The data collection process was used to answer the aim of the research study which was to analyse nurses’ perception related to the quality of the neonatal continuum of care, using the Donabedian model as a conceptual framework. Before the presentation of results, a demographic overview of participants is given, as shown in Table 3.
Table 3
Distribution of the interview participants demographic data
Participant No. | Age range | Healthcare Facility | Specialization in Nursing | Number of years working in the unit |
1 | 20–29 | H | N | 1 |
2 | 30–39 | H | N | 2 |
3 | 50–59 | CHC | CCN | 16 |
4 | 30–39 | H | N | 4 |
5 | 40–49 | CHC | PHC | 11 |
6 | 40–49 | H | PHC | 7 |
7 | 50–59 | CHC | M&N | 18 |
8 | 30–39 | H | CCN | 7 |
9 | 40–49 | CHC | M&N | 14 |
10 | 40–49 | H | CCN | 11 |
11 | 40–49 | CHC | N | 14 |
12 | 50–59 | H | M&N | 16 |
13 | 30–39 | H | CCN | 7 |
14 | 30–39 | H | M&N | 5 |
15 | 40–49 | H | CCN | 6 |
16 | 50–59 | CHC | PHC | 17 |
17 | 30–39 | H | M&N | 11 |
18 | 40–49 | CHC | PHC | 13 |
19 | 40–49 | H | CCN | 14 |
20 | 50–59 | H | M&N | 16 |
21 | 50–59 | CHC | PHC | 14 |
As indicated in Table 3, five participants were males, and the majority were females. The majority of participants (n = 8) were aged between 40 and 49 years of age while the majority (n = 7) worked between 11 and 15 years with neonates.
Donabedian’s quality of care framework was applied to categorise themes and subthemes which were generated from nurses’ interviews which were to analyse nurses’ perception related to the quality of the neonatal continuum of care as shown in Table 4.
Table 4
Summary of participant responses by category, theme and subtheme
Category | Theme |
Structure | - Human resources - Prolong waiting time - Resources |
Process | - Technical quality - Interpersonal development - Nurse-parent relationship |
Nurses’ perceptions of quality within the neonatal continuum of care: A qualitative approach using Donabedian’s Conceptual Framework |
Structure Factors
Structure refers to the conditions under which care is provided and included factors that affect the context in which care is delivered and includes infrastructure, equipment and human resources (Donabedian, 2005). The three themes that were identified in the structure category included human resources and infrastructure.
Human Resources
Human resources referred to the adequate availability of staff and waiting time. The researcher observed that in both research settings, there was a shortage of nursing staff. Nurses continuously mentioned the shortage of staff in their respective departments, and that the staff to patient ratios are essential for quality care, but that this is not possible due to the considerable patient demand.
“We do not have time to always give the care needed as all the patients need to be seen and if we are short of staff, especially night-duty, we have just to make sure the job is done so we do not have time to give quality care that is needed” (Participant 8).
Participants in this study felt that they were not providing quality care due to the large number of patients they have to attend to. The nurses affirmed that they do not have enough time to render the care they desire to due to the shortage of staff and this affects the quality of care they render.
Prolonged waiting time
Prolong waiting time was directly proportional to the availability of beds in the hospital, shortage of staff in the clinics and time it takes for the ambulance to fetch the patient.
“We have to make space in the unit to accommodate the patient even if it means the place is overcrowded, which places them at risk of maybe getting a hospital-acquired infection. These things all affect quality but we cannot do anything because we must do what is expected of us. I feel as if justice is not being done to the patients in terms of quality care as we are not only short of staff and equipment but we have to rush through seeing the patients in order to get the job done” (Participant 5 and 9).
While most participants were aware about the long waiting period that patients have to endure due to the limited availability of beds, shortage of staff or even waiting for an ambulance to fetch the patient, they were worried that the prolonged waiting time can increase a patient’s morbidity and mortality. Patients who are critically ill, are referred to the referral hospital within the district.
Resources
The resources referred to infrastructure, equipment and supplies. Patients had to be admitted as treatment could not be refused despite the lack of and availability of beds.
“We cannot refuse care these days by saying we do not have beds. We must make a plan even if it means there is no space available or even a shortage of staff. This ward only takes twenty-four patients, but the other day, we had thirty-six babies, and we were still short of staff” (Participant 2).
“Here you just have to make a plan. You cannot say you were short of equipment so you couldn’t do the task it requires. You are responsible……….We lack equipment. This is a serious problem.......The monitors we need are the monitors that we do not have. Equipment is never enough and looks like management isn’t always doing enough” (Participant 4).
While participants were faced with challenges of limited bed space and the lack of supplies and equipment, they strived to complete the given tasks. However, they were aware that this deficiency had an impact on the quality of care they were able to render to the patient.
Process Factors
Process looks at the way systems and processes work to deliver the desired outcome. The three major themes that emerged in this category were technical processes, interpersonal development and nurse-patient relationship.
Technical quality referred to the adherence of following guidelines and procedures according to the nursing process. This will include the assessment, diagnosis, planning, implementation and evaluation of care.
“there is always a shortage of staff and we cannot always delegate tasks as needed. This results in patients waiting for long periods and also a low nurse to patient ratio” (Participant 6).
“We are so busy trying to get the task done so we can complete the next task that we do not always have time to provide the psychological care the mom requires” (Participant 8).
The researcher observed that alarms are often ignored and vital signs on monitors are not set according to required limits. It would appear that the nurses have become desensitised to the sound of the alarm. The researcher also noticed that some healthcare professionals do not adhere to the universal principles of infection control and this was evident by nosocomial infections some patients acquired while in hospital.
Interpersonal development. Within the Community Health Centre nurses indicated that they were given support for attending professional development courses and pursuing higher education,
“Despite the shortage of staff at times, we are given an opportunity to attend workshops and seminars so we can be up to date with what is currently happening and changes introduced” (Participant 7).
However, in the hospital, staff were not always given an opportunity to commit to doing a specialised course as this will result in a shortage of staff for a year or two.
“I really want to do the critical childcare course, but I cannot because it means I have to be out of work for a year and not get paid, there is a need for nurses who are specialised in neonatal and child care. Here we mainly have critical care nurse and those specialised in Midwifery and Neonatology”.
Nurse-parent relationship. This was seen as an essential concept in ensuring quality. The nurses also stated that they feel there is a lack of continuity especially between the hospital and the community health centre,
“Continuity of care is important but here we see the patient once and there are not always follow-ups between the hospital and the community health centre. You do not even know if the patient is alive or their health has improved. I wish there can be continuity and this will also result in quality care” (Participant 11).
Participants in this study felt that they are doing an injustice to the patient and the family at times by not being able to deliver the quality care and even spending time to assess the psychological well-being of the parent, as this has an impact on the care of the child after discharge or a follow-up appointment. They also felt dissatisfied with to having an opportunity to specialise which was mainly related to the shortage of staff and for management to ensure a “full staff composition”.