A phenomenographic study: Exploring the variations of registered nurses’ perceived roles and experiences as HIV counselors

Abstract

Objectives

The study explored the variations of registered nurses’ perceived roles and experiences before, during and after HIV counseling.

Methods

The study is anchored on Parse's Human Becoming Theory structured around three abiding themes: meaning, rhythmicity, and transcendence. A qualitative phenomenographical approach was used and the data were collected through semi structured, face-to-face, in-depth interview sessions with ten registered nurses who were eligible under the set criterion: HIV counselors employed in both government and private health facilities with HIV Testing and Counseling facilities and services in Iligan City and Cagayan de Oro City. Verbatim transcriptions were analyzed in iterative process using Jan Larssons and Inger Holmstrom's (2007) seven simple steps of phenomenographic analysis. Triangulation and validation established rigor and trustworthiness of the data.

Results

Emergent themes of differences in participants’ perceived roles and experiences conveyed in a metaphor: The Employee vs. The Educator; The Professional vs. The Shepherd.

Conclusion

The variations ascertained the association of perceived roles and experiences of HIV Counselors and posited equally vast challenges as nursing takes the core in collaboration for the care of persons living with HIV toward a dignified death.

Introduction

Since the beginning of the epidemic, 75 million people have been infected with the HIV virus and about 32 million people have died of HIV.¹ The kind of disease process indicates a lifetime treatment and consistent association with healthcare services. Nurses play a significant role in patients living with HIV throughout the duration of the process even toward the realm of a dignified death.

HIV/AIDS is a major problem in the Philippines with a gradual increase in the number of people who are infected with HIV. Since 1984, there have been 59,135 confirmed HIV cases reported to the HIV/AIDS & ART Registry of the Philippines.² There are 42 individuals who are affected with HIV/AIDS in Iligan City as reported in the official website of the government of Iligan City in April 2017³ and the number of cases of HIV/AIDS is rising on a very alarming rate.

HIV testing centers manned by HIV counselors are sprouting in the region to provide quality care to the people who submit for tests. A tremendous responsibility has been placed among counselors as they occupy the front line of HIV/AIDS service delivery in the healthcare sector⁴ cited. The counselors educate individuals about HIV/AIDS, on how to reduce the risk of contracting the virus, administer appropriate medical testing, and provide counseling before, during and after the test especially in clients who turn out to have positive test results to help clients cope with emotional, psychological and social challenges having HIV/AIDS.

This paper aimed to explore the variations of nurses’ perceived roles and their experiences as HIV counselors before, during, and after HIV counseling and testing. The study is anchored on Rosemarie Rizzo Parse's Human Becoming Theory ⁵ focusing on the quality of life of people based on their individuality.

Method

Research design

This qualitative study used the phenomenography method that is empirically based approach and aimed to identify qualitatively different ways in which different people experience, conceptualize, perceive, and understand various kinds of phenomena. Within this framework, learning assumes a central importance as it represents a qualitative change from one conception concerning some particular aspect of reality to another ⁶ In contrast with phenomenology, phenomenography focuses on the differences rather than the similarities of the participants’ perceptions and experiences on their roles before, during, and after HIV counseling.

Population and study setting

A purposive sampling covered the three existing HIV Counselors in Iligan City and convenience sampling in Cagayan de Oro City with seven HIV Counselors was utilized following the inclusion criteria: must be a registered nurse (may it be those who undertake routine HIV testing as part of a diverse role and those who are specifically trained as HIV counselors), regardless of their years of experience. A sum of ten HIV counselors willingly participated in the study.

Data collection

The data were gathered through semi-structured interviews lasting for at least 30–45 min for each participant using a set of questions to identify and explore the participant's perception and experiences. The entire interview was recorded, after an informed consent was secured. The “mother tongue” Visayan language was used, hence, maximizing their expression. Interviews were conducted within the health care facilities subsequently after working hours, while some took place outside the workplace. Field notes and reflexivity on salient points shared during the interview session complemented audio recordings with consent.

Data analysis

All qualitative data were transcribed and analyzed after each interview session and observations. The narratives were analyzed using seven simple steps of phenomenographic analysis.⁷

Rigor, validity and trustworthiness

Published Lincoln and Guba (1985)⁸ Evaluative Criteria on trustworthiness stating that important to evaluating its worth includes credibility, transferability, dependability, and confirmability. Rigor and trustworthiness were established through prolonged engagement, persistent observation, member check sessions, peer debriefing, audit trail, triangulation, and inquiry audit.

