Discussion 11

Advances in Nursing Science Issue: Volume 32(2), April/June 2009, p E94-E108 Copyright: (C) 2009 Lippincott Williams & Wilkins, Inc. Publication Type: [Article] DOI: 10.1097/ANS.0b013e3181a3d754 ISSN: 0161-9268 Accession: 00012272-200904000-00017 Keywords: HIV/AIDS, HIV testing and counseling, nursing education, qualitative research, Uganda [Article] The Impact of HIV Education on the Lives of Ugandan Nurses and Nurse-Midwives Harrowing, Jean N. RN, MN Author Information Faculty of Health Sciences, University of Lethbridge, 4401 University Dr W, Lethbridge, Alberta, Canada. Corresponding Author: Jean N. Harrowing, RN, MN, Faculty of Health Sciences, University of Lethbridge, 4401 University Dr W, Lethbridge, AB T1K 3M4, Canada ([email protected]). This work was supported by the Canadian Institutes of Health Research; Faculty of Nursing, University of Alberta; Alberta Registered Nurses Educational Trust; Killam Trusts; and Canadian Nurses Foundation. The author thanks the nurses and nurse-midwives of Uganda; Dr Judy Mill, doctoral supervisor, for her gentle patience and wise counsel; and Dr david Gregory for his helpful comments and encouragement. ---------------------------------------------- Outline Abstract BACKGROUND RESEARCH STUDY Purpose METHODS Participants FINDINGS Reconceptualizing the practice of nursing Gaining and sharing power Challenging the image and role of nursing Systemic challenges DISCUSSION LIMITATIONS AND FUTURE RESEARCH CONCLUSION REFERENCES Abstract In this ethnography, I explored the impact of an HIV/AIDS education program on the lives of 24 Ugandan nurses and nurse-midwives. Nurses who previously had viewed themselves simply as providers of advice and sympathy now saw themselves as more holistic, collaborative caregivers. They voiced an increased awareness of their role as leaders and advocates in the community with respect to policy. The education program had positive and synergistic effects on the nurses' professional practice, communication and problem-solving skills, confidence, and engagement in political and social change activities. ---------------------------------------------- IN THE CONTEXT of the devastating HIV/AIDS pandemic in sub-Saharan Africa, nurses and nurse-midwives face overwhelming challenges. Stigma and discrimination,1-4 inadequate knowledge,5 frustration and stress related to heavy workloads,6,7 negative attitudes,8 and lack of access to basic protective supplies combine to render nursing staff vulnerable to infection 9,10 and severely constrained in their attempts to provide competent, safe care. Furthermore, African nurses (the vast majority of whom are women) continue in their caregiving roles outside of the workplace, by offering countless services to family and community members. If the trajectory of the AIDS pandemic is to be reversed, it is essential that the voice and wisdom of nurses be heard and included in the design and implementation of effective prevention, care, and treatment strategies. The purpose of this article is to discuss the impact of a project that provided continuing professional education about HIV and AIDS interventions to nurses and nurse-midwives in a national referral and teaching hospital in Kampala, Uganda. Through a focused ethnographic approach, participants shared the journey of their unanticipated transition to new understandings of nursing, its image, and its practice, as well as the process of individual and collective empowerment over a 2-year period. In addition, they discussed the difficulties of bringing new perspectives, enthusiasm, and ideas to a workplace that did not always welcome innovation. Their words resound in the relative silence of the literature regarding the obstacles that nurses face "on the ground" as they struggle to cope with the HIV pandemic in Africa. BACKGROUND The Republic of Uganda is situated in East Africa and has a population of 28.8 million people.11 Life expectancy at birth is 48 years for men and 51 years for women in a country with an estimated 1 million HIV-infected people.11 More than 900000 Ugandans have died from the disease since the epidemic began 25 years ago.12 Virtually every family has experienced loss because of AIDS, and every healthcare provider has treated countless patients with the illness. Despite evidence of an overall decline in new infections, the number of Ugandans already infected and progressing to AIDS is increasing.13 However, as the demand for health services has increased, there has been a concomitant reduction in the number of available healthcare providers.14,15 As in other African countries, about 20% of Ugandan healthcare workers have already died from AIDS.16 It is critical that strategies be implemented to achieve the universal antiretroviral therapy (ART) coverage that is required to slow the pandemic; yet without interventions to increase the number and capacity of healthcare workers, that goal will be almost impossible to achieve.5,14,17,18 Employment and social conditions are not conducive to good mental or physical health for Ugandan nurses and nurse-midwives. Their workload is staggering: the country recently reported a nurse-population ratio 19 of 6:10000, with 1 to 2 nurses per 100 patients reported in some units of its largest tertiary care facility.16 The health of female nurses is disproportionately affected by HIV, given their frequent exposures to the virus because of their gender and high-risk work environments. Women account for 59% of all those infected with HIV in sub-Saharan Africa 20 and are considered to be particularly vulnerable to infection, as compared with men, for a number of physiological, social, and cultural reasons.21-26 Many customary and statutory laws discriminate against Ugandan women in areas of marriage, divorce, and property rights,27 diminishing further their capacity to protect themselves against the effects of HIV infection. Failure to attend to the many challenges that face African nurses will undoubtedly result in ongoing devastation of the continent by the deadly virus.26,28 RESEARCH STUDY In an effort to enhance the knowledge and skills required to provide nursing care for persons with HIV, funding was obtained in 2005 by the hospital's senior nursing administrator to allow 25 staff nurses and nurse-midwives (hereafter referred to as nurses) to participate in a 6-month educational program. Provided by The AIDS Support Organisation (TASO) of Uganda,29 the highly regarded counselors' course comprised 5 modules covering topics such as basic physiology and pathology of HIV and its effects on the body and mind; the HIV testing process; communication, counseling, and health promotion skills; common sexually transmitted infections; contraception and family planning; positive living following the diagnosis of HIV infection; prevention and treatment of the infection; and dealing with specific groups or populations (eg, adolescents, children, adults). Each module was covered in 5 to 10 days of case study, role playing, group assignments and discussion, storytelling, and other interactive strategies. Two 8-week counseling practice components were completed among the classroom modules. Participants were assessed on their clinical performance, case-study reports, and a final examination. Immediately following their successful completion of the program in June 2006, the nurses were invited to enroll in the current study to explore their perceptions of the education's impact. Purpose The purpose of this study was to investigate aspects of the lives of a group of Ugandan nurses