Building an ethical South Africa Reg. No. 1999/020697/08

CHRIS HANI

BARAGWANATH HOSPITAL

ETHICS AUDIT

Willem A. Landman

Ethics Institute of South Africa

Johann Mouton

Centre for Interdisciplinary Studies, University of Stellenbosch

Khanyisa H. Nevhutalu

Ethics Institute of South Africa

Research Report No. 2

© 2001

i

TABLE OF CONTENTS Page

List of Tables v

List of Figures vii

List of Boxes viii

List of Diagrams ix

ACKNOWLEDGEMENTS x

EXECUTIVE SUMMARY xii

SECTION 1: INTRODUCTION 1

1.1 Background 1

1.2 Research aims 6

1.3 Outline of report 9

SECTION 2: RESEARCH DESIGN AND METHODOLOGY 11

2.1 First phase: Focus groups 11

2.2 Second phase: Design and construction of pilot

questionnaires 12

2.3 Third phase: The ethics survey 12

SECTION 3: SAMPLE PROFILE 15

3.1 Staff profile 15

3.2 Patient profile 16

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SECTION 4: THE PHYSICAL PLANT/INFRASTRUCTURE,

MATERIAL RESOURCES, AND SECURITY 19

4.1 The physical plant 19

4.2 Medicine and linen 21

4.3 Cuts to the health-care budget 26

4.4 Quality and maintenance of equipment 27

4.5 Safety and security 27

Salient points 29

4.6 Concluding comments 29

SECTION 5: ORGANISATIONAL CULTURE AND VALUES 31

5.1 Perceptions of staff relations 31

Summary trends 36

5.2 Ratings of organisational values 36

Salient points 37

5.3 Ratings of professional values 38

5.4 Recommendations by respondents 43

5.5 Concluding comments 45

SECTION 6: LEADERSHIP, MANAGEMENT, AND

CHANNELS OF COMMUNICATION 47

6.1 Leadership and management 48

Salient points 48

6.2 Channels of communication 52

Salient points 54

6.3 Concluding comments 55

SECTION 7: HUMAN RESOURCES ISSUES 57

7.1 Job satisfaction 57

7.2 Conditions of service 58

7.3 Staff shortages 59

7.4 Concluding comments 60

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SECTION 8: MISCONDUCT AND STANDARDS OF CARE 63

8.1 Rank ordering of instances of misconduct 63

Salient points 65

8.2 Reasons for misconduct 67

Four main findings 68

8.3 Misconduct and the need for an ethics committee 68

8.4 Concluding comments 69

SECTION 9: PROBLEMS AND SOURCES OF STRESS 71

9.1 Most serious problems for the organisation

as a whole 73

9.2 Most serious problems for each category of staff 73

9.2 Most serious problems within each of four

categories of problems 75

9.4 Concluding comments 76

SECTION 10: PATIENT PERSPECTIVES 77

10.1 Relationship with nurses and doctors 77

Discussion 80

10.2 Levels of satisfaction with various aspects of

hospital services 81

Summary 83

10.3 Experience of unethical behaviour by hospital staff 83

10.4 Treatment by student nurses and student doctors 84

Discussion 86

10.5 Various ethical issues 86

Salient points 89

10.6 Concluding comments 89

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SECTION 11: CONCLUSIONS AND RECOMMENDATIONS 91

11.1 Conclusions 91

The foundation 92

First pillar: General organisational culture 93

Second pillar: Clinical care culture special to a

hospital as an institution 93

The pinnacle 93

11.2 Recommendations 93

Management and leadership 94

Human resources 96

Material resources 98

Admissions 101

Discipline and ethics 101

Patient care 103

Gauteng Department of Health and the Treasury 104

APPENDICES 105

Appendix 1: Letter accompanying questionnaires,

addressed to respondents 105

Appendix 2: Questionnaire: Management 107

Appendix 3: Questionnaire: Doctors 117

Appendix 4: Questionnaire: Allied Health Professionals 127

Appendix 5: Questionnaire: Nurses 137

Appendix 6: Questionnaire: Support Staff 147

Appendix 7: Questionnaire: Patients 157

Appendix 8: National Patients� Rights Charter

(National Department of Health) 163

Appendix 9: Mission Statement:

Chris Hani Baragwanath Hospital 167

v

LIST OF TABLES

Table 2.1: Comparison of designed and realised samples 13

Table 3.1: Average working experience by employee category 16

Table 3.2: Returning patients (How many times have you

been a patient?) 17

Table 4.1: Do you experience an under-supply of medicine

at CHBH? 21

Table 4.2: Do you experience a general shortage of line

at CHBH? 22

Table 4.3: Reasons for under-supply of medicine 22

Table 4.4: Reasons for linen shortage 24

Table 4.5: Perceptions about safety and security measures 28

Table 5.1: Ratings of organisational values 37

Table 5.2: Rank ordering of values 37

Table 5.3: Ratings of professional values 38

Table 6.1: Leadership, management, and channels of

communication 47

Table 6.2: Perceptions of channels of communication 53

Table 7.1: Perceptions of job satisfaction 57

Table 7.2: Perceptions of conditions of service 58

Table 8.1: Rank ordering of instances of misconduct 63

Table 8.2: Clinical staff�s observations of instances of

misconduct 66

Table 8.3: Reasons for misconduct 67

Table 9.1: Ratings of the main problems 71

Table 9.2: Most serious problems identified by doctors 73

Table 9.3: Most serious problems identified by nurses 74

Table 9.4: Most serious problems identified by allied health

professionals 74

Table 9.5: Most serious problems identified by support staff 75

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Table 10.1: Assistance by nurses on day duty 81

Table 10.2: Assistance by nurses on night duty 81

Table 10.3: Quality of medical treatment received 82

Table 10.4: Linen on your bed 82

Table 10.5: Quality of food 82

Table 10.6: The room you are in 82

Table 10.7: Incidents of unethical behaviour experienced

by patients 84

Table 10.8: Do you mind being cared for by student nurses? 85

Table 10.9: Do you mind being examined by student doctors? 85

Table 10.10: Patients who give money to staff at CHBH for

services or treatment act wrongly 87

Table 10.11: Staff at CHBH do not have sufficient time to treat

patients with the necessary compassion and

understanding 87

Table 10.12: Language barriers make it difficult for staff to

convey to patients proper information about their

diagnosis and treatment 87

Table 10.13: I sometimes find it difficult to understand what

doctors tell me about my illness 88

Table 10.14: I am always told what is wrong with me and why

certain medicines are given to me 88

Table 10.15: I usually find it easy to understand what nurses

tell me about my illness 88

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LIST OF FIGURES Figure 3.1: Age distribution of sample 15

Figure 3.2: Age distribution of patients 16

Figure 4.1: Physical plant: Clean to dirty ratings (staff and patient rating) 19

Figure 4.2: Physical plant: Safe to unsafe ratings (staff and patient rating) 20

Figure 4.3: Physical plant: Attractive � unattractive ratings (staff and patient rating) 20

Figure 4.4: Physical plant: Cheerful � depressing ratings (staff and patient rating) 21

Figure 5.1: Honest � dishonest 31

Figure 5.2: Respectful � disrespectful 31

Figure 5.3: Loyal � disloyal 32

Figure 5.4: Trusting � distrusting 33

Figure 5.5: Professional � unprofessional 33

Figure 5.6: Relaxed � tense/stressed 34

Figure 5.7: Ratings of doctors by others 43

Figure 5.8: Ratings of nurses by others 43

Figure 6.1: Management takes suggestions from below

seriously 49

Figure 6.2: There are proper incentives to improve staff

performance 49

Figure 6.3: Staff members have a say in decision making 50

Figure 6.4: Hospital management is clear about employees�

career prospects 50

Figure 6.5: Top management has no secrets from employees 51

Figure 6.6: Management at CHBH is basically powerless 51

Figure 10.1: Nurses and doctors: Respectful � disrespectful 78

Figure 10.2: Nurses and doctors: Professional � unprofessional 78

Figure 10.3: Nurses and doctors: Relaxed � tense 78

Figure 10.4: Nurses and doctors: Caring � uncaring 79

Figure 10.5: Nurses and doctors: Compassionate � cold 79

Figure 10.6: Nurses and doctors: Approachable � unapproachable 79

Figure 10.7: Nurses and doctors: Trusting � distrusting 80

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LIST OF BOXES

Box 4.1: Medicine supply and control 23

Box 4.2: Linen shortage 25

Box 4.3: Theft of linen and equipment 25

Box 4.4: Budget 26

Box 4.5: Equipment 27

Box 4.6: Security concerns 28

Box 5.1: Respect for other professionals 32

Box 5.2: Professionalism and professional ethics 33

Box 5.3: Ethical values 34

Box 5.4: Discipline 35

Box 5.5: Staff relationships 35

Box 5.6: General working conditions 36

Box 5.7: Patient care related issues 39

Box 5.8: Problems encountered with patient admission 40

Box 5.9: Problems encountered with patient discharge 41

Box 5.10: Patient care and HIV/AIDS pandemic 41

Box 5.11: In-service and continuing education and training 44

Box 5.12: Need for team building 44

Box 6.1: Involvement of staff in decision making 48

Box 6.2: Management and leadership 52

Box 6.3: Communication 54

Box 7.1: Incentives 58

Box 7.2: Staff shortages 59

Box 8.1: General observations about staff misconduct 64

Box 8.2: Ethics and disciplinary committees 69

Box 10.1: Treatment by student nurses 85

Box 10.2: Treatment by student doctors 86

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LIST OF DIAGRAMS

Diagram 1.1: Conceptual framework for data collection

and analysis 8

Diagram 11.1: A hospital as an institution: Foundation,

cultural pillars, and pinnacle 92

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ACKNOWLEDGEMENTS

The authors wish to commend the Chief Executive Officer (CEO) of Chris

Hani Baragwanath Hospital (CHBH), Reg Broekmann, who had the

courage of his conviction to commission this audit in the same year that

he took charge of the management of what is said to be the world�s

largest hospital. He faces a daunting task, within a public health-care

system under severe strain due to transformational changes, inadequate

budgetary provisions, an HIV/AIDS pandemic of momentous proportions,

and the like.

A number of people contributed significantly to various aspects of this

project. We wish to express our sincere gratitude to all of them. They are:

• Catharine Payze (University of South Africa), for conducting the

focus-group interviews at CHBH, and Marius van Wyngaard (Alpha

Transcriptions), for recording and transcribing them

• Brigitte Smit (University of Pretoria), for processing the data

generated by the focus-group interviews

• Brigitte Smit (University of Pretoria), Lesley Henley (University of

Cape Town), Donna van Bogaert, Percy Mahlati (CEO, South African

Medical Association), Ingrid Lohr (Ethics Resource Center,

Washington, DC, USA), and Catharine Payze (University of South

Africa), for participating in the workshop where we developed the

framework for the six questionnaires

• Joshua Joseph (Ethics Resource Center, Washington, DC, USA),

Lesley Henley (University of Cape Town), and Donna van Bogaert,

for critical comments on the questionnaires

• Jean Johnstone, Phinda Magwaza, Peggy Mohlamme, Claude

Mondzanga, Vis Naidoo, Salome Mothopi, Noxolo Nhose, Alice

Serobatse, and Johanna Sethsedi at CHBH, and Dorah Thekwe (St

Johns Eye Hospital), for assisting with arduous fieldwork at the

hospital

• Marthie van Niekerk (University of Stellenbosch), Dawie van

Niekerk, Maria Mouton (University of Stellenbosch), Charline

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Mouton, and Nelius Boshoff (University of Stellenbosch), for the

data capturing

• Nelius Boshoff (University of Stellenbosch), for the data formatting

• Lesley Henley (University of Cape Town) and Donna van Bogaert,

for critical comments on the recommendations

• Annelize Worst (Ethics Institute of South Africa), for preparing the

manuscript for publication

The Ethics Institute of South Africa (EthicSA) wishes to acknowledge the

financial support of The Merck Company Foundation, based in New Jersey

in the United States of America, which funds EthicSA�s infrastructure while

safeguarding its complete independence and integrity. The Merck

Company Foundation is a constituent of Merck and Company, the

multinational pharmaceutical company.

Willem A. Landman

CEO, Ethics Institute of South Africa

Johann Mouton

Director, Centre for Interdisciplinary Studies

University of Stellenbosch

Khanyisa H. Nevhutalu

Operations Director, Ethics Institute of South Africa

Pretoria

South Africa

2 November 2001

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EXECUTIVE SUMMARY

1. Background and objectives of the ethics audit

Various studies and surveys during recent years have highlighted that public

hospitals in South Africa are in a precarious state. Staff shortages, deteriorating

infrastructure, increased centralisation, equipment failures and shortages, and

an increased influx of (especially HIV/AIDS) patients, have all been identified as

factors contributing to a progressively worsening public health-care situation. In

the final analysis, such conditions seriously compromise the quality of patient

care.

An in-house survey, done in May 2000, found many of these problems exist at

Chris Hani Baragwanath Hospital (CHBH) as well. In addition, there were

indicators that the ethical fabric of the hospital was seriously problematic.

Towards the end of 2000, and against this background, CHBH approached the

Ethics Institute of South Africa (EthicSA), requesting it to undertake a

comprehensive ethics audit of the hospital. This study reports on the results of

the audit.

The specific objectives of the study were formulated as follows:

1. To identify the key ethical issues and problems that live in the �minds� of

the various �actors� in the hospital.

2. To establish what the general working environment is like at CHBH, and

the possible effects that factors in that environment might have on the

personal and interpersonal conduct of employees.

3. To describe in detail the �ethics culture� at CHBH by identifying the

salient attitudes, beliefs and values employees hold and the way in which

these affect everyday conduct in the hospital.

2. Research design and methodology

With a view to addressing these objectives rigorously and objectively, a design

consisting of three major phases was developed.

xiii

• First phase: Focus groups

In order first to identify the key ethical issues in the hospital (the first objective),

during April 2001 focus-group interviews were conducted with the five main

�categories of health personnel�, namely, central hospital management, doctors,

nurses, allied health professionals, and support staff. A sixth group consisted of

patients. Each group comprised of 8-12 individuals, except for the management

group that consisted of four individuals. The main purpose of the focus-group

interviews was to gather initial information that would reveal trends indicative of

ethical problems in the organisation. The main categories for the questionnaire

were developed on the basis of these discussions.

Second phase: Design and construction of pilot questionnaires

Six questionnaires, one for each of the subgroups, were then developed. Pilot

versions of each questionnaire were distributed in the hospital during July 2001.

The results of this pilot study were captured and analysed statistically. This led to

changes to all versions of the questionnaire. As a final check, the revised

questionnaires were sent to a panel of experts for comments. The final versions

of the six questionnaires were completed early August 2001.

Third phase: The ethics survey

The main component of the study was a sample survey conducted at CHBH. A

stratified multistage sampling design was used. Approximately 1 200

questionnaires were hand distributed with the help of staff and under the

supervision of one of the authors. This took place during the latter part of August

and early September 2001. On the basis of information provided to the research

team by the hospital, we were able to stratify the population into six categories.

3. Sample profile

The analysed dataset consists of 772 members of staff and 205 patients.

Concerning staff, a comparison between the sample categories and the overall

staff complement confirmed the representativeness of the sample. The salient

demographic features of the sample are as follows:

• Respondents were predominantly female (70%), with 30% male.

• When asked to indicate whether they belonged to a labour union, 89% of

respondents answered in the affirmative.

• The average respondent was at the hospital for 14 years, with no

differences between male and female employees.

xiv

Concerning patients, the following describes the main demographics of this

sample:

• In respect of gender, 65% of the 205 patients were female, 35% male.

• The vast majority of patients interviewed (95%) said that they were South

African citizens.

• Slightly more than a third (34%) indicated that they were first-time

patients at CHBH.

4. Physical plant/infrastructure, material resources,

and security

This section covers three aspects of the environment: the physical plant

(buildings), resources (especially medicine and linen), and security arrangements.

• Majorities of staff (on average) rated the buildings as dirty, unsafe, and

unattractive. Ratings by patients were, on the whole, very similar.

• A majority of staff (51%) indicated that there was, in their opinion, an

under-supply of medicine.

• A substantial majority (86%) of staff indicated that there was a general

shortage of linen at CHBH.

• In both cases � under-supply of medicine and linen shortage � cuts to the

health-care budget were cited as the most important reason for these

problems.

• More than two-thirds of staff agreed that the number of security staff was

inadequate (64%), and that they were poorly equipped to do their job

(76%).

• A majority of staff (57%) also believed that screening of visitors was

problematic.

• Nearly three-quarters (73%) were of the opinion that it was government�s

responsibility to ensure a safe environment.

Three summary conclusions can be drawn:

• The overwhelming majority of staff viewed the physical environment as

unacceptable.

• The shortage of linen was regarded as a much bigger problem than the

under-supply of medicine. In both cases staff listed a combination of

contributing factors.

• There is a huge lack of confidence in the capacity and ability of security

staff to ensure a safe environment.

xv

5. Organisational culture and values

Perceptions of staff relations:

• Two out of every five staff members were negative about various aspects

of staff relations, between 15 and 20% were undecided, with the

remaining 30-45% more positive.

• The one exception relates to whether staff relations are relaxed or tense

(stressed), a majority of staff (57%) rating this aspect negatively.

• It is clear from qualitative comments that morale is low and that most staff

members do not think that enough is being done to promote and establish

a healthy working climate in the hospital.

Organisational values:

In response to the question which of a number of values CHBH stands for, the

responses (in descending order of importance) are as follows:

• Serving the greatest number of patients possible (75%)

• Avoiding bad publicity (50%)

• Not having strikes and social unrest (45%)

• Balancing the books (38%)

• Good work ethic (35%)

• Providing the best possible working environment (32%)

These results show that more �administrative values� (number of patients served;

publicity; balancing the books/financial issues; good order) are valued higher than

a good work ethic and having a good working environment.

Professional values:

• Staff is clearly divided about whether doctors and nurses care for patients,

with 50% (on average) saying that doctors and nurses show sufficient

commitment to various aspects of patient care (�care� means compassion

for patients, confidentiality of patient information, and respect for the

dignity and well-being of patients), while the other 50% was split evenly

between 25% undecided and 25% negative about/disagreeing with the

quality of patient care.

• Concerning differences between the ratings of clinical-care provision by

doctors and nurses (as perceived by other staff members), the results

clearly reveal a significant gap, with doctors being rated higher than nurses

xvi

6. Leadership, management and channels of communication

Main points:

• There is little evidence of a participatory management culture, with three-

quarters (76%) of staff indicating they had no say in decision making. An

even higher proportion of doctors - 84% - held this view.

• There is clearly an insufficient degree of transparency in the hospital. This

is evidenced by rumour (the �grapevine�) being an important source of

information, too little communication between management and staff, and

too much secrecy.

• According to respondents, there is not enough commitment on the part of

central hospital management to staff development, incentives are

inadequate, and performance evaluations are insufficient.

• A substantial proportion of staff (45%) did not believe that employees

were allowed to say what they really thought.

• Communication between employees and their supervisors is less than

optimal - 50% of staff said their complaints had not been acted upon, and

nearly two-thirds (65%) said they had not received regular feedback from

their supervisors.

• A clear majority (54%) of staff also did not believe that there was a

system in place for reporting instances of misconduct.

• The fact that 62% of staff said that rumour was a common source of

information in the hospital is yet another indicator that existing channels of

and procedures for communication were regarded as inadequate.

One�s overwhelming impression, having analysed the data on management and

communication, is of an organisation that does not treasure participation and

consultation in decision making, where views of ordinary staff members do not

matter, and where opportunities for constructive communication are limited, if not

non-existent.

7. Human resources issues

Key findings:

• Respondents are generally satisfied with their jobs, and they find their jobs

interesting and even stimulating.

• Two-third of staff (66%) is proud to be associated with CHBH.

xvii

But there are also some less positive results:

• A very large proportion of staff (40%) frequently thought of quitting their

jobs.

• A clear majority (58%) felt as if they were working for a �second-class�

hospital.

• There was general dissatisfaction with salaries (75%) and workloads

(66%).

• Large proportions (over 50%) were dissatisfied with conditions of service

and prospects for promotion.

We believe that these results lead to two major conclusions:

• There is a kind of �split image� at work here. On the one hand, there is the

positive legacy or ideal of CHBH, but, on the other, its quality is declining �

or, rather, that is the perception.

• Although staff is positive about their own jobs and job contents, they are

very negative about staff development (no prospects for promotion; high

workload).

8. Misconduct and standards of care

Our key finding is that the extent of misconduct � as reported by staff � is serious

and points to a situation that is not conducive to professional and responsible

patient care. The following are some of the more salient points to emerge from

this analysis:

• There is widespread (physical and verbal) abuse of staff by patients, as

well as incidents of abuse of patients.

• This result is confirmed by the fact that nearly half of staff said that they

had observed incidents of negligence in patient care, and nearly one-third

indicated having witnessed substandard post-operative care.

• There is strong evidence that patients� rights are being violated - nearly

two out of every five staff members indicated that they had witnessed

incidents where informed consent had not been obtained, and one-third

said they had seen incidents where confidentiality of patient information

had been breached. These results are supported by evidence provided by

patients themselves.

• Although other forms of misconduct, such as bribery and over-ordering of

medicine, do not seem to occur as frequently as the ones listed above, it

must be emphasised that these are nevertheless transgressions of basic

ethical principles and require urgent attention.

xviii

•

• Given reported staff shortage, the fact that such a huge proportion of staff

(37%) seems to be involved in some form of moonlighting, clearly

warrants further investigation.

Responses suggest four clusters of possible reasons for observed instances of

misconduct.

• The reasons having most support among staff concern the lack of punitive

measures - no real or visible disciplining of misconduct occurs (60% of

staff)

• Working conditions - the heavy workload that leads to inadequate attention

to care (60% indicated it as a main reason)

• No consensus about ethical values - there is clearly insufficient agreement

about the meaning of misconduct as evidenced by the fact that substantial

proportions of respondents do not believe �tipping� and �fraud� to be

wrong.

• The demographics of patients, especially the existence of language

barriers, lead to misunderstanding and possibly abuse (about 50%-50%)

9. Problems and sources of stress

What are the main problems and sources of stress experienced and identified by

CHBH staff? We presented staff with 20 possible problems and asked them to

indicate which of these they rated as being the most serious problems.

Key findings:

The six most serious problems for the organisation as a whole are the following:

• Shortage of staff (83.1%)

• Linen shortage (70.9%)

• Substandard care because of large numbers (67%)

• Poor remuneration (65.5%)

• Unhygienic conditions (63.6) and lack of safety (63.4%)

• Poor maintenance of buildings (60.8%)

The five most serious problems for each category of staff are as follows:

• Doctors - general shortage of staff; unsanitary/unhygienic conditions;

poor/outdated equipment; poor remuneration; and long shifts

• Nurses - general staff shortage; linen shortage; substandard care because

of large numbers; poor remuneration; and lack of safety

xix

•

• Allied health professionals - general shortage of staff; poor maintenance of

buildings; poor remuneration; lack of safety; and poor staff communication

• Support staff � general shortage of staff; linen shortage; poor staff

communication; substandard care because of large numbers; and poor

remuneration

Concluding comments:

It is significant that the same basic issues (staff shortages; linen shortages;

substandard care; poor remuneration; lack of safety; and unhygienic conditions)

are recurring problems and sources of stress across all staff categories. This

suggests that these problems are hospital-wide and prevalent across departments

and staff functions, and, therefore, should receive urgent attention.

10. Patient perspectives

The views of patients were integrated into the report where they related to issues

common to all categories of respondents. Our attention here is on patients�

perspectives as they pertain to other issues.

Majorities of patients rated nurses and doctors as respectful, professional, caring,

approachable, and trustworthy. Although these figures, in broad outline, do

present a positive picture and might give cause for complacency, it is still worth

pointing out the following:

• 15% of patients viewed nurses and doctors as being disrespectful

• 22% of patients viewed nurses as being unprofessional

• 20% of patients experienced nurses as being uncaring and cold

• 19% of patients said nurses were unapproachable

• 20% of patients rated nurses as being distrusting

Expressed as numbers of patients, these findings relate to the actual experiences

of hundreds of patients (more than 500) in the hospital at any given time.

In order of satisfaction (combining �very satisfied� and �satisfied�), patients

indicated that they were the most satisfied with the following:

• Assistance received from nurses on day duty (74%)

• The quality of medical treatment received (74%)

• Assistance received from nurses on night duty (65%)

• Their rooms (62%)

• The quality of food (61%)

• The linen on their beds (58%)

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•

Salient points:

• The vast majority of patients (70%) agreed that giving money to staff for

treatment was wrong.

• A similar proportion of patients (71%) agreed that hospital staff did not

have sufficient time to treat them properly.

• Language barriers between staff and patients are a serious problem given

that three-quarters of patients said that such barriers posed difficulties for

mutual understanding. A similar proportion of patients (72%) indicated

that they had had problems understanding what doctors had told them

about their illness.

• Nearly two-thirds of patients (64%) claimed that they had not been told or

informed what was wrong with them and why they had received certain

kinds of medication.

• There seems to be better communication between patients and nurses,

with 62% of patients indicating that they found it easy to understand what

nurses told them about their illness. By contrast, almost three-quarters of

patients (72.5%) sometimes found it hard to understand what doctors

tried to communicate to them about their illness.

One�s overarching impression is that most patients are not well informed about

their illness, or the reason for the treatment or medication they receive, which are

basic patients� rights.

Concluding comments:

• Majorities of patients (ranging between 65 and 75%) rated nurses as being

respectful, professional, relaxed, compassionate, and the like. A small

minority of 10-20% of patients rated nurses to be disrespectful,

unprofessional, uncaring, and the like. However, it is interesting � and a

cause for concern � that nurses and doctors consistently received different

ratings for clinical care. These results are in line with earlier findings -

doctors get more positive ratings, within a range of 15�20% higher ratings

on all dimensions.

• Patients are mostly satisfied with the assistance and quality of medical

treatment they received. They are less satisfied with their rooms and the

quality of food, and least satisfied with the linen on their beds.

xxi

• There are unacceptably high levels of verbal abuse, especially by nurses

and support staff, patient information is not always treated in confidence,

and the quality of health care and professionalism leaves much to be

desired. These results are cause for grave concern and require immediate

action by hospital management.

• Relatively small proportions of patients indicated reservations about being

examined by student nurses and student doctors. Common reasons for

such reservations relate to perceived lack of professionalism, inexperience,

and possible lack of quality care.

• Concerning informed consent and general sharing of medical information,

most patients are not well informed about their illness or the reasons for

treatment or medication regimes.

xxii

1

SECTION 1 INTRODUCTION

1.1 Background

Almost on a daily basis, media reports describe the conditions of public

hospitals in South Africa as �appalling�, �shocking�, or, putting it more

strongly, as being in �dire straits�. In addition, numerous accounts of

profoundly unprofessional and unethical conduct often border on the

surreal. Health-care professionals, particularly doctors and nurses, in

public hospitals are reported to work in harsh and often squalid

conditions. In addition, extreme power differentials between nurses and

their poor, often illiterate or semi-literate, patients continue to exist. It is,

therefore, not surprising that nurses have been reported to employ

humiliation, verbal coercion and even physical violence to assert their

authority and control patient behaviour.1

The media regularly reports on alleged misconduct by doctors and other

health-care professionals. In November 2000, five months before the end

of that financial year, hospitals in the Eastern Cape ran out of money for

medicines and food for patients.2 In January 2001, a nursing sister at

Natalspruit Hospital�s paediatric department was reported to have been

haunted by the crying of babies. She and two of her colleagues took care

of more than sixty ill babies, aged between one and 12 months, in two

12-hour shifts a day. Their working conditions are not unique in what

appears to be an emerging trend in many public hospitals, plagued by a

variety of inadequacies, such as ageing buildings, a shortage of

equipment and medicines, understaffed units, and a growing population

of patients.3

Some of the hospitals were built as far back as 1860. Natalspruit Hospital

was constructed in 1973, but some of the buildings are said to be in a

state of disrepair. Over the past two years, the staff complement at

1 Tagwireyi, S. (2001). Public hospitals in dire straits. Mail & Guardian, 2-8 February 2001, 11. 2 Jewkes, R. et al. (1998). Why do nurses abuse patients? Reflections from South African Obstetric Services. Social Science and Medicine, 47(11):1781-1795. 3 Tagwireyi, S. (2001). Public hospitals in dire straits. Mail & Guardian, 2-8 February 2001, 11.

