Challenges pertaining to health in developing countries are well documented.1-3 Although the Global Burden of Disease 2017 study indicated that several sub-Saharan African countries had large gains in life expectancy from 2005 to 2017, this region accounts for the most years of life lost due to communicable, maternal, neonatal, and nutritional diseases.4 Historical factors including economic climate, social inequities, and substandard pharmaceuticals administered in resource-poor settings contribute to this problem.5,6 The scarcity of healthcare personnel available to administer medical services has produced the most crippling of effects.7 The South African government has supported many initiatives to improve healthcare delivery. One strategy undertaken in this century was the introduction of a new type of healthcare professional, the clinical associate (known as clinical officers in much of Africa and physician assistants [PAs] or associates in the United States and United Kingdom, respectively).8 Studies demonstrate the effectiveness of these providers to assume tasks, roles, and responsibilities through task shifting to improve health outcomes.9-11
Table 1 shows a timeline of the degree training of clinical associates offered by Walter Sisulu University (started in 2008) and University of Witwatersrand and University of Pretoria (started in 2009). The 3-year undergraduate degree, known as the bachelor of clinical medical practice (BCMP), trains students who have graduated from secondary school to practice medicine registered with the Health Professions Council of South Africa. The curriculum includes didactic courses on anatomy, physiology, pathology, pharmacology, and counseling as well as a significant amount of clinical, district-hospital based training. The medical knowledge and clinical skills taught pertain to the needs of South Africa. The clinical associate role models that of the PA, working in collaboration with the healthcare team with a specific focus on the common conditions and procedures relevant to district hospitals.8 District hospitals are first-level hospitals, staffed by generalist physicians, that offer primary and secondary care, with support from specialists in regional hospitals. Clinical associates perform consultations, order and interpret tests, diagnose, and manage patient care under the supervision of a medical practitioner.8 This strategy offers greater efficiencies in healthcare. Two South African studies demonstrated improved patient care when healthcare teams include clinical associates.12,13 However, as with all innovative strategies, challenges exist about the clarity of the scope of practice, defining roles, funding for implementation, availability of posts, competency, and job title issues.8,14,15 Hence, studies pertaining to the acceptance of the new cadre in the clinical environment have been conducted. Findings indicate clinical associates are competent at performing their designated role, contribute to task sharing, and are making a contribution to the work of the healthcare team.8,16
This study aimed to determine the opinions of supervising physicians about the introduction of clinical associates at South African district hospitals in two provinces in 2012. The focus was to identify the perceived effects of this new cadre of healthcare professionals along with the concerns of the supervising physicians for their inclusion in healthcare services delivery. At the time of the study, 93 clinical associates were practicing in South Africa, with 37 employed in the two provinces in the study.17 The study is important to document a baseline of the acceptance of clinical associates, to address concerns that may exist, and to adjust training to better meet the needs of district hospitals.
Cross-sectional qualitative interviews were conducted to explore the opinions of physicians who supervised clinical associates in district hospitals in North West and Gauteng provinces (Figure 1).
Population and sample
The population consisted of 28 physicians who directly supervised clinical associates at 17 district hospitals in the North West and Gauteng provinces. Twenty-four participants agreed to participate in the study, resulting in an 85% response rate. The participants were all physicians; 22 were general medical officers, one was a community service physician, and one was a district family physician. The 24 physicians directly supervised one or two clinical associates, for a total of 37 clinical associates, in a variety of clinical departments including emergency, internal medicine, obstetrics and gynecology, outpatient, orthopedics, and surgery. Of the 17 district hospitals, 12 were in North West province, and five were in Gauteng province.
The participants were interviewed from January to March 2012 either one-on-one or by telephone depending on their availability and using an interview guide. All the interviews were conducted by an experienced researcher who was a nonclinician member of the team who described their role and intent of the study. Before participation in the study, each participant gave informed consent for the interview lasting 20 to 30 minutes. The interview guide included demographic information with open-ended questions to explore the opinions of the supervising physicians for the effect of clinical associates in the workplace as well as the supervisor's concerns of the implementation of the new cadre.
Data were captured on an electronic spreadsheet and an inductive content analysis was conducted to generate themes emerging from interviews. The analysis involved developing codes and identifying subthemes and themes that were most prevalent in the feedback. An interpretivist approach was used by a researcher who was not directly involved in the clinical associate training program. Direct quotations from participants were used to support the identified themes. Coder reliability was ensured through rigorous interrogation of codes by authors, along with peer debriefing, until total agreement was reached.
The University of the Witwatersrand human research ethics committee provided ethical approval before the execution of the study. The two district hospitals also permitted data collection with the supervising doctors.
