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PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION PROFESSIONAL BOARD FOR DIETETICS AND NUTRITION

An Evaluation of Dietitians’ Competencies, Experiences and Challenges during the Experiences and Challenges during the 2009 Community Service Year

P d b D N li S & D Wh di h P k

HSRC Seminar Series

Presented by Dr Nelia Steyn & Dr Whadi‐ah Parker

HSRC Seminar Series 1st February 2011

ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS

Co‐authors / Co‐investigators: Dr Z Mchiza (HSRC) Dr G Nthangeni (DCS) Prof X Mbhenyane (Univen) Assoc Prof E Wentzel‐Viljoen (UNW) j ( ) Prof A Dannhauser (UFS) Ms L Moeng (DOH) g ( ) Data capturers and statistical reports: Ms N Sa nders & Mr V Leiber m Ms N Saunders & Mr V Leiberum

INTRODUCTION INTRODUCTION

Top causes of death in South Africa in 2000 Percentage p g

HIV/AIDS 29.8 Stroke 5 8 Stroke 5.8 Ischemic heart disease 5.6 Vi l 5 3 Violence 5.3 Tuberculosis 5.1 Lower respiratory infections 4.3 Diarrhoeal diseases 3.2 Hypertensive heart disease 3.1 Road accidents 3 1 Road accidents 3.1 Type 1 Diabetes mellitus 2.6

INTRODUCTION INTRODUCTION

The infant mortality rate = 59 per 100 000 y p The under 5 mortality rate = 95 per 100 000 However, large differences occur between provinces g p

• Eg. Under‐5 mortality

W Cape (46 per 100 000) vs KZN (116 per 100 000)

• W. Cape (46 per 100 000) vs KZN (116 per 100 000)

These differences are mainly associated with differing levels of development & service delivery.

INTRODUCTION INTRODUCTION

The burden of diseases provides many challenges for the p y g development of an efficient & sustainable workforce, particularly for nutrition‐related disorders particularly for nutrition related disorders

(under and overnutrition, micronutrient deficiencies, chronic diseases )

Primary prevention requires a workforce of health professionals who are adequately trained in public health and / or community nutrition and are available to reach even the remotest communities. Dietitians who complete a 4 year degree are best trained

(therapeutic and community nutrition and food service administration)

INTRODUCTION INTRODUCTION

Many developing countries including South Africa, y p g g , do not plan, produce and manage their kf d l t d t l workforce development adequately Planning: By December 2008, there were 1704 dietitians registered with HPCSA but less than 650 employed registered with HPCSA but less than 650 employed in the public sector. The population was 49 million, 80% of whom rely on the public health sector, resulting in a ratio of 1 : 60308

INTRODUCTION INTRODUCTION

Production: Not only is the workforce inadequate in y q number often the curriculum & teaching methods

• veremphasise training specialists rather than
• veremphasise training specialists rather than

community health professionals

Although there are attempts to focus curricula on primary Although there are attempts to focus curricula on primary health care the focus on clinical medicine has continued

Management: Poor management of health services g g resulted in geographic & skills imbalances

urban vs rural and private vs public health differences urban vs rural and private vs public health differences

INTRODUCTION INTRODUCTION

The Health Sector Strategic Framework 2004‐2009 g identified human resource development as a priority. The DOH developed the National Human Resources for / Health plan in 2005/6 One of these strategies is the introduction of compulsory community service for health professionals after community service for health professionals after completion of the academic training programme.

INTRODUCTION INTRODUCTION

This ensures that newly qualified health professionals y q p do a year of community service for the DOH before they can register for independent practice with the they can register for independent practice with the HPCSA. Aimed at ensuring an equitable distribution of newly lifi d h lth f i l i d d qualified health professionals in under‐served communities, particularly in remote rural areas. In 2002, this policy became compulsory for dietitians

INTRODUCTION INTRODUCTION

Despite initial resistance, community service has been p , y implemented & evaluated for most professionals

(doctors, dentists, pharmacists, physiotherapists, clinical psychologists)

These professionals are exposed to heavy workloads, These professionals are exposed to heavy workloads,

• ften without the necessary supervision

However, this system has played a major role in bringing health professionals into remote communities and to disadvantaged people.

INTRODUCTION INTRODUCTION

Since 2003 more than 100 dietitians have been employed in community service each year. To date only two studies on community service dietitians:

• 1. National mail survey determining experiences of CSDs
• 1. National mail survey determining experiences of CSDs

after the first community service year in 2003 2 P i i l lit ti t d i 2005

• 2. Provincial qualitative study in 2005

CSDs training and competencies have not been evaluated nationally.

AIM AIM

To evaluate if CSDs knowledge, skills and competencies g , p are perceived to be adequate to undertake the duties expected of them during their community service year expected of them during their community service year To explore CSDs experiences and challenges during To explore CSDs experiences and challenges during their community service year To review CSDs suggestions for training institutions and f h f l h i i for the Department of Health to improve service delivery and the overall community service experience.

