Nursing care in serodifferent relationships: an analysis in the light of Imogene King

Abstract

Objective

to reflect on the possibility of using Imogene King’s assumptions as a theoretical basis for nursing care in HIV-serodifferent partnerships.

Method

a descriptive study of a reflective nature, with the theoretical contribution of Imogene King’s Goal Attainment Theory.

Results

the reflections gave rise to two axes of analysis: in the first, it is necessary to detail Imogene King’s conceptual assumptions and goal attainment, and in the second, the convergence of King’s theory in caring for serodifferent relationships is explored with regard to their limits, possibilities and developments in the personal, interpersonal and social systems. Concepts such as perception, interaction and organization form the central axes of the systems and enable a broader understanding of serodifferent partners’ demands with a view to balancing stress factors for maintaining health.

Final considerations and implications for practice

the understanding of open systems applied to people living with HIV individually and in a dyad with their partner, both inserted in groups in society, results in a better understanding of their needs and thus contributes to planning targeted goals.

Keywords:
Nursing Care; Nursing; HIV; Sexual Partners; Health Services

Resumo

Objetivo

refletir sobre a possibilidade de utilização dos pressupostos de Imogene King como fundamentação teórica para os cuidados de enfermagem a parceiros sexuais sorodiferentes ao HIV.

Método

estudo descritivo de caráter reflexivo, com o aporte teórico da Teoria do Alcance de Metas de Imogene King.

Resultados

as reflexões deram origem a dois eixos de análise: no primeiro, cumpre-se detalhar os pressupostos conceituais de Imogene King e o alcance de metas, e no segundo, explora-se a convergência da teoria de King no cuidado às relações sorodiferentes no que concerne aos seus limites, possibilidades e desdobramentos nos sistemas pessoal, interpessoal e social. Conceitos como percepção, interação e organização formam os eixos centrais dos sistemas e possibilitam a compreensão ampliada das demandas dos parceiros sorodiferentes com vistas ao equilíbrio dos fatores estressores à manutenção da saúde.

Considerações finais e implicações para a prática

o entendimento dos sistemas abertos aplicados à pessoa que vive com HIV individualmente e na díade com seu parceiro, ambos inseridos em grupos na sociedade, resulta em uma melhor compreensão de suas necessidades e, assim, contribuem com o planejamento de metas direcionadas.

Palavras-chave:
Cuidados de Enfermagem; Enfermagem; HIV; Parceiros Sexuais; Serviços de Saúde

Resumen

Objetivo

reflexionar sobre la posibilidad de utilizar los supuestos de Imogene King como base teórica para el cuidado de enfermería en parejas VIH-serodiferentes.

Método

estudio descriptivo de carácter reflexivo, con el aporte teórico de la Teoría del Logro de Metas de Imogene King.

Resultados

las reflexiones dieron lugar a dos ejes de análisis: en el primero, es necesario detallar los supuestos conceptuales de Imogene King y el logro de objetivos, y en el segundo, se explora la convergencia de la teoría de King en el cuidado de las relaciones serodiferentes en cuanto a sus límites, posibilidades y desarrollos en los sistemas personal, interpersonal y social. Conceptos como percepción, interacción y organización forman los ejes centrales de los sistemas y permiten una comprensión más amplia de las demandas de las parejas serodiferentes con vistas a equilibrar los factores de estrés para mantener la salud.

Consideraciones finales e implicaciones para la práctica

la comprensión de los sistemas abiertos aplicados a personas que viven con VIH individualmente y en pareja con su pareja, ambas insertadas en grupos de la sociedad, resulta en una mejor comprensión de sus necesidades y, así, contribuye a la planificación de objetivos específicos.

