Calape, Divina (2011) Pre-registered Nursing students beliefs, attitudes and perceived knowledge of Hepatitis C and standard universal precautions. [Dissertation (University of Nottingham only)] (Unpublished)

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[I]

Pre-registered Nursing

students beliefs, attitudes

and perceived knowledge of

Hepatitis C and standard

universal precautions

Divina Calape

Dissertation submitted for Master of Nursing Science

School of Nursing, Faculty of Medicine, University of Nottingham

I declare that this dissertation is my own work

Signed:

Date:

[II]

ACKNOWLEDGEMENTS

I would first and foremost like to thank Stacy Johnson, my dissertation supervisor for her

guidance in spite of her work load. Your advice was invaluable and I truly appreciate the support

and belief you had in me to complete. Thank you.

Secondly, I would also like to those who took the time to participate in the study, as without your

openness this study would not exist.

Furthermore, I would like to thank the Medical School Ethical Committee for their help in gaining

permission to conduct this study, as well as the School of Nursing for allowing me to access to

students.

Finally I would like to thank my family for their patience and support whilst undergoing this piece

of research, as well as my friends whose proof reading skills, intense library sessions and

continuous encouragement saw me through the process with my sanity intact.

You are all very much appreciated!

[III]

CONTENTS

Acknowledgements II

Contents pages III

Abstract VI

1: Introduction 1

1.1 Hepatitis C: a problem 2

1.2 Hepatitis C: the Facts 2

1.3 Treatments 3

1.4 Cost of Burden 4

1.5 Lack of Awareness 4

1.6 Rationale 5

1.7 Aim 6

1.8 Objectives 6

2: Background Literature 7

2.1 Introduction 8

2.2 Literature Search 8

2.3 Transmission and exposure risks 9

2.4 The Healthcare Professional and Prevention 11

2.5 Infection Control and Universal Precautions 13

2.6 Education 14

2.7 Attitudes and Stigma 16

2.8 Gaps in the Literature 18

2.9 Rationale 19

2.10 Summary 20

3: Methods and methodology 21

[IV]

3.1 Introduction 22

3.2 Quantitative versus Qualitative research 22

3.3 Methodology: Design 25

3.4 Data Collection: Semi-structured Interviews 27

3.5 Participants 28

3.6 Setting and Data Collection 30

3.7 Reliability, Validity, and Credibility 30

3.8 Analysis 32

3.9 Ethical Considerations 33

3.10 Summary 36

4: Findings 37

4.1 Introduction 38

4.2 General knowledge and understanding of hepatitis C and 38

universal precautions

4.2.1 Lack of knowledge 39

4.2.2 Significance of universal precautions and infection control 41

4.3 Education and experience 42

4.3.1 Education 42

4.3.2 Learning in practice 45

4.4 The ﾐ┌ヴゲWげゲ ヴﾗﾉW ｷﾐ ｴWヮ;デｷデｷゲ C ﾏ;ﾐ;ｪWﾏWﾐデ 47

4.4.1 Safety and protection 47

4.4.2 Free of judgement 48

4.4.3 Fear of contraction 49

4.4.4 Needle stick injuries 50

4.5 Health Promotion 51

[V]

4.6 Summary 53

5: Discussion 54

5.1 Introduction 55

5.2 General knowledge and understanding of hepatitis C and universal 55

precautions

5.3 Education and experience 57

ヵくヴ TｴW ﾐ┌ヴゲWげゲ ヴﾗﾉW ｷﾐ ｴWヮ;デｷデｷゲ C ﾏ;ﾐ;ｪWﾏWﾐデ 59

5.5 Health Promotion 62

5.6 Knowledge and Health Promotion 62

5.7 Limitations 67

5.8 Implications for Nursing Practice 68

5.9 Recommendations for Nursing Education 69

5.10 Recommendations for Future Research 71

5.11 Summary 71

6: Conclusion 73

6.1 Outline of Findings 74

6.2 Reflection 75

References VIII

Appendices

1: Ethics approval XIV

2: Poster XVII

3: Information sheet XIX

4: Consent form XXIII

5: Interview schedule XXVI

Word Count: 15, 987

[VI]

ABSTRACT

Hepatitis C is a growing health issue. With no cure or vaccine in sight, and the burden and

cost of the disease proving expensive to both the National Health Service and the patient,

its increase in incidence is worth noting, especially since the implementation of universal

precautions can help reduce the spread of infection. Yet many studies have documented

a lack of basic knowledge and understanding with regards to the disease or compliance

with infection control, amongst registered health professionals. This can have negative

effects on patient as care, and lead to discriminatory practice. As a result, the aim of this

study is to explore pre-registration nursing students perceived knowledge, attitudes and

beliefs surrounding Hepatitis C and universal precautions.

