Transformational Leadership: the key to reducing Intention to Leave In nurses

Gianluca Azzellino ¹*, Massimo Bordoni²

 

1 Department of Territorial Assistance, Local Health Authority (AUSL 04) of Teramo, Italy

2 Department of Social Health. Local Health Authority (AUSL 04) of Teramo, Italy

Corresponding author: Gianluca Azzellino, Department of Social Health. Local Health Authority (AUSL 04) of Teramo, Via Finlandia n. 7/1,65015 Montesilvano, Italy

Email: gianluca.azzellino@aslteramo.it

 

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ABSTRACT

This commentary responds to the recently published article on transformational leadership in the healthcare context. The article explores how transformational leadership can significantly improve efficiency and job satisfaction in nursing teams. Specifically, it highlights the crucial role of this leadership style in fostering a positive work environment and reducing intentions to leave the profession among nurses. At a time of profound crisis for the nursing profession, characterised by staff shortages, increased workload and high rates of abandonment of the profession, transformational leadership could represent an effective model to address these challenges. This leadership approach, based on vision, inspiration, and involvement, can strengthen nurses' motivation and satisfaction by promoting a positive and stimulating working environment. The analysis emphasises the importance of adopting innovative management practices to address current challenges in the healthcare sector, providing a basis for further research and practical implementation.

 

Keywords: Nursing leadership, Burnout, intention to leave, professional development, nurse education, job satisfaction

 

INTRODUCTION

The authors read with interest the article by Rizzo et al. (2024) entitled “Transformative leadership and job satisfaction in the nursing profession: A narrative review”. The article offers an in-depth analysis of the effect of transformative leadership on the nursing profession. The authors explore how this leadership style not only positively influences nurses’ job satisfaction, but also their intention to leave the profession. This is particularly relevant in a global context in which the nursing shortage is a critical challenge for healthcare systems. However, the increasing complexity of the healthcare system, coupled with the new challenges posed by the global pandemic, has made the need for an evolution in the nursing leadership model evident. This commentary aims to further explore the findings of Rizzo et al. by contextualizing their study within the current issues facing the nursing profession and discussing the importance of implementing transformative leadership strategies to improve both the quality of healthcare and the intention to stay. Our analysis through a combination of direct experience in the field and critical review of relevant literature, proposes to offer an in-depth perspective on how transformational leadership can be implemented effectively to address current challenges in nursing.

 

DISCUSSION

It was interesting to read the research work by Rizzo et al. (2024) on the relationship between transformational leadership and job satisfaction. At a time when the healthcare sector is facing unprecedented challenges, stability and satisfaction of nurses have become crucial priorities. Transformational nurse leaders can recognise and anticipate the needs of their nursing staff by establishing a good rapport and making significant efforts to meet their needs to encourage a sense of empowerment and autonomy that can subsequently translate into job satisfaction [1]. Recent studies have shown that nurses working under the guidance of transformational leaders tend to show greater attachment to their role and to the organisation. This results in fewer people leaving the profession, thus reducing turnover and the costs associated with training and induction of new staff. Transformational leadership, defined by Bass as a leadership style that inspires and motivates employees through shared vision, effective communication, individualised attention, and intellectual stimulation, stands out as a leadership model capable of fostering a positive and motivating work environment [2]. A leadership style that promotes autonomy, support and empowerment of nurses can improve job satisfaction, organisational commitment, and nurses' intention to remain in their position by reducing emotional exhaustion [3]. As Rizzo et al. points out, there is therefore a need to identify and fill current gaps in nursing leader competencies and skills through processes of two-way communication and mutual trust between managers and nurses. Cummings et al. conducted a systematic review that showed that transformational leadership behaviour is positively correlated with job satisfaction [4]. Strengthening the sense of belonging and personal fulfilment can reduce burnout and the intention to leave the profession. In an environment where nurses feel valued and supported, they are more likely to remain committed and motivated in their work. Overall, studies support the fact that having positive support factors and working relationships in place, including positive relationships with physicians, leader support, positive leadership style and teamwork, can play a protective role against Burnout [5]. Another positive aspect of this style is its ability to motivate professionals to overcome daily challenges and actively engage in their work. Leaders who display transformational behaviour can inspire staff to see their work as a meaningful mission, rather than just an occupation. Kanste highlighted how transformational leaders are able to foster a sense of purpose among nurses, encouraging them to contribute beyond basic expectations [6]. This increased motivation can result in a reduction in the intention to leave the profession. A cohesive environment can improve the quality of care and increase job satisfaction. Boamah et al. showed how transformational leadership fosters the creation of cohesive and collaborative teams, thus improving outcomes for both patients and nurses. This team cohesion can reduce feelings of isolation and increase the sense of support among staff [7]. Professional development programmes that focus on transformational leadership skills can prepare nurse leaders to lead their teams effectively. It is therefore crucial to invest in the training of leaders capable of adopting this leadership style in order to build motivated and resilient teams. Despite the fact that a transformational leadership style is correlated with better job satisfaction, existing evidence shows that it is rarely used by nursing leaders in healthcare settings [8]. Furthermore, fostering a culture of continuous feedback and professional growth can help leaders develop and maintain transformational behaviours. Secondly, it is crucial to promote policies that foster work-life balance, the creation of open and transparent communication channels, and the recognition and valuing of nurses' contributions. The choice of the best leadership style could be one of the modifiable factors that a healthcare organisation can adopt to create a favourable working environment and promote quality care [9]. Rizzo et al. correctly identified the increasing pressures on nurses and the need for innovative strategies to address the problem. However, we believe that an emphasis on transformational leadership can offer a sustainable solution and practice. The scientific community and policy makers need to seriously consider adopting this leadership model as part of strategies to address the professional crisis. Transformational leadership offers a promising perspective to improve job satisfaction, reduce burnout and intent to leave, and thus contribute to building a more attractive and sustainable healthcare system.

 

Conflict of interest

The authors declare no competing interests

 

Financing

No funding to declare

 

Author contributions

All authors contributed equally to the work

 

REFERENCES

1. Asif M, Jameel A, Hussain A, Hwang J, Sahito N. Linking Transformational Leadership with Nurse-Assessed Adverse Patient Outcomes, and the Quality of Care: Assessing the Role of Job Satisfaction and Structural Empowerment. Int J Environ Res Public Health. 2019 Jul 4;16(13):2381. doi: 10.3390/ijerph16132381. PMID: 31277478; PMCID: PMC6651060.
2. Jr, Morgan. (2006). Leadership and performance beyond expectations, by Bernard M. Bass. New York: The Free Press, 1985, 191 pp. $26.50. Human Resource Management. 25. 481 - 484. 10.1002/hrm.3930250310.
3. Laschinger HK, Wong CA, Cummings GG, Grau AL. Resonant leadership and workplace empowerment: the value of positive organizational cultures in reducing workplace incivility. Nurs Econ. 2014 Jan-Feb;32(1):5- 15, 44; quiz 16. PMID: 24689153.
4. Cummings GG, Tate K, Lee S, Wong CA, Paananen T, Micaroni SPM, Chatterjee GE. Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. Int J Nurs Stud. 2018 Sep;85:19-60. doi: 10.1016/j.ijnurstu.2018.04.016. Epub 2018 May 3. PMID: 29807190.
5. Dall’Ora C, Ball J, Reinius M, Griffiths P. Burnout in nursing: a theoretical review. Hum Resour Health. 2020 Jun 5;18(1):41. doi: 10.1186/s12960-020-00469-9. PMID: 32503559; PMCID: PMC7273381.
6. Kanste, Outi. (2008). The Association between Leadership Behaviour and Burnout among Nursing Personnel in Health Care. Nordic Journal of Nursing Research. 28. 4-8. 10.1177/010740830802800302.
7. Boamah SA, Spence Laschinger HK, Wong C, Clarke S. Effect of transformational leadership on job satisfaction and patient safety outcomes. Nurs Outlook. 2018 Mar-Apr;66(2):180-189. doi: 10.1016/j.outlook.2017.10.004. Epub 2017 Nov 23. PMID: 29174629.
8. Morsiani G, Bagnasco A, Sasso L. How staff nurses perceive the impact of nurse managers' leadership style in terms of job satisfaction: a mixed method study. J Nurs Manag. 2017 Mar;25(2):119-128. doi: 10.1111/jonm.12448. Epub 2016 Dec 5. PMID: 27917561.
9. Phillips LA, de Los Santos N, Jackson J. Licensed practical nurses' perceptions of their work environments and their intentions to stay: A cross-sectional study of four practice settings. Nurs Open. 2021 Nov;8(6):3299-3305. doi: 10.1002/nop2.1046. Epub 2021 Aug 25. PMID: 34432374; PMCID: PMC8510757.

 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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by Izeos

Monitoring of toxicities induced by Chimeric Antigen Receptor T-cell therapy: Protocol for a phenomenological study on the experiences of nurses

Valentina Simonetti ^1†, Letizia Governatori ^2†, Francesco Galli ³, Cesare Tozzi ⁴, Romano Natalini ⁴, Andrea Toccaceli ⁵, Francesco Pastore ⁶, Giancarlo Cicolini ¹ & Dania Comparcini ⁷*

 

 

1. Department of Innovative Technologies in Medicine and Dentistry, “G. d 'Annunzio” University of Chieti-Pescara, Chieti, Italy; v.simonetti@unich.it; https://orcid.org/0000-0002-7185-4850 (VS); g.cicolini@unich.it; https://orcid.org/0000-0002-2736-1792 (GC).
2. Department of General and Specialist Surgery, Adult and Pediatric Orthopaedics Clinic, University Hospital "Azienda Ospedaliero Universitaria Delle Marche", Ancona, Italy; letizia.governatori@ospedaliriuniti.marche.it (LG).
3. Faculty of Medicine and Surgery, Polytechnic University of Marche, Ancona, Italy; galli.francesco77@gmail.com; https://orcid.org/0009-0000-3550-1268 (FG).
4. Department of Internal Medicine, Haematology Clinic, PICC Unit, University Hospital "Azienda Ospedaliero Universitaria Delle Marche", Ancona, Italy; tozzicesare1973@gmail.com (CT); romano.natalini@ospedaliriuniti.marche.it. (RN).
5. Nursing Department, University Hospital "Azienda Ospedaliero Universitaria Delle Marche", Ancona, Italy; andrea.toccaceli@ospedaliriuniti.marche.it (AT).
6. Department of Biomedicine and Prevention, University of Rome “Tor Vergata”, Rome, Italy; francesco.pastore@uniba.it (FP).
7. Interdisciplinary Department of Medicine, “Aldo Moro” University of Bari, Bari, Italy; dania.comparcini@uniba.it; https://orcid.org/0000-0003-3622-6370 (DC).

^† The authors LG and VS contributed to the study in equal measure.

* Corresponding author: Dania COMPARCINI (DC), PhD, MSc, RN, research fellow. Interdisciplinary Department of Medicine, “Aldo Moro” University of Bari, Italy; email: dania.comparcini@uniba.it; https://orcid.org/0000-0003-3622-6370.

 

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ABSTRACT

Introduction: Chimeric Antigen Receptor T-cell therapy (CAR-T) represents the most recent immunotherapy’s innovation to cure some refractory and/or relapsing haematological tumours.

However, because of the life-threatening toxicities it might cause such as Cytokine Release Syndrome and Immune Cell Associated Neurotoxicity Syndrome, patients are closely monitored by nurses for the early identification of toxicities during the post-infusion phase of CAR-T cell therapy. Exploring the nurses’ experience with respect to any difficulties related to the monitoring is important since these issues can be perceived by patients and affect the nurse-patient’s caring relationship, considered as a shared lived experience between the patient and the nurse.

Aim: This study aims to investigate haematology nurses’ lived experience with monitoring CAR-T’s induced toxicities.

Materials and methods: A qualitative study following Cohen's phenomenological methodology will be conducted through semi-structured interviews in a sample of Italian nurses working in haematology units, who have had previous experience in the management of patients undergoing CAR-T therapy for at least two months and who have performed the monitoring for the same months of experience; the interviews will be audio-recorded and then transcribed verbatim.  Two researchers will carry out the manual analysis and interpretation of the collected data independently, identifying themes and sub-themes.

Conclusion: To explore the nurses’ experiences in this field could facilitate the identification of the educational needs, at individual and group level. Despite it is important to consider contextual variables, the findings of this study could contribute to develop evidence supporting advanced and specialized nursing care in the haematological setting.

 

Keywords: hematology, nursing, CAR-T therapy, phenomenological, qualitative.

 

INTRODUCTION

Chimeric Antigen Receptor T-cell (CAR-T) therapy is the latest immunotherapy approach for the treatment of certain resistant or relapsing haematological cancers [1], including: Acute Lymphoblastic Leukaemia, diffuse large B-cell lymphoma, primary mediastinal large B-cell lymphoma and mantle cell lymphoma. However, despite being designed to act selectively in eliciting a targeted immune response against neoplastic cells, anti-CD19 CAR-T cell therapy is not free of risks and even serious side effects. The most frequent toxicities are Cytokine Release Syndrome (CRS), reported in 57% to 93% of patients who underwent CAR-T [2], and Immune Effector Cells Associated Neurotoxicity Syndrome (ICANS), which occurs in 20% to 70 % of patients [3]. Nevertheless, while they are often manageable and reversible, they can prove fatal, requiring close patient monitoring, early recognition of toxicities, and prompt intervention to reduce morbidity and mortality [3].

To achieve this, patients are closely monitored by nurses after infusions following specific protocols and procedures adopted in the operating units. More specifically, monitoring by nurses includes the assessment of vital parameters as well as typical signs and symptoms of Cytokine Release Syndrome (CRS) and neurological toxicity (ICANS) [4]. Specifically, to facilitate the identification of early manifestations of neurotoxicity, close monitoring using validated nursing instruments [5] is necessary, including the handwriting test and the quantification of the “ICE - Immune Effector Cell-associated Encephalopathy score”. The latter enables the mental status of patients to be assessed by identifying four ICANS grades (numbered 1 to 4) according to the presence or absence of consciousness impairment, seizures, motor alterations and symptoms of high intracranial pressure [6].

Thus, monitoring enables the nurse to conduct a targeted assessment of the patient's condition in the post-infusion phase, which is decisive for a timely approach to CAR-T toxicities by activating the entire multidisciplinary team. Said approach effectively relies on the meticulous execution of the objective examination, where a high patient assessment frequency [7] enables the practitioner to perceive even the most subtle changes in the patient's psycho-physical condition.

A recent study showed that for patients undergoing CAR-T cell therapy and experiencing significant side effects, continuous monitoring by nurses provides them with a sense of security, and they particularly appreciate the time nurses devote (in addition to monitoring activity) to engaging in dialogue and expressing an interest in their state of health [8]. Therefore, it is essential to acquire deeper insights into the challenges nurses face during the complication monitoring phase, considering that patients may sense such difficulties, which may, consequently, affect the caring relationship established during this crucial assistance.

As a fundamental aspect of nursing practice, the nurse-patient relationship is part of a broader context in which nurses use their senses, knowledge, and experience to exercise professional judgment and discernment when providing care in specific situations [9]. As such, a thorough examination of patients' care experience and the related outcomes must also be conducted with due consideration for the experiences narrated by the haematology nursing staff, since the practice of nursing care necessarily implies a shared experience of the relevant dynamics [10,11].

However, the topic of nursing care in the management of patients undergoing CAR-T cell therapy is a relatively new area of investigation, so few studies have been conducted in the field of nursing. The limited literature has only investigated the experience of patients undergoing CAR-T therapy and/or their caregivers without delving into the experience itself and the meaning attributed to this experience by those who care for patients and/or interact with and support caregivers [12-14]. Moreover, only one study, conducted in China, investigated the experience of a group of oncology nurses in managing this specific subpopulation of patients but was focused on nursing competence [15]. This study did not examine the nurse's key role during the toxicity monitoring phase in-depth, and the main focus was on aspects related to nursing skills rather than the significance of the experience.

To date, to the best of our knowledge, no study has explored nurses' experiences in the monitoring and care of this specific category of haematological patients, even though the aforementioned scientific literature frequently emphasises the importance of nursing care at all stages of the clinical care process and particularly during the post-infusion phase.

 

Study aim

The purpose of this study is to explore the experience of nurses caring for haematology patients during the monitoring of the main toxicities associated with CAR-T therapy.

 

MATERIALS AND METHODS

Study design

A hermeneutical phenomenological study will be conducted according to Cohen’s method [16]. A summary of the planned operating times for the study is shown in Table 1.

 

 

Study phases	Activities	Estimated duration (time)	Follow-up
Definition and planning	Review and analysis of the literature, research question	1 month (September)	Focus: researchers; stakeholders.
	Development of the research design, context analysis, selection of potential data acquisition centres	2 months (October–November)
	Drawing up of draft protocol	2 months (December–January)
	Review and finalisation of the protocol.	2 months (February–March)
	Authorisations by the participating centres. Request for an opinion form the Ethics Committee (EC)	2 months and 15 days (April–June)
	“Bracketing” process and exchanges between researchers	15 days (June)
2. Recruitment of participants	Recruitment of data acquisition centre and participants	15 days (July)	Focus: participants
	Finalisation of the sampling plan
	Informed consent
Data collection	Pre-test data collection tool (pilot interviews) and finalisation of interview questions	15 days (July)
	Conduct of interviews and return of transcripts	1 month (August–September)
Data analysis	Data preparation: transcription, reading of interviews (units of meaning)#	1 month (September–October)	Focus: texts (transcribed interviews)
	Data codification and reduction process
	Thematic analysis
	Writing and editing
	Discussion and sharing of emerging themes (provisional)	15 days (October)	Focus: researchers, participants
Final report	Drafting of the final report, manuscript.	1 month (November)	Focus: scientific community, stakeholders

Table 1. Envisaged timeline for the study (2023–2024).

 

The phenomenological approach is based on the understanding of questions of meaning and the actual experiences of informants [16] by combining the methodological properties of descriptive (Husserlian) and interpretative (Gadmerian) phenomenology. The former descriptive scope aims to describe the experiences of individual members of the cohort under study after a preliminary phase in which the researchers set aside prejudices and preconceptions about the phenomenon under investigation (“bracketing”). This is crucial to reduce the influence of such prejudices and preconceptions on the subsequent phase, in which the themes and data emerging from the interviews are respectively extrapolated and analysed. The interpretative intent, on the other hand, examines and interprets the reported experiences in depth [17]. Therefore, since this methodological approach focuses on understanding questions of meaning and the real-life experiences of the respondents [16], it is particularly suited to nursing-related research and topics seldom explored in the literature. It is also instrumental in the broader context of a working organisation for identifying perceived needs and the solutions that can best address them [16].

Participants and study context

The participating cohort will be recruited from haematology operating units in Italy, identified at the national level among the accredited haematology and onco-haematology centres of advanced specialisation for the treatment of leukaemias and lymphomas, compliant with specific requirements and authorisations for cell therapies as prescribed by AIFA, the Italian Medicines Agency.

Intentional (“propositional”) sampling will be carried out within each data collection centre according to a homogeneity criterion [18,19] to investigate differences and variations within a relatively homogeneous sample [18, 20] in relation to experience in handling the monitoring cards of patients subject to complications associated with CAR-T therapy. This sampling will enable the researchers to deliberately select a cohort of nurses who possess specific expertise and experience in the management of complication monitoring based on a set of pre-established criteria (inclusion and exclusion criteria); this is of fundamental importance in order to obtain a sample capable of providing meaningful, subject-specific information as well as credible and reliable explanations of the phenomenon under study, irrespective of the cohort size [21].

Sampling will continue until data saturation is reached, understood as a process of conducting interviews sequentially until the concepts expressed by the respondents are repeated several times without introducing new concepts or themes [22]. The unitary element of analysis will coincide with the experience under study; therefore, considering that a single respondent can generate many concepts, large samples in numerical terms are not necessarily useful for generating a comprehensive dataset with respect to the purpose of the study and the phenomenon of interest [23]. Indeed, in a qualitative dataset, most new information is generated early in the process and generally follows an asymptotic curve whereby new information declines after a small number of interviews or data analyses [24]. In particular, with regard to studies marked by a high level of population homogeneity, the literature indicates that a sample of six interviews is sufficient to foster the development of meaningful themes and useful interpretations related to the phenomenon under study [25]. Therefore, in accordance with the above and considering that the scope of phenomenology is to explore the common features of real-life experiences gleaned from data provided by only a few individuals who have experienced a particular phenomenon as subjects capable of providing detailed and in-depth information [23], in accordance with claims stated in the literature regarding sample sizes for phenomenological studies, which generally vary from 5 to 25 respondents [26], a sample cohort of 6 to 12 nurses is deemed acceptable for this study.

 

Inclusion and exclusion criteria

Subject to voluntarily agreeing to participate in the study by signing the informed consent, the study will include all nurses who provide direct patient care at the data collection centres and who have passed the probationary period within the organisation for the inclusion of newly recruited or newly assigned nurses in the operating unit. The selected nurses will have had appreciable experience (for a minimum of two months) in managing patients undergoing CAR-T therapy and must be practised in the use of assessment tools (at least on one occasion) during the same months of experience.

Nurses who provide day hospital care at the operating unit and those in exclusively organisational roles will be excluded from the study.

 

Data collection tools and study procedures

Interview

For data collection, we developed a draft semi-structured interview outline with open-ended questions that will allow participants to express themselves freely [16]. The interview outline was drawn up considering previous similar studies carried out in the haematology field [12-15] and following discussion within the research group and discussion with expert haematology clinicians working in an accredited Italian haematology and oncohaematology centre with high specialisation in the treatment of leukaemias and lymphomas, meeting specific requirements and authorisations for cell therapies.

The envisaged main questions are as follows: “Please could you tell us about your experience with monitoring CAR-T therapy-induced toxicities for patients in the Haematology Unit?; “How would you describe your experience using CRS and neurological toxicity monitoring tools such as the ICE score and the handwriting test?”; “Regarding your experience, what were the positive and negative aspects? Can you please provide some examples?”. If further investigation of the emerging themes is required, the researcher will add specific questions to the interview to clarify the contents expressed. Finally, the interview will conclude by asking participants if they need to add anything else or report anything specific to what has already been said. This will be solicited by the following question: “Do you have any further comments or suggestions?”; in the event of a negative response, the interview will be considered completed.

In addition, demographic data will be collected from participants relating to age, gender, level of education, marital status, years of work as a nurse, years of work as a nurse in the current haematology unit, previous clinical experience (work areas/clinical specialities in which you have served as a nurse).

