Participant Demographics
The community-driven discovery injury involved 30 nurses (4 FGDs) and 36 clients (5 FGDs) and 12 stakeholders (administrators, NGO representatives and a representative of the Health Facility Governance Committee). Co-design meetings involved an equal number (10) of nurses, clients, and stakeholders. The validation inquiry involved 22 nurses (3 FGDs) and 26 clients (3FGDs). Refinement meetings involved 15 nurses, 15 clients and 10 stakeholders. Females accounted majority of participants (90% discovery), (90% co-design), (96% validation) and (90% refinement participants). On the one hand, most nurses had a higher level of education level (those with college and above were 77% of discovery; 90% co-design; 100% validation and 85% refinement participants) as compared to clients (those with secondary and below, 86% discovery; 70% co-design; 100% validation and 90% refinement participants). On the other hand, most clients had a high number of children as compared to nurses, some of whom had no children (Table 1).
Table 1: Participants’ demographics
|
Community Driven-Discovery
|
Co-design meetings
|
Validation Inquiry
|
Refinement meetings
|
Category
|
Nurses
(%)
n=30
|
Clients
(%)
n=36
|
Admin
(%)
n=12
|
Total
(%)
N=78
|
Nurses
(%)
n=10
|
Clients
(%)
n=10
|
Admin
(%)
n=10
|
Total
(%)
N=30
|
Nurses
(%)
n=22
|
Clients
(%)
n=26
|
Total
(%)
N=48
|
Nurses
(%)
n=15
|
Clients
(%)
n=15
|
Admin
(%)
n=10
|
Total
(%)
N=40
|
Gender
Female
Male
|
26(87)
4 (13)
|
36
0
|
8 (67)
4 (33)
|
70(90)
8(10)
|
10
0
|
10
0
|
7(70)
3 (30)
|
27(90)
3(10)
|
20(91)
2(9)
|
26(100)
0
|
46(96)
2(4)
|
13 (87)
2(13)
|
14(93)
1(7)
|
8(80
2(20)
|
35 (87.5)
5 (12.5)
|
Age
<30
31-40
41-50
>50
|
6 (20)
14(46)
5(17)
5(17)
|
22(61)
13(36)
0
1(3)
|
0
3(25)
8(67)
1(8)
|
28(36)
30(38)
13(17)
7(9)
|
1(10)
5 (50)
3(30)
1(10)
|
4(40)
6(60)
0
0
|
0
1(10)
7(10)
2(20)
|
5(17)
12(40)
10(33)
3(10)
|
5(23)
6(27)
6(27)
5(23)
|
20(77)
4(15)
1(4)
1(4)
|
25(52)
12(25)
7(15)
4(8)
|
7(47)
6(40)
2(13)
0
|
3(20)
8(53)
4(27)
0
|
0
1(10)
8(80)
1(10)
|
10 (25)
15(37.5)
14(35)
1(2.5)
|
Education
None
Primary
Secondary
College
University
|
0
1(3)
6(20)
21(70)
2(7)
|
5(14)
17(47)
9(25)
4(11)
1(3)
|
0
0
1(8)
2(17)
9(95)
|
5(6)
18(23)
16(21)
27(35)
12(15)
|
0
0
1(10)
6(60)
3(30)
|
1(10)
3(30)
3(30)
2(20)
1(10)
|
0
0
1(10)
4(40)
5(50)
|
1(3)
3(10)
5(17)
12(40)
9(30)
|
0
0
0
21(95)
1(5)
|
0
16(62)
10(38)
0
0
|
0
16(34)
10(21)
21(44)
1(2)
|
0
1(7)
5(33)
8(53)
1(7)
|
3(20)
9(60)
2(13)
1(7)
0
|
0
0
0
8(80)
2(20)
|
3(7.5)
10(25)
7(17.5)
17(42.5)
3 (7.5)
|
No. of children
(Nurses & clients)
None
1-2
3-4
>5
|
4(13)
20(67)
4(13)
2(7)
|
0
21(58)
8(22)
7(20)
|
NA
|
NA
|
1(10)
5(50)
2(20)
2(20)
|
0
5(50)
3(30)
2(20)
|
NA
|
NA
|
2(9)
11(50)
9(41)
0
|
0
22(85)
1(4)
3(11)
|
2(4)
33(69)
10(21)
3(6)
|
NA
|
0
10(67)
3(20)
2(13)
|
NA
|
0
10 (66.7)
3 (20%)
2(13.3)
|
Years of MCH work/leadership (nurses & administrator)
<2
2-4
>5
|
4(13)
20 {673)
6(20)
|
NA
|
1(8)
2(17)
9(95)
|
NA
|
1(10)
7(60)
2(20)
|
NA
|
2(20)
6(60)
2(20)
|
NA
|
6(27)
9(41)
7(32)
|
NA
|
NA
|
NA
|
NA
|
2(20)
4(40)
4(40)
|
2(20)
4(40)
4(40)
|
Findings From the Community-Driven Discovery Inquiry
The findings of community-driven inquiry have been published elsewhere [38]. In summary, the factors shaping nurse-client relationships were heuristically categorized into nurse, client, and health system factors. The contributors to poor nurse-client relationships on the part of a nurse included poor reception and hospitality, not expressing care and concern, poor communication and negative attitudes, poor quality of services, job dissatisfaction and unstable mental health. The contributors to poor nurse-client relationships on the part of the clients included being ‘much known’, late attendance, nonadherence to procedures and instructions, negative attitudes, poor communication, inadequate education and awareness, poverty, dissatisfaction with care, faith in traditional healers and unstable mental health. The contributors to poor nurse-client relationships on the part of the healthcare system and healthcare facilities were inadequate resources, poor management practices, inadequate policy implementation and the absence of an independent department or agency for gathering and managing complaints. These findings formed the basis for subsequent HCD steps, that is co-design meetings.
