Developing a novel sexual health counseling training for HIV healthcare providers in the Netherlands: A mixed method study

Members were selected based on their academic experience and expertise in IM, nursing care, and HIV care. The 11 experts had various expertise: interdisciplinary social science/IM, applied psychology/IM, health psychology/IM, nursing science/HIV patient care, physician/HIV patient care, three HIV experts and three HIV nurses: one specialized in sexual health and one the principal investigator (PI). This planning group convened on a monthly basis in various compositions to guide the IM process.^[14] Planning group members are encouraged to think about adoption and implementation from the start.

Four empirical studies were conducted.^{[18,19,20,21]} First, a cross-sectional survey was conducted among all Dutch HIV physicians (N = 110) and HIV nurses (N = 82) in order to gain further insight into their roles in SHC within routine HIV care.^[20] Participants were recruited via the Netherlands Association of HIV Physicians (NVHB) and the Netherlands Professional Association of HIV Nurses (VCH). Participants completed an online questionnaire about their current practice and involvement in SHC. SHC was provided less by physicians (26.1%) than by nurses (83.9%; p < .001). Nurses were more likely to discuss issues about patient well-being and psychosocial functioning. The main reason for not providing SHC was the presence of a third party. Physicians reported this 9% of the time, nurses 60.4%. The second reason was insufficient time due to the limited duration of consultations. The third was that patients themselves do not initiate conversations about SHC, interpreted as meaning that SHC should not be initiated by a physician or nurse. Both groups indicated a need for more practical knowledge and skills about sexual health issues and counseling. The planning group decided on the need for an intervention promoting SHC, specifically by nurses in routine HIV care. Additionally, as HIV in the Netherlands primarily affects men who have sex with men (MSM), the intervention should support HIV nurses in addressing sexual (risk) behavior during routine consultations with MSM with HIV. The second study focused on the experiences of HIV nurses in discussing SHC with MSM.^[18] This involved three semi-structured focus group discussions (FGDs) with 22 HIV nurses from 17 HIV treatment centers. The FGDs were transcribed and analyzed to identify meaningful patterns.^[22] HIV nurses infrequently initiated SHC, and lack of time was again the main barrier. Presence of a third party was never mentioned as a reason for not providing SHC; other reasons included embarrassment and having to cover many issues during routine HIV care, making prioritization difficult. Nurses mentioned that feeling confident about their knowledge and skills is a prerequisite for SHC.

The third study was an online survey on the determinants of HIV nurses’ discussing SHC with PWH, based on the Theory of Planned Behavior ^[23,24] and the findings of the qualitative study.^[19] Seventy-nine HIV nurses completed a self-report questionnaire. Consistent with previous studies, the intention to prioritize SHC was impeded by time concerns and competing priorities. Supportive determinants were positive attitude, high perceived self-efficacy, and confidence in their own skills discussing sexual health. The intention to initiate and discuss sexual risk behavior was again found to be influenced by time concerns and other priorities during consultations, contrasted with a positive attitude and high perceived self-efficacy regarding SHC and confidence in knowledge and skills.^[20]

The fourth study comprised the analysis of video recordings of routine HIV consultations of HIV nurses with PWH from four Dutch HIV treatment centers, using real-life data from clinical practice to assess whether nurses’ behaviors during consultations were in line with previous findings.^[21] Four participants from four hospitals consented to participate, and 16 recordings of consultations were analyzed. The duration of consultations, time spent on sexual health issues, topics addressed, and the communication functions and skills employed were all recorded. When sexual health was discussed, the time spent on this topic was relatively brief, with nurses typically adopting a more directive approach rather than engaging in conversation. SHC was not typically discussed during consultations. When discussed, effective communication was rare, and attention to psychological and social factors was limited. Nurses predominantly used technical communication skills and provided STI-test results and medical treatment.

In the Netherlands, HIV care is provided in 24 HIV treatment centers by 110 HIV physicians and 86 HIV nurses. PWH visit an outpatient clinic once or twice a year for consultation with an HIV nurse who monitors patients’ health, addresses medical and psychosocial needs, provides additional support and care, or refers to another specialist. All HIV nurses are registered nurses specialized in HIV care and members of the Dutch association of HIV Nurse Consultants. Some obtained a post-graduate qualification, and some completed dedicated sexual health training, provided by STI/AIDS Netherlands, the center for STI-prevention.

