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Curationis

versión On-line ISSN 2223-6279
versión impresa ISSN 0379-8577

Curationis vol.43 no.1 Pretoria  2020

http://dx.doi.org/10.4102/curationis.v43i1.2011 

Section B consisted of guidelines and explanations on how to complete the questionnaire. Section B consisted of two sections, and section 1 included biographical questions. Table 1 shows the components addressed in section 2 of the questionnaire.

 

 

Data collected in previous studies with this instrument showed the scales to be valid and reliable (Gagné et al. 2014; Rhoades et al. 2001; Van den Broeck et al. 2010). Cronbach's alpha coefficient is the statistical procedure used for calculating internal consistency (Burns et al. 2013).

In the above-mentioned studies, the Cronbach alpha for autonomy, competence and relatedness was on average more than 0.80 (Van den Broeck et al. 2010). This indicates that the instrument is 80% reliable with 20% random error. For support, it was measured between 0.74 and 0.80 (Rhoades et al. 2001), which indicates that the scale has a 74% - 80% reliability for the questions regarding support, and for different types of motivation it was measured above 0.70, which shows a 70% reliability score (Gagné et al. 2014).

Data analysis

Data were analysed statistically by means of the IBM SPSS 22.0 program. The findings of the study were presented both as descriptive and inferential statistics. The descriptive statistics were presented as frequencies (f) that refer to the number of responses (n) on items using a five-point Likert scale (n = 49); the mean (x˙) of each item that will be presented in a table format from the highest to the lowest mean value; and the standard deviation (SD) of each item. The following descriptive statistics were analysed: autonomy, competence, relatedness, support, amotivation, extrinsic regulation - social, extrinsic regulation - material, introjected regulation, identified regulation and intrinsic motivation as an aspect of motivation. Inferential statistics were derived at by means of factor analysis and statistical significance. The varimax principal component analysis was used for factor analysis. Factor analysis was conducted on the responses between the following aspects of nurse leaders and motivation: age of the respondents, years in a managerial position of the respondents, gender of the respondents, level of qualification of the respondents and staff-reporting structure to the respondents.

Ethical considerations

The respondents were made aware that participation was not compulsory and that they could withdraw at any stage. Each respondent signed written consent that they were participating voluntarily. No compensation was offered to any respondent. Permission to use the questionnaire was obtained from the relevant parties. Ethical approval was obtained from the University of Johannesburg Higher Degrees Committee (HDC-01-168-2015) and the Research Ethics Committee (REC-01-243-2015).

 

Results

Table 2 indicates a breakdown of the characteristics of the respondents and the aspects that were investigated. In this study, age, gender, highest qualification, years in a managerial position and staff-reporting structure did not have an impact on the respondents' motivation.

The ages of respondents were between 31 and 62 years. It was established from the data obtained that the largest group was between 41 and 50 years (47%). The smallest age group was the group older than 61 years (n = 3), which accounted for 6%. The group with ages between 31 and 40 years constituted 20% of the respondents, and the third group identified was the age group of 51-60 years, which totalled 27% of the respondents.

The highest qualified leaders were in the age group of 50-59 years who will soon enter retirement age and will leave a gap in the intellectual capital. The age group with the highest amount of degrees was between 50 and 59 years; this group had eight degrees (16%), while the group between 40 and 49 years had six degrees (12%) and the group between 31 and 39 years had three degrees (6%). The age group older than 60 years had no degrees. Only 17 of the 49 respondents, which is 35%, had a degree.

Only 6% of the respondents were men who participated; this illustrates that the nursing leadership roles are predominantly led by women. As shown in the Table 2, the majority of the respondents (39%), (n = 19), were in a managerial position for more than 7 years. The majority of the respondents (51%), (n = 25), had more than 20 staff members reporting to them. The demographic information is shown in Table 2.

The descriptive analysis revealed that the following aspects influenced nurse leaders' motivation. Influencing factors consisted of five items (support, relatedness, competence 1, autonomy relatedness and competence 2), and five motivation factors (identified regulation, extrinsic regulation - social, amotivation, intrinsic motivation and introjected motivation) were shown to influence motivation in nurse leaders.

Relatedness or sense of belonging

With a mean value of 4.4694, item 2(at work I feel part of the group) showed the highest mean value - 98% either strongly agreed or agreed that they feel part of the group. The results indicate that the majority of the respondents felt related at their job. Table 3 shows an illustration of the results.

Competence

This refers to feeling a sense of capability in the leader's own ability to relate with their environment as well as obtaining opportunities to express capacities on a regular basis (Allan et al. 2016). Six items were included.

Item 8, which read 'I feel competent in my job', scored the highest mean value (x˙ = 4.6939). All the 49 respondents either strongly agreed or agreed with this statement. In other words, most of the respondents felt that they were competent in their job and were certain about their capabilities and competencies. Table 3 shows the results as discussed.

Autonomy

Autonomous motivation is a form of self-regulation whereby leaders act as a result of their deep values, goals and interests (Graves & Luciano 2013). Five items were included.

The highest mean value (x˙ = 4.1837) was scored for item 15 (The tasks I have to do at work are in line with what I really want to do), where 92% either strongly agreed or agreed that they were doing tasks at work which were in line with what they wanted to do.

Most of the responses were positive in that the nurse leaders did feel a sense of autonomy. Table 3 shows the results for this section.

Support

Strong and supportive leadership is a strong predictor of leader's motivation and morale (Chipeta et al. 2016). Support consisted of four items.

Item 19, 'Nursing management cares about my well-being', scored the highest mean value (x˙ = 3.96). Of the respondents, 10% strongly disagreed or disagreed, 10% were undecided, while 80% either agreed or strongly agreed. This means that the majority (80%) felt that this statement was true, and that 20% felt that management did not care about their well-being.

It can thus be concluded that the majority of the respondents felt that the management supported them. Table 3 shows the results for this section as discussed.

Motivating factors

Amotivation

Amotivated people usually feel disengaged and helpless in doing activities and will therefore easily quit an activity or task (Chen & Bozeman 2013). A leader lacking motivation will thus only have a minimum level of determination to work (Rizal et al. 2014). Three statements were included.

The highest mean value (x˙ = 1.31) was scored for item 22 (I will not put effort into my job because I really feel that I am wasting my time at work). All 49 respondents either strongly agreed or agreed with these statements, that is, they all agreed that they were not wasting their time at work and therefore would make an effort at work. After analysing these data, it can be said that not one of the respondents was a motivated. Table 4 shows the results for this section.

Extrinsic regulation - social

Extrinsic motivation is an external force, leading the nurse leader to meet personal and organisational goals. This occurs because of external activities, such as pressure or instruction, which influence leaders to perform tasks and reap the rewards in return (Hee & Kamaludin 2016). Here three items were included.

Item 26, 'I put effort into my job because other people will respect me more', scored the highest mean value (x˙ = 2.98): 40% strongly agreed or agreed with this statement, 8% were undecided and 52% either disagreed or strongly disagreed. A majority of respondents (52%) disagreed with this statement, which indicates that gaining the respect from others was not a motivating factor for the respondents.

This analysis indicates that extrinsic motivation, especially the social components of motivation, did not play an important role for the respondents (see Table 4 for an illustration of these results).

Introjected regulation

This type of motivation refers to motivation arising from a desire to satisfy the demands from others, that is, acting to avoid feelings of guilt or out of a psychological need to prove something (Gaston et al. 2016). Introjected regulation consisted of four items.

Item 32, 'I put effort into my job because it makes me feel proud of myself', scored the highest mean value (x˙ = 4.80). This statement regarded pride in oneself because of a job done. Of the 49 respondents who responded, 96% strongly agreed or agreed with the statement, 2% were undecided and 2% disagreed. After analysing the data, it could be established that introjected regulation was an important motivator for the respondents. Table 4 shows an indication of these results.

Identified regulation

Identified regulation represents the lower end of the spectrum regarding autonomous motives and refers to motivation arising from a longing to accomplish a result, which is personally valued by the leader (Gaston et al. 2016). This consisted of three items.

Item 36, 'I put effort into my job because putting effort into this job aligns with my personal values', had the highest mean value (x˙ = 4.86). Of the 49 respondents, 86% strongly agreed and 14% agreed. This showed that personal values and job alignment were important aspects for the respondents. The analysed data thus showed that identified regulation is an important factor of motivation. Table 4 shows the results of this section.

Intrinsic motivation

Intrinsic motivation is an internal force that leads leaders to meet personal and organisational goals. This type of motivation can be described as inherently interesting and enjoyable that creates behaviour and encouragement to act (Hee & Kamaludin 2016). Three items were included.

Item 40, 'I put effort into my job because the work I do is interesting', scored the highest mean value (x˙ = 4.44). A majority of 68% agreed with this by either strongly agreeing or agreeing, 8% were undecided and 4% disagreed with this. Item 38 was about having fun while doing the job: 94% agreed with this, 4% were undecided and the remaining 2% strongly disagreed.

Thus, most of the responses showed that the respondents favoured intrinsic motivation and regarded it as an important component of their motivation level. In Table 4, the results for this section are presented.

For this study, the Cronbach alpha for autonomy was 0.660; for competence, it was 0.770; and for relatedness, it was 0.732. For support, it was 0.886. The different types of motivation scored as follows: amotivation, 0.828; extrinsic regulation - social, 0.847; extrinsic regulation - material, 0.793; introjected regulation, 0.523; identified regulation, 0.878; and intrinsic motivation, 0.920.

 

Discussion

Age, years as a manager, qualification and number of staff reporting to the nurse leaders do not seem to be potential predictors of autonomy, competence and relatedness, and do not serve as motivation factors in this study on nurse leaders. Support was identified as one of the important aspects of motivation for nurse leaders, as they needed to feel that they were cared for and that their well-being was important to the organisation.

Relatedness was identified as another aspect that influenced motivation in nurse leaders, and therefore it was important for them to feel part of the team and that they could connect with others at work. In this way, they did not feel isolated and alone. It is thus important that nurse leaders feel that they have someone to talk to, as this will enable them to voice their opinions and be autonomously motivated. Competence is an important aspect of motivation, and leaders need to be empowered and encouraged to up skill and improve their competencies to enable them to deal with difficult tasks.

It was found that most of the respondents in this study were intrinsically motivated. Introjected and identified regulation, which are part of extrinsic motivation, were identified as important aspects in this study.

Feelings of competence, relatedness and autonomy encourage autonomous motivation by allowing leaders to act from the underlying self (Graves & Luciano 2013). Furthermore, leaders expect an environment of emotional support, warmth, friendliness and trust, which ensures a conducive working environment (Wipulanusat, Panuwatwanich & Stewart 2017). Leaders can achieve high levels of motivation when they feel related and can act effectively with personal initiative (Toode et al. 2014). Nurse leaders are expected to have substantial knowledge as well as leadership and management competencies in a changing environment (Kantanen et al. 2017). Intrinsic motivation is regulated by personal enjoyment, interest or pleasure, and it involves the performance of an activity for the inherent satisfaction of the activity (Naile & Salesho 2014). When leaders are intrinsically motivated, they tend to experience emotional well-being (Nunez & Leon 2016). Introjected regulation is somewhat less controlled and is represented by behaviours driven by internal rather than external rewards and punishment. The leader is motivated to avoid self-conscious emotions and obtain positive self-related affects and appraisals (Nie et al. 2015). Identified regulation is a more autonomous form of motivation in which the leader is motivated because the behaviour is congruent with the individual's personal goals and values (Nie et al. 2015).

This study showed that nurse leaders engage in their tasks and activities because they are important to them. In fact, they find their work exciting and interesting. They also show pride in their job by achieving their goals.

Financial rewards and job security were not important motivators, and therefore it can be concluded that the respondents in this study were intrinsically motivated and that support, relatedness and competence were important motivators for them. Factors influencing the motivation of nurse leaders were determined, and therefore it can be concluded that the research problem was dealt with.

 

Limitations

Because of the small sample size of 49 nurse leaders who participated in this study and the fact that the study was restricted to five hospitals in Gauteng in South Africa, the results cannot be generalised to other hospital groups. The male population of nurse leaders was not well represented.

 

Recommendations

As identified from both literature and this study's results, a few focus areas emerged, which must be addressed to ensure that nurse leaders stay motivated. The following recommendations can assist in the motivation of unit managers.

Autonomy

It is allowing unit managers to work independently and make decisions on how to execute tasks (Miyata, Arai & Suga 2015), as well as supporting unit managers in decision-making skills and including them in strategic planning sessions (Papathanasiou et al. 2014).

Relatedness

It is encouraging one-on-one relations-building sessions between unit managers and supervisors (Graves & Luciano 2013) and allowing unit managers to discuss their successes and challenges in group sessions. A sense of belonging will be established when team-building sessions with colleagues are encouraged (Utvær & Hagan 2016).

Competence

It is establishing constructive feedback sessions on the unit managers' competence on creating a culture of recognition for work well done (Van Dierendonck & Driehuizen 2015). Time for development must be allowed, and training needs should be identified. Mentoring by supervisors on expectations will assist in developing competence. Courses to up skill nurse leaders must be identified, addressed and budgeted for, and available conferences should also be budgeted for (Van Dierendonck & Driehuizen 2015).

Support

It is showing interest in nurse leaders' opinions and suggestions (Shariff 2015). By being involved in caring for their well-being (Wipulanusat et al. 2017), nurse leaders' goals and values should be considered and included in their development plan (Solansky 2014). An open door policy with nurse leaders and supervisors must be encouraged (Wipulanusat et al. 2017). Confidence in their development should be shown by including them in succession planning (Van Dierendonck & Driehuizen 2015).

Intrinsic motivation

It is ensuring that fun components are included in the nurse leaders' work, by exploring what is exciting for these nurse leaders, and incorporating those at into their work (Chen & Bozeman 2013), as well as keeping their work interesting and having regular discussions with them to identify their specific needs (Naile & Salesho 2014).

Identified and introjected regulation

It is encouraging nurse leaders to put effort into their jobs and also to align their work and personal values (Nie et al. 2015). Nurse leaders need to be allowed to prove that they can execute certain tasks successfully and should be appreciated for a task well done (Gagné et al. 2014). These achievements by nurse leaders must be recognised in public, and they should be encouraged to give feedback on positive outcomes (Witges & Scanlan 2014).

  • Encouraging nurse leaders to put effort into their jobs and also to align their work and personal values.

  • Nurse leaders need to be allowed to prove that they can execute certain tasks successfully and should be shown appreciation for a task well done.

  • These achievements by nurse leaders must be recognised in public and they should be encouraged to give feedback on positive outcomes.

All of these activities will ensure that nurse leaders are motivated, and it will also keep them motivated.

 

Conclusion

Nurse leaders who are not motivated cannot contribute to the profession, and therefore it is important to establish what motivators are important to leaders. Nursing is a constantly changing environment with new technology and policy changes being introduced all the time. Nurse leaders must therefore be empowered to adapt to these constant changes. This can happen only when nurse leaders are motivated and empowered. Motivation and overall work performance can be enhanced when attention is given to factors that are important to nurse leaders. Autonomous motivation is important for nurse leaders, and therefore it is important to allow them to make decisions and attempt to complete tasks in the manner they deem fit and to support their decision-making skills. When they are allowed to act autonomously, they can use their creativity, which can be advantageous for the organisation. This study determined that nurse leaders are intrinsically motivated and that introjected and identified regulation plays a role in their motivation. Autonomy, relatedness, competence and support are factors that influence their motivation. Recommendations that can enhance these factors and ensure that these nurse leaders stay motivated were listed.

 

Acknowledgements

The authors would like to thank the respondents for their participation in the research.

Competing interests

The authors have declared that no competing interest exists.

Authors' contributions

M.B. initiated the study and was responsible for the data collection, data analysis and writing of the manuscript, as part of her master's study. C.D. and H.A. assisted in the conceptualisation of the study design, preparation of the manuscript, data analysis and critical revision of the article.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for profit sector.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

 

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Correspondence:
Charlene Downing
charlened@uj.ac.za

Received: 22 Sept. 2018
Accepted: 07 Dec. 2019
Published: 27 Feb. 2020

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ORIGINAL RESEARCH

 

Final-year student nurses' experiences of caring for patients

 

 

Sewela C. Kobe; Charlene Downing; Marie Poggenpoel

Department of Nursing, University of Johannesburg, Johannesburg, South Africa

Correspondence

 

 


ABSTRACT

BACKGROUND: Shortage of nurses in South African hospitals has affected the nurse-patient ratio, thus prompting nurses to be focussed on completing nursing-related duties with less or no caring for the patient. Caring involves having a therapeutic relationship with the patients, and it can be challenging and demanding for final-year student nurses who are still novices in the nursing profession.
OBJECTIVES: To explore and describe the experiences of caring for patients amongst final-year student nurses in order to develop and provide recommendations to facilitate caring.
METHODS: A qualitative, descriptive and contextual design was used. Data collection was done through eight in-depth individual interviews. Giorgi's five-step method of data analysis was used, along with an independent coder. Measures to ensure trustworthiness and ethical principles were applied throughout the research.
RESULTS: Four themes with 12 subthemes emerged from the data: therapeutic relationship with patients as an integral part of caring, teamwork - team spirit makes caring easy, continuous caring that promotes quality and safe nursing, as well as satisfaction amongst staff and patients, and various barriers that contributed to lack of caring in the unit.
CONCLUSION: The majority of student nurses had positive experiences of caring, which included therapeutic relationships between nurses and the patients, teamwork and team spirit that fostered safe and quality nursing care, rendered effortlessly. Barriers to caring were also highlighted as negative experiences.

Keywords: nursing; nursing students; experiences; qualitative research; caring; patients.


 

 

Introduction

Final-year nursing students are expected to care for patients during the clinical allocation of their training. Caring is one of the attributes student nurses should exhibit during training, and it is a quality that should continue after training to enable them to render quality nursing care. Final-year student nurses are destined to become the professional nurses of tomorrow, and they will be expected to function independently to facilitate patients' health.

The caring attitude and responsibility, which they would need as professional nurses, need to be developed whilst they are still student nurses. Therefore, careful attention to the quality of students' clinical learning experiences about caring is needed to prepare them to be effective and caring practitioners in the future (Watts & Davis 2014:1153). Adamson and Dewar's (2014:161) study showed that educators need to ensure that curriculum content actively prepares the final-year student nurses for caring, in order for them to learn and develop values of caring. A study by Baillie et al. (2015:679) noted that caring is an essential part of the final-year student nurses' role, and that they must be prepared for caring during their years of training. The knowledge and skills that have been imparted to them about caring will assist them to improve the quality of their caring attitudes towards patients. Rodrigues et al. (2016:5) added that there is a need for the development of caring attitudes amongst final-year student nurses in their caring activities with patients.

The purpose of this research was to develop an understanding of final-year student nurses' experiences of caring for patients and to provide recommendations to facilitate caring by final-year student nurses for patients. The study explored and described final-year student nurses' lived experiences of caring for their patients.

 

Background and literature review

Shortage of nurses in South African hospitals has affected the nurse-patient ratio, thus prompting nurses to be focussed on completing nursing-related duties with less or no caring for the patient. Caring involves having a therapeutic relationship with the patient where nurses interact with patients when performing their nursing duty. Patients appreciate a caring nurse, and they feel the essence of caring from nurses. When there is a caring environment in the unit, patients feel welcomed, respected and their compliance to treatment improves, thus reducing the number of readmissions. Final-year student nurses are expected to care for patients as part of training in order to become qualified registered nurses who are safe practitioners and beneficial to the society. In order to render quality nursing care, caring is an attribute, which final-year student nurses need to learn and acquire whilst they are still in training.

In nursing, caring also encompasses Ubuntu, translated as 'human kindness to others', and patient satisfaction (Downing & Hastings-Tolsma 2016:215; Jooste 2010:7). Nurses are in a unique position to engage in caring to promote health and improve the well-being of ailing patients. Caring is the central practice of nursing, and it exists in every society (Jooste 2010:7). It is a shared experience in which nurses and patients interact to facilitate the overall health of the patient (Watson 2005:34). According to a South African historical perspective, caring involves the application of Ubuntu, which promotes the standard of moral behaviour amongst people. It embraces tolerance and fairness and includes reaching out and relating to others in a meaningful and trusting way (Downing & Hastings-Tolsma 2016:215; Jooste 2010:7).

