Nurses’ Attitudes Towards Their Job in Outpatient HIV Facilities in Namibia: A Qualitative Descriptive Study

Gillian I Adynski (  gillian.adynski@duke.edu ) Duke University https://orcid.org/0000-0003-0991-8232 Jennifer Leeman University of North Carolina at Chapel Hill School of Nursing Harry Adynski University of North Carolina at Chapel Hill School of Nursing Alasia Ledford University of North Carolina at Chapel Hill School of Nursing Pamela McQuide IntraHealth: IntraHealth International Inc Ria Bock IntraHealth: IntraHealth International Inc Francina Tjituka Namibia Ministry of Health and Social Services Cheryl Jones University of North Carolina at Chapel Hill School of Nursing


Page 3/20
Background Namibia faces severe shortages of health workers, especially nurses, relative to the care delivery demands of the nation's population (1). Of particular concern, is the shortage of health workers needed to address the country's HIV epidemic. In 2018, 11.8% of Namibia's population between the ages of 15-49 reported as living with HIV (2), and some regions having prevalence as high as 22.3% (3). Starting in 2015, Namibian nurses' role in HIV services grew substantially due to a program called the Nurse-Initiated Management of Antiretroviral Therapy (NIMART).
To address the nursing shortage, Namibia needs to retain its current workforce and ensure that its nursing workforce is performing to its full capacity. Extensive prior research has demonstrated that nurse retention and performance are in uenced by their job attitude, which are de ned as beliefs about, feelings toward, and attachment to one's job (4)(5)(6)(7). Nurses' attitudes are also conceptualized as job satisfaction, job engagement, work motivation, and burnout (8-11). Past research highlights that several factors increase positive nurse job attitudes such as higher nurse salaries (12,13), positive relationships with clients and colleagues (12,14,15) (14,16,17) and lower workloads (18)(19)(20)(21). Individual nurse personality traits may also impact job engagement (22). The purpose of the this study was to understand Namibia nurses' job attitudes as a rst step towards optimizing retention and performance.

Theoretical Approach
The Job Demands Resources (JD-R) Model suggests that the relationship between job demands/resources and organizational outcomes is mediated by job attitudes (23). These Job Factors are various job-related physical, psychological, social, and organizational factors that affect an individual's ability to achieve work-related goals. The achievement of those goals then contributes to organizational outcomes (23). The JD-R Model conceptualizes job attitudes as including two constructs: (1) job motivation, or an employee's engagement, energy, and satisfaction arising from their work and (2) job strain or job-related anxiety, exhaustion, or dissatisfaction that arises from an individual's job (23)(24)(25). This paper combined those two constructs together as a spectrum of job attitudes. JD-R theory proposes that worker's job motivation and/or strain can positively or negatively mediate the relationship between job demands/resources and organizational outcomes (23). The theory further posits that a worker's personal factors may prevent negative job attitudes even in times of high job demands (26,27). [need to de ne personal resources and psychological capital] There are very few studies about Namibian nurses' job attitudes. One study of nurses' job attitudes at state hospitals in Namibia found that nurses had high level of work engagement despite stressful working conditions (28), and that only 55% of nurses reported that they were motivated at work (29). No studies have used the JD-R Model to guide research to understand what impacts nurses' attitudes and what is the impact of nurses 'attitudes.

Methods
The aim of this qualitative descriptive study is to 1) describe Namibian nurses' attitudes toward their jobs, 2) identify the factors that contribute to Namibian nurses' job attitudes, and 3) examine how Namibian nurses' job attitudes affect their ability to do their jobs. A better understanding of nurses' job attitudes in providing HIV services will inform policy makers about how to empower nurses to do their jobs well both in Namibia and similar settings globally. Guided by the JD-R Model, this qualitative descriptive study used semi-structured interviews with Namibian nurses' to understand their experience and perspectives of working in outpatient HIV health service settings.

