1. GUIDELINES TO IMPROVE CLINICAL COMPETENCIES OF LEARNERS OF THE PROGRAMME – PHC: Clinical Nursing, Diagnosis, Treatment and Care By: Nomasonto Buso Doris Magobe RSA University of Johannesburg Faculty of Health Sciences School of Nursing

2. Introduction In South Africa, a specialised group of registered nurses – Primary Clinical Nurses (PCNs) function independently as frontline providers of clinical PHC services within public health care facilities (DoH, 1996: 18).

3. Introduction – (continued) Global PHC approach by WHO at the Alma Ata conference (1978) South African Nursing Council (SANC) (1981) insertion of Section 38A (Gov. notice R1248) within the Nursing Act 50, 1978 National Department of Health: Policy document on restructuring of the health system in South Africa (DoH, 1996: 17)

4. Introduction – (continued) University of Johannesburg (context of the study) Learning programme - PHC: Clinical Nursing, Diagnosis, Treatment and Care High standard of clinical competencies to ensure quality health provision within PHC clinics.

5. The learning programme Post Basic Diploma – 2yrs. 2 nd year - development of clinical competencies Limited contact programme – 5 times per year Three days per contact session: Day 1: theory by lecturer and others Day 2 & 3: clinical practise supervised by PHC clinical instructors In-between contact sessions – clinical skills practice at appropriate PHC facilities under the clinical supervision of preceptors (PCNs / GPs)

6. The research problem Despite the input of the lecturers and the clinical supervision of instructors and preceptors, the majority of learners (61% - 2002 results) still displayed poor clinical competencies at end of learning programme. Findings in previous research studies show that qualified PCNs in the PHC clinics are not displaying acceptable clinical competencies (Mofukeng: 1998, Monamodi: 1998 & Oskowotz, et.al: 1997)

7. Research Question What are the reasons for poor clinical competencies of learners of the programme – PHC: Clinical Nursing, Diagnosis, Treatment and Care?

8. Research Purpose To identify the reasons for poor clinical competencies of learners of the programme, and as informed by the findings to describe guidelines to improve clinical competencies of learners of the programme - PHC: Clinical Nursing, Diagnosis, Treatment and Care within the context of the university.

9. Research Objectives 1. Explore and describe the perceptions of both clinical instructors and learners, respectively, with regard to reasons for poor clinical competencies of learners of the programme (PHASE ONE – Qualitative in nature)

10. Objectives (continued) 2. To explore and describe the demographic profile of learners registered for the programme at the university in the academic year 2003 with regard to reasons for poor clinical competencies. (PHASE TWO – quantitative in nature)

11. Objectives – (continued) 3.To explore and describe the relationship between scoring/rating of learners by clinical evaluators during summative clinical evaluations of learners registered for the programme in 2003, to ensure inter-rater reliability with regard to reasons for poor clinical competencies of learners of the programme (PHASE THREE- quantitative in nature)

12. Objectives – (continued) 4. To describe guidelines to improve clinical competencies of learners of the programme; as informed by the research study findings. (PHASE FOUR)

13. Research Design A mixed methodological design, qualitative and quantitative in nature (Creswell, 1994: 184; De Vos, 2001: 261; Creswell, 2003: 213 ) Sequential Exploratory Strategy QUAL QUALquanquan Interpretation DataDataDataData of Entire Analysis Collection/AnalysisCollectionAnalysis QUAL quan

14. Rationale for use of the Sequential Exploratory Strategy Primary focus – is to explore the phenomena, which is reasons for poor clinical competencies of learners. Priority was given to the qualitative aspect of the study, and the quantitative findings assisted in the interpretation of qualitative findings Initial phase - qualitative data collection and analysis Followed by a phase of quantitative data collection and analysis Findings of both qualitative nd quantitative data were integrated during the interpretation phase (Creswell, 2003: 215)

15. Research method Sampling Qualitative samplingQuantitative sampling Purposive sampling of consenting learners (n=34) Purposive sampling of consenting clinical instructors (n=6) Purposive sample of consenting learners (n=34) (learner profile) Total sample (n=38) of all learners who went through the summative clinical evaluation (inter- rater reliability)

16. Data collection Qualitative dataQuantitative data x4 focus groups interviews of learner participants (n=34). x1 focus group interview of clinical instructor participants (n=6). Self-administered questionnaire for demographic learners profile (n=34). Clinical competencies evaluation instrument (Checklist) for summative clinical evaluations n=38).

17. Data analysis Qualitative analysisQuantitative analysis Tesch (1990)s open coding method of data analysis (Creswell 1994) Statistics were analysed using a computer programme (SPSS)

18. Trustworthiness (Qualitative) Validity and reliability (Quantitative) TrustworthinessValidity and Reliability Lincoln and Guba (1985)s trustworthiness method ensured throughout the study: Credibility Transferability Dependability Confirmability Statistician engaged - used a reliable package SPSS. Face validity Content validity Inferential validity Inter-rater reliability Observational reliability

19. QUANTITATIVE FINDINGS Summative clinical evaluation of learners results Statistical results of t-Test (n=38) MeanCorrelationSignificant diff. Peads Evaluator 1 Evaluator 2 48.97 50.03 981. 000 (P< 0,05) Adult acute Evaluator 1 Evaluator 2 53.82 54.03 898000 (P< 0,05) Adult chronic Evaluator 1 Evaluator 2 57.24 54.00 882000 (P< 0,05)

20. Qualitative findings: Question to participants A central question posed to learners and clinical instructors in their respective focus groups was: What are your perceptions with regard to reasons for poor clinical competencies of learners of this programme

21. Qualitative findings Two Main Themes Theme 1Theme 2 Challenges within the PHC clinical practice field (contributing to poor clinical competencies of learners) Challenges within the PHC learning programme (contributing to poor clinical competencies of learners).

22. Qualitative findings Themes, major and sub categories ThemesMajor categoriesSub-categories Theme 1: Perceived challenges within the PHC clinical practice field (contributin g to poor clinical competenci es of learners) 1.1 Lack of human and material resources 1.1.1 Shortage of staff 1.1.2 Learners regarded as workforce 1.1.3 Lack of clinical equipment 1.2 Staff burnout 1.2.1 Low morale and negative attitude of preceptors.1.2.2 Lack of recognition, support and incentives for preceptors 1.3 Lack of quality control 1.3.1 Lack of continuing education 1.3.2 Lack of feedback from the preceptors and referral resources 1.3.3 Lack of appropriate qualifications by preceptors 1.3.4 Lack of adequate staffing

23. Qualitative findings Themes, major and sub categories ThemesMajor categories Sub-categories Theme 2: Perceived challenges within the learning programme (contributin g to poor clinical competenci es of learners) 2.1 Poor selection criteria of learners. 2.1.1 Lack of learners personal interest to apply for the programme 2.1.2 Lack of clinical opportunities 2.2 Lack of collaboration between university and preceptors 2.2.1 Lack of clear guidelines for preceptors 2.2.2 Lack of communication between the lecturer and the preceptors 2.2.3 Lack of follow up of learners 2.3 Lack of national standardization of the learning programme

24. 24 Development of Guidelines Guidelines to improve clinical competencies of learners of the programme PHC: Clinical Nursing, Diagnosis, Treatment and Care were developed as informed by qualitative and quantitative findings.