Nurses are expected to possess knowledge and skills to contextualise caring in order to meet the unique needs of individuals (Loke et al. 2015:421-429). South African public hospitals are dedicated to provide compassionate and quality nursing care for patients, but the rise in medico-legal and negligence cases has raised a concern (Nt'sekhe 2018:np). The National Department of Health has become one of the distressed departments because of the high numbers of complaints, allegations and many challenges regarding caring of patients in public hospitals (Pelompe 2018:np). Jooste (2010:24) alludes that compassion, commitment, confidence and competence are the attributes of caring that final-year student nurses should develop during their training. It is recommended that final-year student nurses should be exposed to clinical areas to gain caring experiences and attributes (King-Okoye & Arbber 2014:448). This view is also supported by Yuh-Shiow et al. (2016:3317), who added that caring behaviour amongst final-year student nurses in a clinical setting is essential and can be developed by being exposed to a caring environment.

Caring by novice student nurses can be challenging and demanding, as it involves an interconnectedness of body, mind, emotions, spirit, and social and cultural relationships between the student nurses and the patients (Temane et al. 2016:2). Yuh-Shiow et al. (2016:3317) stated that the most crucial caring behaviour is 'knowing the patient', whilst the least important one is 'advocating.' This includes respecting the patients' and their family's best interests, and it has been found to be difficult for final-year student nurses to practise.

 

Definition of key concepts

Experience

Experience refers to the process of doing things, seeing things and having things happen to you (Merriam-Webster 2017). It also refers to an event or occurrence, which leaves an impression on someone (Oxford Dictionary 2017). Experience means observing, encountering or undergoing of things generally as they occur over a course of time (Free Dictionary 2017). In this study, experience means final-year student nurses' observing, encountering and undergoing the caring of patients.

Caring

Caring is defined as a feeling and exhibition of concern and empathy for others, and showing or having compassion (Collins 2014). It is also referred to as displaying kindness and concern for others, characterised by love, compassion, support and involvement (Jooste 2010:6). In this study, caring means the ability of final-year student nurses to render patient-centred care based on the interaction between a nurse and a patient, which promotes the nurse-patient relationship and increases patient satisfaction.

Student nurse

A student nurse is a person undergoing education and training in nursing, who has complied with the prescribed conditions and who has furnished the prescribed particulars for a training programme at a nursing education institution. The person must be registered with the South African Nursing Council as a learner nurse (Nursing Act No. 33 of 2005). In this study, a student nurse refers to a person who is in his or her final year of study as a nurse at an accredited nursing college and is enrolled as a student nurse under Regulation 425 (SANC Regulation 425 of 1985).

Patient

A patient refers to a holistic being and is regarded as someone consisting of physical, spiritual, emotional intellectual and social aspects (Awalkhan 2016:98). The patient is a person who is receiving nursing care or treatment in a hospital or has previously received care, whose health needs must be met and health status must be maintained by the nurse (SANC Regulation 387:1). In this study, a patient means a person to whom final-year nursing students are providing patient-centred care in order to promote and restore health.

 

Methods and design

In this study, a qualitative, descriptive design was used to describe and understand final-year student nurses' experience of caring for patients from the student nurses' point of view.

Setting

The study was conducted in a nursing college in the Gauteng province of South Africa. Student nurses who were doing their final (fourth) year of study and who had completed 80% of their coursework participated in this research. The participants were rich informants of the context of the study as they were nearing the completion of their training, with a maximum of only 20% of their course work left for the final year of study. Most of them were allocated to a clinical area, namely, the primary healthcare centres and the different units in the hospital.

Population and sampling

The target population for the study included 122 student nurses registered at a nursing college in Gauteng. Student nurses in their fourth year of study, having completed 80% of their required course work and willing to participate were the inclusion criteria. The purposive sampling method was used for data collection. A total of eight student nurses participated in the interviews until data saturation was reached.

Data collection

In this study, multiple methods of data collection were used to reach the point of data saturation. This included in-depth individual interviews, observations and field notes. During the interview, the researcher asked a central question to initiate the interview: how is 'caring' in your nursing practice? The primary mode of interview involved open-ended questions. The major aim of the interview was to explore the participants' responses to the questions. Each interview lasted for 45-60 min. Subsequent questions were determined by the final-year student nurses' responses to the central question. The researcher probed for more details until the experience was thoroughly described. Communication techniques that were utilised during interviews included clarification, reflection, probing and summarising (Mack et al. 2011:31).

Data analysis

Giorgi's (2013:243-273) five-step method of data analysis was used, which entailed making sense of the whole meaning, discrimination of the meaning of each unit whilst focussing on the phenomenon being researched, transformation of the subjects' expressions by going through the meaning of the units and reflecting on them to come up with the essence of participants' experiences, conducting a synthesis of transformed meaning of the units into a consistent statement of the structure of the participants' experiences and doing the final synthesis where all statements regarding each participant's experiences were synthesised into one consistent statement of the structure of experiences that described and captured the essence of the experiences of caring. An independent coder who was experienced in qualitative research was involved to reduce the risk of biased decision and personal interpretation through collaboration. The independent coder analysed the transcription of the interviews and compared it with the subset of the researcher's coding decision for coding consistency. Consensus discussion between the independent coder and the researcher was conducted.

Ethical considerations

Permission to conduct the study was obtained from the Research Ethics Committee of the Faculty of Health Sciences at the University of Johannesburg, reference number: REC-01-82-2017 as stipulated in the National Health Act No. 61 of 2003. The principles of autonomy, beneficence, non-maleficence and justice were also applied (Dhai & McQuoid-Mason 2011:38). Autonomy: the participants were given an explanation and information letter about the proposed study, which included information about their right to voluntary participation, right to withdraw without penalty, a request to sign the informed consent after reading and understanding the letter, request to record interview, as well as their reassurance to confidentiality, anonymity and privacy. Beneficence and non-maleficence: there were no direct benefits for participating in the study, but recommendations were developed and provided to facilitate caring amongst final-year student nurses, to ensure that no harm was experienced by the participants during the study. Justice: the researcher adhered to the principle by ensuring that there was fair recruitment in the process of selection of the participants.

 

Results

The results were informed by the participants and were divided into the following sections: socio-economic profiling and themes and subthemes.

Socio-demographic profile

The research study comprised eight final-year student nurses (fourth year) who had completed 80% of their module work. There were three male and five female participants, with ages ranging from 22 to 47 years. The average age of the participants was 29 years. All participants were Africans, and their home languages were Zulu, Tswana, Venda, Tsonga and Pedi. Six were single, and two were married. Only three participants had children. During the data collection process, all participants were assigned either to hospitals, primary healthcare institutions or clinical institutions or settings.

Themes and subthemes based on the experiences of final-year student nurses of caring for patients are described in Table 1.

 

 

Theme 1. Final-year student nurses experienced a therapeutic relationship with patients as an integral part of caring

From the interviews conducted, it became clear that a therapeutic relationship with the patients was an essential part of caring. Therapeutic relationships between the patients and the nurses created a caring atmosphere and let the patients know that nurses understood how they felt. Participants experienced that the therapeutic relationship enhanced caring, which patients could notice and be grateful for. The participants identified respecting patients, nurses showing empathy towards the patients, open communication with the patients, building trust between the nurses and the patients, loving kindness and involving family members in caring for the patients as part of a therapeutic relationship. The following participant quotes support this theme:

'Patients being easy to care also mean that, nurses can develop a relationship with the patient. I think that a relationship with the patient enhances caring; patients can notice your care and be thankful.' (Participant 4, aged 29 years, male)

'We need to care for the patient to make them better, patients come to the hospital to get better. If we don't get time to sit down and talk to them about their problems, and explore the other part of the patient's life, then we won't be able to manage the patient's illnesses.' (Participant 6, aged 23 years, female)

'There are little things that nurses can do, that can make a great difference to the patients.' (Participant 3, aged 25 years, female)

A therapeutic relationship is essential for the nurses in creating a caring environment, as it promotes understanding and helps to generate a beneficial relationship between the nurses and the patients (Geyer et al. 2016:278). Feo et al. (2017:54) asserted that establishing a positive and trusting therapeutic relationship with the patient has been long recognised as a vital and effective part of caring. Patients need communication and information to reduce their uncertainty and to understand their situation whilst in the hospital. Brown, Scott and Rossiter (2016:54) emphasised that when there is a poor therapeutic relationship between the nurses and the patients, the quality of caring becomes negatively affected. A therapeutic relationship can be utilised for providing care and compassion, and it allows nurses to understand how care should be delivered to the patients (Percy & Richardson 2018:200).

Respect for human dignity is an essential part of a caring nurse. Participants in this study reported the need for patients to be treated with respect and dignity. The main features of delivering patient-centred care are through compassion, dignity and respect. This is supported by the following quote:

'I would say caring and respect go together, that patient would not have listened if I was not respectful. Before we can care for patients we need to respect them. Some patients will come to the ward very dirty, we need to care and respect them. Respecting the patients also creates a trusting relationship.' (Participant 7, aged 24 years, female)

Hinkler and Cheever (2017:26) stated that respect goes beyond accepting the impression or attitude that people have a right to independent decision-making. Nurses, in their professional relationships, need to practise with compassion and respect for dignity, worth, privacy and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes or the nature of the health problems.

Theme 2. Final-year student nurses experienced teamwork: Team spirit made caring easy

From the interviews conducted, it became clear that teamwork and team spirit were crucial in caring for the patients. Teamwork and team spirit enabled nurses to work together effectively and efficiently to meet the objectives of the unit and to promote quality care. Participants reported that teamwork and team spirit made nurses work together in harmony, and that they were able to help each other in the caring process.

Participants identified open communication amongst nurses as part of teamwork that promotes caring, which includes discussion amongst the staff members about the problems in the unit and giving each other feedback on various ways of promoting teamwork and team spirit. Nursing was continuous and therefore was caring. Effective communication amongst nurses promoted continuation of caring, and this could be noticed during the handover between the different shifts. When the handover was done effectively, there was a continuation of caring from one team to another. Participants also reported that communication took place by sharing information amongst nurses. The sharing of information included discussion on individual patients and how to treat certain conditions. Participants stated:

'In my whole training I have learnt that nursing is continuous and so is caring. Caring becomes effective when there is communication among nurses. For example, during handover, we hand over to the other shift so that caring can continue even on a different shift.' (Participant 4, aged 29 years, male)

'Nurses need to share knowledge and information to promote caring. The information we share as nurses include managing individual patients and their condition.' (Participant 5, aged 22 years, male)

McEwan et al. (2017:24) defined teamwork as the range of interactive and interdependent behavioural processes amongst team members that transmit team inputs into outcomes. Teamwork includes continuous communication between team members in the unit. Thakur et al. (2016:52) mentioned that effective communication amongst nurses is one of the bases of professional nursing practice and the art of caring comprehensively and holistically for patients. Bello (2017:11) asserted that effective communication amongst team members remains a key factor in the improvement of interpersonal relationships and subsequently the improvement of patients' care and the quality of patients' recovery.

Participants experienced that report and feedback amongst nurses was a way of promoting open communication in the unit. Nurses should give each other feedback regarding the conditions of the patient to encourage the continuity of care. They also reported that nurses need to acknowledge feedback from the patient so that they can improve the quality of service. The following quote supported this category:

'Nurses' communications in the unit should include giving each other feedback about the patients' conditions and also receiving feedback from the patients.' (Participant 3, aged 25 years, female)

Meyer et al. (2009:170) stated that giving each other feedback in the nursing unit promotes an effective two-way communication. The multidisciplinary team can discuss the patients' progress and/or plan therapy, and the information can be obtained from the daily ward reports when feedback is received. Kodama and Fukahori (2016:217) stated that nurse managers need to give constructive feedback to nurses to increase motivation and inspiration. When there is a problem and the tension is high in the unit, nurse managers need to consider the timing, contemplate when to communicate and give productive feedback about the identified problems and solutions to staff members.

Theme 3. Final-year student nurses experienced continuous caring, which promoted quality and safe nursing, as well as satisfaction amongst the staff and the patients

From the data collected, the participants reported continuous caring, which promoted quality and safe nursing, as well as satisfaction amongst the staff and the patients. When there was continuous caring in the nursing unit, patients' compliance with treatment improved, and patient complaints became less, thus reducing the number of readmissions. Participants also reported that quality care and safe nursing enable nurses to take responsibility and feel proud about executing their nursing duties. The benefits of continuously caring for patients were that patients recovered sooner whilst taking responsibility for their own health. Participants identified caring, which promoted quality and safety of nursing; nurses felt appreciated and motivated as part of continuous care in the nursing unit. Caring meant that patients were assisted on time, which reduced complications and litigations. Nurses took responsibility for their actions and proudly executed their nursing duties. Participants also reported that caring in the unit made patients recover sooner and take responsibility for their own health. Participants explained:

'When there is caring in the nursing unit, you won't afford seeing some things not done to your patients, e.g., wound dressing, and this will reduce complaints in the unit, there won't be disagreements where you find patients complaining about nurses.' (Participant 7, aged 24 years, female)

'Yes mam, my caring has grown from being just the scope of practice to something that comes from within. I would say I have become the image of my profession.' (Participant 8, aged 26 years, male)

Nikfam, Pourghane and Ebadi (2017:6) asserted that continuous caring in the nursing unit is the key to patient satisfaction, cooperation and recovery, thus improving quality of care provided by the nurses. Sarpong et al. (2017:4) conveyed that quality care can be improved by allowing patients and families to participate during the ward rounds and decisions, promoting transparency in decision-making. It was shown that such patients' and family's satisfaction improved and there were confidence and trust amongst the nurses. Ultimately, the patients and families recommended the hospital to others.

The participants identified that when the patients complied better with treatment and fully understood their conditions, patient complaints decreased, the number of readmissions decreased and medical risks decreased, as part of caring that promoted quality and safe nursing.

Participants experienced that continuous caring in the nursing unit decreased patient complaints, which prompted nurses to care for the patients without complaints and resentment. Participants also reported that when nurses care for their patients, they need to open the channels of communication so that patients do not communicate to them through a suggestion box or a complaints box, but instead they express themselves if there are problems. This category was supported by the following quotes:

'When nurses give patients explanations, they understand the situation and that reduces the complaints in the nursing unit because they understand what is going on.' (Participant 4, aged 29 years, male)

'We need to open channels of communication so that patient must not communicate to us through the suggestion or complaints box.' (Participant 5, aged 22 years, male)

Norouzinia et al. (2016:65) alluded that good communication in the nursing unit is a vital element in providing high-quality nursing care, leading to patient satisfaction and health promotion. Increased patient satisfaction, acceptance, compliance and cooperation with the nursing staff improve the physiological and functional status of the patient and thus lead to fewer complaints and dissatisfaction in the nursing unit. Aiken et al. (2017:6) in their study on patient satisfaction found that patients expressed a high level of confidence and trust in nurses, and their satisfaction with hospital care was high. Ensuring an adequate number of nurses at the hospital and improved hospital clinical care environments were strategies used to improve patient satisfaction with caring.

Theme 4. Final-year student nurses experienced various barriers that contribute to a lack of caring

From the interviews conducted, participants reported various barriers that contributed to a lack of caring in the unit. These barriers affected caring in the nursing unit by reducing communication in the unit, whereby patients were scared to inform the nurses about their concerns. Patients were also afraid to ask questions about their health and treatment and therefore could not make informed decisions. Participants reported that barriers made patients feel neglected and the quality of nursing became compromised. Different barriers to caring had been noted as an overload of patients, negative attitudes of nurses towards the patients, routine tasks-orientated caring and lack of interaction with the patients. Participants explained:

'I was working in a surgical ward and there was a patient on a vacuum drainage, which was blocked for the weekend. When I asked her, "why you didn't ask for help", she said she feared the nurses who were working over the weekend.' (Participant 7, aged 24 years, female)

'Nurses have built a barrier between them and the patients, and patients have accepted nurses as being like that. Nurses need to involve patients in their treatment, but patients fear nurses. We need to come with the solution to remove this fear of nurses.' (Participant 3, aged 25 years, female)

Woith et al. (2017:217) noted that patients in their study reported an experience of incivility from nurses; they described nurses as not taking their health concerns seriously. Patients did not believe that healthcare providers listened to them. Stalpers et al. (2017:47) alluded that there is an increased administrative burden on nurses in the healthcare setting besides their usual nursing care practices. Nurses are more engaged in the administrative work and have little or no time for patient care. Participants explained that nurses were wearied owing to an overload of patients, which reduced their caring ethics.

Nurses found themselves not coping well owing to the high numbers of patients versus the few nurses. The shortage of nurses resulted in overloaded and overworked nurses in the nursing unit. High levels of expectations were placed on nurses in spite of their smaller number, and this resulted in nurses having negative attitudes towards the patients and thus affecting their pledge of service concerning the aspect of caring. This category was supported by the following quotes:

'In the public hospital, it is very sad. It is difficult to give 100% care. It is impossible. Sometimes, you have three critically ill patients in one cubicle, and other 10 patients to attend to. You still need to write the report of everyone, and while still writing the report, the other patient complicates and sometimes you are only two nurses in the cubicle. Now you are rushed to change and make patients clean, so that the family finds a clean patient.' (Participant 1, aged 47 years, female)

'I think there is also lack of caring among nurses, I think it is because of shortage again, they end up being burnt out. One will find that two registered nurses are working with lots of patients, and they say that they are going to do only that which they can, because there is too much work for too little nurses.' (Participant 2, aged 37 years, female)

Nolte et al. (2017:4366) described compassion fatigue as a state of exhaustion that is reliant on a caring relationship with a loss of coping ability amongst nurses. The consequences of compassion fatigue include sleep disturbance, hypervigilance, fear, anxiety, difficulty concentrating, physical sensations such as tight muscles, feeling burdened, fatigued and overwhelmed with hopelessness and isolation, along with disengagement. MacPhee, Dahinten and Havaei (2017:3) mentioned that heavy nurse workloads were associated with burnout and emotional exhaustion. Without adequate resources and support to meet workload demands, nurses grow dissatisfied, emotionally exhausted and experience being burnt out.

Participants reported that the negative attitude of nurses towards patients affected caring. The negative attitude of nurses resulted from anger that emanated from various factors such as high number of patients, increased workload, shortage of nurses and poor remuneration. Participants also reported that nurses' anger reduced their productivity and resulted in patients ended up being neglected, as evident in the following quotes:

'Nurses are angry, so much anger. Most of them are overworked due to high number of patients in the unit, they are also short staffed, and they are not paid very well. Patients end up being neglected because of the anger and when nurses are angry their productivity becomes affected.' (Participant 3, aged 25 years, female)

'Patients tell you that nurses are rude, they shout at them. When a nurse shouts at one patient, others are also affected. This makes patients to be scared to ask nurses anything because they will be treated like the one who has been shouted at.' (Participant 4, aged 29 years, male)

Nolte et al. (2017:4366) affirmed that there are reports of patient abuse by nurses, including hitting, slapping and neglecting of patients. Such behaviour in nursing may be a consequence of what has been described as compassion fatigue. The result of anger amongst nurses is failure to care, poor quality of care and nurses who cannot provide care during the critical times of illness. Woith et al. (2017:212) reinforced the fact that nurses' negative attitudes and implied biases towards the patients could affect their ability to provide compassionate care to vulnerable patients, further contributing to poor health outcomes. Woith et al. (2017:212) further stated that patients reported feeling lonely; they said they were dehumanised and ignored by the nurses on a daily basis. Patients described being judged and treated with a lack of empathy and compassion; they stated their care was rushed and they were seen as a number rather than as persons.

 

Discussion

The objective of this study was to explore and describe the final-year student nurses' lived experience of caring for the patients. In this study, final-year student nurses experienced caring for patients as a therapeutic relationship with patients, as an integral part of caring, which was made easy by teamwork and team spirit. They also experienced continuous caring that promoted quality and safe nursing, as well as satisfaction amongst the nursing staff and the patients. The participants also expressed various barriers that contributed to a lack of caring as a negative experience.

A therapeutic relationship with the patients was an integral part of caring. The relationship created a caring atmosphere in the nursing unit where patients felt loved, welcomed and valued. The therapeutic relationship enhanced trust between the nurses and the patients, where the patients felt free to communicate with the nurses, which led to improved quality of caring in the unit. The relationship with the patients involved respecting, showing empathy, having open communication and loving kindness. Respect went beyond accepting the impression or attitude that people had a right to independent decision-making. Nurses in their professional relationships needed to practise with compassion and respect for dignity, worth, privacy and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes or the nature of health problems (Hinkler & Cheever 2017:26). The positive impact of empathy in the nursing practice has been recognised and has been associated with the relief of pain and worry (Alkan 2017:61). Nurses' ability to communicate with the patient, having time to listen and be attentively present was of great importance for the well-being of patients (Timmermann, Uhrenfeldt & Birkelund 2017:66). Coropes et al. (2016:4924) alluded that when patients get sick, the family, and their community, also gets sick. In this situation, nurses can go further in caring and need to have an open listening ear that favours the integral part of caring.

