There is global recognition of the importance of the health workforce illustrated by the 2013 Global Forum on Human Resources for Health which asserted that the foundation for Universal Health Coverage and the post-2015 development agenda focuses around health care workers. Locally and internationally nurses are majority of health care providers in any health care system. In South Africa the majority of primary health care (PHC) clinics are managed by nurses. Currently, South Africa is on the brink of another wave of major health system reforms that underscore the centrality of PHC. Nurses will play a critical role in these reforms, requiring new leadership, management skills and competencies. There has been limited use of the diary method in nursing management contexts, particularly in low and middle income settings. Diary methods involve, “intensive, repeated self reports that aim to capture events, reflections, moods, pains or interactions near the time they occur” (Iida M 2012). Reflexive diaries can unravel the successes, ambiguities or challenges faced by nursing managers. This paper discusses and explores the lived experiences of primary health care clinic nursing managers in two South African provinces using the diary method.
During 2012, a sub-set of 22 nursing managers were selected from a larger survey sample in two South African provinces. After informed consent, participants were requested to keep individual diaries for a period of six weeks, using a clear set of diary entry guidelines. Nursing managers were asked to write about one thing that happened at work that week that really had an effect on them with specific instructions that said: please write a date whenever you make an entry about: (1) What was the event? (2) Why did it stand out for you or why did it stick in your mind? (3) How did it make you feel? (4) What did you learn from it? (5) How will it affect the way you work in the future? Reminders consisted of weekly short message service reminders and telephone calls. Diary entries were analysed using thematic content analysis and MAXQDA version 11. A diary feedback meeting was held with all the participants to validate the findings.
Fifteen diaries were received, five were lost by the courier company and two nursing managers did not participate in the diary study representing a 98% response rate. The majority of respondents were female, aged 31 to 60 years with at least five years of work experience. Most participants made their diary entries at home. Diary entries largely reflect negative emotions and were dominated by primary health care nursing managers’ reflections on: staff shortages or challenges; patient care or community issues; excessive workload; unsupportive supervision; and health system deficiencies. Key text from the diaries relating to the themes were extracted, below is a brief description of the themes: Staff shortages is a theme that occurred when shortages of professional nurses, nursing assistants, clerks, pharmacists, doctors, social workers, gardeners etc were mentioned. It also includes staff shortages induced by absenteeism, abuse of sick leave, staff leave, study leave, actual resignations and lack of staff retention. Patient care/Community related to PHC nursing managers concern about any aspect of patient care, disease programme management, patient complaints about perceived dedication and commitment of staff, political expectations from the community and long waiting times. Excessive workload includes diary entries that were made relating to overtime, taking work home, missing tea and lunch breaks and neglecting admin work over patient consultations, doing what is perceived to be other people's work, e.g. ordering drugs is pharmacist role, being blamed when things go wrong, as well as a focus on the actual practise environment in PHC clinics. Unsupportive supervision related to negative remarks made by the clinic supervisor to the clinic manager, tensions between supervisors, vertical communication or leadership, delays in supporting clinic managers when requests for relief staff are made, missing appointments, disorganisation and the resultant confusion in clinic managers' schedules caused by clinic supervisors because of poor coordination and lack of planning. The fifth theme on health system deficiencies included issues such as management inefficiencies and lack of attention to human resources for health, lack of delegation and authority leading to disempowerment, paralysis caused by role confusion, high level decisions on operational issues that affect clinic management but are made without managers’ consultation, disabling practice environment, problems with infrastructure, shortages of consumables, drugs and water.
The diary entries reveal the complexities, nuances and ambiguities of nursing management at the PHC level especially staff shortages and how they impact negatively on all clinic management activities. For research purposes, diaries are an innovative method in capturing the nature and dynamics of nursing management. The results from our study show that diaries were used as a tool for reflection and provided sufficient empirical information on nursing management experiences at the PHC level as well as the reality that they experience in the workplace vs. theory of nursing management. Diaries as a research method also provided nursing managers with a space for anonymity and confidentiality often not possible with other qualitative research methods. Nursing managers were able to write about sensitive information and experiences relating to specific aspects around which organisational norms in PHC clinic settings are organised. The results apply to the local South African context but may also be applied in an international context because most of the issues that concerned clinic managers such as staff shortages or challenges; patient care or community issues; excessive workload; unsupportive supervision; and health system deficiencies are universal. Therefore, the expressed concerns of nursing managers must be addressed to ensure the success of PHC re-engineering reforms and health systems strengthening at the PHC level.
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