Exploring the relationship between nurses and community health workers and the perceived impact on service delivery in Lesedi Sub-District

Abstract

BACKGROUND: In the low- and middle-income countries, community health workers (CHWs) play a key role in providing primary health care services, particularly in resources constrained settings. The CHWs bridge a gap between the community and the health care facilities, by bringing healthcare directly into the homes of individuals. They are vital in contributing to the management of non- communicable and communicable diseases through disease prevention and health promotion campaigns, following up and collecting medication for patients. Despite this, there are challenges experienced by the CHWs programmes. These challenges include lack of working tools, poor supervision and relationship with the healthcare systems and community structures. The aim of the research was to examine the relationship dynamics experienced by CHWs with the other health care facility staff, particularly the primary care nurses, and the possible perceived impact on patients care which forms part of difficulties in integrating CHWs within the health care system. The study was underpinned by the theoretical framework of Interprofessional Health Collaboration (IPHC), which emphasizes effective communication, teamwork, and shared responsibilities across professional boundaries. METHODS: This study is a secondary analysis of qualitative data collected as part of Batlhokomedi Project. The project studied the implementation of the national CHWs program in six primary healthcare (PHC) facilities in Sedibeng district of Gauteng Province. The Batlhokomedi project sample was made of CHWs, supervisors, clients, facility staff members and community representatives. The current analysis is from focus group discussions (FGD) and individual interviews from two clinic’s participants (Clinic A and Clinic B). The clinics were selected purposely because of their geographical location. Using thematic analysis method, 6 FGDs from CHWs (Clinic A and B), 1 interview from the facility manager (professional nurse, Clinic A), 2 interview transcripts from team leaders (assistant nurses, Clinic A and B) and 1 interview from the health promoter (Clinic A) were analyzed. v RESULTS: The study found that inter-professional communication within WBOTs, including reporting and referral systems, was functional but inconsistent. CHWs submitted regular reports and referrals, yet delays in feedback limited timely decision-making and coordination of patient care, which in turn affected patients’ access to appropriate and continuous care. Appreciation and recognition from clinic staff and higher-level stakeholders were infrequent, leaving CHWs feeling undervalued, which negatively influenced their motivation and engagement, ultimately impacting the quality of care delivered to patients. Team functioning varied: one team demonstrated effective planning, coordination, and knowledge sharing, which supported smoother task execution, strengthened collaboration, and improved patient follow-up. In contrast, the other team experienced poor planning, role confusion, and low morale, creating gaps in service delivery and potentially undermining patient trust in the healthcare system. Collaborative leadership differed across hierarchical levels: co-worker support was generally strong, supervisor support varied between teams, and clinic staff support was limited. Conflicts arose over resources, uniforms, and perceived power dynamics, reflecting systemic tensions that affected team cohesion and the ability to deliver coordinated care. Overall, these findings highlight variability in team performance, communication, and support mechanisms within the WBOT program, with direct implications for patient care and the quality of relationships within the healthcare team. CONCLUSIONS The CHWs within the Ward based outreach teams (WBOT) experience several challenges which affect their relational encounter with clinic staff. The negative relational dynamics forms a larger systemic challenge within the WBOT. The systemic challenges which affect service delivery. Hence, affecting the integration of CHWs within the CHWs program, translating into challenges with service delivery model. RECOMMENDATIONS To strengthen CHW integration and improve health outcomes, a collaborative effort among stakeholders is needed. This includes revising policy frameworks to enhance interprofessional collaboration, ensuring adequate resources and infrastructure support, providing continuous vi training, and leveraging digital technologies within CHW programmes. Embracing the principles of Interprofessional Health Collaboration is key to enabling CHWs to function effectively within the broader health system.