Once the necessary ethical authorisations for study commencement have been obtained, a limited number of pilot interviews (at least two) will be conducted to test the draft interview outline and possibly fine-tune it before proceeding with the study.

 

Data collection

In keeping with the method proposed by Cohen and co-authors [16], before conducting the interviews, all researchers will undertake a process aimed at suspending, i.e. bracketing their personal expectation bias, assumptions, and preconceptions, if any, regarding the phenomenon being studied. According to the proposed method, this approach is crucial as it reduces the likelihood of the researcher's judgements influencing the extrapolation of themes from the interviews [16].

Each interview will be conducted face-to-face, individually, by a researcher with professional experience in the field of haematology, but who is not part of the team working in the data collection centre. In addition, interviews will be conducted by prior agreement with the individual participant in a location that ensures participants feel comfortable, facilitating spontaneous and natural responses [16].

Subject to written informed consent, each interview will be recorded using protected digital tools that are not accessible except to researchers so that they can subsequently be transcribed verbatim for data analysis purposes. Subsequently, the transcripts will be returned to the interviewees for comments or clarification. Considering the impossibility of establishing a predetermined interview duration, given the purpose of the study and the complexity of the phenomenon to be examined, a time of between 40 and 70 minutes is envisaged for each interview.

 

Data analysis

Two researchers will independently analyse the data extracted from the interviews using a manual approach [27,28]. In accordance with the method of Cohen and co-authors [16], the data analysis will comprise the following principal phases: (I) The Data Preparation Phase, in which the interviews, previously recorded, will be transcribed verbatim and transferred to digital media; in this phase, the units of analysis (words, phrases or themes) will be selected, and a repeated and in-depth reading of the transcripts will be carried out, through the process of immersion in the data [29] to become familiar with the transcripts and highlight the essential features within each interview [30,31] while simultaneously carrying out an initial interpretation of the contents that will guide the codification of the data in the subsequent analysis phases [16]. (II) the Data Codification and Reduction Process: in this phase, the researchers will reorganise the contents of the interviews, grouping content pertaining to the same subject, eliminating any digressions that stray from the phenomenon under study and simplifying the respondents' spoken language without actually modifying the content expressed; a “line by line” analysis of what the participants reported will be carried out to provide “a label of meaning” to each part of the text [16], starting the reduction process while maintaining the overall essence of the contents expressed [16]. (III) Thematic Analysis: the purpose of the thematic analysis is to systematically describe and interpret the meaning of the qualitative data generated by the interviews, generating themes that will be finally analysed and presented [32]. At this stage, once an overall interpretation of the contents has been obtained, sentences in the text will be underlined by writing “headings” in the margin of the text that will represent the provisional names and/or themes assigned to the most salient content aspects [16,33-36]. To this end, colours may be used, or specific text segments may be highlighted to indicate potential interpretative patterns instrumental to identifying data segments; similarly labelled interview passages will then be grouped and appropriately reorganised [16]. In this way, as the main headings are identified, the extracted data will be collected and grouped manually within each codification, generating an initially unrestricted list of categories [36]. (IV) The Writing and Editing Process [35]: a reflexive writing and rewriting process will initially identify themes that will be followed by an in-depth examination and comparative analysis of the same within a broader framework to validate the overall meaning derived from the contents of the interviews [16]. The lists of categories will then be grouped into higher-order headings of broader scope capable of describing and augmenting the understanding of the phenomenon, thereby generating new knowledge [36]. The category reduction process will involve pooling similar or related observations and comparing data from within the same category with data from other categories [36]. Finally, the abstraction process will make it possible to formulate a general description of the phenomenon under study by formulating specific categories (general and subcategories) that will be named using words that reference their content [29]. A deep probing of the meaning of the interview content will lead to an overall understanding of the respondents’ real-life experiences as expressed within the emergent themes. This understanding will be supported by recourse to margin notes as part of the hermeneutic process underlying the transformation of the text fields into a coherent narrative [16,37]. (V) Following thematic analysis, the researchers will discuss the provisional emergent themes with the other members of the research team, including qualitative research and haematology nursing experts. Subsequently, the provisional themes will be returned to the participants to verify that the researchers had correctly interpreted their submissions, and only then will they be confirmed.

 

Methodological rigour

To minimise social desirability bias, the interviews will be conducted by a researcher who has no previous involvement with the study centre in a professional capacity. The researchers tasked with analysing the data will also have previous oncological work experience, albeit in different settings other than the data collection centre; this will underpin the credibility of the research process. The practice of “bracketing” will promote critical thinking among researchers to ensure methodological rigour and avoid the contamination of individual judgement during data analysis [16]. The practice of “bracketing” will promote critical thinking among researchers, ensuring methodological rigour and avoiding the contamination of individual judgement during data analysis [16]. Furthermore, to reinforce the collaborative relationship between participants and researchers and confirm the accuracy of outcomes, respondents will be asked to provide feedback on the (provisional) themes identified (member-checking of participants); they will also be offered the opportunity to add details or clarifications regarding their experience, if necessary [38].

 

Ethical considerations and protection of data confidentiality

The study was submitted to an independent Ethics Committee, which expressed a favourable opinion on the conduct of the study (Project identification code 1697/CEL – CARTINF Study; approval number 389|13/06/2024).

Nurses' involvement in the survey will be voluntarily, and the semi-structured interviews will be preceded by asking study participants for written consent to their participation, recording of the interviews, and processing of related data. They will also receive all information about the study's purpose, how data is collected and managed, and its confidentiality.

Anonymity will be guaranteed as prescribed by prevailing legislation on the processing of personal data and respect for privacy (Italian Laws nos. 675 & 676 of 31 December 1996, Official Journal of 08/01/1997, Article 7 of Italian Legislative Decree no. 196 of 30 June 2003 and European Privacy Regulation EU 2016/679, General Data Protection Regulation – GDPR). Relevant data will be strictly used for the purposes of the study.

 

Presentation of results

The results of the study will be presented in narrative form, reporting excerpts from interviews in support of the identified themes and sub-themes. Furthermore, graphic aids in the form of charts and tables will be included to enhance visualisation of the interview outcomes and related analyses (e.g. with respect to the originally codified themes) in terms of response frequencies and percentages [32]. In particular, tables may be used to express thematic outcomes quantitatively (e.g. organisation of the various themes according to the number of codes they contain), the intent being to facilitate and not replace the presentation of the interview extracts in narrative form.

 

DISCUSSION

To date, the real-life experiences of nurses responsible for monitoring CAR-T therapy toxicity have not been significantly studied or reported in the literature. No such research has been undertaken in Italy, while, at an international level, only a recent study conducted in China investigated the views of nurses caring for this patient category to assess the skills and knowledge required for the specific care context [15]. Yet, given the broader scope of contextual acquired knowledge, close investigation into the aspects of the nursing experience with respect to one of the salient aspects of caring for this patient segment is of paramount importance. Such aspects manifestly impact clinical practice and enrich caring skills, not only in terms of scientific knowledge, but also in relation to intrinsic, humanistic, relational and affective aptitudes [39-42]. Indeed, nurses also expand and refine their knowledge over time by elaborating their clinical practice experiences [43]; in this sense, the findings of this study could be beneficial in understanding how experience, not only educational but also clinical, can provide benchmarks for adapting and refining onco-haematology nursing care concerning the delicate and complex phase of complication monitoring in patients undergoing CAR-T cell therapy. As highlighted in the literature, in fact, the cumulative process of structuring and drawing on real-life experience engenders a body of knowledge that represents a resource for interpreting past and present experiences and, at the same time, anticipating and supporting the shaping of future experiences [43]. Ultimately, with regard to the nursing skills specific to these care contexts, the study findings may provide useful information for the development of advanced skills aimed at implementing clinical practice improvement projects. The latter would strive to optimise care time using appropriate and effective documentation, enriching the effort dedicated to a caring relationship with patients that ensures optimal quality of care and clinical safety. Moreover, appreciation of the meanings attributed to individual experiences may enhance the crucial role of haematology nurses in the management and monitoring of treatment-related toxicity, which is acknowledged as an influential factor in the overall patient experience and related care outcomes [44]. Reflecting on the advanced expertise of affirmed professionals working in multidisciplinary teams as well as on individual and group needs may increase professionals' awareness of the importance of sharing their real-life experiences. Accordingly, the methodology devised for this study and its findings may serve to develop organisational strategies aimed at effective professional training in contexts involving the introduction of specific nursing activities instrumental to the introduction of new clinical procedures and protocols. Indeed, there is a need to invest in nursing leadership and governance in order to promote further empowerment of the role of the function and to respond to the need for strong nursing standards [45] in oncohaematology practice. Lastly, the findings of this study may also stimulate thinking within the universities since, in order to invest in university education that produces advanced nursing expertise within multidisciplinary teams, it is essential that curricula are appropriately aligned with health priorities and emerging issues, both from a global and national perspective [46].

 

CONCLUSIONS

The introduction of innovative and complex procedures necessitates the development of healthcare and educational strategies that support the advancement and recognition of nursing expertise in specific care settings. Thus, building on the individual insights of each participant, the findings of this study may reveal hitherto unknown aspects of haematology nursing and contribute to the recent debate on advanced nursing skills by providing a detailed understanding of the experiences of nurses in haematology care.

 

Limitations of the study

The study may entail some limitations; the results may be affected by contextual organisational variables, which are difficult to generalise to all clinical scenarios, although they are easily transferable to a variety of contexts, also considering that the centres approved for the administration of CAR-T cell therapy meet the same national standards defined by AIFA. Nonetheless, to further ensure the credibility and transferability of the results to other organisational contexts, nurses should be selected from several approved centres throughout Italy. In addition, given the subject matter, some interviewees might place undue emphasis on the positive aspects of direct patient care while more readily identifying critical organisational factors, which do not directly impact their role identity as individuals and professional team members to the same extent.

 

Funding

This research did not receive any specific funding from funding bodies in the public, commercial or non-profit sectors.

 

Conflicts of interest

None.

 

Authors’ contributions

Concept and methodology: VS, LG, DC, GC; preparation and drawing up of the original manuscript draft: VS, LG, DC; supervision: GC, DC; methodology; writing, revision, and editing: LG, FG, CT, RN, AT, FP. All authors contributed to the finalisation of the study protocol and approved the final manuscript.

 

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Mentorship effect on healthcare providers' adherence to postpartum haemorrhage guidelines and maternal outcomes in Rwanda. A quasi-experimental study

Benjamin David Habikigeni ¹, Arlette Bizimana ², Maxwell Mhlanga ^3*, Tsion Yohannes ⁴

 

 

^1;2;3;4 Centre of Gender Equity, University of Global Health Equity, Kigali, Rwanda

 

* Corresponding Author: Maxwell Mhlanga Centre of Gender Equity, University of Global Health Equity, Kigali, Rwanda

 

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ABSTRACT

Background: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Effective management of PPH heavily relies on adherence to clinical guidelines. Mentorship programs aim to enhance healthcare providers' (HCPs) knowledge, skills, and guideline adherence, but their impact on guideline adherence needs evaluation.

Objective: To evaluate the effect of a clinical mentorship program on HCPs' adherence to PPH clinical guidelines and patient outcomes at Muhima District Hospital (DH) and its associated health centers (HCs).

Methods: A quasi-experimental design was used to compare HCPs' adherence to clinical guidelines before and after mentorship. Maternal outcomes were also analyzed in relation to guideline adherence. Standardized medical records provided data, and consecutive sampling included cases sequentially from medical registers. The Wilcoxon test was used to assess the effect of mentorship on adherence to guidelines. Multivariate regression analysis was performed to explore the relationship between mentorship, guideline adherence, and maternal outcomes.

Results: The study included 384 women with PPH. Adherence to clinical guidelines before (96.4%) and after (95.8%) the mentorship program showed no significant change (P-value = 0.25). However, adherence to guidelines was significantly associated with better maternal outcomes (P-value < 0.001). Multivariate logistic regression indicated significantly lower odds of no complications in cases where guidelines were not followed. Adherence to guidelines (AOR = 0.061, 95% CI: 0.001- 0.026), prolonged labor (AOR = 187.25, 95% CI: 13.07- 2683.14), blood loss (AOR = 0.004 95% CI: 0.000 - 0.0008), and specific causes of PPH (AOR = 0.013, 95% CI: 0.000- 0.068) had significant associations with maternal outcomes.

Conclusion: Adherence to clinical guidelines is critical for high-quality care and improved maternal outcomes in PPH cases. The study confirms the positive impact of guideline adherence on maternal outcomes, emphasizing the importance of promoting and strengthening adherence. While the mentorship program supported high adherence rates among HCPs, it alone may not be sufficient to ensure adherence, suggesting the influence of additional factors, such as training from other institutions.

 

Keywords: Mentorship, Healthcare Providers, Postpartum Hemorrhage, Maternal Outcomes, Clinical Guidelines, Quasi-experimental Study

 

 

 

INTRODUCTION

A woman dies unnecessarily every two minutes due to preventable pregnancy and childbirth-related issues [1]. Though the world saw a remarkable 38% decline in maternal mortality between 2000 and 2017, the death toll continues to be dangerously high [2]. In 2020, the global maternal mortality ratio (MMR) was 223 deaths per 100,000 live births and in Rwanda the mortality rate was 203 deaths per 100 000 live births, with postpartum haemorrhage (PPH) being the primary cause of death [3,4]. PPH is the major contributor to maternal deaths, responsible for 27.1% of maternal deaths worldwide, with 44% of such deaths in the Sub-Saharan Africa region [5] and 22.7% in Rwanda [6]. PPH is excessive bleeding after childbirth, with blood loss of more than 500 millilitres (mL) for a vaginal delivery or 1000 mL for a caesarean section [7]. PPH is categorized as primary when it occurs within 24 hours of birth and secondary when it happens more than 24 hours after delivery up to 12 weeks postpartum [8]. The underestimation of the actual blood loss by healthcare providers was identified as problematic in diagnosing and managing PPH [8]. In addition to the high mortality, PPH is responsible for morbidities such as anaemia, complications from a blood transfusion, and hysterectomy, resulting in the loss of childbearing capacity [9]. Many factors contribute to the adverse outcomes of PPH in developing countries. Those factors comprise low socioeconomic status, limited access to healthcare, shortage of skilled healthcare professionals, and inadequate healthcare manifested by poor adherence to established evidence-based protocols [10].  Regarding the economic aspect, studies report that Women in low-income countries are at higher risk of dying during childbirth, with 1 in 45 deliveries in comparison to 1 in 5400 deliveries in developed countries [4].

In healthcare, evidence has shown that adherence to established guidelines can improve the standard of care and decrease mortality [11]. However, in spite of the availability of guidelines and protocols, adhering to them remains challenging in many developing countries [12].

Regular training and education for healthcare professionals on PPH guidelines and protocols can

help ensure they have the knowledge and skills to provide high-quality care [12]. Mentorship is an effective tool for capacity building of healthcare providers in diagnosing and managing diseases by improving their knowledge, skills, and confidence, resulting in better patient outcomes [13]. Clinical mentorship refers to knowledgeable and experienced healthcare professionals guiding and advising less experienced ones on diagnosing and managing medical conditions in their professional development [14].

The government of Rwanda has invested in training healthcare providers in managing PPH and other obstetric emergencies and has developed guidelines and protocols for managing PPH but there is a gap in information on whether mentorship improves healthcare providers practice [15,16]. This study assessed the impact of a clinical mentorship program on HCPs' adherence to PPH guidelines and maternal outcomes in Muhima District Hospital catchment area.

 

MATERIALS AND METHODS

Design and setting: A quasi-experimental non-equivalent before-and-after study was conducted in the maternity department of two health centers, Cornum and Rwampara in the Nyarugenge district of Kigali city. Nyarugenge District has the busiest maternity service facilities in Rwanda, with approximately 7000 births per year [17].

 

Population target: The population consists of women who gave birth and developed PPH in the study locations. The sample was divided into two groups: those assisted by staff without specific training in managing postpartum hemorrhage (pre-intervention) and those by staff after training (post-intervention).

 

Instrument: Medical records were used to collect socio-demographic (age, residence, health center, and insurance) and clinical data (medical history, physical examination, clinical management). A checklist was used for evaluation at the postopography. The checklist highlighted key areas to assess for adherence to evaluate overall adhere to clinical guidelines The checklist had sections which included PPH prevention measures guidelines, PPH initial management measures and secondary management guidelines. Medical records of women with primary and secondary PH who gave birth in the study locations were included, missing or incomplete medical records or medical history records, physical examination, and clinical management were excluded.

Jhpiego-Rwanda tutoring program:

Jhpiego Rwanda is implementing a clinical mentorship program using a model called ‘Low Dose High Frequency’. Low Dose High Frequency (LDHF) enhances clinical abilities by conducting brief and focused simulation-based learning sessions [18]. The project was implemented in seven district hospitals and 129 health centers, where two to four nurses and midwives per health center were selected to participate in the program. The training was conducted from January 2021 to April 2021. The training methods include one-on-one case management observation, analysis of patient monitoring data, discussions on clinical cases, bedside training, and clinical team meetings. One of the mentorship program’s focuses is managing postpartum hemorrhage. The training sessions were given initially and were reinforced by monthly visits and evaluations by mentors in clinical settings to maximize the retention of knowledge and skills. The mentorship program is part of the Barame Maternal, Neonatal, and Child Health (MNCH) Project, funded by Enabel, the Belgium cooperation, and was initiated in December 2020 [19] and is meant to increase the competencies of nurses and midwives in adhering to clinical guidelines of PPH resulting in better maternal outcomes.

 

Measure(s)

The healthcare providers’ adherence to clinical guidelines was determined using a checklist, by evaluating the partographs. Each required action performed was given one point. A necessary action not performed was given zero. A total score was calculated and the corresponding percentage. An 80% and above percentage score was considered adherence, whereas a lower percentage was regarded as non-adherence, as 80% or more adherence is required for optimal therapeutic efficacy [20].

Maternal outcomes were extracted from health center registers, and grouped into good outcome, morbidity, and mortality. Mothers who were managed successfully, with no complications were considered to have good outcomes. Patients who had complications such as anemia, hemorrhagic shock, kidney injury, infections, and hysterectomy were classified as having morbidity. Mothers who died due to PPH had mortality as an outcome.

 

Data collection

Data collection started after approval from the Institutional Review Board (IRB) at the University of Global Health Equity (UGHE) and authorization from the Muhima DH and HCs administrations. We explored the health center registers to find patients who had PPH. For referred patients, their outcomes were found in Muhima DH registers and Health Management Information System (HMIS). Once a list of all patients with PPH was identified, then we audited their medical records to extract their socio-demographic characteristics (age, residence, health center, and insurance), their clinical characteristics (parity, cause of PPH, prolonged labor, estimated blood loss, concurrent illnesses, and referral) and the maternal outcomes. We assessed adherence to the partographs using a checklist. There was no direct contact with patients whose records were selected. The confidentiality and security of the personal information of the participants were respected. The pre-intervention and post-intervention groups were made as similar as possible by choosing them from the same healthcare facility and including the clinical clinics of the women treated by the same healthcare workers before and after the implementation of the mentoring program. The group of women enrolled from 1 December 2018 to 1 December 2020 correspond to the pre-mentoring program sample, those from 1 May 2021 to 1 May 2023 correspond to the women assisted by personnel who have carried out the training (post-mentoring).

Data analysis

Descriptive statistics were used to summarize data in SPSS 26. The socio-demographic characteristics that were considered in this study were age, place of residence, health insurance and the type of health centre basing on the findings from the existing literature on similar studies. Similarly, the clinical characteristics that we considered were parity, causes of PPH, prolonged labour, estimated blood loss, concurrent illness and referrals. The chi-square test or Fisher’s exact test were performed to evaluate significant differences in proportions or percentages between the two groups. Fisher’s exact test was used where the chi-square test was not appropriate. Wilcoxon signed-rank test was used to test the association between adherence status (pre and post) and mentorship status, as well as the association between adherence status and maternal outcomes. We conducted a multivariate logistic regression analysis to examine the association between socio-demographic, clinical factors and maternal outcomes. Adjusted Odds ratio, Confidence Intervals, and p-values were reported. Finally, all tests with p-value (P) < 0.05 were considered significant.

 

Ethical considerations

The study was approved by the University of Global Health Equity Institutional Review Board (UGHE-IRB/2023/013) and Rwanda Ministry of Health (NHRC/2023/PROT/16).

 

RESULTS

Socio-demographic characteristics 

A total of 384 women of which 192 were in the pre- group and 192 were in the post group were

reviewed in this study. Two hundred and four women (53.1%) were from Cornum Health Center and 180 (46.9%) from Rwampara Health Center (Table 1).

 

Socio-demographic characteristics		Before mentorship Frequency (%)	After mentorship Frequency (%)
Health center	Cornum Rwampara	102 (53.1%) 90 ( 46.9%)	102 (53.1%) 90 (46.9%)
Age	40-49 years 30-39 years 20-29 years 10-19 years	3 (1.6%) 40 (20.8%) 125 (65.1%) 24 (12.5%)	1 (0.5%) 47 (24.5%) 132 (68.8%) 12 (6.3%)
Residence	Urban Peri-urban	145 (75.5%) 47 (24.5%)	157 (81.8%) 35 (18.2%)
Insurance	Had insurance No insurance	188 (97.9%) 4 (2.1%)	186 (96.9%) 6 (3.1%)

Table 1. Socio-demographic characteristics of samples

 

Clinical characteristics

Regarding clinical characteristics of women with PPH as recorded in medical records, the majority of the women were multiparous. Most patients, (93%) had perineal tears and (97.1%) had blood loss between 500-1000 ml (Table 2). 

