There has been a lack of literature available to nurses on care provision to gay individuals with HIV/AIDS. Research nurses’ interaction with gay patients with HIV/AIDS is important for providing and improving such nursing care.
MethodThis study used a qualitative descriptive design. Data was collected using depth interviews from 14 participants gay with HIV/AIDS in Indonesia, which were analyzed using thematic approach.
Research resultsThis research yielded three themes: (1) nurses’ acceptance of gay with HIV/AIDS; (2) extensive knowledge among nurses about gay and HIV/AIDS; and (3) communication nurses are warm and without barrier.
ConclusionAttitudes, knowledge, and communication are key issues impacting the nursing care of gay with HIV/AIDS. Attitude and other non-verbal communication should be considered by nurses when providing care. Value of culture should be considered by nurse when providing care for gay patient.
Gay is a behavior in which males who identify this way feel a sense of interest in the same sex.1 The number of individuals who identify as gay continues to increase each year, and among them, some are at risk of contracting HIV/AIDS.2,3 The number of gay individuals worldwide is still not known for certain, but Unaids estimated that 1–3% of the world's adult male population aged 15–59 years is gay.4 Being gay contributes to the majority of new infections of HIV/AIDS.5
Individuals who are gay and have HIV/AIDS are often stigmatized and the victims of discrimination.6 Gay individuals with HIV/AIDS-related illnesses suffered double the stigma for their sexual orientation.7,8 Such can lead to decreased quality of life, feelings of intimidation, and delays in seeking out medical assistance. Fear of being stigmatized may also result in individuals choosing to be guarded in disclosing details of their condition.9–11 A late diagnosis of HIV infection impacts both individual health and the health of the general public, since the transmission rate from people who do not realize they have been infected by HIV is 3.5 times higher than from those who know they are infected.12
Several things can cause gay individuals with HIV/AIDS to not use health services to treat the disease, including the feeling of intimidation and fears that they will be treated differently by health workers due to their sexuality gender identity.3 Getting individuals who are gay to use health services requires creating comfortable conditions for them, and ensuring that they do not suffer discrimination when seeking medical attention or treatment,13 as well as creating awareness of such conditions and anti-discrimination efforts. It is important for nurses to understand the impact of stigma on people living with HIV/AIDS because when they feel stigmatized, those individuals tend to be less likely to seek out or use health services.14
Ensuring that people are accessing health services could be one solution in reducing the rate of HIV/AIDS transmission among individuals who are gay. These individuals expect, and should receive, a professional attitude from health workers while under their care.12 By adopting a professional attitude, health care professionals can empower gay individuals with HIV/AIDS to seek out treatment so that transmission rates can be decreased.15
Nurses are only one part of the health service field, but they are often at the forefront of health services provision. Some nurses have a negative attitude and are reluctant to provide care to people with HIV/AIDS, resulting in poor quality of nursing care.16 Care-givers often experience anxiety and fear when providing nursing care to individuals who are gay with HIV/AIDS. This may stem from differences in values and nurses’ personal beliefs. However, it affects the quality of the nursing care given.17
Nursing intervention to prevent the transmission of HIV/AIDS among individuals who are gay should be sufficiently sophisticated to meet the needs of this population.2 Nurses have a huge opportunity to reduce the stigma associated with having HIV/AIDS. Indicators of quality of care expected by individuals who gay include confidentiality, respectful attitudes, and nondiscriminatory treatment.18 The quality of health services must not be compromised. More research on nursing care for individuals who are gay with HIV/AIDS would be very useful for guiding nurses in providing them with nursing care.19
MethodThis study is a qualitative descriptive study that defines and presents a situation or phenomenon as it is and seeks a solution based on the data resulting from the investigation.15 Fourteen people participated in the study, which employed purposive sampling, which has been used in qualitative descriptive studies because it can improve the accuracy of the research.
