Image-based online study shows no benefits, however, of virtual room designs incorporating the golden ratio
In an online study, virtual hospital rooms designed according to the principles of evidence-based design or the principles of Feng Shui were associated with greater potential benefit for viewers than virtual representations of standard hospital rooms. Emma Zijlstra of Hanze University of Applied Sciences in the Netherlands and colleagues present these findings in the open-access journal PLOS ONE on June 5.
Hospital designers might consider employing specific design principles in an effort to improve patients’ experiences. Growing evidence suggests there are beneficial outcomes from an approach known as evidence-based design. For instance, exposure to more daylight in hospitals is associated with lower stress and pain. Other well-known design approaches include Feng Shui, a Chinese system based on hypothetical energy flow, and the use of proportions following the golden ratio.
Despite these well-known options, experimental evidence on their relative benefits in hospitals is lacking. To help clarify, Zijlstra and colleagues randomly assigned each of 558 study participants to view online representations and information about a virtual hospital room designed with one of four approaches: Feng Shui, the golden ratio, evidence-based design or, as a control, a standard design from a real-life hospital. Only people who had previously been hospitalized at some point in their lives were invited to participate.
After experiencing the virtual rooms, participants completed a questionnaire that included standard measures of anxiety and other outcomes. Statistical analysis of their answers showed that, compared to participants who viewed the standard rooms, those who viewed rooms with evidence-based design reported less anxiety and greater senses of control, social support, distraction from negative thoughts, and pleasantness of the room.
Feng Shui design was not directly associated with lower anxiety, but participants who viewed the Feng Shui rooms did have greater senses of social support, positive distraction, and pleasantness of the room. There was no evidence for any benefits of golden ratio-based design.
On the basis of their findings, the authors suggest that rooms designed according to the principles of evidence-based design or Feng Shui might benefit patients. They note similarities between the two approaches, such as incorporation of greenery. However, they caution, it is unclear how well these online findings might translate to real-life hospital settings.
The authors add: “To our knowledge, this is the first and largest randomized controlled trial linking design principles, partly ancient and world-renowned, directly to anxiety in hospital rooms. This study showed that both Feng Shui and Evidence-Based Design are capable in effecting anxiety and it is important that large follow-up studies are conducted to examine the effect of specific design features.”
The healthcare sector in South Africa is beset with numerous challenges, ranging from high turnover rates to skilled staffing shortages and complex regulations in addition to stressful working environments, and communication barriers.
Despite these formidable obstacles, patients have the right to expect top-tier care from their medical facilities. Here, specialised Temporary Employment Services (TES) providers can become indispensable partners, adeptly assisting medical facilities to navigate these challenges in their quest to ensure a seamless continuum of care.
Streamlining healthcare staffing to counter shortages
Specialist TES providers offer a multifaceted remedy to the relentless staffing challenges in healthcare. Capable of promptly supplying temporary staff to bridge immediate gaps, TES providers ensure that all resources have already been rigorously screened, recruiting qualified professionals to function as a buffer against high turnover and staffing scarcities. Through tailored training, specialist providers ensure that their temporary staff placements align seamlessly with organisational expectations to consistently uphold care standards. Furthermore, specialist TES providers alleviate the burden of complex healthcare regulations on management and staff by taking on the responsibility of handling the entire employment relationship, from end to end, including managing human resources and labour relations components, as well as payroll. This provides significant relief for healthcare facilities giving them the staffing resources that they need, without the additional administrative complexities involved with recruiting, on-boarding and managing such resources.
Addressing skills gaps to raise the bar on healthcare resources
Maintaining consistent levels of patient care without compromising quality is challenging in the face of staffing shortages and high turnover rates. With so many specialised healthcare staff, including ICU personnel, leaving for better opportunities abroad due to financial considerations, such an exodus necessitates urgent strategies to retain and fill gaps within healthcare facilities. Specialist TES providers are already playing a critical role in addressing these concerns by focusing on nurse competencies and facilitating targeted courses to upskill their resources. These courses address critical gaps in patient safety and empower nurses to provide better care. Through the development of these essential courses, such as ECG interpretation and cannulation, TES providers are taking significant steps to ensure nurses possess the necessary skills and knowledge. This proactive approach not only enhances patient care at a facility level, but also contributes to nurse competence and job satisfaction, ultimately benefiting the healthcare ecosystem.
