PRIMARY HEALTH CARE RENDERED FROM MOBILE UNITS : CAN COMPUTERS HELP ?

The objectofsurvey was to assess which aspects o f the nurses ’ work in mobile clinics could be com put^ised with a beneficial effect on the quality o f Uvrk. This paperJs an analysis o f how much time the nursing staff"spent on various tasks. The results show that nurses are satisfied with their work, even in the face o f difficult working conditions an d a high w orkload. It was also found that com puter and communications technology can prom ote greater efficiency in activities that represent 35% o fa nurse's time.


INTRODUCTION
In regard to nursing activity, the small amount of time spend on direct patient care and the excessive adm inistrative burden o f nursing staff stands out various studies.Categorisati on and quantification o f nursing activities in an outpatient departm ent w as reported in Joseph (1990:21-22).The time allocated to various activities by registered nurses in a large metropolitan hospital w as assessed by Barrj' et al (1 9 9 0 :4 0 ) an d H e n d ric k so n et al (1990:33).Hedtcke et al. (1992:19) did a study on how home health nurses spend their time.Concerning developing countries, M oiduet al.
(1 992:38) reports that com m unity health w orkers at the peripheral health delivery units s p e n d 4 0 -5 0 % o f th e i r w o r k in g tim e compiling data for higher authorities.W ays to reduce this burden significantly so that nurses can do w hat they w ere train ed for is a challenge, w hich to this day, has not been overcom e satisfactorily.A study o f the activities involved in PHC as provided by m obile clinics and cars in a developing country is reported nowhere to the best of the authors knowledge.This paper deals with the first part of the study which is to assess and quantify the activities o f nurses rendering a primary health care service out of a mobile unit.

M ETHODS
The study w as done in the rural areas of the O range Free State.This province, which is approxim ately in the centre o f the Republic o f South Africa, com prises 10% o f the surface area o f the country.The province is divided into four hospital regions, north, south, east and west.A professional nurse and a nursing assistant, using a mobi le cl inic, are responsible for providing PH C services in designated areas.
Structured interviews w ere conducted with m ost o f the senior nursing service managers to discover their view s on issues surrounding the study.A s a further prelim inary step a day was sp e n t w ith one m o b ile c lin ic to observe firsthand what the w ork in the mobile clinic entailed.Exam ples o f all the different forms, cards and reports w ere collected for a detailed study o f the inform ation w orkload o f the nurses.
A questionnaire w as designed that reflected dem ographic details and a profile of typical activities for a nurse in charge o f a mobile clinic as well for the area in w hich she works.Som e questions i ndicati ng attitudes rel ating to her w ork and interpersonal relationships were in c lu d e d in th e q u e s tio n n a ire .S everal ac tiv ities co m prising a n u rse's task w ere identified.The am ount o f time spent on each activity also w as included in the questionnaire.A pilot study w as conducted to eliminate unclear and confusing questions and to make certain that the activities covered a nurse's task.
N urses vi si 11 hei r area duri ng the fi rst four days o f the w eek and the fifth day they use for adm inistrative purposes.A nurse's activities vary from day to day and week to week.Therefore, to find the am ount o f time spent on the different activities, the amount of time spent on each activity over a period of one month w as studied.The nurses were asked w hat w as the estim ated am ount o f time spent on each activity.An activity log would have provided more reliable results, but the authors decided to use the above approach because of lack o f time and the heavy workload of the nurses involved in the study.
The questionnaires w ere completed during the monthly in-service training sessions and most o f the nurses therefore partook in the study.Only those nurses w ho could not attend the training session on the specific day were excluded.The author w as present during these sessions to ensure that everybody interpreted the questions similarly.
T h e d a ta w e re p ro c e s se d on a C onvex m in i-c o m p u te r, u sin g S P S S (S ta tistic a l Package for the Social Sciences).Crosstabs mostly were used to obtain the num bers and percentages for the different categories.In one instance Pearson's C orrelation C oefficient w as calculated.F-tests w ere used to test for differences in means.

Response rate
Ninety-five questionnaires w ere completed.This represents 80% of the professional nurses providing PHC services on farms.This is an excellent response rate and the conclusions therefore can be considered as representative o f nurses working in this environment.