Palabras claves:
Atención de Enfermería; Enfermería; VIH; Parejas Sexuales; Servicios de Salud

INTRODUCTION

The establishment of affective relationships serodifferent to the Human Immunodeficiency Virus (HIV) has been shown to be possible and increasingly amenable to an optimistic prognosis regarding the maintenance of sexual partners’ mixed serological status.¹ This reality is the result of the promising reach of drug treatment and the adoption of preventive technologies available in Brazilian Health System services.²

The monitoring and healthcare provided to these partnerships relies on a multidisciplinary team that works in the Healthcare Network for people living with HIV (PLHIV) through specialized services and Primary Health Care (PHC). Among the professionals working on the team are the doctor, psychologist, pharmacist, social worker, and nurse.³

Nursing, a science that brings care in its essence, seeks, together with serodifferent partners, a comprehensive and human understanding of their needs and care promotion that addresses the various nuances that surround relationships of this nature.⁴ The desire for fertility and safe reproduction, access to antiretroviral treatment and prophylaxis, strategies for maintaining safe sex, fears, doubts and anxieties, among others, are demands that require professional nursing practice to provide healthcare capable of acting in the face of these challenges.⁵

In order to seek improvements to practice aiming at comprehensive care, nursing seeks to implement theoretical assumptions that encourage a humanistic care model that values patients in their biological, psychological and social dimensions. Nursing theories, especially those of an interactionist nature, such as that of Imogene King, have been a strong foundation in the care and scientific spheres for understanding and directing nursing care that values these dimensions and human relationships and is, therefore, effective and resolute.⁴-⁶

The Goal Attainment Theory proposed by King consists of a theoretical framework that guides nursing actions and can reveal important understandings regarding the perspective of its application in the context of HIV serodifference, since the theory states that, through interaction between nurse and patient, individually or in groups, it becomes possible to jointly establish the needs of each individual and, thus, attain the established goals, enabling the maintenance or improvement of patients’ health conditions with a view to their autonomy.⁷

This interaction takes place through a structure of open and interacting systems (personal, interpersonal and social systems) that, according to the theory, translate what individuals are and reinforce the premise that their theory starts from an understanding of the personal to the environment.⁷

In this regard, as it is a context in which PLHIV’s needs are highlighted as a subject who makes it possible to experience a serodifferent affective relationship, according to partners’ needs as a dyad and partners’ needs inserted in society, King’s theory can represent a reference valuable for directing conduct and improving the nurse-partner relationship to attain the goals set.⁷

Therefore, this study aims to reflect on the possibility of using Imogene King’s assumptions as a theoretical basis for nursing care for HIV-serodifferent sexual partners.

METHOD

This is a descriptive text with a reflective nature, which analyzed aspects related to nursing care in HIV serodiversity under the auspices of Imogene King’s theoretical assumptions about attaining goals. The results of the reflection were presented through two axes of analysis: in the first, it is necessary to detail Imogene King’s conceptual assumptions and goal attainment, and in the second, the convergence of King’s theory in caring for serodifferent relationships is explored with regard to their limits, possibilities and developments in the personal, interpersonal and social systems.

RESULTS AND DISCUSSION

King’s Goal Attainment: a brief overview

Imogene King was born in 1923 in West Point, Iowa, in the United States and was responsible for developing the Goal Attainment Theory. Her theory had its genesis in the 1960s with the evolution of the conceptual assumptions that the theorist believed underpinned nursing care actions. The conceptual basis of her thinking emerged from the relationship between nurse and patient with a view to attaining objectives, outlined and executed through the process of interaction between them and individuals with the environment.⁷

King based her theory on Ludwig von Bertalanffy’s Systems Theory, considering that the science of the whole that is addressed in the model gave her hope that the complexity of nursing could be analyzed as “an organized whole”. King’s theory contributed to strengthening nursing education, serving as a structure for several nurse training programs.⁸

King’s theory is considered a grand theory within the holarchic structure of nursing knowledge, having served as a reference for researchers around the world in the development of medium-range theories and in empirical research situations as well as in nursing practice itself.⁸

In her work, “Toward a theory for Nursing: General Concepts of Human Behavior”, published in 1971, King proposes a conceptual structure for nursing, a fundamental initial concept that led the author to evolve towards her theory. Soon after, King published “A Theory for Nursing” in 1981, a work that expands her initial concepts and identifies the structure of open systems, the main concept that shaped her theory.⁸