A qualitative approach was adopted, and eight semi-structured interviews were

performed on pre-registration nurses on the masters and Diploma/Degree programme.

Interviews were transcribed, coded and interpreted using thematic analysis. The four

themes of General knowledge and understanding of hepatitis C and universal

ヮヴWI;┌デｷﾗﾐゲが ES┌I;デｷﾗﾐ ;ﾐS W┝ヮWヴｷWﾐIWが デｴW ﾐ┌ヴゲWげゲ ヴﾗﾉW ｷﾐ ｴWヮ;デｷデｷゲ C ﾏ;ﾐ;ｪWﾏWﾐデ ;ﾐS

Health Promotion, were identified.

The findings suppoヴデWS デｴW ﾉｷデWヴ;デ┌ヴW ;ゲ デｴW ゲデ┌SWﾐデ ﾐ┌ヴゲWげゲ SWﾏﾗﾐゲデヴ;デWS ヮﾗﾗヴ ﾗﾐ H;ゲｷI

hepatitis C knowledge, due to a lack of education and experience with the disease. This

also had an effect on the quality of care they were able to give, as it prevented them for

implementing health promotional interventions which help to decrease the incidences of

infection. Attitudes towards hepatitis C patients were generally positive, yet evidences of

discrimination against infected hepatitis C patients, was expressed particularly drug

[VII]

users. However this was not due to the stigma associated with such groups, but due to a

けaW;ヴ ﾗa Iﾗﾐデヴ;Iデｷﾗﾐげく Participants were highly knowledgeable about the theory and

principles of infection control, and thus associated needle use with hepatitis C

transmission, which resulted in cautious behaviours amongst students, which could be

translated as discriminatory.

It was therefore proposed that education needs to be more explicit within nursing

training due to its influence on developing ゲデ┌SWﾐデげゲ ﾆﾐﾗ┘ledge with regards to hepatitis

and universal precautions, and can help to clarify negative assumptions and beliefs about

hepatitis C patients, in order to ensure care is provided that is of a high standard and free

of judgement.

[VIII]

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TヴW;デWS MW LｷﾆW ; LWヮWヴざ “デｷｪﾏ;デｷ┣;デｷﾗﾐ ;ﾐS デｴW Q┌;ﾉｷデ┞ ﾗa LｷaW ﾗa P;デｷWﾐデゲ ┘ｷデｴ HWヮ;デｷデｷゲ Cく

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[XIV]

Appendix 1:

ETHICS APPROVAL

[XV]

[XVI]

[XVII]

Appendix 2:

POSTER

[XVIII]

[XIX]

Appendix 3:

INFORMATION SHEET

[XX]

The University of Nottingham, Division of Nursing

Pre-registered Nursing students beliefs, attitudes

and perceived knowledge of Hepatitis C and

standard universal precautions

Participant Information Sheet

You are being invited to take part in a research study. Before you decide whether or not to take

part, it is important for you to understand why the research is being done and what it will involve.

Please feel free to get in touch with us by using the contact details provided if there is anything

that is not clear or if you would like further information. Please take time to read the following

information carefully before deciding whether or not you wish to take part. Thank you for reading

this,

Background

This study is being conducted as part of a dissertation research study, in order to explore pre-

registered health professionals (perceived) knowledge, beliefs and attitudes towards Hepatitis C

and universal precautions. As pre-registered Nursing students soon to arrive in clinical practice,

these professionals are more likely to come into contact with an individual infected by Hepatitis

C. Therefore, the research aims to look at their attitudes towards Hepatitis C, and explore

whether they feel that they have been sufficiently educated enough on the disease in order to

effectively care for and manage a patient with Hepatitis C.

What does the study involve?

