The Needs of Nurses to Improve Nursing Care for HIV-Positive MSM in Indonesia: A Qualitative Descriptive Study

Introduction

According to the most recent Ministry of Health Indonesia data, the number of HIV cases spread across the provinces remains quite high, with over 50,000 cases recorded until October 2017.¹ It is important to note that the number of new cases has increased year after year, from 7000 in 2006 to 48,000 in 2017.² In Indonesia, unsafe sexual activity is the leading cause of HIV transmission, particularly among high-risk groups such as commercial sex workers and men who have sex with men.

The existence of HIV-positive men who have sex with men (HIV-positive MSM) in Indonesia is controversial because it goes against current norms. They frequently face stigma and discrimination in the form of social rejection, which ultimately causes stress and contributes significantly to health disparities, both physical and mentally.³ They must also deal with consequences that affect many aspects of their daily lives, including social, sexual, emotional, physical, and health issues. This is visible in mental and emotional well-being.^4,5 These factors all contribute to the disease’s worsening spread in Indonesia.

One factor contributing to the high stigma of HIV-positive MSM among healthcare workers is a lack of understanding among healthcare workers about caring for HIV-positive MSM.⁶ Furthermore, a phenomenology study on HIV-positive MSM in the United States revealed that they were dissatisfied with the healthcare services they received, particularly when discussing sexual issues, sexual orientation (gay), and HIV status.⁷ They also believed that healthcare workers lacked sufficient knowledge about meeting the health needs of gay clients, resulting in inappropriate expressions and insufficient attention. They want to be treated like any other human being, to be respected, to be treated with compassion when they are sick, to receive professional care, and to have privacy when it comes to divulging their identity/sexual orientation. As a result, they are unable to reveal their true selves to themselves.

A qualitative study about nurses’ perspectives on caring for HIV-positive MSM showed negative nurse perceptions in the early phase of treatment, nurse attitudes contrasting with negative perceptions, and nurses with knowledge of HIV.⁸ Furthermore, it has been discovered that negative perceptions from nurses only appear during the initial phase of treatment, followed by a positive attitude. After interacting with patients and receiving HIV training, nurses appear to have a better understanding of caring for HIV-positive individuals. To reduce the prevalence of HIV in Indonesia, it is critical to raise nurses’ awareness and understanding of caring for HIV-positive MSM, as well as improve access to healthcare services.^9–11 Thus, this study aims to explore additional experiences and the needs of nurses to improve nursing care for HIV-positive MSM.

Materials and Methods

Study Design

The qualitative descriptive method is used in this study. This method is used to investigate issues such as the recognition and sharing of diverse and interactive experiences that are inextricably linked to human interaction.¹² The authors developed in-depth interview guidelines based on research objectives and expert knowledge on aspects that are poorly understood in the health care context. Indonesia language used for during interview to the participants.

Research Characteristics and Reflexivity

This study’s researchers are both men and women with backgrounds as psychiatric nurse specialists. They personally performed semi-structured interviews and have prior experience and training in qualitative research and international publication.

Participant and Setting

This study included nurses who cared for HIV-positive MSM in the Indonesian government and private hospitals. The sampling technique used for this study was purposive sampling, which is highly recommended in qualitative research that requires closeness or intimacy as a decision-making criterion.¹³ Participants were chosen based on specific inclusion criteria, which included being a nurse, working at the study’s chosen hospital location, caring for gay clients with HIV in the inpatient unit, and having a Nursing Diploma as a minimum education level. Participants who were not nursing interns were among those who were excluded.

Ethical Considerations

The Ethics Committee of the Faculty of Nursing at the Universitas Indonesia approved this study with No. 153/UN2.F12.D/HKP.02.04/2018. The consideration we chose Universitas Indonesia for ethical clearance due to the main researcher was at Universitas Indonesia at the time of the study. Participants have the option of answering or not answering any question that makes them feel uneasy. Participants have the right to withdraw from the study at any time. Furthermore, the researchers kept their identities hidden throughout the interview. All recorded data is anonymized using P1-P15 coding and publication. This study’s participants are volunteers, and there is no risk of physical or mental harm to them.

Data Collection

The researchers conducted semi-structured and in-depth interviews with nurses to explore their perspectives on the care needs of HIV-positive MSM at both Government and Private Hospitals in Indonesia from May to July 2018. Before conducting the interview, informed consent was obtained and permission was requested to record the interviews. All participants had signed a consent form prior to the interview, which included the publication of anonymized responses. The interviews lasted between 30 and 77 minutes. The researcher served as the primary instrument in this study, and the tools used included a tape recorder, mobile phone, semi-structured interview guide, and field notes. At the start of the interview, trust was established between the participant and the interviewer. “Could you explain to me what the care needs are in efforts to improve nursing care for HIV-positive MSM patients?” asked the interviewer.

