Nursing diagnoses associated with human needs in coping with HIV

Abstract

Objective:

To identify the implications and changes in the life of people taking into consideration the moment at which the HIV diagnosis was revealed and to develop nursing diagnoses suitable to the human needs related to these implications and changes.

Methods:

Retrospective descriptive study, with a qualitative approach, which included interviews with 20 people who participated in a nongovernmental organization. The analysis corpus was organized into three categories: “influence of the diagnosis on employability”, “religious support”, and “health worsening”, from which nursing diagnoses were developed in accordance with the 2015 version of the ICNP^® and human needs.

Results:

The present study identified changes in the daily routine when people were faced with the diagnosis, including the influence on employability, religious support, and health worsening, in addition to 35 nursing diagnoses related to self-esteem, safety and protection, and social needs, 26 to the self-recognition need, seven to the physiological need, and 18 to the spiritual need.

Conclusion:

The identification of the categories, nursing diagnoses, and human needs provides nurses with subsidies to carry out their practice grounded in a standardized language, helping improve nursing care.

Keywords
HIV; Nursing diagnosis; Nursing process

Resumo

Objetivo:

Identificar as implicações e mudanças na vida do indivíduo, considerando o momento da revelação do diagnóstico de HIV, e construir diagnósticos de enfermagem adequados às necessidades humanas relacionadas às implicações e mudanças.

Métodos:

Pesquisa descritiva retrospectiva, de abordagem qualitativa. Foram entrevistadas 20 pessoas que participam de uma organização não governamental. O corpus de análise foi organizado em três categorias: “influência do diagnóstico na empregabilidade”, “apoio religioso” e “piora da saúde”. A partir delas foram elaborados diagnósticos de enfermagem, de acordo com a CIPE^®, versão 2015, e segundo as necessidades humanas.

Resultados:

Frente ao diagnóstico, foi relatado modificações no cotidiano como a influência na empregabilidade, apoio religioso e a piora da saúde. Foram identificados 35 diagnósticos de enfermagem relacionados às necessidades de autoestima, segurança e proteção e sociais, 26 relacionados à necessidade de autorreconhecimento, 7 à necessidade fisiológica e 18 à necessidade espiritual.

Conclusão:

com a identificação das categorias, dos DE e necessidades humanas, o enfermeiro se apropria de subsídios para a realização de uma prática pautada em uma linguagem padronizada auxiliando na melhoria da assistência de enfermagem.

Descritores
HIV; Diagnóstico de enfermagem; Processo de enfermagem

Resumen

Objetivo:

Identificar las implicaciones y cambios en la vida del individuo, llevando en cuenta el momento de la revelación del diagnóstico del VIH, y construir diagnósticos de enfermería adecuados a las necesidades humanas relacionadas con las implicaciones y cambios.

Métodos:

Investigación descriptiva retrospectiva, de abordaje cualitativo. Fueron entrevistadas 20 personas que participan de una organización no gubernamental. El corpus de análisis fue organizado en tres categorías: “influencia del diagnóstico en la empleabilidad”, “apoyo religioso” y “empeoramiento de la salud”. A partir de ellas se elaboraron diagnósticos de enfermería, de acuerdo con la CIPE^®, versión 2015, y según las necesidades humanas.

Resultados:

Frente al diagnóstico, se relataron modificaciones en el cotidiano, como la influencia en la empleabilidad, el apoyo religioso y el empeoramiento de la salud. Se identificaron 35 diagnósticos de enfermería relacionados con las necesidades de autoestima, seguridad, protección y sociales, 26 relacionados con la necesidad de autorreconocimiento, 7 con la necesidad fisiológica y 18 con la necesidad espiritual.

Conclusión:

con la identificación de las categorías, de los DE y necesidades humanas, el enfermero se apropia de subsidios para la realización de una práctica pautada en un lenguaje estandarizado, auxiliando en la mejora de la asistencia de enfermería.

Descriptores
VIH; Diagnóstico de enfermería; Proceso de enfermeira

Introduction

The epidemic of HIV infection, identified in the early 1980s, remains a global phenomenon. It was estimated that over 36 million people lived with HIV in 2016 worldwide.⁽¹⁾ In Brazil, the calculated number of people infected with the virus in 2017 was approximately 883,000 people.⁽²⁾

When faced with the diagnoses of diseases in general, affected people end up making cognitive and behavioral efforts to help coping with the difficulties and overload associated with finding out about the illness.⁽³⁾ Consequently, the definition of the medical diagnosis of HIV/AIDS may result in difficulties related to social interaction, acceptance of the disease, and an impact on professional life, originating individual and family conflicts.

