Building therapeutic relationships in HIV care with Michelle Croston

Let's Talk Nursing with Michelle Croston.

In this episode, Samina is joined by Michelle Croston, lead HIV specialist nurse at Manchester University NHS Foundation Trust. They discuss providing person-centred care for patients with HIV and the core components of developing therapeutic relationships. 

Throughout the episode, they explore a variety of topics, including:

• The history of HIV care
• How nurses can build therapeutic relationships in their practice
• Michelle's personal experiences in patient advocacy

Listen to hear Michelle's three key actions for providing effective person-centred care, and work through the reflective exercise at the end of the episode to apply the discussion to a real-life scenario.

Access the reflective exercise and read more on: https://www.bjninform.com/person-centred-care/person-centred-care-for-people-living-with-hiv-developing-therapeutic-relationships/ 

About Michelle:

Michelle Croston is a lead HIV specialist nurse at Manchester University NHS Foundation Trust. She has worked in HIV care since 1999, and has a special interest in mental health and psychological support. She is also the host of HIV Matters, a podcast that explores conversations around HIV.

Contact Michelle:

LinkedIn: linkedin.com/in/michelle-croston-049233185
Twitter/X: @MichelleCrosto2

More information and resources:

HIV Matters podcast
Article on BJN inform: Person-centred care for people living with HIV: building therapeutic relationships
Resources about U=U:
https://www.unaids.org/en/resources/presscentre/featurestories/2018/july/undetectable-untransmittable
https://www.unaids.org/sites/default/files/media_asset/undetectable-untransmittable_en.pdf

BJN inform:

For more information and resources, go to: https://www.bjninform.com/lets-talk-nursing-podcast/

New to the platform? BJN inform is a mentor-in-your pocket digital resource for nurses, nurse associates and nursing students, providing you with easy-access articles on topics across clinical areas, person-centred care, career and nurse wellbeing.

If you would like to speak with us about a no-commitment demo or trial, please get in touch at: institutions@markallengroup.com

Transcript

Let's Talk Nursing is brought to you by bjninform.com, a learning platform for bite-sized evidence-based content that supports all aspects of nursing. I'm Samina Hashimi, editor of BJN inform, and in each episode I chat with experts about topics across person-centred care, nurse, wellbeing and career development. Together, we'll explore their experiences and discuss practical tips and insights that you can apply to your nursing practise. 
 
 Hello and welcome to this person-centred care episode of Let's Talk Nursing the BJN inform podcast. I'm joined today by Michelle Croston, lead HIV specialist nurse at Manchester University NHS Foundation Trust. She's worked in HIV care since 1999 and has a special interest in mental health and psychological support. Michelle, thank you so much for joining me.

You are very welcome. Thank you for the opportunity to talk to you today about something I'm really passionate about. So thank you so much.

I'm very excited to dive into it. So in this week's episode, we're going to be talking about developing therapeutic relationships and providing person-centred care for people living with HIV. If you're interested in learning more about caring for patients with HIV, I highly recommend heading over to Michelle's podcast HIV Matters, where she chats with experts about the current issues that people living with HIV face. If you'd like to see more information about developing therapeutic relationships, Michelle has also written a fantastic article about this topic on BJN inform, and you'll be able to find a link to this in the description box. So to start off with, since HIV care is so entrenched in its history and social context, it might be helpful first of all to discuss the beginnings of HIV. So when this first became a known condition in the 1980s, what did care for patients with HIV look like?

