PRIMARY HEALTH CARE THE ROLE OF THE NURSE

In die Suid-Afrikaanse situasie is die verpleegkundige 'n kernfiguur in die lewering van primêre gesondheidsorgdienste. In die voorsiening van ’n veilige omgewing het sy ’n sekondêre rol in behoefteidentifisering en voorligting en dieselfde geld vir die aspek van toereikende voeding. Haar rol in basiese voorkomende gesondheidsorg en die sorg van bejaardes, gestremdes en chroniese siekes word reeds algemeen aanvaar. Dit is op die gebied van sifting, behandeling en verwysing waar daar verwarring oor die verpleegkundige se rol en die meeste weerstand teen verandering is. Verpleegkundiges kan hier benut word en in baie areas lewer sy in hierdie opsig reeds met welslae 'n diens. Sy is nie 'n bedreiging vir die mediese praktisyn nie, daarenteen kan sy horn help en aanvul. Die land se gekwalifiseerde verpleegmannekrag kan ook beter benut word indien die verpleegkundige in privaatpraktyk in hierdie rol ge­ bruik word.


WHAT IS PRIMARY HEALTH CARE?
Primary Health Care, as the words imply, is the initial, or first level of health care given to individuals needing or seeking that care.The whole popula tion needs primary health care, for it is basic to attaining, retaining or regaining health, or making the best use of what health is left.
In a Joint Report by The World Health Organisation and the United Nations' Children's Fund (1978, p .2.) to the Alm a-Ata conference in Septem ber, 1978, the following definition was given: Primary Health Care is essential health care made universally accessible to individuals and families in the com munity by means acceptable to them, through their fu ll participation and at a cost that the community and the country can afford.It

form s an integral part, both o f the country's health system o f which it is the nucleus and o f the overall social and economic development o f the community.
It is thus not only curative, but pre ventive, promotive, rehabilitative and maintenance care.
Primary health care is also generally felt to be that form of health care given at the first point of contact of the client or patient with a member of the health care team.That health care team member, in the reality of the South African health care system, is very often a nurse.
In this article other workers are men tioned, many of whom are often forgot ten as being health care workers.They are, however, absolutely essential to the provision of basic health services to all members of the community.They are an integral part of the health care system -health care in our present-day social system would be impossible with out these workers.
Primary health care, if it is com munity oriented and is to have com munity acceptance, as stated by the Alm a-Ata conference, must include: • The provision of a safe environment.Safe, that is, in terms of basic hygiene and housing, which will include safe water, food and safe disposal of excreta and other waste matter.This aims at preventing any first contact with other health care workers because of illhealth.It therefore provides primary care, or basic care of first importance to health.
• Adequate nutrition for all.
• Basic preventive health care such as immunisation, ante-and post-natal care, obstetric care, family planning and health education.Encouragement of in dividuals to accept responsibility for their own health and health practices.
• Care for the aged, handicapped and chronic sick • Screening of persons coming for specific health care because of a break down in health, and referral of those who need secondary level health care to more sophisticated services.This is fol lowed by their reception back after treatm ent, and their ongoing monitoring and care at the first basic or primary level once more.
• Provision of services needed to ensure that basic health care can reach all groups of the population, and not only people in the lower or upper income groups.This includes all mem bers of all people falling in groups such as: mother and child, toddler and pre school child, school child, adolescents, the groups receiving tertiary education or post-school training, the workers, the retired, the incapacitated and the aged.
Having identified the contents of pri mary health care, it is now proposed to take a look at those groups of health care workers who will be involved if good primary health care is to be pro vided for all members of the popula tion.In taking an overall look at the workers in each identified area of care, the role of the nurse will be highlighted.

A SAFE ENVIRONMENT
Many persons are involved here, includ ing those who will be foreign to many readers as fitting into a category of pri mary health care worker, but without whom our health services would be overburdened, if not brought to a com plete standstill.H ere are included those who ensure a safe water supply for the community, food that is safe to eat, hy gienic standards in public eating places, safe milk, those who ensure adequate sewerage and waste disposal, those re sponsible for housing, for slum preven tion, and for the eradication of infection carrying insects and rodents -all are primary health care workers.
The role of the nurse in this area is secondary, and may be difficult for some to perceive.However, communtiy nurses can identify and point out prob lem areas such as a breakdown in ser vices, the complete absence of the ne cessary services in some areas which she visits, or in observing and reporting conditions in the community which are not conducive to healthy living.Here role in this area may also include teaching people how to observe hygienic prac tices is child and home care which will ensure a safe environment for the family, and thus, for the community.