The Systems Theory designed by King defines health as a continuous harmony with stressors in the environment, whether internal or external to the subject. These systems, according to the theory, form individuals and present themselves as dynamic and interacting in the search for ensuring balance and health. King named the three systems personal, interpersonal, and social.⁷

The personal system consists of visualizing each individual’s characteristics that, according to King, will react to the events experienced according to their perceptions, expectations and anxieties. Therefore, each individual has their own personal system and holds their uniqueness. Among the main concepts that form the personal system are perception, ego, growth and development, body image, space, learning and time.⁷

The interpersonal system reflects one of the concepts that underlie the theory: interaction. In this way, human beings live in interaction in the environment, forming dyads, triads or groups as human relationships are established through communication, another concept that appears in this system as well as transaction, role and stress, which will be detailed on the next axis.⁷

The social system encompasses individuals’ living in society, which includes the family environment, religious groups, educational systems, work systems, among others. The main concept of this system is related to organization, in which each human being has roles and lives in society based on social rules, behaviors and practices aimed at the well-being of this social organization, which is related to attaining both personal and organizational goals.⁷ In addition to organization, concepts such as authority, power, status, decision-making and control also constitute this system.⁷

It is through these three systems, according to King, that nurses are able to interact with patients and reach an understanding of their needs, in which each of them has relevant concepts that must be considered in care planning.

HIV serodifference in personal, interpersonal and social systems

In the context of HIV serodifferent relationships, the personal system proposed by King can be visualized in the figure of PLHIV, in the search to understand their individual needs based on the idea of how these people see themselves, develop and perceive themselves in the environment in which they live.

Perception, the main concept of this system, refers to the representation of what is real in each human being, processed by their senses and memory and, finally, interpreted, i.e., it is subjective and personal.⁷ This concept can be related to how each PLHIV understands and deals with the infection, such as their feelings, the impact of diagnosis on their life, and their understanding of prospects for having a quality life.

Perception is closely related to the concept of ego, considering that it is composed of thoughts and feelings that constitute a person’s perception of their individual existence.⁷ From access to diagnosis to continued adherence to antiretroviral treatment (ART), PLHIV can experience different perceptions regarding the virus and the possibility of having a relationship with a serodifferent partner, such as living from the perspective of fear, non-acceptance of diagnosis, adoption of secrecy as protection, escape from treatment, as well as the reproduction of infection-related stigma.⁹-¹¹

According to the theory, perception is formed from information availability in the present moment.⁷ Thus, it is common for patients to experience a critical moment at the beginning of their diagnosis, as they do not have sufficient and up-to-date knowledge about advances in HIV-related therapy, such as the importance of ART in reducing viral load to non-communicable and available strategies for safe family planning.¹² Thus, nurses establish a collaborative link to promote the construction of a basis for perception formation.

Growth and development in the personal system encompasses the evolution of people throughout their lives as well as changes that may affect their goals and care needs.⁷ When discovering oneself as a PLHIV, negative feelings can rule this moment, such as fear of pain and death, anguish because they think they can infect partners, thinking that their emotional/sexual life is doomed, or even believing in the impossibility of having a healthy child. These feelings originate because it is an incurable sexually transmitted infection and is still a socially stigmatized disorder shrouded in myths and prejudices.¹²,¹³

These demands are overcome as individuals enter healthcare services, adhere to treatment and, above all, establish a bond with nurses who, upon identifying these nuances, outline the necessary goals. Thus, PLHIV go through this process of construction and transformation, in order to update the self and have a vision of themselves as a human being who harbors a virus in their body, but which may have a life expectancy, in addition to being able to experience experiences, such as having a relationship again with a partner who may have a different serological status.¹⁴,¹⁵

The personal system still highlights body image, characterized by the way in which subjects conceptualize not only their own appearance, but the reactions of others to it.⁷ Body image can be affected by several factors related to the infection and, in many cases, by the side effects of treatment that affect the body, also related to low self-esteem due to having a negative self-perception and representing a risk to their partners with negative serology.¹⁶ Such aspects can lead to changes in quality of life and emotional well-being.

