Perspectives from the frontline: Nurses’ experiences of adolescent engagement in sexual and reproductive health services

Abstract

Background:

Nurses have a critical role to play in the delivery of sexual and reproductive health (SRH) services to adolescents and young people. Nurses’ interactions with adolescents and young people can shape sexual and reproductive behaviours and outcomes, including willingness to access and engage with healthcare services. However, little research from low- and middle-income contexts has explored nurses’ firsthand perspectives regarding their relationships with adolescents and young people in the context of SRH service provision, especially since the COVID-19 pandemic.

Aim:

This study explored nurses’ perceptions of working with adolescents and young people as well as how these impressions manifest in one-on-one exchanges between nurses and young patients.

Method:

Semi-structured interviews were conducted with 20 nurses providing SRH services to adolescents and young people and based at public health facilities in urban, peri-urban and rural areas within a health sub-district of the Eastern Cape province of South Africa. Data were analysed using an inductive thematic approach.

Results:

While many nurses described the challenges facing adolescents and young people in an empathic way and expressed a desire and willingness to engage with and educate them, some found it ‘difficult to break through’. Nurses linked this difficulty to the shame adolescents and young people feel when discussing SRH concerns, but also to them having ‘attitude’ and ‘not listening’. Findings highlight how while nurses may genuinely care about providing services to their young patients, internal and social biases may impact their motivation and willingness to effectively support adolescents and young people within the context of SRH service provision. To improve patient–provider relations, we suggest a focus on practical and participatory interventions to improve interpersonal dynamics.

Introduction

Addressing adolescent and young peoples’ sexual and reproductive health (SRH) needs is critical to supporting a healthy transition into adulthood. However, adolescents and young people tend to under-utilise available SRH services, especially in sub-Saharan Africa, which has some of the highest rates of adolescent pregnancy and HIV in the world (Jonas et al., 2018). Evidence has highlighted core structural barriers to healthcare access, such as insufficient transport options or lack of funds (Melesse et al., 2020), as well as interpersonal barriers that deter care-seeking for SRH at a pivotal life stage (Jonas et al., 2018). South Africa’s National Department of Health has prioritised policies to promote Adolescent and Youth-Friendly Health Services (AYFHS); however, most healthcare facilities do not meet the minimum criteria for youth-friendly service provision (James et al., 2018).

Healthcare providers are key to supporting the SRH needs of adolescents and young people, especially in the context of providing high-quality AYFHS. However, relationships between young patients and healthcare providers are often complicated. Adolescents and young people may be deterred from seeking care, or staying retained in care, after experiencing or even hearing about the negative behaviours and attitudes of healthcare providers (Jonas et al., 2018). Specifically, research has shown that judgemental, scolding and unfriendly treatment from healthcare providers discourage adolescents and young people from seeking SRH and HIV-related services and attending clinic appointments (Jonas et al., 2017, 2018, 2019; Muller et al., 2018). Conversely, engagements with healthcare providers that are kind and respectful are associated with higher predicted probabilities of antiretroviral therapy (ART) adherence, clinic attendance and viral suppression (Toska et al., 2024). While healthcare providers may be motivated to meet the needs of adolescents and young people, their provision of services to and interactions with their young patients may conflict with their own personal beliefs, morals and values, as well as broader societal norms (Jonas et al., 2017; Muller et al., 2018).

In the South African public healthcare system, which is largely characterised by high demand and limited capacity, nurses are usually responsible for providing SRH services to adolescents and young people, which may encompass health promotion, education and counselling (Jonas et al., 2017; Muller et al., 2018). In this context, youth-friendly service provision is essential in overcoming communication challenges and enabling nurses to interact with their young clients in a more personal manner (Alli et al., 2012). While context-specific challenges in healthcare are important to consider, the role of interpersonal relationships in shaping healthcare outcomes is also critical.

