RESON Colloquium July 2012

CHP researchers shared research findings of the Research on the State of Nursing (RESON) project at an interactive colloquium on 12 July 2012 which wrapped up the four-year research project funded by The Atlantic Philanthropies. This work aimed to develop and strengthen the evidence for improved nursing policy development and practice in South Africa through three main research areas:

1) Policy analysis – scope of practice, qualifications framework, occupational specific dispensation, and the country’s nursing strategy

2) Casualisation: Nursing agencies and moonlighting

3) Nursing management and quality of care

Over 40 stakeholders from the private and public sector, national and provincial health departments, academics and NGOs including DENOSA and the South African National AIDS Council (SANAC) attended the last meeting of the RESON Advisory Committee to hear the findings of these three core research projects, and to propose strategies for getting this research into policy and practice.

RESON’s project leader,Prof Laetitia Rispel,presented an overview of the project which has led to an improved understanding of nursing policies and practices in South Africa, based on empirical evidence. The research has enhanced nursing policy discourse, and led to improved design of human resource plans and support systems for nurses. Importantly, the work has improved understanding of casualisation and moonlighting practices, and nursing supervision and management. It has contributed to substantial capacity development, providing support for four Masters students, two PhDs and three National Research Foundation interns. Through the RESON Advisory Committee, the project has created a forum for broader engagement on the nursing crisis and established a network of key nursing stakeholders to advocate for critical policy issues.

The Committee has been instrumental in guiding the research process, and was highly committed to the project remains remarkably high, with over 80% of members attending meetings over the duration of the project since 2008. “We need to leave a legacy after this research. Nurses need to need to be put at the forefront, and I feel proud to be a nurse among nurses here,” was the view of one RESON Advisory Committee member.

RESON’s three key projects focused on nursing policy development and implementation, agency nursing and moonlighting, and nursing management and quality of care in hospitals.

Nursing policy development and implementation in SA: A paradox?Prudence DitlopoandDuane Blaauw

South Africa’s nursing crisis has resulted in several initiatives over recent years, including the Nursing Act (2005), the Human Resources for Health Strategic Plan (2006) and financial incentives. In 2008, the Nursing Strategy for SA was published, followed by updated scopes of practice, the new qualifications framework, and the Nursing Summit and Compact in 2011.

This study described in detail the development and implementation of selected policies in relation to content, context, actors and process. Policies studied included the nursing strategy, new scope of practice, new qualifications framework and the OSD for nurses. Data was collected through key informant interviews, in depth interviews and questionnaires from 2010 to early 2011.

The results found that it was difficult for key informants to separate health system policies from policies affecting the profession; there were opportunities to contribute to nursing policy development post-apartheid, but some felt the spaces to contribute were limited – nurses were regarded as reactive rather than proactive. “We are happy to respond to what people say about us, rather than challenge them” (nursing manager). There was a sense among key informants that issues were taken up based on the individual rather than collective action. There is still a gap between policy and implementation, but several researchers pointed out that these problems were not unique to SA.

The presentation prompted discussion on disunity in nursing which did not enhance cohesion or engagement with policy making. “Seemingly we don’t learn from history - those you want to rule, divide,” one stakeholder commented.

On the issue of strengthening nursing policy and development capacity, Dr Duane Blaauw agreed that there was a limited amount of policy training for nurses.

“Capacity building needs to occur with nursing students and also with DENOSA and Nursing Council where there isn’t much expertise in policy development. This is something that can be taken forward. The fact that we have nursing policies doesn’t mean much unless they’re implemented. A key challenge is the tensions between sub groups of nurses, and we should focus on areas where there is collective agreement,” he said.

Health system consequences of agency nursing and moonlighting:Pascalia Munyewende

This was a large research project undertaken in 2010 on casualisation, agency nursing and moonlighting. Anecdotal and literature indicates there are negative consequences for health delivery due to moonlighting. Moonlighting is not unique to nursing but also applies to other professions such as education and agricultural. Moonlighting is not the same as overtime, which is additional paid work by the primary employer.

