Development and psychometric evaluation of the nurse behavior toward confirmed and suspected HIV/AIDS patients (NB-CSHAP) scale

Caring can be classified into two generalized types as follows: instrumental caring and expressive caring.² Instrumental caring involves behaviors that are related to the technical aspects of care, such as performance of nursing intervention at bedside, and performing other professional expertise in providing care. In contrast, an expressive caring behavior pertains to the psychoemotive role invested by a nurse toward the patient. Examples of such behavior may refer to actions such as active listening, offering emotional support, and ensuring genuine presence.² In nursing practice, caring is universal and nondiscriminatory. However, its vulnerability to being influenced by several human and social factors is indisputable. Undeniably, the existence of stigma and discrimination in health care settings, particularly toward human immunodeficiency virus or acquired immunodeficiency syndrome (HIV/AIDS), continuously grow in number, causing late presentation and poor health outcomes of persons living with HIV (PLHIV).^3,4 Ideally, it is projected that by the year 2030 90% of those with HIV will be diagnosed, and 90% of those diagnosed will be on HIV antiretroviral therapy (ART), and 90% of them shall be undetectable of HIV.⁵ Although there are efforts initiated by different health sectors such as government, private, and non-government organizations in controlling the incidence of stigma and discrimination in their countries to meet the global goal of 90-90-90, the issue remains a challenge up to the present time, especially among low resource countries.

One of the most discussed topics in the literature that is linked to HIV/AIDS stigma and discrimination is the attitude of the health care workers toward these patients. A study strongly suggest the importance of an organization-led intervention to implement strategies where all ofits constituents and not only those on direct patient care, practice quality improvement in responding to organization-wide mitigation of HIV stigma and discrimination.⁶ The literature discussed that the lack of proper training and education on HIV among nurses contributes to the stigmatizing and discriminatory attitudes.^7,8,9 When there is a repeated opportunity to care for these patients, it is revealed that training and education reduce prejudicial attitudes and fear of HIV/AIDS.¹⁰ When nurses feel more confident and have enough awareness of how they can protect themselves, they display more willingness to care for HIV positive patients.^11,12

There are instruments and scales developed by various researchers that can be used in measuring the nursing practices in HIV care, which will help in improving it. There are valid and reliable scales assessing HIV stigma among nurses and their interaction with patients, and this includes the HIV stigma instrument-nurse (HASI-N).¹³ Similarly, the provider perception inventory (PPI)¹⁴ assesses health provider stigma on HIV/AIDS, substance abuse, and behaviors of men having sex with men. There are also scales measuring three dimensions, including self-stigma of the patients, their social stigma, and stigma in health facilities.¹⁵ Another study came up with a scale that measures not only the inducer to stigma in health facilities but also the attitudes of the health personnel toward PLHIV.¹⁶ There are also studies examining the attitudes of the care providers such as those conducted in Iran,¹⁷ Egypt,¹⁸ and Italy.¹⁹

Notably, however, there is a scarcity of observational studies, especially on the use and development of scales measuring the behaviors of care providers, particularly the nurses caring for both suspected and confirmed HIV/AIDS patients. There is a growing number of reports suggesting the lack of awareness of nurses of them being perceived as discriminatory by their patients.^20,21,22 It is on this note that the authors came up with this preliminary study to identify these behaviors and develop a measure on the nurses’ behaviors toward people with confirmed or suspected diagnosis of HIV/AIDS.

The apparent lack of a necessary instrument that centers on the nurses’ behaviors toward these population (confirmed and suspected HIV) prompted this initiative. This study aims (1) to explore the experiences of nurses in caring for patients with suspected or confirmed HIV; (2) to develop a valid and eliable instrument to measure nurses’ behaviors toward these clients, and (3) to explain the relevance of utilizing a mixed method design in the conceptualization and development of a scale.

In this phase, descriptive qualitative inquiry was utilized to assess their experiences. The participants were asked to use the guide question, “How was your experience in caring for a suspected or confirmed HIV patient?” Subsequent probing questions were asked from our informants, which facilitated gathering of rich qualitative information.

In this phase, the first draft of the instrument was explored for content validity and reliability.

There were two overarching dichotomous themes revealed from the textural interview data. The first over-arching theme found throughout the nurse participants’ stories were their quintessential behaviors: The positive or quintessential behaviors were related to the following clusters coded as Compassion, Nondiscrimination, Connecting, Self-preservation, Mentoring, Professional Competence, Confidence, Humor, Generosity, Altruism, and Presence. The second overarching theme found throughout the nurse participants’ narratives were related to some of their negative behaviors. These negative behaviors were mostly related to the following clusters: gossiping, excessive personnel protective equipment (PPE) use, refusing to care, detachment, anxiety, and fear.

We utilized the principal component factor as the factor extraction method in the developed instrument. There were two methods utilized to assist the researcher in the decision of retaining factors. The first step used was the Kaiser's criterion or the eigenvalue rule, which suggests that factors with an eigenvalue of 1.0 or more are retained for further analysis. The eigenvalue of a factor represents the amount of the total variance explained by that factor. The results revealed that there were four factors that have eigenvalues of >1.00. This suggests that four factors may be extracted from the NB-CSHAP scale (Table 4). When these four factors are extracted, this can explain 59.3% of the scale's total variance. To verify this, the researcher used the second approach, which is Cattell's scree test. This is a more visual guide in determining the number of factors that were retained (Figure 2).

