A Culture of Discontent Within the Free State Department of Health (FSDoH)

1. A Culture of Discontent Within the Free State Department of Health (FSDoH) Shirley du Plooy Anthropology Department & CHSR&D

2. Background • PN in PHC facilities • Emotional & psychological distress • Negative implications for service delivery • Necessity to monitor staff wellbeing • Feedback sessions from such a project

3. Methodology • Six feedback workshops in 2006 • Five district management • One FSDoH top management • 173 attendees • Purpose: Communicate findings & opportunity to respond • Detailed notes & observations by researchers

4. Results & Discussion • Valuable insights into burnout & compassion fatigue reported by PNs in FS • Overt & latent matters

5. Primary findings: • Meaningful & relevant retention strategies • Work re-design measures • Instilling institutional trust • Non-clinical training & skills development • Action

6. 1. Meaningful & relevant retention strategies • Workload & overload exacerbated by: • Number of programmes • Patients seeking health care interventions • Comprehensive range of activities • However… • Remuneration & promotion • Competitive packages • Entry-level remuneration & rank promotion • Promotion & career development • Administrative & managerial positions

7. continued…Meaningful & relevant retention strategies • Moonlighting • Staff shortages a given • Implementing new programmes • Unfilled posts • Heavy reliance on volunteers • “can’t see an increase in training and a concerted effort from the Department of Health to address this issue” • Need to revisit the budget

8. 2. Work re-design measures • “Outsourcing of tasks” • More non-nursing posts • Nurses used to “plug up the holes in the system” • Supervisors overload staff with tasks • “nurses should be recognised as nurses” … “how can they do a proper job, if they are doing so much?” • Devise creative ways to make “unbearable tasks more bearable” • Prioritising tasks • Clinic-attending behaviour

9. 3. Instilling institutional trust • Performance appraisal system • Standardised performance measures • Budget constraints • Jealousy • Communication, support & staff wellness • Good at district level • Poorer between district & local area levels • e.g. the ART & PHC case

10. continued…Instilling institutional trust • No wellness programme • Psychologists – mental health of patients • EAP fixed at provincial level • Little faith in EAP personnel • “Confidentiality can’t be guaranteed” • Own resourcefulness in seeking counselling or therapy • Employer read as unsympathetic, therefore not trusted • Actively engage in reducing absenteeism

11. continued…Instilling institutional trust • Broken promises • Rural & scarce skills allowances • Only in two districts – “it is still on the table” • Devolution process • Lost travel allowances & accumulated leave; contribute more to medical aid & insurance policies • “the [Department of Health] broke promises before, why will they not do the same now. Why should they be believed or trusted now?”

12. continued…Instilling institutional trust • Lack of consultation in decision-making • When considered “nothing comes of the decisions, or the opposite of those decisions (made by someone else) is implemented”

13. 4. Non-clinical training & skills development • Current curriculum not adequate • Needs revision • Comprehensive practical vs. theoretical training • Orientation programme needed • Mentoring (problem: already overloaded) • “Delegation of accountability” & assertiveness • Person-directed training • e.g. family matters & personal finances

14. continued …Non-clinical training & skills development • Management-related training • e.g. financial management, meeting procedures & “training in the programme they are managing” • Coping skills • Promote management of workload, stress, fatigue & burnout • Minor attempts to relieve stress & burnout • Once-off workshops & sports-days • “when they [nurses] return to work, they must do double the work to catch up, and that increases the stress they experience”

15. 5. Action • Top management must: • Acknowledge the problem • Take decisions • Support lower levels • Middle management feel • Don’t have the resources or the influence • District & facility level actively engaged • “action needs to follow”, stop “passing the buck”, “as this has a negative trickle-down effect”

16. Conclusion • Reasons for ‘decision-making paralysis’ • No HOD for 2 years • High turnover at top-management levels • Acting Heads & acting managers • Lack commitment to make decisions & take action • Organisational structure & culture • District differences not pronounced • Well-resourced (staff, incentives & equipment) • Begs an answer • Larger culture of discontent

17. Recommendations • Need to instil & adopt: • Higher levels of organisational moral • Perceived institutional justice • Sense of responsibility & pride • Symptomatic relief & wellness

18. Acknowledgments Sincere gratitude to the following institutions and individuals: • The Free State Department of Health • The researchers and fieldworkers of the CHSR&D • This project was made possible by: • the Foreign Assistance Agencies of: • AusAID • DFID • USAID • UNDP • JEAPP • IDRC • MRC