The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence.

JBI Database of Systematic Reviews & Implementation Reports

2015;13(12):130-286

The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence Catrin Evans

1,2

Sylivia Nalubega

1,2

1,2

John McLuskey

Nicola Darlington Michelle Croston

1,2

3 1,2

Fiona Bath-Hextall

1 School of Health Sciences, University of Nottingham, United Kingdom 2 University of Nottingham Center for Evidence Based Healthcare: a Collaborating Center of the Joanna Briggs Institute, United Kingdom 3 HIV Specialist Services, North Manchester Hospital, United Kingdom Corresponding author: Catrin Evans [email protected]

Executive summary Background Global progress towards HIV prevention and care is contingent upon increasing the number of those aware of their status through HIV testing. Provider-initiated HIV testing and counseling is recommended globally as a strategy to enhance uptake of HIV testing and is primarily conducted by nurses and midwives. Research shows that provider-initiated HIV testing and counseling implementation is sub-optimal. The reasons for this are unclear. Objectives The review aimed to explore nurses’ and midwives’ views and experiences of the provision and management of provider-initiated HIV testing and counseling. Inclusion criteria Types of participants All cadres of nurses and midwives were considered, including those who undertake routine HIV testing as part of a diverse role and those who are specifically trained as HIV counselors.

Evans et al. The views and experiences of nurses and midwives in the provision and management of providerinitiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 130


2015;13(12):130-286

Types of phenomenon of interest The review sought to understand the views and experiences of the provision and management of provider-initiated HIV testing and counseling (including perceptions, opinions, beliefs, practices and strategies related to HIV testing and its implementation in practice). Context The review included only provider-initiated HIV testing and counseling. It excluded all other models of HIV testing. The review included all countries and all healthcare settings. Types of studies This review considered all forms of qualitative study design and methodology. Qualitative elements of a mixed method study were included if they were presented separately within the publication. Search strategy A three-step search strategy was utilized. Eight databases were searched for papers published from 1996 to October 2014, followed by hand searching of reference lists. Only studies published in the English language were considered. Methodological quality Methodological quality was assessed using the Qualitative Assessment and Review Instrument developed by the Joanna Briggs Institute. Data extraction Qualitative findings were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. Data synthesis Qualitative research findings were pooled using a pragmatic meta-aggregative approach and the Joanna Briggs Institute Qualitative Assessment and Review Instrument software. Results This review included 21 publications from 18 research studies, representing a wide range of countries and healthcare settings. There were 245 findings which were aggregated into 12 categories and five synthesized findings: 1. Nurses/midwives are supportive of provider-initiated HIV testing and counseling if it is perceived to enhance patient care and to align with perceived professional roles. 2. Nurses’/midwives’ ability to perform provider-initiated HIV testing and counseling well requires an appropriate infrastructure and adequate human and material resources. 3. At the organizational level, nurses’/midwives’ engagement with provider-initiated HIV testing and counseling is facilitated by an inclusive management structure, alongside the provision of ongoing training and clinical supervision. Provider-initiated HIV testing and counseling is hindered by difficulties in fitting it into existing workloads and routines.



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4. Nurses/midwives perceive that good quality care in provider-initiated HIV testing and counseling involves finding a balance between public health needs and individual patient needs. Good care requires time and the ability to apply a patient centred approach. 5. The emotional work involved in provider-initiated HIV testing and counseling can be stressful. Nurses/Midwives may require support to deal with complex moral and ethical issues. Conclusions This review shows that provider-initiated HIV testing and counseling is supported by nurses/midwives who strive to implement it according to principles of good care and a patient centered approach. Nurses/midwives face multiple operational, infra-structural, resource and ethical challenges in the implementation of provider-initiated HIV testing and counseling. Implications for practice The implementation process for provider-initiated HIV testing and counseling would benefit from using a quality improvement framework. Nurses/midwives undertaking provider-initiated HIV testing and counseling require management support, ongoing training and adequate infrastructure/resources. Additional guidance is required on legal/ethical issues in testing of children and in third party disclosure. Implications for research Operational research is required to determine an optimal skill mix and optimal methods of integrating provider-initiated HIV testing and counseling into existing work routines. Keywords HIV testing, provider-initiated, nurses, midwives, HIV

Background Globally, HIV remains one of the world’s most significant health problems, with approximately 34 1

million people affected. Enormous effort has been invested in recent years into scaling up prevention, treatment and care. More people now than ever have access to antiretroviral therapy (ART). The latter development is particularly encouraging due to new research that suggests that, under certain 2

conditions, effective treatment can prevent onward transmission of HIV. Indeed, the World Health Organization estimates that ART has substantially contributed to a global decrease of 20% in the 3

estimated number of new HIV infections between 2001 and 2011. There is now a tantalizing prospect that an end to the era of AIDS may be a possibility. Thus, whilst behavioral prevention interventions 4

(such as condom use) remain a priority, there is increasing policy focus on ‘treatment as prevention’. As such, several governments are considering altering their HIV treatment guidelines towards a ‘test and treat’ policy.

5, 6

Enhancing treatment efforts as a public health measure is contingent on many health system and service delivery factors, the most important one being to encourage the widespread uptake of HIV 7,8

In many countries, between 25-80% of the HIV positive population is unaware of their HIV

9,10

For individuals who are HIV positive, HIV testing is the gateway through which the

testing. status.



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complications associated with late diagnosis can be minimized, effective treatment started and onward transmission avoided.

11

For those who are HIV negative, HIV testing still offers an important

opportunity for discussion of concerns, and for health promotion around lifestyle related risk factors.

12

A wide range of models have been developed to promote HIV testing which is now usually conducted using a ‘rapid’ test (this involves a saliva swab or finger prick, with the results available in one to 20 8,13

minutes, depending upon the test). Historically, the most common route of HIV testing has been through a client-initiated model referred to as voluntary counseling and testing (VCT). Within this model, clients seek testing in response to a concern or as a result of a referral from a health provider. Voluntary counselling and testing centers are often run by the voluntary sector, but may also be offered as a separate service within public sector provision. Within a VCT model, the HIV test is usually accompanied by extensive pre- and post-test counseling. Services may be run by nurses, community health workers, volunteers or other providers such as social workers. In spite of wide spread coverage of VCT services, HIV testing rates have remained low in many settings. In response, provider-initiated (‘routine’ or ‘opt-out’) HIV testing and counseling models are now being strongly 7,14

promoted.

These are often referred to as ‘provider-initiated HIV testing and counseling’ (PITC).

This HIV testing model is operationalized in the context of routine every day care within existing health facilities and services. Patients do not seek out an HIV test; rather, the health provider will offer the test as a routine part of care (regardless of the presenting complaint), and clients need to opt-out if they do not wish to be tested. One of the most common forms of PITC is found in ante-natal services where, for example, as a routine part of care, pregnant women will be offered an HIV test.

15

In many countries, HIV guidelines

recommend that anyone presenting to health facilities for any reason should be offered an HIV test. 16,17

7,

In reality, most health services have interpreted the guidelines more selectively due to resource

implications. Currently, in addition to antenatal services, the most common settings for PITC are tuberculosis (TB) clinics, sexually transmitted infection (STI) clinics, emergency departments (EDs) or primary care facilities. Within a PITC model, the time allocated to counseling and patient support is greatly reduced; brief information giving is recommended instead. Likewise, there is no requirement to 7

record written consent, with brief verbal consent considered sufficient. Other models of HIV testing are being implemented or piloted in countries around the world, including community initiatives to enable home-based testing, self-testing, and community/mobile outreach testing to target hard to 8

reach groups. Nonetheless, PITC remains a key model that has the greatest potential to reach the largest numbers.

14

The PITC policy has challenged health services to develop care pathways that incorporate testing into routine procedures, with minimal additional resource requirements. In reality, the implementation of PITC relies heavily on nursing and midwifery staff. In many countries, particularly in the global South, nurses and midwives are a single profession sharing a common initial training and registration 18

process.

Hence, the discussion below refers to both nurses AND midwives. Likewise, this review

uses the terms interchangeably, although for ease of reading, the single term ‘nurse’ is used to refer 13,19-23

to both groups.

Research and anecdotal evidence suggest that many nurses, especially non-specialists, remain hesitant about their HIV-related knowledge, about adopting a diagnostic role and their ability to provide adequate support to clients through the process. in lower prevalence countries, such as the UK and

19, 24-27

This seems to be particularly the case

USA, where non-specialist nurses have


JBI Database of Systematic Reviews & Implementation Reports 25,27-30

traditionally had limited involvement with HIV care, health sector remain sub-optimal.

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and where levels of HIV testing within the

31

Some researchers and activists have also raised concerns about the ability of nurses to provide patients with the level of information, education, care and support required during HIV testing and counseling, in contexts where there may be a high throughput of patients, limited time and limited 19

access to specialist back-up.

In such contexts, some commentators have expressed serious

concerns that poor quality PITC may breach patients’ human rights to informed consent and to confidentiality, and may compromise the effective linkage to ongoing care.

19,32-35

Training on PITC for nurses is based on information giving to fill a perceived gap in HIV-related knowledge.

36,37

Yet, studies suggest that even where specialist training is provided, nurses may still

struggle to incorporate HIV testing and counseling effectively into routine care.

26,29

The reasons for

this are unclear, but some studies suggest that this may relate to heavy workloads, role ambivalence, lack of organizational support, lack of professional autonomy, staff shortages or poorly designed care pathways.

19,28,38-48

There have been several systematic reviews of factors influencing the uptake of HIV testing and counseling from a client perspective.

49-51

These have shown that perceived trust in, and quality of,

health services have a major impact on HIV testing uptake and subsequent retention in care. It is essential therefore that the clients’ experience of HIV testing is a positive one – but this hinges to a large extent on nurses’/midwives’ attitudes, confidence and competence. The concerns expressed about nurses or by nurses regarding PITC point to a need to undertake a review of the existing literature on nurses’ views and experiences of PITC. Such a review would identify more clearly the key areas of concern and perceived issues that affect practice. The review results can then be used to further develop innovative training materials and methodologies, and to make recommendations for improvements to service delivery processes.

52

A search for previous systematic reviews on the topic was conducted in five databases, including the JBI Database of Systematic Reviews and Implementation Reports, Prospero, the Cochrane Library, CINAHL and MEDLINE. Three reviews were found that were related to routine HIV testing (summarized below). i.

‘A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa’ by Musheke, Ntalasha, Gari et al.

53

This review had a specific

geographical focus (sub-Saharan Africa). It considered uptake of HIV testing in terms of any model of testing, not specifically PITC. It included 42 papers, the majority of which focused on the patient/lay perspective. Only eight papers included health workers in their sample, but none of these specifically focused on nurses/midwives. Findings from this review were that the factors that most influenced a person’s uptake of HIV testing were deterioration in health status and the death of a partner or a child, while the main barriers included perceived low risk of HIV infection, mistrust of health personnel maintaining confidentiality and fear of HIV related stigma. This review also established that the widespread roll out of HIV testing initiatives, such as PITC and mobile HIV testing, had improved HIV testing uptake by alleviating people’s fear of HIV related stigma and reducing financial costs. The review established that PITC is an acceptable HIV testing strategy in sub-Saharan Africa; however it did not specifically identify provider perspectives or issues related to implementation.



ii.

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‘Provider-initiated HIV testing and counseling in low and middle income countries: a systematic review’ by Kennedy, Fonner, Sweat et al.

51

This was a quantitative review that

sought to determine the impact of PITC on testing uptake and other behavioral outcomes. The findings showed that PITC was an effective intervention for increasing uptake of HIV testing. Authors recommended that PITC should continue to be expanded and its implementation evaluated in different settings. iii.

‘Provider-initiated testing and counseling programs in sub-Saharan Africa: a systematic review of their operational implementation’ by Roura et al.

54

This was a broad mixed methods

review focusing only on sub-Saharan Africa. It included experimental and observational studies reporting outcomes such as uptake of HIV testing and patient satisfaction with HIV testing. It also included qualitative studies of patient and provider experiences. Of the latter, only two papers specifically described the nursing or midwifery perspective around PITC, and one of these was a discussion paper rather than primary research.

19

19,55

In contrast, the

current review found 18 studies (21 publications), nine of which were from sub-Saharan Africa. The Roura et al. (2013) review showed that there was considerable variation in acceptance and implementation of PITC across countries and clinical sites, and there was poor linkage of those who tested HIV positive to care services. The main health system challenges for the implementation of PITC included “weaknesses at the level of infra54(p621)

structure, supplies, data registers, coordination and human resources”.

The two papers

about nurses described problems related to additional workload and occupational stress. The review concluded that PITC provides a good opportunity for identifying HIV positive people who are already in contact with healthcare providers, but that more investment and effort are needed to enhance effective implementation. The objectives, inclusion criteria and methods of analysis for the current review were specified in 56

advance and documented in a published protocol.

Review objectives/review questions This review aimed to explore nurses’ and midwives’ views and experiences in the provision and management of provider-initiated HIV testing and counseling (PITC) in healthcare settings. The review sought to address the following questions: 1.

What are nurses’/midwives’ views and experiences of conducting PITC?

2.

What are nurses’/midwives’ views and experiences of establishing and managing PITC?

3.

From a nurse/midwife’s perspective, what personal factors, practices or contexts facilitate or hinder the implementation of PITC within their role or setting?

4.

From a nurse/midwife’s perspective, what constitutes high quality care in the provision of PITC and what factors facilitate or hinder the provision of high quality care in PITC services?



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Inclusion criteria Types of participants All cadres of nurses and midwives were considered, including those who undertake routine HIV testing and counseling as part of a diverse role and those who are specifically trained as ‘HIV counselors’. Studies whose sample included different cadres of healthcare providers were included if more than 50% were nurses or midwives. The review team was unable to locate any published methodological guidance on how to treat such ‘mixed’ samples, and had to make a difficult choice regarding whether to include them or not. In the end, it was decided to include such studies if nurses and midwives constituted more than 50% of the sample, based on the assumption that their experiences would be dominant within the core themes presented. However, findings from these studies were only included if they were specifically identified as relating to a nurse/midwife participant. A similar strategy is reported in a qualitative review on HIV testing amongst men who have sex with men.

57

Studies where the nurse/midwife proportion of the ‘provider’ sample was less than 50% were

included if the views of nurses/midwives were reported separately to those of other providers. In such cases, the findings from the nurses/midwives were included, but not those of the other providers. Studies focusing on other health professionals were excluded. In cases where the sample was not clear (e.g. when it referred to generic ‘health workers’, ‘practitioners’ or ‘providers’), the paper’s authors were contacted requesting clarification. Types of phenomenon of interest The review sought to understand the views and experiences of nurses and midwives on the provision and management of routine provider-initiated HIV testing and counseling, including perceptions, opinions, beliefs, practices and strategies related to HIV testing and their implementation in practice. Context In terms of models of HIV testing, only provider-initiated HIV testing and counseling (PITC) were included, and VCT, outreach, home-based testing or self-testing initiatives were excluded. This was because the key aim was to focus on nurse/midwife experiences of integrating HIV testing and counseling into mainstream service provision. The review adopted a multi-context, inclusive approach to key contextual variations that may have affected the synthesis.

58,59

All healthcare settings were considered (e.g. primary, secondary, tertiary

care, in-patient and out-patient; rural/urban; and public/private/voluntary). Likewise, all countries (high, low and middle income) were included in the review. This was because the key issue concerned the introduction of a new technology into practice, involving a stigmatized illness, requiring the development or expansion of nursing/midwifery roles. Therefore, it was felt that, differences in resource and health system contexts notwithstanding, the core issues were likely to be comparable. This assumption was based on the review team’s own research and practice experiences in several countries and on the existing body of evidence. In addition, the team felt that the review findings were more likely to be transferable and useful if they adopted a comprehensive approach. Types of studies This review considered studies that focused on qualitative data including, but was not limited to designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Methods of data collection such as interviews, focus group discussions and observations



2015;13(12):130-286

were considered. Qualitative elements of mixed method studies were included if they were presented separately within the publication.

Search Strategy The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract of relevant articles, and of the index terms used to describe the articles. Initial keywords used were: views, experiences, perceptions, strategies, HIV testing, PITC, nurses and midwives. A second search using all identified keywords and index terms were then undertaken across all included databases: CINAHL, MEDLINE, SCOPUS, ASSIA, PsycINFO, Web of Science and EMBASE (Appendix I). The search for unpublished studies included: reports and guidelines from professional organizations (WHO, UNAIDS), conference abstracts and dissertations. This search was initially conducted in July 2013 and then repeated in full in October 2014. In a final third step, the reference lists of all identified reports and articles were hand searched for additional studies.

Limitations to the scope of searching Because of time and resource constraints, only studies published in the English language were considered for inclusion in this review. Studies prior to the advent of widespread antiretroviral therapies (published prior to 1996) were not considered for inclusion; hence the review included studies published from 1996 onwards. Antiretroviral therapy has significantly altered the prognosis and quality of life for people living with HIV. Hence, the meaning of an HIV diagnosis and associated counseling care and support needs are now different to the pre-ART era.

Assessment of methodological quality Qualitative papers selected for inclusion were assessed by two independent reviewers (CE and SN) for methodological validity prior to inclusion in the review. The team used standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review 60

Instrument (JBI-QARI) (Appendix II),

after which, the reviewers met to discuss the results of the

appraisal. Any disagreements that arose between the reviewers were resolved through discussion. There was no need to refer to a third team member.

Data extraction Qualitative data was extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix III). The data extracted included specific details about the phenomenon of interest, population, HIV testing model, context, study methods, and outcomes of significance to the review questions and specific objectives. Two team members (CE & SN) read each paper several times to gain an overall understanding of the key findings and to set them in context. One team member (SN) then extracted the findings from included studies, variously reported as themes, metaphors or categories. Where possible, each extracted finding was supported by a verbatim quote from a research participant to illustrate its meaning. Where this was not possible, the author’s narrative was extracted. All findings were assigned a level of credibility (unequivocal, credible and unsupported). Levels were assigned



2015;13(12):130-286

depending on the extent to which supporting quotes, detail and relevant context were available and lent weight to the finding’s credibility, as per JBI guidelines:   

61

Unequivocal: Findings were accompanied by illustrations that were beyond reasonable doubt and therefore not open to challenge. Credible: Findings were accompanied by illustrations that lacked a clear association and were therefore open to challenge. Unsupported: Findings not supported by data.

Team members CE and SN both reviewed the extracted findings and the assigned levels of credibility and reached agreement that they were appropriate for each paper.

Data synthesis Qualitative research findings were analyzed using JBI’s meta-aggregative approach. Two key analytical processes were involved. First, quality-rated individual findings (Level 1 findings) from across the studies were reviewed and grouped together based on similarity in concepts/meanings. Categorization involved the aggregation of these findings to generate a set of statements (referred to as categories or Level 2 findings) that represent that aggregation. The quality of the findings was taken into account by considering their relative importance in shaping the core constructs of the category. Only findings rated unequivocal [U] or credible [C] were used to develop the meta-synthesis. Second, these categories were then compared, contrasted and synthesized further to produce a set of synthesized findings (Level 3 findings), defined as an overarching description of a group of categorized findings that allow for the generation of recommendations for practice. In accordance with JBI’s underlying pragmatist philosophy, synthesized findings were formulated in such a way as to present possible ‘lines of action’, that would be clearly understandable by, and useful for, policy and 62

practice.

One team member (CE) led the meta-synthesis process, which was highly iterative, involving review of the findings/categories/synthesized findings, going back to the original papers for clarification where necessary, and discussion with the whole team until agreement was reached. The synthesis process paid particular attention to context-specific similarities or differences and these are highlighted where relevant in the Results and Discussion sections of this review. However, despite the differing contexts of the papers, the team identified a high level of theoretical saturation in the metasynthesis.

63

Remarkably similar findings emerged across the studies, with clear factors identifiable to

account for differences.

Results Following a comprehensive literature search, 24,897 articles were identified (Figure 1). A total of 7692 duplicates were removed leaving 17,205 articles to be assessed. A total of 17,023 articles were excluded on reviewing the titles, 99 were excluded on reviewing the abstracts, leaving 83 articles for full text review. Of these, 55 articles were excluded for not meeting the inclusion criteria, nine articles were excluded for failing to establish the details to assess eligibility (included multiple participants, the number of nurses not being indicated, and the results of all participants being reported together), while two articles were excluded for failing to access their full text (Appendix V). This left 17 studies eligible for inclusion in the review. Through reading the references of eligible studies, four more



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eligible papers were identified making a total of 21 eligible publications assessed for quality. Hence,

Identification

the review included 21 publications from 18 discrete research studies. (Appendix IV).

Number of records identified

Number of additional records

through a systematic search

identified through other sources

(N=24,897)

(N=4)

Number of records after duplicates

Included

Eligibility

Screening

removed (N=17,209)

Number of records

Number of records

screened (N=17,209)

excluded (N=17,122)

Number of full-text articles assessed for eligibility (N=87)

Number of full text articles excluded (N=66)

Number of articles included in qualitative synthesis (N=21) representing 18 separate research studies

From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097

Figure 1: Flow chart of the search and study selection process



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Description of studies This review included 21 publications from 18 research studies. Appendix IV shows the details of included studies. Although the search was limited to studies from 1996 onwards, all included papers were published within the past 11 years, i.e. from 2004 to 2014. Out of these, all but one paper

64

were

published within the past five years. The included papers represented a wide range of countries, regions and continents. Of the 18 research studies, nine (representing 12 papers) were from developing countries while six were from high income countries. All studies from the developing 65-67

countries were from sub-Saharan Africa and were represented by six countries (two from Uganda, 26,55,68,69

three from South Africa,

70,71

72

one from Kenya,

one from Cameroon,

one from Ghana,

73

and

74

one from Zimbabwe ). The majority of studies (seven out of nine) in the developed countries were 75-81

from the USA,

one study was from Canada

82

64

and one study was from the UK.

In relation to the broader study aims/objectives, the majority of studies

55,64-67,69-71,73,78

explored views

and practices related to routine HIV testing (although these varied in the clinical settings, e.g. antenatal settings, emergency, in patient, community based centers, etc.). Twelve studies

26,68,70-72,74-82 64

used rapid tests where the results were available before clients returned home, one study

used

general blood testing in which HIV testing was done with the rest of other routine blood tests and the clients had to return for the test results, while five studies

55, 65-67,69,73

did not clearly indicate the type of

HIV test used. Nine studies evaluated a specific, recently introduced HIV testing service development 82

initiative (such as Point of Care HIV Testing [POCT], 26,68

Initiated HIV Testing and Counseling [PITC],

oral testing,

75,77,79

HIV rapid testing,

Nurse Initiated HIV Rapid Testing,

80

76

Provider-

and PITC

74

among children ). One study evaluated a specific aspect of routine HIV testing (confidentiality and partner notification),

72

81

while one study

was formative research investigating the use of a testing tool

in routine HIV testing. The sample for nine studies

64,66 67,72,74-77,80,81

included mixed participants, of which nurses/midwives

formed the majority (50% and above). In five studies,

26,65,68,69,73,78

the nurses’/midwives’ views were

represented separately from the rest of the participants, while four studies

55,70,71,79,82

included only

nurses as their participants. Regarding the professional background of the participants, the majority of studies

26,55,68-72,74-82

included staff labelled as ‘nurses’, while four studies

64-67,73

included ‘midwives’.

The number of nurses/midwives who participated in the included studies totaled 237 (with an exception of two studies

73,82

where the number of nurses/midwives were not stated). Of these, 200

were nurses while 37 were midwives. One study without a specified number of participants only nurses in their sample while another

73

82

included

had the views of midwives represented separately. 55,66,67,73,78,81

Although many of the included studies took place in hospitals,

the majority were in lower

level healthcare units, described differently among the various research studies. These included 65

health centres, 64

study

69,82

clinics,

medical centres

72,79,80

26,68,74-77

and primary healthcare centres.

70,71

took place in both hospitals and a maternity service center, while another study

One

drew upon

participants from hospitals and health centers. The types of clinical settings represented differed widely and included: TB clinics,

55

antenatal clinics, 82

transmitted infection (STI) clinic,

66,67,73

76,78 80,81

a sexually

26,68

was in a

emergency departments, 69,75,77

and primary healthcare clinics.

One study

primary healthcare setting but also included STI patients, one study drew upon participants from both 70,71

inpatient and outpatient departments,

one study was in a substance use disorder sub-clinic, 72

study covered four HIV/AIDS treatment centres,

79

one

one study was in both general hospital (teaching


JBI Database of Systematic Reviews & Implementation Reports 64

and non-teaching) and a maternity service centre,

2015;13(12):130-286 74

one study was in an acute care setting,

and one

65

study was in an antenatal clinic, a maternity ward and a post-test club. 64,73,76-81

Eight studies were in an urban setting, one study was in a rural setting, majority of studies

65

66,67,69-72

four were in both a rural and an urban setting,

26,55,68,74,75,82

The

66,67

was

while five studies did not clearly state the location.

26,55,64,65,68-71,73 78,79,81,82

were in public-sector-health care settings, one study 72

conducted in public, private and faith based health care settings, one study based and public hospitals, four studies (in the USA)

75-77,80

was connected to faith 74

were in a veteran setting, and one study

did not clearly state the study setting.

Methodological quality All papers assessed for quality were included in the review (Table 1). The role of critical appraisal in qualitative evidence synthesis is contested and there is a lack of agreement over the appropriateness of excluding studies, the potential impact (or not) of excluding eligible papers on review outcomes, and, indeed, over the criteria on which quality should be established. suggested by Hannes & Pearson (2012),

86

60,83-85

For these reasons, as

the team took an inclusive approach, using the critical

appraisal process to enable an in-depth understanding of each paper and to facilitate a critical, questioning approach to the study findings. There was variation in the quality of included studies (Table 1). Only five papers (out of the 21 included papers) indicated the methodological approaches used. These were the interpretative qualitative methodology,

64,70

the pragmatic approach,

26,68

and grounded theory.

72

Hence, the majority

of the papers presented rather descriptive a-theoretical analyses with minimal discussion of context. This may have been due to word limits imposed by journals, but, nonetheless, it limited the review team’s ability to explore the extent to which particular contextual features influenced particular 87

categories, and therefore, the transferability of the results. included studies as only four papers

64,68,72,79

There was very little reflexivity among the

indicated the influence of the researcher on the research

or stated the researcher’s cultural or theoretical position. Therefore, the dependability of the findings and the extent to which the findings may have been influenced by the researchers’ own professional backgrounds or theoretical presuppositions is unclear.