in such a way that social injustices and inequities and power differentials might be identified and analyzed. The following question formed the lens through which this examination occurred: What is the impact of an HIV/AIDS education program on the lives of a group of Ugandan nurses and nurse-midwives? Education is a precious commodity in Uganda, particularly for women, and I anticipated that participants' narratives around these experiences might reveal and represent patterns of oppression, marginalization, and vulnerability on several different levels. To achieve the research goal, I planned to probe not only the immediate and direct effect of education on the professional practice of nurses, but also to explore possible sequelae in the personal, social, and political lives of the women. For example, I was curious about the effect on the nurses' understanding of their role as caregivers, advocates, and community members. I wondered about their relationships and interactions with colleagues and supervisors in the workplace and the impact on nurses' ability to influence decisions and policy that affect care and treatment of clients. Were their perceptions of vulnerability altered because of increased visibility and contact with HIV-infected persons in a country where stigma is a barrier to care and social contact? Did participation in continuing education provoke questions about or enhance awareness of their power to make changes to any aspect of society? Did the healthcare system accommodate any shifts in the nurses' perceptions or practices? If so, how? There was no intention to evaluate the education program itself; it has been described and evaluated elsewhere.30,31 Rather, the intent was to learn about its relevance and impact from the perspective of those nurses who participated. METHODS The questions that guided the study are the ones that challenge social practices and knowledge and require systematic uncovering and analysis of multiple layers and dimensions. Consequently, I chose to use the critical ethnographic methodology as outlined by Carspecken.32 This approach was chosen to gain understanding, within a defined duration of time, about how the participants interacted with and interpreted the social and political forces that influenced their lives as women, registered nurses and midwives, and community members in a low-income country. Guided by a belief that science is subtly biased in favor of privileged groups, the critical ethnographer endeavors to disrupt commonly held assumptions and reveal underlying operations of power and control.33,34 The 5 stages of the research process described by Carspecken are designed to allow the researcher to study social action and to explore (1) the significance of and (2) the interactions among the subjective experiences of the participants, the locale in which those interactions occur, and the larger system in which the participants are situated. The research study was reviewed and approved by 3 ethical review boards, 1 at a Canadian university and 2 in Uganda. To avoid any perceptions of coercion from the hospital's nurse administrator, I shared no information with her about any aspect of the research process once it was underway. Written informed consent was obtained from each participant at our initial contact and was reconfirmed at subsequent data collection points. Data were gathered primarily through individual semistructured interviews with participants. In addition, I observed counseling sessions between participants and clients; participants engaged in their regular duties at the work site; and meetings of the participants. An interview guide was developed at the outset of the project and revised over time to reflect themes that began to emerge from the data. Interviews lasted 60 minutes to 100 minutes and were audiotaped with the consent of the participant; extensive notes were taken during and after the interview for 1 person who preferred not to be recorded. Tapes and field notes were transcribed and entered into a qualitative data management software program (NVivo7): thematic coding occurred simultaneously with data collection. I also sought opportunities to engage in and learn about community activities (eg, attending cultural events and church services, traveling on public transportation, learning the local language, reading local newspapers and magazines, and sharing meals in private homes). Rigor was enhanced through the choice of appropriate methodology, frequent consultation and debriefing with experienced qualitative researchers throughout the process, maintenance of detailed field notes and memos, prolonged engagement and persistent observation, and ensuring the concurrent collection and analysis of data.35 As a researcher from a high-income country with only an outsider's understanding of the culture of Uganda, I was obligated to ensure that the research questions and study design were relevant to and respectful of the participants and indeed the people of the country. Therefore, the study proposal was developed in collaboration with the nurse administrator who initiated the implementation of the education program for the nurses. She was interested in learning about the program's impact on the nurses in the Ugandan context-a context in which everyone is affected by HIV, working conditions are poor, stigma remains a problem, and there is pressure on nurses to emigrate to other countries where the quality of life is perceived to be better and surplus earnings can be sent home to support destitute family members. Participants All but one of the 25 nurses selected by the nurse administrator for the educational program participated in the research study: 1 nurse was on extended medical leave and was therefore unavailable. Participants included senior nursing staff with 15 to 35 years of experience; many were in management or supervisory positions and were within 10 years of retirement (mandatory at age of 60 years). All were women who represented a cross-section of nursing specialties, including emergency, pediatrics, obstetrics, intensive care, oncology, radiation therapy, public health, education, and outpatient clinics. All of them held diplomas in nursing, 2 had baccalaureate degrees, and 1 was working on a master's degree. Many were dually trained as midwives, while others had completed various postbasic certificates. Of the 24 participants, 10 were interviewed once, 13 were interviewed a second time, and 1 was interviewed 3 times. Fourteen nurses were observed for 100 hours in their work sites and/or in counseling sessions with clients. Prior to ethical review, I visited Uganda to begin the groundwork for recruitment and data collection. Twelve potential participants were available to meet with me to learn about the proposed study. All of them were deeply honored to have been chosen to attend the education program and were very enthusiastic about the research. Following ethical approval, 3 more site visits were made. The first one began immediately after the TASO program was completed and consisted of 10 weeks of intensive data collection. The second, a year later, lasted 4 weeks, during which preliminary findings were shared and more interviews were conducted. Finally, 12 months after the second, a third trip of a week allowed for general follow-up as well as the sharing of findings with participants. FINDINGS Study participants toiled under conditions that a nurse from a high-income country would find extremely difficult, yet the discussion of such challenges in this article may be a source of discomfort