It is important for people to cope with the disease so they can accept the diagnosis, handle changes, life adaptations, and for their well-being.^(4-7) The literature shows the relevance of adopting ways to cope with the HIV diagnosis to minimize stressful effects and the feeling of guilt, escape, or retreat.^(6,8,9)

According to this line of argument, nursing diagnoses are fundamental to the practice of nursing professionals responsible for the care to people living with HIV (PLHIV) because these diagnoses allow to plan interventions and provide a basis for decision-making, aiming at a comprehensive, humanized, and individualized care⁽¹⁰⁾ to help increase the quality of life of these people.⁽¹¹⁾

The greatest difficulty in the steps necessary to deliver care to this population is the nursing diagnosis (ND) because it requires interpreting and assembling collected data, so the nursing intervention can be directed toward the intended result. Related studies that name nursing diagnoses for care to PLHIV indicate the use of the NANDA International (NANDA I) taxonomy in its different versions^(12-13) and the International Classification for Nursing Practice (ICNP^®).^(14-19) These investigations identified care needs related to the treatment and presented the implications in the change of the daily routine. However, there is a gap regarding the diagnoses concerning the moment the diagnosis is revealed, a process in which professional and user share the discovery of the serology, to help the post-diagnosis coping process.

The present paper reports results of an investigation whose objectives were to identify the implications and changes in the life of people taking into consideration the moment at which the HIV diagnosis was revealed and to develop nursing diagnoses suitable to the human needs related to these implications and changes.

Methods

The present study is descriptive, retrospective, and used a qualitative approach. Its development followed the Consolidated Criteria for Reporting Qualitative Research (COREQ).⁽²⁰⁾

The investigation was carried out at a nongovernmental organization (NGO) that provides PLHIV with health care, guidance, prevention and counseling, praying groups, and leisure activities. The institution is located in the city of Ponta Grossa, state of Paraná, Brazil. In 2014, when the study was developed, the NGO had 158 registered patients.

During the four months that preceded data collection, the researchers had an immersion in the institution to get to know the participants, insert better in the environment, and develop bonds. The following inclusion criteria were established: being at least 18 years old, regardless of gender; having knowledge about their serologic condition; and having physical and psychic conditions to participate in the investigation. These conditions were evaluated using medical records, by analyzing psychiatric diagnoses and sick leaves. There were no exclusion criteria. Twenty people agreed to participate in the study.

Initially, the participants answered an individual interview carried out by the researchers in the NGO's nursing care room. The interview was oriented by open- and closed-ended answers containing data on the participants and a guiding question: What are the perceived changes in your life after the HIV diagnosis? The interaction was also used to approach the following subjects: discovery of the HIV infection, time of HIV diagnosis, and feeling when confronted with the diagnosis.

The interview was recorded with a digital recorder and it was not necessary to carry out new interviews after the first data collection, which occurred from March to June 2014 and had an average duration of 16 minutes. After data were collected, the recorded speeches were presented to the participants so they had the chance to make further comments. No participant complemented the original interview.

Collected data were interpreted using content analysis.⁽²¹⁾ The records were listened to for checking the audio clarity and the reports were transcribed individually. Each participant was identified with the letter “F” followed by a number from 1 to 20. The transcriptions were double checked by the researchers and categorized during analysis. The reports and their categories were organized in an electronic spreadsheet. Three categories were identified: “influence of the diagnosis on employability”, “religious support”, and “health worsening”.

The development of NDs from the reports followed the ICNP^® instructions, which agree with the ISO 18104/2013 standard.⁽²²⁾ An ND is a title given to a finding, event, situation, or other health aspect resulting from data collection and can be expressed as an evaluation on an emphasis or a simple expression of a clinical finding showing an altered state, behavior, function, or structure. In this regard, the first form of description of the ND requires an evaluation and an emphasis descriptor, whereas the ISO 18104/2013 standard shows that for the second form the description of the ND can be designed as a clinical finding, in which the inclusion of an evaluation is not mandatory.⁽²²⁾ For each category, the NDs were identified using the 2015 version, available at the website of the International Council of Nurses, in Portuguese, at the time the study was in progress.⁽²³⁾

The choice of this terminology was justified by the familiarity of the researchers with its use, as well as the extent and complexity of the terms, which could represent the scope of the nursing practice for the studied population. After the step of developing NDs by category, the researchers organized them according to human needs⁽²⁴⁾ following the process of ND representation framework proposed on the ISO 18.104:2014 standard.⁽²²⁾

The diagnoses that emerged from analysis of the reports were presented to the NGO after the study was completed so they could be used as a means of operationalization of the nursing process under the supervision of a nurse.