Teamwork and team spirit were the fundamentals of caring for the patients in the nursing unit. It enabled nurses to work together effectively and efficiently to meet the objectives of the unit in order to promote quality care. Teamwork involved open communication amongst nurses, which included having discussions amongst team members about the problems in the nursing unit, as well as giving each other feedback in addition to reporting on the condition of the patients. In order to ensure the effective implementation of quality care and decisions, there should be a discussion of the problem amongst the nursing personnel. Personnel input should be considered to enhance the quality of the suggested care or solution (Meyer et al. 2009:171).

Giving each other feedback in the nursing unit promotes effective two-way communication. The multidisciplinary team can discuss the patients' progress and/or plan therapy, and the information can be obtained from the daily ward reports when feedback is received (Meyer et al. 2009:170).

Continuous caring in the nursing unit promoted quality and safe nursing, as well as satisfaction amongst the staff and the patients. It improved compliance to treatment and the understanding amongst the patients. The patients had to be given information about their condition and treatment to gain their cooperation, which made them aware of their condition, which in turn increased self-care at home. Continuous caring in the nursing unit decreased patient complaints, which also prompted the nurses to care for the patients without complaints and resentment. Nurses were required to open the channels of communication so that patients would not communicate to them through a suggestion or complaint box, but instead could express themselves directly to the nurses if there were problems. Kemp, Quan and Santana (2017:17) explained that patients who are involved in their care decisions and who are given information about their illness whilst in the hospital comply better with treatment than those who do not receive any information. Such patients understand the purpose of taking all their medications and understand their responsibility in managing their own health, resulting in decreased readmissions. Haftu et al. (2017:110) asserted that quality nursing care enhances the effectiveness of treatment. For example, patients treated by a compassionate caregiver show more understanding, thus improving compliance.

There were also various barriers that contributed to a lack of caring in the nursing unit. These barriers affected caring in the nursing unit by reducing communication in the unit, whereby patients were scared to apprise the nurses of their concerns and worries. An overload of patients, which left the nurses tired, resulted in the negative attitude of nurses towards the patients, wherein the focus of caring was on the routine tasks and not on interacting with the patients. MacPhee et al. (2017:3) mentioned that heavy nurse workloads were associated with burnout and emotional exhaustion. Negative attitude of nurses towards patients also affected caring. The negative attitude amongst nurses resulted from anger that emanated from various factors, such as high numbers of patients, increased workload, shortage of nurses and poor remuneration. Participants also reported that nurses' anger reduced their productivity and resulted in patient neglect.

Woith et al. (2017:212) stated that patients reported feeling lonely; they said they were dehumanised and ignored by the nurses on a daily basis. Patients described being judged and treated with a lack of empathy and compassion; they stated that their care was rushed and they were seen as a number rather than as persons. Nurses focussed on the work to be done and forgot about caring of the patients. Most nurses viewed caring as a waste of time because they have a routine that needs to be followed and completed. Spending time getting to know and interact with the patient was perceived as neglecting their nursing duties. Taleghani et al. (2017:255) concurred that task-orientated nursing results in nurses paying more attention to physical care and obeying physicians' orders. Their devotion to nursing duties affects the nurse-patient empathy. Instead of paying attention to patients' psychological needs, nurses perform tasks and meet the patients' physical needs. Task completion is considered more important than patients' psychological well-being.

 

Limitations of the study

During the initial phases of the research, some participants displayed uneasiness, which was managed by conducting a pre-interview to reassure and make them feel free. The study was conducted in one nursing college in Gauteng province; therefore, the findings of the study are not representative of all final-year student nurses in Gauteng. The study results are therefore contextual in nature.

 

Recommendations

Based on the outcomes of this study, the following recommendations are made directed towards nursing research, nursing management, nursing education, nursing practice and policy development:

  • Individualised caring should be emphasised for final-year nursing students as it promotes a therapeutic relationship.

  • Pre-service or in-service training programme on teamwork should be designed by the nurse managers.

  • Reinforcement of the usage of suggestion, complaint or compliment boxes by the patients and their families should be encouraged.

  • Introduction, planning and implementation of wellness programmes for trained and training nurses should be practised.

  • Replication of the study, which will include more nursing campuses from different provinces, employing different or similar research approaches, should be accomplished.

  • Theoretical and clinical evaluation methodologies on caring should be employed throughout the nursing training period.

  • Patient-centredness in caring for patients by all healthcare professionals should be introduced and promoted.

  • Patient and family support systems should be formulated.

 

Conclusion

The purpose of this research was to develop an understanding of final-year student nurses' experiences of caring for patients and to formulate recommendations to facilitate caring so that these student nurses could become more caring towards their patients.

The results indicated majority of positive experiences of caring that promoted quality and safe nursing care. The negative experiences, which were barriers to caring, were also highlighted. Recommendations to facilitate caring amongst final-year student nurses were outlined. This will ensure that resources are mobilised to promote, maintain and restore caring and quality nursing care.

 

Acknowledgements

The authors would like to thank the participants for their participation in the research.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors' contributions

C.K. initiated the study and was responsible for data collection, data analysis and writing of the manuscript as part of her Master's study. C.D. and M.P. assisted in the conceptualisation of the study design, preparation of the manuscript, data analysis and critical revision of the article.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Disclaimer

The views and opinions expressed in this article are the authors' own and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

 

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Correspondence:
Charlene Downing
charlened@uj.ac.za

Received: 27 Nov. 2018
Accepted: 29 Oct. 2019
Published: 02 Mar. 2020

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ORIGINAL RESEARCH

 

Employees' knowledge and practices on occupational exposure to tuberculosis at specialised tuberculosis hospitals in South Africa

 

 

Lusanda NdlebeI; Maggie WilliamsI; Wilma ten Ham-BaloyiII; Danie VenterII

IDepartment of Nursing Science, Nelson Mandela University, Port Elizabeth, South Africa
IIFaculty of Health Sciences, Nelson Mandela University, Port Elizabeth, South Africa

Correspondence

 

 


ABSTRACT

BACKGROUND: To prevent the spread of infection of tuberculosis (TB), sufficient knowledge and safe practices regarding occupational exposure are crucial for all employees working in TB hospitals
OBJECTIVES: To explore and describe the knowledge and practices of employees working in three specialised TB hospitals in Nelson Mandela Bay, Eastern Cape, regarding occupational exposure to TB
METHODS: A quantitative, descriptive and contextual study was conducted using convenience sampling to have 181 employees at the three hospitals elected to complete the self-administered questionnaire, which was distributed in December 2016. Three scores on a scale of 0-10 were calculated per participant: knowledge, personal practice and institutional practice. Descriptive and inferential statistics were utilised
RESULTS: Approximately, one-third (34%) of the participants were between the ages of 36 and 45 years. Most of the participants (63%) attended high school and less than one-third (28%) had a tertiary qualification. The majority of participants (62%) had not received any clinical training. Participants displayed high scores (> 6) for knowledge (75%; mean = 6.65), personal practice (68%; mean = 6.12) and institutional practice (51%; mean = 6.15). The correlation between knowledge and personal practice was found to be non-significant (r = 0.033). An analysis of variance revealed that Knowledge is significantly related to age and education level
CONCLUSION: Employees' knowledge regarding occupational TB exposure was generally high, but they were not necessarily practicing what they knew. Further research is required regarding appropriate managerial interventions to ensure that employees' practices improve, which should reduce the risk of occupational TB exposure

Keywords: employees; occupational exposure; knowledge; practices; tuberculosis.


 

 

Introduction

Tuberculosis (TB) is currently regarded as the leading cause of death from infectious diseases. Tuberculosis is ranked ninth as the leading cause from a single infectious agent, ranking above the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS). The latest World Health Organization global report states that in 2017, there were approximately 10.4 million incident cases of TB alone, and approximately 1.6 million people died from this disease (World Health Organization 2017, 2018). Although the disease burden caused by TB is decreasing globally in most countries, this is not sufficient to obtain the first (2020) milestones of the End TB Strategy as part of the sustainable development goals (SDGs). This strategy entails specific targets for 2030 for a 90% reduction in the absolute number of TB deaths as well as an 80% reduction in TB incidence (new cases per 100 000 population per year), compared with levels in 2015 (World Health Organization 2018).

South Africa is among the top 30 countries with the highest burden of TB (World Health Organization 2018), with an estimated prevalence of 438 000 cases of active TB in 2016. The incidence of TB in South Africa during the past 15 years has increased by 400% (World Health Organization 2017). It is estimated that in South Africa, in a population of approximately 56 million people, 560 000 people (1%) develop active TB disease each year and that 336 000 (60%) of these cases are co-infected with HIV (World Health Organization 2017).

Tuberculosis is an infectious disease caused by the bacteria Mycobacterium tuberculosis (Hershkovitz et al. 2015). Transmission of tuberculosis (TB) is by inhalation of droplet nuclei (Iseman 2013). The risk of exposure to TB is higher for employees at healthcare institutions, particularly specialised TB hospitals (Nienhaus et al. 2014; World Health Organization 2017). An evaluation of exposure to TB among employees at a medical centre in the United States revealed that healthcare personnel are at a three times higher risk of occupational exposure to TB than the general population and that there are gaps in the implementation of administrative, engineering and respiratory protection controls (De Perio & Niemeier 2014). Infection of TB can occur when employees and patients come in contact with persons who have unknown TB, and not receiving treatment, and who have not been isolated (Centres for Disease Control 2005, 2006; Curry International Tuberculosis Center 2007). All healthcare institutions need an infection-control programme in order to have rapid detection of TB, employ airborne precautions (such as opening of windows and wearing of N95 masks) and ensure treatment of people suspected of having TB or are diagnosed with TB (National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention 2012). It is thus important to ensure that all hospital employees have adequate knowledge of all potential sources of infection, relevant control measures and practices to ensure that appropriate measures are implemented to reduce risk related to exposure to TB (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 2012).

Avoidable TB infections among employees can be prevented with good knowledge and practises related to infection control principles, underpinned by a good standard of hygiene. Of particular significance is having the personal discipline to undertake simple, repetitive tasks such as hand washing, frequently and thoroughly (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 2012). Furthermore, a good standard of facilities in order to clean, sterilise or disinfect possibly contaminated equipment, and the availability of signs indicating hygiene and cough etiquettes are essential to facilitate adherence to infection control principles (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 2012).

There is an urgent need to improve existing TB infection, prevention and control measures in specialised TB hospitals by providing training to healthcare workers and ancillary staff to develop good practices in applying organisational infection control policies and procedures (Grobler et al. 2016). This would help to promote a culture of good infection control practice among employees working in specialised TB hospitals (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 2012). The currently poorly enforced infection prevention control policies, the over-crowded TB facilities with insufficient ventilation to allow for appropriate environmental infection control and the number of infectious TB patients all contribute to healthcare workers' increased risk of exposure to TB in South African healthcare facilities in general, and Nelson Mandela Bay's facilities in particular (Globler et al. 2016). It is therefore essential for hospital employees to receive ongoing education and training regarding occupational TB and infection control to ensure optimal infection control (World Health Organization 2004).

In South Africa, the health and safety of all employees at work is covered by the Occupational Health and Safety Act, No 85 of 1993 (Republic of South Africa 1993). There is also a national infection prevention and control policy for TB, multi-drug-resistant tuberculosis (MDR-TB) and extensive drug-resistant tuberculosis (XDR-TB), which acts as a guide for both management and employees to minimise the risk of TB transmission in healthcare facilities where there is increased risk of TB transmission (Department of Health 2014). Furthermore, screening and surveillance for TB among hospital employees is vital (Department of Health 2014). Interventions to improve efficiency, quality, safety and access to care have been introduced by the National Department of Health, the most significant to date being the framework for assessment of health establishments. Core standards were introduced to achieve this aim. Among the action areas covered by the safety domain is that of infection prevention and control, which intends to reduce occupational exposure to infections (including TB) through monitoring and management (Department of Health 2011). In spite of these interventions, the risks of contracting TB and rates of TB among hospital employees (also referred to as occupational TB) are poorly documented, especially in the Eastern Cape province. It is commonly known that knowledge is one of the potential promoting factors for good practices (Tada, Watanabe & Senpuku 2014). A number of studies have been conducted on the knowledge and practices of employees regarding infection control and occupational exposure to TB with various results. For example, a study conducted at Dr George Mukhari Academic Hospital in Rarankuwa revealed that the majority of participants had a good level of knowledge regarding TB-control measures, but more than 70% of participants did not comply with the correct practices in this regard (Mndzebele & Kandolo 2014). Farley et al. (2012) found that employees with a higher level of clinical training (e.g. medical doctors and allied health workers) are associated with a greater infection control knowledge and more appropriate attitudes and practices. Contrary, a study conducted in Botswana by Tlale et al. (2016) established that among categories with a reasonable level of clinical training, health education assistants and doctors had the same level of knowledge as other categories. This could be because of a number of factors including suboptimal quality or technique of training or insufficient knowledge retention (Tlale et al. 2016).

The hospitals in this study had active infection control programmes in place and were expected to provide the workers in these institutions with sessions where they are equipped with the relevant knowledge and practices to have information on infection control and occupational exposure to TB. However, the researcher observed discrepancies in terms of infection control practices. For example, employees only wore protective coats as protection against cold in winter but did not wear protective coats in summer. Because of lack of office space, there were no patient consultation rooms for part-time doctors which led to the nurse's duty rooms being used for consulting patients. The same duty rooms that were used for patient consultations were used as dining rooms during tea and lunch breaks for staff. Even though there were hand-washing basins in all wards, employees seldom washed their hands. Furthermore, although patients are regarded as highly infectious during admission, neither of the employees who work in the admission desk wore a mask when admitting patients. General assistants, workshop employees and drivers also seldom wore masks even when working in the wards or while transporting patients. It was unclear whether workers had sufficient knowledge regarding these practices in order to prevent occupational exposure. Therefore, the researcher aimed to explore and describe the knowledge and practices of employees in three specialised TB hospitals in Nelson Mandela Bay in the Eastern Cape, South Africa, regarding occupational exposure to TB.

 

Design and methods

A quantitative, descriptive and contextual study was conducted in 2016 at three specialised TB hospitals in Nelson Mandela Bay, in the Eastern Cape, South Africa.

At the time the study was conducted, the three hospitals A, B and C had approved bed capacities of 350 with a total of 100 employees (hospital A), 333 with a total of 90 employees (hospital B) and 186 with a total of 63 employees (hospital C). During the period the study was conducted, the total number of employees in all three hospitals was 253 of which 137 were nursing and clinical personnel, with the remaining 116 being non-clinical personnel, such as cleaning, maintenance and administration personnel. The hospitals are all specialised TB hospitals admitting patients diagnosed with TB responsive to all drug therapy, whereas hospital C also admits patients with drug-resistant TB types such as MDR-TB and XDR-TB. As the population size was small, a convenience sample of the entire population (N = 253) was used.

Data collection tool

A self-administered questionnaire was used, which was adapted and piloted with permission from a study that was conducted by Bhebhe, Van Rooyen and Steinberg (2014). The questionnaire, which was written in English, contained 27 questions in three sections, namely, sections A, B and C. Section A included four items with demographic data, including age, gender, education level and clinical training, such as medical or nursing training. Section B (knowledge of TB) included four multiple-choice questions, seven true and false questions and three filter and follow-on questions regarding an infection control policy. Section C included the following questions regarding practices of employees regarding infection control: four filter questions regarding personal practices, two questions regarding protective clothing, such as masks and hand washing, and three filter questions regarding institutional practices - the availability of consultation rooms, dining hall and patient transportation. Questions were asked regarding standard infection control precautions as well as specific precautions for TB.

To measure participants' knowledge and practices on a quantitative scale, various techniques were used to convert the responses to questionnaire items to scores in the range 0 (all incorrect or inappropriate responses) to 10 (all correct or appropriate responses). The knowledge score was the average of the scores for each of the six sections on knowledge. The personal practices and institutional practices scores were related to the questionnaire items on personal and institutional practices, respectively.

Based on the guidelines of infection control practice, a judgement was made about whether an answer reflected sound, fair or poor knowledge and good, fair or bad practice. With the assistance of a senior statistician, it was determined that a high score was regarded as between 6.01 and 10.00, an average score from 4.00 to 6.00 and a low score from 0.00 to 3.99. These scores were calculated as follows: quartiles 1 and 3 were used to separate respondents into three groups: lower group: score less than quartile 1; middle or average group: score between (inclusive) quartiles 1 and 3; and higher group: score greater than quartile 3. This technique ensures that approximately 25% of the respondents are in the lower group, 50% in the middle group and 25% in the higher group.

Validity of the questionnaire was ensured in the current study by conducting a literature review and seeking the advice of experts such as the researcher's supervisors and statistician to ensure that the questionnaire adequately covered the research question. Reliability was ensured by conducting a pilot study.

Data collection process

The data collection using the self-administered questionnaire was conducted by the first author in December 2016. Appointments with the hospitals were made prior to the data collection date. On the data collection date, all participants were gathered in one venue and were informed about the project, and the research process was explained to them. Data collection for the three hospitals took 3 days (1 day per hospital). The data collection was conducted on site, using the communal hall in each hospital, after obtaining signed, informed consent from each participant. The participants were requested to answer the questionnaires independently. The questionnaire took approximately 5-10 min to complete, and the questionnaires were collected on the same day. Questions were asked in English as this was the language the participants were proficient in.

Data analysis

The data were captured and analysed using descriptive and inferential statistics. A Microsoft Excel spreadsheet was prepared based on the pre-coding performed in the data-gathering instrument. Descriptive statistics, including frequency distributions, means and standard deviations, were used to summarise and describe the demographic profile of the sample and the knowledge scores obtained by the respondents. The following inferential statistics were used to investigate the relationships among variables: chi-square test, Pearson product moment correlation and analysis of variance (ANOVA).

Pilot study

To test the questionnaire, a pilot study was conducted over a 1-week period in November 2016, prior to the data collection. The pilot study utilised five employees from different areas of work, namely, administration, admissions, clinical, general assistant and nursing in one of the specialised TB hospitals in the Nelson Mandela Bay. After the pilot test, there were minor amendments to the questionnaire including adding extra options such as 'I don't work with TB patients' and 'I don't know' as these options were absent in the original questionnaire. The pilot study results were not included in the data analysis of the actual study.

Ethical considerations

Ethics approval was obtained from the Ethics Board of the Faculty Postgraduate Studies Committee (FPGSC) at Nelson Mandela University (ethics number H16-HEA-NUR-025) as well as from Eastern Cape Department of Health (ethics number EC_2016RP28_145). Permission was obtained from the Chief Executive Officers who acted as gatekeepers of the three TB hospitals included in the study. No names or identifiers were recorded in the questionnaires to ensure the anonymity and confidentiality of the employees. Individual written informed consent was obtained from each participant. The participants were informed that their participation was voluntary and that they had the right to withdraw at any time. A copy of the questionnaire was kept in a locked place and accessed by the second author only.

 

Results

The overall response rate was high, with 181 out of a potential 253 employees agreeing to willingly participate in the study. The sample thus represents 72% of all workers employed by the three specialised TB hospitals in Nelson Mandela Bay. The results per section of the questionnaire will now be outlined.

Demographic data (Section A)

The demographic profile of the sample is reflected in Table 1.

 

 

It was concluded from the demographic data that approximately a third (34%) of the participants were between the ages of 36 and 45 years and the majority were women (71%). Most of the participants (62%) indicated high school as their highest level of education and less than a third of the participants (27%) had a degree or diploma as the highest level of education. The majority of participants (60%) had not received any clinical training.

Knowledge of employees regarding tuberculosis and infection control (Section B)

Section B of the questionnaire had various questions to determine the knowledge of employees regarding TB and infection control, standard infection control precautions such as washing hands, as well as precautions for TB. The extent to which participants gave the correct responses to these questions is summarised in Table 2.

 

 

As reported in Table 2, more than 90% of the participants gave the correct response for most of the questionnaire items in Section B - Knowledge. The items with less than 90% correct responses are in bold text in Table 2.

Knowledge regarding infection control policy

When asked about whether there is an infection control policy in the hospital, the majority of participants (78%, n = 141) knew about its availability; however, only approximately half of the participants (49%, n = 89) reported to have actually read the document. Slightly more than half of the participants (58%, n = 105) indicated to have received training on the infection control policy.

Practices of employees regarding infection control (Section C)

The questionnaire items in Section C relating to practices were divided into personal and institutional practices. The extent to which participants gave the correct responses to these questions are summarised in Table 3.