The VCH (2015) has developed guidelines; however, these are not recent and reflect a biomedical perspective.^[25] VCH guidelines refer to the relevant European guidelines, which state that all HCPs should ask PWH about their sexual and reproductive health to make sure that PWH receive appropriate and ongoing reproductive counseling. They do not include recommendations on what should be addressed, and how.^[26,27] The work of HIV nurses is mostly based on guidelines developed by the National Organization of HIV Physicians. Hospital managers also determine what and how nurses do their jobs.

The results of the needs assessment were summarized in the form of a logic model of the problem (see Figure 1) which identifies the overarching problem to be addressed on the right: suboptimal quality of sexual health and quality of life. Moving to the left, problems arise because PWH may experience multiple sexual health issues, plus the behavioral and environmental factors that may influence their sexual health. The planning group identified these behavioral factors as critical. At the far left of the model the determinants of providing SHC are shown which should be addressed by our intervention.

Figure 1.

Logic model of the problem of HIV nurses in the Netherlands regarding providing sexual health counseling

The planning group discussed the findings of the needs assessment and used their expertise to define program goals for the three most important and changeable SHC-behaviors of HIV nurses “during routine HIV consultations”:

1) Nurses initiate SHC

2) Nurses discuss and follow up SH topics more in depth

3) Nurses apply effective communication for SHC.

A multidisciplinary planning group formulated outcomes for the program goal, defined in step 1.5. The PI defined desired changes at the behavioral level (POs), to promote and increase the provision of SHC by nurses, making the required behavior of the nurse specific.

PO 1: Nurses initiate SHC during routine HIV consultations twice a year. Sexual health communication currently does not meet the needs of patients; nurses have expressed that they only discuss sexual health when patients raised the topic.^[20,28,29] Moreover, sexual health was not sufficiently addressed between patients and nurses. These findings revealed a strong discrepancy between patients’ and nurses’ views on who is responsible for initiating this discussion and the willingness and comfort levels. Consequently, nurses should take the initiative, when necessary.^[30,31]

PO 2: Nurses discuss SHC and follow up those topics linked to sexual health more in depth, twice a year, during routine HIV consultations. Patients regard effective sexuality communication as essential and feel comfortable with it.^[5,31]

PO 3: Nurses communicate effectively about sexual health during routine HIV consultation twice a year. In our observational study, HIV nurses only occasionally applied communication skills (i.e., asking open questions) and rarely checked if the patient had understood the information given;^[21] in line with earlier studies.^[19,20]

After formulating these POs, we selected their determinants, based on relevance, strength of the association with the behavior, and changeability. Similarly, setting priorities, because other topics need attention during consultation, which negatively affects nurses’ attitude towards SHC as well as the quality of SHC. For example, the presence of a third party (e.g. a translator) is not changeable, but may have influence. Some HIV nurses feel negative emotions, such as embarrassment and discomfort, indicating that perceived skills and personal norms and values are relevant. These insights indicate critical determinants of SHC which are changeable through training, supervision, and support. Finally, a multidisciplinary approach is needed to generate a supportive social norm, encompassing guidelines for HIV nurses, and additional training tailored to the needs of HIV healthcare providers. We identified attitude, social norm and self-efficacy/skills (and their underlying beliefs), as determinants in the matrix of change objectives.

COs were formulated that match each determinant with its PO, guided by the needs assessment. For example, for “Nurses apply effective communication for talking about sexual health during routine HIV consultation”, “attitude” is one of the determinants; we formulated the CO “Describe applying communication skills as necessary and important”. This CO is necessary and achievable because sexual health is not always discussed during routine HIV consultation and, if brought up, often without structure and/or communication strategies.