88



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Table 1: Quality appraisal for included studies

Studies

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10

Total score

Medley and Kennedy (2010)

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

U

Y

Y

Y

Y

Y

N

Y

Y

Y

8

U

Y

Y

Y

Y

U

N

Y

Y

Y

7

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

U

Y

Y

Y

Y

N

N

Y

N

Y

6

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

U

Y

Y

Y

Y

Y

N

Y

Y

Y

8

U

Y

Y

Y

Y

Y

N

Y

Y

Y

8

U

Y

Y

Y

Y

Y

Y

Y

Y

Y

9

U

Y

U

U

Y

U

N

N

Y

Y

4

U

Y

Y

Y

Y

U

N

Y

Y

Y

7

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

10

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

10

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

Y

Y

Y

Y

Y

U

Y

Y

Y

Y

9

U

Y

Y

Y

Y

Y

N

Y

Y

Y

8

67

Pope, Atkins, DeLuca et al. (2010)

55

Schnall, Clark, Olender et al. (2013)

78

Spielberg,Kurth, Severynen et al. (2011)

81

Pindera, Becker, Kasper et al. (2009)

82

Horwood, Voce, Vermaak, et al. (2010)

69

Evans and Ndirangu (2011)

70

Evans and Ndirangu (2009)

71

Conners, Hagedorn, Butler, et al. (2012)

79

Chen, Goetz, Feld, et al. (2011)

80

Leon, Lewin, Mathews (2013)

89

Leon (2011)

90

Pellowe (2004) Medley (2008)

64

66

Njozing, Edin, Sebastián et al. (2011)

91

Kranzer, Meghji, Bandason et al. (2014)

74



2015;13(12):130-286

Knapp, Hagedorn and 92 Anaya (2014a)

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

Knapp, Hagedorn and

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

U

Y

Y

Y

Y

Y

N

Y

Y

Y

8

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

U

Y

Y

Y

Y

N

N

Y

Y

Y

7

Anaya (2014b)

93

Solomon, Bokhour, Butler et al. (2014)

94

Kwapong, Boateng, Agyei-Baffour et al. (2014)

73

Vernooij and Hardon (2013)

95

Criteria (Y=yes, N=no, U=unclear)

Findings of the review There were 245 findings, which were aggregated into 12 categories. The 12 categories were then meta-aggregated into five synthesized findings (Table 2), and are described in more detail below. Key concepts within the categories are illuminated using representative textual excerpts from selected findings (which includes their quality rating). Where possible, excerpts from low income and high income contexts are included. Contextual differences are highlighted where relevant. Due to the large number of findings, they have not been listed in full in the main body of this report. Rather, two appendices have been created where the reader can view the full details of the findings (Appendices VI and VII).



2015;13(12):130-286

Table 2: Synthesized findings and their associated categories

Synthesized finding

1.

Nurses and midwives are supportive of PITC if it is perceived to enhance patient care and to align with perceived professional roles.

Categories

i. ii.

Embracing or resisting PITC: enhancing or damaging care Alignment of PITC with perceived professional roles

2.

Nurses’ and midwives’ ability to perform PITC well requires an appropriate infrastructure and adequate human and material resources.

iii. iv.

Environment Human and material resources

3.

At the organizational level, nurses’ and midwives’ engagement with PITC is facilitated by an inclusive, management structure, alongside the provision of ongoing training and clinical supervision. PITC is hindered by difficulties in fitting it into existing workloads and routines.

v. vi.

Support, recognition and involvement Impact of PITC on existing working practices Equipped to practice

4.

5.

vii.

Nurses and midwives perceive that good quality care in PITC involves finding a balance between public health needs and individual patient needs. Good care requires time and the ability to apply a patient centered approach.

viii.

The emotional work involved in PITC can be stressful. Nurses and midwives may require support to deal with complex moral/ethical issues.

xi. xii.

ix. x.

Introducing the test: negotiating choice and consent Communication and result giving Maintaining care and follow-up after a positive result Carrying an emotional burden Ethical dilemmas in negotiating disclosure



2015;13(12):130-286

Synthesized finding one: Nurses and midwives are supportive of PITC if it is perceived to enhance patient care and to align with perceived professional roles. Nurses’ views about PITC and their motivation to engage in it are associated with their perception of how it relates to ‘care’ and how it relates to their professional role. Nurses are more motivated to implement PITC when it is understood as enhancing patient care and when it is seen to be in alignment with their existing professional role. This synthesized finding consists of two categories. Embracing or resisting PITC: enhancing or damaging care This category refers to nurses’ views towards PITC. Nurses’ views were affected by the extent to which PITC was perceived to be in alignment with their professional values, in particular, whether PITC was conceptualized as enhancing or damaging care. On the whole, most nurses were supportive of PITC in principle. They perceived it as aligning with their professional values of providing care for the public good and for the individual. Number one is patients finding out their HIV status, that is the benefit. Then there’s the ease of getting the result. It’s not invasive. The nurses don’t need a doctor’s order to test….Staff is amenable because it is viewed as an important thing to do. If a patient is positive, appropriate treatment can be started right away [U]. (p.4) USA Veteran Care Context

77

Now that ART was more widely available, nurses supported the view that HIV should be normalized and seen as any other disease. Routine testing was seen as helping to raise the topic of HIV with patients, making it easier to discuss HIV, to integrate it into consultations and thus dispel stigma. Nurses saw it as important to identify the undiagnosed so that they could access treatment. Likewise, increased testing was seen as important in order to protect the wider public good. Some nurses did express reservations about PITC. In these cases, the main concern centered around an apprehension that PITC might compromise or damage patient care. For example, nurses working in a TB clinic in South Africa expressed concern that HIV testing might cause further distress and negatively affect patients who were already coping with a TB diagnosis: There appears to have been resistance by some nurses to the introduction of HIV counseling too early, when patients were still very ill from TB. One key informant referred to this as a ‘‘Catch-22’’ (Key informant 3).Nurses didn’t want to pressure the patients to take the test and 55

at the same time they did not want to lose patients by postponing the Counseling [C]. (p.243)

In another example, some nurses expressed concern that lack of privacy within the clinic/hospital setting might compromise confidentiality, thereby damaging care: Sometimes in our set ups we have patients who have to share beds and the next patient sees the result so I feel at that point we’ve lost it [U]. (FGD1:2). (p.23)

71

Likewise, some nurses working with marginalized groups (e.g. the homeless or drug users) worried that patients might not fully understand the testing process or feel pressurized into testing, thus compromising informed consent.



2015;13(12):130-286

I would be concerned about them completely understanding what they are being tested for and why. And especially in the ER setting, that may be difficult [U]. (Site A-RN) (p.214) USA, ED

81

For these reasons, some nurses were concerned about the recommended reduction in pre-test counseling. Some nurses were worried that PITC would deter patients from seeking help. Others felt that PITC was unnecessary in every consultation and that patients might feel judged or offended to be asked about HIV during a consultation for a very different condition. Some nurses recognized that 70,

some of their negative views about PITC were influenced by the ongoing social stigma around HIV. 71

Findings from 14 studies [16 papers] contributed to this category, including three from South Africa in different clinical settings (i.e. a TB clinic

55

and Primary Health Care (PHC) clinics

26,68,69

); six from

76,78,80,81

different clinical settings in the USA, such as Emergency Department (ED), 79

Use Disorder (SUD); Kenya;

70, 71

77

one in a primary care setting; 64

one in a maternity setting in the UK;

one in both inpatient and outpatient settings in

one in an acute care setting in Zimbabwe; one in 65

Antenatal Care (ANC), a maternity ward and a post-test club in Uganda; treatment centers in Cameroon.

and Substance

and one from HIV/AIDS

72

Alignment of PITC with perceived professional roles This category refers to the extent to which nurses saw PITC as fitting with their existing professional roles. Where nurses saw PITC as complementing and/or extending their existing roles, they were supportive of the policy. With me, even though there wasn’t this project, whenever I was treating an STI, I always talked about HIV. So is not a new thing. The only difference is that now I have the opportunity to do the HIV test [U]. (p.12) South Africa

89

However, where PITC was not seen as part of their professional role, it was resisted. The most obvious role contradiction was for nurses working in ED or Emergency Room (ER) settings. The studies from these sites revealed frequently reported views that PITC was considered to be part of preventive rather than emergency ‘curative’ care. As a result, in some cases, it was actively resisted or de-prioritized. HIV is an odd thing to do in the ED because in the ED we address things we can treat. HIV cannot be ‘treated’ in the ED [U]. (p.421) USA Veteran ED Setting

80

Role contradictions were also reported from settings where PITC was being implemented through task shifting (e.g. in a TB clinic,

55

where nurses were uncomfortable with the idea of devolving HIV

counseling to lay health workers as they felt it was a core nursing role): Many, however, saw HIV counseling and testing as the responsibility of the TB nurse because of the relationship between the patient and the nurse, usually described as an ‘‘attachment,’’ ‘‘confidence,’’ or ‘‘trust’’ [C]. (p. 241-242) South Africa

55

There were findings from seven studies (seven papers) in this category, including one from South 55

Africa in a general clinic, care setting,

75

78,80,81

five from USA in different settings (i.e. three in EDs, 79

one in a primary

68

and one in SUD, ) and one in an STI clinic in South Africa.



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Synthesized finding two: Nurses’ and midwives’ ability to perform PITC well requires an appropriate infrastructure and adequate human and material resources. Nurses’ ability to perform PITC well requires adequate space, time, equipment and staff. This synthesized finding consisted of two categories. Environment This category refers to the impact of the physical environment on the HIV testing process. Several studies reported a lack of space or unsuitable design/layout of an existing department. Lack of private space potentially compromises patient confidentiality and affects the quality of care that can be provided. Lack of private rooms, spaces or even screens to cordon off an area meant that privacy for HIV testing was compromised, and/or that the process could become disturbed due to frequent interruptions. This issue was reported from both high and low income contexts. We’re chronically short of staff and this needs a dedicated person. …There’s not a lot of privacy out there, and people get offended if we ask them in an open space in the waiting room [U]. (p.282) USA, ER

78

Counselors also said some exam rooms used for HIV counseling lacked privacy. Some rooms had half walls, curtains in place of doors, or glassless windows. Counselors were forced to give HIV test results in a low voice, and women crying could be heard by others in the waiting area [C]. (p.92) Uganda, antenatal settings

67

Some studies reported that this may have been because the areas had been built before HIV testing became routine, hence the infrastructure needs for this service had not been taken into account. There were findings from six studies (six papers) in this category encompassing a diverse range of settings, including one ED setting from the USA, an acute care setting in Zimbabwe, Kenya.

74

78

an antenatal setting in Uganda

a TB clinic setting in South Africa

55

66,67

and Ghana,

73

and an in-patient setting in

70

Human and material resources This category refers to the impact of staffing levels and procurement processes on the HIV testing process. This category referred primarily to reported staff shortages (nursing and support staff, such as lab technicians) in a context of high patient numbers. It also referred to lack of equipment and supplies. Both issues resulted in a perceived poor quality service for patients in which the testing process was rushed, superficial, delayed, created long patient waits or was not done at all. Staffing was an issue in both high and low income contexts. A nurse said, “We’re chronically short of staff” [U]. (p.282) USA, ED

78

Sometimes you find like in my ward you are alone . . . you have all the clients for testing-so what we do is sketchy - you know - shallow, not deep [U]. (N11) (p.1295) Kenya

70


JBI Database of Systematic Reviews & Implementation Reports 66

In situations where the problem lay with lack of lab staff,

2015;13(12):130-286

there were long delays for patients in

obtaining the test result. In some cases, testing was carried out but patients were told to return on 66

another day for the results, potentially risking a loss to follow-up. testing could be done.

66

When test kits had run out, no

Lack of supplies was a challenge reported only by studies from low income

contexts. We are normally short of OraQuick, which we use as a confirmatory test. At times we ask patients to go and come because we have to send their blood samples to the reference laboratory at Komfo Anokye Teaching Hospital and many go and do not come back. (HIV Counselor, key informant interview, health facility in Kumasi) [U]. (p.6) Ghana, antenatal 73

setting.

Some studies reported that nurses working under these conditions became frustrated and burnt out. Frequent stock-outs of clinic supplies were a source of intense frustration for counselors as stock-outs prevented them from providing quality care to expectant mothers [C]. (P.93) Uganda, antenatal

67

Nurses adopted a variety of strategies to conduct testing under these difficult circumstances, for example, (in antenatal settings) by including post-test information in the pre-test group information sessions, or by shortening counseling of those who were HIV negative to enable more time for those 66

who were positive. In one study,

nurses suggested recording counseling via video screening in the

waiting rooms to make the process more efficient. There were findings from 11 studies (12 papers) in this category, including antenatal care in the UK and Ghana,

73

three ED settings in the USA

76,78,80

64

55,65-67,70,74,77

and six different settings in Africa.

Synthesized finding three: At the organizational level, nurses’ and midwives’ engagement with PITC is facilitated by an inclusive, management structure, alongside the provision of ongoing training and clinical supervision. PITC is hindered by difficulties in fitting it into existing workloads and routines. Nurses’ motivation and engagement with PITC requires an inclusive, ‘listening’ management structure. Organizational support is required to enable nurses to fit PITC into existing workloads and work routines and to provide adequate training and supervision. The latter should be ongoing (rather than one-off) and should focus on knowledge and skills but also on operational issues, and should also include clinical supervision. This synthesized finding consisted of three categories. Support, recognition and involvement This category refers to the ways in which nurses were (or were not) provided with support and recognition for their work in PITC and the ways in which nurses were (or were not) provided with opportunities to be involved in developing the PITC service. It considers the impact that support and involvement had on nurses’ motivation and ability to undertake PITC well. There was an expressed need for support, recognition and greater involvement in the PITC implementation process at various levels: (i) Managerial support was required to adequately recognize the additional burden that PITC was placing on nurses. Several studies described a tension between nurses’ focus on quality and a management preoccupation with reaching targets:



2015;13(12):130-286

Okay one of the challenges we as nurses we also face in terms of HIV is that we are judged by the number of clients we see but not with the quality of work … because if you see all those mothers at the PMTCT they will be very happy when they come for the supervisory visit but they will not bother to find out the quality of work you did with each client … And then – reporting – you come at the end of the month and you find that the whole table is full of papers, books – if you miss to fill one copy like this, somebody comes on your neck the next day and says that you are late for this or that report – what – so you find the nurse is overwhelmed and the nurse is doing the work of the clinician, the doctor, the clerk, and even a counselor … You have been saying that the nurse is the backbone but it is coming to a time when the backbone is breaking so someone needs to recognize that (FGD2:3) [U]. (p.23) 71

Kenya

Several studies reported that nurses wanted to be involved in decision making around PITC, including learning about their progress, policy implementation and finding out how their patients are doing (i.e. whether the HIV test has ensured that patients enter into and are retained in care). Where this took place, PITC seemed to be implemented more smoothly and staff were more satisfied. This is exemplified in the two quotes below taken from two different sites in the USA – one which had good management support, with regular feedback and one which did not: I don’t recall seeing or feeling that [support]. Only the people in the ER were encouraging upper management never got involved with this. We just never heard anything from them…… There was one meeting with a graph. It would have been good to see outcomes more regularly to let us know if what we’re doing is really working [U]. (p.880) USA, ED

76

They give us the time to complete the class. They excuse us from clinic to attend class. They encourage us to do more like, oh, we reached this goal, now we have to do more. They were not just supportive but pushing us to do more. They pat us on the back and say good job [U]. (p.5) USA Veteran primary care

77

In situations where management were perceived as unsupportive, nurses reported feeling demotivated and burnt out.

71

(ii) Inter-departmental support was an important issue in some settings where referral systems and patient pathways needed to be established for PITC to work effectively. …There was one clinic where counselors felt that the nursing staff did not appreciate the value of HIV counseling and testing. For example, the antenatal staff would sometimes provide women with antenatal services without referring them for either counseling or HIV testing. This meant that many women at this clinic left before being tested for HIV [C]. (p.175)

66

(iii) Support from senior colleagues or ‘champions’ was recognized as being highly motivating and helpful for trouble shooting. The nurse manager admitted that more involvement on her part would have increased testing and nurses in her clinics reported that when she was present it was a good motivator [C]. (P.802) USA, Veteran Substance Use Disorder Clinic

79



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(iv) Support and clarity on the legal implications of PITC and partner notification was a concern for nurses in some settings in the USA children was involved.

81

and Africa,

69, 72

and particularly in cases where testing of

69, 96

Very few come with their parents or legal guardians. That’s where we face challenge. You will always need consent. Even if you see a sick child you have to encourage the person who came with the child to get consent. The child stays with the grandmother but comes with the aunt to the clinic. The aunt does not stay there...So that will create problems in cases of follow-ups and adherence…For those whose parents are outside the country, some of them are not getting permission to be tested. We will then feel that our hands are tied. We will not be able to test the child without legal guidance. We will treat the child and ask the caregiver to go and talk to the parents of the child and come back. But they never come back [U]. [female head nurse] (p.4) Zimbabwe

97

There were findings from 11 studies (14 papers) in this category, including one in Antenatal clinics in 66,67

Uganda,

26,68,69

clinics, clinic,

77

64

UK,

three from South Africa in different clinical settings including a TB clinic and PHC 76,81

four from different clinical settings in USA such as ED, 70,71

one in both inpatient and outpatient settings in Kenya,

SUD

79

and a primary care

one in a maternity setting in the

72

and one from HIV/AIDS treatment centers in Cameroon.

Impact of PITC on existing working practices This category refers to the ways in which PITC, as a new service requirement, ‘fits’ and ‘flows’ into existing working practices. In this category, ‘fit’ referred to the timing and sequencing of the test in relation to other nursing tasks. It also referred to how much information giving/counseling and documentation were required. Where the latter was minimal, the process was easier to implement. But in some cases, the prevailing concerns about protection of patients’ rights (especially to informed consent) meant that processes became operationally cumbersome (e.g. needing lengthy paperwork to be filled in).

26,92,93

‘Fit’ also

referred to how different services worked together – whether or not HIV testing was integrated into a single patient pathway or whether time consuming additional referrals were required, for example, in antenatal settings when patients needed to be referred to a different center for HIV testing to take place.

66,69

In settings where PITC was streamlined into existing practices or was incorporated without too much additional work, nurses tended to be more satisfied and positive about the process. Truthfully I thought I didn’t want to be bothered …yup I couldn’t have cared less. (But) it’s so easy, because I’ve incorporated it, I’ve made it such an easy tool that it’s just there. I don’t forget doing it because it’s the first thing I do (nurse at site 3) [U]. (p.801) USA, substance abuse clinic

79

However, in some settings, the PITC delivery process was perceived as awkward, as time and labor intensive or as disrupting existing work flows. When nurses were asked about the challenges posed by the intervention, they indicated that the added time was the main obstacle. The main reason for this, they said, was that they were required to convey too much information: ‘We have to do too much talking and writing’. Related to this was the greater interaction with patients as a consequence of introducing HIV



2015;13(12):130-286

into the STI consultation: “We have a lot of information to discuss with them, and the clients are also asking a lot of questions.”… Observation of clinical practice indicated that although they were able to perform all the new tasks….they struggled to do so in an integrated manner. The level of efficiency of deployment varied among the nurses observed, most often resulting in long extensions to consultation times [U]. (P.12) South Africa, STI Clinic

89

The nurses also articulated displeasure with all the paperwork…They felt there were too many steps to go through…and found it, administratively, to be “a lot of extra work” [U]. (P.22) Canada, Primary Care

82

Two studies noted that the facilitative, counseling discourse associated with HIV was different to the more authoritative and didactic approach usually adopted by nurses in those settings (South Africa, Uganda),

26 90,95

posing challenges to the delivery of a smooth or efficient consultation:

The new intervention challenged the conventional provider-patient communication used in the STI consultation. For the most part, nurses used a more provider-centered authoritative communication style in which they took the authoritative role of providing knowledge and advice. However, the tasks linked to assessing patient readiness for testing and obtaining informed consent required more patient centered forms of communication and did not fit easily with the task orientated nature of the STI consultation. The tension between these two styles challenged the clinical communication skills of the nurses and limited their ability to integrate the tasks efficiently [C]. (p.13) South Africa

89

The issue of ‘fit’ and ‘flow’ had several consequences. In an ED setting, for example, it meant that nurses would offer HIV testing only when the department was not busy as it had not been integrated 80

into routine practice.

In an STI clinic, the lengthy consent and documentation process meant that 26, 68

consultations were greatly extended, putting additional pressure on staff.

There were findings from 11 studies (12 papers) in this category, including three from South Africa, 55

26,68,69

one in a TB clinic; settings in USA,

75,77

and two in PHC clinics,

82

one STI clinic in Canada,

78 80,81

three ED settings in USA,

two primary care 79

and one from three SUD clinics in USA.

Equipped to practice This category refers to the knowledge and skills required by nurses to enable them to confidently and effectively carry out PITC. The category includes training needs, content and processes that nurses identify as important. The studies showed that, depending upon the setting, nurses identified the following range of training needs: basic knowledge about HIV, advanced knowledge about HIV (e.g. HIV in pregnancy, pediatric HIV or infant feeding), ethical issues (e.g. informed consent, confidentiality), how to practically administer the test, legal issues (especially around partner notification and testing of children) and how to deal with ethical dilemmas (e.g. sero-discordant couples). Existing training was variable in focus, duration, content and frequency. Participants in several studies reported a desire for ongoing 64,66,67,69

training and supervision rather than just a one-off event.

The majority of Counselors felt they needed more training. Counselors felt they lacked current information [……]. All counselors emphasized that training should not be a static, onetime event. Instead, they wanted ongoing training and periodic refresher courses to improve their skills and keep up with rapid changes in prevention and treatment sciences [C]. (p.91)

67



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In terms of content, studies reported that existing training for PITC seemed to focus mainly on knowledge, skills and policy guidelines (e.g. protection of patient rights), rather than the operationalization of PITC (i.e. how to implement, integrate and sequence PITC within existing work practices and roles). Another factor contributing to reduced skillset workability was the training. There was disagreement between the project leadership and the HIV trainers about the duration and content of the training for the STI nurses. It was evident from participant observation that training focused on teaching nurses counseling skills so that they could assess patient readiness and facilitate ‘true’ informed consent. Most of the time was spent on trying to rapidly teach nurses to use patient-centered counseling techniques and on how to provide health education to ensure that the patient was fully informed. In contrast, there was little to no guidance in the training on managing the operational challenge of efficiently integrating the new tasks into a standard STI consultation [U]. (P.13) South Africa, STI Clinics

89

There were findings from 11 studies (13 papers) in this category, including one in Antenatal clinics in 66,67

Uganda,

one in an STI clinic in Canada, 76,78,80

settings i.e. ED,

SUD

79

82

and a primary care setting, 64

one from a maternity center in UK,

69

one from a PHC setting, 77

five from USA in different

one from South Africa in a PHC clinic,

26 68

72

and one in an HIV treatment center in Cameroon.

Synthesized finding four: Nurses and midwives perceive that good quality care in PITC involves finding a balance between public health needs and individual patient needs. Good care requires time and the ability to apply a patient centered approach. The routinized processes underlying PITC create two contradictions for everyday nursing practice. First, nurses strive to implement a patient centered approach within a public health intervention (PITC), in which they have to balance individual patient needs against a population based public health imperative. Second, in contrast to the normalizing impetus underlying the PITC strategy, nurses recognize that for many clients, the enduring stigma of HIV means that testing is not perceived as a routine procedure and that HIV is not perceived as a normalized condition. From a nurse’s perspective therefore, ‘good care’ in PITC requires time and nurses adopt a range of strategies to encourage clients to test and to provide adequate information, counseling and support where required. This synthesized finding consisted of three categories. Introducing the test: negotiating choice and consent This category refers to the strategies used by nurses to introduce the HIV test in the context of their service or consultation and explores their experiences. A core concept emerged of having to strike a balance between individual patient choices and life circumstances with the imperative to test. I am supposed to counsel that lady, until she accepts to test. Then it is upon her to refuse the results. But again for me as a midwife it is my obligation to convince that mother to accept the results. She is supposed to choose a feeding option. She is supposed to accept nevirapine. How will I do this unless I re-counsel her to convince accept the results? Because my target is to have a live baby. To try and prevent transmission [U]. (Midwife, Sara). (p.561)

65



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Nurses emphasized the importance of informed choice and reported several strategies to gently persuade their clients to accept a test. Several of these strategies required considerable time and the need to develop trust with the client. The luxury of time was not always available however. Some nurses

71

felt that the more extensive pre-test counseling was required, rather than the recommended

shortened information giving, in order to adequately prepare patients who may be HIV positive. Many nurses were not convinced about the PITC guideline to minimize pre-test discussions in order to expedite client through-put. Their own experience was that in many cases (because of HIV related stigma), patients did require in-depth pre-test discussions to help them to overcome their fears and to give consent. In such cases, nurses’ narratives indicated that, where possible, they adapted the guidelines, tailoring their discussions to an in-depth understanding of the patients’ situation “With this patient, I knew I had to take longer. So I took her very slowly through everything. She didn’t want to test, but then, after some persuasion, she decided to let me go ahead.” [U]. (N12) (p.1294)

70

For HIV testing in pregnancy, nurses tended to present the test as for the benefit of the baby and as a ‘routine’ thing (just one of many tests). We offer it as a test along with all the others so we can prevent transmission and don’t put too much emphasis on it because of the fact that people who get worried about it tend to say ‘NO’ [U]. M7 (P.55) UK antenatal

98

Most women were described as accepting of the test. Nurses found it very stressful when women refused the test and reported a range of strategies that they used to convince them. These included repeated requests at each appointment, using individual rather than group pre-test counseling, being highly flexible, willing to let them come back later and encouraging couple counseling where possible. They noted that success was more likely if they were able to build up a trusting relationship with their patients. It also helped if patients were already informed about what to expect in an antenatal 64,66,67,73 95

consultation, for example, by using patient education leaflets.

In some situations, nurses challenged patients’ risk perception if they refused a test (e.g. by trying to 64

show how they may indeed have been at risk).

In two studies (from African settings), some nurses

reported pushing quite hard (bordering on coercion) where a patient was refusing to test and where 70,71,73

they knew that they were very likely to have HIV.

In these studies, nurses justified their actions

as ethical by drawing upon a discourse of acting in the patients’ ‘best interests’. Sometimes you find a patient where you know the spouse or a child has died because of AIDS and they refuse to be tested despite the counseling and all that. It is challenging because upon discharge you will lose that patient. So you find you might be aggressive for the sake of helping them, not because you want to create harm, but just because you want them to benefit, even though you have to use a cold and aggressive way of handling such a situation . . . Like there was a girl on the ward and I told her _ either you lose your life or comply with the protocols of the hospital . . . then, you see . . . it was like forcing . . . but at the end of it she accepted. But it was for her benefit (N2) [U]. (p.1294)

70

There were findings from eight studies [10 papers] in this category, including one from antenatal 66,67

settings in Uganda, 69

PHC clinics,

two from South Africa in different clinical settings, i.e. general clinics 81

one in emergency settings in USA,

55

and

one from both inpatient and outpatient settings in



Kenya,

70, 71

one in an acute care setting in Zimbabwe,

74

2015;13(12):130-286

one in an ANC setting in Ghana,

73

and one in

64

a maternity setting the UK.