to Ugandan healthcare administrators. Nevertheless, it is important to provide a general sense of the context in which frontline nurses struggled to raise awareness and create momentum for change. Supplies and equipment such as gloves were rationed despite the increased risk of disease transmission and injuries to staff members and patients. Some managers found themselves using storage closets as offices, where a broken gurney might serve as a desk; boxes of syringes and medications were stacked against walls and under furniture; and the nurse occasionally would be greeted in the morning by a flood because of damaged water pipes in the ceiling. Units with 18 beds often admitted 80 or more patients by making use of mats on the floor and with 2 nurses on duty to provide care. Frequent maintenance problems, such as blocked toilets, challenged the hospital's ability to respond. In 1 unit, nasogastric tubing was creatively adapted for use with a single oxygen tank that was intended to serve all patients in need. Items such as toilet paper and drugs sometimes had to be provided by patients. Family members bathed, dressed, fed, and comforted the patients. Staff members were often unable to get to work on time as the public transportation was limited, expensive, and subject to frequent disruption. Some workers came directly from another job to work a shift at the hospital and often arrived late, fatigued, and hungry. Many care providers, from physicians to porters, worked on a volunteer basis, as there were no employment opportunities: these workers were compensated with a cup of tea. It was under these circumstances that study participants labored to lead, support, and nurture staff and provide quality services to patients and their families, all the while trying to personally sustain the motivation and positive attitude necessary to remain committed to their work. Overall, participants expressed great satisfaction with the content and process of the TASO program. It addressed topics and skills they felt to be essential, although a few areas for improvement were identified; many of the nurses indicated that more emphasis on the counseling of children and adolescents would have been useful. Generally, however, the knowledge and confidence gained and the opportunities to practice and receive feedback on their counseling skills exceeded the nurses' expectations. The nurses recognized that the TASO educators modeled the behaviors and attitudes they were trying to instill in the learners, who were very impressed with the quality and commitment of their mentors. The nurses were most grateful for the "golden chance" to attend the course, as the cost of tuition prohibited most of them from taking it as private students. Participation in the TASO program had a major impact on the nurses' lives. They described the effects in their professional practice as well as their personal, political, and social lives. Many initially undertook the education with some hesitation as they were uncertain about the final benefits and anxious about the expectation that they would have to demonstrate their skills. The group members, not all of whom were known to each other at the outset, quickly formed a cohesive collective and began providing support and encouragement to each other. As the weeks went by, participants found themselves gaining interest and seeing new opportunities to put the skills to good use, both in the short term and later in their careers. My conversations with the participants revolved around a theme that focused on a revisioning of their potential as individuals, nurses, and members of a collective struggling within a structured and resource-poor system. They described experiences and awareness that reflected a new understanding of what it meant, or could mean, to be a nurse. They revealed a growing sense of empowerment, which applied both to themselves and to their clients and colleagues. Finally, they recounted their impressions of the changing image of nurses in society and their role in and contribution to that evolution. Threaded throughout their narratives, however, was an intimate awareness of the constraints of the environment. Reconceptualizing the practice of nursing The most obvious impact of the TASO program was the enormous shift it sparked in the way the participants conceptualized nursing practice. As Laura exclaimed, "The thing is when you do counseling, then you start talking the real nursing!!" Trained during the 1970s, their basic nursing programs prepared them as "advisors and sympathizers" and dispensers of instructions and medications. The TASO approach required them to listen with empathy and encourage clients to identify and choose workable solutions for themselves. Although participants reported that prior to the course they had not placed much importance on, or deliberately practiced, therapeutic communication behaviors (eg, attentiveness, open body posture), they consistently demonstrated such skills in my presence. Clients were encouraged to articulate their feelings and thoughts, as well as their ideas about the solutions that would work best for them, while the nurses listened carefully and supported or challenged as required. Grace spoke for many of the participants when she explained how the TASO education enabled her to engage in helping relationships with her clients: If I'm able to listen then I'm able to respect and give the services where this client expects me to do my best for her or him for that matter. It has improved my approaches to my clients; it has given me more room to realize they have their rights. They have their rights that I should respect, they have-they easily come with their own predetermined mind of what they would want to be done. So, it is up to me to see whether this can be done and how I can put it back to them. The nurses found that they were humbled through the experience of engaging in dialogue with clients. Ruth reflected, "With the clients, I seem to understand them more. I seem to understand their conditions in the ward. I see the suffering in there, in them, and compassion in my heart is great." Lorna gained awareness about the importance of listening without judging: "I'm trying my best to listen this time. And not to judge-to judge the problem before I listen-it's important not to judge because you never know, anybody can get a problem without knowing." Paula recognized a new perspective about her own involvement with the client: "I feel it is a privilege if I can help them because you can reduce the complications which might infringe on someone[horizontal ellipsis].With the counseling [the nurse] can change [her] attitude." Participants reported that the outcomes for clients were far more satisfying for both parties, as the proposed interventions were more likely to be successful if the nurse listened carefully and engaged the client in generating feasible solutions. Furthermore, clients returned more readily for follow-up visits, which allowed the nurses to monitor progress, provide support, and anticipate problems. Paula suggested, "Usually here in Uganda, clients when told to come back, they do because they feel you are a part of them. They have that feeling that you are a part of them, you've assisted them here and there." Evelyn agreed, saying that "they feel I should be their counselor, not anybody else." Maintaining an ongoing relationship was seen as a beneficial outcome of good counseling skills that enhanced the overall health status of the client. Eunice was convinced that her new ability to facilitate