The demographic characteristics of healthcare providers are provided in Table 1 below:
Table 1
Characteristics of healthcare providers who participated in the study (n = 20)
|
Demographic characteristics
|
Number
|
(%)
|
|---|
|
Age
|
|---|
|
20–30
30–39
> 40
|
8
10
2
|
40
50
20
|
|
Staff cadre
|
|
Manager
Doctor/Physician Assistant
IPC Coordinator
Nurse/Midwife
Other (Cleaner, Health Assistant)
|
2
5
2
7
4
|
10
25
10
35
20
|
|
Years in current position
|
|
0–5
6–10
> 10
|
10
8
2
|
50
40
10
|
|
Location/Service level
|
|
Tertiary (TH)
Regional (SH)
|
10
10
|
50
50
|
|
Gender
|
|
Male
Female
|
8
12
|
40
60
|
The demographic characteristics of postnatal mothers are described in Table 2.
Table 2
Characteristics of patients and postnatal mothers who participated in the FGD (n = 44)
|
Demographic characteristics
|
Number
|
(%)
|
|---|
|
Age
|
|---|
|
15–19
20–29
30–39
40–49
|
4
22
14
4
|
9
50
32
9
|
|
Marital Status
|
|
Single/Other
Married
|
14
30
|
32
68
|
|
Education
|
|
None
Primary
Secondary
Tertiary
Postgraduate
|
6
18
12
6
2
|
14
41
27
14
4
|
In the paragraphs that follow, we present a thematic analysis of findings.
The Hospital Context: Roles and professional identity of healthcare professionals
Both hospitals have a medical director who is the head of the hospital management team. The core hospital management team comprises the administrator, accountant, pharmacist, and director of nursing services. The roles of the management team include planning, organizing, coordinating, budgeting, innovation, representing the organization, etc.
There are several clinical departments in each hospital with a medical doctor as the Head of Department (HOD). Doctors identify as powerful and perceive themselves to be in charge in relation to other staff groups. Doctors delegated authority to other team members based on the workload and team dynamics, and as they deemed appropriate.
In the maternity departments of the hospitals where this study was conducted, there were several wards, and each ward has a ward manager (senior nurse) or ‘Matron-in-charge’, who oversees day-to-day administration on the ward and is directly responsible for supervising nurses and supporting frontline health workers in the wards. Medical and nursing students are often found on the wards for short rotations or internships. Healthcare assistants (with some basic training in nursing care) and “orderlies” (cleaners) perform various roles on the wards.
Facilitators and barriers of IPC.
We identified four themes denoting IPC facilitators, including Leadership commitment and support, Perception of IPC as a form of professional care for patients, Training and education for IPC, and IPC as a form of Self-care. Five thematic areas represent IPC barriers, comprising, the ‘invisibility’ of HAIs, low prioritization of IPC by managers, Lack of goals and sufficient activities for IPC care, discretionary use of protocols (use of ‘mindlines’ vs guidelines), and communication-related challenges.
Leadership commitment and support towards infection prevention and control
Healthcare providers described their commitment and that of the hospital management teams to improve IPC on the wards. On the maternity wards in both hospitals, there were posters of clinical protocols, guidelines for emergencies, and pictures portraying the importance of hand hygiene, demonstrating steps in hand washing with soap and water or with the alcohol hand rub, etc.
Aside the management team, there were other operational teams in the hospitals to whom various tasks were assigned. Some actions by management were identified to be supportive of IPC. These included the formation of IPC committees in TH and Quality Assurance committees in SH to identify gaps in IPC and provide support to improve IPC and the delivery of quality care.
In TH, IPC focal persons, also known as IPC champions, were appointed among the healthcare providers as local ambassadors for IPC. Part of their responsibility was to drive the implementation of IPC protocols on the wards. In SH the Quality Assurance team is responsible for overseeing quality of care standards in the hospital. This team was headed by a Senior nurse who is also in charge of IPC. She mentioned that she was responsible for coordinating IPC activities and conceptualizing innovative ways to improve IPC on the wards.
