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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 18-23

Time-motion study of auxiliary nurse midwives of a primary health center from Wardha District of Maharashtra


1 Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
2 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra, India

Date of Submission25-Aug-2018
Date of Acceptance12-May-2019
Date of Web Publication10-Jul-2019

Correspondence Address:
Dr. Abhishek V Raut
Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha - 442 102, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAMR.IJAMR_50_18

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  Abstract 


Introduction: In the rural health-care delivery system of India, auxiliary nurse midwife (ANM) is the key frontline field-level functionary who interacts directly with the community. A heavy responsibility of implementation of health programs rests on the shoulders of ANMs. As ANMs are central to the delivery of services under the National Rural health Mission including supervision of the work done by the accredited social health activist, we thought it prudent to analyze their work pattern so that their efficiency could be improved upon. Objective: The objective was to study the workload and work pattern of ANMs and identify the causes for improving work efficiency of ANMs. Materials and Methods: This was an observational cross-sectional study conducted among four purposively chosen ANMs from a primary health center (PHC) in Central India using time-motion study as the tool. An ANM's work pattern and workload were studied by constructing 24-h recall. One ANM was followed for a week, similarly the other ANM for another week so that the activities of entire month were covered. To ensure quality, work schedules reported by the ANMs each day were cross-checked with the concerned supervisor or medical officer PHC. Results: A free-listing and pile-sorting exercise was performed with the ANMs, and the 41 activities reported by them were clubbed in to five major categories. It was found that on meeting day, meeting and record keeping were the most performed tasks, whereas other tasks were hardly performed. On the day of home visits, ANMs performed the disease-related activity for most of their time, and record keeping or supporting tasks were the second most performed activities. Majority of ANM's time spent over the week was on supporting tasks which were not directly related to their job profile. Conclusion: We conclude that clarity about job responsibilities of ANMs is lacking and available working time is not effectively utilized. Time spent on supporting tasks such as travel and waiting is maximum. Training to manage time for priority tasks and to improve skills is required.

Keywords: Auxiliary nurse midwife, time management, time-motion study


How to cite this article:
Bhombe I, Raut AV, Taywade M, Deshmukh P. Time-motion study of auxiliary nurse midwives of a primary health center from Wardha District of Maharashtra. Int J Adv Med Health Res 2019;6:18-23

How to cite this URL:
Bhombe I, Raut AV, Taywade M, Deshmukh P. Time-motion study of auxiliary nurse midwives of a primary health center from Wardha District of Maharashtra. Int J Adv Med Health Res [serial online] 2019 [cited 2019 Oct 22];6:18-23. Available from: http://www.ijamhrjournal.org/text.asp?2019/6/1/18/262492




  Introduction Top


In the rural health-care delivery system of India, the auxiliary nurse midwife (ANM) is the key frontline field-level functionary who interacts directly with the community.[1] It is increasingly recognized that ANM is a key health worker for the delivery of quality public health care. The services delivered by ANMs are considered essential to provide safe and effective care and as a vital resource. It is a well-known fact that it is through their activities that community perceives health policies and strategies. Furthermore, the policy-makers and health planners gain insight into the health problems and needs of the rural people. A heavy responsibility of implementation of health programs rests on the shoulders of ANMs.[2]

The role of ANM has also changed over a period of time in India, especially after the launch of the National Rural Health Mission (NRHM) in 2005 and with the changing program priorities. Under NRHM, there is a provision for additional ANM for the subcenter to improve the access and quality of services provided including the curative services. The present focus in the country is to provide accessible, affordable, accountable, equitable, effective, and reliable health care, especially to poor and vulnerable sections of the rural population, the responsibility for which inevitably rests on the ANMs.[2]

One of the key strategies under NRHM is to have a community link worker or accredited social health activist (ASHA). She is a volunteer who acts as a bridge between the community and the available health-care system. She is selected to help ANMs in implementation of various national health programs in her own village envisaging that it will have an important impact on the outreach services in rural areas and fill the gaps in health-care delivery system.[1],[3]

In spite of impetus received for improving the public health-care system in India because of the launch of the NRHM, changes at the grassroots levels are rather slow and lack focus. In general, as the research indicates, nursing professionals have little participation either in policy formulation and also in-service training. Supervision and mentoring is lacking which brings stagnation to their roles. The lack of supportive supervision and hand-holding limits the efficient use of the frontline health workers such as ANMs.[4] Researchers and program managers are not able to fathom the reasons behind the lack of supervision and weak management.