Demographic information
O nly o n e ( l% ) m ale n u rse c o m p le te d a questionnai re.The other personal de tail s o f the n u rs e s c o n s is tin g o f a g e g ro u p , h o m e language, qualifications and experience are reported in

Area Served
Table 2 outlines the areas o f reponsibility of the professional nurses.Sixty three percent of the nurses reported that they w ere responsible for rendering a service on 100 to 200 farms.In 55% o f the cases the num ber o f stopping poi nts per area served is betw een 100 and 200.Nearly half (49% ) o f the areas served have at le a s t 3 0 0 0 r e s id e n ts .A p p ro x im a te ly two-thirds of these people are served with PHC services.W ith every visit it w as found that on average 20% o f the farm inhabitants have moved away from the area served to unknown destinations.This creates problems with follow-up, statistics and administration.A further 17% is not present on the visiting day d espite pre-arrangem ents.N urses usually leave a visiting card giving the date o f the next visit.Farm s are visited six weekly in 68% o f the cases.Six w eeks between visits is ideal because it corresponds to the time between immunizations.Family planning return dales are also more easily ensured (12 w eekly) but it is a long wait for child health, tuberculosis and certain other services.

Attitudes
Table 4 details to w hat extent nurses agreed or disagreed with statem ents made concem ing their work.Sixty-nine percent o f the nurses are satisfied with their present jo b and 87% enjoy w orking with their co-workers; 49% o f the nurses disagreed w ith the statem ent that their productivity level is below w hat it should be.
Productivity w as defined in this regard as the amount o f time available for quality patient care.T his reflects the fact that nurses are so busy with "other" things that direct patient care is neglected.The majority (73% ) agreed that the utilization o f computers could improve productivity.This is substantiated by the next question which stated that PHC is neglected b e c a u s e o f a p r e o c c u p a tio n w ith d a ta collection.Seventy-three percent o f the nurses agreed with this statem ent and data collection is clearly one area w here computers can play a m ajor role.A contributing factor is the m ovem ent o f people from the area which 84% o f the nurses felt m ade information processing difficult.

Activities
The final and m ost im portant part of the study was finding out how the nurses spend their time.T able 5 outlines the definitions of a a iv itie s o f the nurse.
The amount of tim e spent on each activity during one month (185 hours) is reported in Table 6.For this part o f the analysis 26 cases had to be om itted because the num ber o f hours did not add up to 185.Information from 69 respondents was analysed.
A univariate F-test revealed a significant difference betw een the m eans for four o f the a c t i v i t i e s .T h e s e a c t i v i t i e s w e re A dministrative w ork(significanton ,05 level), S tock con trol (sig n ific a n t on ,05 lev el), Training Students (significant on ,01 level) and Personal time (significant on ,05 level).The differences in the Personal tim es can be explained by different philosophies in the regions on the taking o f tea tim es, lunches, etc. Students are not allocated evenly to all the regions for training and that explains the differences in that regard.The differences in the Stock control v alu es can possibly be attributed to the distance from the main centre.The high mean value in the Eastern region for the adm inistrative activity, which is the reason for the difference betw een the mean values, is difficult to explain.
Only the validity o f Travelling time could be established by correlating it with the number o f k ilo m etres per m onth, w hich w as an accurate figure.A correlation coefficient of 0,42 w as obtained which w as significant at the 0,01 level.Consideri ng that the tim es provided by the nurses are estim ates, the m eans for the four regions are rem arkably close.M ean values o f the four regions combined therefore provide a good indication on how nurses spend their tim e and these values will be used in the further analysis.

Workload of the staff
Not w ithstanding the vastly different sizes of farms in the Orange Free State it is clear that the majority o f nurses visit 4 to 8 farm s per day.V ast distances are travelled per day in

Definition
This represents the time spent on all paper work, i.e. paper work conceming the vehicle, supplies, patients £uid management.This is the time spent driving the mobile clinic or car.This is the accumulation of all the time spent on one-to-one interaction with the patients This is the time spent managing (unpacking, counting, distributing, etc.) supplies.This is the time spent searching through the hospital information system for information on patients from a particular area who were discharged.
The time spent in meetings.
Before leaving the area, supplies for the day must be loaded in the vehicle and on return the remaining supplies must be unloaded.In the case of a car, the loading/unloading can take place at each stopping point.The vehicle must be cleaned, and taken for service and repairs.
Liaison with the farmer concerning the workers on the farm, visits to farm schools and contact with other organisations like agricultural unions.
Educating the farm workers on health matters and addressing the public on various health topics.
fo llo w up o f tu b e rc u lo sis su ffe re rs and children at risk w hich could save lives, cannot be provided as new records are constantly being made out by health care providers in a area.Building a therapeutic relationship of trust is constantly lost.
The feasibility of com puterization o f records with a link up to a central data bank clearly needs to be studied to alleviate this problem.

