Implementation of Primary Health Care (PHC) services has been a long outstanding aspect to be of priority in many low- and middle-income countries but workplace violence amongst PHC nurses continues to hinder progress towards achieving quality patient care [1]. PHC is essential health care based on scientifically sound and socially acceptable method and technology that makes universal health care accessible to all individuals and families in a community. PHC involves the provision of integrated and accessible health care services at the first level of contact [2, 3]. PHC clinics are the access point for clients who need preventative care and diagnosis and management of minor ailments [4].

Globally, the consequence of increased workload is an area of concern for both primary and secondary health care facilities, and this is due to staff shortages [5]. The commission report [6] alluded that resources, such as equipment, are given to health facilities in large cities instead of being allocated to the underprivileged rural health care areas where they are needed most. The PHC services render 24-hour services using a call system to attend the emergency patients. Moreover, non-emergency cases also visit the clinics for consultation as nurses are always available on a 24 hours call system [7].

A study conducted in Limpopo province revealed that there is a lack of human resources in rural areas, hindering the integration and implementation of a comprehensive approach in the delivery and management of about 3,000 government PHC clinics and community health centers [8, 9]. The quality of health care services at the PHC level is affected by factors, such as devastating workload, hygiene in the work environment, poorly maintained infrastructure, and inadequate equipment and supplies [3, 10]. The South African Basic Conditions of Employment Act No 11 of 1997 [11] stipulates the minimum work hours; an employer may not allow an employee to work more than nine hours per day or more than 45 hours per week. The country faces a nursing crisis characterized by staff shortages, declining interest in the profession, lack of caring ethos, and disjuncture between the nurses’ and communities' needs [12].

In a study conducted in Canada, 33,000 nurses admitted that when they have heavy workloads, they leave essential responsibilities undone, compromising professional nursing [13]. When nurses are allowed a greater chance to work in clinics with adequate staff, improved job satisfaction has been observed [14]. A safe working environment ensures free movement and execution of tasks in a relaxed atmosphere [15]. Research studies found that job satisfaction is achieved in a safe working environment with good infrastructure [16]. A study conducted in Free State, South Africa, indicated that the main public health system challenges include staff shortages, financial issues, compliance with quality standards, effective management practices, and distribution of adequate healthcare resources [17, 18].

Nurses working in PHC clinics with insufficient working areas and unsafe environments predispose them to violate occupational health and safety standards, thereby compromising nurse and patient safety [19]. Despite efforts for effective PHC service delivery, some challenges still exist; therefore, this study seeks to explore and describe the challenges experienced by PHC nurses when rendering 24-hour services at designated clinics of Musina local area, Limpopo province.

The themes and sub-themes of challenges experienced by PHC nurses working at a designated 24-hour service are reflected in Table 1 below.

The findings of this study revealed that there are inadequate human resources for rendering 24-hour services at the designated clinics. A shortage of nurses and support staff is reported to make 24-hour services successful. It has been observed that the shortage of staff at clinics negatively impacts patient waiting times, leading to low patient satisfaction, poor compliance with medications, and even missed appointments [23]. Furthermore, it was reported that the number of nurses at clinic facilities should be increased to reduce the increased workload caused by many programs rendered at the clinics, thereby hindering the comprehensive PHC approach from being effectively implemented [7]. The findings are supported by a study [24], indicating that nurses working in primary healthcare settings face emotional and physical stress and have excessive workloads due to the shortage of human resources. Furthermore, nurses are overburdened, and this impacts the patient waiting time. There is also a lack of supportive supervision of short-staffed nurses working in primary health care facilities [25].

Another challenge revealed by the study is the shortage of equipment and supplies, including medications which affect the quality of care provided to patients at the clinics. The finding is congruent with that of a study conducted previously [26], which indicates that the shortage of medicines is a challenge that prevents nurses from prescribing appropriate medicines to patients. Shortage of functional equipment and other essential resources, including unavailability of ambulances to transfer patients to hospitals, is a barrier that affects the provision of effective care for patients. The quality of health care services is still affected by several aspects, like devastating workload, the cleanliness in the work environment, poor clinic infrastructure, and nurses' perception of the environment that lacks equipment [8]. Furthermore, shortage of equipment affects the quality and follow-up of patients as some of the specific procedures cannot be done without necessary equipment [8].