ADEQUATE NUTRITION
Many agencies are concerned with this, as was only too evident in the recent drought, during which the lack of water and famine were causing so much breakdown in health.Specific workers who are concerned with nutrition, and thus with health, include those in agri culture, dieticians, paediatric specialists and other medical practitioners, as well as nutritionists generally.
The nurse, who so often has continous direct contact with consumers of health care, more so than any other health professional, can give informed advice on basic nutritional needs to clients or patients.This is seen very clearly in the area of child health.
The nurse also often has to act as the interpreter of instructions given by others.The patient, the m other of a child, the family member dealing with someone ill at home or recently dis charged from hospital, will often ask the nurse for clarification of advice that has been given to them .The need for such explanation often arises from the person concerned not wanting to appear stupid to those originally giving the advice, or being too emotionally dis turbed at the time to listen properly.
Because the nurse has the opportunity for a more comfortable relationship with the client or patient than is often possible in the shorter doctor-patient contact, the person is more ready to ask the nurse if there is confusion in her mind about what was meant.

BASIC PREVENTIVE HEALTH CARE
Here the role of the nurse is more read ily and generally understood.
Immunisation services are, on the whole, dependent on the nurse for their successful operation.
The nurse-midwife, particularly in the rural areas, gives ante-natal and post natal care and delivers a large number of babies.She knows when she needs the medical man, especially when prob lems occur which are beyond her scope of practice and expertise.
The family planning services also rely, to a very large extent, on nurses to reach the people.
Health education, particularly at a personal, one-to-one level, and not just in the form of a dose o f health educa tions supplied by posters on clinic walls as it has been described, can be given very effectively by the nurse.She does this by means of simple, appropriate advice, given at the right time, in the right place, in the applicable situation, using any teachable m om ent which may present itself.She also gives health edu cation, unconsciously and by example, in her work and in community activities.
The nurse can encourage the indi vidual to accept responsibility for his own health practices, often by subtle means, by reassurance and by tactfully pointing out alternatives.Again, the ready availability of a nurse in hospitals, clinics, in health care centres and in the community makes this possible.

CARE OF THE AGED, HANDICAPPED, AND CHRONIC SICK
This often falls fairly and squarely on the shoulders of the nurse.Physiothera pists and other also have an important part to play, as do medical practitioners who are on tap in case of need.The monitoring of the chronic sick in oldage homes or at home is being carried out more and more by nurses.This is basic, or primary care which is given in these circumstances.

SCREENING, TREATMENT AND REFERRAL
The m odern professional nurse, who has completed at least four years of edu cational preparation, can and is being used to provide this service in many areas.D r. J. W essels, co-ordinator of pri mary health care services in the Eastern Cape and Border A rea, says in his report dated January 1983, that the chronic shortage of medical practition ers in the densely populated area with which he has been associated, made the provision of health care by selected reg istered nurses essential if any sort of health care was to be given to the people in that area.
It is in this field of primary health care that the greatest confusion concerning the role of the nurse exists and where the most severe form of the Resistance to Change factor is being experienced.
At the outset, let is be clearly stated that the nurse involved in screening, treatm ent and referral poses no threat to anyone.H er function is to assist and complement, and not to replace the medical practitioner in clinics, out patient departm ents and other health services.A medical practitioner can only practise within the param eters of his education, training and expertisewith the professional nurse the situation is exactly the same.
Section 38 (a) of the Nursing A m end m ent Act of Septem ber, 1981 makes provision, in controlled situations, for the nurse to: -physically examine any person; -diagnose any physical defect, illness or deficiency in any person; -keep prescribed medicines and to supply; administer or prescribe them under the prescribed conditions; -prom ote family planning, provided that the services of a medi cal practitioner or a pharm acist, as the cirsumstances may require, are not available.
The way for the nurse to perform in a wider sphere has thus been legally opened and the South African Nursing Council is at present drafting regula tions under this Section of the Act, which will serve as a guide for nursing practitioners and others.
We are all aware that there is a com plete maldistribution of medical practi tioners in the Republic of South Africa.Beaton and Bourne give the following figures: in 1975 the doctor to patient ratio was 1 to 875 in urban areas and 1 to 12 773 in rural areas.Q uite a con trast, you will agree.Further unpub lished information from the same source states that 24% of the doctors in rural areas were not South African and that between 1975 and 1981 half of this 24% had disappeared from the Reg isters of The South African Medical Council.This means that continuity of care and a chance to learn the language of the indigenous population would be very difficult.