On the various clinical teams, doctors and nurses discussed the shared value of safe practice and quality care and emphasized the importance of teamwork. Administrative tasks were often associated with status, and nurses were careful to dedicate time during their shifts to ‘handing over’ and ‘taking up’. One midwife stated:
Ok, when we come in the morning… you take up from the previous shift. After taking up, you go through the ward to give medications. Then, maybe, we share our roles in the various suites …(IDI-1F, Midwife, SH)
Another nurse stated the following:
… after taking up, we pack our delivery instruments for sterilization… then we go to the laundry for bedsheets, delivery towels, and theatre gowns. Then, after that, if anyone is in labour, you monitor. Here, what we normally do is we share the duties among ourselves so when this person is doing this, the other one is doing that.
Nursing staff took care of ward logistics and administrative issues such as documentation of admission or discharge of patients and attending meetings. Some nurses disclosed that doing this right signifies the power or authority of the matron-in-charge and reflects responsibility toward her role. According to a Matron-in-charge:
I have to schedule the work for everyone to work. We have six suites, so I put one midwife in each suite, and if I have rotation midwives or nurses, I add them up…then I send someone to the theatre as well to receive the babies there. Then, the rest … we have to do admission and discharges as well. …If there is any difficult delivery, then I have to be called …sometimes I have to call on a doctor to come and intervene. (IDI-3F, Midwife, SH).
Likewise, senior doctors led ward rounds, a process during which doctors and students alike were taught and medical knowledge was flaunted. Core clinical care and management of patient conditions were regarded as essential by healthcare providers. These were prioritized by HPs, possibly due to the organizational priority to improve clinical care and personal motivation to project an image of a competent professional to patients and caregivers.
Nurses engaged in providing care to patients by measuring and recording vital signs, administering medications, and changing wound dressings. They also gave medications to patients and recorded them on the medicine charts, which were a vital tool for ward rounds. Proper documentation was a means to avoid getting into trouble with doctors during ward rounds. Nurses also paid attention to tasks such as setting up the trolley with the right instruments for ward rounds. A nurse said:
You make sure that you have the things that you are going to work with for the day... suction machine... an oxygen flow outlet ready and working... radiant heater working… you make sure that you have empty cots or incubators to receive babies…then syringes, cannulas, gloves… you make sure you stock your cubicle so that you reduce the walking back and forth to the store area to pick things.
A matron-in-charge indicated the importance of setting up a complete nursing trolley to avoid the risk of contamination or infection:
The first thing is you have to do… one… you have to take your tray or set your trolley with your stuff along. If you do, … there wouldn’t be the risk of you getting yourself injured. If you use the cannula and it’s not working, the only thing is that you drop it into the shaft. You wouldn’t risk getting pricked... uh huh. And then if you’ve set all your things and all your things are available… methylated spirit, swab, cannulas… if your items are there… you will use them. But if it is not there, you will be tempted to re-use it … the old one.
Perception of IPC as a form of professional care for patients
Resident doctors, medical officers, and interns stayed behind to manage the wards after the morning rounds. They reviewed patients’ folders and performed any tasks assigned by the consultants during ward rounds and took care of any new admissions and emergencies arising.
Clinical emergencies were attended to promptly. It was indicated that sometimes a doctor could be called while conducting ward rounds to attend an emergency in the theatre.
Cleaners described the importance of their work in ensuring that the ward was clean, so that healthcare providers could do their work without any distractions.
Although healthcare providers admitted that the work of the cleaners was essential and central to maintaining hygiene in the ward, their roles were not highly regarded, partly due to the low level of education of most of the cleaners. Nurses also complained when cleaners were absent from the ward for prolonged periods. This usually happened when the cleaners were sent on other casual errands by some doctors or nurses.
Some healthcare providers mentioned that cleaners were expected to adopt some delegated tasks as part of their duties.
