External supportive supervision and local management
All hospitals were informed of the nature of the study and agreed to join before being assigned to full or partial intervention groups. However, meetings were held with the senior management teams of full intervention group hospitals around the time of introductory training and after the results of each six-month survey. Such meetings, less formal meetings with managers during supervisory visits, and the lines of communication maintained through hospital facilitators helped establish what was expected of hospitals in terms of performance improvement, and clarified management's responsibilities and expected actions. While these did not constitute formally constructed, written agreements, this dialogue helped develop a 'soft-contract' with partners aware of and, to a degree, committed to supporting improved care. Further effects of supportive supervision were dependent on additional mediating factors: the actual hospital managers and their internal leadership and relationships; managers' competing priorities; the personal relationships with supervisors; the credibility and acceptance of the performance feedback; and the balance achieved between praise and positive reinforcement in areas going well as well as de-motivation or defensiveness where progress was less obvious.
'They [senior managers] never even come to see how we work here, to ask what challenges we encounter, they don't even come..... So they never come to see how we are doing, they just depend on hear say and rumors, and may be they say we are doing good work because they have never heard complaints that we are not doing the work.'
'[The supervision] has assisted us in improvement, at all levels because there is no feedback that you have given us that we have not acted on, we have acted on all of them, but the resource factor, that is a problem. We may note something, but if we do not have the resources then that's it. The feedbacks have been very important to us, not just in helping us improve, but they have made us do a quick survey and like I told you we did a quick survey and we realized we need to talk to people about their attitudes.'
'If we are all stuck then we consult our pediatrician, because he really assists us. In fact you don't have to go to the office to ask them to call him for you, just call him on your phone and he will come immediately if he is within, and if he is not within he will look for somebody who is going to assist us.'
'Because these days when you need some drugs, you find that they are there. Even though we have shortage of staff you find that you are doing the right thing because you find the right drug there, you manage and then you move to the next patient unlike the previous days.'
[Interviewer]: 'What do you think of the accuracy of the information that we present during these feedbacks?'
[Person 1]: 'Yes, its true, its very true.... so I can say the feedbacks I don't think they try to put us down I think they are doing a good job.... I think we are really improving... even here in the ward....'
[Person 2]: 'Like on the areas we have improved, we feel proud.'
[Person 1]: 'Yes, after listening to the feedbacks, the ones that the team brings to the boardroom, that is better than having these books [written reports] which I will have to read because those books, I don't know, copies are given to the ministry of health.... I think it does not feel good, knowing that these copies are going to the ministry, it feels discouraging a bit.'
Facilitation within intervention hospitals
Facilitators were either nurses from within the hospital (with a status similar to that of a deputy ward in-charge) or a clinical officer (a non-physician clinician) with training and experience in paediatric care. Their roles and experiences have been described elsewhere [
29]. Here we concentrate on what aspects of their role seemed critical to promoting performance improvement amongst the wider set of clinicians and nurses responsible for care in their hospitals. Although not senior personnel within the hospital hierarchy, these actors had a central responsibility for blending the explicit knowledge and expectations encapsulated by the intervention with implicit knowledge of their environment [
48]. In this sense, they were formally expected to be the 'earliest adopter' [
49], to encourage other early adopters, and to negotiate with or cajole late adopters into delivering correct care. Actions and efforts that characterized successes in this role included: orientation of new staff (establishing a culture) and more widely being available and recognised as a teacher of new skills and use of new tools; agitation for, gaining management approval of, and subsequent implementation of small changes in workflow, procedures, or responsibilities; clear displays of good practice 'at the coal-face' as a role model and advocate for better care; and becoming a visible reminder of the performance expected -- an external conscience.
'Hey, he [the facilitator] is very helpful. You know he is a link between us and the hospital in case there are shortages in terms of supplies; he makes sure we get them or any other problems we are facing. Again he is always there on the forefront sensitizing people when it comes to ETAT even when you see that people are not willing, and then he is also there to arrange for CMEs.'
'In terms of ETAT... and every other time in the HMT [hospital management team] meeting when the managers are there I [the facilitator] am given an opportunity and I give them feedback... I tell them... on this one we are not doing well... on this one we are doing very well... and most of those things are discussed in the meeting and people have given... people chart a way forward on how to overcome some of those things....'
'Like there was a time we came early that morning and there was this child who had been admitted at 5 a.m. with dehydration, had no line because they had tried to get IV access with no success, we gave the child intra-osseous and the child came up. When they were discharged the mother bought us a crate of soda, we felt so nice. The way we worked on that child, [the facilitator] did the intra-osseous, someone else got the fluid, someone fixed an NG tube.....'
'I think that they [facilitators] make sure that work is done... they supervise actually. Like I say if we need oxygen in OPD and it is not there, [the facilitator] will go there and make sure it is availed for any baby who comes, he goes around in nursery supervising and he also coordinates the CMEs and also has lessons on the same.'
