The experiences of non-direct patient care genetic counselors in South Africa-A qualitative study.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Genet Couns . 2026 Apr 16;35(2):e70212. doi: 10.1002/jgc4.70212 Search in PMC Search in PubMed View in NLM Catalog Add to search The experiences of non‐direct patient care genetic counselors in South Africa—A qualitative study Reagan Chidrawi Reagan Chidrawi 1 Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Find articles by Reagan Chidrawi 1, ✉ , Monica Araujo Monica Araujo 2 Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and the National Health Laboratory Service, Johannesburg, South Africa Find articles by Monica Araujo 2 , Katryn Fourie Katryn Fourie 2 Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and the National Health Laboratory Service, Johannesburg, South Africa Find articles by Katryn Fourie 2 Author information Article notes Copyright and License information 1 Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 2 Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and the National Health Laboratory Service, Johannesburg, South Africa * Correspondence , Reagan Chidrawi, Division of Human Genetics, National Health Laboratory Service and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. Email: [email protected] ✉ Corresponding author. Revised 2026 Apr 1; Received 2025 Oct 9; Accepted 2026 Apr 6; Issue date 2026 Apr. © 2026 The Author(s). Journal of Genetic Counseling published by Wiley Periodicals LLC on behalf of National Society of Genetic Counselors. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. PMC Copyright notice PMCID: PMC13084293  PMID: 41987711 Abstract Having first emerged in the 1970s, genetic counseling is a relatively young profession in South Africa (SA). Historically, genetic counselors (GCs) in SA have been employed through academic and public health institutions, with only a few practicing in private healthcare. Recently there has been a noticeable shift in the employment trends of GCs worldwide and in SA, transitioning away from patient‐facing roles and gravitating toward practice in new or expanded roles. It is, therefore, becoming more common to find GCs employed in laboratory, research, and industry settings. These roles typically involve far less direct patient care, redefining the role of a GC. Although this trend has been researched elsewhere, mainly in the United States of America (USA) and Canada, it has yet to be explored locally. Therefore, this qualitative study aimed to explore the perspectives and experiences of GCs employed in non‐direct patient care (NDPC) such as laboratory, research, and industry‐based settings in SA. Using semi‐structured interviews, this research gathered data from qualified GCs employed in NDPC positions. Reflexive thematic analysis revealed three themes: No choice but to pivot , Quality of life , and Professional identity . These findings offer new insights into an unexplored topic and offer an in‐depth understanding of NDPC GCs based in SA, their motivations that drive this trend, and the evolving professional landscape of genetic counseling in SA. They address the scarcity of patient‐facing employment opportunities for qualified GCs, advocate for the inclusion of exposure to roles outside of clinical practice during training and highlight the potential to guide workforce policies to address the employment gap. Keywords: driving forces, employment trends, laboratory, non‐direct patient care genetic counselor, professional identity What is known about this topic Genetic counselors are not only fulfilling patient‐facing roles but are employed in other sectors such as research, laboratories, and industry. This trend has been explored in the United States of America and Canada mainly, but it lacks exploration in other parts of the world, such as South Africa, where it is similarly well established. What this paper adds to the topic This paper presents qualitative data on the lived experiences of genetic counselors working in non‐direct patient care positions in South Africa, such as laboratories, research, and industry. Although the trend is evident in the field, there is a lack of research into the perspectives and experiences of these professionals, which is crucial to understanding the motivations behind this career shift. This paper addresses that gap by taking an in‐depth approach to explore and offer insights into the broader employment landscape for genetic counselors in South Africa. 1. INTRODUCTION Having first emerged in the 1970s, genetic counseling is a relatively young profession in South Africa (SA). Historically, genetic counselors (GCs) in SA have been employed through academic and public health institutions, with a small number practicing in private healthcare (Kromberg et al., 2013 ). However, in recent years, there has been a noticeable shift in the employment trends of GCs worldwide, including in SA, transitioning away from patient‐facing roles and gravitating toward practice in a variety of settings. (Cohen et al., 2017 ; Schwartz et al., 2023 ; Strohmeyer et al., 2023 ; Waltman et al., 2016 ; Wessels et al., 2024 ). It is, therefore, becoming more common to find GCs employed in laboratory, research, and industry settings. Although this trend has been explored elsewhere, mainly in the United States of America (USA) and Canada, it is yet to be explored in SA. Therefore, there is a need to provide context to the local genetic counseling profession and the changing landscape of employment opportunities for GCs, focusing on the experiences of non‐direct patient care (NDPC) GCs. 1.1. Employment trends A patient‐facing genetic counseling role involves responsibilities such as pre‐ and post‐test counseling, assessing family history for risk calculations, providing education on testing options, inheritance patterns, management options, and counseling to promote autonomy in making informed choices (Resta et al., 2006 ). These roles are typically performed within clinical settings, such as private and public hospitals. According to the 2024 National Society of Genetic Counselors Professional Status Survey (NSGC; PSS), 56% of GCs in the USA and Canada work in a direct patient care position, defined as “a role that primarily involves counseling patients.” These GCs also contribute to research, education and teaching, scientific writing, and program development. However, GCs are increasingly employed outside of these roles. As documented by the PSS, NDPC GCs work in laboratories, universities, biotechnology and pharmaceutical industries, non‐profit organizations, and government. These roles do not involve direct patient care and account for 26% of GCs in the USA and Canada. The remaining 16% possess mixed roles, which combine elements of both direct and non‐direct patient care (National Society of Genetic Counselors, 2024 ). 1.2. The genetic counselor in non‐direct patient care Advancements in genomics, the growing accessibility of genetic testing, and the limited genetic proficiency among non‐genetics professionals have broadened employment opportunities for GCs beyond patient‐facing roles (Swanson et al., 2014 ). This shift has highlighted the evolving roles of GCs outside direct patient care. McWalter et al. ( 2018 ) referred to GCs working in these roles as “NDPC GCs”, and this term will be used throughout the paper. Christian et al. ( 2012 ) first delineated these roles in the USA and Canada, which investigated laboratory GCs working in customer liaison, administration, result communication, report writing, and policy development. Follow‐up studies have expanded on these roles and found NDPC GCs involved in a range of duties, some of which include next generation sequencing analysis and result interpretation, variant interpretation, and research grant writing (Cohen et al., 2017 ; Field et al., 2016 ; Swanson et al., 2014 ; Waltman et al., 2016 ). 