A job analysis of selected health workers in a district health system in Kw aZu lu-Natal Part one : Jo b analysis of nurses in hospital settings

The aim of this descriptive survey was to do a job analy­ sis of different categories of nurses in a District Health System in order to clarify job expectations, describe current practice of nurses in hospitals and clinics and to make recommendations about skills mix in district services. A mail questionnaire requested the sampled nurses to rate the frequency and importance of the tasks they perform. Only 19% of the nurses (41 nurses of all cat­ egories) returned the questionnaire, and an index tak­ ing into account frequency and importance, was calcu­ lated. The self-report data was compared with data from non-participant observation done over 19 days in 14 units in all three hospitals. A total of 39 tasks were done more than six times per week, of which most (16) were in the category of clinical assessment and recording. Counselling and teaching ( 8 tasks), were the second most frequent type of task. Only two tasks were rated as very important (giving injections and assessing respiratory status). When fre­ quency and importance were combined into a Task In­ dex, a large number of tasks scored in the middle range, with very few very high or low. Respondents identified 33 tasks that did not appear on the questionnaire. The observations showed that all categories of nurses shared many tasks in hospital settings. However, Reg­ istered Nurses were involved in specialized treatment and care, as well as administration of the unit. The spe­ cialists type tasks of Registered Nurses were also clear in Operating Theatre settings. The implications of the study are discussed and recom­ mendations are made. Introduction Problem statem ent In the light of the fact that about 60-80% of operating costs are from staffing, cost containment programmes demand that the right skills are employed at the right place. The term skills mix has been coined to describe a range of hu­ man resource options to contain cost while delivering opti­ mal care. It may involve the mix of posts in the establish­ ment, the mix of employees in the post, the combination of skills available at a specific time and/or the combination of activities that comprise each role (Buchan, Ball and O ’May, 2000: 18). These authors summarized the eight main ap­ proaches to determining skill mix, which includes task analy­ sis and job analysis, interview s/role reviews. The ap­ proaches vary in terms of the level of staff involvement (and therefore acceptance of results), quality of data, cost and time demands. In South Africa the nursing resources consists o f three categories of nurses: • registered nurses, with at least four years of educa­ tion after 1 2 years of school, • enrolled nurses, with at least two years of educa­ tion after ten years of school, and • nursing auxiliaries, with at least one year of educa­ tion after eight years o f school. The Scope of Practice regulations of the South African Nursing Council makes inadequate distinction between the registered and enrolled categories, with almost all func­ tions listed exactly the same (SANC, 1984). A recent gov­ ernment task team has also requested that these regula­ tions be revised, since they do not allow for the shortage of 32 Curationis November 2003 professionals to be addressed creatively (Department of Health, 2000). To ensure the most rational human resource planning with regard to skills mix, job analyses can be done. However, Buchan, Ball and O ’May (2000) point out that most skills mix studies have been done in the USA, most have meth­ odological flaws and most did not provide appropriate evaluation of outcomes in terms of quality or cost. In accordance with the South African Qualifications Au­ thority Act of 1995 (South Africa, 1995) a Nursing Standard Generating Body was constituted in South Africa to estab­ lish the standards for all nursing qualifications. One of the methods used in establishing the standards for an occupa­ tion is to do a job analysis of the current practice. This has never been done in South Africa. A study was therefore done to describe the jobs of all cat­ egories of nurses and selected other health workers at Pri­ mary Health and Secondary Care level in one health district in order to allow for human resource planning and training decisions to be based on empirical data. Although the study involved nurses in hospital and community settings, this article deals only with hospital settings. The study will be described in three sections. Section one will deal mainly with data about nurses work­ ing in hospital settings. Section two will deal with nurses working in PHC settings, as well as contextual factors and a comparative analysis of the burnout risk of nurses in both settings. Section three will deal with other health workers in both settings, and conclude with the recommendations of the total study. Literature survey Job analysis: In a discussion of job analysis, Landau and Rohmert (1989: 4) highlight that a job analysis process should adhere to the following principles: 1. It should be based on a theoretical model that al­ lows a practical interpretation of the results obtained. 2. Offer complete coverage of all demands that are present on a worker. 3. Offer maximum cost-effectiveness with regard to application, data processing and data evaluation. 4. Go beyond merely verbal work description and al­ low quantitative statements at least at the ordinal scale level. They also identify a number of issues that should be taken into account or form part of the job analysis (Landau and Rohmert, 1989:10). These include: • Preparation for the job (setting up the environment for the job). • The possibility of the worker influencing the dura­ tion or the tasks which makes up the job (full, lim­ ited, no). • Type of utilization of other workers and equipment (full, limited, no). • Work order (interrupted, uninterrupted). • The types of demands made by the job (information reception, information processing, information out­ put or activity). In Diagram 1 the thick arrow refers to the tasks the worker performs. Each task comprises of a specific performance, which is either mainly mental or physical or a combination. Figure 1 : Jo b analysis fram ew ork (adapted from La n d au and Rohm e rt, 1 9 8 9 :1 7 )