Yeah. Thank you for that. That's a really good question. So back, obviously when I started in HIV care, what we call the HIV care landscape looked very, very different. So back in the early 80s and then towards the later kind of 90s, there wasn't a lot of treatment available, if any. So the health condition at that time was very life limiting. How the palliative care type illness so you receive your diagnosis. And then there was a period of time where what we could do was provide care to help people die well, as in as comfortable as possible. Thankfully there is the evolution of antiretroviral therapies. Antiretroviral therapy is the treatment for HIV and we've seen massive scientific advances in this field. So we've gone from having like, say no treatment to one treatment available. So now we're living in an age where we can have injectable therapy. So again, back in the day when I started in 1999, injectables seemed quite futuristic, quite science fiction. But actually we do have injectable options now for people living with HIV. Emerging data showing that it could be in the future that in vaccines, we may have a cure. We may even be able to offer injections twice a year. So actually the science behind HIV care has moved on massively. Unfortunately, due to the origins as you've mentioned, in HIV care, what hasn't really advanced is the stigma. So it is this kind of… there are the medical advances, but actually when we're thinking about stigma, there is still this is a condition that's steeped in a lot of stigma. And probably one thing that is noteworthy to share with listeners is, depending on how much you do or don't know about HIV or how much of that is an interest to you, one thing that I would invite you to think about is this concept called U=U. So if somebody is living with HIV and they're on treatment and their viral load, which is a measure of their health condition, is undetectable, they can't pass that virus on to anybody through sexual contact, through anything like that. So that's definitely a massive scientific revolution as well. And hopefully this will help people to test and remain on treatment.

Yeah, that's a really good point in terms of not just being aware of the clinical aspects of transmitting disease, but also eradicating stigma around that, because I'm sure there are so many people who aren't aware of U=U and their lives would really benefit from that knowledge.

Yeah, definitely. Sorry, just to jump in there. So yeah, U=U is something that we feel within HIV care that is a message that we'd like to get out into the general public. So we talk about goals within HIV care about ending the HIV epidemic and the success and the key to that is getting people tested who may not think that they need a test or may not know a lot about HIV or may be too scared to get a test. So we feel if more people knew that then actually testing would be something that people could feel able to do as well.

Hmm.

And you mentioned there about the advent of antiretroviral medication. What did care look like after medication became available? And did this change the person-centred nature of care?

Yeah. So that's a really valid point. So some of the things that attracted me to HIV care was that very person-centred approach. We didn't have treatment options, but there wasn't any, like, known… All we could do was keep people comfortable. It was all about the person. How could we make the last days, years, months of somebody's life good? It was all about the person then. Thankfully, we did get antiretroviral therapy, but then there was a period in our HIV history, other colleagues may disagree, but it became about treating the virus because we had treatment options and conversations were around side effects around tolerability of drugs, around kind of treating and getting people successfully on treatment, because we have this in our toolkit now. And what we're seeing now, we've kind. They've got successful treatment and side effect profiles have got better. What we're seeing now is a massive return back to person-centred care. There is some UNAIDS targets I mentioned briefly about ending the HIV pandemic and these targets are to get to 0 transmissions by 2030. I think what's maybe worth mentioning is that this isn't.. this may be some kind of bold and kind of like leaderistic, like future thinking or kind of rhetoric. But actually there's lots of clever people that have done a lot of work around this, and essentially there's something called the U AIDS targets of 90-90-90, which essentially means that if 90% of people are diagnosed with HIV, 90% of people are on treatment and 90% of those people have an undetectable viral load, then that ambition is possible that we could end onwards transmission of HIV and basically end the HIV epidemic. What we're looking for also within that, that's very much around as you were talking about treating the virus. So what researchers and myself included, have been advocating for what we call the fourth 90, which is all about quality of care. And that's where person-centred care would fit in. So we're in a position where people are ageing. And actually now care is moving around, actually this what we call the fourth 9th  where we're talking about quality of care and where person-centred care fits in. Now again, if you're good at maths, if you add up the three 90s, it doesn't come to 360, but if you're adding the fourth 90, it does come to 360. So that's kind of that full look at the person. So in answer to your question, I think care has evolved and it's gone full circle and that's amazing, especially when it's been just over 40 years of HIV.