The strategic advantages of enhancing workforce dynamics
In addition to operational bolstering and sector-specific upskilling, specialist healthcare TES providers present strategic benefits for healthcare facilities. Access to a diverse, extensive talent pool makes it simpler for medical organisations to find the ideal fit for each role, effectively mitigating the risk of hiring mismatches usually associated with permanent placements. Medical facilities also benefit from the cost-effectiveness of the TES operating model, which aligns with the dynamic nature of healthcare to optimise resource allocation. This is particularly important in hospitals where patient occupancy levels fluctuate daily. Many healthcare organisations now operate with a 50/50 ratio of permanent placements and temporary resources, which gives them the flexibility to accommodate the ever-shifting demands of patient care staffing, while safeguarding the delivery of quality care. By efficiently managing both permanent and agency staff, TES providers optimise recruitment efforts and ensure that the right candidates are placed in suitable roles, benefiting the healthcare organisation’s operations and patient care. TES providers uphold patient confidentiality and provide comprehensive training, ensuring staff are cognisant of privacy protocols and handle sensitive information appropriately.
Boosting patient care excellence: the vital role of specialist TES providers
In an era where healthcare value is intricately tied to workforce excellence, TES providers play a pivotal role in elevating the sector by helping medical facilities conquer their industry-specific challenges, enabling the fundamental mission of enhancing patient well-being. Ultimately, Specialist TES providers represent a crucial element in the healthcare sector’s quest for excellence, as their strategic approach to staffing not only addresses immediate needs but also upholds patient care standards, while easing administrative burdens, and enhancing workforce competencies. As such, collaboration with specialist TES providers is a progressive strategy that medical organisations should prioritise to effectively navigate the intricate challenges of the healthcare landscape today while significantly enhancing patient care outcomes.
With only 22 090 nurses to serve the country’s public health sector of more than 50 million citizens1, urgent intervention is required to bolster their numbers and protect the wellbeing of our nation. After all, without their tireless dedication, who will be there to guide you through the corridors back to health? writes Bada Pharasi, CEO of the Innovative Pharmaceutical Association of South Africa (IPASA)
As the global healthcare industry commemorates International Nurses Day on 12 May, it is an opportune moment to reflect on the role of nurses as the heartbeat of healthcare systems globally. Amid turmoil and triumph, nurses stand as the unsung heroes and compassionate caretakers who embody empathy, endurance and expertise.
In South Africa, where healthcare challenges often loom large and resources are stretched thin, nurses serve as the frontline warriors, bridging the gap between suffering and healing. Yet, despite the invaluable role they play, a concerning trend looms.
Minister of Health, Joe Phaahla, recently revealed a pressing concern – the anticipation of a staggering 30% of South African nurses retiring within the next decade, and 38% retiring the decade thereafter. Compounding the issue, 5060 vacancies remain unfilled on the back of crippling budget constraints1.
Representing over 90% of global healthcare workers2, nurses are indispensable in the healthcare ecosystem, and addressing this impending crisis of their reducing numbers demands comprehensive and multifaceted solutions that approach the challenge from every angle.
The nurse shortage crisis in South Africa stems from multiple factors. Firstly, the escalating healthcare needs of a growing population, compounded by the burden of infectious diseases such as HIV/AIDS, have strained the healthcare system to breaking point.
Another factor is the restricted capacity of the private sector to train nurses comprehensively due to existing regulations. Moreover, poor working conditions, particularly in the public sector, and comparatively low salaries have led to high turnover rates, prompting nurses to explore alternative career paths or seek employment opportunities abroad3.
While there are many challenges to defusing the proverbial ticking time bomb which is the declining number of qualified nurses in South Africa, increased investment across the board is critical to strengthening their ranks.
Despite financial investment being central in realising this, addressing the problem demands a focus on improving the working conditions of nurses. Healthcare facilities must prioritise nurses’ well-being by offering competitive salaries, manageable workloads, and opportunities for career growth. By creating a supportive work environment, South Africa can retain more nurses and deter them from seeking opportunities abroad3.
Furthermore, granting private hospitals full participation in nurse training programmes is crucial. Private sector entities, such as Netcare, have the capacity to train as many as 3,500 nurses annually. However, limited accreditation from the government hampers their potential contribution to resolving the nurse shortage. Expanding private sector involvement in nurse training could substantially increase the number of trained nurses in the country3.
In addition to these measures, collaborative efforts between the government, healthcare institutions, and nursing organisations are essential. Such partnerships can identify and implement strategies to alleviate the shortage, including targeted recruitment drives, mentorship programmes, and initiatives to improve nurses’ job satisfaction and work-life balance3.
