Out of the 86 participants trained in 2018–2019, 37 were reached and 22 consented and completed the interviews. Many of the interviewees were nurses in varying capacities, including public health nurses, nurse matrons, and nurses-in-charge. We combined the roles medical officers and medical superintendents under the category of physicians. District health managers are also licensed physicians, but they were categorized separately because their leadership roles spanned both clinical and management responsibilities within their districts (Table 1). Seven of the 10 districts in Lesotho were represented. Twenty of the 22 interviewees (90.9%) had initiated a project designed at the PSBH workshop they attended (Table 2). Generally, projects included efforts to improve clinical documentation, reduce patient wait-times, and improve the supply of medications, among others.
Table 1
Description of Interviewees (n = 22)
Role | n ( %) |
District health manager | 5 (22.7%) |
Physicians | 3 (13.6%) |
Pharmacy staff | 3 (13.6%) |
Laboratory staff | 3 (13.6%) |
Nurses | 7 (31.8%) |
PSBH Facilitator | 1 (4.5%) |
District in Lesotho | |
Leribe | 9 (40.9%) |
Mafeteng | 4 (18.2%) |
Mokhotlong | 1 (4.5%) |
Berea | 4 (18.2%) |
Butha Buthe | 1 (4.5%) |
Thaba Tseka | 3 (13.6%) |
Table 2
PSBH Projects Designed by Interview Respondents
1. Helping the hospital attain and maintain hygienic toilets |
2. Conducting supportive supervision in local health centers |
3. Improving documentation and upgraded implementation of laboratory quality management systems and increasing performance |
4. Raising the quality of nursing documentation |
5. To decrease percentage of patients who are waiting for care at the end of day at the general outpatient department |
6. Reducing the number of emergency cesarean sections referred to [hospital name] on weekends and public holidays |
7. Addressing documentation gaps which lead to poor nursing care |
8. Improving service delivery in the pharmacy |
9. Increasing competency in resuscitation among casualty staff |
10. Reducing the percentage of nurses who do not adhere to the use of “Integrated Management of Childhood Illness” guidelines |
11. a) Improving the productivity of District Health Management Team monthly meetings b) Expanding primary care for local miners |
12. Improving upper management’s performance with quality assurance scores |
13. Ensuring adequate drug supply in the casualty department |
14. Decreasing patient wait-times in the outpatient department |
15. Address long-term stock-out of Pentrol 400 (a lab reagent) |
16. Obtaining new and repairing broken lab instruments |
17. Increasing percentage of “Category A Commodities” (pharmaceuticals) that are stocked according to standards |
18. Reducing the percentage of non-compliant prescribing nurses when treating common illnesses |
19. Increasing screening for renal complications |
20. Improving management and quality of care for malnourished children |
The analysis resulted in the identification of four themes. Each key theme is discussed below with quotes from the participants included to exemplify each finding.
Participant perspectives on the impact of PSBH training
Most participants described PSBH as an effective skills-building workshop that shifted the way in which they viewed everyday workplace problems. One participant illustrated this by describing what they took away from the workshop:
“Why is it a problem, what that problem is, and why is that problem your problem? So those are the best things that I took from the training, because if I know all those answers then it helps me to go to the root, the cause, of the problem. It also helps me to shape my outcome, the expected outcome and things that are going to lead me to that expected outcome. Even if those things, [if] I've got them, if they are feasible and if they are doable. If not doable, then I know then I should be looking for things that are doable.” (District Health Manager 1)
When asked about weighing the benefits and time needed to attend a PSBH workshop, participants generally agreed that its impact outweighed the costs and described the real-world, patient-level impact that PSBH projects have had on their healthcare facilities:
“You can see the improvement that has happened, that it wasn't just for the sake of having the workshop. Now [because of the impact of my project] the patients are returning happy, being seen by the doctor. […] They were taking their whole day to come to see the doctor. But now if they can take a few hours, they will still go to do other things afterwards, or they will still go to back to work afterwards.” (Physician 1)
Another participant noted that designing a quality-improvement project using PSBH methodology was beneficial because it provides a data-oriented approach in daily work and has the potential to impact the health of the community while saving costs.
“I think it will be beneficial, yes, because we are encouraging nurses to use their data. If you use your data, you will see the hiccups. So, where we see that we are having the problems with the immunization, they can see how many projects we can do in order to improve that indicator for child survival […] it’s going to benefit the whole country. Economically we are going to be able to save the country so much money, without them [the MOH] coming down to us to try and solve things for us. So, it’s at the local level [that] we try to provide many solutions for ourselves, and not depend on the whole country.” (District Health Manager 2)
Engagement and continued use of PSBH skills
Many trainees learned from carrying out their PSBH projects and practicing PSBH tenets in everyday work. Below are examples contextualizing this statement using data organized in three subtopics according to the conceptual framework: (1) intrinsic motivation, (2) personal participation, and (3) interpersonal participation.