The project adopted a mixed methods approach (quantitative and qualitative) informed by consultation with the Advisory Committee. Data were analysed from 44 key informant interviews, 19 focus group discussions and surveys in four provinces at 80 hospitals which yielded 3715 responses. The team experienced high response rates from nursing agencies, the private sector and front line nurses.
Among the findings were that up to about one third of nurses indicated they had done in moonlighting over the past year. The qualitative findings showed that agency nurses’ performance was affected through moonlighting. One respondent commented:“...I think this leads to the burnout of our staff because when they’re off they don’t rest, they go and work because they need the money. So we sit then with people that come and work they are tired, they are grumpy...”

Quantitative results showed that 45.7 % were too tired to work while on duty; and 12% paid less attention to nursing duties while on duty. Nineteen per cent said that they had argued with doctors or other nurses. Moonlighters are also more likely to take sick leave when not sick. The methodology provided qualitative insights which supported the finding of the quantitative survey. The researchers concluded that there was a need for improved management of nursing agencies and open debate about moonlighting.

Asked whether there were any positive findings, Pascalia Munyewende commented that, at the individual level, moonlighting allowed nurses to earn more money which is paid promptly. “Respondents said that moonlighting gave them the flexibility to choose where to work, and moonlighting at better health facilities than where they were employed also gave them skills. At health system level, moonlighters helped to alleviate staff shortages,” she said.

Nursing management and quality of care in hospitals: summary of methods, results and health system implications:Sue Armstrong, Loveday Penn-Kekana, Eunice Matingo

Initial assumptions at the start of the study were that nursing management is at the core of any sustainable solution to improved health system performance; nurses are the largest group of health care providers and therefore influential in determining the quality of care; and nurse managers at unit/ward level have a direct influence on the quality of care.

The study was conducted in Gauteng and Free State to describe the context, nature and dynamics of nursing management in private and public hospitals; to determine the motivate and job satisfaction of nursing managers, and explore the links between management and the quality of patient care provided. The core focuses was at unit/ward level for internal medicine, surgery, paediatrics and maternity. Mixed methods of qualitative and quantitative data collection included observation of time allocation, diaries, semi-structured interviews with the unit manager, patient interviews and a quality link review (performance appraisal) among unit manager, front line nurses and the nursing services manager.

The research found that nurse managers averaged 36 activities per hour with numerous interruptions. Diaries revealed mainly sad stories, with conflicts with staff, patients and relatives and perceived lack of support by managers. Unit managers reported high levels of ‘frustration’ and isolation. There were many more negative stories from the diaries than in other tools. Unit managers never blamed themselves, and complained of poor communication at all sites despite spending so much time in meetings. They ‘craved’ visible leadership from their managers, and felt isolated when problems were not addressed. Unit managers believed they were indispensable, , but generally blamed poor quality of care on staff shortages. From feedback sessions, the unit managers clearly wanted more autonomy and respect. They confirmed the results of the information contained in the diaries and the time allocation studies.

The research found considerable burnout and high levels of frustration. While 60% indicated they were satisfied in their jobs, it is unknown whether this is a high or low level of satisfaction for unit managers. There was very little difference regarding motivation and job satisfaction of nursing managers in the two provinces. “While our sample size was small and may not have gained statistical significance, the research revealed insights from the use of multiple tools which we would not have gleaned otherwise. The concept of the ‘shortage of staff’ needs to be challenged, as the problem is likely to be more to do with training, motivation and quality of staff,” said Dr Sue Armstong.

This was one of the first studies to explore nursing management and quality of care in tandem. The variety of tools illustrated challenges of researching nursing management. Unit managers are important people in terms of quality of care.

The afternoon session was dedicated to three small group discussions on translating research into policy and practice; nursing management and quality of care; and a project on documenting the history of nursing in South Africa. The latter project arose out of the RESON project and will result in a book entitled:Igniting dreams, confronting reality: Documenting the history of nursing in SA from 1960 until 2010.

At the end of the day, participants were asked for final comments, and the two comments below reflect the spirit of the meeting:

“This project has enhanced networking among nurses, and has assisted to take nursing to the next level - thank you for the opportunity to be involved.”

“It has been an honour to participate in the project - this project has given me hope - I have learned a great deal. I hope you are going to publish the process of involving people.”