A job analysis of selected health workers in a district health system in Kw aZu lu-Natal Part tw o : Jo b analysis of nurses in primary health care 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 cur­ rent practice of nurses in hospitals and clinics and to make recommendations about skills mix in district serv­ ices. This article deals with the clinics only. A mail questionnaire requested the sampled nurses to rate the frequency and importance of the tasks they per­ form. A total of 71 % of the nurses (60 nurses of all cat­ egories) returned the questionnaire, and an index taking into account frequency and importance, was calculated. The self-report data was compared with data from non­ participant observation done over 11 days in five clinics. The respondents rated 11 tasks as being performed more than six times per week, and no task as being important in that more than 70% of respondents felt it could never be omitted. However, on the task index, which com­ bines frequency and importance, 57 tasks received the highest possible score of ten, and few (25%) were rated below five. The work context of nurses in PHC settings and hospi­ tals was compared using Exhaustion-Disengagement Model and it was proposed that hospital nurses had higher job demands and lower job resources, and there­ fore ran a higher risk of both exhaustion and disengage­ ment. A clear difference in the roles of different categories of nurses was found, although they have many tasks in common.


Introduction
Clinics and health centers are at the primary level o f care and problems that cannot be dealt with at this level must be referred to the secondary level.Primary health care (PHC) addresses the main health problem s in the community in a District Health System providing promotive, preventive, curative and rehabilitative service accordingly.The cur rent primary health care team to population ratio o f 1:30 000 need to be reduced to 1:15 000 (Departm ent o f Health, 1997:55).
The Government Notice N667 (Department of Health, 1997: 54) states that the skills, experience and expertise o f all health personnel should be used optim ally to ensure maxi mum coverage and cost effectiveness.In this regard the composition of primary health care teams is important.This governm ent notice o f 1997 states, that a primary health care team need to include a unit o f health personnel with appropriate skills to deal with common conditions and ex ecute referral to the next level of care.Such team should be based at health units such as clinics and community health centers.The primary health care team members are identi fied as community health nurses, primary health care nurses, midwives, doctors, enrolled nurses and nursing auxiliaries, oral therapist, psychiatric nurses, clerical and support staff and rehabilitation personnel.
There has been some attention given recently to the com petencies needed by Primary Health Nurses.Strasser (2000) is currently doing a study in which she specifically looks at the com petencies needed by PHC nurses for their clinical role, based on a Delphi survey.However, no jo b analysis studies o f nurses or other workers at PHC level have been published.W hat nurses and those in closest working con tact with them is therefore actually doing, and how that compares to what they should be doing, is not clear.

Literature Survey
Primary health care is an integral part of the National Health System o f South Africa.The declaration o f Alm a-Ata de fined primary health care as essential health care based on practical scientifically sound and social acceptable meth ods and technology made universally acceptable to indi viduals and families in the community through their full participation and at a cost that the community and the coun try can afford to maintain every stage of their development in the spirit of self-reliance and self-determination.The Alm a-Ata Declaration (WHO, 1988: 16) highlighted five principles underlying primary health care as follows: -Equitable distribution of resources, which imply that health care services, must be equally accessible to all.
-Community participation in decision-making, referring to the dimensions of community participation, which include:

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The organization o f services on a community ba sis; • The contribution o f the community to the operation and m aintenance o f the services; • Community participation in the planning and the m anagement of services; • Community input into the overall strategies, poli cies and work plan o f the programme.-Focus on preventative/promotive health service, referring to the focus on disease prevention and health promotion rather than curative services.
-Appropriate technology, which means the material and methods used in health system, should be acceptable and relevant, including the human resources with appropriate skills, adapted to local needs.
-A multi-sectoral approach, which means that health care is regarded as one part or elem ent o f total care which in clude education, nutrition, water supply and housing which are all essential for the achievem ent of well being.According to Alma Ata Declaration (WHO, 1978:24) eight essential elem ents o f primary health care services are: • Education concerning prevailing health problems and methods o f preventing and controlling them.
• Promotion o f food supply and proper nutrition.
• An adequate supply of safe w ater and basic sanita tion.
• Maternal child health care including family planning.
• Im munization against major infectious diseases.
• Prevention and control o f locally endemic diseases.
• Appropriate treatm ent o f com m on diseases and in juries.
• Provision o f an essential drug supply.
The prim ary health care package of South A frica (Depart ment o f Health, 2001: 10) sum m arized the services to be provided through district health system, in addition to the services based on elements o f prim ary health care are: • Mental Health Service, • School Health Service, • Accidental and emergency services, and