Figure 2

Cronbach's alpha was determined twice (Table 5): (1) totality of the scale, and (2) per factor (subscale). Results revealed an acceptable internal consistency of 0.73 reliability score³¹ for the entire 16-item scale. However, when per factor internal consistency was examined, it showed that Factors 1 and 2 have acceptable reliabilities, while Factors 3 and 4 have low-reliability scores. This may be because of the low number of items in the subscale.

The behaviors which are negatively stated are reverse-scored such that the highest score of 5 are scored as 1, and the lowest score of 1 is scored as 5. The items for reverse coding are those that belong to discriminatory behaviors subscale. The highest possible score for this scale is 80. Specifically, the scores are described as appropriate/caring behaviors (53–80 points); mediocre behaviors (26–52 points), and undesirable/stigmatizing behaviors (0–25 points).

The sequential exploratory mixed method on this study is an appropriate method in unifying techniques in designing and developing an instrument. The qual-quan sequence observed on this study illuminated qualitative exploration of the nurses’ experiences in caring for patients with HIV/AIDS which were the basis on which a reliable scale can be developed.

The four identified factors were named discriminatory behaviors, service-oriented behaviors, openhanded behaviors, and perceptive behaviors, which were described based on the items the factor categories.

Factor 1. Refers to behaviors showing service-oriented behaviors. The seven items under this factor describes a nurse who displays behaviors true to her professional calling. Nursing is a profession that provides caring services to patients who are in need. Typical examples discussed in the literature highlights the importance of these behaviors in nurse-patient interaction.^36,37,38 Service-oriented behaviors in the nursing profession are acts that imbibe the expression of compassion, professionalism, nondiscrimination, and mentoring. An example under this category is item number three that states, “I offer guidance to my junior nurses who are new in handling critical cases.” Communicating with colleagues such is vital for quality patient care.³⁹ The behavioral exchange that transpires during this process is anchored on the goal of patient safety.

Factor 2 refers to discriminatory behaviors. These are items that describe stigmatizing and discriminatory behaviors. Here four items are included that depict acts of gossiping, avoidant behavior, and detachment. Literature explicitly discussed that care providers such as nurses are prone to display negative behaviors especially when they lack adequate knowledge of HIV.^11,40

Factor 3 refers to openhanded behaviors. These are benevolent behaviors that reflect the acts of presence, generosity, and the provision of holistic care. Holistic caring behaviors are always emphasized in nursing as a necessity to be practiced by those in the profession. To be a holistic nurse entails the provision of care on the entirety of human facets comprising the physiological-psycho-social and spiritual needs. Bakar et al.⁴¹ suggest nurses have more caring attributes when they are spiritually rooted.

Factor 4 refers to perceptive behaviors. These are behaviors that pertain to being sensitive when the need arises. These are behaviors of humor and altruism. A sympathetic nurse can inject humor while at work, especially in stressful situations. Similarly, altruistic actions such as risking the self when necessary are selfless behaviors where a nurse prioritizes what is for the best interest of patients under her care. Alavi et al.⁴² discussed how nurses tend to possess empathetic tendencies and self-sacrifice in their workstations. Perceptive behaviors are related to the sense of the sensitivity of a nurse to make difficult situations as pleasing as possible.

In summary, the NB-CSHAP scale is generally classified into two distinct behaviors: the caring behaviors and stigmatizing behaviors. Caring behaviors comprise the SOP in caring which consists of service-oriented behaviors, openhanded behaviors, and perceptive behaviors. The SOP behaviors are the quintessential behaviors a nurse must possess when caring for patients suspected or confirmed with HIV/AIDS. On the other hand, behaviors considered as stigmatizing behaviors are prone to be misconstrued as offensive and discriminatory.

The value of the qualitative component in designing the instrument using mixed-method design relies on the fact that the items included in the devised tool were organic on the experience of the participants. Following this premise, it makes the instrument a legitimate and authentic instrument on the construct it intends to measure.

The scarcity of a scale to measure the nurses’ behaviors in the literature is an indication that the construct has not been explicitly contextualized, particularly toward patient care with suspected and confirmed HIV/AIDS. This novel initiative in measuring behaviors will provide a deeper understanding of specific actions that are often misinterpreted or challenging to understand. The authors believe that studies related to HIV care can be improved further and not limited to determining only the knowledge and attitudes of nurses but rather include assessment of their behaviors. These behaviors are essential in involving and engaging into the secluded life of persons with HIV.⁴³ The newly developed NB-CSHAP scale can support studies and investigations related to the nurse's interaction with an HIV patient. The scale can be used by health facilities, especially among nurse supervisors, to assess the behaviors of their nurses to foster an improved behavior toward patients with HIV/AIDS. Nurse leaders can strategize measures to enhance the caring behaviors of nurses, which is an essential step in reducing HIV stigma in health facilities. Reducing, if not eliminating stigma prone behaviors, will not only improve the quality of nursing practice but also ultimately achieve improved patient outcomes.