Communication and result giving This category refers to perceptions about good quality care in relation to performing the HIV test and giving the result. A key concept related to result giving was the need for sufficient time to do adequate post-test counseling or discussions. Nurses from high and low income contexts felt that patients needed a lot of time and support to come to terms with a positive result and were concerned that this time was often not available due to their own heavy workload or due to the fact that patients sometimes needed to rush off because of their own domestic circumstances. Lack of time was perceived as affecting quality of care and created stress for nurses. The thought to me of getting [giving] a positive HIV test is a nightmare, too, because of all the post counseling [U]. (p.214) USA, ED (Site A-NP)

81

Even when the HIV test result was negative, nurses felt that it would be important to counsel patients about risk reduction and some reported that there was also not enough time for this activity. In order to prevent women from leaving many counselors felt the need to rush through posttest counseling sessions so that all women could receive their results. Counselors also described how clients, especially those who tested HIV negative, would often decline further HIV counseling after learning their HIV test results and were uninterested in discussing risk reduction plans or other post-test counseling items. “For her, she has come for check-up but she has to go back and dig. If you take long talking to her, like counseling should take at least 30 minutes, don't you see? They don't want that. She wants you to talk to her and then she goes because she has problems at home. If you take long, they don't want.” (Midwife/Counselor, rural clinic) [U]. (p.171) Uganda, antenatal

66

Communication during testing was sometimes difficult due to language barriers. Sometimes family members had to act as interpreters, potentially compromising patient confidentiality. These were findings from nine studies [10 papers] in this category, including two from Uganda in 65-67

different care settings,

two from South Africa, including a general care setting 81

two from USA, including different clinical settings such as EDs, setting from Canada,

82

79

SUD clinics,

55

26

and an STI clinic,

eight in an STI clinical 71

one from both inpatient and outpatient settings from Kenya,

maternity setting within UK.

and one in a

64

Maintaining care and follow-up after a positive result This category refers to the importance that nurses placed on having systems in place for post-test follow up and care. The findings indicate that a key part of quality care in the PITC process is providing accessible HIV care/treatment and having systems in place to ensure that patients are subsequently linked into these services. Certainly, we want our patients to be tested for HIV, but knowing on the other hand then, that if there is not good follow up, then they get lost……….to have time to sit down with them and make appropriate referrals, what happens when that person leaves out of here at three in the morning and their life is turned upside down as a result of positive results? [C]. (site B-SW) (p.214) USA ED

81



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A source of stress and frustration for nurses was when follow-up systems did not work well or were not available. Services for HIV are often fragmented, so mothers and children have to see different health workers to receive all the services they need, leading to poor compliance. “We have the PMTCT follow-ups at our antenatal clinic on Fridays. Now the problem is, if those children present with any minor ailment, then they are sent up to us., then they refer them to the doctor, if they need to go on ARV’s or whatever, but we are sending them up and down, up and down, that’s how we do it.” [U]. (Nurses FGD5). (P.316) South Africa

69

It was important for some nurses to find out what had happened to patients who they had invested time and effort into helping. Not receiving feedback on such patients was experienced as frustrating. Likewise, nurses felt frustrated when they lost patients to follow-up and then saw them (or their children) return sick. Because counselors were unable to follow-up with women who dropped out of antenatal care they were unable to track the success of the program. We need to test ourselves, to know our effort. If you attend to the mother during pregnancy, she delivers well, why don't you know the outcome? Is the baby okay? The nevirapine, was it wasted? Did you find the baby after 18 months? And you test that baby. Is she negative? Is he negative? That is the fruits when you see the outcome; what we have achieved in the program. Because if we don't know the outcome of our baby that means we have worked a lot but at the end of the day nothing was done [U]. (Midwife/Counselor, urban clinic) (p.171)

66

These were findings from four studies [five papers] in this category, including one from antenatal 66, 67

settings in Uganda,

81

one from EDs in USA,

69

one from PHC clinics in South Africa,

and one in a

64

maternity setting in UK.

Synthesized finding five: The emotional work involved in PITC can be stressful. Nurses and midwives may require support to deal with complex moral/ethical issues. Implementation of PITC can be stressful for nurses due to the emotional work required to support clients in difficult situations and due to being confronted by moral/ethical dilemmas on a regular basis. Nurses respond to these dilemmas through a discourse of professional ethics, although professional and normative understandings of ethical principles are sometimes in conflict. The stress of PITC is exacerbated by working conditions in which nurses feel overworked and/or under-supported. This synthesized finding consists of two categories. Carrying an emotional burden This category refers to the stress and/or burn out experienced by counselors as a result of PITC. There were three main reasons for stress associated with PITC: (i) Delivering a positive result. This was a particular concern when PITC was first introduced and its associated anxiety reduced with time, training and experience. However, the findings suggest that result giving can remain a source of anxiety and stress, especially in sub-Saharan Africa where nurses are dealing with higher levels of HIV in contexts where there may be limited resources to provide adequate care.



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The greatest concern as reported by five nurses was anxiety or discomfort with delivering preliminary HIV-positive test results. Sources of this anxiety included not knowing how the patient would react upon receiving the results, inexperience delivering HIV results and concern over the process of linking the patient to care. To overcome this, all of these nurses came up with their own plans on how to they would engage other providers or mental health services in the event of a positive result. [C]. (p.802) USA, Veteran SUD Clinic

79

When you do the test, you pray: “Please God, it mustn’t be this one…” You have to take a deep breath when you are still waiting for the result and you pray [U]. [STI nurse] (p.198) South Africa, STI Clinics

89

(ii) Dealing with patients who were experiencing difficult life situations and feeling powerless to help. You test them and then they tell you their history and you just don’t know what to do next. They are poor and they can’t afford food, and then you ask yourself ‘‘what can I do to help this person. It really affects me.” [U]. (N10) (p.1295) Kenya, in & out patient

70

(iii) Coping with large numbers of patients every day, leading to emotional exhaustion. Yeah you can become emotionally drained, definitely, like last week…I’m going to use the word divorced. I divorced myself from the testing. And my clients. Because I found that I, I felt that I was emotionally drained, man. To see all these patients . . . on a regular basis. Some of them respond well, some of them don’t respond well [U]. (Focus Group 1). (p.243) South Africa, TB Clinics

55

In some settings, nurses identified a need for peer support and clinical supervision to help them to improve their practice, to deal with their stress and to cope with difficult situations. None of the 10 clinics had a formal program of counselor support, such as a counseling supervisor or counselor support groups. However, several counselors described how they informally sought out other counselors for support after a particularly bad day. Several counselors requested formalized retreats where they could share their experiences and challenges with other counselors, have an opportunity to be counselled by them, and come up with solutions to common challenges that arose during counseling sessions. Other suggestions included having music playing in the break room to help counselors relax between clients [C]. (p.184) Uganda, antenatal

66

There were findings from nine studies [10 papers] in this category, distributed over a wide range of 65-67

geographical and clinical settings. These included two from different clinical settings in Uganda, two from South Africa in a general clinic

55

68

and an STI clinic,

one from inpatient and outpatient settings in Kenya, 64

70

82

one from an STI setting in Canada,

one from a SUD clinic in USA,

79

one in a

72

maternity setting in UK, and one in an HIV/AIDS treatment center in Cameroon. Ethical dilemmas in negotiating disclosure

This category refers to the challenges and moral/ethical dilemmas experienced by nurses/midwives in supporting clients to disclose their HIV status to others who may be at risk. This was a particular issue within the sub-Saharan African context. Whilst recognizing and supporting the general principle of confidentiality, nurses in several studies questioned its universal applicability in situations where serious harm could be done to others. They felt constrained by professional norms and the law which was perceived as unjust – particularly from a Evans et al. The views and experiences of nurses and midwives in the provision and management of providerinitiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 156


2015;13(12):130-286

gendered perspective, as it was often women who were deemed to be at risk. Indeed, gender-power relations were commonly cited as significant factors that complicated scenarios around disclosure. Common situations included when women were frightened of informing their partners due to fear of domestic violence or social ostracism, where men refused to inform their female partner and nurses strongly suspected that they would not use condoms. Nurses felt it was their duty to encourage their HIV positive client to inform their sexual partners of their status, so that they could also get tested. In situations where clients indicated that they would not or could not do this, nurses could feel significant ethical and moral distress.

66, 67

Although the participants who held this view acknowledged the importance of respecting patients’ autonomy, they felt that it was their duty to also protect patients’ sexual partners at risk of HIV exposure, and to enable them to seek prompt treatment if already infected. “The law states that we should respect peoples’ privacy or confidentiality...but I like to inform the partner because I know from experience that people who refuse to disclose to their partner will infect them.... What if the wife comes tomorrow and is diagnosed positive?... It will be my fault because I did not inform her...” [U]. (Male Counselor, 35 years old) (p.6) Cameroon, TB Clinics

72

From the HIV care coordinator’s experience, there is a desire to offer the woman’s partner an HIV test and, if necessary, provide treatment. However, this has to be balanced against issues of safety for the woman. One woman was beaten up by her partner [U]. (M2) (p.67) UK, antenatal

98

As described above, in some cases, nurses admitted to using pressure or threats to persuade 66, 72,70 73

someone to disclose or they experienced distress from not knowing what to do.

See, the relative is the one paying the bill and they are asking all the time ‘‘what has the doctor said?” . . . As a nurse you are fixed because on the one hand there is confidentiality and on the other there is the relatives’ vulnerability . . . Mostly it is women, and you see that they will not be able to take care, so you just go ahead and give information to that person 70

[U]. (N10) (p.1295) Kenya]

Nurses reported several strategies (most commonly, couple counseling) to support disclosure. Couple counseling was experienced as stressful as nurses recognized that the future of a relationship or a client’s well-being was at stake.

67

Also, the tragedies here...we get discordant cases. For them it is hard, it is trouble to counsel them because you can find that the woman is positive and the man is negative. To counsel those couples it is really a tug-of-war because you have to be sure to tug that matter very, very carefully so that you cannot confuse those people in their marriage. Because if you don't tug it very carefully, you can confuse them and cause them to divorce from each other [U]. (Midwife/counselor, rural clinic) (p.185) Uganda, antenatal

66

In terms of how best to support nurses to deal with these difficult situations, respondents in one 72

paper,

noted that specific ongoing training regarding such situations had helped them to develop the

confidence to manage such difficult ethical situations. When we started...most of us were inexperienced. We never knew how to present most of the things to most of the patients but with the trainings we take our time to give the best counseling to the patients so that they will not have misconceptions...it has made most of the



2015;13(12):130-286

patients to be understanding. [U]. (Male counselor, 35 years old) (p.6) (p.6) Cameroon, TB Clinics

72

In addition, they called for greater legal clarity and health sector guidelines. However, they all acknowledged that in order for them to notify noncompliant patients’ sexual partners, the government has to step in with a policy that legally protects health care providers against litigation. “My proposal is that there should be a law or by law protecting the health professionals in such special cases that they have the right to protect partners for public health benefits.” [U]. (Male Counselor, 27 years old) (p.7) (p.6) Cameroon, TB Clinics

72

These were findings from five studies [six papers] in this category, including two from different settings in Uganda,

65-67

70

one in both inpatient and outpatient settings in Kenya,

64

setting in UK, and one in an HIV/AIDS treatment center in Cameroon.

one in a maternity

72

Discussion The synthesized findings established in this review provide clear insights into each of the research objectives. These are considered below. Views on PITC In terms of nurses’ views regarding PITC, the review shows that nurses/midwives are supportive of PITC in principle and see value in its public health objectives as well as in its individual patient care benefits. The main apprehensions around PITC relate to fears over whether good care can indeed be delivered in a particular healthcare context. These concerns relate to whether it is a feasible and/or an appropriate intervention in that context (e.g. in an ED setting) and whether sufficient resources, time and support are available to ensure that it can be effectively implemented. In such situations, resistance to PITC may be encountered. Understanding nurses’ views around PITC in terms of ‘good care’ extends the insights of previous research in this area which tends to argue that resistance or concerns relate primarily to lack of knowledge or lack of self-confidence.

27

Factors that facilitate or hinder PITC implementation In relation to factors that facilitate or hinder PITC implementation, the review has identified a range of infra-structure and resource related operational challenges (e.g. staffing, space, supplies). The need 54

for adequate infrastructure and resources has been highlighted in previous systematic reviews.

This

review has identified infrastructure and resource related challenges across all contexts; however these were particularly pronounced in the sub-Saharan African countries. Together, the evidence suggests, unsurprisingly, that adequate infrastructure and resources are foundational elements of PITC, upon which all other aspects of quality care and the patient/provider experience depend. However, in addition to challenges posed by infrastructure and resources, this review has also highlighted the key role that particular implementation processes play in supporting or hindering PITC (e.g. training, management support, consultation, on-going feedback). The review has identified that implementation is also affected by the ways in which PITC can be sequenced in relation to other tasks and the ease with which it can be fitted into existing practices and processes. Previous studies have highlighted aspects of these implementation issues (e.g. the need for staff training) but have tended to examine particular issues in isolation. This review suggests that PITC implementation could benefit from using a change management or quality improvement model or



2015;13(12):130-286

theory to guide the process, so that all key elements are addressed. For example, several of the papers in this review used such models (e.g. Sustainability Index,

99

Normalisation Process Theory

100

)

and, consequently, were able to show very powerfully how important it is to get implementation processes right and to ensure that all are given due attention.

26,76,77,94

For example, in two studies, the

evaluation was based on the Sustainability Index Framework. They were able to show that where implementation processes were strong, PITC were mainstreamed and sustained, were weak, the intervention fizzled out over time.

93

but where they

76

Another key finding in relation to implementation relates to training, both in terms of content and frequency. This review has highlighted that nurses from various settings identify a need for training to be more than a one-off occurence. Training needs will vary depending on the setting and context but a common theme was that training should not only take place at the beginning of the PITC process, but follow-up training is also required to help nurses understand and address particular issues that emerge for them in the course of their practice. Likewise, the review has highlighted that training should not only cover HIV basics and practical aspects of the test but also address ethical and legal issues, and, importantly, help nurses to consider how best to sequence and operationalize the test into their everyday routines. Quality of care in PITC In terms of quality of care in relation to PITC, nurses identified patient-centred care as the hallmark of good quality. The aforementioned infrastructure, resource and operational issues all had an impact on nurses’ perceived ability to adopt a patient centred approach. This is a very different emphasis to the public health requirement (that nurses also acknowledged as important) to maximize the number of people tested. Practitioners dealing with individual patients will invariably face tension between public health targets and the need to deal with complex individual issues which can take time and which require the development of trust. Nurses in this review particularly identified a need to have sufficient time and care pathways in place to support patients who were reluctant to test or those whose result was positive. This review shows, how nurses, caught between the two imperatives, responded, i.e. by (i) exerting pressure on patients to test sometimes, and, (ii) innovating to try and create more time for those who need it most (e.g. using lay counselors, group based or couple counseling or computer66,67,73

aided pre-test information giving).

These dilemmas, which were particularly acute in sub-

Saharan African contexts, and their associated strategies have received relatively little attention in the literature to date, suggesting that training or guidelines need to focus more on how to balance patient needs with patient throughput. Likewise, innovations in this area need further exploration and evaluation. Much of the discussion in the existing literature around quality of care in PITC reflects an HIV ‘exceptionalist’ view in which human rights advocates argue for special emphasis on ensuring 32,101,102

patients’ rights to informed consent.

Related research often has a similar focus, for example,

by exploring the extent to which patients feel coerced to test.

49,103

Where examples of pressurization

are identified, nurses or other health professionals are reproached for adopting a coercive or authoritarian stance.

34,41,104

However, the findings from this study suggest that, where coercion

occurred, nurses were limited in their choice of response by shortages of staff and time or by the realization that patients would soon be lost to follow-up due to health system inadequacies. As such, one could argue that the patient centered philosophy articulated by many of the findings in this review show that, rather than disregarding human rights, nurses do seek to recognize patients as individuals



2015;13(12):130-286

and wish to be able to adapt their strategies to individual patient circumstances, but are hindered by structural constraints. The literature on patient acceptability of PITC proposes that for many patients, a quick and functional approach to HIV testing may be suitable, and that copious paperwork or lengthy pre- or post-test information giving may not be required.

26,30,53,105-108

This review supports such a minimalist approach,

but suggests that where nurses feel that extra attention is needed, the system should be able to accommodate it. This review indicates that a more selective, patient centred approach within the PITC process may, therefore, enable and enhance HV testing (i.e. normalize it) rather than hinder it, if it can be applied on a needs-based rather than a population-based model – as with other medical conditions. Nurses experiences of conducting PITC This review has found that, whilst generally supportive of PITC, nurses can find it stressful as they deal with difficult patient situations and high patient numbers, often in resource constrained circumstances. Nurses from all contexts reported ‘result giving’ to be stressful. Dealing with ethical dilemmas around disclosure of a positive result where the patient or a third party was potentially at risk of harm was a particular issue for nurses in sub-Saharan Africa. Again, for nurses in sub-Saharan Africa, the review identified a problematic lack of clarity around legal and ethical issues for testing of children and/or notifying sexual partners. These were all issues for which there was no easy solution, but additional training, ongoing clinical supervision and management support could empower nurses to develop appropriate patient centred guidelines and strategies. Contextual issues in PITC implementation Each of the categories in this review contained findings from both high and low income contexts, lending support to the decision to adopt an inclusive approach to the geographical context. Resource constraints were more commonly reported from the sub-Saharan African studies and were more severe; however perceptions of staff shortages and infra structure problems were relative, and hence were reported from multiple settings. In terms of health care setting, problems with PITC implementation seemed to be greatest in ED settings where a preventive process proved difficult to integrate within the philospohy and practice of such fast moving acute areas. The patient group that appeared to pose the greatest difficulty was children – due to a lack of clear legal/ethical guidelines – reported exclusively in the African context.

Limitations of the review This review sought to explore the views and experiences of nurses and midwives regarding PITC. It is important to note however that the sample in nine of the 18 included studies also comprised other health professionals, although nurses/midwives were in the majority. Further methodological research on the impact of including mixed (but majority) samples in reviews is required. Due to this issue, the extent to which the review findings apply specifically to nurses/midwives or also reflect the views of other groups who are involved in PITC implementation is unclear. It is likely that many of the issues would be similar (particularly around infrastructure, operational challenges or ethical dilemmas).

54

However, the importance that nurses/midwives attach to the provision of patient centred care and the need for PITC to be framed and evaluated according to this philosophy may be distinct and is strongly linked to the experience of stress or, conversely, satisfaction, with the process.



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Conclusions This review shows that PITC is supported by nurses who strive to implement it according to principles of good care and a patient centred approach. Nurses face multiple operational, infrastructural, resource and ethical challenges in PITC implementation. This review has identified a range of possible actions that could enhance effective implementation and, in turn, support the nursing workforce. Recommendations Recommendations for practice arising from the review are provided in Table 3 and, as per guidelines from the Joanna Briggs Institute, have each been assigned a ‘Grade’ of recommendation. The methdology for assigning a Grade is provided in Appendix VIII. Grade A is a strong recommendation, whereas Grade B is a weaker recommendation. Recommendations for research are provided in Table 4. Table 3: Recommendations for practice Recommendation

Grade

When implementing PITC, it is important to involve nurses in the process so as to ensure their buy-in and to hear their concerns.

A

PITC should be framed in terms of promoting good patient care and the public good.

B

PITC implementation must ensure adequate physical infrastructure and human and material resources.

A

It may be beneficial to use a quality improvement/change management model to guide PITC implementation processes.

B

PITC implementation should provide visible management support and provide feedback to maintain motivation and continuous service improvement.

A

Where possible, PITC should be streamlined to ‘fit’ smoothly into existing workloads and working practices.

A

PITC implementation should include ongoing training (rather than just at the beginning). In addition, training around PITC should go beyond the basics to include more complex patient situations. Training should focus particularly on result-giving to build confidence in this area.

A

PITC implementation should also include regular clinical supervision to empower nurses to deal with complex ethical scenarios.

A

Clear context-specific legal guidelines need to be developed to help nurses who are working with children.

A

Likewise, clear ethical guidelines are required to help guide partner notification processes.

A

Clear pathways and processes that link HIV positive patients to care are required.

A



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Table 4: Recommendations for research

Recommendation

Grade

Given the wide spread human resource challenges identified in this review, operational research should be undertaken to implement and evaluate different approaches to PITC in terms of optimal staff skill mix.

B

Likewise, operational research should be conducted to evaluate different ways of streamlining and integrating PITC into existing practices, including how to ensure patients’ rights whilst minimising the bureacracy around consent and counseling.

A

Additional research should be undertaken to more precisely identify the ethical and moral dilemmas faced by nurses/midwives in implementting PITC. A greater understanding of these is required in order to inform training materials and practice guidelines.

B

Conflicts of interest The authors declare that there were no conflicts of interest.

Acknowledgements The team would like to thank the UK National HIV Nurses Association (NHIVNA) for funding this review.



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Appendix I: Search strategy Medline 1946 to October 2014 (searched October 22, 2014) #

Search terms

Hits

1

view*.mp.

321089

2

experience*.mp.

691861

3

understand*.mp.

623042

4

concern*.mp.

389130

5

opinion*.mp.

77311

6

Attitude/ or attitude*.mp.

319560

7

perspective*.mp.

174142

8

belie*.mp.

197970

9

knowledge.mp. or Knowledge/

441004

10

perception*.mp.

299779

11

strateg*.mp.

585030

12

practice*.mp.

760823

13

practise*.mp.

7148

14

technique*.mp.

2054293

15

evaluat*.mp.

2507251

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 6960057 15

17

nurs*.mp.

560394

18

health worker*.mp.

12476

19

practitioner*.mp.

108798

20

Counseling/ or Counselor*.mp.

30059

21

Counseling/ or counselor*.mp.

32272



2015;13(12):130-286

22

Midwifery/ or midwi*.mp.

26134

23

health?care worker*.mp.

5185

24

nurse?led.mp.

4

25

provider*.mp.

93617

26

health professional*.mp.

31405

27

17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26

785303

28

HIV/ or HIV.mp.

276232

29

Human immunodeficiency virus.mp.

78477

30

AIDS.mp. or Acquired Immunodeficiency Syndrome/

185321

31

Acquired Immunodeficiency Syndrome.mp.

87005

32

28 or 29 or 30 or 31

368856

33

test*.mp.

2871452

34

screen*.mp.

517659

35

diagnos*.mp.

2025324

36

HIV test*.mp.

8992

37

VCT.mp.

825

38

opt? out test*.mp.

63

39

counsel*.mp.

90632

40

provider? initiated test*.mp.

67

41

routine test*.mp.

2931

42

33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41

4802924

43

16 and 27 and 32 and 42

7034

44

limit 43 to (english language and yr="1996 - Current")

5494



2015;13(12):130-286

PsycINFO 1806 to October 2014 (searched October 22, 2014) #

Search terms

Hits

1

view*.mp.

252561

2

experience*.mp.

500828

3

understand*.mp.

371032

4

concern*.mp.

242534

5

opinion*.mp.

44762

6

Attitude/ or attitude*.mp.

353094

7

perspective*.mp.

216110

8

belie*.mp.

169744

9

knowledge.mp. or Knowledge/

231063

10

perception*.mp.

381765

11

strateg*.mp.

256545

12

practice*.mp.

356144

13

practise*.mp.

2277

14

technique*.mp.

177869

15

evaluat*.mp.

439487

16

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 2285131 or 15

17

nurs*.mp.

79395

18

health worker*.mp.

3642

19

practitioner*.mp.

69335

20

Counseling/ or Counselor*.mp.

22401

21

Counseling/ or counselor*.mp.

52941

22

Midwifery/ or midwi*.mp.

2323



2015;13(12):130-286

23

health?care worker*.mp.

742

24

nurse?led.mp.

3

25

provider*.mp.

43799

26

health professional*.mp.

24962

27

17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26

251213

28

HIV/ or HIV.mp.

40792

29

Human immunodeficiency virus.mp.

5187

30

AIDS.mp. or Acquired Immunodeficiency Syndrome/

39200

31

Acquired Immunodeficiency Syndrome.mp.

673

32

28 or 29 or 30 or 31

57765

33

test*.mp.

744094

34

screen*.mp.

82305

35

diagnos*.mp.

277906

36

HIV test*.mp.

3143

37

VCT.mp.

282

38

opt? out test*.mp.

25

39

counsel*.mp.

106595

40

provider? initiated test*.mp.

11

41

routine test*.mp.

199

42

33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41

1071170

43

16 and 27 and 32 and 42

3004

44

limit 43 to (english language and yr="1996 - Current")

2427



2015;13(12):130-286

CINAHL (searched October 22, 2014) #

Search terms

Hits 63,950

S1

"view*"

S2

"experience*"

S3

"understand*"

S4

"concern*"

S5

"opinion*"

S6

(MH "Attitude") OR "attittude*"

S7

"perspective*"

S8

"belie*"

S9

(MH "Knowledge") OR "knowledge"

S10

"perception*"

S11

"strateg*"

S12

"practice*"

S13

"technique*"

S14

(MH "Evaluation") OR "evaluat*"

S15

S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR 1,400,209 S10 OR S11 OR S12 OR S13 OR S14

S16

"nurs*"

207,011

117,378

82,151

22,318

11,259

71,913

49,710

116,264

86,300

131,530

394,650

149,041

555,435

693,916



2015;13(12):130-286

4,777

S17

"health worker*"

S18

"practitioner*"

S19

(MH "Counselors") OR "Counselor*"

S20

(MH "Counselors") OR "counselor*"

S21

(MH "Midwives") OR "midwi*"

S22

(MH "Health Personnel") OR "health care worker*"

S23

"nurse led"

S24

"provider*"

S25

"health professional*"

S26

S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR 824,067 S24 OR S25

S27

"HIV"

S28

(MH "Human Immunodeficiency Virus") OR "Human 22,111 immunodeficiency virus" OR (MH "Acquired Immunodeficiency Syndrome")

S29

"AIDS"

S30

"Acquired Immunodeficiency Syndrome"

S31

S27 OR S28 OR S29 OR S30

S32

"test*"

61,308

3,419

4,827

37,372

24,819

2,474

54,093

24,252

71,394

43,972

13,981

96,501

626,484



S33

"screen*"

S34

(MH "Diagnosis") OR "diagnos*"

S35

"HIV test*"

S36

"opt out test*"

S37

(MH "Counseling") OR "counsel*"

S38

"provider initiated test*"

S39

"routine test*"

S40

S32 OR S33 OR S34 OR S36 OR S37 OR S38 OR S39

S41

S15 AND S26 AND S31 AND S40

2015;13(12):130-286

100,062

587,652

3,508

31

45,141

14

320

1,129,501

3,313



2015;13(12):130-286

Appendix II: JBI-QARI critical appraisal instrument

Criteria

Yes

1.

There is congruity between the stated philosophical perspective and the research methodology

2.

There is congruity between the research methodology and the research question or objectives

3.

There is congruity between the research methodology and the methods used to collect data

4.

There is congruity between the research methodology and the representation and analysis of data

5.

There is congruity between the research methodology and the interpretation of results

6.

There is a statement locating researcher culturally or theoretically

7.

The influence of the researcher on the research, and vice-versa, addressed

8.

Participants and their voices are adequately represented

9.

The research is ethical according to current criteria or, for recent studies; there is evidence of ethical approval by an appropriate body

10.

Conclusions drawn in the research report do appear to flow from the analysis, or interpretation, of the data

No

Unclear

N/A

Comment

the

Overall appraisal: Include: ……Exclude: …… Seek further information: …………………….. Comments

(including

reasons

for

exclusion)…………………………………………………………………………



2015;13(12):130-286

Appendix III: JBI-QARI data extraction instrument Reviewer:……………………………………………………………………………Date: ……………………. Author:…………………………………………………………………………………Year: …………………. Journal:………………………………………………………………………………… Record Number: …………….. Study Description Methodology

Method

Phenomenon of interest Setting

Geographical

Cultural

Participants

Data Analysis

Author’s conclusion

Reviewer’s comments



2015;13(12):130-286

JBI Extraction of Findings Findings

Illustration from publication (page number)

Evidence Unequivocal

Extraction of findings complete: Yes

Credible

Unsupported

No

Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 183


2015;13(12):130-286

Appendix IV: Table of included studies

A

Author(s)/year

Country

Clinic setting

Geographical setting

Health sector setting

Methodological approach

Type of HIV test

Sampling strategy

Types and number of participants

Categorization of study aims/objectives

Medley and Kennedy 67 (2010)

Uganda

Antenatal clinics

Both urban and rural

7 public hospitals

Not stated

Not well stated

Mixed participants but midwives made up 50%.

11 full time PMTCT counselors, 15 midwifecounselors, 3 clinic directors , and 1 volunteer counselors

Exploration of routine HIV testing views and practice.

