RESEARCH ETHICAL STANDARDS FOR THE OCCUPATIONAL HEALTH-NURSING PRACTITIONER REGARDING THE HIV POSITIVE PERSON IN THE WORKPLACE

M Otto Master sh~dent,Department of Nursing Science Rand Afrikaans University

AC Botes Professor, Department of Nursing Science Rand Afrikaans University ABSTRACT The occc~pationalhealth-nursing prncfitioner often becomes involved in ethical c1ilemma.s with regard to the handling of HIV-positive people in the workplace in that the interests of the HIV-positive people conflict with the interests of the employeyel: Therefore, the occr~patiunalhealth-nursing practitioner could find himself? herselfacting as mediator between the hvoparties. Despite the existence of legal norms ancl ethicirl stanclarcls to regulate the interests of the HN-positive person in the workpl~ce,no grridelines exist as to how these norms and standards should be opercltionalised during interaction between the HN-positive person, the occc~potional health-nursing practitioner crnd the employer: The occr~pputionalhealth-nursing practitioner is therefore rrncertain us to the manner in which to act professionally within the laid-ilown ethical standardsfor H N positive people in the cvorkplace. The purpose of this shrdy is to provide gr~iclelinesand criteria for the operationalisation of ethical stcmdcrrds for the occc~parionalhealth-nursing practitioner regarcling the HN-positive person in the workplace. This is done through a literatrrre stcrdy with specijc reference to crrrrent ethical fri~meworkswithin the occrrpational health context, after which the research is focrrsed on two target grocyx, namely the occr~pationalhenlthnursing practitioners and HIV-positive persons in the workplace. The de.~ignof the research is qrralitative, explorative and descriptive. In order to assist the occr~pationnlhealth-narr.singpractitioner to handle the HIVpositive person in the workplace in an ethical mannei; gr~idelinescrnd criteria were compiled for the operationuliration of the standards.

OPSOMMING Die beroepsgesondheidsverpleegkr~ndigeraak dihvels in etiese dilemmas betrokke ten opsigte van die

bantering van clie MWpositievve persoon by clie werkplek deurrlnt die belange van die MWpositiewe persoon botsend is met die belnnge van die werkgecvez Die beroepsgesondheidsverpleegkr~ndigebevincl hornhoar as tcrssenganger en advokaat trrssen die hvee partye, naamlik (lie ~verkgeweren die MIV-positiewe persoon. Ten spyte van die voorsiening van wetlike norme en etiese standacrrde om die belange vein clie MN-positiewe persoon by die werkplek te regrrleer; bestaan daar geen praktykriglyne oor hoe hierdie wetlike noime en etiese stanclaarde geoperasionaliseer moet woril tydens die interaksie trrssen die MIV-positiewe per.soon, die beroepsge.sonclheidsverpleegkr~r~~fige en die werkgewer nie. Dit skep onsekerheidoor hoe hy/sy as professjonele persoon vanriit die gestelde efiese sfanclczarde teenoor die MWpositiewe penvoon by clie werkplek behoort op te tree. Hierdie st~rdiehet ten doe1 om riglyne en kriteria vir die operc~sionali.~ering van etiese stcmdacrrde vir die

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HEALTH SA GESONDHEID Vo1.6 No.? 2001

beroepsgesondheidsverpleegk~indigeoor die MN-positiewe persoon by die werkplek te beskiyf deur eerstens

die literatu~irte verken en te beskryfmet spesifieke verwysing na die huidige wetlike en etiese raamwerke van die beroepsgesondheidskoi~teks, en tweedens die verkenning en beskrywing van probleme en oplossings van die twee teikerrgroepe, rucarnlik die heroepsgesoizrlheidsverpleegk~indigesen die MIV-positie~vepersoon by die werkplek. Die navorsingsontwerp is kwulitatieS, verkennend en beskrywend. Ten einde die beroepsgesondheidsvelpleegk~indigete help om die MIV-positiewe persoon by die werkplek eties te hnntee~is riglyne en kriteria vir die operasinnalisering van die etiese stanclaarde opgestel. to nurses and other health care providers. It primarily