MATERIALS MATERIALS AND AND AND AND METHODS METHODS METHODS METHODS

Study Design and Sample Selection Study Design and Sample Selection

A cross sectional study design utilising both y g g quantitative and qualitative methods was used Study population: CSDs in community service in South Africa in 2009 and the provincial nutrition coordinators A list of CSDs and their placements (N = 168) and a list of Africa in 2009 and the provincial nutrition coordinators A list of CSDs and their placements (N = 168) and a list of provincial coordinators (N = 16) were obtained. A subsample of 45 CSDs (n= 5 in each province) were purposively selected for the qualitative study purposively selected for the qualitative study

• n the basis of the size and location of their placements

Instruments Instruments

i i d l d b h h

Quantitative (CSD survey)

A questionnaire, was developed by the researchers to elicit information regarding CSDs working environment and perceptions regarding their knowledge and practices in community service settings. The questionnaire was first pre‐tested on a sample of q p p dietitians (n=10) who had recently (2007 and 2008) completed their community service year. completed their community service year. Minor corrections were made before data collection commenced commenced

Instruments Instruments

h i i d l d f O i i l

Quantitative (provincial nutrition coordinator survey)

A short questionnaire was developed for DOH provincial coordinators in order to evaluate their opinions regarding the competencies of CSDs in their regions.

Qualitative (CSD interviews)

Interviews were held using a semi structured interview Interviews were held using a semi structured interview schedule to further explore issues which arose from the quantitative study within the limits of the sample quantitative study within the limits of the sample framework in an attempt to reach data saturation.

Data Collection Data Collection

Q i i d li d CS d i i l

Quantitative (both surveys)

Questionnaires were delivered to CSDs and provincial coordinators at the facility where they were stationed, via post, email, fax or in person and returned the same way.

Qualitative (CSD interviews)

Interviews were conducted by trained fieldworkers, either telephonically or in person and captured with the use of a tape / digital recorder. All interviews were conducted in English or Afrikaans All interviews were conducted in English or Afrikaans and transcribed verbatim.

Data Management and Analysis Data Management and Analysis

f b h d i i f

Quantitative data

Data for both surveys was captured in Microsoft Access and analyzed using SPSS.

Quantitative data

Transcripts underwent a quality assurance process Afrikaans transcripts were translated & back translated. Data was managed using the Atlas ti software program Data was managed using the Atlas ti software program. Data was analysed using thematic content analysis and Data was analysed using thematic content analysis and coded according to predetermined themes & categories.

Ethical Approval Ethical Approval

Received from Medical Research Council Confidentiality was ensured Confidentiality was ensured All questionnaires were completed and returned All questionnaires were completed and returned voluntarily All interviews were conducted and recorded l anonymously.

RESULTS RESULTS RESULTS RESULTS

SAMPLE SAMPLE CHARACTERISTICS CHARACTERISTICS CHARACTERISTICS CHARACTERISTICS

Response Rates Response Rates

Provincial Representation Provincial Representation

Representation of training institutions Representation of training institutions

Placement Placement

Placement Placement

Placement Placement

Placement Placement

Si il lt Similar results reported for internet access internet access.

Supervision Supervision

General General

General General

General General

RESULTS RESULTS RESULTS

ACADEMIC TRAINING

RESULTS

ACADEMIC TRAINING ACADEMIC TRAINING ACADEMIC TRAINING

Academic Training Academic Training

“The basics are instilled… it’s not like you come here and y can’t do anything.” “I have received a very high standard of training. I never feel that I need to stand back or be hesitant” I never feel that I need to stand back or be hesitant “I only realised the extent to which it equipped me once I only realised the extent to which it equipped me once I got into my community service year.” “From a theoretical point of view, yes but community i h i h l lif i i ” service teaches you to cope in the real life situation.”

Academic Training Academic Training

Overall 30‐40 % were prepared for most situations, p p , while the rest were able to deal with more than half the situations they faced with some help. situations they faced with some help. The majority of these CSDs indicated that they required j y y q emotional guidance and support in these situations rather than additional knowledge and skills, g , EXCEPT in practical departmental management They were only partially prepared for the management aspects and dealing with community entry and aspects and dealing with community entry and community development.

Academic Training Academic Training

CSDs reported inadequacy related to communication or p q y language barriers. 26% were only partially adequate or inadequate, while a further 25% required additional knowledge and skill a further 25% required additional knowledge and skill even though they felt they were adequately prepared. 13.5% felt incompetent to organise continuing f i l d l t (CPD) ti iti professional development (CPD) activities.