1.3. Experiences of non‐direct patient care genetic counselors Having outlined NDPC GCs' roles and responsibilities, their experience in and perspectives of their unique roles have been further investigated in the USA (Cohen & Tucker, 2018 ; Schwartz et al., 2023 ; Strohmeyer et al., 2023 ). This included factors driving GCs out of direct patient care, how prepared they felt going into a NDPC role, their professional identity, and their job satisfaction. Leaving a patient‐facing role was previously stigmatized as “moving to the dark side” in the USA—a narrative shared among GCs in these roles (McWalter et al., 2018 ). Consequently, GCs hesitated to leave patient‐facing roles due to negative stereotypes, including the belief that they were driven by money, not considered “pure”, and did not have “real jobs” (Schwartz et al., 2023 ), impacting their professional identity. Despite this, GCs have left patient‐facing roles due to high workloads and feeling undervalued, wanting to pursue personal growth opportunities, better‐earning potential, and the chance to learn new skills (Cohen & Tucker, 2018 ; Field et al., 2016 ; Rabideau et al., 2016 ). Among those who still work in patient‐facing roles, 33% said they think about leaving their jobs at least once a month. This was associated with working in a hospital (clinical) environment that involves direct patient care (Cohen et al., 2017 ). Most NDPC GCs have felt underprepared for their role, due to a drastic shift in duties and the technical nature of the work, saying that more exposure to these opportunities in their training would have been beneficial to prepare them. (Field et al., 2016 ; Schwartz et al., 2023 ; Strohmeyer et al., 2023 ). However, they note that their flexibility and the adaptability facilitated an easy transition and there is recognition that skills learnt in genetic counseling training serve as an asset for this transition (Schwartz et al., 2023 ). With this, NDPC GCs had high job satisfaction, with reasonable and flexible work hours contributing to this, as well as opportunities for growth (Cohen et al., 2017 ; Field et al., 2016 ). 1.4. The landscape of genetic counseling in South Africa Although literature has explored the experiences of NDPC GCs in the USA and Canada, there is a paucity of literature in SA. The genetic counseling profession was established over 35 years ago in SA and is regarded as a niche field, with only 56 GCs registered with the Health Practitioners Council of South Africa (HPCSA) from 1995 to April 2024, according to a recent audit (Gomes et al., 2024 ). Becoming a GC in SA requires a minimum of 7 years of training. This pathway includes a relevant four‐year Honors undergraduate degree, followed by a Master's (MSc) in Genetic Counseling. The Master's is accompanied by a mandatory 24‐month internship accredited by the HPCSA, designed to provide sufficient clinical exposure to qualify as a GC (Wessels et al., 2024 ). Of the 56 registered GCs, 46 are actively registered—with 28 (61%) GCs practising in the country and the remaining 39% having emigrated. Of those practising locally, 10 work in the public sector and 18 in the private sector. In the public sector, GCs fulfill patient‐facing roles and often hold joint appointments across institutions, being employed by universities including the University of Witwatersrand and the University of Cape Town, as well as the Department of Health and the National Health Laboratory Service (NHLS), the public sector's diagnostic laboratory service. They provide genetic counseling services at various genetic clinics weekly, including cancer, prenatal, and general clinics (Gilfillan et al., 2025 ; Kromberg et al., 2013 ). Additionally, they are involved in teaching, training, and supervising students, as well as part‐time research and genetic testing analyses. In the private sector, GCs also fulfill patient‐facing roles, often running their own practices and collaborating with one or two specialists from whom they receive referrals. It is known that NDPC GC s in SA are employed by research programs or commercial laboratories that offer genetic testing, with the first laboratory GC employed by a private laboratory in 2013 (Wessels et al., 2024 ). Some GCs hold mixed roles that combine direct and non‐direct patient care, typically involving part‐time laboratory‐ or research‐based positions as their primary employment, alongside patient‐facing genetic counseling in private practice (Gilfillan et al., 2025 ; Wessels et al., 2024 ). The Genetic Counselors South Africa (GCSA) group keeps a record of all GCs and their employment, and according to the GCSA secretary, there are 12 GCs that fit the definition of a NDPC GC (M. Duvenhage, GCSA secretary, personal communication, 2024). 1.5. Relevance of this study Our understanding of the NDPC GC remains based on global studies, emphasizing the need for local investigation. Without comprehensive research on the topic, the parallels between the experiences of NDPC counselor GCs in SA and those globally remain uncertain. Therefore, the aim of this study was to explore the perspectives and experiences of NDPC GCs in SA, to establish the landscape of the genetic counseling profession in SA and the employment opportunities available within the country. 2. METHODS 2.1. Design The study was situated in a constructivist paradigm, which assumes that reality and meaning are socially constructed and co‐created between researchers and participants (Wainstein et al., 2023 ). A phenomenological orientation informed the study design, as the researchers aimed to explore the lived experiences of GCs working in NDPC settings in SA. This orientation guided the development of interview questions and the interpretive focus of the analysis, emphasizing participants' subjective experiences and meanings. Data were analyzed using reflexive thematic analysis (RTA) (Braun & Clarke, 2024 ), an approach consistent with an interpretivist stance and phenomenological orientation. This enables researchers to identify and interpret patterns of meaning across a dataset while recognizing the active, reflexive role of the researcher in generating themes. This approach was selected for its flexibility and effectiveness in capturing the perspectives of NDPC GCs (Braun et al., 2023 ). Research ethics approval was granted by the University of Witwatersrand Human Research Ethics Committee (Medical) M240611 MED24‐04‐566. 2.2. Recruitment Non‐direct patient care, as adapted from definitions in previous studies, was defined as employment outside of clinical, patient‐facing settings such as public and private hospitals. Eligible participants were over the age of 18, proficient in English, held a Master's degree in Genetic Counseling, registered with the HPCSA, and, at the time of the interview, were employed for at least 6 months in a NDPC role, spending over 50% of their time in this role if mixed. Those with less than 6 months' experience may not have had sufficient time to gain relevant experience and provide valuable insights. Genetic counseling interns and HPCSA‐registered GCs who currently practice abroad were not included in this study. Participants were recruited using purposive sampling via the GCSA listserv, as HPCSA‐registered GCs are affiliated with this group. Invitations to participate included an overview of the study and a Google Forms link to provide the participants' contact information. Thereafter, eligible participants were contacted privately via email by the first author, and interviews were subsequently scheduled. 