2 faith based 1 secular private

B

Pope, Atkins, DeLuca et al. 55 (2010)

South Africa

Clinics provided a range of services including TB clinics

Unsure

Public hospital/cli nic

Not stated

Not stated

Only nurses participated

18 nurses participated in the FGDs, and 5 unspecified key informants from TB or HIV clinics were interviewed


C

Schnall, Clark, Olender et al. 78 (2013)

New York, USA

2 emergency department sites in two city teaching hospitals;

Urban

Public

Not stated

Rapid test

Mixed participants . Views of nurses reported

Emergency department care providers (13 physicians




Author(s)/year

Country

Clinic setting


2015;13(12):130-286



Type of HIV test

separately

Site one is a tertiary care centre and a level 1 trauma centre, and site two is a tertiary care center D

Spielberg, Kurth, Severynen et al. 81 (2011)

Washin gton State and Marylan d, USA

2 Emergency Care Settings (ECSs)

Sampling strategy

Urban

Public hospital

Rapid test

Mixed participants , nurses were more than 50%

(3 MD, 2 nurse practitioners, 7 registered nurses), counselors (1), an ECS technician (1), and (1) front office staff

Formative research to investigate a wider issue (the CARE) tool and how it can be utilized to facilitate rapid HIV testing.

Not stated

Rapid test

Only nurses were included

2 FGDs (numbers not specified) and 2 interviews with nurses

Evaluation of a specific routine HIV testing intervention (POCT).

Site B is an academic ED located in a Level 1 trauma center E

Pindera, Becker, Kasper et al. 82 (2009)

Manitob a, Canada

A nurse managed STI drop-in clinic which offers testing and treatment to those most at

unsure

public


Not stated

Academic ED

Site A is a nontrauma side of a public hospital ED

Types and number of participants (EPs), 17 residents, and 19 nurses)



Author(s)/year

Country

Clinic setting

2015;13(12):130-286




Type of HIV test

Sampling strategy



risk for STIs F

Horwood, Voce, Vermaak, et al. 69 (2010)

South Africa

Primary health care (PHC) clinics, implementing IMCI

Urban and rural

Public

Not stated

Not stated

Mixed participants . Views on nurses reported separately

20 IMCI trained nurses, 10 mothers and caregivers of children

Exploration of routine HIV testing views and practices in the context of IMCI implementation.

G

Evans and Ndirangu 70 (2011)

Kenya

Inpatient settings and outpatient patients and management (hospitals/healt h centres)

Urban/rural

Public

Interpretative qualitative methodology

Rapid test

Only nurses

25 nurses representing 11 different health care facilities

Exploration of routine HIV testing views and practices.

H

Evans and Ndirangu 71 (2009)

Kenya

In-patient wards (medical or TB wards), health centres (of which one was an HIV comprehensive care centre) and in an HIV treatment project (hospital/health centres)

Urban/rural

Public /NGO

Not stated

Rapid test

Only nurses

27 nurses




2015;13(12):130-286

Author(s)/year

Country

Clinic setting




Type of HIV test

Sampling strategy



I

Conners, Hagedorn, Butler, et al. 79 (2012)

USA

Substance use disorder (SUD) sub-clinics at three urban VHA medical centres. Site 1 is located on the west coast and site 2 is a geographically separate ambulatory care centre associated with site 1. Site 3 is located in the north eastern USA. All 3 sites have a high to medium HIV prevalence rates.

Urban

Public

Not stated

Rapid test

Only nurses

16 nurses

Evaluation of a specific routine HIV testing intervention (nurse-initiated HIV oral testing).

J

Chen, Goetz, Feld, et al. 80 (2011)

USA

West Los Angeles Veterans Affairs Medical Centre.

urban

Veteran

Not stated

Rapid test

Mixed. Nurses form more than 50%

14 Nurses and 8 Physicians

Evaluation of a specific routine HIV testing intervention (HIV rapid test?).



Author(s)/year

Country

Clinic setting

2015;13(12):130-286




Type of HIV test

Sampling strategy



unsure

Public

Pragmatic

Rapid test

Mixed, participants .

13 Lay counselors, 15 STI nurses and 11 facility managers (participated in FGDs); 10 STI nurses (and clinical supervisors) and 12 lay counselors (participant observation of training); 20 patients (interviews); 13 unspecified observations, and 3 interviews involving 5 team members

Evaluation of a specific routine HIV testing intervention (PITC).

Emergency department K

Leon, Lewin, Mathews 89 (2013)

South Africa

Primary healthcare services (among STI patients)

Views of nurses reported separately



Author(s)/year

L

M

Leon (2011)

90

Pellowe (2004)

64

2015;13(12):130-286

Country

Clinic setting




Type of HIV test

Sampling strategy



South Africa

Primary healthcare services (among STI patients)

Unsure

Public

Pragmatic

Rapid test

Mixed, participants .

13 lay counselors, 15 STI nurses and 11 facility managers (participated in FGDs); 10 STI nurses (and clinical supervisors) and 12 lay counselors (participant observation of training); 20 patients (interviews); 13 unspecified observations, and 3 interviews involving 5 team members

Evaluation of a specific routine HIV testing intervention (PITC).

Public hospitals,

Urban

10 HIV positive mothers, 10

Exploration of routine HIV testing views and

UK

Views of nurses reported separately

Public

Interpretivist approach??

Blood tests (wait

Mixed participants . Midwives



Author(s)/year

Country

Clinic setting


2015;13(12):130-286



Type of HIV test for results )

Sampling strategy

Not stated

Not well stated

maternity service

N

Medley (2008)

66

Uganda

Antenatal clinics

Rural and urban

7 public hospitals 2 faith based 1 secular private

Types and number of participants HIV care coordinators (specialist midwives), 10 booking midwives, and 5 lecturers in midwifery

Categorization of study aims/objectives practices.

Mixed participants but midwives comprised of 50%.

11 full time PMTCT counselors, 15 midwifecounselors, 3 clinic directors , and 1 volunteer counselors


formed more than 50% of participants . Midwives’ views reported separately

O

Njozing, Edin, Sebastián et al. 91 (2011)

Camero on

HIV/AIDS treatment centres

Rural and urban

Faithbased hospitals and a public hospital

Grounded theory

Rapid test

Mixed participants but nurses comprised of 50%.

30 TB/HIV counselors and 2 legal professionals (included 16 nurse counselors)

Evaluation of a specific aspect of routine HIV testing (confidentiality and partner notification).

P

Kranzer, Meghji,

Zimbab

Primary health

Unsure

Not stated

Not stated

Rapid

Mixed

6 Nurses and

Evaluation of a



Q

Author(s)/year

Country

Clinic setting

Bandason et al. 74 (2014)

we

care facilities

Knapp, Hagedorn and 92 Anaya (2014a)

USA


2015;13(12):130-286



Type of HIV test test

Sampling strategy

Rapid test

Mixed participants .

acute care

Veterans Affairs Primary Care Clinic

Urban

Veteran

Not stated

participants . Nurses comprised 50% of the sample

Nurses comprise more than 50% of participants . R

S

Knapp, Hagedorn and 93 Anaya (2014b)

Solomon, Bokhour, Butler 94 et al. (2014)

USA

Primary care settings

Urban

Veteran

Not stated

Rapid test

emergency department setting

USA

Veterans Affairs primary care settings

Mixed participants . Nurses comprise more than 50% of participants .

Unsure

Veteran

Not stated

Rapid test

Mixed participants .

Types and number of participants 6 counselors

Categorization of study aims/objectives specific routine HIV testing intervention (PITC among children).

9 clinic staff. One medical director, 1 nurse manager, 4 RNs and 3 licensed vocational nurses (LVNs)

Evaluation of a specific routine HIV testing intervention (nurseadministered HIV oral rapid testing).

8 staff members: 1 physician 1 ED nurse manager, and 6 RNs

Evaluation of a specific routine HIV testing intervention (nurse-initiated HIV rapid testing).

23 participants including nurses and

Evaluation of a specific routine HIV testing intervention



Author(s)/year

Country

Clinic setting


2015;13(12):130-286



Type of HIV test

medical centres

T

Kwapong, Boateng, AgyeiBaffour et al. 73 (2014)

Ghana

Sub metro health facilities providing HTC services in the Metropolis

Nurses comprise more than 50% of participants Urban

Public

Not stated

Not well stated

Not specified,

Not well stated

Mixed participants . % age of midwives less than 50 but their views are specified

ANC U

Vernooij and 95 Hardon (2013)

Uganda

Health Center IV ANC, Maternity ward, Post-test club

Sampling strategy

Rural

Public

Not stated

views of midwives reported separately

Types and number of participants physicians. 15 of these were nurses

Categorization of study aims/objectives (OraQuick Advance

12 Participants (types and numbers unspecified)


12 participants. 2 post-test counselors, 2 midwives, 2 clinical officers, 2 laboratory technicians and 2 PMTCT managers


HIV-1/2 Rapid Antibody Test)



2015;13(12):130-286

Appendix V: List of excluded studies Study

Reason for exclusion

1.

Anaya, Bokhour, Feld et al. 109 (2012)

Percentage of nurses not specified. Contacted authors but did not get any response.

2.

(Angotti, 2012)

3.

Beckwith, Bazerman, 111 Cornwall et al. (2011)

110

Did not focus on nurses/midwives. Number of nurses unspecified. Nurses’ views mostly reported together with other participants. Contacted authors but did not get any response.

4.

Bokhour, Solomon, Knapp et 39 al. (2009)

5.

Butt (2011)

6.

Cappi, Jesus, Nichata et al. 112 (2001)

In Portuguese.

7.

Castro and Sandesara (2010)

Did not focus on nurses/midwives.

40

Percentage of nurses less than 50%. Views of providers were presented together. A discussion paper, not a research article.

113

8.

Chandia, Hackman, Mfenyana 114 et al. (2003)

Did not specify the number of nurses. Views of staff were presented together. Contacted authors but did not get any response.

9.

Christopoulos, Koester, 115 Weiser et al. (2011)

Percentage of nurses less than 50%.

10.

Corneli, Jarrett, Sabue et al. 116 (2008)

Number of nurses not specified among participants.

11.

de Paoli, Manongi and Klepp 117 (2002)

Considered VCT.

12.

Downing, Mulia, Vernon et al. 118 (2000)

Considered community HIV testing.

13.

Grinstead, Seal, Wolitski et al. 119 (2003)

Nurses not specified among participants. Nurses’ views presented separately but very limited.

14.

Gruber, Campos, Dutcher et 120 al. (2011)

Focused on referral of HIV clients not HIV testing.

15.

Grusky, Roberts 121 Swanson (2006)

Nurses not specified among participants.

16.

Oscar Grusky, Roberts, 122 Swanson et al. (2005)

Nurses not specified among participants. Many models of testing.

17.

Oscar Grusky, Roberts, 123 Swanson et al. (2009)

Nurses not specified among participants. Mobile testing units (MTUs).

18.

Hamilton, Okoko, Tolhurst et 124 al. (2008)

Used VCT.

19.

Harris (2013)

125

and

Number of nurses not specified, results reported together.



2015;13(12):130-286

20.

Henry, Hagedorn, Feld et al. 126 (2010)

Nurses are not well specified among the providers. Contacted authors but did not get any response.

21.

Johnson, Mimiaga, Reisner et 44 al. (2011)

Nurses not among participants.

22.

Jurgensen, Tuba, Fylkesnes 127 et al. (2012)

Focused on VCT.

23.

Kabbash, Mekheimer, Hassan 128 et al. (2010)

Focused on VCT.

24.

Kapologwe, Kabengula and 129 Msuya (2011)

Used quantitative methods.

25.

Katongole, Nyanzi, 130 Ruberantwari et al. (2005)

Used VCT.

26.

Kebaabetswe, Ndase, 131 Mujugira et al. (2010)


27.

Kerr, Grafsky, Miller et al. 28 (2011)


28.

Knapp and Anaya (2010)

29.

MacPherson, Lalloo, Choko et 133 al. (2012)

Did not focus on views about HIV testing.

30.

Mavhandu-Mudzusi, Netshandama and Davhana134 Maselesele (2007)

Focused on VCT.

31.

McMullen, Griffiths, Leber et 135 al. (2012)

Failed to access full article. Contacted authors but did not get any response.

32.

Meetze (2012)

33.

Mill (2003)

34.

Mkhabela (2007)

35.

Mkhabela, Mavundla 139 Sukati (2008)

36.

Mlay, Lugina 140 (2008)

37.

Moore, Palmer, Anderson141 Allen et al. (2008)

Used quantitative methods and the study did not include nurses.

38.

Mutanga, Raymond, Towle et 142 al. (2012)

Methods and participants not very clear.

39.

Myers, Worthington, 45 Aguinaldo et al. (2007)

Nurses not clearly indicated. Contacted authors but did not get any response

132

136

Not a research article.

Nurses less than 50%. Results reported together but views of nurses are thin.

137

Did not focus on HIV testing. 138

and

Considered VCT. and

Considered VCT.

Becker

Considered VCT.



2015;13(12):130-286

40.

Myers, Worthington, 46 Haubrich et al. (2003)

Model of testing not specified. Number of nurses not specified. Views of nurses not reported separately. Contacted authors but did not get any response.

41.

Myers, Koester and Dufour 143 (2011)

Did not include nurses

42.

Negin, Wariero, Mutuo et al. 144 (2009)

Focused on home based testing.

43.

Njau, Watt, Ostermann et al. 145 (2012)

Focused on home based testing.

44.

Njeru, Blystad, Nyamongo et 146 al. (2009)

Focused on VCT.

45.

Njeru, Blystad, Shayo et al. 147 (2011)

Did not include nurses.

46.

Nulty and Edwards (2005)

47.

Oosterhoff, Hardon, Nguyen 149 et al. (2008)

Percentage of nurses less than 50%.

48.

Orne-Gliemann, Tchendjou, 150 Miric et al. (2010)

Number of nurses fewer than other workers. Results did not clearly reflect nurses’ views.

49.

Prost, Chopin, McOwan et al. 151 (2007)


50.

Richards and Marquez (2005)

Assessed experiences of HIV Counseling only and not testing.

148

152

Focused on VCT.

51.

Roberts, Grusky 153 Swanson (2008)

and


52.

Roura, Urassa, Busza et al. 154 (2009)


53.

Sheikh and Porter (2009)

54.

Sherr, Hackman, Mfenyana et 156 al. (2003)

55.

Silva and Ayres (2009)

56.

Simmons, Brown, Syle et al. 158 (2011)

57.

Sivyour (2009)

58.

(Taegtmeyer, Martineau, 160 Namwebya et al. (2011)

Nurses not specified among participants. Focused on VCT.

59.

Tripathi, King, Finnerty et al. 161 (2013)

Percentage for nurses less than 50%. Findings reported together.

60.

Turan, Miller, Bukusi et al. 162 (2008)

Did not focus on HIV testing.

155

157

159

Nurses not specified among participants. Percentage of nurses not specified. Results reported together. Contacted authors but did get any response. Full text in Portuguese. Nurses not mentioned among providers. Could not get contact for authors. Not a research article.



61.

Valenti, Szpunar, Saravolatz 163 et al. (2012)

62.

Ward (1999)

63.

Watson (2001)

64.

Wertheimer (2011)

65.

Williams (2010)

66.

Yakam and Gruenais (2009) 168

164

2015;13(12):130-286

Used a quantitative approach. Not a research article (report).

165

Not a research article (report). 166

167

Nurses not specified from other service providers. Contacted authors but did not get any response. Failed to access full text. Could not get contact for authors.

Not a very clear article. Focuses on task shifting, not HIV testing.



2015;13(12):130-286

Appendix VI: Meta-synthesis of findings of nurses’ and midwives’ experiences of provision and management of PITC Findings Adaptability of the improvement process (U) Agreement about the need for training but disagreement on the content (C) Change in nurse attitude with experience (U) Difficulties with administering the test (C)

Categories

Synthesized findings

Equipped to practice

At the organizational level, nurses’ and midwives’ engagement with PITC is facilitated by an inclusive, management structure, alongside the provision of ongoing training and clinical supervision. PITC is hindered by difficulties in fitting it into existing workloads and routines.

Importance of training (C) Inadequate focus of training (C) Inadequate supervision (U) Inadequate training (U) Inadequate training on how to offer the test (U) Insufficient training (C) Perceived competence (C)

Nurses’ motivation and engagement with PITC requires an inclusive, ‘listening’ management structure. Organizational support is required to enable nurses to fit PITC into existing workloads and work routines and to provide adequate training and supervision. The latter should be ongoing (rather than one-off) and should focus on knowledge and skills but also on operational issues, and should also include clinical

Perceived lack of training (C)

supervision.

Perceived lack of training on specific topics (C) Staff involvement and training to sustain the process (U) The role of communication skills and a good counselor-client relationship in supporting disclosure (U) Training needs to cover sero-discordant couples (C) Uncertain provider knowledge about follow-up procedures (C)



Findings

2015;13(12):130-286

Categories


Uncertain provider knowledge about the type of HIV test (C) Usefulness of clinical reminder (C) Varied levels of comfort with performing medical procedures(C) A well-functioning antenatal PMTCT program (C) Additional burden (C)

Impact of PITC on existing working practices

Balancing time with logistics (U) Challenges in sequencing the required tasks (U) Conflicting roles (administration and clinical roles) (C) Congruency with existing care (U) Customization of printouts (U) Decreasing enthusiasm (U) Ease of test administration (C) Electronic documentation (C) Fear of detraction from caring for other patients (C) Fit of the HIV testing within existing work (C) Flexibility to tailor screening efforts according to patient volume (C) Implementation strategies (C) Integration and interaction of programs with outside services



Findings

2015;13(12):130-286

Categories


(C) Logistics of implementation (C) Perceived feasibility of the PITC intervention (C) Poor organization of health (HIV) services (U) Staff time (C) Structural changes to patient care (C) Tensions in provider vs patient centered communication (C) Testing process requires time (U) The convenience of NRT (C) The ease in both offering and administering the test (U) Time (C) Time consuming (C) Time saving (C) Timing and sequencing of the test offer (C) Too many administrative requirements (U) Type of test (C) Varied prioritization of testing in the clinic workflow (C) A target-driven approach (U) Adaptability of the improvement process (U)

Support, recognition and involvement



Findings

2015;13(12):130-286

Categories


Burnout (U) Clients not returning for care (C) Clinical leadership engagement (U) Effectiveness of the system to monitor progress (U) Effectiveness of the system to monitor progress (U) Fear of legal repercussions (C) Feeling of disempowerment (U) Frustration with limited ability to follow-up with clients (C) Inadequate support from management (C) Lack of incentives to take on additional roles (U) Lack of involvement (of booking midwives) in ongoing care (C) Lack of involvement in policy/service development and implementation (U) Lack of involvement of senior staff (C) Lack of nurses involvement in policy formation (U) Lack of recognition for nurses (U) Lack of recognition of their expertise and of their hard work (U) Lack of support and motivation (C) Lack of support from colleagues (C) Lack of team work & reciprocity (C) Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 200


Findings

2015;13(12):130-286

Categories


Communication and result giving

Good care in PITC requires time and the

Legal concerns (C) Mechanisms of implementation leadership and support (U) Motivated by positive reactions from patients (C) Need for legal protection for health workers to support partner notification (U) Over-worked and over-whelmed (U) Poor Cooperation between Antenatal Staff and Counselors (U) Positive client outcomes as motivation for nurses (U) Pressure of meeting targets versus ensuring patient choice (U) Recording of clinical findings on the patient record card (C) Role of management support (C) Senior leadership engagement (U) Senior/clinical leadership engagement (U) Staff involvement and training to sustain the process (U) Support from other workers (community) (C) Validity and expertise of knowledge and role divisions underpinning the work (C) Addressing the impact of the result requires adequate time (U) Anxiety and discomfort of delivering the results (C)

ability to apply a patient centered approach. Nurses strive to implement a patient centered

Challenge of breaking the bad news (U)



Findings

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Categories

Synthesized findings approach to a routine test (PITC) recognizing

Clients don't have time for adequate post-test Counseling (U)

that for many clients, the enduring stigma of

Concern about delivering positive results (C)

HIV means that testing is not perceived as a

Concern that condensing pre-test Counseling fails to

routine procedure and that HIV is not

adequately prepare patients for a positive result (U)

perceived as a normalized condition. Good care in PITC requires time and nurses adopt

Contacting women with a positive result – giving a lady time

a range of strategies to encourage clients to

(U)

test and to provide adequate information, counseling and support where required.

Educating whilst testing (C) Language (U) Language barriers (C) Language barriers hindering communication (C) Managing the impact of diagnosis (U) Nurses’ experiences delivering the test results (U) Tensions in provider vs patient centred communication (C) The role of Counseling (U) Acceptability of the test (by women) (U) Catch 22: to pressure or to lose patients? (C)

Introducing the test: negotiating choice and consent

Clients declining to take an HIV test or receive their test results (C) Clients Declining to take an HIV test or receive their test results (C)



Findings

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Categories


Competing life demands (C) Confusion about testing guidelines and regulations (U) Different opinions regarding the best time to test (C) Different opinions regarding the extent of Counseling required (C) Discomfort with talking about HIV in a routine setting (U) Forcing the test (C) Getting the timing right for the test (C) Importance of confidence and trust in the midwife (U) Lack of patient information leaflet/education about the test (C) Lack of patient interest in HIV testing (C) Low male involvement in antenatal care and PMTCT programs (C) Low male involvement in antenatal clinics and PMTCT programs (C) Negotiating patient consent (C) Reasons for test refusal (U) Strategies of persuasion (U) Techniques for normalization (U) Testing without consent (U)



Findings

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Categories


The need for patients’ informed consent (C) The tension of ensuring patient choice within a routine test context (U) Variation in managing follow up (C) Clients not returning for care (C) Clients not returning for postnatal care and/or Nevirapine

Maintaining care and follow-up after a positive result

tablets (C) Domestic challenges (C) Follow-up (C) Frustration with limited ability to follow-up with clients (U) Inadequate referral and support services (C) Lack of involvement (of booking midwives) in ongoing care (C) Lack of Referral Services (C) Need for supportive and consistent care to prevent loss to follow up (U) Inadequate space for Counseling (C) Inadequate working space (U) Lack of adequate space for Counseling (U) Lack of space (C)

Environment

Nurses’ and midwives’ ability to perform PITC well requires an appropriate infrastructure and adequate human and material resources. Nurses’ ability to perform PITC well (according to the principles of ‘good care’) requires adequate space, time, equipment

Lack of space (U)



Findings

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Categories

Synthesized findings and staff.

Privacy (U) Privacy and confidentiality (U) Space (U) Unfavorable ward environment to maintain dignity and confidentiality (U) Clinic logistics (C)

Human and material resources

Heavy workload (C) Heavy Workload (U) High workload and understaffing affecting post-test Counseling (C) Infrastructure for sustainability (U) Infrastructure for sustainability (U) Insufficient staff affecting quality (C) Insufficient staff to deal with client load (C) Lack of Lab Personnel (U) Lack of pre-test information video equipment (C) Lack of staff, resources and time (U) Lack of time (C) Limited time (U) Limited time for proper discussion of the test (U)



Findings

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Categories


Alignment of PITC with perceived

Nurses and midwives are supportive of PITC

professional roles

if it is perceived to enhance patient care and

Shortage of lab personnel (C) Shortage of working materials (U) Staff (U) Staff shortages (C) Stock-outs of clinic supplies (C) Stock-outs of clinic supplies (U) Time constraints (C) Time constraints (U) Agreement on feasibility and roles in HIV testing (C) Behavioral intention to discourage HIV testing (C) Behavioral priming (C) Belief that screening is not a core ED duty (U) Comfort with the increased responsibility (U) Congruence with their current practice (U) Creating demand for HIV testing; conflict over preventive care in the ER (C)

to align with perceived professional roles. Nurses’ views about PITC and their motivation to engage in it, is associated with their perception of how it relates to ‘care’ and how it relates to their professional role. Nurses are more motivated to implement PITC when it is understood as enhancing patient care and when it is seen to be in alignment with their existing professional role.

HIV testing a nursing (not lay Counselor) responsibility (C) It is part of the nurses’ duty (C) Longer term sustainability (C) NRT is manageable (C) Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 206


Findings

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Categories


Professional boundaries and HIV testing process (C) Routine Counseling work perceived as contradictory to educator/care provider role (C) Self-efficacy for HIV testing (C) TB nursing is a calling (C) Acceptability of the testing model (by midwives) (U) Addressing HIV/AIDS as any other chronic and treatable

Embracing or resisting PITC: enhancing or damaging care

disease (normalizing HIV) (U) Agreement on the meaning and consequence of the work (U) Benefits of enhancing access to HIV testing (C) Breach of confidentiality among health workers (C) Comprehension and consent (U) Concern about reduction in pre-test Counseling (C) Concerns about PITC for children (U) Congruency with care (C) Costs and savings (C) Credibility of benefits (U) Credibility of benefits(U) Different opinions regarding the relationship between TB and HIV and the patient’s willingness to test (C)



Findings

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Categories


Fear of possible outcome of testing (C) Fears that confidentiality is easily breached, especially in overcrowded ward environments (U) Fit with organization’s strategic aims and culture (U) Fit with the organization’s strategic aims and culture (U) Importance of confidentiality (U) Importance of good patient-staff relationships (C) Improve public health (U) Judgmental Attitudes (C) Less pre-test Counseling & normalization (U) Linkage to care (C) Literacy and education level (U) Normalizing a highly stigmatized disease (U) Patient attitudes towards testing (C) Patients may feel pressurized or coerced into having a test (C) People may be deterred from seeking care if they know it will involve an HIV test (C) Perceived opportunity to improve care (C) PITC enables comprehensive care (U) PITC may affect the trust between patient and professional (C)



Findings

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Categories


Carrying an emotional burden

The emotional work involved in PITC can be

Reducing stigma (U) Resonating with professional norms (C) Routine testing unnecessary (U) Social stigmatization of HIV (C) Staff attitudes toward sustaining the change (U) Staff attitudes towards sustaining the change (U) Stigma affecting nursing care (U) Support for normalization (U) Support for PITC in principle (C) Support from other workers (community) (C) Taking the pressure off the patient (C) Target driven care (U) Testing is compulsory (C) Testing mothers is important for the protection of midwives and the baby (C) Trying to maintain a client-centered philosophy of care within a routinized context (U) Welcoming normalization (C) Anxiety and discomfort of delivering the results (C) Challenge of breaking the bad news (U)

stressful. Nurses and midwives may require



Findings

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Categories

Synthesized findings support to deal with complex moral/ethical

Concern about delivering positive results (C)

issues.

Emotional burden of facing ethical dilemmas (U)

PITC implementation can be stressful for nurses due to the emotional work required to

Emotional burn out (U)

support clients in difficult situations and due Emotional involvement and distress (U)

to being confronted by moral/ethical dilemmas on a regular basis. Nurses respond

Emotional labor (U)

to these dilemmas through a discourse of

Frustration - inability to reach male partners (U)

professional ethics, although professional

Inadequate support (C)

and normative understandings of ethical principles are sometimes in conflict. The

Nurses’ experiences delivering the test results (C)

stress of PITC is exacerbated by working

Stress associated with HIV Counseling (C)

conditions in which nurses feel overworked

Stress associated with HIV Counseling (C)

and/or under-supported.

Challenge of partner notification (U) Challenge of low HIV sero-status disclosure to partners (U)

Ethical dilemmas in negotiating disclosure

Counseling discordant couples (U) Counseling discordant couples (C) Ethical dilemma about partner notification (C) Inability to convince women to disclose (C) Low rates of HIV sero-status disclosure to partners (C) Managing non-disclosure and confidentiality (U) Resort to coercion to support disclosure (U)



Findings

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Categories


Respecting patients’ autonomy (U) Safeguarding patients’ autonomy or protecting partners’ safety? (U) Strategies to encourage and ensure that patients willingly notify their partners (U) Supporting disclosure (C) The role of communication skills and a good Counselor-client relationship in supporting disclosure (U)



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Appendix VII: Table of extracted findings Medley AM and Kennedy CE. Provider challenges in implementing antenatal provider-initiated HIV testing and counseling programs in Uganda. AIDS Educ Prev. 2010; 22 (2): 87-99.