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Curative services for some chronic diseases.The norms and standards set in the package are com pre hensive to be used by the staff to assess their own per formances and that o f the clinic and the community to as sess the quality of service entitled to them.This is in line with the Service Delivery Principles of Batho Pele (People First) (Department o f Public Service and Administration, 2001:10), which are as follows: • Consultation -which means that people should be consulted about the level and quality o f service they received and wherever possible should be given a choice about services they are offered.
• Service standard -the community should be told what level and quality of service they will receive so that they are aware o f what to expect.
• Access -all citizens should be treated with cour tesy and consideration.
• Information -the community should be given full, accurate information about services provided at pri mary health care clinics.
• Openness and transparency -people should be told how departments are run, how much they cost and who is in charge.
• Redress -if the promised standard o f service is not delivered, the community should be offered an apol ogy, a full explanation and speedy and effective rem edy.A positive response should be made to com plaints.

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Value for money -services should be provided eco nomically and efficiently.
A district Health System comprises of a population living within a clearly delineated administrative geographical area (Department o f Health, 1995: 33).The Alma Ata Declara tion stressed the need for health care at Primary Health care level and to be accessible to all people and therefore the District Health System is a framework for its im plem enta tion (WHO, 1978:58).According to W HO (1978:34) com munity participation in the planning, provision, control and m onitoring o f health services is essential.The develop mental and inter-sectoral approach required empowering individuals and communities to take full responsibility for the prom otion and m aintenance of health, to ensure m axi mal health-gain is achieved at the lowest cost (Department of Health, 1995:5-6).

Aim and objectives
The aim o f this study was to do a job analysis of all catego ries o f nurses working in a district health system.

Definition of terms
A task: is a m eaningful unit of work activity generally performed on the job by one worker within some limited tim e 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 perform ance o f the job and any other physical or social factors influencing the level dem ands or strain o f the job.Burnout: Burnout is an occupational syndrome o f feelings of emotional exhaustion, depersonalization, and reduced personal accomplishment (Demerouti, Bakker, Nachreiner, and Wilmar, 2000:455).
Exhaustion: Emotional exhaustion refers to intensive physi cal, affective and cognitive strain, as a long-term conse quence of prolonged exposure to work stressors (Demerouti etal, 2000:455).
Disengagem ent: This refers to a person distancing self from one's work, and negative attitudes towards the work object, work content, or one's work in general (Demerouti etal, 2000:455).

R ES EA R C H D ESIG N
This was a descriptive study.A mail survey was done, asking nurses to rate the frequency and importance of listed tasks.The data from this survey was com plem ented 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.

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 be checked against the list of activities used in the job analysis o f 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 important they thought the task was (whether it could sometimes be omitted 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 completed 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 Planning and M anagem ent (33 items) A total of 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 instrum ent 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 mailing 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, w ithout nurses in the same setting working on the questionnaire at the same tim e and there fore influencing each other.

Observation schedule
The observation schedule was developed to focus on the contextual factors o f tasks performed, such as environmen tal factors (physical and social environment), interruptions, and control over speed of task perform ance 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.Sam pled units were approached by mail to explain the research and ask for their participation.They were requested to answ er 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 perm is sion was obtained.The intrusiveness was limited by m eas ures such as sitting outside of the nurse-patient circle, and using a registered nurse as observer.
The project was approved by the University o f Natal Eth ics Com m ittee 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 o f 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 classi fication: • 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% o f 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 o f respondents.
The methodology used to calculate the frequency-importance index was based on that highlighted in the article "Certified Occupational Health Nursing -Job Analysis in the United States of America" (Burgel; Wallace; Kemerer & Garbin 1997: 45).This methodology enables one to com pare the both the frequency and the importance o f a task, giving more weight to the latter.As highlighted by the abovem entioned article, this methodology is common in job analysis studies for the health professions, as the less frequent tasks are often the most im portant tasks, e.g.ad

Task frequency for PHC group
Eleven items were rated as very frequently performed tasks, perform ed 6 or more times per week by more than 70% of nurses.Six were assessm ent tasks, one treatm ent task, three counseling and one preventive and promotive task.
The frequently performed tasks were forty-four items, per formed 1 or more times per week as rated by 50% and above nurses.
Only one task, urinary catheterization (men), was rated as "very rarely perform ed" by 80% o f nurses.Rarely per formed tasks were those related to equipment, multi-disciplinary team, maternity and preparation of a patient as rated by 50% and above nurses.

