Introduction: The decentralization of Subdistrict Health Promoting Hospitals (SHPHs) to Provincial Administrative Organizations (PAOs) in Thailand represents a significant structural reform with direct implications for nurses working in primary healthcare settings. This study aimed to develop a competency model for nurses employed in SHPHs under PAO jurisdiction, ensuring alignment with decentralization policies and local health system needs. Methods: A mixed-methods design was used in 2 phases. Phase 1 employed qualitative methods to explore current nursing roles through in-depth interviews and thematic analysis. Phase 2 involved developing the competency model using quantitative data and the Delphi technique with expert consensus. Results: Findings from phase one indicated that nurses continue to play a vital role in community-based health promotion and care for vulnerable populations. Following decentralization, nurses have adapted to new responsibilities involving local workforce coordination, budgeting, and health information systems, necessitating expanded competencies. The competency model delineates stratified expectations by facility size: small SHPHs require generalist proficiency for autonomous service delivery; medium SHPHs necessitate specialized and collaborative competencies for programmatic functions; and large SHPHs demand advanced skills in systems management, strategic planning, and specialized care to align with institutional complexity. Conclusion: Although nurses’ core responsibilities in primary care remain central, decentralization has introduced new demands requiring advanced clinical, technological, data management, and interprofessional collaboration competencies. These expanded roles have strengthened nurses’ contributions to local health governance under the PAO system.
BACKGROUND: The Durban University of Technology (DUT) Faculty of Health Sciences (FHS) in KwaZulu-Natal, South Africa, is embarking on a project to implement a Decentralized Clinical Training Program (DCTP). The DUT FHS DCTP project is being conducted in response to the growing demands of students requiring clinical service placements as part of work-integrated learning. The project is also geared toward responding to existing gaps in current practices related to the implementation of a DCTP, which has mainly been through traditional universities providing training to medical, optometry, occupational therapy, and physiotherapy students. In South Africa, a DCTP is yet to be implemented within the context of a university of technology; it is yet to be implemented within health science faculties that offer undergraduate health science programs in mainstream biomedicine and alternative and complementary disciplines. OBJECTIVE: We aim to design, pilot, and establish an effective DCTP at the DUT FHS in KwaZulu-Natal, South Africa. METHODS: Participatory action research comprising various designs-namely, appreciative inquiry, qualitative case study design, phenomenography, and descriptive qualitative study design-will be used to conduct the study. Data will be collected using individual interviews, focus group discussions, nominal group technique, consensus methodology, and narrative inquiry. Study participants will include various internal and external stakeholders of the DUT, namely, academic staff; students; key informants from universities currently using successfully established DCTPs; academic support staff; staff working in human resources, finance, procurement, and accounting; and experts in other disciplines such as engineering and information systems. Overall, 4 undergraduate health science programs-namely, Radiography, Medical Orthotics and Prosthetics, Clinical Technology, and Emergency Medical Care and Rescue-will be part of the project's pilot phase. Findings from the project's pilot phase will be used to inform scale-up in the other undergraduate programs in the DUT FHS. The project is being implemented as part of the university's strategic objective of devising innovative curricula and pedagogical practices to improve the mastery, skill set, and competence of health science graduates. RESULTS: The study has currently commenced with the situational analysis, consisting of engagement with external stakeholders implementing DCTPs. The data to be generated from the completion of the situational analysis are anticipated to be published in 2024. CONCLUSIONS: This project is envisioned to facilitate collaboration among the universities of technology, traditional universities, Ministry of Health, and private sector for clinical placement of undergraduate health science students in health establishments that are away from the university, thereby exposing them to real-life experiences related to health care. This will facilitate authentic learning experiences that will contribute to improved competencies of graduates in relation to the health needs of society and the multiple realities of the South African health system. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52243.