Opinions about clinical associates: Effects
- Professionalism of the new cadre. The most prominent comments relating to the positive theme of professionalism pertained to the support provided to physicians by the clinical associates. Participating physicians described how their own work improved.
“I like to have a ClinA [clinical associate] with me when I am on call.” (Participant 7)
“[with] Shortages of doctors—ClinAs assist in doing duties to speed up the process of attending to patients.” (Participant 11)
The level of professionalism also was displayed by their collaborative, rather than competing role, which aligns with the clinical associate scope of practice.
“They [clinical associates] play a supportive role to senior doctors, MOs [medical officers] and specialists.” (Participant 15)
“They [clinical associates] understand their role as doctors' support and do not find this a competing issue.” (Participant 24)
Additionally, professionalism was reflected by good performance in clinical work, showing learning interest, good communication, and teamwork.
“If you teach her [clinical associate], she improves on it.” (Participant 4)
“[They have] good communication with other professionals.” (Participant 6)
“We consider them as part of the clinical team.” (Participant 15)
An attitude of professionalism was displayed in their willingness to seek guidance and consult with supervising physicians when they were uncertain of a task. This is reflected below by a few participants who indicated that:
“[Clinical associates] know their limits—when they are stuck they call.” (Participant 9)
“Some things he [clinical associate] is not sure of, but he always asks in such a case.” (Participant 16)
- Skill level of clinical associates. The next most prominent positive theme included supervisor comments on the ability of the clinical associates to perform skills and procedures. A number of participants highlighted history taking, examinations, as well as making appropriate diagnoses as the skills they possess.
“[Clinical associates] can take patient history, assess, examine and make diagnoses.” (Participant 13)
Clinical associates were also perceived to have appropriate clinical judgment in regards to patient management skills and the ability to manage a range of therapeutic procedures.
“Good clinical skills and judgment.” (Participant 3)
“[Clinical associates are] great with assessment and management [of patients].” (Participant 6)
“Impressed by the range of procedures they can do.” (Participant 13)
- Patient management efficiency. Another positive theme identified was efficiencies in patient management highlighted by opinions of shortened patient waiting times, decreased patient complaints, more time spent with patients, and increased patient satisfaction.
“Patient waiting times and complaints have reduced” (Participant 2)
“[Clinical associates have] very good impact on service delivery.” (Participant 4)
“They form an excellent bridge between patients and health professionals as they spend a lot of time with patients.” (Participant 24)
“Patient satisfaction has increased.” (Participant 18)
Taking advantage of task sharing, participants commented that clinical associates enabled physicians to have more time to perform other tasks and generally reduce the overall workload.
“They [clinical associates] are able to do ward rounds, which freed me up for theater.” (Participant 10)
“Doctors are freed up for more complicated cases.” (Participant 20)
“Workload of doctors [is] decreased.” (Participant 15)
Several participants indicated the relief provided by clinical associates, indicating the need for more clinical associates to improve the delivery of healthcare.
“I feel if we had three more [clinical associates], all our departments will be covered.” (Participant 6)
“One in each unit would be great.” (Participant 8)
“We were very shortstaffed in surgery. ClinAs made it possible for us to run both theaters.” (Participant 10)
Opinions about clinical associates: Concerns
- Overtime and calls challenges. The most prominent concerns about the introduction of clinical associates pertained to administrative issues such as overtime and calls in the absence of clear guidelines of their roles. This is reflected by a few participants who said:
“Lack of clear space and structure, for overtime duty, that would enable facilities to tap into scarce clinical resources.” (Participant 24)
“All hospitals should be given guidelines on what clinical associates' role and what is expected from the facility.” (Participant 10)
- Prescription-writing challenges. A further concern raised by participants was the inability of the clinical associates to prescribe medication without countersignatures by their supervising physician. Supervisors highlighted this as a limitation to the scope of the new cadre as well as a drawback in terms of providing greater efficiency.
“[Clinical associates] should be allowed to function independently: scripts.” (Participant 1)
“We weren't sure of the scope of practice, so not sure what they can do.” (Participant 13)
- Supervision challenges. A third prominent negative theme was concern related to the supervision of clinical associates for their independence during practice and lack of training in some disciplines.