Yeah, that's really interesting. I mean, like you said, that care has sort of come full circle, starting out with a focus on the person-centred nature of care because no treatment was available, then moving to almost medicalisation and forgetting the person behind the condition and then coming back to actually we need to look at the person if we want to provide person-centred care and that fourth 90 that you spoke about. So moving on to building therapeutic relationships, could you explain what therapeutic relationships are both generally and specifically in the context of HIV care?

Yes. So again thinking about therapeutic relationships, we talk about this a lot and sometimes the words slip off our tongue quite easily and it's probably worth spending a little bit of time unpicking what actually do we mean by therapeutic relationships. Lots of the work that I've done around this stems from a thinker who's called Carl Rogers, who works in counselling, and he did a person-centred counselling approach to look at therapeutic relationships. So I guess in general it's any dynamic or any dyad, if you want the adding an extra layer of philosophy here, any dynamic between two people is classed as a relationship. The difference with the relationships in care is that in order for care to be given, there needs to be some kind of therapeutic aspect to that as well. Listeners may want to Google and get familiar with their own understanding of what does it mean to have a therapeutic relationship with somebody. It could just mean some relationships in care could be quite transactional. I'll give you tablets off you go. But actually if it's in a person-centred way then there is maybe some kind of therapeutic or person-centred approach to that. So going back to kind of some of the philosophies that we draw on when we're thinking about developing person-centred relationships and the work of Carl Rogers, we talk about this concept of unconditional positive regard. Now when I say unconditional positive regard, that means accepting somebody's perspectives, opinions, regardless if they differ from your own. And sometimes that can be easy in care, and sometimes that can be really, really challenging. And I think each person has their own responses to ill health and what that means for them and also as we've talked about, people don't live in a vacuum, so health is just one part of who they are in this big Venn diagram of what makes up that person. So again, there's multiple factors that impact on people's responses to life events. So again, thinking about specifically, if you receive a diagnosis of HIV that will have, as we've talked about, lots of different connotations or there's been lots of different contexts, such as what does this mean for me physically and mentally, psychologically, socially, all the full shebang. So it's kind of thinking about people's responses and holding that with what they call unconditional positive regard. So respecting where they're coming from, even if that differs from your own. Probably the second one, which is probably harder to articulate, they call it congruence, which is this kind of idea of being authentic and genuine when you're providing care. So sometimes it's about naming, and when I say naming that's kind of a therapy kind of term, just by stating in a respectful way, I can see this is important. To you, I may have a different opinion, and that's okay. So it's being honest within a relationship as well within this care dynamic. And again, labelling where that's appropriate and it's also being transparent and open around why you may be asking things and other thing that we can think about and here is trauma-informed care. So thinking about if somebody in HIV, they decided that they didn't want to take treatment. There is a danger that we could get into this push and pull, if I don't want to take treatment, and being really clear the reason why I'm asking you these things is because I'm concerned about your wellbeing. So I'm being transparent about why you may be asking some of these questions as well. And then the key one or the icing on the cake or the thing that you would know as a person if it wasn't there, there's this idea of empathy or being able to relate to somebody. Not necessarily what we call sympathy, because that's a different kind of reaction, but really kind of being able to get alongside somebody when they're experiencing difficulties and showing that care and compassion. Brene Brown does a really good clip on empathy and what that means. And thinking about how we support people to make choices in this kind of landscape of empathy, and that's kind of fundamental to therapeutic relationships.

And, you've mentioned, so you've gone through the three core components of building therapeutic relationships. How can nurses implement these into practise?