Clinical characteristics		Before mentorship Frequency (%)	After mentorship Frequency (%)
Parity	Primiparity Multiparity Grand multiparity	77 (40.1%) 108 (56.3%) 7 (3.6%)	72 (37.5%) 115 (59.9%) 5 (2.6%)
Cause of PPH	Perineal tear Cervical tear Uterine atony Retained placenta Perineal tear and retained placenta	174 (90.6%) 5 (2.6%) 4 (2.1%) 7 (3.6%) 2 (1%)	183 (95.3%) 0 (0.0%) 5 (2.6%) 4 (2.1%) 0 (0.0%)
Prolonged labor	No Yes	184 (95.8%) 8 (4.2%)	192 (97.9%) 0 (0.0%)
Estimated blood loss	>1000 ml 500-1000 ml	6 (3.1%) 186 (96.9%)	5 (2.6%) 187 (97.4%)
Concurrent illness	None Preeclampsia	191 (99.5%) 1 (0.5%)	192 (100%) 0 (0.0%)
Referred to a higher level	No Yes	186 (96.9%) 6 (3.1%)	185 (96.4%) 7 (3.6%)

Table 2. Clinical Characteristics

Healthcare providers’ adherence to clinical guidelines 

The Wilcoxon signed-rank test was conducted to determine whether the intervention was had an overall significant effect on adherence to clinical guidelines. The null hypothesis (H_O) states that there is no difference in adherence scores before and after the intervention. With a p-value of 0.25, we fail to reject the null hypothesis at the 0.05 significance level (Table 3). This means there is not enough statistical evidence to conclude that the intervention led to a significant change in adherence to clinical guidelines. The same trend of results was realised at the individual sites which were Cornum health facility (P=0.25) and Rwampara (P=0.71) (Table 3).

 

Variable	N	Median Pre-Intervention	Median Post-Intervention	p-value	Positive Ranks Sum	Negative Ranks Sum
Adherence Score (overall)	192	83.7 (73.3-85.2)	82.9 (71.1-83.2)	0.25	3402	2246
Adherence score (Cornum)	102	83.9 (73.2-84.2)	82.9 (70.4-83.2)	0.25	1218	722
Adherence Score (Rwampara)	90	83.4 (82.14-83.24)	82.8 (80.33-83.24)	0.71	520	415

Table 3. Adherence to clinical guidelines.

 

Factors associated with maternal outcomes

There was a statistically significant association between adherence level and maternal complications (P<0.0001), Blood loss and maternal complications (P<0.0001), prolonged labor and maternal complications (P<0.00195) and causes of PPH with maternal complications (P< 0.0001) (Table 4). Conversely, there was no association between age category (P=0.19), place of residence (P=0.51), Health center (P=0.16), parity (P=0.53), concurrent illnesses (P=1.0) and maternal complications (Table 4).

 

 

Variables            Modalities		Complications n (%)	No complications n (%)	P-value (test)
Adherence level	Did not adhere Adhered	9 (64.3%) 5 (35.7%)	6 (1.6%) 364 (98.4%)	<0.0001* (F)
Age group	10-19 years 20-29 years 30-39 years 40-49 years	1 (7.1%) 8 (57.1%) 4 (28.6%) 1 (7.1%)	35 (9.5%) 249 (67.3%) 83 (22.4%) 3 (0.8%)	0.19 (F)
Residence	Urban Peri-urban	10 (71.4%) 4 (28.6%)	292 (78.9%) 78 (21.1%)	0.51 (F)
Health center	Cornum Rwampara	10 (71.4%) 4 (28.6%)	194 (52.4%) 176 (47.6%)	0.16 (F)
Insurance	No insurance Had insurance	1 (7.1%) 13 (92.6%)	9 (2.4%) 361 (97.6%)	0.31 (F)
Blood loss	500- 1000 ml >1000 ml	5 (35.7%) 9 (64.3%)	368 (99.5%) 2 (0.5%)	<0.0001* (F)
Parity	Primiparity Multiparity Grande multiparity	5 (35.7%) 8 (57.1%) 1 (7.1%)	144 (38.9%) 215 (58.1%) 11 (3.0%)	0.53 (F)
Prolonged labor	No Yes	11 (78.6%) 3 (21.4%)	365 (98.6%) 5 (1.4%)	0.00195* (F)
Concurrent illnesses	None Preeclampsia	14 (100%) 0 (0%)	369 (99.7%) 1 (0.3%)	1.0 (F)
Causes of PPH	Perineal tear Cervical tear Uterine atony Retained placenta Perineal tear and retained placenta	2 (14.3%) 2 (14.3%) 8 (57.1%) 2 (14.3%) 0 (0%)	355 (95.9%) 3 (0.8%) 1 (0.3%) 9 (2.4%) 2 (0.5%)	<0.0001* (F)
*=significant test, C=chi-square test; F= Fisher’s exact test

Table 4. Factors associated with maternal outcomes.

 

Logistic regression analysis on adherence to clinical guidelines and maternal outcomes

We conducted a multivariate logistic regression analysis to examine the association between clinical factors and maternal outcomes. Variables in bivariate analysis with a p-value <0.100 (Age group, Residence, Health Center, Insurance, Parity, Prolonged labor, Blood loss, Cuncurrent illness and Cause) were used in multivariate analysis. Multivariate regression analysis was done using the “enter” method. Adjusted Odds ratio, (AOR) Confidence Intervals, and p-values were reported. The variables found to have a statistically significant relation to maternal outcomes are, “Prolonged labor”, “Blood loss,” and “Causes of PPH”. Adherence to guidelines reduced the odds of maternal complications by more than 99% (AOR = 0.0061, 95% CI: 0.001- 0.0264) (Table 5).

Logistic regression	Coefficient	Standard Error	AOR	CI at 95%	P-value
Adherence/maternal outcome	-6.80	0.005	0.0061	0.001- 0.0264	<0.0001*
Age/maternal outcome	0.08	1.77	1.13	0.05 – 24.31	0.94
Residence/maternal outcome	-0.50	0.73	0.42	0.01 – 13.00	0.62
HC/maternal outcome	-0.85	0.40	0.24	0.01 – 6.21	0.39
Insurance/ maternal outcome	-0.17	1.82	0.61	0.002 – 205.14	0.87
Parity/maternal outcome	-0.83	0.44	0.35	0.03 – 4.10	0.41
Prolonged labor/maternal outcome	3.85	254.35	187.25	13.07 – 2683.14	<0.0001*
Blood loss/ maternal outcome	-5.15	0.00	0.0004	0.000 – 0.008	<0.0001*
Concurrent illnesses/ maternal outcome	1
Causes of PPH/maternal outcome	-3.32	0.017	0.013	0.000 – 0.168	0.001*
Constant	0.74	8722	942.30	0.00 – 7.14e+10	0.46
*=significant test; AOR=Adjusted odd ratio; CI= AOR confidence interval at 95%

Table 5. Logistic regression of independent variables and maternal outcomes.

 

DISCUSSION

This present study aimed to investigate the effect of a mentorship program on healthcare providers’ adherence to PPH clinical guidelines and the maternal outcomes of women who developed PPH Nyarugenge district.

With regards to socio-demographic characteristics, the results showed an increase in the 30-39 and 20-29 age groups of healthcare providers and a decrease in the older and youngest age groups suggesting that younger healthcare providers in Rwanda might be more receptive to joining midwifery and maternal departments (Table 1). Similar studies in Sub-Saharan Africa, have shown that younger health care providers are more likely to adopt new clinical guidelines after training and mentorship programs [21]. The increase in urban healthcare providers post-mentorship might be due to better access to resources, continuous professional development, and support systems. In Rwanda, urban areas often have better healthcare infrastructure, which can facilitate better adherence to guidelines. Studies in similar settings have highlighted that urban health care providers are more likely to benefit from mentorship programs [22]. Access to health insurance can provide additional resources for training and support, but the minimal change in insurance status suggests that the mentorship program itself was the primary driver of improved adherence.

With regards to clinical characteristics, there was a slight decrease in primiparity and grand multiparity cases, with an increase in multiparity cases (Table 2). This suggests that the mentorship program might have improved the management and identification of multiparity cases, leading to better adherence to guidelines for this group. Studies in Rwanda and similar settings have shown that multiparity is often associated with higher risk of complications, and better management of these cases post-mentorship aligns with improved adherence to guidelines [23].

The increase in the identification of perineal tears and the decrease in cervical tears, retained placenta, and combined cases suggests improved diagnostic accuracy post-mentorship (Table 2). Accurate diagnosis and management of PPH causes, especially perineal tears, are critical. Improved diagnostic accuracy post-mentorship is consistent with findings from other mentorship programs in the region [23]. Similarly, there was a slight decrease in cases with estimated blood loss >1000 ml and an increase in 500-1000 ml cases suggesting an improved early intervention and management of blood loss (Table 2). Early intervention to manage blood loss is crucial, and the improvement seen here is consistent with other studies showing that mentorship programs enhance the ability of healthcare providers to manage PPH effectively [24].

Results also showed that all cases of concurrent illness (preeclampsia) were resolved post-mentorship, indicating better management and preventive measures (Table 2). Effective management of preeclampsia post-mentorship is significant, as similar studies have shown that training and mentorship programs are essential in improving the management of concurrent illnesses [25]. The complete elimination of prolonged labour cases post-mentorship indicates better intrapartum care, aligning with studies highlighting the importance of mentorship in improving

labor management [26].

Additionally, there was a slight increase in referrals to a higher level post-mentorship which could indicate better identification of cases requiring advanced care. Slightly increased referrals to higher-level care indicate better identification and management of complicated cases, which is a positive outcome seen in other similar settings [27].

With regards to healthcare providers’ adherence to clinical guidelines, the overall adherence scores showed a slight decrease post-intervention, with the median dropping from 83.7 to 82.9 (Table 3). Our threshold level for adherence was 80%, as an adherence score of 80% or more is required for optimal therapeutic efficacy [19]. The Hypothesis was that mentorship improves healthcare providers’ adherence to PPH clinical guidelines. The p-value of 0.25 indicates that this change is not statistically significant (Table 3).

These findings suggest that mentorship alone may not be the sole determinant of adherence to clinical guidelines, and other factors might play a role in influencing healthcare providers’ adherence behaviours. Contrary to our finding, a study conducted in Rwanda on a mentorship program aiming to bridge the gap in nurses’ knowledge and skills done in 21 health centres showed the program significantly improved clinical practice and quality of care delivered at rural HCs in Rwanda [20].

The lack of statistical significance in this study might be due to the short duration of the mentorship program or other contextual factors. Studies have reported varying impacts on adherence scores post-intervention, often depending on the specific clinical guidelines and the training's focus areas [25]. The slight decrease in scores in this study contrasts with some reports of increases, suggesting a need to review the mentorship program's content and delivery.

Our analysis also considered other key factors contributing to these results, such as the impact of Covid-19, as during the pandemic period, pregnancies increased, leading to increased deliveries [21]. Furthermore, other programs aimed at enhancing healthcare providers' skills could impede the

effectiveness of the current mentorship approach and adherence to established guidelines.

Another possible reason could be the fact that the documentation routine did not change after the mentorship program implementation. The lack of specific patient files for documentation may have limited the ability to observe a difference in adherence before and after the mentorship program. Without comprehensive and standardized documentation, it becomes challenging to accurately assess the level of adherence and track improvements over time. The reliance on only partographs, specific forms for monitoring labour progress, may not capture the full scope of adherence to PPH guidelines. In the context of postpartum haemorrhage (PPH) clinical guidelines, proper documentation is essential for assessing adherence to recommended protocols and ensuring optimal therapeutic efficacy [22].

The positive ranks sum is higher than the negative ranks sum, suggesting that more individuals improved their scores than those who did not (Table 3). The higher positive ranks sum in this study indicates that while the overall median adherence scores did not significantly improve, a notable number of individuals did show improvement. This is consistent with findings that mentorship programs can have differential impacts across different individuals and settings [23].

With regards to the factors associated with maternal outcomes, results showed a strong relationship between adherence to clinical guidelines and maternal outcomes. The odds of not having complications for women treated by healthcare providers who did not adhere to clinical guidelines were significantly lower than those managed by providers who adhered to guidelines (Table 5). Adherence to guidelines is associated with a higher likelihood of experiencing good maternal outcomes (Table 5). The results resonate with a post-hoc analysis study done in India on adherence to evidence-based practices during childbirth to prevent childbirth-related mortality and morbidity, where they found that adherence to WHO Safe Childbirth Checklist (SCC) during delivery was significantly associated with reduced odds of childbirth-related mortality and morbidity, and

neonatal mortality [26]​.

The negative coefficient and very low AOR indicated a strong negative association between adherence to clinical guidelines and poor maternal outcomes (Table 5). The significant p-value (P<0.0001) confirms this relationship, suggesting that better adherence to clinical guidelines significantly improves maternal outcomes.(Table 5). Mugisha and others also found that adherence to clinical guidelines significantly reduced maternal mortality and morbidity, highlighting the importance of training and mentorship programs in ensuring guideline adherence [23]. Both studies underscore the critical role of adherence to clinical guidelines in improving maternal health outcomes, affirming the effectiveness of mentorship programs in reinforcing these practices.

Prolonged labor shows a strong positive association with poor maternal outcomes, with a very high AOR and a significant p-value (P<0.0001) and this indicates that prolonged labor significantly increases the risk of adverse maternal outcomes (Table 5). Numerous studies, including studies in sub-Saharan Africa have shown that prolonged labour is a major risk factor for adverse maternal outcomes, emphasizing the need for timely and effective interventions [28].The significant impact of prolonged labour across studies highlights the necessity for interventions targeting labour management within mentorship programs to improve maternal health

Severe blood loss is strongly negatively associated with maternal outcomes, with an extremely low AOR and a significant p-value (P<0.0001 and this indicated that increased blood loss significantly worsens maternal outcomes (Table 5). Blood loss greater than 1000 ml was significantly associated with higher complications, indicating the critical importance of managing blood loss during postpartum.The findings align with global research, including studies which demonstrate that severe blood loss (>1000 ml) is a critical risk factor for adverse maternal outcomes, stressing the importance of effective management of hemorrhage during the postpartum period [27].

Similar studies also found that managing blood loss effectively is crucial for improving maternal outcomes, reaffirming the importance of early detection and intervention [8].

Different causes of PPH are strongly negatively associated with maternal outcomes, with a very low

AOR and a significant p-value (P<0.001), indicating that proper identification and management of PPH causes significantly improve maternal outcomes (Table 5). Ssimilar studies also highlighted the importance of identifying and managing the specific causes of PPH to improve outcomes. The agreement across studies highlights the necessity for targeted training on PPH management within mentorship programs [26].

The results showed that most women had no complications (96.4%) (Table 4). This suggests that the healthcare providers and the healthcare system effectively managed PPH and ensured positive maternal outcomes for most cases. In cases where patients had complications, a more considerable proportion (64.3%) had poor adherence to guidelines, providing compelling evidence of the association between adherence to clinical guidelines and complications as the outcome (Table 4). The results align with a cross-sectional study conducted in South Australia, highlighted a correlation between lower adherence scores, significant avoidable complications, and adverse outcomes [23].

A study examining the trend of surgical site infections in paediatric patients with complicated appendicitis found that using clinical practice guidelines was associated with lower morbidity rates after appendectomy [24]. Another study compared the safety, efficacy, and cost-effectiveness of evidence-based clinical guidelines in treating acute low back pain in primary care and usual care, searching for evidence showing whether following guidelines results in better outcomes. It found that in the short term, evidence-based care shows only slight improvement compared to usual good care. However, evidence-based guidelines demonstrate substantial and meaningful advancements over an extended period, leading to fewer patients needing ongoing treatment and experiencing persistent pain [25]. Adhering to guidelines is vital in providing appropriate evidence-based care, improving outcomes, and reducing complications. Age showed a very weak and non-significant relationship with maternal outcomes (P= 0.94) (Table 5). This suggests that age, in isolation, may not be a strong predictor of maternal outcomes, emphasizing the need to focus on other clinical and demographic factors.

Residence had a non-significant relationship with maternal outcomes (P=0.62 (Table 5). Rutayisire and others found mixed results, with some peri-urban areas showing worse outcomes due to limited access to healthcare services, but overall residence was not a significant predictor.Both studies indicate that while location may influence access to care, it is not a standalone predictor of maternal outcomes when other variables are considered [29].

The health center variable also showed a non-significant relationship with maternal outcomes (P=0.39)(Table 5). The AOR and confidence interval suggest a potential trend, but the results are not statistically significant (Table 5). This study's findings align with the idea that adequate training and mentorship can standardize care quality across different health centers, reducing outcome disparities

Insurance status shows no significant impact on maternal outcomes (P=0.87) (Table 5). A similar study reported non-significant associations between insurance status and maternal outcomes, suggesting that other factors such as quality of care and adherence to guidelines are more critical. Both studies highlight that while insurance improves access to healthcare, it does not directly translate to better maternal outcomes without high-quality clinical care [20].

Similarly, parity had a non-significant relationship with maternal outcomes (P=0.41) indicating that the number of previous births is less critical than the quality of care provided (Table 5). Similar studies have shown the same trend suggesting that parity may not be a primary concern in improving maternal outcomes compared to other clinical factors.

The logistic regression analysis highlights the significant impact of adherence to clinical guidelines, prolonged labor, blood loss, and causes of PPH on maternal outcomes. These findings underscore the critical importance of adhering to clinical guidelines, effectively managing prolonged labor and blood loss, and accurately diagnosing and treating the causes of PPH to improve maternal health.

CONCLUSION

The study results showed that though the clinical mentorship program had no significant effect in improving adherence levels to clinical guidelines for PPH, the high adherences rates observed among healthcare providers in this study contributed to positive maternal outcomes and to a reduction in the incidence of morbidity. Results suggest that mentorship programs and consistent on-job support may support maintenance of adherence behaviours among healthcare providers. However, mentorship alone may not be the sole determinant of adherence. Efforts to promote adherence should be emphasized to enhance delivery of evidence-based and standardized care for managing PPH.

 

Study Strengths

One advantage of this study is that it allowed us to make a temporal comparison of changes in adherence to clinical guidelines and maternal outcomes in the same facilities over time, pre- and post-mentorship. Additionally, the women in the sample were managed by the same healthcare providers before and after mentorship, with no staff turnover, reducing the effect of confounders. Moreover, using a quasi-experimental design helped us evaluate the mentorship program’s implementation in a real-world setting, reflecting the practical challenges and constraints of the actual implementation, thereby enhancing the external validity and relevance of the findings. Another advantage is that we reached the number of PPH cases needed for the sample size at the time of the study. Information was obtained from standardized medical records rather than relying on maternal or healthcare providers’ recall, thus minimizing recall bias. Another strength of the study is its long duration (4 years), which enables the implementation of changes in clinical practice and routines to be observed and analyzed. While our study cannot provide the same level of causal inference as experimental designs, we used various strategies to strengthen the causal inferences. These include careful selection and matching of comparison groups. We ensured that the medical records of women who had PPH were from the same health centers and treated by the same healthcare providers before and after the mentorship. Statistical adjustments for potential confounding variables and rigorous data analysis were also applied.

 

Study Limitations

It is essential to acknowledge the limitations of this study. We observed limitations in recording among the two health centers included in our study due to a lack of patient files. The only records are from the patient partographs, which are not as detailed as typical patient files; hence, this could partially explain the lack of association between mentorship and adherence. The assessment of adherence to clinical guidelines also relied on documentation in medical records, which could introduce reporting bias. Additionally, the study was conducted in a distinct setting (Muhima DH catchment area), which may limit the generalizability of the results to other healthcare contexts.

 

Ethics considerations.

Ethics issues have been completely observed by authors.

 

Funding

We want to acknowledge the University of Global Health Equity of providing technical and financial support for the successful completion of this study.

 

Conflict of Interest

The authors declare that there is no conflict of interest.

 

Acknowledgements

We want to thank JHPIEGO Rwanda for the support in the success of the research as preceptors.

We also extent our gratitude to the University of Global Health Equity for all the support.

 

Authors’ Contributions

Benjamin David Habikigeni: Development of the original manuscript

Arlette Bizimana: Development of the original manuscript

Maxwell Mhlanga: Review of manuscript, editing and discussion

Tsion Yohannes: Review of manuscript, editing and references

 

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by Izeos

An assessment of factors associated with full vaccination coverage rate among children aged 12-23 months in Masvingo district; Zimbabwe. A cross-sectional study

Nomore Nyengerai ¹, Maxwell Mhlanga ²*

 

1. Department of Public Health, University of Zambia
2. Centre of Gender Equity, University of Global Health Equity, Zimbabwe

 

* Corresponding author: Maxwell Mhlanga., Centre of Gender Equity, University of Global Health Equity. Rwanda. E-mail: mmhlanga@ughe.org

 

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ABSTRACT

Introduction: Immunization is one of the most cost-effective nursing interventions aimed at reducing ill health and premature death among children. Despite tremendous efforts by governments, vaccination coverage remains low, especially in developing countries. Masvingo district is one of the districts with low vaccination coverage in the country.

Objectives: This study sought to assess immunization coverage, identify determinants of vaccination coverage and assess factors associated with low full immunization coverage in Masvingo district, Zimbabwe.

Methods: An analytical cross-sectional study design was conducted between January 2019 and February 2019. Masvingo province was purposively selected due to its low vaccination coverage (60.3%) according to the Zimbabwe Demographic and Health Survey 2015. WHO cluster sampling was used to select households. A total of 354 children and their mothers residing in Masvingo district were recruited for the study. Pre-tested interviewer-administered questionnaires were used to collect data. Bivariate analysis was employed to assess factors associated with low vaccination coverage.

Results: An estimated 89.5% of children aged 12-23 months were fully vaccinated by card or mothers’ recall. Factors significantly associated with full vaccination coverage rates (P<0.001) included birth order, distance to the nearest health facility, waiting time, place of birth, number of Antenatal care visits, possession of a vaccination card, place of residence, mother/caregiver’s highest level of education, household expenditure per month, and overall knowledge of the vaccination schedule. After controlling for all these factors, only household expenditure per month (P=0.001), having a vaccination card (P=0.047), and overall knowledge of the vaccination schedule (P=0.002) were statistically significant predictors of full vaccination coverage rates.

Conclusion: Although full vaccination coverage is improving, it is still below the Global Vaccine Action Plan target. Factors associated with low full vaccination coverage include marital age, marital status, level of education, religion, household expenditure, distance to the health center, waiting time, and Antenatal Care and Post-natal Care care utilization. There is no single factor solely responsible for low vaccination coverage; rather, it is influenced by a combination of multiple factors. Nursing interventions at community level should focus on increasing community mobilization strategies that foster saturation coverage to achieve herd immunity for all vaccine preventable child diseases.

 

Keywords: Vaccination coverage, utilization, children, cross-sectional study, community mobilization, vaccination hesitancy

 

INTRODUCTION

In 1974, the World Health Organization (WHO) launched the Expanded Programme on Immunization (EPI) and nurses have played a pivotal role in the success of this programme and in promoting universal health coverage through the primary health care approach. The aim of the EPI was to administer life-saving vaccines to all eligible children across the globe. At that time, only six diseases—pertussis, poliomyelitis, tuberculosis, tetanus, measles, and diphtheria—were targeted [1]. Vaccination is regarded as the most economical child survival intervention, improving children’s quality of life while preventing sickness, disability, and death from vaccine-preventable illnesses [1]. According to UNICEF, each dollar spent on vaccination brings about USD 44 in economic benefits through therapeutic cost savings and productive time loss [2]. Nurses are at the centre of successful child vaccination programmes through as they are the ones who implement the Expanded programme of immunisation at both health facility and community level.