2

Natalspruit has shrunk from 1 093 to 871. Resigned nurses have not been

replaced. The remaining staff has been put under immense pressure by

having to cope with an average of 15 000 patients per month. The

situation is further aggravated by the impact of HIV/AIDS. �Admission is

around 110% and sometimes goes up to 140%�.4 A hospital the size of

Natalspruit needs about R106,5 million a year to function properly;

however, according to matron Khumalo at the hospital, government

allocates only 75% of that amount. 5

According to a media report6, doctors and hospital superintendents in

Gauteng presented a memorandum to the province in November 1998,

warning that �patients will die� if staff and budgetary cutbacks at

hospitals were not halted.7 The memorandum reads as follows:

�We cannot in good conscience accept that financial constraints will

mandate the collapse of health services in Gauteng. We are tired of

being held responsible by patients for dirty wards, long queues, no

beds, unfriendly and inadequate services. It is time for those in

power to stand up and be accountable for this crisis in public

hospitals�.

Hospital superintendents warned that health services were heading

toward �irreversible collapse�. During the same period, four babies at

Chris Hani Baragwanath Hospital (CHBH) died of klebsiella, a condition

resulting from unhygienic conditions. Only four nurses were on duty to

care for 35 babies in intensive care (IC), while the standard of care would

recommend a minimum ratio of one nurse for every two babies.8

An audit9 commissioned by the government in 1996 to investigate the

state of public hospitals nationwide, similarly reflected a bleak picture.

The report indicated that about 30% of hospitals are in a serious crisis,

11% of these need to be replaced, while 19% need major upgrading. The

audit report recommended that in order to remedy the deteriorating

4 Ibid. 5 Ibid. 6 Ibid. 7 Ibid. 8 Ibid. 9 Ibid. Despite numerous efforts by EthicSA, we were unable to obtain a copy of the original audit report from the Gauteng Department of Health.

3

condition of public hospitals, government has to review the state of most

of its 359 hospitals, upgrade some and replace others altogether.

According to Dr T Sibeko, the then Director of Hospitals in the Gauteng

Department of Health (DOH), �hospitals have been neglected over the

past years.�10

According to a 1998 study11, many of the patients interviewed reported

clinical neglect, and verbal and physical abuse by nursing staff, which was

at times reactive and, at others, ritualised in nature. Analysis of the data

revealed a complex interplay of concerns including organisational issues,

professional insecurities, a perceived need to assert �control� over the

environment, sanctioning of the use of coercive and punitive measures to

that end, and an underpinning ideology of patient inferiority. The study

asserts that the use of violence has become commonplace because of a

lack of local accountability for services and a lack of action by managers

and higher levels of the profession against nurses who abuse patients.12

The lack of a powerful competing ideology of professional patient care and

nursing ethics was identified as one of the factors leading to deterioration

in nurse-patient relationships, which became considered as �normal� in

nursing practice.

The national DOH13 emphasised government�s commitment to improve

the quality of care provided in the public health sector as a key challenge

during the next four years. The department highlighted the following as

critical: (1) the role of health-service users in ensuring that their needs

are met, and (2) the quality of care being of acceptable standard. The

DOH asserted that health-care providers also have an important role to

play in improving quality of care in the public health sector.

Worldwide, popular and professional discourses characterise nursing as a

profession of dedicated staff, exhibiting qualities of care, nurturing,

10 Ibid. 11 Jewkes, R. et al. (1998). Why do nurses abuse patients? Reflections from South African Obstetric Services. Social Science and Medicine, 47(11):1781-1795. 12 Ibid. 13 National Department of Health (1999). Health Sector Strategic Framework (1999-2004).

4

comfort and concern, and motivated by the desire to help people.14 The

same convictions and ideals are cherished and valued by the medical and

allied health professions. Nevertheless, the South African public health-

care situation is both intricate and confusing. A survey conducted in April

1999 by the Gauteng provincial government on the state of five public

hospitals in the province � namely, CHBH, Natalspruit Hospital, Pretoria

Academic Hospital, Sebokeng Hospital and Thembisa Hospital - identified

the following problems: poor management, shortage of staff and

medicines, long queues, and poor staff behaviour.15 The survey report

stated that surgical procedures had been compromised by a shortage of

basic supplies and services, and that nurses who had resigned from some

of these hospitals had not been replaced. This resulted in the remaining

staff working under stressful conditions with an average of 15 000

patients per month in some of these hospitals.

Sibeko blamed bad management for the poor state of most of the

province�s hospitals.16 This resulted in misconduct as well as ethically

unacceptable behaviour and attitudes of doctors and nurses.

According to the South African Health Review 200017 issued by the Health

Systems Trust (HST), the combined levels of bed provision in central and

tertiary hospitals in Gauteng and the Western Cape significantly exceed

the affordable norms of the Health Strategy Project (HSP). The HST

recommends that beds in these institutions be reduced in order to shift

funds to the resourcing of beds in feeder facilities. Alternatively, central

and tertiary hospitals should be resourced appropriately for multiple levels

of care. Lack of clarity about the levels of care provided in affected

hospitals impedes national planning. Capital infrastructure and equipment

are deteriorating at levels significantly exceeding existing spending on

rehabilitation, maintenance and replacement. The HST argues that

hospitals in a very poor condition (grade 1-2) would in most cases be

14 Davis, A.J. and Aroskar, M.A. (1983). Ethical dilemmas and nursing practice, 2nd edition. Norwalk: Appleton-Century-Crofts. 15 Tagwireyi, S. (2001). Public hospitals in dire straits. Mail & Guardian, 2-8 February 2001, 11. 16 Ibid. 17 Health Systems Trust. South African Health Review 2000. http://www.hst.org.za/sahr/2000/chapter11.html (Chapter 11: �Hospital restructuring�, authored by Boulle, A., Blecher, M., and Burn, A.)

5

written off. Data on the national pool of medical equipment are poor.

Models by the national DOH suggest serious problems with deterioration

of medical equipment. Models of replacement and maintenance suggest

an annual requirement of R1,02 billion per year. Backlogs of medical

equipment, repairs and maintenance exist in much of the country.

The HST review advises, however, that the key to efficient utilisation of

hospital services is the strengthening of the integrity of the various levels

of care and the referral systems between them, based on a clear

understanding of the differential costs of treating patients at the various

levels in the health-care system. Real increases in funding for hospital

services have on aggregate not translated into increased staffing or

outputs, but are likely to have been spent largely on increased salaries

and benefits.

A wide-ranging survey of the ethics of South African doctors� business

practices, conducted by the Ethics Institute of South Africa (EthicSA) in

2000, yielded strong evidence of widespread unethical business practices

among the country�s doctors (general practitioners and specialists),

including those in the public sector.18, 19

Given this background, EthicSA is convinced that there is a wide range of

issues relating to the (business) ethics of organisational and management

performance, involving public hospitals� organisational relationships with

employees, contractors, the public, and government. A second set of

issues relates to the (clinical) ethics, of relationships between health-care

professionals (doctors, nurses, and others) and patients. These two areas

of ethical concern - business and clinical ethics - are often interrelated,

and both form aspects of the organisational ethics of a hospital as an

institution.

18 Landman, W.A. and Mouton J. (2000). A Profession Under Siege? Medical Practice and Ethics in South Africa. Pretoria: Ethics Institute of South Africa, 4pp (Technical Report No. 1). 19 Landman, W.A. and Mouton J. (2001). A Profession Under Siege? Medical Practice and Ethics. Pretoria: Ethics Institute of South Africa, 93pp. (Research Report No. 1).

6

It is against this background that EthicSA was approached to undertake

an exploratory study of CHBH in order to examine (audit) its ethics

culture, commonly known as an �ethics audit�. We also wished to

ascertain the root causes of the reported appalling conditions at the

hospital, rather than concentrate merely on manifestations or symptoms

of poor performance of CHBH as an institution.

1.2 Research aims

The problems identified by the survey20 of five hospitals in Gauteng in

April 1999, highlighted the need for appropriate remedies. However, an

appropriate remedy requires identifying the nature of the organisation�s

problems by conducting an enquiry into its performance. One forms of

enquiry normally conducted is an ethics audit to assess the values and

beliefs, as well as the specific actions informed by them, of individuals or

personnel employed by an organisation.

The CHBH, situated on the outskirts of Soweto, has been considered

Africa�s largest hospital, and the largest in the southern hemisphere. In

1997, CHBH was entered in the Guinness Book of Records as the largest

hospital in the world, a claim that has, to our knowledge, not been

challenged. It has 3 400 authorised beds, of which 2 888 were occupied at

the time of writing. It caters for more than two million patients/clients per

calendar year, from Soweto and surrounding areas, with a staff

complement of 4 885 (in all categories of workers).

CHBH is a public hospital. The vast majority of South Africans (86%) are

not members of medical schemes, and are consequently completely

dependant on the public tier of our public/private health-care system. And

public hospitals account for 62% of public sector health expenditure.21

20 Tagwireyi, S. (2001). Public hospitals in dire straits. Mail & Guardian, 2-8 February 2001, 11. 21 Health Systems Trust. South African Health Review 2000. http://www.hst.org.za/sahr/2000/chapter11.html (Chapter 11: �Hospital restructuring�, authored by Boulle, A., Blecher, M. and Burn, A.).

7

Currently, CHBH does not have enough doctors or nurses to cope with

demands. Its resources and infrastructure are poor by world standards, as

well as South African standards. CHBH, like any organisation, is located in

� and influenced by - a larger environment, which includes people, other

organisations, social and economic forces, and public-policy and legal

constraints. More specifically, the environment includes markets (clients

or customers), suppliers, government and regulatory bodies, and

technological and special-interest groups.

In May 2000, CHBH conducted an in-house survey22. Areas covered by

the survey included a few questions on ethics, which indicated that a high

degree of mistrust exists amongst staff members - 57% did not think that

staff at CHBH value honesty; a significant proportion of staff found

corrupt ways to enrich themselves; and when pressed, many staff

members would lie to avoid adverse consequences for themselves.23

Following the survey report, CHBH committed itself to addressing the

problem of �weak ethics� over a five-year period. This current ethics audit

by EthicSA is the first major step by the hospital to address the ethical

problems identified by the earlier in-house survey.

Problems at public hospitals, highlighted by various sources in this

literature review, are complex, requiring multiple solutions. The findings

of the different surveys and audits, and their analyses, provide pointers

towards solutions, but considerable further research into the nature of the

problems and possibilities for change is required. Undoubtedly, the first

step for South Africa is to acknowledge that there is a problem and then

to embrace efforts to investigate it further and seek solutions. This ethics

audit of CHBH is only one step in such a process, but we believe it to be

important in the prevailing compromised circumstances.

The preceding literature review assisted us in developing the following

conceptual framework that guided the data collection and analysis in the

22 Chris Hani Baragwanath Hospital (May 2000): Employment Equity Report and Plan in terms of the Employment Equity Act (Act 55 of 1998). Johannesburg. 23 Ibid.

8

study (see Diagram 1.1 below). The underlying argument of the

framework can be summarised in the following set of premises:

1. Recent studies in South Africa all point to the fact that public hospitals

are under huge and increased pressures in terms of inadequate

funding, deteriorating infrastructure, and insufficient staffing.

2. These conditions in public hospitals put staff under increasing stress

and strain; most health-care professionals work in an �unhealthy�

environment.

3. These factors could - and this becomes the main question of the study

- produce behaviours and practices that are unprofessional and

unethical. It is a commonplace that �normal� patterns of behaviour

become difficult to maintain in �abnormal� circumstances.

Diagram 1.1: Conceptual framework for data collection and analysis

Internal organisational environment of the hospital: policies, procedures, values, culture

The actors:• Management • Doctors • Nurses • Other health

professionals • Support staff • Patients

The health discipline and profession: codes of conduct

The external environment: government, professional bodies, general public

9

1.3 Outline of report

In the next section (Section 2), we present an outline of the research

design and methodology used in this study.

This is followed, in Section 3, by a description of the sample profile.

The remainder of the report is organised as follows around different

categories of the findings:

Section 4: The physical plant/infrastructure, material resources, and

security

Section 5: Organisational culture and values

Section 6: Leadership, management, and channels of communication

Section 7: Human resource issues

Section 8: Misconduct and standards of care

Section 9: Problems and sources of stress

Section 10: Patient perspective

In the final section - Section 11 - we bring together our broad conclusions

in diagrammatic form, and put forward twenty-six recommendations,

based on the data and analysis of this report.

10

11

SECTION 2 RESEARCH DESIGN AND METHODOLOGY

The specific objectives of the study were formulated as follows:

1. To identify the key ethical issues and problems that live in the

�minds� of the various �actors� in the hospital.

2. To establish what the general working environment is like in CHBH,

and the possible effects that factors in the environment might have

on the personal and interpersonal conduct of employees.

3. To describe in detail the �ethics culture� at CHBH by identifying the

salient attitudes, beliefs and values employees hold, as well as the

way in which these affect everyday conduct in the hospital.

In order to address these objectives rigorously and objectively, a design

consisting of three major phases was developed.

2.1 First phase: Focus groups

In order first to identify the key ethical issues in the hospital (the first

objective), during April 2001 focus-group interviews were conducted with

the five main �categories of health personnel�, namely, central hospital

management, doctors, nurses, allied health professionals, and support

staff. A sixth group consisted of patients. Each group comprised 8-12

individuals, except for the management group that consisted of four

individuals. The main purpose of focus-group interviews was to gather

initial information that would reveal trends indicative of ethical problems

in the organisation. The data generated through focus-group interviews

were captured and transcribed and thoroughly discussed during a

workshop of experts held in Pretoria on 24 May 2001. The main

categories for the questionnaire were developed on the basis of these

discussions.

12

2.2 Second phase: Design and construction of

pilot questionnaires

Six questionnaires, one for each of the subgroups, were then developed.

Pilot versions of each questionnaire were distributed in the hospital during

July 2001. The results of this pilot study were captured and analysed

statistically. This led to changes made to all versions of the questionnaire.

As a final check, revised questionnaires were sent to a panel of experts

for comments. The final versions of the six questionnaires (see

Appendices 2-7) were completed early August 2001.

2.3 Third phase: The ethics survey

The main component of the study was a sample survey conducted at

CHBH. A stratified multistage sampling design was used. On the basis of

information provided to the research team by the hospital, we were able

to stratify the population into six categories. Detail on these categories is

as follows:

1. The management group includes the CEO, departmental heads, and

members of the Board of Management, which includes organised

labour unions.

2. The doctors group includes levels of the medical profession across

the board, for example, specialists, general practitioners, and

medical interns.

3. Nurse categories include a range, such as general trained nurses,

midwives, and enrolled nursing assistants.

4. The allied health professions group encompasses a variety of health

professionals, for example, pharmacists, physiotherapists,

occupational health therapists, speech and hearing therapists,

psychologists, social workers, dental therapists, medical scientists,

laboratory technicians, medical technologists, and radiographers.

5. Support staff includes porters, messengers, cleaners, cooks,

drivers, laundry workers, and security officers.

6. Patients are those admitted to any of the wards at CHBH with

chronic, acute, or terminal illnesses. They may also be patients

seen at CHBH�s out-patient departments or special clinics.

13

All questionnaires were hand distributed to participants by the respective

heads of departments or units at CHBH during the latter part of August

and early September 2001. An explanatory letter, addressed to

respondents, accompanied the questionnaires (see Appendix 1). One of

the authors of this report, Ms Nevhutalu, spent more than three weeks in

the hospital ensuring high rates of returns and assisting respondents

where needed. The realised sample is compared with the sample as

designed in Table 2.1 below.

Table 2.1: A comparison of the designed and realised samples

CATEGORY TOTAL

NUMBERSAMPLE

(DESIGNED) SAMPLE

(REALISED)Management 8 8 8Doctors 565 220 124Nurses 2 141 440 421Allied Health Professionals 227 160 88Support staff 1 944 150 131STAFF TOTAL 4 885 978 772Patients (general wards) 100 105Patients (outpatient depts.)

100 100

TOTAL QUESTIONNAIRES

1178 977

All questionnaires were subsequently captured in MS Access 2000. This

enabled us to capture all numeric and textual data. Numeric data were

then exported into SPSS Version 10 for statistical analysis. Cross checks

were made on the data to ensure high quality. A number of statistical

procedures were also run as validation checks.

Of the 1 178 questionnaires distributed in the hospital, a total of 977 were

completed (a sample realisation rate of 84%). In order to ensure

representativeness, the statistical data were subsequently weighted to

correct for any skewness in the sample. The realised sample (977 out of

the population of 4 885) constitutes a sample size of nearly 20%. The

large sample size, together with the stratified design and weighting of

data, have produced a dataset that is representative of the hospital in

every respect.

14

15

SECTION 3 SAMPLE PROFILE

Our design involved drawing two different samples: a representative

sample of staff (see description in previous chapter), and a representative

sample of in-patients and out-patients. We describe the key demographic

features of each sample separately.

3.1 Staff profile

Respondents were predominantly female (70%), with 30% male. The age

distribution of the sample is presented in Figure 3.1 below.

Figure 3.1: Age distribution of sample

When asked to indicate whether they belonged to a labour union, 89% of

respondents answered in the affirmative.

We also asked respondents to indicate how long they had been working at

CHBH. The average respondent was at the hospital for 14 years, with no

differences between male and female employees. There are, however,

significant differences between different employee categories, as is

evident from Table 3.1 below. This Table also includes a column showing

the total years working experience for each category.

0

50

100

150

200

250

Age groups 9 145 246 220 95 13

<21 years

21 - 20

31-40 41-50 51-60 >60

16

Table 3.1: Average working experience by employee category

Employee category N Total years working experience Years working at CHBHManagement 8 24.00 13.50Doctor 117 11.42 7.26Nurse 398 15.68 14.35Allied Health Professional 79 10.51 7.86Support Staff 119 19.75 17.68Total 721 15.19 13.01 3.2 Patient profile

The sample of patients drawn for this study comprises equal proportions

of in-patients and out-patients. Assistance was given to those patients

who could, because of mother tongue preferences or illiteracy, not

complete questionnaires themselves.

In respect of gender, 65% of the 205 patients were female, 35% male.

The age distribution of the patient sample is presented in Figure 3.2

below.

Figure 3.2: Age distribution of patients

The vast majority of patients interviewed (95%) said that they were South

African citizens. Slightly more than a third (34%) indicated that they were

first-time patients at CHBH. Table 3.2 below shows the pattern of

returning patients.

0

10

20

30

40

50

Age groups 17 39 44 26 28 27

<21 years

21 - 20

31-40 41-50 51-60 >60

17

Table 3.2: Returning patients (How many times have you been a

patient?)

Frequency Percent Valid

PercentCumulative

PercentValid Once before 34 16.6 21.4 21.4

Twice before 40 19.5 25.2 46.5Three times before 21 10.2 13.2 59.7Four or more times before

64 31.2 40.3 100.0

Total 159 77.6 100.0Missing System 46 22.4

Total 205 100.0

18

19

SECTION 4 THE PHYSICAL PLANT/INFRASTRUCTURE, MATERIAL RESOURCES, AND SECURITY

It stands to reason that the environment in which one works and the

material resources (infrastructure, equipment) with which one works are

important factors in determining job satisfaction and overall work

performance. This section looks at three aspects of the environment: the

physical plant (buildings), resources (especially medicine and linen), and

security arrangements.

4.1 The physical plant

Staff and patients were asked to rate various aspects of their physical

environment on a seven-point scale. The results are summarised in

Figures 7.1�7.4 below.

Figure 4.1: Physical plant: Clean to dirty ratings (staff and patient rating)

0

10

20

30

40

50

Clean - dirty

Staff 3.6 1.7 5.1 11.5 25 9.1 44

Patients 24.5 6 7.6 12 9.2 1.6 39.1

1 2 3 4 5 6 7

20

Figure 4.2: Physical plant: Safe to unsafe ratings

(staff and patient rating)

Figure 4.3: Physical plant: Attractive � unattractive ratings (staff and patient rating)

0

10

20

30

40

50

Safe - unsafe

Staff 3.7 3.6 7.5 6.8 18.4 15.1 44.8

Patients 29.4 7.3 7.9 8.5 7.9 2.3 36.7

1 2 3 4 5 6 7

0

10

20

30

40

50

Attractive - unattractive

Staff 4.1 1.7 8.5 10.1 22.3 15.7 37.7

Patients 17.6 4 10.8 9.7 11.9 1.7 44.3

1 2 3 4 5 6 7

21

Figure 4.4: Physical plant: Cheerful � depressing ratings (staff and patient rating)

These figures show that majorities of both staff and patients (50-80% on

average) consistently indicated that the hospital is dirty, unsafe, and

unattractive. These quantitative results are borne out by qualitative

remarks made in the open-ended questions.

4.2 Medicine and linen

Two issues emerged from previous studies as being of grave concern to

hospital managers and staff: under-supply of medicine, and shortage of

linen. We report on these two issues in this section. The first two tables

give the overall responses regarding supply of medicine (Table 4.1 below)

and shortage of linen (Table 4.2 below).

Table 4.1: Do you experience an under-supply of medicine at

CHBH? Frequency Percent Valid Percent

Valid Yes 351 46.1 50.6

No 123 16.2 17.8

Don't know 219 28.8 31.6

Total 693 91.1 100.0

Missing System 68 8.9

Total 761 100.0

0

10

20

30

40

50

Cheerful - depressing

Staff 22.4 7.2 8.2 13.7 20.8 8.7 18.9

Patients 22.9 4.6 9.7 8.6 9.7 2.3 42.3

1 2 3 4 5 6 7

22

Table 4.2: Do you experience a general shortage of linen at

CHBH?

Frequency Percent Valid

Percent

Valid Yes 601 79.0 85.7

No 24 3.1 3.4

Don't know 77 10.1 10.9

Total 702 92.2 100.0

Missing System 59 7.8

Total 761 100.0

As is evident, a majority of staff (51%) indicated that there was, in their

opinion, an under-supply of medicine. A substantial majority (86%) of

staff indicated that there was a general shortage of linen at CHBH.

What are the reasons for the under-supply of medicine? Table 4.3 below

lists the reasons in descending order of importance, whereas Box 4.1

below contains some of the qualitative comments made on this topic.

Table 4.3: Reasons for under-supply of medicine

Very great /

great extent

Moderate extent

Small / No extent

Total

Decreasing health care budget Count 308 42 94 444 % 69.3% 9.5% 21.2% 100.0%HIV/AIDS pandemic Count 281 53 112 446 % 63.0% 11.9% 25.1% 100.0%Influx of non-South African patients

Count 233 67 153 453

% 51.4% 14.8% 33.8% 100.0%Theft of medicines from hospital stocks by staff

Count 195 76 183 453

% 43.0% 16.7% 40.3% 100.0%Over-ordering of medicines by ward sisters

Count 95 82 287 464

% 20.5% 17.7% 61.8% 100.0%

23

To summarise, the main reasons for under-supply of medicine (combining

the first two categories) are:

• Health-care budget decrease (69%)

• HIV/AIDS patients (63%)

• Influx of non-South African patients (51%)

• Theft by staff (43%)

• Over-ordering of medicine (21%)

Box 4.1 Medicine supply and control Zulu speaking female radiographer at Radiology for three years: �Employ more pharmacy workers since there are long queues for medication and to order more; more medication since patients come a long way; some of them do not have money to travel every week because of medication insufficiency.� English speaking female doctor for 18 months at CHBH: �Under-supply of medicine I believe is due mainly to a shortage of funds due to budget cuts.� English speaking female doctor for one year at CHBH: �Proper seating facilities for patients waiting for medication should be provided as there are always long queues.� English and German speaking female doctor for eight years at CHBH: �Pharmacy: no pharmacy assistants � too many mistakes! They don�t bother to phone us with information if something is out of stock � just sent patient home.� Southern Sotho speaking female nurse at the Maternity Section for eight years: �There should be a pharmacist allocated in the special units, e.g. labour ward, who would see to it that adequate medicine is ordered as it is difficult to order for instance once in a week in a quick turnover department.� Zulu speaking female nurse at St Johns Eye Section for ten years: �With regard to medicines, I recommend that the hospital employs other pharmacists and some dispensaries to be open 24 hours and even over weekends and holidays as per needs.� Zulu speaking female nurse at the Medical Section for 13 years: �Supervisors to attend meetings with chief pharmacist regularly and ward pharmacist to visit the ward at least weekly to check the stock.� Northern Sotho speaking male nurse at the Medical Admission Section for one year: �Dispensary to be opened at night (24 hrs); staff given internal accommodation in Bara - like any other hospital; this will help nurses who come on duty early.� Tswana speaking female nurse at Paediatrics for 17 years: �Most outsiders (non-South Africans) are pharmacists. They steal a lot of expensive medicine. They claim that they earn little money � this is a great problem and a great concern for us South Africans.�

24

Box 4.1 (continued) Xhosa speaking female nurse at Psychiatric Department for 15 years: �I think the new government has introduced free medicine to all. Has created a big problem because government is trying for each patient to get medicine by supplying cheap stuff for medicine that makes them to come to hospital every day.� Swazi speaking female nurse at the General Section for 12 years: �Medicine should be given according to the needs of each department and not according to the needs of each pharmacy's preference or representatives� demands. As there is a high death rate related to AIDS, our patient might also attack staff members.�

Concerning linen shortage, Table 4.4 below summarises the main reasons

(organised in descending order of importance).

Table 4.4: Reasons for linen shortage

Very great / great extent

Moderate extent

Some / Very little

extent

Total

Decreasing health care budget

Count 352 76 144 572

% 61.6% 13.3% 25.2% 100.0%Increased patient population related to the HIV/AIDS pandemic

Count 333 88 170 591

% 56.3% 14.9% 28.8% 100.0%Ineffective logistical and practical arrangements

Count 307 137 124 569

% 54.0% 24.2% 21.9% 100.0%Stealing of linen by hospital staff

Count 293 79 230 601

% 48.7% 13.1% 38.2% 100.0%Linen theft committed by patients

Count 132 97 351 580

% 22.8% 16.7% 60.5% 100.0%

Summary of reasons for shortage of linen:

• Health-care budget decrease (62%)

• HIV/AIDS patients (56%)

• Ineffective logistics (54%)

• Theft by staff (49%)

• Theft by patients (23%)

25

We have included two boxes on the issue of linen shortage. The first box

(Box 4.2 below) contains comments about linen shortage in general; the

second (Box 4.3 below) lists remarks that specifically comment on the

theft of linen and other hospital equipment.