Data Analysis

This study used NVIVO 12 software to help with data categorization and organization based on participant quotes and observations (QSR International). Thematic analysis was used to analyze the interview results, which included the following stages: (1) familiarizing oneself with the data; (2) generating initial codes; (3) searching for themes; (4) reviewing themes; (5) defining and naming themes; and (6) report writing.

Triangulation and Trustworthiness

In this study, triangulation included source, technique, and time triangulation. The interview results were verified, and the interviews were terminated when saturation was reached. We ensured data credibility through member checks and self-reflection, and we achieved transferability by adapting research findings to the thesis statement. In quantitative research, dependability or reliability tests were carried out by replicating the research process and auditing the entire research process. In addition, an inquiry audit was conducted, and the dependability aspect was achieved because the researcher was the sole interviewer in this study.

Results

Characteristics of Participants

Participants in this study were nurses working in the inpatient departments of two government and private hospitals. A total of 15 people, 11 female nurses, and 4 male nurses participated. Participants’ ages ranged from she was 26 to she was 49. Participants had varying levels of education. Eight participants graduated with Diploma in Nursing, six participants completed the Bachelor of Nursing program, and one participant completed the Professional (Nursing) program with 3–20 years of medical experience. (Table 1).

Table 1 Characteristics of Participant

Themes

The research identified three overarching themes: (1) Effective therapeutic communication techniques for MSM patients with HIV. (2) There is an increase in the skills and knowledge of nurses; (3) Continuing Care. Detailed information on major and minor topics is described below and shown in Table 2.

Table 2 Superordinate, Subordinate Themes, and Participants’ Quotations

Theme 1: Effective Therapeutic Communication Techniques for HIV-Positive MSM

The first theme presented is related to effective therapeutic communication techniques for MSM patients with HIV. Communication is the basic capital that must be owned by nurses. In that theme, we raise three subordinate themes: (1) humor; (2) using the patient language; and (3) non-verbal communication.

Humor

The nurse inserts a humorous technique to break the ice when digging for information from the client. This strategy makes HIV-positive MSM patients feel more comfortable and closer to the nurses. (See quotes 1–2)

Using the patient’s language

Verbal communication used by nurses, namely using daily conversation used by patients, is felt to facilitate communication between nurses and patients to be more intimate and able to improve the ability of nurses to explore clients. (See quote 3)

Non-Verbal Communication

Nurses in establishing familiarity, openness, and comfort in dealing with patients, utilize non-verbal communication techniques using body language such as kissing on the cheeks. It turns out that this is quite effective in reducing gaps or boundaries in interactions. This kind of communication is usually done by female nurses (See quote 4)

Theme 2: Need to Increasing Skills and Knowledge of Nurses

The second theme expressed by nurses was related to the need for nurses to increase their knowledge and skills expressed by several participants. In this theme, we obtained three subordinate themes which constructed the superordinate theme.

HIV education that must be up to date

The nurse emphasizes the need for periodic updating of HIV education. This can assist nurses in educating and answering questions from patients appropriately. (See quote 6)

VCT, CST, Initiation, and Palliative Care capabilities

Nurses stated that they needed to acquire special skills in dealing with MSM with HIV, including VCT, CST, Initiation, and Palliative Care skills. This can support their ability when dealing with patients. (See quotes 7–8)

Improvement of communication skills and the need for a communication guide

Then another ability increase that is no less important according to the participants is an increase in their communication when dealing with patients and they need communication standard guidelines in dealing with patients, so they have guidelines. (See quotes 9–10)

Theme 3: Continuing Care

Caring in the community

There needs to be continuous care that can reach the client community so that the nursing care process does not stop at the hospital but is continuous so that it becomes more effective. (See quote 11)

The Role of the Community Nurse

In addition, it is necessary to have the role of community nurses in continuing care so that they can reach patients in a wider realm or scope. In addition to continuing care in the community, community nurses can also provide education and health promotion efforts for vulnerable groups like this to prevent HIV. (See quote 12)

Discussion

This study showed the need for nurses to improve nursing care for gay clients with HIV, among which they suggest that there was a need for mastery related to the implementation of therapeutic communication techniques, comprehensive improvement of nurse knowledge and skills related to HIV, both in terms of transmission, early detection efforts, treatment, and treatment so that nurses can provide the best nursing care for clients and the existence of continuous care.