Task importance for PHC group
No task was rated as im portant (never to be omitted) by 70% or more o f the respondents.Twenty-seven tasks were rated as important by 50% and above nurses.Six were assessm ent tasks, eight treatm ent tasks, six counselling tasks, six managem ent and one related to preparing speci mens.

Task index for PH C group
W hen looking at the task index (which com bined task fre quency and importance), there are 57 items (40% ) rated at 10 (the highest possible index).A much lower proportion o f tasks was rated below 5 (35 or 25%) than in the hospi tals.The role category rated the lowest by PHC nurses is preventive and promotive care (5), while they rate unit man agement highest (7,67) (see table 2.3).
Respondents rated a num ber o f crucial tasks very low: • the assessm ent of suicide risk was rated at 3.
• the use o f rehydration was rated at 3. They also rate counselling tasks regarding mental prob lems (e.g.dementia, depression) lower than counselling tasks with regard to physical illness (e.g.diabetes, hyper tension).

Data from observations
With regard to the PHC settings, the most frequent tasks were: • History taking (total 111 of which 92 by RNs), • Prescribing and dispensing m edication according to Essential Drug List (EDL) (total 81 of which 77 by RNs), • Documenting and record keeping (total 76 with 53 by RNs), • Taking blood pressure (total 6 6 of which 27 by EN, 18 by RN), and • W eight and measure height o f patients (total 57 of which 26 by SASO and 15 by EN).O f the total of 990 tasks observed, 637 (64%) were attrib uted to RNs.The tasks o f the RNs and other categories seem to be different, with RNs doing midwifery care, diag nosis and treatment o f minor and common ailments, pre scribing and dispensing of drugs, management and a high level of counselling.
Two additional categories of workers were identified in the settings.They were Auxiliary Service Officers (ASO) and Specialised Auxiliary Service Officers (SASO).ENs, ASO and SASO seem to do much of the routine measurement (BP, height and weight, vital signs urinalysis), interpreta tion, immunization and some counselling.

The environment in PHC settings
Clinic 1: The building was described as "small and con gested", "over-crowded" and it was indicated that privacy was a problem.All nurses shared one exam ination room, and this caused long delays.They also used the labour ward for antenatal care.W hen describing the social fac tors, the poverty in the community was mentioned repeat edly, with high incidence o f teenage pregnancy and unem ployment.Safety was also a problem, with patients coming Curationis November 2003 to the clinic with guns.There was no security person at this clinic.All the staff had to share one stethoscope.Clinic 2: Electricity was "on and o f f ', there was no rest room for nurses, and the dressing room was too small for a stretcher.There was no protective clothing in the labour ward and the television was not working, and could not be used for health education.However, this community did not look as poor as the one served by clinic one, and used the health care provided.This was the only clinic in the area providing a service at night, and that made the work demanding.The observer described the clinic as "having a good personality" .
Clinic 3: The male toilet had been out o f order for a long time.The clinic was small and patients often had to stand outside.There was no labour room and the emergency room served multiple purposes, e.g.storing o f trolleys.The w a ter supply was unreliable, and was cut off without warning.Unem ploym ent and teenage pregnancies were social prob lems in the area, and the incidence of HIV/AIDS and TB was high.The community had a poor toilet system, and transport was also a problem.There was a chronic staff shortage.
M obiles: The observer indicated that there was no build ing where the mobile stopped, and nurses were working in a garage, with no water, toilets or electricity.The other mo bile did not use a building at all.Some patients had to cross a river to attend, and attendance was poor on rainy days and during harvest.The road was not good, and worse when it rained.Health projects had been politicized by some community members.HIV/AIDS prevalence was high in this area.Teenage pregnancy, early school leaving, unem ployment, and child neglect were problems in the area.