Research and theory suggest that individual behaviours within interpersonal interactions are influenced by perceptions of the self, others and the context in which the interaction occurs (Bylund et al., 2012). Patient experiences are shaped by various factors, including their perceptions of provider expertise, trust and perceived judgement (Jonas et al., 2018). High-quality patient–provider communication is pivotal to foster a supportive and conducive healthcare environment, wherein patients feel comfortable expressing their needs and concerns (Bylund et al., 2012). On the other hand, language barriers, cultural differences and power differentials between patients and providers can hinder effective interpersonal communication and impede patients’ ability to fully engage in their healthcare interactions (Camara et al., 2020). Moreover, patients may experience fear of judgement, embarrassment or stigma when discussing sensitive topics, further exacerbating communication challenges (Jonas et al., 2019).

Premised on the understanding of healthcare as not merely a transactional exchange of education and services, but a deeply interpersonal process (Chichirez and Purcărea, 2018), this study sought to explore firsthand the perspectives, experiences and strategies of nurses working with adolescents and young people in public health facilities of the Eastern Cape province of South Africa. The focus in the study was twofold: first, to understand nurses’ perceptions of working with adolescents and young people (including perceptions relating to the COVID-19 pandemic ¹ ); and second, to explore how these impressions manifest in one-on-one exchanges between nurses and young patients. The study investigated nurses’ perspectives on which factors shape their relationships with adolescents to identify where they see gaps and opportunities – a frequently overlooked insight within patient–provider exchange. An interpersonal lens (Camara et al., 2020) on nurses’ views was adopted regarding the complex motivations for care-seeking and narratives of adolescent behaviour, with an overarching aim to better understand patient–provider interactions through in-depth qualitative engagement, and then use the findings to consider how to improve these interactions.

Methods

Study design and participants

We adopted an exploratory qualitative approach (Creswell, 2013), foregrounding the experiences of nurses (n = 20) providing SRH services to adolescents and young people, at public health facilities ² in urban, peri-urban and rural areas within a health sub-district of the Eastern Cape province of South Africa. Nurses were recruited through existing networks the research team had in the district as well as via snowball sampling. In 2020, the research team interviewed n = 13 nurses in the district about their experiences providing services during the height of the COVID-19 pandemic, some of whom provided services to adolescents and young people specifically (n = 6) (see Kelly et al., 2021, for the findings of this study). Our research team contacted these same nurses for the current study, via telephone and in-person visits to their facilities, to invite them to participate in this study (n = 4 agreed). During these engagements, they were also asked to provide the contact details of other nurses offering services to adolescents and young people, which resulted in an additional n = 16 who agreed to participate in the study (final sample n = 20). In line with the inclusion criteria of this study, all nurses were involved in providing SRH services to adolescents and young people, including family planning, maternal care and HIV-related services.

Data collection and analysis

Semi-structured, face-to-face interviews were used to collect data. Open-ended questions were asked to provide participants with an opportunity to talk without feeling limited (Flick, 2013). Adopting a consultative process, an interview guide was developed by members of the research team. ³ The guide focused on nurses’ views on and experiences of SRH service provision for adolescents and young people, with particular emphasis on (1) challenges they may have experienced in relation to delivering these services (both in relation to the COVID-19 pandemic and in general); (2) strategies they used to overcome potential challenges and meet the needs of their young patients; and (3) questions relating to their views on adolescents and young people and how they might experience service delivery.

Interviews took place in a private venue at the nurses’ workplaces and were conducted in isiXhosa and English by members of the research team, including two graduate students who all received training on qualitative research and semi-structured interviewing. Interviewers completed reflection forms after each interview and the team met regularly for debriefing sessions. During these sessions, the team regularly discussed preliminary insights from the interviews and after 20 interviews concurred that data saturation had been reached as common themes and complementary perspectives had been identified. Audio recordings of the interviews were transcribed and translated into English by bilingual members of the research team as well as an external transcription company (all transcribers signed a confidentiality agreement). Each participant and health facility was de-identified from transcripts and assigned a serial number to ensure anonymity.