Box 4.2 Linen shortage English speaking male therapist at the Rehabilitation Section for 18 months: �Possibly contracting of laundry services to outside/private companies, e.g. for handling of linen.� Tswana speaking female nurse at Ophthalmology for 13 years: �The linen problem is because there is no effective mechanism in place to sort it out. Staff in laundry are not well supervised. Stealing is mainly by them (staff) as they have access to mostly new linen. Patients also contribute to this shortage as they also steal it. Education should be done to community at large to tell them that if they remove linen from the hospital they will be prosecuted. Towels of the hospital are at the taxi rank and no one makes an effort to collect them. Strong disciplinary action should be used to stop stealing, e.g. pay (salary) deduction to buy the stolen goods, or work without pay and, ultimately, dismissal. Southern Sotho speaking female radiographer at Radiology for 21 years: �Each department - stock control of linen. Penalties for shortage - that way a department will make sure linen is counted correctly every time.� Venda speaking female nurse at the Medical Section for 19 years: �Good maintenance and repair of equipment, servicing of laundry machines, since they are mostly not working. Control measures to avoid theft need to be considered when issuing linen since we have AIDS epidemic, to send linen daily and have all linen type packed, not just e.g. trousers without pyjamas.� Zulu speaking female nurse at Psychiatry for five and half year: �Buy more linen and have it washed or delivered two times a week. Have more equipment that is up to date.�

Box 4.3 Theft of linen and equipment English speaking female speech therapist at the Speech Therapy/Audiology Section for ten years: �More staff should be employed to develop and instate systems to improve these areas, also improved stock control (theft by staff).� Southern Sotho female speaking therapist at the Occupational Therapy Section for one year: �Theft - no one is allowed to leave the hospital with any equipment; security should start taking their job seriously and stop accepting bribes from staff and visitors.� Venda speaking female nurse at the Medical Ward for 19 years: �Rooms to be kept locked at all times. Report anyone suspected of stealing, and measures to be taken.� Xhosa speaking female nurse at the Surgical Section for 14 years: �Everybody, regardless of position he or she is holding in the hospital, must be searched to avoid theft.� Zulu speaking female nurse at the Surgical Section for 32 years: �Devise means of controlling theft by placing surveillance cameras around the hospital.�

26

Box 4.3 (continued) Tswana speaking female nurse at Ophthalmology for 13 years: �Stealing is mainly by them (staff) as they have access to mostly new linen � Strong disciplinary action should be used to stop stealing, e.g. pay (salary) deduction to buy the stolen goods, or work without pay, and ultimately, dismissal.� English speaking female doctor at CHBH for four years �Much of the non-medical activities such as porters, linen supply and cleaners need to be outsourced, as these are areas of usage of resource base in a very inefficient manner. It will also allow for the medical staffing and remuneration issues to be dealt with more efficiently.�

4.3 Cuts to the health-care budget

In the cases of both under-supply of medicine and linen shortage, cuts to

the health-care budget were cited as the most important reason for these

problems. Box 4.4 below summarises some of the comments made about

budget cuts.

Box 4.4 Budget Swazi speaking female dietician at Human Nutrition Division for five months: �Increase health-care budget together with logistical and practical arrangements; can help in improving or resolving resource management.� English speaking male doctor at CHBH for six years: �Realistic budget, budget based not on money saving but on real needs of community. Decentralised ordering system.� English speaking female doctor at CHBH for 18 months: �Under-supply of medicine I believe is due mainly to a shortage of funds due to budget cuts - if the pharmacy budget is increased, I believe this problem would be alleviated.� Xhosa speaking female nurse at the Maternity Section for 12 years: �That CHBH should not be declared as an only referral hospital in Gauteng region without enquiring [at] Bara [about] enough budget and staff - because that leads to overcrowding in hospital. That patients must pay for the service they get.� Zulu speaking female nurse at the Maternity Section for 17 years: �I think if there can be control over patients flocking from all over South Africa and outside countries, e.g. from Malawi to Bara, maybe we can manage to have enough because most of our budget finances are wasted by outside people whilst they leave their places where their health monies have been allocated to them.� Zulu speaking female nurse at the Medical Admission Ward for 19 years: �Government should increase budget to hospitals as they say patients should be treated for free. They (government) legalised TOPs [termination of pregnancy patients] free of charge and legalised the influx of non-South Africans to South Africa, hence the high number of patients, hence the shortage. Patients should be referred back to their nearest hospitals unless being referred by a doctor from their nearest hospital for e.g. specialist treatment or therapy.�

27

4.4 Quality and maintenance of equipment

Although not separately probed, the issue of the quality and maintenance

of equipment was mentioned so frequently that we list the qualitative

comments in Box 4.5 below.

Box 4.5 Equipment Xhosa speaking female nurse at Psychiatry for five years: �Equipment must have big and bold wording that will embarrass the person stealing.� Afrikaans speaking female dietician at Human Nutrition Division for five year: �Hospital should be broken down into more manageable units where better control can be exercised over equipment, etc.� Southern Sotho speaking male radiographer at Radiology for 21 years: �Staff must take care of equipment, there must be service contracts with good, reliable and reasonable companies assigned to check on these equipment.� Zulu speaking female nurse at CHBH for 18 years: �People must be taught about the expense and proper usage of items to prevent shortage, e.g. know of cost of a machine; maybe when they handle things they will always be conscious.� Tswana speaking female nurse at the Ophthalmology Division for 13 years: �Management should involve staff that use equipment before ordering. Some equipment is forced on staff; therefore there is a reluctance to use them, e.g. needle incinerators. When staff request equipment that they feel they need, they are told there is no money, e.g. defibrillators or ECG machines, but useless things are bought.� Southern Sotho speaking female nurse at the Maternity Section for 14 years: �Equipment used at CHBH is very old. Though not all, but most of it is old. It must be replaced with new equipment here and there to assist the old equipment, because it malfunctions many a time; send for repairs and within no time it is again out of order, because it is overused due to an overflowing hospital.� Southern Sotho speaking female nurse at the Medical Ward for three years: �There is nothing more frustrating than running around the whole hospital looking for equipment, especially at night.� Xhosa speaking female nurse at the Maternity Section for 28 years: �Equipment - follow up by department, or any department, to various firms that are repairing, to solve the problem immediately. Some of the equipment, they go up to 12 months or more to a supposed servicing company without any report being sent to CHBH informing the hospital as to whether or not the equipment is being condemned or not.�

4.5 Safety and security

A recurring theme during previous studies, as well as during the focus-

groups interviews with different staff categories, is the lack of adequate

safety measures. There are feelings of insecurity and perceptions that

security staff at CHBH are not well-trained and are � in fact � more part of

the problem than the solution. These issues were raised in both the close-

28

ended (see Table 4.5 below) and open-ended questions (see Box 4.6

below).

Table 4.5: Perceptions about safety and security measures

Agree Disagree No opinion

Total

The screening of visitors leaves much to be desired

Count 406 219 89 714

% 56.8% 30.7% 12.5% 100.0%

The unsafe environment at CHBH can be related to the influx of non-South African patients

Count 227 376 111 714

% 31.8% 52.7% 15.5% 100.0%

The number of security staff at CHBH is sufficient to combat crime

Count 187 455 70 713

% 26.3% 63.9% 9.9% 100.0%

Security staff at CHBH is well equipped with the necessary skills and facilities to combat crime

Count 93 543 83 718

% 13.0% 75.5% 11.5% 100.0%

The security screening of applicants for employment leaves much to be desired

Count 265 228 199 692

% 38.3% 32.9% 28.7% 100.0%

It is the responsibility of government to ensure a safe environment at CHBH

Count 527 155 42 724

% 72.8% 21.5% 5.7% 100.0%

Box 4.6 Security concerns Zulu speaking female nurse at the General Section for 16 years: �Proper training of security staff and proper searching of cars and people leaving the hospital. I think the securities, too, should be searched because they also take hospital properties outside.� Zulu, Sotho and Xhosa speaking female nurse at the Medical Section for 22 years: �I think the best suggestions is to exchange securities at the gates because they are being bribed by the people; moreover dispensary people, stores people and kitchen people they eat together and share whatever, and there is this senior security [name edited out], who is treating people very badly. He likes Zulu people in hospital; he still has apartheid; even his colleagues are threatened because of him and his group. Some of group still want medication and they are buying expensive posh cars. You will even wonder where does he get all this money because of the drugs they are stealing. Thank you.�

29

Salient points

• More than two-thirds of staff agreed that the number of security

staff was inadequate (64%), and that they were poorly equipped to

do their job (76%).

• A majority of staff (57%) also believed that the screening of visitors

was poor.

• Nearly three-quarters (73%) were of the opinion that it was

government�s responsibility to ensure a safe environment.

4.6 Concluding comments

There are three summary conclusions:

• Without question the overwhelming majority of staff views the

physical environment as being unacceptable.

• As regards resources, it is significant to note that the shortage of

linen is regarded as a much bigger problem than the under-supply

of medicine. Interestingly, in both cases staff lists a combination of

factors that contribute to this situation.

• There is a huge lack of confidence in the capacity and ability of

security staff to ensure a safe environment.

30

31

0.00%

10.00%

20.00%

30.00%

Honest/Dishonest

15.60%

7.70%

12.90%

21.70%

23.50%

4.00%

14.60%

1 2 3 4 5 6 7

0.00%

10.00%

20.00%

30.00%

Respectful/Disrespectful

15.50%

10.40%

17.30%

15.90%

21.50%

6.20%

13.10%

1 2 3 4 5 6 7

SECTION 5 ORGANISATIONAL CULTURE AND VALUES

Three aspects of the organisational culture were examined:

• Perceptions of staff relations

• Ratings of various organisational values

• Ratings of various professional values

5.1 Perceptions of staff relations

How does staff rate their relations with their colleagues at the hospital?

Six value sets were given to respondents to rate on a seven-point scale,

ranging from very positive (Point 1) to very negative (Point 7). The results

for the hospital as a whole are summarised under each value. (Points 1-3

represent degrees of positive ratings, Point 4 represents the middle

category or �neutral� option, and Points 5-7 represent degrees of negative

ratings.)

Figure 5.1: Honest � dishonest

Similar proportions rated

honesty (36%) and

dishonesty (42%) equally,

with 22% selecting the

middle category (see Figure

5.1).

Figure 5.2: Respectful - disrespectful

The sample was split on its

ratings, with 43% selecting

the �respectful� end of the

spectrum, 16% the

�neutral� option and 41%

the �disrespectful� end of

the scale (see Figure 5.2).

Box 5.1 summarises some of the qualitative comments made with regard

to the issue of respect.

32

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Loyal/Disloyal 15.00 8.50 18.40 16.30 22.70 7.70 11.30

1 2 3 4 5 6 7

Box 5.1 Respect for other professionals Male radiographer at X-Rays for one year: �All we need is respect. Seniors, juniors and students should respect one another and respect patients. We should be informed of what is going to be done in our department in time so that we can have a say, you know! More staff should be hired to reduce stress.� Female doctor at CHBH for four years: �There is a total lack of respect in all ranks � clerks, cleaners, medical staff, nurses. Unfortunately, individuals don't know their job descriptions, and this would be the first step in rectifying the situation. Employing more staff.� Female nurse at Orthopaedic for 13 years: �Respect goes a long way and personally I feel everyone seems to feel nurses are their punching bags. So, if the multi-disciplinary team can acknowledge that each of us has an important role to play, things will be much better.� Female nurse at Surgical Section for six years: �Respect and professionalism have to exist among staff members. People should respect each other and they should behave professionally.� Female nurse at Medical Ward for 15 years: �Supervisors should respect their subordinates, treat them with dignity, then everything will run smoothly. Supervisors should also be approachable, have listening skills.� Female nurse at Ortho-gynaecology for eleven years: �Our seniors must respect our juniors, e.g. when I am in the middle of something the senior must suggest an appropriate time to see him/her and not demand now. They should also address us in private and not in front of patients.�

Figure 5.3: Loyal - disloyal

The split in responses is

quite even: 43% loyal;

16% middle; and 41%

rating staff relations high

on disloyalty (see Figure

5.3).

33

0.00%

10.00%

20.00%

30.00%

Trusting/Distrusting 14.00 7.10 16.50 22.00 18.30 8.60 13.50

1 2 3 4 5 6 7

0.00%

10.00%

20.00%

30.00%

Professional/Unprofessional

20.90%

11.50%

12.50%

13.80%

21.50%

7.80%

11.90%

1 2 3 4 5 6 7

Figure 5.4: Trusting � distrusting

The sample was split on

its ratings, with 38%

selecting the �trusting�

end of the spectrum, 22%

the �middle� option, and

41% the �distrusting� end

of the scale (see Figure

5.4).

Figure 5.5: Professional � unprofessional

Nearly half of the sample

(45%) rated staff

relations to be

professional, 14% chose

the middle option, and

41% the �unprofessional�

end of the scale (see

Figure 5.5). Some of the

comments made on the issue of professionalism and professional values

are listed in Box 5.2.

Box 5.2 Professionalism and professional ethics Female occupational therapist at Occupational Therapy for one year: �Professionalism should be emphasised in the work place.� Male radiographer at Radiology for seven years: �Patient care has to be the first priority.� Female doctor for four years: �Senior nurses should not be cleaning and feeding patients. These tasks can be performed by competent nursing auxiliaries. We need more staff!� Male person at Management for two years: �Commitment to professional ethics.� Female radiographer for Radiology for 21 years: �Polite communication. Call patient by name. Make him/her feel good or like a human being. Respect [patients�] religion, race, culture, behaviour wishes, fears, etc. Be patient.�

34

0.00%

10.00%

20.00%

30.00%

40.00%

Relaxed/tense 10.70 7.60% 9.00% 15.90 12.40 10.20 34.30

1 2 3 4 5 6 7

Figure 5.6: Relaxed � tense/stressed

A significant majority

(57%) of staff believed the

climate in the hospital to be

tense or stressed, 16%

chose the middle option,

and only 27% rated the

climate as being relaxed

(see Figure 5.6).

Qualitative responses commenting on ethical values in general are listed

in Box 5.3 below.

Box 5.3 Ethical values Female radiographer at Radiology: �Transparency, honesty, trust, no favouritism in allocating work to people. Respect your juniors and remember they are adults.� Female dietician at Human Nutrition for five months: �Staff need to be honest, respectful (etc).� Female doctor at CHBH for one year: �Lack of trust among colleagues is a major problem.� Female nurse at the Operating Theatre for 27 years: �Tolerance, accepting each other, professionalism, professional secrecy, no gossip, avoid people's affairs because they are none of your business. All under the cover of love; love each other.� Female nurse at the Surgical Section for 30 years: �Respect most important, supervisors to stop loving this one and disliking that one, stop receiving �threats� from subordinates. Things must be explained well to both senior and subordinates; any changes tell on how her conduct is. Be professional.� Female nurse at the Maternity Ward for six months: �Staff members should conduct themselves professionally, improve their respect to both fellow workers and patients, and treat them with dignity.� Female doctor at CHBH: �Some ways or means of ensuring that all employees fulfil their work obligations should be put in place. Many patients are on medical aids, or are foreigners who give false local addresses - the hospital loses out on revenue from these patients. Measures should be instituted to detect this.� English speaking male doctor at CHBH for 5 years: �The hospital needs a complete makeover of attitude, management and ethics.� Xhosa speaking female nurse at Paediatrics for 24 years: �The government should allocate people to be their investigators and they should be honest and responsible.�

35

Box 5.3 (continued) Male Tsonga speaking support staff at Procurement Section for 25 years: �Orientate newly appointed persons about conditions of employment - code of conduct, etc. - and make them sign a document to that effect.� Female Tswana and Zulu speaking support staff for 19 years: �There is no more dignity at the hospital.� Tswana speaking female nurse at the Surgical Section for 24 years: �Patients should come first. Effective customer service to be emphasised. Improvement of the hospital environment - staff concerned to do their work as expected.�

Boxes 5.4 and 5.5 below list some of the more specific comments relating

to �discipline� and �staff relationships�, whereas Box 5.6 below contains

comments relating to working conditions in the hospital.

Box 5.4 Discipline Female dietician at Human Nutrition for five years: �Management should be allowed to discipline staff and to fire staff if necessary. It would lift the morale of every staff member if we can get rid of people who are not pulling their weight. People should be promoted and rewarded according to performance not years of service.� Male doctor at CHBH for five years: �Dismissal of non-functioning staff.� Female nurse at JD Allen Operating Theatre for 20 years: �Some of the staff are still fighting on hospital premises or in their departments.� Female nurse at Medical, Surgical, Maternity, Paediatric, Ortho and St Johns Eye Hospital for 13 years: �Discipline must be proactive when a staff member is problematic.� Female administrator/clerical for 14 years: �Administration supervisors must do all they can to attend to conflicts among staff members and execute disciplinary measures where necessary to maintain control and satisfaction among subordinates.�

Box 5.5 Staff relationships Male doctor at CHBH for two years: �Doctor-nurse relationships can be severely strained at times, but this predominates when the workload is at unmanageable levels. This is unlikely to improve if the workloads remain as they are.� Female nurse at Medical Ward for ten years: �Doctors should work hand-in-hand with nurses for the sake of the patient. Doctors tend to forget that they are also health workers, and want the nurses to work for them, e.g. messing up the area and want the nurses to tidy up.� Female nurse at Surgical Section for one year: �Good working relationship creates a harmonious place to work and a healthy environment, decrease stress levels.�

36

Box 5.6 General working conditions Female nurse at Medical Ward for 19 years: �Improve staffing and proper personnel utilisation. Decrease the workload; seminars for stress relief; in-service education and on-the-job-training; detect teachable moments for staff to regain job satisfaction. Stop being biased. Do work according to job description.� Female doctor at CHBH: �Everybody is stressed; staff shortages; too many patients; long hours; poor standards of working conditions lead to poor staff relations; patient load; improve working conditions.� Female support staff at Auxiliary Services for 12 years: �Create mechanisms to boost staff morale.� Female nurse at Maternity Ward for eight years: �Minimise stress in all respects; seniors to respect juniors and juniors to respect seniors.�

Summary trends

Two out of every five staff members are negative about various aspects of

staff relations, between 15 and 20% are undecided, with the remaining

30-45% more positive. The one exception relates to the question whether

staff relations are relaxed or tense (stressed), a majority of staff (57%)

rating this aspect negatively.

In addition, it is clear from qualitative comments that morale is low and

that most staff members do not think that enough is being done to

promote and establish a healthy working climate in the hospital.

5.2 Ratings of organisational values

Respondents were also asked to indicate which values CHBH stands for. A

summary of responses is presented in Table 5.1 below, in descending

order according to which values were rated most positively.

37

Table 5.1: Ratings of organisational values

Very great extent

Great extent

Moderate extent

To some extent

Very little extent

Serving the greatest number of patients as possible

N 416 129 85 67 25

% 57.6% 17.9% 11.7% 9.3% 3.4%

Not having strikes and social unrest

N 159 145 158 102 105

% 23.7% 21.7% 23.6% 15.2% 15.7%

Balancing the books N 118 132 222 93 95

% 17.9% 20.0% 33.6% 14.1% 14.4%

Good work ethic N 126 110 192 161 89

% 18.6% 16.3% 28.3% 23.7% 13.1%

Providing the best possible working environment

N 111 105 125 136 213

% 16.2% 15.2% 18.1% 19.7% 30.9%

Avoiding bad publicity

N 138 199 197 85 60

% 20.4% 29.3% 29.0% 12.5% 8.8%

Table 5.2: Rank ordering of values

1 Serving the greatest number of patients as possible

75% 12 13

2 Avoiding bad publicity 50 29 21

3 Not having strikes and social unrest 45 24 31

4 Balancing the books 38 34 28

5 Good work ethic 35 28 37

6 Providing the best possible working environment 32 18 50

Salient points

If one combines the first two and last two categories, the rank ordering

(from more to less important) above (see Table 5.2) is obtained.

Interestingly, more �administrative values� (number of patients served;

publicity; balancing the books/financial issues; good order) are valued

higher than a good work ethic and having a good working environment. If

38

this is a fair reflection of the organisational culture at CHBH, it does not

augur well for staff relations. In fact, this rank ordering is consistent with

results reported earlier.

5.3 Ratings of professional values

The final set of values included in this section refers to the clinical

situation. We wished to establish two things: first, whether staff believes

that doctors and nurses care for patients; and secondly, whether doctors

and nurses are given similar ratings for clinical care by other groups. The

results are summarised in Table 5.3 below.

Concerning the first question about clinical care (whether staff believes

that doctors and nurses care for patients), staff is clearly divided, with

50% (on average) saying that doctors and nurses show sufficient

commitment to various aspects of patient care (�care� means compassion

for patients, confidentiality of patient information, and respect for the

dignity and well-being of patients). However, the other 50% is split evenly

between 25% undecided and 25% being negative about/disagreeing with

the quality of patient care. Qualitative comments pertaining to patient

care are listed in Box 5.7 below.

Table 5.3: Ratings of professional values

Very great extent

Great extent

Moderate extent

To some extent

Very little

extent

Doctors: Compassion for patients

N 188 210 183 71 36

% 27.3% 30.5% 26.6% 10.4% 5.3%

Nurses: Compassion for patients

N 166 180 144 126 58

% 24.6% 26.8% 21.3% 18.8% 8.6%

Doctors: Confidentiality of patient information

N 257 171 126 52 69

% 38.0% 25.3% 18.7% 7.7% 10.3%

39

Nurses: Confidentiality of patient information

N 220 164 154 84 58

% 32.4% 24.0% 22.6% 12.4% 8.6%

Doctors: Respect for dignity of patients

N 180 163 167 84 74

% 27.0% 24.4% 25.1% 12.6% 11.0%

Nurses: Respect for dignity of patients

N 183 140 167 104 81

% 27.2% 20.7% 24.7% 15.5% 11.9%

Doctors: Respect for well-being of patients

N 216 195 146 70 39

% 32.4% 29.2% 21.9% 10.6% 5.9%

Nurses: Respect for well-being of patients

N 205 157 164 97 68

% 29.6% 22.7% 23.7% 14.1% 9.8%

Box 5.7 Patient care related issues Female radiographer at Radiology for four years: �Patients must not be scared to report unsatisfactory treatment. Staff members shouldn�t be scared to voice out if not satisfied. That is, management must be approachable, and responsive.� Female doctor at CHBH for one year: �Disregard / disrespect of certain patients - senior members of clinical staff surely influence how subordinates behave.� Female doctor at CHBH for 26 years: �Clinical performance should be more clearly maintained, and professional people should be answerable for poor patient management.� Male doctor at CHBH for 31 years: �Assaults on patient and staff to be reported and followed up. A small number of nurses and doctors behave unethically and need to be disciplined or dismissed.� Female nurse at General Surgical Section for two years: �Staff should have good conduct towards their co-workers, do their work professionally, know about patient rights, and know about patients� charter.� English speaking male doctor at CHBH for 31 years: �Adequate screens to ensure patients� privacy. Adequate bedpans and urinals. Glasses and water should be provided for bedridden patients, as nurses are often too busy to bring patients water and to supervise feeding.� Tswana speaking female nurse at Paediatrics for 18 years: �Resources need no compromises because of the high influx of patients coming to the hospital, especially patients with conditions related to HIV and AIDS.� Zulu speaking female nurse at the Maternity Ward for 17 years: �I think there can be control over patients flocking from all over South Africa and outside countries, e.g. from Malawi to Bara. Most of our budget finances are wasted by outside people whilst they leave their places where their health monies have been allocated to them.�

40

Box 5.7 (continued) Female nurse at the Surgical Section for six years: Non-South Africans to pay more admission fees. Patients with medical aids to use them.� Southern Sotho speaking female at the Maternity Ward for 14 years: �I would suggest that free health services should come to an end. Patients should be responsible and pay for their health so that the government should buy equipment, linen and medicines. If patients were paying, overcrowding of the hospital wouldn't be there.� Tswana speaking female nurse at the Nursing / Casualty Section for 25 years: �Influx of patients must be controlled. Non-South African patient must be treated in their hospitals by origin. AIDS patients� families must be taught home care. Remuneration for public holidays, weekends to make staff happy.� Southern Sotho speaking female nurse at Paediatrics for ten years: �Non-South African patients should pay for services, free services should be stopped, patients under six and pensioners should pay less unlike not paying at all.� Tswana speaking female nurse at Ophthalmology for 13 years: �Patients also contribute to this shortage as they also steal it [linen]. Education should be done to community at large to tell them that if they remove linen from the hospital they will be prosecuted.� Female Tsonga speaking support staff at Casualty Admission for 20 years: �All patients, including clinics and those who come for TOP [termination of pregnancy], must pay at least a minimum amount.�

In addition to these general comments on patient care (Box 5.7 above),

three more specific issues were frequently raised in the open-ended

questions. These relate to patient admissions (Box 5.8 below), patient

discharge (Box 5.9 below), and patient care directly influenced by the

HIV/AIDS pandemic (Box 5.10 below).

Box 5.8 Problems encountered with patient admission Male radiographer at Radiology for ten years: �Care should be given to emergency clinic patients as most of them lose their lives before seeing a doctor.� Male nurse at Medicine for 20 years: �Long queues. Long wait for admissions.� Male doctor at CHBH for five years: �Admission bottlenecks occur due to sub-standard organisation in casualty - casualty can be markedly improved.� Female nurse at Pediatrics for 18 years: �More admission wards should be created to reduce the work load. There will be fewer patients in a ward, proper treatment will be done, and patients will be discharged sooner.� Female nurse at Medical Section for 19 years: �Patients to be admitted when there is a need and beds for them to sleep on because that is where the problems start because they get lost and are unmanageable and impossible to care for.�

41

Box 5.9 Problems encountered with patient discharge Female radiographer at Radiology for 32 years: �On discharge, staff have to go and collect medicines for patients, like before, thus curbing the long queues at the chemist. Some patients actually collapse whilst in that queue.� Female occupational therapist at Occupational Therapy Department for 18 months: �Transport for patients who get discharged while they are not well enough, because several times one witnesses patients collapsing on the bridge after being discharged.� Female physiotherapist at Physiotherapy for one year: �Patients should not be discharged just because it is intake and they need more beds, without any regard to whether the patient is ready to go home - will the family cope at home?� Female doctor at CHBH for one year: �Patients must not be discharged from Ward 20 on next day unless adequate follow-up is arranged and especially to get speedy TB results one month later in the clinic!! Patients should remain in hospital until TB results back.� Female nurse at General Section for 21 years: �Patients must be discharged really when they are fit for discharge. I met two patients on the highway, collapsed. With the help of public I brought the patient back to the hospital and admitted.�

Box 5.10 Patient care and HIV/AIDS pandemic Female student radiographer at X-Rays for three years: �The patients are discharged without being better in their condition, more especially when the patient is HIV positive; they discharge them because there's this thing that he is going to die so there's no use to keep him in the hospital. Which is wrong.� Female doctor at CHBH for five years: �Home-based AIDS care and hospital are needed to relieve the burden of the hospital coming from terminal patients.� Male doctor at CHBH for two years: �Admission of HIV patients and their treatment needs review and protocol to save resources.� Female nurse at Medical, Surgical, Maternity, Paediatric, Ortho and St Johns Eye Hospital for 13 years: �Community must be taught how to take care of full-blown AIDS patients and very frail patients, to minimise admissions due to shortage of staff, and so that quality care can be rendered. Before discharge, relatives to be informed early and be taught how to take care of the patient at home.�

We conclude our discussion of the first question about patient care

(whether staff believes that doctors and nurses care for patients) with

some quotations on patients� rights. They illustrate quite clearly the

concern expressed about violation of these rights and the absolute need

for re-establishing a culture of respect for patients and their rights.

Significantly, the five most common patients� rights recognised in

42

declarations and the literature24 are the rights to respectful care,

information (regarding the caregiver�s name, diagnosis, treatment

options, and prognosis), informed consent, confidentiality of private

information, and refusal of treatment.

Female radiographer at Radiology for 26 years: �Staff members should respect every patient they handle and treat them like human beings, give them the proper service they are expected to give them. There should be some good communication between staff members and the patient they nurse.� Male radiographer at X-Ray for one year: �Be compassionate to patients. Respect them, e.g. explain to them everything until they understand. Patients who are not harassed won�t harass us.� Male radiographer at Radiology for ten years: �There should be mutual respect and understanding between staff and patients. Staff members should be polite and communicate with patients and should listen to what patients are saying.� Female radiographer at Radiology for 20 years: �Privacy, especially regarding information about patients� illnesses.� Female nurse at Orthopaedic for 13 years: �Staff to learn to respect different cultures and also to treat them with respect, and in turn patients need to be educated that we are not the �enemy� and that they are in good hands.�

The second question about the clinical care concerns differences between

the ratings of doctors and nurses, respectively, by others (whether

doctors and nurses are given similar ratings for clinical care by other

groups). The results clearly reveal a significant gap between the ways in

which doctors� and nurses� respective clinical care was rated by others,

with doctors being rated significantly higher overall. These ratings are

visually displayed in Figures 5.7 and 5.8 below.25

24 See, for example, the following: National Department of Health (November 1999). National Patients� Rights Charter. Pretoria. (see Appendix 8); Wilson Silver, M.H. (1997). Patients� rights in England and the United States of America: The Patients� Charter and the New Jersey Patient Bill of Rights: A Comparison. Journal of Medical Ethics 23:213-220; Neary, I. (1999). Patients� Rights. http://privatewww.essec.ac.uk/inj/HR/patients/pa_general.html 25 Figure 5.7, which contains the ratings of doctors, excludes doctors� own ratings; similarly, nurses ratings of themselves were excluded from Figure 5.8.

