Seven nurses were interviewed; two of these providers were trainers for the critical care training program, while the rest were participants in the program. Three interviewees were male. All participants had had some level of exposure to QI in the past.
Qualitative Interview Analysis
Following analysis of the in-depth interviews (IDI), five themes emerged. These themes address the perceptions and lived experiences of critical care providers faced with limited resources and demonstrate the on-going needs in this setting as well as avenues for success in promoting quality. Participants identified numerous facilitators and barriers to QI, especially in the context of the training they either led or participated in and recognized the role that change management played as part of the process. Many of the major themes had subthemes that aligned across respondents. The themes that emerged are referenced in Table 1 with description. The themes that emerged are the following:
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Positive Impact of QI at the National Hospital
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Human Resources and Support of Leadership Contribute to the Success of QI Efforts
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Barriers that Inhibit the Success of QI and the Critical Care Skills Training Program
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Sustainability of Successful QI Programs is of Utmost Importance
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Change Management Led to Positive Culture Shift and Increased Feeling of Competence
Table 1
Salient Quotes from Major Interview Themes
Themes | Description |
Theme 1: Positive Impact of QI at the National Hospital |
Subtheme 1: QI Cuts Across Multiple Sectors at the National Hospital | The project impacts different and dissimilar departments of the hospital |
Subtheme 2: QI Brings a Culture Shift Across the Institution | Increased focus on the individual patient and their needs |
Theme 2: Human Resources and Support of Leadership Contribute to the Success of QI Efforts |
Subtheme 1: Engagement of Nurses at Different Levels along with Providers to Strengthen the Team Dynamic | Breaking the concept of the hierarchy and instead a willingness to work as a team |
Subtheme 2: Champions to Support QI initiatives and Participant Learning | Certain individuals assuming the role of leaders to encourage QI |
Subtheme 3: Drive to Help Patients | Demonstrated determination to help patients |
Theme 3: Barriers Exist that Inhibit the Success of QI and the Critical Care Skills Training Program |
Subtheme 1: Varied Nursing Education Level | Despite varied levels of nursing education, the team aspect allows for others to be uplifted in their learning |
Subtheme 2: Outside Influences Affect QI | External factors prove to affect the ability for QI programs and initiatives to succeed |
Subtheme 3: Limited Physical and Human Resources | Shortages of nurses and professionals limits the ability for QI programs and initiatives to be successful |
Subtheme 4: Change is Hard | Significant motivation is needed to change perceptions and processes |
Theme 4: Sustainability of Successful QI Programs is of Utmost Importance |
Subtheme 1: Knowledge Dissemination | Expressed desire and recognition of the importance to share knowledge learned with other healthcare workers |
Subtheme 2: Continued Evaluation of Resource Needs and Availability | Many resource constraints persist and demonstrate a need for new approaches |
Subtheme 3: Continuation of Trainings | Recurrent trainings are integral to maintaining skills and learning new concepts |
Theme 5: Change Management Led to Positive Culture Shift and Increased Feeling of Competence |
Subtheme 1: Supportive Team Dynamic | Knowledge and skill is no longer in a silo for each healthcare worker; team members rely on each other to care for patients |
Subtheme 2: Positive Attitude Toward Culture of Change | Recognition of the importance to lead and respond in emergency situations to save patients |
Subtheme 3: Positive Culture Change Towards Environment | Change management dynamics underscore how the environment can impact speed and level of change across the ward. |
Subtheme 4: Positive Attitude Toward Training and Increased Confidence | Increased self-efficacy due to knowledge gained |
Subtheme 5: Increased Usage of Learned Skills Promoting Sustainability | Utilization of skills will enable positive outcomes –from both a prevention and reaction framework |
Theme 1: Positive Impact of QI at the National Hospital
The first theme amongst respondents concerned how they felt about QI and how they experienced it at the Hospital. All the respondents had exposure to QI at the hospital. Respondents highlighted that there has been changes in programming and support since QI has been introduced at the Hospital. The subthemes from this first theme include: QI is an institution-wide initiative and QI brings a culture shift across the institution.