Setting
This study was set at 73 hospitals, health centers and clinics that provide HIV health services in regions of northern Namibia with a high HIV burden. The setting was chosen as these were the facilities in which IntraHealth International, a partner global health organization for this project, had been working in to complete their project entitled "USAID HIV Clinical Services Technical Assistance Project," which aimed to enhance health worker's abilities to deliver high-quality HIV services.

Sample
Nurses in charge and health administrators at each facility were contacted after IRB Approval to seek help in informing nurses of the study prior to contact. The PI approached eligible nurses to invite them to participate. Nurses were eligible to participate if they were ENs or RNs working in HIV services or ART clinics at facilities that used IntraHealth's UTAP project. Purposeful sampling was used to sample two types of Namibian nurses, registered nurses (RNs) and enrolled nurses (ENs), as they both provide HIV services for the goal of getting broad representation. However, due to who was available and interested in participation our nal sample re ected 11 RNs and 7 ENs. We broke our sample up into the north-central and the northeast areas and purposefully sampled as a 2:1 ratio between those two areas, as we have more facilities in the north central but still sought representation from each of these two areas. Finally, we purposefully sampled nurses between two categories of hospitals and health centers/ clinics together.
While there is no exact sample size for qualitative interviews, adequacy and comprehensiveness of interviews were evaluated on an ongoing basis throughout data collection to ensure data saturation, and purposeful sampling, as was done, also ensured representative samples (30).

Research Ethics
Institution Review Board (IRB) approval was obtained from the University of North Carolina at Chapel Hill and the Namibian Ministry of Health and Social Services (MoHSS). All health facility and individual nurses' identities remained con dential. Participation was voluntary and verbal consent was obtained prior to data collection to ensure anonymity. All interviews were completed in con dential and private locations. Data was de-identi ed upon transcription.

Data Collection
Nurses who agreed to participate were interviewed in person in the facilities where they worked. All interviews were conducted in English, as English is the o cial language in Namibia and is used in most o cial transactions in public and private health facilities. Interviews were recorded and saved on a secure password protected server at UNC. They were downloaded, transcribed, and, ultimately, deleted from the server after transcription was completed and data review and analysis had begun. Data collection continued until no new themes or codes were identi ed. Demographic data was collected to describe the sample in order for nding to be relatable to other similar setting (31,32). A semi-structured interview guide was developed by the PI with the purpose of asking questions about nurses' job and their feelings and attitudes towards their job. Some example of questions were "How do you feel about your job?", "What aspects of your job give you a sense of accomplishment or frustration?" and "What characteristics of the workplace support you to be able to do your job well?" Semi-structured interviews were used to allow for content to emerge from the participant nurses (33). Two pilot interviews with Namibian nurses at an HIV service clinic were conducted to re ne the interview guide prior to the beginning of data collection. Interviews lasted 45 minutes each. Interviews were audio recorded and then transcribed and de-identi ed.

Data Analysis
Demographic data were descriptively analyzed to ensure transferability of results to other settings (31,32). Directed content analysis guided code development from the JD-R Model (25,33). An initial codebook was derived from the JD-R Model and additional codes were developed inductively when appropriate. Two coders analyzed the data, using Atlas.ti to reduce bias (34). Codes were sorted into themes to achieve meaningful interpretation of code (33,35). Table 1 indicates the codes used. After all codes and themes were clearly de ned, relationships between codes were noted (33). Relationships were determined based on the words of the participants, as nurses described what factors contribute to their job attitudes and how their job attitudes impacted their work. At each stage of data analysis, the two coders met to resolve any con icts that occurred about codes, themes, or relationships. If consensus was not achieved, a third coder would have been asked to read the transcripts to assist in the nal decision (34), however two coders were able to reach consensus. To ensure dependability, an audit trail of all work was saved including raw data, data synthesis and process notes (31). Positive job attitudes are an employee's engagement, energy, and satisfaction that arise from their work (23) and a positive state of vigor, dedication, and absorption about one's job (24).

