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).

Results
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. By comparing HIV infection to hypertension and then stating that, "it could happen to any other person", the nurse-counsellor disguises the important behavioural components implicated in HIV transmission.

Thus, in the interests of alleviating distress what we find is the nurse-counsellors suppressing information regarding both the causes and consequences of HIV infection; information which is essential to behaviour compatible with health promotion goals.

Both these examples therefore suggest that interventions geared towards distress alleviation may prove to be at variance with health promotion goals.

The second point of importance here, is that the construal of emotional support as distress alleviation is widely regarded, in contemporary approaches to counselling, as counter-productive. While reassurance and comfort may provide short-term relief, it is now recognised that this is not ultimately conducive to the development of effective coping strategies on the part of the patient (Bor & Miller, 1988). The alleviation of distress per se is not only unhelpful to the patient, but may result in repetitive demands for emotional 'first aid' which cannot be sustained by counsellors, especially nurse-counsellors who have heavy work-loads (Bor et al., 1992).

In addition, the comfort offered may be rejected rather than embraced, rendering the counsellor as helpless and ineffective in their supportive function, as some nurse-counsellors themselves attested to:

"Before you say any word of comfort to this person, she knows what you are going to say to her. ... she'll never want to listen to you. So, I have found myself crying with the clients at the clinic when the client was actually telling me about the consequences of the disease, as if I do not know." (Interview 1).

Information-Provision as Health Promotion
Nurse-counsellors considered the provision of information regarding HIV/AIDS to be essential to effective health promotion, where health promotion was seen to include both the prevention of further spread of infection, and interventive treatment for those already infected. In some cases, the provision of information was regarded as sufficient for achieving these health promotion goals. As one nurse-counsellor pointed out with regard to the prevention of HIV transmission:

"I feel they must know the cause [of transmission], it's very important ... because once they know the mode [of transmission], I expect them to change their lifestyle." (Interview 2).

For the most part, however, nurse-counsellors felt that the neutral provision of information may often be insufficient to achieve health promotion objectives. As a result, nurse-counsellors felt that they had a further role to play in the process of decision-making and problem-solving which the achievement of these objectives entail. This additional role was commonly described as the provision of 'guidance'.

Counselling as Guidance
The nurse-counsellors interviewed placed considerable emphasis on the role of guidance in HIV/AIDS counselling. What is of interest here, again, is not only how guidance was construed, but the form this construal took.

Nurse-counsellors distinguished between what they call 'guidance' and more authoritarian and didactic methods for achieving health promotion goals, (for example, threatening to break confidentiality and/or contact tracing). While not overtly authoritarian, however, the guidance strategies described do incorporate directive or persuasive health promotion techniques:

"Its not easy to convince, especially again male people, to use a condom." (Interview 6).
"If you advise them on termination of pregnancy - I've never had anyone give consent to that." (Interview 5).
"When I insist his partner should be tested or use a condom, he says, 'maybe next time', so it's frustrating to keep confidentiality." (Interview 2).

What is noticeable in these examples is not only the use of words like "convince", "advise" and "insist", but the explicitness of the directives given. The result is a situation in which non-compliance, as opposed to compliance, is clearly identifiable:

"You know, you feel happy that at least I've done something and here's a person who is going to comply." (Interview 7).
"What is rewarding about it is when I can see I have reached the patient and she agrees also that she is going to abide by the set rules, such as prevention of further spread of disease." (Interview 8).
"My main problem is my patients being non-compliant." (Interview 4).

These quotations demonstrate that nurse-counsellors often referred to their ability to provide effective guidance in terms of the relative achievement of compliance or non-compliance. And certainly, they indicate that nurse-counsellors find counselling interventions in which compliance is effected, more rewarding. This construal of the relation between information provision and guidance, on the one hand, and health promotion goals, on the other, has two important, potentially negative implications.

Firstly, because information-provision and guidance are practised in the mode of advice-giving, they are re-incorporated into a compliance model which, if unsuccessful, produces an increased sense of frustration and/or inadequacy on the part of the nurse-counsellor. By contrast, a facilitative approach, which is now widely regarded as definitive of counselling (Nelson-Jones, 1982), does not involve explicit advice-giving and therefore does not have to confront non-compliance in the same way. Because it is not prescriptive, facilitative counselling can, in fact, be successful even in the absence of compliance.

The second consequence of the way in which guidance is construed concerns its implications for the achievement of health promotion. In fact, counselling was introduced into HIV/AIDS care in the light of the now well established failure of traditionally didactic health promotion techniques to achieve health promotion objectives (Rodmell & Watt, 1986; Carballo & Miller, 1989; Taylor, 1990). The re-incorporation of didactic techniques such as instruction and advice-giving into HIV/AIDS counselling, in the interests of health promotion, therefore makes little sense.