Findings



1. Heavy workload

Credible

Unsupported

Although all respondents took HIV counseling seriously, they often felt they lacked the time to provide quality counseling. To manage the



heavy `workload, some respondents streamlined counseling for HIVnegative women to allow more time to counsel HIV-positive women. (P.90) 2. Staff shortage

Heavy workloads were often the result of counselor shortages. Private clinics had the highest client to counselor ratios owing to counselor



attrition, as counselors could receive better salaries and benefits working for public clinics or research studies. One private clinic reported losing two thirds of its trained counselors in the first year. (p.91) 3. Stress associated with HIV counseling

It was emotionally difficult for counselors to give HIV-positive results, especially to young women who were pregnant for the first time. The toll



of repeatedly giving HIV-positive results caused some counselors to feel overwhelmed and burned out. (P.91) 4. Inadequate support

None of the clinics had a formal program for counselor support, such as a counseling supervisor or counselor support group. Moreover, the



stress associated with counseling was often compounded by the fact that counselors felt inadequately supported and supervised by district health officials. Several respondents described how they informally sought support from other counselors by discussing difficult cases. However, they requested official retreats where they could share their experiences, receive support from other counselors, and brainstorm



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solutions to common challenges. (p.91) 5. Perceived training

lack

of

The majority of counselors felt they needed more training. Counselors felt they lacked current information [……………………………………]. All



counselors emphasized that training should not be a static, onetime event. Instead, they wanted ongoing training and periodic refresher courses to improve their skills and keep up with rapid changes in prevention and treatment sciences. (P.91) 6. Clients declining to take an HIV test or receive their test results

“Another challenge is maybe when you really see a mother with those signs and she declines that test. First of all, you can't do it unless she



consents, but you can see... she is sick and the mother is refusing to take the test. Like yesterday we had one who was referred here [for HIV testing], but she declined the test and the baby was positive and she said, "I wish I knew. What can I do now?" And it's too late. So, you feel also that really, how can I help this mother?” (P.91) Counselors employed several techniques to convince women to test for HIV. Women who declined during group pretest counseling sessions were pulled aside for individual counseling. If they still refused, a note was made on their antenatal card. At their next visit, they were given additional counseling and again offered an HIV test. (P.91)

7. Low male involvement in antenatal care and PMTCT programs

Providers believed strongly in the importance of couple counseling and repeatedly emphasized to women the importance of bringing their male



partners for HIV testing. Counselors employed several strategies to increase male involvement. First, for both HIV testing and antenatal services, women attending with partners were given priority over women attending alone. Counselors hoped this would encourage other women to bring their partners to future visits. (P.92) Counselors also said some exam rooms used for HIV counseling lacked



8. Inadequate space for counseling

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privacy. Some rooms had half walls, curtains in place of doors, or



glassless windows. Counselors were forced to give HIV test results in a low voice, and women crying could be heard by others in the waiting area. Counselors also said sessions were frequently interrupted by other health staff entering offices to retrieve files and suggested door signs would improve privacy. (P.92)

9. Stock-outs of clinic supplies

Counselors reported frequently running out of other supplies, including condoms, reagents for syphilis testing, gloves, disinfectants, and



cotrimoxazole prophylaxis. Although counselors discussed the risks of dual infection and the high risk of infection during pregnancy and breast-feeding, they were sometimes unable to provide condoms owing to a countrywide shortage. Frequent stock-outs of clinic supplies were a source of intense frustration for counselors as stock-outs prevented them from providing quality care to expectant mothers. (P.93) 10. Shortage personnel

of

lab

Most clinics did not have lab personnel dedicated to the antenatal clinic. Instead, blood tests were sent to a central hospital lab which often took



a long time to process the results. Thus, nurses/midwives often finished examining women hours before test results were ready. Because of the long wait, some women left before obtaining their results. To prevent this, counselors requested that they be trained to draw blood and run tests themselves instead of relying on lab personnel. (P.93) 11. Language barriers

Although most Counselors spoke English and KiLuganda and/or KiLusoga, they sometimes encountered clients who did not speak these



languages. Counselors were forced to use symbols and hand gestures to give these women their HFV test results. However, they felt unable to provide preventative counseling for HIV-negative clients or PMTCT counseling for HIV-positive clients. In some cases, the woman's partner or another relative would translate during the HIV counseling session.



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Although this violated confidentiality, it was often the only way counselors could provide services to these women. (P.93) 12. Counseling discordant couples

Counselors also felt pressure to prevent the breakup of marriage that sometimes resulted from HIV discordant results. One respondent



likened counseling these couples to a tug-of-war. "If you don't tug it very carefully," she said, "you can confuse them and cause them to divorce." In some cases, counselors experienced an ethical dilemma when one member of a discordant couple refused to disclose his or her status to the other. (P.93) 13. Clients not returning for care

Counselors also expressed frustration that women frequently did not attend their 6-week postnatal checkups unless they had a medical



complaint or the infant was sick. This failure to return severely hampered the success of PMTCT programs. (P.94) "If we don't know the outcome of our baby," explained one midwifecounselor, "that means we have worked a lot but at the end of the day, nothing was done." (P.94) 14. Inadequate referral and support services

All counselors described a need for additional care and support programs for HIV infected women including nutritional support, support



for infant feeding decisions, and financial support programs such as school fees and income generating activities. (P.94) 15. Low rates of HIV sero-status disclosure to partners

According to counselors, the most common challenge to PMTCT programs was low rates of HIV serostatus disclosure to partner(s)



among antenatal clients. (p.94) Women who were afraid to disclose their HIV status were told to bring their partners to the clinic, where both members of the couple would receive counseling, and disclosure would be facilitated during a joint posttest counseling session. (P.95)



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Pope DS, Atkins S, DeLuca AN, Hausler H, Hoosain E, Celentano DD and Chaisson RE (2010) South African TB nurses' experiences of provider-initiated HIV counseling and testing in the Eastern Cape Province: a qualitative study. AIDS Care. 2010; 22 (2): 238-245. Findings



1. Insufficient staff to deal with client load

Credible

Unsupported

. . . It’s may be only one sister doing comprehensive now she has to do the antenatal, she has to do counseling; she is the only one that’s been



trained for VCT [voluntary counseling and testing]. She has to do all these things. . . (Focus Group 2) (p.241) 2. Insufficient staff affecting quality

. . . unfortunately, if you’re not gonna give staff to see to the numbers that we are seeing every day, then you’re just pushing numbers then,



you’re not seeing clients, you’re not seeing them in totality or holistically, you’re seeing NUMBERS. (Key informant 4). (P.241) 3. HIV testing is a nursing (not lay Counselor) responsibility

Some nurses, especially in intervention clinics that performed less well, found lay health workers helpful in relieving staff shortages, […………]



but others considered their presence insufficient to decrease workloads, and presented additional problems related to confidentiality, skills, and need for supervision. Many, however, saw HIV counseling and testing as the responsibility of the TB nurse because of the relationship between the patient and the nurse, usually described as an ‘‘attachment,’’ ‘‘confidence,’’ or ‘‘trust.’’ (p. 241-242)

4. TB nursing calling

is

a

Many seemed to believe that being a TB nurse needed to be a calling. Key informants put the most emphasis on training and skills of nurses,



in addition to ‘‘talent’’ that could not be learned, that facilitated HIV counseling and testing. “Some nurses are incredibly committed and motivated to make a difference . . . that’s a very important factor, combined with whether they are supported or not by their superiors”.



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(Key informant 2) (p.242) 5. Lack of team work and reciprocity

Problems with staff shortages were compounded by TB nurses being asked to help in other departments. There appeared to be a lack of



reciprocity in this arrangement; TB nurses were expected to pitch in, but when the TB nurse was absent the TB tasks were left for her return: “. . . if you are not there, that patient will wait for you . . . because you are not there, the TB nurse, they won’t do it”. (Focus Group 1) (p.242) 6. Lack of space

Space within clinics to conduct counseling was also identified as an important issue, related to high patient loads and resulting in a lack of



privacy. Nurses reported having to wait for empty rooms and, in some cases, having to chase other staff and patients out of a room in order to conduct confidential HIV counseling. (p.242) 7. Conflicting roles (administration and clinical roles)

Report and labelling . . . It takes time . . . for you to do that. Meaning

8. Inadequate support from management

. . . we keep on talking to management, we keep on telling management

that now you must rush rush your patient. (Focus Group 1) (p.242)

that is the situation, and the answer is ja, you just gotta cope. (Key





informant 4) (p.242) 9. Integration and interaction of programs with outside services

. . . we’ve seen for instance in TB that it just doesn’t work if you have a big clinic and the TB unit is on the one side and then the HIV unit is on



the other side . . . you have to refer patients from one side to the other side . . . firstly they’ll never arrive there . . . (Key informant 2) (p.242)

10. Support for PITC in principle

Despite never being stated explicitly, there appeared to be universal support of HIV counseling and testing of TB patients; it seems there



was implicit understanding that there was a health benefit for the patients knowing their HIV status. However, the TB nurses and key



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informants articulated a variety of opinions about when and how HIV counseling and testing should be carried out. (p.242) 11. Routine counseling work perceived as contradictory to educator/care provider role

The role of nurse as care provider and educator appears to have been

12. Different opinions regarding the relationship between TB and HIV and the patient’s willingness to test

A participant in Group 1 stated that when the information on TB and HIV

perceived as a contradiction to what was required to routinely HIV



counsel TB patients. (p.243)

was given as a package, patients would return to be tested. In the



control focus group it was expressed that patients’ views of the link between TB and HIV discouraged them from the testing _ the prevailing belief in the community being that if you have TB you must have HIV (p.243)

13. Importance of good patient-staff relationships

Participants also emphasized the importance of the relationship between the staff and patient. Patients were reported to want to see the



same nurse at each clinic visit, and participants felt that HIV counseling and testing could be facilitated if the patient dealt with one person only.(p.243) 14. Emotional burn out

However, they (participants) also expressed the difficulties that HIV Counseling and testing presented for them “Yeah you can become



emotionally drained, definitely, like last week I _ I’m going to use the word divorced. I divorced myself from the VCT. From the testing. And my clients. Because I found that I _ I felt that I was emotionally drained, man. To see these patients . . . on a regular basis. Some of them respond well, some of them don’t respond well . . .” (Focus Group 1). (p. 243)



15. Concern delivering results

about positive

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Some nurses expressed reluctance to start counseling when they wouldn’t have time to do it well; internal conflict was ongoing between



the potential long-term gain for the patient and the short-term suffering perhaps caused by learning HIV status. Nurses expressed concern about their ability to provide positive HIV test results, both because of their awareness of time constraints and empathy for the TB patients. (p.243) 16. Different opinions regarding the best time to test

Both intervention focus groups preferred to counsel in the afternoon, when the clinic was quieter, and most asked patients to go home and



return for Counseling. (p.243) 17. Different opinions regarding the extent of counseling required

There appears to have been resistance by some nurses to the introduction of HIV counseling too early, when patients were still very ill



from TB. Two key informants felt that long counseling sessions were not feasible and that a shorter alternative should be sought. A suggestion was made for a compromise between the long counseling session and ‘‘uninformed consent.’’ (p.243)

18. Getting the timing right for the test

Two stakeholders and Group 1 reported negative reactions to HIV counseling and testing from patients: ‘‘shock’’ and ‘‘trauma.’’ Nurses



from the control clinics, and some key informants, felt that TB patients had enough stress when diagnosed, and the issue of HIV testing should not be broached on the same day. This opinion was less pronounced in the intervention groups. Group 1 mentioned that at times, the patients were not surprised because they had been ‘‘diagnosed from the community.’’ Patients often arrived already knowing their status. (p.243) 19. Catch 22: to pressure or to lose patients?

There appears to have been resistance by some nurses to the introduction of HIV counseling too early, when patients were still very ill



from TB. One key informant referred to this as a ‘‘Catch-22’’ (Key



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informant 3).Nurses didn’t want to pressure the patients to take the test and at the same time they did not want to lose patients by postponing the counseling. (p.243)

Schnall R, Clark S, Olender S and Sperling JD. Providers' perceptions of the factors influencing the implementation of the New York state mandatory HIV testing law in two urban academic emergency departments. Academ Emerg Med. 2013; 20 (3): 279-286. Findings



1. Self-efficacy for HIV testing

Credible

Unsupported

Participants did not feel that HIV testing in the ED aligned with their personal vision of an EM provider. One nurse explained, “we believe in



the true definition of emergency care.” (P.281) 2. Behavioural intention to discourage HIV testing

“And they (residents) want them to decline it because they’ll say it at the

3. Professional boundaries and HIV testing process

In addition to self-efficacy, there were many different views among

end of discharge, and the patient is like, ‘No, no, I’m good, I’m good,



just get me out of here.’” (nurses) (p.282)

participants on who should make the offer for HIV testing to patients.



“…another nurse said, “in an ideal world, it would be a nurse!” (p.281) 4. Uncertain provider knowledge about the type of HIV test

“How many of the positive tests are false-positive?” (nurse) (p.282)

5. Uncertain provider knowledge about follow-up procedures

One nurse questioned, “So who is following up? … Who is making that



phone call when the blood test comes in how ever many days later, to



let them know, to counsel them over the phone, in Spanish?” (p.281) Participants discussed how patients already have long wait times, and

6. Time

testing patients for HIV would only lengthen their stays. (p.281)





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“And that’s going to be an extra thing that we have to go to draw the blood. And if that’s the only thing that they’re waiting for.” (nurse) (p.283) 7. Staff

A nurse said, “We’re chronically short of staff.” (P.282) “If you had a dedicated person we could potentially discharge them



from the emergency department knowing that this dedicated person in real time had obtained a real phone number and was going to really call them back an hour later or maybe they could call them when they were sitting in the waiting room having a snack.” (nurse) (p.283) 8. Space

Participants expressed concern about the ability to offer an HIV test in a private setting. One nurse explained, “There is not a lot of privacy out



there, and people already get a little offended when you ask them in an open space in the waiting room.” (P.282) Participants expressed their frustration at already not having enough space in their ED. One nurse said, “We opened a whole new area, and our ER was still full when we walked in last night.” (P.282) 9. Type of test

Providers felt that to enable efficient testing and proper follow- up then a point-of-care test was necessary. In addition, there were concerns over



using a blood draw as a means of testing patients. Another nurse explained, “This population believes if you take multiple tubes of blood from them you’re draining their blood.” (P.282) Cheek swabs were seen as an enabler in that they are “about 99.9% accurate, so it’s not like patients are getting false positives when you’re doing that” [nurse], but other nurses said they would prefer to do blood draws because “I do it all the time and feel comfortable and won’t need to be trained.” (P.282)



10. Timing sequencing test offer

of

and the

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More specifically, another nurse described, “I’ve had one or two occasions where the blood was drawn and then three or four hours later



we get around to the question, and then they (patient) say yes, and that is an annoyance.” (P.282) 11. Benefits of enhancing access to HIV testing

There was an overwhelming sense that this legislation would increase access to HIV testing. In particular, one resident said that this will “catch



the population that would not otherwise be tested.” “There are people in the world who are concerned they have HIV who do not have a primary care provider and don’t know where they can go for testing.” (resident) (p.283) 12. Linkage to care

In addition to access to HIV testing, participants reported that this legislation has the potential to link people to HIV care. One resident



recalled, “I just had a person the other day who I felt he had no clue when he tested positive, and now he’s going to be plugged into CSS (HIV clinic at site 2) … and I just think that for me (that) completely made a difference.” (P.283) “Are there any studies that say the patients or people who have found out that they’re HIV positive, what is the percentage of those that actually go and get treatment?” (nurse) (p.283) 13. Improve public health

Participants also thought that the legislation had the potential to improve public health. One nurse said, “This is the way of seeing a



public health initiative to really help identify people and save people from going undiagnosed.” (P.283) 14. Costs and savings

Coverage for the testing was a concern among many participants, with a sentiment that if the test was covered then providers would be more



willing to offer the test. A nurse was concerned over, “So who pays for this? The majority of our patients are not insured.” (P.284)



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There was an acknowledgement as one resident said, “This idea is actually a great idea if the state is willing to foot the bill and the resources.” (P.284)

Spielberg F, Kurth AE, Severynen A, Hsieh YH, Moring-Parris D, Mackenzie S and Rothman R. Computer-Facilitated Rapid HIV Testing in Emergency Care Settings: Provider and Patient Usability and Acceptability. AIDS Educ Prev. 2011; 23 (3): 206-221. Findings



1. Fear of detraction from caring for other patients

Credible

Unsupported

In both sites, staff raised several system-level concerns about HIV positive test results, including (a) lack of time for thorough post-test



counseling, (b) detraction from caring for other patients, (c) lack of appropriate referral capacity, (d) false positive HIV test results, (e) legal concerns, and (f) concerns that more acceptable HIV testing strategies would attract additional people to the ECS for care. Staff perceived that it would require several hours to provide a positive test result, which was considered unacceptable with their current workload. (p.213) “The thought to me of getting [giving] a positive HIV test is a nightmare, 2. Time constraints

too, because of the post Counseling.” (Site A-NP) (p.214)



“Time is a barrier. We all want the best for our patients and we’re all interested in the public health of this community and so I can’t think of a better thing that we can offer besides free HIV testing, and not just for them but for their partners. Unfortunately, just the nature of the work that we do, it’s hard to feel like you’re appropriately counseling somebody on such an important test when you’re constrained for time.” (Site B-MD) (p.214)



3. Privacy

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“Everywhere from the registration all the way to patient rooms, privacy is a bit of an issue in this ER, because you got a lot of people in a very



small space and not a whole lot of private rooms.” (Site A-NP) (p.214) 4. Follow-up

“And I agree with that policy at this point [of not providing HIV testing] because I really feel like that does put our necks on the chopping block



in terms of, you know, privacy and follow up. And you have these HIV positive HIV tests, and not having a good way to follow up.” (Site A-NP) (p.214) 5. Creating demand for HIV testing; conflict over preventive care in the ER

“As similar to diabetes and hypertension, if they do have a chronic condition such as HIV . . . they deserve to know and have some



treatment options. But that is really tough to treat, as is diabetes, out of the ER.” (Site A-NP) (p.214) “When you see 40 patients a day, it becomes very difficult, and I just don’t know if the emergency room is the place for a lot of preventive care.” (Site B-MD) (p.214)

6. Legal concerns

Legal concerns were raised in both groups as barriers to provision of HIV testing related to privacy, confidentiality, and recommendations for



follow-up with negative or positive test results. (p.213 & 215) “Are we now responsible for every patient that gets screened if it’s not clearly documented that we explained to them that although your test is negative you need to have your partner and yourself tested in six months?” (Site B-MD) (p.214) 7. Comprehension and consent

“I would be concerned about them completely understanding what they are being tested for and why. And especially in the ER setting, that may



be difficult.” (Site A-RN) (p.214) 8. Competing

life

“Most of our clients are . . . worried about where they are going to sleep


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tonight. They are not the people that are really going to be terribly



concerned about HIV, I don’t think because it’s just—their primary concerns are where am I going to get my next meal.” (Site A-RN) (p.214) 9. Lack of patient interest in HIV testing

“They are not reliable. The only thing they want to do is be taken care of

10. Literacy education level

“We take care of all people, regardless. We see a lot of people from

and



right now.” (Site A-RN) (p.214)

very low walks of life. A lot of them don’t have the intelligence to get



through that.” (Site A-RN) (p.215) “If they’re illiterate to begin with, how are they going to be able to choose the right box [on the CARE tool] for them?” (Site B-RN) (p.215) 11. Language

“Something to think about with this type of program is . . . what level of English speaking they have. A number of our patients are Hispanic or



come from Africa or come from a lot of countries where English is their second language or half language.” (Site A-NP) (p.215) 12. Customization printouts

of

“I like the fact that there’s a printout at the end, the referral at the end because sometimes just for regular referrals we get lost in trying to find



the number…if its linked to [ED’s] resources, I think that’s an added benefit.” (Site B-RN) (p.215) 13. Time saving

“I think it would be really good for us. It would take a lot of the work out



of it for us.” (Site B-RN) (p.215) 14. Behavioral priming

“I think it’s great because a lot of EDs have pamphlets about safe sex and we don’t have any of that. I think a lot of our patients don’t



understand [risk factors] but when they’re… in the waiting room… and so I think this would you know start, ‘oh okay I didn’t realize I was at risk’.” (Site B-RN) (p.215)



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“It provides a lot more information and is more thorough so that they can kind of get the full picture of what are the different risk factors and what they can be doing in their life that they could change.” (Site B-RN) (p.215)

Pindera C, Becker M, Kasper K, Carnochan T, Sorensen T, Migliardi T. Nine Circles Community Health Centre: Rapid Point-of-Care HIV Testing (POCT) Demonstration Program – Evaluation Report. 2011; Winnipeg, Canada: Nine Circles Community Health Centre. Findings



1. Difficulties administering Test

with the

Nurses

expressed

dissatisfaction

around

the

mechanics

Credible

Unsupported

of

administering the test, for logistically there were some challenges. For



example, the small lids, tubes and capillary can be awkward to handle and getting a good draw could be difficult. They indicated that a POCT is a messier and more risky test than any other (i.e. the exposed blood). (P.22) 2. Too administrative requirements

many

The nurses also articulated some displeasure with the paperwork that accompanies the POCT. They felt there were many steps to go through



when performing the test and found it, administratively, to be “a lot of extra work”. [……..] They felt the procedure and process could be strengthened to improve efficiency and ease of conducting the test. They suggested the ending of parallel testing would eliminate the extra step of also conducting a conventional test. (P.22)

3. Educating testing

whilst

Upon receiving a non-reactive result, nurses felt clients often did not stop to hear much else they had to say, in particular the regular post-



test education assigned. Some nurses believed that this was a missed opportunity for further education and discussion around adoption of



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harm reduction strategies. (P.23) 4. Nurses’ experiences delivering the test results

In terms of their own emotions, nurses expressed that, on the whole, giving a reactive HIV result is difficult regardless of whether it is by a



POCT or conventional test. When giving a client a reactive result, nurses indicated that it was somewhat easier for them to handle delivering such information when utilizing a conventional test. In such situations, providers have more opportunity and time to prepare themselves, as one of the nurses reported: “you’ve checked your emotions ahead of time”. (P.23)

Horwood C, Voce A, Vermaak K, Rollins N and Qazi S. Routine checks for HIV in children attending primary health care facilities in South Africa: Attitudes of nurses and child caregivers. Soc Sci Med. 2010; 70 (2): 313-320. Findings



1. Discomfort with talking about HIV in a routine setting

Credible

Unsupported

In every FGD, nurses expressed reservations and fears about discussing HIV with mothers, saying that it was painful to raise the



topic, or describing it as ‘embarrassing’ or ‘shocking’. Nurses reported that it was difficult to speak about HIV at every consultation, particularly if the mother had previously reported being HIV negative, and that mothers avoid clinics or health workers where IMCI is being implemented to avoid the HIV-related questions. ‘You have to ask every mother that comes about the [HIV] status, it’s so embarrassing. You ask, but it is so embarrassing, because after they go outside (they say) ‘‘I will never come back to this clinic: that nurse in that consulting room asked about HIV’’. She tells others outside there, so it’s embarrassing’ (Nurses FGD5). (P.315-316)

2. Fear

of

possible

Nurses expressed fears about possible outcomes of routine checks for


JBI Database of Systematic Reviews & Implementation Reports outcome of testing

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HIV; they were afraid they could be sued, that mothers would avoid



coming to them in the future, or would make a complaint. There was apprehension about possible emotional reactions from the mother, like distress or anger, and the possibility of being assaulted or threatened was also raised in one focus group. ‘Once you check the child for lymphadenopathy or anything, the mother says ‘‘so you are suspecting that my child is not well, but you didn’t say anything’’. So you can end up in a court of law because she is assuming that you are suspecting the child of having HIV when she does not have HIV. Maybe the child is just having mumps that makes the child to have a lump’ (Nurses FGD4). (P.316) 3. Fear of repercussions

legal

In all FGDs, some nurses expressed the view that it was unacceptable 

to mothers for the nurse to ask about the HIV status or even to check the child, although the examination required is not specific to HIV. Nurses expressed fears about possible outcomes of routine checks for HIV; they were afraid they could be sued, that mothers would avoid coming to them in the future, or would make a complaint. (p.316) 4. Routine unnecessary

testing Many nurses were hostile to implementation of the HIV guideline,



feeling that it was unnecessary to check every child, particularly if the child was well and had no obvious signs of HIV. Some nurses admitted that they did not routinely ask about HIV, and one said that the HIV component ‘should be scrapped’ (Nurses FGD5). (P.316) ‘No, I don’t feel that we have to routinely do all children, because some of them they are healthy and good, and even if you assess the road to health chart they don’t come as a regular client. Some they just come when there is an outbreak of flu’ (Nurses FGD1). (P.316) 5. Judgemental

‘They [nurses] tell the [pregnant] women they have indulged themselves


JBI Database of Systematic Reviews & Implementation Reports attitudes

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in unprotected sex and now it is easy for them because the government



has put this PMTCT program in action. So they must test [for HIV] because they have done this thing’ (Nurses FGD4). (P.316) ‘We’ve got a lot of blacks living in [this area] now and they come to the clinic, but they are not like poor, or something, where you can say, ‘‘okay, that’s a child I can suspect [of having HIV]’’’ (Nurses FGD1). (P.316) 6. Recording of clinical findings on the patient record card

Concerns were frequently raised about recording the IMCI classification of ‘suspected symptomatic HIV’ on the child’s card, particularly before



the HIV status has been confirmed; the major concern was about legal liability. IMCI does not provide clear guidelines in this regard. ‘According to South African what–what, there is something that says you cannot suspect someone is positive. So you cannot say that this child is positive, whereas the child has not tested, and you have to write on the card ‘symptomatic of HIV’ and they have not tested’ (Nurses FGD4). (P.316) 7. Inadequate training

Another strong theme identified was that nurses felt their training and knowledge of HIV was inadequate. Nurses described sometimes being



unable to answer the mother’s questions; this made them feel inadequate and they did not have anyone to refer to for advice. ‘That is a bit contradictory .even for me, myself as a practitioner, I usually get confused but in front of the mother I shouldn’t be., something must be done to explain to the practitioners’ (Nurses FGD4). (P.316) ‘It [talking about HIV] is difficult and needs skills. Everyone should have done VCT [voluntary Counseling and testing training] so that you have those skills. I am not transparent with the mother; I just say that there is somebody else who can examine the child’ (Nurses FGD2). (P.316)



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Nurses recommended that IMCI include more information about HIV, that all IMCI-trained health workers be trained in HIV/ AIDS Counseling and PMTCT, and that there be updates for IMCI trained nurses. (P.316) 8. Inadequate supervision

Nurses also suggested that increased supervision would improve implementation. ‘If IMCI could have, on the part of suspected



symptomatic HIV.., have more symptoms that we are going to look for.., some of the clinical features that the children present with, more of that, and how to treat them’ (Nurses FGD 5). (P.316) 9. Time consuming



Other barriers mentioned included that implementing the HIV guideline was time consuming. Pg316

10. Domestic challenges

You will try and explain that ‘‘you must come back monthly and take this treatment’’, but usually, most of them they won’t comply. Because today



it is granny bringing the child, and tomorrow it is aunt, that day it’s the sister’ (Nurses FGD4). (P.316) 11. Poor organization of health (HIV) services

