All participants were NIMART-trained nurses, of whom 17 were female (70.8%) and only seven were males (29.2%). Age of the NIMART-trained nurses ranged from 24 to 58 years. The experience ranged between 3-4 years and they were working in both PHC (n= 11) and CHC (n= 13). The two themes that emerged were positive attitudinal needs and positive behavioural change. Positive attitudinal needs incorporated improved accessibility to development and implementation of treatment guidelines; motivation, support and supervision; adaptation to practice change; and improved knowledge and awareness. The Positive behavioural change incorporated Organisational-structural changes, user-friendly guidelines and patient responsiveness. Table 1 present the summary of the themes and sub-themes that emerged from the analysed data.
1. Factors facilitating trained NIMART nurses’ adherence to treatment guidelines.
The possibility of improved usage and adherence to treatment guidelines was raised in this study. NIMART trained nurses indicated that adherence to treatment guidelines can be improved. The findings revealed two factors or themes, thus: Positive attitudinal needs and positive behavioural change. Hence, these were regarded as factors that nurses felt can promote their level of adherence to treatment guidelines.
1.1 Positive Attitudinal Needs
Among the nurses initiating and managing ART and anti-TB treatment in KZN and NWP, the following needs were identified and expressed, namely: improved accessibility, usability and availability of Treatment Guidelines; motivation, support and supervision; adaptation to practice change and improved knowledge and awareness.
1.1.1 Improved accessibility, usability and availability of Treatment Guidelines
NIMART trained nurses expressed that a simplified and easy to go through guideline (e.g., handbook, pocketbook and flowcharts) which is more user-friendly can improve the usage of treatment guidelines and therefore promote adherence to treatment guidelines. The participants expressed their views as follows:
“A portable guideline that can be accessible and owned by any health care provider can ease and promote adherence, not just one guideline for the clinic.” (P9, FGD 4, male, 44 years old)
“If they can change just a little bit of the size so that it can be like a handbook that is easy to use and quick to go through.” (P 4, FGD 1, female, 56 years old)
1.1.2 Motivation, Support and Supervision
Nurses need support in their caregiving role to follow or comply with the treatment guidelines correctly and accurately. This study’s findings revealed that NIMART trained nurses can adhere better to treatment outcomes if they are given support and are being supervised in their caregiving role. This was evident when a participant said:
“We need support and encouragement to be able to carry our nursing duties at ease and to the best of quality possible. Weekly or monthly supervision or support visits can increase the level of adherence and guidelines usage among nurses and this will promote the quality provision of care to our patients.” (P 10, FGD 2, male, 34 years old)
However, NIMART trained nurses felt that if there is a good working relationship between health care workers, patients can be treated well and with a higher level of adherence to treatment guidelines. Participants articulated:
“A good working relationship can promote adherence to treatment guidelines as not only nurses provide care to TB and HIV patients.” (P 8, FGD 2, female, 41 years old)
“We are supposed to work hand-in-glove [hand in hand] with one another for the provision of quality care to our patients.” (P 11, FGD 4, female, 33 years old)
1.1.3 Adaptation to practice change
Participant nurses said that they do want to change, but the system does not allow them as the pressure of task-shifting is catching up with them as the implementers. One participant verbalised:
“The department of health should allow us, nurses, to move slowly as this was not our scope of practice to be well orientated, knowledgeable and skilful. The reason we don’t want to move from our past routines is that it takes time to acclimatise to the new things. I was trained for NIMART in 2011, but I still find it hard to fully understand the initiation and management of ART.” (P 10, FGD 2, male, 34 years old)
A gradual change of the health care system may be useful to provide nurses with relevant time to become on par with the changes in health care practice and the TB & HIV service needs. Some participants feel that as they do not always keep up with the sudden growth in practice and this reduces their adherence to treatment guidelines. So, a gradual orientation to the NIMART can really improve their adherence to treatment guidelines.