Speaking of a cleaner’s role, a nurse narrated:
If a patient is discharged, you must remove the bedsheet. You have to use chlorine to rinse the soiled part and put it in the linen basket. Then, clean the bed and the locker…But they are like children… you have to tell them… they must know it is their duty.
Education and training for IPC
Management members informed us during the interviews that newly employed staff are taken through an orientation process during which IPC training was also done. Discussions on IPC were sometimes a part of the agenda at monthly unit meetings and weekly ward rounds, where issues related to patient care were discussed and shared to improve the quality of care.
Some nurses described how they implemented knowledge acquired from IPC training and workshops. For example, a nurse described efforts at waste segregation and the use of safety boxes on the wards:
Like our safety box here, we have each in every suite and we discard the needles appropriately. In addition, then we also separate our waste bins. We have bins for infectious waste and general waste yeah. (IDI-2F, Midwife, SH).
From our observations, however, waste was often not segregated as described. Whereas health providers talked about the use of color-coded bins, we observed the nonuse of color codes several times on the wards.
Patient education, patient orientation, and patient counseling during antenatal care (ANC) visits were said to improve quality of care and attitudes towards hygiene practices. We found that these avenues also enabled healthcare providers to interact with mothers and empower them to make informed decisions about their health and the care of their babies after childbirth.
Some of the women we interviewed had been referred from other hospitals for further treatment at TH or SH. Although they attended antenatal clinics (ANC) at other hospitals, there were similarities in the information they received from ANC education at the various hospitals. A mother stated:
I learned about nutrition and how to protect myself from illnesses. When you’re pregnant, there are a lot of factors to consider so you have to watch over what you eat (AC1).
Most of the women shared that they gained knowledge through engagement with nurses during their hospital visits.
When asked what they understood by the term puerperal infection, some women explained:
"It is extensive bleeding after birth." (AC 4)
"It is a sickness you get when you deliver or when you are operated on and maybe you did not treat it well. The diseases that will enter later on will give you problems … (AC 7)
A participant shared an experience where she felt her wound was exposed to water, causing an infection. She described that “the wound started smelling, and some water too started coming out from there”. She also described that she ‘felt weak’ and ‘experienced chills’.
Women further described some symptoms associated with puerperal infections, such as feeling unwell, increased temperature, bleeding, headaches, and loss of appetite.
Self-care and protection from infections
Healthcare providers mentioned contact with dirt as a key driver in behaviour conducted to reduce the risk of infection. Where patients were perceived to be not clean, healthcare providers discussed the risks of infection if relevant precautions were not followed in their care.
A nurse narrated:
For the patient, I think that for some of them, when they are in labor, they don’t even take their bath until they come here so their skin is dirty. To set IV (intravenous) lines on them, we do alcohol swabbing, but sometimes you are in a hurry, and you wouldn’t do it very well before you push the needle in. So, I think that one too, infection can occur. (IDI-1F, Midwife, SH).
Another nurse added that when setting IV lines,
You have to wear gloves and clean the skin surface so that you are assured that you and the patient are protected. (IDI-5F, Midwife, SH).
During ward rounds, healthcare providers would ensure the use of gloves if a patient had a wound that was considered infected. Sometimes multiple gloves were used, and the hands were washed thoroughly with soap and water after handling such wounds.
Another nurse indicated that whereas nurses would usually put on gloves to discard body fluids, patients sometimes ask their relatives to go and discard their urine for them ‘without gloves’.
A nurse expressed concern about patients’ relatives and their risk of exposure to infections:
And the relatives who stay around… sometimes you see some of them sleeping on the floor. They are even exposed more than the patients (IDI-6F, Nurse, SH).
Some healthcare providers mentioned that they felt vulnerable to acquiring HAIs from patients and mentioned that some of their other colleagues had previously acquired infections because of providing care to patients.
A nurse narrated:
Sometimes after delivery, if the client has a tear, you have to suture… and maybe the person has STDS, and you can get it through blood contact (IDI-6F, Nurse, SH).