'I think if he [the facilitator] were not there, then the... [guidelines] if I can call it that, would not have that meaning, that it has to us. I think we would have just practiced it for a few months and then forgotten all about it.'
'He [the facilitator] does not come as a supervisor, he just comes and works with you all through.'
'During the rounds, I see her [the facilitator] instructing the CO interns on what to do, even on the drugs, the management.'
'...[the facilitator] is... a tank of support and he is... was my conscience when I was working in pediatrics... because may be there were times when I would be tired... maybe I have just finished a ward round and I just want to run away... but then he would remind me.'
So far we have presented thinking on the direct creation of the mediating conditions for practice change linked to the intervention's components and hospitals' management and facilitators. Further downstream effects depended on the ability of local actors to influence internal working routines, commitment, or capabilities (the micro-system), or were influenced by the actual nature of the task required of health workers. These are now discussed.
Teams, competencies, responsibilities, and expectations
A recurring feature of observations within these hospitals, experiences in other similar hospitals not enrolled in the study, and a theme clearly supported by data was the finding that formal clinical team working was largely absent pre-intervention. Links between cadres (doctors, clinical officers, and nurses), links between departments (outpatient, paediatric ward, newborn unit) were generally hierarchical and perfunctory. Within the intervention sites, training, problem identification and solving, supervision, and facilitation all implicitly emphasized the need for more integrated service provision, although no recipe for achieving this was provided. Where more integrated working evolved, it appeared to be associated with greater satisfaction, a greater sense of team responsibility, greater organizational citizenship behavior, and growing reciprocity and trust. Within intervention hospitals, facilitators were often central to this process, but their achievements seemed dependent on at least the endorsement of senior managers and, for greater success, more active support from management to recognize good performance and help solve resource constraints. Some examples in control hospitals also indicated that engaged managers had the capacity to foster such changes, although successes were more limited. For example, engaged outpatient managers achieved excellent performance for clinical documentation of admissions in one control hospital. However, in the same hospital paediatric drug prescribing remained very poor.
Commenting on past relationships
'Well we only meet as cadres.... Like you will find that there is a nurses' meeting, or a clinical officers' meeting but for all those five years I have never seen an OPD (outpatient department) meeting.... I have never.'
'... between the COs and the nurses there is even hate-love relationship over time, the COs and the MOs have the kind of relationship that is pull and push always. So I can't call it a dream team, there is no team, we work together but there is no system of working.'
Transforming teams, competence, trust, and reciprocity
'... before the guidelines, you would deal with your emergencies alone, we didn't have an emergency room or emergency drugs in the consultation room, so we used to lose so many patients because of running around trying to resuscitate the patients. We did not have oxygen in the OPD, but now we have it and things are better.'
'Through the efforts of the administration we were able to secure heaters, oxygen concentrators, ambubags, also in nursery, for the admitted pre-terms with sick mothers or no immediate family, we asked the administration whether we can have Nan or lactogen [formula feeds] and they availed it. Sometimes the Med Supt would come to the ward to see whether we are using the PAR forms [job aides] and make sure that things were in line and also for CSF analysis in the lab, people never used to do it, because they used to set it aside and leave it like that but through the pressure of the Med Supt's office they are doing it and you even get the results in 24 hours.'
'Let me give you an example... we supposed to have this glycerin alcohol-based hand wash, in fact there was no glycerin but there was a lot of alcohol in the hospital, so one matron had to buy the glycerin. And we put it in to practice, after every patient that you see you wash, and even the person who are doing rounds with is the matron who bought it, she carries it around so that she makes sure that even if you forget, its not in her presence, so there is a lot of motivation.'
'You see we work as a team, because like if we admit a patient, then that patient will end up in the ward. So when the feedback is given then you will know its the problem in the IMCI [outpatient clinic] or is it in the ward and then that way, you will find a level ground on how the problem will be solved so its good when we work as a team.'
'Usually how the emergencies are handled... like if you get an emergency here, you get that everybody is involved, the nurses, the lab people are there. So we just handle it as a department and we do it perfectly....'
'What I can say is that this place is very busy and I love working with the COs because they are good and they know their work; there are times I stay here [until] 4:30 [p.m.] without going for lunch, so I sacrifice my time because I like the place so much but my colleagues do not like it because they find it too busy.'
[Facilitator]: 'One thing, it has taught me how to network with people, that one is for sure. This programme has made me be a team builder, before, I just used to make sure that everything that I do, I do it right; but when I became a facilitator, it dawned on me that I have to make the other person do it perfectly. So it has made me be a team player to ensure that other people do it right. So I came from being an individual to interacting with the other people to talking to the clinicians, talking to the other nurses, getting very close to the administration especially getting things done'
'Sometimes a patient comes having been prescribed drugs in full and then the BS (malaria test) comes positive and the child is not alert, and there is no quinine (prescribed), and that is at night. The next morning you will come and find that the nurses have already prescribed and even started the treatment.'