Effective Therapeutic Communication Techniques for HIV-Positive MSM

The general competencies that nurses who treat HIV clients should possess include good communication skills, empathy, flexibility, stability, and attention to detail related to HIV.¹³ The communication skills of a nurse, are the basic capital of the nurse in digging up client information. A type of communication that helps the nurse in extracting information from clients, including verbal and non-verbal communication. Communication can be carried out in various ways and can be verbal, non-verbal, oral, written, personal, or general, it can specifically concern an issue or relationship-oriented communication.¹⁴

The verbal communication used by almost all participants was to use the language used by the client such as a special language for gay client communication and insert humorous techniques when interacting with them. In a study, nurses could communicate the feelings of respect shown to clients by adapting the client’s linguistic style.¹⁵

The humor technique used by almost some participants is a form of communication technique that is quite effective to dilute the atmosphere. Humor is a basic part of a person’s personality and gains a place or portion to establish a therapeutic relationship.¹⁵ Humor can provide positive benefits for clients such as fostering relationships, reducing stress, increasing social closeness, reflecting on social change, expressing emotions, providing opportunities for clients to reassemble events cognitively, helping the process of self-strengthening, avoiding conflicts, facilitating cultivation, and providing hope. But what needs to be considered regarding humor is that if the use is inappropriate such as humor that insults the client, or shrinks the client, it will damage the relationship and will increase distance and add non-adaptive coping responses for the client.

Then non-verbal communication is used to establish familiarity with clients such as kissing on the cheeks when meeting with clients. Kissing on the cheeks is a type of non-verbal communication in the form of touch. A study explained that this technique is considered a very personal message from non-verbal communication.¹⁵ Touch is a way for a person to express feelings of caring, empathy, and even caring. However, communication techniques like this should be used with caution because behavior can be misinterpreted. So overall, it can be concluded that nurses who treat gay clients with HIV conditions need to understand in depth the good and appropriate communication strategies for identifying clients.

In addition, there were other recommended training related to improving communication skills and the need for specific communication guidelines for nurses related to gay clients with HIV. A study explained that the communication skills that nurses needed to have in caring for HIV / AIDS clients were communication that prioritizes nursing ethics and cultural competence.¹⁶ So that, nurses who can carry out the nursing code of ethics well can be fair in providing care, while nurses who can understand the culture so that nurses know how to communicate related to HIV without offending their patient’s beliefs such as the religion or culture that clients adhere to. Then related professional communication skills can be developed by the nurse by regulating emotional responses, developing self-efficacy (self-confidence), and deciding what to give the client which will ultimately provide a good response between the client and the nurse so that the maximum nursing care goals can be achieved.¹⁴ Researchers believed that based on the results of research and literature studies that had been carried out related to the need to increase the knowledge and skills of nurses in caring for gay clients with HIV will have an impact on improving the quality of nursing care services so that they can lead to better client-oriented care.

There is an Increase in the Skills and Knowledge of Nurses

In addition to communication, in improving the knowledge and skills of nurses in caring for gay clients with HIV there needs to be special training, as recommended by some participants such as training on HIV and training related to palliative care. Based on the results of research conducted in the United States said that nurses who are often included in training activities are intensely proportional to their compliance in carrying out care for clients.¹⁷ This will ultimately have an impact on clients especially in increasing their satisfaction with the nursing care that nurses have provided.

There were several other recommended training by participants including VST, CST, Officer Initiation or PITC training as well as palliative care training. Those competencies are the same as what is stated in the Regulation of the Minister of Health No. 10 of 2015. It states that one of the indicators of nursing counseling for HIV is discussing the competencies that nurses must have in providing counseling, those who have been trained in VCT (Voluntary Counseling Testing), CST (Case Support Treatment), and PITC (Provider Initiated Test Counseling). Nurses perceive that they need knowledge and skills related to counseling when treating patients with HIV / AIDS, ARV and its side effects, self-awareness, management of signs and symptoms in handling patient complaints, nurse skills in providing mental support to patients, and handling when nurses are exposed to HIV.¹⁸

The following is an explanation of the counseling skills that nurses who are consensual in dealing with HIV clients, including nurses who care for gay clients with HIV, must have. The first is VCT, VCT (Voluntary Counseling Testing) is a voluntary counseling activity that provides psychological support, the existence of information and knowledge related to HIV / AIDS including prevention of HIV transmission, efforts to promote responsible behavior change, ARV treatment, and ensuring problem-solving related to all problems related to HIV / AIDS.¹⁹ Meanwhile, CST (Case Support Treatment) is a form of continuous integrated service to provide support for clients both in managerial, medical, psychological, and social aspects that aim to reduce the impact or solve problems faced by PLHIV (People Living with HIV) during treatment and treatment.²⁰ And PITC is a form of HIV testing and counseling based on initiatives from health workers to health service visitors as part of medical service standards. Carried out by officers to make it easier for officers to make clinical decisions or special medical services that are impossible without knowing in advance about a person’s HIV status such as ARV administration.¹⁹

Based on the results of several related studies, it is stated that programs such as VCT, CST, and PITC have proven effective in helping to overcome problems experienced by HIV / AIDS clients.^20–22 Nurses as health professionals need to understand VCT, CST, and PITC to have competence in meeting client needs for HIV / AIDS counseling and testing, prevention efforts, support, treatment, and treatment related to HIV / AIDS.

