How to manage organisational change and create practice teams: experiences of a South African primary care health centre.

BACKGROUND: In South Africa, first-contact primary care is delivered by nurses in small clinics and larger community health centres (CHC). CHCs also employ doctors, who often work in isolation from the nurses, with poor differentiation of roles and little effective teamwork or communication. Worcester CHC, a typical public sector CHC in rural South Africa, decided to explore how to create more successful practice teams of doctors and nurses. This paper is based on their experience of both unsuccessful and successful attempts to introduce practice teams and reports on their learning regarding organisational change. METHODS: An emergent action research study design utilised a co-operative inquiry group. The first nine months of inquiry focused on understanding the initial unsuccessful attempt to create practice teams. This paper reports primarily on the subsequent nine months (four cycles of planning, action, observation and reflection) during which practice teams were re-introduced. The central question was how more effective practice teams of doctors and nurses could be created. The group utilised outcome mapping to assist with planning, monitoring and evaluation. Outcome mapping defined a vision, mission, boundary partners, outcome challenges, progress markers and strategies for the desired changes and supported quantitative monitoring of the process. Qualitative data were derived from the co-operative inquiry group (CIG) meetings and interviews with doctors, nurses, practice teams and patients. FINDINGS: The CIG engaged effectively with 68% of the planned strategies, and more than 60% of the progress markers were achieved for clinical nurse practitioners, doctors, support staff and managers, but not for patients. Key themes that emerged from the inquiry group's reflection on their experience of the change process dealt with the amount of interaction, type of communication, team resilience, staff satisfaction, leadership style, reflective capacity, experimentation and evolution of new structures. CONCLUSION: The group's learning supported a view of change that sees the organisation as a living system in which information flow, participation and the development of resilience are key aspects. These themes fit well into an understanding of change based on complexity theory. If managers of the health system wish to enhance organisational change, then their goal may need to shift from optimising health care delivery in a mechanistic model to optimising health care workers in a living system.

Building capacity for antiretroviral delivery in South Africa: a qualitative evaluation of the PALSA PLUS nurse training programme.

BACKGROUND: South Africa recently launched a national antiretroviral treatment programme. This has created an urgent need for nurse-training in antiretroviral treatment (ART) delivery. The PALSA PLUS programme provides guidelines and training for primary health care (PHC) nurses in the management of adult lung diseases and HIV/AIDS, including ART. A process evaluation was undertaken to document the training, explore perceptions regarding the value of the training, and compare the PALSA PLUS training approach (used at intervention sites) with the provincial training model. The evaluation was conducted alongside a randomized controlled trial measuring the effects of the PALSA PLUS nurse-training (Trial reference number ISRCTN24820584). METHODS: Qualitative methods were utilized, including participant observation of training sessions, focus group discussions and interviews. Data were analyzed thematically. RESULTS: Nurse uptake of PALSA PLUS training, with regard not only to ART specific components but also lung health, was high. The ongoing on-site training of all PHC nurses, as opposed to the once-off centralized training provided for ART nurses only at non-intervention clinics, enhanced nurses' experience of support for their work by allowing, not only for ongoing experiential learning, supervision and emotional support, but also for the ongoing managerial review of all those infrastructural and system-level changes required to facilitate health provider behaviour change and guideline implementation. The training of all PHC nurses in PALSA PLUS guideline use, as opposed to ART nurses only, was also perceived to better facilitate the integration of AIDS care within the clinic context. CONCLUSION: PALSA PLUS training successfully engaged all PHC nurses in a comprehensive approach to a range of illnesses affecting both HIV positive and negative patients. PHC nurse-training for integrated systems-based interventions should be prioritized on the ART funding agenda. Training for individual provider behaviour change is nonetheless only one aspect of the ongoing system-wide interventions required to effect lasting improvements in patient care in the context of an over-burdened and under-resourced PHC system.

