The professional relationship between professional nurses and clinical associates in selected district hospitals

Abstract

INTRODUCTION The South African public health sector is facing the crisis of a shortage of healthcare professionals, particularly physicians. Even though the shortage is global, South Africa is more affected due to the high number of citizens receiving their medical care from the public healthcare sector. In developing countries such as South Africa, the shortage of healthcare professionals, particularly physicians and nurses, inequitable distribution of workforce, and a lack of resources have seen to it that the global policy on universal health coverage, which was developed to ensure positive service delivery and quality patient care, is not met. The South African government employed multiple strategies to address the shortage of physicians with varying degrees of success. One of the strategies was adopting a double-pronged strategy to increase the number of physicians to meet the healthcare needs; this entailed an output of local training institutions and outsourcing medical training to Cuba by annually sending 1 000 students from poor rural communities to train as physicians. The other strategy adopted was the introduction of the relatively new cadre of professionals known as clinical associates. Clinical associates were introduced to augment the shortage of physicians especially in district hospitals and primary healthcare settings. This meant that the clinical associates have to work closely together with professional nurses. Due to the relative newness of the clinical associates’ profession and lack of clarity about the role of clinical associates, some of the healthcare professionals, especially professional nurses, were not well informed about their scope of practice and role and that has led, in the practical experience of the researcher as a professional nurse, to conflict in the practice environment, causing a lack of professional relationships among especially these healthcare professionals which could negatively affect service delivery. RESEARCH PURPOSE The purpose of the study was to explore and describe the professional nurses and clinical associates’ perceptions of the professional relationship between them. RESEARCH DESIGN A qualitative description design was used in this study. RESEARCH METHOD Data collection took place in district hospitals (N=7; n=4) in Gert Sibande district, Mpumalanga province. Twelve (N=12) semi-structured individual interviews were done consisting of six (n=6) professional nurses and six (n=6) clinical associates. All interviews were recorded with a digital voice recorder in a private room after consent had been obtained from all participants. The anonymous interviews were then transcribed by an independent transcriptionist and thereafter data were analysed using Tesch’s eight steps of data analysis with the assistance of a co-coder. After independent analysis of the data by the researcher and co-coder, the results (main themes, and sub-themes) where confirmed by both parties and the supervisors to ensure a true reflection of the results to ensure trustworthiness. RESULTS The findings of the study indicate that although professional nurses and clinical associates understand what a professional relationship is and their role in the district health system, challenges are present and could negatively impact service delivery. Many of the findings between the professional nurses and clinical associates were similar, but there were a few unique findings. Three main themes emerged from the professional nurses’ interviews namely professional relationship defined (1), professional relationship characteristics (2) and professional relationship challenges (3). The first main theme professional relationship defined had two sub-themes namely colleagues working together and relationship amongst professionals. Sub-themes for main theme two named professional relationship characteristics consisted out of positive and negative characteristics and main theme three professional relationship challenges included sub-themes attitude, functional – clinical associates and ministerial, interdepartmental and intra-professional collaboration. Four main themes emerged from the clinical associates’ interviews, namely: (1) professional relationship defined, (2) professional relationship characteristics, (3) professional relationship challenges, and (4) personal professional challenges. Main theme one (professional relationship defined) had interaction between two people, collegial relationships, and goal orientation as sub-themes. The second main theme’s (professional relationship characteristics) sub-theme was positive characteristics. Main theme three (professional relationship challenges) had the sub-themes attitude, functional – clinical associates, functional – professional nurses, and ministerial collaboration. Lastly, the fourth main theme (personal professional challenges) included the sub-themes lack of independence, poor remuneration, poor career progression, and supporting profession to physician shortages. CONCLUSION Professional relationships form the basis of success for the healthcare system. The professional relationship between professional nurses and the relatively new cadre of healthcare professionals called clinical associates has not been the focus of research studies. There are various challenges in this relationship that need to be addressed as it can negatively impact service delivery. Although some challenges revealed by both professional nurses and clinical associates were very similar in the practice environment, there were also unique personal professional challenges that the clinical associates had. Both populations could define a professional relationship between themselves, although the clinical associates had perceptions of a more personal connection in their professional relationships by mentioning that it is a ‘collegial relationship’, ‘interaction between two people’, and ‘goal orientation’, whereas the professional nurses’ perception was that it was only ‘colleagues working together’ and ‘relationship amongst professionals’, i.e., there does not have to be a relationship between themselves. The professional nurses added positive and negative professional relationship characteristics whereas the clinical associates only perceived positive characteristics in their relationship with professional nurses. The professional relationship challenges revealed that both populations perceived attitude as a challenge, whereas the professional nurses only experienced functional challenges related to clinical associates; clinical associates, on the other hand, perceived that there were functional challenges for themselves and the professional nurse. Both populations revealed that there is a ministerial collaboration challenge that needs to be addressed, while the professional nurses added interdepartmental and intra-professional collaboration. Lastly, clinical associates also added that they have personal professional challenges, such as a lack of independence, poor remuneration, and career progression, and that it is a supporting profession to physician shortages which was not perceived by the professional nurses. Although there are many types of challenges affecting the professional relationship between professional nurses and clinical associates, these challenges could be addressed without difficulty through ministerial, interdepartmental, and intra-professional collaboration. Ministerial collaboration though media, workshops, and roadshows could be an accomplishable method to communicate. Interdepartmental (outpatient, casualty, and theatre departments) communication could be improved through meetings and availability of the scope of practice of all healthcare practitioners including the new cadre of clinical associates in the standard operating procedure files. Intra-professional communication signifies two or more disciplines (professional nurses and clinical associates) within the same profession (healthcare) engaging in learning and collaborating together in the practice environment through in-service training. In-service training can focus on what a professional relationship entails and how to improve and address positive and negative professional relationship characteristics and professional relationship challenges. Lastly, personal professional challenges of the clinical associates should be addressed on a governmental level by the Minister of Health or a regulating body such as the Health Professions Council of South Africa.