A job analysis of selected health workers in a district health system in Kw aZu lu-Natal Part three : Other categories of health workers

This article described the third part of a study aimed at doing a job analysis of nurses and non-professional health workers in a district health system. This article describes the tasks of five categories of workers, their training and their work-load over an ordinary week. Interviews were done with 52 workers from three hospi­ tals and five clinics, of whom 14 were men and 38 women. The three PHC guards had a much more varied job than the hospital security staff (also three). All o f them have had specific task related training. The six General Assist­ ants in Primary Health Care settings were almost exclu­ sively involved in cleaning, while the 23 in hospitals added food and drink management and running errands to their work. Only one had training pertaining to the specific tasks. All three clerks were found in the PHC setting, and their tasks were mainly that of receptionist. None had specific task related training. The three Ground’s Men worked at gardening and cleaning at PHC clinics, but a range of other tasks were added from time to time. Por­ ters, of whom ten were interviewed, did mainly transport­ ing of patients and running errands. GA’s and security staff were also used to control violent patients and visi­ tors, something for which none of them have had train­ ing. Recommendations were made about training and work redesign in the district.


Introduction
Human resource development is a critical factor in the im plem entation o f health and social development.The South African G overnm ent proposed that education and training program m es should be aimed at recruiting and developing personnel who are com petent to respond appropriately to the health needs o f the people they serve.
According to the Human Resources for Health document, one option to ensure adequate staffing in rural services is to expand the skills o f existing technical workers with en hanced competencies.They go further to suggest that a m ultipurpose unskilled or semi-skilled w orker could mean com bining driver, cleaner, ground -care (Department of Health, 2000: 78).It is therefore im portant to explore the work o f everybody in such settings, and not ju st the nurses.

Literature survey
According to Buchman, Ball and O 'May (2000) the level and mix o f staff deployed is a central elem ent in determ in ing the cost of care and quality of care.These authors describe skill mix as the mix of employees in a post, mix of post in the establishment, combination of skills available at a specific time or combination of activities that comprise each role.Skill mix review requires a broader vision of re source planning and need to be linked to other initiatives and organizational development.
These authors identify approaches to skill mix as follows: • Task analysis Group discussion / brainstorm ing session Each approach has its strengths and limitations.Work redesign (also called job restructuring job enrich ment or restructuring care systems) is an effort to reduce cost, increase operational flexibility, im prove quality, strengthen organizational integration, and improve effi ciency by macro-level or micro-level restructuring (Kelly and M aas, 1995: 7).The first step in the redesign process is assessm ent o f existing roles in order to accurately diag nose the need for redesign.The second step is to formulate

Aim and objectives
The aim o f this study was to do a job analysis of all catego ries of nurses working in a district health system, as well as of selected other health workers in the same health district.
The job analysis with regard to nurses working in hospitals was described in part one of this series o f articles, and that of primary health care (PHC) nurses in part two.In this article the job analysis o f non-professional health workers in clinics and hospitals will be dealt with, and also the rec ommendations based all three parts.The specific objectives addressed in this article are to: 1. Describe the current jobs, training and work distri bution of Security Staff, General Assistants (GA), Clerks, G round's M en and Porter 2.
Identify skills and knowledge gaps in current prac tice o f these workers in relation to job expectations or future deployment.

3.
M ake recommendations about skills mix in district services.

Methodology
The work of the non-professional clinic staff was surveyed using individual interviews.Sample: Two fixed clinics and one health centre was ran domly chosen and all workers in the five categories listed in objective one were interviewed.In hospital settings a convenient sample of workers at five different types of units per hospital was included in the sample.Again, all workers on duty on the day o f the visit were interviewed.
Interviews were done with 53 health workers of these cat egories.Only one o f them was a Health Educator, and since this is too small a sample, this category was not explored.
The sample description is summarized in table 3.1.Sampled PHC settings and hospitals were approached by mail to explain the research and ask for their participation.
A reply sheet was provided.On receipt of a positive an swer, arrangements for the interview visit were made with the person in charge of the service, who arranged with individual units.Individual workers were approached and asked to participate.Interviews took place during on-duty tim e in a place the respondent chose.
Data collection instrument: An interview schedule was used since these workers may not have been able to complete their own task lists.It consists o f m ainly open -ended questions and was used to provide data similar to that ob tained from nurses through the questionnaire.It dealt with their tasks, the training they had for this job, their busiest and least busy times during an ordinary week, and their suggestions for im provement of the service delivered in their setting.