The proposal describing the present study was approved by the Research Ethics Committee of the Universidade Estadual de Ponta Grossa as per report no. 164/2011.

Results

Regarding sociodemographic characteristics, 60% of the sample were women, 40% belonged to the age group from 40 to 49 years, 55% had incomplete elementary school, 80% earned up to two minimum wages per month, 50% were married or in a consensual union, and 90% declared to be heterosexual (Table 1). Seven participants reported that their partner was a PLHIV.

Table 1
Sociodemographic characteristics of the participants

Characteristics		n(%)
Gender
	Female	12(60)
	Male	8(40)
Age
	20 to 39 years	7(35)
	40 to 49 years	8(40)
+ 50 years		5(25)
Level of education
	Illiterate	2(10)
	Incomplete elementary school	11(55)
	Complete elementary school	4(20)
	Complete high school	2(10)
	Complete higher education	1(5)
Family income
	< 1 minimum wage	6(30)
	1 to 2 minimum wages	10(50)
	2 to 3 minimum wages	4(20)
Marital status
	Married	6(30)
	Common-law marriage	4(20)
	Single	5(25)
	Widow(ed)	5(25)
Sexual orientation
	Heterosexual	18(90)
	Homosexual	2(10)
Total		20(100)

The time living with the virus for 45% of the participants ranged from 1 to 10 years, and the main form of discovery of seropositivity was the development of diseases, which reveals a late diagnosis.

Influence of the diagnosis on employability

This category identified the presence of situations of prejudice and discrimination against PLHIV experienced at the work environment, as illustrated by the following speech excerpts:

“I was fired after I told I was HIV positive.” (F16).

“I was fired and I had been working there for 12 years.” (F14).

“The main problem was not getting a job, the doors closed. And nobody gives an opportunity to people with AIDS.” (F5).

“Right after I had the news, I had to collect cardboard to survive because I lost my job. No one wanted a seropositive employee. I lost many jobs after they found out.” (F9)

“I still work at the same place, as a maid. But my boss does not know it and I am really afraid that she finds out. I think that if she finds out she will fire me.” (F2).

Religious support

The influence of religiosity on the disease was revealed in the reports of the interviewees and translated in the sense of promotion of hope and emotional and spiritual comfort and as a way to soothe desires. Speech excerpts related to this category are shown:

“I think that what changes is that we start to get attached to God. I was not very fond of going to church, but today I am really attached to God. I have become a minister of the church.” (F6).

“One day, at the hospital, I saw an image of Saint Mary of Graces, and then I thought ‘She is going to heal me’.” (F9).

“I started to be more assiduous at church, because only God can give me strength to go through all this.” (F15).

Health worsening

The interviewees reported the perception that after the diagnosis and introduction of the antiretroviral medication there was a worsening in their overall health condition compared to the period before the diagnosis, which was highlighted in their reports:

“My health condition got a lot worse, I got many diseases… I got the pig disease [cysticercosis] and toxoplasmosis. […] I cannot sleep very well.” (F7).

“My health deteriorated a lot, I feel always tired, have no wish to do anything.” (F12).

“My health condition got a lot worse, I did not get as sick as I do now, I had stamina, I feel always tired. My AIDS exams are good, but it is the opportunistic diseases that cause this.” (F5).

“I feel very weak, have many health problems.” (F16).

When beginning using antiretroviral drugs, PLHIV experience unpleasant adverse effects such as nausea, vomit, and diarrhea. Additionally, the decrease in immunity resulting from the disease makes them susceptible to develop opportunistic diseases. These situations were pointed out in the speeches:

“Everything changes, now I cannot live without the medicines, I have got to take them all at the right time.” (F10).

“The real change was the medication issue, which is hard to get used to at the beginning. It is a way of life you have to adapt to from that moment.” (F18).

Human needs and nursing diagnoses

Self-esteem, safety and protection, and social needs were identified in the categories religious support, influence of the diagnosis on employability, and health worsening, so 35 nursing diagnoses were identified. The categories influence of the diagnosis on employability and health worsening were identified in the self-recognition need, with a total of 26 nursing diagnoses. The category health worsening was identified in the human physiological need, with seven nursing diagnoses. The category religious support was identified in the human spiritual need, with 18 nursing diagnoses.

The description of the human needs and the respective categories and nursing diagnoses are shown in figure 1 and chart 1.

