Diagrama de despliegue

In South Africa, primary care is provided through 8-hour clinics and 24-hour community health centres that are led by nurses called Clinic Operation Managers. These nurses were initially selected as the most senior nurse in terms of year of qualification, but recently, the DoH has started competitive interviewing for these positions. From the clinic observations

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and semi-structured interviews with the Clinic Managers, it is apparent that their roles have been more of patient care (consultation of patients) than managerial tasks (financial and human resource management, and quality control). Most clinic operation managers reported that the shift in the focus of their tasks has been as a result of an increasing patient load against a perceived limited number of nurses.

There is a cadre of Professional Nurses also known as Registered Nurses. These have either a diploma or degree in general nursing. They can further specialize in a particular field such as midwifery. Their role includes consultations with patients. They assess, screen, diagnose and give treatment. They also supervise the junior nurses. The junior nurses comprise Enrolled Nurses (also known as Staff Nurses) and Enrolled Nursing Assistants. They help Professional Nurses with taking vital signs, dressing of wounds, immunization of children, and family planning among others. Enrolled Nurses can help with consultations of patients under supervision of Professional Nurses. Enrolled Nursing Assistants undergo a one year training and another year long training to upgrade to an Enrolled Nurse. An Enrolled Nurse undergoes a two-year bridging course to become a Professional Nurse.

What I have just described is the ideal roles and responsibilities of nurses in the clinics.

However, in practice I have observed that responsibilities vary according to available staff in the clinic. When Professional Nurses are few, Enrolled Nurses consult with little or no supervision. When Enrolled Nurses are few, Professional Nurses take up both the roles of Professional Nurses and enrolled nurses thereby delaying the patients. In clinics without clerks, the nurses are responsible for retrieving and replacing the files. Based on the need and gap, nurses reorganize and take up tasks they are not meant to perform.

Clinics are situated within communities they serve. Medical care in South Africa is free of charge. The structures are fenced and private companies provide security. The structures mainly include a reception, 3-4 consultation rooms, a labour room, a pharmacy, a filing room and a separate structure called the nurses’ home, where nurses have their lunch and tea breaks. These vary across clinics and the variations in the study clinics will be explained in detail under infrastructure section.

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When patients arrive at the clinic in the morning, they queue outside the fence until the gates open at 7am. They obtain queuing numbers from the security guards and proceed to queue at the main waiting area/ reception. All patients (both acute and chronic) are in one queue except women coming for antenatal care. Patients receive their files which contain their records before having their vital signs measured. Measuring vital signs entails approaching a station (mostly located at the reception in view of other patients) and having blood pressure, temperature, pulse and weight measured. This is done every time for all patients attending the clinic. For known diabetic patients, it includes blood glucose and for pregnant women, it includes urine. All this is recorded in the patient file. Patients then proceed and queue again for consultation. For most clinics, patients receive medication in the consultation room before leaving the clinic and only in a few; the medication is distributed using the pharmacy.

Some authors on the status of rural clinics in South Africa have described what affects delivery of primary care services. A recent (2016) study has highlighted among other issues;

shortage of health care workers with overwhelming workload, lack of drugs, stationery and inadequate workspace (infrastructure) due to poor designs, as some of the factors affecting the implementation of NIMART in primary health care clinics of Limpopo Province in South Africa(58). In another study on experiences of nurses working in a rural primary health-care setting in Mopani district, Limpopo Province, among others nurses mentioned shortage of nurses and inadequate supplies of drugs as barriers to patient care(59). As earlier stated, another 2016 study identified that malfunctioning of BP machines and staff shortages were affecting ICDM implementation within the LHW study clinics(49). Munyewende et al (60) engaged primary health care nursing managers in South Africa to explore their work experiences by use of diaries. She found out that shortage of medicines and lack of running water were some of the impeding factors to management of primary health care.

Other authors have noted other contextual factors affecting operations of clinics.

Insubordination, lack of professionalism, and avoidable mistakes by staff have affected clinic operations (60). Others include negative remarks by supervisors, demands for health information (monthly statistics) and difficulties in managing staff and their performance

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(60). On the other hand, high workload, limited resources i.e. equipment and lack of recognition and communication with management are key factors affecting nurses (61).

Systematic reviews on turnover of nursing staff, job satisfaction and leadership style have raised similar factors affecting the nursing profession. Worldwide, reasons why nurses leave their work places are complex but summarized as a result of work and the nature of work environment, economic and, personal reasons (62). Among others it includes lack of relational and transformational leadership styles that is supportive and considerate of the nurses’ needs and that focusses on building relations (63), workplace stress as a result of high workloads or poor relations with colleagues, and workplace locations i.e. rural areas with limited services. Personal reasons might be as a result of ‘personal’ experiences outside the work place i.e. availability of accommodation and schools for kids especially in rural areas and economic reasons includes perceived low remuneration (62).