If you choose to participate, you will be interviewed by me on a one-to-basis to discuss your

thoughts and experiences surrounding Hepatitis C and universal precautions. The interview

should take between 30 minutes to 45 minutes, depending on how much you have to say on the

topics. The interview will be audio recorded, and you will be asked to agree to this by signing a

consent form prior to it taking place. Following the interview there will be an opportunity for you

to further discuss the study with me, in order to fully address any questions or concerns you may

have.

The interview will take place in private, quiet interview room located within the Medical School

ヮﾗヴデｷﾗﾐ ﾗa デｴW Q┌WWﾐげゲ MWSｷI;ﾉ CWﾐデヴW ふNﾗデデｷﾐｪｴ;ﾏ Uﾐｷ┗Wヴゲｷデ┞ Hﾗゲヮｷデ;ﾉぶ ゲｷデWが ﾗヴ ;ﾉデWヴﾐ;デｷ┗Wﾉ┞ ｷﾐ ;ﾐ interview room at the Nottingham University site., between the dates of March 15

th to March

22nd

. If you decide to participate in the study, a specific time and date for your interview will be

arranged to match your preference and availability.

[XXI]

Why have you been chosen?

You have been invited to take part because you are currently in your final year at university,

undergoing a course in Nursing.

Do you have to take part?

The study is entirely voluntary. You are under no obligation to take part and do not need to give

any reason for not doing so. However, the information obtained throughout this study may not

directly help you during your studies; your input will contribute to the collection of research

surrounding hepatitis C. By participating in this study you will be assisting those seeking to

ｷﾏヮヴﾗ┗W ヮヴﾗaWゲゲｷﾗﾐ;ﾉげゲ ﾆﾐﾗ┘ﾉWSｪW ﾗﾐ HWヮ;デｷデｷゲ C ;ﾐS Uﾐｷ┗Wヴゲ;ﾉ ヮヴWI;┌デｷﾗﾐゲが ;ゲ ┘Wﾉﾉ ;ゲ ｴWﾉヮｷﾐｪ デﾗ highlight whether students are sufficiently prepared to effectively care for and manage a patient

with Hepatitis C. You may also find that through the interview process, you may learn some new

information about Hepatitis C or universal precautions.

What are the possible disadvantages and risks of taking part?

Participating in the study will use up some of your time, for which you will not receive any

financial compensation. Also, despite the stringent efforts that will be made to anonymise data,

there is a slight possibility that someone may recognise you simply from the sequence of events

within an account of a situation that you have described. The interviews will be reported in such a

way that seeks to avoid this. Finally, whilst the interview will not specifically ask about topics of a

sensitive nature, there is some possibility that you may find recounting certain events to be

emotionally troubling.

What if something goes wrong?/Who can I complain to.

In case you have a concern or complaint, you can initially approach the lead investigator, Stacy

Johnson (see contact details below). If this achieves no satisfactory outcome, you should then

contact the Ethics Committee Secretary (see contact details below)

Will my taking part in this study be kept confidential?

Yes, all information you provide is strictly confidential and will be seen only by the researcher and

research collaborator. Ethical and legal practices will be adhered to in order to protect your

confidentiality. The exception to this is where there is an account of dangerous practice which

be discussed with my dissertation supervisor who may take appropriate action according to

School policy.

What will happen to the results of the research study?

Prior to the interview you will be asked to choose a unique pseudonym (made-up name). All

audio recordings, transcripts and extracts will only be identified by this pseudonym. I will not

retain any link between your real name and pseudonym. Names of potentially identifying third-

parties, companies, locations, and so on, will be 'bleeped out' to produce anonymised audio

[XXII]

copies of the original interview recording. Similarly, such names will be substituted with

pseudonyms to produce anonymised transcripts. Having done this, the original recording will be

destroyed, so there will therefore be no means of identifying you or anyone else from data that is

published or retained by me after the end of the project.

Who is organising and funding the research?

This research is being organised by the University of Nottingham and is being funded by the

student researcher.

Who has reviewed the study?