BACKGROUND, RATIONALE AND PROBLEM STATEMENT

deals with morality, moral problems and moral

Since 1982 when the first person was diagnosed as

judgements. In its most basic form, ethics has to do with the interpretation of words like "right",

being HIV-positive in South Africa, major changes

"wrong", "good", "bad, "ought to" and "obligation"

in the relevant labour legislation, economy of businesses and health services delivery in the

(Deloughery, 1995:178-179).

workplace have resulted. Employers set different criteria for new employees, resulting in the

It implies that

occupational health-nursing practitioners have to comply with ethical standards in every possible

introduction of several discriminating practices, for

action and interaction in the workplace. Ethical standards are representative of the minimum

instance the rejection of H1V-positive applicants,

requirements for ethical behaviour that are setting

unfair dismissal of employees diagnosed as being

benchmarks for measuring compliance with ethical

HN-positive as well as labelling and ill-treating of

behaviour in a particular profession. It refers to the

HN-positive employees. It is to be recognised that

expected standard and behaviour as described in the

the prevalence of HIV in young employees can have

professional code of behaviour for a specific group

a serious impact on productivity of the individual

(Pera & Van Tonder, 1996:4). While ethics deal with

and the economy as a whole. Such people can successfully contribute to the economy for many

correct and expected behaviour amongst people of a

years before they develop full-blown AIDS, which will result in them becoming incapacitated.

designed to regulate the behaviour of people on a larger scale, ensuring that law and order is maintained

Discriminatoiy practices were therefore prevented by new concept legislation aimed at protecting the

without anybody being placed above that law.

HIV-positive employee against unfair testing for the

Occupational health-nursing practitioners are

HI-virus, unfair dismissal and the segregation of

confronted daily with ethical questions and the lack of operational guidelines expose these practitioners

m - p o s i t i v e prisoners (WHO, 2000:6-30; Arendse, 1988:218-219). There are at present sufficient ethical standards and legal norms available to regulate the handling of, and interaction with, HN-positive persons in the workplace. Examples of such legal norms are the Labour Relations Act, No 66 of 1995 and The Bill of Rights, as entrenched in The Constitution of the Republic of South Africa, No 108 of 1996. Medical and nursing ethics deal with issues regarding professional behaviour that is of great importance

HEALTH S A GESONDHEID V01.6

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No.1 2001

certain profession, the legislation of a country is

to medico-legal accountability. "Good" and "other" as two central concepts in ethics mean that a person acts ethically when heishe acts in hisher own interest, whilst taking care of the interests of other people. An ethical dilemma is created, however, when there is conflict of interests between parties or persons. An ethical dilemma involving the Wpositive person is created at the workplace in a situation where the interests of the HIV-positive person are in conflict with the interests of the employer. The occupational health-nursing practitioner fmds himselfherself acting as a mediator

between the two parties, namely the employer and the HIV-positive person. Despite the existence of

Regulation 879, as amended. This nurse is also in possession of a post-basic certificateldiploma in

legal norms and ethical standards to regulate the

Occupational Health, registered as an additional

interests of the HIV-positiveperson in the workplace,

qualification with the South African Nursing Council

no guidelines exist as to how these norms and

(Act No. 50 of 1978).

standards should be operationalised during interaction between the HIV-positive person, the occupational health-nursing practitioner and the employer. The occupational health-nursing practitioners can therefore ask themselves, as professional people, how to handle the HIV-positive person in the workplace according to a set of ethical standards.

PURPOSE AND OBJECTIVES The purpose of this study is to describe guidelines and criteria for the operationalisation of ethical standards for the occupational health nurse regarding the HTV-positive person in the workplace. This primary objective is achieved through the following secondary objectives: Exploring and describing literature with specific reference to current legal and ethical frameworks within the occupational health context regarding interaction with the HIVpositive person in the workplace in order to formulate the required ethical standards. Exploring and describing problems and solutions for the following target groups regarding tKe ethical aspects regarding the HIV-positive person in the workplace: Occupational health-nursing practitioners The HIV-positive person in the workplace.