RESULTS RESULTS RESULTS RESULTS

DUTIES AND DUTIES AND COMPETENCIES COMPETENCIES COMPETENCIES COMPETENCIES

Duties Duties

Duties Duties

80% of CSDs time

Competencies Competencies

Lif l

Don’t do Poor Fair Average Good V Good

Lifecycle

Don’t do Poor Fair Average Good

• V. Good

Breast feeding

9 2 8 32 50

Infant feeding

2 7 40 47

I f i h HIV

5 2 11 40 42

Infant with HIV

5 2 11 40 42

Nutrition in childhood

5 13 49 32

Nutrition in pregnancy

8 1 4 29 40 19 9 23 2

Nutrition for the elderly

9 7 23 40 21

Competencies Competencies

Th ti N t iti

Don’t do Poor Fair Average Good V Good

Therapeutic Nutrition

Don’t do Poor Fair Average Good

• V. Good

Allergies

19 8 18 32 21 3

Anaemias

7 9 35 33 16

Type 1 diabetes

5 1 5 19 28 43

yp Type 2 diabetes

3 1 3 34 59

Enteral feeding

11 2 4 14 38 31

Enteral feeding

11 2 4 14 38 31 Heart disease & hyperlipidaemia 5 3 18 41 34

Hypertension

2 3 33 62

Competencies Competencies

Th ti N t iti

Don’t do Poor Fair Average Good V Good

Therapeutic Nutrition

Don’t do Poor Fair Average Good

• V. Good

Severe malnutrition

2 2 8 41 47

Micronutrient deficiencies

5 2 8 31 42 12

Nutrition and TB

3 2 4 10 36 46

Nutrition and HIV

2 8 29 61

Renal diets

22 3 11 25 22 17

Renal diets

22 3 11 25 22 17

Vitamin A deficiency

13 1 3 21 37 25

Weight management

1 11 34 54

Competencies Competencies

F d S i Ad i i t ti

Don’t do Poor Fair Average Good V Good

Food Service Administration

Don’t do Poor Fair Average Good

• V. Good

Menu Planning

31 2 4 10 33 22

Food Ordering & Receiving

49 3 2 14 20 11

M b d i

60 2 5 17 12 5

Menu budgeting

60 2 5 17 12 5

Management of staff

52 2 2 18 19 7

Training of staff

44 2 3 17 26 8

l d

36 2 5 12 27 19

Managing special diets

36 2 5 12 27 19

Competencies Competencies

C it N t iti

Don’t do Poor Fair Average Good V Good

Community Nutrition

Don’t do Poor Fair Average Good

• V. Good

Community Assessment

28 3 6 10 30 24

Growth Monitoring

11 1 2 9 25 54

Anthropometry

12 1 5 11 33 39

p y

Protein Energy Malnutrition

7 2 4 5 30 56

Project planning

30 3 6 15 30 16

Project planning

30 3 6 15 30 16

Research

51 3 4 15 19 9

Vegetable gardens

40 5 3 15 25 13

Nutritional management of paediatrics & neonates Nutritional management of paediatrics & neonates

“ i fi h d i h di i O “During my first month I started with paediatrics... Our training wasn’t sufficient because we didn’t really deal with premature babies” “Clinical paediatrics... it’s complicated… breastfeeding & p p f g protein energy malnutrition was adequate… but there are a lot more sections… if I had to go into a hospital are a lot more sections… if I had to go into a hospital now and start working, I wouldn’t be confident.”

Practical application of theoretical knowledge Practical application of theoretical knowledge

“ d ’ hi k l k d h k l d h kill “I don’t think I lacked the knowledge or the skills to perform, just the practical training in that field.” “They can put in a lot more practical stuff … if you go in the community to tell people how they’ve got to eat and y p p y g people don’t even have money to eat…. now I must tell them to eat more vegetables, more fruit but they don’t them to eat more vegetables, more fruit but they don t even have money for porridge.”

Administration Administration

Ordering feeds & recording statistics

l h h S d h i l i Although CSDs are exposed to a hospital environment during their internship, they are not afforded the

• pportunity to familiarise themselves with its

administration procedures. One CSD highlighted that fact that although they are trained to order food in a FSM environment, they are trained to order food in a FSM environment, they are never exposed to ordering nutritional supplements.

Establishing and managing a department Establishing and managing a department

h i i hi d ll h i b h Their internship does not allow them to gain both financial and administrative management experience. “I’m the only person here I don’t have a supervisor I I m the only person here… I don t have a supervisor… I manage the department on my own. We need to know how to go about setting up a We need to know how to go about setting up a dietetics department, because not all of us will be l d h th h b di titi b f placed where there has been a dietitian before. We do a bit of management in our food service module b h d ff d d ” but that is different setting up a dietetics department”

Other Other

h i l d d f i i These included aspects of sports nutrition, implementation of the baby friendly hospital initiative, planning health days and private consultation skills. Some CSDs noted that interpersonal relationships were a further issue to be addressed. “Co‐worker relations… we were academically prepared but not really for the more human side of it”