the patients' comprehension of their health conditions and treatment options resulted in better healing. She felt it was necessary for the individual to trust that problems could be overcome before symptom relief could occur. She credited the counseling training for her new awareness of the mind-body connection and its role in health maintenance. Jane concurred, and added that: This training has helped us to remove stigma from these patients who have HIV/AIDS. Perhaps when we are handling them, we handle them like any other patient, unlike these nurses who have not trained in HIV who will even fear them, they would not wish to touch them, you see? But for us they are like any other patient. We go and sit with them, we talk to them so they feel they are part of us. You see? So they heal very fast. Evelyn felt that an important part of her role as counselor was to help people find hope, to understand that with appropriate treatment they could live well. Anne noted the value of asking open-ended questions that would allow "the story [to] flow out better." In this way, she could validate the patient's experiences while learning the information that would improve clinical care. All the nurses commented on their renewed understanding of the fundamental importance of patience, empathy, and confidentiality in the counseling process. Angela confirmed that: Now I have to listen and hear from what the client tells me and then build out from what he has told me. I don't give instructions to them but we just talk and we give them options[horizontal ellipsis].And it has also helped me in confidentiality. Much as we are supposed to keep confidentiality as nurses, I did not value it so much at the time, but right now I value it[horizontal ellipsis].It is not our duty to disclose, just educate and talk to the person and keep that confidentiality. Observations made at the outset of the study of the nurses' counseling interventions with clients revealed their clear but limited focus on HIV and its diagnosis, treatment, and prevention. These interactions tended to be formal and structured and usually took place in a vacant office or room in the workplace setting. A year later, the nurses' activities had expanded significantly to include individual and group counseling with all age groups. The nurses recounted casual and spontaneous sessions in a variety of settings regarding such concerns as palliative care, grief, substance abuse, marital issues, parent-child relationships, suicide risk, infertility, and sexuality. The nurses were pleased to observe that their efforts to facilitate problem-solving strategies with a client were often rewarded by requests for counseling from other individuals who had been referred by the index client. The nurses viewed this outcome as validation of their genuine interest in and commitment to providing excellent services, as well as a useful approach to improving the health of families and communities. They were not concerned that they had limited or no formal education in some of the specific issues raised by clients; rather, they felt that the process of listening, supporting, and encouraging was their primary role. In addition, the participants pointed out that there were scarce or no resources for the clients, so, anything they could provide was likely better than nothing. Another aspect of practice that was influenced by the newly acquired communication and facilitation skills concerned the nurses' leadership and management abilities. Prior to the TASO education, nurses who had supervisory responsibilities often referred staff members with personal or workplace problems to more senior administrators. During the year following the program, Anne found that as the manager of a nursing unit: "I can handle the staff now more than I used to handle, too. I used to transfer the responsibility to others. Now I don't." Sandra agreed, noting that she made a greater effort to understand the staff member's perspective before reaching conclusions. She also considered a range of possible alternatives for conflict resolution: "The options, I make use of them such that our relationship in the ward with my staff has improved a great deal." Wallis aspired to lead her colleagues to a holistic approach to nursing that she called "ideal nursing-really caring for the patient all around." The participants expressed a heightened sense of satisfaction, pride, autonomy, and confidence as they acknowledged their new capabilities to empower their colleagues. Gaining and sharing power In describing the challenges that face Ugandan nurses, participants indicated that their ability to affect significant changes in the healthcare system was negligible, despite recognition of their own expertise and the enhancements that could be made. Several participants described attempts to raise and resolve issues, only to receive responses perceived to be unjust or negative (eg, being overlooked for promotion or being transferred to a less-appealing work assignment). Submission of reports that outlined dismal conditions or proposals that suggested improvements seldom achieved their goals. Discrimination on the basis of tribal background was reported to be a common phenomenon both within and without the institution. Participants agreed that they had limited capacity to alter the forces that shaped the patient care environment and drove healthcare practices. Interestingly, participants' completion of the TASO program segued into a growing awareness of a subtle change in their power and status. The simple fact of their selection for the program and their partial release from usual duties marked them as members of a unique group. The increasing frequency of requests from staff members and colleagues to teach new skills and knowledge contributed to their status. Their participation in my research project aroused curiosity, and being sought out by clients made them the object of attention. Such acknowledgment strengthened the participants' sense that they had something worthwhile to contribute. More important to the participants than status, however, was a perception of an enhanced capacity to empower themselves and others. They realized that their new skills and knowledge offered an avenue to greater financial security and improved job opportunities. They began to speculate about the potential of their group to collectively lobby for primary healthcare initiatives that would directly impact the health of their communities and improve sustainability of services. The participants found that incorporation of the TASO principles into their counseling practice resulted in the empowerment of clients who were then able to assume greater responsibility for their own health concerns. To the nurses, this was initially a foreign and uncomfortable experience as it meant relinquishing a degree of control. As soon as they recognized the benefits for clients, however, the participants' apprehension changed to a sense of pride and accomplishment as they acknowledged their contributions to clients' improved well-being. At the personal level, the nurses found that the TASO education led to new ways of communicating with their own families. They found that a solid knowledge base and improved communication skills enabled them to talk about sensitive issues with their children and partners in a more effective way. Lorna observed: "They are very happy, my kids[horizontal ellipsis] they feel Mummy can also do something and when you talk to them they seem to think that maybe I understand more since that training." When recounting