In light of recent policy and thrust on the role of ANMs for reducing maternal and neonatal death under NRHM, the role of ANM needs to be revived. As ANMs are central to the delivery of services under NRHM including supervision of the work done by the ASHA, we thought it prudent to analyze their work pattern so that their efficiency could be improved upon.

“Time-motion study” is a useful tool to analyze the performance of health-care providers for careful management of human resources. It is not just an assessment tool, but it also results in positive bias among health workers who are observed, meaning that the documented productivity is higher in health workers under observation.[5],[6],[7],[8],[9]

Hence, the present study was conducted with the objective to study the workload and work pattern of ANMs and identify the causes for improving work efficiency of ANMs, who are key health workers with professional training for health-related activities, using the time-motion study tool.


  Materials and Methods Top


This was an observational cross-sectional study conducted using time-motion study as the tool among four purposively chosen ANMs from a single primary health center (PHC) in Central India. This PHC caters to a population of around 35,000 through five subcenters and was chosen considering the feasibility for implementing the research. The PHC has eight ANMs working in it, of which four ANMs were chosen purposively so that their typical working days were represented.

Written informed consent was obtained prior to their inclusion in the study. The study was initiated after approval from the Institutional Ethics Committee. The study was carried out between August and September 2014.

A free-listing exercise was done to identify the different activities undertaken by the ANMs as part of their job profile which was followed by a pile-sorting exercise to club the various activities done by the ANMs for identifying broad domains for analysis.

An ANM's work pattern and workload were studied by constructing 24-h recall. Each ANM was asked to self-report the tasks performed by her on the previous working day using a semi-structured, pretested, open-ended tool to construct the previous day's work. One ANM was followed for a week, similarly the other ANM for another week so that the activities of entire month were covered.

To ensure quality, work schedules reported by the ANMs for each day were cross-checked with the concerned supervisor or medical officer (MO) PHC, and in case of disparity, it was corrected in agreement with the ANM being studied.

This being a time-motion study, primary outcome variable for analysis was the time spent on various activities as a proportion of total working time. The time spent data were analyzed using Microsoft Excel to estimate the total and average time requirement and percentages. For tasks such as organizing Village Health and Nutrition Day (VHND) and home visits in villages under her subcenter that were done more than once a week, average time duration was estimated.

A force-field analysis was done with the ANMs to identify the driving and inhibiting forces affecting their effective functioning. This was followed by a root cause analysis exercise for finding the distal causes and for possible solutions to the problems identified.


  Results Top


All the ANMs were above 35 years of age with a median age of 46 years. Three of them had received education till class 12th, whereas one was educated till class 10th. Two of four ANMs resided at the subcenter and other two at nearby towns. Three ANMs were married and one was a widow. One ANM was working on contractual basis, whereas the rest were permanent.

The ANMs in this study work 6 days (Monday–Saturday) a week. In a typical week, an ANM generally performs the following tasks:

  • Organizing VHND (twice a week)
  • Home visits in villages under her subcenter (twice a week)
  • Attending meeting at PHC (once a week)
  • Organizing camp/assisting in camp organization (once a week).


A free-listing and pile-sorting exercise was performed with the ANMs, and the 41 activities free-listed by them were clubbed in to five major categories as follows:

  1. Maternal and child health (MCH) activity


    • Antenatal care (ANC) home visits
    • Postnatal care (PNC) home visits
    • Immunization of children at VHND
    • ANC checkup, counseling, immunization at VHND
    • ANC checkup at outpatient department (OPD)
    • PNC checkups counseling at VHND
    • PNC checkups at OPD
    • Conducting delivery
    • Observation of delivery case
    • Follow-up of expected delivery case
    • Follow-up of tubectomy case


  2. Communicable and noncommunicable disease-related activity


    • Home visits in village for counseling people
    • Container survey for vector breeding
    • Survey for filariasis, leprosy, fever, tuberculosis, and cataract
    • Providing medicines for minor ailments
    • Conducting orthotolidine test
    • Blood smear collection
    • Sputum collection
    • Monitoring of blood pressure
    • Monitoring of blood sugar
    • OPD at subcenter and treatment for minor ailments at subcenter
    • Tablet albendazole distribution


  3. Record-keeping activity


    • Writing report
    • Filling up record register
    • Data entry in computer
    • Anganwadi visit
    • Gram panchayat visit


  4. Group activity


    • Meeting at PHC
    • Meeting with medical officer
    • Giving information about epidemics to people
    • Gram sabha (public gatherings) for awareness
    • Cleaning of subcenter
    • Camp for noncommunicable diseases or awareness on diseases/health practices or tubal ligation candidates' admission procedure, home visits during camp


  5. Supporting activity


    • Travel
    • Waiting for any reason
    • Water sample collection
    • Meeting sarpanch to report water sample collection
    • Disposal of vaccines
    • Gathering villagers/students for awareness/camp
    • Preparation of VHND/camp
    • Inspection by higher authority.


