiting, abdominal discomfort and headache. These symptoms coaespond to the lcnown possible pharmacological side-effects of the drugs (McNichoU, 2006: Online).

Thoughts about the incident
Five of the participants related that after three months they still felt affected and tense when they thought about the exposure incident. Excepting three of the participants who specifically said that they wanted to forget about the incident as soon as possible, the rest indicated ttiat the experience would remain part of their memories for the rest of their lives.

"It's a relief that the results were negative, although I didn't really expect Four participants reported no side-effects anything else. But it's always at the back from the prophylactic treatment, and in spite of their experience of side-effects, of your mind.. .Just supposed...". only one of the remaining eight discontinued the course of aati-retroviral Physical experience of the therapy prematurely on medical advice.

exposure-on-duty

Eight of the participants in the study experienced physical side-effects due to the treatment with anti-retroviral therapy. A particular problem that emerged in the study was that the side-effects of treatment with anti-retroviral were very closely linlced to the physical symptoms experienced in the grieving process. Complaints of nausea, with or without vomiting, insomnia, fatigue and exhaustion; palpitations, lightheadedness and dizziness; muscular tremors and trembling; diarrhoea, headache and malaise often occur in both stressed and traumatised persons as well as in those experiencing side-effects of prophylactic anti-retroviral therapy (McNicholl,2006:Online). "Ivomit in any case when I'm nervous ". All eight of the affected participants
20

Field notes
All the observations and notes were taken into account during the transcriptions so that the data could be reproduced completely. Non-verbal behaviour was added next to the quotations.

Conclusions and recommendations
Exposure on duty to possible HIV infection was a traumatic experience for the participants in the study. As stated by Bandolier Extra (2003: Online) and Stoker (2004: Online), its impact was not limited to the exposed person alone - it rippled outwards to the family, employer and the subsequent job performance of the victim.

Experience of support
It was quite evident that the private lives.

The post-exposure experience of the nurses had such an effect on their emotional and physical condition, as weU as on their performance, that specific action on the part of the employer was justified (Stoker, 2004:Online).

should manage the immediate postexposure counselling, blood tests and prophylactic treatment of the staff member in terms of the hospital's established protocol. A buddy system may be built into the support system, where a previously exposed person or group who has/have worked through the recovery period, support(s) a recently exposed staff member in eamest (Holmes, 2003 : Online; McNally, 2004: Online).

Emotional aspects
The emotional aspects of exposure to possible HIV infection and consequent support led to most comment on the part of the participants.

prickers, syringes with needles or butterflies, while giving directpatient care or elearing up after a procedure. In contrast all the learner nurses were exposed to splashes of body fluid while giving patient care or clearing up afterwards, such as coughing in their faces after taking medication, or a splash with contaminated washing water while empfying a used washbasin. Most of the incidents took place in the busy periods of the day shift, on weekdays and a few hours into the shift. More registered professional nurses than leamers were exposed. Two incidents took place in the theatre in the evening at the end of the day shift. The only conclusion to be drawn from this is that staff that has been on dufy for a few houis is more prone to exposure on duty. This conclusion is confirmed by the literature: the more exhausted the worker is, the fewer staff on dufy per shift and the more pressure of work is exeited on individual staff members, especially on night duty, the greater the risk of sustaining an injury on dufy (Radecki et al, 2000:Online; Balachandran, 2002:Online). Tired staff shows an inevitable decline in vigilance, cognitive ability and motor function (Ayas etal, 2006: Online).

The experience of the grieving response by the exposed participants
The literature review provided sufficient evidence that the participants were in at least one of the stages of the grieving response during the interviews.

Physical experience
Although the emotional aspects of their exposure on dufy weighed significantly more heavily than the physical experience on a number of the participants, the physical experience carried considerable weight in terms of the total view of the findings of the study.

Experience of support
Participants reported that the protocols and infrastructure of the hospital provided them with immediate and satisfactory physical and emotional support. However, the application of the protocols and quality of service to individual participants was influenced by the pressure of work in the Emergency department and the unique empathetic approach of the individual counsellors who worked with each participant.

