Background
Monitoring the surgical patient’s vital signs can allow for early recognition of surgical or anesthetic complications, which in turn, can lead to timely intervention. Oxygen saturation measured via a pulse oximeter is recognized as a key vital sign to monitor in order to detect hypoxemia earlier than clinical signs alone. Such monitoring is important to reduce perioperative morbidity and mortality. The first commercial pulse oximeter was introduced in the late-1970s and over the next two decades was incorporated into clinical care. One of the initial widespread uses was in anesthesia, where, in 1986, it was included in mandatory monitoring standards recommended by leaders in the field. [
1,
2] Just a few years later in the late 1980s pulse oximetry had expanded to settings beyond the operating room and were recognized as a key monitoring device for early detection of hypoxemia. [
3] Now, pulse oximetry is a mainstay of patient care and measuring oxygen saturation during vital signs assessment in high-income countries (HICs) is routine.
Although its importance in patient monitoring has been identified, many low- and middle-income countries (LMICs) still lack adequate access to pulse oximeters. [
4] Efforts to change this have been initiated by increased dedication to equitable access to safe surgical care. WHO published the Guidelines on Safe Surgery in 2009, providing the first report to identify key aspects of safe surgical care. The Guideline recommends the use of pulse oximetry monitoring during surgery in LMICs as a means to detect hypoxemia and prevent airway and respiratory complications. However, the cost of and adequate training in the use of pulse oximeters was an important consideration. [
5,
6] In addition to the WHO Guidelines on Safe Surgery, the 2015 Lancet Commission on Global Surgery united global public health support around the recognition of safe surgery as a right and bolstered commitments to increasing surgical capacity and perioperative training globally. [
7]
Expansion of pulse oximetry use and training is one targeted effort that can improve patient care and safety in the perioperative space. While it is known that pulse oximetry education provides immediate improvement in knowledge of its use through quantitative and descriptive studies, to our knowledge, no qualitative study has been conducted focusing on how pulse oximetry training and provision has affected the clinical practice of non-physician anesthetists (NPAPs) in LMICs. [
4,
8‐
12] Therefore, we conducted semi-structured qualitative interviews with non-physician anesthetists in Zambia to understand qualitatively how pulse oximetry provision and training affected them and their perioperative care and what, if any, capacity gaps remain.
Methods
Setting
In Zambia, anesthesia providers come from multiple training backgrounds: Consultant anesthesiologists, who are physicians with further specialty training in anesthesia; nurses with additional training in anesthesia to become Nurse Anesthetists; and Clinical Officer Anesthetists, who are graduates of an advanced diploma in clinical anesthesia program. Nurse Anesthetists and Clinical Officer Anesthetists work throughout the country and can practice in a hospital with or without a consult physician anesthesiologist present. Throughout this manuscript, these two roles will collectively be referred to as non-physician anesthetists (NPAPs).
Lifebox is a non-profit organization aimed at promoting safer surgery and anesthesia around the world, particularly in Low and Middle Income Countries (LMICs), [
13] and has distributed over 28,000 pulse oximeters designed specifically for use in low-resource settings in over 100 countries. Lifebox works closely with local healthcare workers to provide education about pulse oximetry use and the management of perioperative patients. Many courses are delivered each year, including in Zambia. The course in Zambia is open to anesthesia providers (physicians and non-physician anesthetists) from all hospitals and regions in the country and attracts providers representing multiple practice settings. It is delivered over four days by a team of instructors, including Zambian anesthesiologists, and covers Lifebox pulse oximetry training as well as Safer Anaesthesia From Education (SAFE) Obstetrics training. [
14,
15] The training workshop includes lectures, hands on sessions, and pre- and post-training written exams on pulse oximetry material covered.
Study Design
This qualitative study used semi-structured interviews and a descriptive qualitative inquiry approach.
Recruitment
Thirty-five participants representing hospitals throughout the country participated in the 2019 Lifebox course, and all were invited to participate in this study through email and WhatsApp messages by the primary author (MEP). The initial study invitation was sent in July 2020 and two additional reminders were subsequently sent July–August 2020. There was no financial incentive to participate. Course participants were eligible for inclusion if they were a practicing non-physician anesthetist, participated in the Lifebox course in 2019, provided anesthetic care for at least six months prior to the Lifebox course, and had a working level of English for the interview. Interested participants first completed a demographic survey to indicate their willingness to participate and provide background characteristics and were subsequently scheduled for an interview. Recruitment stopped once thematic saturation was achieved in the interviews, which we estimated beforehand to be 10–15 participants since all participants underwent the same training. [
16]
Interviews
Semi-structured interviews were conducted in English via a Zoom or WhatsApp call by MEP from July–October 2020. The interview guide (Table
1) was developed by two authors (MEP and TGW) with expert feedback from an anesthesiologist (BMA). Audio recordings of the interviews were obtained after a verbal review of consent information by MEP and used to obtain deidentified transcripts through a professional transcription service. The transcriptions were reviewed by MEP for transcription errors prior to uploading in Dedoose for qualitative analysis (Dedoose Version 8.3.35, Los Angeles, CA: SocioCultural Research Consultants, LLC
www.dedoose.com.).