Provincial Coordinator Survey Provincial Coordinator Survey

Profession Percentage Dietitian 88 Nurse / Doctor Nurse / Doctor Other 12 Rating regarding service of CSDs Poor Fair Good 38 Good 38 Very Good 56 Excellent 6

Provincial Coordinator Survey Provincial Coordinator Survey

Competencies to be improved Percentage

Paediatrics 25

Communication facilitation & presentation skills

25

Communication, facilitation & presentation skills

25 High care and critical care 19 BFHI and WHO severe malnutrition 19 TPN and enteral feeds 13 TPN and enteral feeds 13 Computer skills and report writing 13

Others included:

Behaviour change, HIV/AIDS, TB, PMTCT, ART, Surgery, Ward rounds Policy analysis Project management Strategic thinking rounds, Policy analysis, Project management, Strategic thinking, Programme planning & development, Monitoring & evaluation

Provincial Coordinator Survey Provincial Coordinator Survey

“ h j i f CS d h i i i “The majority of CSDs opt to do their community service year doing therapeutic/clinical nutrition. This does not serve the purpose of having a community service year if resources will continue to be limited to facilities that already have human resources. Nationally our nutrition challenges are concentrated at y g community level. Training institutions should gravitate their teaching Training institutions should gravitate their teaching towards prevention and support to make students understand the role they should play in public health understand the role they should play in public health and hopefully make community nutrition a first choice”

Provincial Coordinator Survey Provincial Coordinator Survey

b dd d b i i i i i % Areas to be addressed by training institutions % Training emphasis clinical vs community 69 g p y Work ethics / professional conduct 56 Abili / fid k i d d l 25 Ability / confidence to work independently 25 Clinical knowledge differs wrt institution 19 g Patient confidentiality and record keeping 19 M f i l di fi 13 Management of resources including finances 13 Practical application of theory 13 pp y Language 13

RESULTS RESULTS RESULTS RESULTS

SUGGESTIONS FOR SUGGESTIONS FOR SUGGESTIONS FOR TRAINING INSTITUTIONS SUGGESTIONS FOR TRAINING INSTITUTIONS TRAINING INSTITUTIONS TRAINING INSTITUTIONS

Course Structure Course Structure

Specialist streams

ll f di i h ld b h i d ll “I would encourage them to keep doing what they are All aspects of dietetics should be emphasized equally I would encourage them to keep doing what they are… not making one part more important but emphasising everything most dietitians won’t like food service everything… most dietitians won t like food service management and think they will never do it but when i ll l h t d thi th we in a small place we have to do everything, the ARV’s, the kitchen and therapeutics” “Too much work in too little time …many subjects are

• uc
• e

e a y subjec s a e unnecessary … cultural eating patterns & communication”

Course Structure Course Structure

Evaluation, Examination, Exposure

l i f h i l f i l l i Evaluation: from theoretical focus to practical evaluation. “ h l h k h

th

h “The occupational therapists work in their 4th year; then wrote tests, then worked again… we worked whole year and write exams on all 3 years at the end of the year. You kind of lost the ability to learn… you need a gap in the practical training, a chance to recap & learn, instead of studying everything at the end of the year. Exposure to both the private and public health sectors f y g y g f y Exposure to both the private and public health sectors and to all levels of health care (PHC, district and tertiary).

Course Structure Course Structure

Practical Component

l hi d (29%) i d i l i Almost a third (29%) required more practical experience. Including more practical therapeutic experience and administration and systems within health care facilities and more practical community experience “We get more practice from 1st year to get exposure to what you gonna end up doing… I don’t think we know what being a dietitian is about until our 4th year” g y Each theoretical module should be taught concurrently Each theoretical module should be taught concurrently with its practical component to facilitate learning’.

Course Structure Course Structure

Practical Component

“ d ’ h h i li d f l h d “I don’t have the specialised formulas we had at Tygerberg… teach us how to use other things” “My training did not give me the true picture of what I am doing in the community now… the theory and practical differs so much.” p ff “We’re in the foodservice unit for 3 months but we are We re in the foodservice unit for 3 months, but we are not allowed to be managers, we are kitchen assistants, we spread bread dish food cut tomatoes that doesn’t we spread bread, dish food, cut tomatoes… that doesn t teach you how to develop and implement a menu

Course Components Course Components

Requiring more training

3% f f h 9 i i i id ifi d di i 13% from 4 of the 9 institutions identified paediatrics B b F i dl H it l I iti ti (BFHI) Baby Friendly Hospital Initiative (BFHI), Integrated Nutrition Programme (INP), ( ) Prevention of Mother To Child Transmission (PMTCT) Integrated Management of Childhood Illnesses (IMCI) Severe Malnutrition (WHO’s 10‐ steps)

O h i l d d i h l i i b l l Others included: weight loss, sports nutrition, cerebral palsy, allergies, micronutrient supplementation, tube feeding, i i i i i HIV/AIDS d ARV nutrition interventions in HIV/AIDS and ARV treatment, counselling patients within the community.

