Primary health care (PHC) focuses on health promotion and disease prevention; however, acute episodes and emergencies still occur at this level of care. The World Health Organization (WHO) proposes strengthening emergency care at a PHC level as a way of lessening the burden of disease on the overall health system. It is not known how health care practitioners at the PHC level experience management of emergencies.
To explore and describe the experiences of PHC practitioners dealing with emergencies at PHC facilities in Gauteng, South Africa.
The study was conducted in the District Health Services of Gauteng province in South Africa, including clinics, community health care centres and district hospitals.
Using a qualitative approach, semi-structured interviews were conducted with a purposively selected sample of professional nurses and doctors from various levels of the district health care system. Data were transcribed and analysed using qualitative thematic analysis.
Various themes were identified related to the individual confidence and competence of the PHC practitioner, the team approach, the process of role and task allocation and the need for training.
The study provided a voice for the needs of health care practitioners dealing with emergencies at the PHC level. The designing of a targeted and contextually appropriate approach to emergency care training of health care practitioners in the PHC setting that improves team dynamics and team performance, is recommended.
The insights of PHC practitioners dealing with emergencies contribute contextual relevance to any strategic improvement of care at this level.
Described as a situation involving a serious and unexpected, life-threatening illness or injury, medical emergencies are time sensitive in nature and require immediate action.
The adoption of the World Health Assembly Resolution regarding Health Systems and Emergency Care Systems has given credence to the call to improve emergency care access and availability, globally. This resolution underscores the important role of strengthened emergency care systems in reducing the burden of disease from acute illness, trauma and emergencies in populations with varied socioeconomic circumstances, particularly in middle- and lower-income countries.
The vital components of effective emergency care at the PHC level include early recognition, using a team approach, clinical decision-making and intervention to stabilise patients and prevent further deterioration or complications. Inherent in this statement is the expectation that PHC practitioners possess the knowledge and skills to execute these tasks. However, PHC practitioners reportedly lack specialised training to deal with medical emergencies.
The public health care system in South Africa is divided into four levels of care, each level offering a different package of services. Level one facilities include PHC clinics, community health care centres and district hospitals. At level two, regional hospitals provide basic definitive care with referral to tertiary and academic hospitals with specialist services in level three. Level four hospitals include all central and specialist hospitals.
It is important to note the difference in skills mix in the team at the different levels of care. In sub-Saharan Africa, PHC services are considered nurse-led with support from care workers, doctors and allied medical professionals.
Health care practitioners are thus expected to be able to manage emergencies at all levels of the health care system. With the roll-out of improvement strategies such as the Ideal Clinic Framework and the need for improved access as a goal of the proposed National Health Insurance scheme, understanding the current context of emergency care is vital.
An exploratory descriptive qualitative method was adopted to gain insight into the experiences of PHC practitioners, managing patients in need of emergency treatment.
The study was conducted in one province in South Africa, focussing on the three levels of the district health services, namely clinics, community health care centres and district hospitals. The province of interest, Gauteng, is divided into five districts with a total of 392 PHC facilities. Primary health care in this context is largely nurse-led with support from medical doctors and clinical associates increasing at higher level facilities and allied health services provided at larger community health care clinics and district hospitals. The district health services focus on primary care and prevention of disease and function in a variety of settings from urban to semi-urban and semi-rural communities within the Gauteng province. While emergency care is not the focus in the context of primary health care, it still requires the mangement of nurses, doctors and clinical associates in resource constrained settings with overwhelming patient numbers and long delays in emergency transfers.
The population included all health care practitioners dealing with emergencies at a PHC level at the time of data collection. Purposive sampling was used to select a sample of health professionals working in a variety of PHC facility types and districts.
Inclusion criteria for participants included the following:
A registered health care professional.
Dealing with emergencies at a PHC facility.