Consistent with ideas around change and adoption of new practices [
49,
50], workplace performance [
43], and planned behavior [
41], health workers must not only know how to perform a task (
e.g., prescribing) but be willing to perform it. The intention to act and consequential behavior seemed, from our findings, to be affected by: how cognitively simple the task became, perhaps because of its innate simplicity, or through repetition or training; the degree of effort required to perform the task, linked often to its simplicity; the directness of control over the full execution of the task, linked to trust in colleagues' or team members' co-performance and resource availability; positive experiences of better outcomes; and whether the task was considered a core, personal responsibility or a good fit with existing routines, both linked to the ability of managers or facilitators to change the micro-system if required.
Task simplicity, effort and outcomes
'Initially we had problems because you see, when you start new things its really difficult but as time goes by and you have changed your attitudes it becomes simple, you get used to it.'
'Well actually what has kept me going is the results... the changes that are brought from the management of these children in the wards.'
'Because the drugs are not put there especially the anti-malarial Coartem, its really restricted, even in the ward. Initially if a patient had a Coartem prescription, you have to take it to the pharmacy to get it, its not just left to the wards to get access to it. Some will take it and sell it to make money, so the pharmacy really controls it...'
'You see as clinicians we the ones who have a say in terms of clinical care, a nurse cannot prescribe something like multi-vitamins or folate, Vit.A, and we are the ones who calculate the feeds but that was something that was not being done. So that one I realized we had failed in our responsibilities.'
'Feeding used to be just like kienyeji [just anyhow]... actually not knowing ile [the] amount utapeana [you'll give] but now we have a guideline to show... and with the drugs the same... drugs were being prescribed with any dose lakini [but] now there's a standard... there's always a guideline there to show... something else like resuscitation... resuscitation was history... and now we've started resuscitation in nursery and in theatre after delivery... so it means since we started with ETAT+ we have been able to minimize the number of admissions... now this resuscitation is very effective in labor ward and also in theatre... so it means we used to have so many babies in nursery oh... poor score... poor score... poor score... but now they are very few...'
The extra mile--contrasting attitudes to conducting a lumbar puncture to investigate meningitis
'I remember even [two named clinicians] are doing LPs in the IMCI [walk-in clinic], every child who comes requiring an LP, it is done and the specimen is sent to the lab directly and they are CO's.... [but]... the CO in charge [says] there is no room, no place where the LPs can be done so I do not understand what he imagines he needs to do an LP, I do not know what course he needs to do an LP.'
'There are people in this hospital that have actually done us proud and if the other people would approach the programme the way they have done, we would be up there. One of them is positive, motivated, ready to work with other people she is not the kind of lady that you will tell, 'I am the in charge here and you cannot do LPs here?' She will tell you, 'I will do an LP because this child needs it and as long as I have all the tools and the right environment, I do not see why not. I was taught in class and I know I am able to do it, ' then she does.'
Core responsibilities and capability
[Person 1]: 'The other thing that ETAT has really helped in is in the management of emergencies, because you know before ETAT came, nothing was an emergency to us. We just used to admit, you don't even care, as long as you have made your diagnosis and the patient is taken to the ward. So with ETAT you take a lot of time to find out what exactly is wrong with the child, like last week we had a very sick neonate who had all these shock, hypothermia, hypoglycemia, she was cyanosed all over. So we told the other patients to hold on and we...'
[Person 2]: 'We resuscitated the baby in fact, she was taking the last breath...'
[Person 1]: 'We resuscitated the baby for three hours, even the pediatrician was so happy. So we took the child to the ward and then later on she was referred to Kenyatta [the national hospital]. So you see when I flashback I see that we have lost so many patients in the past, just because of ignorance but with this ETAT at least now we go an extra mile to save a life. By the way at the end of the day I feel happy because I know that I saved a life...'
Two examples of correct prescriptions help illustrate some of these issues. Major changes were achieved in modernizing prescribing practices for a commonly used drug, gentamicin. This required a relatively simple switch in practice by clinicians, supported by job aides and training, when using a drug they might prescribe as a core clinical role to several patients in a single day. The practice change was of potential benefit to nursing colleagues because the frequency of administration was reduced and changing prescribing habits required no alteration to routines or the micro-system. In contrast, prescribing milk-based feeding regimens for severely malnourished children is more complex, although also supported by job aides, and is a task less frequently undertaken. Further, availability of milk feeds and nursing capacity to administer them was often limited, reducing trust in their delivery, and traditionally 'feeding' had often been the preserve not of clinicians but of nurses and, if available, nutritionists. Correct feeding prescription practices were not as easily achieved, or not achieved at all in several hospitals, and even where progress was made, it was often slow and only in response to continued feedback and discussion.