¿Valorar al paciente con enfermedad renal crónica por patrones funcionales?

As part of understanding nurses’ perceptions and experiences of changes happening in the primary health care system, we also asked nurses for their understandings of their job and if their job description reflects they daily duties at work. We first asked participants if they believed they had a clear job description and thirteen out of the eighteen participant of the participants believed that this was true. They further elaborated, the job description described what they did in the health facilities although it did not cover everything they were doing in the facilities. The participant’s narratives are shared below:

PN7: Yes, I have a clear job description… it clearly states what I do.

PN10: As for the stipulation of the job description, yes, I agree… job description and

stipulation I think they are correct and relevant.

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All of the narratives above stated positive reviews of nurses job descriptions as provided by the district. According to Tunc and Kutanis (2009), having a clear job description helps employees understand their responsibilities, what is expected from them, know the different stakeholders they are answerable to, and understand their goals and limitations. The above excerpts represent participants affirming that they had clear job descriptions, indicating a clear link between what is stipulated in their job description and what happens in practice.

However, it is important to note that although many of the participants felt as though they had a clear job description, twelve out of eighteen participants also mentioned that they were doing more than what was stated in the document. These participants mainly attributed these differences were due to the shortage of health professionals in facilities, as well as an increase in their workloads.

PN4: We do more because the workload increases every now and then. Therefore, they

need to go back and review our job description

PN9: We go the extra mile especially here in (mentions the name of the facility ),

essentially we are short staffed … sometimes you will be running the maternity ward alone… then baby clinic, if there is an emergency you also need to attending those things. So to me huh ah… we are working too much…

PN11: Yes, I think that it is clear in terms of what we are supposed to do. Sometimes

the things they do change, like maybe now we must enrol more patients, maybe there is less time to do more Pep smears but they so let us know if maybe we are underperforming. So yeah, I do think it’s clear what we should do.

PN13: Because of staff shortages, we must go an extra mile. For example, we currently

don’t have an assistant pharmacist so now I must go there and assist. We don’t have a cleaner so we must wipe and our councillors should stand in front and help with the files.

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PN17: For me, there are many things I do but not within my scope of practice…

basically actually our job description is so limited, it doesn’t explain or expand on other things… sometimes I help at the male circumcision section of which they don’t even apply in my scope of practice.

The above excerpts argue that because of the shortages of health professionals as well as an increase in work demands, professional nurses do more than what is required for them as per job description. Nurses play various extra roles for example as stated by PN 9, sometimes professional nurses are expected to manage various programs and services offered in facilities and sometimes should handle programs which are outside their scope of practice as mentioned by PN13. In addition, when there is no one to handle various tasks such as administration and cleaning, they also make up for those gaps even though this is not part of their job description. According to Littlejohn et al. (2012), there has been a global shortage in the nursing profession and in the case of South Africa, it is bound to have a negative impact on the quality of care delivered to patients as well as the well-being of nurses that ultimately bear the increased workloads due to staff shortages. This is what is currently being experienced by professional nurses in PHC facilities.

The way in which an individual accepts and performs their role in the workplace is outlined by the Organisational Role Theory (Rizzo et al., 1970). Rizzo et al. (1970) argue that Organisational Role Theory defines role conflict as expected behaviours which are inconsistent, has and have a negative outcome on performance and employee well-being. Floyed and Lane (2000) reported that role conflict is inevitable and a by-product of changes happening in any workplace or work environment. Therefore, Floyed and Lane (2000) argue that it is important that organisations come up with innovative ways to decrease these effects such as hiring more staff to do the different roles that one employee may occupy.

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Rizzo et al. (1970) conceptualised role overload as a type of role conflict and argued that it occurs in a situation where expectations, demands, instructions regarding the role, exceed the amount of time, resources and energy available to that individual (role occupant) for their effective execution. The above excerpts represent the role conflict experienced by professional nurses in PHC facilities because of the changes that have brought about through the introduction of NHI and various other programs. This has resulted in an increase in workload as well as a shortage of health professionals in health facilities forcing nurses to play active roles that are not stipulated in their job descriptions. This is also aligned to the findings by Atefi et al. (2014) in their study on South African registered nurses. The authors argue that nurses perceived their responsibilities as unclear and that they carried out extra responsibilities which was not stipulated on their job descriptions such as those carried out by auxiliary nurses and security responsibilities.

The above excerpts also highlight the new role played by nurses which is broader than what is mainly stipulated by their job description, as PN4 suggested that this needs to be expanded upon. According to Atefi et al. (2014) the role of a nurse has transformed from mainly being an assistant to a doctor to a more proactive role, as nurses are now in the frontline and one of the first health professionals in PHC facilities that a patient comes into contact with. Nurses are also the ones that manage and help implement new health intervention programs and manage or run departments in facilities such as the maternity ward, male circumcision section, baby clinic amongst many others. As mentioned by the participants these roles are usually not stipulated in the job description, nor does it take into consideration the shortage of staff amongst other challenges that force nurses to take more responsibility in facilities.

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4.4 Theme 3: To understand challenges associated with changes happening in primary