Innovative approaches to addressing the nurse shortage in South Africa extend beyond traditional solutions. Telemedicine platforms are emerging as a promising tool, allowing nurses to deliver care remotely and reach patients in underserved areas.
Additionally, community health worker programmes are being expanded to complement nursing services and extend healthcare access to marginalised communities. Furthermore, initiatives to empower and support nurse entrepreneurs are gaining traction, encouraging the development of innovative care models and healthcare solutions.
These diverse approaches reflect a multifaceted response to the nurse shortage crisis, leveraging technology, community engagement, and entrepreneurship to strengthen the healthcare workforce and improve access to care for all South Africans.
April 16 2024 – The Chris Hani Baragwanath Hospital School officially opened in its new location today, marking a key milestone in the partnership between Wits University and the academic hospital. The school caters for all learners in need of longer-term and chronic treatment for various paediatric conditions. Learners between Grades R and 12 are taught.
“Sick children have multiple needs, and it’s our duty to ensure that they don’t miss out on any schooling. Everyone deserves the right to be educated and to contribute meaningfully to their communities as adults,” said Professor Shabir Madhi, Dean of the Wits Faculty of Health Sciences.
Professor Madhi noted that the previous school building will be used as a campus for medical students and to grow the university’s teaching and learning footprint at Chris Hani Baragwanath Academic Hospital.
The school district representative for Johannesburg Central, Ronica Ramdath, said that often sick children forfeit their education, which can be mitigated through the correct teaching approach and through supportive facilities. “When I first came to the school some years back, I was amazed at the teachers’ dedication. I remember seeing a teacher load all their educational resources in a bag and walk to the paediatric ward to teach sick children. Today, these children all benefit from such support,” she said.
The Wits Faculty of Health Sciences heads of schools were present, together with hospital and teaching representatives.
Meanwhile, Professor Madhi said that the university’s wifi is available at Chris Hani Baragwanath Hospital, underpinning Wits’ commitment to invest in a world-class academic hospital facility. “We are very proud of our footprint at the hospital and hope to continue to add value through research and clinical work,” he said.
Spotlight visits Rahima Moosa Mother and Child Hospital and sees progress for the struggling hospital but also the reality that there’s a long road ahead to undo what a health ombud report suggests has been years of neglect and poor management.
Rahima Moosa Mother and Child Hospital serves up to 2 300 people admitted per month as well as 10 000 outpatients each month. (Photo: Denvor de Wee/Spotlight)
By Ufrieda Ho for Spotlight
It’s been a year since a damning Health Ombud’s report on the Rahima Moosa Mother and Child Hospital (RMMCH) was released. This month also marks the end of the last deadline the Gauteng Department of Health had to act on recommendations in the report.
At 80 years old, RMMCH is an iconic landmark on the western edge of Johannesburg. But it has gone from a one-time outlier for excellence to being in steady decline, marked by what the Ombud’s report criticised as incompetent leadership, neglect and crumbling infrastructure.
In May 2022, the hospital suffered a public low point when paediatric gastroenterologist, Dr Tim de Maayer, penned an open letter, slamming multiple failings at the facility. Public outcry from the letter, complaints from hospital users, and a widely circulated video of pregnant mothers sleeping on hospital corridor floors prompted the ombud’s investigation.
When Spotlight visited the hospital at the end of February (2024), there were positive outward signs that recent maintenance work had been completed, per the Ombud’s recommendations. Some areas have been painted and surfaces where underground sewer pipes had to be unblocked have also been tarred. The stench from overflowing sewage appears to be a thing of the past. Renovations to the antenatal care ward, shown in the video that went viral, are also near completion and the ward is expected to be operational again by the middle of March.
More signs that RMMCH is blipping on radars again include a new granite plaque at the entrance ready to be unveiled to commemorate the hospital in its 80th year. On noticeboards were flyers that advertised a community fun-walk for the end of February. It was an event intended to “reconnect” hospital staff with the immediate community it serves.
The hospital is also part of the roll-out of the provincial health information system (HIS) and admin staff were seen enrolling new patients on the system. The HIS is a long-awaited system to modernise patient file storage and make patient files accessible at facilities province-wide. Spotlight previously reported on the system.
These encouraging advances since the Ombud’s investigation get the thumbs up from hospital insiders. But they flag that even though the Gauteng Department of Health has announced a six-year renewal plan for the hospital and R53 million was approved in December 2023 for the next phase of renovations, the department is playing catch-up and still dragging its feet.