Ethical aspects

Strict university ethical protocol was adhered. Prior to data gathering, the paper was subjected for review and approval by the College Research Ethics Committee. Informed consent from participants was secured assuring confidentiality and disclosure of information. The participants were reminded of their right to refuse or withdraw from participating in the study at any time they deem fit.

Results

Characteristic of participants

Table 1 presents the participants’ profile. The participants’ ages ranged between 27 and 57 years old. Three of the participants are males and seven are females. Ten are BSN graduates, while three have Master's Degrees while one completed only nine (9) units for Master's degree and one is currently taking up Master's Degree who did not specify the number of units. Seven worked at a government facility and only three worked at a private facility.

Table 1.

Characteristic of participants.

Participant's code name	Sex	Age	Educational background	Years of being an HIV counselor	Type of workplace
“Laidback Counselor”	Female	57 years old	BSN Graduate; Master's Degree	15 years	Government Facility
“Passionate Counselor”	Male	27 years old	BSN Graduate	1 year	Government Facility
“Confident Counselor”	Male	28 years old	BSN Graduate, took 9 units Masters	2 years	Private Facility
“Busy Counselor”	Female	33 years old	BSN Graduate	4 years	Private Facility
“Motherly Counselor”	Female	45 years old	BSN Graduate, Master's Degree	4 years	Private Facility
“Energetic Counselor”	Female	26 years old	BSN Graduate	3 years	Government Facility
“Friendly Counselor”	Male	32 years old	BSN Graduate	5 years	Government Facility
“Serious Counselor”	Female	32 years old	BSN Graduate, Master's Degree	2 years	Government Facility
“Persuasive Counselor”	Female	56 years old	BSN graduate; On-going Masteral	1 and 1/2 years	Government Facility
“Benevolent Counselor”	Female	49 years old	BSN Graduate; Master's Degree	7 years	Government Facility

In the analysis of the interviews with HIV-AIDS counselors, four ways of understanding the counselors’ work were identified. A metaphor was assigned to each category to better understand the meaning as shown in Fig. 1. The four categories were: (a) seeing their role as what their job prescribes them to do, doing only tasks that they are required or supposed to do: the employee; (b) perceives themselves as professionals in their field of work, assures confidentiality between them and avoids any relationship aside from the counselor-client relationship: the professional; (c) focuses on the emotional wellbeing of the patient, guides, listen, and empathizes with the client sees their position as HIV-AIDS counselors more than just a job: the shepherd; (d) seeing themselves as teachers on HIV-AIDS, promoting awareness and sharing information on the topic: the educator.

Figure 1.

The counselor's work-map, collectively representing the understanding of their perceived roles in their work as HIV-AIDS counselors.

These four categories of understanding together with their internal relation will compose the outcome space. In this study, there is a logical relation between understandings (a) and (b), (c), and (d). Counselors with understanding (a) do the tasks that they are supposed and prescribed to do. But, being a counselor is a multi-task position and includes many aspects aside from the actual counseling. One must also educate and teach clients on the topic, guide, help clients and significant others through the process, bringing understanding (b), (c) and (d) into focus. Moreover, counseling is more effective when one sees the work not just as a vocation but one's passion, therefore making understanding (c) well-connected into the whole logical relation.

Discussion and conclusion

The study participant's own views were subjected for analysis guided with the three main principles of Parse's Human Becoming Theory relating to the paradigms of nursing, person, environment, and health. HIV counselors represent the person in the paradigm since the counselor is an open being, who conducts HIV counseling, which focuses on nursing, knowing that HIV counseling is a human science and art which uses an abstract body of knowledge to serve people. The counselor's perception of their roles and their experiences before, during, and after HIV counseling falls under health since it involves the synthesis of values and lived experiences. The variations in their perceived roles and experiences represent the environment, being everything in the person and experiences.

• (a)

  The Employee: Focus is on what their job requires them to do.

Being an HIV-AIDS counselor entails a lot of tasks to do and follow. This certain way of understanding focuses on only fulfilling what their job requires them to do so – nothing more, nothing less. They only mentioned what is necessary, and that is being a counselor to their clients. For instance, “Laid Back Counselor” stated her experiences on dealing with patients:

[It does not matter (on how I do it). I just do my job. I prepare the forms before counseling.] I just arrange calls for their transportation to a better facility.]

The interviewees articulated that they only care about their job and fulfilling the requirements of that job. The answers reflected what the counselors believe as they go on day to day with their job? A prominent theme in this way of understanding is “do what you have to do and nothing else.”

• (b)

  The Professional: Focus is on them maintaining professionalism in their field of work.