Introduction
Problem statement In the light of the fact that about 60-80% o f operating costs are from staffing, cost containm ent program m es demand that the right skills are em ployed at the right place.The term skills mix has been coined to describe a range o f hu man resource options to contain cost while delivering opti mal care.It may involve the mix o f posts in the establish ment, the mix o f em ployees in the post, the com bination of skills available at a specific time and/or the com bination of activities that comprise each role (Buchan, Ball and O 'May, 2000: 18).These authors summarized the eight main ap proaches to determining skill mix, which includes task analy sis and jo b analysis, interview s/role review s.The ap proaches vary in terms o f the level of staff involvement (and therefore acceptance o f results), quality o f data, cost and tim e demands.
In South A frica the nursing resources consists o f three categories of nurses: • registered nurses, with at least four years of educa tion after 1 2 years o f school, • enrolled nurses, with at least two years o f educa tion after ten years o f school, and • nursing auxiliaries, with at least one year of educa tion after eight years o f school.The Scope o f Practice regulations o f the South African Nursing Council makes inadequate distinction between the registered and enrolled categories, with almost all func tions listed exactly the same (SANC, 1984).A recent gov ernment task team has also requested that these regula tions be revised, since they do not allow for the shortage of professionals to be addressed creatively (Department of Health, 2000).
To ensure the m ost rational hum an resource planning with regard to skills mix, job analyses can be done.However, Buchan, Ball and O 'May (2000) point out that most skills mix studies have been done in the USA, m ost have meth odological flaws and m ost did not provide appropriate evaluation of outcomes in terms of quality or cost.
In accordance with the South African Qualifications Au thority Act of 1995(South Africa, 1995) a Nursing Standard Generating Body was constituted in South Africa to estab lish the standards for all nursing qualifications.One of the methods used in establishing the standards for an occupa tion is to do a job analysis of the current practice.This has never been done in South Africa.
A study was therefore done to describe the jobs of all cat egories o f nurses and selected other health workers at Pri mary Health and Secondary Care level in one health district in order to allow for hum an resource planning and training decisions to be based on empirical data.Although the study involved nurses in hospital and com munity settings, this article deals only with hospital settings.The study will be described in three sections.
Section one will deal m ainly with data about nurses w ork ing in hospital settings.Section two will deal with nurses working in PHC settings, as well as contextual factors and a com parative analysis of the burnout risk of nurses in both settings.Section three will deal with other health workers in both settings, and conclude with the recom m endations o f the total study.

Literature survey
Job analysis: In a discussion o f job analysis, Landau and Rohmert (1989: 4) highlight that a job analysis process should adhere to the following principles: 1.
It should be based on a theoretical model that al lows a practical interpretation of the results obtained.

2.
Offer complete coverage of all demands that are present on a worker.

3.
Offer maximum cost-effectiveness with regard to application, data processing and data evaluation.4.
Go beyond merely verbal work description and al low quantitative statements at least at the ordinal scale level.They also identify a num ber of issues that should be taken into account or form part of the job analysis (Landau and Rohmert, 1989:10).These include:

•
Preparation for the job (setting up the environment for the job).

•
The possibility o f the worker influencing the dura tion or the tasks which makes up the job (full, lim ited, no).
• Type o f utilization o f other workers and equipment (full, limited, no).

•
The types of demands made by the job (information reception, information processing, information out put or activity).
In Diagram 1 the thick arrow refers to the tasks the worker performs.Each task comprises o f a specific performance, which is either mainly mental or physical or a combination.