Factors Determining the Vulnerability of Women to Sexually Transmitted HIV: a Literature Review

Gender-related vulnerability is described as a crucial factor contributing to increased susceptibility of women to HIV; accounting for more women than men being infected. At the same time; empowerment interventions are being promoted as effective strategies for increasing the ability of women to adopt protective behaviours. The aim of the review was to identify; collate and categorise the factors determining the gender-related vulnerability of women to sexually transmitted HIV. A review of literature from theoretical and empirical studies using diverse methodologies was undertaken. Reports included those identified through electronic and manual searching. Twenty factors; forming five clusters; were identified as influencing the ability of women to adopt protective behaviours. Each factor was analysed to describe its component parts and the relationship between a factor; gender-related vulnerability; HIV risk level and empowerment status. Further analysis provided a description of markers named predictors and indicators. The literature portrays markers that can be identified and used to describe gender equality status; HIV risk level and related empowerment. This provides the potential to identify factors in gender equality status and HIV risk level to address in programmes designed to empower women in order to lower their risk to sexually transmitted HIV

Parents' Lived Experience of Providing Kangaroo Care to their Preterm Infants

Premature and low birthweight infants pose particular challenges to health services in South Africa. While there is good evidence to demonstrate the benefits of kangaroo care in low birthweight infants; limited research has been conducted locally on the experiences of parents who provide kangaroo care to their preterm infants. This phenomenological study explores the lived experience of parents who provided their preterm infants with kangaroo care at a tertiary-level maternity centre in the Western Cape. In-depth interviews were conducted with six parents: four mothers and two fathers. Data was analysed using an adaptation of the approaches described by Colaizzi (1978:48-71) and Hycner (1985:280-294). To ensure trustworthiness; the trustworthiness criteria described by Guba and Lincoln (1989:242-243) were applied. Kangaroo care is a phased process; each phase bringing a unique set of experiences. The eight themes that emerged are described: unforeseen; unprepared and uncertain - the experience of birth; anxiety and barriers; an intimate connection; adjustments; roles and responsibilities; measuring success; a network of encouragement and support; living-in challenges; and living with the infant outside of hospital. Challenges facing health care providers are described and recommendations for information about kangaroo care and support for parents are made

Parents' Lived Experience of Providing Kangaroo Care to their Preterm Infants

Premature and low birthweight infants pose particular challenges to health services in South Africa. While there is good evidence to demonstrate the benefits of kangaroo care in low birthweight infants; limited research has been conducted locally on the experiences of parents who provide kangaroo care to their preterm infants. This phenomenological study explores the lived experience of parents who provided their preterm infants with kangaroo care at a tertiary-level maternity centre in the Western Cape. In-depth interviews were conducted with six parents: four mothers and two fathers. Data was analysed using an adaptation of the approaches described by Colaizzi (1978:48-71) and Hycner (1985:280-294). To ensure trustworthiness; the trustworthiness criteria described by Guba and Lincoln (1989:242-243) were applied. Kangaroo care is a phased process; each phase bringing a unique set of experiences. The eight themes that emerged are described: unforeseen; unprepared and uncertain - the experience of birth; anxiety and barriers; an intimate connection; adjustments; roles and responsibilities; measuring success; a network of encouragement and support; living-in challenges; and living with the infant outside of hospital. Challenges facing health care providers are described and recommendations for information about kangaroo care and support for parents are made

Introducing human rights and health into a nursing curriculum.

AIM: The introduction of a module in Health and Human Rights into a Postgraduate diploma curriculum for registered nurses is described. BACKGROUND: An important component of nursing programmes in South Africa has been teaching of the principles of ethical practice and relevant ethical codes. A number of factors have contributed to the need to include human rights as an integral component of nursing curricula in South Africa. These include the Bill of Rights in the Constitution of South Africa and the implications thereof for health care delivery, the primary health care approach in the delivery of health care in South Africa, the development and acceptance of Patients' Rights Charters, and the recognition of the role that health professionals played--whether through lack of knowledge and awareness or direct involvement--in the human rights violations in the health sector exposed during the hearings of the Truth and Reconciliation Commission. MODULE DESCRIPTION: An outline of themes covered in the course content is described, together with examples of learning activities and teaching materials. Reflections of the course convenor and students are used to highlight the importance of inclusion of health and human rights as foundational to ethical nursing practice, regardless of the health care setting.