2.3. Data collection The first author conducted nine individual, semi‐structured interviews with participants. This method of interviewing was chosen to allow participants to speak freely and for unexpected themes to emerge. An interview guide was developed by the first author based on relevant literature that explored similar topics and areas of interest (Christian et al., 2012 ; Field et al., 2016 ; Schwartz et al., 2023 ; Strohmeyer et al., 2023 ). It was comprised of eight open‐ended questions with follow‐up prompts regarding topics such as job description, leaving a patient‐facing role, preparedness, experience in the field, and reflection on a patient‐facing role (Appendix S1 ). One pilot interview was conducted with a registered GC at the NHLS to test the guide and develop interview skills. No changes to the interview guide were required prior to participant interviews, which were conducted either in‐person or virtually via Zoom, with the average interview length being 40 min (Table 1 ). Interviews were recorded and verbal and written consent was obtained at the start of each interview. In line with the constructivist paradigm and the principles of RTA, data sufficiency was guided by the concept of information power, evaluating whether the richness, relevance, and depth of the dataset were sufficient to meaningfully address the study aim (Malterud et al., 2016 ). The final sample size of nine participants provided adequate information power to support a robust and credible analysis. TABLE 1. Participant employment and interview information. Category Number of participants ( N =) or mean (range) Total number of participants a 9 Type of interview In person 1 Online via Zoom 8 Average interview length 40 min 52 s (24 min 04 s to 60 min 04 s) Type of role Exclusively NDPC 4 Research 3 Laboratory 1 Mixed 5 Research 2 Laboratory and industry 3 Average experience in NDPC role (years) 4 years 3 months (10 months – 9 years 4 months) Open in a new tab a Due to the small sample size, descriptive statistics are reported as mean and range to provide clearer representation of the dataset. Furthermore, demographic data has been intentionally limited to protect participant anonymity, given the small, highly interconnected group of GCs in SA. 2.4. Analysis Automated interview recordings generated from Zoom were cross‐checked against the first author's audio recording and transcribed verbatim on Microsoft Word. All identifying data was removed or anonymized to ensure participant confidentiality. Data were analyzed using Braun and Clarke ( 2024 ) six‐phase framework for RTA, and reported in line with the Reflexive Thematic Analysis Reporting Guidelines (Braun & Clarke, 2024 ). Coding was inductive, allowing codes and themes to be developed from the data rather than from pre‐existing concepts. Themes were actively generated, reflecting patterns of shared meaning across the dataset. Final themes were refined to clarify their interpretive focus, and each was defined and named to capture their central organizing idea. Throughout the process, the researchers engaged in reflexive dialogue to consider how their own professional backgrounds and assumptions shaped interpretation. Reflexive journaling supported ongoing self‐awareness and analytic transparency. 2.5. Positionality statement The first author was a genetic counseling student at the University of the Witwatersrand and the NHLS at the time of the study, with academic and clinical exposure to the South African genetic counseling context exclusively within the public sector. The second and third authors were qualified genetic counselors employed by the NHLS, with experience in both public and private practice. All authors were therefore positioned within the profession under study, and this insider positioning may have shaped the interpretation of participants' accounts, particularly in relation to patient‐facing roles, career pathways, and professional identity. In keeping with reflexive thematic analysis, these positions and related assumptions were critically considered throughout the research process to support a reflexive, contextually grounded interpretation of the data. 3. RESULTS 3.1. Participant employment information In total, nine participants with either mixed or exclusively NDPC roles were interviewed during this study and had an average of approximately 4 years' total experience in NDPC (Table 1 ). The duties of NDPC GCs in exclusively research and laboratory settings are summarized below (Table 2 ). Those who have a mixed role reported spending approximately 30% of their time doing patient‐facing genetic counseling in private practice, which entailed risk assessment, counseling, and admin‐related work after each consultation. This included writing letters and motivations to medical aids, billing, and writing appropriate referral letters. In private practice, GCs are not employed by private hospitals as such, but rather own their own practices and consult with specialists in private healthcare settings (Wessels et al., 2024 ). TABLE 2. Non‐direct patient care genetic counselors' roles and responsibilities in research and laboratory‐based positions. Employment setting a Research Laboratory Roles and responsibilities Recruitment Pre‐ and post‐test counseling Supervision Data keeping and collection Community engagement Research projects Variant interpretation Writing research reports Gatekeeping of test requests Advising on availability of tests Advising clinicians on test selection Writing content for company websites Explanation of results Open in a new tab a Based on data obtained through individual participant interviews. In this study, we opted to use the words “non‐direct patient care” rather than “non‐clinical” to describe GCs in these environments, as many NDPC roles may still be perceived as clinical in nature, despite not being patient facing. However, participants use the words “traditional” and “clinical,” as well as “non‐traditional” and “non‐clinical” interchangeably. Therefore, these terms are considered synonymous and should be interpreted as such. 3.2. Themes The data are summarized by three main themes: “No choice but to pivot,” “Quality of life,” and “Professional identity,” which are discussed in detail below. 