Patient's experiences of diabetes care at a tertiary health facility in Lilongwe, Malawi.

BACKGROUND: Little is known about experiences of rural people with diabetes care at a tertiary health facility in low-income settings. Understanding their experiences is essential for developing effective diabetes care interventions. METHODS: The study employed a qualitative narrative inquiry. Participants were identified at a diabetes clinic at a tertiary-level healthcare facility. Ten participants from the rural areas attending the diabetes clinic were purposively selected. Data were collected through in-depth interviews in the privacy of the homes of the study participants and analysis was done using the Riessman approach to thematic narrative analysis. RESULTS: In this study, the following four themes emerged: (1) the long pathway to a diagnosis of diabetes; (2) Poverty-related hardships and diabetic clinic attendance; (3) The impact of health worker attitudes and behavior on diabetes care; and (4) Low resources and their impact on self-management. CONCLUSIONS: Rural-based patients living with diabetes encounter enormous challenges as they access diabetes care. One of the challenges is delayed diagnosis of diabetes. There is a need to introduce point-of-care (POC) testing to improve diabetes diagnosis. In addition, there is a need to strengthen awareness campaigns among the population so that people are well informed about the signs and symptoms of diabetes to promote early diagnosis. Diabetes care must be decentralized from tertiary hospitals to primary health centers. This will improve access to diabetes care and reduce the burden associated with traveling a long distance to access diabetes care in Malawi.

Assessment of ethical competence among clinical nurses in health facilities.

BACKGROUND: Ethical competence in nursing practice helps clinical nurses to think critically, analyse issues, make ethical decisions, solve ethical problems and behave ethically in their daily work. Thus, ethical competence contributes to the promotion of high-quality care. However, studies on ethical competence in Malawi are scanty. OBJECTIVES: The aim of this study was to explore ethical competence among clinical nurses in selected hospitals in Malawi. METHODOLOGY: A cross-sectional survey was conducted in four selected hospitals in Malawi with a sample of 271 clinical nurses. Data were collected using self-administered questionnaires, which included a Moral Competence Scale for Home Care Nurses. Descriptive statistics and logistic regression were computed for the dataset using STATA version 12.0. ETHICAL CONSIDERATION: The study protocol complied with all ethical requirements and was approved by the College of Medicine Research Ethics Committee under the University of Malawi. RESULTS: The clinical nurses in Malawi are ethically competent. However, there is a significantly high number (p < 0.05) of nurses 57% (n = 135) with low ethical competence. There was no significant association between respondents' demographic variables and level of ethical competence (p > 0.05). Three determinants of high ethical competence level (strong will, judgement skills and recognition of discrepancy of intention) were identified through a reduced model after stepwise logistic regression analysis. Furthermore, results show that indicators of ethical competence include caring, confidentiality and observance of nurses dressing code. The study has also confirmed that the Moral Competence Scale for Home Care Nurses is a reliable tool to assess ethical competence in low-resource settings. CONCLUSION: The majority of nurses who completed the survey had low ethical competence. However, clinical nurses with high ethical competence level are required to competently manage complex ethical challenges in health facilities. Strategies for enhancing ethical competence such as continuing ethics education, establishment of ethics committees and provision of supportive supervision are recommended to enable nurses in Malawi attain a high level of ethical competence.

Emotive responses to ethical challenges in caring: a Malawian perspective.

This article reports findings of a hermeneutic phenomenological study that explored the clinical learning experience for Malawian undergraduate student nurses. The study revealed issues that touch on both nursing education and practice, but the article mainly reports the practice issues. The findings reveal the emotions that healthcare workers in Malawi encounter as a consequence of practising in resource-poor settings. Furthermore, there is severe nursing shortage in most clinical settings in Malawi, and this adversely affects the performance of nurses because of the excess workload it imposes on them. The results of the study also illustrate loss of professional pride among some of the nurses, and the article argues that such a demeanour is a consequence of burnout. However, despite these problems, the study also reveals that there are some nurses who have maintained their passion to care.

Chronic illness experience in the context of resource-limited settings: a concept analysis.

AIM: This review describes the ways in which individuals experience chronic illnesses in resource-limited settings; to define the concept and understand its attributes, antecedents and consequences. METHODS: A comprehensive analysis of the databases CINAHL, PubMed and Google Scholar was conducted. During literature search the following limits were applied: articles published in English with available full-text; articles that focused on living with chronic illness in adults from the patient's perspective. RESULTS: The following three attributes of chronic illness experience were identified: transformational experience, acceptance and self-management. Prominent predisposing factors (antecedents) were: genetic inheritance, malnutrition and poverty, high levels of stress and unhealthy lifestyle. The most dominant consequences were as follows: impact on quality of life; self-management burden; burden to others and economic stressors. CONCLUSIONS: The findings underscore the need for health-care professionals to understand the chronic illness experience in the context of resource-limited settings and its consequences. The greater insights into the concept of chronic illness experience in resource-limited settings will guide nurses to support people in the realities of chronic illness experience in resource-limited settings in developing countries. This knowledge can guide nurses in providing competent care to chronically ill individuals, including meeting their individual needs with such illnesses.