her new, gentler approach with her offspring, Evelyn compared it to her previous strategy this way: "Before I sort of used force, which I don't do now." Jane described joking with an extended family member who wanted to come and live with her, telling her: "All those who stay with me, I always test them." To her surprise, the young woman indicated that she wanted to be tested and to initiate treatment if it was indicated. This response emboldened Jane to raise the subject with other family members, who often disclosed their worries and lack of information. Jane appreciated the opportunity to provide support and direction to her family, although like all the nurses, she was careful to refer family members to other counselors to ensure confidentiality and objectivity. Those participants who had been reluctant to be tested for HIV were challenged to reconsider their decisions. A number of them had not been tested yet or had been tested but had never returned for the results. Following the counseling education, many of those nurses believed that they could no longer work to convince clients to know their status if they themselves refused to go through the same process. As Evelyn said, after learning her test results, "So, I felt very good and that stigma in me also went out." The nurses were amazed to notice their own improved physical and spiritual health because of learning and applying the principles of counseling to their own personal situations. Ruth commented that: Even when I face difficulties at home or at my place of work, I tend to counsel myself that it will pass[horizontal ellipsis].I could get headaches and I think that was stress. You know, stress, too much stress. I don't now-once in a while, once in a while. Yes, it helped me physically. She went on to say that counseling helped her to grow spiritually: Now that you become a patient person, I think those are the things that the spirit of God can teach you. Yeah, you become patient, you're enduring the time of the suffering, and you know that it will-they don't stay there forever. And the fact that even if a problem is there, you don't have to put yourself inside it. From a pragmatic perspective, the nurses saw their new skills as an important career opportunity. With mandatory retirement looming for most of them, and in the absence of government pension plans, they all faced the problem of financial security for themselves and their families once they were required to leave their current employment. With a credential that was recognized and respected by private and nongovernmental organizations and knowledge and skills that were in high demand, the nurses viewed their futures with much greater confidence. Although barriers to prevention interventions were easily identified, participants consistently assessed and worked with the assets of their target populations. For example, mothers were often found to be very interested in and committed to learning how to protect their children from HIV infection. The nurses took the opportunity, when responding to these women, to determine the possibility of engaging their sexual partners in discussions about HIV prevention and treatment. If the men declined the invitation to address these issues, the nurses ensured that the women were aware of approaches they could take to enhance their own safety and that of their children. Women were also counseled extensively about income-generating activities in which they might become involved should they find themselves solely responsible for providing for the family. Referrals were often made to the International Federation of Women Lawyers, where women were able to access legal services for little or no cost. Following completion of the TASO program, participants formed a Nurse Counselors Association to maintain contact with one another, promote volunteer community service and research projects, collect evidence about the work they were doing and its impact, and facilitate ongoing professional development. The group scheduled monthly meetings, elected an executive, and collected membership fees. The nurses felt that it was essential to provide ongoing support to one another as they encountered challenges while practicing their new skills. They also took the opportunity to celebrate their triumphs and successes. The nurses recognized the need to monitor and describe the impact of their work on the health of the community. They felt that it was important to promote more widespread education of nurses in counseling skills. Furthermore, they believed that they had the ability to influence other organizations concerned with nursing issues, such as the national nursing association and the professional registration and licensing council. There was a perception that the nursing voice in Uganda was fragmented, but that collectively, the profession could create an agenda that would enable it to advocate for change at the policy level thereby improving the healthcare system's capacity to accommodate the needs of the population. Challenging the image and role of nursing Participants expressed great concern about the public perception of nurses. Virtually all agreed that they are often regarded as rude and uncaring by members of the public. They attributed this opinion in large part to fatigue brought on by the overwhelming workload that prevented nurses from offering holistic individualized care to each and every client. In addition, the hospital is a tertiary care center at which people often arrived in advanced stages of illness or disease, and often there was little that could be done. The nurses, as frontline workers, found that they often took the brunt of the anger, confusion, and distress experienced by distraught family members. If a midwife was the only healthcare provider present at the moment when a woman died in childbirth, she was likely to be the one who witnessed the family's emotional response. Participants were quite distressed by the low regard with which they were viewed but were uncertain about what could be done to improve it, given the constraints of the healthcare system. However, as participants grew into their new roles as caring counselors, they began to see their newly framed relationships with clients as an important step toward improving their image in the minds of the public. They found that when they took the time to hear concerns, they were able to engage with the client and family to provide more sensitive care, and the clients responded more positively. According to Jackie, the resulting partnership between nurse and client "gives the clients more room to draw closer to the health workers." By enabling the clients to participate in the decision-making process, the nurses found that the clients were grateful and freely expressed their appreciation. This, in turn, enhanced the satisfaction and pride the nurses felt about their work. Outside their work lives, the nurses discovered that their capacity for contributing to the well-being of their communities was greatly enhanced by their awareness of new approaches to health promotion and illness prevention. Although most of the nurses had limited professional experience outside the hospital environment, one of their course assignments necessitated that they work with clients in the community. Through witnessing the daily realities of a client's life, the nurses were better able to understand their role as supporter and facilitator. It became clear to them that involving the client in developing realistic and appropriate strategies for better health often resulted