3.2.1. Theme 1: No choice but to pivot This theme relates to participants' motivation for leaving a patient‐facing role. Evidently, limited job availability in these settings has been the main driver of this trend, as all newly qualified GCs had to find alternative work after their internship. This reality for GCs is expressed by participant 7, saying, There weren't like particular posts that were advertised that I could be like, ‘Okay I'm making a choice now between being employed as a medical scientist or as a genetic counselor’ – there weren't any posts. – P7 Participant 2 echoed the sentiment by saying, There's such limited genetic counseling positions in the whole of South Africa, that [position] seemed to be the next step for me, and so I think it's almost forced, but yeah, I think it's basically forced and not necessarily planned or unplanned. It's forced. – P2 Given the “forced” nature of the transition, participants were asked how prepared they initially felt going into a NDPC role. Their feelings were based on their internship exposure; those with relevant experience felt more equipped and applied that knowledge in their current role. For instance, participants working in research had prior involvement in either the same or similar projects, easing their transition compared to those without. Some upskilled themselves by taking courses in variant interpretation. This sense of preparedness is illustrated by participant 3, “I felt very prepared and very equipped, and there's so many aspects that are required that I feel I completely fit in, and there's a need that I find myself being able to fill that gap.” Others felt unprepared, needing to learn new systems and figure out work dynamics, which highlights acclimatizing to a new role—something that anyone might feel unprepared for. This was reflected by participant 5, “Not even remotely [prepared], not at all. But it's fine, you learn as you go. So the first few weeks were like, quite intense like, it's a sharp learning curve.” However, many participants noted that their genetic counseling internship taught them how to manage high workloads and stress effectively. Participant 4 explained, “[It was] the internship training, I think, who really gave me the upper hand in the sense that I could manage a lot of stress.” Given that many newly qualified GCs enter NDPC roles directly, it is important to evaluate whether the internship sufficiently prepares them for these roles. Additionally, some participants noted uncertainty about the expectations of their role, as both they and their employer were unclear about what their position entailed. While these organizations recognized that GCs could add value to the team, they had a limited understanding of exactly what that value was and, therefore, what their job description was. Participant 1 emphasized this, saying, “I think in the beginning I struggled because there isn't like a lecture on how to be a Research Genetic Counselor.” Further, participant 8 noted, They hadn't had a genetic counselor before, nobody really knew what to expect or what the role should look like or I started without a job description as an example, because they didn't know. – P8 Although stepping into a NDPC role initially brought feelings of unpreparedness and anxiety, all participants described how specific skills acquired in their genetic counseling training have greatly enabled them to adapt. Participants mentioned active listening and effective communication as skills that have been essential in their role and, in fact advantageous. Participant 3 reflects this, stating, You have to identify certain mechanisms that people use during communication, and also, like, pick up a lot about the person and how best you can help them in their situation so that they make informed decisions. So, you also have to be like managing the anxiety, managing the uncertainties that come with all this, and the genetic counseling skills come in very handy at that point. – P3 Similarly, participant 8 noted, You're speaking with patients to really listen, to hear what are they saying, not just the words that they're using, but you know, body language, all of the other things that go along with that and then being able to simplify things because sometimes things can just be overcomplicated from a lab perspective. – P8 Participants raised the importance of simplifying complex genetic information for diverse audiences; patients, laboratory scientists and technicians, and referring clinicians. They further expressed that these skills have set them apart from non‐genetic specialists and could not imagine another individual fulfilling their role. Overall, this theme speaks to the forced nature of the movement of GCs into NDPC given a lack of job availability in clinical settings. However, GCs voiced their appreciation for their genetic counseling training that enabled them to adapt quickly to their role, which they perceived to be advantageous when compared to other professionals. 3.2.2. Theme 2: Quality of life This theme explores participants' overall well‐being in their NDPC role, reflected by their level of job satisfaction and opportunities for professional and intellectual growth. Most participants noted that they experienced a shift in work stress when moving into a NDPC role, related to a change in work dynamics. Patient‐facing roles were described as high‐stress environments and subsequently, they felt less stressed and “calmer” in a NDPC environment, where stress is “manageable”. Participant 2 describes, “Research is not as high paced as the clinical space and so there was time to learn a lot of things.” Similarly, participant 4 explained, I think every workplace essentially would cause, you know, like these different stresses. But I do feel, that I have more time for myself now as an individual which I really appreciate…It's calmer…Different stresses, but yeah, a little bit less frantic. – P4 However, some participants explained the stress in these roles—particularly private laboratories—was more related to logistical pressures and the demanding nature of managing critical samples. Participant 5 emphasized this, stating, “It's different stress. I was gonna say it's less stressful, but I think it's a different stress, because of all the things I'm trying to do at the same time.” Flexibility was an aspect of a NDPC role that was raised by participants and contributed to their job satisfaction. This was particularly evident in those who worked in a mixed role, who could control their schedules in private practice, those who worked part time in laboratories, and those who worked independently in research. This aspect was of high importance for those who were parents and had children, being able to do the “school run” and watch sports games. This was expressed by participant 6 who explained, I'm a mom. I've got young kids, so being able to have that work‐life balance, and for me to be able to organize that myself, rather than working for someone who's telling me I need to be here during these hours. And you know, I think to have that flexibility is nice, and the research as well again, that you work very much independently. So you have a lot of flexibility. – P 6 For others, the flexibility meant running their own schedule in research and the laboratory, and managing their own time, something that would not be as easily possible in a patient‐facing role. This was reflected by participant 8 who noted, What this role has allowed me, which I sometimes overlook until I am reminded by colleagues that are in different roles and positions, is it allows me flexibility, which I think goes a very long way at different points in your life. – P8 A challenge that most participants who had a mixed role expressed was that managing this can get overwhelming and hamper their quality of life as they have less time for themselves. Participant 9 shared, So there's a lot of sacrifice that comes into doing all of these things, but I think that's just purely because I have now these two things that I have to juggle and like, I said, they're very intensive if you just have…if it was just the research job I had, it would have been much easier of a life, I guess, when it comes down to personal kind of quality of life. – P9 This experience is further highlighted participant 6, who explained, I think having the luxury of being able to do both is has really been beneficial, and I'm very grateful for that. But I would