 

 

According to Table 3, the only items with more than 90% correct responses were regarding opening of windows (96%) and hand washing after taking care of TB patients (94%). These responses indicated the participants' knowledge of best practice in the control of TB in the ward situation, that of essential cross-ventilation. The lowest correct percentages were observed for wearing protective gowns (19%), masks (22%) and the availability of isolation glass in patient vehicles (21%). It appears as though the wearing of masks and protective clothing is not a regular practice. Staff noted the lack of isolation glass in the patient vehicle but it was not noted if they understood the necessity for the use thereof, that of adequate practice in the prevention of transmission of TB. Staff noted the absence of a dining hall and concurred that most staff eat lunch in their offices, or in the vicinity of the wards, which means limited time away from infected patients.

Knowledge and practice scores

Descriptive statistics for the various summated scores that were calculated to measure participants' knowledge and practices are reported in Table 4. As described in the Methods section, all the scores are in the range from 0 to 10, with scores from 6.01 to 10.00 regarded as high, from 4.00 to 6.00 as average and from 0.00 to 3.99 as low.

According to Table 4, mean values that can be described as good (M > 6.00) were observed for most of the knowledge and practice scores, the exceptions being: B3 TB diagnostic tool (M = 3.61, 10% high) and B6 Availability of infection control policy (M = 5.42, 52% High).

The majority of the participants displayed a good knowledge of TB (M = 6.65, 75% high) and had good scores for practice personal (M = 6.12, 66% high) and practice institutional (M = 6.15, 51% high).

Relationship between knowledge and personal practices

The relationship between participants' knowledge and their personal practices was found to be non-significant (r = 0.033, p = 0.659; Chi2 [df = 4, n = 181] = 6.83; p = 0.145). The relationship between knowledge and institutional practices was not investigated, given that institutions' practices are not related to their employees' personal characteristics.

Relationships between socio-demographic characteristics and knowledge and practice

The results of the ANOVA that was conducted to investigate the relationships between the participants' socio-demographic characteristics and their TB knowledge and practice are summarised in Table 5.

 

 

It is concluded from Table 5 that the only statistically significant relationships were those between age and knowledge and between education and knowledge. Post-hoc tests for these relationships revealed the following:

  • Age and knowledge: The 36-45 years age group (n = 61, M = 6.31, s = 1.68) had a significantly (Scheffé's p = 0.041, Cohen's d = 0.55) lower level of knowledge regarding average than the 46-55 years age group (n = 41, M = 7.25, s = 1.70). No significant differences were observed for the 18-35 years age group (n = 45, M = 6.51, s = 1.57) nor for the over 55 years age group (n = 30, M = 6.69, s = 1.80).

  • Education and knowledge: The group with a degree or diploma (n = 49, M = 7.48, s = 1.40) had a significantly (Cohen's d = 0.72) higher level of knowledge regarding average than those with neither a degree nor diploma (n = 128, M = 6.32, s = 1.70).

 

Discussion

Participants in this study generally displayed high knowledge and practice scores regarding TB and infection control, although scores for knowledge were generally higher than those for practices. Therefore, it can be concluded that participants in this study were knowledgeable about TB and infection control; however, they did not always practise what they knew. This is similar to the findings of a study conducted in Rarankuwa, which revealed that 93% of the participants had a good level of knowledge regarding TB-control measures, but the majority (about 70%) of participants did not comply with the correct practices in this regard (Mndzebele & Kandolo 2014). Furthermore, a similar study conducted regarding knowledge, attitudes and practices of general assistants towards infection control at a hospital in Lesotho displayed both moderate knowledge and practices of infection control (Peta 2014).

Most employees in this study were aware of the availability of an infection control policy, but this policy was kept in the infection controller's office, and therefore, employees did not always read the policy. Similar results to the current study were displayed in a qualitative study conducted regarding the TB infection prevention and control experiences of South African nurses. The results revealed knowledge about the availability of a TB infection policy at the hospital; however, most participants were unaware of its content (Sissolak, Marais & Mehta 2011). In the aforementioned study, a hospital TB policy existed but seemingly had not been made known to all ward nurses (Sissolak et al. 2011).

Items on knowledge that specifically obtained lower scores included transmission of TB, symptoms of TB and diagnostic tools and the type of TB that spreads. Airborne and direct contacts as modes of TB transmission were not answered correctly by participants. Participants failed to identify loss of weight, fever and night sweats as symptoms of TB. Furthermore, participants failed to identify pleural fluid aspirate analysis as a TB diagnostic tool. Pulmonary TB as the type of TB that spreads from person to person was also not correctly answered by all participants. Some of the true or false statements were also incorrectly answered such as the statements on HIV making a person more vulnerable to TB, as well as TB being a preventable disease. A survey conducted regarding knowledge, attitudes and practices on TB among healthcare workers in Kingston & St. Andrews, Jamaica, yielded slightly different results (White 2011). Most participants in the survey managed to identsify cough for more than 2 weeks, coughing of blood, weight loss, night sweats as well as fever as symptoms of TB (White 2011). Regarding TB diagnostic tools, most participants in the survey failed to identify sputum smear culture as a primary diagnostic tool (White 2011).

Practices that were particularly not adhered to and yielded a low score in this study included wearing personal protective equipment such as gowns and masks, which was also found in similar studies (Sissolak et al. 2011; White 2011). Another practice that was not well adhered to is the availability of isolation glass in patient vehicles. This should be adhered to as there is a general finding that using public transport independently is associated with a high risk of contracting active TB (Feske et al. 2011; Furukawa et al. 2014).

The current study indicated a strong association between knowledge and age (specifically the 36-44 age group) and knowledge and education level (specifically diploma and degree). Previous studies have shown that knowledge and practices can be improved with provision of appropriate supplies and strengthening training and supervision (Peta 2014). More than half of the participants did not have any clinical training, and did not possess a degree or diploma. It is therefore recommended that training should be provided to non-nursing or non-clinical personnel, taking into consideration their scope of work, level of education, level of clinical training and specific risks attached to their work environment. Furthermore, training material matching the tasks and education level of non-clinical employees and facilitation of opportunities to learn and read about infection control needs to be designed. Specific attention should be given to TB transmission, symptoms, diagnostic tools as well as the type that spreads TB in the in-service training. Furthermore, information and demonstrations should be given on the wearing of protective gear in order to reduce the occupational exposure to TB. Finally, specific attention should be given to the quality or technique of training and ways in which sufficient knowledge retention can be established as Tlale et al. (2016) observed the same level of knowledge among categories with a reasonable level of clinical training such as health professionals as compared to other categories.

In addition, management in specialised TB hospitals must ensure the availability of an infection control policy to all employees. The implementation of the infection control policy should be monitored by management. Furthermore, management should ensure the availability of masks as well as placing isolation glass in patient transport vehicles at all times, as these were the practices that were scored the lowest by the participants in this study.

Several limitations were observed. Questions, such as the Xpert as an option for the question how (extra)pulmonary TB is diagnosed as well as questions about respiratory precautions in the questionnaire, could have been included in the questionnaire. However, the questionnaire was developed for participants with both clinical and non-clinical backgrounds. An item establishing whether participants attended any information-sharing sessions on the knowledge and the expected practices was not included in the questionnaire, but would have added value. It is therefore recommended that the questionnaire should be further revised and tested.

This study was the first of its kind to explore and describe knowledge and practices regarding occupational exposure to TB in specialised TB hospitals in the Eastern Cape. Considering the limited research performed on occupational exposure to TB, especially in the Eastern Cape, further explorative studies could be conducted as to why certain knowledge and practices scored lower. Research in terms of impact studies can be performed to determine the effectiveness of the infection control training offered by the hospitals, particularly related to implementation of the knowledge. In addition, the current study can be replicated in all specialised TB facilities in the Eastern Cape, as this will allow for further validation of the questionnaire as well as be of benefit in determining the knowledge and practices of a wider population of employees in such facilities.

 

Conclusion

In conclusion, the knowledge of employees regarding occupational exposure in specialised TB hospitals in the Nelson Mandela Bay scored generally high. A strong correlation was found between knowledge and age as well as knowledge and education level. Further opportunities for education, practice and research to explore and investigate occupational exposure to TB were provided.

 

Acknowledgements

The authors would like to thank the participants for taking part in the study.

Competing interests

The authors have declared that no competing interests exist.

Authors' contributions

L.N. was involved in conception and design of the study; acquisition, analysis and interpretation of data; drafting of the article; and the final approval of the version to be published. M.W. and W.t.H.-B. were involved in the conception and design of the study, analysis and interpretation of data, revising the article critically for important intellectual content and the final approval of the version to be submitted. D.V. analysed and interpreted the data, revised the article critically for important intellectual content and accorded the final approval of the version to be submitted.

Funding information

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Data availability statement

Data will be available from the authors on request.

Disclaimer

The views and opinions expressed in this article are the authors' own and not an official position of the institution or the funder.

 

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Correspondence:
Wilma ten Ham-Baloyi
wilma.tenham-baloyi@mandela.ac.za

Received: 05 Dec. 2018
Accepted: 25 Jan. 2020
Published: 01 Apr. 2020

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ORIGINAL RESEARCH

 

Perceptions of professional nurses regarding the National Core Standards tool in tertiary hospitals in KwaZulu-Natal

 

 

Winnie T. Maphumulo; Busisiwe R. Bhengu

Department of Health, Faculty of Nursing, University of KwaZulu-Natal, Durban, South Africa

Correspondence

 

 


ABSTRACT

BACKGROUND: Internationally, healthcare providers share a common goal of providing safe and high-quality care to every patient. In South Africa, the National Core Standards (NCS) tool was introduced to improve the quality of healthcare delivery.
OBJECTIVES: This article is aimed to determine the perceptions of nurses concerning the use of NCS as a tool to measure quality care delivery in tertiary hospitals in KwaZulu-Natal.
METHOD: This was a cross-sectional descriptive survey, where a purposive sampling technique was used to select hospitals. Six strata of departments were selected using simple stratified sampling. In each stratum, every second ward was selected from the provided list of wards using a systematic random sampling. The population of professional nurses in selected departments was 3050, from which 437 participants were selected by systematic random sampling. The collected data were analysed using Statistical Package for the Social Sciences (SPSS®) version 25.
RESULTS: The study indicated that 53.5% respondents believed that the NCS tool allows them to identify areas of weakness, pointing to risks in basic human rights. However, only 49.7% respondents believed that the NCS tool allows staff inputs to identify relevant innovations. The study recommends improvement in the organisational climate and adoption of strategies that add value to patient care.
CONCLUSION: Professional nurses perceived the NCS tool as a good tool for improving quality of healthcare delivery, but there is a need to improve environmental practice and involvement of all healthcare establishments to increase its effectiveness.

Keywords: NCS; perceptions; professional nurses; tertiary hospitals; quality.


 

 

Introduction

Globally, the healthcare providers share a common goal of providing safe and high-quality care to every patient all the time (Babiker et al. 2014:10). The government established the Office of Health Standards Compliance (OHSC) to fulfill the constitutional obligation of ensuring the delivery of safe and high-quality care in health establishments (National Department of Health (NDoH) 2013:8). The OHSC introduced a quality assurance mechanism to regulate the quality of health services against a prescribed set of norms and standards prescribed in the National Health Amendment Act (Act No. 12 of 2013) (NDoH 2013:8). The OHSC developed the National Core Standards (NCS) tool, which serves as a guide for managers at all levels, explaining the expected level of service delivery (NDoH 2013:23). The NCS tool provides the minimum standards of care that are mandatory in all health establishments in South Africa (Ranchod et al. 2017:106). The main aim of NCS is to develop a common definition of quality care and to launch a benchmark against which healthcare organisations could be assessed (NDoH 2013:17).

Commonly, professional nurses constitute a larger part of healthcare industry. Therefore, their perceptions of the NCS tool are essential because they can influence the implementation of the tool either positively or negatively. Professional nurses are also gatekeepers of quality care delivery and often have a role of coordinators of a multidisciplinary care. The purpose of the study was to assess the perceptions of nurses concerning the use of NCS as a tool to improve quality care delivery. Success in the implementation of any quality initiative in a healthcare organisation is determined by its acceptability by the largest possible number of employees in that organisation (Boonstra, Versluis & Vos 2014:370). Gaps in the interpretation of the NCS tool could indicate a need for education to empower users regarding their roles and responsibilities. This article reports on part 3 of the author`s main study called 'Analysing the process of implementation of the National Core Standards as a tool for ensuring quality care delivery in tertiary hospitals in KwaZulu-Natal'.

 

Background

Concerns about the quality of healthcare delivery and performance improvement are driving significant changes in healthcare systems globally (Whittaker et al. 2011:60). However, it has to be acknowledged that the term 'quality in healthcare' is a subjective and multifaceted concept, which many authors define in different ways, and these definitions vary amongst countries and stakeholders and over time (Hakeem & Thanikachalam 2014:415). No single definition of quality in healthcare services applies in all situations, and understanding the definition of quality requires many different measures (Nylenna et al. 2015:3). The Department of Health in South Africa defines quality as the ability to attain the best possible health outcomes using the available resources (NDoH 2013:16). The literature related to the meaning, definition and perception of nurses about quality nursing care is limited (Burhans & Alligood 2010:10). According to the Burhans and Alligood's (2010:21) study, nurses defined the quality of nursing care as related to six vital themes, such as empathy, caring, responsibility, intention, respect and advocacy. However, the nursing literature often uses 'Donabedian's definition of quality' and 'Donabedian's model' (Kelley et al. 2011:155). Donabedian's framework, the Lean system (Poksinska 2010:319). and the NCS tool formed the conceptual framework of this study.

 

Conceptual framework of the study

For this study, a questionnaire was developed using the Donabedian variables, Lean principles and the seven domains of NCS to determine the perceptions of professional nurses regarding the ability of the NCS tool to improve the quality of healthcare delivery.

Donabedian's definition of quality care embodies the entire range of variables from structures to processes to health outcomes (Nocella et al. 2016:20). Structure denotes the features of the setting in which care takes place. Structure measures system inputs such as human resources, infrastructure, availability of equipment and supplies, including operational tools such as policies and protocols (Nocella et al. 2016:20).

Process measures what is really carried out when providing care. It addresses activities or interventions carried out within an organisation for the care of patients, such as patient education, training, promotion of teamwork, patient care activities, equipment maintenance and so on (Nocella et al. 2016:20). Donabedian understood that organisational structure has an impact on the ability of healthcare organisations to successfully implement and sustain quality improvement initiatives if well-designed systems or processes are implemented. Outcomes refer to the effect of intervention (e.g. an improvement in quality healthcare delivery) subsequent to the health services received. This includes intended outcomes, such as relief from pain, and unintended outcomes, such as complications (Nocella et al. 2016:20). According to Donabedian, good structure increases the likelihood of good process, and good process increases the likelihood of good outcome. His work led to an understanding of the system's approach in evaluating health establishments (Halasa et al. 2015:98).

Another push for continuous improvement is the need for removal of waste from available resources and concentrating on value-added processes whilst respecting the employees as recommended in the Lean system (Sisson & Elshennawy 2015:263). This was fueled by the increasing costs of healthcare (Moraros, Lemstra & Nwankwo 2016:151). According to Poksinska (2010), Lean principles are as follows: to determine value from a client's standpoint, define the value stream, maintain a continuous flow, pull production, integrate the supply chain, focus on quality, visual management, use technology that serves employees and processes, human resource development and continuous improvement.

The NCS tool addresses crucial issues that are vital for providing quality care (NDoH 2011:7). In order to attend to life-threatening issues in quality delivery and patient safety, the NCS tool was structured into seven domains (NDoH 2011:6). According to the World Health Organization (WHO, 2006:6), a domain is a part of service delivery where safety or quality could be jeopardised. Table 1 shows the NCS tool as tabulated by NDoH.

 

 

Operational definitions of different terms

Perception: It is the act of noticing or being aware or a comprehension or an understanding of something, and interpreting it from the external world by means of sensory receptors (Pickens 2005:53). In the study, perceptions mean understanding or comprehension of professional nurses, unit managers and nurse managers regarding the NCS tool.

Tertiary hospital: A hospital that provides a highly specialised consultative healthcare service for inpatients and outpatients on referral basis from a primary or secondary healthcare service. It has advanced expertise and technical equipment for advanced medical investigations and treatments National Department of Health (NDoH 2013:2).

Professional nurse: A person who has completed a 3- or 4-year diploma or 4-year degree course and is registered under the Nursing Act No. 50 of 1978 and renders comprehensive nursing care independently in clinical area (Republic of South Africa 2005:25). In this study, professional nurse means a nurse who has a basic diploma or degree in nursing, including a nurse having a postgraduate diploma and degree in nursing.

 

Problem statement

South African Medical Association (SAMA, 2015:40) contends that government tools and frameworks are usually implemented poorly because they are often impractical and look 'good' only on paper. South African Medical Association (2015:42) also states that it is impossible to expect that the NCS tool will dramatically improve the quality of healthcare delivery in the under-resourced environment because of lack of financial and human resources accompanied by mishandling of funds by government officials. This literature may negatively influence the perceptions of nursing practitioners who carry most of the burden of quality improvement and innovations.

The principal investigator, with over 10 years of experience working with the NCS tool, believes that this is a good tool. However, she aligns herself with SAMA's argument, as she has also experienced the impracticability of the tool in real situations related to shortage of staff and equipment. Moreover, the users of the tool around KwaZulu-Natal seem to be unclear and frequently mourn about its implementation. This could mean that there is a problem of perception of NCS tool amongst its users.

The study was carried out in KwaZulu-Natal because between 2008 and 2015, there was a drastic rise in medico-legal claims (Pieterse & Erasmus 2017); the province still has an amount of over R5 billion as pending claims. It was also convenient for the researcher to conduct thorough study because she was based in KwaZulu-Natal.

 

Research methodology

Study design

A cross-sectional descriptive survey was carried out amongst professional nurses in selected hospitals from 15 January 2017 to 30 May 2017. The researcher made appointments with nurse managers and assistant nurse managers in each of the four hospitals selected to explain the nature and purpose of the study. Delays were experienced whilst trying to have appointments with management, and further delays occurred in some hospitals whilst waiting to have suitable dates for data collection. Data were collected intermittently because of the different dates provided by different departments of different hospitals for data collection.

Study purpose

The aim of this study was to assess the perceptions of nurses concerning the use of NCS as a tool to measure quality care delivery in KwaZulu-Natal.

Research site

This study was conducted in four hospitals that offer tertiary services in KwaZulu-Natal, South Africa. KwaZulu-Natal province was chosen because of its diversity amongst the South African provinces in terms of languages, culture and provincial legislature, which can interpret and implement national policies differently.

Two tertiary hospitals (A and B) situated in the eThekwini district provide both secondary and tertiary services. The third tertiary hospital (C) is located in Pietermaritzburg in the Msunduzi district serving the western half of KwaZulu-Natal, which includes the following districts: uMgungundlovu, uThukela, uMzinyathi, Amajuba and Harry Gwala. The fourth hospital (D) is situated in Empangeni in the uMkhanyakude district, serving uThungulu, uMkhanyakude and Zululand health districts.

Study population

The target population for the study included 3050 professional nurses employed on a full-time basis in four selected hospitals. Professional nurses are leaders in the implementation of the NCS tool, so their perspectives and experience could provide important information to improve tool's quality. Hence, their positive engagement in the implementation of quality improvement programmes could lead to positive health outcomes.

Eligibility criteria

Inclusion criteria: All professional nurses having more than 2 years of experience in the field, permanently employed in these selected hospitals, willing to participate and available during the study period were included in the study. Both day and night nurses were considered.

Exclusion criteria: Professional nurses who were off duty or on leave (vacation, maternity, sick or study leave) during data collection were excluded. All professional nurses who were having management positions of all levels as well as who have less than 2 years of experience in the field were also excluded from the study.

Sampling technique

Purposive sampling was used to select four hospitals offering tertiary services in the province. These were further stratified into six strata by using simple stratified sampling, namely, stratum 1: medical, stratum 2: surgical, stratum 3: critical care unit, stratum 4: high care, stratum 5: paediatrics and stratum 6: obstetrics. In each stratum, every second ward was selected from the list of wards provided by the nurse manager using systematic random sampling. Convenience sampling was used to select professional nurses from both day and night shifts in these selected hospitals. A total sample size of 437 respondents was used. The number of respondents in each stratum was as follows: stratum 1: medical = 125, stratum 2: surgical = 95, stratum 3: critical care unit = 127, stratum 4: high care = 17, stratum 5: paediatrics = 60 and stratum 6: obstetrics = 13.

Sample size

A sample size of 543 respondents (±6%) was required to estimate the correct proportion of professional nurses' perceptions of the NCS tool. This number provided a 95% probability of achieving the study's objectives and assumed that 50% would yield a clear picture of their perceptions of the tool. The sample size was computed by using the Stata V13 statistical software. The command was power one proportion. Figure 1 shows the sample calculated using Stata V13 statistical software.