Negative job attitudes
Negative job attitudes are de ned as job-related anxiety, exhaustion, and dissatisfaction that arise from one's job (23) Factors that contribute to nurses' job attitudes

Job factors
Job factors are both job resources and job demands. Resources are physical, psychological, social, and organizational aspects of their jobs that help individuals do their work and achieve workrelated goals. Demands are various physical, psychological, social, organizational aspects of jobs that help individuals do their work and achieve work-related goals (23) Personal factors Any other personal factor (i.e., not a job resource or demand) or psychological capital of a nurses that nurses describe as having an impact on their job attitudes (26, 27).
How nurses' job attitudes shape nurses' perceptions of job performance and their ability to do their jobs well Outcomes Because this project focuses on nurses' attitudes that shape their job performance, outcomes represents nurses' perceptions of job performance and their perceptions of their ability to do their jobs well. Table 2 summarizes demographic results from the descriptive analysis of the nal sample of 18 nurses. Notably, 50% (N=9) of all nurses had only completed their nursing education within the last three years, and 44.4% (N=5) of nurses had less than one-year of experience at their current facility. The majority of nurses (72.2%, n=13) had received NIMART training. Nurses identi ed both positive and negative job attitudes that they experienced at work. Nurse' perceptions of positive job attitudes were categorized into the following themes: motivation (n=17, 94%), satisfaction (n=17, 94%), pride (n=16, 89%), and empowerment (n=7, 39%).