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Each task also comprises of an object, which can also be mental or physical, and may require means such as material or equipment.It is done somewhere and at a specific time for a specific time.M any o f the job analysis approaches described in the literature (Fisher, Schoenfeldt and Shaw, 1999:28-42) have the aim of comparing the weight of differ ent jobs.Since that is not the purpose of this study, many of these methodologies, which aim to classify all tasks into a few general categories, are not appropriate for this study.
For educational purposes: T anner(2000:141-2) criticized as being biased the curriculum development approach in which the individual or group devises programmes, which decide on the content based on their opinions and experi ences rather than reality o f nursing practice.She compared the content of the current theatre nursing course devised by individual schools against the content determ ined through research observed skill undertaken by nurses and knowledge required to perform those activities. In

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The participants are also asked to do frequency rat ing and critical rating for each o f 2 2 2 activity state ments.Frequency rating and critical rating are then com bined to provide an "importance" rating.The importance weight for each of the activities is deter mined.D ata is collected by means of m ailed ques tionnaires, and factor analysis perform ed to group activities that cluster together.D ata is given to the examination committee for interpretation and reflect the current practice o f nurses (National Council of State Boards of Nursing, NCSBN, 1991).According to Burgel, Wallace, Kem eer and Garbin (1997: 581), educational programmes need to be based on current practice to maintain validity.In a job analysis that was performed by the American Board for Occupational Health Nurses, four approaches were used, that is local analysis, direct observation, critical incident technique and task in ventory.Job analysis reflected com prehensive description of the diverse knowledge skills needed by occupational health nurses.
In South Africa Troskie (1998:3) evaluated the competency of newly qualified nurses by looking at com m unication skills, managem ent and clerical skills.The instrument the researcher used for the study was constructed based on a number of scales from the literature.These instruments need to be re-evaluated and expanded, so as to be used for job analysis purposes.

Objectives
The objectives o f the study were to: 1.
Clarify the job expectations o f the identified catego ries based on all documentation related to job de scriptions, including the core package and service description.

2.
Describe the current practice of the nurses in hospi tals in terms of frequency and importance o f tasks performed, environmental factors impinging on the job, task demands and immediate outcomes: 3.
Identify the skills and knowledge gaps in current practice o f these workers in relation to job expecta tions.4.
Make recommendations about skills mix in district services, by also referring to cost.This article deals only with objectives one and two and only related to nurses in hospital settings.Definition of terms A task: is a meaningful unit o f work activity generally performed on the jo b by one worker within some limited time period.It is a discrete unit, which represents a com posite o f methods, procedures and techniques.A job: is a group o f positions that are identical with respect to their m ajor or significant tasks and sufficiently alike to justify them being covered by a single analysis.Environm ental factors: This refers to the availability of necessary resources for the performance o f the jo b and any other physical or social factors influencing the level demands or strain o f the job.

Research design
This was a descriptive study.A mail survey was done, asking nurses to rate the frequency and importance o f listed tasks.The data from this survey was complemented by non-participant observation by an expert practitioner of the functioning o f all targeted workers.This focused spe cifically on tasks performed, job demands, and environ mental factors.

Sam pling for the mail survey
Two stratified random samples of nurses were drawn from a sample frame of the district for the task analysis (see table 1.1).The planned sample in hospital settings (216) was big enough to compare district hospitals and regional hospital, and also to compare the different categories o f workers, except for supervisors.It was small enough to allow for two samples that do not overlap to be drawn from the popula tion o f all nurses in district and regional hospitals in the district (720).