43

Figure 5.7: Ratings of doctors by others

Figure 5.8: Ratings of nurses by others

5.4 Recommendations by respondents

Respondents put forward various recommendations, but two major

categories emerged as priority areas: education and training of staff

(Box 5.11 below), and the need for team building (Box 5.12 below).

0

10

20

30

40

50

Compassion for patients 36 32 41

Confidentiality of patientinfo

47 26 27

Respect for dignity ofpatients

36 27 37

Respect for well-being ofpatients

39 29 32

Positive ratings

Neutral rating

Negative rating

0

10

20

30

40

50

60

70

Compassion for patients 60 23 17

Confidentiality of patientinfo

64 17 19

Respect for dignity ofpatients

54 23 23

Respect for well-being ofpatients

63 19 18

Positive ratings

Neutral ratingNegative

rating

44

Box 5.11 In-service and continuing education and training Female radiographer at Radiology for 21 years: �In-service training in departments must be on ongoing basis. Interdepartmental talks or visits by representatives from one to the other just to give a broad view of what takes place, in that particular department. At least every department will know what other departments are doing, in that way we will respect each other and also understand each other better.� Female doctor at CHBH for one year: �Intercultural courses promoting staff relations should be given in the form of in-service or continuing education.� Female person at Management for 36 years: �Workshops should be provided on communication skills and human relations in general.� Female nurse at Maternity Ward for seven years: �Staff to be in-serviced in communications, ethics. �De-stressing� programmes to be put in place for staff problems to be attended individually.� Female nurse at General Surgical Section for two years: �Supervisors to go for some sort of training on interpersonal skills and relationships whereby they will be taught communication skills and how to deal with their subordinates in a more friendly way without being too authoritarian. Channels of communication to be easy for all staff members and to do crisis management course.�

Box 5.12 Need for team building Female occupational therapist at Occupational Therapy Department for 18 months: �Team buildings of staff to be encouraged, which will improve communication of staff. Staff incentives will also boost staff morale. Proper training of supervising staff to be taken seriously as this seems to cause power-struggles.� Female therapist at Speech Therapy/Audiology for ten years: �At present, there is no staff for the programme. Money needs to be allocated and team development and team building, as well as stress management, need to be looked at.� Female therapist at Speech Therapy/Audiology for three and half years: �Team building exercises between departments are pivotal to the effective and smooth running of the hospital.� Female dietician at Human Nutrition for eleven years: �Staff working in the different departments work in isolation from one another. Having tea in the dining halls (or even smaller communal tea rooms) will improve communication. Welcoming/orientation of new staff and farewell of old staff need more attention. Start staff forums. This will keep supervisors in touch with activities on ground level (especially in bigger departments, like kitchens, cleaning department.)� Male doctor at CHBH for 31 years: �Nurses and doctors should work together. At present, we are working separately and nurses are often too busy with routine duties to obey doctors� instructions.�

45

5.5 Concluding comments

This section has been devoted to a discussion of the organisational culture

at CHBH, under three headings: staff relations, organisational values, and

professional values. Concerning perceptions of staff relations, we have

seen that two out of every five staff members are negative about various

aspects of them. These results are confirmed by qualitative comments

which show that staff morale is generally low.

Which organisational values are rated highly? Again, results showed that

most employees believe that more �administrative values�, such as the

number of patients served, avoiding bad publicity, and not having strikes,

are more important (to management?) than a good work ethic and the

best possible working environment.

Finally, with regard to professional values, staff is clearly divided: equal

percentages believe that doctors and nurses show compassion for

patients, treat patient information confidentially, and respect the dignity

and well being of patients. These results also revealed that ratings of

doctors on these aspects are consistently higher than the ratings given to

nurses.

The overall picture that emerged from these analyses is not a positive

one. It unequivocally shows that the organisational culture of the hospital

is not healthy, that staff is not positive about the institution, and that

morale is low.

46

47

SECTION 6 LEADERSHIP, MANAGEMENT, AND CHANNELS OF COMMUNCIATION

In this section, we address issues regarding hospital leadership and

management, and the degree to which effective communication occurs in

the organisation. Table 6.1 below presents the summary responses for the

sample. Qualitative comments about staff perceptions of staff involvement

in decision making at CHBH are summarised in Box 6.1 below.

Table 6.1: Leadership, management, and channels of Communication

Strongly

agreeTend to

agreeTend to

disagree Strongly disagree

The hospital management takes suggestions from below seriously

Count 77 157 226 260

% 10.7% 21.9% 31.3% 36.1%

There are proper incentives in place to improve staff performance

Count 65 141 172 328

% 9.2% 19.9% 24.4% 46.5%

Staff members have a say in matters of decision making

Count 51 115 166 373

% 7.2% 16.3% 23.6% 52.8%

The hospital management is clear about the career prospects of employees

Count 84 176 208 234

% 12.0% 25.1% 29.6% 33.3%

Top management has no secrets from employees

Count 60 124 179 323

% 8.8% 18.0% 26.1% 47.1%

Management at CHBH is basically powerless

Count 138 162 200 210

% 19.4% 22.9% 28.1% 29.6%

48

Box 6.1 Involvement of staff in decision making Female nurse at General Ward for nine years: �Good staff relations can be improved by inviting staff in decision making concerning management of the ward/department, by promoting teaching sessions in the ward. Prevent favouritism, and praise an individual if she has done something good.� Female nurse at Nursing Division for 26 years: �Supervisors should involve staff in decision making for co-operation sake; also the issue of over-emphasising one's position, e.g. director etc., and looking at others as beggars instead of co-operates. The senior personnel should develop staff more than destroying.� Female nurse at Medical Ward for 12 years: �Involve grassroot people in decision making. Cultivate culture of respect for subordinates especially in general category by proper orientation of staff, hierarchy of institution clearly defined, work expectations and procedures, adequate staffing to relieve work load.� Male radiographer at Radiography for seven months: �Open dialogue among staff members and ensure feedbacks and positive response and implementation on resolutions made.� Female nurse at Medicine for 13 years: �Staff members, especially the so-called bosses or supervisors, to come down to our level, not to think of themselves as being high and mighty. Our complaints to be listened to. Let us be involved in decision making and not be told that this is in place without being informed. Let us respect one another, senior or junior.� Female nurse at Ophthalmology for 13 years: �Management does not involve people at grassroot in decision making. Most issues are forced on the working people therefore the negative attitude towards management. Management is also not visible to the people on the ground. They rule in offices. New rules are not in place for what staff has to do when dissatisfied with decisions management makes. Some unions seem to enjoy management support.�

6.1 Leadership and management

Salient points

• There is little evidence of a participatory management culture, with

three-quarters (76%) of staff indicating they had no say in decision

making. An even higher proportion of doctors - 84% - held this

view.

• There is clearly an insufficient degree of transparency in the

hospital. This is evidenced by rumour (the �grapevine�) being an

important source of information, too little communication between

management and staff, and too much secrecy.

• There is also not enough concern for and commitment to staff

development, there are inadequate incentives, and there is

insufficient performance.

49

Further analyses of the subgroups reveal that two of the most professional

groups (doctors and allied health professionals) are even more negative

about leadership and management issues than the rest of staff. In the

following figures, we grouped together doctors, nurses and allied health

professionals (under the heading of �clinical professional group�) and

compared their views on each of these questions with those of

management and support staff. These differences are summarised in

Figures 6.1 to 6.6 below.

Figure 6.1: Management takes suggestions from below seriously

Figure 6.2: There are proper incentives to improve staff performance

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

Management 37.50% 50% 12.50%

Clinical professional 7.60% 20.60% 32.70% 39.10%

Support staff 14.60% 25.20% 29.30% 30.90%

SA A D SD

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

Management 37.50% 37.50% 25.00%

Clinical professional 8.40% 18.70% 24.60% 48.30%

Support staff 9.60% 20.00% 26.10% 44.30%

SA A D SD

50

Figure 6.3: Staff members have a say in decision making

Figure 6.4: Hospital management is clear about employees� career prospects

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Management 12.50% 62.50% 25.00%

Clinical professional 6.80% 14.90% 29.00% 49.30%

Support staff 7.80% 19.00% 15.50% 57.80%

SA A D SD

0

0.1

0.2

0.3

0.4

Management 37.50% 25.00% 37.50%

Clinical professional 9.00% 26.70% 31.60% 32.70%

Support staff 15.50% 22.40% 26.70% 35.30%

SA A D SD

51

Figure 6.5: Top management has no secrets from employees

Figure 6.6: Management at CHBH is basically powerless

In addition to the quantitative ratings presented in the figures below, we

have selected a number of qualitative comments that reflect staff

perceptions about management, leadership style, and practices at the

hospital. They are presented in Box 6.2 below.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Management 37.50% 12.50% 37.50% 12.50%

Clinical professional 5.20% 18.60% 32.30% 44.00%

Support staff 14.80% 17.40% 16.50% 51.30%

SA A D SD

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Management 25.00% 37.50% 12.50% 25.00%

Clinical professional 17.00% 24.30% 31.60% 27.10%

Support staff 22.70% 21.00% 22.70% 33.60%

SA A D SD

52

Box 6.2 Management and leadership English speaking female doctor at CHBH for four years: �Better overall management at different levels. Management to take responsibility and also to be evaluated. Insight into problem, reasonable solution, application of solution and follow�up. There is lack of insight at almost all levels by higher management: rest of the �steps� cannot be carried out satisfactorily. Zulu speaking male at Management for seven years: �Management needs enough authority to make decisions.� English speaking female at Management for 36 years: �Appoint appropriately qualified personnel to supervise.� Xhosa speaking nurse at the Medical Section for 20 years: �Management should be changed within one year or six months; they must be educated and have better skills.� Tswana speaking female nurse at the General Section for 13 years: �Management must work hand-in-hand with staff and listen to our concerns.� Zulu speaking female nurse at the Medical Section for 15 years: �Management should reach people on the ground to hear their views.� Tswana speaking female nurse at CSSD [Central Sterilising Service Department] General for 24 years: �Management in this hospital doesn't care about nurses.� English speaking nurse at Orthopaedic for 21 years: �Management to be truly changed rather than old-fashioned people. It must provide enough medicines, like the old government.� Female Tswana speaking support staff at Administration for 20 years: �Management should stop using money for buying expensive furniture for their offices; use that money to buy patients� medicine, linen and other equipment which are needed in other wards.� Male Northern Sotho speaking support staff at Security Department for 21 years: �The management of hospital must check departments if they are clean, like before 1992.�

6.2 Channels of communication

Open channels of communication, regular feedback from one�s superiors,

access to official forms of communication, and the freedom to express

oneself without fear of reprisal, are all indicators of a culture of open and

free communication in an organisation. How does staff at CHBH feel about

these and other matters of communication? Responses are summarised in

Table 6.2 below.

53

Table 6.2: Perceptions of channels of communication

Strongly

agree

Tend to

agree

Tend to

disagree

Strongly

disagree

Employees are not allowed to say what they really think

Count 234 169 195 131

% 32.1% 23.2% 26.7% 18.0%

Clear guidelines exist regarding staff members' responsibilities

Count 188 256 182 72

% 26.9% 36.7% 26.1% 10.3%

My supervisor effectively follows up on complaints that I direct via him/her

Count 186 214 153 163

% 26.0% 29.9% 21.4% 22.8%

My supervisor regularly gives me feedback about my performance

Count 117 132 178 275

% 16.7% 18.8% 25.4% 39.1%

I am always last to be informed about decisions that concern my work

Count 162 142 192 207

% 23.0% 20.2% 27.3% 29.5%

There is a system in place that employees can use to report instances of misconduct without being victimized

Count 139 185 158 221

% 19.8% 26.3% 22.5% 31.4%

Rumour (the �grapevine�) is a common source of information at CHBH

Count 258 185 130 137

% 36.3% 26.0% 18.4% 19.3%

One of the issues that appeared very prominently in the qualitative

comments concerns communication. We list some of these in Box 6.3

below.

54

Box 6.3 Communication Female radiographer at Radiology for 26 years: �Good communication between staff- members can make the workplace a stress-free area, and patients will receive a better service. Also, there should be enough staff employed for work to be easy as well as good remunerations to prop them up.� Female radiographer at Radiology for 17 years: �Talk openly about things that affect relations directly.� Male doctor at CHBH for three years: �Better communications between doctors and nurses, and between departments.� Male doctor at CHBH for 25 years: �Improved communication is essential. We need to engineer a caring ethos and provide quality work. Teamwork needs to be stressed. Sufficient nurses need to be employed to restore morale.� Male doctor at CHBH for 23 years: �Better communication between top management and staff, and especially Gauteng Health. Staff need to develop a pride and care for CHBH!!� Male doctor at CHBH for 27 years: �There is no common language (working) at the hospital. English should be made a common working language for the hospital.� Female doctor at CHBH for two years: �Language courses to be encouraged. More communication with people above us.� Female nurse at Maternity Ward for three months: �English must be the medium/language of communication.�

Salient points

• A substantial proportion of staff (45%) did not believe that

employees were allowed to say what they really thought.

• Communication between employees and their supervisors was less

than optimal - 50% of staff said their complaints had not been

acted upon, and nearly two-thirds (65%) said that they had not

received regular feedback from their supervisors.

• A clear majority (54%) of staff also did not believe that there was a

system in place for reporting instances of misconduct.

• The fact that 62% of staff said that rumour was a common source

of information in the hospital was another indicator that existing

channels of and procedures for communication are regarded as

inadequate.

55

6.3 Concluding comments

One�s overwhelming impression, having analysed the data on

management and communication, is of an organisation that does not

treasure participation and consultation in decision making, where the

views of ordinary staff members do not matter, and where opportunities

for constructive communication are limited, if not non-existent.

56

57

SECTION 7 HUMAN RESOURCES ISSUES

This section addresses matters related to perceived job satisfaction,

perceptions of the hospital as a workplace, conditions of service, prospects

for promotion, and other related human-resource matters. Table 7.1

below presents the overall findings on a number of scaled items relating

mostly to job satisfaction.

7.1 Job satisfaction

Table 7.1: Perceptions of job satisfaction

Strongly agree

Tend to agree

Tend to disagree

Strongly disagree

I am often bored with my job Count 108 103 151 320 % 15.8% 15.2% 22.2% 46.9%I am satisfied with my job for the time being

Count 211 203 114 142

% 31.5% 30.3% 17.0% 21.2%Each day of work seems like it will never end

Count 167 135 156 214

% 24.9% 20.1% 23.2% 31.8%I find real enjoyment in my work Count 243 168 141 123 % 36.0% 24.8% 20.9% 18.2%It feels as if I am working in a �second-class� hospital

Count 202 181 136 149

% 30.2% 27.0% 20.4% 22.3%I feel proud to be associated with CHBH

Count 286 177 99 114

% 42.3% 26.1% 14.7% 16.9%My opinion of myself increases when I do my job well

Count 405 180 56 43

% 59.3% 26.3% 8.1% 6.3%I frequently think of quitting my job

Count 151 116 138 273

% 22.2% 17.1% 20.4% 40.2%

Table 7.2 below summarises the ratings on various aspects of conditions

of service in the hospital, whereas Box 7.1 below lists some of the

numerous comments and suggestions regarding the use of incentives in

performance management.

58

7.2 Conditions of service

Table 7.2: Perceptions of conditions of service

Very satisfied

Quite satisfied

Somewhat satisfied

Quite dis-

satisfied

Very dis-satisfied

Immediate supervisor

Count 213 165 182 60 88

% 30.1% 23.3% 25.7% 8.4% 12.5%Salary Count 31 42 106 143 399 % 4.3% 5.8% 14.7% 19.8% 55.3%Cooperativeness of colleagues

Count 153 173 232 93 71

% 21.2% 23.9% 32.2% 12.9% 9.8%Conditions of service

Count 78 93 175 144 205

% 11.3% 13.4% 25.2% 20.7% 29.4%Workload Count 60 83 94 125 332 % 8.7% 11.9% 13.5% 18.1% 47.9%Career progress at CHBH thus far

Count 97 130 193 90 181

% 14.0% 18.8% 27.9% 13.1% 26.2%Prospects for promotion

Count 75 101 120 109 299

% 10.6% 14.4% 17.0% 15.5% 42.5%

Box 7.1 Incentives Female therapist at Speech/Pathology/Audiology for eight months: �Providing more incentives; having highest [possible] basic salary to retain more staff members.� Male radiographer at X-Rays for three years: �Government should improve salaries of employees so as to make them love their jobs. Workshops should be conducted among workers to make them improve their services.� Female nurse at Paediatrics for 13 years: �Staff mustn't strike to have their salaries increased; management must be fair and give staff a raise every year. According to the grapevine, monies are sent to management every year but they dilly and dally, not knowing whether to give the money to us.� Female nurse at CHBH for four years: �As staff is overworked, I feel there should be an increment to their salaries. They must not be lastly considered compared to other departments, e.g. safety and security or educator. If they are supposed to get an increment, they must get it in time, not lastly. Bonuses are not well calculated and people who were born before April are really suffering in this hospital.� Female nurse at Psychiatry for 27 years: �System of replacing lost staff. Improving salary. Free, comfortable and elegant uniform to enhance staff esteem. At present, nurse shoe allowance is R4,50 since inception of Baragwanath Hospital.�

59

Box 7.1 (continued) Female support staff at Casualty Admission for 20 years: �Incentives must be implemented in order to boost the morale of staff. Employees should be promoted or demoted and be merited (a happy worker produces more).�

7.3 Staff shortages

There is no question that the biggest human-resource issue consistently

referred to in the survey � both in the close-ended and open-ended

questions - is the shortage of staff. We selected (from a very long list of

comments) some of the remarks made in this regard for inclusion in Box

7.2 below.

Box 7.2 Staff shortages Female student radiographer at X-Ray Department for three years: �Government must get more employees because really there is a shortage of staff. Patients think that we are not working, but the problem is that we are short staffed.� Female doctor at CHBH for eight and half years: �Most problems related to being short staffed, but there is hope for Bara. Sisters seem not to care for patients and night staff usually sleep at night. Numerous times doing ward calls. Also having to take attitude from radiographers who do not X-ray as ordered having to report to radiographers. If staff not corrected in time.� Female doctor at CHBH for three years: �The shortage of nurses leads to poor relations between nurses and doctors. Wards are ridiculously short staffed and many nurses seem to have stopped caring due to poor working conditions and low salary.� Female dietician at Human Nutrition for five years: �This could be improved by relieving pressure from staff, by employing more staff. Thus enabling staff to spend time with patients.� Female physiotherapist at Physiotherapy for nine years: �Number of staff - doctors, nurses, paramedics - must be increased; enforce discipline when patients� rights are violated, and enforce an atmosphere of �compassion� and high standards! - perhaps incentives?� Male nurse at Cardiology for three and half years: �If more nursing and auxiliary staff is employed, relations would improve.�

60

Box 7.2 (continued) Male doctor at CHBH for four years: �Increased number of staff will increase level of care at the hospital.� Female person at management for 36 years: �Increase the number of medical and nursing staff to allow better communication.� Female nurse at General Ward for 16 years: �More staff will reduce some of the problems, e.g. long stays in hospital. To have enough and modernised equipment, enough medicines. Encourage staff to attend in-service.� Female nurse at Maternity Ward for 14 years: �Due to staff shortage there is no time for staff to have good relations with our patients. At least one nurse for two or three patients will give a chance to know patients.� Female nurse at Maternity Ward for six years: �If staff is enough there will be time to attend to patients and nurse them in totality, thus improving nurse-patient relationship.� Female nurse at Surgical Section for 32 years: �Address the problem of human-resources shortage. How can one nurse look after 40 patients and be expected to be OK (well) at the end of the shift? Revise nursing activities - facing one individual, then pushing the person to the edge?� Female nurse at the Theatre for 20 years: �More nurses should be employed to improve the nursing standard. To relieve overstretching from nurses. We work without meals because of pressure of work. Staff is prone to illness. We get added responsibility by transfers (patients) from other hospitals.� Female nurse at Maternity Ward for 14 years: �For good relations to improve, the government should employ more staff for coverage of workload. The work overload doesn't help people to relate well because they are always under stress. Everyone thinks she works more than the other one.�

7.4 Concluding comments

A number of positive findings emerge from this section of the survey.

• Respondents are generally satisfied with their jobs, and they find

their jobs interesting and even stimulating.

• Two-thirds of staff (66%) was proud to be associated with CHBH.

But there are also some less positive results:

• A very large proportion of staff (40%) frequently thought of quitting

their jobs

• A clear majority (58%) felt as if they were working for a �second-

class� hospital

• There was general dissatisfaction with salaries (75%) and

workloads (66%)

• Large proportions (over 50%) were dissatisfied with conditions of

service and prospects for promotion

61

We believe that these results lead to two major conclusions:

• There is a kind of �split image� at work here. On the one hand,

there is the positive legacy or ideal of CHBH, but, on the other, its

quality is declining � or, rather, that is the perception.

• Although staff is positive about their own jobs and job contents,

they are very negative about staff development (no prospects for

promotion; high workload).

62

63

SECTION 8 MISCONDUCT AND STANDARDS OF CARE Two of the main objectives of our ethics audit were to establish the

existence and degree of instances of ethical misconduct, and the reasons

offered for such misconduct.

8.1 Rank ordering of instances of misconduct

In respect of the first objective (occurrence and weighting of instances of

ethical misconduct), staff was asked to indicate how often they had

witnessed various forms of misconduct. Table 8.1 below lists responses in

descending order � from instances that recorded the highest response

rate to the lowest.

Table 8.1: Rank ordering of instances of misconduct

Once or more

Never No opinion

Total

Patients verbally abusing staff Count 457 98 112 667 % 68.6% 14.7% 16.7% 100.0%Professional negligence in patient care

Count 342 201 156 699

% 48.9% 28.7% 22.4% 100.0%Lack of compassion for patients Count 313 167 165 646 % 48.5% 25.9% 25.6% 100.0%Staff verbally abusing patients Count 333 203 162 699 % 47.7% 29.1% 23.2% 100.0%Patients physically abusing staff Count 318 226 140 684 % 46.6% 33.0% 20.5% 100.0%Special groups of patients getting different levels of care (TOP, AIDS, Aliens, Pregnant women, TB)

Count 284 140 265 688

% 41.2% 20.3% 38.5% 100.0%Lack of informed consent Count 257 183 244 684 % 37.5% 26.8% 35.7% 100.0%Moonlighting by staff Count 259 205 234 697 % 37.1% 29.4% 33.5% 100.0%Breach of confidentiality of patient information

Count 224 229 210 663

% 33.7% 34.6% 31.7% 100.0%Substandard post-operative care Count 217 189 271 677 % 32.1% 27.9% 40.1% 100.0%Staff physically abusing patients Count 198 315 167 680 % 29.1% 46.4% 24.5% 100.0%Over-ordering of medicine Count 182 147 363 691 % 26.3% 21.2% 52.5% 100.0%Patients/visitors bribing staff Count 127 328 240 695 % 18.2% 47.2% 34.6% 100.0%

64

The rank ordering of instances (from highest to lowest) where staff

observed different kinds of misconduct at least once is as follows:

• Patients verbally abusing staff (68.6%)

• Professional negligence in patient care (48.9%)

• Lack of compassion for patients (48.5%)

• Staff verbally abusing patients (47.7%)

• Patients physically abusing staff (46.6%)

• Special groups of patients getting different levels of care (41.2%)

• Lack of informed consent (37.5%)

• Moonlighting by staff (37.1%)

• Breach of confidentiality of patient information (33.7%)

• Substandard post-operative care (32.1%)

• Staff physically abusing patients (29.1%)

• Over-ordering of medicine (26.3%)

• Patients/visitors bribing staff (18.2%)

Box 8.1 below lists some of the qualitative comments made with regard to

misconduct.

Box 8.1 General observations about staff misconduct Female doctor at CHBH for one year: �Doctors are often very superficial, discharge patients prematurely without adequate explanation or follow-up. Interns check blood results the following day so don't act on acute emergencies. Very little effort is made to explain proceedings; doctors shout at patients, throw specimen bottles at them, patients are not seen for days on end and found a week later either dead or much sicker. A patient in Ward 15 was not seen by any other officer except the consulted service for 20 days!! Social workers are useless for ward patients. They almost never see them in the ward and uncommonly actually help. Nurses drag patients along the passage by the pajama collar (Ward 16). Nurses tell patients to go home and die; nurses drink tea and chat instead of attending to their duties.� Female doctor at CHBH for eight years: �Peer pressure - work by example to junior staff. Consultants shouldn't be leaving by 10am - what example to junior staff? Those doing limited private practice - should be limited! Treatment modalities neglected at Bara - the same teams would have treated patient immediately if they were in private practice � ICU [Intensive Care Unit]/orthopaedics. One should treat as one would like and expect to be treated. Two different sets of medical ethics, or is it all money?� Male doctor at CHBH for five years: �Clinical misconduct only surfaces when a medical-legal problem arises. There is no routine review of clinical performance - or very little.�

65

Box 8.1 (continued) Female nurse at Pediatrics for 15 years: �General workers, especially cleaners, are not properly supervised because they work whenever they like to, they go off as early as 10:00 in the morning.� Female nurse at the Theatre for 20 years: �General assistants are not cooperative in the workplace. Most of the time they are not there. They also add stress in the set-up.� Female nurse at Comprehensive Sections for four years: �General workers must stop abusing patients, as it implicates on the nursing staff as if they are the ones who are treating ill patients. They must allow to be disciplined, not ignore junior sisters as they are now.� Female nurse at Ortho-gynaecology for eleven years: �There are still those people who are untouchable because they are so-and-so - and if so-and-so cannot be touched, even having misconduct herself, so I am also going to develop a strategy of don't touch.� Female nurse at Maternity Ward for ten years: �People found drunk on duty must be suspended because they can be dangerous to patients.� Female nurse at Paediatrics for four months: �Stealing of medication can be controlled by counting them always when giving medication; and talk to the staff in the ward. Ask them how they feel about shortage of medication and do they know that they can go to jail for stealing.� Female nurse at Medical Ward for 18 years: �Staff to behave in an appropriate way, come on duty on time. Patients to be given medication, meals at the correct times.� Female nurse for 28 years: �Unsober behaviour, sleeping on duty - instant dismissal.�

Salient points

The following are some of the more salient points to emerge from this

analysis:

• The widespread (physical and verbal) abuse of staff by patients,

together with the fact that nearly 50% of staff also witnessed

incidents of abuse of patients, is clear evidence that there is a

serious lack of a culture of respect and care between staff and

patients.

• This result is confirmed by the fact that nearly half of staff said that

they had observed incidents of negligence in patient care, and

nearly one-third indicated having witnessed substandard post-

operative care.

• There is strong evidence that patients� rights are being violated -

nearly two out of every five staff members indicated that they had

witnessed incidents where informed consent had not been obtained,

and one-third said they had observed incidents where

66

confidentiality of patient information had been breached. These

results are supported by evidence provided by patients themselves

(see Section 10 below).

• Although other forms of misconduct, such as bribery and over-

ordering of medicine, do not seem to occur as frequently as the

ones listed above, it should be emphasised that these are

nevertheless transgressions of basic ethical principles and require

urgent attention.

• Given reported staff shortage, the fact that such a huge proportion

of staff (37%) seems to be involved in some form of moonlighting,

clearly warrants further investigation.

In an attempt to get a clearer picture of the experiences of clinical staff at

CHBH (doctors, nurses, and allied health professionals), we analysed

separately this combined (clinical) group�s responses to the questions on

observed misconduct. Although the ranking does not change radically, it is

interesting to note that some of the percentages have changed

considerably. Table 8.2 below contains the rank ordering of the top seven

categories of misconduct observed by clinical staff.