Findings From Consultative Co-Design Meetings
The synthesis meeting formed the first series of co-design meetings. Community-driven inquiry findings were presented, and participants examined the findings considering personal insights, experiences, and questions to generate a deeper understanding of the challenges of nurse-client relationships in Shinyanga. The results of the synthesis meeting indicated a broad consensus on the contributors of poor nurse-client relationships with some refinement and addition of the contributors. For instance, the ineffectiveness of suggestion boxes was highlighted by fears of retaliation among clients, the unfriendliness of suggestion boxes and the lack of feedback on how complaints were handed among the additions.
The ideation meeting involved group discussion to brainstorm and generate “how might we” questions. This facilitated the development of 82 ideas for potential solutions. These ideas were then reorganized by the research team into 24 broad categories each with several activities considering conceptual convergence and similarities between them (Table 2). A prototype and co-creation meeting brought together participants in three groups to evaluate the ideas generated during the ideation meeting and the emerging categories considering pros, cons, and feasibility as well as elements crucial to its testing (features, modality, responsible person, etc.). Through consensus building, participants in each group rated the 24 categories (and their related activities) considering feasibility (0-10scores) and acceptability (0-10scores) among nurses and clients. The total scores ranged from 58 for disciplinary measures for abusive nurses and clients (highest), followed by 56 for awards and recognition for nurses, 52 for strengthening complaints mechanisms, 49.5 for improving nursing school curriculum, 49.5 for ensuring availability of resources, 49 developing nursing leaders and 48 for promotion of patient-centred care to 32.5 for ensuring availability of mental health services and support for nurses and clients (Lowest) (Table 2). The meeting resolved to consider the seven interventions with the highest scores as part of the ‘rough prototype model’ that was then subjected to the next HCD step.
Table 2: Rating of 24 interventions that emerged from the ideation meeting.
|
PROPOSED INTERVENTION
|
PROPOSED ACTIVITIES
|
RATING
|
ACCEPTABILITY
|
FEASIBILITY
|
TOTAL
SCORE
|
|
|
|
GROUP 1
|
GROUP 2
|
GROUP 3
|
GROUP 1
|
GROUP 2
|
GROUP 3
|
|
1
|
Disciplinary measures for nurses and clients
|
• Simple disciplinary measures for bad nurses
• Community to create bylaws for clients who abuse nurses
|
10
|
10
|
10
|
10
|
8
|
10
|
58
|
2
|
Awards and recognition for good nurses
|
• Establishment of awards for nurses (monthly/yearly) at the level of facility, district, and region
• Giving letters of congratulations and posting good nurses on hospital notice boards or recognizing them in formal meetings
|
9
|
10
|
10
|
7
|
10
|
10
|
56
|
3
|
Improving complaints mechanisms
|
• Having a separate entity for gathering handling and communicating complaints
• Improving suggestion boxes by educating clients on how to complain, strengthening privacy and feedback to clients.
• Conducting Exit interviews with clients before they leave the facility.
• Having a performance evaluation desk for nurses
|
10
|
10
|
10
|
8
|
8
|
6
|
52
|
4
|
Improving nursing curriculum
|
• Increasing the number of hours and credits on the communication skills course.