Mail survey instrument
The job analysis questionnaire was developed based on the core Prim ary Health Care Package (D epartm ent of Health, 2001:21-35).The list of tasks developed in this way was checked against the list of activities used in the job analysis of entry level registered nurses in the USA (Kane, Kingsburg, Colton & Estes, 1986).The list was then final ized and the 141 tasks were listed in a format which required respondents to rate how often they performed each task (less than 1 per week, 1 -5 per week, 6 -10 per week and over 1 0 times per week) and how im portant they thought the task was (whether it could sometimes be om itted or could not be omitted).The questionnaire also included a dem o graphic section that included gender, age, professional rank and the area where the respondent works.A third section dealt with activities that the respondent perform but were not included in the list provided.
Three experts checked the instrum ent for clarity.The as sessment o f the stability of the instrument was done dur ing a pilot study using test-retest reliability.Five nurses were selected for the pilot study and com pleted the ques tionnaire on two separate occasions at an interval of two weeks and the scores obtained were compared.A 100% correlation was obtained for 139 tasks, 80% for ten tasks, and 60% for three tasks.No changes were made to the instruments.
Developing an instrument based on the Primary Health Care (PHC) Package and services provided ensured content va lidity.Criterion-related validity was ensured by checking that all items covered by Kane et al (1986) in the American instrument, was also covered in this instrument: Preventive and prom otive services (45 items) Curative Service (39 items) Maternal and Child Health Service ( 8 items) Mental Health Service (16 items) Rehabilitative Service (10 items) Planning and M anagem ent (33 items) A total o f 21 items address more than one category.Since all categories of the PHC package were well represented in the instrument, and provision was made for respondents to add items, it can be argued that the instrument was valid.
The instrument was mailed to the first sample with a cover ing letter explaining the research and asking for participa tion.Respondents were supplied with a stamped envelope to return the com pleted questionnaire to the University.The m ailing was followed up with a rem inder letter four weeks later.Three months later the same questionnaire was sent to the second sample.This was done to allow for enough respondents, without nurses in the same setting working on the questionnaire at the same time and there fore influencing each other.

O b se rva tio n schedule
The observation schedule was developed to focus on the contextual factors of tasks performed, such as environmen tal factors (physical and social environment), interruptions, and control over speed o f task performance and task de mands.The observations were done over one-hour peri ods, with each category being observed at least on two different days and at least once in the m orning and once in the afternoon.Sampled units were approached by mail to explain the research and ask for their participation.They were requested to answer on the answ er sheet provided.
On receipt o f a positive answer, arrangements for the ob servation visit were made with the person in charge of the service, who arranged with individual units.The field worker was trained to use all the data collection m ethodologies in the research plan.This com ponent of the research could be seen as intrusive, and the presence o f the observer was therefore explained to patients/clients, and their permis sion was obtained.The intrusiveness was limited by meas ures such as sitting outside o f the nurse-patient circle, and using a registered nurse as observer.
The project was approved by the University o f Natal Eth ics Committee and by the provincial and district health au thorities.Individual institutions and sampled individuals were then approached and their informed, voluntary par ticipation sought.

Data analysis
The frequency and importance rating of each task was cal culated, and an index of frequency x importance was calcu lated for each item.
Frequency was calculated, based on the following classifi cation:

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Very frequent: all tasks performed 6 times or more per week as indicated by 70% or more o f respond ents.
• Frequent: all tasks performed 6 times or more as in dicated by 50% of respondents • Rarely performed tasks performed less than once per week by 50% or more o f respondents.
• Very rarely performed: all tasks performed less than once per week by 80% or more of respondents.
The m ethodology used to calculate the frequency-importance index was based on that highlighted in the article "Certified Occupational Health Nursing -Job A nalysis in the United States o f America" (Burgel et al, 1997:45).This m ethodology enables one to com pare the both the fre quency and the importance of a task, giving more weight to the latter.As highlighted by the abovementioned article, this methodology is common in job analysis studies for the health professions, as the less frequent tasks are often the most important tasks, e.g.administering cardio-pulmonary resuscitation (CPR).
The calculation is done as follows: 1.

2.
Importance was rated on a 3 point scale: 1 = does not apply, 2 = can sometimes be omitted, 3 = can never be omitted.

3.
The ratings for the frequency index and importance index was summed, with importance given twice the weight o f frequency.The sum o f the tw o indices yields an index score per task.

4.
The highest possible index score is 10 (frequency 4 + importance 3x2).A mean index was calculated by dividing the sum ratings from all respondents for each task by the num ber o f respondents.To compare the roles of different categories o f nurses, cross tabulations of frequency o f task perform ance was done based on category, and the Chi Square correlation was cal culated to identify significance o f observed differences.