Data were analysed with the aid of NVivo software (Version 11) using a thematic inductive approach (Braun and Clarke, 2006: 16–22). The initial analysis was conducted by the two graduate students in collaboration with two senior researchers in the team. Analysts first familiarised themselves with the data through repeated readings of the transcripts. Next, initial codes were generated based on all the data. Third, these codes were translated into categories, with codes that did not have enough supporting data, or which did not speak to the aims of the study being discarded. Then, these categories were grouped to form themes, followed by reviewing and refining themes (Braun and Clarke, 2006).

To ensure trustworthiness in the study, regular debriefing meetings were held during data collection and transcription to resolve queries that arose and ensure consistency across interviews and transcriptions. In addition, regular consultations during data analysis were held to discuss and confirm initial interpretations of the data (Levitt et al., 2017). In particular, two senior researchers explored the refined themes in more depth and consulted with the data collection team before finalising and defining them (Braun and Clarke, 2006).

This study received ethical approval from the research ethics committees at the Universities of Cape Town (Clearance No. 226/2017) and Oxford (Clearance No. R48876/RE003) and followed the principles of informed consent, confidentiality and voluntary participation (Willig, 2008). Before interviews began, nurses were provided with an information sheet and consent form (in both English and isiXhosa, depending on their preferred language) which they needed to sign before proceeding with interviews. The consent form explained that the information provided in the interviews would be confidential and that there would be no way of identifying them when findings are reported; that data collected would be stored on secure, password-protected and encrypted databases; and that their participation was voluntary and choosing not to participate would not have any negative impact on them or their work.

Findings

Across three thematic areas, findings provided insight into nurses’ perceptions of how adolescents and young people engage with SRH services, barriers and facilitators to effective interpersonal relationships, and the complexities involved in patient–provider interactions. The nurses consisted of 16 women and 4 men. Most (n = 17) were based at primary healthcare clinics (2 in urban areas, 5 in rural areas and 10 in township areas), with 3 nurses based at community health centres (all in township areas). Eighteen were professional nurses while two were operational managers at the facilities.

Working with adolescents

Certain patterns of compassionate care emerged in the data, some specific to extenuating circumstances such as the COVID-19 pandemic.

Acknowledging adolescents

The data obtained from nurses highlighted an acknowledgement of the stress that adolescents and young people often grapple with in healthcare settings:

Since you would be working with adolescents, sometimes you need to sit them down and talk to them, plead with them sometimes because you would notice others have anger [because] of [their] sickness. (A038)

In reflecting on challenges delivering services to adolescents and young people, one nurse noted:

There was no relationship. That’s what made things difficult. There was no relationship between us. (A049)

This suggests that the lack of a meaningful connection can exacerbate the uncertainty that young people may experience when seeking healthcare. Another nurse highlighted fear specific to contracting COVID-19, stating:

They were coming even though they were not coming on the appointment dates because people were not coming on their dates and they would say ‘I was afraid, I was afraid of [COVID-19] . . . That was one of the challenges’. (A038)

Also related to the pandemic, nurses recognised the far-reaching impact of stress, especially concerning the loss of loved ones. As one nurse shared,

It was a stressful situation because they were losing parents. Losing people close to them. They didn’t know what to do, so I think it was painful. (A039)

Understanding adolescents’ and young peoples’ perspectives

Nurses expressed admiration for the fortitude adolescents and young people exhibited despite the challenges COVID-19 presented:

Maybe it was annoying for them because we had our way doing things and they were already familiar with the old way, so maybe the change was very difficult and hard to adapt to these new changes. They knew that when they come to collect, they don’t wait this long, so the change was very irritating. (A031)

Some nurses refrained from judgement overall and commended adolescents and young people for their conscientiousness, acknowledging the unique perspectives of adolescents and understanding the complexities of their lives:

I wouldn’t say that it’s their fault and judge them maybe by saying that they were careless. (A036)

Nurses also acknowledged adolescents’ and young people’s resourcefulness, saying that ‘some of them did not belong in this clinic, but they were here’ (A038). The nurses were likewise inspired by adolescents’ dedication to their treatment, saying things like, ‘I think she was a strong child’, even in challenging circumstances (A035).

