Background
Methods
Design
Setting
Study population
Study sample and sampling procedure
Qualitative sample
Sampling strategy
Quantitative sample
Sampling strategy
Data collection technique and tool
Qualitative data collection tool
Quantitative data collection tool
Data analysis
Qualitative data analysis
Quantitative data analysis
Data entry and management
Data analysis was carried out in three stages
Stage one
Stage two
Stage three
Results
Qualitative results
Socio-demographic characteristics
SN | Participants’ category | Age | Sex | Education Level | Experience in the respective community |
---|---|---|---|---|---|
1 | Enrolled Nurse (01) | 43 | F | Form IV | 5 years |
2 | Enrolled Nurse (02) | 32 | F | Form IV | 8 years |
3 | Enrolled Nurse (03) | 24 | F | Form IV | 2 years |
4 | Enrolled Nurse (04) | 33 | F | Form IV | 5 years |
5 | Enrolled Nurse (05) | 35 | F | Form IV | 5 years |
6 | Enrolled Nurse (06) | 40 | F | Form IV | 11 years |
7 | CL (07) | 45 | M | STD VII | > 10 years |
8 | CL (08) | 44 | F | Form IV | 10 years |
9 | DI (09) | 53 | M | Form IV | 9 years |
10 | DI (10) | 32 | F | Form IV | 5 years |
11 | DI (11) | 38 | F | Form VI & University | 6 years |
12 | DI (12) | 53 | F | Form IV | 4 years |
Themes
Approval of the performances of ENMs in meeting community health needs
“When a woman in labour pains is brought at night, the nurses will be called from their home. We have two guards here; they call the nurses when they see clients around…if they live far, the guards will call the motorcycle owner to pick up the nurse; the nurse will immediately arrive to serve the woman…when clients are on nocturnal injections, the nurses attend them… Nurses are good. Whenever they are called they come immediately” (CL 08).
“They [nurses] perform all duties… Although this is a dispensary where services should end on Friday, but even on Sundays, the nurses provide services … on Monday there are many clients, and all of them get services. Nobody will tell you that he/she missed services because of coming after working hours…”(CL 07).
“From her [ENM] knowledge, there are other aspects that I can learn from her [ENM]… She knows things which I don’t know. For example in the labour ward, I am not doubtful at all because I know she can handle everything. When she says, ‘Doctor, this woman will deliver without complications, truly, the woman will deliver without problems’. If she suggests sending the patient further [referral], you [I] do that. Even on treatment issues, she advises me the type of medicines to give…” (DI, 11).
“She [EN] takes care of the cases that are within her scope. The diseases that even a layman can understand and what type of medicines ones should take. For example malaria, cough, she knows according to her work experience…she knows to treat urinary tract infections [UTIs]…she can order malaria test, Hb [amount of blood] plus urine tests” (DI 12).
“They [community] know what they [ENMs] do. For example, I had never seen a patient returning, presenting with complaints that I was attended by so and so and things went wrong… Overall they [ENMs] are knowledgeable. They know when the patient presents with this, what to give …When they attend patients, the patients get cured...” (DI, 11).
“I had never received complaints about her [ENM]. .. The way I see it, when I travel she is responsible for all duties [Nursing/Midwifery and Medical]. She treats patients and the RCH [reproductive and child health] services continue to run smoothly” (DI 12).
“Everybody has a weekly schedule to assist deliveries at night after working hours. We often start at 7:30AM and work until 3:30PM, but then continue to work throughout the night. Tonight, they [guards] call us, the guards call us and tell us ‘there is a woman here who is expecting to deliver’… Per day you may assist 5-6 deliveries” (ENM 03).
Experienced difficulties of meeting the community health needs
“There are those who come to start clinic [ANC], you have to carry out Prevention of Mother To Child Transmission [PMTCT] investigations. If there is one who is positive [HIV], there is the issue of registering her on option B plus regime and opening a file; things like that. Per day you may end up with six pregnant women; that is too much. Then there are follow up cases…The population is large…our plan is to serve 13 women per month, but currently we are enrolling more than 38!” (ENM 01).
“I have too much to do. For example, as I am working at this dispensary, it will reach time when I am to go home ..., just before taking off my uniform, I was called back to attend a woman in labour pains…After assisting her, another woman came in. It is not surprising to spend the whole night, and in the morning I have to start my regular shift” (ENM 06).
“Responsibilities are more than what I expected because sometimes I may plan to do this perfectly, but I encounter challenges. Therefore, I find myself trapped in responsibilities that extend beyond my capacity” (ENM 04).
“At night you may receive a woman who is in labour pains, but you have nothing [delivery equipment]. A small percent of women understand the situation, but others feel that we are being rude to them. They [clients] think that we receive medical equipment plus medicines and sell them! If you refer to the registry, no Oxytocin [special medicine for inducing labour] has been supplied here [at the dispensary]!” (ENM 03).
“The environment in this dispensary does not offer privacy and safety. Somehow it is a problem. Women want to give birth at this dispensary, but the space is very small…the delivery room is small and there is no electricity… No delivery kit; medicines do not arrive on time… Therefore, clients are not comfortable…We may lose [death] clients” (ENM 01).