Results
The tasks, training, and busiest and least busy times and suggestions for improvem ent in the unit will be discussed separately for each category.
It would seem that the m ost busy time for all categories of workers at the PHC settings were the mornings during the week, and the least busy times were the afternoons during the week, and weekends (if the service functioned over weekends).In hospital settings it differed for different cat egories, and will be discussed with each category.

Security staff (n = 7)
From table 3.2 it would seem that PHC guards have a more varied role than the hospital guards.Both have direct pa tient contact, but it is limited.The most common training of security staff w'as shooting (n = 4), but two in the Hospital settings also had security updating, and one in the PHC setting had a course on com m unication and working con ditions.Hospital security respondents described the same pattern as the PHC respondents, with the mornings being the busiest, and afternoons and weekends less busy.
Suggestions for improvement of the functioning of the clinic or hospital from this group dealt mainly with making their own work easier or more effective: creating a small gate for pedestrians to enter (hospital and clinic), a shelter at the main gate so that they are protected (hospital), fit a boom gate (PHC), return their guns which was taken away with out explanation, especially for nights, provide a heater, stove and fridge, as well as search machines (all this from one person at a PHC settings), monthly m eetings (PHC), and a remote control to open the gate on rainy days.
Two comments, however, dealt with the functioning of the service in general.One person suggested extending the clinic, and another suggested building a pit toilet, since the inside toilets broke down all the time and took long to re pair.This respondent also suggested that the clinic oper ate daily, and that more chairs be provided for patients to sit on while waiting.
General assistant (n = 29) W hile the role o f the General Assistants in PHC are almost exclusively cleaning, the GAs in hospital settings add the food and drink managem ent and the running of errands as two m ajor roles.They are also involved in restraining pa tients, while the direct contact of PHC GA's with patients have to do with community campaigns (Table 3.3).
GA's in Hospital settings seem to be most busy on a M on day (n = 7) and Wednesday (4), although all other days except Sunday is also mentioned.They are the least busy on weekends (n = 10) and perhaps on Fridays (n = 4).Their

Clerk (n = 3)
The main role of this category seems to be that of receptionist, but in each setting a few other du ties were added (see table 3.4).In one setting this involved the clerk with medication to a substan tial degree.One clerk had Batho Pele training.
Clerks suggested that they be provided with PCs, additional filing cabinets and training about medi cation to make things better.
Ground's man (n = 3) Gardening and cleaning seems to be the main roles of this category, but again, other tasks were added in most cases (see table 3.5).One ground's man had Batho Pele training.One ground's man asked for a lawn mower (probably the one who cuts the grass every single day!), and another suggested security training.

Porters (n = 10)
The porters' main role is that of transporting pa tients within the hospital, and running errands (see table 3.6).Much o f the errands have to do with specimens and supplies.One porter had a first aid course.For improving the situation, por ter suggested that nurses should help push the trolleys, someone else should check oxygen in the wards, and males should do heavy lifting.
One also suggested that doctors come to work earlier, so that admissions can take place earlier.
most busy time of the day are early, from when they get on duty until 09h00, and their least busy period is late morning around lOhOO to 12h00 (n = 7) or in the afternoon 14h00 (n = 7), 15h00 (n = 2), or 16h00 (n = 3).
None o f the GA's in PHC had any training, w hile in Hospi tals 6 has Fire drill training, 6 had Batho Pele training, 1 had a cleaning course and 1 had a first aid course.
With regard to suggested im provements, the suggestions from GA's in different settings differed in character.Only two of the 23 G A 's in Hospitals made positive suggestions (keep communicating to keep people informed, and let them start working at 06h00, so that the ward is clean when the nurses start).M ost of them wanted more staff (n = 7), that some of their jobs be taken away (dishing up and running errands).Especially the errands seem to be a problem for them "We are not messengers.It makes us not complete other tasks," said one.