It was found that on meeting day, meeting and record keeping were the most performed tasks, whereas other tasks are hardly performed [Table 1]. In [Table 2], it is observed that on the day of home visits, ANMs performed the disease-related activity for most of their time, and record keeping or supporting tasks were the second most performed activities. In [Table 3], observations indicate that on VHNDs, most time was spent on MCH activity or supporting tasks. In a week, three ANMs worked for 45.5 h on an average and ANM#1 worked 20 h more than the average, but tasks contributing to her time excess were observation of delivery case which is a passive process and traveling. Thus, extra work time as such was not a significant contribution to her job responsibility. Majority of her time spent over the week was on supporting tasks which were not directly related to her job profile.
Table 1: Work distribution for auxiliary nurse midwives on meeting day

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Table 2: Work distribution for auxiliary nurse midwives on home visit day

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Table 3: Work distribution for auxiliary nurse midwives on Village Health and Nutrition Day

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[Figure 1] depicts the time distribution for activities of ANMs over a week.
Figure 1: Time distribution for activities of auxiliary nurse midwives over a week

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To find the causes and factors affecting ANM's work, force-field analysis and root cause analysis were done with participation of ANMs in a group discussion. [Figure 2] depicts the enabling and inhibiting forces for ANMs to carry out their work effectively. [Figure 3] depicts the reasons hindering the work effectiveness of ANMs as reported by them.
Figure 2: Force-field analysis

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Figure 3: Root cause analysis

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  Discussion Top


This observational cross-sectional study was conducted using time-motion study as the tool with the objective to study the workload and work pattern of ANMs. An ANM's work pattern and workload were studied by constructing 24-h recall to construct the previous day's work. Time periods reported for each of the ANMs are different because actual time periods for which they have worked have been reported.

Manzi et al. found that attending meetings, collecting vaccine, and other supplies from higher health center act as distractions and undermine the ability to provide services. In the present study, on meeting day, other tasks were hardly performed as weekly record has to be submitted during meeting. Supporting activities for attending the meeting such as travel to PHC, waiting for the meeting to begin consume more time than the actual meeting thereby contributing to wastage of time. The time for meeting needs to be fixed in prior consultation with all participating members to avoid wastage of time in waiting. The compulsion to submit records during weekly meeting places undue emphasis on record-keeping activity.[6]

Mavalenkar and Vora stated in their article that ANM's midwifery role mainly prioritizes immunization and family planning. However, it needs to be more comprehensive to include more of neonatal, PNC, and reproductive tract infection/sexually transmitted infection (RTI/STI) components to achieve the goal of decreased maternal mortality as mentioned in various planning documents of the Government of India.[1]

Santhya and Jejeebhoy also found that only one-third of their study participants provided delivery care and postnatal visits within 2 days of delivery were very few. Some activities such as MCH and disease-related activities were performed most only on specific days of VHNDs and home visit days, respectively. In MCH activity of the present study, it is observed that major share is of immunization done on VHNDs. PNC and neonatal care hold smaller share, and also, the RTI/STI component is neither covered in MCH nor in disease-related tasks. Only one of the four ANMs conducted delivery at her subcenter in the week of observation.[10]

Sharma et al. observed that maximum time spent was in travel which was because they do not have assigned vehicle to visit field area. Supporting activity is the most performed of which travel and waiting time for patients or colleagues are major ones. The reasons for more travel time in this study can be ANMs not residing at subcenter, more distance between workplace and residence, and unavailability of assigned vehicles.[9]

Manzi et al. found that productivity varies with patient flow, and when a patient was not present, nurses lacked the initiative to undertake other activities. Waiting time is more as patient flow is not constant and also some colleagues do not arrive on time for meeting. Thus, waiting time can be reduced by performing alternative tasks such as record keeping during that interval; thus, time can be saved for other important activities.[6]

On camp day, the most performed activity is group activity, and other activities such as MCH and disease-related activities hardly have any place in work schedule of that day. Tasks such as escorting and completing the admission procedure for tubal ligation candidates on camp day and giving information about diseases/health practices find no direct mention in her job profile[3] and so can be considered unrelated causing undue consumption of time.