Additional Courses Required Additional Courses Required

“More training on management. You learn as you go but g g y g there are places where you the only dietitian and have to start your own department and you don’t know how” start your own department and you don t know how “More business orientated… not just for community i b t f th f t h ld b d b i service but for the future… we should be good business women… if they could teach us financial planning and marketing… that’s really, really important.”

Additional Courses Required Additional Courses Required

“It’s quite difficult to do but it will be helpful at the q ff pf universities if they give a 3rd language… it could be basic Xhosa or basic Zulu… So that you can counsel in a basic Xhosa or basic Zulu… So that you can counsel in a different language.” Others: behaviour change and motivational psychology, professional conduct & ethics, anatomy, counselling skills, advocacy of the profession, establishment of campaigns y p , p g & fundraising, how to work with limited resources

Internship Placement Internship Placement

Hospital staff : student ratio during placements. p g p “We should be sent to bigger hospitals… the hospital I went to didn’t have other departments... that’s why I’m not well‐equipped with burns and ICU.” q pp “A l h did ’ k i ” “At some places, they didn’t know we are coming” “The way some staff treat students… they are not very helpful with the students at times” helpful with the students at times”

Internship Duration Internship Duration

“A little bit longer in the clinical setting… you learn best g g y by observing and being interactive with patients. I can only imagine how much better the learning I can only imagine how much better the learning experience would be if students could see the patients reaction whereas if you sitting in a classroom you don’t reaction, whereas if you sitting in a classroom you don t really see the impact that you have on the patient.” “There’s so much more to learn in the community than There s so much more to learn in the community than what we do in 3 months, I think it’s too short or maybe just see what is important to do in the community” just see what is important to do in the community.

General General

Providing feedback to training institutions g g Establishing standardised treatment protocols for g p disease conditions across all universities. Standardisation of the statistics in the country such that training institutions provide training on this. training institutions provide training on this. Registration with the HPCSA ‐ outline procedures as Registration with the HPCSA outline procedures as well as what registration encompasses annually.

RESULTS RESULTS RESULTS

EXPERIENCES

RESULTS

EXPERIENCES EXPERIENCES EXPERIENCES

Enjoyed the year Enjoyed the year

More than 60% of CSDs reported they enjoyed the year. p y j y y This response was consistent across all provinces, p p , irrespective of urban or rural placement. “Community service was the cherry on the top of 4 years

• f studies It’s a very good initiative by the government
• f studies. It s a very good initiative by the government.

It’s a stepping stone from Varsity to the working world.” Good accommodation, a warm reception and a good support structure within the workplace

Good learning opportunity Good learning opportunity

Learning from senior dietitians, multidisciplinary teams g , p y & fellow CSDs that studied at other training institutions. “It didn’t just teach me, the community can see now where nutrition comes into their daily lives.” y “You learn a lot about the community and how to make You learn a lot about the community and how to make do with what you have & you grow a lot as a person.” “Community service is an essential way to introduce y y graduates to the DOH and how the structures work.”

Positive Experiences Positive Experiences

Positive experiences

Percentage

Gained practical experience

34

Professional development & personal growth

28

Professional development & personal growth Personally rewarding

20

h l d l

16

Interaction with multidisciplinary team

16

Good supervision / support structure

15

Learning new cultures and languages

7

Exposure to all aspects of dietetics

5

Exposure to all aspects of dietetics

5

Others included: Good remuneration, exposure to community dietetics & outreach services, reduced Good remuneration, exposure to community dietetics & outreach services, reduced anxiety of securing employment, built relationships with other health professionals, learn to work with limited resources, advocate the dietetics profession

Experiences Experiences

A number of CSDs stated that their placement was p challenging at first but had improved with time Most challenges stemmed from the lack of supervision and guidance. “It was challenging... for the first six months I was alone. a d gu da ce g g f f I didn’t have a supervisor… I learned a lot from not having a supervisor... because I did things on my own.” having a supervisor... because I did things on my own. Some stated that the lack of supervision allowed them Some stated that the lack of supervision allowed them to be innovative.