say, juggling both is hard – finding that balance. For example, my research day that I've dedicated to doing research and university‐based work, there'll always be moments where you get a phone call because there's a clinic emergency, or an email will pop in with results that urgently need to be delivered. So separating it and kind of keeping it in two different separate boxes is quite hard on a day‐to‐day basis. – P6 Those with a mixed role felt this fulfilled both sides to them and gave them the balance of both direct and non‐direct patient care genetic counseling. Participant 6 reflects this, stating, I think I have a love for both [research and traditional genetic counseling], but I also think that both areas really complement each other. I think having the luxury of being able to do both is has really been beneficial, and I'm very grateful for that. The research now I think you know I'm kind of doing it because I'm passionate about it, and I enjoy it. – P6 Similarly, participant 9 highlights the importance of maintaining patient interaction, noting, I'm very, very happy to have this, because I feel like if it was only the research position it would become, become a bit too much for me, I think, because it doesn't have necessarily as much of that patient interaction on a regular basis, or as much of the core roots of what a genetic counselor would do. – P9 Participant 5 further illustrates this need to retain patient‐facing work, explaining, I think that for a lot of us, and I know for me, like you become a genetic counselor because you want to talk to people, and then you go into a lab and you're not seeing patients…So you're sitting behind a desk and behind a computer which is not really the kind of profession that you wanted to be in, so I think that's why I see patients privately. – P5 In contrast, participants who did not have a mixed role longed for patient interaction, an element described as “missing” from their current job. Participant 2 reflects this, stating, “I think the only thing that makes it a less enjoyable role is the decrease in patient contact, which is something that I would prefer to have.” Further, participant 4 highlights this by saying, Now for the position that I'm in, I can see the result, for example, or I can deliver it to who it needs to go to, but I don't see how it is conveyed, or how it is delivered to a patient. So it's good that you know that there is an end in the job aspect of, I did my job, but that ending point of delivering or explaining results is lacking, I must say. – P4 Some participants also raised the issue of financial instability and inadequate pay for GCs in the country. Participant 7 explains, “So I definitely enjoy all of those different things and the only thing that I would say kind of hampers that a little bit is the financial aspect of it,” and participant 5 states, “I think that the pay is really poor. I don't think that they pay genetic counselors well all round – [in] the labs, [and in] universities.” However, participant 2 had a different perspective, explaining However, I think I do realize that with the stress levels that come with the job, so does the pay. And so obviously, that is something that I am, I want to say, missing out on in my role, but I am not sure that that is the worst thing to happen, is that I think I am willing to lose out on that money and have a better quality of life. – P2 Participants noted that opportunities for professional growth in a NDPC role enhanced their job satisfaction and quality of life. Participant 3 notes, It's just satisfying for me whether [I'm] doing it as a researcher or as a counselor but the fact that I can communicate and educate and help people to understand and make choices, you know, and raise awareness, and all of that about such an important field. – P3 Similarly, participant 7 states, I'm always acquiring new skills, doing courses that I never would have done if I only had my role in genetic counseling. So that's the rewarding part for me is always like learning new things, and meeting new people in different spaces, and kind of trying to bring those things like seeing where they can meet each other halfway. – P7 Although participants enjoyed their NDPC role and saw opportunities for growth, some still desire to work in a patient‐facing setting, under specific conditions. For some, they would consider moving into this setting if the work was purely patient‐facing genetic counseling. This is echoed by participant 2 who describes, I think I'm not opposed to it. I think I'm more inclined to it. However, I think just strictly clinical is something that I want, and not a mixture of this and that…I'm not sure how the rest of the genetic counseling profession feels, but I think if there were more clinical genetic counseling vacancies or positions to hold, I think there'd be a lot more people within those roles. – P2 Others aimed to own a private practice and described their current job as an intermediary step for this. Some felt content with their mixed role and what it offered for them. Others felt they were meeting a need and were not considering moving into a patient‐facing role completely. Participant 3 reflects this, noting, Well based on where I am at right now, based on that, I feel more happier in in what, in the setting in the setting that I am now, I feel like I would rather continue contributing in the community engagement work, you know, in the sense of being the center of community of communities and engaging people in terms of research and education focus groups, raising awareness. – P3 Expanding on this decision, some participants would consider moving into a purely patient‐facing role as they feel the description of a GC in South Africa is changing. Participant 7 captures this, noting, I think even the traditional roles are expanding so I definitely would consider moving into the clinical sort of traditional role, because I think in the future, even in the new future, it's not going to look the same as it looks. Now, I think that transition is slowly happening… And whatever I'm doing now will definitely, I think, be applicable and add value to any future clinical role that I might undertake. – P7 Further, participants shared advice for newly qualifying GCs, which is demonstrated by participant 6 saying, “I suppose a lesson going forward for other genetic counselors who are just qualifying that like, don't close yourself off to other areas in terms of our skill set and what we can do.” This theme reflects the high levels of job satisfaction that NDPC GC s have in their role, primarily driven by flexibility and personal time. However, all participants who possessed exclusively NDPC roles expressed a strong desire to work in a direct patient care setting if given the opportunity. In contrast, participants with mixed roles highly valued both direct and non‐direct patient care aspects to their role, while acknowledging the challenges of balancing both. 3.2.3. Theme 3: Professional identity This theme evaluates how participants perceive and define their identity in NDPC environments. Terms such as “medical scientist”, “genetic application specialist”, “laboratory genetic counselor”, “research associate”, “research genetic counselor”, and “research coordinator” were used to describe their job title in their particular role. However, participants expressed that they inherently view themselves as GCs. Participant 4 voices this, saying, I think a genetic counselor maybe intrinsically implies that you do clinical service, which I do