Participants were gay males who tested positive for HIV/AIDS, are undergoing medical treatment (both inpatient and outpatient care) and have interacted with nurses while undergoing treatment. The data was collected through semi-structured interviews and supported by field notes to ensure the accuracy of the results obtained. The data were analyzed using thematic analysis by Braun & Clark, which includes the introduction of data, coding, a search for themes, reviewing the potential of themes, defining and naming themes, and writing.19 Ethical approval of the study was obtained from The Faculty of Nursing, Universitas Indonesia Ethics Committee.
The recruitment of participants for this study involved four key informants, who helped researchers to find potential participants in accordance with the inclusion criteria. After obtaining the names of candidates, the investigators contacted all prospective participants by telephone and arranged appointments. In meetings with prospective participants, the researchers explained the benefits of research studies, how they were selected, and that confidentiality would be assured. Researchers then asked about the prospective participants’ willingness to engage in research, but allowed time (24h) for participants to make a decision. The time given participants to decide whether they wanted to be included in the study matched the design and purpose of the study.13 After the prospective participants agreed to be part of the study, the researchers provided them with informed consent to be signed, and then set the time perform an interview. Interviews ranged from 26min to 75min in duration.
The validity of the data in this study consisted of credibility, dependability, confirmability, and transferability. The credibility of this research was achieved by checking the results of the data to the participants and continued with thematic analysis. In addition, during conducting research the researchers conducted reflexivity to realize and acknowledge the possibility of subjective perceptions that influence the data collection process. Dependability of this research is that all researchers conducted meetings regularly to reveal the possibility of bias, assumptions, and mistakes made by researchers. Confirmability in this study was carried out by clearly explained the research method and procedure, making the sequence of data collection, analysis and presentation methods and checking verbatim transcripts from the results of interviews, data analysis process, to the formation of themes to find out the truth of the research results.20 For transferability, the researchers mad a description that contains narratives from the research context starting from the process, participants, and the relationship between participants and researchers that are described in a complete, detailed, systematic and trustworthy manner.20
Results| Characteristics of participants | |
|---|---|
| Variable | N |
| Age | |
| 20–30 | 5 |
| 31–40 | 4 |
| 41–50 | 3 |
| 51–60 | 2 |
| Education | |
| Senior high school | 4 |
| Diploma | 1 |
| Bachelor | 8 |
| Master | 1 |
| Have been diagnosed with HIV/AIDS | |
| 6–8 months | 4 |
| 1–2 years | 4 |
| 5–8 years | 5 |
| 24 years | 1 |
| Contact with the nurse participants | |
| 6–8 months | 4 |
| 1–2 years | 4 |
| 5–8 years | 5 |
| 17 years | 1 |
Gay with HIV/AIDS expressed a desire for acceptance from their nurses. More specifically, they wanted a nondiscriminatory attitude; welcoming, nonjudgmental care; and to be embraced like any other patient. The following comments are representative of these individuals’ desires from nurses: “[They] … should not be judgmental, should not discriminate under any circumstances, even if the patients who are less able … (P3, 83)” “[They should make people feel]… very welcome. When I was isolated, even though at that time… the beginning of the treatment plan … they ask me how things are today … (P1, 13)”
An interesting finding is that nurses sometimes discriminate without realizing it, such as by washing hands immediately after shaking hands with a gay patient with HIV/AIDS. This was disclosed two by participants as follows: “… After he shook hands, he immediately wash his hands … (P5, 12)” … “[I] shake hands and then [they] wash their hands more than 10 times … (P3, 53)”
Having extensive knowledge related to individuals who are gay and have HIV/AIDS is very helpful for nurses tasked with treating these patients. According to the study participants, the average nurse they encountered already had a good knowledge of the subject. Having knowledge was believed to make that patients were not treated discriminatorily. This was revealed by some participants as follows: “…so if there are nurses… with little knowledge about gay sexual orientation, I’m sure the nurses can care gays with HIV quite well and they [the gay with HIV] might not be intimidated as well… (P8, 21)”