CT scan empty promises
For Dr Z, the biggest of her current concerns is that the hospital’s CT scan has not been in operation for the past 14 months. Dr Z asked not to be named because of the risk of victimisation.
“We have to beg other hospitals to do our scans. So even when you have a patient who actually needs a CT scan, you think twice – you ask yourself do they really, really need it or should you just watch them for another couple of months. It’s very demoralising and we keep hearing empty promises from management,” Dr Z says.
A shortage of clerical staff means clerks are shared between departments, resulting in inevitable administrative glitches and delays, Dr Z says.
There is also a growing need for child mental health services but the hospital doesn’t have in-patient psychiatry services and only has sessional psychological services.
“We serve an ever bigger community that has changing needs but our infrastructure has stayed the same and our staff numbers have not increased,” says Dr Z. The doctor has worked at RMMCH for nearly two decades – “my second home” she calls it.
The hospital has around 1200 staff members. They serve up to 2300 people admitted per month as well as 10 000 outpatients each month.
Dr Z tries to stay hopeful, saying “we look to the positive things and we do what we can”, but RMMCH can be a daunting place to work. Safety and security has resurfaced as a concern this February. This comes on the back of a car hijacking that took place in the hospital’s parking area at the beginning of the month. The Ombud’s report also looked into the hijacking of an intern’s car that took place in its investigation period.
Parking too is a daily frustration – there are only 300 parking spots for staff on the hospital campus but at least 400 vehicles that need a place to park at peak times. Visitors are told to park on the streets.
‘Mr Fixer’
Acting CEO of the hospital Dr Arthur Manning met with Spotlight to answer questions put to him and to the Gauteng Department of Health.
Manning took up the job in September 2022 as part of the Ombud’s recommendation to redeploy the previous CEO, Dr Nozuko Mkabayi, whom the government oversight body found to be a dismal failure.
Manning calls himself “a fixer”. His role, he recognises, has been to help stop the slide for RMMCH, also to boost staff morale, restore communication channels and regain the community’s trust in the facility.
“We are a system under pressure and we know there is burnout and low morale but we have improved counselling support and we try to recognise and thank people. We held a nurse’s awards dinner last year exactly for these reasons,” he says.
Manning says the hospital organogram was last updated in 2006, but he has submitted a revised one to the Gauteng Department of Health. It makes the case for more admin and support staff, more junior and training doctor posts and bolstering psychiatric and psychological services. These, he says, are especially necessary because services for children are particularly neglected.
The broken CT scanner at Rahima Moosa Mother and Child Hospital. (Photo: Denvor de Wee/Spotlight)
On the matter of the CT scanner, he says “procurement is underway”. It’s a planning failure that the machine is five years beyond its expected lifespan and was not replaced sooner, resulting in the current gap. Manning says the Gauteng Department of Health is now piggybacking on Limpopo’s procurement contract. Piggybacking refers to provisions in the Public Finance Management Act, that under certain conditions, allow a department in one province to procure goods and services via a contract that a department in another province has concluded with a service provider.
According to Manning, the Gauteng province is currently concluding an X-ray equipment tender that has delayed the procurement of the CT scanner for RMMCH. “Without a tender in place, procurement is more difficult,” he says. Approval to use Limpopo’s tender contract cuts out some red tape and means the CT scanner and maintenance contract has been secured at the price of R30 million. By May, he says, the hospital will also have an MRI-scanning facility.
Staff helps to spruce up waiting area
Manning has been credited by some for shifting morale and competently overseeing the interventions set out by the Ombud’s report. On a hospital walkthrough with Spotlight, he engages casually with staff and patients. He’s also evidently proud of staff-driven initiatives to improve the hospital experience for patients. He points out a freshly painted waiting area in one of the departments where children are playing with new toys and crawling on bright green astro turf. More than half the money for this project came from doctors and nurses raising funds cycling and running in race events in the city.
Keeping staff motivated means their concerns and working conditions – including the parking problem and safety and security – have to be priorities, he says.
Cars are double and triple-parked in the overcrowded staff parking area. Currently, informal management of this is done via Whatsapp groups. People on the groups are notified to move their cars as spots free up. Manning says the hospital is working to secure nearby grounds for additional parking. On safety and security, he says the hospital has stepped up collaboration with local police and the community policing forums to increase patrolling around the hospital especially around shift changes. He adds: “We have expanded our CCTV camera coverage, requested for armed security control and we’re exploring panic button systems.”