Factors that Contribute to Job Attitudes
Nurses perceived that both job factors and personal factors affected their attitudes towards their job. In addition, once the code of outcomes were reviewed, it became clear that patient outcomes impacted nurses' attitudes and also affected nurses' attitudes toward their jobs. This section will outline three categories: job factors, personal factors, and outcomes that contribute to nurses' job attitudes.
Job Factors. Job Factors that contributed to nurses' attitudes are re ected in the following themes: coworkers, workload, access to information, patient rapport, and material resources. Each of these are described below. Table 3 outlines a list of all factors that affected nurses' attitudes toward their jobs with descriptions from the interviews. Co-Workers. All nurses (n=18, 100%) expressed support from co-workers contributed to their positive job attitudes, with co-workers de ned as the availability of nurses and other health professions, appropriately trained, who are able to work together as a team to provide care to patients. Most nurses (n=16, 89%) also described lack of support from coworkers as a factor contributing to their negative job attitudes.
Nurses described teamwork, mentorship, and recognition from organizational leaders as important elements of this theme. Nurses described that through teamwork, all workers were able to share workloads, and that less experienced nurses who did not know how to care for a patient could ask more experienced team members. Mentorship from nurse and physician mentors helped nurses provide high quality care, solve problems, and improve at their jobs. Nurses also expressed more positive job attitudes when they received recognition and praise for their work efforts from organizational leaders, administration, or governmental entities. Each facet of support from coworkers, teamwork, mentorship, and recognition from leaders positively impacted nurses' attitudes toward their jobs.
Several nurses also described the burden of lack of staff and lack of trained staff, which negatively impacted their job attitudes. Although strong teamwork and strong mentorship were described by nurses as positively impacting their attitudes toward their jobs, nurses who described a lack of teamwork and con icts with peers or mentors elicited a more negative attitude toward their jobs. One nurse described how a lack of staff at a facility led to greater frustration at work by expressing: "To be alone [at the health facility], that makes me sometimes feel frustrated, feel exhausted all in once, oneness, all program, it becomes the very toughest challenge. And people think that this is just something that you do right and you give medicine but it requires thinking. And I don't like getting tired psychologically, it affects me badly. It's just the workload itself." (Participant 3, EN, <1 Year of Nursing Experience) Workload. All nurses (n=18) described high workload de ned as nurses' perception of busyness at work or the amount of work they had. High workload was associated with negative job attitudes. Nurses described high workload due to high volumes of patients, too many tasks to be done, the need to be available 24/7 in case of patient emergencies, staying late past 5pm until sometimes midnight and the increased burden brought about by the recent integration of HIV services with general primary care. After integration of services, a nurse described how busy the workload has been: "Quite busy. We are always busy here in the clinic. ... But when integration came, we're forced to do things beyond our scope of practice, like... We're also doing antenatal care visit. We are doing postnatal, we are doing immunization, we're immunizing babies. We are also seeing general patients. That's why the day is quite busy." (Participant 13, EN, 2-5 Years of Nursing Experience) Access to Information. Access to information was de ned as job resources that improved nurses' knowledge needed to do their jobs. Fifteen nurses (83%) identi ed having information as improving their job attitudes, while 11 nurses (61%) identi ed lack of information as worsening their job attitudes.
The main knowledge resources identi ed were training opportunities, including NIMART, and practice guidelines, which were booklets that outline care plan policies. Nurses stated these training were essential since HIV care is complex and goes above and beyond basic nursing training. Nurses reported that NIMART training increased their knowledge about caring for HIV patients, which improved their job of Nursing Experience) Personal Factors. The results of this analysis indicate that nurses' personal factors of ability to be emotionally aware of and resilient to work stressors and the nurses' spirituality positively impacted job attitudes. In all cases, personal factors that impact nurses' job attitudes evoked more positive feelings from nurses about their jobs than negative ones, thereby highlighting nurses' reliance on coping mechanisms to deal with stressors at work Resilience and Emotional Awareness. Sixty-seven percent (n=12) of nurses described an ability to be aware of their own negative emotions and having control over them as a way to remain positive at work.
They described their ability to depersonalize professional matters to avoid the negative internalization of job stressors that would impede their ability to do their work. One nurse stated: I just tell myself, "Okay…" It's like I've got control… I've got these self-regulating feelings that I have inside me that tells me that I should not take professional works too personal. But it's just like, I take every challenge as a learning opportunity, that's how I take my profession. Spirituality. Twenty-eight percent (n=5) of nurses described their spirituality as allowing them to maintain hope, acceptance and positive attitudes despite stressors at work. In Namibia the primary religion is Christianity [36] and all spiritual references were Christian oriented.
Outcomes That Affected Job Attitudes. While the JD-R proposes that job attitudes impact outcomes, an interesting discovery in this study was nurses' reports that patient outcomes affected their job attitudes (n=16, 89%). When patients were improving, their viral loads were suppressing, and patients were more adherent with their medications, nurses described experiencing positive attitudes about their jobs, while worse patient outcomes worsened nurses' job attitudes. One nurse described how she felt increased motivation when patients' viral loads became suppressed: So, and then the fact that most of the people, like the ARV [antiretroviral]s, the aim is actually to suppress the viral load. Now most of them, they are suppressed. That motivates me, that makes me like, "Wow, we are doing the job well and they are doing well too." (Participant 8, RN, >10 Years of Nursing Experience) Nurses' Job Attitudes Impact on their Ability to Do Their Job Well The nal aim of this paper was to explore nurses' perceptions of how their job attitudes affected their job performance and ability to do their jobs well. Job performance were organized into the two themes of positive and negative outcomes related to nurses' job attitudes. Nurses described how positive job attitudes improved their job performance (n=12, 67%), whereas negative job attitudes had the opposite effect (n=9, 50%). Table 4 outlines speci c outcomes the nurses described.

Discussion
This study explored nurses' perceptions of their job attitudes, the factors that contributed to their job attitudes, and the ways that their job attitudes affected their ability to do their jobs well through the lenses of the JD-R Model (23). Study ndings highlighted factors that impacted job attitudes, and the impact of nurses' job attitudes on organizational outcomes.

Nurses' Perceptions of Their Job Attitudes
Nurses in this study described both positive and negative attitudes. This aligned with past research on Namibian nurses' job attitudes as a mix of positive and negative attitudes, with one study reporting high nurse engagement despite high stress level (28), and the other study reporting many nurses feeling unmotivated at work (29). Further research is needed to understand how nurses describe their job attitudes.