Challenges working with adolescents

Nurses shared perceptions linked to adolescents’ and young people’s maturity, particularly identifying their perceived lack of patience and respect in interpersonal communication:

That age is impatient . . . adolescents don’t want to wait in lines. (A039)

Nurses described how they believed this ‘impatience’ could pose a particular challenge in relation to HIV treatment adherence:

We have that challenge with the youth that when it comes to their treatment there are very few that are honest or those who take their treatment . . . I think I could say that one of the [reasons] that the clinics get full is because the youth [are] not patient or [willing to] wait. (A040)

Patient–provider dialogue also emerged as a key interpersonal barrier to effective engagement with adolescents and young people regarding HIV:

If we talk [directly to them], then we prevent them from engaging in the activities that would lead them to coming here and taking treatment for HIV. (A030)

These impressions underscore the complex dynamics that exist between providers and patients, shedding light on the intersection between long waiting times and the perceived impatience of adolescents. Nurses also spoke about the perceived dishonesty of adolescents within healthcare settings:

I am trying to give you a picture about the adolescents, sometimes they lie and sometimes they tell the truth, you see. (A035)

This potential dishonesty added an element of unpredictability to nurse–patient interactions and could contribute to the broader perception of adolescent ‘immaturity’. The issue of HIV treatment adherence also surfaced again here, with one nurse noting,

They don’t listen . . . they don’t come on their appointment dates even when you tell them to come on their dates. (A038)

In addition, nurses described how adolescents could become reticent when faced with different healthcare providers:

Adolescents become introverts about this and say I am not going to repeat my story to someone else, instead I will go back and come again when my usual nurse is around. (A031)

Nurses also recounted instances in which they felt adolescent patients exhibited challenging behaviours in clinical settings:

They are self-centred, they don’t care about anything else or anyone else . . . so you must always be friendly so that you can get through them . . . otherwise if you want to use ‘no’, it becomes difficult. (A047)

Nurses also described how gender differences could create additional challenges when working with young adolescents:

But boys they do listen . . . you’d find out they listening, they asking. But the girls, they don’t engage, they just look at you talking, they be shy in that moment. (A030)

While not common to all nurses, some shared examples of interactions with adolescents which appear to be quite judgemental. In recounting an interaction which she had with an adolescent mother, one nurse shared:

But I say to her, ‘No, hold on because after all . . . you have sinned so understand your mother when she is angry . . . when the baby is here, she will buy milk for you, you see because you are learning, you don’t have money, at the end where would you get it? At the end, it’s your mother that you are putting into trouble whereas you are a problem . . . because the boyfriend is young as well, he will want to do his own things and he’s not working, he’s schooling’. (A033)

Societal stigma

Given the challenges that nurses may encounter when working with adolescents, it is useful to examine insights from the data that elucidate how nurses understand stigma in the context of adolescents’ and young peoples’ healthcare-seeking behaviour.

HIV denial

In South Africa, HIV denial and its associated stigma continue to have substantial repercussions for adolescents’ and young peoples’ health. One nurse shared a case that illuminates this issue:

I had a client, not so long ago, she tested positive, said she was not ready. I think three months back, she was here a week ago, presenting with STI, and I tried to tell her it won’t really go away if you’re not taking your meds, but still she was not ready to take it. It’s always there. The stigma has been there for quite a time. (A030)

Adolescents and young people often grapple with the confusion and stigma that surrounds HIV. As another nurse explained,

The problems we have are those that were born with HIV and then now, HIV was stigmatised with sex, so [. . .] She does not understand, ‘Why am I taking this medication?’ So, they have anger, are in denial, and end up defaulting on the treatment. (A039)

These fears and misconceptions can contribute to a reluctance to undergo HIV testing, as one provider notes:

I mean the challenge that we have is that people, children don’t want, children don’t want to test for HIV, and you would find out that they know their statuses – they don’t know their statuses, but they have a fear of the unknown. (A036)

This suggests that the stigma around the link between HIV and sexual behaviour can lead to emotions such as anger and denial, ultimately resulting in non-adherence to treatment regimens. In addition, concerns about disclosure in both personal and professional relationships were prevalent; for instance, adolescents and young people may be reluctant to take treatment when their partners are present, fearing abandonment:

It’s difficult to take the treatment when they are with their partner because they don’t want them to see. They can’t disclose to their partner because they are scared they’ll leave. (A039)

Even when adolescents are in receipt of antiretroviral treatment, disclosure can remain complex, potentially impeding consistent treatment adherence:

What did not work for us properly is that some of the children did not disclose, so even if you would follow up with them, you have to be careful on what you are going to say or how you are going to put it and what will be the reason you have been looking for her. (A042)

These challenges can lead to adverse outcomes, such as unintended pregnancy and substance use:

The challenges would be them getting pregnant and not wanting to take treatment, you see. And to, and now what they are doing is they . . . most of them are using drugs. (A043)

Feelings of shame

Feelings of shame among adolescents and young people can have implications for their interactions with healthcare providers, as well as relationships within their families and communities. One nurse described the discomfort she saw in her patients:

That was the challenge because they get uncomfortable because of having to start again to say I came for this and that and I was told to come back, and I have talked about this before. (A031)

The COVID-19 pandemic exacerbated the existing fear of being identified as someone seeking specific SRH services, which is particularly distressing for adolescents and has the potential to lead to avoidance and reduced utilisation of healthcare services. As another nurse pointed out,

I think adolescents, cause when I talk with them most of them, they don’t want to be seen when they come in collection for meds. So, they like to hide, so that was very exposing for them. Cause now they need to sit, and we will see those that are here for medication-please be seated on this side, and now they could be easily identified what they have, and it made them not come as much at all. (A030)

Social stigma could extend to issues related to dating and sexual health, as adolescents and young people may fear judgement and disclosure to their peers or neighbours, further complicating their healthcare experiences:

The 15-year-old had an attitude when it comes to prevention because of the remarks from people saying that ‘She is dating’. So, [she is] scared to be seen by the neighbour and the neighbour would tell the girl’s mother that she saw her at the clinic preventing. (A040)

Ultimately, external factors such as shame and stigma not only impede open communication with healthcare providers but also limit the support adolescents and young people receive from their families and communities, potentially hindering their overall well-being:

You see, and then again you find that our society . . . I don’t know how we were created, there are very few people who accept a child who has some illness especially around HIV and teenage pregnancy. You find that now another one may say ‘No, I’ll tell my mom, or I will come with her on my next visit’. They aren’t receiving that support we are expecting. So, you find the child is not doing well because of that. (A030)

Defensive responses

When working with adolescents, healthcare providers often described finding themselves in situations where they must engage in honest, sometimes vulnerable conversations:

Maybe they tested [for HIV] before even having a boyfriend or girlfriend, they got it from their mothers, and you would find that others don’t accept the situation. But we would try to talk to them. (A038)

Such conversations were not always straightforward; responses could vary from acceptance to resistance and anger, as adolescents grapple with the stigma that surrounds their health condition. Providers have to navigate these delicate situations. As another provider mentioned,

Then we would tell the child that what happened is this and that and that. Then the response can be good, or it can be bad because the other ones have that denial and anger. (A044)

While nurses may strive to educate and support adolescents, the enduring stigma can hinder progress, making it challenging to break through. Nonetheless, healthcare providers are cognisant that adolescents may respond defensively due to shame and societal pressure:

So, I think the stigma is still there [. . .] that’s the only problem cause when I asked her, ‘are you still practising unsafe sex?’ She said yes. So, I’m telling her that you are putting the other person at risk. So, you try to educate, but you find it’s difficult to break through them. (A030)

Interactions such as these highlight the complexity of working with adolescents and young people, who may have to grapple with shame, denial and the need to protect themselves from social judgement by others.