This study has been reviewed and approved by the University of Nottingham Medical

School Ethics Committee

Contacts for further information:

Divina Calape (Principal Student Researcher)

Post: Master of Nursing Science - Adult Branch Student (Sept 2007 - 2011)

Organisation: Division of Nursing, University of Nottingham

Work Address: B Floor (South Block Link),

Queen's Medical Centre,

Nottingham

NG7 2HA

Telephone: 07783984696

(This number is dedicated entirely for the purposes of this study, only, and is not of

any personal uses)

E-mail: ntybdgc@nottingham.ac.uk

Or

Stacy Johnson - Dissertation Supervisor

Post: Lecturer,

Organisation: Division of Nursing

University of Nottingham

Work Address: B Floor (South Block Link),

Queen's Medical Centre,

Nottingham

NG7 2HA

Telephone: 0115 8230877

E-mail: stacy.johnson@nottingham.ac.uk

Mrs Louise Sabir - Ethics Committee Secretary

Post: Secretary

Organisation: Division of Therapeutics and Molecular

Medicine

Work Address:D Floor, South Block

Q┌WWﾐげゲ MWSｷI;ﾉ CWﾐデヴW

Nottingham

NG7 2UH

Telephone: 0115 8231063

E-mai:l louise.sabir@nottingham.ac.uk

[XXIII]

Appendix 4:

CONSENT FORM

[XXIV]

University of Nottingham, Division of Nursing

Title of Project:

Pre-registered Health professionals perceived knowledge, beliefs and attitudes

towards Hepatitis C and standard universal precautions

Name of Investigators:

Divina Calape (Principal Student Researcher and Interviwer)

Volunteer’s Consent Form

Please read this form and sign it once the above named or their designated

representative, has explained fully the aims and procedures of the study to you

I voluntarily agree to take part in this study and that it is my right to decline to

answer any question that I am asked.

I confirm that I have been given a full explanation by the above named and that I

have read and understand the information sheet given to me which is attached.

I have been given the opportunity to ask questions and discuss the study with one

of the above investigators or their deputies on all aspects of the study and have

understood the advice and information given as a result.

I agree that the interview may be electronically recorded.

I authorise the investigators to disclose the results of my participation in the study

but not my name.

I understand that information about me recorded during the study will be kept in a

secure database. If data is transferred to others it will be made anonymous. Data

will be kept for 7 years after the results of this study have been published.

I understand that my name and identity will remain confidential in any publications

or discussions, and that my name will not appear on any tapes or transcripts

resulting from the interview.

[XXV]

I understand that I can ask for further instructions or explanations at any time.

I understand that I am free to withdraw from the study at any time, without

having to give a reason for withdrawing.

Name: ……………………………………………………………………………………………………………………………

Address: …………………………………………………………………………………….………………………………

Telephone number: ………………………………………………………………………….…………………………

Signature: ………………………………………….………………………… Date: ……………………………….

I confirm that I have fully explained the purpose of the study and what is involved to:

……………………………………………………………………………………………………………………………………………

I have given the above named a copy of this form together with the information

sheet.

Investigators Signature: ………………………………… Name:

…………………………………………

[XXVI]

Appendix 5:

INTERVIEW SCHEDULE

[XXVII]

Each interview will be conducted by the principal student researcher (Divina

Calape)

TOPIC GUIDE

Perceived knowledge & Education

Can you explain to me how Hepatitis C affects the body?

- It primarily affects the liver, what do you think are the possible (long term) side effects of

this?

- From where did you obtain this information from?

- Can you explain to me how Hepatitis C might be transmitted from one individual to another?

さHWヮ;デｷデｷゲ C ｷゲ C┌ヴ;HﾉWざ Sﾗ ┞ﾗ┌ ;ｪヴWWい

- Why do you agree/disagree?

- (If mentions treatment) What is your understanding concerning the treatment options

available for an individual infected with Hepatitis C?

- Do you believe these options to be successful at treating the virus? Can you explain

further why you think this?

What groups do you think are more at risk of being infected with Hepatitis C and why?

- Is there any particular reason you have chosen these individuals?

- (if they state that they read it somewhere, or was told from a colleague) From what

source was this information gathered?

Attitudes & Beliefs

Iデ ｷゲ ┘Wﾉﾉ ﾆﾐﾗ┘ﾐ デｴ;デ H┞ ｷﾏヮﾉWﾏWﾐデｷﾐｪ けｷﾐaWIデｷﾗﾐ Iﾗﾐデヴﾗﾉげ ﾗヴ け┌ﾐｷ┗Wヴゲ;ﾉ ヮヴWI;┌デｷﾗﾐゲげ ｷﾐ ヮヴ;IデｷIWが ｷデ will stop the spread of viruses に do you agree with this or do you disagree and think there are

a;Iデﾗヴゲ ┘ｴｷIｴ ｴ;┗Wﾐげデ been taken into consideration?