Factors That Contribute to Nurses' Attitudes
The JD-R proposes that the main contributors to job attitudes are job and personal factors (i.e., job demands and job resources) (23,26,27). The job factor of coworker support often was described by nurses as having coworkers available from proper sta ng. This aligned with patient nurse sta ng research which showed that outpatient perceived nurse sta ng adequacy has been associated with lower burnout (20, 36) and increased job satisfaction (15,16).
Nurses also emphasized the importance of knowledge, information and trainings. Nurses who speci cally took part in NIMART training described feeling empowered and able to work independently with their patients. These ndings were an important job factor nding as NIMART training was relatively new to Namibia and was well received by nurses as making them empowered and improving their abilities to do their jobs well.
The personal factors of resiliency and spirituality that impacted nurses job attitudes also aligned with past research. Lower levels of resiliency in nurses has been associated with higher rates of personal mental health disorders such as posttraumatic stress disorder, anxiety, depression, and increased burnout (37). Previous research results also support the importance of spirituality in nurses as past work indicates that fostering spirituality at work increased nurses' resilience (38). Future research on predictors of nurses' job attitudes should include the constructs of both job factors and personal factors without negating either one.
Our ndings showed that job attitudes and organizational outcomes had a bidirectional relationship. The JD-R proposes that worker's job attitudes are a predictor of organizational outcomes (23), however this study added that organizational outcomes also predict nurses' job attitudes. Similar to our ndings, a cross-sectional survey of 114 nurses across six units of a hospital reported that nurses who witnessed death or suffering in patients also reported higher levels of nurse burnout (39). This bidirectional relationship between nurses' job attitudes and patient outcomes needs to be explored through future research to better understand how improvements in patient outcomes can be used to promote positive attitudes among nurses about their jobs.

How Nurses' Job Attitudes Affect Their Ability to Do Their Jobs
This study indicates that nurses perceived that their positive job attitudes in uenced positive organizational outcomes. This was aligned with past research about nurse attitudes in outpatient settings indicating that higher levels of nurses' job satisfaction was associated with lower levels of nurse turnover (5-7) and patient falls (40). These ndings have implications for health policy as they indicate a need to invest in job and personal factors that promote positive job attitudes, so nurses can do their jobs well.

Limitations
The major limitations of this study pertain to the sampling process. While attempts were made to evenly represent ENs and RNs, logistical challenges prevented this and RNs were overrepresented compared with the original sampling goal. In addition, 50% of nurses in the sample had graduated from their nursing programs within the previous three years. There answers varied greatly by years of experience, with junior nurses describing access to senior nurses for support as a job resource; whereas senior nurses described the constant need to support junior nurses as a job demand. Further research should take years of experience nursing into account when exploring factors that impact nurses' job attitudes.

Conclusions And Recommendations
Namibian nurses working in outpatient settings that deliver HIV services expressed both positive and negative job attitudes about their work. These attitudes were impacted by several job related and personal factors as well as patient outcomes. Nurses perceived that job attitudes impacted job performance. To understand the interventions needed to promote positive nurse job attitudes, further research is needed on ways to increase positive job factors, such as making investments in human resources (improving support form coworkers), providing material resources, facilitating positive patient relations, and supporting nurses by providing opportunities to increase their knowledge, especially training on ART prescribing. A primary recommendation is to further investigate resiliency among Namibian nurses, both what it represents and how it can be promoted. While this work was done in Namibia its ndings are generalizable to many other outpatient health service settings around the world staffed by nurses. Thus, continued research on the nursing workforce globally needs to address factors that in uence nurses' job attitudes in outpatient health service settings in order to develop and implement interventions to promote positive job attitudes to assure the highest quality health services to populations all around the world.

List Of Abbreviations
Enrolled nurses-ENs PM-Guided research design and interpretation of results.
RB & FT-provided country expertise to guide interpretation of results and provide revision of draft papers.
CJ-Guided research design, data collection, data analysis and writing of this paper.