Based on the findings of root cause analysis, the following recommendations may help to improve the work efficiency of ANMs:

  1. Clearly defined job responsibilities
  2. Training for capacity building and multitasking
  3. Training for microplanning of activities, and
  4. Supportive supervision and on-the-job training.


ANMs are central to implementation of public health programs in countries like India. The effective implementation for prevention and control of any health problem depends on efficient functioning of the ANMs. This study has helped to identify the bottlenecks in effective functioning of ANMs and may guide in deciding strategies for effective functioning of ANMs for improving the public health scenario in India and other developing countries similar to India.

The finding of the present study should be interpreted taking into consideration the following limitations:

  • Smaller sample size of only four ANMs with whom the study was conducted
  • Recall bias during construction of 24-h work schedule
  • Overreporting of self-activities by ANMs may be a possibility
  • The external generalizability of the study will be limited as it was conducted with only four ANMs of a single PHC.



  Conclusion Top


We conclude that the ANMs are not effectively utilizing the available working time. Most of the time is being spent on supporting tasks such as traveling and waiting. Clarity about job responsibilities is lacking. Training to manage time for priority tasks and to improve skills for microplanning is required.

Acknowledgment

  • We thank Professor and Head, Department of Community Medicine, MGIMS, Sevagram, for allowing us to conduct the research in the department.
  • My sincere thanks to the staff at PHC Kharangana Gode (MO and ANMs) without the support of whom it would not have been possible for us to complete this research project.


Financial support and sponsorship

This short research project was done as part of the Indian Council of Medical Research's Short Term Studentship (ICMR-STS) program (ICMR-STS Reference ID: 2015-00246).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mavalenkar D, Vora KS. The Changing ROLE of Auxiliary Nurse Midwife (ANM) in India. Implications for Maternal and Child Health (MCH). Indian Institute of Management; 2008. Available from: https://pdfs.semanticscholar.org/992d/48c292c49a7656d3f9402cd4220e4803161b.pdf?_ga=2.8042801.2051991108.1556920705-1376953801.1556920705. [Last accessed on 2019 May 04].  Back to cited text no. 1
    
2.
Malik G. Role of auxiliary nurse midwives in national rural health mission. Nurs J India 2009;100:88-90.  Back to cited text no. 2
    
3.
Vaz LS. Organization of Health Care in India. Textbook of Public Health and Community Medicine. 1st ed. Pune, India: Deprtment Community Medicine, AFMC, in collaboration with WHO, India office, Delhi; 2009: p. 463.  Back to cited text no. 3
    
4.
Bagga R. Study on Nursing and Midwifery in India: A Critical Review. National Institute of Health and Family Welfare; November, 2012. Available from: http://planningcommission.gov.in/data/ngo/csw/csw_nurse.pdf. [Last accessed on 2019 May 04].  Back to cited text no. 4
    
5.
Odendaal WA, Lewin S. The provision of TB and HIV/AIDS treatment support by lay health workers in South Africa: A time-and-motion study. Hum Resour Health 2014;12:18.  Back to cited text no. 5
    
6.
Manzi F, Schellenberg JA, Hutton G, Wyss K, Mbuya C, Shirima K, et al. Human resources for health care delivery in tanzania: A multifaceted problem. Hum Resour Health 2012;10:3.  Back to cited text no. 6
    
7.
Burke TA, McKee JR, Wilson HC, Donahue RM, Batenhorst AS, Pathak DS. A comparison of time-and-motion and self-reporting methods of work measurement. J Nurs Adm 2000;30:118-25.  Back to cited text no. 7
    
8.
Finkler SA, Knickman JR, Hendrickson G, Lipkin M Jr., Thompson WG. A comparison of work-sampling and time-and-motion techniques for studies in health services research. Health Serv Res 1993;28:577-97.  Back to cited text no. 8
    
9.
Sharma B, Roy S, Mavalankar D, Ranjan P, Trivedi P. The Role of the District Public Health Nurses: A Study from Gujarat. Ahmedabad: Indian Institute of Management; 2010. Available from: https://web.iima.ac.in/assets/snippets/workingpaperpdf/2010-02-04Sharma.pdf. [Last accessed on 2019 May 04].  Back to cited text no. 9
    
10.
Santhya KG, Jejeebhoy SJ. Providing Maternal and Newborn Health Services: Experiences of Auxiliary Nurse Midwives in Rajasthan; 2012. Available from: https://knowledgecommons.popcouncil.org/cgi/viewcontent.cgi?article=1090&context=departments_sbsr-pgy. [Last accessed on 2019 May 04].  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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