• Adding customer care courses to the nursing curriculum
• Improving practical learning environment for nurses to practice ways of improving relationships with clients
|
10
|
10
|
10
|
8
|
2.5
|
9
|
49.5
|
5
|
Improving the availability of resources
|
• Improving procurement process for medications out of stock at MSD
• Increasing availability of medicine and medical equipment
• Improving healthcare infrastructure
• Engaging stakeholders in the availability of resources
• Designing internal income generation activities without burdening the clients
|
9
|
10
|
10
|
8
|
5
|
7.5
|
49.5
|
6
|
Improving the efficiency of nursing leaders
|
• Encouraging leaders to adhere to leadership ethics.
• Conducting regular mentorship to leaders
• Training on good leadership
• Punishment for leaders with many complaints
|
8
|
10
|
10
|
6
|
6
|
9
|
49
|
7
|
Improving patient/Client-Centred Care
|
• Emphasis on clients’ rights e.g., the right to choose providers.
• Offering information to clients on deficits at the facility
• Avoidance of discrimination during care provision
• Encourage clients to speak freely.
• Engaging clients in treatment decisions
• Informing clients in advance on the process of care (steps to go through to receive care)
• Continuous client education on the care they deserve from nurses
|
8
|
8.5
|
9
|
7
|
7
|
8.5
|
48
|
8
|
Improving health service delivery
|
• Using professional meetings to remind nurses of the need to adhere to ethics.
• Encourage equality in nursing care.
• Establishment of service packages for different income groups without conflicting quality
• Training nurses on different aspects of nursing care
|
9
|
10
|
8
|
8
|
7
|
6
|
48
|
9
|
Improving and dissemination of service delivery guidelines
|
• Improving existing service guidelines
• Ensuring that service guidelines are disseminated to all nurses
|
8
|
10
|
10
|
5
|
5
|
9
|
47
|
10
|
Improving the implementation of the National Health Policy
|
• Ensuring the availability of resources as promised in the national health policy.
• Strengthening cost recovery mechanisms for groups who receive free care.
• Improving the effectiveness of health facility governance committees
• Developing and dissemination of clients’ service charters
|
8
|
10
|
9.5
|
5
|
4
|
9
|
45.5
|
11
|
Improving workplace policy and procedures
|
• Improving work policy and procedures
• Improving shift arrangements by putting good and bad nurses on a similar shift for co-learning
• Rotating nurses in different departments
|
7
|
10
|
8.5
|
6
|
5
|
8.5
|
45
|
12
|
Community sensitization
|
• Educating community on early healthcare seeking, early clinic attendance, healthcare service delivery process and the importance of and responsibilities of nurses
• Continued community education through media outlets (TV & Radio), community meetings, and health education sessions at the clinic CHWs.
• Establishing social welfare and community education department at the facility
• Establishing a system for monitoring and controlling of the correctness of health-related social media content
|
8
|
10
|
7
|
8
|
5
|
7
|
45
|
13
|
Continued professional development for nurses
|
• Establishing orientation packages and orienting new employees on customer care.
• Using formal meetings for reminding nurses about nursing ethics
• Mentorship for less experienced by experienced nurses
• Putting less experienced nurses on a similar shift with experienced nurses
• Frequent training on customer care skills, Nursing delivery process, clients’ rights, use of electronic health information systems and mental health (online or face-to-face)
|
7
|
10
|
10
|
5
|
4
|
9
|
45
|
14
|
Improving nursing workforce
|
• Hiring more new nurses
• Use of nursing volunteers
|
5
|
10
|
10
|
5
|
5
|
9.5
|
44.5
|
15
|
Team building activities for nurses
|
• Design and implement team-building activities that bring together nurses from within and outside facilities.
• Training on team-building skills
• Team building trips within and outside the facility, district, region, and country
|
8
|
10
|
10
|
4
|
3
|
9
|
44
|
16
|
More research on provider-client relationships
|
• Stakeholders to conduct more research on effective strategies for improving provider-client relationships
|
5
|
10
|
10
|
2
|
10
|
6.5
|
43.5
|
17
|
Use of religious leaders
|
• Inviting religious leaders to train nurses on ethics and loving care
|
2
|
10
|
10
|
1
|
10
|
10
|
43
|
18
|
Dialogue between facilities and communities
|
• Engage health facility committees in coordinating dialogues between facilities and community members.
• Using community meetings to educate communities on the healthcare delivery process
|
5
|
10
|
10
|
5
|
8
|
4.5
|
42.5
|
19
|
Improving salaries and Allowances
|
• Salary increments for nurses.