Facilities were selected from a list of all PHC facilities in Gauteng by using an automated random selection formula on a prepared excel spreadsheet. A clinic, community health care centre and district hospital were randomly selected, from which particpants were recruited. The process was repeated until data saturation was reached. The final sample included 22 doctors and professional nurses (
For data collection purposes, semi-structured interviews were conducted; participants were asked to describe their experiences of managing emergencies at a PHC facility with the opening question ‘What is your experience in dealing with emergencies in a primary health care facility?’. An interview guide was used to elicit information about practical issues regarding emergency care, and probing sub-questions were used for elaboration.
Data were analysed using thematic analysis with the aim of identifying important aspects of the content, to present them clearly and effectively.
Familiarisation with the data by reading and re-reading of transcripts.
Concepts and patterns were identified and coded.
Codes were then organised into categories that were built into overarching themes for interpretation.
Trustworthiness, described by Graneheim and Lundt (2003), is a concept employed in qualitative research to ensure that the findings of a study are presented in a way that is a true representation of the data collected. The findings were analysed and presented in an unbiased manner allowing for readers to formulate their own interpretation; this was done by including adequate representation of quotations from the data. The use of a qualitative data analysis software package, MAXQDA®, assisted in ensuring good data management and organisation. A clear audit trail was kept in an electronic format and the methods of analysis are transparent.
Ethical clearance and approval to conduct the research were granted by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand (No. M171115). Written informed consent was obtained from health professionals for participating in the study and for the digital recording of the interviews. Confidentiality and anonymity were maintained for the participants and the facilities through allocating pseudonyms or numbers to the participants and transcripts. The information letter informed participants of their choice to participate and option to withdraw at any stage of the research process.
Of the participants, 63.63% (
Primary health care clinicians accounted for 54.54% (
Demographics of participants (
Category | Frequency ( |
Percentage (%) |
---|---|---|
Female | 5 | 22.72 |
Male | 17 | 77.27 |
Black | 16 | 72.72 |
White | 1 | 4.54 |
Indian | 1 | 4.54 |
Coloured | 2 | 9.09 |
Other | 2 | 9.09 |
Nurse | 8 | 36.36 |
Doctor | 14 | 63.63 |
Management | 12 | 54.54 |
Non-management | 10 | 45.45 |
The number of years working in the current facility and within the district health services ranged greatly and increased in participants who held management positions. This ensured that the experiences shared covered a vast range of professionals from the most junior to those who have had many years of experience.
Of concern is the absence of updated emergency skills training among these professionals; 50% (
Years of experience and last emergency training of participants (
Category | Frequency ( |
Percentage (%) |
---|---|---|
5 or less | 8 | 36.36 |
6–10 years | 1 | 0.05 |
11 or more years | 2 | 0.09 |
No training | 11 | 50.00 |
5 or less | 11 | 50.00 |
6 to 10 | 4 | 18.18 |
11 to 20 | 3 | 13.63 |
21 or more | 1 | 4.54 |
Undefined | 3 | 13.36 |
5 or less | 6 | 27.27 |
6 to 10 | 4 | 18.18 |
11 to 20 | 4 | 18.18 |
21 to 30 | 4 | 18.18 |
31 or more | 1 | 4.54 |
Undefined | 3 | 13.36 |
Three broad themes and eight subthemes (
Summary of themes and subthemes.
Themes | Subthemes |
---|---|
Personal experience in managing emergencies | Presentation of emergencies |
Perception of competence | |
Independence versus isolation | |
Emergency management team | Team performance |
Team roles | |
The pecking order | |
The call for training | Regular and rigorous training |
Nursing capabilities |
Participants were asked to describe their experiences in managing emergencies at a PHC facility. Giving their personal accounts, participants expressed feelings of confidence, or a lack thereof, and also shared the types, severity and frequency of emergencies they encounter daily. Variation in the nature of emergencies would, understandably, test practitioners’ feelings of confidence and competence as cases present at their facilities.
