Introduction

The international figures provided by UNAIDS reveal that in 2014, 36.9 million people in the world lived with the Human Immunodeficiency Virus (HIV), while the figures in Latin America for the newly infected were approximately 87,000 cases, 17% less than in the year 2000 ¹. As for Chile, there has been a progressive increase in reported cases of HIV, reaching a 44.6% increase in 2015 compared to 2010, where a significant number is in the AIDS stage at the time of confirmation ². Consequently, many patients must be treated in tertiary care service institutions, where the nursing professional has a fundamental role in their care. According to Vidal, Adamuz and Feliu the establishment of the therapeutic relationship is key when it comes to providing care; for this reason, care may be affected according to the perception that the professional has on the person treated, and therefore, may alter the health-disease process of the person living with HIV (PLHIV) ^3,4.

We focused in the analysis of the experiences, the identification of the tools, knowledge about the strengths and what can be improved in the nursing professionals that care for PLHIV, in order to know more about how they perceive the care given to these people in tertiary health care service institutions in Chile. Our intention is to contribute to the profession promoting the reflection that the professional must do in his work in order to provide humanized care to the PLHIV.

Methodology

A qualitative case study was conducted, allowing to address situations in a more profound way and helping to understand it better ⁵ . This investigation was carried out in a hospital in the Metropolitan Region of Santiago de Chile, between March and November of 2017. The choice of the participants was through convenience sampling, basically depending on their accessibility ⁶ . Along with this we used the principle of data saturation, where information was collected until finding repetitive arguments in the statements that led to the fulfillment of the objectives. There were seven nurses participating, between 25 and 45 years old, all of them belonging to the hospital's medical services and with an average of four years working in the institution. As inclusion criteria it was considered that the nurses had cared for PLHIV, had graduated at least two years before the study and had a minimum experience of one year in the hospital. Nurses who were on medical leave of absence during the process of selection and / or development of the research were excluded.

In this investigation the basic ethical requirements for a research proposed by Ezekiel Emanuel were followed ⁷. These requirements were explained in the informed consent form, specifying the protection that their identities and the provided information would receive. This was read and explained prior to each interview and signed by the participants, thus granting their authorization to participate.

The criteria for rigor considered for the development of this research were those described by Egon G. Guba ⁸. The credibility was contemplated interpreting as faithfully as possible the statements given by the participants. Researchers who did not participate in the development of the interview performed the triangulation of the data. Regarding transferability or applicability, the hospital context and the participants´ context were described. We expect that the information obtained from this research will be useful in other contexts, or that it will serve as a basis for future studies contributing to the profession. The confirmability or neutrality was respected by giving exact transcriptions of the interviews and using textual citations in the analysis of the information. Finally, the dependence or consistency was covered by means of active listening to the stories of the participants, omitting value judgments and avoiding suggesting anything that could induce a certain response on their part.

The method of gathering information was carried out through the preparation and application of a semi-structured interview, which presents a greater degree of flexibility, adjusted to each participant ⁹ . Each interview was conducted by two researchers in the hospital premises in a safeguarded and intimate environment, with an average duration of 30 minutes.

The methodology used to process the information was the discourse analysis of semiotic type, where the researchers transcribed the interviews which were then coded ¹⁰. The study of these interviews was initiated using textual statements in order to classify the discourse into categories and emerging subcategories. Subsequently, a classification table was created where all the relevant information was associated afterwards, which was used to extract a final analysis relating all the interviews and thus establishing the final conclusions. It is emphasized that this research was approved by the Ethics Committee for Research on Human Beings, with the Approval Act of project No. 105-2017.

Results

The results of this research were divided into six categories (tools, perception, first experiences, nurse/patient relationship, strengths, aspects to be improved) and some subcategories that described them more thoroughly; later, all this information was interrelated in order to present the results in a more integrated way. Below are the results where textual citations of the interviews are exposed (in italics, the Spanish original version followed by an approximate translation). These statements begin with a code including the interview number and quote location. The participants reported receiving their nursing education mainly with a holistic approach, with a comprehensive visualization of the person and its biopsychosocial well-being, with the main emphasis placed in biomedical sciences, scientific contents and nursing discipline. Regarding HIV, the approach was mainly related to managing the pathology.

E2. (76-80): “Los PAE (...) harta anatomía, fisiopato en realidad, y a raíz de eso uno toma los conocimientos que tiene y los respalda básicamente. Eso fue lo que más se nos recalcó a nosotros.”

E2. (76-80): “The PAE (Nursing Attention Process) (...) lots of anatomy, actually fisiopathology, is the basis of the knowledge that one acquires, our basic back-up. They insisted mainly on that.”

