Like much of Africa, provision of more universal HIV services in Uganda created extraordinary health systems demand that could not be met using traditional physician dependent models. In the context of this PEPFAR-funded community-university partnership emphasis was placed on utilizing every available human resource to its full potential. The three-pronged approach of training, provision of necessary resources, and continued support allowed the rapid integration of services and care despite some notable human resource constraints. Both the nurse managers and the staff nurses found that the training and support to the nurse cadre helped to improve the services delivered to patients under this newly structured program. Our data agree with others who found that good health outcomes can be achieved by enhancing the role of the nurse [8
The primary intent of this study was to evaluate the impact of introducing PEPFAR clinical services into the local KCC urban government clinics. In actuality it identified the effectiveness of empowering nurse in their role of providing primary care as they scale up the quality of care provided HIV patients as well as other services provided. Two of the largest dilemmas experienced universally by nurse managers are having problems that appear impossible to solve due to a lack of adequate resources, and individual staff apathy [10
]. Effective provision of resources is key to the empowerment of staff and essential for work effectiveness, for nurses to function autonomously, for patient’s safety and quality care, and to promote collaborative/collegial relationships. According to the nurses, this project provided those resources in a well-managed approach that helped solve some of the insoluable problems and immediately engaged staff interest.
With triangulation of the data from the nurse managers and staff nurse, the responses reflected similar views and perceptions. All of the nurses agreed that the increase in training provided new skills and knowledge that could be immediately implemented in the direct service to the patients at the clinic. Immediate implementation of the new information is likely to increase the trainees’ interests and efforts [11
]. The nurses also agreed that the care was improved and that specifically the staff nurses had more time to spend with the individual patient. The improvement in infrastructure and particularly increased lab capabilities, more space, and reliable sources of medications with no stock outs were also named as important developments under the project. Improvement in the nurse’s work environments in health centers has the potential to empower the nurses, simultaneously reduce high level of job burnout and decrease the risk of turnover [2
]. It also increases job satisfaction [13
] and there has been increased patient satisfaction with care at the KCC clinic [14
]. The staff nurses, however, were in agreement that they had more work with the restructuring, even though the nurse managers felt the work load had not increased. Although, in general, the nurses were very satisfied with the collaboration, there was some concern that pediatric care decreased in a few of the clinics; an issue that warrants further exploration.
A skilled nurse manager can be a huge asset to the effective functioning of a clinic, and actions that can be taken to enhance any of the components of an effective manager will be reflected in the provision of better health care. According to Tappen there are seven components to an effective nurse manager: leadership, planning, providing staff direction, monitoring the operations, distributing fair rewards, staff development, and representation with administration [6
]. The nurse managers in their interviews volunteered all seven of these components as actions that were enhanced as part of the partnership, and the nurses considered each component as an important part of a successful improvement of the clinic nurse manager role. They were appreciative of the extensive management training that they received that equipped them with the skills, knowledge, and competencies to carry out their roles. The nurse managers by participating in the partner meetings had knowledge of organizational decisions giving them the ability to make decisions that contributed to the organizational goals.
Research indicates that low levels of job satisfaction are prevalent among nurses and this poor satisfaction leads to job turnover. Sources of low satisfaction are associated with factors that interfere with patient care, feeling overloaded with work responsibilities, poor relations with co-workers, personal factors, organizational factors, and a lack of power in the job setting. Nurses’ ability to moderate aspects of the work environment correlates with job satisfaction [15
], and in this project, the nurses repeatedly talked about how they modified and improved their environment through provision of necessary drugs and supplies on top of the training received.
The difference in satisfaction levels is also directly related to resource availability (e.g. working equipments, medication, examination facilitates) [16
]. This partnership was important because it demonstrated that you can empower nurses in a public, local government facility. This partnership translated into more efficient, effective health care in a comfortable environment which ensured that the patients were a priority, their needs were better met, and they were satisfied with the services.
In this study, we found that the nurses were dissatisfied working in the public clinics because the salary was low. This is a big contributor to job dissatisfaction [16
]. The issue of nurse remuneration in public sectors in Uganda has been an enduring one and needs to be addressed by the MoH. To guarantee that increased remuneration produces a better product, the MoH could link portions of the salary to performance that includes measuring quality of care, resource conservation and patient satisfaction, as well as to consider non financial rewards (e.g. career development, gratitude, and recognition). The nurses in these clinics received a small additional remuneration and this may partially account for their increased satisfaction.
Burn out and intentions to leave the job are associated with increased work load as a result of a nursing shortage and a larger demand for health care [13
]. Excess work load has been shown to significantly contribute to lower morale and productivity of nurses. In addition to training the staff in better time utilization this project allocated extra nurses that were deployed on project days to decreases the stress to the system. This may also account in part for the increased job satisfaction.
The knowledge and skills the nurses acquire, in part, increased their ability to provide good
nursing care. These finding agree with those of Pillay [16
] who found that career opportunities and training afford individuals recognition, the prospect of further developing themselves, and growing within the ranks of their career. Nurses have more motivation and stay on the job when the environment is challenging. The nurses were also appreciative of the quality of the training they received and, in particular, noted that the training was conducted by reputable and knowledgeable people, was current information, and was structured to allow immediate implementation. For nurses in Uganda additional education is highly regarded within the context of their culture.
This study was limited by the small sample of nurses, all working in KCC clinics in an urban environment. It is difficult to clearly determine which factor or combination of factors had the largest impact and contributed to increased job satisfaction with the partnership. It could have been the small increase in salary, the increased valuing of their work, the additional education, or the better work environment. They also may have felt empowered by a broader role in the clinic, or a clearer understanding of the goals of the clinic.