Paper presented at the 1st Annual Qualitative Methods Conference: "A spanner in the works of the factory of truth"
20 October 1995, University of the Witwatersrand, South Africa

Nurse-counsellors' perceptions regarding HIV/AIDS counselling objectives at Baragwanath Hospital, Soweto
Joanne Stein, Malcolm Steinberg, Susan Van Zyl, Cliff Allwood, Alan Karstaedt & Pierre Brouard
In this study, an attempt is made to gain insight into the ways in which nurse-counsellors at Baragwanath, a large South African hospital in an area of high HIV endemicity, understand HIV/AIDS counselling objectives. Semi-structured interviews, with all nurse-counsellors who had at least one year's experience (n=8), were conducted in order to elicit participants' descriptions of their counselling role. Findings suggest that to the extent that (a) the provision of emotional support is interpreted as the alleviation of immediate distress, and (b) the facilitation of health promotion is interpreted as the provision of information and advice, the HIV/AIDS counselling goals of emotional support and health promotion are set at variance in unsuspected ways. It is suggested that the development of adequate standards for the initial training and ongoing supervision of HIV/AIDS nurse-counsellors in South Africa, as elsewhere, is imperative.

One of the most critical of the challenges facing health care providers is the need to better define and characterize HIV/AIDS counselling (Bor & Miller, 1988; Balmer, 1992; Schopper & Walley, 1992). In South Africa, feasible and appropriate objectives for counselling services, both within and outside hospital settings, are only beginning to be properly debated and evaluated (Fleming, 1992; Tallis, 1992). For this reason, a study was conducted in which we attempted to gain insight into both the ways in which nurse-counsellors at Baragwanath Hospital in Soweto understand and experience their role as counsellors, and their perceptions of the factors mitigating against achieving their counselling objectives.

This paper, however, will focus only upon research findings relating to nurse-counsellors' perceptions regarding their counselling objectives, and not address the factors they saw as mitigating against achieving these objectives.

The Study Site
The study was undertaken at Baragwanath hospital, in Soweto, which serves a population of approximately 2.4 million black South Africans in an overcrowded and impoverished urban area of high HIV endemicity (Chimere-Dan, 1993).

Serosurveillance of ante-natal sentinel groups in the area indicate that 8.1% of the sexually active adult population of Soweto were infected at the end of 1993. In the STD sentinel group, 18% of males and 24% of females were infected at this time (National Institute for Virology, 1994). According to demographic modelling of the HIV/AIDS epidemic it is estimated that AIDS will have caused 31 000 to 41 000 deaths in Soweto by the year 2000 (Lee et al., in press). There can be little doubt then that, despite limited resources, Baragwanath hospital will have to cope with increasing numbers of HIV/AIDS patients.

Both the kind and degree of HIV/AIDS counselling training which nurse-counsellors at Baragwanath hospital have received is varied. While some nurse-counsellors have attended five day introductory skills training courses, the majority have attended a series of lectures, but received little in the way of basic practical training. At present, about 20 nurse-counsellors regularly engage in counselling activities. However, 130 nurses have received some degree of informal HIV/AIDS counselling training.

It is also important to point out that counselling services at Baragwanath are generally confined to post-test counselling for HIV-infected patients, and very little pre-test counselling occurs. Doctors are responsible for obtaining informed consent and for informing patients of their HIV positive status and all subsequent post-test counselling is done by nurse-counsellors (Allwood et al., 1992). As a result, this study is limited to an exploration of nurse-counsellors' perceptions regarding their objectives in post-test counselling alone.

Study Design
The study group comprised eight nurse-counsellors from a variety of hospital departments, all of whom had at least one year's counselling experience. All were fully qualified registered nurses, four of whom were in charge of nursing services in their departments. All were black African, second language speakers of English.

The data gathered takes the form of verbatim transcriptions of approximately one-and-a-half hour, semi-structured interviews.

The qualitative analysis conducted falls broadly within the parameters of grounded theory methodology and was specifically oriented towards thematic material (Glazer & Strauss, 1967).

The results of the study indicate that the major counselling objectives identified by nurse-counsellors were:

  • the provision of emotional support
  • the provision of information, and
  • the provision of guidance in decision-making and problem-solving.

However, in-depth analysis of interview transcripts indicates that these counselling objectives are regularly interpreted as:
(a) the alleviation of distress, and
(b) the facilitation of health promotion goals.

It is the implications of construing their objectives as HIV/AIDS counsellors in these terms, that is the central point for discussion in this paper. Many of these implications will be seen to be negative. It must therefore be pointed out in advance that nurse-counsellors' objectives should be understood in terms of a variety of pragmatic and institutional constraints inherent in their workplace setting.

Support as the Alleviation of Emotional Distress
Careful examination of the transcripts makes it clear that nurse-counsellors consistently described their support role in terms which suggest that, for them, support amounts to the alleviation of the patient's immediate distress. Support was thus often described as the provision of "reassurance" and "comfort". What is interesting about this interpretation of support is not merely that it occurs, but the form which it regularly takes.

Firstly, the alleviation of distress was seen to entail an active demonstration of "loving" or "caring", sometimes referred to as "mothering":

"At least to show love and make this person feel she's still wanted in the world." (Interview 5).

Secondly, and for our purposes in this paper, more importantly, strategies for the alleviation of emotional distress were seen to involve the provision of alternative, seemingly preferable ways, for the patient to understand and respond emotionally to his or her situation.

For example, many nurse-counsellors tended to alleviate fear and despair in the face of possible death, by invoking the inevitability of eventual death for all, as well as the uncertainty of its time of arrival:

A: "...and [I] say, 'Look, we are all going to die anyway. Don't you know that?' And then when they say, 'Yes', I say, 'Look now, ... it's only the Lord knows when a person is going to die. I can also die when I go out through the hospital gates and get knocked down by a car." (Interview 6).

Likewise, in order to alleviate guilt, nurse-counsellors considered it necessary to impart the understanding that HIV/AIDS is no different from any other disease, and is, therefore, illegitimately stigmatized:

B: "Like for instance, I might be hypertensive, not because God is punishing me, but because I'm having Hypertension. ... We try to set up simple examples so that to a certain extent she can be able to accept it ... that it's not because of your callousness, it's not a punishment due to your misbehaviours, or what, but it's just an illness. It just happened to you like it could happen to any other person." (Interview 3).

Two points of importance emerge from this data; one directly, and the other by implication. The first concerns the consequences of these interventions for the nurse-counsellor's health promotion and HIV prevention goals.

In quotation A, the nurse-counsellor implies that being HIV positive doesn't put you in a different relation to death from anyone else. The logical extension of this view is that patients need not take any special measures regarding their health, as a result of their HIV status.

In quotation B, the nurse-counsellor's admirable attempt to point out that HIV infection cannot be construed as a "punishment" and that its cause should not be thought of as "misbehaviour" has an equally unfortunate upshot.