Opportunities for growth

Despite the stigma surrounding engagement with SRH services, nurses identified various strategies and opportunities for enhancing these services for adolescents and young people in the Eastern Cape. Several nurses described the potential of technology to reach adolescents, in particular during times of crises such as the COVID-19 pandemic:

I think we would improve by having technology, Wi-Fi so that they can be able to receive information about the prevention of STIs and about general health. (A039)

It should be a voice note like ‘Sister, you are this far along [in your pregnancy], and you should expect this and that and that, since you have these number of months it’s normal’. (A049)

Others emphasised the importance of education and outreach activities:

I would encourage education and equip them with things they need like as we do so that when you are in university, we support them so that the ones who are in schools can stay in school. (A042)

Other nurses underscored the importance of adopting a non-judgemental approach towards youth-focused programming and planning:

What is important is to be friendly and not judge them because as elders we are judgemental [. . .] They want people like that if you notice them. (A035)

For me, I wish that if there can be openings like a youth day in the clinic each week, they would benefit much more. (A036)

At a systems-level, nurses advocated for a more cross-sectoral approach to healthcare, with one provider emphasising the need to establish better links with schools:

If we were to have services that we link . . . our services should include the school as well, find out what are their challenges that the teachers are facing at school so that when they go to the health facility, the health facility [will understand]. (A041)

Recognising the gravity of these barriers, nurses emphasised the importance of sensitive education and creating safe spaces for adolescents and young people to discuss their concerns, aiming to dismantle the persistent stigma surrounding HIV and enhance healthcare outcomes for members of this often vulnerable population:

Those that are under ART, firstly you do education, you try to find the reason why the other one defaulted and they would say they were staying on another place and now they are staying with their aunt, and they didn’t want to, because they didn’t disclose their [status], even the boyfriend is not the ordinary boyfriend. So, it’s not like for example when I get into a new relationship it’s my routine of knocking ‘Like no, I’m taking ART’. Yes, it’s nice and good, but there are stigmas that are involved. (A044)

Discussion

Findings from this study highlight the complex interpersonal dynamics that exist between nurses and their young patients. On one hand, nurses may display a willingness to engage with and educate adolescents and young people, indicating that they are cognisant of the challenges that they face in engaging with SRH services. Nurses may also recognise the kinds of changes that need to be made in healthcare settings to meet adolescents’ and young people’s needs. On the other hand, nurses can find it ‘difficult to break through’ to younger service users and struggle to engage with them in a meaningful way, often linking this to their perceptions of maturity levels.

Although not always explicit, the data suggest that at times this difficulty was rooted in nurses’ personal beliefs and biases and influenced by broader societal norms surrounding adolescents’ sexual behaviour and lack of engagement in healthcare services. These findings parallel those in other qualitative work with nurses in South Africa who seemed highly motivated to provide adolescents with SRH services, but struggled with their own personal norms and values regarding adolescent’s SRH needs and services (Jonas et al., 2018). In the context of fostering cooperation between nurses and adolescent patients, the data from this study makes clear that there exists a delicate balance between the potential challenges and opportunities that arise from provider–patient interactions. The data highlight how interpersonal barriers can be perceived as conflict by nurses, thus jeopardising the development of a trusting patient–provider relationship and negatively impacting SRH and HIV outcomes of adolescents, as evidenced in existing research and supported by this study’s findings (Camara et al., 2020; Jonas et al., 2017).