Comparisons The work context
The observer had to com m ent on four task related factors (interruptions, delays, necessity to use people or material and demands) and three environmental factors.The ob server rated so few instances o f using people or material and demands, that those two categories were disregarded in the analysis.
The average frequency of interruptions and o f delays was calculated per category, and is reflected in table 2.4.From this data it would seem that nurses in the PHC setting com plete more tasks per hour, and has twice as many interrup tions and delays as their counterparts in the hospital set ting.

Comparison of settings in terms of burnout risk
In order to understand these factors better, they were coded for each setting according to Exhaustion-Disengagement Model suggested by Demerouti et al (2000:454-462)  Supervisor support: Support is high in terms o f ori entation and teaching at PHC settings (tasks 104 +109 +13) com pared to hospital for almost double the observation time.

2.2
Feedback: Feedback is higher in hospital settings (task 103) than in PHC settings, where every nurse works relatively independently.

2.3
Participation in decision-m aking: The workforce is small and more o f a primary group in PHC settings than in hospital settings.This leads to greater sharing o f power.

2.4
Control over job: PHC workers control their own jobs to a large extent.The frustration o f hospital General Assistants about "running errands", which interferes with their own.

2.1
Rewards available: None was mentioned.However, RNs have rewards such as working in a consulting room, and engaging in high status jobs such as deliveries, and dispensing medication.The rewards of hospital nurses may be in doing ward rounds with high status colleagues such as doctors or matrons.However, few of them are involved in this.

2.6
Task variety: According to the task frequency, PHC nurses perform 55 tasks frequently or very frequently, and 7 infrequently.In contrast, hospital nurses perform 42 tasks frequently or very frequently, and no task infrequently.It would therefore seem that hospital nurses perform a greater variety o f tasks.The same is true o f hospital workers in other categories.
If this analysis is accepted, it would seem that hospital nurses have a higher Job Dem ands and low er Job Re sources.They can therefore be expected to run a greater risk o f both exhaustion and disengagement.Both o f these lead to lower life satisfaction according to Demerouti et al (2000:457).

Comparison between different categories of nurses
To compare the frequency o f tasks performed by different categories o f nurses each item was cross tabulated with category (RN, EN, ENA), and to test for the significance of the differences observed, a Chi Square was calculated for each item.There was a significant difference between cat egories only on 19 items, but a further 1 0 showed a strong trend towards a significant difference.These items (Table If one scrutinizes these scores there seems to be only three tasks that are regularly performed, mainly be RNs (wound closure by suture; arrange environment to promote patient safety; and attending community meetings).In contrast, there are many tasks that are shared by RNs and ENs, but are regularly done by ENs (see items 4 ,1 8 ,2 1 ,2 5 ,2 7 ,4 2 ,4 8 , etc in table 2.6).These tasks include diagnostic tests such as reading glucose finger pricks (task 32), counseling (task 55,7) and management (task 109).Although ENs might not do a lot o f formal in-service training, they seem to do a lot of orientation of new staff members, and informal teaching to individuals.This is done more frequently than the more formal teaching done by RNs.However, the dom inant im pression left by the comparison o f roles is that there are not a great difference, and that there are very few tasks exclu sive to RNs.
If one considers the data based on the observations, the picture looks a bit different.Many o f the tasks reported by ENs as frequently done by them, was never observed W hen this data is compared to that collected through ob servation, questions arise about the validity of especially the EN ratings.For instance ENs report themselves to be performing a number of tasks more than ten times per week, but they were never observed to be perform ing them dur ing the 160 hours o f observation.These tasks include counseling clients about depression (task 55,7), adm inis tering local anesthesia (task 78), and counseling victims of abuse (task 79).Furthermore, these tasks were not observed being done by any nurse during the observations.A n other set of tasks which the ENs rate them selves as per forming more than 1 0 times per week is shown by observa tion to be done mainly by RNs, who rated the frequency much lower.This set o f tasks include assist with personal hygiene (task 4), Teaching parenting skills (task 72), Super vising su b o rd in ates (task 103), and S ta ff in -service (task 109).It might therefore be the case that ENs, tend to over-estim ate the frequency of tasks they perform.