Challenges to creating primary care teams in a public health centre: a co-operative inquiry

"Background: Effective teamwork between doctors and clinical nurse practitioners (CNP) is essential to the provision of quality primary care in the South African context. The Worcester Community Health Centre (CHC) is situated in a large town and offers primary care to the rural Breede Valley Sub-District of the Western Cape. The management of the CHC decided to create dedicated practice teams offering continuity of care; family-orientated care; and the integration of acute and chronic patients. The teams depended on effective collaboration between the doctors and the CNPs.Methods: A co-operative inquiry group; consisting of two facility managers; an administrator; and medical and nursing staff; met over a period of nine months and completed three cycles of planning; action; observation and reflection. The inquiry focused on the question of how more effective teams of doctors and clinical nurse practitioners offering clinical care can be created within a typical CHC.Results: The CHC had established three practice teams; but met with limited success in maintaining the teams over time. The group found that; in order for teams to work; the following are needed: A clear and shared vision and mission amongst the staff. The vision was championed by one or two leaders rather than developed collaboratively by the staff. Continuity of care was supported by the patients and doctors; but the CNPs felt more ambivalent. Family-orientated care within practices met with limited success. Integration of care was hindered by physical infrastructure and the assumptions regarding the care of ""chronics"". Enhanced practitioner-patient relationships were reported by the two teams that had staff consistently available. Significant changes in the behaviour and roles of staff. Some doctors perceived the nurse as an ""assistant"" who could be called on to run errands or perform tasks. Doctors perceived their own role as that of comprehensively managing patients in a consultation; while the CNPs still regarded themselves as nurses who should rotate to other duties and perform a variety of tasks; thus oscillating between the role of practitioner and nurse. The doctors felt responsible for seeing a certain number of patients in the time they were available; while the CNPs felt responsible for getting all the patients through the CHC. The doctors did not create space for mentoring the CNPs; who were often seen as an intrusion and a threat to patient privacy and confidentiality when requesting a consultation. For the CNPs; however; the advantage of practice teams was considered to be greater accessibility to the doctor for joint consultation. The identification of doctors and CNPs with each other as part of a functioning team did not materialise. Effective management of the change process implied the need to ensure sufficient staff were available to allow all teams to function equally throughout the day; to be cognisant of the limitations of the building design; to introduce budgeting that supported semi-autonomous practice teams and to ensure that the staff were provided with ongoing opportunities for dialogue and communication. The implications of change for the whole system should be considered; and not just that for the doctors and nurses.Conclusions: Key lessons learnt included the need to engage with a transformational leadership style; to foster dialogical openness in the planning process and to address differences in understanding of roles and responsibilities between the doctors and the CNPs. The unreliable presence of doctors within the practice team; due to their hospital duties; was a critical factor in the breakdown of the teams.. The CHC plans to further develop practice teams; to learn from the lessons so far and to continue with the co-operative inquiry."

The Practical Approach to Lung Health in South Africa (PALSA) intervention: respiratory guideline implementation for nurse trainers.

AIM: This paper describes the design, facilitation and preliminary assessment of a 1-week cascade training programme for nurse trainers in preparation for implementation of the Practical Approach to Lung Health in South Africa (PALSA) intervention, tested within the context of a pragmatic cluster randomized controlled trial in the Free State province. PALSA combines evidence-based syndromic guidelines on the management of respiratory disease in adults with group educational outreach to nurse practitioners. BACKGROUND: Evidence-based strategies to facilitate the implementation of primary care guidelines in low- to middle-income countries are limited. In South Africa, where the burden of respiratory diseases is high and growing, documentation and evaluation of training programmes in chronic conditions for health professionals is limited. METHOD: The PALSA training design aimed for coherence between the content of the guidelines and the facilitation process that underpins adult learning. Content facilitation involved the use of key management principles (key messages) highlighted in nurse-centred guidelines manual and supplemented by illustrated material and reminders. Process facilitation entailed reflective and experiential learning, role-playing and non-judgemental feedback. DISCUSSION AND RESULTS: Preliminary feedback showed an increase in trainers' self-awareness and self-confidence. Process and content facilitators agreed that the integrated training approach was balanced. All participants found that the training was motivational, minimally prescriptive, highly nurse-centred and offered personal growth. CONCLUSION: In addition to tailored guideline recommendations, training programmes should consider individual learning styles and adult learning processes.