A list of possible determinants was compiled, and refined based on evidence from the literature and needs assessment. The Matrix of Change Objectives was developed connecting Performance Objectives with identified relevant and changeable Determinants, guiding the development of the training program (see Table 1). In the final task of step 2, we created the logic model of change for the intervention, combining performance objectives with determinants. As part of the later program evaluation, questions can be asked to determine whether HIV nurses achieved the performance objectives, which provides valuable information for evaluating the program’s effectiveness.

To ensure the intervention met the needs of HIV nurses, a linkage group of five full-time HIV nurses from various hospitals supported the planning group. This group provided input on specific questions and tested ideas. Discussions with the linkage group resulted in several general themes for the intervention. First, nurses needed to be aware of a number of topics to be discussed with patients regarding sexual health. In addition, they required more knowledge about sexual health from both medical and psychosocial perspectives. With regard to communication strategies, nurses expressed a desire to exchange counseling experiences with other nurses. These themes were aligned with the earlier needs assessment.

Another vital finding was related to the mode of delivery. The linkage group recommended a flexible, hybrid, 1.5-day face-to-face training program to accommodate users’ needs and time constraints. The final intervention was a 1.5-day training program. In our intervention, we used elements of a five-day course from 2005 designed for HIV nurses on basic knowledge regarding anatomy and physiology.^[25,32]

For the training, we reviewed literature on interventions for healthcare professionals in clinical settings. Verrasto (2020) found that participation in sexuality education programs significantly improved HCPs’ ability to address patients’ sexuality issues.^[33] The review emphasized the need for sexual health education and highlighted the importance of investing in training to enhance nurses’ skills and comfort. Case studies and role-playing have considerable advantages over traditional lectures. This review supports the importance of providing HCP with at least some training, and the opportunity to organize longer training sessions with interactive activities to enhance their comfort and confidence when counseling patients on sexual issues.

During three interactive sessions, based on the formulated objectives of the program, the planning and linkage group selected theory- and evidence-based methods for achieving the change objectives. Based on the nurses’ experience and the results of the literature search, the most suitable methods were selected and translated into potentially feasible practical applications.^[14,33]

As the HIV nurses in the linkage group mentioned time as a barrier, time management was chosen as an important issue. Moreover, the planning group selected methods and applications appropriate for the context and clinical practice. Examples of the outcomes for PO1 is are presented in Table 2. Methods and applications for PO1 (remaining), PO2 and PO3 are described in the supplementary files.

The determinants of the previous steps led to a choice of behavioral change methods that fit into a 1.5-day workshop. The final intervention needed to be flexible in use and easy to adjust, either face-to-face or online.

Translating behavioral change methods into applications requires a sufficient understanding of the theory behind the method, especially the parameters necessary for the effectiveness of the change process in practice.^[15] Table 2 provides an overview of the intervention for PO1: “Providers initiate SHC”, including theory-based change methods, their translation into practical applications, and how these relate to earlier determinants. E.g., the change objective “Feel positive about initiating SHC during consultation” is related to ‘attitude’, leading to methods for changing attitudes, e.g. “Direct experience, to encourage a process whereby knowledge is created through the interpretation of experience”. Theoretical knowledge about sexuality was taught by multiple experts, each of whom tried to transfer their knowledge through examples from practice. The participants were then asked to practice initiating SHC during the training and in their own clinics. On the second day, role-play was used again to assess the nurses’ attitudes when actively initiating SHC.

The project group developed a program based on all input, which was then presented to the linkage group for discussion and adjusted in two meetings. The project team, composed of three field experts, finalized the program based on established parameters, which include methods, applications, and specific details, outlined in the sections on the SHC pilot program (see Table 2, 2.1 and 2.2).

The 2005 sexual health training for HIV nurses consisted of five full days; nurses found this to be an excessive burden on their daily practice. We designed the new training to be one full and one-half day, with an interval of three months to increase the learning effect. The training was designed for all HCPs providing care for PWH and working in a hospital or public health organization. It was anticipated that approximately 33% of all HIV nurses in the Netherlands would participate: 28 participants. The training was accredited for both physicians and nurses in the field of HIV by the Accreditation Committee of the Quality Register. HCP are required to earn a certain number of these points in order to maintain their registration.