Sample realization and description
The response rate was poor, even though services were telephoned, and nurses rem inded once by mail.Only 19% (42) of the randomly selected nurses in hospitals responded, and this represents only 6 % o f the total population in the hospitals o f the District (see table 1.1).N evertheless, the distribution across the different strata was m aintained as planned, and all the relevant groups are represented.The sam ple was accepted because the data was also being checked against direct observation data.
Not a single respondent from one district hospital returned the questionnaire.This hospital had no m ember on the re search team, and was also going through significant tur moil during the research period.The response rate from enrolled and enrolled auxiliary nurses was poorer than that from registered nurses.These groups are not used to com pleting questionnaires, and a mail survey might not be the best way of involving them in a survey.
O f the 38 respondents who gave their ages, there was a relatively equal spread of about 60% ( 1 2 ) o f the regional hospital nurses between the ages o f 25 and 49, and the rest (9 or 43%) were over 50.In the dis trict hospitals the majority o f re spondents (13 or 76%) were under the age o f 39.Older nurses seem to dominate in the regional hospital, while younger nurses dominate the district hospitals.O f the 41 respondents, only five were males, and three worked in the regional hospital.

Sample Description for observations
A

Task frequency
According to the respondents only three tasks were very frequently performed, that is 6 or more times per week by 70% or more o f respondents, and these were assessing the patient's health status, taking a blood pressure, and at taching m onitoring equipm ent to the client.How ever if one looks at the items perform ed frequently, or more than six times per week by more than 50% of respond ents, the num ber increases to 39.These 39 tasks can be classified as follows: Clinical assessm ent and recording (16 items) Planning (3 items) Giving treatment (5 items) Doing counseling and teaching ( 8 items) Collaborating (2 items).There were no very rarely perform ed tasks or rarely per form ed tasks, but the tasks most infrequently done were preparing a patient for investigating procedures, assess ing m aternal and fetal status during labour.The last item indicates that few respondents worked in labour units.

Task importance
Only two tasks (assess respiratory status and giving an intramuscular injection) was rated as very important, or can never be omitted, by more than 50% o f respondents.

Task frequency and importance (task index)
In contrast to the task index o f the PHC settings, only 6 tasks (4%) were given a 10, but only 11 got indexes lower than 5 (8 %).The tasks were categorized into six roles, and the average task index for each role calculated.These cat egories and the tasks data o f each are reflected in table 1.3.Nurses rated their counselling and teaching tasks most highly (8,67) and their management o f the unit the lowest (5,56).Tasks infrequently done are highest in the role of preventive and promotive health care.

Additional tasks
A t the end o f the questionnaire respondents were asked to add any task, which they perform and could not find in the questionnaire.Respondents identified 128 such tasks.On analysis it was found that 56 of them (44%) actually did appear in the questionnaire, but in a more general form.For instance, "weighing pregnant women" was already included in task 19.One respondent indicated that paediatric proce dures such as "Inserting an IV infusion to a paediatric pa- tient" should be listed separately.This is a valid point, but will depend on whether the research has a specific focus on paediatric care.Another respondent listed separately the activities included in task 4 and 92 (hygiene and activi ties of daily living).
Two items were not clear ("creativity clinics" and "sew ing").However, a total of 33 tasks could be added from the list provided by respondents, and 4 tasks could be changed to make them more inclusive.The categories in which the additional tasks were added, are indicated in table 1.3.

Observation of tasks
In the Hospital settings, the most frequent tasks were tak ing blood pressure (total 174 of which 142 by ENA's); inter preting for doctor (total 166 o f which 78 were by ENs, and 59 by RNs); recording (133 of which 54 by ENAs and 52 by RNs); taking vital signs (total 94 o f which 71 is by ENAs); directing patients and fam ilies (total 81 o f which 30 by ENAs); bedmaking (total 79 of which 32 by ENs, and 26 by RNs) and history taking (total 62 of which 28 were by RNs).
The variety of tasks is bigger in the hospital setting than that found in the PHC settings, but they are done less sel dom.Nevertheless the RN has a num ber o f therapeutic or specialised tasks (e.g.Applying Plaster of Paris and splints 10 times; Putting up or discontinuing IV 28 times; Checking patients, sorting them out 32 times), The administrative tasks o f the RNs seems to be higher, especially arranging movements of patients (13 times), carry out stock checks (7 times), com pleting forms ( 8 times).Two tasks that seem to take a lot o f time o f all categories of nurses are interpreting for doctors (166 times) and directing patients and families (81 times).Although both of these tasks were also seen in the PHC settings, it is on a much smaller scale.