 

 

Instrument for data collection

A closed-ended questionnaire was used for collecting data. This questionnaire's design was based on the researcher's use of specific items of the NCS tool, Donabedian framework and the Lean system, which were modified to suit the purpose of this study.

Data collection technique

Although the time taken to complete each questionnaire was approximately 20 min, the researcher had to personally obtain consent, hand out questionnaires, explain them and collect the data. This was carried out during the nurses' available time, for example, during tea or lunch breaks or on rare occasions during a ward meeting arranged by management for day and night nurses. After every meeting, respondents deposited their completed questionnaire in the enclosed box provided in the duty room. Participants were provided enough time to complete the questionnaire at their will if they desired so. For the latter participants, the questionnaires deposited in the box were collected by the researcher approximately 1 week after the initial meeting.

Scientific rigour

The questionnaire was tested and validated to ensure understanding and meaning of the presented concepts and simplicity of statements, and to determine the time taken for completing it during the pilot testing. The respondents used in the pilot study were marked by using wards not used in the main study to enable them to be excluded from the main population. Readability and comprehension were verified by the supervisor having research background and two quality managers from two participating hospitals in the eThekwini district. A content validity was also performed, whereby the items of the research instrument were compared with the objectives of the study to ensure that the tool was measuring what it purported to measure. The degree of correlation between items on a scale was validated using Cronbach's alpha coefficient. The questionnaire had a good internal consistency with a Cronbach's alpha coefficient of 0.851. Pilot data did not lead to the modification of materials or procedures.

Data analysis

Data were analysed using the Statistical Package for the Social Sciences (SPSS®) version 25 software. A structured questionnaire was used to measure professional nurses' perceptions for the use of the NCS tool using the Likert scale. Data on 5-point Likert scale were coded as follows: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree and 5 = strongly agree. The Likert scale data were recoded to agree (strongly agree and agree), disagree (disagree and strongly disagree) and neutral (neutral and missed). Data were reported on both demographic data and perceptions of professional nurses about three features of quality interventions as described by Donabedian, namely, structure, processes and outcomes.

 

Ethical consideration

Ethical approval was obtained from the Humanities Research Ethics Committee of the University of KwaZulu-Natal (HSS/1905/016). Permission was obtained from the KwaZulu-Natal Department of Health and the managers of participating institutions and departments. Written consents were obtained from the respondents after explaining the research study, including potential risks and their mitigation. Risks would include disruption in ward activities and relaxation time, and these were mitigated by giving them questionnaires to be completed during break periods. The respondents requiring longer time to complete questionnaires were allowed to take them along and asked to deposit completed questionnaires within a week in the sealed box provided in the unit. Participation in the study was voluntary. Confidentiality and anonymity of the respondents were maintained throughout the study by using assigned codes and numbers to each questionnaire so that it was not possible to link questionnaire with individual respondent.

 

Results

Although the minimum calculated sample size requirement was 543 participants, a total of 500 professional nurses available in the wards were approached for participation in the study. About 466 questionnaires were returned, yielding a response rate of 93.2%. After discarding 29 questionnaires for non-adherence to instructions, the final sample included 437 questionnaires (87.4%). Table 2 shows the strata-wise distribution of respondents.

 

 

Socio-demographic characteristics of respondents

This study included only full-time employed professional nurses. Respondents were distributed across the institutions as follows: hospital A = 147/437 (33.6%), hospital B = 82/437 (18.8%), hospital C = 108/437 (24.7%) and hospital D = 100/437 (22.9%). The majority of respondents (351/437, 80.3%) were females. Most respondents (224, 51.3%) had a basic diploma in nursing (R425 and R63), and 115 (26.3%) had a specialty diploma in addition to their basic qualifications. The results also showed that most of these respondents (386, 88.3%) had a working experience ranging from 6 years to more than 20 years.

Perceptions of nurses about the application of structure standards of the National Core Standards tool

Slightly more than half of the respondents (225, 51.4%) felt that the organisational arrangements encouraged them to apply the NCS tool well as they had clear job descriptions. Only 183 (41.8%) respondents believed that the organisational arrangements offered clear lines of communication to enable them to apply the tool well. The lowest score in this section was 169 (38.6%), where respondents felt that the organisational arrangements encouraged them to apply the tool well because they had autonomy in decision-making. Table 3 shows the perceptions of the nurses about the structure standards of the NCS tool.

 

 

Perceptions of nurses about the application of process standards of the National Core Standards tool

The highest level of agreement was for 'adherence to existing standards and guidelines is part of staff performance criteria', with 252 (57.6%) respondents agreeing with this statement. Most respondents (232, 53%) felt that the standards put into the NCS tool encourage patient-centred care. The lowest level of agreement was for 'implementation of the NCS and its success is completely dependent on nurses only', with only 164 (37.5%) respondents agreeing with this statement.

A significant number of respondents (251, 57.4%) believed that the NCS tool emphasised on multidisciplinary approach and the need for harmony at the workplace. The majority of respondents (248, 56.7%) indicated that they believed that monitoring patient satisfaction surveys helped health establishment to determine the needs of customers, and about 247 (56.5%) respondents felt that the NCS tool allowed for the continuity of patient care. About 207 (47.3%) felt that the NCS tool allowed them to practise according to their scope of practice. Less than half of the respondents (193, 44.1%) believed that nurses' skills were utilised appropriately when implementing the tool.

The highest level of agreement for the elimination of waste processes was for 'NCS ensures the elimination of waste due to production defects, e.g. medication errors', with 207 (47.3%) respondents agreeing with this statement. The lowest level of agreement was for 'NCS ensures the elimination of waste due to excess processing, e.g. ordering more diagnostic tests than the diagnosis warrants', with 187 (42.7%) respondents agreeing with this statement. Only 206 (47.3%) respondents felt that the NCS tool improved waiting period of patients awaiting treatments, whilst 203 (46.4%) believed that the NCS tool ensures that wastage of time looking for equipment is eliminated.

About 205 (46.9%) respondents felt that the NCS tool ensures that product waste is eliminated when transporting or waiting for surgical sundries to arrive, whilst 202 (46.2%) believed that the NCS tool ensures that the waste in excess processing is reduced. Table 4 shows nurses' perceptions about process standards of the NCS tool.

Perceptions of nurses regarding outcome standards of the National Core Standards tool

The highest level of agreement for this section was for 'the NCS promotes the use of feedback to improve service delivery', with 232 (53%) respondents agreeing with this statement. The lowest level of agreement was for 'the NCS promotes the mentoring system', with only 193 (44.1%) of the nurses agreeing with this statement.

More than half (220, 50.3%) of the respondents felt that the NCS tool allows for acceptance of staff inputs, whilst less than half (217, 49.7%) felt that the NCS tool has promoted the use of staff inputs to identify relevant innovations.

To determine the opinion of respondents on the contribution of NCS tool to their professional development, the following scores were obtained: the respondents believed that the NCS tool promotes continuous professional development (216, 49.2%), the sense of responsibility (205, 46.9%), the culture of learning (199, 45.5%), accountability (198, 45.3%) and mentoring system (193, 44.1%). Table 5 shows perceptions regarding lessons learnt from NCS.

 

 

Mean scores and standard deviation

The perceptions of professional nurses for using the NCS tool were measured using 28 items on an ordinal scale from 'strongly agree' to 'strongly disagree'. For the 10 items used for structure of the NCS tool using the content of the tool as a construct, the mean score was 31.2 ± 9.9 (α = 0.8). To determine the mean score and standard deviation for the structure of the NCS tool using the organisational climate as a construct, three items were included, and the mean score was 6.7 ± 2.6 and Cronbach's alpha was undetectable because there were too few items. To determine the ability of the NCS tool to ensure the elimination of wastage of available resources (process), including time, seven items were included, and the mean score was 21.6 ± 7.4 (α = 0.9). For the lessons learned from the NCS tool used to determine the outcomes, eight items were included, providing a mean score of 25.5 ± 7.8 (α = 0.8). Table 6 shows descriptive statistics and Cronbach's alpha for these measurements.

 

 

Discussion

Nurses' perceptions about the application of structure standards of the National Core Standards tool

Regarding the application of structure standards of the NCS tool, the highest level of agreement was for the availability of clear job descriptions in the organisation which enables application of the NCS tool. The other items were perceived by respondents as not offered by their organisations to enable the application of the NCS tool. These items had a below 50% level of agreement, with autonomy in decision-making being the lowest, scoring 38.6%.

The low rating of the practice environment poses a major concern because most authors have established a relationship between the nurse practice environment and health outcomes (Coetzee et al. 2013:163). Some authors believe that positive organisational climate is related to increased worker satisfaction (Castro & Martins 2010:2). Karam et al. (2018:71) stipulate that organisations are to create an environment that supports good interdisciplinary communication and collaboration between nurses and other healthcare workers.

Nurses' perceptions about the application of process standards of the National Core Standards tool

About 53% respondents felt that the standards put in NCS focused on patient-centred care. Patient-centredness means that the healthcare provider would respect and respond to patient's needs, values and preferences, and the ethical decisions of health professionals would be guided by patient's needs (Brand & Stiggelbout 2013:225). Effective implementation of patient-centredness requires motivated healthcare workers with a range of competencies and can partner with patients, families and other health workers (Bernabeo & Holmboe 2013:451). However, SAMA argued that the framework of accreditation offered by NCS is narrow, not covering all dimensions of quality as defined by the WHO, for instance, effectiveness, efficiency, accessibility and acceptability/patient-centredness (SAMA 2015:33).

Over half of the respondents (57.6%) believed that adherence to existing standards and clinical guidelines was part of staff performance criteria. This means that all respondents did not believe that adherence to the existing clinical guidelines and standards as provided in the NCS tool would improve staff performance. Kredo et al. (2017:1) asserted that presently there is no existing guidance or standard method in South Africa to efficiently and effectively develop and adapt clinical guidelines.

The results revealed that only 37.5% respondents believed that the implementation of NCS and its success to improve quality delivery was completely dependent on nurses, meaning a multidisciplinary approach is necessary. This means that most of the respondents believed that the implementation of NCS would be successful when other health professionals are involved in the process. Most authors believe that all healthcare professionals play an integral role in the coordination and delivery of quality healthcare (Balbale, Turcios & Lavela 2015:417; Bernabeo & Holmboe 2013:250). In order to provide high standard of healthcare and a better quality of life, quality initiatives must be engrained in the entire value chain of healthcare delivery (SAMA 2015:40)

This study reflected that 53.5% respondents believed that the NCS tool enabled them to identify areas of weakness, pointing to risks in basic human rights. Madisha (2015:25) mentioned that the purpose of developing NCS was to identify the health system's strengths and gaps, to assess the current and future needs as well as the planning of future services, namely, planning for the implementation of National Health Insurance.

The analysis of the results revealed that 56.7% respondents believed that monitoring patient satisfaction surveys helped health establishments to determine the needs of their customers. Being direct recipients of care, patients are genuine assessors of quality (Izumi 2012:262). Patient satisfaction is defined as the extent to which patient's expectations are met in the care provided. It depends on patient's expectations, sex, age, education, type and stage of illness (Izumi 2012:263).

Most respondents felt that an independent body should do accreditation of health establishments to ensure credibility of findings. According to Standards Council of Canada, accreditation bodies should perform their work independently (ECONEX 2010:4). Independence is the primary purpose of accreditation to eradicate the presence of biased assessment that is likely to compromise accuracy. The question is the objectivity of the South African Office of Health Standard Compliance, it being government's fully funded accreditation body (ECONEX 2010:4).

About 57.4% respondents believed that the NCS tool emphasises the multidisciplinary approach and the need for harmony at the workplace. According to Babiker et al. (2014:9), the best tool for constructing a more effective patient-centred healthcare delivery system, recognised globally, is by using an effective teamwork. In addition, Aiken et al. (2012:1717) declared that organisation must ruminate on nurses' complaints as early warning signs for eroded quality care delivery, investigate these complaints and work on their solutions.

Evidence has emerged from data that most respondents did not believe that the NCS tool eliminates waste as suggested by the Lean system because of the low level of agreement, which was below 50%, with the ability to eliminate waste because of overproduction being at the lowest level, scoring just 43%.

Nurses' perceptions about outcome standards of the National Core Standards tool

This study revealed that about 53% respondents believed that the NCS tool promotes the use of feedback to improve delivery of service, and 51.4% of respondents believed that the tool promotes the use of adverse events as a learning opportunity. Percival et al. (2016:1) believed that any quality initiative could improve the quality of healthcare delivery by engaging frontline health practitioners through participatory feedback. The results showed low rating in the following: use of staff inputs to identify relevant innovations 217 (49.7%); promote continuous professional development 216 (49.2%); promote the culture of learning 199 (45.5%); and the lowest score being 193 (44.1%) for the response that the NCS tool has promoted the mentoring system. According to Mosadeghrad (2014:78), quality standards are more difficult to establish in service operations; therefore, organisations must invest in the continuous development of their employees to obtain positive outcomes in healthcare.

 

Limitations of the study

Data collection was limited to professional nurses at few selected hospitals in KwaZulu-Natal. The study was confined to just one province of South Africa. Therefore, the results cannot be generalised to other provinces. As the NCS tool is used only in public institutions of South Africa, the results cannot be generalised for private institutions.

 

Conclusion

In conclusion, a survey design was used to elicit nurses' perceptions of NCS as a tool to improve the quality of healthcare delivery in public hospitals in KwaZulu-Natal tertiary hospitals. The findings of this study are as follows:

  • Respondents disagreed that implementation of NCS and its success is completely dependent on nurses, meaning multidisciplinary approach is necessary. Currently, NCS is implemented, monitored and evaluated only by the nursing staff. Failure to involve other categories of healthcare workers leads to the misconception that NCS is only for nurses.

  • Respondents believed that NCS enabled them to identify areas of weakness, pointing to risks to basic human rights. Less than half of the nurses believed that the NCS tool allowed staff inputs to identify relevant innovations. The NCS tool is structured into seven cross-cutting domains, whereas domain is defined as an area where quality and safety might be at risk (WHO 2006:8). Users' inputs must be considered to ensure proper implementation of this tool.

  • Respondents felt that the standards put in NCS focused on patient-centred care. According to De Jager and Du Plooy (2011:421), it is vital to implement health programmes that are patient-centred.

  • Respondents believed that monitoring patient satisfaction surveys helps health establishments to determine the needs of their customers. Patient satisfaction is considered an important service quality indicator (Lyu et al. 2013:362). Several authors believed that knowing patients' views about delivered healthcare is important because satisfied patients tend to adhere to treatment as well as treatment guidelines (Manary et al. 2013:201; Peltzer 2009:117).

  • Most respondents did not believe that the NCS tool has an ability to ensure elimination of waste as suggested by the Lean system of quality care. The first step towards waste reduction is to identify value-added steps in every process, identify the value stream by providing value-added activities and eliminate everything which does not generate value to the product (Aziz & Hafez 2013:680; Kimsey 2010:53).

 

Recommendations

  • According to Ngidi and Dorasamy (2013:34), it is an arduous challenge to achieve lasting quality-improvement system in healthcare. The government of South Africa has a challenge to ensure that implementation of NCS involves all categories of workers employed in a healthcare setting. A quality coordinator must be employed in each area to oversee training and implementation of NCS by all healthcare workers.

  • Standardised training, especially during orientation and induction programmes, should be instituted.

  • In order to achieve the best possible results using available resources, any process undertaken should add value in terms of patient care. If it does not add measurable value, it is a waste and should be discontinued. Health information technology (computerised charting) should be instituted to have a link between all public hospitals so that all institutions could view a patient's chart and avoid duplication. Waste represents misuse of resources; therefore, it must be reduced through education and training.

 

Acknowledgements

The authors wish to thank Prof. B.R. Bhengu (supervisor) for critically reviewing the article and Fikile Nkwanyana (biostatistician) for her help in analysing the statistical data.

Competing interests

The authors declare that no competing interests exist.

Authors' contributions

W.T.M. and B.R.B. conceptualised the article and did the literature research, collected and analysed the data and drafted the article.

Funding information

This research was supported by KwaZulu-Natal University.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

 

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Correspondence:
Winnie Maphumulo
thembimap@gmail.com

Received: 29 May 2018
Accepted: 29 Oct. 2019
Published: 01 Apr. 2020

^rND^sAiken^nL.H.^rND^sSermeus^nW.^rND^sVan Den Heede^nK.^rND^sSloane^nD.M.^rND^sBusse^nR.^rND^sMckee^nM.^rND^sAziz^nR.F.^rND^sHafez^nS.M.^rND^sBabiker^nA.^rND^sEl Husseini^nM.^rND^sAl Nemri^nA.^rND^sAl Frayh^nA.^rND^sAl Juryyan^nN.^rND^sFaki^nM.O.^rND^sBalbale^nS.N.^rND^sTurcios^nS.^rND^sLavela^nS.L.^rND^sBernabeo^nE.^rND^sHolmboe^nE.S.^rND^sBoonstra^nA.^rND^sVersluis^nA.^rND^sVos^nJ.F.J.^rND^sBrand^nP.L.P.^rND^sStiggelbout^nA.M.^rND^sBurhans^nL.M.^rND^sAlligood^nM.R.^rND^sCastro^nM.L.^rND^sMartins^nN.^rND^sCoetzee^nS.K.^rND^sKlopper^nH.C.^rND^sEllis^nS.M.^rND^sAiken^nL.H.^rND^sDe Jager^nJ.^rND^sDu Plooy^nT.^rND^sHakeem^nM.A.^rND^sThanikachalam^nV.^rND^sHalasa^nY.A.^rND^sZeng^nW.^rND^sChappy^nE.^rND^sShepard^nD.S.^rND^sIzumi^nS.^rND^sKaram^nM.^rND^sBrault^nI.^rND^sVan Durme^nT.^rND^sMacq^nJ.^rND^sKelley^nT.F.^rND^sBrandon^nD.H.^rND^sDocherty^nS.L.^rND^sKimsey^nD.B.^rND^sKredo^nT.^rND^sAbrams^nA.^rND^sYoung^nT.^rND^sLouw^nQ.^rND^sVolmink^nJ.^rND^sDaniels^nK.^rND^sLyu^nH.^rND^sWick^nE.C.^rND^sHousman^nM.^rND^sFriechag^nJ.A.^rND^sMakary^nA.^rND^sManary^nM.P.^rND^sBoulding^nW.^rND^sStaelin^nR.^rND^sGlickman^nS.W.^rND^sMoraros^nJ.^rND^sLemstra^nM.^rND^sNwankwo^nC.^rND^sMosadeghrad^nA.M.^rND^sNgidi^nT.L.^rND^sDorasamy^nN.^rND^sNocella^nJ.M.^rND^sDickson^nV.V.^rND^sCleland^nC.M.^rND^sMelkus^nG.D.E.^rND^sNylenna^nM.^rND^sBjertnaes^nO.^rND^sSaunes^nI.S.^rND^sLindahl^nA.K.^rND^sPeltzer^nK.^rND^sPercival^nN.^rND^sO'Donoghue^nL.^rND^sLin^nV.^rND^sTsey^nK.^rND^sBailie^nR.S.^rND^sPickens^nJ.^rND^sPieterse^nC.^rND^sErasmus^nJ.^rND^sPoksinska^nB.^rND^sRanchod^nS.^rND^sAdams^nC.^rND^sBurger^nR.^rND^sCarvounes^nA.^rND^sDreyer^nK.^rND^sSmith^nA.^rND^sSisson^nJ.^rND^sElshennawy^nA.^rND^sWhittaker^nS.^rND^sShaw^nC.^rND^sSpieker^nN.^rND^sLinegar^nA.^rND^1A01^nCynthia Z.^sMadlabana^rND^1A01^nInge^sPetersen^rND^1A01^nCynthia Z.^sMadlabana^rND^1A01^nInge^sPetersen^rND^1A01^nCynthia Z^sMadlabana^rND^1A01^nInge^sPetersen

ORIGINAL RESEARCH

 

Performance management in primary healthcare: Nurses' experiences

 

 

Cynthia Z. Madlabana; Inge Petersen

School of Applied Human Sciences, Discipline of Psychology, University of KwaZulu-Natal, Durban, South Africa

Correspondence

 

 


ABSTRACT

BACKGROUND: The use of the performance management (PM) system is highly contested by public servants in South Africa, although its value as essential to the appraisal and management of staff is undeniable.
OBJECTIVES: The aim of this study was to explore nurses' perceptions and experiences of the PM system at primary healthcare (PHC) facilities in relation to the current health system's reforms.
METHOD: An exploratory, descriptive and qualitative design was utilised. Participants were selected through purposive sampling. A semi-structured interview tool was used to collect data from 18 nurses in four sub-districts of Dr. Kenneth Kaunda district in the North West province. Data were analysed through thematic analysis.
RESULTS: The findings of this study confirmed that PM is implemented to some extent. However, various loopholes in its implementation threaten the accuracy and transparency of the system and leave it vulnerable to perceived organisational injustice and unfairness, with the objectivity of the system questioned. The limitations of the current PM system revealed by this study include (1) the lack of alignment with current health system reforms towards comprehensive and integrated care that demands person-centred care; (2) the system's usefulness for career progression, performance improvement and rewarding exceptional performance.
CONCLUSION: Performance management is inadequately applied in PHC facilities at district level and needs to be realigned to include the appraisal of key attributes required for the current health system's reforms towards comprehensive and integrated care, including the provision of person-centred care, which is central for responding adequately to South Africa's changing disease profile towards multi-morbidity.