A bigger budget and a permanent CEO
There are two key outstanding issues from the Ombud’s report. The first is reclassification of the hospital that is also an academic and training hospital, from a regional facility to a tertiary hospital.
“This is something that involves national, but when reclassification is done it will means RMMCH’s budgets and grants will be adjusted and we will be able to do so much more,” says Manning.
The second issue is the appointment of a permanent CEO, which Manning says is “being handled by central office”. He side-steps a question on whether his name is in the mix. It’s expected that an announcement on the new CEO will take place in April.
Professor Ashraf Coovadia is academic head of Paediatrics and Child Health at Wits University and heads up this department at RMMCH. He says Manning has “been good for RMMCH” but he says above the level of CEO, it’s the Gauteng Department of Health that needs to get its house in order . He says there has been a lack of communication, consultation, transparency and decisive action from the Gauteng Department of Health for years.
“A CEO can do only so much. When we have having acting heads in so many departments who are in acting positions for forever, it’s a joke. It means decisions don’t get made or decisions don’t get made for the long run and this compromises how the hospital is run and the care we give patients,” he says.
He adds that when there is less “hospital floor” consultation and more bureaucratic centralisation from the department it alienates doctors and nurses. “It becomes more and more difficult to try to motivate especially junior doctors who start off wanting to give back to the public health service but become so frustrated they don’t stay.”
Back to the 1900s
Like Dr Z, Coovadia highlights the CT scan issue, as well as the long delays and the excuses for the delays.
“Working without a scanner takes us back to the 1900s; we are not practising modern medicine and we are not able to diagnose patients early enough,” he says.
Coovadia adds that even though water and electricity supply issues at RMMCH have improved, infrastructure fixes remain patchy. “There are fewer issues of burst pipes and flooding, but it’s still happening.”
Coovadia has been with the hospital for 26 years, he knows better than most the precariousness of the situation and why the hospital is not yet out of the woods. He says: “The negative attention on the hospital did bring about some positive change. But it can make you cry when you see the slide over the last ten years… The hospital is not collapsing, but there are daily collapses.”
NOTE: Coovadia is on the board of SECTION27. Spotlight is published by SECTION27, but is editorially independent – an independence that the editors guard jealously. Spotlight is a member of the South African Press Council.
Physicians argue that trying to combat dwindling numbers with increased medical school places ignores the real problem: gruelling hours and low pay
At several major South Korean hospitals, thousands of doctors walked out on Tuesday, causing widespread disruption in a protest at the government’s plan to increase the numbers of medical school students, The New York Times reports.
On Monday, over 6000 doctors had submitted resignations at Seoul’s five hospitals and left at 6am on Tuesday, the Health Department reported. One of the hospitals had up a sign saying that its emergency department was only handling cardiac arrest cases; the other four were on “red alert”.
Government sources state that 7813 doctors had walked off the job, Reuters reports.
South Korea may have one of the most advanced healthcare systems in the world, but it is plagued by a critical shortage of doctors. The protestors, interns and residents, say that this shortage is confined to certain areas such as emergency medicine, which are poorly compensated by the government and insurance providers. Cosmetic medicine on the other hand, is highly profitable.
One survey found that doctors in training regularly work shifts longer than 24 hours and many work for more than 80 hours a week. (In South Africa, a 2012 study found that interns regularly put in 150–200 hours of overtime per month, working out to 80–90 hours a week.)
Other factors such as an ageing population are putting more and more strain on doctors.
Early this month, the government announced a plan to increase South Korea’s medical school admissions quota from 3000 to 5000. The Ministry of Health and Welfare regulates the licences to practice medicine. Doctors were immediately critical of the plan, protesting with placards saying things like “end of health care.”
Health workers at Groote Schuur Hospital and Red Cross Children’s Hospital in Cape Town are starting to feel the effects of an ongoing freeze on the hiring of critical medical staff.
According to senior officials at these hospitals, speaking to GroundUp anonymously, the situation has reached a point where managers are struggling to fill shift rosters. An impact on patient care and waiting times is inevitable, the officials say.
A senior hospital manager at Groote Schuur told GroundUp that almost half of medical officer (doctor) posts in the medicine department are vacant, in addition to hundreds of other nursing and operational posts.
Another senior official at Red Cross Children’s Hospital told GroundUp that “critical medical posts” are being left vacant, including medical officer, registrar (doctors in training for a speciality), and specialist posts.
Groote Schuur Hospital is one of the largest government hospitals in the Western Cape and Red Cross Children’s Hospital is the largest children’s hospital in Sub-Saharan Africa. The Daily Maverick reported in November that the budget shortfall for these two hospitals amounts to more than R300-million for 2023/2024.
