Challenges to creating primary care teams in a public health centre: a co-operative inquiry

"Background: Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care; family-orientated care; and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs.Methods: A co-operative inquiry group; consisting of two facility managers; an administrator; and medical and nursing staff; met over a period of nine months and completed three cycles of planning; action; observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care can be created within a typical CHC.Results: The CHC had established three practice teams; but met with limited success in maintaining the teams over time. The group found that; in order for teams to work; the following are needed: A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors; but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of ""chronics"". Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available. Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an ""assistant"" who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation; while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks; thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available; while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs; who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs; however; the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialise. Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day; to be cognisant of the limitations of the building design; to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered; and not just that for the doctors and nurses.Conclusions: Key lessons learnt included the need to engage with a transformational leadership style; to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team; due to their hospital duties; was a critical factor in the breakdown of the teams.. The CHC plans to further develop practice teams; to learn from the lessons so far and to continue with the co-operative inquiry."

The Role of Educational Strategies to Reverse the Inverse Performance Spiral in Academically Isolated Rural Hospitals

The importance of continuous professional development for health care workers is widely acknowledged; but the identification of optimal implementation strategies remains a challenge; particularly in academically isolated rural areas. We report the results of a qualitative study that evaluated the effect of an educational intervention aimed at rural doctors in the Western Cape Province; South Africa. We also present a conceptual framework for developing best practice educational strategies to reverse the inverse performance spiral in academically isolated rural hospitals. Doctors felt that participation in relevant learning activities improved their competence; increased the levels of job satisfaction they experienced; increased their willingness to stay in a rural environment; and impacted positively on the quality of services provided. However; the success of educational strategies is heavily dependant on the local environment (context); as well as the practical applicability and clinical relevance of the activities (process). Successful educational strategies may help to reverse the inverse performance spiral previously described in academically isolated rural hospitals; however; this requires effective local leadership that creates a positive learning environment and supports clinically relevant learning activities. The study findings also indicate the need for health care providers and institutions of higher education to join forces to improve the quality of rural health care

A qualitative study on the relationship between doctors and nurses offering primary health at KwaNobuhle (Uitenhage)

"Background Primary health care; which was the domain of the nursing profession; was popularised by the introduction of free health services by the South African legislature. In addition; the district health system was developed with the aim of keeping people healthy by creating small management systems adapted to cater for local needs. These measures increased public access to healthcare centres; leading to an increased workload at primary health level. The government; being a large organisation; relies on groups that include doctors and nurses to accomplish its goals; and the effectiveness of these groups plays a major role in determining the effectiveness of the overall organization. ""The nurse has an ethical responsibility in the interest of the welfare of her patient to be a loyal and competent colleague to the doctor. The nurse and the doctor must be able to rely on each other. Mutual respect is vital."" Nurses have dependent; independent and interdependent roles in their interaction with doctors; and both professions should embrace the Patient's Rights Charter; which requires a good standard of practice and care of patients. International journals have published numerous letters citing doctor-nurse disagreements in their interactions. Historically; the doctor-nurse relationship is an unequal one characterised by the dominance of the doctor; with nurses assuming a position of lower status and dependence on physicians. One qualitative study showed that nurses perceive the quality of communication with doctors as being poor. Lack of teamwork in the relationship resulted from different expectations and a confusion of roles. Both professions have however demonstrated a willingness to promote teamwork in hospitals. A journal review on interventions to promote collaboration between nurses and doctors showed positive gains once collaboration was embraced. Method This was a descriptive qualitative study in which the experiences of Kwa-Nobuhle general practitioners and professional nurses were explored. An equal number of nurses and doctors (five each) were purposefully selected; for the free-attitude interviews used for data collection. All interviews were analysed using the thematic analysis method. Themes were integrated into a single model. Results Majority of respondents experienced a relatively good relationship. The positive factors were balanced by negative experiences by almost all respondents. The positives were personal growth; efficiency at work; opportunity for education and learning at the primary healthcare level. The negatives were doctors' inconsistent clinic visits; role confusion (with doctors being confused with policymakers); dominance of the doctor in the relationship; and lack of doctor-nurse forums for communication; with subsequent suspicion and tension. The impact of the conflicts was neutralised by the track record of the relationship and the behaviour of the participants towards each other. Conclusion This study showed congruence with other studies; where the doctor-nurse relationship was influenced by a power differential;collaboration; role confusion; impact of the respondents' com etence; the significance of recognising the nurses' hierarchy and continuity of the care they provide at the primary health level. Maximum variation; strict admission criteria and data validation through a member check addressed issues of bias in this study. The exploration of relationships is a sensitive issue and a different methodology may produce different results. The environment where this research was conducted may differ from others; leading to discrepancies in findings. Future research could further focus on team building and the essential elements to sustain the doctor-nurse-patient team."

A Qualitative Study on the Relationship between Doctors and Nurses Offering Primary Health at KwaNobuhle (Uitenhage)

"Background: Primary health care; which was the domain of the nursing profession; was popularised by the introduction of free health services by the South African legislature. In addition; the district health system was developed with the aim of keeping people healthy by creating small management systems adapted to cater for local needs. These measures increased public access to healthcare centres; leading to an increased workload at primary health level. The government; being a large organisation; relies on groups that include doctors and nurses to accomplish its goals; and the governess of these groups plays a major role in determining the effectiveness of the overall organization. ""The nurse has an ethical responsibility in the interest of the welfare of her patient to be a loyal and petent colleague to the doctor. The nurse and the doctor must be able to rely on each other. Mutual respect is vital."" Nurses have dependent; independent and interdependent roles in their interaction with doctors; and both professions should embrace the Patient's Rights Charter; which requires a good standard of practice and care of patients. International journals have published numerous letters citing doctor-nurse disagreements in their interactions. Historically; the doctor-nurse relationship is an unequal one characterised by the dominance of the doctor; with nurses assuming a position of lower status and dependence on physicians. One qualitative study showed that nurses perceive the quality of communication with doctors as being poor. Lack of teamwork in the relationship resulted from different expectations and a confusion of roles. Both professions have however demonstrated a willingness to promote teamwork in hospitals. A journal review on interventions to promote collaboration between nurses and doctors showed positive gains once collaboration was embraced.Method: This was a descriptive qualitative study in which the experiences of Kwa-Nobuhle general practitioners and professional nurses were explored. An equal number of nurses and doctors (five each) were purposefully selected; for the free-attitude interviews used for data collection. All interviews were analysed using the thematic analysis method. Themes were integrated into a single Model.Results: Majority of respondents experienced a relatively good relationship. The positive factors were balanced by negative experiences by almost all respondents. The positives were personal growth; efficiency at work; opportunity for education and learning at the primary healthcare level. The negatives were doctors' inconsistent clinic visits; role confusion (with doctors being confused with policymakers); dominance of the doctor in the relationship; and lack of doctor-nurse forums for communication; with subsequent suspicion and tension. The impact of the conflicts was neutralised by the track record of the relationship and the behaviour of the participants towards each other.Conclusion: This study showed congruence with other studies; where the doctor-nurse relationship was influenced by a power differential; collaboration; role confusion; impact of the respondents' competence; the significance of recognising the nurses' hierarchy and continuity of the care they provide at the primary health level. Maximum variation; strict admission criteria and data validation through a member check addressed issues of bias in this study. The exploration of relationships is a sensitive issue and a different methodology may produce different results. The environment where this research was conducted may differ from others; leading to discrepancies in findings. Future research could further focus on team building and the essential elements to sustain the doctor-nurse-patient team."