Services for HIV are often fragmented, so mothers and children have to see different health workers to receive all the services they need,



leading to poor compliance. ‘We have the PMTCT follow-ups at our antenatal clinic on Fridays. Now the problem is, if those children present with any minor ailment, then they are sent up to us., then they refer them to the doctor, if they need to go on ARV’s or whatever, but we are sending them up and down, up and down, that’s how we do it’ (Nurses FGD5). (P.316) 12. Positive client outcomes as motivation for nurses

Nurses who use the HIV guidelines reported that mothers are usually willing to disclose their HIV status, and nurses gained confidence by



seeing HIV-positive children get better with treatment. ‘Once you put the child on bactrim [co-trimoxazole] you don’t find them [attending] every week with a cough or cold, because before you even scold them ‘‘why



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are you here every week? ’but once you put the child on bactrim you are able to follow the child up’ (Nurses FGD5). (P.316) 13. A well-functioning antenatal PMTCT program

A well-functioning antenatal PMTCT program was a strong enabling factor for IMCI-trained nurses to implement the HIV guidelines, because



the mother already understands the need for follow-up of the baby. Another enabling factor was support from other IMCI-trained nurses in the clinic, so that consistent information is given to mothers, and relevant information recorded on the card, although this was also used as a way of avoiding discussing HIV with the mother. ‘[mothers] knew their status during antenatal care, so it is easy from me. when I do IMCI because I don’t even ask their status; I just peruse the card and I just see this is an HIV positive child’ (Nurses FGD4). (P.317) 14. Support from other workers (community)

‘We’ve got quite a number of community health workers who are living with this community, who are teaching this community from their own



environment, and when they [the community] come to the hospital, they know everything about AIDS. And they know about this shared confidentiality so it has helped us a lot’(Nurses FGD1). (p.317)



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Evans C and Ndirangu E. Implementing routine provider-initiated HIV testing in public health care facilities in Kenya: A qualitative descriptive study of nurses' experiences. AIDS Care. 2011; 23 (10): 1291-1297. Findings



1. Normalizing a highly stigmatized disease

Credible

Unsupported

Nurses felt that routinisation now facilitated more open conversations. “Before, a patient will come _ inside his heart wanting to do the test _



but just asking you would be a problem for him, but now it’s all in the open….. On the other hand, nurses recognized that in the public mind HIV was not yet a ‘‘routine’’ illness due to the stigma that surrounded it.” (N13) (p.1294) 2. Stigma affecting nursing care

Indeed, many participants commented that some nurses themselves still stigmatized HIV and could exhibit a damaging judgmentalism: “We



talk as if it’s a bad thing; we also discuss these patients despite saying that we are going to keep the confidentiality _ so of course patients will not want to test.” (FGD1, P5) (p.1294) 3. Trying to maintain a client-centred philosophy of care within a routinized context

Many nurses were not convinced about the PITC guideline to minimize pre-test discussions in order to expedite client through-put. Their own



experience was that in many cases (because of HIV related stigma), patients did require in-depth pre-test discussions to help them to overcome their fears and to give consent. In such cases, nurses’ narratives indicated that, where possible, they adapted the guidelines, tailoring their discussions to an in-depth understanding of the patients’ situation “With this patient, I knew I had to take longer. So I took her very slowly through everything. She didn’t want to test, but then, after some persuasion, she decided to let me go ahead.” (N12) (p.1294)

4. Target driven care

Many of the participants (particularly from outpatient settings) felt that routine testing had created a target rather than client-centered





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approach to HIV care and that this inevitably compromised quality of care. “If you see the crowds at the clinic they [the supervisors] will be very happy . . . but they will not bother to find out the quality of work you did with each client . . . They are pressurizing the staff . . . if you do not test this many numbers then you are a failure . . . and we are wondering where this 50 will come from. If we coerce these patients to be tested _ then they won’t come back. It won’t be provider-initiated; it will be provider-coercion.” (FGD2, P1) (p.1294) The data indicated that PITC sometimes created acute ethical 5. Negotiating consent

patient

dilemmas within nurses’ everyday practice that were experienced as



very stressful. A commonly cited situation was where patients refused to have the HIV test. In dealing with such cases, nurses repeatedly returned to the principle of ‘‘do no harm’’ to justify their decision-making. “Sometimes you find a patient where you know the spouse or a child has died because of AIDS and they refuse to be tested despite the Counseling and all that. It is challenging because upon discharge you will lose that patient. So you find you might be aggressive for the sake of helping them, not because you want to create harm, but just because you want them to benefit, even though you have to use a cold and aggressive way of handling such a situation . . . Like there was a girl on the ward and I told her _ either you lose your life or comply with the protocols of the hospital . . . then, you see . . . it was like forcing . . . but at the end of it she accepted. But it was for her benefit.” (N2) (p.1294) It happens many times when the doctors are doing their rounds. Many are the times they don’t inform the patients what is wrong with them. The doctor notes down the test and the next thing you know, the clinical officer is poking into this patient drawing blood and the patient doesn’t



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know why. The patients are so innocent; they trust that whatever you are doing is for his own good . . . they do not demand to know. (N6) (p.1294) 6. Managing disclosure confidentiality

nonand

Another difficult situation was when HIV positive clients refused to disclose their status to others who were potentially at risk. Again, in



most cases, nurses spoke of having to accept and respect a patient’s choice. Nonetheless, in four interviews, nurses admitted to breaching confidentiality. “You know, this whole issue is gender biased because the men, they keep it to themselves and the women perish. That part of the confidentiality _ I think it’s killing us. It should be mandatory that the spouse news is told to the other spouse. It is not opening up other people’s issues, but it is just taking care of the others.” (FGD1, P4) (p.1295) See, the relative is the one paying the bill and they are asking all the time ‘‘what has the doctor said’’? . . . As a nurse you are fixed because on the one hand there is confidentiality and on the other there is the relatives’ vulnerability . . . Mostly it is women, and you see that they will not be able to take care, so you just go ahead and give information to that person. (N10) (p.1295)

7. Emotional involvement distress

and

Nurses also described becoming demoralized at the sheer number of patients who tested positive and at their sense of powerlessness to help



those in need. “You test them and then they tell you their history and you just don’t know what to do next. They are poor and they can’t afford food, and then you ask yourself ‘‘what can I do to help this person’’. It really affects me.” (N10) (p.1295)

8. Lack of staff, resources and time

A major source of stress and frustration for the participants related to their working environments. Lack of staff, lack of resources and lack of



time were the most common complaints leading to patients being kept Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 234


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waiting, being sent away, untested or being dealt with abruptly. “Sometimes you find like in my ward you are alone . . . you have all the clients for testing-so what we do is sketchy- you know -shallow, not deep.” (N11) (p.1295) 9. Unfavorable ward environment to maintain dignity and confidentiality

Many nurses identified the overcrowded ward environment (where beds are shared or positioned close together, where there are no screens



and where relatives may be present at all times) as a challenge to maintaining dignity and confidentiality. “We don’t have cubicles . . . so it forces us to go bed by bed as we give a report . . . patients have come to realize the language we use and then you say ‘‘this immunosuppressed patient or this is a p24 patient’’ and it just gives away the whole story to the others.” (N13) (p.1295)

10. Lack of recognition for nurses

Many participants expressed the view that the additional burden created by PITC had been insufficiently recognized in their workplaces, leading



to de-motivation and a task-oriented mentality. “When it comes to doing PITC, if you are trained and the other nurse counselor is not there, you are not much willing to do it _ there is no recognition for it, so you just wait until she comes back.” (N8) (p.1295) 11. Lack of nurses involvement in policy formation

Indeed, a general perception that nurses were undervalued at the wider policy level was strongly expressed in the focus group discussions. “If



you look at all the program implementation _ anything on HIV _ it ends up with the nurse. If the nurse does not implement it, the whole program falls back. But if you look at the people who are being rewarded for that particular program, the nurse is at the back. So there is a lot of demotivation. . . People are creating policy up there, they are not coming down. (FG1, P2).” (P.1295)



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Evans C and Ndirangu E. 'People are creating policy up there, they are not coming down': Nurses' views on the expansion of routine provider-initiated HIV testing and Counseling in Nairobi, Kenya. HIV Nurs. 2009; 9 (2): 20-25. Findings



1. Social stigmatization of HIV

Credible

Unsupported

The social stigma surrounding HIV was cited as the most significant obstacle to HIV testing. Nurses noted that people are very reluctant to



have a test in a clinic in their own locality due to fears over confidentiality. The focus group discussions generated a great deal of debate about how nurses themselves contributed to stigma and fear. They noted their own reluctance to get tested and to discuss HIV openly within their communities “As staff, we need to change our own attitudes towards the testing. I remember there was a time we were just in a session for PITC and I was asking how many of us can go to the VCT we have in the hospital to be tested, and nobody raised their hand. So the question is, if I cannot access the VCT, how do I expect somebody who is a stranger to access it? It shows I have no confidence in the system … if I cannot believe in it, how can I sell the same policy to somebody else? If I have never been tested, I don’t know how it feels to wait anxiously for a result to come through? For us to move, we have to open up. Let us talk not from a point of ignorance but of knowledge. ‘I know my status and this is why I’m attending to you and I can declare it if called upon’” (FGD2:2). (p.21) Let it start with us, first we have to kill the stigma within ourselves and within our colleagues…we should just kill that so that we can implement PITC (P15:15). (p.22) 2. Breach confidentiality

of among

In addition, there was an open recognition amongst nurses that, at


JBI Database of Systematic Reviews & Implementation Reports health workers

times,

an

organizational/professional

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culture

of

gossip

and



judgementalism (directed towards other nurses as well as patients) was contributing to HIV-related stigma and fear of testing. ” I also think that the attitude of the health worker … we have not really improved so much, I think we are also discussing these patients despite saying that we are going to keep the confidentiality. I think it has killed the morale of the community” (FGD2:1). (p.22) 3. Reducing stigma

I think stigma is reduced, because most patients you see, they get diagnosed and they go back into the community and have seen the



importance of testing and treatment. So you find one patient will bring another – and says – ‘if it was not because of this hospital set up and the testing I would have been dead by now’ (P4:17). (P.22) 4. Less counseling normalization

pre-test and

I think pre-test counseling is a way of stigmatizing HIV/AIDS. It is stigmatizing the disease because we are treating it as a special case. It



is a special disease, you must be protected, you have to do this and this counseling for you to give consent. Consent for what? You would have cancer, it would also kill you and hypertension it’s going to kill you. If we make it one among many that stigma will come down (FGD2:2). (P.22) 5. Taking the pressure off the patient

I think it is a good idea. Before that, a patient would come inside his heart wanting to do the test but just asking would be a problem, so



when you come forward and tell them, most of them accept (FGD1:1). (P.22) 6. Prevention unnecessary and death

7. Enhancing efforts

of illness

prevention







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8. Reducing waiting times due to use of rapid tests



9. People may be deterred from seeking care if they know it will involve an HIV test

Many people would run away from hospitals. They will seek healthcare

10. Patients may feel pressurized or coerced into having a test

The patient will look at you like you are the superior and just opt for the

from other places. Back doors, pharmacies and wrong places (P6:15).



(P.22)

test even when they were not really psychologically prepared (FGD1:2).



(p.22) 11. PITC may affect the trust between patient and professional

Some patients will wonder, why is she telling me to go for an HIV test, what does she think of me? They might think you are judging them



when you are not (FGD1:5). (P.22) 12. The need for patients’ informed consent

People should be given health education so that you can know the advantages and disadvantages of being tested so they can make an



informed decision. You are not forced (P5:17). (P.22) 13. Fears that confidentiality is easily breached, especially in overcrowded ward environments

Sometimes in our set ups we have patients who have to share beds and the next patient sees the result so I feel at that point we’ve lost it



(FGD1:2). (P.23) … In a maternity setting, it is the office that you receive reports, that doubles as a Counseling room that doubles as a discharge room. You know it is everything so it becomes very difficult to say that you can assure privacy and confidentiality (FGD2:3). (P.23)

14. Concern that condensing pre-test counseling fails to adequately prepare patients for a positive result

In 10 minutes the thing is done…and when they end up positive, you find most of them are not able to cope (FGD1:3). (P.23)





15. Feeling disempowerment

of

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If you look at all the program implementation, anything on HIV, it ends up with the nurse. If the nurse does not implement, then the whole



program falls back. But if you look at who is being rewarded for that particular program, the nurse is at the back, so you see there is a lot of de-motivation and if a new program comes it is received with a lot of negativity because it is an increase in their work load. Somebody is going to be funded for that program, they are going to have their papers well done because of that program, yet it is the effort and the sweat of a certain nurse who did the hard work, yet they are not recognized (FGD2: 6). (P.23) 16. Lack of involvement in policy/service development and implementation

I would say that so long as our state policy shall continue to be formulated in ivory towers, and the nurses and the patients, the



consumers, are never involved – we shall continue to suffer. So long as people come there and they sit in Grand Regency, sit intercontinental and they say, now, let us introduce a new program … but we are not going to be down there to see this nurse who has seventy patients. People are creating policy up there, they are not coming down (FG1:4). (p.23)

17. Lack of recognition of their expertise and of their hard work

Like when you have the donors who may be funded the training, they also want their numbers to justify the money for the training. So you find



that they are pressurizing the staff such that you are no longer interested in the patient welfare and this has been really a complaint from many health workers. Such that you are given numbers – if you do not test this many numbers then you are a failure…and the providers are wondering where this 50 will come from, if we coerce these patients to be tested then we are going to sound a scaring alarm to most of them who are coming around and they won’t even come. And then it won’t be provider-initiated, it will be provider-coercion (FGD2:5). (p.23)



18. A target-driven approach

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Okay one of the challenges we as nurses we also face in terms of HIV is that we are judged by the number of clients we see but not with the



quality of work … because if you see all those mothers at the PMTCT they will be very happy when they come for the supervisory visit but they will not bother to find out the quality of work you did with each client … And then – reporting – you come at the end of the month and you find that the whole table is full of papers, books – if you miss to fill one copy like this, somebody comes on your neck the next day and says that you are late for this or that report – what – so you find the nurse is overwhelmed and the nurse is doing the work of the clinician, the doctor, the clerk, and even a Counselor … You have been saying that the nurse is the backbone but it is coming to a time when the backbone is breaking so someone needs to recognize that (FGD2:3). (p.23) 20. Over-worked and overwhelmed

So you find the nurse is overwhelmed and the nurse is doing the work of the clinician, the doctor, the clerk, and even a Counselor … You have



been saying that the nurse is the backbone but it is coming to a time when the backbone is breaking so someone needs to recognize that (FGD2:3). (p.23-24) 21. Burnout

Some nurses expressed a sense of burnout, overwhelmed with the quantity and complexity of the work they were being expected to do.



This attitude was in marked contrast to that of the few interviewees who were lucky enough to work in supportive environments where they had been encouraged to develop autonomous roles. “ It was a new role for nursing, which when I look at critically had also been the missing link in assisting our patents to understand HIV/AIDS at an early stage. Other nurses felt it was an added burden to them and were afraid of giving the wrong results. But I felt that at least as a nurse, I had ownership of HIV



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patients because my opinions on management and treatment were highly regarded”. (P1:1). (P.24) 22. Lack of incentives to take on additional roles

Even when it comes to doing PITC, if you are trained and the other nurse Counselor is not there, you are not much willing to do it – there is



no recognition for it, there are no funds, so you just wait until she comes back (P2:5) … The doctors feel you are undermining them – there is so much you know, but you are not allowed to practise (P5:9). (p.24)

Conners EE, Hagedorn HJ, Butler JN, Felmet K, Hoang T, Wilson P, Klima G, Sudzina E and Anaya HD. Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics. Intl J STD AIDS. 2012; 23 (11): 799-805. Findings



1. Change in attitude experience

nurse with

Credible

Unsupported

About half of the nurses reported having a positive attitude about HIV rapid testing prior to and throughout the intervention. “I had had about it



(rapid testing), where you swab the mouth, but I thought it was the most ridiculous thing in the world. But now that I have actually participated in this study I wholeheartedly support it. Once you’re educated, everything falls into place” (nurse at site 1). (P.801) 2. The ease in both offering and administering the test

Truthfully I thought I didn’t want to be bothered …yup I could have cared less. (But) it’s so easy, because I’ve incorporated it, I’ve made it



such an easy tool that it’s just there. I don’t forget doing it because it’s the first thing I do (nurse at site 3). (P.801)

3. The convenience of NRT

The convenience of NRT was cited as the most important benefit as the patient does not have to follow through with a separate appointment to



go to the laboratory, the test is easily integrated into patient intake appointments, results can be delivered immediately, and no needles are



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involved with the testing process. (p.801) 4. It is part of nurses’ duty

the

All nurses interviewed reported that it was appropriate for SUD nurses to be conducting this point-of-care HIV rapid testing. Reasons given



included that it is the duty of nurses to educate patients and encourage screening tests, and that patients are more comfortable with and trusting of the nurses because they see them on a regular basis. (P.802) 5. Varied prioritization of testing in the clinic workflow

Although HIV testing was stated to be as being important in this highrisk population, in practice, the actual prioritization of testing in the clinic



workflow varied. Nurses reported that the culture of site 3 already placed a high emphasis on infectious disease testing in the SUD population and therefore HIV rapid testing was naturally a high priority. (p.802) 6. Varied levels of comfort with performing medical procedures

At sites 1 and 2, the nurse manager stated that staff had varying levels of comfort with performing medical procedures (e.g. influenza



vaccinations) and suggested that in clinics where such procedures are not conducted regularly, a testing champion from another clinic could offer tests instead. (p. 802)

7. Importance of training

All nurses reported that the training was helpful; on site 3 staff especially appreciated the interactive portion where nurses performed



practice tests. Two nurses at site 1 suggested that on-job-training ‘see one (rapid test), do one’, would be helpful for those nurses who are apprehensive about testing. (P.802) 8. Usefulness of clinical reminder

All clinics reported using the clinical reminder in high numbers but the experience and comfort level with using varied. A common theme in



many of the interviews was that there should periodically be refresher courses on the clinical reminder and NRT. “May be more in-services,



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especially for people who haven’t been doing this…they have to stay excited about it and feel comfortable doing it” (nurse at site 1). (P.802) 9. Implementation strategies

At site 3, nurses incorporated the test offer into the hour-long intake interviews required for all new patients. At site 1 and 2, nurses primarily



reviewed their entire patient cohort, identified patients with outstanding clinical reminders and created a master list of potential patients to testcircumventing the need to be in front of a computer during the test offer. (P.802) 10. Patient attitudes towards testing

Nurses reported that patients were satisfied with the strategy and that

11. Anxiety and discomfort of delivering the results

The greatest concern as reported by five nurses, was anxiety or



patients preferred the oral swab over traditional blood draws. (P.802)

discomfort with delivering preliminary HIV-positive test results. Sources



of this anxiety included not knowing how the patient would react upon receiving the results, inexperience delivering HIV results and concern over the process of linking the patient the patient to care. To overcome this, all of these nurses came up with their own plans on how to they would engage other providers or mental health services in the event of a positive result. The automatic confirmatory testing order and ID consult was also reported to relieve some of this anxiety. (p.802) 12. Lack of support from colleagues

Part of the requirement for the NRT at sites 1 and 2 was that a physician or nurse practitioner needed to sign off on the nurse testing



orders. At one sub-clinic, a nurse stated s/he was unable to test because the physician in his/her clinic refused to do so. (P.802) 13. Lack of involvement of senior staff

A facility-level barrier was that the nurse manager at sites 1 and 2 had to split her time between multiple sub-clinics and so was not physically



present in each sub-clinic on a consistent basis. The nurse manager admitted that more involvement on her part would have increased



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testing and nurses in her clinics reported that when she was present it was a good motivator to participate and continue NRT. (P.802)

Chen JC, Goetz MB, Feld JE, Taylor A, Anaya H, Burgess J, De Mesa Flores R, Gidwani RA, Knapp H, Ocampo EH and Asch SM. A provider participatory implementation model for HIV testing in an ED. Am J Emerg Med. 2011; 29 (4): 418-426. Findings



1. Time constraints

Credible

Unsupported



“Sometimes if busy, no room for HIV testing. If not busy, perfect. If busy, too time consuming.” (P.421)

2. Electronic documentation

Primary operational barriers included time required for provider to complete separate written informed consent and time required for nurse



to document HIV testing in the electronic medical record (both cited by 5/22 staff members; 23%). (p.421) 3. Perceived competence

Other reasons include lack of comfort with sensitive topic, lack of knowledge of test availability, and provider's personal assessment of



patient's lack of risk. (P.421) 4. Belief that screening is not a core ED duty

The belief that screening activities are outside the scope of ED duties or dilute the primary ED mission. “HIV is an odd thing to do in the ED



because in the ED we address things we can treat. HIV cannot be ‘treated’ in the ED.” (P.421) 5. Ease of administration

test

“[Rapid testing] offers a quick an easy diagnosis and is more appropriate for the types of patients we see.” “… when changed to [sic]



limited time frame, more workable.” (P.421) 6. Flexibility to tailor screening efforts according to patient volume

Ability to structure HIV RT on nonpeak times. Flexibility to alter screening efforts according to patient census was recommended to



sustain HIV RT in the ED. “[Rapid testing] offers a quick an easy



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diagnosis and is more appropriate for the types of patients we see.” and “… when changed to [sic] limited time frame, more workable.” (P.421) 7. Congruency with care

Belief that patient population is at high risk for HIV and a belief that patient population is less likely to access primary care was a facilitator



to RT. (P.421)

Leon N, Lewin S and Mathews C. Implementing a provider-initiated testing and Counseling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalization process model. Implement Sci. 2013; 8 (1): 97. Findings



1. Perceived opportunity to improve care

Credible

Unsupported

The framing of PITC as both an opportunity to address a service gap and an opportunity to improve the standard of STI care may have



strengthened the willingness of nurses to consider its implementation. Nurses were acutely aware that the current VCT system did not provide optimal access and resulted in missed opportunities for HIV testing for STI patients (P.9). This is to be able to treat STI fully. It will ensure that clients are offered all services, even HIV testing…we want to offer full care (p.11). 2. Resonating with professional norms

Appeals to improving clinical care resonate with professional norms about providing quality services and, as such, are likely to have



strengthened the acceptability and the interactional workability of the new intervention. P9 & 11. A STI nurse explained her experience of the gap in HIV testing for STI patients: ‘When I used to refer them [STI patients] for VCT, they always say: “Oh, how long will I have to wait? Do I have to see a Counselor?”’ The nurse elaborated: ‘That was always an issue. They would say: “I am willing to take the test, but if I have to go to



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the lay Counselor, I’m not going to test”… it's too time consuming for them.’ (P.11) 3. Concern about reduction in pre-test counseling

However, two other concerns, mainly from HIV trainers, were less easily resolved. One was an ethical concern about reducing pre-test



counseling requirements (p.11). 4. Welcoming normalization

Nevertheless, nurses, as the main implementers, were willing to proceed despite their own concerns about how the new tasks might add



to their workload. Nurses in a focus group at the start of the intervention were generally positive toward the change. A STI nurse commented: ‘There are limitations, like the time constraints, but we should go ahead. We should integrate routine screening to all parts of medical care.’ (P.11). 5. Mechanisms implementation leadership support

of

Project support was delivered via site visits at clinics as well as through

and

quarterly ‘cluster’ meetings with smaller groups of staff from two to three



clinics at a time. These cluster meetings were considered a key mechanism for promoting accountability and confidence amongst staff…………..While implementation leadership and support would have strengthened staff confidence, nurses may also have been motivated by their own sense of the utility of the intervention (p.11).

6. Perceived feasibility of the PITC intervention

Another nurse commented on the feasibility of the PITC intervention, highlighting the close fit with the routine clinical care that she delivered:



‘With me, even though there wasn’t this project, whenever I was treating an STI, I always talked about HIV. So it’s not a new thing. The only opportunity I have now is that I have to do the HIV test’ (P.12) When asked to reflect on their capacity for implementing these new

7. Congruency existing care

with

tasks, nurses consistently pointed to the congruence with standard STI



care. As one nurse explained: ‘I think that we always did talk about HIV.



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People know it’s a virus, they know it has to do with sexual transmission. But I think we spend more time now pointing to the benefit to the patient of testing. Previously we would refer them to VCT and because we weren’t really involved with the testing, we didn’t go into depth such as discussing issues like, “How this is going to benefit you. What services are available for an HIV-positive patient, whether they know how they can prolong their life.”’ (P.12) 8. Testing process requires time

When nurses were asked about the challenges posed by the intervention, they indicated that the added time was the main obstacle.



