The views and perceptions of training in physical health care amongst mental health nurses, managers of mental health nurses and trainers: A systematically constructed narrative synthesis

People with serious mental illness have higher morbidity and mortality rates compared with the general population. Mental health nurses are in an optimal position to address physical healthcare needs and inequalities experienced by this group. Research evidence suggests that mental health nurses may lack appropriate skills and confidence. The training needs of mental health nurses in physical health care of patients with serious mental illness and the perceived effectiveness of training that is provided to mental health nurses are explored in this review. A narrative synthesis approach (PROSPERO protocol registration ID=CRD42021230923) involved searching five electronic databases (PsycInfo, Cinahl, Embase, Medline and Web of Science) from 1990 to 2021. Study quality was assessed, and analysis and synthesis were initially deductively guided by a theoretical framework of training effectiveness prior to inductive data analysis. Eleven studies met the inclusion criteria. For studies examining perceived effectiveness of training, four themes were derived from the theoretical framework (individual trainee characteristics, work environment, learning outcomes, transfer of training to job) and further theme (service user factor) generated inductively. For studies examining training needs, three themes were derived inductively (knowledge and skills requirements, modality of training, service and healthcare factors). The study highlights the need for ongoing learning to improve practice. It also provides another perspective in terms of understanding the influence of service user factors (motivation and mental state) in designing and implementing of future training in mental health settings.

Training Proposal in Palliative Care for Primary Care Nurses in a Health Area in Spain

BACKGROUND

Primary Health Care nurses express deficits in their training in Palliative Care. The purpose of this study is to design a Palliative Care training plan and a bereavement care protocol for Primary Health Care nurses of the Dr. Peset Health Department according to their needs.

METHODS

Assessment of theoretical and practical training needs and literature review for the design of the training plan.

RESULTS

A training plan was elaborated that included a protocol of care for the bereaved. The plan was adjusted to the needs detected in Primary Health Care nurses of the Dr. Peset Health Department. Important training deficits were detected in clinical practice; Conclusions: Improving the care of people with palliative needs in Primary Health Care requires adequate training of the nurses who care for them so their knowledge is the basis of their interventions. This study was not registered.

Mary Merryweather - Nursing pioneer and proto feminist

Mary Merryweather was the first Lady superintendent of Liverpool's first school of nursing. The school was a pioneer in nurse training at the very moment the definition of modern nursing was becoming fixed. She went on to manage the school of nursing at the Westminster hospital in London, at a time of great change and controversy. In addition to this she was very active in the fields of womens' health, womens' suffrage and the rights of women to a career. She was a friend to numerous Victorian feminist notables and was published in a variety of feminist Publications.

[The impact of district nurses in screening visual impairments]

INTRODUCTION

The children's physical and mental health is determinative for the whole society. Parents, teachers, district nurses, and doctors share the duty to ensure their uninterrupted visual development. District nurses compose key elements in connecting families and health care providers, since they have the chance to detect any visual anomalies, and to refer the children to a pediatrician, ophthalmologist, or a neurologist. Their team work yields advantages to the whole community as beyond preserving good vision, children get a real chance of right physical and mental development.

OBJECTIVE

Our aim was to recollect district nurses' areas of activity and to collect data about their present status in visual screening programs. Furthermore, to assess their screening methods and circumstances, and to reshape their continuous learning programs linked to the universities.

METHOD

Questionnaires were sent online anonymously to district nurses in practice, in order to collect data referring to their focuses during the visual screening methods. Administration of online parental tutorials was assessed, and measures of professional support in nurses' education was debated.

RESULTS

Visual screening among infants looks for potential strabismus, and among school-age children looks for potential refractive errors. Vision tests and stereo tests are usually available as screening tools, but pen lights are underused. Only a few nurses suggest online tutorials to enhance patient education, but nurses are highly motivated in postgraduate courses about vision screening.

CONCLUSION

Our results reflect good adherence to the screening protocols but there is some uncertainty in some fields. In harmony with the results, adequate technical and educational support and specific training were compiled for postgraduate district nurses. Coaching and training in visual screening (in the form of seminars or e-learning) should be available in spring 2023. Orv Hetil. 2023; 164(3): 88-95.

Employability, organizational commitment and person-organization fit among nurses in China: A correctional cross-sectional research

AIM

This study aimed to explore the effect of training on organizational commitment, the mediating effect of employability and the moderating role of person-organization fit.