Discussion
The security staff and General Assistants seem to have the task of dealing with violent people (under the influence of substances or not), without any training for such a task.This would seem like a priority in terms of in-service educa tion.
General assistants in hospitals do many tasks related to food and drink management, and share this with the ENA's according to observations.None of them has had any train ing.This needs to be rectified, since the clean handling of food and drink cannot be assumed with this group.
Since this group of workers also deal with linen, teaching them about the cleaning and care of linen might contribute to the good care o f linen.
GA's in PHC clinics do mainly cleaning, but get involved in community projects.It might be possible to enlarge this role by judicial teaching The suggestions from GA's in the PHC setting dealt with asking for washing machines (n = 3), cleaning equipment, stronger gloves, and a machine for cleaning floor tiles.One suggested that there should be more nurses on night duty, because "there are only sisters, and nobody to do the nurs ing work" !GA's and porters do much o f the running o f errands, and complain that this interferes with the performance o f sched uled tasks.It might be better to appoint specific GA's as messengers, give them specific routes, and times when units can expect them.Scheduling this activity might make it less frustrating for all concerned.GA's in this setting can be trained to be more involved in community projects, and grounds men could be trained to assist with food gardens in the community.
In Hospital settings the launching o f a messen ger service with regular rounds should be seri ously investigated.The combination of three cat egories o f nurses seems to be working well, but it might be possible to increase the ENs and de crease the RNs in the light of the overlap in func tions.All other categories are also functioning within well-delineated roles.
If the District decides to do some work redesign projects, this should be evaluated through re search.

Conclusion
Grounds men seem to have a gardening function, which can be enlarged through training.They can then be in volved in community projects such as starting community gardens, or in supplying additional food for needy patients with chronic conditions.
Jobs descriptions and job establishments develop over long periods of time due to local, regional and national factors, as well as time-lim ited and enduring factors.Often the jobs and establish ments no longer serve the system optimally.Com prehen sive reviews might not be done since there are always more pressing problems and priorities, and people resist "fixing what ain't broke" .Nevertheless, much can be gained by having a close look at the skills mix in health services, the real jobs people perform, and their developmental needs.
Porters seem to have very little preparation for their work, and first aid and resuscitation train ing seems to be indicated.They do not indicate that they assist with restraining o f patients, but if they were trained with security staff to deal with this task, this would be useful.

Recommendations
Recomm endations with regard to other health workers: It is recom mended that the District em bark on a process o f work redesign and continuing edu cation to enhance system efficiency, decrease the threat of staff burnout, and improve quality o f care by giving attention to the following: It is recom m ended that detailed job descriptions be developed for the support staff, and that these be used to prepare regular in-service education.Security staff, porters and GA's: Dealing with violence in a non-violent way.GA's in hospitals: Working with food, and work ing with linen.Porters: First Aid and resuscitation.Groundsmen: M aking food gardens.

Recom m endations with regard to skills mix:
In PHC settings, it would seem that the RN, EN o lle c t and d e liv e r d isp e n sary trunks 3 lO.Accompny patients to other hos pitals 1 11 .Interpret for doctor 1 1 2 .Help in the dental clinic 1 12.Tidy and clean stock room 1

Table 3 .
1 Health workers interviewed according to age and sex.

Table 3
.2 Tasks of security s ta ff and frequency mentioned in different settings 1 4.Help lift oxygen cylinders 1 * Starred items are performed more than once a day.

Table 3 .
3 Tasks of General Assistants and frequency m entioned in different settings

Table 3 .
4 Tasks of clerks and frequency mentioned in different settings 1 Only once l.D o statistics of medication with 1 or rarely assistance of RN

Table 3 .
5 Tasks of ground' s men and frequency mentioned in different settings

Table 3 .
6 Tasks of porters and frequency m entioned in different settings