The main reason for this, they said, was that they were required to convey too much information: ‘We have to do too much talking and writing’. Related to this was the greater interaction with patients as a consequence of introducing HIV into the STI consultation: ‘We have a lot of information to discuss with them, and the clients are also asking a lot of questions’. Another nurse linked the change in the interaction with patients to an increase in consultation time: ‘I think it boils down to the fact that we are actually spending more time with each client… As you’re talking you win their trust, and they are perhaps giving you information that they wouldn’t have given before’ (P.12) 9. Challenges sequencing required tasks

in the

Observation of clinical practice indicated that although they were able to perform all the new tasks….., they struggled to do so in an integrated



manner. The level of efficiency of deployment varied among the nurses observed , most often resulting in long extensions to consultation times (p.12) 10. Inadequate focus of training

Another factor contributing to reduced skillset workability was the training. There was disagreement between the project leadership and



the HIV trainers about the duration and content of the training for the STI nurses. It was evident from participant observation that training



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focussed on teaching nurses counseling skills so that they could assess patient readiness and facilitate ‘true’ informed consent. Most of the time was spent on trying to rapidly teach nurses to use patient-centred counseling techniques and on how to provide health education to ensure that the patient was fully informed. In contrast, there was little to no guidance in the training on managing the operational challenge of efficiently integrating the new tasks into a standard STI consultation (P.13) 11. Tensions in provider vs patient centered communication

The new intervention challenged the conventional provider-patient communication used in the STI consultation. For the most part, nurses



used a more provider-centered authoritative communication style in which they took the authoritative role of providing knowledge and advice. However, the tasks linked to assessing patient readiness for testing and obtaining informed consent required more patient centered forms of communication and did not fit easily with the task orientated nature of the STI consultation. The tension between these two styles challenged the clinical communication skills of the nurses and limited their ability to integrate the tasks efficiently (p.13) 12. Motivated by positive reactions from patients

Nurses also pointed out that the positive reactions of patients provided

13. Role of management support

The dedicated project management support, even if part-time, was an

14. Fit of the HIV testing within existing work

This way of organizing the service, with a mixed role in a busy setting,

them with further motivation to continue with the intervention (P.14)

important resource to ensure successful implementation (p.14)

may have been an added barrier to nurses offering HIV testing more







widely to their STI patients (p.14)



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Leon N. An evaluation of a provider-initiated HIV testing and Counseling (PITC) intervention for patients with sexually transmitted infections in Cape Town, 2011; South Africa. PhD Thesis, University of Cape Town. Findings



1. Congruence with their current practice

Credible

Unsupported

Nurses shared the belief with management that the PITC intervention was congruent with their existing activities in the STI consultation and



that the intervention only required a small shift in their practice. They also saw the potential benefits by increasing the comprehensiveness of STI care and reducing barriers to HIV testing: “This is to be able to treat STI fully. It will ensure that clients are offered all services, even HIV testing… we want to offer complete care and treatment.” [STI nurse (p.190) “With me, even though there wasn’t this project, whenever I was treating an STI, I always talked about HIV. So is not a new thing. The only opportunity I have now is that I have to do the HIV test. When I used to refer them for VCT, they always say: ‘Oh, How long will I have to wait? Do I have to see a Counselor?’ That was always an issue. They would say: 'I am willing to take the test, but if I have to go to the lay Counselor, I’m not going to test‘... it's too time consuming for them…” [STI nurse] (p.191) 2. Agreement on the meaning and consequence of the work

There were concerns among nurses with the increase in workload associated with offering HIV testing though this did not detract from



their support for the intervention: “There are limitations, like the time constraints, but we should go ahead. We should integrate routine screening to all parts of medical care.” [STI nurse] (p.191)

3. Validity and expertise of knowledge and role divisions

Nurses were required to take on tasks previously performed by lay counselors, who were then required to give up some of their tasks




JBI Database of Systematic Reviews & Implementation Reports underpinning the work

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(p.192) Some of the planning activities that increased relational integration included developing ownership through stakeholder involvement in the PSC, agreeing on the need for project management support and for additional training of nurses, and detailing monitoring and evaluation mechanisms to assess progress (P.193) STI nurses usually receive supervisory support and support from HIV/TB/STI coordinators, in addition to their line management support from the facility manager (P.193)

4. Agreement on feasibility and roles in HIV testing

Nurses and management also concurred about the feasibility of adding HIV testing to the standard STI treatment. There was a high level of



agreement between management and the nurses (who were the main implementers) about their roles, about the utility of the intervention, and about the credibility of the knowledge requirements (P.194) 5. Comfort with increased responsibility

the

For example, nurses agreed that their STI consultation already dealt with several elements of the HIV testing process, such as sexual risk



assessment, prevention education, and condom distribution. The quote below expressed a common sentiment among nurses about their comfort with the increased responsibility in practice. “I think that we always did talk about HIV. People know it’s a virus, they know it has to do with sexual transmission. But I think we spend more time now pointing to the benefit to the patient of testing. Previously we would refer them to VCT and because we weren’t really involved with the testing, we didn’t go into depth [such as discussing], ‘How this is going to benefit you. What services is available for an HIV positive patient, whether they know how they can prolong their life’.” [STI nurse] (p.194195)



6. Agreement about the need for training but disagreement on the content

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The project leadership and nurses showed appreciation of the need for patient informed consent but they did not think this required specialist



counseling skills. They were more concerned with the practical challenge of how to integrate HIV testing tasks efficiently with the rest of the STI consultation (P.195) Stakeholders agreed about the need for additional training for nurses and lay counselors and that this was important for promoting confidence in the intervention. However, there was disagreement and a lack of clarity about what skills were required for nurses to implement the intervention (P.196)

7. PITC enables comprehensive care

Nurses were enthusiastic about the intervention from the start; they remained positive throughout and appeared to have internalized the



paradigm shift to normalizing HIV testing (P.198) Nurses thought that the benefit of the PITC intervention was that they could offer a more comprehensive clinical service to STI patients but also a more holistic service by building rapport with patients through discussing behavioral and emotional issues: “I think it boils down to the fact that we are actually spending more time with each client… as you’re talking you win their trust and they are perhaps giving you information that they wouldn’t have given before.” [STI nurse] (p.198) 8. Emotional labor

A nurse illustrated how having a discussion about HIV can lead to deepening of rapport with the patient: “I asked ‘How are you gonna feel



if you’re HIV positive?’ and he said ‘Ugh, I don’t want to think about it’, and I asked ‘What do you think you’d do?’ And he said ‘I don’t know’. I said ‘How have you dealt with stress before in your past?’ and he said ‘I tried to commit suicide’ and he describes this horrific personal life with an abusing father who is still abusing his mother… And you know, he



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was in tears… that someone cared enough to feel about his problems and to try to do something about it.” [STI nurse] (p.198) One of the challenges of taking on HIV testing was that nurses felt the emotional burden of dealing with HIV on a daily basis. In particular, they struggled with their emotions when someone tested HIV positive: “When you do the test, you pray: ‘Please God, it mustn’t be this one’… You have to take a deep breath when you are still waiting for the result and you pray.” [STI nurse] (p.198) 9. Balancing time with logistics

When asked what the biggest limitation was of the PITC intervention, nurses reiterated their earlier concern that it took too long to implement.



The amount of information they were required to convey was a problem as they were trying to balance patient participation with the need for efficiency: “We have a lot of information to discuss with them and the clients are also asking a lot of questions.” [STI nurse] (p.201-202) Another respondent explained this plainly: “We have to do too much talking and writing.” [STI nurse] (p.202)



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Pellowe CM. The Educational preparation of midwives to undertake HIV antenatal screening. Does it meet the needs of women? 2004; PhD Thesis, University of London, UK. Findings



1. Acceptability of the testing model (by midwives)

Credible

Unsupported

No, I prefer optional tests only because it gives the woman more control of the situation. It’s how the information s given. When it was optional, I



would say more time was spent talking to the woman about the way HIV is acquired, high risk groups, what is it, you gave more information I think rather than saying it’s routine, it’s universal. (BM6) (p.54) However, from the HIV care coordinator’s perspective, the move to universal testing had been an important aspect of normalizing the test and identifying those infected. “I think the whole thing with pre-test counseling is probably thought of as a bit of mistake now. Because it’s the only test you get, where there is a pre-test counseling, and in the antenatal setting you haven’t got the time to sit with someone over the test”. (M10) (P.54) 2. Support normalization

for

“We offer it as a test along with all the others so we can prevent transmission and don’t put too much emphasis on it because of the fact



that people who get worried about it tend to say ‘NO’. M7 (P.55) 3. Inadequate training on how to offer the test

Apart from a bit we do on our course, we have like a trigger that we look at. I think sometimes even though you learn things at college, when



you’re actually in the environment where you have to actually implement what you’ve learned, it’s different. 9BM2) (P.55) I haven’t been to a study day on HIV (they’re available) since I qualified. (I get my understanding from) generally reading up because you, even though you mightn’t be looking after them antenatally you would be with them postnatally, so you need to be up-to-date. (BM5) (P.55)



4. Lack of patient information about the test

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They’re supposed to have a leaflet sent about infection in pregnancy […] so I suspect sometimes women don’t end up seeing them. Now, the



other problem in this hospital is you know 58%, about that figure are not from England and there’s over 100 languages spoken. (BM6) (P.55) There is a book sent out and it does state the booking blood tests that we do. However, I’d say probably 20% of our population would be able to read that, or would bother to read it. So, from the patient’s point of view because we have so few people here that have English as their first language, then it’s not always helpful. It’s not offered in other languages to my knowledge. (BM7) (P.56) 5. Techniques normalization

for

I always have some discussion, and what I do is I say what the test is for. I say what we’re doing it for. HIV is one of the test in ‘the list’. (BM1)



(P.56) I just explain to them, this is a test that we offer every woman that comes in here, that it’s because of the high increase in HIV and that there’s so much more we can do for the mother and baby if it happens to be positive. It’s something that every woman is offered. (BM5) (P.56) 6. Limited time

A certain amount of time is given to the booking slot and yet we’re doing more and more investigations, not just for HIV. I’m talking about the



various screening tests, so where does the emphasis lie? And I suspect it’s a tradeoff where you have to talk about a new kind of screening system, information about other tests tends to fall to the background. (BM6) (P.56) 7. Acceptability of the test (by women)

I think they’re used to being to being asked about screening tests and I think women do view pregnancy as an opportunity to think about their



own health and none of them seem surprised currently. I think in the pat they were, they were very surprised that when they’re pregnant, we



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then start to discuss HIV. (BM2) (p.57) 8. Strategies persuasion

of

Sometimes I’ll say, “Go away and think about it and let me know next time.” If she says then that she doesn’t want it, you’ve given her enough



time. I think it would be a good idea to refer them to the specialist midwife so that she could pick it up and double check she really doesn’t want it. (BM2) (P.57) I’ll get bleeped if there’s any woman particularly concerned, if they’ve had a one-night stand or a chequered sexual history, or just concerned really. And I’ll get bleeped and go and see them about it, so they get extra counseling from me before the test’s done, and then I’ll get the test done urgently and I’ll ring them with the result in two days. (M10) (P.58) 9. Importance of confidence and trust in the midwife

It’s definitely the midwife that offers the test that ensures whether the woman will have the test or not. We’ve had women booked by one



midwife, say two years ago, and gets a lot of declines, and they’re booked by another midwife this year and they accept without any problem at all. So that shows me that it’s definitely down to the midwife and the way it’s said. (M10) (P.58) Sometimes when they (team member) say a woman declines HIV, I ask why. If it’s just the silliest case I go in to speak to her and most of the time I convince them. (BM10) (P.58)

10. Reasons refusal

for

test

Some of them will say, “Oh I had it done last year or when I we were travelling we needed it.” Some occasionally you find out don’t want to



know. Then most of them will say, “ Oh I had it done when I was coming to France. I had to have it done.” Even if they decline you still try to pursue it like most of them will say, “Oh I have done it last year” and we’ll say “That’s more reason you should do it again, that you know



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again and again and again you are not HIV positive.” Some of them will say, “Oh I’m with only one partner for 10 years.” “You can only trust yourself, you cannot trust anybody or men, it’s only you can know about. Try and do, I’m not asking, I’m not forcing, it’s not a prison but it’d be better for you to do it.” (BM10) (P.58) 11. Variation in managing follow-up

Among the booking midwives, there was some confusion about whether a woman who refused the test would be re-offered the test later in



pregnancy. “No, you’d offer it again later on.” (BM9) pg59 “Not necessary. I suspect it can be raised again. If you did to some it might imply you’ve some suspicions. (BM6)” (P.59) 12. Contacting women with a positive resultgiving a lady time

I write to her to say we now have the results of your recent blood tests and give her an appointment to come in. Obviously that does not say



anything about HIV. (M1) (P.61) All positive results come through to me from the consultant or registrar in microbiology. I’ll get the woman’s notes. Basically I do all that work, get the notes, see what gestation age she is, and then write her a letter or depending on her gestation. I’ve had some booked late and I’ve actually had to ring them and ask them to come in. In the letter, I just say we’ve made a further appointment for you to see the midwife to discuss well. I do them all individually. (M9) (P.61) 13. Lack of involvement (of booking midwives) in ongoing care

Considering the booking midwife offered the test and obtained the woman’s consent, the HIV care coordinator could discuss the situation



with her before contacting the woman. She could even involve the midwife in the woman’s ongoing care but this did not appear to be the case. Most of the booking midwives were never informed of the woman’s result, or had discovered it by coincidence. “(It was a) coincidence really, because the HIV specialist midwife is always here on Mondays and Thursdays, which are my clinic days”. (BM6) (p.62) Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 256


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“I don’t think so, I’m not sure but I don’t think so. She’d be seen here at the clinic and (specialist midwife) would see her then at the time of our team appointment so I’d see her then going to her”. (BM4) (p.62) 14. Challenge breaking the news

of bad

One coordinator described often thinking as she entered the room to inform the woman of her diagnosis: “I’m going to ruin the rest of your



life. You’ll always be HIV positive but we’ll do the best we can for the baby” (M2) (p.62)

15. Addressing the impact of the result requires adequate time

And then I’ll meet them and give them as much time as they need, blank out the whole day. And they, once we’ve talked here, about what



care can be provided and the fact that HIV doesn’t equal death, that kind of thing, we take them over to (GUM) for baseline bloods. They can meet the health adviser at (GUM), they can meet with them then or make an appointment to meet them later on. Sometimes it’s too much in one day. (M7) (p.63)

16. Managing the impact of diagnosis

I think what they need is continuity of care, they need everybody looking after them and I hate this expression, to be ‘singing from the same song



sheet’, you know what I mean by that, because it’s a very confusing time. They need people to understand that things like disclosure, is a big issue (sic), and it’s not going to happen overnight. They need time. They need somebody who can tolerate their …well…the role roller coaster of emotions that can come up. They do need to have somebody who’s pretty stable secure base, if you like, to contain all of that and a lot of that comes from continuity. They need to know that their confidentiality is going to be respected even though some people might have difficulties with the things they are keeping confidential. (M1) (p.67) 17. Need for supportive and consistent care

There are some…I haven’t actually had it happen but I know from some



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to prevent loss to follow-up

in the past who’ve gone into denial……some react against us and the

18. Supporting disclosure

From the HIV care coordinator’s experience, there is a desire to offer



system (p.67)

the woman’s partner an HIV test and, if necessary, provide treatment.



However, this has to be balanced against issues of safety for the woman. “One woman was beaten up by her partner” (M2) (P.67) With so little information about the woman prior to the first meeting, the HIV care coordinator always raised issues of disclosure at the first meeting although all relevant matters were not necessarily resolved upon this first occasion. “But I have got one partner who wanted to see me because he was worried about his relationship. I met him one but that makes it difficult because you are in the middle, and my role is to see the woman through her pregnancy, so I refer them to (GUM). After that initial contact, if they want counseling themselves I put them in contact with someone else so my role is not compromised with the woman”. (M7) (P.68) 19. Limited time for proper discussion of the test

The one hour is crammed full of 101 things. It’s not just about HIV or

20. The tension of ensuring patient choice within a routine test context

It’s also how it’s offered isn’t it? I was recently on a ‘return to practice’

anything that might be seen as important, it’s about the whole plan of



the pregnancy so it’s difficult to get it all in (ML2) (p.90)

course and it was the HIV counselor who said “we usually test for HIV,



is that alright?” and I don’t feel that is really offering the woman a choice (ML6) (p.90)

21. Pressure of meeting targets versus ensuring patient choice

Certainly, midwives in the antenatal screening module had real problems because they say there is pressure, rightly or wrongly, put on



them to keep the results up. And if the results are lower, if you talk to



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some of the community midwives why their results, and compared across and some midwives have much lower uptake rates, the question is always asked “what are you doing”? and that again is saying “why aren’t you getting 100%”? as opposed to accepting that you’re giving the women the decision [ML4] (p.91) 22. Insufficient training

Educational provision concerning the purpose and value of antenatal testing was at best patchy and many appeared to have ‘learned on the



job’. “Putting it in context, midwives have a number of statutory requirements for study over a period of a year, two years and may find it difficult to access any of them regardless of whether its HIV or moving & handling” [ML4] (p.95)

Medley AM. Antenatal HIV counseling and testing in Uganda: Women's experiences, counselors' challenges, and men's attitudes. 2008; PhD Thesis, The Johns Hopkins University, USA, Baltimore, Maryland. Findings



1. Clients declining to take an HIV test or receive their test results

Credible

Unsupported

Counselors reported feeling frustrated that they were unable to help women who showed signs of being HIV-infected but refused to test for



HIV. Counselors used a number of techniques to convince women to test for HIV. If women decline during group pre-test counseling sessions, they are pulled aside and counseled individually. If they still refuse, a note is made on their antenatal card that they received pretest counseling but declined HIV testing. At their next visit, they are pulled aside for further counseling and again offered an HIV test (p.169)

2. Clients not returning for postnatal care and/or Nevirapine tablets

Counselors expressed frustration that women often waited until the child was malnourished and really sick before returning to the clinic,



(p.170)



3. Frustration with limited ability to follow-up with clients

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Because counselors were unable to follow-up with women who dropped out of antenatal care they were unable to track the success of the



program, “We need to test ourselves, to know our effort. If you attend to the mother during pregnancy, she delivers well, why don't you know the outcome? Is the baby okay? The nevirapine, was it wasted? Did you find the baby after 18-months? And you test that baby. Is she negative? Is he negative? That is the fruits when you see the outcome; what we have achieved in the program. Because if we don't know the outcome of our baby that means we have worked a lot but at the end of the day nothing was done. (Midwife/counselor, urban clinic) (p. 171)

4. Clients do not have time for adequate post-test counseling

In order to prevent women from leaving many counselors felt the need to rush through post-test counseling sessions so that all women could



receive their results. Counselors also described how clients, especially those who tested HIV negative, would often decline further HIV counseling after learning their HIV test results and were uninterested in discussing risk reduction plans or other post-test counseling items. “For her, she has come for check-up but she has to go back and dig. If you take long talking to her, like counseling should take at least 30 minutes, don't you see? They don't want that. She wants you to talk to her and then she goes because she has problems at home. If you take long, they don't want”. (Midwife/counselor, rural clinic) (p.171) 5. Challenge of low HIV sero-status disclosure to partners

The main problem is when we are counseling especially the positive mothers is reinfection. Because when you counsel a positive mother



you tell her that you should not re-infect yourself, you should use a condom. But she says, 'I fear to tell my spouse. If I tell him, he is going to chase me away.' Then you get stuck. You talk about infant feeding. You will breastfeed only for three months. She will tell you, 'Massawo, I fear my man and even we don't have money.' (Counselor/midwife,



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urban clinic) (p.172) For women who were afraid to disclose, counselors would instruct women to tell their partners that they were needed at the antenatal clinic. If the partner arrived, counseling would be provided to both members and the counselor would facilitate disclosure during a joint post-test counseling session (p.173) 6. Low male involvement in antenatal clinics and PMTCT programs

Counselors tried to emphasize the importance of bringing partners in for HIV testing during both pre- and post-test counseling sessions.



However, male involvement in antenatal settings remained low. The main reason for low male involvement cited by counselors was poverty (p. 173) Counselors

described

a

number

of

strategies

that

they

had

implemented to increase male involvement within the antenatal setting. The first strategy was to give priority to women who came with their partners for both HIV testing and antenatal services. These women would be attended to first before women attending services alone. It was hoped that this would act as an incentive for other women to come with their partners at future visits. Furthermore, during the pre-test counseling session, women were asked if any of them had come with their partner to the antenatal clinic. It is common, especially in rural areas, for men to escort women to the clinic but then remain outside. By asking women if they had come with their partner, counselors hoped to identify couples for counseling (p. 174) The most common suggestion, however, was to provide funds and transport so that counselors could go out into the community and do outreach programs to sensitize both men and women about PMTCT programs. Counselors also suggested providing counseling services in areas where men tend to congregate, such as sporting events, bars, Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 261


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and restaurants (p. 175) 7. Poor cooperation between antenatal staff and counselors

While most of the 10 clinics reported good cooperation between clinic staff and counselors, there was one clinic where counselors felt that the



nursing staff did not appreciate the value of HIV counseling and testing. For example, the antenatal staff would sometimes provide women with antenatal services without referring them for either counseling or HIV testing. This meant that many women at this clinic left before being tested for HIV, as illustrated by the following statement;

“All of the

nurses they are not qualified in this PMTCT. So, it's really a problem even to dealing with them for us counselors. Thus, they will not assist us with dealing with that program. They don't take counseling as important (Counselor, rural clinic) (p.175) 8. Lack of adequate space for counseling

Most counselors reported a lack of space for counseling, mostly attributable to the fact that antenatal clinics were designed before HIV



counseling and testing was integrated into antenatal services. Thus, there was a lack of small, private rooms suitable for counseling. Counselors reported improvising to obtain privacy for counseling (P.175) Counselors also discussed how some of the exam rooms they were using for HIV counseling lacked privacy. These rooms often had walls that did not go all the way to the ceiling, or had a curtain instead of a door at the room's entrance. Counselors were forced to give results in a low voice, and if a woman cried, it could often be heard by women waiting on the other side of the curtain for services. Other counselors described rooms with large glassless windows open to the outside. Although they used curtains to block viewing inside the room, it was still possible for people passing by to hear what was being said (P.176) Counselors also talked about how their sessions were frequently Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 262


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interrupted by other health staff coming in or out of offices to retrieve files and/or other information. They discussed the need for signs to put on the door to let others know that a session was in place so that the privacy of the counseling sessions could be increased (P.176) 9. Stock-outs of clinic supplies

Maintaining a steady supply of HIV test kits was a challenge faced by most clinics, with seven clinics reporting stock-outs of test kits in the



past year ranging from a few days to three months. During that time, women were provided pre-test counseling and then asked to come back at a later date for HIV testing. On the antenatal clinic records, counselors would make a note that they had been counseled but not tested in order to identify those women needing a test during their second antenatal visit (P.177) Other supplies counselors reported frequently running out of included reagents for syphilis testing, gloves, disinfectants, and condoms. Six of the ten clinics reported being currently out of stock of reagents to test for syphilis. Gloves were often in short supply, as well, especially in rural clinics. This forced counselors and lab personnel to draw blood without gloves. Moreover, although counselors discussed the risks of dual infection and the high risk of infection during pregnancy and breastfeeding, Counselors were unable to provide condoms due to a countrywide shortage (p.178) These frequent stock-outs were a source of intense frustration for counselors as they prevented them from providing quality care to expectant mothers, “Maybe after giving the positive results you tell the women that it is not good to be reinfected. But these days we don't have condoms. These days there are no condoms and some they can ask for them. [The woman says], 'So you have told me that it is not good to meet when he has not put on a condom, now you give me



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some condoms'. Then you have a problem. (Midwife/counselor, urban clinic) (P.178) 10. Lack of information equipment

pre-test video

Counselors reported that in group pre-test counseling sessions women had a wide range of knowledge regarding HIV testing and the PMTCT



program. Some women were familiar with both, while others had heard of HIV testing but were unaware of the procedure for HIV testing or that it was offered as part of antenatal care. Thus, they requested videotapes and a TV that they could set up in the waiting room. Such videos could expose women to the benefits of HIV testing and the PMTCT program prior to pretest counseling and could save time during the counseling session. The videos could also provide real-life testimonials, something that clients often wanted to see (p.178-179) 11. Lack of lab personnel

Most clinics did not have lab personnel dedicated to the antenatal clinic. Instead blood tests went to a central hospital lab which often took a long



time to process the results due to the long queue of lab tests needing to be processed. Thus, nurses/midwives often finished examining women long before test results were ready. Women sometimes had to wait up to 3-hours for HIV test results [……..].To prevent this problem, counselors requested that they be trained to draw the blood and run the tests themselves instead of relying on lab personnel, “ Another thing I could suggest is that if there is any training it should include testing women's blood instead of carrying their blood to the lab. Anyway the problem is that in the laboratory there are few people and they are supposed to do all of the work for the whole health unit. And for us also, our mothers, they don't want to sit for a long time. So if we are taught how to test that blood it is easy. You take, you test, you give her [the results] and she goes back. (Counselor/midwife, rural clinic) (p.179) 12. Lack

of

referral

Long-term anti-retro viral treatment programs were available at six of


JBI Database of Systematic Reviews & Implementation Reports services

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the ten clinics. At several rural clinics where such programs were not



available, counselors would refer women to the district hospital which was located some distance away. Counselors at these clinics requested that programs be located closer to their clinic as it was often difficult for women to travel such a long distance for treatment (p.179-180) 13. Language barriers hindering communication

Most of the counselors in this study could speak English and KiLuganda and/or KiLusoga. However, women from the northern part of the country



often did not speak any of these languages, and thus providing counseling was not feasible. Instead, counselors used symbols and hand gestures to provide women with their HIV test results but they were unable to provide preventative counseling in the event of a negative result or PMTCT counseling in the event of a positive result. In some cases, the woman's partner or another relative would act as translators during the HIV counseling session. Although this was a potential violation of the women's confidentiality, it was often the only way counselors could provide services to these women (p.181)

14. Heavy workload

All counselors believed that their workload was too heavy. Counselors reported seeing 20-30 clients a day, of whom approximately three



would be HIV-positive. This heavy workload caused counselors to feel rushed in their counseling sessions, as they were mindful of the large number of women waiting. During particularly busy days, counselors worked without lunch or tea breaks. “ …Sometimes I feel I am rushed because the patients in the antenatal, I don't want to delay the mothers at the antenatal because some of them come from very far. And that's the problem. So I feel I have to be fast so that we can catch up on time and they go back very quickly to home” (Midwife/counselor, urban clinic) (p.181)



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One strategy HIV counselors used to deal with the heavy workload was to streamline HIV counseling for HIV-negative women in order to make time for longer counseling sessions with HIV-positive women. Additionally, they would include a lot of information from the post-test session in the group pre-test session, in order to shorten the post-test session, “When there are too many, some matter that would have come in the post-test [session] at times you find that you have to include it in the pre-test so that now when it comes to giving results you can give a short

session

especially

for

those

who

are

negative.”

(Midwife/counselor, urban clinic) (p.182) A few counselors reported that when they felt really rushed for time, they would counsel some of the women and give the rest an appointment to come back for their HIV test results. “What we do when we are caught up by time, like I counsel some and the rest I tell to come back. I give them a return visit” (Midwife/counselor, urban clinic) (p.182) 15. Lack of support and motivation

Counselors often felt like their work was underappreciated. They felt their salaries were not commensurate with the services they rendered.



They also complained that, unlike hospital staff, they did not receive money from general funds to buy tea or bread for breaks. Many also felt that they lacked adequate supervision from district health officials. This lack of supervision did not allow them to know if their job performance was acceptable, nor did it allow them to improve their services. The limited supervision from district health officials caused many counselors to feel like the district did not appreciate their efforts (p.183) 16. Stress associated with HIV counseling

It was emotionally difficult for counselors to give HIV-positive results, especially to young women on their first pregnancy. Counselors



reported putting a lot of pressure on themselves—to give every woman counseling, and to convince every woman to test for HIV. Several Evans et al. The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence © the authors 2015 doi: 10.11124/jbisrir-2015-2345 Page 266


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counselors mentioned the reward they felt when they were able to help a client overcome a problem (p.183) To deal with the stress of counseling, counselors reported keeping a professional distance between themselves and the client. Although they empathized with clients, they didn't become personally involved in their situation. However, as human beings counselors were sometimes unable not to be moved by the client's situation. The toll of repeatedly giving

HIV-positive

results

caused

some

counselors

to

feel

overwhelmed and burnt out (p.184) None of the 10 clinics had a formal program of counselor support, such as a counseling supervisor or counselor support groups. However, several counselors described how they informally sought out other counselors for support after a particularly bad day. Several counselors requested formalized retreats where they could share their experiences and challenges with other counselors, have an opportunity to be counseled by them, and come up with solutions to common challenges that arose during counseling sessions. Other suggestions included having music playing in the break room to help counselors relax between clients (p.184) 17. Counseling discordant couples

Counseling HIV serodiscordant couples was a challenge discussed commonly by many counselors. This often had to do with a lack of



knowledge among counselors about how HIV discordancy could occur in couples with a long history of having unprotected sex. When clients would ask, "Why is it that I am positive and my husband is negative?" counselors would have a hard time answering to the client's satisfaction. Counselors also felt pressure to prevent the break-up of marriage that sometimes resulted from HIV discordant results, as described below. “Also, the tragedies here.. .we get discordant cases.



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For them it is hard, it is trouble to counsel them because you can find that the woman is positive and the man is negative. To counsel those couples it is really a tug-of-war because you have to be sure to tug that matter very, very carefully so that you cannot confuse those people in their marriage. Because if you don't tug it very carefully, you can confuse them and cause them to divorce from each other.” (Midwife/counselor, rural clinic) (p.185) 18. Ethical about notification

dilemma partner

Counselors also felt stuck in an ethical quandary when one member of a discordant couple refused to disclose his or her status to the other.



They could not force disclosure, but they were unsure of how to proceed (P.185) 19. Training needs to cover sero discordant couples

Counselors also felt stuck in an ethical quandary when one member of a discordant couple refused to disclose his or her status to the other.



They could not force disclosure, but they were unsure of how to proceed. As a result, counselors recommended that they receive further training on how to counsel discordant couples (p.185) 20. Perceived lack of training on specific topics

In addition to a desire for more training how to best counsel HIV discordant couples, counselors identified a number of other areas for



training. The majority of counselors felt they needed more training regarding

long-term

anti-retroviral

treatment

(ART)

programs.