In addition to hiring freezes at Groote Schuur and Red Cross, the Western Cape Department of Health decided to de-escalate services at the hospitals for a period of four weeks over December and January. Hospital managers were also told to reduce spending on consumables by 50%, according to the Daily Maverick.
At the start of 2023, large cuts were made to the conditional grants that fund these hospitals. And then in the middle of the year, National Treasury announced significant austerity measures including a R21-billion reduction in national government spending for 2023/24.
In August last year, a letter by National Treasury to provincial governments recommended several “cost containment” measures for the 2023/24 financial year and suggested a freeze on hiring of new employees.
It appears that each province’s health department is dealing with the “cost containment” measures in different ways. In the Eastern Cape, for example, hiring freezes have been implemented but not for clinical staff, Sizwe Kupelo, spokesperson for that province’s health department, told GroundUp.
In the Western Cape, as of May 2022, the vacancy rate of medical posts was 5%, compared to 14% in the Eastern Cape, 20% in Gauteng and 28% in KwaZulu-Natal. Health experts are concerned that budget cuts and hiring freezes will have a devastating impact on these provinces.
Hospital officials at Groote Schuur and Red Cross told GroundUp that there has been a lack of clarity from the provincial department on how long hiring freezes will last and whether there will be a permanent reduction in medical posts.
Senior officials fear that the hiring freeze is undoing decades of investment by the government in the capacity of state hospitals. Newly graduated doctors looking to specialise need to take up a registrar post in a state facility, but with registrar posts frozen in the Western Cape, this is almost impossible for them to do.
Hospital managers told GroundUp that some medical officers have resigned from Western Cape hospitals to take up registrar posts in other provinces or even other countries.
Officials are also concerned that if hiring freezes are implemented in primary and secondary care facilities, referrals to hospitals will increase, putting further pressure on an already overburdened tertiary health system.
Dwayne Evans, spokesperson for the Western Cape Department of Health, told GroundUp that the department is unable to respond to specific questions on budget shortfalls or the number of posts frozen, as the 2024/25 budgets are being finalised.
Evans told GroundUp that as part of the hiring freeze, the filling of vacant posts now needs to be authorised by the provincial department to attain “provincial consensus”. 820 vacant nursing posts and 441 doctor positions have been “earmarked to be filled soon”, Evans said.
“We are doing everything we can to reduce the impact on our patients. No patients will be refused emergency and basic medical care and treatment,” he said.
The National Department of Health did not respond to GroundUp’s questions despite several follow-up attempts. National Treasury said that guidance will be given during the upcoming budget speech by Finance Minister Enoch Godongwana.
The healthcare sector in South Africa is beset with numerous challenges, ranging from high turnover rates to skilled staffing shortages and complex regulations in addition to stressful working environments, and communication barriers. Despite these formidable obstacles, patients have the right to expect top-tier care from their medical facilities. Here, specialised Temporary Employment Services (TES) providers can become indispensable partners, adeptly assisting medical facilities to navigate these challenges in their quest to ensure a seamless continuum of care.
Streamlining healthcare staffing to counter shortages
Specialist TES providers offer a multifaceted remedy to the relentless staffing challenges in healthcare. Capable of promptly supplying temporary staff to bridge immediate gaps, TES providers ensure that all resources have already been rigorously screened, recruiting qualified professionals to function as a buffer against high turnover and staffing scarcities. Through tailored training, specialist providers ensure that their temporary staff placements align seamlessly with organisational expectations to consistently uphold care standards. Furthermore, specialist TES providers alleviate the burden of complex healthcare regulations on management and staff by taking on the responsibility of handling the entire employment relationship, from end to end, including managing human resources and labour relations components, as well as payroll. This provides significant relief for healthcare facilities giving them the staffing resources that they need, without the additional administrative complexities involved with recruiting, on-boarding and managing such resources.
Addressing skills gaps to raise the bar on healthcare resources
Maintaining consistent levels of patient care without compromising quality is challenging in the face of staffing shortages and high turnover rates. With so many specialised healthcare staff, including ICU personnel, leaving for better opportunities abroad due to financial considerations, such an exodus necessitates urgent strategies to retain and fill gaps within healthcare facilities. Specialist TES providers are already playing a critical role in addressing these concerns by focusing on nurse competencies and facilitating targeted courses to upskill their resources. These courses address critical gaps in patient safety and empower nurses to provide better care. Through the development of these essential courses, such as ECG interpretation and cannulation, TES providers are taking significant steps to ensure nurses possess the necessary skills and knowledge. This proactive approach not only enhances patient care at a facility level, but also contributes to nurse competence and job satisfaction, ultimately benefiting the healthcare ecosystem.