In this study, participants also expressed great hope that nurses’ knowledge about individuals who are gay and HIV/AIDS, and how to handle both physical and psychological issues related to treating such patients, would improve. Three participants stated the following: “… She must have knowledge of how to deal with people with HIV, so as to know how to address people like that … (P8, 80)” … “[I] hope they also have an understanding of psychiatric problems. Their curriculum may be improved [by showing them] how to deal with patients with psychological problems, and how to motivate patients … (P11, 77)”
Communication—both formal and informal and verbal and non-verbal—is key to the success of any relationship. Communication with all patients should be warm, because this was highly anticipated by gay individuals with HIV/AIDS from their nurses. Warm communication, such as friendly joking and proactive conversations. The warm communication meant by participants, as stated below: “… [Be] just cool (enjoyable) … (P2, 140)” “… Lighten our load … (P10, 75)” “… [Feel] friendly… (P9, 32)” “… [Be] cooperative … [and] proactive … (P9, 86)”
The gay participants expressed their desire in relation to warm on verbal communication including light touch, hugging, kissing cheek, smiling, not keeping one's distance, not wearing double-gloves to shake hands, and not behaving stiffly. In addition, using language that is often used by gay individuals and maintaining an equally friendly demeanor toward all patients are considered to be helpful. This was revealed by six of the fourteen participants, as shown below: “… touches, [saying] good morning, without them uncomfortable to be in touch with the patient will be a sign of love … (P1, 16)” “… hugs, kisses may be [most important for] people like us because we [may] never get home … (P7, 18)” “… say hallo, kiss the right cheek and kiss the left cheek, [like you are] already accustomed [to doing] … (P2, 38)” “… grammar which I’ve hilarious so … already understand the languages of our (languages of gay)… (P7, 43)” “… no need to use double gloves [when providing care]… (P3, 46)”
A few participants were amazed by the attitude, knowledge, and communication level and style of their nurses. Admiration for the nurses in this study points to general acceptance of gay individuals among many nurses, as well as a broad knowledge of the issues facing gay individuals with HIV/AIDS and their communication needs. Related to the first theme, one suggestion that emerged was that nurses should not respond excessively when patients inform them of their sexual orientation, and then should not discriminate or maker judgments based on that information alone. In addition, to help patients feel welcome, the attitude of nurses should be one of visible concern with their patients’ condition. The conscious or unconscious action of washing hands after shaking hands or touching gay patients with HIV/AIDS was considered by participants to be outright discrimination that did not contribute to patients’ comfort.
Acceptance by nurses has an impact for the quality of nursing care provided. The professional attitude of nurses greatly affect the quality of health care provided to gay individuals with HIV/AIDS.12 Other studies reached a similar conclusion.7,16 Negative attitudes from nurses toward such patients are usually derived from differences in values and can sometimes unwittingly result in stigma or discrimination.17 Self-reflection and can help nurses align their values with the quality of care they are expected to provide.
In connection with the second theme, a broad knowledge of individuals who are gay and HIV/AIDS is one of expectations from a nurse. In this study, the nurses’ knowledge about gay individuals with HIV/AIDS and how to handle patients without discriminating was deemed sufficiently good. Since the lower the health worker's knowledge is about HIV/AIDS, the higher the stigma and discrimination that people living with HIV will face.21
Improved knowledge and attitudes toward gay individuals with HIV and AIDS and informed prevention efforts can help eliminate stigma and discrimination against people living with HIV.22 Comprehensive knowledge about HIV/AIDS among nurses can also reduce the risk of transmission of HIV/AIDS among gay individuals because they can discuss topics related to the risks sexual behavior during consultations.23
The link between the attitudes, perceptions, and knowledge of nurses toward gay patients with HIV/AIDS is influenced by the level of knowledge and education of the nurses.22 The reflective exercises for nurses, and particularly nurses who care for patients with HIV/AIDS, can also improve quality of care.