- Why do you agree/disagree?

- Do you feel confident in implementing these procedures in practice?

- Where did you learn these procedures? に In school or out in practice?

As reported by the Health Protection Agency (2008), the number of individuals diagnosed with

Hepatitis C is increasing, and could be a potential health problem. Do think there is anything we

can do, as health professionals, to prevent this problem arising?

- Are we doing enough to tackle this problem?

- What more can we do?

Do you think that the social and psychological aspects of care are equally as important as dealing

with the physical and biological aspects when treating a patient with hepatitis c?

- Can you explain why?

- Do you feel that one aspect is more important than the other?

- Do you think that each aspect of the individual (social, psychological, biological) is given

sufficient priority during care?

Do you believe experience is more important than education when it comes to treating a patient?

- Can you explain why you believe this?

[XXVIII]

- Have you ever experienced a case where by experience was more important than

education when dealing with a patient?

- Was it a positive or negative learning experience?

Do you think that patients, who are known to be infected with hepatitis c, are treated differently

in comparison to patients who are not known to be infected with the virus?

- In what way?

- Do you think this is done intentionally?

- Do you think that has an effect on the way the patient feels about their care?

Similarl┞ デﾗ デｴW ┘;┞ デｴ;デ ゲﾗﾏW ｷﾐSｷ┗ｷS┌;ﾉゲ Sﾗﾐげデ HWﾉｷW┗W ; ゲﾏﾗﾆWヴ ┘ｷデｴ ﾉ┌ﾐｪ I;ﾐIWヴ ゲｴﾗ┌ﾉS ヴWIWｷ┗W treatment, in your opinion, do you think an individual who became infected with the virus as a

result of their sexual behaviour or intravenous drug use should receive treatment for Hepatitis C?

- Wｴ┞ ゲｴﾗ┌ﾉSっﾐげデ デｴW┞い - (If individual thinks they should receive treatment) what treatment should they receive?

- Do you think that contracting hepatitis because of sexual behaviour or intravenous drug

use is self inflicted?

Personal Experiences/ Course Related Experiences

Wｴ;デ ｴ;ゲ HWWﾐ ┞ﾗ┌ヴ W┝ヮWヴｷWﾐIW ﾗヴ ゲﾗﾏWﾗﾐW ┘ｷデｴｷﾐ ┞ﾗ┌ヴ Iﾗ┌ヴゲWげゲ W┝ヮWヴｷWﾐIW ﾗa HWｷﾐｪ ｷﾐ Iﾗﾐデ;Iデ with or looking after an individual who has Hepatitis C, whether this was during a placement or a

personal experience?

- Do you feel it was a positive or negative experience? Why?

- Did you agree with the outcome of this interaction?

- How could you have improved on the outcome of this experience?

Implications for practice

Do you think that enough emphasis is put on the prevention of hepatitis c contraction within

┞ﾗ┌げヴW ゲIｴﾗﾗﾉ ﾗa N┌ヴゲｷﾐｪが デｴW ｴﾗゲヮｷデ;ﾉが ;ﾐS ヮ┌HﾉｷI I;ﾏヮ;ｷｪﾐゲい

- What is being done right?

- What do you think that health professionals are doing wrong in order for contraction to

occur?

- Have you seen preventative precautions, such as infection control, being implemented

out in practice?

If you were on placement right now, and had to look after a patient with Hepatitis C, do you feel

that you have sufficient skills and knowledge to properly manage this patient AND their

condition?

- (If no) What do you think you could do in order to increase this?

- Is the a fault of the school, placement experience, or public campaigns?

- (If yes) What has helped to ensure you have all the correct knowledge on the condition

and had are at the appropriate skills level that you are?

Can you create for me an incident which describes bad practice in dealing with a Patient with

Hepatitis C patient?

- What did they do wrong?

- How would this have affected their patient?

[XXIX]

- What should they have done?

- How would this have benefited their patient?