The strategic advantages of enhancing workforce dynamics
In addition to operational bolstering and sector-specific upskilling, specialist healthcare TES providers present strategic benefits for healthcare facilities. Access to a diverse, extensive talent pool makes it simpler for medical organisations to find the ideal fit for each role, effectively mitigating the risk of hiring mismatches usually associated with permanent placements. Medical facilities also benefit from the cost-effectiveness of the TES operating model, which aligns with the dynamic nature of healthcare to optimise resource allocation. This is particularly important in hospitals where patient occupancy levels fluctuate daily. Many healthcare organisations now operate with a 50/50 ratio of permanent placements and temporary resources, which gives them the flexibility to accommodate the ever-shifting demands of patient care staffing, while safeguarding the delivery of quality care. By efficiently managing both permanent and agency staff, TES providers optimise recruitment efforts and ensure that the right candidates are placed in suitable roles, benefiting the healthcare organisation’s operations and patient care. TES providers uphold patient confidentiality and provide comprehensive training, ensuring staff are cognisant of privacy protocols and handle sensitive information appropriately.
Boosting patient care excellence: the vital role of specialist TES providers
In an era where healthcare value is intricately tied to workforce excellence, TES providers play a pivotal role in elevating the sector by helping medical facilities conquer their industry-specific challenges, enabling the fundamental mission of enhancing patient well-being. Ultimately, Specialist TES providers represent a crucial element in the healthcare sector’s quest for excellence, as their strategic approach to staffing not only addresses immediate needs but also upholds patient care standards, while easing administrative burdens, and enhancing workforce competencies. As such, collaboration with specialist TES providers is a progressive strategy that medical organisations should prioritise to effectively navigate the intricate challenges of the healthcare landscape today while significantly enhancing patient care outcomes.
Like many countries, South Africa has a shortage of healthcare workers – particularly of doctors. One response to such shortages is task-shifting – in short, to let doctors focus on the things only they can do, and to shift some other less specialised tasks to other healthcare workers like nurses or pharmacists.
Task-shifting can take many forms. Earlier this year Spotlight reported on a court case that gave the green light to specially trained pharmacists to dispense antiretroviral treatment without a script (the judgement is being appealed). Similarly taking pressure off public sector clinics, the Department of Health has for several years now allowed some people to pick up their medicines at participating private sector pharmacies or other pickup points. Less well implemented, was the introduction of clinical associates in 2008 as a new type of mid-level healthcare worker that can take some of the pressure off of doctors and stand-in for them in some situations.
Probably the most impactful example of task-shifting in South Africa, however, was the introduction of Nurse Initiated and Managed Antiretroviral treatment (NIMART) in 2010.
What is NIMART?
Dr Silingene Ngcobo, a lecturer at the School of Nursing and Public Health at the University of KwaZulu-Natal and a Board Member of the Southern African HIV Clinicians Society, says NIMART is a clinical management program for people living with HIV which is driven by registered nurses. This means that registered nurses can independently manage a person living with HIV, starting from screening and diagnosis, all the way to treating, and monitoring throughout the HIV care continuum in the absence of a medical doctor.
As explained by Mmotsi Moloi, Training Programme Manager at the Aurum Institute (an NGO), prior to the introduction of NIMART in 2010 only doctors were authorised to prescribe antiretroviral therapy.
The rollout of antiretrovirals in South Africa technically started in 2004, but it only gathered momentum after the end of state-backed AIDS denialism in 2008. It soon after became clear that South Africa would not have enough doctors to handle the demand for HIV treatment and nurses would have to be roped in.
“The waiting lists became long, and the doctors could not meet the increasing demand of clients in need of antiretroviral treatment, this led to the death of clients while awaiting to be initiated,” says Moloi. “There was an urgent need to remedy the situation which was to decentralise management of HIV to Primary health care facilities and professional nurses to be trained and authorised to manage HIV infected clients.”
Ngcobo says nurses are often the only healthcare providers available to provide HIV prevention, care, and treatment services. She says the South African healthcare delivery system approach has changed from hospital-centred care to promotion of health and prevention of disease through primary healthcare and the introduction of NIMART fits this shift.