Continuing with the ethical training, it was mentioned the existence of specific branches of this topic as well as its transversal approach, considering it an essential part of patient care and emphasizing the importance of confidentiality as part of it.

E1. (191-193): “(…) lo más importante siempre va a ser la ética. Uno tiene que saber que el diagnóstico del paciente es privado totalmente; si él no quiere que la familia lo sepa, entonces la familia no tiene porqué enterarse.”

E1. (191-193): “(…) the most important issue will always be the ethics. One has to know that the diagnosis is an absolutely private issue; if the patient does not want the family to know it, then there is no reason to inform the family.”

Also the development of skills around humanized care was emphasized, such as empathy, friendly treatment, establishment of a therapeutic relationship and keeping the patient informed, highlighting that, in the perception of care, it should always be the same for every patient, with no differences in the treatment given to the PLHIV. The importance of reinforcing these skills from the undergraduate level was stressed, in order to establish a therapeutic relationship with all the patients.

E7. (121-126): “Porque eso se trabaja del cuidado, porque cuidar no solamente es poner un apósito, cuidar es también estar pendiente de la sensación del paciente, si está triste, aburrido, eufórico, o sea, sino eso hace parte del cuidado. Así que eso está relacionado. Porque uno está tratando con persona, no tratando con una hoja, que no siente nada, que da lo mismo si la arrugas; no, uno tiene que tener harto de tacto con la gente, porque no, así eso siempre, siempre, siempre.”

E7. (121-126): “Caring is not just to put a dressing, it is also to be on the lookout for the patient´s feeling, if he is sad, bored, happy, that is part of the care, it is related. Because one is dealing with a person, not a sheet of paper that has no feelings, that it does not matter if you crumble it; no, one has always to have a lot of tact with the people, always, always, always.”

However, a differentiation was observed in the attention towards PLHIV regarding the use of standard precautionary measures. Some emphasized the need for more protection when performing procedures for PLHIV and some others stated that the same measures are necessary in procedures to any patient, no matter the pathology.

E2. (178-180): “Por ejemplo, no es lo mismo hacer un procedimiento a un paciente que es positivo, o con algún tipo de virología positiva, a un paciente que no lo tiene, ¿ya? Uno lo hace con más cuidado, con mayor precaución.”

E2. (178-180): “In example, it is not the same to treat a patient that is positive, or with some kind of positive virology, that to treat one who does not, OK? One is more careful, works with more precaution.”

E5. (150-155) “En realidad es lo que te comentaba, es un paciente más, nomás. No hago la diferencia como que “el paciente que vive con VIH”. Sí, claro, obviamente uno tiene como más precaución. De repente, uno por costumbre, tiene la pinta de pinchar a un paciente sin guantes. De hecho, ahora último igual como que tomamos un poco más de conciencia, en general; por ejemplo ahora yo no punciono a un paciente sin guantes, sabes que aunque me haya tocado VIH o no sea VIH, no me arriesgo a… o sea, me protejo ante un eventual accidente cortopunzante o punción con alguna bacteria, o algo (…)”

E5. (150-155) “Actually is what I told you, any patient is just one more patient. I do not consider him “the patient that lives with HIV”. Of course, one has more precaution. Maybe one is used to give a shot to a patient without using gloves. Actually, lately we are…like a bit more conscious, in general. Now I do not give a shot to any patient without using gloves, no matter if he is or not an HIV patient, I don´t take chances… I mean, I protect myself from a potential accident involving blood, a bacteria, whatever (…)”

The nurse/patient relationship is in addition to the care given. The dedication and patience that each care requires was mentioned, together with the difficulty of avoiding growing fond of the patients. Many times this relationship depends on the patients, who are sometimes more reluctant to care.

E5. (211-214) “(...) igual uno es como inevitable de repente encariñarse, de repente no sentir nada, o al contrario, de repente vamos a encontrar de todo como que …. Sí, hay pacientes que tienden a ser un poquito más hostil, pero igual uno los va a atender de la misma manera… va un poco en el tema de las relaciones personales.”

E5. (211-214) “(...) it is unavoidable sometimes to grow fond, or sometimes not to feel anything, or suddenly we will find everything, like…. Yes, there are patients with a tendency to be a little more hostile, but anyway one will look after them in the same way… it is a matter of personal relationships.”

Regarding the PLHIV, the complications in their treatment were highlighted due to the implications of this specific pathology and the lack of pharmacological adherence perceived by the nursing professionals. However, it is considered that PLHIV can achieve a good quality of life if they attend their health checks regularly and have their pharmacological treatment up to date.