Recommendation
An exposed staff member, who experiences problems while receiving prophylactic anti-retroviral treatment, should negotiate about service concessions with nursing management and the occupational health section of the hospital. Service concessions such as flexi-time, the granting of sick or compassionate leave or the possibilify of voluntary temporary or permanent transfer to another ward with lighter service demands, other working circumstances or an altemative patient profile may also be negotiated (Stoker, 2004:Online). The aim would be to keep the staff member on duty as far as possible, but to accommodate her/him to ease the treatment. To refute the fear of the side-effects of prophylactic anti-retroviral therapy, positive information about its effectiveness and availability and its successful management must be emphasized at every information opportunify such as World Aids Day and any other occasion, without glossing over the potential of side-effects or problems.

Official exposure-on-duty protocols
The occupational and human resource sections of the health care facilify must ensure that exposed staff follows the health care facility's prescribed injury and/or exposure-on-duty protocols. Telephone calls and/or official reminder letters may be used to help staff remember, or arrangements may be made for phlebotomists from private laboratories to visit busy staff members at work to take the required blood specimens.

Thoughts about the events
After three months a few of the partieipants reported that they continued to apply the safer behaviour pattem for all patient care procedures that were intioduced after their exposure. Staff that may be exposed to HIV infection on duty therefore require continuing support in terms of their own needs, not only in the crisis period immediately following the incident.

Recommendation
There should be a 24-hour crisis management service available to exposed staff members. The service should come into operation automatically after an exposure incident to help the staff member with the necessary compassion and to provide emotional support. (Chagdud Tullcu, 2006: Online). A designated team of trained professionals (possibly including an infection control and/or occupational health nursing consultant or counsellor, a doctor, a psychiatrist and/or a psychologist)

Concluding remarks
"...Somewhere out there. Someone's been infected with a deadly virus just because they went to work one day... " Lynda Amold Staff intei-view, 1998 This is the realify with which nurses in most health care institutions in Southem Africa are confronted every day.

General conclusions
Possible reasons for the exposure of participants
Most of the registered professional nurses were exposed to injury with sharps such as intravenous sets, skin
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References
AYAS, NT; BARGER, LK; CADE, BE; HASHIMOTO, DM; ROSNER, B; CRONIN, JW; SPEIZER, FE; CZEISLER,CA 2006. Extended work duration and the risk of self-reported percutaneous injury in intems. JAMA. Vol. 296 No. 9, September 6,2006. http:// www.jama.ama-assn.org/cgi/content/frill/ 296/9/1055 [Accessed on 6 September 2006]. BABBIE, E 2004. The practice of social researeh. 10"" edition. Belmont: Thomson Wadsworth. BALACHANDRAN, S 2002. Nurses and the occupational risk of blood-borne infections. Indian Journal of Medical Ethics. 10(4): OCT-DEC http://www.issuesinmedicaletMcs.org/ 104di088.html [Accessed on 14 October 2004]. BANDOLIER EXTRA - EVIDENCE BASED HEALTH CARE. Needle stick injuries. July 2003. www.bandolier.com [Accessed on 20 September 2004]. BLOEMFONTEIN MEDI-CLINIC HUMANRESOURCES SECTION: injuiy on duty records / incident reports (per participant) BLOEMFONTEIN MEDI-CLINIC / MEDI-CLINIC GROUP, Infection Control Manual September 2003. IBl; MH-B4;IA5. BOWERS, R [s.a.]. Coping with the 5 stages of grief and bereavement: What is grief? http://www.york-unitedkinpdom.co.uk/funerals/grief [Accessed on 19 June 2006]. BRAHM, E 2004. Trauma healing. http://www.beyondintractabilitv.org/ essav/trauma healing/ [Accessed on 21 June 2006]).BRINK, H. 1996. Fundamentals of researeh methodology for health care professionals. Kenwyn: Juta en Co, Ltd. BURNS, N &GROVE, SK 2005. The praetice of nursing research - conduct, critique and utilization. 5* edition. St Louis: Elsevier Saunders Company. CALLAHAN, C; JAFFE, J; SEGAL, R & SEGAL, J 2005. Help guide mental help issues. Coping with loss: A guide to