“Constant supervision is necessary.” (Participant 15)
“Can you place them alone or must they always be supervised?” (Participant 14)
“[They do] not have enough exposure to emergency situations.” (Participant 6)
“They should be exposed more to surgery during their training.” (Participant 3)
The results of the interviews illustrate an overall acceptance and approval by the study participants of the new cadre in 2012, 1 year after their introduction, in the South African healthcare system. An article published in 2017 described the positive effects of clinical associates in a rural district hospital that supports the continued inclusion of this new cadre in the clinical setting.12 The supervising physicians' views suggest that the clinical associate graduates in 2012 displayed a high level of professional attitude with a desirable level of skills. These positive results are similar to findings in a 2015 report of newly placed PAs in the New Zealand healthcare system.18
The interviews also identified positive effects of the clinical associates on patient management and on promoting efficiency in healthcare. These findings suggest that clinical associates can contribute to reducing the workload for physicians and nurses, and reducing patient waiting times. A 2014 study of PAs supports a reduction in waiting times when an additional provider is involved in patient care.19 These findings are similar to those published by Hooker and Everett, who found that PAs play a complementary role in primary care settings in the United States.20
Such opinions are valuable indicators that can be used to improve aspects of the curriculum and identify potential gaps in training. Like all societies, South Africa has an ongoing challenge to develop the curricula in response to its population's changing healthcare needs. As an example, several participants noted that clinical associates needed more emergency and surgery training. In response, the University of the Witwatersrand clinical associate program increased the number of hours dedicated to didactic and clinical training in emergency medicine and surgery in 2014 for undergraduate students.21 To further promote emergency medicine training, the University of the Witwatersrand in 2017 started a 1-year postgraduate BCMP honors degree in emergency medicine.22
The limited number of comments related to the supervision of the clinical associates suggests a certain level of physician confidence about clinical associates' ability to practice appropriately. Such findings are similar to a 2012 study in the United States of PA productivity and patient satisfaction.23
This study highlights concerns related to the practice of clinical associates. Participants expressed uncertainty about overtime and calls, concerns about the inability of clinical associates to prescribe medication independently, as well as some issues involving supervision. All of these issues relate to policy and governance, rather than to whether the graduates are fit-for-purpose and able to make a significant contribution to healthcare. The concerns can be attributed to a lack of information or understanding regarding the identity, training, and scope of practice of the clinical associates. Clinical associates were a new cadre in 2012; the regulations on their scope of practice were not yet formally promulgated during the period in which this study was conducted. The scope of practice was eventually passed in November 2016 with clear guidelines for practice and supervision.24
Some of the concerns raised were anticipated at the onset of the study and correlate with findings of studies of similar types of healthcare workers in other parts of the world.25 Of concern, a meta-analysis of similar supervised healthcare workers found that the quality of care is of low standard when the supervised healthcare provider lacks appropriate supervision or training.11 Therefore, our study highlights the need to continue to disseminate information and education to other healthcare providers, particularly supervisors of clinical associates, as to their role, scope, and supervision requirements. As of 2019, clinical associates are not authorized to prescribe medication independently, which is less a reflection of their training than regulations that govern healthcare in South Africa. Change is expected because the published scope of practice included prescribing rights, but the required legislative changes are still awaited, which is an illustration of the challenges faced in introducing a new category of professionals.23 As articulated in an editorial by Sanele Ngcobo, vice chair of the Professional Association of Clinical Associates of South Africa, the government must do its part to support and promote the clinical associate profession to overcome continuing challenges.26
In our study, we purposefully selected all the physicians who directly supervised clinical associates in the district hospitals in the two provinces at the time. However, four did not respond, which may influence thematic saturation. Another limitation is inherent in the inductive approach to developing themes. Among measures to reduce this was peer debriefing during the coding process. A significant limitation was the delay in publishing this work following the research being undertaken, largely related to the protracted illness, and subsequent withdrawal from the project, of a lead researcher.
The study provides important baseline data and serves as a springboard for additional work in the area of human resources for healthcare. Further investigations include a follow-up to this study with a larger population of supervisors of clinical associates. As of 2019, South African universities have graduated 1,071 clinical associates, with 851 registered to practice in 30 district hospitals across all nine provinces.17
Research is needed in countrywide studies of the effect of clinical associates in the delivery of healthcare as well as a study of patient perceptions of clinical associates. Such studies will provide further insight into the needs of South African society. The list of needs includes curriculum validation and changes, as well as informing South African district hospitals of developing and improving roles of clinical associates.
Clinical associates are a recent inclusion of medical personnel in South Africa and are modeled after PAs. This study on the perception of supervisors in two provinces in 2012 found the clinical associate growing in recognition, competence, and availability. The key findings are promising for the future of clinical associates as demonstrated by the acceptance and positive effect of the new cadre. Baseline opinions helped to enhance curriculum and highlight the significant contribution clinical associates play in improving the quality of district-level healthcare in South Africa. The study points to the need to document the work done by clinical associates across the country. The results support the need for increased training, graduation, and deployment of clinical associates.
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