RESULTS RESULTS RESULTS

CHALLENGES

RESULTS

CHALLENGES CHALLENGES CHALLENGES

Challenges Challenges

Challenges Percentage

Limited Resources

25

Language

18

Lack of supervision, guidance and support

14

Staff shortage

10

g Referrals

8

Placement process & orientation

8

Placement process & orientation

8

Establishing & marketing a department, administration & systems

8

Lack of acceptance & acknowledgement of dietetics profession

7

Lack of acceptance & acknowledgement of dietetics profession

7

Others included: Accommodation, location of placement, interpersonal relationships, self confidence and time management relationships, self confidence and time management * 9% of CSDs experienced no problems, those who reported problems stated it improved with time

Interpersonal relationships Interpersonal relationships

“You are 22 years old and you have to go into a clinic y y g and speak to a sister who’s 50 years old and you have to tell her what to do… they don’t want to listen to you” tell her what to do… they don t want to listen to you “People don’t seem to understand clearly what your People don t seem to understand clearly what your role is as a dietitian in the institution.” “It took a while for people to acknowledge you as a f i l Th b li th t d ’t h h

• professional. They believe that you don’t have enough

knowledge so instead of coming to you, they want to do h h ld b d ” what you should be doing”

Language Language

“I can only speak English, about 5 to 10% of the time I’d y p g , f get another dietitian to interpret or ask a Sister and that doesn’t work… they’ll add their own things and won’t doesn t work… they ll add their own things and won t interpret correctly, they won’t be direct translators.”

Limited resources Limited resources

“I don’t have an office… I don’t have any privacy with the ff y p y patients… I can’t do proper counselling, I don’t have a budget… I can’t order feeds… I don’t even have a proper budget… I can t order feeds… I don t even have a proper storeroom for feeds”

Establishing & Marketing the Department Establishing & Marketing the Department

“I had to market myself with the departments and the y f p patients… They had to know that the service was available, I had to liaise with the core departments , get available, I had to liaise with the core departments , get to know everyone and get them to refer patients to me.”

Systems and Administration Procedures Systems and Administration Procedures

“Learning how the systems work, how the organograms g y g g function, how supervisor posts work and how to order … no one person can tell you exactly how it works. finding

• o e pe so ca te you e act y o

t

• s f d g

procedures and policies is quite a challenge.”

Staff Shortages Staff Shortages

“We were 3 dietitians for a 900‐bed hospital... of which f p f two were CSDs.” “Being the only dietitian in the hospital… It’s not a big hospital but there’s surrounding clinics and other areas hospital but there s surrounding clinics and other areas I’ve got involved in.”

Referrals and Support Referrals and Support

“You can go to the Sisters, you can write letters ‐ jy kan vergaderings toe gaan en vir hulle sê ‘verwys verwys’ vergaderings toe gaan en vir hulle sê ‘verwys, verwys’ They don’t do it.”

Lack of continuity and duration of service Lack of continuity and duration of service

“There’s a problem in the sense that CSDs come in and p go away again… the projects and programme you are trying to put in place is not continuous” trying to put in place is not continuous “It takes a few months to get used to the working world, by June July you start initiating projects because you by June, July you start initiating projects because you feel more confident and you know it’s almost the end of th I f d th t it diffi lt d ’t h the year… I found that quite difficult… you don’t have enough time to follow through on what you initiated.”

RESULTS RESULTS RESULTS

SUGGESTIONS FOR THE

RESULTS

SUGGESTIONS FOR THE SUGGESTIONS FOR THE DEPARTMENT OF SUGGESTIONS FOR THE DEPARTMENT OF DEPARTMENT OF DEPARTMENT OF HEALTH HEALTH

Placement Options Placement Options

“If they could send Comserves to those hospitals which f y p have everything... where you can learn a lot… ” “A tertiary provincial hospital for 3‐6 months… then rotate to community At the end you have managed to rotate to community. At the end you have managed to do all your key performance areas.” “I think that if you could choose it would be good. If you k I’ i t d th ti th d i th t knew… I’m going to do therapeutic there and in that district I will do that.”

Placement Procedures Placement Procedures

“They put you at a hospital and then you not sure if you y p y p y f y doing food services or if you going to do therapeutic or are they going to send you to the clinics… As soon as you are they going to send you to the clinics… As soon as you have applied to be placed somewhere, they must first inform you precisely what you are going to do there ” inform you precisely what you are going to do there. “I f th CEO’ d h it l t th t “Inform the CEO’s and hospital managers… get them to know exactly who is placed there, what is their role and h i d f h what is expected of them. That way people know exactly what they should be doing for us and what we should be doing for them.”

Orientation Programme Orientation Programme

“All our orientation programmes were in May or in July p g y y which is not appropriate when we begin in January… it needs to be in late January/early February; so we can needs to be in late January/early February; so we can be aware of the programmes running, what’s expected

• f you and what they expect at a provincial level”
• f you and what they expect at a provincial level

C f h hi h CSD ld Create awareness of the things that CSDs would encounter at health facilities that they would previously not have been d d i i i i exposed to at academic institutions. Employee performance systems Ad i i t ti d Administration procedures HPCSA registrations.