Table 8.2: Clinical staff�s observations of instances of misconduct

Once or more

Never No opinion

Patients verbally abusing staff Count 328 52 40 % 78.1% 12.4% 9.5%Staff verbally abusing patients Count 229 120 84 % 52.9% 27.8% 19.3%Lack of compassion for patients Count 200 112 87 % 50.1% 28.1% 21.9%Patients physically abusing staff Count 208 159 59 % 48.8% 37.3% 13.9%Professional negligence in patient care Count 206 141 85 % 47.7% 32.6% 19.7%Moonlighting by staff Count 199 136 95 % 46.3% 31.6% 22.2%Lack of informed consent Count 178 151 95 % 42.0% 35.6% 22.4%

67

These results reveal even better to what extent the relationship between

staff and patients is characterised by abuse and negligence, rather than

respect and care. This is perhaps the most serious finding of the study

since it concerns the basic rationale of an institution devoted to the care

and healing of human beings. The fact that such a large proportion of staff

reports instances of abuse of patients, and by patients, is an indication of

seriously deteriorated relationships. Unless a culture of mutual respect is

(re)instated, it is impossible for staff at CHBH to do their job in a

professional and responsible manner.

8.2 Reasons for misconduct

What are the reasons for this state of affairs? We asked respondents to

indicate the extent of their agreement or disagreement with a list of

possible reasons. Table 8.3 below summarises the results.

Table 8.3: Reasons for misconduct

Agree Disagree No opinion

Total

Misconduct at CHBH relates mainly to lack of discipline

Count 435 215 72 722

% 60.2% 29.8% 10.0% 100.0%

Disciplinary measures at CHBH are not �visible�

Count 403 212 65 680

% 59.3% 31.1% 9.6% 100.0%

Health professionals at CHBH do not have sufficient time to treat patients with the necessary compassion and understanding

Count 421 200 90 711

% 59.2% 28.1% 12.7% 100.0%

Employees who engage in threatening or violent behaviour on the job are seldom subjected to immediate disciplinary action

Count 362 225 126 713

% 50.8% 31.5% 17.7% 100.0%

Language barriers make it difficult for health care professionals to convey to patients proper information about their diagnosis and treatment

Count 300 328 84 711

% 42.1% 46.0% 11.8% 100.0%

68

Payment to employees at CHBH by patients or their family for services or treatment given is fraud

Count 270 276 184 730

% 37.0% 37.8% 25.2% 100.0%

Because of the heavy workload at CHBH it is fair for employees to ask for small incentives ("tips") for services

Count 163 452 100 715

% 22.8% 63.2% 14.0% 100.0%

Four main findings

Responses suggest four clusters of possible reasons for observed

instances of misconduct.

• The reasons having the most support among staff concern the lack

of punitive measures - no real or visible disciplining of misconduct

occurs (60% of staff)

• Working conditions - the heavy workload that leads to inadequate

attention to clinical care (60% indicate it as a main reason)

• No consensus about ethical values - there is clearly insufficient

agreement about the meaning of misconduct as evidenced by the

fact that substantial proportions of respondents do not believe

�tipping� and �fraud� to be wrong.

• The demographics of patients, especially the existence of language

barriers, lead to misunderstanding and possibly abuse (about 50%-

50%)

8.3 Misconduct and the need for an ethics committee

In response to the question whether a hospital ethics committee would

assist in guiding professional conduct, more than two-thirds of staff (69%)

answered positively. Box 8.2 below lists some of the remarks and

suggestions about such a committee.

69

Box 8.2 Ethics and disciplinary committees Female nurse at Medical Section for 12 years: �Proper code of conduct [should] be in place and copies given to staff members. Disciplinary code clearly defined. Grievance procedure clearly defined to all staff members.� Female doctor at CHBH: �Managing committee to deal with misconduct without alienating the complainant.� Female doctor at CHBH for four years: �Disciplinary committee - comprising management staff, doctors, and nurses.� Female nurse at Surgical Section for 20 years: �There should be a disciplinary committee available for every employee category.�

8.4 Concluding comments

This section vividly illustrates the severity of problems at CHBH. The

extent of misconduct � as reported by staff � is serious and points to a

situation not conducive to professional and responsible patient care. It is

imperative that hospital management addresses these issues as a matter

of priority. And, as suggested by the quotations below, a starting point

should be issues related to the current lack of discipline in the hospital.

Female speech therapist at Audiology for ten years: �Systems

need to be in place and offenders immediately punished - CEO

needs to have delegated authority.�

Male doctor at CHBH for one year: �Need policing body to police

the general running of the clinical disciplines, i.e. not bureaucratic,

[but] a medical body to review the running of the disciplines.�

Male doctor at CHBH for 27 years: �The following mechanisms

must be put in place urgently: senior supervision - daily ward

rounds by consultants; regular mortality and morbidity meetings;

regular meetings for nursing staff; and limitation of excess work.�

70

Female nurse at General Surgical Section for 13 years: �Clear

guidelines and lines of communication to be spelled out so that if

personnel have a problem they should know where to go.�

71

SECTION 9 PROBLEMS AND SOURCES OF STRESS

What are the main problems and sources of stress experienced and

identified by CHBH staff? In the first table below (Table 9.1), we list the

results for the complete list of twenty possible problems presented to

staff.

Table 9.1: Ratings of the main problems

Very great /

great extent

Moderate

extent

Some / Very

little extent

Total

Poor/outdated equipment Count 422 116 179 717

% 58.9% 16.1% 25.0% 100.0%

Not enough medicine Count 313 143 238 694

% 45.1% 20.6% 34.3% 100.0%

Linen shortage Count 500 97 108 705

% 70.9% 13.8% 15.3% 100.0%

Poor remuneration Count 455 98 142 695

% 65.5% 14.1% 20.4% 100.0%

Long shifts Count 351 155 184 691

% 50.9% 22.4% 26.7% 100.0%

Night duty Count 323 150 211 684

% 47.3% 21.9% 30.8% 100.0%

General shortage of staff Count 586 54 66 705

% 83.1% 7.6% 9.3% 100.0%

Poor staff communication Count 356 166 176 698

% 51.0% 23.8% 25.2% 100.0%

Supervision/issues of authority Count 346 162 179 688

% 50.3% 23.6% 26.1% 100.0%

Patients with low levels of

schooling

Count 174 151 373 698

% 25.0% 21.6% 53.4% 100.0%

Long-stay patients Count 282 122 290 694

% 40.7% 17.6% 41.7% 100.0%

72

Impossible/demanding patients Count 302 152 238 692

% 43.7% 22.0% 34.4% 100.0%

Substandard care because of

large numbers

Count 463 91 137 690

% 67.0% 13.1% 19.8% 100.0%

Language difficulties in dealing

with patients

Count 203 171 321 695

% 29.2% 24.6% 46.1% 100.0%

AIDS patients Count 315 117 258 690

% 45.7% 17.0% 37.3% 100.0%

Influx of non-South African

patients

Count 248 107 222 577

% 43.0% 18.6% 38.5% 100.0%

Unsanitary/unhygienic

conditions

Count 454 93 167 713

% 63.6% 13.0% 23.4% 100.0%

Poor maintenance of buildings Count 427 107 169 703

% 60.8% 15.2% 24.0% 100.0%

Lack of safety Count 456 113 149 718

% 63.4% 15.8% 20.8% 100.0%

Vandalism Count 342 124 226 692

% 49.4% 18.0% 32.6% 100.0%

In the remainder of this section, these results are organised in three

forms:

• The six most serious problems for the organisation as a whole

• The five most serious problems for each category of staff

• The two most serious problems within each of four categories of

problems

73

9.1 Most serious problems for the organisation as a whole

For all staff at CHBH, these are the six most serious problems in order of

importance:

• Shortage of staff (83.1%)

• Linen shortage (70.9%)

• Substandard care because of large numbers (67%)

• Poor remuneration (65.5%)

• Unhygienic conditions (63.6) and lack of safety (63.4%)

• Poor maintenance of buildings (60.8%)

9.2 Most serious problems for each category of staff

The five most serious problems identified by each of the different

categories of staff are summarised in Tables 9.2 to 9.5 below:

Table 9.2: Most serious problems identified by doctors

Count Col % General shortage of staff Very great / great extent 80 94.2% Moderate extent 4 4.1% Some / Very little extent 1 1.7%Unsanitary/unhygienic conditions Very great / great extent 69 79.7% Moderate extent 15 17.1% Some / Very little extent 3 3.3%Poor/outdated equipment Very great / great extent 64 74.6% Moderate extent 15 17.2% Some / Very little extent 7 8.2%Poor remuneration Very great / great extent 62 74.2% Moderate extent 17 20.0% Some / Very little extent 5 5.8%Long shifts Very great / great extent 61 73.1% Moderate extent 18 21.8% Some / Very little extent 4 5.0%

74

Table 9.3: Most serious problems identified by nurses

Count Col %General shortage of staff Very great / great extent 282 86.5% Moderate extent 11 3.4% Some / Very little extent 33 10.0%Linen shortage Very great / great extent 261 80.1% Moderate extent 21 6.4% Some / Very little extent 44 13.5%Substandard care because of large numbers

Very great / great extent 229 71.9%

Moderate extent 37 11.6% Some / Very little extent 53 16.6%Poor remuneration Very great / great extent 200 64.4% Moderate extent 58 18.6% Some / Very little extent 53 17.0%Lack of safety Very great / great extent 222 68.6% Moderate extent 48 14.9% Some / Very little extent 54 16.6% Table 9.4: Most serious problems identified by allied health

professionals Count Col %General shortage of staff Very great / great extent 30 89.2% Moderate extent 2 6.0% Some / Very little extent 2 4.8%Poor maintenance of buildings Very great / great extent 24 69.4% Moderate extent 8 22.4% Some / Very little extent 3 8.2%Poor remuneration Very great / great extent 27 81.7% Moderate extent 3 8.5% Some / Very little extent 3 9.8%Lack of safety Very great / great extent 26 75.3% Moderate extent 5 14.1% Some / Very little extent 4 10.6%Poor staff communication Very great / great extent 22 66.3% Moderate extent 7 21.7% Some / Very little extent 4 12.0%

75

Table 9.5: Most serious problems identified by support staff

Count Col % General shortage of staff Very great / great extent 193 74.3% Moderate extent 37 14.2% Some / Very little extent 30 11.5% Linen shortage Very great / great extent 170 64.3% Moderate extent 48 18.3% Some / Very little extent 46 17.4% Poor staff communication Very great / great extent 133 50.9% Moderate extent 55 21.1% Some / Very little extent 74 28.1% Substandard care because of large numbers

Very great / great extent 147 57.7%

Moderate extent 35 13.5% Some / Very little extent 74 28.8% Poor remuneration Very great / great extent 166 62.1% Moderate extent 21 7.8% Some / Very little extent 80 30.2%

9.3 Most serious problems within each of four categories of

problems

If one divides problems into different categories � namely, those related

to resources, staff, patients, and the environment � the following were

identified as the two most important problems in each of these four

categories of problems.

Resource related problems

• Linen shortage (70.9%)

• Poor/outdated equipment (58.9%)

Staff related problems

• General shortage of staff (83.1%)

• Poor remuneration (65.5%)

Patient related problems

• Substandard care because of large numbers (67.0%)

• HIV/AIDS patients (45.7%)

Environment related problems

• Unsanitary/unhygienic conditions (63.6%)

• Lack of safety (63.4%)

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9.4 Concluding comments

It is significant that the same basic problems (staff shortages, linen

shortages, substandard care, poor remuneration, lack of safety, and

unhygienic conditions) are recurring problems and sources of stress across

all staff categories. This suggests that these problems are hospital-wide

problems and prevalent across departments and staff functions and

should, therefore, receive urgent attention.

77

SECTION 10 PATIENT PERSPECTIVES

�� I will come for the benefit of the sick,

remaining free of all intentional injustice ��

- The Hippocratic Oath, 5th Century BC

Hospitals exist to produce quality health care for their patients. In the final

analysis, all members of the hospital staff should dedicate themselves to

the pursuit of the well-being and health of all patients. Whereas our

concern thus far in the report has been to convey and analyse the beliefs,

values, and practices of different categories of staff, we now shift our

focus to the patient. In the preceding sections, patients� views were

integrated into the report where they related to issues common to all

categories of respondents. In this section, we focus on patients�

perspectives as they pertain to other issues.

Results are presented under the following headings:

• Relationship with nurses and doctors

• Levels of satisfaction with various aspects of the hospital service

• Experience of unethical behaviour by hospital staff

• Treatment by student nurses and student doctors

• Various ethical issues

10.1 Relationship with nurses and doctors

How do patients experience their relationship with nurses and doctors? Do

they view nurses and doctors differently in respect of seven sets of

categories presented to them? The answers to these questions �

comparing patients� experiences of nurses and doctors � are presented in

Figures 10.1 to 10.7 below.

78

0

50

100

Respectful - disrespectul

Nurses 52.1 5.7 8.8 18 5.7 0.5 9.3

Doctors 75 2.1 4.7 4.2 2.1 1.6 10.4

1 2 3 4 5 6 7

0

50

100

Professional - unprofessional

Nurses 48.2 9.9 11 9.9 6.3 4.2 10.5

Doctors 77.4 5.8 1.6 5.8 2.1 1.6 5.8

1 2 3 4 5 6 7

0

50

100

Relaxed - tense

Nurses 48.1 8.1 13 16.2 5.4 1.1 8.1

Doctors 69.7 4.3 7.4 6.9 5.3 1.1 5.3

1 2 3 4 5 6 7

Figure 10.1: Nurses and doctors: Respectful � disrespectful

Figure 10.2: Nurses and doctors: Professional � unprofessional

Figure 10.3: Nurses and doctors: Relaxed - tense

79

0

50

100

Caring - Uncaring

Nurses 48.4 10.5 9.5 10.5 6.8 3.2 11.1

Doctors 74.1 5.8 4.8 3.2 1.6 2.6 7.9

1 2 3 4 5 6 7

0

50

100

Compassionate - Cold

Nurses 48.1 9.2 10.3 11.4 7 2.7 11.4

Doctors 64.8 5.6 7.8 3.9 2.8 2.8 12.3

1 2 3 4 5 6 7

0

50

100

Approachable - unapproachable

Nurses 48.7 9.4 9.4 13.6 4.2 2.1 12.6

Doctors 74.7 3.7 3.7 4.2 2.6 1.1 10

1 2 3 4 5 6 7

Figure 10.4: Nurses and doctors: Caring - uncaring

Figure 10.5: Nurses and doctors: Compassionate - cold

Figure 10.6: Nurses and doctors: Approachable - unapproachable

80

0

50

100

Trusting - distrusting

Nurses 54.2 7.8 7.8 10.4 7.3 3.1 9.4

Doctors 77.2 3.6 1.6 5.7 3.1 2.1 6.7

1 2 3 4 5 6 7

Figure 10.7: Nurses and doctors: Trusting - distrusting

Discussion

Two trends emerge from these figures. First, the overall pattern of

patients� responses with regard to nurses and doctors is very consistent

across all dimensions. If one collapses the three extreme categories at

both ends of the spectrum, one finds that patients rate various aspects of

care by nurses and doctors very similarly across these dimensions. In all

of these cases, 65-75% of patients rated nurses as being respectful,

professional, relaxed, compassionate, and the like. A small minority of 10-

20% of patients rated nurses to be disrespectful, unprofessional, uncaring

and the like.

A second noteworthy trend relates to the different ratings of nurses and

doctors. Results are in line with earlier findings, namely, that doctors

consistently get more positive or higher ratings than nurses � within a

range of 15�20% on all dimensions.

Although these figures, in broad outline, do present a positive picture and

might give cause for complacency, it is still worth pointing out the

following:

• 15% of patients viewed nurses and doctors as being disrespectful

• 22% of patients viewed nurses as being unprofessional

• 20% of patients experienced nurses as being uncaring and cold

• 19% of patients said nurses were unapproachable

• 20% of patients rated nurses as being distrusting.

81

If one were to generalise, this would mean that one in every five patients

have not had particularly favourable experiences of nurses in particular.

Expressed as numbers of patients, these findings relate to the actual

experiences of hundreds of patients (more than 500) in the hospital at

any given time.

10.2 Levels of satisfaction with various aspects of hospital

services

Patients were subsequently asked to indicate their levels of satisfaction

with various aspects of hospital services they had received. Findings are

summarised in Tables 10.1 to 10.5 below.

Table 10.1: Assistance by nurses on day duty

Frequency Percent Valid Percent

Cumulative Percent

Valid Very satisfied 106 51.7 55.8 55.8 Quite satisfied 36 17.6 18.9 74.7 Somewhat satisfied 26 12.7 13.7 88.4 Quite dissatisfied 9 4.4 4.7 93.2 Very dissatisfied 13 6.3 6.8 100.0 Total 190 92.7 100.0 Missing System 15 7.3 Total 205 100.0

Table 10.2: Assistance by nurses on night duty

Frequency Percent Valid Percent Cumulative

Percent

Valid Very satisfied 76 37.1 41.5 41.5 Quite satisfied 42 20.5 23.0 64.5 Somewhat satisfied 26 12.7 14.2 78.7 Quite dissatisfied 13 6.3 7.1 85.8 Very dissatisfied 26 12.7 14.2 100.0 Total 183 89.3 100.0

Missing System 22 10.7 Total 205 100.0

82

Table 10.3: Quality of medical treatment received

Frequency Percent Valid Percent Cumulative Percent

Valid Very satisfied 112 54.6 61.9 61.9 Quite satisfied 22 10.7 12.2 74.0 Somewhat satisfied 30 14.6 16.6 90.6 Quite dissatisfied 9 4.4 5.0 95.6 Very dissatisfied 8 3.9 4.4 100.0 Total 181 88.3 100.0

Missing System 24 11.7 Total 205 100.0

Table 10.4: Linen on your bed

Frequency Percent Valid percent Cumulative percent

Valid Very satisfied 84 41.0 48.3 48.3Quite satisfied 16 7.8 9.2 57.5Somewhat satisfied

29 14.1 16.7 74.1

Quite dissatisfied 15 7.3 8.6 82.8Very dissatisfied 30 14.6 17.2 100.0Total 174 84.9 100.0

Missing System 31 15.1Total 205 100.0

Table 10.5: Quality of food

Frequency Percent Valid Percent Cumulative Percent

Valid Very satisfied 86 42.0 49.4 49.4 Quite satisfied 20 9.8 11.5 60.9 Somewhat satisfied 33 16.1 19.0 79.9 Quite dissatisfied 12 5.9 6.9 86.8 Very dissatisfied 23 11.2 13.2 100.0 Total 174 84.9 100.0

Missing System 31 15.1 Total 205 100.0

Table 10.6: The room you are in

Frequency Percent Valid Percent Cumulative Percent

Valid Very satisfied 87 42.4 47.0 47.0 Quite satisfied 28 13.7 15.1 62.2 Somewhat satisfied 25 12.2 13.5 75.7 Quite dissatisfied 16 7.8 8.6 84.3 Very dissatisfied 29 14.1 15.7 100.0 Total 185 90.2 100.0

Missing System 20 9.8 Total 205 100.0

83

Summary

In order of satisfaction (combining �very satisfied� and �quite satisfied�),

patients indicated that they were the most satisfied with the following:

• Assistance received from nurses on day duty (74.7%)

• Quality of medical treatment received (74.0%)

• Assistance received from nurses on night duty (64.5%)

• Their rooms (62.2%)

• Quality of food (60.9%)

• Linen on their beds (57.5%)

10.3 Experience of unethical behaviour by hospital staff

In this section, we report on incidents of unethical or unprofessional

behaviour as experienced by patients. Table 10.7 below summarises

results with regard to the following issues: incidents of verbal and physical

abuse; breach of confidentiality of patient information; professional

negligence; and substandard medical care.

Concerning aspects of abuse, minorities of patients reported that they had

been physically abused - either by doctors (3.4%), nurses (8.9%), or

other staff (8.3%). Disconcertingly high proportions of patients reported

verbal abuse, by especially nurses (39%) but also other staff (27.3%). In

addition, a small percentage (7.6%) indicated that doctors had verbally

abused them.

Patients must be able to believe that any private information about

themselves and their medical condition would be treated in confidence. A

small but significant percentage (12.5%) indicated that they had

experienced breaches of such confidentiality.

In respect of professionalism and quality of medical care, nearly a quarter

of patients (23%) reported experiencing negligence in care, with a similar

proportion (26%) indicating having received substandard medical care at

least once.

84

There are unacceptably high levels of verbal abuse, especially by nurses

and support staff, one in eight patients having had confidentiality of

private information breached, and quality of health care and

professionalism leave much to be desired. These results are cause for

grave concern and require immediate action by hospital management.

Table 10.7: Incidents of unethical behaviour experienced by patients

Never Once or

twice

Three times

or more

Verbal abuse by a nurse 61 18.7 20.3

Verbal abuse by a doctor 92.4 6.5 1.1

Verbal abuse by another CHBH employee

(such as porters)

73.7 12.2 15.1

Physical abuse by a nurse 91.2 6.1 2.8

Physical abuse by a doctor 96.7 1.7 1.7

Physical abuse by another CHBH employee

(not nurse/doctor)

91.7 6.1 2.2

Breach of confidentiality of patient

information

87.5 8.5 4.0

Professional negligence in patient care 77.6 13.2 9.3

Substandard medical care 74.9 17.3 7.8

10.4 Treatment by student nurses and student doctors

An important aspect of patients� experiences - especially of the quality of

care they receive � relates to their being treated by student nurses and

student doctors. Tables 10.8 and 10.9 summarise patients� responses to

questions regarding this aspect. Boxes 10.1 and 10.2 list some of the

reasons for their concerns.

85

Table 10.8: Do you mind being cared for by student nurses?

Frequency Percent Valid Percent

Cumulative Percent

Valid Yes 42 20.5 22.6 22.6No 144 70.2 77.4 100.0Total 186 90.7 100.0

Missing System 19 9.3Total 205 100.0

Box 10.1 Treatment by student nurses Female patient: �I mind because she is not a professional nurse, she is still a student. She is not a qualified nurse, she is still learning. The best way she must go together with qualified nurse.� Female patient: �I do mind because sometimes a student nurse can make mistakes, she can inject you with a wrong injection, or she/he can use a rectal thermometer instead of an oral one (in the mouth).� Male patient: �Quite number of student nurses not qualified when it comes to examining the patient. They are unprofessional; as a matter of fact, they did not complete the course.� Female patient: �Because she goes out looking for someone to ask, and they are wasting my time. I want a real nurse who knows his or her job.� Female patient: �They might give me the wrong medication.� Male patient: �As a patient or human being, my well-being must be taken care of by someone who is qualified or professional.� Female patient: �Because student nurses are not professionals, they sometimes give patients wrong information or medical treatment, so I do mind.� Male patient: �Because I do not trust that they know what they are doing.�

Table 10.9: Do you mind being examined by student doctors?

Frequency Percent Valid Percent

Cumulative Percent

Valid Yes 36 17.6 19.7 19.7No 147 71.7 80.3 100.0

Total 183 89.3 100.0Missing System 22 10.7

Total 205 100.0

86

Box 10.2 Treatment by student doctors Female patient: �Yes because it took a long time to examine you, as student doctors want to examine you the way he or she wants.� Male patient: �They give wrong medication; often examine the patient, which leads to death.� Male patient: �Sometimes they don�t listen to your problems.� Female patient: �I feel that they are not professional enough and feel that they will not examine me the way I want to be.� Female patient: �Because I don�t feel safe they might give me the wrong diagnosis.� Male patient: �I was once drugged by a student doctor and my hand was swollen for about 7-9 days.� Female patient: �They make lots of mistakes; they are not yet professional.� Female patient: �Especially when coming to operations, I also mind, because they can put your life in danger without being aware that they have done something wrong.� Female patient: �It is hard to trust or believe their judgement unless a full doctor will be consulted afterwards.�

Discussion

Relatively small proportions of patients indicated reservations about being

examined by student nurses and doctors. Slightly more than 20% said

that they had concerns about being examined by student nurses, with a

similar proportion (19%) expressing reservations about being examined

by student doctors. An inspection of the qualitative comments shows that

the common reasons for these reservations relate to perceived lack of

professionalism, inexperience, and possible lack of quality care.

10.5 Various ethical issues

A number of statements were put to patients in order to assess their

general views on various ethical issues as well as the moral implications of

patient care. These issues refer to possible bribery, overworked staff,

ethical issues about informed consent, and adequate patient briefings. The

results are summarised in Tables 10.10 to 10.15 below.

87

Table 10.10: Patients who give money to staff at CHBH for services or treatment act wrongly

Frequency Percent Valid Percent Cumulative

PercentValid Strongly agree 117 57.1 63.2 63.2

Tend to agree 11 5.4 5.9 69.2Tend to disagree 10 4.9 5.4 74.6Strongly disagree 30 14.6 16.2 90.8No opinion 17 8.3 9.2 100.0Total 185 90.2 100.0

Missing System 20 9.8 Total 205 100.0

Table 10.11: Staff at CHBH do not have sufficient time to treat

patients with the necessary compassion and understanding

Frequency Percent Valid percent Cumulative percent

Valid Strongly agree 108 52.7 58.7 58.7Tend to agree 23 11.2 12.5 71.2Tend to disagree 12 5.9 6.5 77.7Strongly disagree 24 11.7 13.0 90.8No opinion 17 8.3 9.2 100.0Total 184 89.8 100.0

Missing System 21 10.2Total 205 100.0

Table 10.12: Language barriers make it difficult for staff to convey to patients proper information about their diagnosis and treatment

Frequency Percent Valid

Percent

Cumulative Percent

Valid Strongly agree 117 57.1 64.3 64.3Tend to agree 18 8.8 9.9 74.2Tend to disagree 10 4.9 5.5 79.7Strongly disagree 18 8.8 9.9 89.6No opinion 19 9.3 10.4 100.0Total 182 88.8 100.0

Missing System 23 11.2Total 205 100.0

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Table 10.13: I sometimes find it difficult to understand what doctors tell me about my illness

Frequency Percent Valid Percent Cumulative Percent

Valid Strongly agree 116 56.6 63.7 63.7Tend to agree 16 7.8 8.8 72.5Tend to disagree 7 3.4 3.8 76.4Strongly disagree 27 13.2 14.8 91.2No opinion 16 7.8 8.8 100.0Total 182 88.8 100.0

Missing System 23 11.2Total 205 100.0

Table 10.14: I am always told what is wrong with me and why certain medicines are given to me

Frequency Percent Valid Percent Cumulative Percent

Valid Strongly agree 33 16.1 21.9 21.9Tend to agree 12 5.9 7.9 29.8Tend to disagree 9 4.4 6.0 35.8Strongly disagree 88 42.9 58.3 94.0No opinion 9 4.4 6.0 100.0Total 151 73.7 100.0

Missing System 54 26.3Total 205 100.0

Table 10.15: I usually find it easy to understand what nurses tell me about my illness

Frequency Percent Valid Percent Cumulative Percent

Valid Strongly agree 69 33.7 37.3 37.3Tend to agree 45 22.0 24.3 61.6Tend to disagree 24 11.7 13.0 74.6Strongly disagree 33 16.1 17.8 92.4No opinion 14 6.8 7.6 100.0Total 185 90.2 100.0

Missing System 20 9.8Total 205 100.0

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Salient points

• The vast majority of patients (70%) agreed that giving money to

staff for treatment was wrong.

• A similar proportion of patients (71%) agreed that hospital staff did

not have sufficient time to treat them properly.

• Language barriers between staff and patients are a serious

problem, given that three-quarters of patients said that such

barriers posed difficulties for mutual understanding. A similar

proportion of patients (72%) indicated that they had had problems

understanding what doctors had told them about their illness.

• Nearly two-thirds of patients (64%) claimed that they had not told

or informed what was wrong with them and why they had received

certain kinds of medication.

• There seems to be better communication between patients and

nurses, with 62% of patients indicating that they found it easy to

understand what nurses told them about their illness. By contrast,

almost three-quarters of patients (72,5%) sometimes found it hard

to understand what doctors tried to communicate to them about

their illness.

One�s overarching impression is that most patients are not well informed

about their illness, or the reason for the treatment or medication they

receive. Given that these are basic patients� rights, it is imperative that

the hospital addresses these issues as a matter of urgency.