DESIGN

A correctional cross-sectional research design was adopted for this study.

METHODS

A questionnaire-based survey of 859 nurses in a public hospital in Western China was conducted to identify their perceptions of training, employability, organizational commitment and person-organization fit. Hierarchical linear regression and conditional process analysis on moderated mediation were performed.

RESULTS

Training had a positive effect on organizational commitment (p < .01). Internal and external employability mediated the relationship between training and organizational commitment (p < .01). Person-organization fit enhanced the indirect effect of training on organizational commitment through external employability (p < .05).

Evaluating Nurse Data Navigation Training Program: A Quality Improvement Project

Nursing ability to navigate data by sourcing, visualizing, and managing data provides for skill and insights development. Effectiveness of clinical, operational and strategic decision making is underpinned by sound understanding of the data. The object of this quality improvement project is to design, deliver and evaluate a nursing specific training program using spreadsheet software Excel to improve nurse competence and confidence in data navigation.

Improving preparation for scalp cooling: Learning from women undergoing chemotherapy for early-stage breast cancer-The COOL study

AIMS AND OBJECTIVES

This study set out to understand the experiences and expectations of scalp cooling among women with early-stage breast cancer. The objective was to develop patient co-produced information resources to better inform and prepare women considering scalp cooling during chemotherapy.

BACKGROUND

Treatment-induced alopecia is a common concern among women preparing for chemotherapy. Evidence indicates that many women feel inadequately prepared for scalp cooling, resulting in potentially mitigable distress and disappointment.

DESIGN

A single-site, sequential, explanatory mixed-methods design was used. Participants included women with early-stage breast cancer who had previously or were currently using, scalp cooling. Women completed an online survey exploring scalp cooling experiences and expectations and self-selecting participants took part in one semi-structured, audio-recorded interview. Guidelines for Good Reporting of a Mixed Methods Study were followed.

RESULTS

Forty-nine women (69%) consented to take part in the survey and 23 took part in an interview. Most women described losing more hair than they expected. Many described feeling inadequately prepared for the discomfort of scalp cooling; the additional time needed to accommodate scalp cooling during treatment and, that they lacked information about self- care to help minimise hair loss. Importantly, several participants described variability in nurses' knowledge and practical skills regarding scalp cooling.

CONCLUSIONS

To optimise experience of scalp cooling, women need comprehensive preparatory information about variability in efficacy of scalp cooling; time needed to accommodate scalp cooling; hair care during treatment, and the potential discomfort associated with it. They also need nurses to be confident and well informed about scalp cooling processes.

RELEVANCE TO CLINICAL PRACTICE

Our study led to the development of online, patient co-produced resources to help prepare and inform women considering using scalp cooling; and an online scalp cooling training module and checklist for nurses. Links to the resources are included in the manuscript.

Nursing Perspective of the Humanized Care of the Neonate and Family: A Systematic Review

This systematic review aims to determine the extent to which published research articles show the perspective of health professionals in neonatal intensive care units (NICU), as facilitators of family empowerment. Studies conducted between 2013 and 2020 were retrieved from five databases (PubMed, Cochrane, CINHAL, Scopus, and Google Scholar). The search was carried out from January to October 2020. A total of 40 articles were used, of which 13 studies (quantitative and qualitative) were included in this systematic review. Its methodological quality was assessed using the mixed methods assessment tool (MMAT). In these, the opinions and perspectives of professionals on the permanence and participation of parents were valued. In addition, the training, experiences, and educational needs of nursing within the NICU were determined. The crucial role of health professionals in the humanization of care and its effect on the neonate-family binomial was estimated. However, conceptual changes are needed within the neonatal intensive care units. To implement humanization in daily care, family participation should be encouraged in them. For this, it is necessary to modify hospital health policies to allow changes in the infrastructure that facilitate open doors 24 h a day in special services.

The Relationship between Nurses' Training and Perceptions of Electronic Documentation Systems

Electronic documentation systems have been widely implemented in the healthcare field. These systems have become a critical part of the nursing profession. This research examines how nurses' general computer skills, training, and self-efficacy affect their perceptions of using these systems. A sample of 248 nurses was surveyed to examine their general computer skills, self-efficacy, and training in electronic documentation systems in nursing programs. We propose a model to investigate the extent to which nurses' computer skills, self-efficacy, and training in electronic documentation influence perceptions of using electronic documentation systems in hospitals. The data supports a mediated model in which general computer skills, self-efficacy, and training influence perceived usefulness through perceived ease of use. The significance of these findings was confirmed through structural equation modeling. As the electronic documentation systems are customized for every organization, our findings suggest value in nurses receiving training to learn these specific systems in the workplace or during their internships. Doing so may improve patient outcomes by ensuring that nurses use the systems consistently and effectively.