QI Cuts Across Multiple Sectors at the National Hospital
Quality improvement has had an impact at the National Hospital by cutting across all activities and divisions. Despite its relative newness, it has become integrated in many different new initiatives. Respondents indicated that in the past there was a focus on “quantity versus quality” (IDI2), a feeling that quality was only “existing in books” (IDI2) and that it has been a problem. Relative to these feelings of what the hospital was like before the introduction of QI at the Hospital, respondents noted the introduction of QI has been in a systems-wide approach:
“If there is need for training we do it in house” (IDI3)
“If there is something we needed, [the QI team] come[s].” (IDI4)
Nonetheless, participants spoke to the infancy of QI at the hospital:
To me, this was a new program at this block, [block name], it’s a new program. It hasn’t been there before, we keep on training our staff as in-house training here, but we didn't have the big program that like which we have now HDU training (IDI3)
When I started here […]there was no ICU, there was a room! with one ventilator, but now we've got six functional ICUs, which can do hemodynamic monitoring, invasive monitoring, we can do all the advanced procedures. So, to me that's a great success… Yes, so, it's only this past few years that we started to implement the quality project, which, of course changes, you know, people are ready to change, it will take some time. (IDI2)
QI Brings a Culture Shift Across the Institution
QI now exists in many initiatives at the National Hospital, which has shifted how participants view quality at the hospital. Participants addressed that there is an increased emphasis on capacity building due to the QI program, which has promoted further quality. Without the QI program, the Hospital would “keep like stagnant…and not provide quality care, [rather] the opposite of it, we provide poor quality care to our clients” (IDI3). Some demonstrated how focusing on quality has materialized in critical care.
Other participants spoke about having a heightened attention and giving increased value to new aspects due to QI. For instance, the role of QI affecting infectious disease or how to improve the safety of the providers and patients while also mitigating the mortality rate due to infectious disease. Participants also identified the need to set standards and apply them across the hospital and the importance of timely care, demonstrating an increased focus on quality aspects.
“[commitment amongst providers] towards improvement of the health of our people, towards rescuing our patients from death. That's what I'd like to see” (IDI7).
Theme 2: Human Resources and Support of Leadership Contribute to the Success of QI Efforts
While the Hospital is considered a resource-limited setting, respondents identified multiple factors that improve quality and attenuate the path to successful QI. These included engagement of nurses at different levels along with providers to strengthen the team dynamic, having champions to support QI initiatives and participant learning and a drive to help patients.
Engagement of Nurses at Different Levels along with Providers to Strengthen the Team Dynamic
Across the interviews, a subtheme that emerged was how a successful program or ward involves a team of different levels of nurses with varying education levels. Doing so allows for the entire team to work together with involvement from all providers.
“We take time to train our nurses” (IDI3).
Respondents remarked how training is necessary for the success of the program and how it was their responsibility to train those providers who may not have had formal training in a critical care setting. In increasing the level of the group by uplifting the individual, respondents felt that this helped to facilitate delivering better care. Since interviewees felt that they had this responsibility to engage other nurses, some viewed themselves as mentors. At the hospital, participants mentioned a weekly one-hour review amongst nurses following the morning report so that any nurse from any ward could attend “so that we can teach each other” (IDI4).
Champions to Support QI initiatives and Participant Learning
A subtheme identified was that there are certain individuals that can champion the QI initiatives across the hospital, which promotes participant learning. Interviewees reported the ability to both learn from others and to show by example to spark change in others. Since some of the participants held more of a supervisor role and were part of the training team in the Critical Care Skills training program, they felt that they were responsible for promoting QI. Interviewees aligning with individuals who share the vision of quality and using that to promote changes across the institution.
Respondents spoke about the importance of having a support network either within the training or as a broader concept for QI at the hospital. They spoke about the institutional level and how having support can ease the facilitation of programs and help to manage change across the hospital. Participants also underlined a need for a strategic plan to forge a path ahead and ensure the sustainability of quality improvement across the hospital. Participants felt that the trainers were helpful and supportive, and how their instruction clearly identified the standard of care’s dos and don’ts.
