Exploring SDM in HIV nursing care
mouth and take them but it isn't that simple is it? I think the chal enge for us as healthcare
providers is saying if someone's internal choices are different to ours, we can't override
that and therefore the shared collaboration is then you know what? I have to go with you
on your journey, if you're going to die I will still offer the best care that we have available.'
(Nurse4,FocusGroup4)
In terms of social factors, al groups raised the issue and impact of stigma on SDM. Nurses
describedstigmaassomethingthatwasstillverymuchapartofHIVandwasseenasabarrier
toSDM,primarilybecausefearandstigmapreventedpatientsfromacceptingordisclosingtheir
diagnosisandengagingwithtreatment:
`Sadly, the stigma is still very much there and the issues around disclosure and sharing
it with anybody is still a massive issue.'(Nurse2,FocusGroup1)
Stigmawasdescribednotonlyasaproblemintermsofpatients'personallivesorreluctance
to engage, but was also identified as a chal enge in terms of the treatment patients received
fromotherhealthcareprofessions.NursesnotedthatpatientswereoftenreferredbacktotheHIV
departmentforthemainpartoftheircare,evenifotherdepartmentsshouldhavebeentakingthe
lead.Thiswasattributedtoongoingstigmafromothernursesandalackofconfidenceamongst
otherprofessionalsinmanagingHIV.Together,theyposedchal engesintermsofachievinganSDM
approachwithinasharedcaremodel:
`We offer some training to practice nurses and stuff and the ignorance that is still around
is unbelievable. The nurses, just, I mean, I know from colleagues from like when I was
district nursing, how their opinion of HIV, and these are professionals ... So, with shared
care, I think we are always going to have to work towards it and I think the stigma will
be a hindrance. I don't personally think the stigma will go in our lifetime but just to keep
chipping away at it and just keep moving forward on it.'(Nurse2,Focusgroup2)
Intermsoforganisationalfactors,akeychal engewastryingtoengagewithSDMundertime
constraints,forexample,shortconsultationtimes,ormanagingverycomplexpatientswhorequired
moretimethanusual.SDMwasperceivedaslengtheningthetimerequiredforconsultations,and
thatwithoutprovidingadditionaltime,SDMwasdifficulttoimplementinpractice:
`Time, you've gotta have time, you've gotta give time to the patient. The more shared it is
I think the longer the time that is needed to go through that process so I think time is a big
factor in that you know appointments are a ticking clock aren't they? You know you have
got to get them through the clinic so I think time ... our clinic at times you know I wouldn't
envy them sitting there that length of time so both from the professionals point of view
but from the client, patients point of view time is a big factor.'(Nurse2,FocusGroup4)
Organisationalfactorsalsoplacedconstraintsondevelopingservicesthatcouldbemoreflexibleor
accessibleandwouldthereforeenablebetterpatientengagementandSDM.Forexample,itwas
suggestedthattheabilitytoworkinthecommunityortoprovidelateorearlyappointments,orto
followupnon-attendeeswasimportantbutnotalwayspossible.
`With us in community, that's what we tend to do, the nurses in the hospital might phone
us and say such and such has DNA'd their appointment ... and then you know, if they're
known to us, we might try and get hold of them or we'l just go round ... on the off
chance if you know it's safe ... In a clinic setting because of course when I was based
in a clinic setting we didn't have those kind of opportunities and that is why I feel such a
privilege to be in the community setting at the moment.'(Nurse2,FocusGroup2)
2016
Participantsalsoidentifiedseveralmoremacro-levelhealth-system-relatedchal engestoSDM.
OneofthemajorfactorswasthatHIVcare,likeotherareasofcare,wasbeingdeliveredinacontext
oflocal,nationalandinternationaltargets,standardsandguidelines.Alldepartmentswereunder
pressuretoachievetargetsaroundtesting,treatmentinitiation,treatmentadherenceandviralloads.
www.nhivna.org
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