Figure 1
Disclosure of the HIV diagnosis: correlation between human needs and identified categories

Chart 1
Nursing diagnoses according to the categories “influence of the diagnosis on employability”, “health worsening”, and “religious support” and related needs

CATEGORIES

Influence of the diagnosis on employability (Health worsening/Religious support)

Human need: Self-esteem; Safety and protection; Social.

Acceptance of the health condition at work, impaired

Adherence to the drug regimen

Anguish

Anxiety

Social support, reduced

Self-care, preserved

Autonomy, effective

Autonomy, interrupted

Low self-esteem

Capacity to manage the drug regimen, impaired

Behavior, negative

Belief, improved

Belief, impaired

Cultural beliefs, hindering

Discrimination

Treatment exhaustion

Social isolation, initiated

Fear of death

Fear of abandonment

Decreased fear

Need for health care and social support

Positive psychological response

Risk of compromising the psychological status

Risk of depression

Risk of discrimination

Risk of stigma

Risk of problems at work

Risk of emotional problems

Risk of isolation

Risk of isolation, reduced

Self-esteem service, reduced

Communications service, reduced

Health promotion service, reduced

Psychological status, diminished

Social status, impaired

CATEGORY

Influence of the diagnosis on employability (Health worsening)

Human need: Self-recognition

Acceptance of the health condition at work, reduced

Adherence to the drug regimen

Anxiety

Self-care, preserved

Self-management of the disease, proper

Self-management of the symptoms, proper

Autonomy, effective

Autonomy, interrupted

Capacity to manage the drug regimen, impaired

Capacity to participate in the care planning, proper

Negative behavior

Knowledge of the medication, proper

Knowledge of the pathological process, impaired

Health belief, decreased

Cultural beliefs, hindering

Deficit of knowledge of the disease

Discrimination

Hope, decreased

Treatment exhaustion

Positive health perception

Information processing, impaired

Risk of discrimination

Risk of problems at work

Self-help service, reduced

Communications service, reduced

Health promotion service, reduced

CATEGORY

Health worsening

Human need: Physiological

Anxiety

Diarrhea

Side effect of the medication

Treatment exhaustion

Nausea

Drug response, effective

Vomit

CATEGORY

Religious support

Human need: Spiritual

Anguish

Anxiety

Spiritual support, reduced

Capacity to communicate feelings, interrupted

Spiritual behavior, improved

Belief, improved

Belief, impaired

Availability for the spiritual status, proper

Hope

Hope, decreased

Fear of death

Fear of abandonment

Decreased fear

Emotional recovery

Positive psychological response

Risk of stigma

Risk of isolation, reduced

Spiritual status, proper

Discussion

Although the number of participants in the present was reduced, the sociodemographic characteristics of the examined PLHIV may help explain the phenomenon in similar scenarios.

Local studies reveal that HIV still prevails in men, especially when coinfection with tuberculosis is taken into account.⁽²⁵⁾ However, tendencies of feminization and pauperization in vulnerable populations have been verified,⁽²⁶⁾ together with the fact that women tend to trust people more when there are positive and support network-related experiences, which justifies the higher number of women in the present investigation.

Level of education and family income have been used as socioeconomic condition markers for patients with AIDS. In the present study, these markers were conditioned to the study setting. The NGO where the participants were recruited has open access, but the presence of a public with a disadvantaged financial condition and a lower level of education was noticed.

The categories identified in the reports of the participants show that the HIV/AIDS diagnosis still leads to situations of prejudice and discrimination. The NDs related to “influence on employability” are directly linked to self-esteem, safety and protection, social, and self-recognition needs. The influence of these needs corroborates several changes caused by the disease such as discrimination and social and family isolation, resulting in suffering at various moments in life, especially the possibility of losing their job, the costs inherent to the treatment, and the quality of life of PLHIV.

A study revealed that the risk of losing the job is associated with the stigma that PLHIV still have to face in the job market and that it interferes with their quality of life, given that it may impact on adherence to treatment.⁽²⁷⁾ These situations become evident in nursing diagnoses such as “Anxiety”, “Autonomy, interrupted”, “Discrimination”, and “Risk of problems at work”.

A metanalysis that examined the relationship between employability and adherence to the antiretroviral treatment concluded that this relationship is stronger (OR=1.85, CI 95%=1.58 – 2.18) in low-income countries.⁽²⁸⁾ Although Brazil is characterized as a developing country, the socioeconomic profile of the participants in the present study resembles that of populations who live in low-income countries, which may justify the situations of prejudice and discrimination.

Living with HIV/AIDS, a disease still very stigmatized by society, may hinder job maintenance or a new access to the job market, increasing the chances of unemployment and financial difficulties. These changes can cause stress, depression to cope with the disease, and difficulties to reentry the job market.