in greater success and satisfaction for the client. In contrast to the lack of respect and autonomy the nurses experienced in the workplace, they found that their expertise was much sought after in the neighborhoods and social settings that comprised their daily lives. Whether they were visiting extended family in the remote villages of their childhood, attending continuing education courses, or walking home after a day's work, they were often stopped and asked for information or advice. The nurses welcomed such encounters and went to great lengths to satisfy the needs of the inquirers. Grace described how she often found herself interacting with people she met in the community: At times I may just be in a taxi, because for us here in our country our people tend to talk at times about their problems loudly, so I easily find myself having time to allay their anxiety[horizontal ellipsis].At times one would have given me a lift and then since they feel I'm a nurse by profession, I'm working in [hospital] which is an international referral hospital, they always consult me here and there. The nurses provided many more examples of spontaneous counseling, education, or advocacy sessions that occurred in the marketplace, at their children's school, or on the veranda in the evening. As Evelyn commented, "You know we health educators don't stop!!" Collectively, the nurses expressed a sense of deep satisfaction in their ability to contribute to the well-being of their communities and did not view their interactions with neighbors as intrusive or burdensome. Systemic challenges Although the educational experience was universally regarded as a very positive one, participants described a number of systemic barriers and the consequent personal costs. Workloads were chronically taxing and resources scarce. To make time for counseling, participants either worked beyond their scheduled shifts or they delegated their usual responsibilities to colleagues. As salaried employees, participants' overtime hours were not compensated financially. Recruiting clients for counseling was not always easy. Participants felt that some hospital departments were reluctant to refer clients to them, so effort had to be expended to seek people in need of counseling. Participants were sensitive to the potential for clients to fall through the cracks of the system because of being expected to move from site to site on the immense hospital campus to attend various clinics and laboratories to which they were referred. Participants who worked in areas where HIV-testing services were unavailable were uncomfortable asking clients to present for counseling, only to be sent off for testing with the expectation that they wait for results and then return for posttest counseling. Participants, at some inconvenience to themselves, often went to other departments in the hospital where testing services were more readily accessible to ease the process for clients. Private space for counseling was usually at a premium; when it was found, it was often in high demand by other practitioners, so sessions were frequently interrupted. Participants expressed the frustration that often accompanied their lack of success in advocating for basic and essential resources for clients and staff members. They were convinced that patient care and staff retention would be enhanced by small incentives such as provision of meals and basic drugs for patients and a transportation allowance for staff. Despite the efforts of the participants to have their concerns and proposals considered as urgent priorities, they felt that their appeals fell on deaf ears at the senior administrative level. They noted the relative luxury with which private patients were accommodated on the quiet and well-appointed upper floor of the facility and questioned why patients on the lower floors, who were financially destitute, received minimal care. Participants were distressed at this inequity but believed that there was little they could do to effect change in what they viewed as the corrupt practices of the bureaucrats and politicians who could afford to purchase special services. DISCUSSION The findings of this study are significant on 2 levels. Not only did the TASO program have a direct and positive influence on the day-to-day professional practice of the participants, but it also served as a powerful inspiration for their new perspectives, awareness, and understanding of nursing and healthcare in Uganda. Participants' descriptions of the challenges of their work illuminated the inequities, injustices, and power differentials that infuse the daily lives of nurses, thus providing us a picture of the complex interplay of forces that perpetuate the oppression of female healthcare providers in the context of the AIDS pandemic. Many authors have described the obstacles faced by nurses and other healthcare providers in sub-Saharan Africa as they try to cope with the HIV pandemic on that continent.5,25,36 Using education to enhance the competence of the nurses in this study to deliver more effective care addressed some of these challenges. Indeed, the findings of this study provided additional evidence that expanding the professional skills of care providers contributes to the implementation of innovative and useful interventions. In their articulation of the impact of the educational program, participants described an unanticipated renewal of their passion for nursing. The course stimulated a remarkable revisioning of the possibilities and potential that might be created and enacted by nurses on behalf of themselves and their patients, families, and communities. The nurses' assessment of the impact of the TASO program on all aspects of their lives was overwhelmingly positive. Their comments regarding the high standard of the program and its instructors are congruent with those found in the literature and heard from other practitioners and clients. Not only did the participants acquire new knowledge and skills, but they also gained confidence in their capacity to improve client care as well as insight into their ability to influence the healthcare system. The positive changes they observed in their practice and in their personal lives renewed their hope and motivation to continue to face the challenges inherent in their daily existence. The participants' observations that they were poorly viewed by some members of society are well supported in the literature.37-39 Marchal and colleagues 36 noted that healthcare providers' negative attitudes and inadequate knowledge combined to increase reluctance to offer quality care to people with HIV. At the same time, lack of public respect for the profession renders a career in healthcare professions less appealing to potential candidates, further reducing the capacity of the system to recruit and retain staff. The participants believed that the public's perception of them would be favorably improved by their new ability to form relationships, communicate effectively, and provide more holistic care. There is an important, reciprocal relationship between feeling respected and the quality of client care nurses deliver 40; the nurses in this study were empowered by their ability to earn respect from clients who appreciated and benefited from their interventions. Furthermore, the participants were often invited by colleagues to provide instruction and mentorship in their own efforts to learn more about HIV care. The growing acknowledgement by participants of their role in the shaping of perceptions about nursing practice and scope and their