Using log diaries to examine the activities of final-year medical students at decentralised training platforms of four South African universities

Background. An important strategy in the transformation and scaling up of medical education is the inclusion and utilisation of decentralised training platforms (DTPs). Objective. In light of the dearth of research on the activities of medical students at DTPs, the purpose of this study was to determine how final-year medical students spent their time during the integrated primary care (IPC) rotation at a DTP. Methods. The study was conducted at Sefako Makgatho Health Sciences University (SMU), the University of KwaZulu-Natal (UKZN), the University of the Witwatersrand (Wits) and Walter Sisulu University (WSU). At each of the participating universities, a voluntary group of final-year medical students completed a log diary by entering all activities for a period of 1 week during the IPC rotation. The log diary contained five activity codes: clinical time teaching time, skill time, community time and free time, with each subdivided into additional categories. The data were analysed for students at each university separately, using frequencies and proportions. Results. A total of 60 students volunteered to complete the diaries: at WSU n=21; UKZN n=11; Wits n=18; and SMU n=10. At each university, students reported that they spent large amounts of time on clinical activities: WSU=46.0%; UKZN=33.8%; Wits=29.6%; and SMU=44.1%. They reported low amounts of time spent on community-based activities: WSU 0.8%; UKZN 7.6%; Wits 6.8%; and SMU 0.0%. Conclusion. Students reported that they spent a sizeable proportion of their time on clinical activities, while reported time spent on community-based activities was negligible. The transformation potential of DTPs will only be realised when students spend more time on community-based activities

The indirect costs of agency nurses in South Africa: a case study in two public sector hospitals

PKBackground: Globally, flexible work arrangements - through the use of temporary nursing staff - are an important strategy for dealing with nursing shortages in hospitals. Objective: The objective of the study was to determine the direct and indirect costs of agency nurses, as well as the advantages and the problems associated with agency nurse utilisation in two public sector hospitals in South Africa. Methods: Following ethical approval, two South African public sector hospitals were selected purposively. Direct costs were determined through an analysis of hospital expenditure information for a 5-year period from 2005 until 2010, obtained from the national transversal Basic Accounting System database. At each hospital, semi-structured interviews were conducted with the chief executive officer, executive nursing services manager, the maternity or critical care unit nursing manager, the human resource manager, and the finance manager. Indirect costs measured were the time spent on pre-employment checks, and nurse recruitment, orientation, and supervision. All expenditure is expressed in South African Rands (R: 1 USD R7, 2010 prices). Results: In the 2009/10 financial year, Hospital 1 spent R38.86 million (US$5.55 million) on nursing agencies, whereas Hospital 2 spent R10.40 million (US$1.49 million). The total estimated time spent per week on indirect cost activities at Hospital 1 was 51.5 hours, and 60 hours at Hospital 2. The estimated monetary value of this time at Hospital 1 was R962,267 (US$137,467) and at Hospital 2 the value was R300,121 (US$42,874), thus exceeding the weekly direct costs of nursing agencies. Agency nurses assisted the selected hospitals in dealing with problems of nurse recruitment, absenteeism, shortages, and skills gaps in specialised clinical areas. The problems experienced with agency nurses included their perceived lack of commitment, unreliability, and providing sub-optimal quality of patient care. Conclusion: Hospital managers and policy-makers need to address the effective utilisation of agency nurses and quality of patient care in tandem

Using diaries to explore the work experiences of primary health care nursing managers in two South African provinces

PKBackground: South Africa is on the brink of another wave of major health system reforms that underscore the centrality of primary health care (PHC). Nursing managers will play a critical role in these reforms. Objective: The aim of the study was to explore the work experiences of PHC clinic nursing managers through the use of reflective diaries, a method hitherto under-utilised in health systems research in low- and middle- income countries. Design: During 2012, a sub-set of 22 PHC nursing managers was selected randomly from a larger nurses’ survey in two South African provinces. After informed consent, participants were requested to keep individual diaries for a period of 6 weeks, using a clear set of diary entry guidelines. Reminders consisted of weekly short message service reminders and telephone calls. Diary entries were analysed using thematic content analysis. A diary feedback meeting was held with all the participants to validate the findings. Results: Fifteen diaries were received, representing a 68% response rate. The majority of respondents (14/15) were female, each with between 5 and 15 years of nursing experience. Most participants made their diary entries at home. Diaries proved to be cathartic for individual nursing managers. Although inter-related and not mutually exclusive, the main themes that emerged from the diary analysis were health system deficiencies; human resource challenges; unsupportive management environment; leadership and governance; and the emotional impact of clinic management. Conclusions: Diaries are an innovative method of capturing the work experiences of managers at the PHC level, as they allow for confidentiality and anonymity, often not possible with other qualitative research methods. The expressed concerns of nursing managers must be addressed to ensure the success of South Africa’s health sector reforms, particularly at the PHC level

The activities of hospital nursing unit managers and quality of patient care in South African hospitals: a paradox?

Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals. This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n=36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis. The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers' recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration. The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care

The activities of hospital nursing unit managers and quality of patient care in South African hospitals: a paradox?

PKBackground: Improving the quality of health care is central to the proposed health care reforms in South Africa. Nursing unit managers play a key role in coordinating patient care activities and in ensuring quality care in hospitals. Objective: This paper examines whether the activities of nursing unit managers facilitate the provision of quality patient care in South African hospitals. Methods: During 2011, a cross-sectional, descriptive study was conducted in nine randomly selected hospitals (six public, three private) in two South African provinces. In each hospital, one of each of the medical, surgical, paediatric, and maternity units was selected (n 36). Following informed consent, each unit manager was observed for a period of 2 hours on the survey day and the activities recorded on a minute-by-minute basis. The activities were entered into Microsoft Excel, coded into categories, and analysed according to the time spent on activities in each category. The observation data were complemented by semi-structured interviews with the unit managers who were asked to recall their activities on the day preceding the interview. The interviews were analysed using thematic content analysis. Results: The study found that nursing unit managers spent 25.8% of their time on direct patient care, 16% on hospital administration, 14% on patient administration, 3.6% on education, 13.4% on support and communication, 3.9% on managing stock and equipment, 11.5% on staff management, and 11.8% on miscellaneous activities. There were also numerous interruptions and distractions. The semi-structured interviews revealed concordance between unit managers’ recall of the time spent on patient care, but a marked inflation of their perceived time spent on hospital administration. Conclusion: The creation of an enabling practice environment, supportive executive management, and continuing professional development are needed to enable nursing managers to lead the provision of consistent and high-quality patient care

Does moonlighting influence South African nurses' intention to leave their primary jobs?

KIMBACKGROUND: Staff retention and turnover have risen in prominence in the global discourse on the health workforce. Moonlighting, having a second job in addition to a primary job, has not featured in debates on turnover. OBJECTIVE: This paper examines whether moonlighting is a determinant of South African nurses' intention to leave their primary jobs. DESIGN: During 2010, a one-stage cluster random sample of 80 hospitals was selected in four South African provinces. On the survey day, all nurses working in critical care, theatre, emergency, maternity, and general medical and surgical wards completed a self-administered questionnaire after giving informed consent. In addition to demographic information and information on moonlighting, the questionnaire obtained information on the participants' intention to leave their primary jobs in the 12 months following the survey. A weighted analysis of the survey data was done using STATA(®) 13. RESULTS: Survey participants (n=3,784) were predominantly middle-aged with a mean age of 41.5 (SD±10.4) years. Almost one-third of survey participants (30.9%) indicated that they planned to leave their jobs within 12 months. Intention to leave was higher among the moonlighters (39.5%) compared to non-moonlighters (27.9%; p<0.001). Predictors of intention to leave in a multiple logistic regression were moonlighting in the preceding year, nursing category, sector of primary employment, period working at the primary job, and number of children. The odds of intention to leave was 1.40 (95% CI: 1.16-1.69) times higher for moonlighters than for non-moonlighters. The odds ratio of intention to leave was 0.53 (95% CI: 0.42-0.66) for nursing assistants compared to professional nurses and 2.09 (95% CI: 1.49-2.94) for nurses working for a commercial nursing agency compared to those working in the public sector

Using log diaries to examine the activities of final-year medical students at decentralised training platforms of four South African universities

