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

Contestations and complexities of nurses' participation in policy-making in South Africa

PKBackground: There has been increased emphasis globally on nurses’ involvement in health policy and systems development. However, there has been limited scholarly attention on nurses’ participation in policy-making in South Africa. Objective: This paper analyses the dynamics, strengths, and weaknesses of nurses’ participation in four national health workforce policies: the 2008 Nursing Strategy, revision of the Scope of Practice for nurses, the new Framework for Nursing Qualifications, and the Occupation-Specific Dispensation (OSD) remuneration policy. Design: Using a policy analysis framework, we conducted in-depth interviews with 28 key informants and 73 frontline nurses in four South African provinces. Thematic content analysis was done using the Atlas.ti software. Results: The study found that nurses’ participation in policy-making is both contested and complex. The contestation relates to the extent and nature of nurses’ participation in nursing policies. There was a disjuncture between nursing leadership and frontline nurses in their levels of awareness of the four policies. The latter group was generally unaware of these policies with the exception of the OSD remuneration policy as it affected them directly. There was also limited consensus on which nursing group legitimately represented nursing issues in the policy arena. Shifting power relationships influenced who participated, how the participation happened, and the degree to which nurses’ views and inputs were considered and incorporated. Conclusions: The South African health system presents major opportunities for nurses to influence and direct policies that affect them. This will require a combination of proactive leadership, health policy capacity and skills development among nurses, and strong support from the national nursing associatio

Prevalence of emotional, physical and sexual abuse of women in three South African provinces.

INTRODUCTION: There is growing recognition in the ranks of the South African government that violence against women is a serious problem facing us all. Until now data on the epidemiology of violence against women in South Africa have been scanty. This report presents the findings of the first major community-based prevalence study. OBJECTIVES: To describe the prevalence of physical, sexual, financial, and emotional abuse of women. METHODS: A cross-sectional study conducted in the Eastern Cape (EC), Mpumalanga (MP) and the Northern Province (NP). The sample included one randomly selected woman aged 18-49 years living in each of 2,232 households. The sample was drawn using stratified, multistage, random methods, and 1,306 questionnaires were completed, giving a 90.3% response rate after adjusting for households without an eligible woman. RESULTS: The prevalences of ever having been physically abused by a current or ex-partner were 26.8% (EC), 28.4% (MP) and 19.1% (NP). The prevalences of abuse in the last year were 10.9% (EC), 11.9% (MP) and 4.5% (NP). The prevalences of rape were 4.5% (EC), 7.2% (MP) and 4.8% (NP). Considerable emotional and financial abuse was also reported, e.g. the prevalences of a partner having boasted about or brought home girlfriends in the previous year were 5.0% (EC), 10.4% (MP) and 7.0% (NP): The prevalences of physical abuse during a pregnancy were 9.1% (EC), 6.7% (MP) and 4.7% (NP). The proportions of abused women who were injured in the year before the survey were 34.5% (EC), 48.0% (MP) and 60.0% (NP). CONCLUSIONS: This study is the first large-scale, community-based prevalence study to be undertaken in South Africa

Envisioning, Evaluating and Co-Enacting Performance in Global Health Interventions

The notion of performance has become dominant in health programming, whether being embodied through pay-for-performance schemes or through other incentive-based interventions. In this article, we seek to unpack the idea of performance and performing in a dialogical fashion between field-based evaluation findings and methodological considerations. We draw on episodes where methodological reflections on performing ethnography in the field of global health intersect with findings from the everyday practices of working under performance-based contracts in the Senegalese supply chain for family planning. While process evaluations can be used to understand contextual factors influencing the implementation of an intervention, we as anthropologists in and of contemporary global health have an imperative to explore and challenge categories of knowledge and practice. Making room for new spaces of possibilities to emerge means locating anthropology within qualitative global health research.</jats:p

The Ambiguity Imperative: "Success" in a Maternal Health Program in Uganda

Global health programs are compelled to demonstrate impact on their target populations. We study an example of social franchising - a popular healthcare delivery model in low/middle-income countries - in the Ugandan private maternal health sector. The discrepancies between the program's official profile and its actual operation reveal the franchise responded to its beneficiaries, but in a way incoherent with typical evidence production on social franchises, which privileges simple narratives blurring the details of program enactment. Building on concepts of not-knowing and the production of success, we consider the implications of an imperative to maintain ambiguity in global health programming and academia

Why didn’t you write this in your diary? Or how nurses (mis)used clinic diaries to (re)claim shared reflexive spaces in Senegal

Between 2015 and 2017, we implemented the clinic diaries project as part of the qualitative component of an evaluation of a supply chain intervention for family planning in Senegal. This project combined different tools including the diaries and participatory workshops with nurses. At the intersection between writings and silences, this paper explores the role played by the clinic diaries to mediate ethnographic encounters, and the iterative nature of ‘doing fieldwork’ to produce knowledge in hierarchical health systems. This paper also reflects on the processes through which the diaries created a space where accounts of lived experiences routinely unfolding in health facilities could be shared, in the context of a health system increasingly dominated by metrics, performances and vertical reporting mechanisms. The clinic diaries research process therefore sheds light on the limits of approaching bureaucratic norms and practices as coming from the top, an approach reinforced by data reporting and coordination mechanisms in the Senegalese pyramidal health system. In contrast, the diaries suggest a role for participative ethnography to identify collegial spaces to reflect on shared experiences in and of bureaucratic spaces. </jats:p

Taking stock: protocol for evaluating a family planning supply chain intervention in Senegal.

BACKGROUND: In Senegal, only 12% of women of reproductive age in union (WRAU) were using contraceptives and another 29% had an unmet need for contraceptives in 2010-11. One potential barrier to accessing contraceptives is the lack of stock availability in health facilities where women seek them. Multiple supply chain interventions have been piloted in low- and middle-income countries with the aim of improving contraceptive availability in health facilities. However, there is limited evidence on the effect of these interventions on contraceptive availability in facilities, and in turn on family planning use in the population. This evaluation protocol pertains to a supply chain intervention using performance-based contracting for contraceptive distribution that was introduced throughout Senegal between 2012 and 2015. METHODS: This multi-disciplinary research project will include quantitative, qualitative and economic evaluations. Trained researchers in the different disciplines will implement the studies separately but alongside each other, sharing findings throughout the project to inform each other's data collection. A non-randomised study with stepped-wedge design will be used to estimate the effect of the intervention on contraceptive stock availability in health facilities, and on the modern contraceptive prevalence rate among women in Senegal, compared to the current pull-based distribution model used for other commodities. Secondary data from annual Service Provision Assessments and Demographic and Health Surveys will be used for this study. Data on stock availability and monthly family planning consultations over a 4-year period will be collected from 200 health facilities in five regions to perform time series analyses. A process evaluation will be conducted to understand the extent to which the intervention was implemented as originally designed, the acceptability of third-party logisticians within the health system and potential unintended consequences. These will be assessed using monthly indicator data from the implementer and multiple ethnographic methods, including in-depth interviews with key informants and stakeholders at all levels of the distribution system, observations of third-party logisticians and clinic diaries. An economic evaluation will estimate the cost of the intervention, as well as its cost-effectiveness compared to the current supply chain model. DISCUSSION: Given the very limited evidence base, there is an important need for a comprehensive standardised approach to evaluating supply chain management, and distribution specifically. This evaluation will help address this evidence gap by providing rigorous evidence on whether private performance-based contracting for distribution of contraceptives can contribute to improving access to family planning in low- and middle-income countries