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African Journal of Primary Health Care & Family Medicine

On-line version ISSN 2071-2936
Print version ISSN 2071-2928

Afr. j. prim. health care fam. med. (Online) vol.11 n.1 Cape Town  2019

http://dx.doi.org/10.4102/phcfm.v11i1.1963 

ORIGINAL RESEARCH

 

Professional nurses' experiences of caring for patients in public health clinics in Ekurhuleni, South Africa

 

 

Tintswalo V. NesenganiI; Charlene DowningI; Marie PoggenpoelI; Chris SteinII

IDepartment of Nursing, University of Johannesburg, Johannesburg, South Africa
IIDepartment of Emergency Medicine, University of Johannesburg, Johannesburg, South Africa

Correspondence

 

 


ABSTRACT

BACKGROUND: Caring for patients is the core aspect of nursing and a cornerstone of all nursing duties. Although caring is seen as a critical component of nursing delivery and an essential characteristic of nursing, there seems to be a gap between theory and practice
AIM: The aim of this article was to explore and describe the experiences of caring for patients by professional nurses in public health clinics in Ekurhuleni
SETTING: The study was conducted in Ekurhuleni, an area east of the Gauteng Province in two public health clinics
METHODS: A qualitative, exploratory, descriptive phenomenological and contextual research design was used. In-depth, individual phenomenological interviews were conducted with eight purposefully sampled professional nurses to explore their experiences of caring for patients in public health clinics in Ekurhuleni. Data were analysed using Giorgi's coding method
RESULTS: Two themes were revealed in the study findings. The first theme was the experienced empowering aspects of caring while the second theme was the experienced disempowering aspects of caring. The experienced empowering aspects of caring had two categories: empowering interpersonal experiences and the empowering experiences through client affirmation. These were identified by the participants as enabling effective caring for patients. The experienced disempowering aspects of caring also had two categories: disempowering interpersonal experiences and the disempowering experiences resulting from public health clinic system challenges. The disempowering aspects were identified by participants as disenabling effective caring for patients
CONCLUSION: The study findings reveal that the professional nurses had empowering and disempowering experiences while caring for patients in the public health clinics

Keywords: caring; professional nurses; empowering; qualitative research; disempowering.


 

 

Introduction

Caring is an act associated with assisting others, accompanied by compassion, kindness, empathy, respect, helpfulness, patience, mercy and integrity. While regarded as an essential feature and expression of being human, caring is widely accepted as a core characteristic of nursing.1 Caring actions by professional nurses are essentially related to helping patients to alleviate their pain and distress in a systematic way, while also being associated with the qualities of respect, patience, trust, honesty, communication, dedication and a positive attitude. As a moral ideal and an essential ingredient, nursing actions attempt to protect, enhance and preserve humanity. Caring must be present if nursing is to be truly effective and give patients a feeling of importance. A caring attitude is vital in the nursing profession to ensure the development of trust in the nurse-patient relationship.2

Nursing is a caring profession that requires the provision of excellent care within an ethical, reflective and knowing framework.2 Caring entails a helping attitude through guiding, advising and providing moral support by encouraging, listening and offering counselling skills. These skills are said to have enabled professional nurses to motivate patients to cope with various diseases by offering care that was patient-oriented and rooted in the needs of the individual patient.3

Although caring is generally viewed as the core of nursing actions that produce therapeutic results in the person being served - with the emphasis being placed on caring as crucial to nursing - there seems to be a gap between theory and practice. It then appears that theory and practice are two different things. Caring in nursing should help patients feel better, while the absence of caring will affect patients psychologically, emotionally and physically.2 Governments and nursing bodies have therefore indicated that patients have a right to be treated with care and compassion; however, reports show that not all patients receive compassionate caring from the nursing staff.4

According to a survey conducted in 2010, Consolidated Report on Inspections of Primary Health Care Delivery Sites on patients in various clinics in Gauteng, South Africa, it was revealed that nurses were lacking in caring.4 Patients revealed that nurses made rude, insulting and abusive remarks towards them. Other aspects revealed by patients included a lack of confidentiality with regard to information entrusted to professional nurses because, while at the clinics, they often overheard nurses gossiping about patients' illnesses. In South Africa, clinics have become the cornerstone of the public health system. It is thus necessary and expected that clinics provide comprehensive and integrated basic health programmes, with members of the public being treated with caring, respect and compassion by all health professionals.4