Grieving and Bereavement, http://

www.helpguide.orp/mental7 grief loss.htm [Accessed on 19 June 2006]
CHAGDUD TULKU 2006. Do-Gooding and Burnout. http://

detail.asp?NaineTD=15068100 TAccessed on 21 December 2004]. HAIKEN, M & HERSCHER, E 2004. Lifestyle, Wellness, stress and chronic illness. http:// hea1thresources.caremark.com/topic/ stressill [Accessed on 23 August 2006]. HASA Newsletter March/April 2003. HASA: Northeliff, Johannesburg; pp. 1215. HIVAN - CENTRE FOR HIV/AIDS NETWORKING: AIDS epidemic update 2003. UNAIDS Press Release 25 November http://wvirw.hivan.orp.za/ arttemp.asp?id [Accessed on 6 October 2004]. HOLMES, L 2003. About mental health. The psyehological effects of trauma. http://mentalhealth.about.eom/cs/ traumaaptsd/a/trauma.htm [Accessed on 23 August 2006]. ENTERDENOMINATIONALCHURCH OFTHE HOLY LANDS 2005. Pastoral care for grief- one to one bereavement counselling - What are the different types of grief? http:// www.interdenominational.net/ pastoral care for grief.htm [Accessed on 1 June 2006]. KELVENS, C 1997. Fear and anxiety. http://www.csun.edu/ ~vcpsvOOh.students/fear.htm [Accessed on 31 May 2006]. KESSLER, D 2005. Frequently asked questions on grief and grieving, http:// www.davidlcessler.org/html/qa grief html [Accessed 1 June 2006]. LABUSCHAGNE, A 2003. Qualitative research - airy fairy orftindamental?The Qualitative Report, Volume 8, Number 1 March2003. http://www.nova.edii.S.SSS/OR/0R8-1/ labuschagne.html [Accessed 29 January 2004]. LEAVER, J 2006. Grief forum, encyclopedia of mental disorders. Grief http://www.minddisorders.com/Flu-Inv/ Grief.html [Accessed 23 May 2006]. LOUGHBOROUGH UNIVERSITY COUNSELLFNSG SERVICE 2005. Help for common problems.- bereavement and loss. http://www Ibnrn ac.ulc/servics/

buddism.kalachakranet.org/ eompassion.html [Accessed on 10 November 2006]. CROSS CREEK Family Counselling. Bereavement. https://www.crosscreekcounseling.com/ bereavement.html [Accessed on 31 May 2006].
DEPARTMENTOFHEALTHREPORT: National HIV Sero-Prevalence Survey in South Afriea, 2005. http:// www.healthlink.org.za/healthstats [Aecessed on 6 July 2006]. DEVOS,AS; STRYDOM, H; FOUCHE, CB & DELPORT, CSL 2007. Research at Grass Roots. Van Schaik Publishers. Pretoria. GOLDBLUM, P [s.a.]. Is AIDS bereavement unique? http:// www.whitecranejournal.com/ wc01071.htm [Accessed on 1 July 2006]. GORLE, HR 2002. Beware the Five Stages - Editorial TLC Group.

http://www.bereavement.or^/ theories.htm. [Accessed on 1 July2004]. GORLE, HR [s.a.]. Hospice net: knowledge of the grief process, http:// www.hospicenet.org/html/ knowledge.html. [Accessed on 1 July 2006].
GP-TRAINING.NET. 2006a. Bereavement, http://gp-training.net/ training/consultation/bereave, htm [Accessed on 31 May 2006]. GP-TRAININGNET. 2006b. Coping. Patient adviee leaflets: Understanding and eoping with your feelings following a traumatic event, http : //gp-ti'aining.net/ pal/mhealth/trauma.html [Accessed on 21 June]. HAIDUVEN, D & FERROL, S 2004. Sharps injuries in the home health care setting: risks for home health care workers. AAOîttU, 52(3): 102-8 2004. http:// www4.infotrieve.com/ n e w m e d l i n e /
22

sei lin g/t) a g e s / p r o b l e m s / hp.reavement.html [Accessed on 23 May 2006].