Then related to the importance of palliative care as expressed by several participants. In line with the results of an exploratory study, palliative care in LGBT clients in Australia is effective in helping to improve care towards death, but in the process is constrained by decision-making regarding palliative care.²³ These barriers come from patients associated with negative experiences in the past, such as feelings of fear of being ostracized or discriminated against regarding their status making it difficult to maintain contact with health services including nurses, then other obstacles related to ethical legal aspects for palliative care that do not involve same-sex partners but for guarantors must come from their families while the conditions of LGBT clients are usually in conflict with the family as a result of his decision to live life as LGBT. Nurses in palliative care have a fairly important role, especially during the transition period, especially in LGBT clients who experience cancer due to HIV to maximize the quality of life for the remaining time.²⁴ In Indonesia, there is no palliative care that specifically treats gay clients with HIV even though palliative care is very beneficial to help clients improve their quality of life toward death.

Continuing Care

Finally, participants expect nursing care in gay clients with HIV to expect ongoing care that is uninterrupted in the hospital environment but reaches the community environment such as involving the role of community and mental nurses to reach clients in the wider realm or scope. In it, there are educational efforts and others. This is particularly relevant to qualitative research conducted in Auckland, New Zealand on gay and bisexual circles of ethnic Chinese and South Indians on community health promotion on HIV among minorities showing that clients’ knowledge of understanding of issues about STIs and HIV as well as health promotion is quite good as their understanding of the importance of condom use during anal sexual intercourse.²⁵ Although it is not specified whether the condoms were intensively used during intercourse. In this study, it was explained related to the results obtained that sometimes condoms are not used for certain reasons such as clients finding couples who both have a history of HIV-negative background, there is a compulsion not to use condoms for certain reasons.

Another effort that can be done by nurses in the community is through promotion with the use of social media. Promotional efforts through social media can effectively raise awareness about the importance of HIV testing in gay and bisexual clients 2.9 times higher from 34.6% to 63.7% of intervention participants reported HIV testing in the last 12 months after intensive health promotion through social media or online promotion entered gay community website chat groups in the United States.²⁶

In addition, the role of mental nurses is also very important in overcoming the impacts that occur on gay clients with HIV / AIDS such as in counseling activities to overcome depression and the high risk of suicide due to the psychological impact faced by clients. Here is the literature that discusses clients seeking help from healthcare workers in dealing with depression and the high risk of suicide due to the psychological impact they experience. Research said that gay clients typically have difficulty finding a healthcare provider who can specifically help address the depression and high risk of suicide they face.²⁷ Based on these limitations, this can be an opportunity for mental nurses to come in and contribute to efforts to address mental health issues experienced by gay clients. Prevention efforts in at-risk groups are very important, this aims to reduce the spread of HIV / AIDS in the community by increasing initiatives and public awareness regarding the importance of prevention efforts.

Study Limitation

Researchers have made various efforts to minimize the obstacles encountered during the study. The obstacles experienced by researchers include during the interview process, according to the agreement with participants, interviews are conducted in a hospital environment, such as in counseling rooms, nurse stations, nurse rooms, and even in open hallways. So, for some participants who have a research place in the nurse station and lobby room, the conducive room setting cannot be set by the researcher optimally, the impact of the interview recording results is not too clear because the interview place is noisy, the effort that the researcher has made is to offer another place or location for the interview, but most participants refuse and continue the process interview. In alternative problem-solving, the researcher finally carried out some validation in the form of a member check related to the results of the recorded interviews with the participants.

Conclusion

The need for nurses to improve nursing care for HIV-positive MSM included using therapeutic communication techniques, improving knowledge and skill in caring, and involving community nurses in continuing care. A nurse with good knowledge and skill can provide comprehensive nursing care and make good relationships between nurses, patients, and other medical personnel. This result can be used as justification to give training or advanced education for nurses. With those three things, it hoped could improve the quality of care for HIV-positive MSM, both in hospital and community settings.