"I found it daunting": An exploration of educational needs and experiences of mental health student nurses working with children and adolescents with eating disorders

WHAT IS KNOWN ABOUT THE SUBJECT?: A therapeutic relationship with a professional who displays an informed approach has a positive effect on outcomes for young people presenting with an eating disorder. There is a dearth of research available on the student mental health nurse experience of working with young people with an eating disorder both internationally and from the Republic of Ireland. Within this limited literature, nursing students were found to hold more negative perceptions towards this group than more experienced clinicians. The causes of eating disorders are complex, which make education and support to understand the individual with an eating disorder essential. Within the Republic of Ireland, child and adolescent mental health historically has received very little attention in the undergraduate mental health nursing curriculum. WHAT DOES THE STUDY ADD TO EXISTING KNOWLEDGE?: Findings from this study recommend that a set of guidelines are made available for students to feel more confident in their role. It is suggested that this resource would include the therapeutic skills to engage the young person with an eating disorder. A specialist clinical placement has been identified as the most appropriate time to consider the development of a study day or days to facilitate learning of the skills and therapeutic techniques to work with adolescents. Application of these skills would occur within the clinical learning environment under supervision and guidance of the clinical preceptor. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Specialized training for student mental health nurses working with this group will enhance confidence and competence levels in forming therapeutic relationships, thereby improving outcomes for those attending the services. Better student experience may also enhance future nursing recruitment into this area. Students need additional support in managing these often complex and ambivalent presentations and their own fears or stigma around people with an eating disorder. This is recommended as taking the form of reflective practice during the placement. There is a need for nursing management to support nurses in their role as preceptor. This would involve protected time for preceptors to engage the student nurse in clinical education and reflective practice. ABSTRACT: Introduction There is limited attention given to child and adolescent mental health in the undergraduate mental health nursing curriculum within the Republic of Ireland. There is a dearth of research available on specifically the student mental health nurse experience both internationally and from the Republic of Ireland. Aim To explore factors that impact on the experience of mental health student nurses working with adolescents who present with eating disorders. Method This qualitative descriptive study was conducted through individual semi-structured interviews with n = 4 mental health student nurses. Data were then subjected to a schematic content analysis. Results The participants experienced developing therapeutic relationships with this group as a challenging process. They believed that the theoretical component of the undergraduate programme facilitated them in their understanding but did not prepare them to engage therapeutically with these adolescents. Discussion Preceptors are identified as the main source of support but improvements to the clinical learning environment would enhance the learning experience. Implications for practice Support for the role of the preceptor in the specialist clinical setting in the form of training and protected time to engage students in clinical education and reflection was suggested as a method to enhance the clinical learning environment.

Survey of nurses' knowledge and practice regarding medication administration using enteral tubes

AIM AND OBJECTIVES

To identify the practice variation of the individual practitioners in medications' formulation modification for patients using enteral feeding tubing and to support health practitioners involved in this process.

BACKGROUND

Blockage of enteral tubes is a common problem that can sometimes be resolved but may require replacement of the tube. Medications are a common culprit.

DESIGN

A survey of 73 registered nurses' practices around medication administration via enteral feeding tubes.

METHODS

A questionnaire study was undertaken within a district general hospital across a broad variety of wards to explore nurses' experiences of medication administration via enteral tubes. The study is reported in accordance with the squire 2.0 guidelines from the EQUATOR network.

RESULTS

Seventy-three nurses responded. Twenty-six per cent reported never checking about drug modification for administration via a tube, 12% check every time and 61% when unsure about a new drug. The volume of fluid flushes administered after medication ranged from 7.5-150 ml. Seventy-one per cent of participants reported stopping feed when medications are required, varying from 1-60 min. Sixty per cent had experienced a blocked tube and 52% the tube being removed for these reasons. The clinical nurse specialist was the commonest first point of call to help. Staff named 15 medications as the most problematic to administer, lactulose and omeprazole were the top two.

