Thesis (DPhil (Psychology))—University of Stellenbosch, 2010. / ENGLISH ABSTRACT: This dissertation examines how nurses in primary health care in South Africa make use of guidelines. Primary level health care is reliant primarily on nurses, who are under-resourced and often overwhelmed by the complex needs of their clients in the context of the TB and HIV/AIDS epidemic. Despite various continuing education strategies to promote current and evidence-based practice, there are many barriers to providing optimal care. Clinical practice guidelines using best evidence are an important tool for updating health professionals in current practice, particularly at primary care level, where busy practitioners often do not have time or sufficient access to the best evidence. Despite this, we know little of the practitioners’ experiences of guideline use. This study describes experiences of nurses in implementing clinical practice guidelines in the delivery of health care in selected primary level contexts in the Free State Province. The primary research question for this study was “What are the experiences of nurses in using guidelines in primary health care facilities?” A qualitative research approach, drawing on a psychoanalytic framework, was adopted. Three linked studies were conducted, utilising secondary data analysis of transcripts collected during the PALSA (Practical approach to Lung Health in South Africa) RCT study (sub-study 1), document description and review of guidelines used in primary care settings (sub-study 2), observation of nurses in practice and during patient consultations, and focus group discussions with nurses in primary health care facilities (sub-study 3). After the introduction of new format guidelines with onsite training and access to good support and updates, nurses reported feeling more confident, as the guidelines were explicit and gave them clear direction as to when a patient would need referral to the medical practitioner. When the guidelines were followed, and the patient responded positively to an intervention, this gave nurses a sense of credibility and validated their role as primary level health care providers. Guidelines available in the primary care clinics covered a wide variety of clinical conditions, were inconsistent, often outdated and even contradictory. A detailed comparison of two selected guidelines, the South African TB control guidelines and the PALSA PLUS guidelines, both in everyday use in the Free State province, shows that the preferences expressed by the nurses in sub-study 1 are evident in the layout, colour, and user-friendliness of the PALSA PLUS guideline. Nurses in the Free State province do use guidelines, but not consistently. Nurses make clinical judgments and decisions based on experience, alternative knowledges and intuitive responses, in consultation with colleagues and through the use of guidelines. Very few guidelines were used regularly, and each nurse had her preferences for a limited number of guidelines which she found useful. There is a clear need for integrated approaches to the information needs and support of nurses and nurse practitioners at primary care level. Guidelines play a role in promoting learning, changing professional practice and strengthening health care delivery by nurse practitioners at primary level. They can also be thought of as a strategy the health care system uses to defend against the possibility of its health professionals not meeting its expectations of providing quality care. Guidelines may contain anxiety and improve the quality of care, or compromise practice through the imposition of controls. The use of guidelines in primary care settings facilitates decision making, may contain practitioner anxiety and improve the quality of care, yet guidelines pose challenges to creative discernment of the patient’s symptoms in relation to his/her personal circumstances and may impact on the personalised holistic care approach which characterises the essence of nursing. Today’s primary care nurse and nurse practitioner needs to be a competent clinician, compassionate carer, and confident co-ordinator – the overlapping roles of caring, diagnosing and treating and managing. The challenge for the nurse in primary care is to combine her traditional caring and co-ordination role into a role which encompasses curing, caring and co-ordination, a new, yet critically important identity for the 21st century nurse. / AFRIKAANSE OPSOMMING: Die proefskrif ondersoek hoe verpleegsters in primêre gesondheidsorg in Suid-Afrika van riglyne gebruik maak. Primêre vlak gesondheidsorg steun hoofsaaklik op verpleegsters, alhoewel hulle verswelg word deur die komplekse behoeftes van hul kliënte in die konteks van die TB en HIV/AIDS epidemie. Ten spyte van verskeie volgehoue onderrigstrategieë om die huidige en bewese basiese te bevorder, is daar verskeie struikelblokke om optimale versorging te voorsien. Kliniese praktyk riglyne voorsien die beste bewyse en is 'n belangrike hulpmiddel om praktiserende professionele gesondheidswerkers, veral op die vlak van primêre gesondheidsorg, op hoogte van sake te hou. Besige programme en onvoldoende toegang tot hierdie riglyne weerhou dikwels die gesondheidswerkers van bestaande inligting. Dit is egter onbekend wat gesondheidswerkers se ondervinding en gebruik van riglyne is. Die studie beskryf versorgers se ervaring van die implementering van kliniese praktyk riglyne vir gesondheidsorg in primêre vlak kontekste in die Vrystaatprovinsie. 