1.1.4 Improved knowledge and awareness
Enough orientation, knowledge, updates, training and follow-up training to NIMART and other nurses were revealed in this study as priorities that can increase the level of adherence to treatment guidelines. One participant responded:
“I think more nurses need to be trained in NIMART or all nurses in each facility need to be trained as this causes gaps in the health care provision. Patients won’t be returned back because of a trained nurse not being available.” (P 6, FGD 1, male, 26 years old)
This sentiment emphasises that the provision of training and education concerning treatment guidelines promotes adherence and use of guidelines. This was further corroborated by the identified need for follow-up training to be conducted within nurse practice settings as this will reduce the shortage of trained nurses. One participant emphasised:
“We know it is impossible to train everyone in time, but if there is something new coming, even if it’s not a formal training but trainers can visit the facilities just to provide an insight on the available change while training is taking place.” (P 4, FGD 3, male, 27 years old)
1.2 Positive Behavioural Change
It was evident from the focus group interviews that changes in behaviour can increase the level of adherence to treatment guidelines and this was regarding the following categories, namely: organisational-structural changes, user-friendly guidelines and patient responsiveness.
1.2.1 Organisational-structural changes
Organisational-structural changes comprised of need for enough time, enough human resource, reduced workload, improved communication, guideline availability and guideline accessibility. If there is enough time, it would be easy for NIMART trained nurses to use and adhere correctly to the guidelines – the participants verbalised this as follows:
“We need enough time to work with patients as well as to follow the guidelines correctly. Instead of the system pushing us to do more quantity meaning more headcount per day, it should provide time for us to provide quality care to our patients. There is no use for a patient to spend the prescribed 2 hours in the clinic and you find that no quality care provided to this patient.” (P 1, FGD 1, female, 43 years old)
“Reduced workload and reduced time pressure can increase adherence to treatment guideline and also promote the provision of quality care to our TB and HIV patients.” (P 8, FGD 2, female, 41 years old)
“We know it is impossible to train everyone in time but if there is something new coming, even if it’s not a formal training but trainers can visit the facilities just to provide an insight on the available change while training is taking place.” (P 10, FGD 2, male, 34 years old)
The availability of treatment guidelines was raised as another approach to promoting adherence to treatment guidelines among NIMART nurses. These guidelines need to be available in every consulting room within each facility and need to be accessible to the NIMART trained nurses providing TB and HIV services. A participant had to say this:
“Guidelines need to be made available in the facilities for easy use and accessibility. However, not just one guideline, but enough for each health care provider as this will reduce the time for looking for a guideline or waiting for one to be done with it so that one can use it.” (P 6, FGD 3, female, 49 years old)
Nurses also verbalised that proper communication channels can promote or be favourable towards the adherence to treatment guidelines and their use thereof. A participant verbalised this aptly:
“A good communication between the implementers, programme managers, coordinators and supervisors can promote adherence to treatment guidelines. Any change needs to be communicated to the implementers’ way beforehand not just in the implementation phase.” (P 7, FGD 4, female, 46 years old)
1.2.2 User-friendly guidelines
Provision of simple, clear and easy to go through treatment guidelines can improve the use and level of adherence. One participant expressed:
“A simple guideline that is clear and at the level of nurses can be of help to us as it will be easy to understand and go through. The chart or handbook or pocketbook will be of greater help. But I like that diagram like poster … Yes, the algorithm type of guidelines. It is simple and easy to follow rather than the book.” (P 12, FGD 4, male, 42 years old)
1.2.3 Patient responsiveness
The ability of patients to fully participate in their ART and TB treatment was raised as an issue that can facilitate adherence to treatment guidelines. Some participants indicated:
“Sometimes we need patients on board; we don’t monitor patients because they are not available or complying to the monthly visits that we set for them. If patients can adhere and follow all that we say to them this can ease our work and promote adherence to treatment guidelines.” (P 5, FGD 3, female, 58 years old)
“I agree with you patients are our customers and their availability and engagement in the provision of ART and TB treatment can increase our adherence.” (P 6, FGD 3, female, 49 years old)