E7. (245-251): “El tema es que hay poca adherencia al tratamiento, hay gente que no le ve la importancia de tomarse un tratamiento antirretroviral, no ve la importancia de continuar el tratamiento, de ser como riguroso, de tomárselo todos los días. Yo creo que hay también de pronto un desconocimiento de las reacciones adversas que tienen lo retrovirales; entonces la gente, “ah no, es que me duele la guata, diarrea, ah, entonces me lo dejo de tomar”, entonces como que no saben de que esos son efectos secundarios de tomar su terapia.”

E7. (245-251): “The thing is that there is little adherence to the treatment; some people do not consider important to start an antiretroviral therapy, do not see the importance of continuing with it, to be rigorous, to comply every day. I think that there is also perhaps a lack of knowledge about the adverse reactions that these treatments carry; then people go “oh no, my belly aches, diarrhea, oh, then I will stop with this”, like they do not know that these are the expected secondary effects of their therapy.”

Regarding the first approaches to a PLHIV, the participants described them as complex, agreeing on the extra precautions in approaching and carrying out procedures, being more meticulous in their actions. The word "fear" was highlighted. This initial fear later disappeared over time, as they understood that PLHIV should not be treated differently. For this reason they stressed the need to know more about HIV in the undergraduate courses, thus avoiding generating fear in the attention.

E5. (168-171) “(...) no recuerdo así como el momento exacto, pero sí yo recuerdo que como por el prejuicio que igual uno siente, como el temor de contagiarse, por lo que conlleva la enfermedad en sí y todo, sí recuerdo como más temor, o sea no sé si temor, como estaba como más ojo, como más precaución, qué se yo (…)”

E5. (168-171) “(...) I do not remember the exact moment, but I do remember like the prejudice that one feels anyway, like the fear of contagion, for what this illness implies, yes, I remember like more fear, I mean, I don´t know if it is fear, but like one was more aware, more cautious, I don´t know (…)”

With regard to the participants' vision of the evolution of HIV, there was a consensus that it changed over the years, stressing that before HIV was a deadly issue. Therefore the precautionary measures taken were much greater, some of them unnecessary considering the transmission mechanism of the virus. This is in contrast to the current reality, where it is considered as a chronic disease. The increase in cases was related to the loss of fear of the population to this infection, and also due to the deficit of sexual education at the population level, not just prevention in the general public but also in PLHIV to prevent the spread of the virus and to encourage their self-care.

E4. (126-131): “(…) uno vivió la etapa del VIH cuando se quemaban colchones porque los pacientes morían, había que meterlos adentro de unas bolsas especiales… era todo un show, pero tú ya vives, uno vive toda esa evolución para delante, entonces ahora el VIH es como... tú ya sabes que no es mortal, que es como una enfermedad crónica, entonces ya no, pero cuando tú llegas a trabajar ya como enfermera se te ha quitado todo el miedo para atrás, ya no tienes ese miedo que tienen ustedes recién egresados.”

E4. (126-131): “(…) One lived the HIV stage when mattresses were burnt because the patients died, we had to put them in special bags… it was like a show, but you live the evolution of the process; now the HIV is like... now you know that it is not deadly, that it is like a chronic illness, not any more; when you work as a nurse the fear is gone, you do not have the fear that you, the just graduated nurses, have.”

When consulting about the strengths, the participants agreed that the main one was to be able to face different scenarios and patients, to be able to speak up and to reach people when giving care. Along with this goes the fact of not discriminating against patients, being always close to care and acquiring new procedural skills over the years.

E5. (225-227) “(...) uno va desarrollando más el tacto, más habilidades blandas, ehh... uno ya empieza a ver cómo llegar a él, de repente bromear con los pacientes, y ahí como que uno va tanteando el terreno… y claro, con respecto como a los procedimientos uno va aprendiendo más (...)”

E5. (225-227) “(...) One gradually develops more tact, more soft skills, ehh... one starts to see how to reach the patient, suddenly to joke with them, and there is like… one is getting the lay of the land… and surely, about the procedures, one learns more and more (...)”

About what can be improved, the participants highlighted the attitude towards family members and patients, emphasizing the different personalities that they have to confront and agreeing that it is always possible to do things in a better way.

E1. (141-143): “yo creo que siempre hay cosas por mejorar. Pero ya va más que nada en el hecho de que a veces uno se cansa de la actitud de la persona, o se aburre un poco de los familiares y esas cosas, hay que mejorar un poco la actitud frente a eso.”