“It is painful because some clients do not have money. The majority of women are not financially capable. When you look at their status you can realize that; that is the situation; we don’t have a mechanism to assist them…” (ENM 03).
“Where I practiced before, it [prescription errors] happened several times. They [ENMs] were giving medicines without investigation results. The medicines were the ordinary ones. But you may find a client [community member] complaining that I told her [ENM] this but she gave me that. This is due to their [ENMs’] level of understanding…” (DI 12).
“She might come across complicated cases and she needs to make decision by herself… my worries about her decision is that she might end up with inappropriate decision!” (DI 11).
“The main problem is availability of medicine; medicines are not adequate… obstetrical delivery services are carried out here; and there is no water supply. Relatives are forced to bring buckets of water when they escort a woman who is in labour pains… It is a challenge especially when there is shortage of water supply in the hospital…The lab has no equipment to carry out all investigations; malaria test yes, but not blood levels [Haemoglobin level]” (CL 08).
Appreciating the performances and competencies of enrolled nurses and midwives
“Sometimes when the doctor [clinical officer] is not available, perhaps if he/she is attending a meeting/seminar, I take over his/her responsibilities…” (ENM 01).
“At the dispensary, a nurse [ENM] performs all duties. I mean in addition to her/his duties such as attending pregnant women and children, she/he treats patients if I am not around… She/he will treat patients and perform all her/his duties as usual…” (DI 11).
“I practice according to my knowledge. I attend those clients whom I can manage within my scope. For example, if the client presents with fever, I take the body temperature, I take blood samples for malaria test; if it happens that he/she has malaria, I give him/her malaria dose. If it happens that he/she presents problems beyond my knowledge, I refer him/her to a large hospital” (ENM 03).
“When the patient complains of this, you give that; we believe there might be side effects that we may not be aware of, but the doctor would know…” (ENM 04).
“You know I have gained experience while working here…the more I work, the more knowledge I gain. Therefore I don’t see any new situations” (ENM 01).
“When you bring a sick child at the health centre [dispensary], the child may be given wrong medicine…that is an error … It happened to my child. The child had to be admitted in a referral hospital. Later on the doctor who attended the child ordered the child to be given milk, stating that the child was overdosed…” (CL 07).
“I had never been trained as a medical prescriber…truly I have realized that is beyond my competence… Therefore, practicing as a clinician lowers my confidence, but you [I] do it because it is your [my] obligation to provide service to the clients... What else can you [I] do?” (ENM 01).
“The duties that I perform are far beyond my competencies which include: making diagnosis and writing prescriptions. In the college, I was not trained to do this …” (ENM 06).
“Here we have medical attendants. We help each other. You know the situation; one person cannot do everything. We have to share the work: one can take care of children [paediatrics], another one provides vaccinations, another one may assess pregnant women and another one can distribute medicines. Things like that …” (ENM 01).
“Personally I gained a lot of benefits from them [HAs]. For example, today I am alone. Therefore, they are helping me to assess pregnant women and they are helping to vaccinate…Truly these health attendants assist, but if problems occur, the blame will fall on us who are responsible” (ENM 06).
“You may wish to have a qualified person to fix the situation [treat the patient], such things would be perfect. But when you see one practicing beyond his/her scope, it is a burden. Extra efforts are needed because there is either mismanagement or errors. We try to make corrections among ourselves; that is how we move along…what else can we do?” (ENM 01).
“We discuss with the patient if he/she can talk. If he/she cannot we collect information from relatives. We carry out assessments and come up with diagnosis and give medicines” (ENM 04).
