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The Performance Management and Development System and its unintended influence on quality of care in re-engineered primary health care health facilities.

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Introduction The concept of performance management (PM) is fairly new within the South African healthcare system. It was introduced into the public sector in 2001 as a tool to assist, measure, develop and monitor the performance of public service employees in an effort to drive service delivery. In the healthcare system, PM provides the opportunity for managing the performance of healthcare workers (HCWs) in order to determine strategies for identifying training needs, and improving professional development and the competencies of healthcare professionals. The effective use of PM systems has many benefits and contributes greatly to successfully managing HCWs. Thus, it is likely to result in improved quality of care and accountability in the provision of health services, thereby ensuring better human resources and health outcomes. This is as desired by national objectives and as stipulated by the national development plan and other national government goals towards improving public services. Presently, the public healthcare sector is engraved with challenges that threaten the provision of quality health services; these challenges include lack of resources, poor staffing and managerial capacity, as well as large health system reforms. Thus, these mentioned challenges have increased the need to further train and develop HCWs to adapt to the evolving health system. This thesis investigated: 1) the implementation of the Performance Management and Development System (PMDS) by professional nurses at primary healthcare (PHC) facilities; 2) the perceptions and experiences on PMDS by professional nurses and nurse managers within the context of re-engineered PHC, national health insurance (NHI) and Integrated Chronic Services Management (ICSM); 3) nurses’ and nurse managers’ attitudes to how performance is evaluated; and 4) nurses’ and nurse managers’ perceptions and experiences of what hinders optimal use of PMDS and what actions could be taken to enhance job performance and quality of care within the context of re-engineered PHC, NHI and ICSM. Research design and method To determine current existing evidence on methods and practices on PM systems in PHC, a systematic scoping review was utilised. For the primary study, a sequential cross-sectional mixed-methods research design was employed, which was divided into two phases. The first phase consisted of a quantitative study, which was a cross-sectional descriptive survey. A self-administered questionnaire was used to collect data from 201 professional nurses and facility managers at the study site. These data were analysed using the Statistical Package for Social Sciences (version 25.0) for descriptive statistics. The second phase was a qualitative study; through purposive sampling, semi-structured interviews were conducted with 18 professional nurses and 14 frontline nurse managers. Data were analysed thematically. Both phases were conducted at four sub-districts of Dr Kenneth Kaunda District Municipality, North West province, South Africa. Results Findings from the scoping review revealed that PM systems methods may differ across various countries; however, the practices that are deemed effective for PM systems are shared, and so similarities between countries were noted. For the primary study, both the quantitative and qualitative findings of this study confirm that the PMDS has been implemented to a certain extent. However, there exist major gaps and flaws in its implementation that threaten its usefulness within the health system in PHC settings. It was evident that the perception exists that it is unfairly and poorly implemented. This, consequently, has a negative impact on staff motivation, team collaboration, nurse-supervisor relationships and performance. Practical/managerial implications The PMDS should not be implemented in isolation; instead, it should be utilised as part of a systems approach to drive effective staff performance to promote quality care within the healthcare reforms for NHI in PHC settings. Evidently, the PMDS is flawed in its current state. Thus, the PM system is arguably unintentionally impacting negatively on staff morale, job satisfaction and the provision of quality care. Instead, its methods and practices should be improved to include the appraisal of attributes that are key to health outcomes, such as the provision of patient-centered care and promoting quality of care. Key terms: Performance management; performance appraisal; quality of care; professional nurses; frontline nurse managers; re-engineered primary healthcare; national health insurance, integrated chronic services management; patient-centred care; human resources for health.


Doctoral Degree. University of KwaZulu-Natal, Durban.