Keywords: performance management; performance appraisals; human resources for health professional nurse; primary health care; national health insurance; integrated clinical services management; person-centred care.


 

 

Introduction

Currently, health systems reforms are underway in South Africa, notably the introduction of National Health Insurance (NHI) and the re-engineering of primary healthcare (PHC) to promote integrated clinical services management (ICSM) of acute and multi-morbid conditions. Given the increase in the prevalence of multi-morbid conditions (Mayosi & Benator 2014), the vertical disease-oriented approach to care is no longer suitable and there is a need for a shift in orientation towards collaborative team-based person-centred care (PCC) to understand the patient holistically as well as engage them in their own healthcare (Maseko & Harris 2018). Person-centred care is defined as an approach to healthcare that emphasises communication with patients, being cognisant of the issues that are beyond any single disease/condition (Jardien-Baboo et al. 2016). Accordingly, organisational systems and processes such as performance management (PM), organisational culture and organisational strategic objectives should be harmonised to align with these reforms. Poor human resource management (HRM) methods and practices in the healthcare system have been found to threaten the successful implementation of quality healthcare in South Africa (Republic of South Africa 2012a). Furthermore, these processes must be managed appropriately to encourage a shared vision, inspire health workers and build a culture of performance that drives the entire health system towards a common purpose.

Given that nurses are at the frontline of healthcare delivery, constituting 80% of health workers of public healthcare providers nationally (Rispel, Moorman & Munyewende 2014; Statistics South Africa 2017) , the need to ensure that nurse-related HRM practices are aligned with the current reforms is not only important but indeed essential.

According to Rispel (2015), South Africa faces a nursing crisis that is characterised by personnel shortage, a declining interest in the profession, staff disengagement and lack of resources. In addition, the nursing profession has come under attack for poor service delivery (Republic of South Africa 2012b). In an attempt to attract and retain nurses within the South African healthcare system, as well as to improve quality of service provision, recently increased attention has been paid on how HRM processes and outcomes influence nurses' experiences, attitudes and behaviour at workplace and ultimately the quality of care they provide (Mayosi & Benatar 2014; Rispel 2015; Rispel & Barron 2012).

Performance management system is an essential component of HRM. It is particularly important within healthcare organisations as it is a formal process that determines progress on expected outcomes versus actual outcomes (Moradi et al. 2017). Health human resource (HR) practitioners and nurse managers are confronted with the need to develop HR practices that support behavioural changes and promote support for structural changes such as the NHI and ICSM that are associated to person-centred care. Previous studies have identified the following factors as essential in the development of a PM system to promote job satisfaction and improve the delivery of care. Firstly, individual factors that reward performance and manage underperformance in a manner that is clear, accurate and fair (Lee & Steers 2017; Steers & Lee 1982). Secondly, management styles that promote supportive leadership and champion good people management practices (Boaden et al. 2008). Thirdly, promotion of teamwork and conflict reduction strategies (Skinner et al. 2018). Fourthly, organisational systems that are aligned with the promotion of person-centred care and empowering organisational environment which allow for decision latitude and job control (Albrecht et al. 2015; Van De Voorde & Beijer 2015).

However, performance management and development system (PMDS) generally is highly contested and perceived as lacking transparency and accountability (Republic of South Africa 2007b) and vulnerable to bias and unfairness (Ghauri & Neck 2014). The South African public service PM system has been criticised for being 'generally poorly implemented', with further research necessary to understand how best to promote good practices and competency as well as the role of continuous professional development for strengthening human resources towards the provision of quality healthcare (Kabene et al. 2006; Mello 2015).

In light of the paucity of evidence on nurses' perceptions and experiences of the PM system in PHC, understanding nurses' perceptions and experiences of the PM system is a vital first step to understand how this system could be improved to promote quality of care in the context of the health system's reforms at PHC level.

Aims and objectives

This study was aimed to explore nurses' perceptions and experiences of the current PM system in relation to the changes in their roles and functions as a consequence of the current health system's reforms in South Africa. More specifically, the objectives of the study were to explore nurses' perceptions and experiences of the PM system and its influence on quality of care within the context of re-engineered PHC, NHI and ICSM that demand PCC. In doing so, the authors describe actions that PHC facilities could consider towards improving the use of the PM system to cultivate a culture that fosters quality of care within the context of re-engineered PHC, NHI and ICSM that demand PCC.

Definition of key concepts

Integrated chronic services management

Integrated clinical services management is a system of managing care that provides for an integrated method for prevention, treatment and care of chronic patients at primary healthcare level. It aims to ensure a transition towards 'assisted' self-management within the community. This could be achieved through the adoption of a patient-centric approach to healthcare that encompasses the full value chain of continuum of care and support (Bodenheimer & Bauer 2016).

National Health Insurance

National Health Insurance is a health financing system designed to pool funds to provide access to quality affordable health services for all South Africans based on their health needs, irrespective of their socio-economic status. Matsoso and Fryatt (2012) have reported that the purpose of NHI is to achieve universal health coverage (UHC) and establish a unified health system.

Quality of care

Quality of care is defined as a process of improving services in health systems. This is achieved by applying safe, effective, person-centred, efficient and equitable services to achieve desired health outcomes (World Health Organization 2006).

Performance appraisal

A performance appraisal system refers to a period of the evaluation of employee's performance against set expectations. It is described by Aguinis (2009) as a systematic description of an employee's strengths and weaknesses.

Performance management system

According to DeNisi and Murphy (2017):

Performance management refers to the wide variety of activities, policies, procedures, and interventions designed to help employees to improve their performance. These programs begin with performance appraisals but also include feedback, goal setting, and training, as well as reward systems. (p. 1)

Performance management and development system

The PM system used by the South African public services is referred to as a PM and development system. It was implemented in 2012.

Re-engineered primary healthcare

According to Schaay et al. (2011), the chief change in the healthcare system is the re-engineered PHC reform initiative. Re-engineered PHC aims to strengthen the district health system with greater emphasis on quality of service delivery, highlighting the social determinants of health.

 

Research methods and design

Research design

An exploratory qualitative design was used to explore professional nurses' (PNs) perceptions and experiences of the current PMDS. Moreover, it is applied to describe nurses' perceptions and experiences on how the PM system can be used to cultivate a culture that fosters quality of care.

Research site

This study was conducted in the Dr Kenneth Kaunda district of the North West Province of South Africa. The municipality has four sub-districts, namely, City of Matlosana, Maquassi Hills, Ventersdorp and Potchefstroom (renamed Tlokwe). The Dr Kenneth Kaunda district has an estimated total population of 807 252. Health services are delivered by one regional hospital, two district hospitals, nine community health centres, 27 clinics (North West Department of Health [NWDoH] 2018). Economically, North West's strongest economic contributions are in mining and agriculture sectors.

This district was chosen because it was a pilot district for NHI and ICSM. Given that the health system's reforms necessary for the introduction of NHI and ICSM were being piloted in this district, it provided an opportune study site to meet the objectives of the study.

Selection of participants and data collection

Upon receiving appropriate ethical clearance, operational managers of all facilities in each sub-district were contacted to schedule a suitable time for the visit of research team. Nurses were informed about the purpose of the research study and invited to participate. Professional nurses were recruited employing a purposive sampling approach. The sample constituted of professional nurses registered with the South African Nursing Council (SANC). Professional nurses are described by the Nursing Act (Act no. 33 of 2005) Section 30 (1) (Republic of South Africa 2005). It defines a professional nurse as follows:

[A] person who is qualified and competent to independently practice comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice. (p. 34)

More nurses who were recruited worked in City of Matlosana sub-district, given that it is the largest sub-district followed by Potchefstroom. The distribution of participants is shown in Table 1.

 

 

Eighteen interviews were conducted with professional nurses using a semi-structured interview schedule. The interview questions were formulated using the guidelines provided by the Public Services' Employee Performance Management and Development System framework (Republic of South Africa 2007a). The interview questions therefore included an understanding of performance standards, performance measures, feedback, leadership and improving quality of care. In addition, the interview schedule also included pertinent questions on working in teams and promotion of change management. The interviews were conducted in English; however, occasionally participants communicated in Setswana and IsiZulu; for such cases, an independent translator was appointed to translate the interviews into English. The interviewers included the first author and a research assistant studying for Masters in Organisational & Industrial Psychology. Both possessed the necessary comprehension of each language. Participants were predominately Setswana-speaking. All interviews were audio-taped, translated (where necessary) into English and thereafter transcribed.

Data analysis

Thematic analysis was used by the first author to analyse the data obtained from semi-structured interviews. This approach is prominent in qualitative research for its accessibility and theoretical flexibility as it identifies and interprets patterns of meaning across data content (Braun & Clark 2006, 2014). Moreover, this analytical framework provides rich and detailed information from data. The process of analysis involved systematically reading the transcripts. In doing so, common themes were identified from the actual words of participants (Braun, Clark & Terry 2014). Furthermore, the process of refining themes and determining coherent patterns was adhered to in order to ensure that the researcher accurately captured the nurses' perceptions and experiences as communicated by the data set. The process of analysis concluded by identifying attributes and conclusions drawn from the themes based on supportive literature and related previous research (Smith 2015). This process required a concise, logical and non-repetitive account of the data, and appropriate literature was used to confirm and/or challenge the research findings.

Trustworthiness

Measures to ensure trustworthiness as highlighted by Lincoln and Guba (1985) formed the present study. These measures are, namely, credibility, transferability, dependability and confirmability. The concept of trustworthiness refers to attaining knowledge and understanding of the true essence and characteristics of the phenomenon and thus providing reliable accounts of data (Marshall & Rossman 1995). To achieve credibility, the researcher took steps to validate the findings through more than one coder and comparing coded data and using thick descriptive data to support resultant themes. Transferability was assured by using a sampling strategy to ensure a good spread of participants from each sub-district of Dr Kenneth Kaunda district. It was further ensured by describing the research processes in detail to enable replication of the study in another setting. Dependability was achieved by external control. The study was part of a larger research project, the supervisor of the project had oversight authority to oversee the study and ensure its dependability. All interview materials (such as audiotapes, transcripts, etc.) are stored safely in a locked cupboard and only available to the research team involved in the analysis of the data. An audit trail of the data collection and analysis was carefully documented for the purpose of audit trail (Lincoln & Guba 1985). Confirmability was ensured by both researcher and research supervisor checking and rechecking the emergent themes obtained from the data; the use of thick descriptive data to support emergent themes; and comparing data with previous research findings (Nowell et al. 2017).

Ethical considerations

Ethical clearance was obtained from the Biomedical Research Ethics Committee (BREC) Board at the University of KwaZulu-Natal (reference number: BE084/16). Once the provisional approval was granted, gatekeeper approval was obtained from the North West Department of Health (NWDoH): policy, planning, research, monitoring and evaluation upon obtaining approval from NWDoH, full ethical clearance was granted by BREC. Ethical protocols, including anonymity and confidentiality, were adhered to. To safeguard participant information, all personal identifying information was removed from the data. Participants were informed that participation in the study was voluntary and they have the right to withdraw from it at any point without any consequences. All participants provided written informed consent to participate in the study. Only the research team had access to collected data. All audio-taped recordings and copies of interview transcripts are stored in a secure vault for a maximum period of 5 years as per ethical stipulation. Thereafter, they would be destroyed and the recordings would be erased and deleted. Participants could request a copy of the final research report.

 

Results

Sample profile

The majority of professional nurses were black (89%; n = 16) and females (83%; n = 15), aged 41-50 years (55%; n = 10). Furthermore, most professional nurses indicated possessing a diploma in nursing (72%; n = 13). The professional nurses' years of experience ranged from less than 5 years' work experience (50%, n = 9), and between 6 and 10 years (44%; n = 8).

The themes that emerged from the data as shown in Table 2.

 

 

The main themes and subthemes reflect on the nurses' perceptions of the current PMDS within PHC healthcare settings. Although quite a good number of nurses mentioned PMDS as a vital HR component, many argued that it could become more relevant if it accurately measures performance and is used for development purposes. McDermott and Keating (2011) and Hyde et al. (2013) suggest that, currently in practice, the PMDS is not used effectively.

Each theme and subtheme is discussed comprehensively below.

Data were coded according to occupation and interview number. As indicated below: PN1-PN18, where PN refers to professional nurse and 1-18 refers to interview number.

Theme 1: Importance of performance management and development system in healthcare

This theme covered the importance of PMDS; it includes the purpose of PMDS and its current use in PHC health facilities.

Performance management and development system as a strategic, administrative and developmental managerial tool: The majority of participants perceived one of the goals of PMDS as being to evaluate performance for the purpose of identifying areas of development in nursing practice and thus assisting nurses in improving the quality of care rendered to patients for the purpose of meeting strategic goals towards better health services delivery. This is captured by the below-mentioned participant who mentioned the development focus of PMDS:

'It is developing because where you are able to see gaps, they are able to come back to you and say, you lack knowledge on this and that and then take you for training.' (PN14, female, 4 years of experience)

It was also observed that if applied correctly, the PMDS has the potential to help improve quality of service delivery through monitoring and evaluating performance for achieving national strategic health objectives. These aspects were mentioned by the participants mentioned below:

'It is like auditing the staff, like how far did you go, are you in line with the working environment and the guidelines etc.' (PN16, female, 11 years of experience)

'It is a good thing to also control performance and to reward people that need rewarding.' (PN11, male, 6 years of experience)

The above-mentioned participants demonstrated that the PMDS has a quality assurance aspect whilst also providing incentives for good performance. The remunerative incentive emerged as a key positive factor for the usefulness of PMDS for a number of participants:

'For remuneration, for payment purposes and rewards, that is the only important part about it. Somehow it encourages us, "If you work hard you will be rewarded". You become more interested in doing your job and wanting to do more.' (PN14, female, 4 years of experience)

The use of PMDS to incentivise performance is discussed in more detail under theme 3.

Theme 2: The system is flawed

This theme covers nurses' perceptions and experiences concerning how the PMDS is implemented at district level. It highlights the inconsistencies in its application across sub-districts as well as its weak accountability control measures.

Experiences of poor implementation of performance management and development system: The majority of participants complained about the poor implementation of PMDS. For example, participants articulated that whilst the appraisal process was meant to acknowledge and reward diligence as reflected in the previous theme, this was not always the case:

'It is failing us because even though we work you end up being at the same salary level for so many years.' (PN1, female, 8 years of experience)

The participant below also mentioned that as a result staff were reluctant to participate in the process. Furthermore, this participant reported there were no serious repercussions if staff chose not to complete the appraisal at all, thus demonstrating how the application of PMDS was compromised:

'Everybody is just reluctant . I don't see any progress in this system even if we don't write it nothing is done.' (PN5, female, 7 years of experience)

Interestingly, another participant (professional nurse 16) also passionately advocated against the use of PM, citing its idealistic aims that create animosity, given the unrealistic demands associated with it and with it having the potential to create an inconducive working environment that is contradictory to the vision of the system:

'The PMDS is out of order, it is unrealistic it is not working, the targets, its numbers, it is just imaginative numbers The PMDS is creating some form of hatred to some people who are working and are not getting it ' (PN16, female, 11 years of experience)

Another related issue was the unrealistic targets set by NWDoH which result in nurses feeling undermined when they do not reach their targets:

'This year you must treat a hundred patients, critical patients who are involved in an accident. Then you find you only have ten patients who are involved in an accident. How are you supposed to do that? Are you now supposed to spread the message to those people to please get into accidents? That is the problem with PMDS. They are not applicable and realistic. The problem with the PMDS is the targets.' (PN16, female, 11 years of experience)

Inconsistencies in the application of performance management and development system across sub-districts: Another complaint to emerge related to inconsistencies in the scoring and rewarding of the PMDS across sub-districts, with more than half of the participants mentioning this was an issue:

'They are not measured in the same way With remuneration same - if I compare myself with a professional nurse with the same experience as mine maybe Klerksdorp, we are doing the same thing like on a daily basis. She will be recognized and I won't be ' (PN14, female, 4 years of experience)

Weak accountability: Most nurses mentioned a lack of process to hold those not providing accurate critique to account for their performance. Half of the participants mentioned that weaknesses in the implementation of PMDS compromised the legitimacy of the system. For example, nurses claimed they were allowed to refuse to participate without repercussions; others were writing anything to avoid being penalised and recycling submissions:

'Last year I refused to write ' (PN3, female, 3 years of experience)

'You just write to get finished, just to get it done because when you don't write they will always be on your neck, putting pressure on you saying, "We need your PMDS we're going to penalize you if you don't write".' (PN4, female, 1 year of experience)

'We are only told to write it, then we copy from others. Then we ask others how you write it, so we only get information from other staff.' (PN3, female, 3 years of experience)

Theme 3: Rewarding performance

The majority of participants repeatedly expressed perceptions and experiences of great dissatisfaction with the rewarding system and further highlighted that the validity of PMDS was compromised by favouritism at facility level.

Rewarding system: Whilst participants acknowledged the potential of PMDS as a system for motivating them to perform better, the majority of them mentioned that there was a strong sense across the board that the manner of distributing rewards was not justified:

'I want them to treat us equally we are all going the extra miles they should also give us some bonus for our hard work we are working very hard compared to other clinics.' (PN3, female, 3 years of experience)

The below-mentioned participant argued that in instances where staff members did not receive a bonus, feedback must be provided on why they did not qualify:

'They [facility managers] should explain why you didn't qualify for a performance bonus [and others do]. We're coming to work every day doing what you are supposed to do.' (PN15, female, 7 years of experience)

The majority of participants identified the need for the PMDS to measure performance accurately, consistently and without any ambiguity. In doing so, these participants expressed great dissatisfaction with how performance decisions were made. Following comments attested to this:

'The people that get it [performance rewards] are the ones who are not working ' (PN3, female, 3 years of experience)

'It is not benefiting the people on the ground who are actually doing the job.' (PN16, female, 11 years of experience)

Like the above-mentioned participants, the following two participants also confirmed the lack of uniformity, and discrepancies, and questioned the fairness of the system:

'Sometimes those that are absent and dodging at the end of the year they are getting [performance rewards] ' (PN9, female, 2 years of experience)

'People that are writing PMDS are getting all these good remarks but they are not doing anything in the clinic.' (PN11, male, 6 years of experience)

Apart from the monetary rewards described above, some participants also mentioned the need for non-monetary plans of recognition and appreciation for hard work that could boost self-esteem and commitment:

'To be appreciated in a way, I don't say they should give money or whatever just to say, "Hey you have done well today". People's self-esteem is being built up. At least I am being appreciated; it doesn't mean it is all about money.' (PN7, male, 5 years of experience)

Favouritism: Almost all the participants suggested that the PMDS was riddled with favouritism at facility level. Participants noted the following as they interacted within their own work environment:

'The manager does play a role they do also have their favourites, it is not fair.' (PN11, male, 6 years of experience)

'It is favouring other people it is the same people that always get PMDS [rewards].' (PN15, female, 7 years of experience)

Other participants indicated that favouritism had a negative impact on performance and how it created conflict between employees:

'It causes friction. It breaks the spirits because if someone gets a reward and I don't get it when we are in the team. What's the difference?' (PN9, female, 2 years of experience)

'I don't think PMDS is working people will tell you that if your manager favours you, it will benefit but if your manager doesn't favour you then you don't benefit.' (PN17, female, 5 years of experience)

Professional nurse 16 cited managers for being responsible for initiating PM initiatives as well as having maximum benefits through favouritism.

'It has some sort of favouritism the managers are getting the PMDS [rewards] but the ones who are working, who are hands on are not getting the PMDS [rewards].' (PN16, female, 11 years of experience)

Overall, participants felt that favouritism ultimately had devastatingly negative consequences for positive work outcomes such as motivation, job performance and team collaboration.

Theme 4: Key considerations for effective performance management

This theme highlights nurses' opinions on key considerations for effective PM. These considerations include the following: (1) re-evaluating the administration of the system; (2) providing adequate training on PMDS for complete staff; (3) evaluating facility managers' competency and capacity to evaluate nurses' performance and (4) team dynamics and their consequences.