Another nurse indicated that exposure to blood and body fluids during the clamping and cutting of the baby’s cord after delivery exposes one to a risk of infection. Some healthcare providers feared that they might be exposed to infection by touching patients during a clinical examination.
When you are checking contractions, you have to put your hands on the person and monitor for 10 minutes before removing your hands. And also, body fluids… So, if the person has Hepatitis B, you are exposed to that (IDI-6F, Nurse, SH).
Fear of contact with dirt, was a key driver in behaviours conducted to reduce the risk of infection.
Health providers described the different ways in which they react when handling emergencies, and some may sometimes compromise the use of PPE in such cases.
Normally, we wear two gloves when delivering. You use the first one to conduct the delivery then you change it. But sometimes there could be an emergency case after you have already delivered the baby… If the baby is not crying, you have to resuscitate the baby. At times, you even forget to remove the first glove (IDI-6F, Midwife, SH).
Some midwives indicated that they would go ahead and receive an emergency birth even without being adequately gowned or gloved, as it involved saving a newborn or a life. High uncertainty activities were prioritized, suggesting that managing uncertainty is centrally important to nursing.
Healthcare providers also discussed situations where they exercised fewer precautions, or precautions were not taken even when it was indicated, for example, when a patient who was known to the HPs and had become acquainted through several encounters.
A nurse spoke about the need to protect patients who shared ward equipment:
Let’s say that you are using the ECG machine, and on our part, we are not able to clean it after it is used on one patient, then you use it on another patient. If the patient has a contagious infection, it spreads. (IDI-6F, Nurse, SH).
Mothers perceived themselves at risk from some activities of healthcare providers where hygiene protocols are ignored. A woman said:
“If they don’t take the right precaution, such as wearing gloves when putting their hands in your vagina, it can give you infection" (AC 10).
Women explained that keeping wounds clean and changing wound dressings daily was important. Women also considered it important to bathe twice daily.
Some of the women associated infections with unclean washrooms, unclean beds, lack of hand hygiene among healthcare workers, and lack of personal hygiene among mothers. There were concerns about other women who would use the toilets without flushing. A woman mentioned that walking around barefoot can cause an infection. Some women also attributed some infections to spiritual causes.
Barriers To IPC Compliance
IPC barriers comprised the ‘invisibility’ of HAIs, lack of prioritization of IPC by hospital leaders, lack of goals and sufficient activities for IPC care, discretionary use of protocols, and communication-related challenges.
The ‘invisibility’ of HAIs
When asked about HAIs, many of the healthcare providers did not have many examples to share. There were no available documents on HAI on their units that could be referenced. Some of the healthcare providers said they had no ‘experience’ with HAIs on the wards. A matron-in-charge narrated:
For here, I have not seen any, because here they don’t keep long here … the maximum they can spend here is maybe 20 hours … because after delivery, after 6–8 hours, they have to move into the ‘lying-in’ ward. (IDI-3F, Midwife, SH).
Another nurse referred to “the usual ones, usually the cold and stuffs. The typical ones like getting pricks” she added “Some do get pricks; I’ve been a victim before”.
Concerns about needle pricks were mentioned by several health providers.
… but there was one orderly who had a needle prick and was put on medication. That was just some months ago (IDI-3F, Midwife, SH).
A nurse explained the possible risks of getting a needle prick if one does not take precautions when setting IV lines and said, “That one is very easy … the patients also have the risk of getting the infection and you have the risk of getting the prick”.
Low Prioritization of IPC-related tasks
Prioritization of tasks was driven by how much attention was given to the task by the more senior health providers, including the HOD and the matron in charge. Senior nurses delegated some nursing procedures, such as wound dressing, and activities, such as cleaning, to junior nurses, students, or healthcare assistants. Likewise, senior doctors delegated tasks to junior ranks during ward rounds. Delegation of tasks meant staff also decided what would be prioritized, what would be done urgently, and what would be passed on or left for later.