Family Involvement in Caring for Inpatients in Acute Care Hospital Settings: A Systematic Review of Literature.

Family members, also known as patients' guardians (PG) are involved in caring for inpatients in acute care hospital settings. The practice is adopted from Family Centred Care (FCC) approach. This literature review aimed to provide an overview of key findings in literature on the practice of involving PGs in acute care hospital settings We used a systematic literature search to select original research articles or systematic reviews published in English between 2008 and 2019 that discussed PGs in acute care hospital settings. Studies that discussed PGs in long-term care hospital or in-home settings were excluded from this literature review. Literature was sought from CINAHL, MEDLINE, and PsycINFO. CASP and JBI checklist was used to appraise the full-text articles for inclusion in the literature review. Twenty-six articles were included. Findings show that there is limited literature on this topic although healthcare institutions involve PGs in their routine inpatient care. Three themes emerged from the review; the FCC approach, roles of PGs in acute care hospitals, and implications of involving PGs in acute care hospitals. PGs offer any care that is left undone by nurses in acute care hospitals to ensure that their patients' needs are met. However, their involvement is not consistent with FCC principles. This leads to physical, psychosocial, and economic implications for PGs. We recommend that nurse practitioners should consistently implement FCC principles to enable PGs to offer meaningful care to their inpatients.

'This disease would suit better those who have money': Insulin-Treated Diabetes Illness Experience in rural Malawi.

Background: Understanding the illness experience among rural-based insulin-treated diabetic patients has implications for practice and policy. However, there is a lack of in-depth knowledge about insulin-treated diabetic patients' illness experiences in rural Malawi. We explored the experiences of people living with insulin-treated diabetes in rural Malawi. Research Designs and Methods: The study used a qualitative narrative inquiry. Participants were identified at Kamuzu Central Hospital Diabetes Clinic. The hospital is a tertiary level health care facility. We purposively selected 10 participants from rural areas attending the clinic. Data were collected through in-depth interviews in the privacy of the homes of the study participants and analysis was done using Riessman approach of thematic narrative analysis. Results: The following five themes emerged: (1) diabetes perceived as the illness for the rich; (2) 'everything is on a standstill'; (3) dietary challenges of the diabetes illness experience; (4) drug-related challenges associated with the diabetes illness experience and (5) experiencing physical effects of the diabetes illness. Conclusion: Rural-based insulin-treated diabetic patients struggled to live with the illness in the context of low resources. There is a need for multi-factorial approaches at both the community and system levels so as to support people living with diabetes in the rural areas in order to improve their experiences.

Factors that influence ethical competence among nurses in health facilities in Malawi.

Background: Clinical nurses' (CNs) ethical competence (EC) is essential for nursing practice because it facilitates high-quality care to patients.To develop ethically competent nurses, factors that positively affect EC must be explored and promoted. Few studies have explored ethical issues in Malawi and the aim of this study was to explore the factors that affect EC. Methods: This study used a qualitative exploratory design to collect data through in-depth interviews from 10 key informants (KI) and 9 focus group discussions (FGD) in the selected government, CHAM and private hospitals in Malawi. It was conducted between April and May 2019.Data were analysed manually using thematic content analysis. The data were coded, and words with similar meaning were organized into categories from which themes and sub themes were developed. The themes and sub themes are reported as the results of the study. Results: One major theme emerged from the thematic content analysis namely: systems influencing EC among nurses in Malawi. The study has identified continuing professional development in ethics, supportive supervision, availability of resources and leadership to be among the major factors that facilitate EC. Factors that hinder EC among the nurses included; inadequate supervision, inadequate resources, lack of teamwork, increased workload coupled with inadequate nursing staff. Conclusion: This study has exposed the factors that influence EC in health facilities and shown that nurse leaders are key to enhancing EC through continuing ethics education, supportive supervision, staffing and provision of resources. Therefore, all the stakeholders in nursing should support the efforts to remove the factors that hinder EC in the health facilities.

The roles and experiences of preceptors in clinical teaching of undergraduate nursing and midwifery students in Malawi.

Introduction: Clinical teaching is essential for undergraduate nursing and midwifery students. Registered nurses/midwives trained as preceptors (an experienced nursing/midwifery professional who teaches, supervises and serves as a role model for a student), guide the students during clinical practices. Literature is scanty on the roles and experiences of the preceptors in Malawi. This study explored the roles and experiences of preceptors during clinical teaching of the students. Methods: A cross-sectional study utilising quantitative research design was conducted at four tertiary level hospitals; a mental hospital; one mission hospital and five district hospitals. A total of 87 preceptors completed a Clinical Preceptor Experience Evaluation Tool. Data were analysed using SPSS version 20 and descriptive statistics were computed. Analysis of variance (ANOVA) and post hoc analysis were used to determine and test significant differences. Results: The study revealed that respondents were confident in performing their preceptor role; with good level of experience and education qualification of BSc in Nursing. ANOVA and post hoc comparisons using the Tukey HSD test indicated that the role domain mean scores for the respondents with 4-5 years of post-registration experience (M = 6.61, SD = 0.36) was significantly different (p=0.02) with those with >9 years (M = 6.13, SD = 0.60). The results showed that respondents with 4 -5 years experience were more confident in their preceptorship role than those with >9 years. Conclusion: This study indicates the roles of preceptors in Malawi to involve facilitating students' clinical teaching and learning. It suggests that registered nurses/midwives with a BSc in Nursing are suitable preceptors to facilitate students' clinical teaching and learning. There is revelation that preceptors with more years of post-registration experience are less confident in their preceptorship role performance.