The linkage group considered it important to start on the first day with plenary expert talks rather than small group discussions, given the lack of knowledge indicated by participants and the discomfort they sometimes felt discussing sexual health. Speakers were selected based on expertise and experience; and invited for a face-to-face meeting to discuss the exact content of their contributions to prevent overlap. The duration varied: 30-45 minutes. Actors were approached through a national network in sexology, and context and case studies were explained during a one-on-one online conversation. A week before the first training day, case-scenarios were reviewed in a joint online meeting involving the project group and three actors. Due to the national nature of the meeting, Utrecht was chosen, being centrally located.

Prior to the training, participants received two assignments: 1) write up a patient case in which the participant encountered difficulties addressing or discussing sexuality; 2) outline a sexology network in their own region, to determine if that network was comprehensive or if there were more potential partners.

The first part of day 1 started with an opening by the project group presenting a case study of their own clinical practice related to positive sexual health when discussing sexual health. Then followed three talks on basic knowledge about sexuality, focusing on sexual health problems linked with attitude, self-efficacy, skills and social norms. All presenters interacted with the audience by asking questions via mentimeter.com.

The second part of day 1 involved translating theory into conversations in daily practice during routine consultation, introduced from the perspective of the nurse, followed by how-to-apply theoretical models during consultation. Then: conversation techniques, illustrated with examples, followed by an explanation which barriers and facilitators nurses and physicians may experience; from the provider’s perspective. This allowed participants gaining a better understanding of how the theoretical concepts can be applied in real-life, and identifying factors that may hinder or support effective communication about sexuality. Small groups reviewed and discussed video recordings of routine HIV consultations. These sessions were mainly interactive to create a safe atmosphere and to build up confidence among participants. At the end of the second part of the first day, participants returned to the earlier case study and were asked to consider in their own network whom they could refer patients to in the region of their hospital.

The third part of day 1 was focused on clinical practice. Participants watched video footage of consultations in small groups and were asked questions (e.g. “what did you notice?”) to engage them in conversations about the practice of SHC. This third part ended with a plenary session in which the importance of a sexology referral network was discussed based on a case study presented by two project group members. After this plenary session, participants were asked to map out their own network at home, make it comprehensible, and bring it to day 2.

On day 2, the focus was on role-playing and practicing case scenarios for sexual health counseling, with the help of actors. Day 2 began with a plenary session, in which the theory from day 1 was integrated into practical examples. Two members of the project group went through a case study. Next, the participants dispersed into small groups and practiced their own case scenarios with actors, focused on skills training. Participants engaged in conversations as both professionals and observers, focusing on key points from a handout. This handout, along with observer notes, later guided evaluations of participants’ attitudes and behaviors during case practice. Participants engaged in simulated scenarios applying their knowledge and skills related to discussing sexual health. These role-plays allowed them to simulate real-life interactions with patients, improving their communication techniques and addressing challenges they might encounter. By actively participating, participants had the opportunity enhancing their confidence and competence in discussing sensitive topics.

Day 2 concluded with a plenary session featuring reflections from one participant per group on their role-playing experiences and interactions with actors. Next, a plenary discussion about sexuality, sexual health guidelines, the clinical setting, how colleagues view discussing SHC during consultation, and possible differences between hospitals. A case study highlighted the importance of a robust referral network. Homework assignments were also discussed, and participants received the fully elaborated case studies from both days, providing a step-by-step guide on paper. Additionally, they were given the theoretical models discussed on day 1 in written form. Table 3 provides an overview of the SHC training program.

The program material compiled by the linkage process consisted of three elements. Initially, all experts provided a PowerPoint presentation to support the talk. The presentations were checked by members of the linkage group to prevent overlap, whether the content was sufficiently relevant; and to make final adjustments. The talks were mostly from a medical perspective; however, after input from the linkage group, more attention was given to the psychosocial aspect of sexuality. After the training, these presentations were sent to the participants at their request. Case studies from day 1 and 2 were three examples from the practice of an HIV nurse who was also a consultant sexologist, fully developed by the linkage group according to the theoretical models explained earlier. The linkage group assessed the case studies on content, relevance and applicability in daily practice, and final adjustments were made. After the training, all participants received the fully developed case studies to take home. An interview guide ensured that they discussed the same questions during their role-play practice.