Guidance and Support: "Tricky Advices"
It is important to point out that the advice nurse-counsellors described does not necessarily take the form of a standardised set of instructions. Nurse-counsellors are aware of the very real difficulties faced by those who disclose their HIV status; including the risk of abandonment by partners, loss of employment, and ostracization in general. As a result, nurse-counsellors' advice may often take the form of problem-solving, such that the difficulties of the patient with regard to health promotion are taken into account. What results is a patient-centred form of advice-giving, but advice nonetheless.

The nurse-counsellors' objectives in the provision of this sort of advice are two-fold:

"We've got to achieve both goals. To prevent on the one hand, and, on the other hand, we give support at all times." (Interview 1).

What is interesting, once again, is the way in which nurse-counsellors described their attempts to achieve a compromise between these two goals:

A: "Tell him, in a diplomatic manner, that you must use a condom. Not saying that, 'I am HIV positive, please use a condom', or, 'I'm afraid that you're HIV positive.' Just say in general that there is this disease and that we are not sure what's going on, how about doing this and this ..." (Interview 5).
B: "I think maybe when the baby's born. Why I at times advise them on that is that if he identifies the baby with him then it motivates him, it makes him feel responsible." (Interview 8).

In quotation A, the counsellor suggests to the patient that the threat of losing her partner may be avoided if she gives excuses for practising safer sex rather than disclosing her HIV status. In quotation B, the nurse-counsellor suggests a strategic delay in disclosure, to avoid the possibility of abandonment.

In both these examples, the nurse-counsellors attempt to reconcile the patient's needs, on the one hand, and the requirements for prevention, on the other. In practice, what is entailed is supporting the patient by giving the kind of advice which takes the potentially negative implications of disclosure into account.

This dual-purpose advice was seen to be appropriately strategic and was vividly described by one nurse-counsellor as "tricky advices". What is important, however, is the fact that what results is a compromise which is less than perfect from the point of view of the provision of either support, or prevention.

Conclusion
The findings of this study suggest that where support is read as the alleviation of distress, and health promotion is read as the provision of guidance, the result will be a spontaneous and uneasy form of reassurance and advice-giving which may well be counter-productive. In particular, the research indicates that rather than being properly articulated and inseparable, the two HIV/AIDS counselling goals of support and health promotion are set at variance in unsuspected ways. It seems unlikely that these difficulties are specific to this particular group of nurse-counsellors alone. To what extent these difficulties are explicable in terms of inadequate training is obviously a key question (Coyle & Soodin, 1992; Burnard, 1992). Clearly, there are numerous other factors in the nurse-counsellors' socio-cultural context and workplace setting which may determine the construal of their counselling role. The fact remains that the provision of reassurance and advice would seem to be precisely what any sensitive and intelligent person would do in the absence of counselling training. What differentiates the counsellor from his or her non-professional counterpart is that kind and quality of training which enables the counsellor to perform a different, and potentially more viable function; that of providing the information and conditions in terms of which HIV infected people may best effect a positive relation to their own behavioural resources (Egan, 1990).

The findings of this study therefore indicate 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.

Acknowledgements
We wish to thank Dr Robert Bor for commenting upon an earlier draft of this manuscript.

References

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Description of the Authors

Joanne Stein
(MA Research Psych) is a senior researcher in the National Aids Research Programme of the Medical Research Council in South Africa. Her previous AIDS research activities include youth-group education programme development in Soshanguve and Alexandra townships. National AIDS Research Programme, Medical Research Council. Tel: 011 489-9881 Fax: 011 489-9882.

Dr Malcolm Steinberg
is an epidemiologist and is leader of the National AIDS Research Programme of the Medical Research Council. His previous AIDS research activities have included adolescent education programme development and impact, and the economic impact of HIV/AIDS.

Dr Susan Van Zyl
is a lecturer in Applied Linguistics and Psychology at the University of the Witwatersrand. She has a special interest in communication and medicine. Department of Applied Linguistics. University of the Witwatersrand. Tel. 011 716-2140 Fax: 011 716-8030.

Dr Alan Karstaedt
is Head of the HIV/AIDS Clinic and the Infectious Diseases Unit at Baragwanath Hospital. His current research includes investigations into both clinical and economic aspects of HIV/AIDS. Baragwanath Hospital. Tel: 011 933-1100 Fax: 011 933-3135.

Dr Cliff Allwood
is Principle Psychiatrist at Tara Hospital and Acting Head of the Department of Psychiatry at the University of the Witwatersrand.

Pierre Brouard
(MA Clinical Psych) is a senior HIV/AIDS counsellor and counselling trainer at the AIDS Training and Information Centre. He conducts workshops on all counselling-related matters for a wide range of community, health and counselling organisations. AIDS Training and Information Centre. Tel: 011 725-6721 Fax: 011 725-5966.


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
critical methods society - www.criticalmethods.org - info@criticalmethods.org