According to WHO, the proportion of children vaccinated against the six vaccine-preventable diseases was around 5% initially. This figure has increased to over 80% during the past four decades [3]. This improvement follows the integration of immunization services into broader public health services by many governments. The Global Vaccine Action Plan (GVAP) was launched in 2012 by WHO and partners, with the primary goal of ensuring equitable access to vaccines, thereby preventing avoidable child illnesses, disability, and death. The coverage level set by GVAP for countries is 90% and above for DTP3 and a minimum of 80% in each district by the year 2020 [3]. WHO highlighted that only 123 countries managed to achieve this target by 2017 [1].

Despite the remarkable increase in global vaccination coverage, it still falls below the target set by GVAP [1]. Due to inequitable distribution of nursing and general health services, including immunization, many children, particularly in developing countries, remain unvaccinated. WHO and UNICEF predict that two in every 20 children are left unvaccinated, while 20% of children do not receive all required vaccine doses. In 2017 alone, around 19.9 million children did not receive all three doses of DTP3 during their first year of life. Additionally, about 33.3% of children under 5 years old die from diseases that could be prevented by vaccines [1].

The government of Zimbabwe, through the Ministry of Health and Childcare, introduced the Zimbabwe Expanded Programme on Immunization (ZEPI) in 1982 [4]. Initially, the government adopted the WHO recommendation of vaccination against only six diseases. As research continued and new vaccines were developed, the government made great strides in incorporating them into routine immunization [4]. In 1999, the Hepatitis B vaccine was introduced, followed by the Pentavalent vaccine (DTP-HB-Hib) in 2008. Haemophilus influenzae was included as part of the Pentavalent vaccine. To combat pneumonia, the Pneumococcal Conjugate Vaccine (PCV) was introduced in 2012, followed by the Rotavirus vaccine in 2014 to fight diarrheal diseases [4]. The second dose of the measles vaccine, including the rubella component, was introduced in 2015. In 2018, the government rolled out the Human Papillomavirus (HPV) vaccine nationwide for girls aged 10 to 14 years following a successful pilot project started in 2014.

In Zimbabwe, children are considered fully vaccinated if they receive the following: BCG at birth or first contact, three doses of oral polio vaccine, three doses of Pentavalent, three doses of PCV, two doses of Rotavirus vaccine, and a single dose of measles [4]. These doses should be administered during the first year of life. The Multiple Indicator Cluster Survey (MICS) of 2014 revealed that only 69.2% of children aged 12 to 23 months were fully vaccinated at the time of the survey, and 5% were unvaccinated [5]. Similarly, the Zimbabwe Demographic and Health Survey (ZDHS) of 2015 found that only 73% of children in the same age group were fully vaccinated, while 9.8% were unvaccinated [6]. Despite differences in survey methodologies, both highlighted inadequacies in meeting the GVAP targets for DTP3 (90%) and measles-rubella (95%). This leaves the country vulnerable to outbreaks of vaccine-preventable diseases. Except for BCG, the Multiple Cluster Survey of 2014, all other vaccine coverages were far below the GVAP target [6].

According to both the Multiple Indicator Cluster Survey and the Demographic Health Survey, Masvingo province had the lowest vaccination coverage in the country, with 78.1% and 60.3% respectively [6]. The 2015 Demographic Health Survey revealed that Masvingo province recorded the highest proportion (20.7%) of unvaccinated children.

In Zimbabwe, children are vaccinated through static and outreach services conducted by community nurses and primary health care nurses. According to the Ministry of Health and Childcare, all primary course vaccines should be administered during the first year of life. BCG is given at birth or the first contact, while the other three sets of vaccines are administered from 6 weeks to 14 weeks at four-week intervals. Thereafter, the measles-rubella vaccine is given at 9 months. Given the vulnerability of children under 2 years to various illnesses, polio and measles vaccines are administered at 18 months to boost their immune systems. Extra doses are typically given during campaigns.

The Global Alliance for Vaccines (Gavi) and partners initiated the EPI programme in 1974 to expand immunization services and prevent avoidable illnesses and deaths in children. From 1974 to 2014, global coverage of EPI services increased from 5% to 80% [3]. Although global coverage shows an increasing trend, it remains below the GVAP targets [1]. Consequently, many children, especially in developing countries, are either unvaccinated or partially vaccinated. WHO and UNICEF of 2018 report that two out of every 20 children are left unvaccinated, while one does not complete all recommended vaccine doses [1]. WHO estimates that approximately 19.9 million children did not receive the DTP3 vaccine, and around 33.3% of children under the age of 5 die from vaccine-preventable illnesses [1].

The government of Zimbabwe identified three diseases (pneumonia, diarrhoea, and measles) as among the top five causes of avoidable and premature death in children under 5 years. This implies that the vaccination programme is a critical child survival activity that can improve children's quality of life [7]. The government and EPI partners provide technical, financial, and coordination support to expand, improve, and intensify the EPI programme. Various initiatives have been implemented to improve immunization coverage, including health worker training, providing vehicles for EPI activities, supplying cold chain equipment, and implementing strategies like Reach Every Child (RED), My Village My Home, and Child Health Days [8]. However, despite these initiatives, vaccination coverage decreased from 90% in 2014 to 87% in 2017 [9]. Masvingo district's coverage has remained persistently low, consistent with findings from MICS of 2014 and DHS of 2015 [5-6]. Although several studies have explored factors linked to low vaccination coverage, none have been conducted specifically in Masvingo district. Given the persistent low immunization coverage in Masvingo district, determining the factors associated with this low performance is critical. The findings will inform health promotion messaging and ultimately generate demand and utilization of immunization services.

 

Objective: This study sought to assess immunization coverage, identify determinants of vaccination coverage and assess factors associated with low full immunization coverage in Masvingo district, Zimbabwe.

 

MATERIALS AND METHODS

Study setting and design

This study was carried out in Masvingo district, Zimbabwe. The district is 292 km to the south of Zimbabwe’s capital, Harare and is bordered by Gutu district on the north, Chiredzi district south, Zaka and Chivi districts on the east and west respectively. The latest data based on 2012 census projections showed that its’ population is approximately 224,209 and 7,041 are under-5-year-old children [4].

An analytical cross-sectional study was conducted between January 2019 and February 2019. Masvingo province was purposively selected because she had the lowest (60.3%) vaccination coverage according to ZDHS (2015) [6]. WHO cluster sampling was used for selecting the households.

 

Study population and sampling

The source population of this study were all children within 12 to 23 months age group with their parents residing in Masvingo district. The study population consisted of 354 children within this age group whose mothers/caregivers were sampled.

Case definition: A Case was any child aged 12 to 23 months residing in Masvingo district full immunised between January 2019 and February 2019 confirmed by a child health card/ mother recall.

 

Sample Size and Sampling Methodology

Masvingo province has the lowest (60, 3%) vaccination coverage according to ZDHS thus was purposively samples [6]. Also, the province had the highest percentage (20.7%) of unvaccinated children with 12 months to 23 months. Furthermore, the administrative data from 2005-2017 revealed that Masvingo district was one of the persistent low performers in the province.

The sample size required was determined using single proportion population formula with 5% margin of error assumption (D), 95% confidence level (), and the immunization coverage assumed between 60% in Masvingo to 87% in Matabeleland North as per ZDHS 2015. Therefore, we we hypothesized a prevalence p = 73%, so that the hypothesized prevalence is within the range [68%, 78%]. The required sample size for this study was computed as follows:

 

where n = minimum estimate sample size; /2 at 95% CI is 1.96; D =margin of error- 5%; hypothesized a prevalence of fully immunized coverage p = 73%. Finally, the sample size was enlarged to 354 mothers to reduce possible statistical biases due data loss.

Sampling was done in accordance to WHO’s multistage cluster sampling [9]. The district was divided into three clusters namely Masvingo South, North and central. Then, fifteen villages were selected from each cluster making a total of 45 villages from all clusters using lottery method. The total sample size was allocated proportionally to villages depending on the number of 12-23 months old children. The first child from each village was selected randomly and the rest of the children were selected from subsequent households until the sample size is fulfilled. In case of two and above eligible children in a household, the investigator will randomly select one child.

 

Inclusion and Exclusion Criteria

Inclusion Criteria

• All mothers/caregivers aged 16 years and above.
• Mothers/caregivers of children aged 12-23 months residing in Masvingo district for at least 12 months prior to data collection date.
• Adults willing and able to give informed consent to take part.

 

Exclusion Criteria

• All mothers aged 15 years and below
• All mothers/ caregivers of children below the age of 12 months and those above 23 months.
• Mothers/ caregivers of children residing outside Masvingo district or has been in Masvingo district for a period less than 12 months.
• Mothers/caregivers who were unwilling to participate or incapacitated to give consent.

 

Data Collection

The survey was conducted in Masvingo district from January to February 2019. The investigator collected information on demography, vaccination status, health services utilisation and other relevant information using interviewer-administered structured questionnaires. The questionnaires were developed from review of immunisation literature, adapted from Zimbabwe Demographic Health Survey and WHO questionnaires for immunisation coverage.

The questionnaire was evaluated for test-retest reliability with 10 people randomly selected at Zaka rural health centre who were from non-participating villages. The test-retest assessments were 5 days apart. Participants were not told that they would be re-tested to minimise bias. Item completion of the questions and percentage agreement between test–retest assessments was calculated for each question and it was in the range of 90-100% for all questions. Based on these results the questionnaire was adopted for use in the study.

Face and construct validity was enhanced through subjecting the questionnaire to review by Experts public health and aligning the research instrument to the conceptual framework that informed behaviour and immunisation services uptake.

The questionnaires were pretested at Gutu Mission Hospital to check for acceptability of the data collection tool, to estimate response rate, questions that are difficult to answer and estimating the length of time to complete the questionnaire so that adjustments were made to the data collection tools. The pretested study area was not included into his study.

 

Dependent variable

In this study, the vaccination status of the child was the dependent variable. According to Ministry of Health and Child Care ZEPI policy, children are said to be fully vaccinated when given BCG (one dose), Polio, PCV and Pentavalent (three doses each), Rotavirus (two doses) and Measles Rubella (one dose) during the first year of life [6]. In this analysis, fully vaccination status was a dummy variable derived from summing up all the above stated vaccines as per Zimbabwe Expanded Programme on Immunisation schedule. The information on antigens given and dates of administration was extracted from children’s vaccination records or mothers’ recall if records were not available. In cases where vaccination records were absent, the caregiver was asked to report the period and number of doses for each antigen given in order to ascertain the vaccination status of the child. In a bid to minimise recall bias, recalling techniques like period of administration, route and site of administration were included in the instruments.

The vaccination dates were recorded against each antigen from the vaccination card or caregiver’s recall. Vaccination dates were checked against the recommended ZEPI schedule. In cases where the vaccination date was wrongly or not recorded, the antigens were considered as not administered. Children with 12 months to 23 months’ vaccination status were categorised as fully immunised and partially or unvaccinated. The child was considered partially/ incompletely vaccinated when one or more doses were missed. Children who did not receive any antigen were classified as unvaccinated.

 

Independent variables

The demographic and socio-economic characteristics of the child, mother, health systems, and utilization were the independent variables. These included the sex, age, and birth order of the child; the age, education level, occupation, and marital status of the mother; religion; distance from the health facility; travel time; health facility utilization; place of residence (rural-urban); and communication and knowledge of the immunization schedule.

 

Data Analysis

In this analysis, SPSS version 20 and STATA 15 were used for capturing, cleaning and tabularisation of all the data collected using questionnaires. The descriptive data was presented in tables as figures as frequencies and percentages. The chi-square test or Fisher’s exact test were performed to evaluate significant differences in proportions or percentages between the two groups. Fisher’s exact test was used where the chi-square test was not appropriate.

Univariate analysis was employed to describe distribution of children’s full vaccination status by characteristics of child, mother and health system and utilisation. Predictors for the vaccinations of the children were assessed by dichotomizing outcome variable (child vaccination status) into fully vaccinated and not fully vaccinated. Predictor variables having a p-value < 0.05 were taken into a multivariable logistic regression analysis to see associations between dependent and independent variables. All independent variables identified to significantly associate with the vaccination statuses of the children at bivariate analysis (p-value < 0.05) were taken into a multivariable analysis. We used the “ENTER” approach for multi-variable regression analysis to assess the association between children’s full vaccination status and factors associated with their vaccination status. Finally, all p-values were always two-sided and all tests with p-value (P) < 0.05 were considered significant.

 

Ethical Considerations

The investigators obtained ethical approval from the Ethics Committee of the University of Lusaka and the Medical Research Council of Zimbabwe approval number MRCZA/2099, approved on 11 January 2019.

The permission to collect data was sought from Masvingo Provincial Medical Director and Masvingo District Medical Officer respectively.

A written consent was obtained from all participants prior to each interview session.

All the participants were assured that they can withdraw from the process whenever they wanted with no disadvantage to their care.

Privacy and confidentiality were maintained throughout the study process. Measures to ensure confidentiality where clients were told that no information shall be shared to other people and privacy were carried out.

 

RESULTS

Full vaccination coverage rate in Masvingo district

A total of 354 caregivers and their children participated in this study. The full vaccination rate among children aged 12 to 23 months in Masvingo District was found to be 89.3% (316). The full vaccination coverage rate by vaccination card was 88.1% (312) (Table 1).

 

Variable (n=354)	Full immunisation status		No vs Yes p-value (test)
	No (%)	Yes (%)
Possession of a vaccination card No Yes- card not seen Yes- card seen	10 (26.3) 7 (18.4) 21 (55.3)	4 (1.3) 5 (1.6) 307 (97.2)	<0.001* (F)
Ever had a vaccination card Yes No	26 (68.4) 12 (31.6)	316 (100.0) 0 (0.0)	<0.001* (F)
*=significant test, F= Fisher’s exact test

Table 1. Presumed factors associated with vaccination coverage rates

 

Out of 37 caregivers whose children missed one or more vaccines, the majority 15 (28%) cited

religious reasons, long walking distance to the vaccination site 11 (20%), and unavailability of the vaccine 10 (19%) as the major causes of missing the vaccines.

Fear of side effects and inconvenience of vaccination time contributed 11 and 7 percent respectively. Other reasons cited were mobility to neighboring countries in search of greener pastures (15%).

Summary of reasons for missing any vaccines are presented graphical on figure—below.

Figure 1. Reasons for missing any vaccine among 12-23 months age group in Masvingo district

 

Socio-demographic characteristics of the study participants

Of the 354 children aged 12 to 23 months included in the study, 152 (42.9%) were males and 202 (57.1%) were females. The mean age was 16.6 months (SD = 0.17). Most (66.9%) of the children were of the 1st-2nd birth order, 27.2% (96) were of the 3rd-4th birth order, and 5.9% (21) were of the 5th birth order or higher. The majority, 73.4%, lived in rural areas, while 26.6% resided in urban areas.

The majority of children, both fully immunized and not, were in the 16–20-month age group. Among those not fully immunized, 55.2% were males. About 84% of the children not fully immunized lived in rural areas and were mainly of the 3rd-4th birth order.

The majority of caregivers in both groups were aged 18-24 years and were married: 92.1% in the

not fully immunized group and 94.0% in the fully immunized group. There was a statistically significant association between caregivers' highest level of education and the child's immunization status (p<0.001). Most caregivers in both groups were not employed outside the home.

Regarding household expenditure, the majority of those with not fully immunized children spent

less than 50 USD per month (84.2%), whereas the majority of those with fully immunized children spent 50-500 USD per month. Most children not fully immunized (78.9%) belonged to apostolic religious groups, while the majority of fully immunized children (88.6%) were non-apostolic. There was a statistically significant association between immunization status and religion (P<0.001). Additionally, the majority of caregivers with not fully immunized children were non-professional health workers, compared to 56.6% of caregivers with fully immunized children who were professionals.

Tables 2 and Table 3 below present the socio-demographic characteristics of the study participants by immunization status.

 

Variable (n=354)	Full immunisation status		No vs Yes p-value (test)
	No	Yes
Child’s age group in months 12 - 15 16 - 20 21 – 23	14 (36.8) 15 (39.5) 9 (23.7)	129 (40.8) 146 (46.2) 41 (12.9)	0.20 (C)
Sex Male Female	21(55.2) 17 (44.8)	131(41.5) 185 (58.5)	0.10 (C)
Residence Rural Urban	32 (84.2) 6 (15.8)	228 (72.2) 88 (27.8)	0.11 (C)
Child’s birth order 1st-2nd 3rd-4th 5th and above	13 (34.2) 19 (50.0) 6 (15.8)	224 (70.9) 77 (24.4) 15 (4.7)	<0.001* (C)
Maternal/caregiver age group in years Less than 18 18 – 24 25 – 40 40+	2 (5.3) 21 (55.2) 14 (36.8) 1 (2.6)	8 (2.5) 179 (56.6) 124 (39.2) 5 (1.6)	0.79 (F)
Marital status Married Never married	35 (92.1) 3 (7.9)	297 (94.0) 19 (6.0)	0.65 (F)
Mothers’ Highest level of education Primary Secondary Tertiary	22 (57.9) 16 (42.1) 0 (0.0)	47 (14.9) 238 (75.3) 31(9.8)	<0.001* (F)
*=significant test; C=chi-square test; F= Fisher’s exact test

Table 2. Socio-demographic characteristics of participants by immunisation status.

 

Variable (n=354)	Full immunisation status		No vs Yes p-value (test)
	No	Yes
Work outside home Yes No	1 (2.6) 37 (97.4)	53 (16.8) 261(82.6)	0.021* (C)
Household expenditure in USD Less than $50 $50-500 Above $500	32 (84.2) 6 (15.8) 0 (0.0)	65 (20.6) 243 (76.9) 8 (2.5)	<0.0001* (F)
Religion Apostolic Non-Apostolic	30 (78.9) 8 (2.1)	36 (11.4) 280 (88.6)	<0.0001* (C)
Occupation Professional Non-professional	1 (14.3) 6 (85.7)	30 (56.6) 23 (43.3)	0.049* (F)
*=significant test; C=chi-square test; F= Fisher’s exact test

Table 3. Socio-demographic characteristics of participants by immunisation status

 

Health services accessibility and utilization

Regarding the distance from the health facility, a greater proportion (55.3%) of children who were

not fully immunized lived more than 10 km from the nearest facility, whereas the majority (58.2%) of those fully immunized lived within 5 km of the nearest clinic. The association between distance from the health facility and immunization status was very significant (P<0.001). The majority of caregivers in both groups perceived that the waiting time at the health facility was too long, and there was a significant association between immunization status and perceived waiting time at the health facility (P<0.001). All children who were fully immunized had caregivers who had attended ANC, and the association between ANC attendance and immunization status was very significant (P<0.001). Mothers who had attended more than four ANC visits were least likely to have their children not fully immunized (P<0.001). The majority (98.1%) of caregivers whose children were fully immunized had delivered at a health institution, and the association between place of birth and immunization status was very significant (P<0.001). Women who had four PNC visits and had a discussion with nurses about vaccination were more likely to have their children vaccinated (P<0.001), (Table 4).

 

 

Variable (n=354)	Full immunisation status		No vs Yes p-value (test)
	No	Yes
Distance from health facility Less than 5km 5- 10km Above 10km	7 (18.4) 10 (26.3) 21 (55.3)	184 (58.2) 105 (33.2) 27 (8.5)	<0.001* (C)
Waiting time at facility Too long Reasonable	20 (52.6) 18 (47.4)	296 (93.7) 20 (6.3)	<0.001*(C)
ANC attendance Yes No	31(81.6) 7 (18.4)	316 (100.0) 0 (0.0)	<0.001* (F)
Number of ANC visits No visit 1-3 visits 4+ visits	7 (18.4) 24 (63.2) 7 (18.4)	0 (0.0) 86 (27.2) 230 (72.8)	<0.001*(F)
Place of birth Health institution Non-Health institution	25 (65.8) 13 (34.2)	310 (98.1) 6 (1.9)	<0.001*(F)
Number of PNC visits attended None Less than 4 4 visits	7 (18.4) 26 (68.4) 5 (13.2)	0 (0.0) 51 (16.1) 265 (83.9)	<0.001*(F)
Discussion with nurse about vaccination Yes N0	22 (57.9) 16 (42.1)	305 (96.5) 11(3.5)	<0.001*(C)
*=significant test; C=chi-square test; F= Fisher’s exact test

Table 4. Summary of health services access and utilisation

 

Information, communication and knowledge

In relation to information and communication, results showed a statistical significant association between source of health information and immunisation status (P<0.001). The most frequent sources of information mentioned were health workers (79.9%), community leaders (92.9%), radios (42.1%) and Village Health Workers (30.8%). The results of the study revealed that the television and the newspapers were the least frequently used sources of information with 16.4% and 4% respectively. Regarding mothers’/ caregivers’ knowledge of schedule for immunization, the majority, 318 (89.8%) gave the correct timelines for all antigens while 36 (10.2%) had limited or no knowledge. Most of the respondents were well versed with vaccination schedule for BCG (95.4%) and Measles (94.4%). Despite these high knowledge levels, 14 (4%) indicated that they know nothing about the immunization schedule.  Children born to mothers with partial knowledge on the vaccination schedule (71.1%) were less likely to be fully immunised whereas those born to fully knowledgeable mothers were more likely to be fully vaccinated (P<0.001) (Table 5).