Hard to quantify
According to estimates from Thembisa, the leading mathematical model of HIV in the country, the number of people taking HIV treatment in South Africa increased from 1.2 million in 2010 to 5.7 million in 2022. How big a part NIMART played in this remarkable scale-up of treatment is hard to quantify, but that it played a pivotal role seems clear.
A review study published in 2021 that looked back at 10 years of NIMART in South Africa, found that adequate NIMART training “results in improved knowledge of HIV management, greater confidence and clinical competence, particularly if accompanied by mentoring”.
The review summarised results from several smaller studies conducted in different provinces on NIMART – which show, on a small scale at least, what potential impact NIMART has had. Among other things, the training of nurses to initiate and manage HIV treatment led to feelings of empowerment, and when coupled with appropriate training and support can “lead to increased quality of patient care, confidence and professional development”.
Studies conducted in Johannesburg cited by the review found that NIMART training increased access to HIV treatment, reduced workloads at referral facilities, and reduced referrals to tertiary hospitals. Nurses also saw an “improvement in the quality of life of their patients and the retention of patients in care, which they felt reflected the success of NIMART”.
When asked how many NIMART-qualified nurses we have in the country, Foster Mohale, spokesperson for the National Department of Health, says he can’t provide an exact number since they no longer collect data on NIMART since it has been incorporated in broader HIV training. He also says that provinces are the custodians of data for all trained healthcare workers and points out that the numbers change all the time due to attrition.
What NIMART nurses do
Ngcobo says NIMART nurses assess and screen people living with HIV for treatment eligibility, initiate antiretroviral therapy, provide adherence counselling and monitoring, screen for opportunistic infections, offer various preventative therapies, psychological support, as well as appropriate referrals to other members of the disciplinary team, and oversee repeat visits throughout the healthcare user’s life while managing any other health condition that the person might have.
Nurses also have to support people with tuberculosis and non-communicable diseases (such as diabetes and hypertension) to take treatment as prescribed.
“For effective management of other diseases, NIMART nurses should actually work with all other conditions because a person living with HIV still can gets various other conditions which still need to be managed. Therefore, the role of [the] NIMART nurse is to wholistically manage the patient and provide all the necessary healthcare services that the healthcare user in front of them will be requiring,” says Ngcobo.
Training requirements
The NIMART programme has changed somewhat since its launch back in 2010. Mohale says the programme now also covers the majority of healthcare professionals like medical doctors, pharmacists, registered or professional nurses, and other healthcare professionals who are authorised by their statutory bodies to assess, diagnose, prescribe, and dispense medications. He says in 2017 NIMART was changed to “Basic HIV for Health Care Professionals”, but the name NIMART is still in wide use.
The essence of the programme however remains that a professional nurse, or other qualifying healthcare professional, must complete special training (see this online course for example) before they are authorised to prescribe HIV treatment and manage the treatment and care of people living with HIV. Training typically requires both an exam and some practical work, ideally with the support of a mentor.
All prescribing by nurses in the public sector relies on section 56(6) of the Nursing Act, which allows an exception to the Medicines Act and other health-related laws, explains Andy Gray, Senior Lecturer in pharmaceutical sciences at the University of KwaZulu-Natal. “They therefore do not need section 22A(15) permits or section 22C(1)(a) dispensing licences in terms of the Medicines Act,” he says.
The legalities of how nurse prescribing works in South Africa is set out in a 2016 policy document issued by the National Department of Health. Amongst others, the document states that, “a nurse may only perform the functions authorised by Section 56(6) in public sector facilities in the district or municipality where the authorisation was granted to him/her”. In other words, nurses who move to jobs at other facilities or in other districts will often require new authorisation before they may prescribe medicines such as antiretrovirals.
Some concerns
But there are signs that training and mentorship is not functioning optimally across the board.
“There is non-standardised training and inadequate mentoring as the country doesn’t have enough trainers,” says Mohale. “There are human resource constraints for both trainers and nurses to be trained. Some districts rely on their district support partners to carry out trainings on their behalf.”
“Staff shortage from the facilities also leads to some nurses not being able to be trained due to demand for other health services at their service delivery points. Some challenges include failure to identify and manage drug-drug and drug-food interactions which are important in making sure that the patients are suppressing their viral loads,” he adds.
Mohale’s comments echo several barriers to the success of NIMART that were identified in the 2021 review study, including: “non-standardised training, inadequate mentoring, human resource constraints, health system challenges, lack of support and empowerment, and challenges with legislation, policy and guidelines”.
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