The time in which changes in perceptions and behaviors occur is relational and can be in accordance with the stages of personal life, as the theorist states. Therefore, each individual experiences their process of change according to their singularities and events.⁷ This understanding is fundamental for nurses to understand PLHIV’s needs, depending on the time each one needs, to build new perceptions about the infection and discard old ones, especially those that constitute obstacles to adherence to treatment and adoption of healthy behaviors.

Thus, as the process of growth and development takes place, the goals set by nurses change and accompany this process of transformation, mediated by patients’ needs. Therefore, established goals change over time.⁷

The interpersonal system formed by the grouping of individuals can be materialized in PLHIV in an affective relationship with their HIV-negative partner as well as a relationship established between professional (nurse) and partner. In this context, serodifferent couples face changes and adaptations in the relationship fostered by the transmissible and incurable nature of HIV.¹⁷ These changes have an impact on the couple’s relationship and affective-sexual behavior, which can range from sexual abstinence between them to attitudes of denial of the risk of acquiring and transmitting viruses.¹²

The concept of interaction is based on the performance of individual roles between those involved during the communication process to develop goals and develop means to attain them.⁷ In this way, the interaction takes place in the nurse, PLHIV and seronegative partner triad; the latter must also be the target of care actions, in order to enhance goal attainment, since therapy in the context of serodifference must be seen as a dyad, in order to strengthen risk prevention and act on the challenges and elucidation of living with the infection.¹⁷

Communication, in its multiple manifestations, consists of the exchange of thoughts and opinions between individuals, as well as requiring nurses’ knowledge and skills to provide quality nursing care.⁷ The core of communication between serodifferent partners and nurses is not limited only to clinical issues, but must also be aimed at promoting qualified listening, health education and emotional support.¹² It is worth highlighting the importance of welcoming and unprejudiced communication to foster the creation of bonds and trust between partners and professionals.¹⁴-¹⁸

Transactions constitute the complex interactions between subjects included in healthcare and the environment, in which nurses are responsible for mediating this continuous process of action and reaction, i.e., it is the process of overcoming difficulties.⁷

In this regard, the concreteness of the transaction is based on attaining agreed goals, involving the triad (nurse-PLHIV-partner) during interactions, such as in nursing consultations regarding dialogue regarding adherence to antiretrovirals, whether as treatment or prophylaxis, the safest preventive method, family planning depending on the couple’s cultural and psychosocial aspects as well as management of existing risks according to partners’ vulnerabilities.¹⁴-¹⁸

The role concept attributed by King reinforces the importance of nurses and partners recognizing that, at one moment, they will find themselves in the role of donor and, at another, of receiver, depending on the space and situation.⁷

Nurses have a range of knowledge and skills that become references for partners to adhere to behaviors that promote well-being, ranging from medication-oriented care (ART, pre-exposure prophylaxis and post-exposure prophylaxis) to behavioral care. In the role of receiver, nurses’ sensitive and welcoming listening encourages the partners’ role of donor by raising their doubts, questions, fears and anxieties regarding the experience of serodifference.¹⁹,²⁰ This concept permeates the three systems and, when there is no adequacy of the “self” to the role to be played, results in stress in the environment.

