Positive practice environments in community health centres of the North West Province: a case study

Thesis (PhD (Nursing))--North-West University, Potchefstroom Campus, 2013.The practice environment of nurses plays a very important role in the delivery of quality health care. However, there is limited knowledge on what positive practice environments entail with specific reference to the primary health context of the public health care sector of South Africa. Nurses in this context are the frontline health personnel and are affected not only by nursing shortages, but also high workloads as the public health care sector serves 83% of the South African population and the private health care sector only 17%. In this study the researcher decided to conduct a study to explore the practice environment of nurses in the primary health care context as no studies have previously been undertaken in this regard. The researcher used a case study design with quantitative and qualitative approaches and implemented descriptive, explanatory and contextual strategies. This design, together with the findings of objectives one, two and three, the World Health Organization Strengthening of Health Systems and Fourteen Forces of Magnetism Frameworks and inductive and deductive logic enabled the researcher to achieve the overarching aim, which is objective four, of this study. Descriptive statistics, confirmatory factor analysis and Cronbach’s alpha assisted the researcher in assessing the demographic profile (objective 1) and the status of the practice environment of community health centres in North West Province (objective 2). Thereafter, the researcher was also able to identify the community health centre with the most favourable practice environment in order to conduct semi-structured individual interviews (objective 3). The descriptive data of objective 1 revealed that community health centres in the North West Province are located on average 36 km from the nearest referral hospital to which an average of five patients per day are referred. The average number of patients consulted per month is 3 545 of which the nurse consults an average of 40 and the physician 15 patients per day. In the community health centres the average age of nurses is 40, with 10 years of nursing experience. There were more female than male nurses of which 65% of the registered nurses had a diploma in nursing and had only started their careers at 31 years of age. There is an average of eleven registered nurses, five auxiliary and one enrolled nurse in the community health centres of which only four of the registered nurses (36%) had a qualification in Clinical Health Assessment, Treatment and Care. The overall staff turnover rates were very low and the satisfaction levels were high. The factor analysis of objective 2 revealed that the Practice Environment Scale of the Nursing Work Index’s sub-scales staffing and resource adequacy and nurse participation in primary health care/community health centre affairs had means below 2.5, indicating that nurses were not in agreement with these sub-scales. However, nurse manager ability, leadership and support; collegial nurse-physician relationships and nursing foundations for quality of care had a mean above 2.5 indicating that the nurses were in agreement with these sub-scales. Lastly, the qualitative findings indicated that although the community health centres with the most favourable practice environment were affected by factors that decrease quality of care which included a lack of resources, limited infrastructure, limited support from pharmacy and staff shortages. These mentioned factors were not in the control of the community health centres. Although the community health centres were affected by the above-mentioned factors these community health centres excelled in support, leadership and governance, collegial nurse-physician relationships and factors influencing quality of care which were in the control of the community health centre.Doctora