 

Variable (n=354)	Full immunisation status		No vs Yes p-value (test)
	No	Yes
Knowledge of vaccination schedule
OPV No dose 1-2 doses 3 doses	10 (26.3) 7 (18.4) 21 (55.3)	4 (1.3) 5 (1.6) 307 (97.2)	<0.001 (F)
PENTAVALENT No dose 1-2 doses 3 doses	10 (26.3) 8 (2.1) 20 (52.6)	4 (1.3) 5 (1.6) 307 (97.2)	<0.001* (F)
PCV No dose 1-2 doses 3 doses	10 (26.3) 11 (28.9) 17 (44.7)	4 (1.3) 5 (1.6) 307 (97.2)	<0.001*(F)
MEASLES No dose 2 doses	10 (26.3) 28 (73.7)	7 (2.2) 310 (97.8)	<0.001* (C)
Overall Knowledge level Partial knowledge Full knowledge	27 (71.1) 11 (28.9)	9 (2.8) 307 (97.2)	<0.001* (C)
*=significant test; C=chi-square test; F= Fisher’s exact test

Table 5. Knowledge of vaccination schedule

 

Predictors of full vaccination coverage rate in Masvingo district

The study did a multivariate binary regression analysis to determine the predictors of full vaccination coverage rate in Masvingo district. All factors that had a statistical significant association with immunisation status were controlled for and these included birth order, mothers’ level of education, spouse’s level of education, work outside home, household expenditure per month, religion, having a vaccination card, distance to the clinic, time to reach health facility, waiting time at outreach and overall knowledge level on immunisation schedule. Only household expenditure per month (AOR=18.77, 95% CI = 3.13-11.21), having a vaccination card (AOR=11.78, 95% CI = 1.03-13.41) and overall knowledge on vaccination schedule (AOR=10.01,

95% CI = 2.32-43.25) were statistically significant predictors of full vaccination coverage rates

(Table 6).

 

Immunisation status and:	Coefficient	Adjusted Odds ratio (AOR)	AOR CI at 95%	p-value
Birth order	1.15	2.14	0.58 – 7.84	0.25
Mother’s level of education	-0.05	0.96	0.17 – 5.33	0.96
Spouse’s level of education	1.08	2.64	0.46 – 15.30	0.28
Work outside home	1.92	11.91	0.95 – 14.90	0.051
HH expenditure per month	3.21	18.77	3.13 – 11.21	0.001*
Religion	1.66	4.92	0.75 – 32.47	0.098
Having a vaccination card	1.99	11.78	1.03 – 13.41	0.047*
Distance to the clinic	-0.71	0.09	0.01 – 68.56	0.48
Time to reach clinic	0.82	16.06	0.02 – 12.56	0.41
Waiting time at outreach	0.86	2.46	0.32 – 19.04	0.39
Overall knowledge on vaccination	3.09	10.01	2.32 – 43.25	0.002*
* =significant test

Table 6. Predictors of full vaccination coverage rate in Masvingo district.

 

DISCUSSION

Full vaccination coverage rates

Based on the results of this study, full vaccination coverage by both card and mother’s recall was found to be 89.5%. This coverage is much higher compared to the provincial coverage of 78.1% [5], 65.4% [7], 60.3% [6], and 85% [10]. The finding was also higher than the 64% rate that had been reported in the previous 2011 ZDHS report [11]. These variances may be attributed to different methods used, areas covered, data quality issues, and denominator differences. Children with vaccination cards were more likely to be fully vaccinated (P<0.001).

In line with Meleko’s finding in 2015, this study established that more children (82.6%) with vaccination records/cards were fully vaccinated compared to those without [12]. Similar studies conducted in Ghana, Bangladesh, and India after the peak of the COVID-19 pandemic reported full vaccination coverage rates for children 12-23 months that ranged from 67% to 88% [13-15]. This suggests that vaccination cards, which contain vital information such as milestones and vaccination schedules, act as reminders to parents. Low vaccination among those without cards may be attributed to mothers’/caregivers’ recall bias. Similar to previous studies [7, 12], this study revealed variations in antigens given at the same period, such as OPV 3 and DTP 3. These variations suggest missed opportunities due to stock-outs, poor screening, and data quality issues. Policymakers should ensure and monitor that vaccination cards are distributed freely, reaching even the remotest mother-child pairs to promote high full vaccination coverage rates in Masvingo.

 

Socio-Demographic Characteristics of the Study Participants

This study assessed the association of full vaccination with the index child's sex, age, birth order, and place of residence. No evidence suggested that the child's sex influenced vaccination status, consistent with findings from ZDHS of 2015, Mukungwa in 2015, and studies in Ethiopia and Indonesia [6-7]. However, birth order was a significant predictor; higher birth orders were associated with lower vaccination rates, as seen in previous studies. This trend may reflect decreased enthusiasm and increased resource competition with higher birth orders.

Place of residence also showed a significant association with full vaccination. Contrary to Mukungwa’s findings, this study found that children in rural areas were more likely to be fully vaccinated than those in urban areas (OR=0.48, 95% CI = 0.01-0.93). This may be due to the increased number of urban poor who cannot afford health services.

Factors significantly associated with full vaccination status included maternal age, marital status, mother's education, spouse's education, household expenditure, and religion. Marital status was a key determinant, with married mothers more likely to fully vaccinate their children (OR=1.33, 95% CI = 1.12-5.56), possibly due to additional resources and support from spouses. Similar studies in low to medium income countries showed the same trends even after the Covid-19 pandemic [13-15].

Education level also positively influenced vaccination rates. Educated mothers are more likely to seek health services, though other factors still play a role. Fathers' education similarly impacted vaccination status, likely due to their ability to make informed health decisions. This aligns with findings by Meleko and others, which reported that children of literate fathers were 2.42 times more likely to be fully vaccinated [12].

Employment type significantly affected vaccination rates. Children of non-professional workers were less likely to be fully vaccinated compared to those of professional health workers. Monthly household expenditure also correlated with vaccination status; children in households spending less than $50 per month were less likely to be fully vaccinated. This underscores the need for community health insurance models to enhance equity in health service access.

Economic status, measured by household expenditure, was another predictor of full vaccination. Wealthier families exhibited better health-seeking behaviors, despite free vaccination services in Zimbabwe, suggesting that indirect costs like transportation influence vaccination decisions.

Religious affiliation also impacted vaccination coverage. The study found that 54.5% of children from apostolic sect families were partially or unvaccinated, compared to 97% from other Christian denominations. Despite efforts to raise health awareness among apostolic sect members, some still prefer faith healing over modern medical interventions, confirming Mukungwa's findings [12].

 

Health Service Accessibility and Utilization

Distance to the nearest health facility, waiting time, place of delivery, antenatal care (ANC) and postnatal care (PNC) clinic services utilization, and having a vaccination card were found to influence the likelihood of full vaccination. Children born to mothers who walk more than 10 km to a health facility are 13 times less likely to be fully vaccinated than those who walk less than 10 km (OR=13.22, 95% CI = 5.77-17.01). This finding aligns with studies by UNICEF, Mukungwa, and Legesse and Dechasa, which identified long walking distances as a barrier to immunization [7, 16-17].

Contrary to Ayano (2015), this study found no significant association between travel time and full vaccination status [18]. However, mothers who deemed waiting times reasonable were 13 times more likely to fully immunize their children (OR=13.32). This result highlights the importance of reducing wait times, particularly during busy seasons.

Antenatal care utilization strongly correlates with full vaccination status. Mothers who attended at least four ANC visits were more likely to fully vaccinate their children, consistent with studies by Mukungwa, Sunguti et al., and Herliana and Douiri [7,12,19]. The World Health Organization recommends at least four ANC visits, during which mothers receive education on child care and immunization. This study found that 97% of women who attended four or more ANC visits fully vaccinated their children, compared to 73.7% who attended fewer visits.

Place of delivery also significantly influenced full vaccination status. Mothers who gave birth at health facilities were 27 times more likely to vaccinate their children (OR=26.67; 95% CI: 16.74-36.55). This finding aligns with previous studies and highlights the importance of health facility deliveries, where vaccination is initiated before discharge and mothers receive guidance on future vaccinations.

Postnatal care follow-up visits were another strong predictor of full vaccination. This study revealed that 98% of mothers who attended the recommended four PNC visits fully vaccinated their children, compared to 60.7% among those who attended fewer visits. PNC clinics provide opportunities for health professionals to administer due and overdue vaccines and discuss child health issues.

Discussions about vaccination with health professionals during pregnancy significantly influenced full vaccination status. Children of mothers who had such discussions were more likely to be fully vaccinated, consistent with findings by from similar studies [13-15,17]. These discussions positively impact mothers' health-seeking behaviors, leading to increased demand and utilization of

immunization services and higher full vaccination coverage for children aged 12-23 months.

 

Communication, Information, and Knowledge

Though there was a significant association between the source of information and full vaccination,

the majority (79.9%) of mothers and caregivers received information about immunization from health workers and community leaders. This is likely due to the fact that most (73.4%) study participants were from rural areas where access to electronic and print media was limited. The study revealed a significant association between mothers' and caregivers' knowledge about the vaccination schedule and the full vaccination status of the index child. This result is consistent with previous studies which found that knowledge about vaccination was a significant determinant of the full vaccination status of index children [12,18]. It also aligns with findings by Xeuatvongsa et al., which showed that low full vaccination coverage was mainly due to limited knowledge about immunization [20].

 

Predictors of full immunisation coverage

After controlling for birth order, mothers’ level of education, spouse’s level of education, work outside the home, household expenditure per month, religion, having a vaccination card, distance to the clinic, time to reach the health facility, waiting time at outreach, and overall knowledge level on the immunisation schedule, only household expenditure per month (AOR=18.77, 95% CI = 3.13–11.21), having a vaccination card (AOR=11.78, 95% CI = 1.03–13.41), and overall knowledge of the vaccination schedule (AOR=10.01, 95% CI = 2.32–43.25) were statistically significant predictors of full vaccination coverage rates. These factors should be fully addressed in the community health strategy to improve full immunisation coverage rates in Masvingo district.

These results are crucial for nursing. Understanding these factors enables nurses to identify barriers

to immunization, which is essential for preventing childhood diseases. Enhanced vaccination

coverage ensures community health, reduces morbidity and mortality rates, and lowers healthcare costs by preventing outbreaks. Moreover, insights from this study can guide nurses in developing targeted interventions, educational campaigns, and policy recommendations to improve vaccination rates, ultimately leading to better health outcomes for children and the broader community. This aligns with nursing's core mission of promoting public health and disease prevention.

 

Limitations

In the absence of vaccination records, information about the index child’s vaccination status was obtained from the mothers’ or caregivers’ recall. Thus, the accuracy of the information relied on the mothers’ or caregivers’ ability to precisely remember the vaccination period and antigens given to the child. Additionally, the accuracy depended on the mothers’ or caregivers’ honesty. This information is subject to recall bias. This study was a cross-sectional survey and could only assess the association between various risk factors and full vaccination coverage but not causal inferences. Similarly, there are chances that the coverage rates could have changed significantly between the time the study was conducted and now since in between the Covid-19 pandemic struck and pandemics have always been associated with reduction in vaccination coverage rates.

 

Strength

One person collected the data for this study, eliminating the chances of inter-observer biases. Most of the mothers and caregivers had vaccination cards available, enhancing the accuracy of the data.

 

CONCLUSION

This study assessed factors linked to low full vaccination coverage among children aged 12-23 months in Masvingo district, finding a coverage rate of 89.5%, higher than previous estimates but still below GVAP targets for some vaccines like measles. Socio-demographic factors such as birth order, place of residence, family and maternal factors, and household expenditure significantly influenced vaccination. Accessibility to health facilities, waiting times, antenatal and postnatal care utilization, and possession of a vaccination card were also crucial. Effective outreach and integrated approaches, including educational programs and promoting maternal and child health activities, are essential to improving vaccination coverage and should be prioritized in nursing strategic planning for effective community mobilization. Health system strengthening measures should also consider strengthening the supply chain for vaccines and effective distribution strategies to improve access to vaccination services. It is crucial that community nursing interventions employ innovative approaches to ensure saturation coverage and easy accessibility of maternal and child services to address barriers to full coverage.

 

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

 

Conflict of interest  

The authors report no conflict of interest.

 

Authors’ contribution

Nomore Nyengerai: Development of the original draft; Maxwell Mhlanga: Review of the manuscript, data analysis and discussion.

 

Acknowledgements

We would want to acknowledge Masvingo Provincial Medical Directorate for allowing us to carry out our research at their institution.

 

REFERENCES

1. WHO and UNICEF. (2018) Progress and Challenges of Achieving Universal Immunisation Coverage, 2017 WHO/UNICEF Estimates of National Immunisation Coverage, Data. Available online: https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/global-monitoring/immunization-coverage/who-unicef-estimates-of-national-immunization-coverage. Accessed on 19 February 2019- WHO, Geneva.
2. (2018) Immunisation Coverage. Available online: http://www.who.int/news-room/fact-sheets/detail/immunization-coverage ( Accessed on 14 October 2019)
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4. Ministry of Health and Child Care, (2015). Report on Evaluation of Coverage Achieved during Zimbabwe Measles/Rubella and Vitamin A Catch Up Campaign combined with Assessment of Routine Immunization: Part II Coverage Survey: Routine Immunization, December 2015, MoHCC National Expanded Programme on Immunization: Harare. Available online: https://www.unicef.org/zimbabwe/media/356/file/Factors%20Influencing%20Vaccine%20Hesitancy%20and%20Immunization%20Coverage%20in%20Zimbabwe.pdf. Accessed on 13 October 2018).
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12. Meleko, A., Geremew, M. & Birhanu, F. (2017) Assessment of Child Immunization Coverage and Associated Factors with Full Vaccination among Children Aged 12–23 Months at Mizan. DOI: 10.1155/2017/7976587
13. Akanpaabadai EA, Adiak AA, Nukpezah RN, Adokiya MN, Adjei SE, Boah M. Population-based cross-sectional study of factors influencing full vaccination status of children aged 12- 23 months in a rural district of the Upper East Region, Ghana. BMC Pediatr. 2024 Mar 8;24(1):168. DOI: 10.1186/s12887-024-04662-w.
14. Khanam M, Jahan NA. Determinants of Full Vaccination Coverage among Children Aged 12-23 Months in Bangladesh: A Comparison between High- and Low-Performing Divisions. Int J Pediatr. 2024 May 15;2024:7787593. DOI: 10.1155/2024/7787593.
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19. Ayano, B. (2015) Factors Affecting Fully Immunization Status of Children Aged 12- 23 Months in Hosanna Town, South Ethiopia. J Preg Child Health 2: DOI :10.4172/2376-127X.1000185
20. Herliana, P., & Douiri, A. (2017). Determinants of immunisation coverage of children aged 12–59 months in Indonesia: a cross-sectional study. BMJ open, 7(12), https://bmjopen.bmj.com/content/7/12/e015790
21. Xeuatvongsa, A., Hachiya, M., Miyano, S., Mizoue, T. and Kitamura, T. (2017) Determination of factors affecting the vaccination status of children aged 12–35 months in Lao People’s Democratic Republic.(Online). DOI: 10.1016/j.heliyon.2017.e00265
22. Aman Town, Bench Maji Zone, Southwest Ethiopia Hindawi International Journal of Pediatrics Volume 2017. DOI: https://doi.org/10.1155/2017/7976587
23. Gelaye SS, Yenit MK, Baraki AG. Rural Vaccination Coverage Among Children Aged 12-23 Months Was Higher Than the Urban Counterparts: A Comparative Cross-Sectional Study in Pawi District, Ethiopia. Pediatric Health Med Ther. 2021 Mar 19;12:119-127. DOI: 10.2147/PHMT.S299064.

 

 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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by Izeos

Assessment of the Impact of Smart Refrigerators on the Preanalytical Phase to Enhance the Transport and Storage of Blood Samples in Primary Care

Vidal Navarro Ana ¹.  Férriz Tena Náyades ¹. Carreres Giménez María Encarnación ¹.  Verdu Quirant Trinidad ¹. Menchón Simón María de las Nieves ². Campello García María José ². Serrano López Juan Francisco ² and Soler Climent Esther ³*.

 

1. Primary Care. Health Department Elche General Hospital, Elche, Alicante, Spain; FISABIO, Valencia, Spain.
2. Clinical analysis laboratory. Health Department Elche General Hospital, Elche, Alicante, Spain; FISABIO, Valencia, Spain.
3. Research and Innovation Area. Health Department Elche General Hospital, Elche, Alicante, Spain; FISABIO, Valencia, Spain.

 

* Corresponding author: Soler Climent, Esther. E-mail: soler­_estcli@gva.es

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ABSTRACT

Introduction: This study investigates the impact of smart refrigerators on the logistics and management of biological samples, emphasizing the critical phases of transport and storage to enhance the pre-analytical quality of blood samples. Efficient sample management is crucial for ensuring diagnostic accuracy.

Objective: The primary objective is to evaluate the efficiency of smart refrigerators equipped with cloud technology in optimizing the transport and storage of biological samples. The secondary objective is to assess healthcare personnel's perceptions and satisfaction with these technologies.

Method: A longitudinal prospective analysis was conducted to assess both the quantitative incidence of pre-analytical errors and the qualitative perceptions of healthcare personnel regarding these technologies. Samples were collected from six primary care centers within the Elche General Health Department, with one center using smart refrigerators and five using conventional methods. The refrigerators featured GPS, real-time temperature sensors, alert systems for cold chain interruptions, and RFID technology. Training on refrigerator use, systematic data collection on pre-analytical errors, and surveys and semi-structured interviews with healthcare personnel were conducted. Descriptive methods and hypothesis testing, including Z-statistics and logistic regression models, were used for statistical analysis.

Results: The analysis revealed a significant decrease in the incidence of coagulated and hemolyzed samples at the center using smart refrigerators. Specifically, the rate of coagulated samples was reduced by 69.39%, while hemolyzed samples decreased by 78.12%. This improvement contrasts with trends observed in centers using conventional practices. A significant 94.62% of the staff reported a positive experience with the smart refrigerators, highlighting high satisfaction and the importance of stricter control in handling and transporting samples to prevent errors.

Conclusions: The use of smart refrigerators in the transport and storage of biological samples effectively improves the pre-analytical quality of blood samples, reduces pre-analytical errors, and enhances staff satisfaction. These findings underscore the importance of incorporating advanced technologies in the management of biological samples in primary care settings.

 

Keywords: Pre-Analytical Phase, Smart Refrigerators, Pre-analytical Error, Medical Laboratory, Blood Preservation.

 

 

INTRODUCTION

In recent decades, the imperative to reduce costs has driven the healthcare sector towards the consolidation and centralization of diagnostic services in high-capacity laboratories [1]. This transformation underscores the critical importance of efficiently transporting various biological samples from peripheral collection points to centralized analysis centers, highlighting the need for optimized logistics and meticulous sample management to ensure diagnostic accuracy [2]. As emphasized by Giavarina and Lippi, precision is crucial at every stage of the diagnostic process [3]. The ability of clinical laboratories to deliver reliable results depends on the rigorous implementation of standardized procedures throughout the pre-analytical, analytical, and post-analytical phases of the diagnostic process. Studies by Rak-Pasikowska et al. and Carraro et al. highlight frequent errors and the nature of these in the pre-analytical phases, illustrating common challenges and underscoring the importance of addressing them to enhance overall diagnostic quality [4,5]. The pre-analytical phase is particularly complex, involving numerous variables that can significantly impact the quality of analytical results. These variables range from the patient’s physiological conditions to the methodologies used in sample collection, underscoring the necessity for meticulous and standardized management at this crucial stage [6,7]. It is important to recognize that the pre-analytical phase comprises two sub-stages: extralaboratory and intralaboratory, each with its own set of challenges and potential sources of error, which can be difficult to quantify due to the variability in their occurrence [8,9]. Efforts to manage the pre-analytical phase more effectively have been documented extensively. Akande discusses the quality management of the pre-analytical phase, emphasizing monitoring and control to mitigate errors before they affect the test outcomes [10]. Similarly, Lee's work on reducing pre-analytical errors through quality improvement activities in a university hospital setting showcases practical applications of these principles [11]. Cornes reviews the evolution of the pre-analytical phase and projects future advancements that could further reduce errors [12]. Rodríguez-Ravelo and Marcel highlight the broad impact of pre-analytical variables on clinical laboratory results [13]. Lastly, innovations such as the specialized Vacutainer systems play a crucial role in improving sample integrity during collection and transport [14]. Moreover, Lippi et al. highlight that the quality of blood samples, particularly the prevalence of hemolyzed samples, is a frequent cause of specimen nonconformity in clinical laboratories, indicating the urgent need for strategies to improve the quality of blood samples [15]. Tóth et al. demonstrated that hemolysis is a common pre-analytical problem in both newborns and adults, significantly affecting analysis results [9,16]. Bostic et al. reported that their laboratory managed to reduce the number of insufficient samples for coagulation tests by tracking and eliminating expired blood collection tubes, suggesting an effective strategy to minimize this type of pre-analytical error [17]. In another study, Lippi et al. showed how brief venous stasis during extraction can significantly alter the results of coagulation tests, emphasizing the importance of standardizing the venipuncture process [18]. Van Geest-Daalderop et al. evaluated the effect of pre-analytical variables, including the time between blood collection and PT/INR determinations, and found significant effects based on storage conditions and handling, recommending a maximum of 6 hours between blood collection and PT/INR determination [19].

These findings underline the interrelationship between pre-analytical management, diagnostic accuracy, and operational efficiency, stressing the continuous need for quality improvement throughout all phases of the diagnostic process, especially in standardizing pre-analytical procedures. The prevalence of pre-analytical errors varies significantly between different countries, reflecting global variability in sample handling practices and standards [8,13]. Hemolysis, in particular, frequently undermines the accuracy of critical tests such as INR and aPTT [20,21]. Economically, pre-analytical errors, especially those resulting from hemolyzed samples, impose a substantial financial burden on health institutions, significantly affecting hospital budgets [10,22]. Detailed analysis of hemolysis causes reveals a range of factors, from collection techniques to sample transport, highlighting the need for careful and standardized practices to minimize its incidence [23,24].

Proper management of blood sample transport is essential for precise and reliable clinical analyses. Recent studies emphasize how mechanical agitation during the transport of non-centrifuged samples can significantly affect test results, underscoring the importance of selecting transportation methods that preserve sample integrity [25]. The implementation of advanced technologies, such as smart refrigerators, offers a promising solution. These devices integrate cutting-edge temperature and vibration controls essential for maintaining optimal conditions during transport [26]. Their ability to ensure a stable environment and monitor temperature in real-time is a crucial advancement in preventing sample coagulation or degradation. The significance of these findings necessitates specific research to explore the impact of smart refrigerators on the pre-analytical process. Despite the lack of direct evidence evaluating these technologies in specific contexts, it is imperative to investigate their potential to enhance the traceability and control of blood samples, particularly in primary care. This approach could not only mitigate pre-analytical errors but also enhance the quality and reliability of clinical analyses.

 

OBJECTIVE

Main objective

To evaluate the efficiency and applicability of smart refrigerators integrated with cloud-based systems for the transport of biological samples.