Stress and Coping Strategies Among Malawian Undergraduate Nursing Students.

PURPOSE: Stress among nursing students has been widely investigated across the globe, and evidence suggests that nursing programs are stressful. Students from resource constrained contexts, such as Malawi, often find it difficult and over stressing to be socialized into the nursing profession. However, this area has not been adequately investigated in Malawi. The aim of the study was to investigate stress and its coping strategies among nursing students in Malawi. METHODS: This was a quantitative study which used a descriptive cross-sectional design that included 102 students in years 2, 3 and 4. Data were collected using the adapted standard tools (Perceived Stress Scale and Adaptive Version of the Nurse Stress Scale) to comprehensively measure levels of stress categorised as clinical, academic and external. The brief Cope was used to measure common coping strategies. Independent samples t test and ANOVA were run at 5% level of significance to analyze the data. RESULTS: Moderate levels of stress were perceived by this sample. Academic category contributed to more stress than clinical and external sources. Lecturers, clinical teachers and nursing staff were the major contributors of stress among students. Similarly, high levels of stress were found among year 2 and self-sponsored students. In terms of coping strategies, active coping and planning were the common coping strategies. However, substance use was also recorded as a coping strategy. CONCLUSION: The study revealed that although nursing students face various challenges in under-resourced environments, teachers and clinical staff highly contribute towards stress. It was then established that stress among nursing students' can be contained by initiating stress reduction interventions. There is also need to further investigate the extent of substance use as it suggests that some students have not been able to cope with current stress levels hence resorting to use of substances.

A qualitative study of childbirth fear and preparation among primigravid women: The blind spot of antenatal care in Lilongwe, Malawi.

OBJECTIVES: This study aimed to explore childbirth fear and childbirth preparation among primigravid women in the late pregnancy from 36 to 40 weeks gestation. METHODS: We purposively recruited 18 primigravid women into in-depth interviews, 21 birth companions, and 13 health workers into focus group discussions. Participants were recruited from two community hospitals' maternity waiting homes in Lilongwe, Malawi. Semi-structured interview guides were used to collect data that were analyzed using content analysis. NVivo11 computer software was used to organize the data. RESULTS: The four categories developed were: "ambivalent pregnancy feelings" , "dependence on traditional childbirth counseling" ,"inadequate prenatal childbirth instruction" and "inconsistent roles of a birth companion" . The findings suggest that primigravid women who were mainly exposed to traditional childbirth mentoring rather than professional care providers, experienced childbirth fear, and lacked proper psychosocial childbirth preparation. CONCLUSIONS: Childbirth fear among primigravid women emanate from personal; family; ineffective traditional counseling; and inadequate antenatal childbirth instruction. Birth companions may increase childbirth stress. However, our findings highlight birth companions as readily available psychosocial support resources among primigravid women. We recommend that professional childbirth instruction during antenatal care should be strengthened to surpass traditional childbirth counseling. Appropriateness and effectiveness of birth companions need to be carefully assessed.

Emotional labour and compassionate care: what's the relationship?

BACKGROUND: Malawi is one of the countries in the Sub-Saharan region of Africa severely affected by the HIV pandemic. This being the case, student nurses' clinical encounters include caring for patients with HIV and AIDS. OBJECTIVES: The study explored the clinical learning experience of undergraduate nursing students in Malawi, with the aim of understanding the nature of their experience. DESIGN: This was a hermeneutic phenomenological study. SETTING: The study took place at a university nursing college in Malawi. PARTICIPANTS: Thirty undergraduate nursing students were purposively selected. METHODS: Conversational interviews were conducted and a framework developed by modifying Colaizzi's procedural steps guided the phenomenological analysis. RESULTS: The participants reported their experience during the early years of their studies and their current experience at the time of the study, depicting them as novice and senior students respectively. The study findings demonstrated an overt fear of contracting HIV infection among novice nursing students. Such fear led students to deliberately avoid taking care of HIV positive patients and develop a sense of legitimate emotional detachment. However, as students progressed in their studies, and their knowledge and experiences increased, they realised that HIV and AIDS patients needed support and empathy. The learning trajectory demonstrate a gradual change from emotional detachment based on fear to a sense of emotional engagement built on knowledge, experiential insights and the notion of emotions management that led to the provision of care driven by compassion as opposed to anxiety. CONCLUSION: The findings illustrate that nursing students need to work on their emotions to provide compassionate care. This is consistent with the concept of emotional labour and the paper argues that undertaking emotional labour is essential in promoting compassionate care.