insights into the advantages and benefits of their new skills and attitudes were important steps toward the creation of positive changes on behalf of all nurses and healthcare providers. It will be critical to sustain the momentum, however, by providing ongoing support to these nurses and by extending similar opportunities to their colleagues. A recent report concluded that the failure of American HIV care providers to offer prevention counseling to their HIV-positive clients could be attributed to the perceived potential of such interventions to harm the client-provider relationship.41 In contrast, the Ugandan nurses were confident that they could successfully address sensitive topics without jeopardizing the therapeutic relationship. It may be that the credibility of the counselors was enhanced by their demonstration of commitment and dedication in a context characterized by increasing societal tolerance of open discussion on the topic of HIV. Study participants were frequently observed raising such topics as sexuality and sexual practices, use of contraception, and effective communication techniques with people of all ages without embarrassment or self-consciousness, and the messages appeared to be received in the same manner. Indeed, such topics were often discussed casually with me by individuals on the street, by taxi drivers, and by university students. People seemed genuinely interested in learning all they could about the topic, and nurses were viewed as informed and trustworthy. The participants began to see themselves as potential change agents-as a collective, they felt they had some power to influence administration and policy. There is a wide discrepancy between macro factors, such as workplace policies, involvement in decision-making roles and gender-based roles, and the capacity of nurses and their leaders to influence those factors. Despite the constraints on their ability to engage in such activities, there are many reasons to aggressively promote the participation of nurses in leadership roles that will further the healthcare agenda.38 According to Ehlers,42 nurses must engage in political debate to ensure that clients receive the care their conditions warrant and that the nurses themselves receive the benefits to which they are entitled. Participants in this study were in the initial stages of discussing possible approaches and strategies within the Nurse Counselors Association. Some had already submitted reports to senior management that they hoped would stimulate further discussion, and others were seeking connections with nurses on the national regulatory Board in anticipation of opening talks at that level. Another participant and I developed and submitted to potential funders a small research proposal that reflected the groups' belief that community interventions were essential to effect change in the pandemic. The nurses' primary recommendation was that funding be sought to enable all nurses to complete the TASO program, as each participant firmly believed that all healthcare practitioners should receive this education. Indeed, the nurses developed and submitted to senior administration a funding proposal to support a Train the Trainer initiative in which they themselves would learn to provide the counselors' course; however, no response has been received to date. Furthermore, the nurses agreed that TASO education or its equivalent should be a component of the basic curriculum for every nurse. They voiced the opinion that a novice practitioner's ability to practice competently could be greatly enhanced by the program. Indeed, as has been demonstrated in this study, the effects of the education were far-reaching and significant. The nurses recognized that the ripple initiated by their increased capacity to provide better care could potentially influence the healthcare system. The nurses were excited and motivated to be part of what they anticipated would be positive change for themselves, their clients, and the country as a whole. It is significant that the nurses acknowledged that it was the process of participating in this research study that led them to the realization that they could aspire to greater influence over their practice through political action. One of the participants had recently been hired as a research assistant for a large international study led by Edwards,43 and her colleagues were anxious to learn about and become involved in the project. The findings of this study are important because little research has been conducted to determine the value or impact of education on the ability of nurses to effect change in the delivery of healthcare to people with HIV in developing or low-income countries. Williams and colleagues 44 described the importance of comprehensive HIV education for nurses in China to change not only their knowledge level about the disease, but also their attitude toward caring for people with the virus. Nurses in Ghana believed that a program to educate members of the profession about HIV counseling would be beneficial in overcoming the stigma associated with HIV testing and treatment.4 My findings support the usefulness of an intensive program for addressing the affective, emotional, and cognitive domains of learning, resulting in new perspectives about many aspects of nursing and healthcare. LIMITATIONS AND FUTURE RESEARCH The findings from this qualitative study are limited by the fact that a small, relatively homogeneous group of nurses working in a particular institution comprised the participants. The assumptions that guided the nurse administrator's selection of candidates for the education program may have been inaccurate or inappropriate and therefore may have influenced any or all phases of the research process. In addition, the nurses experienced only one specific format and curriculum designed to enhance their knowledge and skills. Furthermore, the perspectives of clients and the nurses' coworkers might have contributed additional dimensions to the data. Future research efforts might focus on nurses in different settings, such as clinic, smaller hospital, community, or rural locations. Should funding be found to present a Train the Trainer program, it would be of great interest to investigate the outcomes. Opportunities might be found to explore the progress of the participants in this study regarding their involvement at the systems level. CONCLUSION The extent to which nurses are prepared and enabled to work to full capacity will largely determine a country's ability to effectively cope with the HIV crisis. The initiative of a nurse administrator in Uganda to promote such an opportunity resulted in a transformative outcome for the nurses involved. Beyond the simple acquisition of new knowledge and skills, the nurses gained confidence and vision. They began the TASO program as a collection of disillusioned and uncertain individuals who held out little hope of changing the trajectory of the AIDS pandemic in Uganda. They emerged as a team of collaborative and empowered healthcare professionals who believed in their ability to influence not only clients, but also organizations and the healthcare system itself. If nursing practice is truly "activated by knowledge" as proposed by Purkis and Bjornsdottir,45(p 251) then the participants in this study provide an excellent example of the energy, synergy, and momentum that are created when practitioners grasp an opportunity to learn and apply new knowledge. The project described in this article is only a small-scale initiative-but a contribution nonetheless to empowering a group of nurses to champion the cause of overcoming the devastation of HIV in Uganda. REFERENCES 1. Okafor CB, Holder B. HIV/AIDS related stigma in sub-Saharan Africa: context and consequences. Int J Global Health. 