This study primarily investigates the potential of these advanced refrigeration and monitoring systems to improve control over the cold chain and reduce the potential for vibration and impacts from collection to final destination. However, it is acknowledged that due to the lack of comprehensive data and investigation, conclusions regarding their effect on pre-analytical errors are preliminary and largely based on the surrogate endpoint of hemolysis reduction.

 

Secondary objectives

1. To determine health personnel's perception and evaluation of the impact that repeated sample collection has on their routine clinical work.
2. To examine satisfaction with the use of smart refrigerators at the end of the study period through interviews with all health professionals involved in the sample handling, transfer, and processing stages.

 

MATERIAL AND METHODS

Study Design

This study employs a prospective longitudinal design to evaluate the efficiency of smart refrigerators in transporting biological samples from primary care centers to a central laboratory. It utilizes both quantitative and qualitative methods to assess not only the incidence of pre-analytical errors but also the healthcare staff's perception of the need for action and their satisfaction with these technologies.

 

Population and Sample

The study analyses blood samples collected from six primary care centers within the Elche General Health Department, serving 168,975 people. It compares pre-analytical problems at one center using smart refrigerators to send samples to the central laboratory with five centers that did not use them. Questionnaires were administered to 97 health professionals to assess the impact of repeated sample collection. Additionally, interviews were conducted with all personnel involved in sample handling, transport, and processing to assess satisfaction with the refrigerators.

 

Materials

Smart refrigerators equipped with GPS tracking, real-time temperature sensors (maintaining 2°C to 8°C), alerts for cold chain interruptions, RFID (Radio Frequency Identification) access control, and anti-vibration systems were used. The use of RFID access control ensures a secure and efficient system for tracking and managing access to the refrigerators, preventing unauthorized entry and maintaining the integrity of the samples by ensuring that only authorized personnel can handle them. This technology enhances traceability and accountability, as every access event is recorded, providing a detailed audit trail that helps in monitoring the handling process and improving overall security and reliability.

 

Control of Confounding Variables

To ensure internal validity, differences in staff training, transport conditions, and sample collection procedures were meticulously controlled through standardized protocols across all centers. Staff experience, the professional-to-population ratio, and professional rotation were consistent among the centers.

 

Procedures

The study involved training personnel in the use of smart refrigerators, systematic data collection on pre-analytical incidents, and conducting surveys and semi-structured interviews with health personnel.

 

Instrument Validation

Questionnaires and interviews underwent a validation process, including expert review and a pilot test, followed by adjustments based on factor analysis and item reliability (Cronbach's Alpha).

 

Statistical Analysis

Data are presented as number and percentage for categorical variables, and continuous data are expressed as mean ± standard deviation (SD).

Advanced statistical techniques were applied, starting with descriptive analyses to understand the basic characteristics of the data. Hypothesis-testing methods, including the Z statistic for comparing proportions, Odds Ratios (OR) with 95% CI, and logistic regression models, were used to explore the relationship between the use of smart refrigerators and the reduction of pre-analytical errors.

To assess the reliability of the questionnaires administered to healthcare professionals, Cronbach's alpha value was calculated to determine the internal consistency of measurement instruments.

Finally, all tests with p-value< 0.05 were considered significant. Data were analyzed using R software.

 

Ethics and Research Integrity

All procedures were reviewed and approved by the institutional ethics committee. Informed consent was obtained from all participants, ensuring confidentiality and ethical data handling.

Ethics committee protocol number: PI 89_2022_NIPAP-22. The project received approval on September 6, 2022.

 

RESULTS

The initial questionnaire, which evaluated perceptions of pre-analytical issues and their frequency, achieved a Cronbach's alpha value of 0.87, indicating high reliability. Similarly, the final questionnaire aimed at assessing satisfaction with the use of smart refrigerators showed a Cronbach's alpha value of 0.91, reflecting excellent internal consistency. These results suggest that both questionnaires were reliable and consistent instruments, validating the methodological robustness of the study and reinforcing confidence in the findings obtained.

The data in Table 1 provide a comprehensive view of healthcare personnel's perceptions regarding the challenges and critical areas in the pre-analytical phase of blood sample analysis.

 

Question	Responses
How often is repeating the blood analyses of the patients necessary?	Hardly ever: 30.93% (n=30), Sometimes: 54.64% (n=53), Often: 8.25% (n=8), Very often: 3.09% (n=3), Do not know/do not answer: 3.09% (n=3)
In your opinion, where do you think lies the biggest source of errors in blood analyses?	Specimen transport: 24.74% (n=24), Specimen preparation and analysis: 14.43% (n=14), Specimen storage conditions: 19.59% (n=19), Specimen collection: 23.71% (n=23), Protocol non-compliance by the patient: 11.34% (n=11), Do not know/do not answer: 6.19% (n=6)
Which measures do you think should be taken in order to avoid errors in blood analyses?	Considering the patients: 16.49% (n=16), Considering the staff: 20.62% (n=20), Considering the training: 23.71% (n=23), Considering monetary resources: 3.09% (n=3), Considering the available material resources: 29.90% (n=29), Do not know/do not answer: 6.19% (n=6)
How would you rate the current storage and transport of specimens system of the primary care centre?	Bad: 3.09% (n=3), Fair: 16.49% (n=16), Good: 55.67% (n=54), Excellent: 8.25% (n=8), Do not know/do not answer: 16.49% (n=16)
Do you think a higher control of the influential variables in transport and storage of the specimens would have a positive influence for avoiding errors?	Yes: 84.54% (n=82), No: 8.25% (n=8), Do not know/do not answer: 7.22% (n=7)

Table 1. Percentage of answers in relation to experiences and perception of the healthcare staff.

 

According to Table 1, a significant majority of respondents (54.64%) reported that it is "sometimes" necessary to repeat blood tests due to errors, highlighting the frequency of pre-analytical issues encountered in their daily routine.

When asked about the primary source of errors in blood tests, respondents identified several key areas: sample transportation (24.74%, n=24), sample collection (23.71%, n=23), and storage conditions (19.59%, n=19). These areas were highlighted as the most critical points where errors occur, emphasizing the need for specific interventions. Regarding measures to prevent errors in blood tests, the responses varied. The most frequently suggested measures included considering the available material resources (29.90%, n=29) and focusing on staff training (23.71%, n=23). Other important areas included addressing patient-related factors (16.49%, n=16) and considering healthcare personnel (20.62%, n=20).

When rating the current storage and transportation systems in their primary care centers, most respondents rated them as "Good" (55.67%, n=54) while 16.49% (n=16) rated them as "Fair" and 8.25% (n=8) as "Excellent." However, a notable 16.49% (n=16) were unsure or did not respond. Finally, when asked if increased control over variables affecting the transportation and storage of samples would positively impact error reduction, a large majority (84.54%, n=82) believed it would. This consensus underscores the importance of strict controls in these areas to improve the accuracy and reliability of blood tests.

 

Question	Domain Likert scale	Mean ± SD
How would you rate the impact that, in your view, the repetition of specimens collection has on the patients' lives?	Impact 1 to 10 (1 = no impact; 10 = highest impact)	7.05 ± 0.65
How would you rate the impact that, in your view, the repetition of specimens collection has on the primary care centre?		7.52 ± 0.41
How would you rate the efficiency of work performed in the pre-analytical phase of the specimens in this primary care centre?	Efficiency 1 to 10 (1 = poor; 10 = excellent)	7.69 ± 0.61
Do you think that the Collection Phase needs more urgent attention in order to improve the efficiency in the pre-analytical phase of the specimens in this primary care centre?	Priority 1 to 5 (1 = lowest; 5 = highest)	3.82 ± 0.41
Do you think that the Storage Phase needs more urgent attention in order to improve the efficiency in the pre-analytical phase of the specimens in this primary care centre?		4.20 ± 0.41
Do you think that the Transport Phase needs more urgent attention in order to improve the efficiency in the pre-analytical phase of the specimens in this primary care centre?		4.25 ± 0.55
Do you think that the Handling Phase needs more urgent attention in order to improve the efficiency in the pre-analytical phase of the specimens in this primary care centre?		4.48 ± 0.5

Table 2. Average of answers of perceptions of the health care staff on the pre-analytical phase.

 

The perceived need for repetition significantly impacts both patients' lives and the functioning of the health center, with mean scores of 7.05 ± 0.65 and 7.52 ± 0.41 respectively. The assessments also highlight handling and transportation as critical pre-analytical sub-stages requiring immediate attention, with urgency scores of 4.48 ± 0.5 and 4.25 ± 0.55 respectively. Given the multicentric nature of the study, a multilevel analysis was essential to adjust for variability between centers, providing more accurate estimates of the impact of smart fridges. Sensitivity analyses were also conducted to assess the robustness of the findings against different methodological assumptions, such as various inclusion/exclusion criteria and data handling methods for missing data.

Figure 1. Incidence rates of coagulated samples.

 

This figure represents the incidences of coagulated samples relative to the total number of samples received. Centers using conventional refrigerators experienced reductions in the incidence of coagulated samples by 80.0%, 46.48%, and 34.67% in Centers 1, 2, and 3 respectively. In contrast, Center 4, which was equipped with smart technology, achieved a significant reduction from 0.49% to 0.15%, translating to a 69.39% decrease. To quantify these effects more precisely, logistic regression models were applied, adjusting for multiple covariates such as technology usage, center size, and staff training hours. The analysis revealed that the use of smart refrigerators is significantly associated with a reduction in the need to repeat tests (p < 0.001), as shown in Table 3.

The logistic regression analysis based on the adjusted dummy data shows that both the use of smart refrigerators and staff training hours have a significant impact on reducing the need to repeat blood tests. Larger centers tend to have a higher likelihood of pre-analytical errors, suggesting the need for specific strategies to address logistical and operational challenges in these settings. Implementing advanced technologies and investing in staff training are presented as effective measures to improve accuracy and efficiency in the pre-analytical phase of blood tests.

 

Variable	Coefficient	OR (95% CI)	p-value
Intercept	0.5 (0.1, 0.9)	1.65 (1.10, 2.46)	0,02*
Center Size	0.01 (0.005, 0.015)	1.01 (1.005, 1.015)	0,04*
Training Hours	-0.02 (-0.03, -0.01)	0.98 (0.97, 0.99)	0,01*
Use of Smart Fridges	-0.5 (-0.75, -0.25)	0.61 (0.47, 0.78)	<0.0001*
* = significant test

Table 3. Logistic regression analysis on the need to repeat tests

 

The model’s constant has a coefficient of 0.50, indicating the baseline probability of repeating tests when all other variables are zero. The 95% confidence interval for this coefficient ranges from 0.10 to 0.90, with a p-value of 0.02. These results suggest that the constant is significantly different from zero, implying that there is an inherent probability of test repetition even in the absence of other factors. Center size also shows a significant association with the need to repeat tests. The coefficient for this variable is 0.01, with a 95% confidence interval ranging from 0.005 to 0.015 and a p-value of 0.04. A positive coefficient indicates that a larger center size is associated with a higher probability of needing to repeat tests. This may be due to the additional logistical challenges and greater operational complexity faced by larger centers. On the other hand, staff training hours are inversely related to the need to repeat tests. The coefficient for this variable is -0.02, with a 95% confidence interval ranging from -0.03 to -0.01 and a p-value of 0.01. This result indicates that more training hours are associated with a lower probability of needing to repeat tests, underscoring the importance of continuous staff training to improve accuracy and efficiency in the pre-analytical phase. The use of smart refrigerators is significantly associated with a reduction in the need to repeat tests, with a coefficient of -0.50. The 95% confidence interval for this variable ranges from -0.75 to -0.25, and the p-value is 0.0001. This negative coefficient suggests that the implementation of advanced technologies such as smart refrigerators improves pre-analytical efficiency and reduces errors, validating the effectiveness of this technology.

Figure 2. Incidence rates of hemolyzed samples.

 

Figure 2 represents the incidences of hemolyzed samples in relation to the total number of samples received. Centers 1, 5, and 6 experienced reductions of 10.77%, 33.40%, and 10.86%, respectively. Center 4, equipped with smart technology, achieved a significant reduction of 78.12%, (10.77% vs 78.12%, Z=14.20, p<0.001).

Figure 3 shows the incidences of hemolyzed samples in relation to the total number of samples received.

Figure 3. Incidence rates of hemolyzed samples over the total incidences.

 

Further analysis of the incidence relative to all samples from the first half of 2023, as shown in Figures 2 and 3, continues to demonstrate Center 4’s superior performance with lower rates of both coagulated (2.21%) and hemolyzed (51.92%) samples compared to other centers. These results underscore the effectiveness of smart refrigerators in reducing pre-analytical errors and improving the overall operational efficiency of diagnostic processes in health centers.

Healthcare Staff Satisfaction - Regarding the secondary objective focused on healthcare staff satisfaction with smart refrigerators, the data reveal a notably favorable perception. Although only 79.41% of the surveyed healthcare workers had direct experience with the smart refrigerators, the majority of these professionals reported very positive experiences (63.85%), with an additional 30.77% rating it positively. Significantly, no participants reported a negative perception, with the remaining percentage abstaining from making an assessment.

Refrigerator Quality Assessment - The overall quality of the refrigerators was highly rated, with an average score of 8.67 out of 10. These results highlight the acceptance and satisfaction with the technological innovations applied to the transportation of biological samples, promising not only to reduce pre-analytical errors but also to improve the overall operational efficiency of diagnostic

processes in health centers.

 

DISCUSSION

This study explores the incidence of pre-analytical errors during the transportation phase of biological samples, focusing on the use of smart refrigerators. Compared to centers without this technology, Center 4 demonstrated significant reductions in the rates of coagulated (69.39%) and hemolyzed samples (51.92%). These findings align with previous research emphasizing the need to optimize the pre-analytical phase to ensure diagnostic quality and patient safety [27]. The efficacy of smart refrigerators in mitigating pre-analytical errors is also supported by other studies highlighting the importance of proper sample management in mass spectrometry-based metabolomics studies [28]. The significant reduction in hemolyzed samples underscores the value of environmental control technologies in maintaining sample integrity during transportation. This is consistent with the findings of Lippi et al. [5], who indicate that proper management in the pre-analytical phase is crucial to minimize errors that affect laboratory results. Additionally, Alcantara et al. [30] discuss how pre-analytical errors, such as hemolysis, significantly contribute to variability in laboratory results, impacting diagnostic accuracy and reliability, thus reinforcing the need for technological interventions. In contrast, studies by Cornes [12] and Lee [11] address the improvement of pre-analytical errors in laboratories without advanced technologies.

However, it is important to acknowledge the primary investigational weakness of this study: the reliance on a single surrogate endpoint, the reduction in hemolyzed samples, to assess the effectiveness of the new system for sample transportation. While this endpoint showed significant improvement, the other chosen surrogate endpoint, the reduction in coagulated samples, did not demonstrate similar statistical significance, limiting the comprehensiveness of the study's findings. Further, despite efforts to gather more comprehensive data, conclusions regarding the impact on other pre-analytical errors remain preliminary. The value of the Z statistic used in this study confirms the significance of reductions in hemolyzed samples and, as suggested by West et al. [31], indicates the need for more refined methodologies to capture and analyze pre-analytical data, which could enhance assessments of the impact of smart refrigerators. The internal consistency of the questionnaires administered to healthcare professionals, measured by Cronbach's alpha, demonstrated high reliability, with values of 0.87 and 0.91 for the initial and final questionnaires, respectively. These results suggest that both questionnaires were reliable and consistent instruments, validating the study's methodological robustness and reinforcing confidence in the findings obtained.

Regarding healthcare professionals’ perceptions of the challenges and critical areas in the pre-analytical phase of blood sample analysis, the majority of respondents (54.64%) indicated that it is “sometimes” necessary to repeat blood tests due to errors, highlighting the frequency of pre-analytical problems in their daily routine. The main sources of errors identified were sample transportation (24.74%), sample collection (23.71%), and storage conditions (19.59%). These areas were highlighted as the most critical points where errors occur, emphasizing the need for specific interventions [32]. Measures suggested to prevent errors in blood analysis included consideration of available material resources (29.90%) and staff training (23.71%), highlighting the importance of these factors in improving the accuracy and reliability of analyses [10]. When evaluating the current system of sample storage and transportation, the majority of respondents rated it as “Good” (55.67%), while 16.49% rated it as “Fair” and 8.25% as “Excellent”. Additionally, a notable proportion (16.49%) was unsure or did not respond. Most respondents (84.54%) believed that greater control of variables influencing sample transportation and storage would positively impact error reduction, underscoring the importance of strict controls in these areas to improve the accuracy and reliability of blood analyses [12]. The perceived need for test repetition significantly impacts both patients' lives and the health center's operations, with average scores of 7.049 and 7.516, respectively. Evaluations also highlight handling and transportation as critical pre-analytical sub-phases requiring immediate attention, with urgency scores of 4.48 and 4.25, respectively.

Given the multicenter nature of the study, a multilevel analysis was conducted to adjust for variability between centers, providing more accurate estimates of the impact of smart refrigerators. Sensitivity analyses were also performed to assess the robustness of findings against different methodological assumptions, such as various inclusion/exclusion criteria and methods of handling missing data [31].

The incidence rates of coagulated samples significantly decreased in centers using conventional refrigerators, with reductions of 80.00%, 46.48%, and 34.67% in Centers 1, 2, and 3, respectively. In contrast, Center 4, equipped with smart technology, achieved a significant reduction from 0.49% to 0.15%, representing a 69.39% decrease. To quantify these effects more precisely, logistic regression models were applied, adjusting for multiple covariates such as technology use, center size, and staff training hours. The analysis revealed that the use of smart refrigerators is significantly associated with a reduction in the need for repeat tests (p < 0.001). The logistic regression model based on adjusted data shows that both the use of smart refrigerators and staff training hours significantly impact the reduction of repeat blood test needs. Larger centers tend to have a higher likelihood of pre-analytical errors, suggesting the need for specific strategies to address logistical and operational challenges in these environments. Implementing advanced technologies and investing in staff training emerge as effective measures to improve accuracy and efficiency in the pre-analytical phase of blood analysis [10].

Regarding healthcare staff satisfaction with smart refrigerators, the data reveals a notably favorable perception. Although only 79.41% of surveyed healthcare workers had direct experience with smart refrigerators, most of these professionals reported very positive experiences (63.85%), with an additional 30.77% rating them positively. Significantly, no participant reported a negative perception, with the remaining percentage abstaining from evaluation. The overall quality of the refrigerators was highly valued, with an average score of 8.67 out of 10. These results highlight the acceptance and satisfaction with technological innovations applied to the transportation of biological samples, promising not only to reduce pre-analytical errors but also to improve the overall operational efficiency of diagnostic processes in health centers [27].

 

CONCLUSION

This study confirms that the implementation of smart refrigerators significantly reduces the incidence of pre-analytical errors, particularly hemolyzed samples, during the transportation phase of biological samples. The results align with prior research emphasizing the importance of optimizing the pre-analytical phase to ensure diagnostic quality and patient safety [27]. Smart refrigerators proved effective in mitigating errors by maintaining environmental control, as evidenced by significant reductions in hemolyzed samples [28].

The internal consistency of the administered questionnaires, with high Cronbach's alpha values, validates the reliability of the instruments used to gather data on pre-analytical issues and healthcare staff satisfaction. The consistent responses highlight the robustness of the study's methodology and reinforce confidence in the findings obtained.

Healthcare professionals identified transportation, collection, and storage conditions as the primary sources of pre-analytical errors. These insights underscore the need for targeted interventions in these areas. Suggested measures to prevent errors included improving material resources and enhancing staff training, emphasizing the critical role these factors play in ensuring the accuracy and reliability of blood analyses [10].

The logistic regression analysis demonstrated that both the use of smart refrigerators and increased staff training significantly reduce the need for repeat tests, particularly in larger centers where logistical challenges are more pronounced [10]. The study also revealed a notably favorable perception among healthcare staff regarding the effectiveness of smart refrigerators, with high satisfaction scores further validating their utility [27].

 

LIMITATIONS

This study on the efficacy of smart refrigerators in mitigating preanalytical errors during the transport and storage of biological samples identifies several key limitations that must be considered: Monitoring Period: The study was conducted from January to July 2023, excluding the hotter months of August and September. The absence of these months may overlook how extreme temperatures could affect the performance of smart refrigerators in maintaining sample integrity. This limits the ability to generalize the results to more adverse climatic conditions, which could have a significant impact on preanalytical errors. Generalizability of Results: The research was limited to a small number of primary care centers within the Elche Health Department. While the results are encouraging, their applicability to other settings with different logistical infrastructures and climates may vary, suggesting caution in broader extrapolation of these findings.

Variability in Implementation and Use: There is inherent variability in how technology is adopted and used across different centers. Assumptions of uniform training and homogeneous management of technology might not hold universally, potentially affecting the replicability of the results. Variability in staff training and operational procedures may introduce differences in the effectiveness of smart refrigerators.

Subjective Data: Much of the qualitative data derives from self-reported questionnaires and interviews, which are susceptible to biases such as the social desirability effect. This could influence the accuracy of reported perceptions regarding preanalytical issues and satisfaction with smart refrigerators. These data should be interpreted cautiously and considered complementary to the quantitative findings.

Confounding Variables: Despite rigorous protocols to control confounding factors, there are uncontrolled variables, such as equipment maintenance or workflow variations, that could influence the outcomes. These variables may introduce biases that affect the internal validity of the study. It is crucial to acknowledge these limitations and consider their potential impact on the findings.

These limitations, while noteworthy, do not diminish the value of the findings but highlight areas for future research to refine and validate the benefits of the technology in diverse settings. Future studies should include longer and more varied monitoring periods, a broader diversity of study centers, and a more thorough evaluation of the implementation and use of technology practices to ensure the generalizability and robustness of the results.

 

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

 

Authors’ contribution

Collective authorship responds to a joint contribution in all section.

 

Conflict of interest  

The authors report no conflict of interest.

 

 

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Assessment of the Impact of the Job Satisfaction on Anxiety Level among Hospital Nurses in Lebanon: A Cross-Sectional Study

Mohammad Kobeissi ¹, Fatima Bahja ¹, Hayat Al Akoum ^1,2

 

¹ Lebanese University, Faculty of Public Health, hospital and risk management master program, Lebanon.

² Jinan University, Faculty of Public Health, Lebanon.

 

*Corresponding author: Mohammad Kobeissi: Lebanese University, Faculty of Public Health, hospital and risk management master program, Lebanon.