‘Things like trauma, elevated, uncontrolled hypertension or uncontrolled diabetes that kind of thing.’ (Participant 22, Male Doctor Community Health Care centre)
‘Usually it will be a very sick patient, maybe [
The frequency of emergencies differed according to the facility the participants worked at but the occurrence of emergencies whether frequent or rare remained a reality for all participants, highlighting the need for all health care professionals to be equipped and ready for the event of an emergency admission. Differences in the frequency of emergency cases were expressed as follows:
‘Firstly, we don’t get that many. It’s not a case of we have one every day.’ (Participant 18, Female, Doctor, Primary Health Care clinic)
‘I’ll say yes, because there’s never a day where we don’t have an emergency.’ (Participant 7, Female, Registered Nurse, Primary Health Care clinic)
‘I don’t feel confident and then even the management, I think we need some training, in-service training to bring the confidence back, because we are not confident, because now we are compromising some of the things, so we don’t feel confident.’ (Participant 20, Female, Registered Nurse, Community Health Care Centre)
‘I sometimes feel like we are not well capacitated’ … ‘As long as you are in a health facility, as a healthcare provider, you must be capacitated … you must know. When anybody who walks in, when there is an emergency, you can’t stand there and say, call so and so, you have to be hands-on and my observation was, second thing, you know even, I’m just going to be honest and open with you, even some of the doctors, they don’t know what’s going on when it comes to emergency.’ (Participant 2, Female, Registered Nurse, Primary Health Care clinic)
‘You become so stressed in such a way that at times you think that you know what, I don’t want even to wake up to come to this facility because I’m going to be mad, you see, and then, even the staff, then they become very frustrated too.’ (Participant 10, Female, Registered Nurse, Community Health Care Centre)
‘I’m basically here just as a nurse. You are at the top of the chain. So, you need to function independently in a way.’ (Participant 14, Male, Registered Nurse, Primary Health Care clinic)
‘I can say my experience is that we gain a lot of knowledge because we are on our own, the doctors are not here. So, we have to be more knowledgeable and then we experience different cases. So, we end up knowing some of the emergencies we aren’t being trained on how to manage them.’ (Participant 17, Female, Registered Nurse, Primary Health Care clinic)
Participants are familiar with the deployment of a team in response to emergencies, notwithstanding the factors that may influence team functionality. A team approach to emergency care has proven its efficacy over decades of research and having a functional emergency team is vital for effective emergency care.
‘We are so supportive, we support each other like this, all of us, we work well together.’ (Participant 3, Female, Registered Nurse, District Hospital Emergency Department)
‘You know that always when there’s somebody else you can share ideas.’ (Participant 8, Female, Doctor, Primary Health Care clinic)
On the other hand, some cited the lack of teamwork and the expectation that emergencies are dealt with by doctors on their own, raising concerns about the level of competency of members of the team:
‘There’s no team. At least if they can do that it (training) will give them the idea that this is supposed to be done as a team and not just a doctor alone.’ (Participant 22, Male, Doctor, Community Health Care Centre)
‘It’s easier to manage emergencies when you’re the [
‘[
Participants shared their experiences of the support available to the team during emergencies. Some participants described the availability of support from outside structures such as consultants and doctors from higher level facilities, while others struggled to receive support from colleagues within the facility as well as from other facilities:
‘Ja, there’s good support as long as you call, they will always give you advice especially if you say you are stuck ….’ (Participant 8, Female, Doctor, Primary Health Care clinic)
‘There is actually no one to consult with. You can call a doctor in Mamelodi and say look this is my problem what can I do but you try to avoid that because it takes a lot of time to get somebody on call or the registrar or somebody to say look, I need to talk to you about this. If it’s an emergency, it’s very difficult to get these people. There’s no one that’s sitting at the other end of the telephone just waiting for you to call. So, you try to avoid that and just do your best under the circumstances.’ (Participant 18, Female, Doctor, Primary Health Care clinic)
A decrease in support at night was also a concern raised by participants:
‘But sometimes it is in the middle of the night, and no one answers their phone then you just manage the patient as far as you can and try to transfer them and during the day we actually have more support …’ (Participant 5, Female, Doctor, District Hospital Emergency Department)