Operating theatre nursing
The tasks observed in this setting differs greatly from those in the more general settings, and the observation data is therefore listed in a table.This data is based on 24 hours of observation, 12 o f RNs, five of ENs, and seven o f ENAs in one regional and one district hospital (table 1.4).
Twenty-three tasks were identified, with only the role of the scrub nurse (seven tasks from f to m) exclusive to the registered nurse.In one hospital the Central Sterilization Department is attached to the Operating Theatre (OT), which explains tasks v and w.
The more general tasks also found in the OT, such as re cording, supervising and teaching was discussed with the general data above.

Environment
Observations of the context within which nurses work, were recorded.The district has very hot sum mers and very cold winters.

Regional hospital:
Security is poor during the night, and some patients come in drunk or drugged.Poor patients stay long after they have been discharged.
Surgical ward: Not enough toilets, and only one bath, which is used to soak linen from clean and septic cases.Walls need painting, and the roof leaks.Double-adapters are needed.Patients steal from each other.
M edical ward: Psychiatric patients cause a problem, and the ward is not equipped to deal with them.There is a short age o f bed linen.Elderly and terminal patients put a strain on nurses.
Casualty: Spacious and well-equipped, but toilets next to nurses station is not a good idea.Security is a problem, especially at night, and with psychiatric patients.It was very hot, since the air conditioning was out o f order.Staff who take unpaid leave without notice, and poor supervi sion is a problem.
Operating Theatre: Staff feel over-worked.They often can take no tea -time, have to work over-time, and have to help out in other areas within the theatre.Off-duty roster is un pleasant because o f the shortage, and orientation to the unit is poorly done.The ceiling is in poor condition, light ing poor and air conditioning not very good.

Outpatient Departm ent(O PD):
Inadequate space for pa tients to wait for treatment increases pressure on staff.All communities use the service.There are not enough doc tors, and this causes delays, which are stressful.Also, there is no social worker to attend to Social grants.Air conditioner not working, and it gets very hot.There is no isolation area.

District hospital one:
OPD: There is no toilet for staff, and male and female pa tients share a toilet.Doctors come late, and this causes stress for nurses.The waiting room is small, and so is the dressing room.The community has many problems, such as unem ploym ent and poverty.
Theatre: There is no toilet in CSSD section, and they have to use theatre toilet.There is no porter in theatre, so that two nurses from theatre has to take patients to ward.The theatre also acts as CSSD for the whole hospital.The staff has no resting place, and no lockers to keep bags.

District hospital tw o:
There is only one kit -room for the whole hospital, and it is too small.

Casualty:
The building is old.The place is over-crowded, especially the corridor.All kinds of patients are mixed and casualty and OPD are not separate.There is no privacy to attend to confidential matters.There is no change room, and no duty-room.The dressing room is small.The bed in the POP (Plaster of Paris) room cannot be adjusted.

M edical ward:
The building and ventilation is good, but there are partitions in the ward that are good for privacy, but bad for view.The kitchen is next to the toilets.There is a relative staff shortage, with the categories o f nurses not well balanced, so that there is a skills shortage.Staff also change very often.Staff is often away for meetings and courses.Doctors do rounds late, so that medication to take • home is late and patients cannot go home, and blood sam ples are too late for the laboratory.They nurse many term i nal patients, who need home based AIDS care.

Surgical ward:
The toilets are out o f order and the rough floor looks dirty.They also have many cases that need AIDS home care.They also need a social worker to deal with abuse cases.There is no wall suctioning and oxygen, making it difficult to handle emergencies.Shortage o f staff and over-crowding leads to poor patient care.There are good relationships betw een staff.

Discussion
The Hospital nurses are involved in a far wider range of tasks than the PHC nurses, but perform s each less fre quently.Thus only 42 tasks rate as frequently or very fre quently done, in com parison with the 50 tasks rated as such by PHC nurses.Nurses in hospital settings also rated their tasks as less important than the PHC nurses did.This might be because there are other team members who can take up the slack in a hospital setting, when a nurse omits a task, while that is not the case in PHC settings.The task index o f different tasks indicates the wide range o f tasks done by hospital nurses.This finding is supported by the observations, in which Hospital nurses were observed do ing 67 tasks com pared to the 56 o f PHC nurses.
The role com ponents according to the task indexes, reflect counselling and teaching as first priority, with diagnosis and planning, assessm ent and recording and then preven tion and prom otion next.O bservations put assessment and recording at the top, with treatm ent and care and m anage m ent next.The difference might be based on the fact that tasks such as planning are less visible (observable), but this cannot explain the discrepancy totally.It might be that nurse's under-estim ate the time they spend on the routine tasks o f assessm ent (such as taking vital signs and blood pressure) recording of treatment and care and management.
A num ber o f tasks that were observed very frequently or frequently deserve further discussion.