E1. (141-143): “I think that there is always room for improvement. Mostly because sometimes one gets tired of the attitude of the person, or gets a little bored of the family members and things like that; we must improve our attitude when facing that.”

Emphasis was placed on the difficulty for the nursing professional to participate in the care given to people in general, and especially to PLHIV, due the lack of enough time in the working day, preventing them to become more involved in their health-disease process.

E3. (187-190): “(...) porque muchas colegas que yo he visto que, colegas que pasan cierto, haciendo lo que hay que hacer y poco contacto más allá tienen, pero no sólo con el paciente que tiene VIH sino que con el paciente en general, a veces somos pocas enfermeras, demasiados pacientes, el tiempo se te hace poco (...)”

E3. (187-190): “(...) because many colleagues that I have seen, colleagues that do work doing what has to be done but they have very little contact, but not just with the HIV patient but with all the patients. Sometimes we are just a few nurses, too many patients, very little time (...)”

Finally, regarding the insecurity in their knowledge, the participants agreed that despite having a good academic background, they all felt fear at the beginning. They agreed on the need to better prepare future nursing professionals to educate the population with and without HIV, reinforcing the prevention of the disease and avoiding, in part, its transmission.

Discussion

Currently in Chile, as indicated by the Institute of Public Health (ISP), the prevalence of HIV-infected people is constantly increasing ². This increase, according to a study conducted by the Ministry of Health of Chile (MINSAL), is associated with unsafe sexual behavior, a greater number of sexual partners and not using condoms when having sex ¹¹. This is in agreement with what was reported by the participants, who attributed the increase in HIV cases to risky sexual behavior, adding carelessness in the prevention of the infection. They also attributed it to the change of perception that HIV has had through the time, going from a deadly disease to being cataloged at present as a chronic pathology. They also emphasized the importance of sexual education around the prevention of contagion, along with the need for a change in the approach of education to PLHIV in terms of their responsibility in contagion, having safer sexual behavior and encouraging self-care.

This shows the relevance of how health care is provided to PLHIV, because of the impact that it can generate in the control of the disease, the quality of life and the prevention of new cases. Under this scenario, according to a study carried out in Cali, Colombia, called "Evaluation of knowledge, attitudes, susceptibility and self-efficacy against HIV/AIDS in health professionals", it was evidenced that improving the knowledge and skills of health personnel favors the capacity to provide care to PLHIV ¹² . This is consistent with the present investigation, where the participants agreed that having a high level of knowledge about HIV allows them to provide quality, equal and non-discriminatory care to PLHIV.

Likewise, in the statements of the participants the emphasis was on treating people equally, without making a distinction according to the patient's diagnosis. Even so, they explained that when carrying out procedures to PLHIV, they take greater precautions, in comparison to those carried out in people with negative serology. Therefore there was a discrepancy between the discourse and the actions of the participants where, although they expressed the sense of equality, they unconsciously made differences, which could affect the way in which PLHIV perceive the attention received.

On the other hand, the aforementioned study also showed that health professionals have a certain degree of fear at the moment of treating PLHIV despite having enough knowledge regarding the infection. They maintain certain prejudices that do not allow them to freely engage with these patients. This is in disagreement with the present investigation, where through the analysis developed it was realized that the participants identified this sensation of "fear" only in the first encounters with a PLHIV, since interacting and acquiring knowledge of the pathology gave them security in their daily work. Regarding nursing professional performance, the review article "The Performance of Nursing Professionals" carried out in Cuba and published in 2016 indicates that this is an area that is seldom addressed, despite the challenges that the nursing professional has to face and the particularities that exist in the health system. Therefore the need for an in-depth approach to professional performance in order to favor the management of care is perceived ¹³ . This could contribute and enrich the nursing professional, identificating strengths and aspects to improve that will grant a better attention to the person and achieving a therapeutic relationship that contributes to their health. In another area, a study conducted in Madrid, Spain in 2016 details the importance of filling the professional encounter with meanings, through active listening and validation of the patient ¹⁴. For this reason, it is mentioned that the characteristics of the health professional take a fundamental role in this approach, accepting, offering answers and guiding towards a solution of the patient's problem, leading to generating a relationship of trust and freedom of expression. The objective of health care is not only to give the patient a treatment, but also to get "to change the fear in tranquility, the shame in normality, the confusion in clarity, the doubts in answers, the anger in empathy and the guilt in understanding " ^{(14 )} .From the same research we identified strengths on the part of the health professional in the care of people with STI and PLHIV such as empathy, acceptance of the person independently of their thoughts, active listening, not making judgments, talking about sexuality with normality and empowering the person. This is in contrast to the difficulties encountered in the same study, such as the impediment when talking about sexuality, lack of time, judging, infantilizing, prejudices and lack of communication skills.