So that's a really tough one to ask and I think I've had discussions with colleagues as well thinking about, how do you develop those therapeutic relationships? That's kind of the goal, isn't it, and how do you start off with that? And I think empathy the lead-in to developing this. Kind of meeting people where they are is probably a good starting point to developing any kind of therapeutic relationships. And meeting somebody where they are, but we are key fundamental skill that we say is, in nursing academia, a soft skill and it's actually really, really hard. Listening to somebody to find out where they are. So again, we say it's a soft skill, but it's listening in a way that's active. So listening in a way that somebody knows their listening, listeners may be able to think about in times when they've been chatting to a good friend and they felt heard they felt validated. And that person may not have spoken, they may have just been there in this kind of presence to listen to the story. And also you may be able to relate to those times where you've not felt heard, you've felt dismissed. You're not really sure. You've said words in a sentence cause you know that other person's not listening. So we know when those ingredients are there, that's quite obvious, but we also know when it's not there as well. So it's kind of thinking about how will this… and so coming from a place of where that person is and listening to understand rather than listening to wait to speak.

It's almost like the third key component, empathy, has to exist before you can achieve the fist two.

Absolutely. And it's about saying I accept you where you are, you may be different, you may have different beliefs, values and you may be having any response to this that is very, very different to how I would but I accept that. That's where the empathy comes in. To give that positive regard, and that congruence then probably follows by being true to that.

And that's a really good point about thinking about times when you felt heard or not heard, because it's almost like a role reversal then, you know, if you were the speaker, what would you want the other person to be saying to you? And that's a really great way of embodying empathy and putting yourself in the other person's shoes.

Absolutely. We have been there. We've been there where we've been kind of… my partner always says to me, you know you need to listen, just not wait to speak. And I think there is a difference isn't there? So if you're listening to somebody and you're thinking, right I'm going to raise that with you, I'm going to raise this with you. You're not listening because you're planning what you're going to say. And I think there is a real skill to that, and it's not... and it's a hard one. And sometimes I'll say to people, I may just write a few things down just to help me remember. Don't worry if I write or don't worry if I don't. Because sometimes you may say something that I think, well, that's important. I just want to make a note of that. So at some point, I could come back to that as well and that's okay. And that goes back to that congruence, being really open about what you're doing.

So in terms of personal experiences around providing care for people with HIV, was there ever a person or an event that played a significant role in your understanding of HIV care or affected your professional trajectory in the area?

Yeah. So I think I've been blessed to have a wonderful career in HIV. It's like I mentioned since 1999, and I've seen massive paradigm shifts during that time I've been touched by so many different stories. You know, we're a story telling society, aren't we? We hold meaning in people's stories and actually people shape us. They shape the people we are. I remember, as a staff nurse, somebody saying to me, you know you can help, you can make a difference in somebody's life and actually patients do that as well. They make a difference and they shape us of who we are. And I'm thinking there's been lots on the way, probably too many to name, but one in particular, I think really challenged the core of me, if that makes sense. You know, my values, my beliefs, what I held true, not only about nursing, about care, being person centred, the idea of shared decision making. And also it was at the time when the Mental Capacity Act first came in to play as well. So there was lots of competing factors that kind of really shaped me as a practitioner. This was a young guy who… when I say young, he was the same age as me, so he’s always going to be young. Probably in his maybe mid to late 20s at the time. And he made a decision not to take treatment and that was really hard to get behind. There's no, kind of… the key principles of person-centred care, link really well with shared decision making. So giving people information or advice to make decisions that are best for them. And I think I’d kind of booked on training, read more, developed more. All I think from a place of good intent at the time. I'm wondering kind of on reflection, was I trying to get all these skills in motivation interviewing, therapy, to try and somehow change his mind rather than maybe just respect his wishes. Because I think on lots of levels I couldn't. I couldn't make peace with his decision. And essentially that's what it was, his decision not to take treatment. So I think that really shook my values, and at one point I'll be honest, I didn't want to be a nurse anymore. I didn't want to be a nurse if this was what it meant when we talked about the psychological cost of caring as well, and the impact that has on nurses. And I think also for me it meant often defending decisions, and defending is a really strong, like emotive word. But advocating may be a better one. Advocating for his wishes, even though his wishes weren't in line with my belief system, if that makes sense. And kind of really thinking about why he didn't want to take treatment. And it wasn't because he wanted to die, it was just he didn't want to live with HIV. Again, as a nurse, as a human, as a mum, I've got a nature of wanting to fix things, and obviously I can't fix that. But I could make it better in this landscape of person centeredness and compassion.

