oa South African Family Practice - The role of doctors in provision of support for primary health care clinics in KwaZulu-Natal, South Africa
Background : Most primary health care (PHC) services in South Africa are provided by registered nurses working in clinics. Workload and scope of practice of these nurses have increased in recent years, exacerbated by widespread staff shortages. However, PHC nurses often receive little support and supervision, particularly in relation to clinical practice. Doctors working at district level are usually hospital based, but in many cases they do undertake clinic visits. These visits have the potential to improve quality of care, increase continuity and provide support for PHC nurses. In this study the visits undertaken by doctors to PHC clinics are described. The interactions between visiting doctors and PHC nurses are also explored, including perceptions and experiences of the current role and activities of visiting doctors, and ways in which this role could be developed.
Methods: The study was conducted in three districts of northern KwaZulu-Natal between June and September 2007. Both quantitative and qualitative methods were used to collect data. Fifty-eight randomly selected PHC clinics were visited, and interviews were conducted with clinic managers to obtain quantitative data.
Focus group discussions (FGDs) were held with doctors and nurses in each district. The doctors' FGDs included doctors based in district hospitals who had experience of visiting clinics, and medical managers. Nurses currently working in PHC services were included in the nurses' FGDs.
Results: Fifty of the 58 clinics reported having regular visits from a doctor. On average, doctors spent three hours at the clinic. Activities during visits were mainly clinical: 49 clinics reported that doctors saw patients on chronic medication and 45 clinics reported that doctors attended to patients referred by the nurses. Twelve clinics reported that doctors spent time teaching staff during the visit. Thirty-two clinics reported that the doctor had attended all scheduled visits over the previous three months.
During focus group discussions, both doctors and nurses stated that doctors' visits were generally helpful, but both groups felt strongly that the time spent in the clinic during visits was too short, and that the doctor visiting the clinic changed too frequently. This disrupted the development of meaningful relationships between the visiting doctor and clinic staff.
The current role of the visiting doctor was mainly clinical, with up to 30 patients booked for each visit. Some concern was expressed about the care given to patients on chronic medication given the time pressures. Doctors felt that a lack of essential equipment and drugs at the clinic limited the value of the visits, and that patients frequently were referred inappropriately. Nurses expressed concern that doctors often arrived late and were unwilling to help with the heavy patient workload at the clinic.
Additional roles identified for doctors included an increased role in teaching, development of teamwork and communication, as well as an increased administrative role.
Conclusions: Doctors' visits are not being utilised to their full potential. Additional support for PHC nurses could be provided by doctors if clear roles and activities were set out for clinic visits. These should include skills training for clinic nurses, development of clear referral criteria, and improved communication and feedback. Doctors should spend more time at the clinic during visits and work at the same clinic for a longer period. Expanding the doctors' role would improve teamwork within districts, leading to improvements in the work environment and quality of care. However, this requires commitment of district hospital managers to support doctors in their role and ensure that clinic visits are given priority.
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