In Clinics
Some years back the author had. in the course of her work with the D epart ment of Health, visited many outlying clinics with a large attendance of patients where the nurse was the only health care worker available.H er medi cal cover often came from a very long distance.Physical visits by doctors to those areas may only occur on a weekly, fortnightly, monthly or even longer spaced basis.
The question must be asked: Should patients in those areas be left without treatment fo r such long periods o f time?Surely registered nurses, with perhaps special in-service education to enable them to keep up-to-date and to meet special needs, would be preferable?Some primary treatm ent at least could be given.
The reality of the situation must never be forgotten.Those who have never been confronted with this type of situation may find it difficult to under stand.Nurses in those situations carry the health services, without them there would be none.
In his 1983 report D r Wessels said that, in the year 1982, the trained pri mary care sisters were involved in the management of nearly one million patient attendances in his area which, it must be pointed out, also included urban areas.In a personal discussion with the author he was quite emphatic that at least half a million of those treated would have received no care at all if it were not for the primary health care sisters.He stressed that in order to make such a practice possible required recent diplomates from a good educa tional system who had not yet become set in their ways, or had time to become indoctrinated into the old system.They are specially selected for their know ledge, communication skills and adapta bility and can, if given an in-service, up dating and orientation period of about one month, function very effectively in such a service.
A nother point that Dr Wessels em phasised was that the attitude of the doctors is of vital importance to the suc cess of the use of registered nurses as primary health care workers in the screening and treating of patients.He said:

"I have reason to believe that the resistance by doctors as to the value o f the extended role o f the nurse is based on a lack o f knowledge as to the standard and quality o f modern basic nursing education and, furthermore a lack o f knowledge o f the tremendously high standard o f post-graduate nursing train ing such as the diplomas in Intensive
Care, Orthopaedics, and Theatre.He continued I make this statement as I have had the opportunity to participate in the teaching o f basic nursing and first-aid; tutoring sisters fo r their diploma courses for paediatrics, theatre, intensive care; and thirdly, and perhaps most impor tant, working intimately with them in the clinical situation o f primary care over a prolonged period.
He also emphasised It must in the first instance be stressed that the very first ob jective is to ensure that there is no misun derstanding: our aim is not to create a doctor but to create a super sister who can practise her extended role to the extent necessary as demanded by cirsumstances.
In the Transvaal, Baragwanath with its eight primary health care clinics, or Polyclinics, handles between 60 000 and 70 000 patients a month and refer less than 4% of these to Baragwanath Hos pital.
The primary health care sisters manage 70% of the patients alone, 30% are referred, half to the clinic's pri mary health care doctors and the rest to dentists, tuberculosis clinics, ante-natal clinics, psychiatric clinics and others.In 1981, these clinics handled a total of 1 790 000 patients who were seen by nurses only.Many more such clinics are envisaged in the future.
It is obvious that maximum use is being made of the potential of nurses in such circumstances.It is the stated policy of the authorities concerned with the provision of health care to all that the services will rely heavily on nurses in the future.There is no other alterna tive.
As we have seen primary health care also means a basic, or first level type of health care, which, besides that pro vided in out-patient departments and clinics, is obtained in private practice.Is the maximum use being made of the registered nurse in this area?