Experiences of Registered Midwives assisting with Termination of Pregnancies at a Tertiary Level Hospital

The implementation of the Choice on Termination of Pregnancy Act; Act No. 92 of 1996 brought many challenges; for the registered nurses/midwife assisting in the termination of pregnancy. In the gynaecological wards at a tertiary level hospital; registered nurses/midwives assist with the termination of pregnancies for women in the second trimester (13-20 weeks); using an oral medication; Misoprostol. A qualitative phenomenological study of the experiences of registered midwives who assist in termination of pregnancies was conducted. Registered nurses/midwives; each with at least six months experience in the assistance of terminations of pregnancies participated in this study. Indepth interviews were conducted with the participants. The audiotaped interviews were transcribed and analysed for themes and patterns within the transcriptions. Five theme categories emerged : obstacles experienced by the registered midwives; feelings evoked by the experiences; conflicts encountered; the coping mechanisms utilised and the need for support systems. Recommendations include the provision of support structures for registered midwives working in this setting

beta-Adrenergic stimulation of rat cardiac fibroblasts promotes protein synthesis via the activation of phosphatidylinositol 3-kinase.

beta -adrenergic agonists stimulate neonatal rat cardiac fibroblast growth, albeit the identity of the signaling event(s) remains equivocal. Isoproterenol (ISO) treatment increased intracellular cyclic AMP levels; however, cyclic AMP-elevating agents had no effect on protein synthesis. The tyrosine kinase inhibitor tyrphostin A25, and the inhibition of ras processing by the farnesyltransferase inhibitor BMS-191563 attenuated ISO-stimulated protein synthesis. Concomitant with increased protein synthesis, ISO stimulated extracellular signal-regulated protein kinase (ERK) and phosphatidylinositol 3-kinase (PI3-K) activity. The MEK1/2 inhibitor PD098059 abrogated ISO-stimulated ERK activity, albeit the increase in protein synthesis was unaffected. By contrast, LY294002 inhibited both ISO-stimulated PI3-K activity, and protein synthesis. ISO treatment did not increase the expression of transforming growth factor-beta(1)(TGF-beta(1)) mRNA, whereas a significant decrease in the steady-state mRNA level of TGF- beta(3)was observed. This latter effect was mimicked by cyclic AMP-elevating agents. Angiotensin II (AII) activation of the AT(1)receptor increased protein synthesis, but in contrast to ISO, the growth response was not inhibited by either tyrphostin A25 or BMS-191563, and was associated with the concomitant expression of both TGF-beta(1)and TGF-beta(3)mRNAs. Analogous to ISO, AII treatment increased ERK and PI3-K activity, and PI3-K was required for protein synthesis. These findings are the first to highlight the activation of PI3-K by a Gs(alpha)-coupled receptor, and its essential role in beta -adrenergic as well as AT(1)receptor-mediated protein synthesis in neonatal rat cardiac fibroblasts. However, despite the conserved role of PI3-K, additional disparate signaling pathways are recruited by ISO and AII, which may differentially influence fibroblast phenotype.

Specific effect of maleate on an apical membrane glycoprotein (gp330) in proximal tubule of rat kidneys.

Maleate treatment of rats induces transport defects similar to those seen in the Fanconi syndrome (glycosuria, aminoaciduria, phosphaturia, proteinuria, etc.) and causes an accumulation of apical vesicles in proximal tubule epithelial cells. Because the apical membrane glycoprotein, gp330, is a receptor associated with the apical endocytotic and recycling apparatus in these cells, we examined the effect of maleate on the distribution of this protein and other brush border markers. Rats received sodium maleate (400 mg/kg ip) and were killed at various times between 45 min and 3 h; kidneys were perfusion fixed with paraformaldehyde-lysine-periodate before processing for immunofluorescence and immunoelectron microscopy. In control rats, staining with a polyclonal or monoclonal gp330 antibody showed a uniform distribution on the brush border and in coated pits of all proximal tubule cells. In the S3 segments, the immunofluorescence labeling of the microvilli was generally uniform but at times showed spike labeling, suggesting that gp330 sheds easily from the apical membrane. After maleate treatment, the staining intensity of the brush border was decreased in all proximal tubule segments, and cytoplasmic streaks as well as an intense vacuolar staining were seen. In the S3 segment, a remarkable mosaic pattern of staining was observed, with the brush border of some cells being completely negative, while adjacent cells showed an apparently normal staining pattern. These results were confirmed at the electron microscope level, using the protein A-gold technique. Maleate had no effect on the distribution or staining intensity of four other brush border markers, dipeptidyl peptidase IV, and various lectins (Helix pomatia lectin, peanut lectin, elderberry bark lectin). The urinary excretion of gp330 occurs in normal rats and was already increased as early as 1 h after maleate injection and remained at a twofold increment between 6 and 24 h. These data suggest that the generalized membrane transport derangement seen in this experimental Fanconi syndrome could occur via a specific effect on gp330, which seems to block endocytosis and the recycling apparatus at the late endosome level and inhibits the formation of new dense apical tubules.