Stress corresponds to a state of dynamicity between the subject and the environment, which can affect the physiological, psychological and social segments, with a view to regulating and controlling stressors, in which, whether positive or negative, interferes with individuals’ emotional state, their interactions and the development of their role.⁷ In serodifference, stressful factors can be marked by the adoption of diagnostic secrecy between partners,⁹,¹⁰ partners with different levels of knowledge about the infection, nurses with a lack of knowledge about their actions in the face of serodifference, especially in relation to preventive strategies for safe pregnancy and conception.¹²

In relation to the social system, the theory characterizes it as an organization of groups that have special interests and needs, forming societies, in which constant activities are carried out to attain goals.⁷ In HIV serodifferent relationships, some groups are part of the social relationships established with partners and serve as social support, such as the family, professional, friends and religious community.¹⁹

The family represents an important reference in an individual’s life as it is seen as a support and care network, and, in addition, it can have the power to influence perceptions and decisions.²¹ When knowing about serodifference, partners’ families do not always provide the expected support, especially from seronegative partners, as they focus their perception on a relationship that represents a risk to health.¹⁷

The concept of status is related to the prestige acquired by playing a role.⁷ This concept can be seen when HIV-negative partners are seen as beings in a superior position to partners living with HIV, for not living with the virus, with HIV-positive partners being attributed the role of being unworthy of having an HIV-negative partner by their side.¹⁷

Thus, aiming at the goal of managing existing conflicts and ensuring well-being within the family, many partners opt for the decision to keep diagnosis confidential, with knowledge restricted to partners only.⁹,¹⁹,²¹,²² Or they choose to face the lack of knowledge and prejudices that often constitute motivation for discouraging relationships of this nature. It is worth highlighting the importance of this last conduct being encouraged together with partners, as family network support represents support and encouragement in promoting health and adhering to ART.¹⁰,²¹

This scenario highlights the importance of nurses understanding such a system, as it helps to identify partners’ social structure and the relationships that are established, in order to visualize the social roles and behaviors developed by actors that may or may not be favorable to attaining goals that contribute to maintaining partners’ health.

Another social group worth highlighting in this system are the healthcare services responsible for monitoring partners in therapy, such as specialized services and PHC health units, which share care for PLHIV. These environments in the social organization of serodifferent partners must use their authority and power which, according to King, serve as a guide for the actions of the self and others to welcome, guide and provide healthcare, whenever requested,⁷ even in the absence of a specific flow of care for HIV serodifferent partners in these services.

Thus, it is worth reinforcing that the literature mentions the need for training healthcare professionals in managing HIV serodifferent partnerships and updating knowledge about current possibilities and strategies for maintaining these relationships.¹-²² This need arises in the context of invisibility of serodifference in healthcare services, which can be motivated by stigmatizing behaviors or a lack of knowledge to deal with these demands.¹

The power and decision-making that King portrays can be related to the possibility for nurses to set their own training as a goal, since such concepts are fundamental for an organization. Thus, the search for knowledge makes nurses more prepared to deal with serodifference, because, according to the theory, the judgments made by social actors affect the course of their actions.¹²,²³

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

The reflections listed suggest that the Goal Attainment Theory proposed by King is a strategic and promising foundation for thinking about nursing actions in the context of HIV serodifference. The understanding of personal, interpersonal and social systems, applied to PLHIV individually and in the dyad with their partner, both inserted in groups in society, expands nurses’ perception of the needs that will require goal planning to attain them.

Understanding the interaction of these systems encourages nurses to look holistically and signals the importance of seeking professional preparation at the level of knowledge that serodifference requires and, thus, attaining the goal that nursing continually seeks to attain: offering comprehensive and with quality.

Furthermore, the relationship between King’s theory and serodifference highlights the importance of interactions established between nurse and partner, since they are taken as a starting point for establishing their adherence to healthcare services, whether specialized or at the PHC level, and one of the most important goals outlined by health policies aimed at caring for PLHIV.

A limitation of this study includes the scarcity of literature with approaches to nursing care in the context of HIV serodifference.

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Edited by

ASSOCIATED EDITOR

Antonio José Almeida Filho https://orcid.org/0000-0002-2547-9906

SCIENTIFIC EDITOR

Marcelle Miranda da Silva https://orcid.org/0000-0003-4872-7252

Publication Dates

• Publication in this collection
  19 July 2024
• Date of issue
  2024

History

• Received
  27 Feb 2024
• Accepted
  09 May 2024