title: Using diaries to explore the work experiences of primary health care nursing managers in two South African provinces.
abstract: BACKGROUND
  South Africa is on the brink of another wave of major health system reforms that underscore the centrality of primary health care (PHC). Nursing managers will play a critical role in these reforms.
  
  
  OBJECTIVE
  The aim of the study was to explore the work experiences of PHC clinic nursing managers through the use of reflective diaries, a method hitherto under-utilised in health systems research in low- and middle-income countries.
  
  
  METHODS
  During 2012, a sub-set of 22 PHC nursing managers was selected randomly from a larger nurses' survey in two South African provinces. After informed consent, participants were requested to keep individual diaries for a period of 6 weeks, using a clear set of diary entry guidelines. Reminders consisted of weekly short message service reminders and telephone calls. Diary entries were analysed using thematic content analysis. A diary feedback meeting was held with all the participants to validate the findings.
  
  
  RESULTS
  Fifteen diaries were received, representing a 68% response rate. The majority of respondents (14/15) were female, each with between 5 and 15 years of nursing experience. Most participants made their diary entries at home. Diaries proved to be cathartic for individual nursing managers. Although inter-related and not mutually exclusive, the main themes that emerged from the diary analysis were health system deficiencies; human resource challenges; unsupportive management environment; leadership and governance; and the emotional impact of clinic management.
  
  
  CONCLUSIONS
  Diaries are an innovative method of capturing the work experiences of managers at the PHC level, as they allow for confidentiality and anonymity, often not possible with other qualitative research methods. The expressed concerns of nursing managers must be addressed to ensure the success of South Africa's health sector reforms, particularly at the PHC level.
authors.affiliation: Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; pascalia.munyewende@wits.ac.za.
authors.forename: Pascalia O
authors.initials: PO
authors.lastname: Munyewende
authors.affiliation: Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Laetitia C
authors.initials: LC
authors.lastname: Rispel
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D005260:Female; D006801:Humans; D007857:Leadership; D008297:Male; D008875:Middle Aged; D009718:Nurse Administrators / Q000458:organization & administration / Q000523:psychology; D011320:Primary Health Care / Q000458:organization & administration*; D036301:Qualitative Research; D013019:South Africa; D000078329:Workforce; D055815:Young Adult
keywords: South Africa; diary methodology; health reforms; nursing managers; primary health care