Use of time
Nurses spent only 24% o f their time on direct patient care.Such sm all am ount o f time spent on patient care is alarm ing w hen linked to e x is ti n g m a n p o w e r s h o r t a g e s .T h e adm inistrative activity that consists mainly of co m p letin g form s and p rep a rin g rep o rts account for 23% of a nurse's time.Record keeping is an integral part of nurse patient interaction since the nursing assessm ent forms the basis o f all nursing intervention.This must be recorded as must all nursing intervention to en su re c o n tin u ity o f care and e ffe c tiv e ev alu atio n o f p ro g ress.T he fru stra tio n involved in repeating these comprehensive records when clients move is clear.The need for examination of other m eans of recording patient related data and easy retrieval is indicated.D irect service rendering is what nurses are trained to do and this figure must be increased.One possibility is to decrease the tim es spend on other activities.M ost of these tasks can easily be computerised.

Application of conipiiterisation
E x a m p le s o f a c t i v i t i e s th a t c a n be com puterised are patient records and the identication of these records possibly using bar coding.Sum m arised information can be drawn from the system and for example lists o f immunisation and tuberculosis defaulters can be printed.This will reduce adm inistrative tasks and should improve nurses' effectivness and productivity.The nurses spend one day o f the w eek in their office m ostly doing a d m in is tr a tiv e w o rk .A w e ll-d e s ig n e d com puter system in the field will increase their productivity and allow them nurses an extra day in their area.
O th e r a c tiv itie s in w h ich co m p u ter an d c o m m u n ic a tio n s te c h n o lo g y can p lay a significant role is in the search for information concerning discharged patients from hospital.T his can be accom plished by linking the computer in the nurse's office via modem to the information system o f the hospi tal.N urses have to travel tocentral locationsforin-service training and meetings.Substantial savings in ti me can be achieved i f al I the nurses are I inked in a c o m p u te r n e tw o rk w h ic h p ro v id e computer conferenci ng and electronicbulletin board services.An electronic mail system can a ls o s a v e tim e w ith te l e p h o n e communications.
In total 35% of a nurse's time lends itself to computerization with a subsequent reduction in travelling time.Exactly how this can be done will be reported in a future paper.
The Provincial A dministration o f the Orange Free State (PA O ) is responsible for rendering primary health care (PH C ) services to the inhabitants o f farm s in the O range Free State (O F S ).T h e se se rv ic e s a re re n d e re d by professional nurses and nursing assistants from 126 m obile clinics.The majority o f farms are visited in a 6 to 12 week interval.M ost o f the people who use this service are black farm labourers and their families.The PHC service provided is health education, family planning, ante-natal care, post-natal care, child growth m o n ito rin g , im m u n isa tio n s, c a re o f the e ld e r ly , tr e a tm e n t o f m in o r a ilm e n ts , prom otion o f optimal nutrition and treatm ent o f endem ic diseases such as tuberculosis and sexually transmitted diseases.OBJECTIVES A dm in istratio n form s a large part o f the professional nurse's work.This study was u n d e r t a k e n to o b ta i n d e m o g r a p h ic information from the nurses, their conditions o f w ork and their attitude towards work, to quantify these nurses'activities, to assess what aspects o f their w ork can be computerised and to d e te r m in e a p p r o p r ia t e ty p e s o f computerisation with its costs implications.
. The average number o f years since completing their basic training is 17 years.In contrast the average number o f years experience o f PHC on farms is approxim ately three years.The last mentioned figure is so low because half o f the nurses were former fam ily planning nursing staff who started to render a comprehensive PHC service only from August 1991.

Table 1 .
The predom inant age group is 30 to 39 years with 40% o f the nurses falling into this category.Sixty-five percent o f the nurses fall into the age group o f 30 to 49 years.The majority (72% ) o f the nurses are Afrikaans speaking with Sotho (16% ) as the next highest.O nly 7% o f the nurses are graduates.The rest qualified with a diplom a in general nursing.M ost o f these nurses have done one or more additional courses

Table 4 : Attitude information
At present only 61% o f the nurses are issued w ith mobile clinics.The rest have to provide the PHC services from cars and the authors believe that this is particularly frustrating for the nurses because o f the dusty surroundings, the unloading and loading o f equipm ent at each visiting point and the absence o f an exam ining table.A substantial am ount o f travelling is involved w hich is borne out by the