CONCLUSIONS

Practice varies significantly amongst nurses around medication administration. Theoretically, this may contribute to blocked tubes and excessive fluid administration to some patients. Barriers to medication administration were thematically grouped into: time, difficulty modifying medication, medication interactions and knowledge. Areas identified to support staff include training, devices to crush medications, medication suitability, multidisciplinary approach to streamline care and quick reference guides.

RELEVANCE TO CLINICAL PRACTICE

Health professionals may use these results to reduce and ultimately avoid problems with administering medications through feeding tubes. Organisations may use these results to develop their local practice pathways for prescribing, dispensing and training around administration of medications through enteral tubes. In a community setting, this paper may improve the awareness of patients, caregivers and prescribers of the possible implications of tubing blockages.

Evaluating a Nurse Training Program in the Emergency Surgery Department Based on the Kirkpatrick's Model and Clinical Demand During the COVID-19 Pandemic

Objective: To analyze the application of Kirkpatrick's model in the nurse training program among the emergency surgery department based on clinical demand during the COVID-19 (coronavirus disease-2019). To provide reference for the training of emergency surgical nurses during the outbreak of COVID-19. Design: Guided by Kirkpatrick's model, 35 nurses in the emergency surgery department were trained according to a program that resulted from the clinical demand during the pandemic. The trainees were observed in terms of their performance at reaction level and learning level. Results: At reaction level, the degree of satisfaction scored by nurses was relatively high, with its total score achieving (18.77 ± 3.09). At learning level, the differences between theoretical and operational scores of tested nurses before and after training proved to be statistically significant (p < 0.001). Conclusion: The application of Kirkpatrick's model based on clinical demand during the COVID-19 confirms to be effective for the training program of nurses in the emergency surgery department. It is also beneficial to improve nurses' knowledge and skills during the pandemic, which serves as a positive influence for clinical reference.

Task shifting of intraocular injections from physicians to nurses: a randomized single-masked noninferiority study

PURPOSE

To test if task shifting of intraocular injections to nurses in a real-world setting can result in similar visual function outcome with equal safety profile.

METHOD

All patients with either age-related macular degeneration, retinal vein occlusion or diabetic macular oedema remitted to intraocular injections at a tertiary ophthalmology department in Norway between March 2015 and May 2017, were asked to participate. The participants were randomized to either nurse- or physician-administered intraocular injections of anti-vascular endothelial growth factor. The primary outcome measure was change in best-corrected visual acuity from baseline to 1-year follow-up. The mean difference in the primary outcome between the groups was analysed by a noninferiority test with a margin of three letters in disfavour of the nurse group. Adverse events were recorded.

RESULTS

Three hundred and forty-two patients entered the study. Two hundred and fifty-nine completed the 1-year follow-up and were included in the study sample for the analysis of the primary outcome. Nurse-administered intraocular injections were noninferior to physician-administered injections with 0.7 and 1.6 letters gained, respectively (95% CI of the mean difference, -2.9 to 1.0; p = 0.019, one-sided t-test). Two thousand and seventy-seven injections and three ocular adverse events were recorded.

CONCLUSION

Task shifting of intraocular injections to nurses can be performed without increased risk to visual function. Such a task shift can alleviate the burden of performing intraocular injections in ophthalmology departments. To our knowledge, this is the first RCT on task shifting of a surgical procedure from physicians to nurses in a high-income country.

[Developing students' relational aptitudes]

Role-playing between peers is a pedagogical approach frequently used in training, including for student nurses. As the size of the group has been identified as potentially influencing this practice, a into the effects of role-playing in sub-groups of students on the development of relational attitudes and techniques.

Challenges in Implementing an E-Learning Education Program for Syringe Pump Use

To prevent the incidence of risks imputable to human error during the process of preparing the infusion pump, clarity in teaching and learning are required. Because traditional classroom training is difficult and time-consuming, the aim of the present study was to challenge the implementation of an e-learning education program for syringe pump use. The impact of the e-learning program was evaluated with 100 nurses between March and June 2016. The e-learning program significantly increased general baseline knowledge in syringe pump use; however, aspects of the program confused participants. The feedback from 98 % of nurses on the e-learning program was that it was effective in helping them with this skill. However, only 54 % opted for the e-learning program versus traditional training. The present study showed nurses preferred a blended learning format. Based on our hospital incident and error reports, this study shows local training requires a specific approach strategy for syringe pump education.