Discussion
The picture that emerges for the PHC group is one o f nurses involved most frequently in assessment and recording, and counselling and teaching tasks.When it comes to impor tance, they rate their assessment, treatm ent and care, coun selling and management all at about the same level.W hen these two measures are com bined into the task index, the group seems to perform many very important tasks or per form many tasks frequently, since they have a high per centage o f top rated task indexes.However, there are also many tasks in the instrum ent that is not particularly rel evant to their work, so that 25% o f tasks have indexes of below 5.
W hen looking at the different role com ponents (table 2.3), they rate all high with average tasks indexes ranging from 6,97 to 7,62, except Prevention and Promotion, and perhaps Management.The observations confirm the high frequency o f some assessm ent tasks, such as history taking, assess ing health status, weighing and measuring, assessing un derstanding of normal development with an average obser vation o f 8,5 tasks per hour for this category.Their lowest rating also coincide with the lowest observation index, which is in the category Prevention and Promotion.This low rating in a category, which is usually associated with the task of PHC settings, is probably related to the items included.All four o f the tasks, which were never observed, refer to nurses m oving out o f the clinics and into homes and communities.In the observation schedule, reference was made to the fact that transport was not available to make this possible.
According to Coulson (in HST, 1999: 298), the core pack age of prim ary health care services includes health prom o tion as a community service.She says: "This implies that health promotion should involve outreach work into health districts" (p 298).She further voices doubt that PHC nurses will be able to fit this into their schedule, due to the pres sure o f prim ary curative care.Comm unity rehabilitation, another com ponent o f PHC, is also greatly dependent on home visits being done, and the health worker therefore moving out of the clinic.
In nursing education, the community-based nursing edu cation programmes have adopted the community empow erment approach to health promotion (Naidoo and Wills, 1994: 6-24).In this bottoms-up approach the professional facilitates the community in developing the knowledge, skills and organization to increase their control over their own lives and health.It means giving attention to such strategies as provision of water, the production o f food and income generation.In the community health nursing components of all pre-registration programmes, approaches such as school health, occupational health and illness pre vention is the focus.Strasser (in HST, 1998: 83)  From this data it would seem that PHC nurses might be able to include more outreach activities (home visits, school visits, community projects) in their work, with some rede sign of jobs and services.However, it is important that the question be clarified what the role expectations of the em ployer really are.If the roles of the RNs at PHC clinics are to deliver a primary curative care services, together with mid wifery and illness prevention, then the relevant com po nents to put into the pre-registration programmes are diag nosis, treatment, prescribing skills, Integrated Management of Childhood Illness.In contrast, if the role includes a strong emphasis on working with the community, on health pro motion and community rehabilitation, then it makes sense for the generalist nurse to be prepared in community or public health nursing, and diagnosis, treatm ent and pre scribing to be left for a specialist programme.Strasser (in HST 1998: 8 8 ) pointed out that the post-registration train ing available for nurses that this focuses mainly on primary curative care.Although these efforts lags far behind the real need for these skills in the services, this approach seems to support this approach to the human resource needs of Primary Curative Care.
W hat is happening at the moment is that community-based education, strongly supported by governm ent policy, is m oving in one direction, but in the actual services, the ex p ectatio n seem s to be differen t, and the support for outreach activities is absent.
The fact that PHC nurses rate the estim ation of suicide risk at only 3 is worrying.As PHC workers, they seem to be having the same difficulty as that reported in earlier studies (Hall & Williams, 1987) of identifying depression in clients.The low index of counselling with regard mental illness and its total absence in observations is a problem in a system where long term care for this group of clients is being moved into PHC.It is probably related to lack of knowledge and understanding o f nurses in this field.PHC nurses also score their use of oral rehydration low (item 48).It could be argued that rehydration is done by In terms of job demands, PHC nurses score at 50% and for job support they score 67% (Table 2.3).Although they have a heavy workload and poor working conditions, the other factors balance this out, and this group should not suffer from burnout.From the interviews it would seem that most clinics are less busy in the afternoons.It would be ideal to use this time for out-of-clinic outreach, and for continuing education.