Intrinsic motivation: Participants shared examples of how PSBH helped them to improve the work they do each day, which then motivates to them to continue practicing the problem-solving methods learned from PSBH.
“So, identifying the problem and trying to deal with it, in reality, is not really easy. But the good thing is, should you be able to follow through and be able to follow up to the end, then I’m telling you we are going to celebrate every day. […] I think it [PSBH] can help a lot in helping our service delivery.” (Nurse 1)
Interpersonal participation: Participants stressed the importance of having buy-in from local leaders in their healthcare facility and national health leaders in the MOH for the workshop to have true impact and reach:
“We have to convince the leaders. We need to identify the leaders, people who can actually push it, then we won't have many barriers. It just needs sustainability and ownership (Nurse 1)
Many of the attendees in leadership positions, such as this District Health Manager, commented on how encouraging it was to see the impact of PSBH not only in their work, but also in the work of their coworkers. This participant expressed gaining motivation to continue practicing PSBH from seeing the impact PSBH has on other HCWs:
“For me, I have a great desire [to continue] because I've seen a great impact of [PSBH]. Because even the way that even from our cleaner, from our head of units, from the nurses, from us, everybody, I've actually taught them […] a tactic of saying, "What is the gap? […] What is the cause of this?" So then we turn these 'causes' into to activities. Therefore, with that, we've seen that our planning is very effective, so my desire is to continue doing it because it actually is an effective way of planning.” (District Health Manager 3)
Personal participation: The applicability of the lessons learned from PSBH in their own personal work and everyday activities that mattered to them in their jobs was mentioned by several interviewees. A participant noted that while she had learned problem-solving concepts at the workshop, gaining a fuller understanding of the PSBH method came by practicing the skills through project implementation.
Institutional Impact of PSBH
We found numerous examples of successful participant projects having tangible impact on the function of the hospital or healthcare facility in which they work. For example, this lab manager recounts their success at improving the District laboratory by employing steps learned at their PSBH workshop:
“Yes, it was about implementing QMS (quality management systems) […] The quality starts from where the samples have been taken from the patients up until the results are given back to the patients. We have to monitor all those steps so that other people will see that we have quality results […] We have a tool that we have to use to assess the statistics that was approved by the WHO. So PSBH helps us to achieve our goals to accreditation. Yes, that’s the tool that we used. We really saw the improvement from [using] the tool.” (Lab staff 1)
Another participant recalls an issue they faced with the hospital’s finance department in getting necessary blood pressure machines for the inpatient wards. They explain how the PSBH workshop helped them organize and communicate their problem logically, allowing them to resolve the issue at the local level:
“Before, I would just request, ‘Can I have 1, 2, 3..’ then they’ll just say ‘no, we don’t have.’ You know how finance offices work. When they say they don’t have money, they don’t have money. But after I explained, ‘we are having problems which leads to mismanagement of patients,’ it starts to make some sense now to the Finance Officer […] I had to justify the end strategy. I got the blood pressure machines that I wanted.” (Nurse 3)
Facilitators and Barriers to Dissemination of PSBH
A major facilitator was proactive leadership, such as this participant who implemented informal downstream training of PSBH principles to local clinic nurses:
“They [PSBH lessons] help me a lot because when we are doing our supportive supervision and mentorship, we encourage nurses, if we have problems in their facilities, they can make a three-month to six-month quality improvement project on their own to help improve their indicators in the health centers.” (District Health Manager 4)
Participants who are leaders in their departments stated that their own practice of the PSBH methodology created a ripple effect of new quality improvement projects in their facility. This occurred via an informal process of step-down training and knowledge-sharing from the PSBH workshop participants to other HCWs in the same workplace.
“I did step-down training in the clinic. Now even the cleaners must do a project to improve quality of their work. At the time of their training, they were very motivated […] My junior staff, they no longer ask me to solve problems for them. They now are committed to solving the problems on their own. They suggest steps to solve their own problems.” (Nurse 2)
Another critical facilitator was the generalizability of the workshop, seen by participants who felt that every healthcare worker could benefit from learning the practical lessons that PSBH teaches:
“I think everyone could benefit, everyone. It wasn’t specific for medical officers. It was general, everyone would benefit.” (Nurse 4)
When asked about any foreseeable barriers to the further dissemination of the PSBH workshops across their District and Lesotho, participants mentioned the stresses experienced by the limited number of skilled HCWs. Specially, the same, small number of healthcare professionals often receive specialized workshops and trainings from both the MOH and other NGOs, to the point where they find less time to do their primary clinical and leadership duties. Also mentioned were the lack of resources (money, time, and staff) that make it difficult for existing HCWs to also take on the responsibility of training others to further disseminate the PSBH method:
“The challenge is that we are short-staffed […] I think with these new nurses, I will do it. Because now I will know that I have certain number of nurses in the male ward, and permanently, certain number of nurses in female ward, and other wards. So, when they get the training, on [how to provide better] patient care, I think it would be perfect.” (Nurse 5)