Table 1
Interview guide questions
1. What was the most beneficial part of the training? |
2. What was the least beneficial part of the training? |
3. What important concepts were not covered in the training? |
4. What concepts do you wish were covered more thoroughly? |
5. What concepts were covered that you felt were unnecessary? |
6. Was the training relevant to your clinical practice? Why or why not? |
7. Do you think pulse oximetry monitoring changed surgical care for your patients? If so, how? If not, why not? |
8. Has having a pulse oximeter changed your confidence in your ability to provide safe anesthesia care? |
9. How did the training you received from Lifebox impact your confidence? |
10. Would you be comfortable delivering anesthesia without a pulse oximeter? Why or why not? |
11. You mentioned that X physicians/nurses could benefit from receiving a pulse oximeter and training. In your opinion, would the training need to be altered? If so, how? If not, why not? |
12. You noted that a pulse oximeter was available X amount of the time? Tell me more about that. |
13. Is there anything else that you would like to discuss about pulse oximetry training that we have not talked about? |
Reflexivity
All of the authors have experience working in global health research and participating in global health partnerships. The primary author (MEP) has a background in nursing and public health and is a current medical student, whose multidisciplinary background shaped the approach taken in conceptualizing study participants’ experiences. MEP’s medical and healthcare knowledge guided understanding participants’ perspectives. Attempts were made to take participants’ words at face value and the entire multidisciplinary research team was utilized to conceptualize the work. Field notes were taken after each interview and memos made throughout the analytic process by the primary author to reflect upon the process of data gathering and interpretation.
Analysis
A codebook was developed inductively through an iterative process. Two transcripts were open coded using small segments of data by the primary author (MEP). The open codes were then combined into focused codes based on overlapping definitions and reapplied to the two initial transcripts. A third transcript was coded using these focused codes to further refine the initial codebook and apply the codes to new data. An inter-rater reliability (IRR) test was done with another author (ASM) based on the first three transcripts. The codebook was further iteratively adapted through discussion with several authors (MEP, ASM, TGW, SBM). Two additional transcripts were coded by the primary author, and IRR tests and codebook refinement were repeated until a final, stable codebook emerged and resulted in kappa ≥ 0.7 for all codes. [
17] The final codebook was then applied to all transcripts by the primary author. Initial themes were developed by MEP and then multiple authors (MEP, ASM, TGW, SBM) met to discuss themes that were identified, which were then shared with all authors for feedback and review. [
17,
18]
Ethics
This study was approved by the Stanford University Institutional Review Board (IRB-56841). Written, signed informed consent was waived by the IRB. Verbal informed consent was obtained prior to the interview. This article adheres to the Standards for Reporting Qualitative Research (SRQR) guidelines. [
19] All methods were carried out in accordance with relevant guidelines and regulations along with ethical approval and informed consent to participation.
Discussion
Through qualitative interviews, we assessed how pulse oximetry training and provision affected a cohort of non-physician anesthetists and their perioperative care in Zambia. We found that NPAPs were more confident in their ability to provide safe perioperative care with additional training and expanded monitoring capabilities via pulse oximetry. We also found inter-team communication improved when pulse oximeters were available in postoperative recovery areas so anesthetists could better understand patient status as reported by bedside nurses. Together, these led to qualitative improvements in care for surgical patients. However, continued barriers to perioperative patient care were found in settings lacking dedicated postoperative recovery areas or post-anesthesia care units (PACUs), lacking the ability to monitor oxygen saturations regularly on the wards, and nurse unfamiliarity with pulse oximetry.
Previous studies have explored healthcare provider confidence and the impact of and barriers to pulse oximetry use in LMICs, but, to our knowledge, this is the first qualitative study focusing on these aspects in non-physician anesthetists in Sub-Saharan Africa. Our study found perceptions among NPAPs of improved self-reported confidence and knowledge after training, improved monitoring capacity, and sharing experiences with other anesthesia providers. Perceived improved confidence in the clinical decision making of clinical officers and nurses after pulse oximetry and specialty-specific training has also been seen in Malawi among healthcare workers caring for children with suspected pneumonia.[
20] However, education alone may not be enough to improve confidence and a thoughtful approach to setting and context and clinical role within the healthcare team need to be considered for future education capacity building initiatives.[
21].