‘Unfortunately, it’s not like in the hospital. They actually have nurse 1, nurse 2, like in the hospital in the emergency room. Here, like here in our department, we are only three registered nurses for all these departments. When the emergency come, it means we have to divide ourselves and go in there, that this one is going to help the doctor with the resuscitate, this one is going to give us the drugs when we call, this one is going to phone for an ambulance or whatever.’ (Participant 20, Female, Registered Nurse, Community Health Care Centre)
‘At times I do timekeeping, at times I give medication, whatever the doctor wants, and then I give to the patient. You see, it depends on that day what role you are given.’ (Participant 3, - Female, Registered Nurse, District Hospital Emergency Department)
The nurse’s role in the emergency care team is debated as nurses are often assigned to the tasks that ‘aid’ the team leader. The role of the nurse in the team varied according to the level of care. At the more basic primary care facilities, nurses are expected to take the lead. When a multidisciplinary team is available, the lead role shifts to the doctor. In this regard, nurse participants had the following to say:
‘Yes, I take the lead because we, as I’ve said before, we have a delegation for the month. You’ll find that for that month you are the leader for emergency cases, ja, so I’m always seeing that when I’m allocated for emergency patients.’ (Participant 17, Male, Registered Nurse, Primary Health Care clinic)
‘When an emergency come, we call the doctor and then the doctor will come to emergency room and see what he can do for the patient.’ (Participant 20, Female, Registered Nurse, Community Health Care Centre)
‘The doctor usually takes the role of the team leader.’ (Participant 5, Female, Doctor, District Hospital Emergency Department)
‘You are at the top of the chain. So, you need to function independently in a way. You need to take decisions. So, I’d say the role basically is to lead the team.’ (Participant 14, Male, Registered Nurse, Primary Health Care clinic)
‘The registered nurses’ roles, they’re just to carry out orders, like to give medication or to put up drips, ja, like, but they can’t examine a patient or help.’ (Participant 10, Female, Registered Nurse, Community Health Care Centre)
‘No, it’s [
‘I think more regular training definitely for all staff members; for all staff members not only, doctors and sisters but also the assistants so that everybody has at their level regular training that everybody is up to scratch because you don’t know when an emergency is going to happen.’ (Participant 18, Female, Doctor, Primary Health Care clinic)
‘That would definitely help because they don’t even know that they’re supposed to be a team because when you do BLS they tell you that you have to work as a team. There’s a team leader and everybody has a role in the team, but it doesn’t happen.’ (Participant 22, Male, Doctor, Community Health Care Centre)
Participants expressed mixed views about the availability of resources for training; some facilities relied on the Department of Health or the clinic itself to provide training, while others were specifically innovative in sourcing funding for their own training. It was apparent from the sentiments expressed that many practitioners were not willing to take the initiative or pay for their own training as illustrated below:
‘So, and then the department does allocate money for training. Right now we’re opening an accredited BLS, you know, and then basically we are running it with our own money. We’re already training about 50 something, in the last 2 or 3 months, in BLS. You know we are trying to improve but the department doesn’t, doesn’t help after all. The budget they put for training every year disappear just like that, I mean, nobody go for training or for this and that, you know, it’s a mess-up like that.’ (Participant 22, Male, Doctor, Community Health Care Centre)
‘So, you rely on the clinic to provide training.’ (Participant 6, Female, Registered Nurse, Primary Health Care clinic)
‘Ag, we don’t have like specialised training. The trainings that I give the Sisters [
‘The challenge the majority of the time is the equipment and even the abilities of the nurses, because usually there are three to four nurses working, but only one of them is able to do … to take a line, to do sutures.’ (Participant 21, Female, Doctor, Community Health Care Centre)
‘My views on emergency management at a primary level is I don’t think nurses are that much equipped to deal with certain emergencies, you know.’ (Participant 16, Female, Registered Nurse, Primary Health Care clinic)
Triage, mainly a health practitioner role, is an important process for the effective management of emergencies. The triage process for most of the facilities starts at the administration desk where the clerk or help desk assistant would be expected to triage patients for emergencies. Flaws in the triaging process were expressed as follows:
‘[
‘There’s no proper, ja, so where I worked before the nurse would triage the patient as they walk in. So, here they walk in and they either go sit in male or female where the sister takes the vitals but then they write the vitals down and just put it in. The file is already at the bottom.’ (Participant 5, Female, Doctor, District Hospital Emergency Department)
The experiences of PHC practitioners of emergency care at this level are contextually nuanced by the types and frequencies of emergencies, and the efficiency of care relies on a number of factors including the need for a functional team approach and regular training.