Comparing the above results with the present investigation, when the professionals were asked about the strengths they had attending PLHIV they agreed that the main ones were their ability to face different contexts and people, to be able to express what they think and to be able to reach people at the time of care; no discrimination, closeness and the acquisition of procedural skills over time. Aspects to improve were the attitude towards the relatives and the patient, emphasizing the different personalities that they should be able to face; they also stressed that it was always possible to improve the care provided to the patient. In the statements the lack of enough time was raised as an impediment to participate actively in the care of all people. The lack of enough time was also highlighted in the research carried out in Madrid, Spain, mentioning that the pressure continues to be an insurmountable burden which makes it impossible to grant the time that many situations require ¹⁴.

Based on the above, future challenges for the nursing professional were identified. This is also mentioned in the publication "Nursing in the role of care management": the challenge that nursing professionals must face in terms of leadership in care management and the importance of communication skills and decision making, this being a key point in the training of future professionals ¹⁵. Along with this, as mentioned by Ceballos, it is essential that from the undergraduate stage care must be taught with empathy, regardless of the patient's diagnosis or conditions, also emphasizing the importance of humanized care which allows for personal, professional and social growth within the health team ¹⁶. Finally, although some of the aspects identified are consistent with other researches, both national and international, there were many differences in certain points, which are fundamental when it comes to serving a PLHIV.

Conclusions

There are several conclusions. Nursing professionals perceive the attention given to PLHIV as being equal to patients with negative serology; however, they recognized procedural differences, emphasizing that they take greater care when carrying out procedures for PLHIV. It is noteworthy that only the feeling of "fear" was identified in the first encounters with a PLHIV, in contrast with other studies reviewed in which it is described that health professionals have this "fear" independently of the number of encounters. This is undoubtedly a step forward in terms of attention, since it is demonstrated that the knowledge acquired by the nursing professionals guides their actions and that every day they are closer to full equality in the treatment of all people. In addition, the participants of the present study identified empathy, friendly treatment, the establishment of a therapeutic relationship and keeping the patient informed as tools helping to strengthen the way they act professionally. All this reinforces what was said before. These tools are fundamental in the improvement of humane treatment and in the quality of care.

On the other hand, the nursing professionals agreed on the importance of improving the attitude towards the family and the patient when the relationship becomes complex, this being fundamental for the creation of a bond of trust and mutual security in the care. Along with this, they said that the lack of time and the type of health system in which they work hinders them on certain occasions to carry out a better quality care to the PLHIV and in general to all people.

It is emphasized that through the analysis of the experiences of the nursing professionals interviewed it was possible to identify the tools and skills acquired in the course of their professional life, as well as their own strengths and weaknesses that they present when caring for a PLHIV. In this way, it was possible to fully comply with the stated objective, to know the perception of nurses regarding the attention given to PLHIV in a tertiary health care hospital service.

However, after all this process and with the information obtained there are new questions that arise: in the undergraduate program, are the necessary tools provided so that the future nurses can face the attention of a PLHIV? Are the efforts of the health sector in Chile to stop the HIV pandemic and to strengthen the care given to the already infected population enough? Is the socio-cultural context negatively interfering in the development of a holistic and egalitarian type of care by the health sector towards PLHIV? How do the PLHIV perceive the attention of the nursing professionals? What do the PLHIV expect from health care and nursing professionals? This extends an invitation to continue investigating the attention given to this population, to raise awareness among the nursing professional regarding the care delivered day by day in the different contexts that has to confront.

It is necessary to continue studying and analyzing the perception that the professionals have in relation to the care provided to the PLHIV in order to improve the therapeutic relationship established between nurse and patient. This will reinforce their strengths and the tools already identified, working on what will contribute to the optimal performance of the profession. The vision of the health care managers will enable to work on continuous improvements to fill the gaps and reinforce what has already been achieved. Finally, considering the current increase in HIV prevalence figures in Chile, it is essential that nursing professionals face this situation, improving and reinforcing soft and procedural skills, knowledge and ethical aspects, among other issues, to optimize the establishment of the therapeutic relationship with the PLHIV and contribute in part to stop this problem. Nurses must be agents of change and educators of the entire population. The data obtained can be applied to improve the work of the nursing professional but cannot be generalized to the whole existing context due to the study methodology; however, we expect that it will be useful and contribute to some extent to the nursing profession, encouraging to perform future studies to enrich the information obtained and complement or refute the results exposed in this research, as well as to promote the investigative role in the nursing professionals, exploring new areas of disciplinary performance.