A high-resolution physical map of human chromosome 11.

The development of a highly reliable physical map with landmark sites spaced an average of 100 kbp apart has been a central goal of the Human Genome Project. We have approached the physical mapping of human chromosome 11 with this goal as a primary target. We have focused on strategies that would utilize yeast artificial chromosome (YAC) technology, thus permitting long-range coverage of hundreds of kilobases of genomic DNA, yet we sought to minimize the ambiguities inherent in the use of this technology, particularly the occurrence of chimeric genomic DNA clones. This was achieved through the development of a chromosome 11-specific YAC library from a human somatic cell hybrid line that has retained chromosome 11 as its sole human component. To maximize the efficiency of YAC contig assembly and extension, we have employed an Alu-PCR-based hybridization screening system. This system eliminates many of the more costly and time-consuming steps associated with sequence tagged site content mapping such as sequencing, primer production, and hierarchical screening, resulting in greater efficiency with increased throughput and reduced cost. Using these approaches, we have achieved YAC coverage for >90% of human chromosome 11, with an average intermarker distance of <100 kbp. Cytogenetic localization has been determined for each contig by fluorescent in situ hybridization and/or sequence tagged site content. The YAC contigs that we have generated should provide a robust framework to move forward to sequence-ready templates for the sequencing efforts of the Human Genome Project as well as more focused positional cloning on chromosome 11.

Predictive Modeling of Alkaline Phosphatase Inactivation in a High-Temperature Short-Time Pasteurizer.

In order to support regulations directed towards ensuring the safety of heat processed dairy products, data on inactivation of alkaline phosphatase (AP) in whole milk in a pilot plant high-temperature short-time (HTST) pasteurizer were obtained. A Computer program was designed to calculate the integrated lethal effect, or pasteurization effect (PE), at temperatures of 60 to 74°C and with holding tubes for 3 to 60 s. An equation was derived which related values of PE to log % residual activity (r2 of 0.964). These results suggest that predictive equations based on PE could be used to assess the effectiveness of commercial pasteurization processes.

External ions and direct membrane effects of enkephalins on Amoeba proteus.

We have shown that amphiphilic hormones like vasopressins and endorphins increase water permeability and activate the contractile vacuole (CV) in Amoeba by direct action on the plasma membrane. Using our standard CV assay, the effects of nine opioids, morphine, naloxone and 7 enkephalin derivatives, have been compared in normal, ion-containing growth medium (Chalkley's) and in glass-distilled water. While the absence of external ions does not affect the activity of molecules with net positive charges, opioids with no net charge are devoid of action in glass-distilled water. This shows that, in addition to amphiphilicity, which permits insertion into the lipid core of the membrane, electrostatic interactions with ions and with negative charges of phospholipids membrane and glycocalyx, the thick glycoproteic cell coat of Amoeba, are important in the direct action of these compounds.

Direct membrane effects of morphine and endorphins on Amoeba proteus.