I can see how that would be really difficult, especially when you're the one trying to provide treatment. And yeah, there's just that mismatch of beliefs and decisions.

I think what that taught me as well is the person that you’re providing care for makes decisions based on the way they see the world. It's not the way we see the world. And actually, it's easy to be person centred when the person shares similar goals for their care that you do. But when they don't, it is really, really tricky and I’m fortunate I work in a wonderful team. MDT, and have access to reflective practise, clinical super vision. Also I think what it taught me more than anything that it's okay to have these challenges. It didn't make me a bad nurse. Didn't make me anything other than human, and sometimes I think we don't give ourselves permission as humans, nurses sorry, to be human and accept that sometimes things are tough and we may need a little bit of support with that.

Yeah.

Exactly. I mean, nurses aren't robots.

It would probably be easier if we were robots, wouldn't it? Would we be consistent? Could we? And that's another thing that we talk about as well in nurse education, can you teach empathy? And there's lots of work by amazing colleagues that focus on how we can support people to develop everything as well. And if we were robots with a programme, how would that figure, but I think actually that's the thing we've got on AI, our ability to care and give empathy. So I'm hoping that's why I won't be replaced by an AI generated programme.

A nurse AI.
 Let’s plug her in an see if we can recreate this.

Yeah, let's just move into the sci-fi world of - exactly, yeah - future medical care and robots. Yeah, that's what makes care, you know, on the one hand, so difficult, but also so wonderful because it's humans taking care of each other and you're going to encounter challenges like that. And I guess it's the lessons you learn from it. I have kind of a difficult question, if you had a similar situation now and obviously having gone through that experience, how do you think you would approach it differently?

I've had some situations since with trickier circumstances, with women who couldn't find a way to live with HIV and the impact that would have on families. So the context feels similar but also equally as challenging. I think what I did do differently was I sought support sooner. I didn't suffer as much, if that makes sense. I didn't suffer with all this kind of mental turbulence about doing the right thing. And I did kind of create that in myself, so I sought support a lot sooner and saw that as a strength rather than a weakness. I think last time the first time it happened with that gentleman I mentioned, I saw accessing support and talking about what was happening and acknowledging that I wasn't doing okay as a weakness. This time round and subsequently I've seen that as a superpower. I've seen that as a great way to make sure that the people I'm providing care for get the best care, that I show up every time. The best version of me. And I have a safe space to talk about things that are challenging for me. So I guess that would be what I would always do differently.

Mm-hmm. That's really good to hear. I guess instead of quitting nursing like you said, it sort of pushed you to do the most that you can do for all the patients that you do see.

Yeah, definitely. And I think also as well it made a… I've done lots of work around self-compassion for nurses, thinking about moral injury, looking at the psychological cost of caring. So it's really made me think about actually, that's important as well, that we need to look after ourselves, not only because there's only one of us, but to be able to show up and do our best and I think at one point, nurses are renowned for this, I'm sure all the healthcare professionals are, you know, we don't go to the toilet to help somebody else to go to the toilet, even basic things like that that we just need to get better. So if we do things like that, then looking after our psychological needs are way down. There's a priority. And I think it's about that balance as well, because we have a key component in person-centred care.

Yeah.

And the other half of the therapeutic relationship right with the other half. So if we’re kind of struggling for air, we can't support somebody else.

Yeah, exactly. I mean, the whole point of a relationship is for there to be at least two sides to it. And if one side isn't taking care of themselves, receiving that psychological support, then you don't have any foundation to build a therapeutic relationship on. Thank you so much for sharing that story. So moving on to our three key actions.

Oh, yes.

This is where I'll ask our guests to outline three key practical actions that nurses who are listening can come away with and implement into their practise. So what is the first key action that nurses can take when building these therapeutic relationships with patients with HIV.

