Navigating stormy waters: difficult conversations in HIV care

Chapter description

Working with people living with HIV can be both rewarding and satisfying, yet it can be challenging at both professional and personal levels. Establishing and maintaining effective therapeutic relationships with patients is paramount. Good communication is an essential aspect in creating such professional relationships, and they can have a positive impact on a variety of health outcomes for patients, including increased longevity (Schneider ct al., 2004). This chapter provides an overview of what factors can influence professional relationships between patients and their healthcare providers in an HIV setting. A discussion of a variety of factors that can promote good communication in a clinical encounter is provided, in addition to an overview of what can hinder it. These discussions will be illuminated by case discussions and opportunities for self-reflection.

The emergence of successful antiretroviral therapy treatments has significantly contributed to the improvements in HIV care of the last 20 years. As a result of these medical advances, HIV has been redefined as a chronic manageable condition (WHO, 2017), of which the medical management of HIV may seem quite straightforward. Despite the advances within the disease area, significant challenges remain to achieving successful engagement in care, adherence to treatment and enjoyment of a good quality of life (BillVA, 2018). Therefore, it is important for healthcare professionals to explore how they provide care over a prolonged period of time with patients. Establishing and maintaining therapeutic relationships arc essential to ensuring long-term health outcomes and facilitating engagement in care.

Person-centred communication - Rogers’ core conditions

In 1961, Carl Rogers published a book on counselling that has remained instrumental to this day in understanding how a therapeutic relationship is key to creating conditions for change for patients. In this book, Rogers described three ‘core conditions’ for creating a therapeutic space: unconditional positive regard, congruence or authenticity, and empathy (Rogers, 1961). Unconditional positive regard is often defined as the ability to accept another person’s perspective or opinion, regardless of how much it may differ

Navigating stormy waters 81 from one’s own. Each patient’s response to illness reflects how they respond to life’s challenges. There are multiple different factors that can affect a person’s response to life events. For example, cultural issues, societal factors, religion, gender and sexuality arc just a few that can be interrelated and shape a person’s response to illness. Within HIV care there are a wide range of subcultures that exist that are on the increase as diversity in society in general also continues to develop. This requires nurses to be curious, open, accepting and non-judgemcntal in working with patients who may hold beliefs or positions that are fundamentally different from their own.

Task - consider the following case

Jane has been taking the same antiretroviral medications since her diagnosis nearly 10 years ago. She reports she is beginning to struggle with dizziness and is experiencing sleeping difficulties. After a lengthy discussion about her life at the moment, it appears that Jane’s medication may be playing a role in her symptoms. You suggest she may want to consider changing her antiretroviral medications. You describe what the new treatment may be, how she could take it and the potential side effects. Despite the medications being very similar to Jane’s current regime, she seems very reluctant to change her treatment. In the end, she says that ‘if it ain’t broken, then I don’t want to fix it.’

• • What questions can you ask to gain a better understanding of her perspective without sounding judgemental?
• • How do you convey your understanding of her opinion but share your own in a respectful way?

Like anyone else in the world, patients need to be treated with respect and accepted for their choices. In the end, acceptance does not necessarily mean agreement. However, it is acceptance that needs to be conveyed to patients so they can feel honoured and respected - and it is under these conditions when patients may start to take action to improve their wellbeing. However, they may choose to not take action for reasons unclear, unknown or even disagreed with - and this position needs to be accepted by healthcare professionals if they want to maintain an effective and helpful relationship with their patients. For example, patients may choose not to take medication for a variety of different reasons, and whilst this is often a source of great anxiety for practitioners in HIV care, it is important to respect the patient’s wishes (sec Chapter 6, 7 and 8). This is likely to help maintain the therapeutic relationship, meaning that the provision of client-centred healthcare can continue.

Congruence in a therapeutic relationship requires healthcare providers to be authentic and genuine with their patients. Being congruent is sometimes described as when actions and words match each other (Rogers, 1961). Healthcare providers (HCPs) who demonstrate openness and transparency by not hiding behind a professional façade arc often described as being genuine or authentic - and this helps in promote their trustworthiness and credibility for patients (sec Chapter 1). When such positive interpersonal qualities arc conveyed, their communications will be more influential in promoting behaviour change. As previously mentioned, providing care for people living with HIV will occur over a prolonged period of time; therefore, the need for genuine and authentic care from the HCP is paramount when considering long-term outcomes and encouraging patients to remain engaged in care.

According to Rogers (1961), being aware of one’s own feelings and attitudes that are flowing within the moment is essential for being genuine. When being congruent, there is a close matching between what is being experienced at the gut level, what is present in awareness and what is expressed to the patient. If there is a persistent feeling that is not shifting or changing, it needs to be acknowledged and possibly used in the moment therapeutically with the patient.

Displaying happiness to a patient when they are discussing their hard efforts and success in changing something is being authentic, genuine or congruent. However, it can be more challenging in circumstances when feeling frustrated, stuck or even annoyed when a patient refuses to adopt your perspective on the importance of changing their behaviour. In such circumstances, simply acknowledging the opposing views and proposing to discuss it again at a later point in time may be the best way forward.

Task - consider the following case

David’s engagement with the HIV clinic has been sporadic over the past three years since he was first diagnosed. Today he is giving a blood sample, as this is the first time in eight months that he has been in to the clinic. When asked about how life is going for him, he breaks down in tears as he tells you about a recent job loss and his relationship of five years falling apart with his recent return to drug-fuelled sexual activity. He says that he doesn’t really know if life is worth the continued struggle at the moment. You suggest that maybe he could benefit from meeting the clinic’s psychologist. However, he declines your offer as he doesn’t believe talking about his problems can lead to any change.

• • What would be an authentic or genuine response to David?
• • What could interfere with you being open and transparent about your feelings in this moment?
• • How important is it in this moment to change his opinion about seeing a psychologist?