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Bed making was observed 79 times and 33% of this was by RNs.It is granted that beds have to be made, but it seems a very low skilled job for RNs to engage in.However, it may be that they do this while wait ing for the doctor to arrive, since this is a task from which they can easily withdraw.

•
The task of directing patients and families, observed 81 times, is interesting.Although this also happens in the clinic, it is m uch less.In the old hospitals in the region, full o f nooks and crannies, and a confus ing layout, getting people from one place to another, seems a m ajor problem.A number o f workers re ferred to the fact that there is no easy way (such as a line on the floor), which can assist people with finding their way.This simple solution needs to be explored, and the time spent on these tasks m oni tored.
The high rate o f interpretation for doctors (166 ob servations) needs to be pointed out, especially since 36% of these observations involved RNs.RNs might be interpreting for doctors during doctors' rounds.This practice should be explored more fully.If the ward round is in effect a multi-disciplinary meeting to discuss the treatment o f care o f patients, even though only two people take part, that might be a good use of time.However, if the RN is in effect mainly there as interpreter, this needs work rede sign.It might then be better to supply an ENA to accompany the doctor, and for him to read nursing notes for a patient report.In any case, it would seem that the task of interpretation has always just fallen on the nearest person who speaks the language.Perhaps it is time to plan and implement different models o f supplying an interpretation service for doctors, and evaluate their effectiveness and cost.
The rate o f taking o f vital signs and blood pressure is also high.Perhaps it would be useful to investi gate whether all these observations are really nec essary, or whether much of it is done because of routine.
RNs seem to have an important task o f generally checking on patients, prioritising their care and monitoring their condition (A 8 ,32 times).This is an important task, since the RN does not do routine observations, and therefore might not be in contact with patients on a continuous basis.The continual checking keeps her in touch with what is happening to patients.This was particularly mentioned in rela tion to new patients, and patients in waiting rooms.Another task that takes much o f the RNs time is arranging for transfer of patients (A 1,13 tim es).Al though ENs assist with this task, it is mostly the duty o f the RN.
The roles of nurses in this setting seem to be less differen tiated, with ENs and even ENAs sharing much o f the tasks with RNs.ENAs have an especially wide range o f tasks in this setting.RNs however, remain responsible for some specialized tasks and for managem ent tasks.
The University o f Natal has launched a one-year "Unit management" course that aims to address the continuing education needs of mainly this group of nurses.It includes one semester o f advanced clinical skills, and one semester o f unit m anagement skills.The clinical skills include an in troduction to intensive care nursing, resuscitation, selected mental health and community health competencies.If one compares this programme with the tasks of nurses in the Hospital setting, it seems that there is a basic fit.However, it might be necessary to include a module on splinting tech niques.
With regard to Operating Theatre Nursing the role o f scrub nurse was exclusive to the RN, but all other tasks were done interchangeably by RNs, ENs, and ENAs.The use of the ENAs for duties such as assisting the scrub nurse seems a particularly useful way o f using a person with limited training.It allows for direct supervision in a useful and essential job.

Recommendations
In terms of educational needs, it would seem that hospital nurses in a D istrict Health System need unit management and advanced clinical skills for RNs to enhance current roles.
Planning for and designing an efficient translation service should be considered in these settings, where it is cur rently not a planned activity, and might therefore not be done in the m ost cost-effective manner.
To decrease directing time, hospitals should be equipped with clear markers, understandable to the whole popula tion, which will save time nurses spend on directing pa tients and families.

Table 1 .
1 Sam ple realization (planned sample numbers in brackets)

Table 1 .
3 Task index for hospital nurses with regard to six task categories

Table 1 .
4 Task frequency per category in Operating Theatre