How do nurses spend their time? A time and motion analysis in the context of differentiated service delivery at primary public healthcare facilities in South Africa


BACKGROUND: Among other benefits, differentiated service delivery (DSD) models are expected to reduce the time that clinicians spend with established ART clients enrolled in DSD models and thus potentially increase available provider time for non-DSD ART and non-ART clients. The actual use of provider time after DSD model implementation has not been reported. We measured healthcare provider time utilization in the context of DSD model implementation in South Africa.
METHODS: We conducted a time and motion study at 10 primary clinics in South Africa from August to November 2021. Nurses involved in ART delivery (n=34) were observed for a total of 61 working days; type and duration of activities were recorded. We estimated average minutes spent/nurses/day on each activity and average number of clients seen/nurse/day, stratified by proportion of a facility's ART clients enrolled in DSD models, facility setting, and facility size.
RESULTS: Compared to facilities with DSD model uptake below the median (< 47.7% of ART clients), nurses in facilities with high DSD model uptake worked slightly shorter days (-13 minutes), had more free time/breaks (26 minutes), spent substantially more time on client-related tasks (42 minutes), general administration/meetings (18 minutes), and spent slightly less time on direct client care (11 minutes) (figure). Low or high DSD model uptake did not meaningfully affect the average number of clients seen/nurse/day (26 and 27 clients, respectively). Nurses at facilities with below-median client volumes and in rural areas saw more clients/day. Nurses at rural facilities spent more time on DSD-related tasks and had less free time.

CONCLUSIONS: Nurses in facilities with high DSD uptake spent slightly less time on direct client care but more on related activities; they did not see more clients/day. As DSD model implementation expands, effective reallocation of time may enhance facility performance.

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