Mentorship Mentorship

“They must find the right person to train the CSDs” y f g p “Develop a manual on what is supposed to happen.” p pp pp “Make sure that there’s a senior dietitian the first week Make sure that there s a senior dietitian the first week

• r two... to show you what to do and how to do it”

“Organise that the old CSD and new CSD overlap ‐ to help the new CSDs and show them around ” help the new CSDs and show them around. “A better support system give her a list of numbers or A better support system… give her a list of numbers or details of people she can contact

Resources Resources

“equipment… make sure she has an office, a desk, a q p ff , , scale… make sure she has everything that she needs to do a good job” do a good job “finances & nutritional supplements… they not preparing finances & nutritional supplements… they not preparing the powder feeds as they should, there's lots of cross contamination but there isn’t enough money for the contamination… but there isn t enough money for the ready to hang / ready to use formulas” “transport… They made us wait for the physio and the OT when I could’ve been back at the hospital seeing OT when I could’ve been back at the hospital seeing patients”

Communication Communication

Quarterly meetings with the DOH (district / provincial Q y g ( / p level) with all CSDs post orientation Regular multidisciplinary meetings at all institutions to promote awareness of health professionals contribution Receive feedback or progress reports to CSDs. “advocacy of the profession… some communities don’t know what a dietitian is more emphasis needs to be know what a dietitian is… more emphasis needs to be placed on nutrition therapy and its role in the overall immune status of a patient people tend to overlook immune status of a patient… people tend to overlook dietitians’ jobs and the role we play.”

General General

“motivation for permanent posts… it would improve f p p p service delivery ‐ there’s no consistency in a comm serv coming one year and then not coming the next year.” coming one year and then not coming the next year. “ i i h l i d h i ’ h “catering… patients have complained that it’s the same food every day." “we’re not part of food service management so its difficult to give special diets to patients… staff don’t really comply... foodservice management and the y p y f g dietitians must work together in a hospital.”

General General

“the salary is quite sufficient and I’m very grateful for y q ff y g f f the housing allowance and the rural grant helps a lot!” “I don’t think it’s sufficient It’s moving a lot of us out I don t think it s sufficient… It s moving a lot of us out… wanting to go private instead of staying in government… if it was something that would keep us here it would be if it was something that would keep us here, it would be much better.”

SUMMARY SUMMARY SUMMARY SUMMARY AND AND RECOMMENDATIONS RECOMMENDATIONS RECOMMENDATIONS RECOMMENDATIONS

CSDs Placement CSDs Placement

Community service was implemented by the DOH with y p y the aim of delivering services to underserved communities communities The DOH is succeeding since most CSDs were placed in The DOH is succeeding since most CSDs were placed in rural and peri‐urban communities at district & PHC institutions and many were regularly involved in institutions and many were regularly involved in

• utreach services

Experiences Experiences

CSDs reported that they enjoyed the year, that it p y j y y , provided good work experience, opportunities for personal growth and self confidence. personal growth and self confidence. The DOH should continue the provision of community The DOH should continue the provision of community service for dietitians

Preparation of CSDs & Institutions Preparation of CSDs & Institutions

Both the DOH and training institutions should clarify the g y difference between internship and community service. Community service should be defined to all students, staff and management at hospitals Job descriptions should be clarified prior to placement. Orientation programmes take place earlier. h ld d h DOH should provide receiving institutions with information regarding their allocation of community service officers timeously.

Advocacy of the Dietetics Profession Advocacy of the Dietetics Profession

Lack of understanding of CSDs role by other health g y professionals, lack of recognition of their profession and underutilization of their services underutilization of their services It is therefore crucial that the DOH promote and It is therefore crucial that the DOH promote and advocate the role of the dietitian as well as the role of nutrition therapy in overall patient care nutrition therapy in overall patient care.

Mentorship Mentorship

Lack of supervision and support experienced on site p pp p In 2004 Couper described a programme to develop mentors where a group of senior doctors formed a team

• f mentors to new community service doctors at district
• hospitals. However, it is dependent on having a senior

doctor present at the same facility as the community p y y service doctor. Although this may not be possible with dietitians at every facility it may be possible to set up mentoring y y y p p g groups at district level.

Management and Administration Management and Administration

CSDs reported that at times they felt as if they were not p y y doing what they studied but found that they were more

• ften involved in administrative tasks.
• ften involved in administrative tasks.

Training institutions should ensure that students are g competent in terms of the management and administration skills required to run a dietetics administration skills required to run a dietetics department. The training programme should include exposure to the systems and administration procedures that are the systems and administration procedures that are used in public health institutions.

Lack of Resources Lack of Resources

Although CSDs do not require specialised equipment to g q p q p provide basic services to their clients, they do require resources such as nutritional supplements and nutrition resources such as nutritional supplements and nutrition education material which was reportedly in short supply as a result of financial restrictions at many institutions as a result of financial restrictions at many institutions. The role of nutrition in overall patient care should thus The role of nutrition in overall patient care should thus be advocated such that dietetics departments within public health institutions receive adequate financial public health institutions receive adequate financial resources to operate optimally.