In Private Practice
A medical practitioner is quite ready to accept the observations made by the nurse in the hospital situation, but sometimes seems reluctant to make sim ilar use of nurses in consulting rooms.Here they are frequently used for cleri cal work such as booking appointments, recording visits, obtainig colleagues on the telephone and making tea!Could they not be better employed in taking basic health histories, doing preliminary examinations and carrying out certain tests?
It is not suggested that general practi tioners spend less time with their patients -heaven forbid.However, armed with an essenstial health history and some preliminary observations and test results, more time could be spent in talking to the patient, confirming some problem area, deciding unhurriedly on an appropriate form of treatm ent based on a considered assessment of what he has before him, what he himself has ob served and determined, and what his expertise tells him.It is the premise that, by appropriate use of the skills of the registered nurse, primary care in these circumstances could become more meaningful to patient and practitioner alike.
The registered nurse attached to a private practice could also be used to monitor patients at home and for follow-up visits to assess the effective ness of treatm ent, just as she does in a hospital or clinic.All this will be within the normal parameters of her profes sional practice.This type of practice could also lessen the burden of cost to the patient and add to patients' satisfac tion with the care that they get.
One argument that might be raised is that there is a shortage of nurses.This shortage is probably largely artificial, compounded by the use of nurses for many unnecessary domestic chores which are not directly related to patient care.In Decem ber 1981, there were 57 324 registered nurses on the registers of the South African Nursing Council.With a population of 25 456 700 this is a ratio of 1 : 444, which is not at all bad especially when regard is had to the fact that only 1 0 % of illness that is treated, is treated is hospitals.Futherm ore, there were 18 321 enrolled nurses, with a two-year basic training, on the rolls.
Although we know of areas where posts are not all filled, there are others where no posts are vacant, and yet there are not enough registered nurses to meet all the requirements of the service.This is because, as demand for services increased and the work-week short ened, new posts to meet the changed circumstances were not always created.Some of the reasons were of course economic.In our health care system the salaries of nurses have largely to be met out of the health budget of the State or Province or Local A uthorities, which limits the possible number of staff in creases.Salaries are not the only point at issue in the filling or otherwise of nursing posts, as has been clearly shown by the recent interim report on nursing of the Human Sciences Research Coun cil.
One of the most worrying things is the num ber of registered nurses who are working, but not in nursing.This is not because they do not want to nurse but because as young wives and mothers, the so-called unsocial hours of hospital work make it difficult for them.Set hours in private practice and the use of part-time nurses might bring many back into the profession for which they were trained but which they are not practis ing.

PROVISION OF SERVICES NEEDED
The provision of services for basic health care to reach all groups of the popu lation is the final elem ent of primary health care.Many people in the com munity buy health services, either in their private capacity, or through their medical aid schemes.For the most part these people have services available if they become ill and also have access to preventive services.
However, there are many, many members of the population in the Re public of South Africa, who do not have access to medical schemes and cannot afford to buy services.They would not think of preventive services in any case, except perhaps for compulsory immunsisation for children, and not always even this.It is obvious that if primary care services are to be provided in all the areas such as child health care, oc cupational health care, health care for students and trainees, the handicapped and the senior citizens, then the services of the nurse must be used extensively.
Most of our school health services operate almost exclusively on nursing personnel.Nurses are also being used in psychiatric services, in oncology ser vices, in genetic services and in primary midwifery services.All of them provide basic, first-line or primary health care.

CONCLUSION
The registered nurse follows a con trolled educational programme which is constantly undergoing review and revi sion to meet the changing needs of the times.Nurses from by far the largest group of professional workers in the health field.They are expected to exer cise educated judgm ent in their work.The attitude of those who do make full use of the services of nurses is not in question, but the attitude of those who employ nurses but do not use them opti mally, does require examination.
The best possible care of our patients and clients is the aim of all members of the health care team .Improving the quality of that care by the utilisation of the registered nurse, teaching her skills which she can use but which she may not yet have acquired, and accepting her as a person able to make a valuable contribution in the team approach to patient care, can only be of benefit to all.
From what has been said, it would appear that primary health care is given by members of the community and by health care professionals, including medical practitioners, pharmacists, di eticians and m em bers of the supplem en tary health professions, as well as by social workers.The nurse, however, be cause of the num bers available, the intimancy of her continuous contact with members of the community, well and ill, and her latent expertise which, it has been proved, can be evolved to meet specific needs in a given situation, in many different areas, can be the core figure in the rendering of primary health care.