Workplace The nurse renders primary healthcare and occupational health service to the business sector. The workplace refers to the place where people are practising their occupations (Odendal & Schoonees, 1991:1358). For the purpose of this study "workplace" refers t o the factory where the employees and occupational health-nursing practitioner render a service for remuneration. HN-positive persons Human Immune Deficiency Virus refers to the condition when antibodies against the HI-virus are present in the blood of a human. This virus penetrates the body and establishes itself in the human body affecting as many organs and human tissue as possible. The HIV-positive status is caused by a retrovirus that changes the genetic information in cells from RNA to DNA (Scoub, 1994:31-36).

research DESIGN and methods A qualitative, explorative and descriptive design was used (Polit and Hungler, 1997:21). The research aimed at describing ethical guidelines and criteria for the operationalisation of ethical standards for the occupational health-nursing practitioner, insofar as the HIV-positive person in the workplace is

DEFINITION OF CONCEPTS Ethical standards The minimum requirements against which ethical behaviour is measured to determine if there is compliance with the rules of a particular profession. Occupational health-nursing practitioner A nurse registered with the South African Nursing Council in General Nursing Science in terms of

concerned, was conducted in two phases. During Phase 1 or the conceptual phase, the Iiteratnre was researched with particular reference to current legal and ethical frameworks within the occupational health context, dealing with the interactionwith the EW-positive person in the workplace for the formulation of ethical standards. Phase 2, or the fieldwork, was conducted in

HEALTH SA GESONDHEID Voi.6 No.1 - 2001

following sampling criteria:

two stages:

-

-

During Stage 1 the problems and solutions encountered by occupational health-nursing

They had to be fluent in English and

practitioners in the treatment of an HIV-

factories of the packaging company.

positive person in an ethical manner, was

They had to be between 18 and 60 years

explored and debated during a workshop.

old and be HIV-positive.

The ethical standards, as described as a

They had to be treated and counselled

result of phase 1, were used as base line for

by the occupational health-nursing

the debate. The problems and possible

practitioner at that particular factory.

employed full time at one of the

solutions for each ethical standard were

The occupational health nurses were used to contact

debated.

the W-positive person and to get informed consent

During Stage 2 the problems and solutions

before the researcher interviewed the person.

of the HIV-positive people in the workplace

Interviews were conducted with seven (n = 7) HIV-

were explored and described by means of

positive employees.

semi-structured personal interviews (Bums & Grove, 1993:365).The central questions

to the respondents were formulated with

The researcher adhered to the standards for nurse researchers as described by Denosa (1997).

regard to each of the five ethical standards from phase 1.

Data analysis

Population and sampling and ethical considerations

The data of phase 2 stage 2 was tape-recorded and transcribed. For phase 2 stage 1 the data was recorded as notes from the workshop. For both stages

The occupational health-nursing practitioners as well

the methods of reduction, display, conclusion and

as the HIV-positive people were selected purposively

verification as described by Miles and Huberman

(Burns & Grove, 1993:246). In order for the

(1994:21) were used in the analysis of the data. The

occupational health-nursing practitioners to be

data of the two stages were analysed separately. Data

selected, they had to comply with the following

was reduced and condensed by organising the data

sampling criteria:

into two main categories, namely problems and

They had to be fluent in English and had to

solutions. The following sub-categories were

be employed as an occupational health-

employed to display the conclusions:

nursing practitioner by the packaging

Problems/solutions influencing the

company for at least one year.

individual system.

They had to be registered with the South

Problems/solutions influencing the

African Nursing Council in General Nursing

organisational system. Problems/solution influencing the health

Science and Occupational Health-nursing. They had to be in possession of a Certificate in the counselling of HIV-positive people and had to be involved with the handling of

.

system. Problems/solutions influencing the family system.

W-positive people in the workplace. Eighteen (n = 18) occupational health nurses that

Trustworthiness

met these criteria were included in the workshop. The HIV-positive people had to comply with the

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HEALTH SA GESONDHEID V01.6 No.1 2001

The measures of Lincoln and Guba (1985:290-300) were used to ensure the trustworthiness of the

(no harm).

research. The following measures were employed: the concept of saturation was employed during

RESULTS AND conclusions

data analysis, triangulation of data resources in stages one and

The data collected from the occupational healthnursing practitioners during Stage 1 of Phase 2 was triangulated with the data collected from the HIVpositive people during Stage 2 Phase 2. The solutions identified by the respondents were used as criteria for setting guidelines for the operationalisation of the ethical standards. The categorisation and interpretation of the two sets of data took place within the conceptual framework (Refer to Table 1).

two; peer group debriefing during data analysis; and prolonged engagement.