Recommendations
In terms of further education, it would seem that PHC nurses need additional M ental Health training and training which would support an outreach function related to prevention and health promotion if they are expected to fulfil this func tion.
It is important for educators and those responsible for for m ulating outcomes of nursing education programmes to study the current roles of nurses in order to develop rel evant educational program m es with outcom e competen cies fit for the tasks of nurses are actually required to per form.
It is important to discuss the im plications o f these findings for the newly established Standard G enerating Body for Nursing, and for the SA Nursing Council.In an article de scribing a job analysis done on Occupational Health Nurses in the USA, Burgel and Kemerer (1997:582) states that "For any certification program to be sound, the examination must be reflective o f w hat individuals in the specialty area actu ally 'd o ' in their profession and the knowledge needed to perform those activities.In other words it must validly rep resent practice" .It is also true in the South African situa tion, where the minimum standards from nursing education are in the hands of these two bodies.It would therefore seem to be appropriate that the description of actual task performance in this study be used to: • Compare the content o f nursing education pro grammes for different categories o f nurses.Espe cially the balance between assessment, interven tion, health education and other role components in the curriculum needs to be explored based on the actual proportion of time spent on those roles.
• Compare the evaluation o f nurses in the different categories with the tasks required in practice.The correspondence between, for instance the tasks evaluated in clinical examinations, and the task in dexes of tasks listed here, should be explored.
It is also urgent that the Community Health Nurses, the S A Nursing Council and the Department of Health at all levels discuss the problem of the focus o f Community Health Nursing in the pre-registration programmes and the postbasic program m es.The question is w hether the nursegeneralist (pre-registration programmes) should be prepared for an outreach task (health promotion and communitybased rehabilitation) or for a primary curative care task.Both of these cannot fit into a four -year entry level pro gramme, and one is clearly currently the job of RNs in clin ics, and the other is not.
With regard to further research, job analysis studies should also be done in other kind o f services, so that a valid pic ture can emerge of what nurses actually do.This can in form policy and education.It should also be repeated at regular intervals, to see whether changes in policies and procedures change practice.Since the supervisory nurses in this sample was to few to draw any conclusions, their tasks should be explored in a more targeted research project.

Conclusion
There is no doubt that nurses are the back-bone o f the health services in South Africa.In terms of their numerical strength and their distribution across all services, there is no other health workers that can compare with this group.This study throw some light on the work done by different categories o f nurses in a district health system, and the im plications the work setting has for them.
pointed out in her discussion of PHC training for nurses that the major ity of training is still hospital-based and not district health or PHC focused.If this is to change over the next few years, it is essential that the decision be made what the PHC train ing for pre-registration nurses should focus on, based on the reality in the services.

Table 2 .
1 Sample realization (planned sample numbers in brackets)

Table 2
.2 Age and w orkplace of respondents with column % ( n = 6 1 ) * One respondent did not indicate age Package and services provided ensured content validity.Criterion-related validity was ensured by checking that all items covered by Kane et al (1986) in the American instru ment, was also covered in this instrument.Preventive and promotive services (45 items) Curative Service (39 items) M aternal and child health service ( 8 items) Mental Health Service (16 items) Rehabilitative Service (10 items)

Table 2 .
3 Task index for P H C nurses with regard to seven task categories

Table 2 .
. They have shown that there are six main Job Demands, and six main Job Resources.If the Job Demands are too high, it leads to Exhaustion, and when the Job Resources are too low, it leads to Disengagement (see table 2.5). 4 Frequency of ta sks, interruptions and delays in P H C and Hospital settings per category.

Table 2 .
5 Com parison of settings in terms of Exhaustion-Disengagem ent Model

Table 2 .
6 Com parison of task frequency between categories of nurses.Contradicted by observation data caretakers at home, and not by nurses in PHC settings.The low indexes for tasks which demands that the nurse moves out of the clinic, such as assessing safety at home or school or in the community, attending community meetings and taking part in community projects indicate a service-based approach to PHC instead of a com munity-based approach.There is a clear difference in roles of different categories of nurses according to the observations.RNs diagnose and treat minor and common ailments, prescribe and dispense drugs, manage the clinics, deliver a midwifery service, and do a lot of counselling.In contrast, other categories do routine observation and measurement, immunization, inter pretation and some counselling.Although they do not have many m ulti-disciplinary team members at hand, the task indexes o f the tasks requiring collaboration are quite high.This role o f the RN in diagnosis and treatment in PHC is not a traditional nursing role (Sokhela and Uys, 1999), although it has been developing world-wide over the last few dec ades.Studies usually find that nurses give acceptable care in terms of quality and client satisfaction in these roles (Sokhela and Uys, 1999) In the PHC settings in South A f rica, it seems in this study that it is well-established, and not seen as extra or additional.