Training wrt limited resources Training wrt limited resources

The physiotherapy curriculum at UCT includes a four p y py week placement in a historically disadvantaged community with no access to rehabilitation facilities. community with no access to rehabilitation facilities. Students suggest that it should be developed into a multidisciplinary student rotation. Nutrition / Dietetics departments should adopt a similar programme in which students are taught to provide optimal services within limited resources. ddi i i i h ld l In addition training programmes should also expose students to working within a multidisciplinary team.

Staff ‐ Complement / Retention Staff ‐ Complement / Retention

Although community service is an effective recruitment g y strategy, it is not a retention strategy If the DOH aims to retain staff that has completed their community service not only should more permanent community service, not only should more permanent posts be made available, but more attention should be given to the placement process Where possible CSDs given to the placement process. Where possible CSDs should be placed at the institution identified as their fi t h i d l ithi iti th t first choice and also within a position that complements the area in which they want to specialise.

Continuity of Service Continuity of Service

The DOH should address this by requesting outgoing y q g g g CSDs to provide handover files and where possible amend the duration of community service to facilitate amend the duration of community service to facilitate an overlap between incoming and outgoing CSDs. Concurrently training institutions may be required to empower future CSDs and equip them with regard to empower future CSDs and equip them with regard to facilitation and handover skills. F l i t d t ld h d i ti For example senior students could shadow existing CSDs for a day or 2

Language barriers Language barriers

Can be directly attributed to the lack of qualified y q dietitians from previously disadvantaged backgrounds ‐ due to the lack of equity at training facilities due to the lack of equity at training facilities 10% of graduates from “white” universities are “black”. Training institutions should include a basic African language as part of their training programme as well as a specific module on intercultural communication. The language taught at the various training institutions h ld b k i b h d i h should be taken into account by the DOH during the placement of CSDs.

Language barriers Language barriers

Med students: In 1994 first year enrolment of “black” y students was 29% and this increased to 60% by 2001. An increase in the admission rate does not directly translate into a proportional increase in graduates since translate into a proportional increase in graduates since the attrition rate of “black” students (19.9%) compared to “white” students (3 7%) remains a matter of concern Thus training institutions should make a concerted to white students (3.7%) remains a matter of concern. Thus training institutions should make a concerted effort to address not only the admission rate of “black” t d t b t th tt iti t ll students but the attrition rate as well.

Training Training

Although the theoretical training was adequate, the g g q , practical training could have been better. Training programmes should thus be more practical / applied and practical training should take place earlier applied and practical training should take place earlier. Training institutions should consider the suggestion Training institutions should consider the suggestion that undergraduate evaluation should assume a more ti l / li d h i t d f th t practical / applied approach instead of the current theoretical approach

Competencies Competencies

Although CSDs rated their overall knowledge and g g competencies positively, provincial coordinators highlighted significant differences between CSDs from highlighted significant differences between CSDs from different institutions. Standards are clearly not the same at all institutions. The HPCSA Professional Board for dietitians thus has an i t t l t l h l ti t i i t important role to play when evaluating training at different institutions.

Competencies Competencies

CSDs spend 46% of their time on therapeutic nutrition p p and only 10% on community nutrition. CSDs appear to be more competent with regard to providing therapeutic nutrition services than community providing therapeutic nutrition services than community nutrition services. Their training programmes may need to be adapted to such an extent that CSDs are empowered to provide such an extent that CSDs are empowered to provide better community nutrition services.

Competencies Competencies

Proficient in breastfeeding, infant feeding, infants with g, g, HIV and nutrition in childhood, they require more training on the nutritional management of paediatrics training on the nutritional management of paediatrics and neonates and implementation of public health programmes programmes (BFHI, INP, PMTCT and IMCI). Training institutions need to address these areas quickly if we as dietitians want to contribute to quickly if we as dietitians want to contribute to reducing the infant mortality rate in the country.

CONCLUSIONS CONCLUSIONS

CONCLUSION CONCLUSION

Training institutions: Recommendations related to the g structure and content of the training programmes and admission and attrition rates of African students. admission and attrition rates of African students. DOH and training institutions should clarify the DOH and training institutions should clarify the difference between an internship & a community service placement placement. DOH C ti t d i th it i d DOH: Continue to drive the community service agenda, advocating the nutrition profession, placement and f d

• rientation of CSDs, resources, supervision and support

as well as retention of community service staff.

CONCLUSION CONCLUSION

In the words of Couper, it is important that health p , p professionals at receiving institutions & community services dietitians view themselves as ‘just another services dietitians view themselves as just another dietitian’ In this way CSDs will be viewed, accepted and ultimately perform as fellow health professionals and ultimately perform as fellow health professionals and not as students who require a large amount of supervision and support supervision and support. Both the DOH and training institutions should ensure Both the DOH and training institutions should ensure that this is enforced.

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