The main findings of this study have broadened our understanding of how PHC practitioners experience the management of emergencies that present at different levels of the District Health System. The main presenting illnesses encountered and described by the participants included traumatic injuries, medical emergencies of various acuity levels, complicated chronic illnesses (diabetes and hypertension) and maternity emergencies. Similar to a local study by Obermeyer, the profile of patients includes young people free of chronic disease, presenting with acute illness or injury.
One of the key findings of this study is that the personal experiences of PHC practitioners are shaped by perceptions of their own competence or ability to deal with presenting emergencies and feelings of relative independence transposed with feelings of isolation. For particularly nurses in PHC settings, the lack of support enhances their feelings of isolation and being ‘on their own’, thus displacing their sense of autonomy. The Scope of practice (R2598 under the
Emergency care becomes increasingly advanced at level two, three and four institutions where different specialty services can provide definitive care for patients with acute injuries or illness as opposed to the level one PHC clinics, community health care centres and district hospitals where emergency care would be managed by professional nurses or junior doctors with no specialised training in emergency care.
From a legislative and regulatory perspective, professional nurses are responsible for providing emergency care.
Another key finding is the need for an effective team, where clear roles and embedded emergency care competencies are central to optimal team performance. A team approach to emergency care has proven its efficacy over decades of research.
Thematically conceived as the pecking order in the team, the nurse’s role in the resuscitation team is a contentious issue as nurses are often assigned to the tasks that ‘aid’ the team leader, which is mostly the doctor. Leading and decision-making are presumed to be the role of a doctor and in rare circumstances, a specialist nurse.
Current recommendations are that emergency training should be updated at least every 2 years to reduce the loss of skill over time.
Triage is an important process for the effective management of emergencies. The first response is a defining event for the patient and the rest of the system.
Overall, these perspectives formulate the basis of a resounding need for ongoing training as well as specialised training in BLS. The WHO guidelines for essential trauma care highlight the need for continuous education and training in emergency skills.
At the time of data collection, there were no clinical associates employed at the selected PHC facilities. This cadre of health professionals may provide valuable insight from their own experiences in managing emergencies at a PHC level, and further studies should include their perspectives.
Given the overwhelming call for PHC practitioners to be equipped with skills and knowledge in emergency care, rigorous, regular and targeted training programmes are essential; however, it is recommended that such training adopt a nuanced approach that takes into consideration the context, the presenting emergencies and the scope of practice of the practitioner. In particular, nursing practitioners must be sufficiently capacitated from triage to transfer to strengthen the emergency care response in nurse-led primary care. Improvement in team dynamics, team performance and clarification of team member roles are recommended outcomes of training.
Strengthening emergency care at a PHC level protects the health care system by preventing the overload of higher-level facilities and provides the patient with efficient care at the frontline of health care access. There is a need for formal training programmes to capacitate PHC practitioners with the knowledge and skills to manage emergencies and leading emergency care teams at a PHC level. While access to emergency care is a constitutional right, level one facilities have fallen behind in the realisation of this ideal. Clarification of health care practitioners’ roles, as well as regular training and appropriate support for practitioners working at this level are vital to ensure that the first response to emergencies is effective, and to ensure that they do not feel isolated in their efforts to uphold the first line of care.
Sections of this article are partially based on the author’s thesis of the degree of Doctor of Philosophy in Nursing at the University of the Witwatersrand, South Africa, with supervisor Professor Judith Bruce and Professor Richard Cooke received June 2021, also presented at Sigma Theta Tau International (STTI) nursing conference and available at:
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
M.B., J.B. and R.C. conceived the design and theoretical basis for this study. M.B. conducted the research, supervised by J.B. and R.C. M.B., J.B. and R.C. contributed to the article writing.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The data that support the findings of this study are available on request from the corresponding author, M.B.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.