Care for the caregiver-A clinical guide to supportive and palliative care for HTV/ AIDS. pp. 329-347. OKUN, BF 1997. Effective helping interviewing and counseling techniques. 5* edition. Pacific Grove: Brooks / Cole Publishing Company. PECORINO, PA 2002. Anticipatory grief, death and bereavement: A continuum. http:// www2.sunvsuffolk.edu/pecorip/ S C C C W E B / E T E X T S / DeathandDying TEXT/ [Accessed on 1 May 2006]. POLIT, DF & BECK, CT 2004. Nursing research: principles and methods. 7"' edition. Philadelphia: Lippincott Williams and Wilkins. POPE, C; ZIEBLAND, S & MAYS, N 2000. Analyzing qualitative data. (Qualitative Research in Health Care Part 2). British Medical Journal. Jan. 8, [Accessed on 29 January 2004]. PSYCHOSOCIAL IMPACT OF HI V/ AIDS. Module 2. [s.a.]. http:// userwww.sfsu.edu/~ali 1212/Psvch.html [Accessed on 23 May 2006]. RADECKI, S; ABBOTT, A & ELOI, L 2000. Occupational human immunodeficiency virus exposure among residents and medical students. Archives of Internal Medicine. Vol 160 No 20, November 13; pp 3107-3111. RYAN, G & WEISNER, T [s.a.]. Analyzing words in brief descriptions: fathers and mothers describe their children, http://wwwanalvtictcch.com/ borgatti/rvam'ext.htm [Accessed on 22 October 2004]. SPEZIALE, HJS & CARPENTER, DR 2003. Research in Nursing. J.B. Lippincott Company. Philladelphia. STOKER, R 2004. Anatomy of a needle stick injury. Bxisiness Briefing: Global Healthcare - Advanced Medical Technologies. http ://www.bbrieñngs .com/pdf/950/ ACF59B2.pdf [Accessed on 3 November 2004]. TERREBLANCHE,iVIT, DURRHEIM,K & PAINTER, D 2007. Research in Practice, Applied methods for social
23

sciences. University of Cape Town PrësS. CapeTown. • ;v TESCH, R 1990. Qualitative research: analysis types and software tools. Falmer Press: Hampshire WILBURN, SQ 2004. Needlestick and sharps injury prevention. Online Journal of Issues in Nursing. Vol. #9 No. #3, Manuscript 4. http : www.nursingworld.org.oj in/topic2 5/ tpc25 4.htm [Accessedon 6 June 2006]. WNUK, AM 2003. Occupational exposure to HIV infection in health care workers. HIV AIDS REVIEW. 2003; 2(3/ 4): 140-143. www.msi.com.pl/pub/hiv/ vol 2/no 3-4/5689.pdfrAccessed on27 September 2004].

MACNAIR, T 2005. Ask the doctor bereavement. http-://www, bhc.co.uk/health/ a.sk the doctor/bereavement.shtml [Accessed on 23 May 2006].
McNALLY, R 2004. Psychological debriefing does not prevent posttraumatic stress disorder. Psvchiatric Times. Apdl 2004, Vol. XXI, Issue 4. http:/ /psvchiatrictimes.com/p040471.html [Accessed on 23 August 2006]. McNICHOLL, 12006. Adverse events of antiretroviral drugs. Hivinsite. http:// hivinsite.ucsfedu/InSite?page=ar-05-0l [Accessed on 10 October 2006]. MEDICINENET.COM. 2006. Definition

ofanger. http.//www.medicinenet.com/script/ main/art.asp?articlekey=33 843 [Accessed on 31 May 2006].
MEIENBERG, F; BUCHER, HC; SPONAGEL,L; ZINKERNAGEL» C; GYR,N&BATrEGAY,M2002.Anxiety in health care workers after exposure to potentially HIV-contaminated blood or bodyfluids.SWISS MEDICAL WEEKLY 2002; 132:321-324 http://www.smw.ch/pdf200x/2002/23/ smw-O9988.pdf [Accessed on 7 October 2004]. MENTALHELP.NET. 2005. Grief and bereavement issues — Stage models. http://mcntalhelp.net/poc/ view doc.php?type==docen id=8444 [Accessed on 23 May 2006]. NISC Discover Report - March 2003; Nursing literature review by Ms J. Prophet, SASOL Library, University of the Free State. O'NEILL, JF; SELWYN, PE & SCHIETINGER,H(eds.).2003.Aclinical guide to supportive and palliative cai-e for HIV/AIDS. US Department ofHealth and Human Services, Health Resources and Service Administration, HIV/AIDS Bureau: Washington. http:// hab.hrsa.gov/tools/palliative/ chap20.html [Accessed on 29 September 2004]. O'NEILL, JF& MCKINNEY,MM2003.

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