“To continue this program is important, so we need to have strategic plan on how to make sure these are quality assurance programs and which will include the training to continue so you have, to have like a move to make changes using the training” (IDI3)
“Change champions [is about] making other people to change from their routine ways of doing things into critical care, because we say this is a specialty with the concepts totally different from the general ward” (IDI2)
Drive to Help Patients
Participants remarked heavily on the importance of education and training amongst providers to deliver quality care. Underlining all of this was a demonstrated drive to care for their patients and the population:
“Taking critically ill patients is [a] very nice experience because, you manage a patient totally, you’ll provide a total care that means…one nurse, one patient” (IDI1)
“We are responsible to make sure things are going as its planned, everything in on place, together with a quality team” (IDI6)
Theme 3: Barriers Exist that Inhibit the Success of QI and the Critical Care Skills Training Program
Participants addressed many difficulties in performing quality care and implementing QI initiatives at the Hospital. Respondents spoke to these issues and the following subthemes were found: nursing education level, outside influences affect QI, limited physical and human resources and change is hard.
Varied Nursing Education Level
Participants identified education in the critical care setting as continuing to be a problem for successful QI. According to interviewees, educating in accordance with protocol can limit risk and the spread of disease. Education can reduce mortality, since the education of the individual lifts the level of the group but that this has been lacking at the hospital, and nurses arrived to the critical care units with markedly varying experiences/education in critical care. Participants focused on how knowledge is at the core of being a nurse and how knowledge makes one effective. Similarly, participants recognized that for those who do not perform well, is not often due to intelligence or capability, but rather, on their previous education that did not provide them with the knowledge to make informed decisions and provide high quality care.
Outside Influences Affect QI
Another major idea expounded upon by participants was how lack of prioritization of QI can hamper its efficacy. Respondents mentioned how prioritization is imperative in low-resource settings; a need to focus on the most pertinent topics. Yet, the providers noted that many times there was a lack of support from higher levels of leadership, which acts as demotivation, and also constrains resources and the ability to reach intended goals.
Limited Physical and Human Resources
There was a noticeable mention of the lack of resources and difficulty in acquiring needed equipment. Participants listed all the equipment necessary for a functioning and quality critical care unit, but that it is not always available due to shortages. This, according to interviewees, affects the quality, since resources are not available or do not arrive on time, such as the scarcity of life-saving medications like adrenaline and inotropes during emergency resuscitations.
“Without those equipment [it] is not easy to implement critical care” (IDI1).
Despite limited equipment, participants highlighted that a shortage of staff would render even a functional ICU incapacitated. For instance, they mentioned the standard operating procedure is to have three patients to one nurse in the HDU, but the reality is “one nurse to take care of seven patients” (IDI1) at times. This contributed to overworking nurses, decreasing the quality of care that is possible, and increases in errors. The same participant noted how shortages affect them personally – that they cannot attend additional trainings because of personnel shortages
Change is Hard
Participants spoke to the process of change, that it is hard and that it being hard can affect QI. Respondents addressed the levels of behavior change and how not every person adapts as readily due to motivation levels. Similarly, with it being difficult to change providers, the issue is the willingness to act or ability to adapt, forcing a slower movement to make sure every provider changes themselves and how they deliver care.
“They'll get the knowledge but…they were not motivated” (IDI2).
Theme 4: Sustainability of Successful QI Programs is of Utmost Importance
While respondents noted that they were happy and proud of their work and of the QI initiatives at the Hospital, there were certainly a number of entities that were identified to be improved upon. The subthemes identified from Theme 4 are as follows: knowledge dissemination, continued evaluation of resource needs and availability and continuation of trainings.
Knowledge Dissemination
Participants advocated for a wider dissemination of knowledge across the hospital. Training stimulated change. Some respondents affirmed that as leaders, they will share the knowledge gained to those not in attendance. Other interviewees spoke to this as well, citing that they would like to see more people trained so that more people have new and updated knowledge. Others asked that training materials be readily available to all.
