Clinical mentoring to improve quality of care provided at three NIM-ART facilities: A mixed methods study.

Abstract

BackgroundThe South African Department of Health implemented the nurse-initiated management of antiretroviral treatment (NIM-ART) programme as a policy to decentralise services. Increasing access to ART through nurse initiation results in significant consequences.AimThis study evaluated the quality of care provided, the barriers to the effective rollout of antiretroviral services and the role of a clinical mentor.SettingThe study was conducted at three NIM-ART facilities in South Africa. One clinic provided a high standard of care, one had a high defaulter rate, and at the third clinic, treatment failures were missed, and routine bloods were not collected.MethodsA mixed methods study design was used. Data were collected using patient satisfaction surveys, review of clinical records, facility audits, focus group interviews, field notes and a reflection diary.ResultsNIM-ART nurses prescribed rationally and followed antiretroviral guidelines. Mortality rates and loss to follow-up rates were lower than those at the surrounding hospitals, and 91.1% of nurse-monitored patients had an undetectable viral load after a year. The quality of care provided was comparable to doctor-monitored care. The facility audits found recurrent shortages of essential drugs. Patients indicated a high level of satisfaction. Salary challenges, excessive workload, a lack of trained nurses and infrastructural barriers were identified as barriers. On-going mentoring and support by a clinical mentor strengthened each of the facilities, facilitated quality improvement and stimulated health workers to address constraints.ConclusionClinical mentors are the key to addressing institutional treatment barriers and ensuring quality of patient care.