Reporting of suspected dog fighting to the police, Royal Society for the Prevention of Cruelty to Animals and equivalents by veterinary professionals in the UK

Dog fighting became unlawful in the UK in 1835, yet it continues today (as reported by the Royal Society for the Prevention of Cruelty to Animals (RSPCA) and Crown Prosecution Service), although with an unknown prevalence. We used an online questionnaire to (1) determine the occurrence of dogs suspected of use in fighting in UK veterinary practices; (2) explore relative reporting of incidents to police, RSPCA or equivalent charity by registered veterinary nurses (RVN) and veterinarians; and (3) determine factors influencing reporting. Emails (n=2493) containing the questionnaire were sent to UK veterinary practices: 423 questionnaires (159 by RVNs, 264 by veterinarians) were completed. One or more cases of dog fighting were suspected by 14.4 per cent of respondents in 2015; 182 cases suspected in total. Proportionately more RVNs suspected dog fighting than veterinarians (P=0.0009). Thirty-two respondents (7.6 per cent, n=422) claimed to have reported suspicions to the police, the RSPCA or equivalent charity previously; 59 respondents (14.2 per cent) had previously chosen not to. Reasons not to report included: uncertainty of illegal activity (81.4 per cent), fear of the client not returning to the practice (35.6 per cent) and concerns regarding client confidentiality (22.0 per cent). Further work is required to address under-reporting of dog fighting by veterinary professionals.

Integration experiences of student and qualified nurses with disabilities who graduated from selected KwaZulu-Natal nursing education institutions: An exploratory case study

BACKGROUND

 Despite the introduction of the Disability Policy Guidelines in South Africa (SA), student nurses who have disabilities (SNWDs) are still habitually and effectively excluded from nurse training programmes, and hence from the nursing profession. Yet SNWD may be able to offer a unique perspective.

OBJECTIVES

 To explore and describe the integration experiences of both student and qualified nurses with disabilities who graduated from selected KwaZulu-Natal nursing education institutions (NEIs).

METHOD

 A concurrent mixed-method design based on multiple embedded case studies served as the primary data collection instrument in this paper. The researcher initially conducted a survey of all the private NEIs to determine which had experienced training SNWDs; 3 cases and 10 embedded cases were selected, using non-probability purposive sampling. Individual interviews were conducted with students and qualified nurses with who have a disability (n = 10) who had graduated from NEIs.

RESULTS

 The findings of the study indicated that, largely, private NEIs are paving the way for integrating SNWDs; however, there are still some gaps in meeting the needs of these students. Despite strong legislative policies, an inclusive and enabling teaching and learning environment for SNWDs in nurse training remains largely absent.

CONCLUSION

 The study recommends that NEIs develop policy guidelines for integrating SNWDs in nursing education programmes promoting an inclusive nursing education for SNWDs. The introduction of a disability liaison to assist SNWDs by liaising between key stakeholders and, perhaps, addressing many of the challenges that SNWDs experience in the clinical facilities where nursing personnel are unaware of their disability.

Owner and veterinary surgeon perspectives on the roles of veterinary nurses and receptionists in relation to small animal preventive healthcare consultations in the United Kingdom

Veterinary receptionists and veterinary nurses rarely feature in published practice-based research, yet are integral to small animal veterinary practice in the UK. The aim of this study was to investigate the perspectives of UK-based owners and veterinary surgeons about veterinary nurses and receptionists in relation to their role in preventive healthcare. Semistructured telephone interviews were conducted with 15 dog and cat owners and 14 veterinary surgeons. Interview transcripts were thematically analysed. Reception staff were identified as having a range of important roles, from rapport building to providing healthcare information and advice. The perceived importance of those roles appeared to differ between owners and veterinary surgeons. Veterinary nurses were described as performing a diversity of roles in relation to preventive healthcare, both in the reception area and in the consulting room. Many owners, and some veterinary surgeons, expressed uncertainty about the remit and status of veterinary nurses in relation to providing veterinary advice. This study identifies for the first time the degree of responsibility for preventive healthcare given to veterinary receptionists and veterinary nurses in UK small animal practices. Further work is needed involving reception and nursing staff to fully appreciate and define their roles in small animal practice.

[Cultural competency and practising abroad]

Cultural competency assumes an even greater dimension with foreign patients or when practising abroad. After travelling to Cambodia with the aim of enriching their nursing practices, four student nurses share their experiences, questions and reflections in this area.