Continued Evaluation of Resource Needs and Availability
Alongside desiring well-functioning critical care units, participants sought a more robust QI program by facilitating training and improving both support and communication for the QI facilitators. In terms of a more developed program, there was confusion in developing the training project concerning the questions, the communication across the project and the need for the trainers to take on multiple responsibilities and provide their own materials. By having multiple duties, it can inhibit the ability to create a strong program as well as for the trainees to be able to participate. Other suggested improvements to the program included equipment, training of the trainers and exchange of education with other healthcare professionals.
Continuation of Trainings
In order to create a robust program, all participants spoke to the need for continuous trainings to practice concepts learned and introduce new areas that may be currently lacking. Doing so would promote sustainability of change according to participants. The providers also reiterated certain trainings they would like to see, highlighting the use of machines. Respondents spoke about wanting practice sessions with frequency to apply what they learn during training and prevent future loss of knowledge.
Theme 5: Change Management Led to Positive Culture Shift and Increased Feeling of Competence
Provider participants expanded on change management concepts and attitude changes after training in their responses. The respondents that are trainers or supervisors had much to say on how culture plays a role in delivering quality care. The following subthemes were found: supportive team dynamic, positive culture of change in attitude and positive culture change towards resources.
Supportive Team Dynamic
A supportive team dynamic was highlighted as an important mechanism to utilize in the units following the QI initiative and training. Respondents recognized the success of a team dynamic as a result of change management concepts included in the training and how this has changed behavior on the ward These participants discussed their role as change champions. They felt that change is important and played a role in how they perceive QI initiatives. Change champions have the ability, according to participants, to instigate this change, which has improved others’ ability to work in their role.
“The first, change I wanted was to change their mindset. I'm sure the majority, more than half, I managed to do that. Because it all starts in the mind, if you want to change people.” (IDI2)
“You can have an influence from the management but also how to a deal, personality issues, the attitude issues.” (IDI3)
Others discussed how critical care units such as the HDU are different than that of a normal ward and the need to mold new change champions. In doing so, this enforces the idea of change management and uplifting the group.
“In HDU you are doing much more, you're going a step ahead, and there are some of the things that you're supposed to initiate yourself as a nurse. So, when we're teaching them those things, remember the change management, you are going to be change champion. Let's now forget about what you used to be doing. You need now to be doing like this” (IDI2)
Participants also noted that because of this team dynamic, there is more learning occurring and more of a supportive environment in which to learn.
“The ICU nurses, I see the difference… they are willing to start to learn new things. And also when someone is not aware about the same thing, he or she is not ashamed to ask…And they get to learn (IDI5)
“The culture has been changing, because some things which are going wrong, it's some people's attitudes, but the quality improvement team…has been with us all the time” (IDI7)
Positive Attitude Toward Culture of Change
Another shift identified amongst participants was that they felt positively towards needing to change their mentality towards their responsibilities and actions on the ward. Participants highlighted that this was due to change management concepts included in the QI training.
“change management, which I felt is the most, mostimportant of them all, and it was supposed to be taught after the introduction, but I had not heard about the change management, but just from critically thinking, you know, I say no…Why can’t we start with the change management? So that at least our participant[s] are ready for the change management…which was very helpful…in our topics we’re always referring to the change management and everybody loved the topic” (IDI2)
Other participants who received the training discussed how they felt change management training affected them. Participants discussed how important the change management concepts were in empowering them to advocate for their patients and improve their way of practicing.
“So, every nurse has to assume leadership, despite maybe not entitled as a charge but has to assume responsibility. Assume leadership, in an application of the knowledge you have -- then you can [have a] good output in terms of taking care of patients.” (IDI1)
Respondents said that they recognized the gradient of change due to the training and could see how people change at different rates. They felt the impetus to change in order to assist the patient directly and also work alongside others to take care of the patients.
“I have to change, I have to change, I have to change, you know, sometimes you may, uh, we may fail to take care of critically ill patient, or enduring so many issues that they interfere, impair our ability to take over patient.” (IDI1)
“The good thing I noticed that people now are sharped minded…And they are well organized, because every day we remind each other when there is cardiac arrest what should be done or to what nurse should supposed to do, and avoid panicking during compression or during cardiac arrest, stay calm” (IDI5)
Positive Culture Change Towards Environment
Following training and QI initiatives, participants felt that they were better able to utilize resources and work in the critical care environment. They feel that they are now able to perform their responsibilities with better quality in a critical care setting.