Background. An important strategy in the transformation and scaling up of medical education is the inclusion and utilisation of decentralised training platforms (DTPs). Objective. In light of the dearth of research on the activities of medical students at DTPs, the purpose of this study was to determine how final-year medical students spent their time during the integrated primary care (IPC) rotation at a DTP. Methods. The study was conducted at Sefako Makgatho Health Sciences University (SMU), the University of KwaZulu-Natal (UKZN), the University of the Witwatersrand (Wits) and Walter Sisulu University (WSU). At each of the participating universities, a voluntary group of final-year medical students completed a log diary by entering all activities for a period of 1 week during the IPC rotation. The log diary contained five activity codes: clinical time teaching time, skill time, community time and free time, with each subdivided into additional categories. The data were analysed for students at each university separately, using frequencies and proportions. Results. A total of 60 students volunteered to complete the diaries: at WSU n=21; UKZN n=11; Wits n=18; and SMU n=10. At each university, students reported that they spent large amounts of time on clinical activities: WSU=46.0%; UKZN=33.8%; Wits=29.6%; and SMU=44.1%. They reported low amounts of time spent on community-based activities: WSU 0.8%; UKZN 7.6%; Wits 6.8%; and SMU 0.0%. Conclusion. Students reported that they spent a sizeable proportion of their time on clinical activities, while reported time spent on community-based activities was negligible. The transformation potential of DTPs will only be realised when students spend more time on community-based activities

Assessing missed opportunities for the prevention of mother-to-child HIV transmission in an Eastern Cape local service area

Background. Prevention of new HIV infections is a critical imperative for South Africa; the prevention of mother-to-child transmission (PMTCT) is one of the most efficacious HIV prevention interventions.Objective. Assessment of a PMTCT programme to determine missed opportunities.Setting. The Kouga local service area (LSA), bordering Nelson Mandela Bay Municipality (Port Elizabeth) in the Eastern Cape.Methods. An assessment was conducted in 2007 before implementing technical support for strengthening the PMTCT programme, including: interviews with 20 PMTCT managers, 4 maternity staff and 27 other health workers on service provision, management, infrastructure, human resources and the health information system; 296 antenatal clinic users on their service perceptions; 70 HIV-positive women onHIV knowledge, infant feeding, coping, support and service perceptions; 8 representatives from community organisations and 101 traditional health practitioners (THPs). Observations were conducted during site visits to health facilities, and the District Health Information System (DHIS) data were reviewed.Results. Staff had high levels of awareness of HIV policies and most had received some relevant training. Nevirapine uptake varied by clinic, with an average of 56%. There were many missed opportunities for PMTCT, with 67% of pregnant women tested for HIV and only 43% of antenatal care attendees tested during a previous pregnancy. Only 6% of HIV-positive women reported support group participation.Conclusions. Reducing missed opportunities for PMTCT requires strengthening of the formal health sector, intersectoral liaison, and greater community support. Priority areas that require strengthening in the formal health sector include HIV counselling and testing; family planning and nutrition counselling; infant follow-up; human resources; and monitoring and evaluation

Comparative analysis of healthcare provision to individuals with cleft lip and/or palate at specialised academic centres in South Africa

Background. Cleft lip and/or palate (CLP) is the most common congenital anomaly of the craniofacial complex, with an estimated worldwide prevalence of 1/500 - 700 live births. Affected children require immediate medical treatment and prolonged management by a multidisciplinary team of health professionals.Objectives. To describe and compare healthcare provision to individuals with CLP at specialised care centres in South Africa (SA).Methods. The study was conducted at all CLP care centres in 6 of SA’s 9 provinces that provide specialised treatment and care to individuals with CLP. At each centre, the team leader was interviewed using a semi-structured questionnaire that focused on the point-of-care entry for CLP patients; type of services provided; whether treatment protocols were used, which treatment protocols were used and internal referral systems; and members of the healthcare team. Stata 13 (StataCorp., USA) was used to analyse the data.Results. Eleven CLP team leaders participated in the study, of whom 5 were from Gauteng Province. The point-of-care for CLP patients in the majority of centres was plastic surgery (n=9/11; 81.8%). The majority of centres (n=10/11; 90.9%) followed similar treatment protocols and only 1 centre performed lip surgery at 12 - 18 months. Although all centres reported a multidisciplinary team approach for CLP care provision, there were gaps in the health professions categories, which influenced the type of treatment provided. Hence, surgical repair of the lip and palate (n=10/11; 90.9%) and speech therapy (n=7/11; 63.6%) dominated the type of treatment provided, and patients were referred to other provinces or to the private health sector for other types of treatment.Conclusions. The gaps in services at the CLP care centres in SA need to be addressed to ensure integrated, holistic care provision