KZN Health Learning Complex

Currently CRH's flagship, this project's primary objective is to assist in the establishment of a 'learning complex' of health institutions in three rural districts (Uthungulu, Zululand and Umkhanyakude – Area 3) of KwaZulu-Natal Province. This is being done at a district and hospital level, by facilitating learning opportunities that are responsive and appropriate to the health needs of the rural context. The project runs over three years (2006 – 2008), is funded by Atlantic Philanthropies, evaluated by Health Systems Trust, and functions in close partnership with the KwaZulu-Natal Department of Health. Drawing many of CRH's other projects together, further objectives are to:
• Support and improve the referral system between clinics and hospitals, and between the regional hospital and district hospitals.
• Expose Faculty of Health Sciences staff and students to practice in rural areas.
• Monitor the equity in selected health indicators between urban and rural areas.
• Develop CRH itself into a sustainable organisation in the future.

The plan is to initially develop individual district hospitals into learning organisations, and from there to develop communications and support structures between hospitals at a district and area level, so that these learning organisations can link together to form a learning complex.

The concept of a ‘learning organisation’ is widely described in literature relating to the private sector, and may be defined as the ability of an organisation to take in and communicate new knowledge and, more importantly, to then change organisational behaviour as a result of this new information. The central premise of the project, is that a lack of ongoing learning – rather than the frequently cited issues around isolation, low pay, poor staffing and limited infrastructure – is the most critical factor in the failure of hospitals to retain staff.

"A ‘learning organisation’ may be defined as the ability
of an organisation to take in and communicate new knowledge and, more
importantly, to then change organisational
behaviour as a result of this new information."

Learning within hospitals is seen in the broadest possible way. The key components of an effective learning organisation are not limited to training opportunities, access to educational activities and resources. Although these are important, as important are leadership, teamwork and communication, self-reflection and an organisational culture that supports change and innovation.

So as to evaluate the hospitals as learning organisations, and also to identify the interventions required to develop them into learning organisations, a formal situational analysis of the learning of health professionals in the three identified rural districts was done. The research was undertaken as a baseline study in March, April and May of 2006, and processing of the results and the writing of reports for each hospital was the focus of the project for the second half of the year.

For the research a descriptive cross-sectional design was employed, using qualitative and quantitative methods . The target population was identified as the health professionals, including professional nurses, doctors, therapists, pharmacists, dieticians, and psychologists as well as their managers. A complete sample of all eighteen hospitals in the three districts was taken, so every hospital was visited for data collection. This was done by two CRH staff at a time, in two day visits to each hospital. The researchers engaged with managers and health professionals who were on duty on the days of the visit, using a combination of a self-administered questionnaire, in-depth interviews and the gathering of institutional data.

The results of the research describe the rural realities of remoteness and poor infrastructure, where health professionals feel “forgotten and neglected”. All hospitals have very poor staffing with high vacancy rates. Professional staff express feelings of frustration, lack of support and many feel overworked and burned out. Generally the hospitals are staffed with young inexperienced doctors, including Community Service officers (CSOs), and older, more experienced nurses. There are only a small number of senior doctors. This may lead to problems with teamwork among the professional staff, who feel unsupported, and CSOs may have the attitude of just waiting the year out rarely staying on after their compulsory year.

Many professional staff are accessing formal learning opportunities, but these courses often develop the career paths for the individuals concerned, rather than furthering the overall needs of the hospital or district. Many of the nursing staff work in areas other than those where they have a relevant post basic qualification, and in general also request courses that are unrelated to their work station. Rotation of nursing staff makes it difficult for them to feel committed to developing skills in a particular area, and generally for them a career path means that they are hoping to attain management positions and move away from clinical work.

Many professionals opt to study privately, rather than be bound by the reporting and service obligations of the official route. They bear the costs themselves, taking leave when necessary to attend lectures. There are many health professionals who are keen to develop their careers by registering for courses and postgraduate programmes, but this is primarily for personal advancement rather than collective benefit. Consequently a tension currently exists between personal and organisational goals.

There are relatively few informal learning opportunities, such as teaching ward rounds, journal clubs, or academic meetings for continuing professional development purposes. This may reflect that there are few clinicians with experience to facilitate teaching, leaving staff with the feeling that these sessions are little more than a ‘pooling of ignorance’. Staff returning from courses could share the knowledge and skills they have acquired, but often may not have the skills to do this. Visiting specialists are one way of bringing new skills into an otherwise stagnant environment, but few hospitals have regular visits from consultants. A shortage of staff is not associated with failure to access these opportunities, suggesting that it is not being too busy that prevents people from taking advantage of learning when it is available. The finding of this research is that it is the rating of professionals around leadership and teamwork that is most strongly associated with attendance at informal learning sessions.

Research skills and experience are also lacking in district hospitals with few professionals having participated in any research activity. Developing research capacity may be a way for professionals to increase their skills and to look critically at their practice and at the service provided at their hospital. Considerable time is spent by staff in collecting routine information and statistics, which is sent to the district or provincial level but is not acted on at a local level. This therefore offers another learning opportunity. Quality improvement initiatives are being implemented in many district hospitals and are a good opportunity for using locally available information. As well as providing opportunities for learning, these projects can make the work environment more dynamic and challenging for professional staff.

Resources for learning are lacking in almost all district hospitals. Where they are available they are almost always out of date and not accessible to all the staff at the hospital. Professional staff in rural areas are often required to take responsibility in a wide variety of clinical fields so it is critical that up-to-date information is easily available. In view of the rapidly changing nature of the information, the most practical way for staff to access up-to-date guidelines as well as to access distance learning opportunities is via the internet. The research found that few hospitals have access to internet and computers, and where they are available, many staff are not allowed or do not have the skills to use them.

The findings of the situational analysis offer CRH insights as to how to intervene to begin building the planned learning complex. Recommendations on improving learning were offered to each hospital visited. Furthermore thematic teams (family medicine, maternal health, information and communication technology, HIV and Aids, referrals, rural/urban health equity and rural health advocacy) comprising of CRH staff and partners from within the Department of Health have been formed to begin intervening at specific points within the district health system.

Read the report from the situational analysis:
A Learning Complex in Area 3 of the KZN Department of Health — A Report on Learning Opportunities for Health Professionals , CRH 2006

The following CRH projects form part of the KZN Health Learning Complex:
CRH's own learning
Referrals & Support Project
ARV Site Support
Rural/Urban Health Equity Gauge
ICT for Learning
KZN Neonatal
Family Medicine