not do so…. I think when I have to talk with the doctors or when someone calls me, I still introduce myself as I am the genetic counselor working at [company]. – P4 Similarly, participant 8 explains, Yes, absolutely so, definitely as a genetic counselor, and I think there would be few other health professionals that could fulfil that role because I rely very heavily on my genetic counseling training and skills and knowledge. – P8 Their identity as GCs remained important to them, and therefore, these titles did not reflect their sense of self. Participant 9 strongly emphasizes this, explaining, I don't like seeing myself as a research coordinator as such. I like seeing myself as a genetic counselor, because that's what I want to be… If you are a genetic counselor, you don't want to necessarily, or I don't want to necessarily be just something else. – P9 Some participants described their job title as merely a label that the laboratory provides to characterize their scope of practice, a way to determine their compensation, and reflects a lack of clinical work. All participants expressed that the deviation between these job titles and their sense of self was largely due to organizational structure and does not define how they view themselves as GCs. Although not extensively explored in this study and not a general feeling shared among participants, one participant shared their perception among colleagues. This was due to a shift in roles and responsibilities in a NDPC space, for example a reduction in patient‐facing duties and a change in work schedules. Participant 1 shared, I identified as a genetic counselor, but there were instances where I was probably like made to feel like I'm not a genetic counselor, and I think, ‘cause I worked closely with my with genetic counselors that were purely clinical. – P1 A key concept that arose from participants was the broad professional identity of GCs in SA. Some participants described this identity as “wearing different hats,” inherently shaped by their role as generalists. Participants 4 explains, “At this point all of us are super generalists. Jumping from a mTOP to a cancer patient every day,” and similarly, participant 6 notes, “So a Jack of all trades, really, in terms of which I think most of us are as genetic counselors.” Participants also felt a constant sense of duty to the profession, advocating for the role of GCs in healthcare. They emphasized the importance of their role, stating that “we matter and what we do matters,” highlighting their ongoing struggle with the government and other healthcare professionals to secure recognition, placements, and adequate pay. Participant 5 states, “I just don't think we're valued,” and participant 6 emphasizes, “Getting others to see the value of genetic counseling – it's rewarding but it's draining too.” This tension is further captured by participant 7, stating, “It's like this two‐edged sword, because on the one hand, we know that there is a lack or scarcity of genetic counselors, but, on the other hand, no one's making use of us.” This theme highlights how participants feel a strong sense of identity as GCs despite working in NDPC settings and holding job titles that differ from that of a patient‐facing GC. These terms are described as merely labels provided by employers, but it remains important for them to still feel and be known as a GC. Overall, this theme represents the challenges GCs face with their professional identity in NDPC roles. 4. DISCUSSION Our study revealed different patterns of movement into NDPC roles by GCs in SA compared with those observed in the USA and Canada, as none of the NDPC GCs reported entering these roles by choice or serendipity. Instead, they felt “forced” into these roles due the persistent lack of patient‐facing job availability in a clinical setting, highlighting the structural constraints shaping career pathways for GCs in SA. This is because the implementation of genetic counseling in SA remains limited. With only 28 practicing GCs in SA, the country operates at 5% capacity: 2% in the public sector and 24% in the private sector (Gomes et al., 2024 ). With that, no new patient‐facing genetic counseling positions have been created in government health departments, that is, the public sector, since 2000 (Wessels et al., 2024 ). Additionally, the 2030 Human Resources for Health Strategy does not include provisions for expanding genetic counseling capacity (Gomes et al., 2024 ). Therefore, GCs who want to practice in patient‐facing roles must wait for a post to be vacated, and even then, it is often frozen or terminated. As a result, GCs often seek employment in private healthcare where they start their own practices when feasible, or they move abroad. Since 1995, 62% of the total qualified GCs in SA have emigrated and are practicing abroad (Gomes et al., 2024 ). Despite these constrained career pathways, NDPC GCs reported high levels of job satisfaction, with key contributors being a change in work dynamics and subsequent decreased stress levels, flexibility, and the ability to integrate genetic counseling in a mixed role. They experienced a shift in work‐related stress when moving into a NDPC role, as patient‐facing roles were described as fast‐paced, high‐stress environments, particularly in the public healthcare system due to the number of responsibilities expected. For instance, preparing for multiple genetic clinics within 1 week and the subsequent administrative tasks that follow, lecturing and supervising students, attending several weekly clinical meetings, and coordinating genetic counseling training courses. Hence, NDPC GCs felt calmer, with more time for themselves to develop personally. In laboratories, NDPC GCs explained their stress to be more logistics related. For example, dealing with the demanding nature of couriering precious chorionic villus samples as soon as possible, ensuring the correct sample is delivered to the correct laboratory, and constantly keeping up to date with the available tests. Overall, NDPC GCs described this shift in stress and calmer environment to contribute positively to their quality of life. For those in mixed roles, while their passion for patient‐facing work remains strong, they highlight significant professional growth enabled by their NDPC role. They described being able to build their skills, take new courses, and gain exposure to technologies and sequencing—opportunities often limited in a patient‐facing environment. Therefore, they feel their NDPC role has expanded their professional career. However, NDPC GCs also identified challenges that negatively impact their job satisfaction and overall quality of life. This included decreased patient contact, balancing a mixed role, and financial instability. One common aspect between our study and those globally is that patient contact, or the lack thereof, was not a deciding factor as to whether GCs wanted to move into NDPC roles and is often reported as one of the factors that is least liked about their job (Christian et al., 2012 ; Cohen et al., 2017 ; Field et al., 2016 ). Patient care ranked as one of the three best attributes of patient‐facing roles (Christian et al., 2012 ), and was similarly valued by NDPC GCs in SA, who felt the lack of direct patient care made their NDPC role less rewarding. Many expressed that they pursued a genetic counseling career to talk and engage with people, only to find themselves in an opposite work environment. For instance, some wished to be involved in delivering test results and not