Counselors felt that they had adequate information to provide referrals to treatment programs, but clients often wanted to know information about specific drugs which the counselors did not have adequate knowledge about […………] All counselors emphasized that training should not be a static, one-time event. Instead, they wanted ongoing training and periodic refresher courses in order to keep up with the rapid changes in prevention and treatment sciences (p. 186)



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Njozing BN, Edin KE, Sebastian MS and Hurtig AK. "If the patients decide not to tell what can we do?"- TB/HIV Counselors' dilemma on partner notification for HIV. BMC Int Health Hum Rights. 2011; 11:6. Findings



1. Importance confidentiality

of

Credible

Unsupported

All the participants stated that preserving confidentiality of patients’ HIV result is emphasized during their training, and enforced in their



counseling practice. They revealed that these measures maintain patients’ trust in the health care system, facilitate HIV testing, and ultimately compliance to treatment and care. “A few patients have complained that they have heard their results in the quarters and they did not know how it got there. The authority summoned the staffs who were accused by the patients and they were later sanctioned, and one was dismissed” (Female Counselor, 32 years old) (p.4) “So far we have heard rumors but nobody has come up officially to complain and because of that we have not done anything because we cannot address anybody....You know most of the patients are afraid to come up because they are afraid we might treat them badly after” (Female Counselor, 27 years old) (p.4-5) “Now there is a strategy we have put in place that HIV result of patients is not known to every staff who works in the unit. Only the counselor and nurses in charge of that patient, and the doctor.... When the patient is sent to the lab, the lab test request slips are carried by the counselor and the result is written with codes so that not everybody can understand” (Male Counselor, 33 years old) (p.5) 2. Challenge of partner notification

Encouraging HIV-positive patients to disclose their status, especially to their sexual partners was an important challenge faced by the



participants. “I think from experience this is common with men and it is



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just because of their lifestyle. You know when they have so many women and finally when they become sick.... they will not want to tell their wives... so the ones revealing their status usually follow- up treatment very well. Some will not even use condoms with their wives because they don’t want their wives to know they are HIV-positive” (Female Counselor, 48 years old) (p.5) 3. Respecting patients’ autonomy

“No we cannot do that. That will be against our professional ethics because we are not supposed to disclose a patient’s information without



his consent. If we do that we might run into problems with the authorities [the hospital administration] because they will say we have breached confidentiality.” (Male Counselor, 33 years old) (P.6) 4. Safeguarding patients’ autonomy or protecting partners’ safety?

Although the participants who held this view acknowledged the importance of respecting patients’ autonomy, they felt that it was their



duty to also protect patients’ sexual partners at risk of HIV exposure, and to enable them to seek prompt treatment if already infected. “The law

states

that

we

should

respect

peoples’

privacy

or

confidentiality...but I like to inform the partner because I know from experience that people who refuse to disclose to their partner will infect them.... what if the wife comes tomorrow and is diagnosed positive?... It will be my fault because I did not inform her...” (Male Counselor, 35 years old) (p.6) 5. The role of communication skills and a good counselor-client relationship in supporting disclosure

The participants emphasized that their training and work experience have improved their communication skills and relationship with the



patients immensely. They remarked that if counseling is properly done and much time spent with the patients to gain their trust, the patients would see the need for testing and subsequently informing their partners about their HIV status. “When we started...most of us were inexperienced. We never knew how to present most of the things to



2015;13(12):130-286

most of the patients but with the trainings we take our time to give the best

counseling

to the

patients

so that they will not have

misconceptions...it has made most of the patients to be understanding.” (Male Counselor, 35 years old) (p.6) 6. Strategies to encourage and ensure that patients willingly notify their partners

In contrast to position one where the participants felt that nothing could be done if patients object to notify their partners, the participants in



position two were ingenious at devising strategies to encourage and ensure that patients willingly notify their partners. These strategies included the following: i) couple counseling, although they stated that some men were reluctant to participate, ii) continuous or ongoing counseling of recalcitrant patients, educating them on the benefits of disclosure, iii) seeking consent from the patients to directly inform their partners in the patients’ presence in scenarios where patients lacked the courage to do so personally, and iv) contact tracing, whereby the counselors obtained telephone numbers or physical addresses of patients’ partners and could directly inform them about the possibility of exposure to HIV without releasing the identity of the index patient.(p.6) “One other thing that we have developed is contact tracing where those who are afraid to disclose to their partners we ask them to give us the telephone number of their sexual contact or contacts and we call the partner but we do not release their identity.... The problem here is that if the partner has been faithful, she will definitely know that it is the husband who has infected her and it will cause problems in the house.” (Male Counselor, 41 years old) (p.6)

7. Resort to coercion to support disclosure

They opened that upholding confidentiality in absolute terms was morally wrong, and patients who refused to inform their partners about



their status were selfish by not considering the health and wellbeing of their partners. Although in favor of counselors to directly notify the



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sexual partners of such uncooperative patients, the participants stated that they could not do otherwise because of the legal constraints. To back this position, some participants stated that after all attempts to encourage voluntary disclosure failed; they occasionally ‘threatened’ their patients to make them notify their partners. Although they eventually respected the patients’ autonomy, they claimed this measure was only used as a last resort to encourage voluntary disclosure (p.7). “.... if I try other measures and don’t succeed, I will tell you that if you don’t do it I will do it for you. When you do that many will not want you to be the one to do it. They will rather prefer to do it themselves....it is just a way of getting around because if they resist we will not do it.” (Female Counselor, 48 years old) (p.7) 8. Emotional burden of facing ethical dilemmas

The participants mentioned that in scenarios where patients refused voluntary disclosure, they were constantly in a dilemma between



respecting patients’ confidentiality and disclosing the status to their sexual partners. This was even more disturbing if they were acquainted with the patients’ sexual partners “I think it is different if you know the man is positive but you have never met the wife. In this case [the counselor is acquainted with the wife] the woman came to you. What will you tell? A lie and then she will not trust you because she will discover it later on and it will be worse.... personally I will not sleep well.” (Female Counselor, 33 years old) (p.7)

9. Need for legal protection for health workers to support partner notification

However, they all acknowledged that in order for them to notify noncompliant patients’ sexual partners, the government has to step in



with a policy that legally protects health care providers against litigation. “My proposal is that there should be a law or by law protecting the health professionals in such special cases that they have the right to protect partners for public health benefits.” (Male Counselor, 27 years



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old) (p.7) 10. Addressing HIV/AIDS as any other chronic and treatable disease (normalizing HIV)

This view was most commonly shared by male counselors from faithbased hospitals. They mentioned that during the pre-ART era,



recommending testing for HIV without offering treatment deterred testing. Following the scale-up of free life-time ART to all eligible persons in the country, there is the need to make HIV testing and disclosure

normal

and

routine

processes.

According

to

these

proponents, this measure will benefit many by prolonging peoples’ lives and making them more productive in society.

Although they

acknowledged that such a policy would be difficult to implement, they suggested that it was an initiative worth considering in the not too distant future. “.....because the drugs are available now for free, I don’t see why we should not consider it [routine testing and disclosure of HIV result] as in every other diseases like diabetes, hypertension where people come for check up every time and they also have to take their drugs for life.” (Male Counselor, 33 years old) (p.7)

Kranzer K, Meghji J, Bandason T, Dauya E, Mungofa S, Busza J, Hatzold K, Kidia K, Mujuru H and Ferrand RA. Barriers to Provider-Initiated Testing and Counseling for Children in a High HIV Prevalence Setting: A Mixed Methods Study. PLoS Med. 2014; 11 (5): 9. Findings



1. Confusion about testing guidelines and regulations

Credible

Unsupported

HCWs demonstrated uncertainty about PITC regulations, particularly relating to consent procedures. They expressed confusion about the



age at which a child could choose to test him/herself, what type of caregivers qualified as legal guardians, and whether guardians had to undergo testing themselves first (p.4)



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Very few come with their parents or legal guardians. That’s where we face challenge. You will always need consent. Even if you see a sick child you have to encourage the person who came with the child to get consent. The child stays with the grandmother but comes with the aunt to the clinic. The aunt does not stay there....So that will create problems in cases of follow-ups and adherence. [female head nurse] (p.4) For those whose parents are outside the country, some of them are not getting permission to be tested. We will then feel that our hands are tied. We will not be able to test the child without legal guidance. We will treat the child and ask the caregiver to go and talk to the parents of the child and come back. But they never come back. [female head nurse] (p.4) 2. Concerns about PITC for children

A child is different from an adult because she is vulnerable. I think that is what I can say about counseling a child that it is difficult but we will



now have a [large] workload....So we never have time to sit down with the child so that she really understands and to assess her understanding of what we are doing. We are just testing. [female counselor] (p.4) 3. Lack of time

For those who refuse it’s because of lack of time. They were few counselors to do the testing. The queue might bore them. They will just



slip away. That’s how they refuse most of the time. [female head nurse] (p.5) 4. Lack of space

The other barrier that we have seen is space. You know this



[counseling] requires privacy, [which] we do not have. [male head nurse] (p.4) Knapp H, Hagedorn H and Anaya HD. A five-year self-sustainability analysis of nurse-administered HIV rapid testing in Veterans Affairs primary care. Intl J STD & AIDS. 2014; 25 (12): 837-843.



Findings

2015;13(12):130-286



1. Credibility of benefits

Credible

Unsupported

‘Number one is patients finding out their HIV status, that is the benefit. The ease of getting the result. It’s not invasive. The nurses don’t need a



doctor’s order to test. It’s fast and doesn’t take much staff time. Staff is amenable because it is viewed as an important thing to do. If a patient is positive, appropriate treatment can be started right away’. (p.4) 2. Adaptability of the improvement process

‘They have classes once a year to reteach us. For those of us that don’t do that many tests, the refresher is good. They refresh people’s skills



and make sure the new people know what is going on’. (p.4) ‘When the new RNs and LVNs come on board, they are oriented by their peers and it is incorporated into their interactions with the patients. HIV testing has become a part of the culture’. (p.4) 3. Effectiveness of the system to monitor progress

‘We still get that data (number of tests performed). We use it in staff meetings. We discuss how well or poorly we are doing. We have clinical



reminders in CPRS (computerized patient record system) that tell us when it (HIV test) is due. That reminds everyone to focus on it’. (p.4) 4. Staff involvement and training to sustain the process

‘(Nurse manager) asked everyone about it and talked about and allowed us to talk about it. She did it on an individual basis. I think that



was important. She used informal discussions instead of scheduled meetings. We had informal discussions with her before the training to prepare us for the idea and set the stage for a positive response’. (p.4) 5. Staff attitudes towards sustaining the change

‘I was very excited. I’m very into my patients and I thought this was a good thing to reach more people. I had quite a few people that were



positive doing the blood test. I thought we could find more people’. (p.5)



6. Senior/clinical leadership engagement

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‘They give us the time to complete the class. They excuse us from clinic to attend class. They encourage us to do more like, oh, we reached this



goal, now we have to do more. They were not just supportive but pushing us to do more. They pat us on the back and say good job’. (p.5) 7. Fit with organization’s strategic aims culture

the

‘I think we have a high success rate (with implementation) because we

and

work as a group and once we offer something new and find it to be



successful, we keep it going’. (p.5) ‘We had a team that saw this as being of great benefit to patients. Enthusiasm was high. There was a lot of interest in doing it because it was a good service to the patients’. (p.5)

8. Infrastructure sustainability

for

‘We were given the supplies, the consents, everything. Everything is available’. (p.5)



‘We always have a stock of test kits. We also have a contact person that we can email if we have any problems with supplies or any concerns. It is a high priority’. (p.5) 9. Decreasing enthusiasm

‘The culture of the VA is that we have the disease of the month, things that are of special interest and focus. HIV screening had its heyday and



now it’s on maintenance so nobody gets too excited about it’. (p.6) 10. Staff time

The staff who reported this decreasing enthusiasm attributed it to leadership changes. They did not feel that HIV RT was as high of a



priority for new leadership as indicated by less frequent sharing of the testing data. They also felt that staff time was becoming more of a barrier because of staff shortages and new tasks being continually added to primary care nurse workload. (p.6)



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Knapp H, Hagedorn H and Anaya HD. HIV rapid testing in a Veterans Affairs hospital ED setting: a 5-year sustainability evaluation. Am J Emerg Med. 2014; 32 (8): 878-883. Findings



1. Credibility of benefits

Credible

Unsupported

“Treatment is essential. Lack of treatment leads to death. Also, they could be spreading to others and it’s not like you can tell (that they’re



positive) by looking at them. Nobody here told me any of this, it’s just what I knew and already believed.” (p.880) “It’s good to be able to give a quick test if the patient is worried about something they did that might have put them at risk or if the patient knows that they’re at risk. It’s good because you can just swipe their mouth and let them know in 20 minutes and then talk to them about making some good decisions to help keep themselves healthy.” (p.880) 2. Adaptability of the improvement process

“We haven’t been doing it, it just slowed down, then stopped.” (p.880) “Nobody’s training new staff, staff training stopped about 2-3 months



ago.” (p.880) “The champion MD just recently departed so the staff is unsure if HIV RT is supposed to continue or not. (Training in place?) Yes, but I’m not sure how that works.” (p.880) 3. Effectiveness of the system to monitor progress

“Occasionally, there’s a monthly report on the bulletin board, but it’s not there very reliably.” (p.880)



“There was one meeting with a graph. It would have been good to see outcomes more regularly to let us know if what we’re doing is really working.” (p.880) 4. Staff involvement and training to sustain the

“No, they just gave it to us, they never asked us. It’s just the RNs’ responsibility to do 5 tests per day. The charge RN just gave out the


JBI Database of Systematic Reviews & Implementation Reports process

2015;13(12):130-286

test to us and we knew we had to do one each per shift so we just did



it.” (p.880) “Nothing, just the training on how to do the HIV RT. We needed practice proposing HIV testing. It’s odd for the RN to do it, we weren’t sure why we were doing it so what should I tell the patient?” (p.880) 5. Staff attitudes toward sustaining the change

“At the start it looked like extra work. It was okay when things are slow but it’s hard to do 5 a day to keep the doctor away (referring to 5 per



day quota). Now, it’s the same but we got used to it. It’s easy now, patients get excited about getting an HIV RT, they’re very enthusiastic about the test.” (p.880) “It was annoying at first, just an additional task to do. Also, the HIV RT was introduced at the same time as the rapid triponen test, but we got over it. Now we see the importance of HIV testing, so the attitude’s better. This just had to be done. It’s not an option, the supervisor said do it so we just made it happen. Over time, we got used to it.” (p.880)

6. Senior leadership engagement

“Executive

administration

did

not

express

any

opinion

or

encouragement one way or the other.” (p.880)



“No, we never even heard them talking about it, they’re still silent on this.” (p.880) “I don’t recall seeing or feeling that. Only the people in the ER were encouraging, upper management never got involved with this. We just never heard anything from them.” (p.880) 7. Clinical leadership engagement

“Yes, my manager at the time had to roll it out so he had a vested interest, but his attitude was not really contagious. We just did what he



said.” (p.880) “Yes, especially the lab, they’re very supportive. The lab made it



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important, accessible, easy to do, and emphasized cost effectiveness.” (p.880) “The new RN manager hardly ever mentions it. It’s not his baby, he wasn’t here when it got started, he’s only been here for about a year. He’s got other things to do.” (p.880) 8. Fit with organization’s strategic aims and culture

“It’s a high priority because lots of patients are substance abusers or sexually active or might be embarrassed to go to a clinic for an STD



test.” (p.880) “HIV RT is more successful than most others (other implementation efforts) because it’s easy to do when time is available. The problem is that when things are slow, there’s few patients to test and when things are very busy, we don’t have time to test anyone.” (p.880-881)

9. Infrastructure sustainability

for

“You have to call the lab for them to bring the tests. Depends on when the lab brings them. They’re slow to respond and we don’t call them fast



enough so it’s possible to just run low or run out. We used to take a look at how many were left every Friday and if it was low then we’d just call for a resupply but now nobody cares.” (p.881) “The charge RN used to hand out tests at the start of the shift and that doesn’t happen anymore. We check the crash-carts daily but the HIV RT checklist is gone. The HIV RT is only a day shift thing, but with low staffing and low priority for HIV RT, it just feel off.” (p.881)



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Solomon JL, Bokhour BG, Butler J, Golden JF, Hare K, Kertz B, Kan V, Rodriguez-Barradas M, Knapp H and Anaya HD. Sustaining Nurse-Rapid HIV Testing in the U.S. Department of Veterans Affairs: Lessons Learned from a Comparative Evaluation. J Healthcare Qual. 2014; 36 (5): 26-31. Findings



1. Additional burden

Credible

Unsupported

[NRT] really adds to the burden of the nurses’ schedule: I am willing to participate in a study, but not have it carry out long-term because it



blows the schedules out of the water. It takes a lot of time talking to a patient, maintaining, meeting, and reproducing the laboratory regulation requirements. Nursing takes on the burdens of the world: we just do what everybody wants.(p.28) 2. NRT is manageable

In process and summative interviews, however, participants reported that having added NRT to their responsibilities did not present the



workload and scheduling challenges predicted in baseline interviews. Moreover, participants characterized adopting NRT in quite positive terms. For example, one nurse said, [NRT] has been a great success and a slam dunk.(p.28) But it’s [NRT] been manageable. Nurses can do the test and then go on to the next patient while keeping in the back of your mind that a test is “cooking.” The time issue is not as big as I had thought. We initially thought that we couldn’t see another patient during those 20 minutes, but that has not been the case. (p.28) 3. Logistics implementation

of

I don’t use the suggested note that was provided for us to use. I think it takes too many steps to use that note. I instead make an entry into my



note that the test was negative and that the results were delivered . . . . I started out using the note like I was shown in NRT training] but then decided that didn’t work out and did it my own way.(p.28) If I start an HIV test just as the patient is going to see the doctor, I know



2015;13(12):130-286

that when I go in to put the note, the reminder will come up and [the doctor] will be putting in orders at the same time . . . . Sometimes [HIV] tests don’t get entered properly because there is a conflict when someone else is accessing the patient record at the same time that I am. (p.29) In response to this challenge, nurses developed their own strategies for documenting results and alerting providers of them. A nurse explained: I don’t know what had happened, but at one point I just started calling them [providers]. I just started calling the provider so they can deliver the results when the patient is here. (p.29) 4. Longer sustainability

term

Largely, she [research assistant] oversaw the operations: she made sure we had the [testing] kits; if we haven’t recorded the results in the



computer, she would pick up on that; she is the go-to person for initial questions . . . . I don’t think there will be [nurse] enthusiasm to take on additional tasks that are not related to nursing. These roles need to go to other departments. (p.29) 5. Structural changes to patient care

Now that we have extra triaging [e.g., drawing blood], I have to skip over the [HIV] test. I only offer the test when the patient expresses



concern with his [HIV] status, or if the doctor requests it. Otherwise, I will skip it. (p.29) Furthermore, nurses said that in some cases health technicians had taken over many of the triage responsibilities performed previously by nurses. As a consequence, nurses did not have opportunities to offer NRT to patients. A nurse noted: The new model [PACT] stands in the way of NRT from continuing because we now have health techs seeing the patients first . . . . we’ll need to change NRT to fit this new model. (p.29)



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Kwapong GD, Boateng D, Agyei-Baffour P and Addy EA. Health service barriers to HIV testing and counseling among pregnant women attending Antenatal Clinic; a cross-sectional study. BMC Health Serv Res. 2014; 14 10. Findings



1. Forcing the test

Credible

Unsupported

Some health workers also disclosed that sometimes the use of force becomes the only alternative strategy to get everybody tested.(p.4)



We spot some of them when they are about to deliver. We test them, admittedly,

sometimes

without

their

knowledge”

(Midwife,

Key

informant, health facility in Kumasi). (p.4) “Those who are adamant or so difficult are those who listen to other people and they discourage them from testing, so those are the people we try our possible best to encourage and if they insist they won’t do it, then we either use force or do it without their knowledge (Key informant interviews, health facility in Kumasi). (p.4) 2. Testing consent

without

They explained that some pregnant women after Counseling still refuse to go for HIV testing so they compulsorily do the test for them. We spot



some of them when they are about to deliver. We test them, admittedly, sometimes without their knowledge” (Midwife, Key informant, health facility in Kumasi). (p.4) 3. Privacy confidentiality

and

The issue of privacy at HTC center was buttressed by a health worker during the key informant interviews. She disclosed that some pregnant



women refuse to take the test because they feel someone may get to hear or know their status. (p.5) “Some refused the test because they say the room has not adequate privacy. They believe if they are positive, people will notice and they will be stigmatized” (midwife, key informant interview, health facility in



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Kumasi). (p.5) “The place we are working is not very good. Some patients upon seeing people around the counseling room refuse to enter the room. ….. People even sometimes hear us telling patients they are positive, and that deter others from coming” (HIV counselor, key informant interview health facility in Kumasi). (p.5) 4. Clinic logistics

In most of the facilities visited, HIV education and counseling was done for pregnant women once during ANC days and was done early in the



morning. Those who come in later were most likely to miss the counseling session and therefore will not understand the need to go for HTC. A health worker from one facility disclosed; (p.5-6) “I normally do the counseling for them once; early in the morning when I come to the facility, then I go and sit down and wait for those who will come so I do the testing for them” (HIV counselor, key informant, health facility in Kumasi). (p.6) 5. Shortage of working materials

Some of the challenges cited include inadequate working space, shortage of working materials, lack of motivation and inappropriate



siting of the counseling unit. (p.6) A health worker disclosed: “We are normally short of OraQuick, which we use as a confirmatory test. At times we ask patients to go and come because we have to send their blood samples to the reference laboratory at Komfo Anokye Teaching Hospital and many go and do not come back” (HIV Counselor, key informant interview, health facility in Kumasi). (p.6) 6. Inadequate space

working

“The place we are working is not good enough. It is too small and we can’t even accommodate two people here. We normally ask them to





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wait outside which they are not comfortable of. Some of them will leave when you ask them to sit outside” (health staff, key informant interview, health facility in Kumasi). (p.6)

Vernooij E and Hardon A. 'What mother wouldn't want to save her baby?' HIV testing and counseling practices in a rural Ugandan antenatal clinic. Cult Health Sex. 2013; 15 S553-566. Findings



1. Testing is compulsory

2. The role counseling

of

According to Ann, a midwife who had been working at the clinic since 2004, testing was compulsory: It is a routine, RCT: we make sure that we test each and every mother. .... We are sorry, but the programmes have been [announced] on the radio. All mothers should test. (Midwife, Ann) (p.561) The midwives argued that in order for them to be able to carry out their

Credible

Unsupported





duties of convincing women to take the nevirapine tablet and to choose a feeding option, it was a prerequisite that women be tested and accept their results. The following quotation from Sara illustrates this: I am supposed to counsel that lady, until she accepts to test. Then it is upon her to refuse the results.

But again for me as a midwife it is my

obligation to convince that mother to accept the results. She is supposed to choose a feeding option. She is supposed to accept nevirapine. How will I do this unless I re-counsel her to convince accept the results? Because my target is to have a live baby. To try and prevent transmission. (Midwife, Sara). (p.561) 3. Testing mothers is important for the protection of midwives and the baby

For the midwives, protecting the child from HIV was their main goal — to protect unborn babies, all pregnant mothers should be tested. Hence



the moral imperative dictated primacy of the child's health. Additionally, the midwives wanted to be able to protect themselves when assisting at



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an HIV-positive mother's delivery, for example by wearing two pairs of gloves. In order for them to provide good care, midwives thus saw testing as essential. (p.561) It is important to know the HIV status. .... This is important for our own protection and to follow the protocol of PMTCT; to save the baby. 4. Inability to convince women to disclose 5. High workload and understaffing affecting post-test counseling 6. Frustration – inability to reach male partners

(Midwife, Ann). (p.561) The midwives and post-test counselors at the antenatal clinic expressed frustrations about their inability to convince women to disclose their status to their husbands and of the necessity to come back to deliver in the clinic and take nevirapine (p.562)



They argued that because of high workload and understaffing, there was little time to provide sufficient personal post-test counseling in the



clinic. (p.562) Counselors and midwives were exasperated because they were not



reaching men through PMTCT and women were unable to convince their partners to come for testing. (p.562) We tell them, you go and disclose and tell the husband to use a condom. We are not there to follow condom use. When they come back to the ART clinic, we are always asking them: do you have protected use? Most of them tell us they use a condom. Then eventually we discover some of them are pregnant. after condom, condom, condom! After abstinence abstinence abstinence. We give information. And it is upon them to deceive us every time they are coming. (Midwife, Ann). (p.562)



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Appendix VIII: JBI Grades of Recommendation

JBI Grades of Recommendation

A ‘strong’ recommendation for a certain health management strategy where:

Grade A

1. 2. 3. 4.

it is clear that desirable effects outweigh undesirable effects of the strategy; where there is evidence of adequate quality supporting its use; there is a benefit or no impact on resource use, and values, preferences and the patient experience have been taken into account.

A ‘weak’ recommendation for a certain health management strategy where:

Grade B

1. 2. 3. 4.

desirable effects appear to outweigh undesirable effects of the strategy, although this is not as clear; where there is evidence supporting its use, although this may not be of high quality; there is a benefit, no impact or minimal impact on resource use, and values, preferences and the patient experience may or may not have been taken into account.


The experiences of midwives and nurses collaborating to provide birthing care: a systematic review.

The views and experiences of smokers who quit smoking unassisted. A systematic review of the qualitative evidence.

Nurses' experiences of ethical preparedness for public health emergencies and healthcare disasters: a systematic review of qualitative evidence.

A qualitative study of the allergy testing experiences, views and preferences of adult patients.

Midwives' experiences and views of giving postpartum contraceptive advice and providing long-acting reversible contraception: a qualitative study.

Testing for HIV in the antenatal clinic: the views of midwives.

Nurses' views regarding implementing advance care planning for older people: a systematic review and synthesis of qualitative studies.

Nurses' perceptions and experiences of work role transitions: a mixed methods systematic review of the literature.

Identification of Delivery Models for the Provision of Predictive Genetic Testing in Europe: Protocol for a Multicentre Qualitative Study and a Systematic Review of the Literature.

Rural Doctors' Views on and Experiences with Evidence-Based Medicine: The FrEEDoM Qualitative Study.

Older persons' experiences and perspectives of receiving social care: a systematic review of the qualitative literature.

Does involving volunteers in the provision of palliative care make a difference to patient and family wellbeing? A systematic review of quantitative and qualitative evidence.

Nurses' views and experiences of caring for malnourished patients in surgical settings in Saudi Arabia - a qualitative study.

Experiences of Self-Management Support Following a Stroke: A Meta-Review of Qualitative Systematic Reviews.

Genomic counseling in the newborn period: experiences and views of genetic counselors.

Adult women's experiences of urinary incontinence: a systematic review of qualitative evidence protocol.

Parents' and informal caregivers' views and experiences of communication about routine childhood vaccination: a synthesis of qualitative evidence.

Student and educator experiences of maternal-child simulation-based learning: a systematic review of qualitative evidence protocol.

Patient experiences of depression and anxiety with chronic disease: a systematic review and qualitative meta-synthesis.

In-hospital experiences of families of potential organ donors: A systematic review and qualitative synthesis.

Barriers and enablers in primary care clinicians' management of osteoarthritis: protocol for a systematic review and qualitative evidence synthesis.

How do older people describe their sensory experiences of the natural world? A systematic review of the qualitative evidence.

Contextualizing the findings of a systematic review on patient and carer experiences of dementia diagnosis and treatment: a qualitative study.

Evaluating the CDC program for HIV counseling and testing.