The authors of this article have observed professional nurses to lack a helping attitude and the qualities of dedication in caring for patients. Some patients have been observed to face verbal abuse and substandard care, while others were turned away from the public health clinics without being examined. Such dismissive behaviour by professional nurses has also been reported in various public health clinics in the area concerned. This study's findings identified empowering and disempowering aspects of caring as the main themes. Both themes have two categories each, with those for the empowering experiences identified as empowering interpersonal experiences and empowering experiences through client affirmation. The identified categories for the disempowering aspects of caring were disempowering interpersonal experiences and disempowerment resulting from public health clinic system challenges. Participants in this study identified the empowering aspects of caring as enabling them to render effective caring for patients while the aspect of feeling disempowered because of the public health clinic system challenges was regarded as disenabling. Caring experiences can therefore be empowered through encouraging the maintenance of the important enablers of effective caring for patients such as cooperation, teamwork, collaboration with other colleagues while focusing on the patients' best interests, effective communication by the professional nurses and maintenance of coping strategies such as strong support systems. Caring experiences can be disempowered through factors such as long queues that await the professional nurses each morning, subjecting them to work under immense pressure on a daily basis. Other factors that can disempower caring experiences were mentioned by participants as shortage of nursing staff, shortage of functional medical equipment, limited budget allocation, uncaring behaviours displayed by some professional nurses, language barriers, especially while caring for foreign patients, shortage of medicines and the unavailability of ambulances. The need to address the disempowering experiences was evident in this study as participants indicated that being disempowered by all the factors identified led to deterioration in the quality of caring rendered to patients. The purpose of this study was therefore to gain insight into the professional nurses' experiences of caring for patients.

 

Research methods and design

Study design

A qualitative, exploratory, descriptive phenomenological and contextual design was used. The fundamental point of departure for the researcher to use the qualitative research design was the fact that the qualitative approach is associated with naturalistic inquiry, which focuses on the way people make sense of their experiences and the world in which they live. The use of the exploratory research design was aimed at exploring the phenomenon of interest and shedding light on the various ways in which the phenomenon is expressed.5 The descriptive phenomenological research design was appropriate for this study as one of the research purposes was to describe professional nurses' experiences of caring in the clinics. The rationale for the use of the descriptive phenomenological research design was that it involves careful description of ordinary conscious experience of everyday life, which is a description of 'things' as people experience them. Descriptive phenomenological research design includes such steps as bracketing, intuiting, analysing and describing.6 Bracketing assisted the researcher to identify and hold in abeyance preconceived beliefs and opinions about the phenomenon under study. Intuiting was used to help the researcher to remain open to the meanings attributed to the phenomenon by the participants who experienced it. Analysis enabled the researcher to extract significant statements, categorise and to make sense of the essential meanings of the phenomenon. Describing occurred when the researcher understood and defined the phenomenon. The contextual research design was chosen to assist the researchers to explore, interpret and describe the participants' experiences in detail, in terms of their immediate environment or context.5

Setting

This study was conducted in Ekurhuleni, a metropolitan municipality that forms the local government of the East Rand Region of the Gauteng Province, South Africa. South Africa is a country that comprises nine provinces, with Gauteng being the smallest province of the nine. The Gauteng Province encompasses about 3 379 104 people of diverse cultures, languages and belief practices.7 The name Ekurhuleni is derived from the Xitsonga language, in which it means 'place of peace'. Ekurhuleni is one of the most densely populated areas in the province and the country; it has 94 public health clinics and seven public hospitals that render health care services to the community. The public health clinics provide primary health care services at a local level through the district health system, which is part of the provincial health care system.

Population and sampling

The focus of this study was only on the public health clinics because professional nurses in these health care facilities were observed to be lacking in a helpful attitude and the qualities of dedication in caring for patients. Purposive sampling was used to select 2 of the 94 public health clinics in Ekurhuleni. The two public health clinics were purposively selected for this study because the researchers had reasonable access to the target population.6

These public health clinics provide a wide range of primary health care services, which include immunisation, antenatal care, postnatal care, HIV and AIDS care, TB services, family planning, and care for acute and chronic conditions.