2004;3(1):20-34. 2. Holzemer WL, Uys LR, Makoae LN, et al. A conceptual model of HIV/AIDS stigma from five African countries. J Adv Nurs. 2007;58(6):541-551. Bibliographic Links 3. Mwinituo PP, Mill JE. Stigma associated with Ghanaian caregivers of AIDS patients. West J Nurs Res. 2006;28(4):369-382. Bibliographic Links 4. Mill JE. Shrouded in secrecy: breaking the news of HIV infection to Ghanaian women. J Transcult Nurs. 2003;14(1):6-16. Bibliographic Links 5. Walusimbi M, Okonsky JG. Knowledge and attitude of nurses caring for patients with HIV/AIDS in Uganda. Appl Nurs Res. 2004;17(2):92-99. Bibliographic Links 6. Fournier B, Kipp W, Mill J, Walusimbi M. Nursing care of AIDS patients in Uganda. J Transcult Nurs. 2007;18(3):257-264. Bibliographic Links 7. Mavhandu-Mudzusi AH, Netshandama VO, Davhana-Maselesele M. Nurses' experiences of delivering voluntary counseling and testing services for people with HIV/AIDS in the Vhembe District, Limpopo Province, South Africa. Nurs Health Sci. 2007;9(4):254-262. 8. Mbanya DN, Zebaze R, Kengne AP, Minkoulou EM, Awah P, Beure. Knowledge, attitudes and practices of nursing staff in a rural hospital of Cameroon: how much does the health care provider know about the human immunodeficiency virus/acquired immune deficiency syndrome? Int Nurs Rev. 2001;48(4):241-249. 9. Stallknecht K. Nurses are the key to effective HIV/AIDS prevention and care. Int Nurs Rev. 1998; 45(6):173-174. Bibliographic Links 10. International Council of Nurses. Reducing the Impact of HIV/AIDS on Nursing and Midwifery Personnel. Geneva, Switzerland: International Council of Nurses; 2000. 11. Joint United Nations Programme on HIV/AIDS. Country Situation Analysis: Uganda. New York, NY: Joint United Nations Programme on HIV/AIDS; 2006. 12. World Health Organization. Summary Country Profile for HIV/AIDS Treatment Scale-Up: Uganda. Geneva, Switzerland: World Health Organization; 2005. 13. Okero FA, Aceng E, Madraa E, Namagala E, Serutoke J. Scaling Up Antiretroviral Therapy: Experience in Uganda. Geneva, Switzerland: World Health Organization; 2003. 14. Barnighausen T, Bloom DE, Humair S. Human resources for treating HIV/AIDS: needs, capacities, and gaps. AIDS Patient Care STDS. 2007;21(11):799-812. Bibliographic Links 15. Hall EJ. Nursing attrition and the work environment in South African health facilities. Curationis. 2004;27(4):28-36. Full Text Bibliographic Links 16. Clarke-Jones J. Moving forces. Nurs Stand. 2004;18(30):12-14. Bibliographic Links 17. Joint United Nations Programme on HIV/AIDS. Stepping Back From the Edge: The Pursuit of Antiretroviral Therapy in Botswana, South Africa and Uganda. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2003. 18. Uebel KE, Nash J, Avalos A. Caring for the caregivers: models of HIV/AIDS care and treatment provision for health care workers in southern Africa. J Infect Dis. 2007;196(suppl 3):S500-S504. Bibliographic Links 19. World Health Organization. Working Together for Health: The World Health Report. Geneva, Switzerland: World Health Organization; 2006. 20. The Global Coalition on Women and AIDS. Keeping the Promise: An Agenda for Action on Women and AIDS. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2006. 21. Joint United Nations Programme on HIV/AIDS. UNAIDS at Country Level: Progress Report. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2004. 22. Fournier B. The Role of Ugandan Nurses in the Care of Individuals With HIV Illness [master's thesis]. Edmonton, Alberta, Canada: University of Alberta; 2004. 23. Mill JE, Anarfi JK. HIV risk environment for Ghanaian women: challenges to prevention. Soc Sci Med. 2002;54(3):325-337. Bibliographic Links 24. Zungu-Dirwayi N, Shisana O, Louw J, Dana P. Social determinants for HIV prevalence among South African educators. AIDS Care. 2007;19(10):1296-1303. Bibliographic Links 25. Vitols MP, du Plessis E, Ng'andu O. Mitigating the plight of HIV-infected and -affected nurses in Zambia. Int Nurs Rev. 2007;54:375-382. Bibliographic Links 26. Yeboah IE. HIV/AIDS and the construction of Sub-Saharan Africa: heuristic lessons from the social sciences for policy. Soc Sci Med. 2007;64(5):1128-1150. 27. Garbus L, Marseille E. HIV/AIDS in Uganda. San Francisco: AIDS Policy Research Center, University of California; 2003. 28. Parish C. Africa: the case for more nurses. Nurs Stand. 2005;19(41):14-16. Bibliographic Links 29. The AIDS Support Organisation. Courses on offer and related course fees. http://www.tasouganda.org/course.php. Accessed September 22, 2008. 30. Kaleeba N, Kalibala S, Kaseje M, et al. Participatory evaluation of counselling, medical and social services of The AIDS Support Organisation (TASO) in Uganda. AIDS Care. 1997;9(1):13-26. Bibliographic Links 31. Kalibala S, Kaleeba N. AIDS and community-based care in Uganda: the AIDS Support Organization, TASO. AIDS Care. 1989;1(2):173-175. 32. Carspecken PF. Critical Ethnography in Educational Research: A Theoretical and Practical Guide. New York, NY: Routledge; 1996. 33. Madison DS. Critical Ethnography: Method, Ethics, and Performance. Thousand Oaks, CA: Sage; 2005. 34. Cook KE. Using critical ethnography to explore issues in health promotion. Qual Health Res. 2005;15(1):129-138. Bibliographic Links 35. Morse JM, Barrett M, Mayan M, Olson K, Spiers J. Verification strategies for establishing reliability and validity in qualitative research. Int J Qual Methods. 2002;1(2). http://www.ualberta.ca/~iiqm/backissues/1_2Final/html/morse.html. Accessed July 6, 2008. 36. Marchal B, De Brouwere V, Kegels G. Viewpoint: HIV/AIDS and the health workforce crisis: what are the next steps? Trop Med Int Health. 2005;10(4):300-304. 37. Smit R. HIV/AIDS and the workplace: perceptions of nurses in a public hospital in South Africa. J Adv Nurs. 2005;51(1):22-29. Bibliographic Links 38. Ojo AA, Wambui T, Mutea N, Chelagat D. Presenting oneself as a nurse: a social and professional reality construction. Afr J Nurs Midwifery. 2002;4(2):40-45. 39. Jewkes R, Abrahams N, Mvo Z. Why do nurses abuse patients? Reflections from South African obstetric services. Soc Sci Med. 1998;47(11):1781-1795. Bibliographic Links 40. Faulkner J, Laschinger H. The effects of structural and psychological empowerment on perceived respect in acute care nurses. J Nurs Manag. 2008;16(2):214-221. Bibliographic Links 41. Grodensky CA, Golin CE, Boland MS, Patel SN, Quinlivan EB, Price M. Translating concern into action: HIV care providers' views on counseling patients about HIV prevention in the clinical setting. AIDS Behav. 2008;12(3):404-411. Bibliographic Links 42. Ehlers VJ. Nursing and politics: a South African perspective. Int Nurs Rev. 2000;47(2):74-82. Bibliographic Links 43. Edwards N, Kahwa E, Kaseje D, Mill J, Webber J, Roelofs S. Strengthening health care systems for HIV and AIDS in sub-Saharan Africa and the Caribbean: a programme of research. Caribb J Nurs Midwifery. 2007;2:29-36. 44. Williams AB, Wang H, Burgess J, Wu C, Gong Y, Li Y. Effectiveness of an HIV/AIDS educational programme for Chinese nurses. J Adv Nurs. 2006;53(6):710-720. Bibliographic Links 45. Purkis ME, Bjornsdottir K. Intelligent nursing: accounting for knowledge as action in practice. Nurs Philos. 2006;7(4):247-256. *Participants chose or were assigned pseudonyms. Key words: HIV/AIDS; HIV testing and counseling; nursing education; qualitative research; Uganda