“Before the training, when we have the emergency, we see that most of them people their frightened, lashing, they are tense but now not after the training…after training in case of the change management we have very much improvement because now, for example can say that if we are doing CPR before the training all the time during the emergency and resuscitation the doctors would be the team leader of the resuscitation. So, nowadays that even your nurse can be a leader. Because of the, we have seen, we have been told that the training from anyone who is competent, knowledgeable, experienced can be a leader during resuscitation.” (IDI4)
“The patient was on arrest, but I mobilized the, the, the other staffs to identify this patient is on an arrest, so we have to act immediately. So, I lead them, I instruct them on how to do contact with a, doctor on call. We participate on an intubation in NGT session, and the patient was? Improved!” (IDI6)
In creating this culture shift, interviewees felt that the dynamic of how they work has changed, they are more attuned to the setting that they work in and are focused on improving patient outcomes. They feel that they have a more step-wise approach and protocol to treating patients, imbued with how to work in a critical care environment.
“It reminded us not to do work as a daily routine… we saw the dynamics to change according to the environment. I supposed to do this and this, this is my daily routine. No, everything changes” (IDI5)
“How to approach the emergency patient… how to respond in it? So, you have to assess the patients, check the pulse, no response? No response, you have to start CPR or calling for help, while the help arrive you have to lead them. Yeah, because you're the one with the patient, you know what happened. So, you'd have to lead them on what to do (IDI6)
Positive Attitude Toward Training
Participants spoke about prioritizing critical care concepts including VSDT, CPBR, etc. in formulating the training. All trainees had overall positive feedback about the program and that this affects their peers in the ward. They felt that the topics were not too complicated (the material was easy to understand), were helpful and thought change management to be an appropriate part of the training. Respondents felt the training was productive and were glad to have the ability to ask questions.
“No need to wait [for] somebody, ‘I don't know how to do something. We need to wait for somebody’ no, you have to act because you have the knowledge. So, the knowledge we gained from the training is very good. I like it. And I would prefer for all of, all our staffs will get the same, the, the same knowledge as we get there” (IDI6)
“Training has really helped us” (IDI7).
“[The training] was so amazing” (IDI6)
Participants also discussed an increased confidence in responding to emergencies and being in the critical care setting. One interesting finding was how respondents felt about the duration of training. Many mentioned a desire for increased time for the trainings. Amongst the respondents that have acted as trainers, they noticed that the providers they had taught “started enjoying” the work they now did. Other trainers described their perceptions of how QI has affected the trainees to improve the standard to which they are held and increase trainees’ confidence in the ability to meet that standard.
“You see how the group gets training, but they appreciate it, everyone appreciate[s] it. And I as a supervisor, I see it.” (IDI3)
Increased Usage of Learned Skills Promoting Sustainability
Participants learned the differences in skills needed in the critical care setting as compared to the general ward. This has led nurses responding quickly to changes in patient statuses and being able to perform when the situation calls upon it. Interviewees noted that they have seen a change in both themselves and other trainees – that they are practicing what they have learned. Participants noted outcomes in the SICU, with trainees stopping others from practicing incorrect care procedures after the training. Multiple provider respondents delineated that they learned about the importance of brain resuscitation as opposed to just cardiopulmonary resuscitation. Other participants stated that they learned about the importance of timing in resuscitation and being a leader during resuscitation and that now:
“We are going to save a patient” (IDI5)
Others spoke to seeing changes in resuscitation and the knowledge of how to do resuscitations that focus on the brain component specifically. For instance, some did not know how to correctly perform compressions previously but now felt they could use their skills adequately.
“My knowledge about resuscitation has improved from what I was before” (IDI7)
As such, interviewees felt that the training would have an effect on patient outcomes, reducing mortality rate and improving confidence, since they will regularly use the skills they learned.
“If someone is well knowledgeable, you will never hear…someone complaining…after, because he knows what to do. He knows how to prioritize, he knows how to detect change to patients, you see, so he has to take care of patient according to changes” (IDI1)