This way of understanding believes that being an HIV-AIDS counselor, no matter how personal or intimate the job may get, any relationship built between the counselor and client must always remain professional. This also includes maintaining confidentiality and not letting the personal emotions of the counselor get in the way of their job, especially if it hinders the process.

According to “Busy Counselor”, you need to follow the rules and laws pertaining to confidentiality.

[“(I) just follow the policy in the Republic Act 8504 regarding confidentiality because (my) license will be at stake… then the trust that your patient has given you. Then, (always remember) your responsibilities as a counselor, you need to guide your patient. Do not just treat your patient after the interview as if nothing happened, after interview you still need to follow up the patient. Also, you should not divulge his identity to other people.”]

It suggests the importance of confidentiality and professionalism in their job. It was also found out that the answers in this category have a very technical pattern. It was answered very formally with assertiveness. The prominent theme reflected in this way of understanding is “to always remain professional with the client no matter how personal it can get.”

The employee versus the professional

The Employee focuses more on accomplishing tasks based on set objectives; The Professional maintains professional relationship between two parties. Unlike the two ways of understanding from the aforementioned, it focuses more on the technical aspect of being an HIV-AIDS counselor and less on the feelings and the emotional aspect. Henceforth, both categories fulfill the same purpose but in varying methods.

The Employee way of understanding places itself on fulfilling tasks depending on what is required, meaning, fulfillment is achieved task after task. Meanwhile, The Professional way of understanding achieves fulfillment constantly observing professionalism all throughout the counseling process.

• (c)

  The Shepherd: Focus is on the emotional wellbeing of the patient.

This particular way of understanding gives emphasis on the HIV-AIDS counselors listening, guiding, and empathizing with their clients. Moreover, the position is executed more than just a job and advocacy. Counselors belonging to this way of understanding feel that it is part of their responsibility especially due to stigma.

Most of the interviewees focused on providing emotional support to their clients. This includes motivating, guiding, empathizing, and encouraging. Another statement from “Friendly Counselor” states that he is a motivator to his clients:

[“My role is probably to motivate them (the clients). I am a motivator because some (clients) have not disclosed, their family is not yet open regarding this kind of disease.”]

The claims also revealed that their own perspectives and experiences as well as the perspective of the clients were considered. Emotionality is evident as expressed having a greater purpose in what they do. The most prominent theme is “placing a certain importance on the emotions of the clients.”

• (d)

  The Educator: Focus is on educating other people, promoting awareness, and sharing information on HIV-AIDS.

This way of understanding puts importance on being an educator and promoter of awareness as part of the roles an HIV-AIDS counselor must portray. Counselors conveyed that they should be able to impart knowledge about HIV-AIDS not only to their clients but also to other people.

According to “Passionate Counselor” they are more on promoting awareness and assisting their clients.

[“As counselors, we are more on promoting awareness, assisting patients.”]

The answer emphasized their roles as educators or teachers that help in the disseminating information about HIV-AIDS. The counselors assume the responsibility of informing and educating their clients, other people, and even the community in general. Their answers were straightforward in a manner and very asserting. They believed that education is the key to helping clients especially after the tests. The answers focused less on the counselors and the patient rather on actions that serve as solutions to problems. The counselors have the best plan to help alleviate the growing dilemma of HIV-AIDS stigma in the country. The most prominent theme in this way of understanding is, “educating and promoting awareness as a key in HIV-AIDS counseling.”

The shepherd versus the educator

The Shepherd way of understanding were able to reflect on how they wanted to help the client through guiding, caring, and listening and how they were able to accomplish this successfully based on their own personal experiences. They talked about wanting to help and guide the patient through the process in a way that it feels more than just a job to them. The Educator way of understanding, they truly believed educating is a primary key in solving the problem of HIV-AIDS in the Philippines.

The Shepherd way of understanding anchors itself on what the counselors have to do after the testing process – guiding, listening, and empathizing with the clients; The Educator way of understanding focuses more on what the counselors have to do before the tests. Although there is a fine line drawn here, The Educator has a bigger impact on the people before the testing process since they can be educated and informed on what to do to prevent the risk of having the disease.

The variations ascertained the association of perceived roles and experiences of HIV Counselors and posited equally vast challenges as nursing takes the core in collaboration for the care of persons living with HIV toward a dignified death.

Conflict of interest

The authors declare no conflict of interest.

Acknowledgements

The authors extend heartfelt gratitude to the participants of the study who willingly spared time during off duty hours to share experiences for a lifetime as HIV counselors.