Understanding nurses’ perceptions of, and experiences with, delivering services to adolescents and young people can inform the development of interventions to enhance nurses’ interpersonal interactions with adolescents and young people seeking SRH services (Alli et al., 2012; Jonas et al., 2019). In line with this, several practical recommendations arise from the findings of this study. Future education and training programmes should be tailored to address the specific needs and concerns of nurses working with adolescents and young people, providing them with the knowledge, skills and confidence needed to deliver culturally sensitive and adolescent-friendly care (Camara et al., 2020; Gittings et al., 2024). Other research has highlighted how health professional education and training should focus on the complexity of human development in adolescence, the environment and socio-economic context, and adolescent engagement with the healthcare system and healthcare providers (World Health Organization, 2024). If nurses have a richer understanding of adolescents’ and young people’s lives and living situations, this is likely to improve nurse–adolescent patient relationships and interactions (Jonas et al., 2019). Relatedly, training should also focus on the delivery of non-judgemental care and values clarification, as this will help nurses to clarify and understand their role as healthcare providers and how bringing personal beliefs and biases into their work will shape interactions with younger patients and impact adequate provision of SRH services (Jonas et al., 2018; Muller et al., 2018).

The interpersonal dynamic between provider and young patient is also integral to nurturing positive relationships, as a lack of trust in a healthcare provider can fuel adolescent fear of stigma. There is a need for confidential and private service provision, as well as addressing negative perceptions and biases on the part of the healthcare provider and being cognisant that healthcare providers may not always be aware that their interactions may serve to perpetuate stigmatising norms (Nyblade et al., 2022). To effectively address these perceptions, it is paramount to create opportunities for nurses to clarify their values and subsequently question their own biases and perceptions, ensuring the provision of non-judgemental and supportive care. By encouraging a culture of critical self-awareness and actively addressing the language and behaviours that contribute to stigma and stigmatisation, there is potential to promote inclusivity within the healthcare context (Wagner et al., 2023).

In this study, nurses described various practical strategies to strengthen SRH services to adolescents. They included having dedicated days or times during which adolescents and young people could be seen in the clinic (and if possible, by the same nurse), which may reduce waiting times and mitigate some of the stigma adolescents feel when they are in the clinic with other, older patients (Jonas et al., 2018; Muller et al., 2018). It was also suggested that innovative ways should be found to connect with, and educate, adolescents and young people, including through the use of technology and digital platforms and the provision of outreach services in schools and in the wider community (Jonas et al., 2018). Strengthening intersectoral collaboration and coordination between the health and education sectors (Arije et al., 2022) is another key opportunity not to be missed.

Limitations

As is the case with all qualitative research, what nurses chose to share during interviews was shaped by the personal and professional positioning of the interviewers (Parker, 2010). In an effort to ensure participants felt comfortable sharing their stories in an open and transparent way, the research team conducting interviews underwent training in qualitative research and semi-structured interviewing, including role-playing with the interview guide within the team.

Findings from this study need to be understood in the context of the Eastern Cape public health system which faces systemic challenges, including a critical shortage of healthcare providers, limited access to piped water and electricity, buildings that are often not suitable to providing services, and frequent medicine shortages and stockouts (Treatment Action Campaign, 2018). While this context has relevance and applicability to other similar sites of health and social service provision, different locations have their own unique combination of social and epidemiological determinants of health (Gittings, 2019), and findings from this study should not necessarily be seen as representative of other parts of the region.

A final limitation of this study is that it does not incorporate the views of adolescents and young people themselves – or their perceptions of healthcare providers and experiences of receiving SRH services. Future research would benefit from considering nurses’ views alongside those of their young patients, to provide a more nuanced and balanced understanding of SRH service provision (Jonas et al., 2019).

Conclusion

In summary, this study considered the nuanced perspectives of nurses’ interactions with adolescents and young people in the context of SRH service provision in the Eastern Cape province of South Africa. The results underscore the influence of societal stigma and personal beliefs and values in impacting attitudes and behaviours of nursing staff and thus shaping provider and young patient interactions.

The findings also revealed opportunities for improvement in the delivery of SRH services to adolescents and young people, specifically highlighting the importance of age and context-specific interventions, structural enhancements within healthcare systems, and targeted training programmes for nurses focused on non-judgemental approaches and an emphasis on compassionate communities that can better address the needs of this demographic.