Surgical and anesthesia capacity continues to be constrained in Zambia and targeted improvements in this area could improve perioperative care. [
22‐
24] Qualitative studies in other Sub-Saharan African countries have also found that while many providers acknowledged pulse oximetry assessment was important for hospitalized patients, its use was limited by inadequate availability of pulse oximeters and inadequate education on oximetry benefits for the entire healthcare team. [
25‐
27] Our study found that participant non-physician anesthetists perceived that, often, nurses did not have training in pulse oximetry monitoring and some hospitals lacked pulse oximetry in wards and postoperative recovery areas. Further expansion of pulse oximetry training and monitoring capabilities, especially for staff caring for surgical patients, represents one targeted area where healthcare delivery in these settings in Zambia could be improved.
Postoperative mortality is higher in Zambia and other LMICs compared to HICs and remains an area where increased capacity building could substantially decrease surgical morbidity and mortality. [
28‐
31] When designing interventions to strengthen surgical care in LMICs, the entire continuum of the surgical patient’s stay in hospital should be considered. Although developing equipped PACUs de novo is time and resource intensive, once instituted, it can have tangible patient care benefit. [
32] Our study revealed that, from the perspective of a cohort of non-physician anesthetists, patient safety could be improved through continued strengthening of postoperative recovery areas that include additional resources and monitoring capabilities, even beyond pulse oximetry.
Future surgical capacity building initiatives should be interdisciplinary in nature and inclusive of physicians, non-physician clinicians, and nurses. Our study found that NPAP participants perceived that nurses, who had not undergone the pulse oximetry training with participants, would benefit from the knowledge and skills participants gained in patient monitoring through pulse oximetry. Nurses can play a key role in early detection of patient complications and should be included in global capacity building initiatives aimed at improving care for surgical patients. In Zambia, there is an ongoing educational initiative to train nurses in the topics and skills that are essential to working in a critical care ward as they strive to provide care for increasingly complex medical and surgical patients. [
33] Additionally, a recent priority-setting study highlights the desire of perioperative nurses within Africa to continue prioritizing translating research into their practice and implementing safety procedures into their practice such as utilization of the safe surgery checklist and infection control principles. [
34] Keeping the entire perioperative care team, as well as the entire perioperative period, in mind when designing education initiatives would greatly benefit perioperative patient care.
For years, many have advocated for the expansion of pulse oximetry provision and education, especially in the perioperative space. However, the COVID-19 pandemic has further demonstrated the need for early detection of hypoxemia as a key vital sign for all patients and highlighted the inequitable distribution of pulse oximeters and pulse oximetry training. [
35,
36] Despite organizations, such as Lifebox, distributing thousands of pulse oximeters in LMICs throughout the pandemic, there continues to be need. Efforts should continue after the pandemic for sustainability and continued improvement in patient monitoring capabilities. [
13]
This study is not without its limitations. Due to the COVID-19 pandemic, audio-only interviews were conducted instead of in-person interviews. Audio-only interviews are an accepted method for qualitative semi-structured interviews, but it meant we could not participate in additional observations to supplement the interviews. [
37] Such observations may have allowed for a more comprehensive understanding and analysis of workflow and structural barriers to perioperative pulse oximeter use by directly observing how participants use pulse oximetry within their hospital setting. Although study participants worked in a variety of settings throughout Zambia, their experience may not be representative of all perioperative settings in the country. Additionally, participants may have been hesitant to provide negative information about Lifebox or pulse oximetry. Steps were taken to mitigate this concern, such as Lifebox not having access to study participant names and the interviewer not being a Lifebox affiliate. Limitations notwithstanding, we believe this work will be beneficial for organizations and individuals working in global surgery and capacity development. While the exact successes and difficulties in introducing pulse oximeters and pulse oximetry training will differ depending on the context, since each healthcare system and workforce will have different educational needs and potential structural barriers, this study will provide readers important programmatic considerations.
Acknowledgements
We would like to thank all of the Lifebox team members, including Katie Fernandez, MSc, and course participants and instructors in Zambia who made this project possible. We would also like to acknowledge Janine Bruce, DrPH, MPH for additional qualitative methodology support.
Declarations
All other authors (MEP, ASM, SBM, BMA, IA) declare that they have no competing interests to report.
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