just explaining them to clinicians, and hence most desire to move back into a patient‐facing role. However, the setting influenced this decision. Most NDPC GCs wanted to focus solely on patient‐facing genetic counseling and did not want additional tasks, such as teaching and research, which are typically expected in patient‐facing GC roles in the public sector in SA. In contrast, roles in the private sector generally do not require these additional duties, reflecting the broad professional identity of GCs in SA across public and private healthcare settings. Subsequently, private practice often becomes the only avenue to maintain a connection to patient‐facing genetic counseling. This explains why over half the NDPC GCs in this study possess mixed roles, initially entering a position in NDPC out of necessity and later incorporating direct patient care into their careers. Overall, while NDPC GCs have high job satisfaction, their desire to work in patient‐facing settings is unsurprising, as many were forced into NDPC roles without the opportunity to pursue patient‐facing work after completing their internship. Given the “forced” nature of the transition, participants' preparedness for a NDPC role varied, with their training providing the foundation for it. In SA, the Master's in Genetic Counseling curriculum comprises medical genetics, practices, and principles of genetic counseling ( https://www.wits.ac.za ; https://www.uct.ac.za ). Thus, while variant interpretation and laboratory tutorials, for example, are included in the training, the syllabus focuses strongly on counseling skills rather than exposure to roles outside of direct patient care (Wessels et al., 2024 ). Therefore, NDPC GCs did not feel prepared for their role initially given the lack of direct patient care of the role, new systems, and different work dynamics. This included, for example, the wider range of tests offered in the private sector compared to the public sector, requiring them to expand their knowledge. However, there is recognition of some exposure to these duties in training, contributing to their preparedness and mainly having to deal with new dynamics in their NDPC role. Despite this, many participants expressed confidence in their unique skillset, believing that their training equipped them with strengths—such as communication, critical thinking, and empathy—that made them particularly well‐suited to these positions. In other studies, this feeling of unpreparedness appeared to be more prevalent as GCs have noted their Master's in Genetic/Genomic Counseling did not prepare them for a NDPC role, needing assistance with variant interpretation, genetic testing concepts, test proficiency, and business‐related managerial skills (Field et al., 2016 ; Schwartz et al., 2023 ; Strohmeyer et al., 2023 ). They further emphasized that increased exposure to these roles during their training would have been helpful and felt that courses such as “Business 101” and “A crash guide for switching from clinical to lab/industry” would have better prepared them (Strohmeyer et al., 2023 ). As with our findings and those from Zetzsche et al. ( 2014 ), some NDPC GCs in our study felt uncertain about what was expected of them in their role, as did the organization, highlighting a need for a defined role establishment in NDPC practice. Despite this, one of the key advantages highlighted by NDPC GCs was their effective communication skills and active listening. This was particularly evident in tasks such as ensuring informed consent and autonomy during recruitment for research projects, efficiently gatekeeping test requests, and explaining complex results to clinicians at commercial laboratories. This transferable skillset enables NDPC GCs to make a great interface between the laboratory, patients, and employees, enabling effective team dynamics in these roles broadly. This skill set is not unique to South African NDPC GC but a hallmark of those worldwide. Previous studies also identified communication as a key skill, with NDPC GCs describing it as the quality that “sets us apart” (Christian et al., 2012 ; Cohen et al., 2017 ; Davis et al., 2020 ; Schwartz et al., 2023 ). Their communication, active listening, understanding, empathy, flexibility, and adaptability forms a skillset that facilitates an easy transition into NDPC roles, and makes them valuable team members in these settings. In previous American‐based studies, while 95% of GCs maintain their identity in a NDPC role, the remainder do not for various reasons. Among these, some GCs felt the title “genetic counselor” to be misleading, as they are not involved in direct patient care, and therefore, it misrepresents their role by giving other professionals the impression that they “talk to patients every day” (Strohmeyer et al., 2023 ). Others deliberately chose not to identify as a GC in their job title, perceiving it as limiting. They felt it lowered expectations of senior leaders and reduced their salary bracket, defining their skillset as merely patient‐focused and in turn, reduced respect for their role (Strohmeyer et al., 2023 ). For this reason, other NDPC GCs have referred to their identity as “genetic consulting ” rather than “genetic counseling” to avoid confusion (Schwartz et al., 2023 ). Other GCs have also struggled with their identity, questioning whether they can call themselves GCs if they do not see patients (Zetzsche et al., 2014 ). In contrast, our study highlighted that NDPC GCs in SA maintain a significant connection to their GC identity in NDPC roles, despite being forced into their role and holding alternative job titles. Further, they find it unimaginable for another professional to fulfill their role, given their utilization of valuable skills acquired in genetic counseling training. Similar to our findings, other NDPC GCs have acknowledged their role as different from patient‐facing GCs but continue to identify as a GC because it aligns with how they have always viewed themselves (Stenberg et al., 2024 ). Additionally, they expressed great pride in their title, explaining that it represents a core foundation from which they were taught and a skillset that has been applied in various ways (Means et al., 2020 ; Stenberg et al., 2024 ). Furthermore, NDPC GCs in our study describe their identity as broad and view themselves as generalists—professionals who consult a diverse range of genetic cases in clinical environments. Their generalist identity, a hallmark of genetic counseling in SA, equips GCs to handle a variety and subsequently enables them to adapt to alternative career paths and facilitate smoother transitions into NDPC roles. The difference in professional identity abroad and locally could stem from the unique landscape of genetic counseling in SA and the limited opportunities available for GCs compared to the USA and Canada. In SA, a smaller workforce, limited patient‐facing roles, and the need for adaptability mean that NDPC GCs maintain strong ties to their GC identity despite being employed in an NDPC role. This contrasts with the USA and Canada, where a more established workforce allows for greater role diversity and specialization, leading some to choose to no longer identify as a GC when they move away from direct patient care. While the metaphor, “moving to the dark side,” has been illustrated by previous studies and has been a long‐standing concern in the American GC community (McWalter et al., 2018 ; Strohmeyer et al., 2023 ), it was not raised in ours. Although one participant expressed a feeling