• Improving allowances for nurses
• Timely salary payments
• Establishment of low-interest loans for nurses
|
5
|
10
|
10
|
5
|
3
|
9.5
|
42.5
|
20
|
The motivation of secondary school students to join the nursing cadre
|
• Nursing boards/associations to sensitize and encourage secondary school students to join a nursing cadre
• Establish nursing carrier guidance in secondary schools.
• Improving enrollment procedures to identify students who are self-motivated to become nurses
|
7
|
10
|
9
|
6
|
2
|
8
|
42
|
21
|
Reducing politicization of nursing cadre
|
• Encouraging political leaders to avoid interfering with nursing and healthcare service delivery by creating false expectations for clients.
• Educating clients and community members on the reality of healthcare services (to avoid being swayed by politicians)
|
5
|
10
|
10
|
5
|
3
|
8.5
|
41.5
|
22
|
Improving the effectiveness of nursing profession Boards
|
• Nursing professional boards to promote their work to nurses (visiting nurses in their facilities or media outlets)
• Nursing boards to organize frequent seminars and forums at the district, regional and national levels.
• Nursing Boards to approve customer care and communication skills as CPD courses for nurses.
• Nursing Boards to train nurses in customer care and communication skills
|
6
|
10
|
10
|
5
|
2
|
8
|
41
|
23
|
Improving client’s healthcare purchasing power
|
• Roll of universal healthcare insurance
• Encourage engagement in income-generating activities.
• Training clients on entrepreneurship skills
• Implementing poverty elimination strategies
• Customer segmentation- establishing service packages based on the client’s income without conflicting service quality
|
8
|
10
|
5
|
8
|
4
|
5.5
|
40.5
|
24
|
Mental health support for nurses and clients
|
• Development and distribution of Information, Education and Communication materials on mental health
• Strengthening the linkage of clients and nurses to mental health support entities
• Establishing mental health support office/ personnel at least at the health centres and hospital level
• Posting telephone numbers of mental health personnel/entities on hospital noticeboards
• Training nurses on mental health skills
|
1
|
10
|
8
|
1
|
8
|
4.5
|
32.5
|
Findings From the Validation/Insight Gathering Inquiry
The insights gathered through FGDs with nurses and clients who were not involved in the initial HCD steps indicated a broad consensus that the seven interventions are more likely to improve nurse-client relationships. A range of benefits and disadvantages of these interventions were cited. Of note, the benefits of these interventions cited by participants of validation inquiry are largely similar to those cited by participants of community-driven inquiry. The disadvantages of these interventions included fears among some participants that disciplinary measures will reduce work morale among nurses because poor relationships are often rooted in many health system challenges faced by nurses. Relatedly, a few participants suggested that community bylaws for community members will heighten conflicts between nurses and clients. Furthermore, there was a dominant concern that awards and recognitions for nurses are surrounded by favoritism and offered to high-level nurses who are not directly engaged in the provision of MCH care. Likewise, the awards system does not adequately engage nurses and clients in setting the award criterion. Consequently, a call was made for departmental-level awards, the use of meetings to recognize the best performers and more engagement of nurses, clients, and direct supervisors in the selection of nurses who deserve awards and recognition. Some of these issues can be seen in the following quote:
The intervention about disciplinary measures to nurses is not attractive to me because we have many challenges…. if you say we start implementing disciplinary measures it will reduce our morale when our challenges are not adequately addressed (Nurse, Health Center)
In general, all the interventions were considered acceptable, however, there were some disagreements on the feasibility of curriculum and resource-related intervention. For instance, restructuring curriculum and resource availability were voted by participants of the validation inquiry to be highly acceptable but they were deemed less feasible in the study contexts because of the time and multistakeholder efforts needed for their successiful implementation. Consequently, the rating of the interventions resulted in the scores portrayed in Figure 1 below.
Findings From the Rough Prototype Refinement Meeting
Refinement meetings resulted in a final prototype including four interventions: (i) patient-centred care; (ii) awards and recognition for good nurses; (iii) improving complaints mechanisms and (iv) simple disciplinary measures for bad nurses (Figure 1).
Documentation and sharing the lessons learnt
Several strategies were employed to document and disseminate the results of this interventional study. First, institutional meetings, journal clubs and networks were used to share the research findings. Second, the final report will be shared with district and regional medical officers, nursing and midwifery councils, the Ministry of Health, and the National Institute for Medical Research for dissemination through government channels. This will ensure that the proposed interventions contribute to practice, policy, and strategic plan discussions at the local and national levels. Third and final, the protocol and results of community-driven inquiry have been published elsewhere [33,38]. The findings will also be disseminated through international and local conferences.