Morphine, leu-enkephalinamide, met-enkephalin, alpha-neoendorphin and its Arg8 1-8 fragment increase contractile vacuole output in the freshwater Amoeba proteus at 18 microM. Significant effects of leu-enkephalin and naloxone are obtained at 180 microM. All compounds have reached their maximal activity at 720 microM. Alpha-neoendorphin and leu-enkephalin are inactive in the presence of isotonic, non-penetration sucrose, hence these compounds increase plasma membrane permeability to water. Results from molecular modeling show a clear correlation of activity with amphiphilicity, charge distribution and general flexibility of molecules. We conclude that, like previously-studied vasopressin analogues and non-hormonal amphiphilic peptides, active opioids embed themselves into the Amoeba plasma membrane, disrupting the lipid bilayer and increasing its permeability. In our Amoeba system, naloxone, a general morphine-like inhibitor, blocks active opioids as well as a vasopressin analogue. Naloxone, being less active than other tested amphiphiles, acts as a membrane stabilizer, protecting the lipid bilayer against the disruption action of more active compounds.

The interaction of xylanases with commercial pulps.

When purified xylanases from Trichoderma harzianum E58 or from a clone of Bacillus circulans were incubated with various low-yield wood pulps, little of the original enzyme activity could be detected in the filtrate at the end of the reaction. Partial bleaching of the pulps prior to enzymatic treatment generally resulted in an increased recovery of the xylanase activity. It appears that both nonspecific adsorption and soluble inhibitors may be responsible for the loss of much of the xylanase activity. However, xylanases from Aureobasidium pullulans and Schizophyllum commune were not as inhibited by the pulps, and the activity of the latter enzyme actually increased after incubation with several high-yield pulps. Although a lignin preparation from spent sulfite liquor at a concentration of 0.06 mg/mL could inhibit the xylanase activity of T. harzianum and B. circulans by 65% and 50%, respectively, xylanases from Thermoascus aurantiacus, S. commune, and A. pullulans were activated at similar lignin concentrations. At higher concentrations these latter xylanases were also inhibited. Water-soluble lignins extracted from a variety of pulps and used at a lignin concentration of 2.5 mug/mL resulted in inhibition of more than 65% of the original activity of the xylanase from T. harzianum. Kinetic studies showed that lignin from spent sulfite liquor resulted in noncompetitive inhibition of this enzyme.

The amphiphilic action of vasopressin and analogues on the plasma membrane of Amoeba proteus.

Arginine (AVP) and lysine vasopressin induce a weak but statistically significant increase in the water permeability of Amoeba proteus plasmalemma. Vasotocin and deaminovasopressin, which share the hydroosmotic properties of AVP on classical vertebrate systems, are without effects on Amoeba while SKF 101926, a synthetic AVP antagonist, is even more effective than the parent compound. Theophyllin and dibutyryl-cAMP do not affect AVP action on Amoeba. Lithium, oxytocin, and carbachol are also without effect. Thus, it is unlikely that either V2 (cAMP) or V1 (phosphatidylinositol choline) receptors are involved. A clear correlation has been found between the amphiphilic character of tested peptides and their effect on Amoeba water permeability. Classical amphiphilic peptides, melittin, mastoparan, and fragment 1-8 of alpha-neoendorphin, also increased water permeability in Amoeba. It is known that vasopressin can interact with artificial lipid membranes, increasing their permeability to water. We propose that amphiphilic members of the AVP family interact directly with the lipid phase of the Amoeba membrane. Their incorporation within the lipid bilayer may cause local disruptions or may create micellar water channels as shown for other amphiphilic proteins. Our observations provide a model for the early evolution of peptide hormone systems, preceding the appearance of specific membrane receptors and associated second messenger amplifying mechanisms.

The effects of vasopressin and related peptides on osmoregulation in Amoeba proteus.

We describe the effects of arginine-vasopressin (AVP) and five related peptides on the contractile vacuole, the osmoregulatory organelle of the fresh water Amoeba proteus. Arginine-vasopressin, lysine-vasopressin, and SKF 101926, a synthetic antagonist of vasopressin, cause a significant increase in the rate of output of the contractile vacuole. Deamino-vasopressin (dAVP), oxytocin, and arginine-vasotocin have no such activity, although dAVP interferes with the action of AVP when present in equimolar concentration. Relatively high concentrations are required and the effect of active peptides is readily reversible. When the normal, hypotonic medium (a synthetic pond water) is replaced by isotonic sucrose, the action of AVP on the vacuole is abolished. Thus vasopressin is believed to act by increasing permeability of the Amoeba plasma membrane to water.