In addition to acceptance and having a broad knowledge of the issues faced by gay patients with HIV/AIDS, warm communication may be key to successfully caring for these patients. Communication is a tool; it begins when a nurse conducts a nursing assessment and evaluation, but it should not stop there. All behavior is communication and all communication will influence how patients perceive their care. Communication is a process that goes from a transactional focus to something that is multidimensional, irreversible, and inevitable.24
Communication is very important to the nursing process. Using communication, the nurse can steer patients toward successful nursing actions. Communication is divided into two types: verbal communication and non-verbal communication. Verbal communication entails the use of words but is considered less effective in communicating feelings and understanding of the meaning of others’ actions, because a lot of feeling or thought that may not be said or expressed in words.24
In this research, verbal communication made with a joke in a friendly manner was determined to improve the relationship between nurses with gay patients with HIV/AIDS, thus helping to achieve the purpose of providing high-quality nursing care. The relationship between patients and health care providers affects communication and care, early all participants revealed that humor in communication made gay individuals with HIV/AIDS feel more comfortable. Furthermore, humor is believed to provide therapeutic benefits such as reducing stress and anxiety.25 Humor activates β-endorphins, one type of neurotransmitter that can reduce the level of stress hormones in the body.24 Humor is also an effective communication tool because it helps to cultivate trust between nurses and patients, but its use must be age-, culture-, and gender-appropriate, and should focus on ideas, events, and situations.24 The use of a joke must be preceded by the establishment of trust between the patient and the nurse if the topic is gay orientation sexual.
Communications should be used to provide an atmosphere comfort for gay patients with HIV/AIDS. For this reason, communications that were considered in this study including non-verbal measures such as touching, hug, kiss the right cheek and kiss the left cheek, not keep one's distance, not being stiff, offering friendship, and not using double gloves when performing nursing actions. Touch-based communication can provide much, yet it should be implemented carefully because not everyone may appreciate it. However, touch in communication is one way to express empathy toward patients who are in a vulnerable situation.24
The purpose of communication using touch is to establish contact with clients, improve communication with patients, communicate caring and recognition, and provide assurance and comfort. Communication with touch can be proof of respect and sincerity. Some nurses may feel a bit uneasy or uncomfortable with touch due to their cultural backgrounds. Male nurses who are not gay may also experience discomfort related to the sexual orientation of individuals who are gays and have HIV/AIDS.
Self-reflection can help nurses balance their own believes with their patients’ needs. This information needs to be considered by nurses especially those who care for gays with HIV/AIDS to be able to reflect themselves to be open to different patient backgrounds, but still have self-awareness of the values and cultures that are believed to be able to provide nursing care to the patient without having to sacrifice the values that are believed about the therapeutic communication between nurses and patients.
A frightened nurse may use double gloves when taking blood from a gay patient with HIV/AIDS out of fear of being infected. Increasing nurses’ knowledge of how transmission occurs and their chances of contracting it can help reduce such fears. In that way, they can also improve their non-verbal communication toward such patients.
ConclusionGay individuals with HIV/AIDS require positive attitudes, knowledge, and communication in their care. Nurses should consider their attitudes and what their actions say when providing nursing care so as to ensure they are coming across warmly and not acting in a discriminatory manner Specific conditions, including the values and cultural background of nurses, can affect such communication, but paying attention to these matters can ensure high-quality care for gay individuals with HIV/AIDS. As a follow-up, further research on gay perception or knowledge with HIV/AIDS about nursing care is needed to add to the literature available to nurses in providing care to gay individuals with HIV/AIDS.
Conflict of interestsThe authors declare no conflict of interest.
This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1844/UN2.R3.1/HKP.05.00/2018.
Peer-review under responsibility of the scientific committee of the Second International Nursing Scholar Congress (INSC 2018) of Faculty of Nursing, Universitas Indonesia. Full-text and the content of it is under responsibility of authors of the article.