A lack of water supply for cleaning and consumption in clinics is another challenge for PHC nurses offering 24-hour services. A study conducted in Ethiopia reported patients’ dissatisfaction with care received at the health facility as 61.3% of patients complained regarding the lack of drinking water which affected their care. Problems, such as the absence of water, lack of basic work equipment, and inappropriate staff composition, need to be addressed by the government health department to ensure the provision of comprehensive quality of service [27]. Poor living conditions in rural health facilities, such as unsafe drinking water, impact the quality of services provided to patients [28]. The absence of potable water supply to clinics remains a major concern that affects the working of these facilities and the quality of care provided at the facilities. These become worse in situations where the facility does not have an alternative source of water supply, such as boreholes, to alleviate the effect of water shortage [29].

The study also identifies that the occupational health and safety of nurses are not taken into consideration as there is a poor security system, leading to a feeling of insecurity amongst PHC nurses. The findings were supported by a study conducted previously [30], indicating that the safety of PHC nurses whilst on duty has recently become a serious concern. Furthermore, the safety of PHC personnel is of particular importance as they are mostly female, and only a few nurses are on duty at certain times of the day and night. Every health care provider needs to work in a safe environment as safety is a basic human need and right which should be protected in any case, irrespective of the environment where the service is provided. A safe environment ensures free movement and execution of tasks in a relaxed atmosphere, and a stable community is considered safe and healthy [15]. The problems mostly experienced by healthcare users and nurses in public institutions include lack of cleanliness, poor safety, and security in health settings [31].

Another study revealed that the security gap is also an issue, making health care facilities violent-prone as there is an adequate or complete absence of security guards in health centers. Furthermore, another perceived reason for workplace violence is mainly the attitude problems on the part of nurses and patients, leading to workplace violence [32]. Workplace violence has a negative impact, leading to physical and psychological harm to health workers; therefore, the importance of taking institutional measures for the safety of health workers is essential [33, 34]. This study suggests that workplace violence prevention strategies are urgently needed to provide health care workers with a safe environment [35].

The clinic infrastructure is identified as not safe for work due to poor maintenance and very old buildings. The inadequacies in infrastructure for health care services form part of the inequalities in health services, especially in rural communities, and they need to be addressed to improve service delivery at primary health clinics [36]. Structural challenges, such as inadequate infrastructures, affect services in the clinics [37]. Moreover, in this study, the safety of PHC nurses was explained as being at risk due to the negative attitudes of patients towards PHC nurses. The patients’ relatives/escorts and patients themselves were noted as the main sources of violence against nurses in many instances. A study [38] indicated that there is a high incidence of workplace violence by patients and visitors against nurses in health care settings. The findings of a study conducted in Ghana are in agreement with the findings of this study as the study also found that the poor clinic infrastructures with leaking roofs are not suitable for the provision of comprehensive quality health care services [39]. PHC nurses need to be provided with a conducive and suitable work environment with adequate infrastructure to reduce burnout [40].

Nurses are usually the first person that patients and their families meet in the health facilities. If such facilities have inadequate resources, nurses are often blamed by patients and relatives for late or inadequate health services, putting them at risk of being physically and verbally abused [35]. Nurses, therefore, have to broaden their awareness level on violence so that they can take precautions themselves against workplace violence [41]. There is a need for future interventions that are receptive to the need of the nursing staff to ensure effective avoidance of violence in the workplace [32, 42]. Nurses who experience violence are affected physically, emotionally, and mentally, displaying symptoms of anger, fear, anxiety, post-traumatic stress disorder, and loss of self-esteem [33].

The study was conducted at the designated primary health care facilities in the Musina local area, Vhembe district, Limpopo province, South Africa. The study findings are limited to 24-hour designated clinics and may not be generalized to other clinics in other provinces of South Africa. Other researchers may explore the factors contributing to poor utilization of 24-hour primary health services to assist them in their specific situations.

The study findings confirmed that nurses rendering 24-hour services at designated clinics is still facing some challenges. In this regard, providing them with both human and material resources will help nurses to effectively render 24-hours services. Professional nurses providing 24-hour services need to have a safe infrastructure and trained security guards for 24 hours to ensure their safety. Adequate management support is important to assist those nurses rendering the 24-hour services in all the designated clinics

The provision of 24-hour service at the designated primary health clinics serves as the first level of contact for health care, and the care rendered at this level needs to be comprehensive. PHC nurses require equipment and supply, adequate staffing levels, and proper security to effectively render their services. PHC clinics understand the value of 24-hour service to the community, but they lack the resources to accomplish this goal. Lack of management support also affects the comprehensive approach in rendering effective 24 hours. Therefore, the study recommends the provision of resources and safety measures to assist PHC nurses in the provision of quality 24-hour services in the clinics.

T.E.M conceptualized the research idea and initially drafted the manuscript. V.M assisted in the review of the manuscript, and both the authors agreed to publish the final version of this manuscript.