Some tasks were delegated to health assistants or students. These student nurses were expected to know the rationale behind these tasks and have the competency to carry out these tasks or ask for help if needed. However, observations revealed that this was not always the case. Junior nurses commonly described how they had to learn and find things out by themselves. In doing so, they mentioned that they sometimes made mistakes.
A final-year student nurse on her first day on the job narrated:
There were seven of us from our school—three of us came on night duty—when we got here, they asked us to go and clean the NICU—and then they will orient us afterward. However, when we finished, nobody oriented us, we just came to the ward and started working. So sometimes I get very confused when they say ‘go here and get me this’. I am learning and finding out things around here by myself.
In TH, the IPC coordinator indicated that his concerns about IPC are only channeled through to the management level if his immediate superior or boss is equally interested in these concerns.
I’m the focal person for medicine… if I identify something that I think can help and it’s in line with IPC, I have to communicate that to somebody, and that person will have to discuss that at a management meeting, and once I’m not there to articulate and explain what it is, the person’s interest will influence the outcome of this idea.
The matron-in-charge, therefore, exercises power over the other nursing staff to exert influence over IPC decisions, deciding whether to communicate ideas or IPC challenges to the next level, where management has the authority to act on them.
Some IPC champions mentioned that they were not adequately supported to perform their roles. An IPC champion in TH mentioned that his immediate supervisor did not seem to appreciate the importance of IPC and therefore did not give him the scheduled time he needed to perform IPC roles.
Thursdays are for IPC. I move from ward to ward doing assessments. All the structures and strategies we have put in place… are they going by it? Then, I discuss with the ward manager what I have observed and how we can improve it. Basically, that is what I was doing until they stopped giving me Thursdays off… so on Thursday you are on duty and then you can’t leave your patient and be walking around. That has been the greatest challenge.
Cleaners spoke about the need for more equipment and resources to be provided by their managers to enable them to do their work more effectively.
Healthcare providers mentioned that opportunities to practice IPC were affected by resource limitations.
A doctor said:
… for two days, there has been a water issue, but even then, they got water in the barrels so that we can still wash our hands. (MD1)
Another nurse reiterated that the wards have to depend on water fetched into barrels for handwashing when the tap ceases flowing unpredictably.
Lack of goals and sufficient activities for IPC care.
The aesthetic value of cleaning was emphasized by both healthcare providers and cleaners. Otherwise, no clear goals for IPC were mentioned by participants during the interviews. Cleaners often focused on sensory cues and explained that it was important for the ward to also smell nice. To achieve this, one cleaner described the meticulous process of sprinkling extra bleach on the floor and leaving it for a period to remove any unpleasant smell, then carefully adding nice-smelling detergent to a bucket of water used for mopping the corridors.
However, healthcare providers agreed that a clean floor did not necessarily mean there were no germs, as germs could not be seen with the naked eye. Nevertheless, it was important to keep the floors clean and have the ward smell nice.
A nurse said:
The place is cleaned but not to the extent that you can’t get an infection. The place has been cleaned in such a way that you can use it, but you must still protect yourself. (IDI5)
Another midwife added:
They can use dirty water and clean the place. You might think the place is clean, but actually, the water used may be infected by other organisms… but physically you see it to be clean… but not necessarily free from organisms. In our system, we use detergents and disinfectants together so that as we are tackling the infections, we are also tackling the dirt as well.
Cleaners also sometimes used their discretion to decide which duties were “part of their job”, as there seemed to be no clear job description, and no clear set of activities for them to perform.
Some cleaners also ‘disappeared’ from the wards after early morning cleaning to attend to their personal business.
During observations, our attention was drawn to empty alcohol hand-rub dispensers in the unit. It was suggested that a nurse refill the bottles daily. However, it became evident that the cleaners were expected to refill the dispensers and fill in the gaps for tasks to which no one had been assigned. This was not effective without supervision.
A doctor said:
There are a lot of other things to do so around the NICU - a lot of basic things- adding cleaning and refilling of containers will be additional work.