10.6 Concluding comments

We conclude this section on patient perspectives by highlighting key

findings:

• Majorities of patients (ranging between 65 and 75%) rated nurses

as being respectful, professional, relaxed, compassionate, and the

like. A small minority of between 10 and 20% of patients rated

nurses to be disrespectful, unprofessional, uncaring, and the like.

However, it is interesting � and a cause for concern � that nurses

and doctors consistently received different ratings for clinical care.

These results are in line with earlier findings - doctors get more

90

positive ratings � within a range of 15�20% higher ratings on all

dimensions.

• Patients are mostly satisfied with the assistance and quality of

medical treatment they received. They are less satisfied with their

rooms and the quality of food, and least satisfied with the linen on

their beds.

• There are unacceptably high levels of verbal abuse, especially by

nurses and support staff, patient information is not always treated

in confidence, and quality of health care and professionalism leave

much to be desired. These results are cause for grave concern and

require immediate action by hospital management.

• Relatively small proportions of patients indicated reservations about

being examined by student nurses and student doctors. Common

reasons for such reservations relate to perceived lack of

professionalism, inexperience, and possible lack of quality care.

• Concerning informed consent and general sharing of medical

information, most patients are not well informed about their illness

or the reasons for treatment or medication regimes.

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SECTION 11 CONCLUSIONS AND RECOMMENDATIONS

11.1 Conclusions

Given the nature of its mission, a hospital should embody the highest

human values with the aim of optimal professionalism and quality patient

care. (See Appendix 9 for the mission statement of CHBH.) Further,

because a hospital is an organisation, one would expect a commitment to

other organisational values, such as good staff relations, a good

organisational work ethic, and the like. In short, one would expect to find

the �usual� organisational values, and, in addition, values peculiar to a

�hospital�.

It is important to realise that organisational culture and values are, among

other things, embedded in sets of material conditions - organisations are

not merely institutions that �house� people, their beliefs and values, but

also consist of buildings, infrastructure, equipment, and supplies. Unless

the required material conditions are in place and functioning well, no

institution can operate effectively and efficiently.

We represent the relationship between the material and physical

�foundation�, on the one hand, and more symbolic culture and values, on

the other, in Diagram 11.1 below. But our interest, ultimately, in this

audit, is in how the material/physical conditions, together with the

organisational culture and values, impact on professional conduct of staff

in their relationships with patients. Stated differently: how does the place

where people work, and the values and beliefs prevalent in that

organisation, affect the manner in which they interact with and care for

patients? It is within this context that we examined the nature and extent

of instances of misconduct at CHBH.

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If we take the diagrammatic representation below (Diagram 11.1) as our

point of reference, it becomes possible to summarise the main findings of

the study as follows:

Diagram 11.1: A hospital as an institution: Foundation, cultural

pillars, and pinnacle

The foundation

Evidence from the survey identified serious problems relating to the

physical plant (neglect and poor maintenance; perceptions of

uncleanliness), lack of safety and security, insufficient management of

supplies (linen and medicine), and insufficient and outdated equipment.

PROFESSIONAL

CONDUCT

FIRST PILLAR

GENERAL

ORGANISATIONAL CULTURE

AND VALUES

SECOND PILLAR

HOSPITAL-SPECIFIC

CLINICAL CARE CULTURE

AND VALUES

MATERIAL AND PHYSICAL CONDITIONS

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First pillar: General organisational culture

CHBH staff does not believe it is a hospital with a good working

environment, there is clearly no positive work ethic, and staff relations are

characterised mainly as distrusting, dishonest, and disloyal. Staff displays

unhappiness about the lack of participative management and inadequate

channels of communication. But the biggest concerns relate to staff

shortages and poor conditions of service.

Second pillar: Clinical care culture special to a hospital as an

institution

Concerning staff-patient relationships, there is insufficient recognition of

patients� rights, little mutual respect exists between staff and patients

(abuse is widespread), and, generally, insufficient attention is given to

professional and quality of care.

The pinnacle

The nature and extent of misconduct at CHBH is of grave concern. Staff

and patients reported extensive verbal and physical abuse (by both

patients and staff), bribery and fraud are not unanimously condemned,

and patients� rights are often violated, resulting in substandard quality of

overall patient care.

11.2 Recommendations

The following twenty-six recommendations are premised on our conviction

that appropriately addressing concrete organisational issues would

substantially improve the ethics culture at CHBH � in terms of the beliefs

and values that inform conduct or action, as well as conduct or action

itself.

The ideal is to achieve a good institutional or organisational ethics culture,

for the benefit of all stakeholders - internal (patients, staff, etc.) and

external (the community served by CHBH, contractors, vendors, visitors,

etc.). We do not claim that our recommendations are exhaustive, or that

their implementation alone would achieve this end. They represent the

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understanding we have gained concerning some salient issues raised by

CHBH staff in the course of our ethics audit.

We are, however, convinced that no attempt at addressing the very real

organisational and ethical issues at CHBH could succeed without coming to

terms with our main findings and conclusions, as well as the following core

recommendations emanating from them.

MANAGEMENT AND LEADERSHIP

Recommendation 1:

Managing such an enormous and complex institution

requires that the authority and powers of the CEO and

central hospital management be on a par with those of their

peers in private-sector hospitals, rather than be centralised

in a (distant) government department. In short, substantive

powers should be conferred upon and exercised by central

hospital management (for example, internal budgetary

powers, and powers of hiring and firing, and discipline).

Remarks: New powers26 have indeed recently been delegated to

public-hospital central management, but it is unclear exactly how

these powers would be exercised in Gauteng. Most importantly,

disciplinary powers (for example, powers of dismissal for

misconduct) should not disappear in an administrative or appeals

�black hole�. Still, they should always conform to the canons of

justice and fairness.

26 Gauteng Provincial Government Department of Health: Delegation of Powers and Assignment of Duties in terms of the Public Finance Management Act (Act 1, 1999). Johannesburg, 26 September 2001.

95

Recommendation 2:

Management expertise and professionalism on all levels

should be of the highest order and, to this end, there should

be ongoing sharing of expertise and experiences between

the public and private sectors, and academia.

Remarks: Private hospital groups should see it as part of their social

responsibility to assist public hospitals. Similarly, universities and

technikons, as training facilities for future health-care professionals,

need to shoulder some responsibility for improving management

expertise and professionalism. For example, CHBH would benefit

from relevant research undertaken by business schools and

technikons into management and operations, in essence leading to

useful partnerships.

Recommendation 3:

Management on all levels should, as a matter of urgency,

review the prevailing management style and culture of the

hospital, and should put in place conditions for consultative

leadership, constructive communication, and participatory

decision making at all levels in the hospital.

Remarks: Initiatives such as the following should be considered:

open and free access to official forms of communication, recognition

by superiors, structured and regular feedback from superiors,

freedom of expression without fear of reprisal (including reporting

of misconduct); and creating an atmosphere of joint responsibility,

accountability, and transparency. Ultimately, initiatives are not the

sole responsibility of central hospital management, but are likewise

that of management at all levels of the organisation (heads of

academic departments, laboratory services, nursing services,

cleaning services, etc.)

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HUMAN RESOURCES

Recommendation 4:

Staff numbers should be reviewed as a matter of urgency

with a view to an increased budget allocation, and such a

review could be done with the assistance of private-sector

hospital groups as a social-responsibility initiative.

Remarks: The key criterion in such a review process should be

quality patient care conforming to accepted standards of care. It

stands to reason that existing staff be deployed optimally.

Moreover, organisational initiatives should be directed at creating a

working environment conducive to employee productivity and job

satisfaction as well as thoroughgoing professionalism at all levels

(see recommendations below). Importantly, some sectors of the

hospital (such as general admissions and discharge, casualty

admissions, and the pharmacy or dispensary) seem to experience

particularly acute staff shortages, and such shortages appear to be

at the root of many other problems in the hospital. In addition,

clerical staff must be appointed in admission wards, such as Ward

20, on a 24-hour basis.

Recommendation 5:

Review of staff development should become a matter of high

priority, through in-service and continuing education and

training.

Remarks: Aspects of staff development that need attention relate

communication and other interpersonal skills, (cultural) diversity

training and education, and ethics and human rights. The goals of

staff development should always be informed by the needs of both

staff and patients.

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Recommendation 6:

Institute staff enrichment programmes, through team-

building workshops and other initiatives, with a view to

assuring cooperation, professionalism, and quality service on

all levels.

Remarks: Enrichment (in addition to skills development) focuses on

building competence and self-confidence on a bottom-up level and

with a view to problem solving and effective decision making. It is

worth noting that a pilot study being undertaken in some of the

wards at Kalafong Hospital, Gauteng, may yield a useful model for

such exercises.

Recommendation 7:

Conditions of service of staff should be reviewed

periodically, and this should be done in an open process with

all stakeholders, including staff.

Remarks: Pressing issues relate to general remuneration,

remuneration for overtime work and night duty, accommodation at

or near the hospital, transport, a crèche, and the quality of food.

Recommendation 8:

Structured performance evaluation with a view to

adjustment of remuneration, in particular, should be done in

terms of fair and just criteria, and in an interactive process,

based on regular and constructive feedback, spelling out

avenues for performance improvement, and introducing

incentives.

Remarks: Dissatisfaction with remuneration appears to have more

to do with unilateral changes than public-private sector

discrepancies. Performance evaluation, for example, appears to

cause serious dissatisfaction. Annual salary increases were replaced

by performance evaluations leading to notch increases and leg

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(rank) promotions, but these have reportedly been withheld by the

Gauteng Department of Health.

Recommendation 9:

Induction or orientation programmes should be put in place

to educate new staff about all relevant values statements,

codes of ethics, and rules and procedures; and opportunities

should be created for renewing the understanding and

commitment of incumbents to those documents and the

values they represent.

Remarks: The health professions have international and local

guiding documents in the form of value oriented ethics statements

and compliance oriented codes of conduct. In addition, each

organisation or institution has its own statements, codes and

procedural and disciplinary rules, which should be reviewed and

updated on an ongoing basis.

MATERIAL RESOURCES

Recommendation 10:

The hospital as a physical plant � in terms of appearance,

maintenance, cleanliness, hygiene, and the like � should be

upgraded as a matter of urgency.

Remarks: Many aspects of the physical condition and appearance of

the hospital can be attended to with relatively little expenditure.

Painting walls and keeping wards clean require material resources,

commitment and pride, and some effort.

99

Recommendation 11:

Security in and around the hospital needs urgent review in

order to protect material and human resources; and a

thorough security audit conducted by an independent

security facility needs to be done with a view to putting the

best possible systems in place.

Remarks: Security is a huge concern for respondents,

understandably so. Violent social conditions in the country make

security a top priority. Disregard for others� or the state�s material

possessions (through theft, pilfering, reckless handling, or

destruction) and violence against the person (such as verbal abuse

or physical abuse, assault, etc.) are wholly antithetical to what a

hospital as an institution is supported to stand for. Issues such as

rights of admission, searches upon leaving hospital premises,

identifying marks on equipment, installing surveillance cameras,

introducing effective punitive action, and the like, need to be

explored.

Recommendation 12:

The desirability and feasibility of outsourcing or privatising

certain services - such as security, linen, cleaning, or porters

� need to be investigated. Alternatively, such services need

to be reviewed by independent outside companies, with a

view to skills training, monitoring performance, and the like.

Recommendation 13:

A thorough audit of the state and adequacy of all equipment

necessary for quality patient care and services needs to be

done, with a view to budgeting for repairs, maintenance,

replacement, upgrading, and the like.

Remarks: The state of repair of equipment in the hospital, outdated

equipment, and ordering patterns appear to be a very important

concern to a wide spectrum of employees.

100

Recommendation 14:

The management, control and logistics of the linen supply

need thorough review as a matter of high priority.

Remarks: Overall, linen appears to be an issue more important than

medicine. This is not surprising, since in-patients� bodies are in

almost constant contact with linen, and linen may be regarded as

symbolic of cleanliness, comfort, and personal caring. There

appears to be widespread mismanagement of the supply, cleaning

and security of linen.

Recommendation 15:

There should be a review of the adequacy of medicine supply

in the hospital as a whole, the desirability and feasibility of

decentralising the pharmacy to specialist wards, and security

of stock holding and dispensing.

Recommendation 16:

Given increasing HIV/AIDS admissions, the hospital will

need to obtain, and base policies on, reliable data with a

view to addressing infrastructural consequences for bed

occupancy rates, length of stay, linen, food, and the like.

Remarks: With increasing numbers of very sick patients likely to

become dependent on and dying in public hospitals, the

demographics of such hospitals will increasingly take on a shape

unlike that of hospitals in the past or in other parts of the world.

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ADMISSIONS

Recommendation 17:

Admissions criteria need to be reviewed with a view to

putting in place clear policies, or proclaiming and justifying

existing ones.

Remarks: Staff is concerned about several aspects of admissions,

such as referrals from feeder institutions (clinics and other

hospitals); intake with no apparent match between patient numbers

and hospital capacity; intake of foreigners or non-South Africans;

and members of medical schemes who claim free treatment. The

issue of foreigners came up repeatedly in the open-ended questions

(qualitative data), and raises the spectre of xenophobia. Clear

admissions policies should be enunciated to all stakeholders.

Recommendation 18:

Admissions clerks must be supervised effectively on a 24-hour

basis.

Remarks: It is unacceptable that clerks are absent from duty, or, when on

duty, are unfit to discharge their responsibilities for whatever reason.

DISCIPLINE AND ETHICS

Recommendation 19:

The hospital should develop and adopt an aspirational

(general) values statement.

Remarks: Such a values statement should be brief, set out commitments

to basic ethical values, be displayed, publicised and promoted, and be

reinforced at all opportunities. In short, it should be a living document,

developed by all stakeholders, in a joint process.

102

Recommendation 20:

The hospital should systematically develop new, or review

existing, compliance oriented codes of ethics (conduct), or

disciplinary codes, for all categories of employees; and

sanctions for transgressions should be enforced in fair and

just disciplinary hearings.

Recommendation 21:

Given the recently conferred powers of the CEO and central

hospital management,27 disciplinary committees should be

constituted, their brief should be widely publicised, and they

should operate in an environment of transparency and

fairness. Importantly, disciplinary powers should be in line

with practices negotiated between management and labour

in the private sector.

Remarks: Care should be taken that the appeals procedure in terms

of central management�s newly delegated powers28 does not

become a novel administrative or appeals �black hole� into which

disciplinary cases disappear. Appeals procedures should be fair,

efficient, and speedy.

Recommendation 22:

It is crucially important that appropriate mechanisms be put

in place to protect or shield any employee who reports

unethical or unlawful conduct of fellow employees from

breach of confidentiality, intimidation, or victimisation.

Moreover, at all times every employee should be protected

against intimidation and victimisation through disciplinary

measures.

27 Gauteng Provincial Government Department of Health (26 September 2001): Delegation of Powers and Assignment of Duties in terms of the Public Finance Management Act (Act 1, 1999). Johannesburg. 28 Ibid.

103

Recommendation 23:

The hospital should consider constituting a hospital or

institutional ethics committee that would serve as an

advisory body on ethical issues, including clinical practice, to

which all stakeholders, including patients, can appeal.

Remarks: The purpose of such a committee would be to encourage

a culture of reflection and debate about the complexities of

institutional and clinical decision making, and to advise in disputes.

PATIENT CARE

Recommendation 24:

Health-care professionals at all levels should be thoroughly

conversant with patients� rights as set out in all relevant

documents.

Remarks: Established patients� rights to respect, promotion of

welfare, privacy, confidentiality, informed consent, and the like, are

non-negotiable. There are strong indications that even these basic

rights are not practised adequately in the hospital. Relevant

documents setting out these rights are, for example, the National

Patients� Rights Charter of the national Department of Health (see

Appendix 8) and Nurses and Human Rights (International Council of

Nurses, 1998).

Recommendation 25:

Patients should be made aware of all their rights, and

importantly, their responsibilities upon admission, or at the

bedside when appropriate, and they should have access to

formalised complaints procedures without fear of

victimisation.

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GAUTENG DEPARTMENT OF HEALTH AND THE TREASURY

Recommendation 26:

Since many of these recommendations rely on the

availability of resources, central hospital management

should approach the Gauteng Department of Health with

strong, socially motivated, appeals for budgetary allocations.

Remarks: A provincial Department of Health has a crucial advocacy

role on behalf of its public hospitals in respect of the national

Treasury.

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APPENDICES

APPENDIX 1 LETTER ACCOMPANYING QUESTIONNAIRES, ADDRESSED TO RESPONDENTS

106

Ethics Institute of South Africa (EthicSA) Chris Hani Baragwanath Hospital Sanlam Gables, 1209 cnr Schoeman Old Potchefstroom Road & Duncan Streets, HATFIELD Diepkloof Zone 6, SOWETO PO Box 2427 PO Birkham BROOKLYN SQUARE, 0075 2013 Tel +27(0)12 342 2799 Tel +27(0)11 933 8000 Fax +27(0)12 342 2790 Fax +27(0)11 933 3135

August 2001

An ethics audit at Chris Hani Baragwanath Hospital (CHBH)

Dear Respondent Almost on a daily basis, media reports describe the conditions of public hospitals in South Africa as �appalling�, �shocking�, or, putting it more strongly, as being in �dire straits�. Health-care professionals, in particular doctors and nurses in public-sector hospitals, are reported to work in harsh and often squalid conditions. Budget cuts, the effects of the Aids pandemic, and many other factors all impact on the effective functioning of a public hospital. It is against this background that I have requested the Ethics Institute of South Africa to undertake an ethics audit of CHBH. The aim of the audit is to focus on questions regarding ethical values and beliefs, knowledge of ethical and unethical conduct, and ethical practices and their implications in order to establish (a) whether the moral conduct and attitudes of various subgroups within CHBH are affected by the environment in which they work; and, (b) if so, in what respects. Other issues to be covered include items on job satisfaction, relations between staff and patients, attitudes towards management and labour unions, security and the physical environment in which staff work. The audit will be conducted amongst all staff at CHBH. I would like to urge you to give your fullest co-operation to the research team during the study which will be conducted in July and August of this year. I also wish to emphasize that your responses to this questionnaire are anonymous (you will not be asked to add your name to the questionnaire) and that your responses will be treated with the utmost confidentiality. Yours sincerely,

Dr. Reg Broekmann CEO: Chris Hani Baragwanath Hospital

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APPENDIX 2 QUESTIONNAIRE: MANAGEMENT © EthicSA 2001

108

QUESTIONNAIRE FOR MANAGEMENT SECTION A: ORGANISATIONAL ISSUES Organisational culture 1. Interpersonal relations (i.e. how people behave or act towards each other when they are together)

can be rated on various dimensions. For each pair of adjectives below, please circle the number that, in your view, best characterises interpersonal relations among staff at CHBH in general. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that relations among staff are totally honest, you will circle a 1; if you believe that it is totally dishonest, you will circle a 7. If you believe that it is only somewhat dishonest, you will circle a 5.) PLEASE COMPLETE THE FOLLOWING: (a) Honest 1 2 3 4 5 6 7 Dishonest (b) Respectful 1 2 3 4 5 6 7 Disrespectful (c) Loyal 1 2 3 4 5 6 7 Disloyal (d) Trusting 1 2 3 4 5 6 7 Distrusting (e) Professional 1 2 3 4 5 6 7 Unprofessional (f) Relaxed 1 2 3 4 5 6 7 Tense and stressed

2. Below is a list of six organisational values. Please rate how much CHBH cares about each right now:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Serving the greatest number of patients as possible 1 2 3 4 5 (b) Avoiding bad publicity 1 2 3 4 5 (c) Not having strikes and social unrest 1 2 3 4 5 (d) Good work ethic 1 2 3 4 5 (e) Balancing the books 1 2 3 4 5 (f) Providing the best possible working environment 1 2 3 4 5

3. Below is a list of four professional values in service delivery to patients. To what extent are they practiced at CHBH? In each case distinguish between how much doctors and nurses respectively give expression to these values

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Doctors 1 2 3 4 5 (a) Compassion for patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (b) Confidentiality of patient information Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (c) Respect for dignity of patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (d) Respect for well-being of patients Nurses 1 2 3 4 5

109

Leadership and management

4. Please rate how much you agree or disagree with the following statements concerning leadership and management practices at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) The hospital management takes suggestions from below seriously. 1 2 3 4

(b) There are proper incentives in place to improve staff performance. 1 2 3 4

(c) Staff members have a say in matters of decision-making. 1 2 3 4 (d) The hospital management is clear about the career

prospects of employees. 1 2 3 4

(e) Top management has no secrets from employees. 1 2 3 4 (f) Management at CHBH is basically powerless. 1 2 3 4

Channels of communication 5. Please rate how much you agree or disagree with the

following statements concerning communication practices at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) Employees are not allowed to say what they really think. 1 2 3 4 (b) Clear guidelines exist regarding staff members�

responsibilities. 1 2 3 4

(c) My supervisor effectively follows up on complaints that I direct via him/her. 1 2 3 4

(d) My supervisor regularly gives me feedback about my performance. 1 2 3 4

(e) I am always last to be informed about decisions that concern my work. 1 2 3 4

(f) There is a system in place that employees can use to report instances of misconduct without being victimised. 1 2 3 4

(g) Rumour (the �grapevine�) is a common source of information at CHBH.

1 2 3 4

Resources 6(a). Do you experience an under-supply of medicine at CHBH?

Yes 1 No 2 Don�t know 3

6(b) If Yes, to what extent do the following contribute tothe under-supply of medicine at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Over-ordering of medicines by ward sisters 1 2 3 4 5 (b) Theft of medicines from hospital stocks by staff 1 2 3 4 5 (c) Influx of non-South African patients 1 2 3 4 5 (d) HIV/AIDS pandemic 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5

(f) Other (Please specify:����������.�

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1 2 3 4 5

110

7(a). Do you experience a general shortage of linen at CHBH?

Yes 1 No 2 Don�t know 3

7(b). If Yes, to what extent do the following contribute tothe linen shortages at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Stealing of linen by hospital staff 1 2 3 4 5 (b) Linen theft committed by patients 1 2 3 4 5 (c) Increased patient population related to the

HIV/AIDS pandemic 1 2 3 4 5

(d) Ineffective logistical and practical arrangements 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5

(f) Other: (Please specify:���������.�

��������������������.

1 2 3 4 5

Job satisfaction

8. Some jobs are more interesting and satisfying than others. We want to know how you feel about your job. For each of the following statements please circle one of the alternatives which best describes your opinion. St

rong

ly

agre

e

Ten

d to

agr

ee

Ten

d to

di

sagr

ee

Stro

ngly

disa

gree

(a) I am often bored with my job. 1 2 3 4 (b) I am satisfied with my job for the time being. 1 2 3 4 (c) Each day of work seems like it will never end. 1 2 3 4 (d) I find real enjoyment in my work. 1 2 3 4 (e) It feels as if I am working in a �second-class� hospital. 1 2 3 4 (f) I feel proud to be associated with CHBH. 1 2 3 4 (g) My opinion of myself increases when I do my job well. 1 2 3 4 (h) I frequently think of quitting my job. 1 2 3 4

9. Overall, how satisfied are you with each of the following?

Ver

y sa

tisfie

d

Qui

te

satis

fied

Som

ewha

t sa

tisfie

d

Qui

te

diss

atis

fied

Ver

y

diss

atis

fied

(a) Your salary? 1 2 3 4 5 (b) Cooperativeness of colleagues? 1 2 3 4 5 (c) Your conditions of service, e.g. leave and fringe benefits?

1 2 3 4 5

(d) Your workload? 1 2 3 4 5

111

Physical environment 10. On a scale of 1 to 7, how do you rate the physical environment at CHBH in terms of the following

dimensions? (The closer a number to a value, the more that value represents your experience. For instance, if you believe that CHBH is very clean, you will circle a 1; if you believe that it is very dirty, you will circle a 7. If you believe that it is somewhat dirty, you will circle a 5.)

(a) Clean 1 2 3 4 5 6 7 Dirty (b) Safe 1 2 3 4 5 6 7 Unsafe (c) Attractive 1 2 3 4 5 6 7 Unattractive (d) Depressing 1 2 3 4 5 6 7 Cheerful

11. Please rate how much you agree or disagree with the

following statements concerning security and safety at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) The security screening of visitors leaves much to be desired. 1 2 3 4

(b) The unsafe environment at CHBH can be related to the influx of non-South African patients. 1 2 3 4

(c) The number of security staff at CHBH is sufficient to combat crime. 1 2 3 4

(d) Security staff at CHBH is well equipped with the necessary skills and facilities to combat crime. 1 2 3 4

(e) The security screening of applicants for employment leaves much to be desired. 1 2 3 4

(f) It is the responsibility of government to ensure a safe environment at CHBH. 1 2 3 4

Admission criteria 12. (a) According to what criteria are patients admitted to CHBH?

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����������������������������������������� (b) In your view, do you believe that the admission criteria are strictly adhered to?

Yes 1 No 2 Don�t know 3

13. Should CHBH adopt the policy of other hospitals to close their doors when beds are not available?

Yes 1 No 2 Don�t know 3

112

Labour unions 14. (a) Do you think it is useful to have unions operating within the hospital?

Yes � unions are useful in every aspect 1 Yes and no � unions are useful in some ways but problematic in others 2 No � unions are not useful at all 3

(b) Please give a reason for your answer to Question 17(b):

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����������������������������������������� 15. In your view, to what extent do the unions influence the decisions made at CHBH?

Very great extent 1 Great extent 2 Moderate extent 3 To some extent 4 Very little extent 5

16. Please rate how much you agree or disagree with the following statements concerning labour unions at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) The unions at CHBH serve to enhance discipline. 1 2 3 4 (b) Unions are responsible for much of the chaos at CHBH. 1 2 3 4

SECTION B: MISCONDUCT AND STANDARDS OF CARE

17. During the past year, how often have you witnessed the following happening at CHBH?

Onc

e

Tw

ice

Thr

ee

times

or

mor

e

Nev

er

No

opin

ion

(a) Over-ordering of medicine 1 2 3 4 5 (b) Patients/visitors bribing staff 1 2 3 4 5 (c) Moonlighting by staff 1 2 3 4 5 (d) Staff verbally abusing patients 1 2 3 4 5 (e) Staff physically abusing patients 1 2 3 4 5 (f) Patients verbally abusing staff 1 2 3 4 5 (g) Patients physically abusing staff 1 2 3 4 5 (h) Lack of informed consent 1 2 3 4 5 (i) Breach of confidentiality of patient information 1 2 3 4 5 (j) Lack of compassion for patients 1 2 3 4 5 (k) Special groups of patients getting different levels of care

(TOP, AIDS, Aliens, Pregnant women, TB, Teenage pregnancy)

1 2 3 4 5

(l) Professional negligence in patient care 1 2 3 4 5 (m) Substandard postoperative care 1 2 3 4 5

113

18. Please rate how much you agree or disagree with the following statements:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) Payment to employees at CHBH by patients or their family for services or treatment given is fraud. 1 2 3 4 5

(b) Employees who engage in threatening or violent behaviour on the job are seldom subjected to immediate disciplinary action.

1 2 3 4 5

(c) Misconduct at CHBH relates mainly to lack of discipline. 1 2 3 4 5 (d) Disciplinary measures at CHBH are not �visible�. 1 2 3 4 5 (e) Health professionals at CHBH do not have sufficient time

to treat patients with the necessary compassion and understanding.

1 2 3 4 5

(f) Language barriers make it difficult for health care professionals to convey to patients proper information about their diagnosis and treatment.

1 2 3 4 5

(g) Because of the heavy workload at CHBH it is fair for employees to ask for small incentives (�tips�) for services.