Quantitative
Socio-demographic characteristics
Variable | Frequency | Percent |
---|---|---|
Sex | ||
Male | 2 | 3.4 |
Female | 57 | 96.6 |
Age | ||
≤ 25 | 7 | 11.9 |
26–35 | 18 | 30.5 |
36–45 | 19 | 32.2 |
46 + | 15 | 25.4 |
Education | ||
Primary Education | 16 | 27.1 |
Ordinary Secondary Education | 42 | 71.2 |
Advanced Secondary Education | 1 | 1.7 |
Marital Status | ||
Unmarried | 25 | 42.4 |
Married | 34 | 57.6 |
Work experience (months) | ||
≤ 12 | 5 | 8.5 |
13–60 | 21 | 35.6 |
61–120 | 14 | 23.7 |
121–240 | 10 | 16.9 |
241 + | 9 | 15.3 |
Work experience in the current Dispensary (months) | ||
≤ 12 | 15 | 25.4 |
13–60 | 22 | 37.3 |
61–120 | 13 | 22.0 |
121–240 | 6 | 10.2 |
241 + | 3 | 5.1 |
Work experience as EN/NM (years) | ||
≤ 1 | 5 | 8.5 |
2–5 | 17 | 28.8 |
6–10 | 16 | 27.1 |
11–20 | 11 | 18.6 |
21 + | 10 | 16.9 |
Religion | ||
Christian | 42 | 71.2 |
Moslem | 17 | 28.8 |
Others | 0 | 0 |
The performance and self-perceived competence of ENMs
Levels of performance and self-perceived competence of ENMs
Variable | Performance | Self-perceived competence |
---|---|---|
High (%) | High (%) | |
Participate in implementation of PHC elements | ||
Educate patients and community about their health problems | 55 (93.2) | 54 (98.2) |
Identify and controlling prevailing health problems | 55 (93.2) | 52 (94.5) |
Food supply and nutrition | 20 (33.9) | 17 (85.0) |
Provision of safe water and basic sanitation | 46 (78.0) | 43 (93.5) |
Provision of family planning services, maternal and child health care | 58 (98.3) | 54 (93.1) |
Provision of immunization | 54 (91.5) | 54 (100) |
Prevention and control of endemic diseases | 53 (89.8) | 47 (88.7) |
Appropriate treatment of common diseases and injuries | 58 (98.3) | 54 (93.1) |
Provision of essential drugs | 58 (98.3) | 55 (94.8) |
Provision of mental health care | 17 (28.8) | 12 (70.6) |
Additional duties as EN/EMs | ||
Collect statistical data and prepare report | 57 (96.6) | 57 (100) |
Provide home based care | 40 (67.8) | 37 (92.5) |
Provide counselling services | 56 (94.9) | 55 (98.2) |
Professional development and collaboration | ||
Participation in continue professional development courses | 52 (88.1) | 47 (90.4) |
Use of available supportive supervision | 54 (91.5) | 47 (87.0) |
Perform Medical / Clinical professional duties | ||
Treating patients when the doctor is not available | 57 (96.6) | 55 (96.5) |
Making clinical diagnosis of patients according to signs and symptoms and write prescription | 57 (96.6) | 55 (96.5) |
Requesting for laboratory tests in absence of the doctor | 53 (89..8) | 52 (98.1) |
Referring patients to another Health facility according to their conditions | 58 (98.3) | 55 (94.8) |
Treating children according to their conditions | 58 (98.3) | 55 (94.8) |
Making diagnosis and treating patients during home based care | 45 (76.3) | 38 (84.4) |
Factors associated with overall performance of ENMs
Variable | Overall Performance | P-value | |
---|---|---|---|
Sex | High (%) | Low (%) | |
Male | 1 (50) | 1 (50) | 0.746 |
Female | 28 (49.1) | 29 (50.9) | |
Age | |||
≤ 38 | 10 (35.7) | 18 (64.3) | 0.044 |
38 + | 19 (61.3) | 12 (38.7) | |
Education | |||
Primary Education | 12 (75) | 4 (25) | 0.016 |
Ordinary Secondary Education | 17 (39.5) | 26 (60.5) | |
Marital Status | |||
Unmarried | 11 (44) | 14 (56) | 0.339 |
Married | 18 (52.9) | 16 (47.1) | |
Total work experience (months) | |||
≤ 84 | 29 (49.2) | 30 (50.8) | NA |
84 + | 29 (49.2) | 30 (50.8) | |
Work experience in the current Dispensary (months) | |||
≤ 48 | 13 (40.6) | 19 (59.4) | 0.122 |
48 + | 16 (59.3) | 11(40.7) | |
Participation in continue professional development courses | |||
Yes | 29 (55.8) | 23 (44.2) | 0.006 |
No | 0 (0.0) | 7 (100) | |
Use of available supportive supervision | |||
Yes | 28 (51.9) | 26 (48.1) | 0.187 |
No | 1 (20) | 4 (80) |
Factors associated with overall self-perceived competence of ENMs
Variable | Overall self-perceived competence | P-value | |
---|---|---|---|
Sex | High (%) | Low (%) | |
Male | 0 (0.0) | 2 (100) | 0.503 |
Female | 17 (29.8) | 40 (70.2) | |
Age | |||
≤ 38 | 6 (21.4) | 22 (78.6) | 0.184 |
38 + | 11 (35.5) | 20 (64.5) | |
Education | |||
Primary Education | 6 (37.5) | 10 (62.5) | 0.278 |
Ordinary Secondary Education | 11 (25.6) | 32 (74.4) | |
Marital Status | |||
Unmarried | 6 (24.6) | 19 (76) | 0.344 |
Married | 11 (32.4) | 23 (67.6) | |
Total work experience (months) | |||
≤ 84 | 17 (28.8) | 42 (71.2) | NA |
84 + | 17 (28.8) | 42 (71.2) | |
Work experience in the current Dispensary (months) | |||
≤ 48 | 6 (18.8) | 26 (81.2) | 0.058 |
48 + | 11 (40.7) | 16 (59.3) | |
Participation in continue professional development courses | |||
Yes | 16 (32.7) | 31 (66) | 0.075 |
No | 1 (8.3) | 11 (91.7) | |
Use of available supportive supervision | |||
Yes | 16 (29.6) | 38 (70.4) | 0.550 |
No | 1 (20) | 4 (80) |