Re-evaluating administration of the system: Many participants suggested the need for a change in the current PMDS, wanting it to be aligned with PMDS within the district hospital settings. This was because the latter PMDS was perceived to be more user-friendly, with nurses merely having to rate themselves on certain criteria using tick boxes as opposed to writing in the format used by the PMDS in PHC facilities:

'I came here from the hospital, and usually the hospital, they had already, written it [the appraisals]. It was just for you to maybe tick [rate] yourself and then immediately when I came here I heard that everyone has to write the PMDS. No one showed me how to do it.' (PN5, female, 7 years of experience)

'If you can check Potch hospital, they are not writing they are scoring themselves. They get everything written with a column on the right to score. So you tick.' (PN14, female, 4 years of experience)

Providing adequate training on performance management and development system for complete staff: The majority of participants advocated for compulsory training on PMDS for the complete staff involved. They expressed that they did not feel confident about their capabilities to use the system, and that is why they felt vulnerable to making errors. It was suggested that the training of staff should focus on the process that raters and ratées should follow during the PM cycle, including establishing performance objectives, performance appraisal mechanisms and communication of performance appraisal feedback. These sentiments were shared by the majority of participants and exclusively expressed by the participant below:

'We don't even know how we should write PMDS because always when we write the PMDS, they will always tell you that this is the wrong way; this is not the correct way. But they have never conducted a workshop or training, so that we can all be on board as to what they expect from us.' (PN4, female, 1 year of experience)

Participants also indicated that poor communication of performance appraisal feedback impacted negatively their performance:

'Sometimes they don't even tell you; you will be scoring yourself, take the PMDS, to your supervisor and sometimes she will be scoring you and then attach the signature then send the forms to HR, without knowing the percentage you got.' (PN4, female, 1 year of experience)

Poor feedback of the performance appraisal process was reflected in the participant's following statement:

'If it was useful [the feedback], you would know what to write in the next PMDS and be sure that this is the correct way of writing it. They should call us individually and sit you down, discuss everything that you wrote so you know what it is that you did good [well] and what is it that you didn't do well. Because after presentations, no one is coming back with the feedback.' (PN14, female, 4 years of experience)

Facility managers' competency and capacity to evaluate nurses' performance: Many participants questioned whether facility managers had the time and competency to carry out PMDS effectively. They suggested that nurse managers were involved in much of administrative tasks that consumed substantial amount of their time, compromising contact time with nurses. The following statement illustrates the participant's views:

'The managers. They don't have time. Even when you have a problem or you sitting down with her, she will just tell you this and this and then you must go So we are not satisfied about this PMDS, the evaluation, the improvement and management.' (PN2, female, 4 years of experience)

Some participants suggested that nurse managers did not adequately represent the performance of professional nurses during panel evaluation committee meetings when individual and facility performance rating are evaluated:

'I don't think she is doing enough when she presents us at the panel Maybe she is not doing enough to prove that, "No, this person is really a hard worker".' (PN15, female, 7 years of experience)

Other participants stated that managers were not supportive in assisting them to improve performance and were only concerned with meeting targets. Thus, managers were often not proactive in addressing under-performance:

'They are not supportive, they are concerned about the numbers. They address the problem as it comes. It is only when something happens afterwards, they will come in and say "Why did this happen?" I have seen that at the top, that if the sub-district is not doing well, they come down and they put the pressure on us.' (PN10, female, 1 year of experience)

Team dynamics and their consequences: The majority of participants also perceived PMDS as largely individualistic in nature and consequently not encouraging teamwork, which was regarded as essential to achieve facility performance and improve the quality of collaborative teamwork, which underpins the chronic care model. The existing PMDS system was viewed as working against collaborative teamwork and the need for the PMDS to be aligned with organisational changes promoting teamwork was thus highlighted.

'It [is] dividing the staff. Currently, we are trying to work as a team, but if we are working as a team and then I alone get the PMDS or something but we are doing the same thing together I think that is separating the team work so someone will start only concentrating on the things she is supposed to achieve to get the performance bonus.' (PN15, female, 5 years of experience)

Theme 5: Experience of health system's reforms

This theme provides nurses' experiences with change and how the change is managed. The current changes were narrated in relation to the implementation of re-engineered PHC, NHI and the promotion of quality improvement.

Change is good and bad: Some nurses perceived current changes in a positive light, whilst others protested that there were too many changes all at once as indicated in the following statement:

'Too many changes at the same time .' (PN9, female, 2 years of experience)

In addition, a number of participants indicated that the changes had resulted in increased workload for limited staff as suggested in the following statement:

'I feel like those changes are piling up the workload on us they actually put more pressure on us.' (PN17, female, 5 years of experience)

'It adds more work load these changes of policy and these guidelines. You will be knowing this policy and mastering it and then 2 months later they introduce another one the other one is more work so it is influencing the queuing, the waiting times and the quality care of the patient because now you have to do more on the patient and the writings.' (PN14, female, 4 years of experience)

The training provided to implement the changes was also deemed insufficient to provide them with the necessary competencies to render quality care as explained below:

'Trainings are not enough, they do trainings for maybe 3 days and then they expect us to do this thing thoroughly and perfectly so ' (PN14, female, 4 years of experience)

On the contrary, these negative views regarding the changes were countered by some of the nurses sharing positive narratives on change, particularly in relation to the introduction of guidelines and manuals as suggested below:

'They really help you get a patient, you don't know how you really going to treat this patient, he comes in having these symptoms, you can just go to your guidelines and then you will be checking the different symptoms your patient has.' (PN13, male, 5 years of experience)

'It has improved the way I have been doing my job because now we are now having guidelines instead of me wasting time calling the doctor or someone to give me advice, I just open up the book and see that the patient I can help her this way so it saves a lot of time.' (PN8, male, 3 years of experience)

Notwithstanding these positive aspects of the changes, the majority of participants found that these changes were not managed effectively, with the barriers being mostly organisational - such as lack of resources and staff. Such organisational factors are discussed in length in the next theme.

Theme 6: Improving quality of care

This theme detailed nurses' perceptions on how to use PM system to cultivate a culture of improving the quality of healthcare delivery and factors that need to be considered in this regard.

Quality of care requires staff, resources and time: The majority of participants complained of staff shortage, with pressure to see many patients, and that this compromised the quality of care they were supposed to provide:

'With quality we try our best but the numbers increase and what happens is that we open 08:15 up until 16:30. The clinic can be full up until 16:00 so we hurry up because we want to go home in time. You won't render quality services to your patients you just want them out of here.' (PN13, male, 5 years of experience)

'Work overload so many patients to see, you end up not seeing one patient in totality. We run to push the line, making the hall empty, helping people sitting outside so that we can go. So that affects the quality of care we are rendering the patients.' (PN14, female, 4 years of experience)

One nurse, however, had a different view, highlighting that quality should not be compromised, regardless of long queues. This participant noted the need for nurses to pay attention to individual cases, highlighting the importance of nurses providing health-promoting messages, although she was not optimistic about patients' willingness to receive such care:

'We cannot just hurry up because the queue is long. If you see that this patient needs attention, you just do what we have to do. We have to give quality We encourage patients to keep healthy and also the information we are giving our clients, it must, at least, help them to change their lifestyle In our clinic, patients are discouraged to come because of long queuing. Sometimes, even if you can give them information, they are not listening to go. I think our community lost hope in [the] health system.' (PN9, female, 2 years of experience)

Some participants indicated the need for greater support for the challenges faced by nurses, indicating the need for greater awareness on the part of management in this regard:

'I think support and communication would be the best, if management can come down [sic] and maybe look at the work that we do, so to understand how many patients we administer.' (PN16, female, 11 years of experience)

Many participants further indicated that the current PMDS overemphasised meeting targets (being outcome-based) and the neglect of consideration on the quality of care provided (behavioural-based), which is central to PCC. This is further indicated by the following participant:

'The PMDS is more about the numbers, not the quality of work you are doing. It has nothing to do [with] the people, but the numbers!' (PN16, female, 11 years of experience)

 

Discussion

The importance of performance management and development system in healthcare settings

The vast majority of participants identified the need for a PM system in healthcare settings. They understood that its main purpose was to meet up with and evaluative developmental objectives, and that the value of PMDS dwells in its potential to provide feedback that could be helpful in improving their job performance and the provision of quality care. This developmental ethos in managing performance is supported by Lutwama, Roos and Dolamo (2013), who identified it as one of the three main functions for a PM system (the others being strategic and administrative).

Monetary and non-monetary rewards

Both monetary and non-monetary rewards emerged as important aspects of performance appraisal in this study. The majority of participants expressed that the profession was extremely stressful, and lack of recognition and rewards was one of the major reasons for their job dissatisfaction. Although monetary rewards were reported to be important to improve job satisfaction and retention, the importance of other forms of recognition and acknowledgement also emerged as important. Other forms of appreciation, such as recognition for daily progress, were reported to enhance positive attributes such as dedication, hard work and self-esteem. Abualrub and Al-Zaru (2008), who conducted a study on job stress, recognition, job performance and intention to stay at work amongst Jordanian hospital nurses, found a direct and buffering effect of recognition of nurses' performance on job stress and the level of intention to stay at work. Locally, the importance of recognition for outstanding performance as well as other achievements is also supported by Mokoka, Oosthuizen and Ehlers (2010), who found that both monetary and non-monetary rewards were important for improving retention of professional nurses in South Africa from a nurse manager's perspective.

Evidence of a system that is poorly implemented

The nurses highlighted that the PMDS was poorly implemented. Nurses complained that the way in which PMDS was implemented failed to truly capture performance, did not provide feedback on remedial steps to improve poor performance and did not promote accountability or set realistic performance targets. Mone and London (2018) suggest that if true performance is not captured accurately or consistently, it would decrease the natural motivational climate to enhance performance. On the contrary, if the system is implemented correctly, it would facilitate identification of non-performance and implementation of remedial interventions to improve performance.

Furthermore, the participants in this study perceived the system to be implemented unfairly and lacking impartiality - with the respondents questioning whether those receiving rewards truly deserved them. Monetary gain as an incentive was reported to fuel distrust and promote favouritism, with only few earning monetary rewards. Such beliefs are in line with previous literature that has investigated the perception of PM in the public sector of South Africa (Makamu & Mello 2014; Mello 2015; Swaartbooi 2016). Daskin (2013) found similar experiences in the hospitality industry, with favouritism having the potential to create distrust and causing diligent performers to disengage from the process. Favouritism has been found to be disruptive for productivity and staff morale, creating conflict between employees, and affecting negatively on motivation, job satisfaction, job performance and team collaboration (Alotaibi, Paliadelis & Valenzula 2016; Isaed 2016; Platis, Reklitis & Zimeras 2015). The need for nurse managers to be trained in the negative implications of favouritism in the PMDS process is thus highlighted.

Owing to the perceived unfairness of the system, not feeling competent in how to complete their side of PMDS, as well as lack of feedback on their performance and how it could be improved, nurses purportedly did not take the system seriously or understand why it is necessary (Du-Plessis 2015). They commented that they participated in the process only to avoid being disciplined if they did not comply. Although the tools and processes of PM are based on sound principles, how they are implemented and utilised is contentious (Mboweni & Makhando 2017). One of the greatest challenges in literature on PM systems and performance appraisal involves employees contesting its usefulness in fostering self-development and promotion (Adler et al. 2016; Mone & London 2018). The need for management training for the purpose and use of PMDS to ensure that it is implemented as intended is again highlighted.

Quantity over quality

Nurses in this study also mentioned that the overemphasis on outcome-based measures of performance compromised attention to quality of care and PCC. There were no incentives for professional nurses to practise PCC. Behaviour-based measures of performance that could be used to promote this approach to care were neglected. Examples of such evaluation include measuring the relationship between patient and nurse, patients and nurses agreeing on patient problems, and efforts towards evaluation of medical and other interventions to resolve or improve patient care. Instead, the PMDS encouraged nurses to spend less time on each patient to achieve their targets and to ensure that all patients visiting healthcare facility are served (Hanefeld, Powell-Jackson & Balabanova 2017; Petersen et al. 2006).

In the context of current reforms underway in PHC, the PMDS presents as a valuable tool that could assist in ensuring implementation of these reforms. This is especially the case in relation to reorienting staff to providing a person-centred team-based collaborative care necessary for treating multi-morbid chronic conditions that commonly present at PHC because of the clashing human immunodeficiency virus (HIV) and non-communicable diseases (NCD) epidemics (Kengne & Mayosi 2014). Awases, Bezuidenhout and Roos (2013) warned that the performance of health workers is linked with productivity, whilst provision of quality care within healthcare facilities is neglected. The results of this study call for a review of the (1) current PMDS in light of its goals to improve quality of care and promote patient-centred care, and (2) way it is implemented so as to ensure that the system fully meets its strategic, administrative and development goals without any compromise with its validity and accuracy.

Recommendations

Based on the findings of this study, the following recommendations are made to improve PM in PHC:

  • Review the implementation, validity and accuracy of current PMDS by revisiting discussions on the type of measurements used in PMDS and its systematic implications. Such review should be at a systems level involving all stakeholders and include district level managers as well as all categories of health workers that are subjected to PMDS. It is important that the review should be consultative and promote participation from health managers and providers in all categories. The outcome of this system's review should outline challenges experienced at all levels that have resulted in the flawed implementation of PMDS. The outcomes of the review should also include a detailed action plan on how to change the current status quo and improve the manner in which performance is planned, measured and managed at district level.

  • Provide training on PMDS to all personnel who are part of the performance cycle, including nurses nurse managers, performance panel committees, health district management and HR practitioners to improve its implementation. This training should be provided by specialist in the field of PM, change management and coaching for performance. This training should include the following: clarification of the roles and responsibilities of all personnel as suggested by the Public Service Commission - EPMDS 2007 guidelines. It must emphasise strong accountability chains to ensure accountability in line with expressed roles and responsibilities. It should also provide the purpose of a PM system, how performance is measured as well as how to provide and receive feedback and the relevance and benefit of the system.

  • The use of PMDS as a tool to identify training needs and to motivate staff should be revisited by health district management. The current emphasis on target-driven results should be broadened to include the quality of care provided by nurses. Through relooking at HRM practices, it is especially important to review the instrument and processes used to measure performance, and whether it is in line with the strategic goals of the healthcare system towards ICSM and PCC. Moreover, there is a need to reconsider the distribution of rewards between monetary and other form of recognition strategies.

  • Given the strong culture of compliance rather than active engagement with the PMDS found in this study, there is a need to make changes in the current organisational culture and climate. In this regard, establishment of shared performance goals from district level to facility teams and personal level is recommended. This would require an investigation of readiness to change and interventions that focus on effectively managing change at district level. This could be achieved by providing training to district health managers on transformational leadership and management that is tailored to promote an organisational culture that actively encourages quality healthcare.

  • A periodic review (every 3 years) of nurses' and nurse managers' perceptions and experiences of PMDS is recommended to provide remedial steps to identify challenges that pose threats to the management of performance at PHC level.

It is further recommended that research be conducted in the following areas: (1) use of PMDS as a tool to promote job satisfaction and enhance other psychological resources such as self-efficacy, emotional intelligence and work engagement; (2) relational leadership as an effective managerial development tool and (3) appraising nurses about practices of person-centred care.

Limitation of the study

This study used a qualitative research approach, conducted at an NHI pilot site in North West. A purposive sample of professional nurses employed in PHC facilities was selected, which might limit the generalisability of findings to other healthcare facilities in other provinces and district sites that are not NHI pilots.

 

Conclusion

The current PMDS needs to be overhauled so as to promote healthy working relationships between nurses and nurse managers to facilitate a collaborative working environment that does not promote individual gains over team capacity. Nurses and nurse managers need to be equipped with the necessary understanding of the value and usefulness of PMDS as well as the skills to implement it properly to ensure that nurses' contributions are recognised and rewarded appropriately without any favouritism or unfair practices impeding this process. This would allow it to be fully utilised as a valuable managerial tool used to improve health outcomes, identify training and development needs as well as acknowledge hard work and dedication.

 

Acknowledgements

The authors would also like to thank the Dr Kenneth Kaunda Health District in the North West province for allowing us the opportunity to conduct this study. To the participants who shared their experiences with us, thank you for your valuable time.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

C.Z.M. was responsible for conceptualising the study and prepared this article for submission under the guidance and supervision of I.P. Both authors contributed to the development of the background and planned output of the research as well as the design of the study. Both authors contributed to the reviewed draft version of the article and approved the final version.

Funding information

This research study was funded by the National Research Foundation: Thuthuka Scholarship Programme.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Disclaimer

The views expressed in this article are those of the authors and not of the affiliated institution or the funder.

 

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Correspondence:
Cynthia Madlabana
madlabana@ukzn.ac.za

Received: 10 Oct. 2018
Accepted: 25 Jan. 2020
Published: 30 Apr. 2020

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ORIGINAL RESEARCH

 

Factors influencing motivation of nurse leaders in a private hospital group in Gauteng, South Africa: A quantitative study

 

 

Maria Breed; Charlene Downing; Hafisa Ally

Department of Nursing, University of Johannesburg, Johannesburg, South Africa

Correspondence

 

 


ABSTRACT

BACKGROUND: Nurse leadership is about aligning employees to a vision. This happens with buy-in, motivation and communication. When conducive environments are created by organisations, the motivation of nurse leaders will be enhanced, which will have a positive outcome on the organisation. Highly motivated nurse leaders accomplish more and are more productive. Nurse leadership is an essential source of support, mentorship and role modelling. These attributes tend to be more evident when nurse leaders are motivated.
OBJECTIVES: The objective of this study was to determine the factors that influence the motivation of nurse leaders.
METHOD: A quantitative, descriptive design and stratified sampling was used. Participants comprised unit managers (n = 49) from five hospitals in a private hospital group in South Africa. A self-administered questionnaire, namely, the Multidimensional Work Motivation Scale, was used to collect the data. Data were analysed using the IBM SPSS 22.0 program.
RESULTS: The results indicated that the nurse leaders in this study were intrinsically motivated. Their motivation was influenced by support, relatedness, autonomy and competence. No relationships were found between motivation and age, years in a management position, gender, qualifications and staff-reporting structure.
CONCLUSION: By implication, to understand what motivates nurse leaders and to keep them motivated, recommendations were proposed to nursing and human resources management. It is expected that the implementation of the recommendations will have a positive influence on patient outcomes, organisational success and the motivation and satisfaction of nurse leaders.

Keywords: motivation; leadership; unit managers; quantitative research, nurse leaders.


 

 

Introduction

Leadership is a concept of importance on a global level, as the success of any organisation depends on the quality of its leadership. Today's nurse leaders must motivate and engage a diverse and multigenerational labour force, ranging from employees on their payroll to part-time workers employed on a contract basis (Jesuthasan & Holmstrom 2017). According to Zhang, Fan and Zhang (2015), leaders with a high degree of motivation take the initiative, seek responsibilities, have a positive attitude regarding taking risks and are eager to learn.

Leadership can be described as the ability to organise and influence employees with specific skills to complete delegated tasks to achieve results (Ramchunder & Martins 2014). Leaders formulate a common vision, motivate others and offer stability during times of transformation (Martin 2015). According to Cooper (2015), leadership is the ability to influence others to achieve organisational goals. Ramchunder and Martins (2014) believed that the leader's ability to influence the behaviour of employees can positively influence performance outcomes.

This study concerns the concept of motivation as influenced by leadership, specifically leadership of unit managers. Unit managers are the first-level leaders in nursing. Motivation is the leader's degree of preparedness to apply and preserve an effort to achieve the organisation's goals (Akintola & Chikoko 2016). Motivation is a critical part of leadership as people need to understand each other to be effective leaders. This motivation is a process that directs and influences behaviour (Jooste & Hamani 2017). Motivation is essential in providing nurse leaders with reasons for a certain behaviour and plays an important role in guiding behaviour and decision-making (Frielink, Schuengel & Embregts 2017).

Nurse leaders display different types of motivation. These are driven by three basic needs: autonomy, relatedness and competence (Allan et al. 2016). The need for autonomy and competence relates to engaging with tasks that leaders find interesting and promote growth in their autonomy and competence (Shu 2015). Relatedness is the extent to which nurse leaders feel they are cared for and connected to others. Consequently, relatedness creates feelings of belonging and provides a sense of safety. Nurse leader's competence, on the contrary, refers to a leader's gifts and abilities in a specific domain (Conway et al. 2015).

Because of the high demands that are placed on nurse leaders to produce outcomes and remain professional and motivated, it is important to identify what motivates nurse leaders and provide recommendations to enhance their motivation or keep them motivated. Studies have been conducted on motivation (Akintola & Chikoko 2016) and leadership (Kantanen et al. 2017) in general, but the first author has found a gap in specific research on nurse leaders, specifically concerning nursing unit managers and their motivation in South Africa. No evidence of specific research on nursing leadership, specifically regarding the motivation of unit managers in the private hospital sector, has been found.