CONCEPTUAL FRAMEWORK During the conceptual phase or Phase I of the research, the ethical-legal framework was described and the concepts defined, in order to formulate the standards for the ethical handling of the HIV-positive person in the workplace. The conceptual framework constitutes the legal norms and ethical standards required to be operationalised during the interaction between the HIV-positive person, the occupational health-nursing practitioner and the employer (Refer to Table 1). Table 1: Legal-ethicalframework for the formulation of the ethical standards LEGhL~ETHIC4LFRAMEWORK

1

ETHlCeiL FRAMEWORK

1

LEGAL FRAMEWORK

. . . . .

The Conrfitufon (No 108 of 1996) The LabourRelaiionrAct(No66 of 1991) The Ocrupatonal Health and Safety Pzt (No 151 of1993) The Barlc dond8ilonroiEmploymentAd (hlo 75 of 1597) The compenrat,on for Occupaiimnil 1njur,es and Dtreares k t [No 130 of1993) The Employment Equi* P n ( N o 5 5 of19981 The Nuiilng Act (No 50 af 1978)

I

Guidelines and criteria for the operationalisation of the ethical standards for the occupational healthnursing practitioner in the workplace were formulated. This was achieved by firstly exploring and describing the literature with specific reference to the legal-ethical framework for the occupational health context regarding the interaction with the Wpositive person at the workplace, in order to formulate ethical standards. Secondly the problems and solutions determined by the two target groups, namely the HIV-positivepeople and the occupational health-nursing practitioners, were explored and described. The guidelines formulated for each of the ethical standards was obtained from the problems and solutions identified by the two target groups. The Ethical Standards were made operational by writing guidelines and criteria for every standard. The guidelines and criteria can be used in practice by the occupational health-nursing practitioner for

The following ethical standards were formulated from the conceptual framework for implementation during the empirical phase or Phase 2 of the research: . The HN-positive person in the workplace is entitled to fair and equal treatment. The autonomy of the HN-positive person in the workplace must he respected. . The principles of confidentialityand privacy must be maintained in dealing with the H N positive person in the workplace. . The principles of honesty and truth must be maintained during the interaction with the HIV-positive person in the workplace. . Maintaining the principles of beneficence

self-evaluation to determine whether or not helshe treats the HIV-positive person in the workplace in an ethical way (Refer to Table 2).

RECOMMENDATIONS From the research it is evident that there are many aspects regarding the practical application of ethical standards that require further investigation. The following are examples of such aspects: .

Recommendations for further research Further research can be undertaken to determine the way in which ethical decision-

HEALTH SA GESONDHEID V01.6 No.1 - 2001

Table 2: Operational Guidelines of the ethical standards

I Ethical standard

/,

1: The HIV-positive person in theworkpiace isentitledto fair andequal treatment

'Use the self-evaluation scale to indicate your score O = do not meet the wlteria, = r.fiN,y meei fhe criteria. 2 = fuifyneei ihe criteria

Guidelines

i

Criteriafor expected results I

I

i o

I i understand that I must treat HIV-positive

t

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persons just like peisons with any other disease

P

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0 '

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/D

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exhibiting the right anitude towards HIV-positive persons at the warkpiace

O

0

i i standard of education to be able to handie HiVpositive pelsons in ail facets

0 0 0

O

1 understand that I must be cultuiaiiy sensitive when dealing with HIV-positive persons in the workplace

4

O

1 undeistand that an expanded budget is

5

necessary to meet the requirements of all

I patients in my care

1

2

Ido not label HIV-pasituepersons t do not discriminate in what I say or do I ensure that avaiiabie resouices in my budget are distributed equally to meet the needs of all my patients as far as possible I ensure that the company's sick-have policy is applled without prejudice I suppM and heip the HIV-positwe person to accept and deal with hidhei diagnosis I am sympatheticaiiy and show understanding and empathy 1 am not prejudicedtowards my HIV-positive patients I exhibit a positive attitude towards the HIV-positive

i

persons in the workplace I am receptive and open towaras the HIV-positbe persons who want to ~ I ~ C Uspecific SS problems and thoughts with me