'n Kwalitatiewe navorsingsbenadering wat steun op 'n psigoanalitiese raamwerk, is gebruik. Drie verbandhoudende studies is gedoen wat sekondêre data analise transkripsies gebruik het wat verkry is gedurende die PALSA (Practical Approach to Lung Health in South Africa): RCT (Willekeurig Gekontroleerde Toets) studie (sub-studie 1), beskrywing van dokumentasie en oorsig van riglyne wat in primêre vlak ontwikkeling gebruik is (sub-studie 2), en observasie van verpleegsters in die praktyk en gedurende konsultasies met pasiënte, en fokusgroep besprekings met verpleegsters in primêre vlak gesondheidsorg fasiliteite (sub-studie 3). Na die bekendstelling van 'n nuwe formaat riglyne vir indiensopleiding en toegang tot goeie ondersteuning, het die verpleegsters meer selfversekerd gevoel omdat die riglyne duideliker was en aan hulle 'n beter aanduiding gegee het wanneer 'n pasiënt verwysing na 'n mediese praktisyn benodig het. Wanneer die riglyne gevolg is en die pasiënt positief op behandeling gereageer het, het dit aan hulle 'n gevoel van agting en deug vir hulle rol in primêre vlak gesondheidsorg gegee het. Beskikbare riglyne in primêre sorg klinieke dek 'n wye verskeidenheid kliniese kondisies, is onsamehangend, dikwels verouderd en selfs soms weersprekend. 'n Gedetailleerde vergelyking is tussen twee geselekteerde riglyne gedoen: die Suid-Afrikaanse TB kontrole riglyne en die PALSA PLUS riglyne. Beide word daagliks in die Vrystaatprovinsie gebruik. Die verpleegsters in sub-studie 1 het a.g.v. die uitleg, kleur en gebruikersvriendelikheid die PALSA PLUS riglyne verkies. Verpleegsters in die Vrystaat gebruik wel riglyne maar nie op 'n gereelde grondslag nie. Hulle maak eerder kliniese keuses en besluite gebaseer op ondervinding, alternatiewe kennis en intuïtiewe gevoel, in konsultasie met kollegas en na bestudering van die riglyne. Baie min riglyne is gereeld gebruik, en elke verpleegster het haar voorkeure vir 'n beperkte aantal riglyne wat sy bruikbaar vind. Daar is 'n duidelike behoefte aan 'n geïntegreerde benadering tot die informasiebehoeftes en ondersteuning aan verpleegsters en praktisyns op primêre sorg vlak. Riglyne speel 'n belangrike rol in die bevordering van onderrig, verandering van professionele praktyke en die versterking van gesondheidsorg wat deur verpleegsters in primêre vlak gesondheidsorg gelewer kan word. Dit kan ook gesien word as 'n strategie wat die gesondheidsorgsisteem kan gebruik om te verseker dat gesondheidswerkers kwaliteit diens lewer. Riglyne kan moontlik angstigheid beperk en verhoogde versorgingskwaliteit bring, of dit kan gesondheidsorg benadeel deur die afdwing van kontrolemaatreëls. Die gebruik van riglyne in primêre sorg fasiliteer besluitneming, en mag dalk angstigheid by die praktisyn beperk, wat dan die kwaliteit van versorging kan verhoog. Riglyne bied uitdagings aan die kreatiewe oordeelsvermoë om die pasiënt se simptome te sien binne die konteks van sy/haar omstandighede en mag 'n impak hê op persoonlike holistiese versorging wat die aard en kern van verpleging is. Die huidige primêre sorg verplegingspraktisyn moet 'n bekwame klinikus, ontfermende versorger en betroubare koördineerder wees – met oorvleuelende rolle van versorging, diagnosering en behandeling, en bestuur. Die uitdaging vir die verpleegster in primêre sorg is om die tradisionele versorging en koördinering te kombineer tot 'n omvattende rol van genesing, versorging en koördinasie; 'n nuwe, maar krities-belangrike identiteit vir die 21ste-eeuse versorger.

HIV/AIDS research has proven crucial in an effort to prevent and manage this epidemic. However, there is little research being done in an attempt to understand the internal worlds of those living with HIV/AIDS. The purpose of this research was to begin to explore the relationship that exists between the person living with HIV/AIDS and the virus, as an internal object, inside them. This study focused on 6 women who were on Anti-Retroviral Medication (ARVs), and who have been diagnosed for at least one year. The participants’ mental representations of the virus as an object inside them was explored, as well as how they experienced and viewed the triangular relationship that exists between themselves, the HI Virus, and the ARVs. This exploratory research utilised a qualitative framework in order to understand and explore these relationships and perceptions, with psychoanalytic theory being used a lens through which to view the data that emerged. In depth semi-structured interviews were conducted with the participants, and the corpus of data was analyzed using a thematic content analysis. In addition, the participants were asked to draw the virus inside their bodies. These were analyzed using a technique devised by Paola Luzzatto (1987) in a study exploring the internal world of drug-abusers. For the purpose of this study, a variation of the same art therapy technique was used in that the participants were asked the ‘draw the virus in their bodies’. Whilst the drawings allowed for insight into the internal worlds of the participants, the drawings were also used as a point of departure. For most of the women, HIV was drawn using a red crayon, whilst the ARVs were drawn in either yellow or green. As depicted in the drawings, post diagnosis the HIV/red seemed to cover most of the body, but later when the ARVs/green was added, more of a balance was achieved. Results show that for these women, HIV was often perceived as dangerous and criminal, whilst the ARVs were often associated with security. From the perspective of Kleinian theory, the perception of the HIV and the ARVs seemed to be dependent upon the position from where they were functioning: either a paranoid-schizoid or a depressive position.