Mindlines versus Guidelines
Hygiene practices on the ward were sometimes influenced by what one could see and what one could smell- or what was subject to be inspected or noticed. In preparation for ward rounds, nurses ensured that the ward and working spaces were looking clean and smelling good. Although this was done on most mornings, extra attention was given to this process on the morning of major ward rounds. They considered this as important, as the matrons could also come round for inspection in preparation for major ward rounds, which were held on specific days, once or twice a week. Prescheduled tasks were likely to be performed by nurses or delegated under close supervision. Nurses felt that preparing ahead for these tasks allowed them to be better prepared to be of service and respond to requests for information.
We engaged some of the staff in discussions about the use of protocols and IPC guidelines in their line of work. Some of them indicated that this was not often prioritized.
Sometimes I read … and you know… because of the busy schedule of the ward, sometimes when you come, you have to take up so that the previous people can go home and go and rest. However, sometimes when I am free, sometimes I take them and read (IDI-1F, Midwife, SH).
A matron-in-charge, when asked about the antibiotic policy of the hospital, answered:
It is something that is taught in school; it’s not like the hospital should get a policy for you… For any medication, you have to know the patient you are giving it to, whether the drug is expired, and the strength you are giving. Everything is being taught already; it is part of your midwifery or your nursing training. You don’t have to get a hospital policy before you follow that. (IDI-3F, Midwife, SH).
The cleaners described a way of cleaning, where they defined ‘high-risk’ spaces from ‘low-risk’ spaces. They would, for example, clean the matron’s office with a different mop from what would be used to clean the patients’ bathroom. This was an attempt to follow what was described in the National IPC policy document, which had been modified to suit the discretion of those in charge of the cleaning.
In TH, staff would strictly use the washrooms designated for staff, which were padlocked and the key only accessible to staff. They would typically not visit the patients’ washrooms.
Describing the patients’ washroom, a staff member said:
I won’t say very clean… but it’s clean, because there are different people who come here with different attitudes … and then some people also come and they don’t even know that after using the WC, they have to flush. So … some will even urinate in the bathroom…
Yes, because somebody will go, clean the place or use the place in a nice way but the other person will go and mess up the place for everybody else.” (IDI-1F, Midwife, SH)
In SH, a nurse who happened to visit the patients’ washroom narrated:
It’s clean because the last time when I came, I wanted to visit our urinal, but it was locked, and I had to urinate there. When I went it was okay.
During observations in SH, the bathroom and washroom area often had a clean look and fragrant smell. The matron-in-charge attributed it to regular cleaning by the cleaning company to which the cleaning had been outsourced.
Communication-related challenges.
Women mentioned the importance of good communication with health providers in preventing or managing infection.
A woman narrated:
They removed my plaster 5 days after the operation and they didn’t tell me how to treat the wound…So yesterday one nurse came to ask if they have cleaned my wound, and I told her it’s been 3 days since they cleaned it…She told me to lie down for her to dress it for me, and she said I have gotten an infection in my wound… so I got scared, but she didn’t tell me the cause of the infection.
The woman explained how she felt disempowered to make further inquiries about the cause of the infection. Inadequate education and engagement of the patient were observed to be a hindrance to patient empowerment to participate in care.
Some mothers described that they experienced some HPs being critical and confrontational in their engagement with them. Women who encounter disrespectful behavior develop a distrustful relationship with healthcare providers, which tends to hinder communication and collaboration for care delivery.
Women discussed the support of their partners and other relatives, such as mothers, in-laws and grandmothers, in their care and decision-making. Sometimes women were advised to use alternative or herbal treatments rather than what had been prescribed by health providers. A woman described that she uses steam from hot water to help her recover after childbirth:
“I sit on hot water, and if there are any herbal medications, I drink them (AC5)”.
Another woman also mentioned “Dawadawa” as an example of an herb that “helps heal birth injuries”.
A woman described how to prevent herself from contracting infections:
If I am going to use the washroom, I go with my Dettol and everything to ensure I don’t go and pick up any diseases… When I am done, I wash my hands with soap and water neatly (AC 12).