So I think my three top tips to take away would be, or three key actions would be, first of all to listen. Listen from a viewpoint to understand. So listen to understand and not listen to respond. By listening to understand, you see the world in which somebody is living in and making decisions from. So that's always a basis to create those foundations. Those healthy foundations of, okay, meeting somebody where they are, listening with a view to understanding the world as they see it, not as we see it. Then I think the second one would be to promote the message of U=U. So as we mentioned at the start, let's try and collectively reduce some of that stigma. So anytime you can drop that into a conversation because you don't know who might be listening, that needs to hear it. So mention U=U, so if you're undetectable on treatment, you can't pass the virus on. There's lots of web links that we can signpost people to if they're listening and thinking ‘Oh, I'm not sure, I’m an evidence based practitioner’. Trust me, the evidence is very robust on that. That would be a second invitation. And the third one was please support for yourself. Look after yourself because you're a valuable component to that therapeutic relationship.

Yeah, those are some fantastic actions. I'm sure our listeners will be able to apply this not only to, you know, HIV care, but just generally person-centred care. So to wrap up, we're going to do a quick reflective exercise together. So I'm going to read out a case study. In fact, this is the exact same case study that you included in your original article on BJN inform, which a listener can access via the link in the description box to do the exercise along with us if they wish. So we will then look at the reflective questions and discuss or what you'd look for in a response. So I'll start out with reading the case study. Jane has been taking the same antiretroviral medications since her diagnosis nearly ten years ago. She reports she's beginning to struggle with dizziness and is experiencing difficulties in sleeping. After a lengthy discussion about her life at the moment, it appears that Jane's medication may be playing a role in her symptoms. You suggest that Jane may want to consider changing her antiretroviral medication. You describe what the new treatment may be, how she could take it and the potential side effects. Despite the medications being very similar to Jane's current regime, she seems very reluctant to change her treatment. In the end, she says, ‘If it ain't broken, then I don't want to fix it’. So before I read out the reflective questions, what are the main things that initially come to mind when you're presented with this scenario?

Thank you for that great summary. I guess it's about respecting where people are at, so we have, if you're thinking about the concepts and the principles behind shared decision making, it's about what is being shared within that consultation. So we are the experts, and I'm using those horrible bunny rabbit ears now. So we're the experts in HIV care. So we know about treatment, we know about side effects. We know about the virus. That's what we're bringing to the table and also our experience of providing care for people over a period of time. So that's what we're bringing to the table and we can share that. Then what Jane's bringing to the table is how that fits with her worldview. How that fits with her lifestyle, the psychological, the sociological, the physical implications of all those things. And she then makes a decision based on that information. So I think that's really important to kind of draw out there that as healthcare providers, we can give information, we can provide the information, but then it's up to Jane to think about actually, how does that fit in her world?

Yeah, bringing back those key components of building a therapeutic relationship.

Yeah, and thinking about what matters to her and I guess it's not… maybe opening up those conversations because she's clearly raised those symptoms for a reason and they seem to be bothering her. So it's kind of maybe in exploring that a little bit more. So I guess as we talked about previously, that innate need to fix things so that would be a simple fix. Changing treatments. I think it's your treatments. Let's let's fix that and change your treatment. But actually what we do see often is that it's not about the treatment, it's about something else. So it's kind of trying to dig down deeper within the conversation. To think about, is there something else going on? This could be a cumulative side effects to treatment, or it could be something else that's going on. So I guess I would be curious to find out what's happening in Jane's life. She mentioned there about difficulty sleeping, difficulty sleeping is often a reflection of what's happening during the day. So actually is there something that's happening during the day that's affecting her ability to sleep? So I guess seeing beyond potentially what could be a red herring with the medication as well with dizziness, can she tell us a little bit more about the dizziness and trying to really unpick that? Is there something else that's going on? Often what can happen also, it might be worth mentioning, is people can often present with a physical symptom which can actually be psychological in origin, and sometimes people feel more comfortable talking about physical symptoms than potentially psychological symptoms. So again, it's not missing those cues, I guess from people. Kind of being that curious friend or curious professional friend. And should I say that curious person in the room, can you just tell me a little bit more about your dizziness? How long has it been going on? Does anything bring it on? Are you able to tell me more about your difficulties sleeping? I'm trying to find out a little bit more about that and also if she doesn't want to change treatment, kind of working with that negotiation that sometimes we we say, you know, okay at what point do you think you would want to have this discussion? Also making it really clear that this is a not a, right okay we'll decline treatment this time you're not gonna change it again that's it you're stuck with it now. It's kind of giving that invitation to say, on this occasion you don't want to change treatment. That's absolutely fine. We respect that. However, if you do want to consider changing your treatment, then we can either do that the next visit or you can always phone us up in between time. Then we can do that. Yeah. So kind of giving permission for that to negotiate that.