Theoretical framework

This study is based on the Self-Determination Theory. This theory assists in understanding employees' motivation in the work setting, and focusses on the degree to which needs are satisfied and not necessarily individual differences in needs' strength as discussed by Graves and Luciano (2013:520). It also differentiates between different types of motivation, which falls along a continuum of self-determination from intrinsic, integrated, identified, introjected, extrinsic and amotivation (Jochems et al. 2014:495).

Intrinsically motivated work behaviour creates congruence between work behaviours and one's self-concept, which results in feelings of meaningfulness (Allan, Autin & Duffy 2016). This type of motivation is regulated by personal enjoyment, interest or pleasure, and it involves the performance of an activity for the inherent satisfaction of the activity (Naile & Salesho 2014:177). Putting effort into a job is interesting and exciting.

Introjected motivation drives action to avoid guilt and shame and enhance the ego (Battistelli et al. 2015). Introjected motivation is somewhat less controlled and represented by behaviours driven by internal rather than external rewards. The leader is motivated to avoid self-conscious emotions and obtain positive self-regulated affects and appraisals (Nie et al. 2015:246). Putting effort into a job in order not to feel bad or ashamed about one's self, even taking the risk of losing one's job if it is not satisfactory.

In identified motivation, actions are performed because such actions are personally important and valuable to the nurse leader (Maulana et al. 2016). Putting effort into one's job because you consider it important, because the job aligns with personal values, and because it has personal significance.

Extrinsic motivation arises from the influence of external activities that direct nurse leaders to perform to get rewards in return (Hee & Kamaludin 2016), and amotivation refers to the total lack of any intention to act (Nie et al. 2015). Putting effort into one's job to get other people's approval, other people's respect and to avoid criticism are examples of this motivation.

Motivation tends to differ in leaders who are engaged versus disengaged; therefore, the need to elaborate on these concepts. Engaged leaders motivate behaviour by changing basic values, beliefs, attitudes and assumptions of employees by raising their awareness of organisational goals (Wipulanusat, Panuwatwanich & Stewart 2017). It can be argued that disengaged leaders are less motivated and therefore not able to motivate their employees (Jooste & Ntamane 2014).

The factors that influence the motivation of nurse leaders must be identified to implement targeted strategies for continuous improvement (Zarei et al. 2016: 2250). The purpose of this study was to fill this identified gap by determining the factors that influence nurse leader's motivation. There appears to be no literature that specifically deals with this topic in terms of nurse leaders and therefore the need to address this gap.

 

Aim and objectives

The purpose of this study was to determine factors that influence the motivation of nurse leaders.

 

Research method and design

Research design

A quantitative research design was applied. A quantitative design is defined by Fouché et al. (2014: 64) as an inquiry into a social or human problem, based on testing a theory consisting of variables, measured with numbers and analysed with statistics. The first author conducted an investigation into the factors that influence the motivation of nurse leaders - variables were identified and statistics were analysed, thus leading to the decision to use a quantitative research design. In this study, the opinions of the nurse leaders were taken as a representation of the truth, as their opinions reflected their perceptions of the construct within this study. This research design was effective in obtaining knowledge about nurse leaders' motivation as very little literature is available about the behaviour with specific reference to nurse leaders.

Setting

This study was conducted at five different hospitals of one private hospital group in the Gauteng province in South Africa.

Study population and sampling strategy

The respondents included nurse leaders identified as unit managers. Stratified sampling was used, and all the unit managers from the selected hospitals in the northern region of Gauteng in South Africa had an equal opportunity to participate. Each hospital had about 12 unit managers on their payroll, and they were included. The sample size amounted to 60 (N = 60). The criteria for the unit managers to be included in the study as the target population were as follows: unit managers (1) had to be in a managerial position for more than 6 months, (2) had to be responsible for more than five staff members and (3) had to be working in a private hospital setting of a specific group. Different hospitals were selected by means of the probability sampling method; a simple random sampling method was used. The total accessible population size was N = 60. A total of 49 questionnaires were completed and returned. The return rate was 82%.

Data collection

A two-part questionnaire consisting of 40 questions using a Likert scale, with options ranging from strongly disagree, disagree, undecided and agree to strongly agree, was used. The Likert scale most commonly addresses response choices such as agreement, evaluation or frequency (Burns, Gray & Grove 2013). In this questionnaire, the response choice was for agreement. A self-administered questionnaire was used, using questions from the Multidimensional Work Motivation Scale, the Work-Related Basic Need Satisfaction Scale and the Perceived Organisational Support Survey, to collect the data.

All unit managers in the selected hospitals were invited to complete the self-administered questionnaire. Sixty questionnaires were distributed, either electronically or by hand. Section A included a cover letter explaining the purpose of the questionnaire, the first authors' name and the supervisors involved, and the affiliated university.

Section B consisted of guidelines and explanations on how to complete the questionnaire. Section B consisted of two sections, and section 1 included biographical questions. Table 1 shows the components addressed in section 2 of the questionnaire.

 

 

Data collected in previous studies with this instrument showed the scales to be valid and reliable (Gagné et al. 2014; Rhoades et al. 2001; Van den Broeck et al. 2010). Cronbach's alpha coefficient is the statistical procedure used for calculating internal consistency (Burns et al. 2013).

In the above-mentioned studies, the Cronbach alpha for autonomy, competence and relatedness was on average more than 0.80 (Van den Broeck et al. 2010). This indicates that the instrument is 80% reliable with 20% random error. For support, it was measured between 0.74 and 0.80 (Rhoades et al. 2001), which indicates that the scale has a 74% - 80% reliability for the questions regarding support, and for different types of motivation it was measured above 0.70, which shows a 70% reliability score (Gagné et al. 2014).

Data analysis

Data were analysed statistically by means of the IBM SPSS 22.0 program. The findings of the study were presented both as descriptive and inferential statistics. The descriptive statistics were presented as frequencies (f) that refer to the number of responses (n) on items using a five-point Likert scale (n = 49); the mean (x˙) of each item that will be presented in a table format from the highest to the lowest mean value; and the standard deviation (SD) of each item. The following descriptive statistics were analysed: autonomy, competence, relatedness, support, amotivation, extrinsic regulation - social, extrinsic regulation - material, introjected regulation, identified regulation and intrinsic motivation as an aspect of motivation. Inferential statistics were derived at by means of factor analysis and statistical significance. The varimax principal component analysis was used for factor analysis. Factor analysis was conducted on the responses between the following aspects of nurse leaders and motivation: age of the respondents, years in a managerial position of the respondents, gender of the respondents, level of qualification of the respondents and staff-reporting structure to the respondents.

Ethical considerations

The respondents were made aware that participation was not compulsory and that they could withdraw at any stage. Each respondent signed written consent that they were participating voluntarily. No compensation was offered to any respondent. Permission to use the questionnaire was obtained from the relevant parties. Ethical approval was obtained from the University of Johannesburg Higher Degrees Committee (HDC-01-168-2015) and the Research Ethics Committee (REC-01-243-2015).

 

Results

Table 2 indicates a breakdown of the characteristics of the respondents and the aspects that were investigated. In this study, age, gender, highest qualification, years in a managerial position and staff-reporting structure did not have an impact on the respondents' motivation.

The ages of respondents were between 31 and 62 years. It was established from the data obtained that the largest group was between 41 and 50 years (47%). The smallest age group was the group older than 61 years (n = 3), which accounted for 6%. The group with ages between 31 and 40 years constituted 20% of the respondents, and the third group identified was the age group of 51-60 years, which totalled 27% of the respondents.

The highest qualified leaders were in the age group of 50-59 years who will soon enter retirement age and will leave a gap in the intellectual capital. The age group with the highest amount of degrees was between 50 and 59 years; this group had eight degrees (16%), while the group between 40 and 49 years had six degrees (12%) and the group between 31 and 39 years had three degrees (6%). The age group older than 60 years had no degrees. Only 17 of the 49 respondents, which is 35%, had a degree.

Only 6% of the respondents were men who participated; this illustrates that the nursing leadership roles are predominantly led by women. As shown in the Table 2, the majority of the respondents (39%), (n = 19), were in a managerial position for more than 7 years. The majority of the respondents (51%), (n = 25), had more than 20 staff members reporting to them. The demographic information is shown in Table 2.

The descriptive analysis revealed that the following aspects influenced nurse leaders' motivation. Influencing factors consisted of five items (support, relatedness, competence 1, autonomy relatedness and competence 2), and five motivation factors (identified regulation, extrinsic regulation - social, amotivation, intrinsic motivation and introjected motivation) were shown to influence motivation in nurse leaders.

Relatedness or sense of belonging

With a mean value of 4.4694, item 2(at work I feel part of the group) showed the highest mean value - 98% either strongly agreed or agreed that they feel part of the group. The results indicate that the majority of the respondents felt related at their job. Table 3 shows an illustration of the results.

Competence

This refers to feeling a sense of capability in the leader's own ability to relate with their environment as well as obtaining opportunities to express capacities on a regular basis (Allan et al. 2016). Six items were included.

Item 8, which read 'I feel competent in my job', scored the highest mean value (x˙ = 4.6939). All the 49 respondents either strongly agreed or agreed with this statement. In other words, most of the respondents felt that they were competent in their job and were certain about their capabilities and competencies. Table 3 shows the results as discussed.

Autonomy

Autonomous motivation is a form of self-regulation whereby leaders act as a result of their deep values, goals and interests (Graves & Luciano 2013). Five items were included.

The highest mean value (x˙ = 4.1837) was scored for item 15 (The tasks I have to do at work are in line with what I really want to do), where 92% either strongly agreed or agreed that they were doing tasks at work which were in line with what they wanted to do.

Most of the responses were positive in that the nurse leaders did feel a sense of autonomy. Table 3 shows the results for this section.

Support

Strong and supportive leadership is a strong predictor of leader's motivation and morale (Chipeta et al. 2016). Support consisted of four items.

Item 19, 'Nursing management cares about my well-being', scored the highest mean value (x˙ = 3.96). Of the respondents, 10% strongly disagreed or disagreed, 10% were undecided, while 80% either agreed or strongly agreed. This means that the majority (80%) felt that this statement was true, and that 20% felt that management did not care about their well-being.

It can thus be concluded that the majority of the respondents felt that the management supported them. Table 3 shows the results for this section as discussed.

Motivating factors

Amotivation

Amotivated people usually feel disengaged and helpless in doing activities and will therefore easily quit an activity or task (Chen & Bozeman 2013). A leader lacking motivation will thus only have a minimum level of determination to work (Rizal et al. 2014). Three statements were included.

The highest mean value (x˙ = 1.31) was scored for item 22 (I will not put effort into my job because I really feel that I am wasting my time at work). All 49 respondents either strongly agreed or agreed with these statements, that is, they all agreed that they were not wasting their time at work and therefore would make an effort at work. After analysing these data, it can be said that not one of the respondents was a motivated. Table 4 shows the results for this section.

Extrinsic regulation - social

Extrinsic motivation is an external force, leading the nurse leader to meet personal and organisational goals. This occurs because of external activities, such as pressure or instruction, which influence leaders to perform tasks and reap the rewards in return (Hee & Kamaludin 2016). Here three items were included.

Item 26, 'I put effort into my job because other people will respect me more', scored the highest mean value (x˙ = 2.98): 40% strongly agreed or agreed with this statement, 8% were undecided and 52% either disagreed or strongly disagreed. A majority of respondents (52%) disagreed with this statement, which indicates that gaining the respect from others was not a motivating factor for the respondents.

This analysis indicates that extrinsic motivation, especially the social components of motivation, did not play an important role for the respondents (see Table 4 for an illustration of these results).

Introjected regulation

This type of motivation refers to motivation arising from a desire to satisfy the demands from others, that is, acting to avoid feelings of guilt or out of a psychological need to prove something (Gaston et al. 2016). Introjected regulation consisted of four items.

Item 32, 'I put effort into my job because it makes me feel proud of myself', scored the highest mean value (x˙ = 4.80). This statement regarded pride in oneself because of a job done. Of the 49 respondents who responded, 96% strongly agreed or agreed with the statement, 2% were undecided and 2% disagreed. After analysing the data, it could be established that introjected regulation was an important motivator for the respondents. Table 4 shows an indication of these results.

Identified regulation

Identified regulation represents the lower end of the spectrum regarding autonomous motives and refers to motivation arising from a longing to accomplish a result, which is personally valued by the leader (Gaston et al. 2016). This consisted of three items.

Item 36, 'I put effort into my job because putting effort into this job aligns with my personal values', had the highest mean value (x˙ = 4.86). Of the 49 respondents, 86% strongly agreed and 14% agreed. This showed that personal values and job alignment were important aspects for the respondents. The analysed data thus showed that identified regulation is an important factor of motivation. Table 4 shows the results of this section.

Intrinsic motivation

Intrinsic motivation is an internal force that leads leaders to meet personal and organisational goals. This type of motivation can be described as inherently interesting and enjoyable that creates behaviour and encouragement to act (Hee & Kamaludin 2016). Three items were included.

Item 40, 'I put effort into my job because the work I do is interesting', scored the highest mean value (x˙ = 4.44). A majority of 68% agreed with this by either strongly agreeing or agreeing, 8% were undecided and 4% disagreed with this. Item 38 was about having fun while doing the job: 94% agreed with this, 4% were undecided and the remaining 2% strongly disagreed.

Thus, most of the responses showed that the respondents favoured intrinsic motivation and regarded it as an important component of their motivation level. In Table 4, the results for this section are presented.

For this study, the Cronbach alpha for autonomy was 0.660; for competence, it was 0.770; and for relatedness, it was 0.732. For support, it was 0.886. The different types of motivation scored as follows: amotivation, 0.828; extrinsic regulation - social, 0.847; extrinsic regulation - material, 0.793; introjected regulation, 0.523; identified regulation, 0.878; and intrinsic motivation, 0.920.

 

Discussion

Age, years as a manager, qualification and number of staff reporting to the nurse leaders do not seem to be potential predictors of autonomy, competence and relatedness, and do not serve as motivation factors in this study on nurse leaders. Support was identified as one of the important aspects of motivation for nurse leaders, as they needed to feel that they were cared for and that their well-being was important to the organisation.

Relatedness was identified as another aspect that influenced motivation in nurse leaders, and therefore it was important for them to feel part of the team and that they could connect with others at work. In this way, they did not feel isolated and alone. It is thus important that nurse leaders feel that they have someone to talk to, as this will enable them to voice their opinions and be autonomously motivated. Competence is an important aspect of motivation, and leaders need to be empowered and encouraged to up skill and improve their competencies to enable them to deal with difficult tasks.

It was found that most of the respondents in this study were intrinsically motivated. Introjected and identified regulation, which are part of extrinsic motivation, were identified as important aspects in this study.

Feelings of competence, relatedness and autonomy encourage autonomous motivation by allowing leaders to act from the underlying self (Graves & Luciano 2013). Furthermore, leaders expect an environment of emotional support, warmth, friendliness and trust, which ensures a conducive working environment (Wipulanusat, Panuwatwanich & Stewart 2017). Leaders can achieve high levels of motivation when they feel related and can act effectively with personal initiative (Toode et al. 2014). Nurse leaders are expected to have substantial knowledge as well as leadership and management competencies in a changing environment (Kantanen et al. 2017). Intrinsic motivation is regulated by personal enjoyment, interest or pleasure, and it involves the performance of an activity for the inherent satisfaction of the activity (Naile & Salesho 2014). When leaders are intrinsically motivated, they tend to experience emotional well-being (Nunez & Leon 2016). Introjected regulation is somewhat less controlled and is represented by behaviours driven by internal rather than external rewards and punishment. The leader is motivated to avoid self-conscious emotions and obtain positive self-related affects and appraisals (Nie et al. 2015). Identified regulation is a more autonomous form of motivation in which the leader is motivated because the behaviour is congruent with the individual's personal goals and values (Nie et al. 2015).

This study showed that nurse leaders engage in their tasks and activities because they are important to them. In fact, they find their work exciting and interesting. They also show pride in their job by achieving their goals.

Financial rewards and job security were not important motivators, and therefore it can be concluded that the respondents in this study were intrinsically motivated and that support, relatedness and competence were important motivators for them. Factors influencing the motivation of nurse leaders were determined, and therefore it can be concluded that the research problem was dealt with.

 

Limitations

Because of the small sample size of 49 nurse leaders who participated in this study and the fact that the study was restricted to five hospitals in Gauteng in South Africa, the results cannot be generalised to other hospital groups. The male population of nurse leaders was not well represented.

 

Recommendations

As identified from both literature and this study's results, a few focus areas emerged, which must be addressed to ensure that nurse leaders stay motivated. The following recommendations can assist in the motivation of unit managers.

Autonomy

It is allowing unit managers to work independently and make decisions on how to execute tasks (Miyata, Arai & Suga 2015), as well as supporting unit managers in decision-making skills and including them in strategic planning sessions (Papathanasiou et al. 2014).

Relatedness

It is encouraging one-on-one relations-building sessions between unit managers and supervisors (Graves & Luciano 2013) and allowing unit managers to discuss their successes and challenges in group sessions. A sense of belonging will be established when team-building sessions with colleagues are encouraged (Utvær & Hagan 2016).

Competence

It is establishing constructive feedback sessions on the unit managers' competence on creating a culture of recognition for work well done (Van Dierendonck & Driehuizen 2015). Time for development must be allowed, and training needs should be identified. Mentoring by supervisors on expectations will assist in developing competence. Courses to up skill nurse leaders must be identified, addressed and budgeted for, and available conferences should also be budgeted for (Van Dierendonck & Driehuizen 2015).

Support

It is showing interest in nurse leaders' opinions and suggestions (Shariff 2015). By being involved in caring for their well-being (Wipulanusat et al. 2017), nurse leaders' goals and values should be considered and included in their development plan (Solansky 2014). An open door policy with nurse leaders and supervisors must be encouraged (Wipulanusat et al. 2017). Confidence in their development should be shown by including them in succession planning (Van Dierendonck & Driehuizen 2015).

Intrinsic motivation

It is ensuring that fun components are included in the nurse leaders' work, by exploring what is exciting for these nurse leaders, and incorporating those at into their work (Chen & Bozeman 2013), as well as keeping their work interesting and having regular discussions with them to identify their specific needs (Naile & Salesho 2014).

Identified and introjected regulation

It is encouraging nurse leaders to put effort into their jobs and also to align their work and personal values (Nie et al. 2015). Nurse leaders need to be allowed to prove that they can execute certain tasks successfully and should be appreciated for a task well done (Gagné et al. 2014). These achievements by nurse leaders must be recognised in public, and they should be encouraged to give feedback on positive outcomes (Witges & Scanlan 2014).

  • Encouraging nurse leaders to put effort into their jobs and also to align their work and personal values.

  • Nurse leaders need to be allowed to prove that they can execute certain tasks successfully and should be shown appreciation for a task well done.

  • These achievements by nurse leaders must be recognised in public and they should be encouraged to give feedback on positive outcomes.

All of these activities will ensure that nurse leaders are motivated, and it will also keep them motivated.

 

Conclusion

Nurse leaders who are not motivated cannot contribute to the profession, and therefore it is important to establish what motivators are important to leaders. Nursing is a constantly changing environment with new technology and policy changes being introduced all the time. Nurse leaders must therefore be empowered to adapt to these constant changes. This can happen only when nurse leaders are motivated and empowered. Motivation and overall work performance can be enhanced when attention is given to factors that are important to nurse leaders. Autonomous motivation is important for nurse leaders, and therefore it is important to allow them to make decisions and attempt to complete tasks in the manner they deem fit and to support their decision-making skills. When they are allowed to act autonomously, they can use their creativity, which can be advantageous for the organisation. This study determined that nurse leaders are intrinsically motivated and that introjected and identified regulation plays a role in their motivation. Autonomy, relatedness, competence and support are factors that influence their motivation. Recommendations that can enhance these factors and ensure that these nurse leaders stay motivated were listed.

 

Acknowledgements

The authors would like to thank the respondents for their participation in the research.

Competing interests

The authors have declared that no competing interest exists.

Authors' contributions

M.B. initiated the study and was responsible for the data collection, data analysis and writing of the manuscript, as part of her master's study. C.D. and H.A. assisted in the conceptualisation of the study design, preparation of the manuscript, data analysis and critical revision of the article.

Funding information

This research received no specific grant from any funding agency in the public, commercial, or not-for profit sector.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

 

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Correspondence:
Charlene Downing
charlened@uj.ac.za

Received: 22 Sept. 2018
Accepted: 07 Dec. 2019
Published: 27 Feb. 2020

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