1 2 3 4 5

(h) A hospital ethics committee would assist in guiding health professional conduct. 1 2 3 4 5

SECTION C: PROBLEMS AND SOURCES OF STRESS

19. Please rate the extent to which you consider the following as a problem or source of stress at CHBH:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Resource related (a) Poor/outdated equipment 1 2 3 4 5 (b) Not enough medicine 1 2 3 4 5 (c) Linen shortage 1 2 3 4 5 Staff related (d) Poor remuneration 1 2 3 4 5 (e) Long shifts 1 2 3 4 5 (f) Night duty 1 2 3 4 5 (g) General shortage of staff 1 2 3 4 5 (h) Poor staff communication 1 2 3 4 5 (i) Supervision/issues of authority 1 2 3 4 5 Patient related (j) Patients with low levels of schooling 1 2 3 4 5 (k) Long-stay patients 1 2 3 4 5 (l) Impossible/demanding patients 1 2 3 4 5 (m) Substandard care because of large numbers 1 2 3 4 5 (n) Language difficulties in dealing with patients 1 2 3 4 5 (o) AIDS patients 1 2 3 4 5 Environment related (p) Unsanitary/unhygienic conditions 1 2 3 4 5 (q) Poor maintenance of buildings 1 2 3 4 5 (r) Lack of safety 1 2 3 4 5 (s) Vandalism 1 2 3 4 5

114

SECTION D: SUGGESTIONS FOR IMPROVEMENT 20. What suggestions do you have for improving the functioning of CHBH in respect of the following?

(a) Resource management (medicine, linen, equipment. etc.): ��������������

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(b) Staff relations: ����������������������������.���

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(c) Staff-patient relations .��������������������������.��

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(d) General and clinical misconduct: ���������������������.�.,,�

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(e) Safety and security: ��������������������������.���

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(f) Service quality: ��������������������������.�����

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115

(g) Admission and discharge of patients

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����������������������������������������� SECTION E: DEMOGRAPHICS 21. Gender:

Male 1 Female 2

22. Age:

20 years and younger 1 21-30 years 2 31-40 years 3 41-50 years 4 51-60 years 5 Older than 60 years 6

23. Home language: ��������������������������������.. 24. Highest formal qualification obtained: ������������������������ 25. How long have you been an employee at CHBH? �������� (years) 26. How many years working experience do you have in total? ��.����� (years) 27. Is there anything else that you would like to raise? Anything not covered by this questionnaire or

maybe something about the questionnaire itself?

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THANK YOU VERY MUCH FOR YOUR CO-OPERATION!

116

117

APPENDIX 3 QUESTIONNAIRE: DOCTORS © EthicSA 2001

118

QUESTIONNAIRE FOR DOCTORS SECTION A: ORGANISATIONAL ISSUES Organisational culture 1. Interpersonal relations (i.e. how people behave or act towards each other when they are together)

can be rated on various dimensions. For each pair of adjectives below, please circle the number that, in your view, best characterises interpersonal relations among staff at CHBH in general. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that relations among staff are totally honest, you will circle a 1; if you believe that it is totally dishonest, you will circle a 7. If you believe that it is only somewhat dishonest, you will circle a 5.) PLEASE COMPLETE THE FOLLOWING: (a) Honest 1 2 3 4 5 6 7 Dishonest (b) Respectful 1 2 3 4 5 6 7 Disrespectful (c) Loyal 1 2 3 4 5 6 7 Disloyal (d) Trusting 1 2 3 4 5 6 7 Distrusting (e) Professional 1 2 3 4 5 6 7 Unprofessional (f) Relaxed 1 2 3 4 5 6 7 Tense and stressed

2. Below is a list of six organisational values. Please rate how much CHBH cares about each right now:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Serving the greatest number of patients as possible 1 2 3 4 5 (b) Avoiding bad publicity 1 2 3 4 5 (c) Not having strikes and social unrest 1 2 3 4 5 (d) Good work ethic 1 2 3 4 5 (e) Balancing the books 1 2 3 4 5 (f) Providing the best possible working environment 1 2 3 4 5

3. Below is a list of four professional values in service delivery to patients. To what extent are they practiced at CHBH? In each case distinguish between how much your fellow doctors and nurses respectively give expression to these values V

ery

grea

t ex

tent

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Doctors 1 2 3 4 5 (a) Compassion for patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (b) Confidentiality of patient information Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (c) Respect for dignity of patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (d) Respect for well-being of patients Nurses 1 2 3 4 5

119

Leadership and management

4. Please rate how much you agree or disagree with the following statements concerning leadership and management practices at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) The hospital management takes suggestions from below seriously. 1 2 3 4

(b) There are proper incentives in place to improve staff performance. 1 2 3 4

(c) Staff members have a say in matters of decision-making. 1 2 3 4 (d) The hospital management is clear about the career

prospects of employees. 1 2 3 4

(e) Top management has no secrets from employees. 1 2 3 4 (f) Management at CHBH is basically powerless. 1 2 3 4

Channels of communication 5. Please rate how much you agree or disagree with the following statements concerning communication practices at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) Employees are not allowed to say what they really think. 1 2 3 4 (b) Clear guidelines exist regarding staff members�

responsibilities. 1 2 3 4

(c) My supervisor effectively follows up on complaints that I direct via him/her. 1 2 3 4

(d) My supervisor regularly gives me feedback about my performance. 1 2 3 4

(e) I am always last to be informed about decisions that concern my work. 1 2 3 4

(f) There is a system in place that employees can use to report instances of misconduct without being victimised. 1 2 3 4

(g) Rumour (the �grapevine�) is a common source of information at CHBH.

1 2 3 4

Resources 6(a). Do you experience an under-supply of medicine at CHBH?

Yes 1 No 2 Don�t know 3

6(b) If Yes, to what extent do the following contribute to the under-supply of medicine at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Over-ordering of medicines by ward sisters 1 2 3 4 5 (b) Theft of medicines from hospital stocks by staff 1 2 3 4 5 (c) Influx of non-South African patients 1 2 3 4 5 (d) HIV/AIDS pandemic 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5 (f) Other 1 2 3 4 5 (Please specify:�������������.� ��������������������.

120

7(a). Do you experience a general shortage of linen at CHBH?

Yes 1 No 2 Don�t know 3

7(b). If Yes, to what extent do the following contribute tothe linen shortages at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Stealing of linen by hospital staff 1 2 3 4 5 (b) Linen theft committed by patients 1 2 3 4 5 (c) Increased patient population related to the

HIV/AIDS pandemic 1 2 3 4 5

(d) Ineffective logistical and practical arrangements 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5

(f) Other: (Please specify:���������.�

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1 2 3 4 5

Job satisfaction

8. Some jobs are more interesting and satisfying than others. We want to know how you feel about your job. For each of the following statements please circle one of the alternatives which best describes your opinion. St

rong

ly

agre

e

Ten

d to

agr

ee

Ten

d to

di

sagr

ee

Stro

ngly

disa

gree

(a) I am often bored with my job. 1 2 3 4 (b) I am satisfied with my job for the time being. 1 2 3 4 (c) Each day of work seems like it will never end. 1 2 3 4 (d) I find real enjoyment in my work. 1 2 3 4 (e) It feels as if I am working in a �second-class� hospital. 1 2 3 4 (f) I feel proud to be associated with CHBH. 1 2 3 4 (g) My opinion of myself increases when I do my job well. 1 2 3 4 (h) I frequently think of quitting my job. 1 2 3 4

9. Overall, how satisfied are you with each of the following?

Ver

y sa

tisfie

d

Qui

te

satis

fied

Som

ewha

t sa

tisfie

d

Qui

te

diss

atis

fied

Ver

y

diss

atis

fied

(a) Your immediate supervisor? 1 2 3 4 5 (b) Your salary? 1 2 3 4 5 (c) Cooperativeness of colleagues? 1 2 3 4 5 (d) Your conditions of service? 1 2 3 4 5 (e) Your workload? 1 2 3 4 5 (f) Your career progress at CHBH thus far? 1 2 3 4 5 (g) Your prospects for promotion? 1 2 3 4 5

121

Physical environment 10. On a scale of 1 to 7, how do you rate the physical environment at CHBH in terms of the following

dimensions? (The closer a number to a value, the more that value represents your experience. For instance, if you believe that CHBH is very clean, you will circle a 1; if you believe that it is very dirty, you will circle a 7. If you believe that it is somewhat dirty, you will circle a 5.)

(a) Clean 1 2 3 4 5 6 7 Dirty (b) Safe 1 2 3 4 5 6 7 Unsafe (c) Attractive 1 2 3 4 5 6 7 Unattractive (d) Depressing 1 2 3 4 5 6 7 Cheerful

11. Please rate how much you agree or disagree with the following statements concerning security and safety at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The security screening of visitors leaves much to be desired. 1 2 3 4 5

(b) The unsafe environment at CHBH can be related to the influx of non-South African patients. 1 2 3 4 5

(c) The number of security staff at CHBH is sufficient to combat crime. 1 2 3 4 5

(d) Security staff at CHBH is well equipped with the necessary skills and facilities to combat crime. 1 2 3 4 5

(e) The security screening of applicants for employment leaves much to be desired. 1 2 3 4 5

(f) It is the responsibility of government to ensure a safe environment at CHBH. 1 2 3 4 5

Labour unions 12. (a) Do you think it is useful to have unions operating within the hospital?

Yes � unions are useful in every aspect 1 Yes and no � unions are useful in some ways but problematic in others 2 No � unions are not useful at all 3

(b) Please give a reason for your answer to Question 17(b):

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����������������������������������������� 13. In your view, to what extent do the unions influence the decisions made at CHBH?

Very great extent 1 Great extent 2 Moderate extent 3 To some extent 4 Very little extent 5

122

14. Please rate how much you agree or disagree with the following statements concerning labour unions at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The unions at CHBH serve to enhance discipline. 1 2 3 4 5 (b) I am under pressure to support union decisions

although I don�t want to. 1 2 3 4 5

SECTION B: MISCONDUCT AND STANDARDS OF CARE

15. During the past year, how often have you witnessed the following happening at CHBH?

Onc

e

Tw

ice

Thr

ee

times

or

mor

e

Nev

er

No

opin

ion

(a) Over-ordering of medicine 1 2 3 4 5 (b) Patients/visitors bribing staff 1 2 3 4 5 (c) Moonlighting by staff 1 2 3 4 5 (d) Staff verbally abusing patients 1 2 3 4 5 (e) Staff physically abusing patients 1 2 3 4 5 (f) Patients verbally abusing staff 1 2 3 4 5 (g) Patients physically abusing staff 1 2 3 4 5 (h) Lack of informed consent 1 2 3 4 5 (i) Breach of confidentiality of patient information 1 2 3 4 5 (j) Lack of compassion for patients 1 2 3 4 5 (k) Special groups of patients getting different levels of care

(TOP, AIDS, Aliens, Pregnant women, TB, Teenage pregnancy)

1 2 3 4 5

(l) Professional negligence in patient care 1 2 3 4 5 (m) Substandard postoperative care 1 2 3 4 5

16. Please rate how much you agree or disagree with the following statements:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) Payment to employees at CHBH by patients or their family for services or treatment given is fraud. 1 2 3 4 5

(b) Employees who engage in threatening or violent behaviour on the job are seldom subjected to immediate disciplinary action.

1 2 3 4 5

(c) Misconduct at CHBH relates mainly to lack of discipline.

1 2 3 4 5

(d) Disciplinary measures at CHBH are not �visible�. 1 2 3 4 5 (e) Health professionals at CHBH do not have sufficient

time to treat patients with the necessary compassion and understanding.

1 2 3 4 5

(f) Language barriers make it difficult for health care professionals to convey to patients proper information about their diagnosis and treatment.

1 2 3 4 5

(g) Because of the heavy workload at CHBH it is fair for employees to ask for small incentives (�tips�) for services.

1 2 3 4 5

(h) A hospital ethics committee would assist in guiding health professional conduct. 1 2 3 4 5

123

SECTION C: PROBLEMS AND SOURCES OF STRESS

17. Please rate the extent to which you consider the following as a problem or source of stress at CHBH:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Resource related (a) Poor/outdated equipment 1 2 3 4 5 (b) Not enough medicine 1 2 3 4 5 (c) Linen shortage 1 2 3 4 5 Staff related (d) Poor remuneration 1 2 3 4 5 (e) Long shifts 1 2 3 4 5 (f) Night duty 1 2 3 4 5 (g) General shortage of staff 1 2 3 4 5 (h) Poor staff communication 1 2 3 4 5 (i) Supervision/issues of authority 1 2 3 4 5 Patient related (j) Patients with low levels of schooling 1 2 3 4 5 (k) Long-stay patients 1 2 3 4 5 (l) Impossible/demanding patients 1 2 3 4 5 (m) Substandard care because of large numbers 1 2 3 4 5 (n) Language difficulties in dealing with patients 1 2 3 4 5 (o) AIDS patients 1 2 3 4 5 Environment related (p) Unsanitary/unhygienic conditions 1 2 3 4 5 (q) Poor maintenance of buildings 1 2 3 4 5 (r) Lack of safety 1 2 3 4 5 (s) Vandalism 1 2 3 4 5

SECTION D: SUGGESTIONS FOR IMPROVEMENT 18. What suggestions do you have for improving the functioning of CHBH in respect of the following

(where applicable to you)?

(a) Resource management (medicine, linen, equipment. etc.): ��������������

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(b) Staff relations: ����������������������������.���

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124

(c) Staff-patient relations .�������������������������.���

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(d) General and clinical misconduct: ���������������������.���

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�����������������������������������������

(e) Safety and security: ��������������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(f) Service quality: ��������������������������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(g) Admission and discharge of patients: �����������������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

125

SECTION E: DEMOGRAPHICS 19. Gender:

Male 1 Female 2

20. Age:

20 years and younger 1 21-30 years 2 31-40 years 3 41-50 years 4 51-60 years 5 Older than 60 years 6

21. Home language: ��������������������������������.. 22. Highest formal qualification obtained: ������������������������ 23. How long have you been an employee at CHBH? �������� (years) 24. How many years working experience do you have in total? ��.����� (years) 25. Is there anything else that you would like to raise? Anything not covered by this questionnaire or

maybe something about the questionnaire itself?

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

THANK YOU VERY MUCH FOR YOUR COOPERATION!

126

127

APPENDIX 4 QUESTIONNAIRE: ALLIED HEALTH PROFESSIONALS © EthicSA 2001

128

QUESTIONNAIRE FOR ALLIED HEALTH PROFESSIONALS SECTION A: ORGANISATIONAL ISSUES Organisational culture 1. Interpersonal relations (i.e. how people behave or act towards each other when they are together)

can be rated on various dimensions. For each pair of adjectives below, please circle the number that, in your view, best characterises interpersonal relations among staff at CHBH in general. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that relations among staff are totally honest, you will circle a 1; if you believe that it is totally dishonest, you will circle a 7. If you believe that it is only somewhat dishonest, you will circle a 5.) PLEASE COMPLETE THE FOLLOWING: (a) Honest 1 2 3 4 5 6 7 Dishonest (b) Respectful 1 2 3 4 5 6 7 Disrespectful (c) Loyal 1 2 3 4 5 6 7 Disloyal (d) Trusting 1 2 3 4 5 6 7 Distrusting (e) Professional 1 2 3 4 5 6 7 Unprofessional (f) Relaxed 1 2 3 4 5 6 7 Tense and stressed

2. Below is a list of six organisational values. Please rate how much CHBH cares about each right now:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Serving the greatest number of patients as possible 1 2 3 4 5 (b) Avoiding bad publicity 1 2 3 4 5 (c) Not having strikes and social unrest 1 2 3 4 5 (d) Good work ethic 1 2 3 4 5 (e) Balancing the books 1 2 3 4 5 (f) Providing the best possible working environment 1 2 3 4 5

3. Below is a list of four professional values in service delivery to patients. To what extent are they practiced at CHBH? In each case distinguish between how much doctors and nurses respectively give expression to these values V

ery

grea

t ex

tent

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Doctors 1 2 3 4 5 (a) Compassion for patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (b) Confidentiality of patient information Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (c) Respect for dignity of patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (d) Respect for well-being of patients Nurses 1 2 3 4 5

129

Leadership and management

4. Please rate how much you agree or disagree with the following statements concerning leadership and management practices at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) The hospital management takes suggestions from below seriously. 1 2 3 4

(b) There are proper incentives in place to improve staff performance. 1 2 3 4

(c) Staff members have a say in matters of decision-making. 1 2 3 4 (d) The hospital management is clear about the career

prospects of employees. 1 2 3 4

(e) Top management has no secrets from employees. 1 2 3 4 (f) Management at CHBH is basically powerless. 1 2 3 4

Channels of communication 5. Please rate how much you agree or disagree with the

following statements concerning communication practices at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) Employees are not allowed to say what they really think. 1 2 3 4 (b) Clear guidelines exist regarding staff members�

responsibilities. 1 2 3 4

(c) My supervisor effectively follows up on complaints that I direct via him/her. 1 2 3 4

(d) My supervisor regularly gives me feedback about my performance. 1 2 3 4

(e) I am always last to be informed about decisions that concern my work. 1 2 3 4

(f) There is a system in place that employees can use to report instances of misconduct without being victimised. 1 2 3 4

(g) Rumour (the �grapevine�) is a common source of information at CHBH.

1 2 3 4

Resources 6(a). Do you experience an under-supply of medicine at CHBH?

Yes 1 No 2 Don�t know 3

6(b) If Yes, to what extent do the following contribute to the under-supply of medicine at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

Smal

l ex

tent

No

exte

nt

(a) Over-ordering of medicines by ward sisters 1 2 3 4 5 (b) Theft of medicines from hospital stocks by staff 1 2 3 4 5 (c) Influx of non-South African patients 1 2 3 4 5 (d) HIV/AIDS pandemic 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5 (f) Other 1 2 3 4 5 (Please specify:�������������.� ��������������������.

130

7(a). Do you experience a general shortage of linen at CHBH?

Yes 1 No 2 Don�t know 3

7(b). If Yes, to what extent do the following contribute tothe linen shortages at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Stealing of linen by hospital staff 1 2 3 4 5 (b) Linen theft committed by patients 1 2 3 4 5 (c) Increased patient population related to the

HIV/AIDS pandemic 1 2 3 4 5

(d) Ineffective logistical and practical arrangements 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5

(f) Other (Please specify:����������.�

�.��������������������.

1 2 3 4 5

Job satisfaction

8. Some jobs are more interesting and satisfying than others. We want to know how you feel about your job. For each of the following statements please circle one of the alternatives which best describes your opinion. St

rong

ly

agre

e

Ten

d to

agr

ee

Ten

d to

di

sagr

ee

Stro

ngly

disa

gree

(a) I am often bored with my job. 1 2 3 4 (b) I am satisfied with my job for the time being. 1 2 3 4 (c) Each day of work seems like it will never end. 1 2 3 4 (d) I find real enjoyment in my work. 1 2 3 4 (e) It feels as if I am working in a �second-class� hospital. 1 2 3 4 (f) I feel proud to be associated with CHBH. 1 2 3 4 (g) My opinion of myself increases when I do my job well. 1 2 3 4 (h) I frequently think of quitting my job. 1 2 3 4

9. Overall, how satisfied are you with each of the following?

Ver

y sa

tisfie

d

Qui

te

satis

fied

Som

ewha

t sa

tisfie

d

Qui

te

diss

atis

fied

Ver

y

diss

atis

fied

(a) Your immediate supervisor? 1 2 3 4 5 (b) Your salary? 1 2 3 4 5 (c) Cooperativeness of colleagues? 1 2 3 4 5 (d) Your conditions of service? 1 2 3 4 5 (e) Your workload? 1 2 3 4 5 (f) Your career progress at CHBH thus far? 1 2 3 4 5 (g) Your prospects for promotion? 1 2 3 4 5

131

Physical environment 10. On a scale of 1 to 7, how do you rate the physical environment at CHBH in terms of the following

dimensions? (The closer a number to a value, the more that value represents your experience. For instance, if you believe that CHBH is very clean, you will circle a 1; if you believe that it is very dirty, you will circle a 7. If you believe that it is somewhat dirty, you will circle a 5.)

(a) Clean 1 2 3 4 5 6 7 Dirty (b) Safe 1 2 3 4 5 6 7 Unsafe (c) Attractive 1 2 3 4 5 6 7 Unattractive (d) Depressing 1 2 3 4 5 6 7 Cheerful

11. Please rate how much you agree or disagree with the following statements concerning security and safety at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The security screening of visitors leaves much to be desired. 1 2 3 4 5

(b) The unsafe environment at CHBH can be related to the influx of non-South African patients. 1 2 3 4 5

(c) The number of security staff at CHBH is sufficient to combat crime. 1 2 3 4 5

(d) Security staff at CHBH is well equipped with the necessary skills and facilities to combat crime. 1 2 3 4 5

(e) The security screening of applicants for employment leaves much to be desired. 1 2 3 4 5

(f) It is the responsibility of government to ensure a safe environment at CHBH. 1 2 3 4 5

Labour unions 12. (a) Do you think it is useful to have unions operating within the hospital?

Yes � unions are useful in every aspect 1 Yes and no � unions are useful in some ways but problematic in others 2 No � unions are not useful at all 3

(b) Please give a reason for your answer to Question 17(b):

�����������������������������������������

�����������������������������������������

�����������������������������������������

����������������������������������������� 13. In your view, to what extent do the unions influence the decisions made at CHBH?

Very great extent 1 Great extent 2 Moderate extent 3 To some extent 4 Very little extent 5

132

14. Please rate how much you agree or disagree with the following statements concerning labour unions at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The unions at CHBH serve to enhance discipline. 1 2 3 4 5 (b) I am under pressure to support union decisions

although I don�t want to. 1 2 3 4 5

SECTION B: MISCONDUCT AND STANDARDS OF CARE

15. During the past year, how often have you witnessed the following happening at CHBH?

Onc

e

Tw

ice

Thr

ee

times

or

mor

e

Nev

er

No

opin

ion

(a) Over-ordering of medicine 1 2 3 4 5 (b) Patients/visitors bribing staff 1 2 3 4 5 (c) Moonlighting by staff 1 2 3 4 5 (d) Staff verbally abusing patients 1 2 3 4 5 (e) Staff physically abusing patients 1 2 3 4 5 (f) Patients verbally abusing staff 1 2 3 4 5 (g) Patients physically abusing staff 1 2 3 4 5 (h) Lack of informed consent 1 2 3 4 5 (i) Breach of confidentiality of patient information 1 2 3 4 5 (j) Lack of compassion for patients 1 2 3 4 5 (k) Special groups of patients getting different levels of care

(TOP, AIDS, Aliens, Pregnant women, TB, Teenage pregnancy)

1 2 3 4 5

(l) Professional negligence in patient care 1 2 3 4 5 (m) Substandard postoperative care 1 2 3 4 5

16. Please rate how much you agree or disagree with the following statements:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) Payment to employees at CHBH by patients or their family for services or treatment given is fraud. 1 2 3 4 5

(b) Employees who engage in threatening or violent behaviour on the job are seldom subjected to immediate disciplinary action.

1 2 3 4 5

(c) Misconduct at CHBH relates mainly to lack of discipline. 1 2 3 4 5 (d) Disciplinary measures at CHBH are not �visible�. 1 2 3 4 5 (e) Health professionals at CHBH do not have sufficient time

to treat patients with the necessary compassion and understanding.

1 2 3 4 5

(f) Language barriers make it difficult for health care professionals to convey to patients proper information about their diagnosis and treatment.

1 2 3 4 5

(g) Because of the heavy workload at CHBH it is fair for employees to ask for small incentives (�tips�) for services.

1 2 3 4 5

(h) A hospital ethics committee would assist in guiding health professional conduct. 1 2 3 4 5

133

SECTION C: PROBLEMS AND SOURCES OF STRESS

17. Please rate the extent to which you consider the following as a problem or source of stress at CHBH:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Resource related (a) Poor/outdated equipment 1 2 3 4 5 (b) Not enough medicine 1 2 3 4 5 (c) Linen shortage 1 2 3 4 5 Staff related (d) Poor remuneration 1 2 3 4 5 (e) Long shifts 1 2 3 4 5 (f) Night duty 1 2 3 4 5 (g) General shortage of staff 1 2 3 4 5 (h) Poor staff communication 1 2 3 4 5 (i) Supervision/issues of authority 1 2 3 4 5 Patient related (j) Patients with low levels of schooling 1 2 3 4 5 (k) Long-stay patients 1 2 3 4 5 (l) Impossible/demanding patients 1 2 3 4 5 (m) Substandard care because of large numbers 1 2 3 4 5 (n) Language difficulties in dealing with patients 1 2 3 4 5 (o) AIDS patients 1 2 3 4 5 Environment related (p) Unsanitary/unhygienic conditions 1 2 3 4 5 (q) Poor maintenance of buildings 1 2 3 4 5 (r) Lack of safety 1 2 3 4 5 (s) Vandalism 1 2 3 4 5

SECTION D: SUGGESTIONS FOR IMPROVEMENT 18. What suggestions do you have for improving the functioning of CHBH in respect of the following?

(a) Resource management (medicine, linen, equipment. etc.): ��������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(b) Staff relations: �������������������������������

�����������������������������������������

�����������������������������������������

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�����������������������������������������

134

(c) Staff-patient relations .�������������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(d) General and clinical misconduct: ����������������������.��

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(e) Safety and security: ��������������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(f) Service quality: ��������������������������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(g) Admission and discharge of patients: ���������..�������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

135

SECTION E: DEMOGRAPHICS 19. Gender:

Male 1 Female 2

20. Age:

20 years and younger 1 21-30 years 2 31-40 years 3 41-50 years 4 51-60 years 5 Older than 60 years 6

21. Home language: ��������������������������������.. 22. Highest formal qualification obtained: ������������������������ 23. Hospital section/division: ����������������������������� 24. Do you belong to a labour union?

Yes 1 No 2

25. How long have you been an employee at CHBH? �������� (years) 26. How many years working experience do you have in total? ��.����� (years) 27. Is there anything else that you would like to raise? Anything not covered by this questionnaire or

maybe something about the questionnaire itself?

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

THANK YOU VERY MUCH FOR YOUR COOPERATION!

136

137

APPENDIX 5 QUESTIONNAIRE: NURSES © EthicSA 2001

138

QUESTIONNAIRE FOR NURSES SECTION A: ORGANISATIONAL ISSUES Organisational culture 1. Interpersonal relations (i.e. how people behave or act towards each other when they are together)

can be rated on various dimensions. For each pair of adjectives below, please circle the number that, in your view, best characterises interpersonal relations among staff at CHBH in general. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that relations among staff are totally honest, you will circle a 1; if you believe that it is totally dishonest, you will circle a 7. If you believe that it is only somewhat dishonest, you will circle a 5.) PLEASE COMPLETE THE FOLLOWING: (a) Honest 1 2 3 4 5 6 7 Dishonest (b) Respectful 1 2 3 4 5 6 7 Disrespectful (c) Loyal 1 2 3 4 5 6 7 Disloyal (d) Trusting 1 2 3 4 5 6 7 Distrusting (e) Professional 1 2 3 4 5 6 7 Unprofessional (f) Relaxed 1 2 3 4 5 6 7 Tense and stressed

2. Below is a list of six organisational values. Please rate how much CHBH cares about each right now:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Serving the greatest number of patients as possible 1 2 3 4 5 (b) Avoiding bad publicity 1 2 3 4 5 (c) Not having strikes and social unrest 1 2 3 4 5 (d) Good work ethic 1 2 3 4 5 (e) Balancing the books 1 2 3 4 5 (f) Providing the best possible working environment 1 2 3 4 5

3. Below is a list of four professional values in service delivery to patients. To what extent are they practiced at CHBH? In each case distinguish between how much the doctors and your fellow nurses respectively give expression to these values V

ery

grea

t ex

tent

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Doctors 1 2 3 4 5 (a) Compassion for patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (b) Confidentiality of patient information Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (c) Respect for dignity of patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (d) Respect for well-being of patients Nurses 1 2 3 4 5

139

Leadership and management

4. Please rate how much you agree or disagree with the following statements concerning leadership and management practices at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) The hospital management takes suggestions from below seriously. 1 2 3 4

(b) There are proper incentives in place to improve staff performance. 1 2 3 4

(c) Staff members have a say in matters of decision-making. 1 2 3 4 (d) The hospital management is clear about the career

prospects of employees. 1 2 3 4

(e) Top management has no secrets from employees. 1 2 3 4 (f) Management at CHBH is basically powerless. 1 2 3 4

Channels of communication 5. Please rate how much you agree or disagree with the following statements concerning communication practices at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) Employees are not allowed to say what they really think. 1 2 3 4 (b) Clear guidelines exist regarding staff members�

responsibilities. 1 2 3 4

(c) My supervisor effectively follows up on complaints that I direct via him/her. 1 2 3 4

(d) My supervisor regularly gives me feedback about my performance. 1 2 3 4

(e) I am always last to be informed about decisions that concern my work. 1 2 3 4

(f) There is a system in place that employees can use to report instances of misconduct without being victimised. 1 2 3 4

(g) Rumour (the �grapevine�) is a common source of information at CHBH.