Role of nurses in supporting patients to self-manage chronic conditions

The burden of chronic illness is increasing globally as a result of increased life expectancy, unhealthy lifestyles, and advances in medical interventions and treatments. Therefore, people living with chronic conditions, and their families, will have to assume greater responsibility in managing such conditions. However, to do so they require appropriate support from healthcare services. This article explores some of the tensions that hinder the self-management of chronic conditions. It emphasises the importance of individuals and their families having the desire, and being enabled, to assume an active and decisive role in the management of chronic conditions. Nurses have a role in enabling patients to optimise their self-management skills, but organisational constraints in healthcare services, as well as constraints in nurse training and nursing roles, may mean that nurses are unable to fulfil this role. This article considers some of the factors that may limit the development of patient and nursing roles in relation to self-management of chronic conditions.

Nurses' knowledge about the double-checking process for medicines administration

This study aimed to evaluate nurses' knowledge, perceptions and opinions of double-checking medication administration in a UK children's hospital. Of 119 questionnaires distributed, 48 were returned. Only 30 respondents had seen a written version of the hospital double-checking policy. More than half stated that they had not received formal training in double-checking medications. Of 35 nurses providing a definition of double-checking, one gave a response that reflected hospital policy. Most respondents thought that staffing, workloads and interruptions affected adherence to double-checking; 15 reported that double-checking was easier to do at night; and the results suggested that lack of knowledge and of clear guidelines contributed to medication errors.

Relation between spiritual intelligence and clinical competency of nurses in Iran

Background:

Clinical competency is one of the most important requirements in nursing profession, based on which nurses are assessed. To obtain an effective and improved form of clinical competency, several factors are observed and monitored by the health educational systems. Among these observed factors, spiritual intelligence is considered as one of the most significant factors in nurses’ success and efficacy. In this study, it is aimed to determine the spiritual intelligence status and its relationship with clinical competency.

Materials and Methods:

The descriptive–correlational research was carried out on 250 nurses in Mashhad educational hospitals, selected by multi-stage sampling. Demographic, clinical competency, and spiritual intelligence questionnaires were used for data collection and 212 questionnaires were analyzed.

Results:

About 53.3% of nurses obtained above average scores in spiritual intelligence. Clinical competency was evaluated by both self-evaluation and head nurse evaluation methods. Most nurses (53.8%) were having good level of clinical competency based on self-evaluation, 48.2% were at average level based on head nurse evaluation, and 53.3% were at average level based on overall score. A significant correlation was found between spiritual intelligence and clinical competency.

Conclusions:

In this study, the positive significant correlation between nurses’ spiritual intelligence and their clinical competency is investigated. Because of the positive effects of spiritual intelligence on nurses’ clinical competency and quality of care, it is recommended to develop nurses’ spiritual intelligence during their education and by way of continuous medical education.

Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial

BACKGROUND

Task-shifting is promoted widely as a mechanism for expanding antiretroviral treatment (ART) access. However, the evidence for nurse-initiated and managed ART (NIMART) in Africa is limited, and little is known about the key barriers and enablers to implementing NIMART programmes on a large scale. The STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) programme was a complex educational and organisational intervention implemented in the Free State Province of South Africa to enable nurses providing primary HIV/AIDS care to expand their roles and include aspects of care and treatment usually provided by physicians. STRETCH used a phased implementation approach and ART treatment guidelines tailored specifically to nurses. The effects of STRETCH on pre-ART mortality, ART provision, and the quality of HIV/ART care were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation of the programme.

METHODS

This study was a qualitative process evaluation using in-depth interviews and focus group discussions with patients, health workers, health managers, and other key informants as well as observation in clinics. Research questions focused on perceptions of STRETCH, changes in health provider roles, attitudes and patient relationships, and impact of the implementation context on trial outcomes. Data were analysed collaboratively by the research team using thematic analysis.

RESULTS

NIMART appears to be highly acceptable among nurses, patients, and physicians. Managers and nurses expressed confidence in their ability to deliver ART successfully. This confidence developed slowly and unevenly, through a phased and well-supported approach that guided nurses through training, re-prescription, and initiation. The research also shows that NIMART changes the working and referral relationships between health staff, demands significant training and support, and faces workload and capacity constraints, and logistical and infrastructural challenges.

CONCLUSIONS

Large-scale NIMART appears to be feasible and acceptable in the primary level public sector health services in South Africa. Successful implementation requires a comprehensive approach with: an incremental and well supported approach to implementation; clinical guidelines tailored to nurses; and significant health services reorganisation to accommodate the knock-on effects of shifts in practice.