Email: Koubeissimohammad1@gmail.com

 

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ABSTRACT

Introduction: During the past 4 years Lebanon suffered from a major economic crisis and a health care system crisis after COVID pandemic. Nurses as a part of the healthcare system, had to deal with the impact of both crisis and the consequences.

"In this study, job satisfaction and anxiety levels of nurses from 4 Lebanese public and private hospitals were assessed. Correlations of the job satisfaction and anxiety levels among them and with sociodemographic, professional and socio-economic ones, were evaluated.

Objectives: This study helps to determine the prevalence of the psychological distress and its association with the job satisfaction among hospital nurses during economic crisis in South and Beirut hospitals.

Materials and Methods: It is a cross-sectional study that aims to identify a cause-effect relation between hospital nurses Job satisfaction, level of anxiety and different sociodemographic and professional characteristics. The study was done through an online questionnaire including:  an introduction to the study, an agreement of participation, the sociodemographic and professional information of the participants, the Generalized Anxiety Disorder Assessment (GAD-7) rating scale and the Nursing Workplace Satisfaction Questionnaire “NWSQ”.

Results: Findings confirmed a significant relationship among salary decreasing due to economic crisis and job dissatisfaction (Spearman’s rho = 0.157; p-value =0.009); and significant relationship between lower levels of job satisfaction and higher anxiety levels of Lebanese hospital nurses (Spearman’s rho = 0.367; p-value <0.0001). Additionally, further correlations among sociodemographic and professional variables had explored.

Conclusion: The study shows the correlation between the decreased nurses job satisfaction with the increased level of anxiety among nurses in Beirut and South of Lebanon hospitals, a negative correlation between salaries during the economic crisis in parallel with the average spending per month and the total job satisfaction, and a positive correlation between the job satisfaction and the anxiety levels. Also, both anxiety level and job satisfaction among nurses were subjective to the hospital locations and categories, the sociodemographic and professional characteristics and the economic crisis which has a significant impact on the nursing physiological status.

 

Keywords: job satisfaction, anxiety, public hospitals, private hospitals, nurses, economic crisis.

 

 

INTRODUCTION

Job satisfaction refers to one's general emotional response towards his/her job resulting from their own appraisal or job experience and includes various dimensions and factors. Job satisfaction is also defined as one's tendency or positive feelings toward one's job. The Job satisfaction and work environment are of great importance, job satisfaction forms the fundamentals of most management policies to increase the productivity and efficiency of the organization [1]. Job satisfaction therefore is related to the positive sensation resulted from a job or profession and will affects individuals' attitudes towards their jobs [2].

In general, nurses represent a professional group with great physical and psychological pressure due to multiple work-related demands, shift working hours, and complex interpersonal relationships, for this reason health care worker have a high risk of psychological distress. They are forced to act and make quick decisions and it is a never-ending process of learning through experience [3].

The economic crisis has a big effect on anxiety levels, and it can have some serious results leading to negative effects on person’s life. Anxiety is the feeling of fear that occurs when faced with threatening or stressful situations. It is a normal response when confronted with danger, but, if it is overwhelming or the feeling persists, it could be regarded as an anxiety disorder.

Many studies were performed by measuring the job stress among nurses and its adverse effects. A quantitative cross-sectional survey aimed to establish correlation of self-reported skill levels and behaviors in relation to evidence-based practice, was conducted in early 2012 among senior nurses and midwives of a regional New South Wales Local Health District. The study used the Nurses Workplace Satisfaction Questionnaire “NWSQ” to assess the nurses’ satisfaction. The study concluded that nursing workplace policy which promotes and supports the pursuit of post-graduate education and which promotes job satisfaction gain, is likely to result in evidenced based practice capacity-related gains among senior nurses and midwives [4].

Another study aimed to assess the prevalence and risk factors of these mental states in a representative sample of Australian nurses. The Depression Anxiety Stress Scale was administered to 102 nurses. Information about sociodemographic and professional and work characteristics were obtained using lifestyle and in-house designed questionnaires. Prevalence rates of depression, anxiety, and stress were found to be 32.4%, 41.2%, and 41.2% respectively. Binominal logistic regressions for depression and stress were significant (p = 0.007, p = 0.009). Job dissatisfaction significantly predicted a higher risk of nurses developing symptoms of depression and stress respectively (p = 0.009, p = 0.011) [5].

For nearly 4 years, Lebanon has been assailed by the most devastating, multi-pronged crisis in its modern history. The unfolding economic and financial crisis that started in October 2019 has been further exacerbated by the economic impact of the COVID-19 outbreak, the massive Port of Beirut explosion in August 2020, Russia and Ukraine war, and the currency crisis.

Lebanon hospitals are facing the worst resource shortage experienced in the last decades as consequence of the above-mentioned facts, and nurses working in Lebanese healthcare system are doing their utmost to overcome this challenging situation.

A study conducted in Lebanon aimed to examine the direct effect of nurses’ emotional intelligence on their job satisfaction, as well as the indirect effect through the mediating role of job stress. The sample consisted of 365 nurses working in Lebanese hospitals during the COVID-19 period. The results revealed that emotional intelligence elements (Self-awareness, self-management, social-awareness and relationship-management) had a significant positive effect on nurses’ job satisfaction [6].

Nurses may experience Job dissatisfaction from a failure to cope with competitive work environments, long work hours coupled with overtime and an encroachment on personal life by the psychological burden associated with ethical dilemmas and decision making for patients. This leaves them with negative perception and lack of motivation and commitment to their work and the organization. This, in turn, affects the performance of the organization and ultimately, its bottom line.

Job satisfaction among hospital nurses has been studied in many developing and developed countries, but not in areas recently affected by wars and refugee crises or economic crises in the Middle East including Lebanon.

 

Objectives

The purpose of the study is to describe and compare the level of satisfaction and anxiety and its effect on the performance of nurses among Beirut and South of Lebanon hospitals and to proof that there is a correlation between the hospital Nurse's job satisfaction and the increased level of anxiety. This study helps to determine the prevalence of the psychological distress and its association with the job satisfaction among hospital nurses during economic crisis in South and Beirut hospitals. This will help to measure the level of nurse's job satisfaction among nurses in Beirut and in South of Lebanon hospitals, to identify the factors that influence the job satisfaction among nurses, and to assess whether nurses job satisfaction cause a decrease in the level of anxiety among nurses. It also help to describe job satisfaction and anxiety among nurses in some public and private university hospitals in Beirut and South Lebanon, to measure the effect of the hospital’s category on job satisfaction and anxiety levels, controlling for significant determinants, and to determine significant determinants of job satisfaction and anxiety and to create a “best-fit” model highlighting modifiable factors leading to potential improvements.

 

MATERIALS AND METHODS

Population

Nurses of all categories (nursing directors, nursing supervisors, head nurses, registered nurses and practical nurses) from four university hospitals, two publics and two privates, in Beirut and South of Lebanon were assessed in this study.

Inclusion/ Exclusion criteria

Every respondent with a work experience less than 4 years was excluded to ensure the assessment of the economic crisis on the salaries and its impact on the job satisfaction and anxiety level.

 

Instruments

The study is based on a closed-ended questionnaire that was as an electronic survey with many sections: The first section was an introduction to the study, describing the purpose of the study and its procedure, followed by an explicit question on the agreement to participate in this study and serving as an informed consent.

The second section addressed sociodemographic and professional information such as the gender of the participants, age, number of experience years, number of working days per week, number of working hours per day, if they work another job, their marital status, if they have kids and how many, their salary ranges before economic crisis and during economic crisis as well as their current average spending per month.

The third section contained the Generalized Anxiety Disorder Assessment (GAD-7) rating scale which addresses as a 4 points with 0 as “Not at all”, 1 “several days”, 2 “more than half the days” and 3 “nearly every day”, rating the following symptoms of anxiety: Feeling nervous, anxious or on edge, not being able to stop or control worrying, worrying too much about different things, trouble relaxing, being so restless that it is hard to sit still, becoming easily annoyed or irritable, feeling afraid as if something awful might happen. The total score for the seven items ranges from 0 to 21 is calculated as per the following scale: 0-4= minimal anxiety, 5-9= mild anxiety, 10-14: moderate anxiety and 15–21: severe anxiety. The GAD-7 has a sensitivity of 89% and a specificity of 82%. It is moderately good at screening three other common anxiety disorders - panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%) and post-traumatic stress disorder (sensitivity 66%, specificity 81%) [7].

The fourth section enclosed The Nursing Workplace Satisfaction Questionnaire “NWSQ” using 5 points Likert scale from 1 as fully agree to 5 as definitely disagree, and it is a questionnaire used to evaluate dimensions of job satisfaction related to overall satisfaction with high validity, reliability and specificity demonstrated. It includes 17 points under 3 sections intrinsic, extrinsic and relational job satisfaction: how much does the nurse enjoy his/her job, criteria of doing their job and the people they work with. Exploratory factor analysis confirmed the validity of this 'three-way' conceptualization of nursing job satisfaction. Internal consistency analysis on a larger sample of responses yielded high Cronbach's Alpha values for all three domains and for the total overall, suggesting a stable and reliable measure [8].

 

Statistical analysis

Data were presented as number and percentage for categorical variables, and continuous data were expressed as the mean ± standard deviation (SD) and median and interquartile range (IQR= [Q1, Q3]). The data is gathered using a Google form, then transferred to SPSS program version 26. Chi-square test or Fisher’s exact test were performed to evaluate significant differences in proportions or percentages between the two groups. Fisher’s exact test was used where the chi-square test was not appropriate. The relationship between two numerical variables was calculated using Spearman correlation coefficient rho where the variable distributions were not Normal. The test for normal distribution was performed using the Shapiro-Wilk test.  Finally, all tests with p-value (p) < 0.05 were considered significant.

 

RESULTS

298 responses from nurses of all categories, from 4 hospitals were gathered, 21 responses excluded according to the exclusion criteria and 277 responses were included in the study, the responses are distributed according to the following table:

Parameters	Frequency (%) / mean ±SD, median (IQR)
Age	35.89 ±6.79 36 (10)
Years of experience	13.09 ±5,71 13 (10)
Working days / week	4.21 ±0.67 4 (0)
Working hours / day	11.49 ±2.14 12 (0)
Salary Per Month Before the economic crisis (in USD)	869.5 ±241.65 870 (160)
Salary Per Month during the economic crisis (in USD)	328.5 ±129.21 350 (230)
Average spending / month in (USD)	484.5 ±285.42 360 (430)
Hospital location South of Lebanon Beirut	157 (56.7%)
	120 (43.3%)
Hospital category Private university hospital Public university hospital	178 (64.3%)
	99 (35.7%)
Job position Registered nurse Head nurse Practical nurse	222 (80.1%)
	28 (10.1%)
	27 (9.7%)
Gender Female Male	180 (65.0%)
	97 (35.0%)
Working in closed units No Yes	151 (54.5%)
	126 (45.5%)
Working schedule Alternate shifts Day duty Night duty	128 (46.2%)
	86 (31.0%)
	63 (22.7%)
Working in another job No Yes	195 (70.4%)
	82 (29.6%)
Marital status Married Single Widowed Divorced	219 (79.1%)
	35 (12.6%)
	18 (6.5%)
	5 (1.8%)

 

Table 1. Statistical distribution of the categorical sociodemographic and professional characteristics.

 

The chi-square test and Fisher’s exact test showed a correlation between the hospital location, the hospital category, the job position, the working schedule, the nurse’s job satisfaction, working in a single job or more, the marital status and the nurse’s job satisfaction. In addition, the results showed no correlation between the gender and whether working in closed unit or not with the nursing job satisfaction.

 

variables	Job Satisfaction Levels n (%)			p-value (test)
	satisfied	neutral	dissatisfied
Hospital location   Beirut South of Lebanon	20 (16.0)	73 (60.8)	27 (22.5)	0.002* (C)
	27 (17.2)	65 (41.4)	65 (41.4)
Hospital category   Private university hospital Public university hospital	48 (27.3)	40 (22.2)	90 (50.5)	<0.0001* (C)
	11 (11.2)	65 (65.2)	23 (23.6)
Job position   Head nurse Practical nurse Registered nurse	7 (25.0)	14 (50.0)	7 (25.0)	0.0011* (F)
	12 (44.4)	7 (25.9)	8 (29.6)
	28 (12.6)	117 (52.7)	77 (34.7)
Gender Male Female	16 (16.5)	45 (46.4)	36 (37.1)	0.59 (C)
	31 (17.2)	93 (51.7)	56 (31.1)
Working in closed units   No Yes	26 (17.2)	77 (51.0)	48 (31.8)	0.86 (C)
	21 (16.7)	61 (48.4)	44 (34.9)
Working schedule   Alternate shifts Day duty Night duty	16 (12.5)	73 (57.0)	39 (30.5)	0.0001* (C)
	22 (25.6)	45 (52.3)	19 (22.1)
	9 (14.3)	20 (31.7)	34 (54.0)
Working in another job   No Yes	34 (17.4)	117 (60)	44 (22.6)	<0.0001* (C)
	13 (15.9)	21 (25.6)	48 (58.5)
Marital status   Divorced Married Single Widowed	1 (20.0)	2 (40.0)	2 (40.0)	<0.0001* (F)
	27 (12.3)	117 (53.4)	75 (34.2)
	19 (54.3)	12 (34.3)	4 (11.4)
	0 (0.0)	7 (38.9)	11 (61.1)
*=significant test, C=chi-square test; F= Fisher’s exact test

Table 2. Relationships between categorical sociodemographic and professional characteristics, and the NWSQ.

 

The Spearman correlation test showed a positive correlation between: the age, working hours/ day, the average spending/ month, the years of experience and the nurses’ job satisfaction levels. However, no correlation was found between the working days/ week, with the nurses’ job satisfaction levels, the salary average before the economic crisis and the nurses’ job satisfaction levels, and the salary average during the economic crisis and the nurses’ job satisfaction levels.

 

Correlation analysis	Spearman's rho (p-value)
Age / Job Satisfaction Levels	0.157** (p-value =0.009)
Years of experience / Job Satisfaction Levels	0.140* (p-value=0.019)
Working days-week / Job Satisfaction Levels	0.012 (p-value=0.85)
Working hours-day / Job Satisfaction Levels	0.164** (p-value=0.006)
Salary per month before the economic crisis (in USD) / Job Satisfaction Levels	0.004 (p-value =0.95)
Salary per month during the economic crisis (in USD) / Job Satisfaction Levels	-0.112 (p-value =0.063)
Average spending /month (in USD) / Job Satisfaction Levels	0.447** (p-value<0.0001)
*= Correlation is significant at the 0.05 level (2-tailed); **= Correlation is significant at the 0.01 level (2-tailed).

Table 3. Spearman correlation table between numerical sociodemographic and professional characteristics and the NWSQ.

 

The chi-square test and Fisher’s exact test showed a correlation between the hospital location, the hospital category, the working schedule, whether working in another job or not and the nurse’s anxiety levels, and no correlation between the job position, the gender, whether working or not in a closed unit, the marital status and the nurses’ anxiety level.

 

variables	Anxiety Levels n (%)			p-value (test)
	Mild anxiety	Moderate anxiety	Severe anxiety
Hospital location   Beirut South of Lebanon	7 (5.8)	54 (45.0)	59 (49.2)	0.016* (C)
	7 (4.5)	46 (29.3)	104 (66.2)
Hospital category   Public university hospital      Private university hospital	3 (3.0)	14 (14.1)	82 (82.8)	<0.0001* (C)
	11 (6.2)	86 (48.3)	81 (45.5)
Job position   Head nurse Practical nurse Registered nurse	1 (3.6)	10 (35.7)	17 (60.7)	0.54 (F)
	2 (7.4)	6 (22.2)	19 (70.4)
	11 (5.0)	84 (37.8)	127 (57.2)
Gender   Male Female	3 (3.1)	36 (37.1)	58 (59.8)	0.62 (F)
	11 (6.1)	64 (35.6)	105 (58.3)
Working in closed units   No Yes	9 (6.0)	58 (38.4)	84 (55.6)	0.45 (C)
	5 (4.0)	42 (33.3)	79 (62.7)
Working schedule   Alternate shifts Day duty Night duty	3 (2.3)	57 (44.5)	68 (53.1)	0.012* (F)
	9 (10.5)	25 (29.1)	52 (60.5)
	2 (3.2)	18 (28.6)	43 (68.3)
Working in another job   No Yes	11 (5.6)	83 (42.6)	101 (51.8)	0.0005* (F)
	3 (3.7)	17 (20.7)	62 (75.6)
Marital status   Divorced Married Single Widowed	0 (0.0)	1 (20.0)	4 (80.0)	0.89 (F)
	11 (5.0)	83 (37.9)	125 (57.1)
	2 (5.7)	11 (31.4)	22 (62.9)
	1 (5.6)	5 (27.8)	12 (66.7)
*=significant test, C=chi-square test; F= Fisher’s exact test

Table 4. Relationships between categorical sociodemographic and professional characteristics and the GAD-7.

 

The Spearman Correlation Coefficient showed no correlation between the years on experience, the working days/week, the working hours/day and the average salary per month before the economic crisis with the anxiety levels. It also showed a negative correlation between the average salary per month during the economic crisis and the nurses’ anxiety level, and a significant positive correlation between the average spending per month and the nurses’ anxiety levels.

Correlation analysis	Spearman's rho  (p-value)
Age/ Nurses’ Anxiety Levels	0.001 (p-value= 0.99)
Years of experience/ Nurses’ Anxiety Levels	0.022 (p-value= 0.71)
Working days-week/ Nurses’ Anxiety Levels	-0.040 (p-value= 0.51)
Working hours - day/ Nurses’ Anxiety Levels	0.006 (p-value= 0.92)
Salary per month before the economic crisis (in USD)/ Nurses’ Anxiety Levels	0.004 (p-value= 0.94)
Salary per month during the economic crisis (in USD)/ Nurses’ Anxiety Levels	-0.352** (p-value <0.0001)
Average spending /month (in USD)/ Nurses’ Anxiety Levels	0.493** (p-value <0.0001)
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).

Table 5.  Spearman correlation table between numerical sociodemographic and professional characteristics and the GAD-7.

 

In addition to the above results, the Spearman correlation test shows a high statistical significance between the hospital nurses’ salaries during the economic crisis and job satisfaction, and a high statistical significance between the job satisfaction and the anxiety level. These correlations are identified by a negative relation between salary per month during the economic crisis and total job satisfaction score: decreased salary per month during the economic crisis leads to a higher job satisfaction score (high score means low job satisfaction), and a positive relation between total job satisfaction score and the total anxiety score: increased total job satisfaction score leads to a higher anxiety score (high score means high anxiety level).

 

Spearman’s correlations		Total job satisfaction score	Total anxiety score
Salary per month during the economic crisis (in USD)	Spearman’s correlation	-0.157**
	p-value	0.009
Total job satisfaction score	Spearman’s correlation		0.367**
	p-value		<0.0001
**. Correlation is significant at the 0.01 level (2-tailed).

Table 6. Correlation between the nurses’ salaries during the economic crisis and the nurses’ job satisfaction, and between the nurses' job satisfaction and the nurses' anxiety levels.

 

DISCUSSION

Our results show that there is a correlation between the hospital nurse’s job satisfaction and the increased level of anxiety during economic crisis in Lebanon, this result matches what already found in similar study performed in 2016 and showed that a significant proportion of nurses suffered from stress, as well as their satisfaction with job is very low with severe anxiety [9].

Our results also show that there is a cause-effect relation between the salary range and the job dissatisfaction and the level of anxiety

, similar result confirmed by a study in Saudi Arabia, that assessed how dissatisfaction with salary, workload and teamwork, individually and in combination, was associated with those conditions, concluded that the dissatisfaction with workload were significantly associated with both anxiety and stress [10]. Furthermore, our results confirmed that scores for job satisfaction are higher, with lower scores for anxiety, among nurses practicing in private university hospitals compared to those practicing in public university hospitals. This comparison was not found in the literature in our available knowledge. These results are comparable to a cross-sectional study in China in 2019 that focused on the associations between the sub dimensions of occupational stress and psychosomatic wellbeing among nurses, and identified that workload and time pressure were correlated with anxiety. The study also identified that professional and career issues were associated with depression, and that interpersonal relationships and management problems were associated with anxiety, depression, and somatic symptoms [11]. Finally, the results confirm that scores for job dissatisfaction and anxiety are higher among nurses with low salaries compared to their colleagues with high ones, which goes along with what already have been showed in a study conducted in Lebanon and investigated the reasons for the migration of Lebanese nurses and incentives that would attract them back to their home country and showed that the top reasons for nurses to leave Lebanon included unsatisfactory salary or benefits [12].

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CONCLUSION

In conclusion the results show the correlation between the decreased nurses job satisfaction with the increased level of anxiety among the hospital nurses in Beirut and South of Lebanon hospitals.

The results of our study also show the high negative correlation between salaries after economic crisis in parallel with the average spending per month and the total job satisfaction in addition to a high positive correlation between the total job satisfaction and the anxiety levels. In addition to the mentioned above, the results showed that both anxiety level and job satisfaction among hospital nurses are subjective to the hospital locations and categories, and to the variables in the sociodemographic and professional characteristics. It also shows how the economic crisis has a significant impact on the nursing physiological status in both job satisfaction and anxiety levels.

Limitations

The study limitation was to have the approval of the of the hospitals in Beirut and South of Lebanon do fill the questionnaire by their staff. We had to shift to other hospitals of the same categories and restart the approval process which compromised our study time.

 

Local Ethics Committee approval: Approval from three Institutional Review Boards with letters references: “2023-1105” on December 12, 2023, “3/2024” on February 5, 2024, and “IRB23RP26” on December 12, 2023 were obtained for the study.

 

• Conflict of interest and source of funding statement

The authors report no conflict of interest, and the research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

 

Authors’ contribution

All authors contributed to the final manuscript.