I

I ensure that my interpersonal communication skills are Satisfactow in rnv dealinas with HIV-wsitve oersons in the workpiece ' I ensure that my counselling skilk are adequate to accommcdate Lhe needs of the HiV-posiide person ! anend courses, workjhaps and seminais to expand my knowiedee of the Hi-vim3 and remain updated on develop&ents m this field 1 ensure that the eersons who work for me remain updated an progress in this field, take the necessary ourses and anend woikshops and seminars I ensure that the persons who work far me apply the principlesof equality and fairness I respect HIV-posiwe persons from other cuihires, racial groups and beiieis i am receptbe to the HiV-positive person who experiences problems in accepting Western Ueatment and a change in lifestyle owing to hidher ties to hisiher cunuie and traditions I guide HiV-positive persons from other cutures towards understanding and favouiabiy considering 'Western methods of treatment and a change in llfeslyie I am not prejudiced towards the tiadilionai healer, but try lo invohie himiner in the treatment and handling of the HIV-positNeperson

P O

i negotiate with my manageifor an expanded budget I ensure that funds are available for health education of

P

ail employees in the factory I ensure that my budget makes provision for the basic needs of HIV-positwepersons in the workplace

1

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I

II

Ethical standard 2: Theautonomy of the HiV-positive person in the workplace must be respected. I understand that I must allow the HIV-positive person to make hidher awn informed decisions and determine higher objectives

U

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I ensure that I am sufticiently educated and up to date to assist and suppon the HIV-positive pecson when important decisions have to be made i intercede by ensuring that the HIV-positwe person is suficientiy educated to be able to make an informed decision to protect himseHheiseH against wrong decisions I do not enforce any decisions on the HIV-positve person I empower the HIV-positwe person to make hidhei own decisions i do not Influence the HIV-positie person to make the decisions i prefer

- . 0

Yd'zot aive an" autocratic insVuction3 to the HiVpositive p e k n ' I ensure that I am sensitive in my conduct to accammcdate HtV-positive peisons from aii cutures

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this document can, through further research,

LINCOLN, YS & GUBA, EG 1985: Nahlralistic inquity.

be developed as a complete instrument of

Sage: London.

which the construct validity, quality and reliability can b e tested.

MILES, & HLTBERMAN 1994: Qualitativedata analysis: A sourcebook of new methods. Beverly Hills CA: Sage.

Further research c a n b e conducted t o determine the way in which counselling can

ODENDAL, FF & SCHOONEES, PC 1991: HAT:

address the needs of the HIV-positive

Verklarende woordeboek van die Afrikaanse taal; tweede

person.

Recommendations for the improvement of the occupational health practice and education

uitgawe. Perskor: Johannesburg. PERA SA & VAN TONDER, S 1996: Etiek in die Vespleegpraktyk. Cape Town: Juta.

It is strongly recommended that counselling skills become the central focus of the cumculum for occupational health-nursing students. This should be a requirement for any nursing student undertaking further study in any field requiring interaction with

PILOT, DF & HUNGLER, BP 1997: Nursing research principle and methods; fourth edition. London: Oxford University Press.

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educatedin order to be culture-sensitive,pariicularly in a countly like South Africa with its diverse cultures. This is especially

guide to understanding the virt~sand its consequences.

required if they want to demonstrate care and quality in nursing.

Cambridge: University Press.

It is of utmost importance that nurses be

SUID-AFRIKAANSE INSTITUUT VIR RASSE-

educated to be sensitive to and respect the

AANGELEENTHEDE 1996: Verbod op die segregasie

rights of other people. Guidance of nurses

van MIV-positiewe gevangenes. Pretoria.

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SUID-AFRIKAANSE RAAD OP VERPLEGWG 1991:

recommended, as ethical practice is the

Regulasie No R 2598 soos gewysig. Regulasies

responsibility of all nurses.

betreffende die bestek van praktyk van persone wat Icragtens die Wet op Verpleging, 1978 Pretoria.

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