The target population were all professional nurses working in the public health clinics in Ekurhuleni for 2 years and more, who expressed willingness to share information with the researchers.8,9,10 Eight professional nurses were purposively sampled in order to select information-rich participants for the study and to best understand the central phenomenon.8,9,10 As the purpose of the study was to gain insight into the professional nurses' experiences of caring for patients, participants were selected based on their first-hand experience with the phenomenon of interest. Purposive sampling was therefore used to provide a contextualised understanding of the participants' experiences, which was not guided by a desire to generalise the research findings.6 The guiding principle in selecting the sample for this study was selecting cases that would most benefit the study. Yin11 indicates that all participants ought to have experienced the phenomenon and be able to articulate what it was like to have lived the experience. As one of the research objectives was to explore and describe the experiences of the participants, the researcher specifically looked for participants with diverse demographics who shared a common experience.

Prior to gaining entry to the research sites, the researchers had to negotiate with the authority of the health district for permission to enter into the clinics for study purposes. Before going into the field, the researchers identified the clinics that were to participate in the study.6,11 The researchers made arrangements with the managers of nursing services and facility managers in charge of the public health clinics to communicate their research endeavours with them. Recruitment was managed cooperatively with the intended participants by the facility managers, who assisted the researchers with identifying the relevant participants. The researchers controlled bias in identification of participants by the facility managers by ensuring that the facility managers knew what to look for in prospective participants.11 Once participants expressed a willingness to share information with the researcher, the participants were contacted individually, face to face, on the same day by the researcher to facilitate the establishment of rapport and trust with them. Interview dates and times were set by the researcher, agreed upon with participants on the day of the first meeting and were then communicated to the facility managers. On the day of the interview, facility managers and participants were contacted telephonically to remind them about the scheduled times for the interviews. Informed written consent and permission to voice-record the interview were obtained from the participants on the day of the interviews.12

Data collection

Data were collected by the first author. In-depth, individual phenomenological interviews were conducted in English during working hours in quiet consulting rooms away from the patients' waiting area. With permission from the participants, each interview was audiotaped. In-depth, individual phenomenological interviews were used to allow the researcher to gain insight and in-depth data from participants through exploring of their personal experiences. The interviews were unstructured as they were conversational and interactive in nature.6 The researcher did not have a set of prepared questions for the interviews but discussed the question of interest with the participants by asking them a single broad, open-ended question to describe their experiences of caring for patients in their clinics.11 Interviews lasted approximately 45-60 min, where participants were allowed to respond freely in order to provide the most information possible. During the interviews the researcher gave minimal responses as guided by the central question. Probes, prompts and summaries of participants' last statements encouraged the participants to talk more about their experiences. The probes encouraged elaboration by participants, including questions such as 'anything else?', 'and then what happened?' as well as 'tell me more about it'. Data collection continued until data saturation was reached.6,8,9 Data saturation was reached at the end of the fifth interview, when there was repetition of information. Three additional participants were recruited for verification and confirmation of the previously collected data. At the end of the eighth interview, the researcher was able to determine that the addition of new participants confirmed the findings rather than adding new information. The researcher did not predetermine the number of participants for the study beforehand but continued with data collection until data saturation was achieved. Observational and field notes were made as part of data collection. The researcher received training in conducting interviews. The researcher did not deviate from the role of being the data collection instrument but guided the interviews and maintained focus on the topic under investigation.13

Data analysis

In the initial step of data analysis, the researcher transcribed the audio-recorded interviews verbatim. Transcription of the interviews was completed as soon as possible after the interviews. The transcribed interviews and field notes collected during the interviews were interpreted, which gave meaning to the data. Data analysis was conducted using Giorgi's method, which is used in qualitative studies to identify the units of data, described as 'the marking of what is of interest in the text'.6,12 Data were coded by developing and applying a list of codes to new segments of data when an appropriate segment was encountered. An independent coder, who was an expert with proven knowledge about qualitative research, also analysed the data to ensure the researcher's objectivity and to reduce bias.14 The researcher and the independent coder had a consensus discussion about the findings, and these were recontextualised into the literature.

Trustworthiness

Principles of trustworthiness according to Lincoln and Guba15 were adhered to.6,9 In-depth, individual interviews, field notes and observational notes were used to assure credibility. The researcher used well-established research methods and described them with sufficient detail so that the study can be replicated. Multiple l