AIM: To develop a substantive theoretical explanation that makes sense of the decision-making process that clinical instructors use to place students on a learning contract. BACKGROUND: Clinical instructors are challenged with the task of objectively evaluating students using subjective tools such as anecdotal notes, diaries, unstructured observations and verbal feedback from other nurses. Clinical instructors' assessment decisions have a considerable impact on a variety of key stakeholders, not least of all students. DESIGN: Grounded theory method and its heuristic tools including the logic of constant comparison, continuous memoing and theoretical sampling to serve conceptualisation were used in the process of data collection and analysis. METHODS: Seventeen individual semi-structured interviews with clinical instructors in one university in Western Canada were conducted between May 2016-May 2017. Data were analysed using open, axial and selective coding consistent with grounded theory methodology. The study was checked for the Standards for Reporting Qualitative Research (SRQR) criteria (See Appendix S1). FINDINGS: Three subcategories, "brewing trouble," "unpacking thinking" and "benchmarking" led to the study's substantive theoretical explanation. "Gut feeling" demonstrates how clinical instructors reason in their decision-making process to place a student on a learning contract. CONCLUSION: Placing a student on a learning contract is impacted by personal, professional and institutional variables that together shift the process of evaluation towards subjectivity, thus influencing students' competency. A system-level approach, focusing on positive change through implementing innovative assessment strategies, such as using a smart phone application, is needed to provide some degree of consistency and objectivity. RELEVANCE TO CLINICAL PRACTICE: Making visible the objective assessments currently being done by clinical instructors has the potential to change organisational standards, which in turn impact patient and clinical outcomes.
(Figure 1) The 1996 AJN Patient Care Survey that ran in our March issue is expected to yield more than 10,000 responses from nurses across the country. Preliminary findings, based on the first 5,000 responses, substantiate the declining quality of health care and nursing dissatisfaction (see AJN Newsline, page 69).The survey results are emerging at a critical time, in the wake of the Institute of Medicine report, the NLRB decision, and growing public awareness of the "deskilling" of American hospitals. Whether through the New York State Nurses Association's television infomercials, the Pittsburgh Post-Gazette's investigative series on the use of unlicensed personnel to replace RNs, or Redbook magazine's article on consumer self-protection in hospitals, the public is beginning to realize that entering a hospital is risky business these days, and that the RN is their most vigilant advocate. For years, we have all been caught up in a game of verbal volleyball, with nurses alleging that fewer RNs at the bedside and hospital restructuring are shortsighted solutions geared to economic gain, with no assurance of quality care or safety. The opposing argument (as absurd as it seems to nurses) is that neither is there proof that more qualified personnel ensure better outcomes. Though anecdotal evidence and survey method continue to dominate the research, nursing's voice is growing louder and the reality we describe more explicit. The AJN survey contributes substantially to this evidence. As the public responds to our message, it becomes derelict to postpone action because of the absence of more formal research. (This is not to deny that a research agenda exists here.) Rather, our experience, credibility, and tradition of service speak volumes and deserve to be taken seriously. It is a ready criticism that nurses have a jaded perspective on health care reform, that eroding job security, and inevitable change have prompted negativism. The profession's historic response to personal jeopardy and privation doesn't support this thinking. Generations of labor organizers that have targeted staff nurses can verify that, given fair economic rewards, RNs will rarely speak out on their own behalf. Instead, they are best moved to militancy and action when the safety of their patients is at stake. Traditionally, they've had little to lose. There was always another job to be found, and nurses have been socialized in altruism and subservience. But more recent times are different and more painful, and many nurses have been reticent to speak out about patient safety. Intimidation and the threat of job loss are common. Vengeance falls hard on the shoulders of the single parent, the part-time student, the family breadwinner. The AJN survey preserves anonymity. Without fear of reprisal, respondents describe a workplace in which fewer RNs are caring for more patients (and these patients are more acutely ill than ever), working with more unlicensed assistive personnel, and with supervisory responsibility that should increase proportionately. The survey also reveals substantial losses among nurse-managers and executives, not unexpected given current business trends, but especially troubling to nurses who need a supportive environment to facilitate their practice. The absence of outcomes evidence becomes a myth as respondents document increases in consumer complaints, work-related injuries, patient complications, and incidents and accidents including medication errors, nosocomial infections, and skin breakdown. Most of these developments are byproducts of an unsafe environment, and they're becoming as significant to the informed consumer as they are to the concerned professional. Assistive personnel were introduced so that nurses could concentrate their time in the service of their patients. Yet, our survey respondents report that they have considerably less time to spend on direct care, interdisciplinary, collaboration, coordination of care, teaching, and comfort measures. Overwhelmingly, nurses deny that assistive personnel have improved the quality of care at their institutions. In fact, most claim that the quality of care being delivered does not meet their professional standards, a disturbing finding when you consider that job satisfaction is highly dependent on the ability to believe in the intrinsic value of the work you do. The AJN survey has given the nursing profession an opportunity to speak out with one strong voice, exposing the turmoil and pain the health care industry inflicts on the public when its priorities are poorly defined and its leaders choose to ignore the common sense and decency of those professionals most intimately involved in patient care.