1 2 3 4

Resources 6(a). Do you experience an under-supply of medicine at CHBH?

Yes 1 No 2 Don�t know 3

6(b) If Yes, to what extent do the following contribute to the under-supply of medicine at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Over-ordering of medicines by ward sisters 1 2 3 4 5 (b) Theft of medicines from hospital stocks by staff 1 2 3 4 5 (c) Influx of non-South African patients 1 2 3 4 5 (d) HIV/AIDS pandemic 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5 (f) Other 1 2 3 4 5 (Please specify:�������������.� ��������������������.

140

7(a). Do you experience a general shortage of linen at CHBH?

Yes 1 No 2 Don�t know 3

7(b). If Yes, to what extent do the following contribute tothe linen shortages at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Stealing of linen by hospital staff 1 2 3 4 5 (b) Linen theft committed by patients 1 2 3 4 5 (c) Increased patient population related to the

HIV/AIDS pandemic 1 2 3 4 5

(d) Ineffective logistical and practical arrangements 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5

(f) Other (Please specify:����������.�

�.��������������������.

1 2 3 4 5

Job satisfaction

8. Some jobs are more interesting and satisfying than others. We want to know how you feel about your job. For each of the following statements please circle one of the alternatives which best describes your opinion. St

rong

ly

agre

e

Ten

d to

agr

ee

Ten

d to

di

sagr

ee

Stro

ngly

disa

gree

(a) I am often bored with my job. 1 2 3 4 (b) I am satisfied with my job for the time being. 1 2 3 4 (c) Each day of work seems like it will never end. 1 2 3 4 (d) I find real enjoyment in my work. 1 2 3 4 (e) It feels as if I am working in a �second-class� hospital. 1 2 3 4 (f) I feel proud to be associated with CHBH. 1 2 3 4 (g) My opinion of myself increases when I do my job well. 1 2 3 4 (h) I frequently think of quitting my job. 1 2 3 4

9. Overall, how satisfied are you with each of the following?

Ver

y sa

tisfie

d

Qui

te

satis

fied

Som

ewha

t sa

tisfie

d

Qui

te

diss

atis

fied

Ver

y

diss

atis

fied

(a) Your immediate supervisor? 1 2 3 4 5 (b) Your salary? 1 2 3 4 5 (c) Cooperativeness of colleagues? 1 2 3 4 5 (d) Your conditions of service? 1 2 3 4 5 (e) Your workload? 1 2 3 4 5 (f) Your career progress at CHBH thus far? 1 2 3 4 5 (g) Your prospects for promotion? 1 2 3 4 5

141

Physical environment 10. On a scale of 1 to 7, how do you rate the physical environment at CHBH in terms of the following

dimensions? (The closer a number to a value, the more that value represents your experience. For instance, if you believe that CHBH is very clean, you will circle a 1; if you believe that it is very dirty, you will circle a 7. If you believe that it is somewhat dirty, you will circle a 5.)

(a) Clean 1 2 3 4 5 6 7 Dirty (b) Safe 1 2 3 4 5 6 7 Unsafe (c) Attractive 1 2 3 4 5 6 7 Unattractive (d) Depressing 1 2 3 4 5 6 7 Cheerful

11. Please rate how much you agree or disagree with the following statements concerning security and safety at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The security screening of visitors leaves much to be desired. 1 2 3 4 5

(b) The unsafe environment at CHBH can be related to the influx of non-South African patients. 1 2 3 4 5

(c) The number of security staff at CHBH is sufficient to combat crime. 1 2 3 4 5

(d) Security staff at CHBH is well equipped with the necessary skills and facilities to combat crime. 1 2 3 4 5

(e) The security screening of applicants for employment leaves much to be desired. 1 2 3 4 5

(f) It is the responsibility of government to ensure a safe environment at CHBH. 1 2 3 4 5

Labour unions 12. (a) Do you think it is useful to have unions operating within the hospital?

Yes � unions are useful in every aspect 1 Yes and no � unions are useful in some ways but problematic in others 2 No � unions are not useful at all 3

(b) Please give a reason for your answer to Question 17(b):

�����������������������������������������

�����������������������������������������

�����������������������������������������

����������������������������������������� 13. In your view, to what extent do the unions influence the decisions made at CHBH?

Very great extent 1 Great extent 2 Moderate extent 3 To some extent 4 Very little extent 5

142

14. Please rate how much you agree or disagree with the following statements concerning labour unions at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The unions at CHBH serve to enhance discipline. 1 2 3 4 5 (b) I am under pressure to support union decisions although

I don�t want to. 1 2 3 4 5

SECTION B: MISCONDUCT AND STANDARDS OF CARE

15. During the past year, how often have you witnessed the following happening at CHBH?

Onc

e

Tw

ice

Thr

ee

times

or

mor

e

Nev

er

No

opin

ion

(a) Over-ordering of medicine 1 2 3 4 5 (b) Patients/visitors bribing staff 1 2 3 4 5 (c) Moonlighting by staff 1 2 3 4 5 (d) Staff verbally abusing patients 1 2 3 4 5 (e) Staff physically abusing patients 1 2 3 4 5 (f) Patients verbally abusing staff 1 2 3 4 5 (g) Patients physically abusing staff 1 2 3 4 5 (h) Lack of informed consent 1 2 3 4 5 (i) Breach of confidentiality of patient information 1 2 3 4 5 (j) Lack of compassion for patients 1 2 3 4 5 (k) Special groups of patients getting different levels of

care (TOP, AIDS, Aliens, Pregnant women, TB, Teenage pregnancy)

1 2 3 4 5

(l) Professional negligence in patient care 1 2 3 4 5 (m) Substandard postoperative care 1 2 3 4 5

16. Please rate how much you agree or disagree with the following statements:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) Payment to employees at CHBH by patients or their family for services or treatment given is fraud. 1 2 3 4 5

(b) Employees who engage in threatening or violent behaviour on the job are seldom subjected to immediate disciplinary action.

1 2 3 4 5

(c) Misconduct at CHBH relates mainly to lack of discipline. 1 2 3 4 5 (d) Disciplinary measures at CHBH are not �visible�. 1 2 3 4 5 (e) Health professionals at CHBH do not have sufficient time

to treat patients with the necessary compassion and understanding.

1 2 3 4 5

(f) Language barriers make it difficult for health care professionals to convey to patients proper information about their diagnosis and treatment.

1 2 3 4 5

(g) Because of the heavy workload at CHBH it is fair for employees to ask for small incentives (�tips�) for services.

1 2 3 4 5

(h) A hospital ethics committee would assist in guiding health professional conduct. 1 2 3 4 5

143

SECTION C: PROBLEMS AND SOURCES OF STRESS

17. Please rate the extent to which you consider the following as a problem or source of stress at CHBH:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Resource related (a) Poor/outdated equipment 1 2 3 4 5 (b) Not enough medicine 1 2 3 4 5 (c) Linen shortage 1 2 3 4 5 Staff related (d) Poor remuneration 1 2 3 4 5 (e) Long shifts 1 2 3 4 5 (f) Night duty 1 2 3 4 5 (g) General shortage of staff 1 2 3 4 5 (h) Poor staff communication 1 2 3 4 5 (i) Supervision/issues of authority 1 2 3 4 5 Patient related (j) Patients with low levels of schooling 1 2 3 4 5 (k) Long-stay patients 1 2 3 4 5 (l) Impossible/demanding patients 1 2 3 4 5 (m) Substandard care because of large numbers 1 2 3 4 5 (n) Language difficulties in dealing with patients 1 2 3 4 5 (o) AIDS patients 1 2 3 4 5 Environment related (p) Unsanitary/unhygienic conditions 1 2 3 4 5 (q) Poor maintenance of buildings 1 2 3 4 5 (r) Lack of safety 1 2 3 4 5 (s) Vandalism 1 2 3 4 5

SECTION D: SUGGESTIONS FOR IMPROVEMENT 18. What suggestions do you have for improving the functioning of CHBH in respect of the following?

(a) Resource management (medicine, linen, equipment. etc.): ��������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(b) Staff relations: ����������������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

144

(c) Staff-patient relations .�������������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(d) General and clinical misconduct: ���������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(e) Safety and security: ��������������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(f) Service quality: ��������������������������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(g) Admission and discharge of patients: �����������������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

145

SECTION E: DEMOGRAPHICS 19. Gender:

Male 1 Female 2

20. Age:

20 years and younger 1 21-30 years 2 31-40 years 3 41-50 years 4 51-60 years 5 Older than 60 years 6

21. Home language: ��������������������������������.. 22. Highest formal qualification obtained: ������������������������ 23. Hospital section/division: ����������������������������� 24. Do you belong to a labour union?

Yes 1 No 2

25. How long have you been an employee at CHBH? �������� (years) 26. How many years working experience do you have in total? ��.����� (years) 27. Is there anything else that you would like to raise? Anything not covered by this questionnaire or

maybe something about the questionnaire itself?

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

THANK YOU VERY MUCH FOR YOUR COOPERATION!

146

147

APPENDIX 6 QUESTIONNAIRE: SUPPORT STAFF © EthicSA 2001

148

QUESTIONNAIRE FOR SUPPORT STAFF SECTION A: ORGANISATIONAL ISSUES Organisational culture 1. Interpersonal relations (i.e. how people behave or act towards each other when they are together)

can be rated on various dimensions. For each pair of adjectives below, please circle the number that, in your view, best characterises interpersonal relations among staff at CHBH. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that relations among staff are totally honest, you will circle a 1; if you believe that it is totally dishonest, you will circle a 7. If you believe that it is only somewhat dishonest, you will circle a 5.) PLEASE COMPLETE THE FOLLOWING: (a) Honest 1 2 3 4 5 6 7 Dishonest (b) Respectful 1 2 3 4 5 6 7 Disrespectful (c) Loyal 1 2 3 4 5 6 7 Disloyal (d) Trusting 1 2 3 4 5 6 7 Distrusting (e) Professional 1 2 3 4 5 6 7 Unprofessional (f) Relaxed 1 2 3 4 5 6 7 Tense and stressed

2. Below is a list of six organisational values. Please rate how much CHBH cares about each right now:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Serving the greatest number of patients as possible 1 2 3 4 5 (b) Avoiding bad publicity 1 2 3 4 5 (c) Not having strikes and social unrest 1 2 3 4 5 (d) Good work ethic 1 2 3 4 5 (e) Balancing the books 1 2 3 4 5 (f) Providing the best possible working environment 1 2 3 4 5

3. Below is a list of four professional values in service delivery to patients. To what extent are they practiced at CHBH? In each case distinguish between how much doctors and nurses respectively give expression to these values V

ery

grea

t ex

tent

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Doctors 1 2 3 4 5 (a) Compassion for patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (b) Confidentiality of patient information Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (c) Respect for dignity of patients Nurses 1 2 3 4 5

Doctors 1 2 3 4 5 (d) Respect for well-being of patients Nurses 1 2 3 4 5

149

Leadership and management

4. Please rate how much you agree or disagree with the following statements concerning leadership and management practices at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) The hospital management takes suggestions from below seriously. 1 2 3 4

(b) There are proper incentives in place to improve staff performance. 1 2 3 4

(c) Staff members have a say in matters of decision-making. 1 2 3 4 (d) The hospital management is clear about the career

prospects of employees. 1 2 3 4

(e) Top management has no secrets from employees. 1 2 3 4 (f) Management at CHBH is basically powerless. 1 2 3 4

Channels of communication 5. Please rate how much you agree or disagree with the

following statements concerning communication practices at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

(a) Employees are not allowed to say what they really think. 1 2 3 4 (b) Clear guidelines exist regarding staff members�

responsibilities. 1 2 3 4

(c) My supervisor effectively follows up on complaints that I direct via him/her. 1 2 3 4

(d) My supervisor regularly gives me feedback about my performance. 1 2 3 4

(e) I am always last to be informed about decisions that concern my work. 1 2 3 4

(f) There is a system in place that employees can use to report instances of misconduct without being victimised. 1 2 3 4

(g) Rumour (the �grapevine�) is a common source of information at CHBH.

1 2 3 4

Resources 6(a). Do you experience an under-supply of medicine at CHBH?

Yes 1 No 2 Don�t know 3

6(b) If Yes, to what extent do the following contribute to the under-supply of medicine at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Over-ordering of medicines by ward sisters 1 2 3 4 5 (b) Theft of medicines from hospital stocks by staff 1 2 3 4 5 (c) Influx of non-South African patients 1 2 3 4 5 (d) HIV/AIDS pandemic 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5

(f) Other (Please specify:����������.�

�.��������������������.

1 2 3 4 5

150

7(a). Do you experience a general shortage of linen at CHBH?

Yes 1 No 2 Don�t know 3

7(b). If Yes, to what extent do the following contribute tothe linen shortages at CHBH?

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

(a) Stealing of linen by hospital staff 1 2 3 4 5 (b) Linen theft committed by patients 1 2 3 4 5 (c) Increased patient population related to the

HIV/AIDS pandemic 1 2 3 4 5

(d) Ineffective logistical and practical arrangements 1 2 3 4 5 (e) Decreasing health care budget 1 2 3 4 5

(f) Other (Please specify:����������.�

�..��������������������.

1 2 3 4 5

Job satisfaction

8. Some jobs are more interesting and satisfying than others. We want to know how you feel about your job. For each of the following statements please circle one of the alternatives which best describes your opinion. St

rong

ly

agre

e

Ten

d to

agr

ee

Ten

d to

di

sagr

ee

Stro

ngly

disa

gree

(a) I am often bored with my job. 1 2 3 4 (b) I am satisfied with my job for the time being. 1 2 3 4 (c) Each day of work seems like it will never end. 1 2 3 4 (d) I find real enjoyment in my work. 1 2 3 4 (e) It feels as if I am working in a �second-class� hospital. 1 2 3 4 (f) I feel proud to be associated with CHBH. 1 2 3 4 (g) My opinion of myself increases when I do my job well. 1 2 3 4 (h) I frequently think of quitting my job. 1 2 3 4

9. Overall, how satisfied are you with each of the following?

Ver

y sa

tisfie

d

Qui

te

satis

fied

Som

ewha

t sa

tisfie

d

Qui

te

diss

atis

fied

Ver

y

diss

atis

fied

(a) Your immediate supervisor? 1 2 3 4 5 (b) Your salary? 1 2 3 4 5 (c) Cooperativeness of colleagues? 1 2 3 4 5 (d) Your conditions of service? 1 2 3 4 5 (e) Your workload? 1 2 3 4 5 (f) Your career progress at CHBH thus far? 1 2 3 4 5 (g) Your prospects for promotion? 1 2 3 4 5

151

Physical environment 10. On a scale of 1 to 7, how do you rate the physical environment at CHBH in terms of the following

dimensions? (The closer a number to a value, the more that value represents your experience. For instance, if you believe that CHBH is very clean, you will circle a 1; if you believe that it is very dirty, you will circle a 7. If you believe that it is somewhat dirty, you will circle a 5.)

(a) Clean 1 2 3 4 5 6 7 Dirty (b) Safe 1 2 3 4 5 6 7 Unsafe (c) Attractive 1 2 3 4 5 6 7 Unattractive (d) Depressing 1 2 3 4 5 6 7 Cheerful

11. Please rate how much you agree or disagree with the following statements concerning security and safety at CHBH:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The security screening of visitors leaves much to be desired. 1 2 3 4 5

(b) The unsafe environment at CHBH can be related to the influx of non-South African patients. 1 2 3 4 5

(c) The number of security staff at CHBH is sufficient to combat crime. 1 2 3 4 5

(d) Security staff at CHBH is well equipped with the necessary skills and facilities to combat crime. 1 2 3 4 5

(e) The security screening of applicants for employment leaves much to be desired. 1 2 3 4 5

(f) It is the responsibility of government to ensure a safe environment at CHBH. 1 2 3 4 5

Labour unions 12. (a) Do you think it is useful to have unions operating within the hospital?

Yes � unions are useful in every aspect 1 Yes and no � unions are useful in some ways but problematic in others 2 No � unions are not useful at all 3

(b) Please give a reason for your answer to Question 17(b):

�����������������������������������������

�����������������������������������������

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����������������������������������������� 13. In your view, to what extent do the unions influence the decisions made at CHBH?

Very great extent 1 Great extent 2 Moderate extent 3 To some extent 4 Very little extent 5

152

14. Please rate how much you agree or disagree with the following statements concerning labour unions at CHBH: St

rong

ly

agre

e

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) The unions at CHBH serve to enhance discipline. 1 2 3 4 5 (b) I am under pressure to support union decisions

although I don�t want to. 1 2 3 4 5

SECTION B: MISCONDUCT AND STANDARDS OF CARE

15. During the past year, how often have you witnessed the following happening at CHBH?

Onc

e

Tw

ice

Thr

ee

times

or

mor

e

Nev

er

No

opin

ion

(a) Over-ordering of medicine 1 2 3 4 5 (b) Patients/visitors bribing staff 1 2 3 4 5 (c) Moonlighting by staff 1 2 3 4 5 (d) Staff verbally abusing patients 1 2 3 4 5 (e) Staff physically abusing patients 1 2 3 4 5 (f) Patients verbally abusing staff 1 2 3 4 5 (g) Patients physically abusing staff 1 2 3 4 5 (h) Lack of informed consent 1 2 3 4 5 (i) Breach of confidentiality of patient information 1 2 3 4 5 (j) Lack of compassion for patients 1 2 3 4 5 (k) Special groups of patients getting different levels of

care (TOP, AIDS, Aliens, Pregnant women, TB, Teenage pregnancy)

1 2 3 4 5

(l) Professional negligence in patient care 1 2 3 4 5 (m) Substandard postoperative care 1 2 3 4 5

16. Please rate how much you agree or disagree with the following statements:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) Payment to employees at CHBH by patients or their family for services or treatment given is fraud. 1 2 3 4 5

(b) Employees who engage in threatening or violent behaviour on the job are seldom subjected to immediate disciplinary action.

1 2 3 4 5

(c) Misconduct at CHBH relates mainly to lack of discipline.

1 2 3 4 5

(d) Disciplinary measures at CHBH are not �visible�. 1 2 3 4 5 (e) Health professionals at CHBH do not have sufficient

time to treat patients with the necessary compassion and understanding.

1 2 3 4 5

(f) Language barriers make it difficult for health care professionals to convey to patients proper information about their diagnosis and treatment.

1 2 3 4 5

(g) Because of the heavy workload at CHBH it is fair for employees to ask for small incentives (�tips�) for services.

1 2 3 4 5

(h) A hospital ethics committee would assist in guiding health professional conduct. 1 2 3 4 5

153

SECTION C: PROBLEMS AND SOURCES OF STRESS

17. Please rate the extent to which you consider the following as a problem or source of stress at CHBH:

Ver

y gr

eat

exte

nt

Gre

at

exte

nt

Mod

erat

e ex

tent

To

som

e ex

tent

Ver

y lit

tle

exte

nt

Resource related (a) Poor/outdated equipment 1 2 3 4 5 (b) Not enough medicine 1 2 3 4 5 (c) Linen shortage 1 2 3 4 5 Staff related (d) Poor remuneration 1 2 3 4 5 (e) Long shifts 1 2 3 4 5 (f) Night duty 1 2 3 4 5 (g) General shortage of staff 1 2 3 4 5 (h) Poor staff communication 1 2 3 4 5 (i) Supervision/issues of authority 1 2 3 4 5 Patient related (j) Patients with low levels of schooling 1 2 3 4 5 (k) Long-stay patients 1 2 3 4 5 (l) Impossible/demanding patients 1 2 3 4 5 (m) Substandard care because of large numbers 1 2 3 4 5 (n) Language difficulties in dealing with patients 1 2 3 4 5 (o) AIDS patients 1 2 3 4 5 Environment related (p) Unsanitary/unhygienic conditions 1 2 3 4 5 (q) Poor maintenance of buildings 1 2 3 4 5 (r) Lack of safety 1 2 3 4 5 (s) Vandalism 1 2 3 4 5

SECTION D: SUGGESTIONS FOR IMPROVEMENT 18. What suggestions do you have for improving the functioning of CHBH in respect of the following?

(a) Resource management (medicine, linen, equipment. etc.): ��������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(b) Staff relations: �����������������������������.��

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

154

(c) Staff-patient relations .�������������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(d) General and clinical misconduct: ���������������������.���

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(e) Safety and security: ���������������������������.��

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(f) Service quality: ��������������������������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

(g) Admission and discharge of patients: �����������������.�����

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

�����������������������������������������

155

SECTION E: DEMOGRAPHICS 19. Gender:

Male 1 Female 2

20. Age:

20 years and younger 1 21-30 years 2 31-40 years 3 41-50 years 4 51-60 years 5 Older than 60 years 6

21. Home language:

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������������������������� 23. Hospital section/division:

������������������������������ 24. Do you belong to a labour union?

Yes 1 No 2

25. How long have you been an employee at CHBH? �������� (years) 26. How many years working experience do you have in total? ��.����� (years) 27. Is there anything else that you would like to raise? Anything not covered by this questionnaire or

maybe something about the questionnaire itself?

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THANK YOU VERY MUCH FOR YOUR COOPERATION!

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APPENDIX 7 QUESTIONNAIRE: PATIENTS © EthicSA 2001

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QUESTIONNAIRE FOR PATIENTS SECTION A: QUALITY OF CARE 1. How would you describe the nurses� relationship towards you? For each pair of adjectives below,

please circle the number that, in your view, best characterises the nurses at CHBH. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that the nurses are totally honest, you will circle a 1; if you believe that they are totally dishonest, you will circle a 7. If you believe that they are only somewhat dishonest, you will circle a 5.) PLEASE COMPLETE THE FOLLOWING: (a) Respectful 1 2 3 4 5 6 7 Disrespectful (b) Professional 1 2 3 4 5 6 7 Unprofessional (c) Relaxed 1 2 3 4 5 6 7 Tense (d) Caring 1 2 3 4 5 6 7 Non-caring (e)Compassionate 1 2 3 4 5 6 7 Cold (f) Approachable 1 2 3 4 5 6 7 Unapproachable (g) Trusting 1 2 3 4 5 6 7 Distrusting

2. How would you describe the doctors� relationship towards you? For each pair of adjectives below,

please circle the number that, in your view, best characterises the doctors at CHBH. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that the doctors are totally disrespectful, you will circle a 1; if you believe that they are totally respectful, you will circle a 7. If you believe that they are only somewhat respectful, you will circle a 5.) (a) Disrespectful 1 2 3 4 5 6 7 Respectful (b) Professional 1 2 3 4 5 6 7 Unprofessional (c) Relaxed 1 2 3 4 5 6 7 Tense (d) Caring 1 2 3 4 5 6 7 Non-caring (e) Cold 1 2 3 4 5 6 7 Compassionate (f) Approachable 1 2 3 4 5 6 7 Unapproachable (g) Trusting 1 2 3 4 5 6 7 Distrusting

3. Overall, how satisfied are you with the following?

Ver

y sa

tisfie

d

Qui

te

satis

fied

Som

ewha

t sa

tisfie

d

Qui

te

diss

atis

fied

Ver

y

diss

atis

fied

(a) The assistance by the nurses on day duty? 1 2 3 4 5 (b) The assistance by the nurses on night duty? 1 2 3 4 5 (c) The quality of the medical treatment received? 1 2 3 4 5 (d) The linen on your bed? 1 2 3 4 5 (e) The quality of the food 1 2 3 4 5 (e) The room that you are in? 1 2 3 4 5

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4. Being a patient at CHBH, how often have you experienced the

following?

Onc

e

Tw

ice

3 tim

es

or m

ore

Nev

er

(a) Verbal abuse by a nurse 1 2 3 4 (b) Verbal abuse by a doctor 1 2 3 4 (c) Verbal abuse by another CHBH employee (such as porters) 1 2 3 4 (d) Physical abuse by a nurse 1 2 3 4 (e) Physical abuse by a doctor 1 2 3 4 (f) Physical abuse by another CHBH employee (not nurse/doctor) 1 2 3 4 (g) Breach of confidentiality of patient information 1 2 3 4 (h) Professional negligence in patient care 1 2 3 4 (i) Substandard medical care 1 2 3 4

5. (a) Do you mind being cared for by student nurses?

Yes 1 No 2

(b) If Yes, please give explanations why:

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����������������������������������������� 6. (a) Do you mind being examined by student doctors?

Yes 1 No 2

(b) If Yes, please give explanations why:

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����������������������������������������� 7. Please rate how much you agree or disagree with the following statements:

Stro

ngly

ag

ree

Ten

d to

ag

ree

Ten

d to

di

sagr

ee

Stro

ngly

di

sagr

ee

No

opin

ion

(a) Patients who give money to staff at CHBH for services or treatment act wrongly. 1 2 3 4 5

(b) Staff at CHBH do not have sufficient time to treat patients with the necessary compassion and understanding. 1 2 3 4 5 (c) Language barriers make it difficult for staff to convey to patients proper information about their diagnosis and treatment.

1 2 3 4 5

(d) I sometimes find it difficult to understand what the doctors are telling me about my illness. 1 2 3 4 5

(e) I am always told what is wrong with me and why certain medicines are given to me.

(f) I usually find it easy to understand what the nurses are telling me about my illness. 1 2 3 4 5

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8. On a scale of 1 to 7, how do you rate the physical environment at CHBH in terms of the following dimensions? The environment here refers to the hospital as whole, that is, the wards, the theatres, outpatient departments and so on. (The closer a number to a value, the more that value represents your experience. For instance, if you believe that CHBH is very clean, you will circle a 1; if you believe that it is very dirty, you will circle a 7. If you believe that it is somewhat dirty, you will circle a 5.)

(a) Clean 1 2 3 4 5 6 7 Dirty (b) Safe 1 2 3 4 5 6 7 Unsafe (c) Attractive 1 2 3 4 5 6 7 Unattractive (d) Cheerful 1 2 3 4 5 6 7 Depressing

9. What suggestions do you have for improving the functioning of CHBH in respect of the following?

(a) Relations between staff and patients:..��������������������.��

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(b) Safety and security: ��������������������������.���

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(c) The quality of the service and care that you receive: �������.�����.����

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����������������������������������������� SECTION B: DEMOGRAPHICS 10. Gender:

Male 1 Female 2

11. Age:

20 years and younger 1 21-30 years 2 31-40 years 3 41-50 years 4 51-60 years 5 Older than 60 years 6

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12. Home language: ��������������������������������.. 13. Highest formal qualification obtained: ������������������������ 14. (a) Are you a South African citizen?

Yes 1 No 2

(b) If No, please specify your country below: ���������������������������������������. 15. (a) Is this your first time as a patient at CHBH?

Yes 1 No 2

(b) If No, how many times have you been a patient at CHBH? (Your present stay excluded.)

Once before 1 Twice before 2 Three times before 3 Four or more times before 4

16. What is the length of your current stay at CHBH? (From the day of admittance until now.) �����������������������������.. 17. In which section of the hospital are you a patient? ������������������..����������� 18. Is there anything else that you would like to raise? Anything not covered by this questionnaire or

maybe something about the questionnaire itself?

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THANK YOU VERY MUCH FOR YOUR COOPERATION!

162

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APPENDIX 8 NATIONAL PATIENTS� RIGHTS CHARTER (NATIONAL DEPARTMENT OF HEALTH)

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APPENDIX 9 MISSION STATEMENT: CHRIS HANI BARAGWANATH HOSPITAL

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