The program adopters are HCPs within HIV care. Due to the strong involvement of the linkage group, the focus was on HIV nurses, with HIV physicians being indirectly involved. To bring the pilot training to national attention properly, monthly contact was made with the VCH-board, and three times with the NVHB-board. It was important that HCPs agreed to participate in the entire training program. Sometimes, participants would need to negotiate with their managers and colleagues to secure the time required for attending the training.

The linkage group was a highly active group that kept all relevant stakeholders (VCH, NVHB, and soaids) informed on a monthly basis through periodic mailings. Moreover, from the beginning, this group was in close contact with other HIV nurses, HIV physicians, HIV prevention programmers, sexual health experts, and PWH. The first author provided multiple lectures, to physicians about the results of the needs assessment and to nurses on nursing practice. The request for more attention to sexual health training came from the linkage group itself, and members dedicated extra hours through their own hospitals, ensuring that conditions such as time and intrinsic motivation from the group itself would facilitate the future development of the intervention.

During discussions with the board of physicians (NVHB), we noticed that sexuality was not a priority topic. Therefore, we decided focusing primarily on nurses as future implementers, as described in the performance objectives. Members of the linkage group engaged in lectures and interactive discussions at three meetings with as many nurses as possible, aiming for them to recognize the value of the training and to encourage them to sign up. The program implementers were responsible for the content of the training, ensuring that the speakers’ presentations aligned well with the level and knowledge of the nurses.

Additionally, the curriculum was tailored to the performance objectives of Step 1: “Nurses initiate sexual health conversations during routine HIV consultations, discuss and delve deeper into sexual health topics during routine HIV consultations, and apply effective communication techniques for sexual health conversations during routine HIV consultations”. The determinants attitude, self-efficacy, skills, and social norms were incorporated into the training objectives (IM-Step 1). The linkage group focused specifically on attitude, particularly in the months leading up to the training. In all meetings, it was emphasized that the nurse’s positive attitude towards sexuality is crucial for effectively discussing this topic in consultations. In addition, workshops and discussions were held at conferences targeting SHC in the Netherlands, emphasizing the importance of the performance objective “initiating sexual health counseling” as part of the professional roles of physicians and nurses.

To promote that nurse actually signed up for the training, we employed various methods: persuasive communication, modelling, and mobilization. Alongside addressing nurses’ attitudes, we also focused on the fact that sexuality is not always discussed according to effective communication strategies. Through discussions and lectures, we made the target group realize the need for changing current behavior and engaging in conversations about the findings of the needs assessment and what this means for practice. Articles already published from our needs assessment were circulated among members of the VCH and the NVHB.

Aside from much attention being given to promoting the training among stakeholders, the linkage group and planning group convened to discuss which documents would be best utilized prior to, during, and after the training. First, a video (shared via LinkedIn) was utilized, featuring a nurse in real practical setting addressing the challenges of discussing SHC. The aim of this video was to acknowledge the problem from a practical standpoint and encourage participation in the training. In addition to monthly updates sent via emails to all VCH members to raise awareness about the training, various materials were used on the day itself. Regarding knowledge, the theoretical models used by speakers in their presentations were printed and distributed onsite among participants in consultation with the speakers prior to the event.

Additionally, we incorporated case studies submitted by participants before the training. Speakers integrated these into their discussions. Also, during the first day of training, video footage from the observational study in the needs assessment in IM-step 1 was utilized. These videos were viewed (with permission) to discuss attitudes, self-efficacy, and skills. The goal was to engage in conversations about what is observed in practice and what that means after completing day 1 part two.

We did effectively reach our target audience N = 34. The application of various methods during the training, connected to implementation outcomes, determinants, and objectives, became clear for the participants. They also saw those as integral parts of this nursing training. After 1.5 days, they gained a clearer understanding of the three performance objectives and how those relate to their own practice.

What did not work well in this step was our decision to use experienced actors in role-playing scenarios with participants’ own submitted case studies for the guided practice method: participants found it tense to practice with actors they don’t know, especially with colleagues present.