that their identity was not that of a GC, it was not a general theme across participants, and so while it was not intentionally analyzed, the theme never emerged organically either. This difference seen in the South African genetic counseling community could be because NDPC GCs did not choose to move into these roles. The choice often brings judgment, which may explain why GCs abroad felt judged, ashamed, impure, and perceived as money‐driven by patient‐facing GCs when making the transition (Schwartz et al., 2023 ; Strohmeyer et al., 2023 ), and some felt their placement in the genetic counseling program was wasted (Hippman et al., 2016 ). Some have, in fact, avoided transitioning into NDPC roles out of fear of losing their identity and sense of belonging within the profession (Davis et al., 2020 ). With only 28 practising GCs in the country, the field is considered niche. Therefore, by sharing similar employment struggles after their internship, GCs can relate to and emphasize with each other, creating a highly supportive environment that further encourages mutual support and minimizes judgment. This illustrates why GCs in SA, including NDPC GCs, have a strong sense of duty to advocate for the genetic counseling profession in the country, highlighting its significance and value in healthcare. This collaborative effort is seen in support groups, such as the GCSA, social media advocacy through various genetic counseling pages, and the use of messaging platforms for professional communication and assistance. They discuss the constant challenge within the healthcare system of gaining recognition, adequate placements, and fair pay, all of which impact their sense of fulfillment. Although this advocacy represents GCs' passion for the profession, it has an emotional toll and is described as draining as they constantly strive to be valued in the healthcare system. While this has been found in Cohen and Tucker ( 2018 ), it may also be unique to SA given the lack of genetic counseling awareness and implementation (Gomes et al., 2024 ). Although some NDPC GCs expressed the desire to move back into a patient‐facing position, they provided hopeful advice for newly qualifying GCs, stating that the identity of a GC in SA is already changing and may look different in the future. Therefore, they advise GCs to be open to diverse work settings and not feel restricted with their qualification, as they possess a highly transferable skill set that can be easily translated into a NDPC setting. This provides hope to newly qualifying GCs in the country, ensuring the degree remains highly valued and provides options for employment in diverse settings given the current situation for genetic counseling in SA. 5. RESEARCH RECOMMENDATIONS Since our study focused on NDPC GCs' perspectives and experiences, it may be insightful to evaluate that of the GCs working in patient‐facing positions, outlining how they feel toward the profession and those who work in NDPC roles. Additionally, the study excluded the 16 GCs that have emigrated, and thus exploring their motivations may add to the findings of this study. Future genetic counseling training should incorporate exposure to genetic counseling practice apart from direct patient care to a larger extent, given that the reality for most GCs in SA is to move into these roles upon completion of their internship. This will allow those to feel more prepared for their role, but also to establish networks in these areas of work. 6. LIMITATIONS Most participants' form of clinical work experience was that of a trainee in their internship, which could mean that their comparison to their first actual job was different from comparing two established jobs, as seen in previous studies. Our study did not include the 16 GCs that have emigrated, which could have added depth to the theme, “No choice but to pivot.” 7. CONCLUSION Our study highlights the evolving role of genetic counselors (GCs) in South Africa (SA), with particular focus on GCs working in non‐direct patient care (NDPC). While much of our current understanding of NDPC GCs is drawn from American and Canadian studies, this research provides context to the unique nature of South African NDPC GCs and the collective struggles they face. While GCs abroad move into NDPC by choice and have a subsequent negative connotation associated with that move, our study illustrates that GCs in SA are in fact “forced” into these roles, due to a lack of choice given the shortage of patient‐facing employment. Consequently, most newly qualified GCs are pushed to make pragmatic decisions regarding their employment, changing their career trajectory. Thus, NDPC GCs experience similar struggles which minimize judgment around this trend. Nonetheless, NDPC GCs remain proud to identify as GCs in NDPC, with overall high job satisfaction and feel they are meeting a need. Their unique skillset makes a great interface in the laboratory and facilitates ethical practice in research projects; therefore, they advise newly qualifying GCs to stay open‐minded as to where their skillset can be applied, as this asset has been translatable in a variety of work settings. AUTHOR CONTRIBUTIONS Katryn Fourie: Conceptualizing, methodology, data analysis, writing – review and editing. Monica Araujo: Conceptualizing, methodology, data analysis, writing‐ review and editing. Reagan Chidrawi: Data collection, data analysis, writing – original draft, writing – review and editing, project administration. FUNDING INFORMATION No funding was needed for this study. CONFLICT OF INTEREST STATEMENT The authors, Reagan Chidrawi, Monica Araujo, and Katryn Fourie, declare that they have no conflicts of interest. ETHICS STATEMENT Human studies and informed consent: Research ethics approval was granted by the University of Witwatersrand Human Research Ethics Committee (Medical) M240611 MED24‐04‐566. All procedures followed were in accordance with the ethical standards of the responsible committee and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from participants prior to their inclusion in this study. Animal studies: No non‐human animal studies were carried out by the authors for this article. Supporting information Appendix S1 JGC4-35-0-s001.docx (17.5KB, docx) ACKNOWLEDGMENTS The authors would like to acknowledge all the participants involved in the study. No artificial intelligence (AI) tools were used to generate ideas, analyze data, interpret results, or write substantive content in this manuscript. AI‐assisted tools were used solely for language editing and proofreading to improve clarity and readability. Specifically, ChatGPT (OpenAI, GPT‐5.2) was used during the editing process only, with full author oversight and responsibility for the final content. DATA AVAILABILITY STATEMENT All de‐identified data and materials can be made available from the corresponding author, RC, upon reasonable request. REFERENCES Braun, V. , & Clarke, V. (2024). Supporting best practice in reflexive thematic analysis reporting in palliative medicine: A review of published research and introduction to the reflexive thematic analysis reporting guidelines (RTARG). Palliative Medicine, 38(6), 608–616. 10.1177/02692163241234800 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Braun, V. , Clarke, V. , Hayfield, N. , Davey, L. , & Jenkinson, E. (2023). Doing reflexive thematic analysis. In Supporting research in counseling and psychotherapy: Qualitative, quantitative, and mixed methods research (pp. 19–38). 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