Religiosity and spirituality stand out as multidimensional factors, important to PLHIV/AIDS, especially those who belong to ethnical, gender, and generation minorities. These activities are indicated as mediators between the improvement in quality of life and health and the reduction of the stress originating from stigma and discrimination.⁽²⁹⁾

A study that analyzed the expressions of spirituality of PLHIV highlighted that the diagnosis contributes to reflections based on spirituality.⁽²⁹⁾ Therefore, the identification of nursing diagnoses such as “Belief, improved”, “Spiritual behavior, improved”, “Spiritual status, proper”, and “Hope” is expected.

The identification of nursing diagnoses in the category “religious support” has a close relationship with the category “influence on employability”, mainly regarding self-esteem, safety and protection, and social needs. This fact was also reported in a study that applied the ICNP^® to list diagnoses oriented to pregnant and postpartum women.⁽³⁰⁾

It is important to stress that the NDs in the category religious support related to spiritual human needs revealed that faith or belief in something divine functioned as a support before the adversities faced during the whole process of acceptance and coping after the HIV diagnosis. This fact was also demonstrated in another investigation⁽²⁷⁾ that emphasized the need for nurses to work on psychospiritual needs, an action that can influence coping with the disease.

The category “health worsening” involves five broad areas of human needs: Self-esteem, Safety and protection, Social, Self-recognition, and Physiological. These human needs have a direct relationship with the management of the drug therapeutic regimen, which causes significant side effects. A study that examined adherence of PLHIV to the treatment concluded that there was greater adherence among older patients, higher levels of T CD4 cells, longer diagnosis time, and a lower viral load. This investigation also reported that patients who attended appointments more often showed greater adherence.⁽³¹⁾

Knowing the health condition, side effects, the importance of the daily use of medication and changes in the routine results in an improvement in the quality of life of PLHIV.⁽²⁷⁾ These items help solving problems and show users the best ways to be followed, contributing to adherence to the drug therapy, and personal, social, therapeutic, and healthcare-related improvements.

It is possible to observe the complexity related to treatment withdrawal in the therapy itinerary of PLHIV, which is why due attention must be directed to the protagonism of people in treatment. Consequently, the diagnoses “Adherence to the drug regimen”, “Capacity to manage the drug regimen, impaired”, and “Treatment exhaustion” cannot be defined in isolation, but instead must be related to the self-esteem and self-recognition needs.⁽³²⁾

A general finding resulting from analysis of human needs and categories identified in the present study was that some NDs influence PLHIV directly and can contribute to nurses’ clinical practice. This evaluation is grounded on a data set that examines the individual and the context in which they are inserted, allowing professionals to provide a more human and comprehensive care. Authors sustain that the development of NDs specific for PLHIV is indispensable, because these diagnoses will drive nursing actions and make them tailored for the real needs of users.⁽³³⁾

The development of the present study revealed the need for nurses in the specific care to the public of the NGO, which led to the hiring of a professional who, together with the nursing technician of the institution, carried out the application of the nursing process and a more humanized and individualized work process.

Conclusion

The use of interviews with PLHIV in an NGO allowed to identify the implications of the moment of disclosure of the HIV diagnosis, as well as the NDs according to the ICNP^® and the human needs associated with the categories found. The interviewees reported modifications in their daily life such as the influence on work, attachment to religion, and health deterioration, which succeeded the introduction of the medication. Collected data revealed the numerous difficulties experienced by the patients after the diagnosis, but also demonstrated that, with support from healthcare professionals, the barriers could be overcome. After analysis of the reports, the profile of the studied population and the NDs were developed. The present study identified 86 NDs, among which 35 belonged to the categories religious support, influence of the diagnosis, and health worsening, 26 were associated with the categories influence of the diagnosis and health worsening, 18 concerned the category religious support, and seven were part of the category health worsening. The identification of NDs according to categories and human needs provides nurses with resources for their professional practice through the application of a standardized language, aiming at improving nursing care. The present study was carried out at an NGO in the interior of the Brazilian state of Paraná. This type of study setting may change according to the municipality and region of the country, but the authors believe that the results can encourage the development of new investigations in this type of environment, which would be an opportunity to apply the ICNP^® in nursing care, thus improving the quality of life of the assisted population. Using the nursing process becomes essential for care improvement and nurses’ decision-making.

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Publication Dates

• Publication in this collection
  Jan-Feb 2019

History

• Received
  11 June 2018
• Accepted
  13 Dec 2018