And you've touched on this a bit in your response, but I thought we could also take a look at the reflective questions that you outlined with the case study. So these are, first of all, what questions can you ask to gain a better understanding of her perspective without sounding judgmental? And how do you convey your understanding of her opinion but share your own in a respectful way? So you touched on a few questions that could a nurse could begin with, but is there anything else that you would explore?

So I guess I've probably touched on all the ones that I would kind of necessarily go to first if maybe somebody came to me and presented this as you've done today. These are the things I may say. How have you thought of this? As we're talking about therapeutic relationships, I think it's important to note that the conversation happens within that dynamic, doesn't it? So what I may ask for one person is based on that relationship. So if I've got a, if I've been seeing Jane for 10 years, I will be privileged enough to have other kind of… I will have a history with her that I may be able to draw on. So it might be a question that I asked based on the information that I have. Like I'm just wondering. As they started, since the kids left home, if that's an impact, you know, trying to think about ways to try and help Jane open up and to get to the bottom of the question as well. So I guess that's probably something to bear in mind that no questions are wrong question because often it's in the landscape of that therapeutic relationship. And sometimes I could tell you things I've asked people and you'd be shocked, but actually it was very appropriate within the context of that relationship. So I think that's really important as well. So how do you share… ask questions without sound judgemental. Again, it’s probably being really clear why you're asking those questions and saying, 'I'm just asking so I can understand how to best plan your care, so people don't feel threatened. People don't feel they're backed into a corner where they've may have made a decision. I’m terrible for this, if they've made a decision and I feel like, well, actually that, you know, can I get out of that? If it's just in an instant kind of question. so giving people permission to move, don’t back people into corners. And as well, and giving people that sense of agency and maybe thinking about, is there anything that we could do to help you make a decision or is there any further information or what would be helpful, kind of, that empowerment, giving the power back to the person to say what would be helpful for you? But I guess what I'm trying to get at in a very long way is not kind of getting into that kind of standoff where you've said, right okay, well, this is the fix, but it's not the fix. I don't want it. Okay, what you doing here then? Right off you go.

Yeah. Or we have a difference of opinion, so I can't help you.

Yeah, exactly. I'm not the right nurse for you. You need to see somebody else. And that's not helpful, is it? It and it may be the exact… that may be correct, but I guess it's ways to sort of frame that. And again there's no right or wrong answers. It's just a spectrum of how you would potentially deal with that yourself within your clinical practise.

Exactly. Well, thank you so much for joining me on Let's Talk Nursing. Michelle, you shared so many great points about how nurses can, I guess, go about really prioritising the person in person-centred care. Again, if HIV is your thing, you can find many more in-depth discussions around this topic on Michelle's podcast, HIV Matters. Yeah, thank you so much.

You're very welcome. It's been an absolute pleasure. So thank you for inviting me.

It's been such a pleasure talking to you about this, and I really hope maybe in a future episode we can go into more depth about other topics in HIV care as well.

I'd love that. Thank you. 
 
 Thank you.

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