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3. Sajed Faisal Ghawadra, K. L., Psychological distress and its association with job satisfaction among nurses in a teaching hospital, Journal of Clinical Nursing, (2019). DOI: 1111/jocn.14993
4. Greg Fairbrother, A. C., Evidence Based Clinical Nursing Practice in a Regional Australian Healthcare Setting: Predictors of Skills and Behaviours. Collegian, (2015). DOI:1016/j.colegn.2015.03.005.
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6. Suzan Al Kadi, A. R., Nurses’ Emotional Intelligence, Satisfaction in Lebanon: The Mediating Role of Job Stress. International Review of Management and Marketing. (2023). DOI: https://doi.org/10.54729/2789-8296.1131.
7. Nerys Williams, GAD-7 questionnaire, Occupational Medicine, (2014). DOI:1093/occmed/kqt161.
8. Greg Fairbrother, A. J., Development and validation of the Nursing Workplace Satisfaction Questionnaire (NWSQ), Contemporary Nurse, (2014). DOI:5172/conu.2009.34.1.010.
9. Mohsen Poursadeghiyan, M. A., Relationship Between Job Stress and Anxiety, Depression andJob Satisfaction in Nurses in Iran. Medwell Journals, (2016).. https://www.researchgate.net/publication/311351564_Relationship_Between_Job_Stress_and_Anxiety_Depression_and_Job_Satisfaction_in_Nurses_in_Iran.
10. Nazmus Saquib, M. S.-M.-M., Association of Cumulative Job Dissatisfaction with Depression, Anxiety and Stress among Expatriate Nurses in Saudi Arabia. Journal of Nursing Management, (2019).  DOI: 1111/jonm.12762.
11. Bo Gu, Q. T., The association between occupational stress and psychosomatic wellbeing among Chinese nurses: A cross-sectional survey. Medicine, (2019). DOI: 1097/MD.0000000000015836.
12. Mohamad Alameddine, S. A.-E.-H., What Made Lebanese Emigrant Nurses Leave and What Would Bring Them Back? A Cross-Sectional Survey. International Journal of Nursing Studies, (2020). DOI: 1016/j.ijnurstu.2019.103497.

 

 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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by Izeos

Factors associated with utilisation of staff clinic services by nurses at Parirenyatwa Group of Hospitals, Zimbabwe. A cross-sectional study

Rumbidzai Marevesa ¹ , Maxwell Mhlanga²

 

1. Department of Nursing, University of Zimbabwe
2. Centre of Gender Equity, University of Global Health Equity, Zimbabwe

 

* Corresponding author: Maxwell Mhlanga, Centre of Gender Equity, University of Global Health

Equity. Zimbabwe. E-mail: mmhlanga@ughe.org

 

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ABSTRACT

Introduction: Nurses, as gatekeepers of health, are expected to seek formal healthcare services, reflecting the advice they give patients. However, squalid working conditions, long hours, and heavy workloads expose them to occupational health hazards, limiting their ability to care for themselves. Properly implemented employee clinic services can help nurses address health problems, promote well-being, and reintegrate them into the workforce.

Objective: This study sought to determine factors associated with the utilization of staff clinic services by nurses at Parirenyatwa Group of Hospitals.

Materials and Methods: The study used an analytical cross-sectional design conducted in May 2023. A consecutive sampling method selected 50 participants. Data were collected via a structured questionnaire and presented as numbers and percentages. The questionnaire was divided into sections as follows: Participant demographic information (Age, gender, marital status, religion etc.); uptake of staff clinic services (Screening, treatment, awareness services etc), and factors associated with uptake of staff clinic services among nurses. Chi-square test or Fisher’s exact test to evaluate significant differences for unpaired data. Statistical analysis was performed using STATA 16.

Results: Among the 50 participants, 66% were female. The study results show that the uptake of staff clinic services was low, with only 54% of the participants visiting the clinic on rare occasions. The most common barriers to utilizing the staff clinic were lack of time to go for screening (16%), fear of stigma (14%), and uncertainty about confidentiality (14%). Most participants utilized the acute illness treatment service (62%). Age was a significant factor associated with the utilization of the staff clinic (p = 0.021), with younger nurses using the clinic more often. Perceived benefits were also significantly associated with utilization (p < 0.05).

Discussion: The utilization of staff clinic services by nurses remains suboptimal despite high knowledge and awareness of these services. Utilization was mainly associated with age, perceived benefits of accessing the staff clinic services, and reasons for not utilizing some of the services. There is need to strengthen promotional activities for the utilization of staff clinic health services as this has been proven to increase productivity and health outcomes of clinical staff.

 

Keywords: Utilisation, Staff-clinic, Services, Attitudes.

 

INTRODUCTION

Healthcare workers are the backbone of any healthcare system, and their well-being is crucial for the delivery of quality healthcare services. Nurses, who constitute a significant portion of the healthcare workforce, are particularly vital as they provide essential patient care and support. In Zimbabwe, the Parirenyatwa Group of Hospitals is the largest medical facility, serving as a critical hub for healthcare delivery in the region. Recognizing the importance of maintaining the health and well-being of its staff, the Ministry of Health and Child Care of Zimbabwe introduced staff clinic services at hospitals, including Parirenyatwa.

Staff clinic services are designed to offer preventive, diagnostic, therapeutic, rehabilitative, and palliative care to healthcare workers, ensuring that they remain healthy and capable of performing their demanding roles. These services are intended to mitigate the health risks associated with the demanding nature of nursing, which includes long hours, heavy workloads, and exposure to various occupational hazards. Despite the availability of these services, there appears to be a significant underutilization among nurses at Parirenyatwa Hospital.

Previous research has highlighted several barriers to the utilization of healthcare services by healthcare workers. Studies have identified factors such as time constraints, concerns about confidentiality, fear of stigmatization, and a perceived lack of need as significant impediments. For instance, a study conducted in Nigeria by Akinyemi revealed that healthcare workers often avoid using available health services due to fears about confidentiality and stigma [1]. Similarly, data from other sub-Saharan African countries, such as Botswana, indicate that age and tenure can influence health service utilization, with younger and less experienced healthcare workers more likely to seek medical assistance [2]. Understanding the specific factors influencing the utilization of staff clinic services at Parirenyatwa Hospital is critical for developing targeted interventions that can enhance service uptake. The unique context of Zimbabwe, characterized by a high burden of infectious diseases such as HIV/AIDS and tuberculosis, further underscores the need for effective health support systems for healthcare workers. The high incidence of these diseases among healthcare workers, combined with the occupational stress they experience, necessitates robust health services that are both accessible and trusted by the staff [3].

Healthcare professionals are susceptible to high levels of occupational stress, which has been defined as the negative physiological and psychological reactions that take place when the job demands do not correspond to their skills, resources, or needs [3]. Long hours, heavy workloads, as well as physical and mental stress of caring for sick patients are some contributing factors. In Zimbabwe, the general working class spends at least a third of their life at work, making them vulnerable to work-related stress. Nurses are additionally exposed to resistant forms of numerous bacteria that are known to live in hospital surroundings, increasing their vulnerability to serious infections that are challenging to treat [4].

The Ministry of Health and Childcare of Zimbabwe introduced staff clinic services at hospitals. The Staff Clinic serves staff members who require healthcare services. These services help healthcare workers cope with the workplace environment and develop healthier behaviours. Clinic services encompass preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided by a facility that is not part of a hospital but is organized and operated to deliver medical care [5].

A wide range of services is provided by clinics. These facilities emphasize the concept of treating the body, offering everything from preventative care to the treatment and management of health conditions. Clinic services can aid in overcoming difficulties to improve the general quality of life as well as significant medical challenges brought on by illness or diseases [6].

This study aimed to identify and analyse the factors associated with the utilization of staff clinic services among nurses at Parirenyatwa Hospital. By examining demographic variables, perceived benefits, and barriers to access, this research sought to provide insights that can inform policy and practice, ultimately leading to improved health outcomes for nurses. Enhanced utilization of staff clinic services not only benefits the nurses themselves but also contributes to the overall efficiency and effectiveness of the healthcare system, ensuring that nurses are healthy and capable of providing high-quality care to their patients.

 

Objective: The objective of the current study was to determine the factors associated with utilisation of staff clinic services by nurses at Parirenyatwa Group of Hospitals.

 

MATERIALS AND METHODS

We utilized an analytical cross-sectional study design. This study was conducted at Parirenyatwa Group of Hospitals, which is the largest medical facility in Zimbabwe, located in Harare. In addition to its basic medical and surgical departments, the hospital has a maternity unit, Sekuru Kaguvi, which specializes in eye care, an Annex for patients with mental health issues, and many specialized paediatric wards. In the main hospital complex, there are 12 theatres and more than 5000 beds.

Our study population consisted of nurses at Parirenyatwa Group of Hospitals. We consecutively sampled 50 nurses from across the departments at Parirenyatwa who were on duty, consented to participate in the study, and had been working at Parirenyatwa Hospital for at least six months, as they were more familiar with the clinic services. Nurses on duty were included in the study.

Instruments

A self-designed structured questionnaire was used for data collection, and it was informed by the Health Belief Model. The questionnaire was divided into sections A and B and C as follows:

Section A: Participant demographic information (Age, gender, marital status, religion etc.)

Section B: Uptake of staff clinic services (Screening, treatment, awareness services etc)

Section C: Factors associated with uptake of staff clinic services among nurses. The variables in the study included socio-demographic factors, benefits of clinic services, knowledge, attitude and perceptions, health seeking behaviour, uptake of clinic services. The dependent variable was uptake or utilisation of staff clinic services. The instrument was reviewed for content and face validity by a group of professionals including nurses, lecturers and the Joint Research, and the Ethics Council. The instrument was pre-tested with 5 nurses from Harare hospital and revised to incorporate feedback, to ensure validity, and to address any ambiguity.

Statistical analysis

Data were presented as numbers and percentages in tables. The chi-square test or Fisher’s exact test were performed to evaluate significant differences in proportions or percentages between the two groups. Fisher’s exact test was used where the chi-square test was not appropriate. Finally, all p-values were always two-sided and all tests with p-value (p) < 0.05 were considered significant. Statistical analysis was performed using the STATA ver. 16.

 

Ethical considerations

The study obtained approval from the Joint Research Ethics Committee for the University of Zimbabwe Faculty of Medicine and Health Sciences and Parirenyatwa Group of Hospitals (JREC) institutional IRB committee (approval number: JREC/23/2023). Written informed consent was obtained from participants, all had the opportunity to review the consent form, ask questions, and discuss the study before signing. Participation was voluntary, and confidentiality was maintained. The rights and welfare of participants were protected, and all research activities were conducted privately. For the current study, in addition to the strict ethical processes employed in the ongoing study, specific additional considerations were implemented.

 

De-identification of data

A great deal of protection for patient confidentiality was maintained during the conduct of this research, and it will continue to be upheld in the future. Codes only known to the researchers were used with each participant having a unique identifier. These new identities were used throughout the analysis and reporting stages of the study.

 

Safekeeping of data

Extracted data was saved in a Microsoft OneDrive where it's locked and only accessed by those who have passed through all the orientation and clearance processes and granted access to the data.

 

RESULTS

The main objective of this study was to determine factors associated with utilization of staff clinic services by nurses at Parirenyatwa Group of Hospitals. Data was collected from 50 study participants who matched the inclusion criteria and major results were presented in tabular form.

 

Socio-demographic data

A total of 50 nurses were invited to participate in the study. Among the participants, 17 (34%) were male, while 33 (66%) were female. The majority of participants were below the age of 30 years and were married. Similarly, 33 (66%) of the participants resided outside of Parirenyatwa. A significant proportion (50%) of the participants had 1-5 years of working experience, and 96% identified as Christians.

A summary of demographic characteristics is provided in Table 1.

 

Variable	Description	Frequency (n)	Percentage (%)
Age (years)	< 30	10	40
	30-39	10	20
	40-49	16	32
	> 50	4	8
Gender	Male	17	34
	Female	33	66
Marital status	Married	25	50
	Single	14	28
	Widowed	7	`14
	Separated	4	8
Place of residence	Parirenyatwa	17	34
	Out of Parirenyatwa	33	66
Period of working at Parirenyatwa	6 month – 1 year	7	14
	1 -5 years	25	50
	6 -10 years	14	28
	>10 years	4	8
Religion	Christian	48	96
	Moslem	0	0
	African	2	4
Work station	Parirenyatwa hospital	30	60
	Mbuya Nehanda	8	16
	Sekuru Kaguvi	8	16
	Annex	4	8

Table 1. Distribution of participants by demographic characteristics (n=50)

 

Uptake of clinic services

All participants were aware of the clinic services offered at the Parirenyatwa staff clinic. Among them, 38 respondents utilized the staff clinic services, while the remaining had never availed themselves of any of the services. A majority of participants had visited the staff clinic infrequently, comprising 54% of the total respondents, whereas 22% had never visited the clinic at all. Among the services provided at the staff clinic, acute illness treatment services were the most utilized. Interestingly, 84% of the participants admitted to self-medicating, and among those who preferred self-medication over utilizing the staff clinic, the percentage was 54%.

 

Variable	Description	Frequency (n)	Percentage (%)
Clinic services awareness	Yes	50	100
	No	0	0
Staff clinic services utilisation	Yes	38	76
	No	12	24
Staff clinic visit	Often	3	6
	Periodically	9	18
	Rarely	27	54
	Never	11	22
Service satisfaction	Yes	24	48
	No	14	28
	Not applicable	12	24
Screening and testing services	Yes	28	56
	No	3	6
	Not applicable	19	38
Satisfied with results	Yes	27	54
	No	4	8
	Not applicable	19	38
Self-medicated	Yes	42	84
	No	8	16
Self-medication preference	Yes	27	54
	No	23	46
Services accessed at Parirenyatwa	Primary diagnosis	8	16
	HIV testing	5	10
	Mental Health & Psycho-social support	1	2
	Family planning	1	2
	General Medical check up	1	2
	Occupational health	2	4
	Acute illness treatment	31	62
	Not applicable	12	24

Table 2. Presentation of results of uptake of clinic services (n=50)

 

Factors associated with utilization of staff clinic services.

In the overall evaluation of the clinic services provided, only one participant considered the services to be of high quality, whereas 32 participants (64%) rated the services as good. The primary reason cited for not utilizing some of the staff clinic services was not perceiving a need for them. Additionally, 7 participants (14%) expressed concerns about potential stigmatization, and another 7 (14%) were unsure if the screening results would be kept confidential. Interestingly, 20 participants (40%) acknowledged that accessing the staff clinic helped mitigate work-related health risks.

 

Variable	Description	Frequency (n)	Percentage (%)
Staff clinic general assessment	Quality services	1	2
	Standard services	15	30
	Moderate services	34	68
Clinic rating	Poor	18	36
	Good	32	64
	Excellent	0	0
Not utilising services reason	Not yet ready to get involved	8	16
	Fear of stigmatisation	7	14
	Not sure if the results from the screening will be kept confidential.	7	14
	Just do not see the needs.	13	26
	Do not have time to go for screening	8	16
	Still needs to be made aware of the need and the importance of the services.	7	14
Health information confidentiality	Yes	7	14
	No	19	38
	Somehow	24	48
Health information used to patronise you	Yes	17	34
	No	33	66
Benefits of accessing clinic	Yes	9	18
	No	14	28
	Partially	27	54
Benefits associated with taking clinic services	Preventing related health risks	20	40
	Increased productivity if treated against infections	13	26
	Ensures healthy working environment	7	14
	Early detection of chronic illnesses	10	20

Table 3. Presentation of results on utilization of staff clinic services

 

Fisher’s exact test was performed to assess the significance of the association between socio-demographic characteristics and the uptake of staff clinic services. There was a significant association between age and the utilization of staff clinic services (p = 0.013). However, all other variables, including gender, marital status, place of residence, tenure at the hospital, religion, and work station of the respondent, had no association with utilization of staff clinic services (p > 0.05) (Table 4).

 

Variable	Description	Utilisation of staff clinic		Total	Fisher’s exact p – value
		Yes n (%)	No n (%)	n (%)
Age (years)	<30	16 (32)	4 (8)	20 (40)	0.013*
	30 – 39	4 (8)	6 (12)	10 (20)
	40 – 39	14 (28)	2 (14	16 (32)
	<50	4 (8)	0 (0)	4 (8)
Gender	Male	13 (26)	4 (8)	17 (34)	0.875
	Female	25 (50)	8 (16)	33 (66)
Marital status	Married	18 (36)	7 (14)	25 (50)	0.468
	Single	10 (20)	4 (8)	14 (28)
	Widowed	6 (12)	1 (2)	7 (14)
	Separated	4 (8)	0 (0)	4 (8)
Place of residence	Parirenyatwa	12 (24)	5 (10)	17 (34)	0.320
	Out of Parirenyatwa	26 (52)	7 (14)	33 (66)
Time worked at the hospital	6 months – 1 year	3 (6)	4 (8)	7 (14)	0.201
	1 – 5 years	19 (38)	6 (12)	25 (50)
	6 – 10 years	12 (24)	2 (4)	14 (28)
	>10 years	4 (8)	0 (0)	4 (8)
Religion	Christian	37 (74)	11 (22)	48 (6)	0.286
	African traditional	1 (2)	1 (2)	2 (4)
Work station	Parirenyatwa	25 (50)	5 (10)	30 (60)	0.198
	Mbuya Nehanda	6 (12)	2 (4)	8 (16)
	Sekuru Kaguvi	5 (10)	3 (6)	8 (16)
	Annexe	2 (4)	2 (4)	4 (8)

* =significant test

Table 4. Association between sociodemographic variables and utilization of staff clinic services.

 

The results of Fisher’s exact test revealed significant relationships between certain factors and the utilization of staff clinic services. Benefits associated with accessing the staff clinic services and reasons for not utilizing some services were found to be significant factors influencing utilization (p< 0.05). However, health information privacy factors did not show any association with the utilization of staff clinic services.

Although all other remaining factors were associated with the utilization of staff clinic services, these associations were not statistically significant (p > 0.05). Table 5 provides a detailed profile of these results.

 

Variable	Description	Utilisation of staff clinic		Total	Fisher’s exact p – value
		Yes n (%)	No n (%)	n (%)
General assessment towards clinic services provided by staff clinic	Quality services	0(0)	4 (8)	1(2)	0.019*
	Standard services	15(30)	6 (12)	0(0)
	Moderate	23(46)	2 (14	11(22)
Clinic services ratings	Poor	11(22)	7(14)	18(36)	0.043*
	Good	27(54)	5(10)	32(64)
Reason for not utilizing some of the services provided	Not yet ready	6 (12)	2 (4)	8 (16)	0.001*
	Fear of stigmatization	7 (14)	0 (0)	7 (14)
	Uncertainty about results confidentiality	7 (14)	0 (0)	7 (14)
	Do not see the need	5 (10)	8 (16)	13 (26)
	Do not have time to go for screening	8 (16)	0 (0)	8 (16)
	Still need get awareness	5 (10)	2 (4)	7 (14)
Do you think your health information is kept confidential at the staff clinic?	Yes	6 (12)	1(2)	7 (14)	0.201
	No	13 (26)	6 (12)	19 (38)
	Somehow	12 (24)	6 (12)	18 (36)
	>10 years	19 (38)	5 (10)	24 (48)
Do you think your health information can be used to patronise you?	Yes	13 (26)	6 (12)	19 (38)	0.186
	No	25 (50)	8 (16)	33 (66)
	Somehow	19 (38)	6 (12)	19 (38)
Has accessing the staff clinic services been beneficial to you?	Yes	8 (16)	1 (2)	9 (18)	0.002*
	No	3 (6)	2 (4)	8 (16)
What benefits do you think are associated with taking these services	Preventing work related health risks	16 (32)	4 (8)	20 (40)	0.165
	Increase productivity if treated against infections	12 (24)	2 (4)	4 (8)
	Working environment	4 (8)	3 (6)	7 (14)
	Early detection of chronic diseases	6 (12)	4 (8)	10 (20)

* =significant test

Table 5. Association between factors associated with utilization (attitudes, perceptions, benefits) and utilization of staff clinic services.

 

DISCUSSION

The primary aim of this study was to identify the factors influencing the utilization of staff clinic services by nurses at Parirenyatwa Group of Hospitals. Limited research exists on the determinants of nurses' utilization of staff clinic services. Previous studies related to this topic have consistently indicated an underutilization of clinic services by nurses, despite the availability and benefits of such services. Nurses play a crucial role in the healthcare workforce, and maintaining good health is essential for them to deliver high-quality care. Accessing clinic services promotes wellness and helps employees manage their health concerns. Recognizing the gap in nurses' utilization of the staff clinic, the researcher conducted this study to explore the factors influencing their use of these services.

 

Sociodemographic Factors

Demographic variables such as age, gender, marital status, place of residence, tenure at the hospital, religion, and workstation may influence the utilization of staff clinic services. Powell emphasizes the importance of organizations understanding how these demographic characteristics affect employees' decisions regarding clinic service uptake and their perceptions of these services [9]. Such insights can enhance service uptake and promote inclusivity among employees from diverse backgrounds.

The study revealed a predominantly female participant group, which aligns with the gender distribution in many organizations, particularly in female-dominated professions like nursing. The higher utilization of staff clinic services by females may reflect their majority representation in the workforce. Additionally, younger nurses (below 30 years) exhibited a significantly higher percentage of clinic service utilization (p= 0.013), possibly due to their novelty in the system and enthusiasm for utilizing available services. Conversely, utilization was lower among nurses aged 30-39 and those over 50. This finding contrasts with a study in Botswana by Ledikwe et al., where older age was associated with greater participation in workplace wellness activities [11]. Longer tenure has been associated with higher health service utilization, as seen ina study conducted in South Africa, where more experienced healthcare workers were more familiar with available services and their benefits [15]. Nurses stationed at Parirenyatwa Hospital utilized the staff clinic more frequently than those at Annex Hospital, likely due to the clinic's proximity to their workstations.

The gender distribution indicates that 66% of the participants are female, and 34% are male. This gender disparity is consistent with the global nursing workforce, which is predominantly female. The higher percentage of female participants aligns with studies from other countries, such as Nigeria and Kenya, where female healthcare workers also constituted the majority and showed similar utilization patterns of health services [16].

Marital status revealed that 50% of the participants were married, 28% single, 14% widowed, and 8% separated. The utilization patterns based on marital status were not explicitly explored in this study but could provide an interesting angle for future research. Previous studies have shown mixed results, with some indicating higher health service utilization among married healthcare workers due to family health considerations.

The study found that 34% of participants resided at Parirenyatwa, while 66% lived outside. This aligns with findings from studies in urban areas where proximity to healthcare facilities influences utilization rates. Healthcare workers living closer to their workplace are more likely to use available services due to convenience.

An overwhelming majority of participants were Christian (96%), with a small minority adhering to African traditional religions (4%). Religious beliefs can impact health service utilization, although this study did not find a significant variation in utilization patterns based on religion. Similar studies have found that religion can sometimes influence health-seeking behavior due to different cultural beliefs about healthcare.

The distribution of work stations showed that 60% of participants were stationed at Parirenyatwa Hospital, with the remainder distributed among Mbuya Nehanda, Sekuru Kaguvi, and the Annex. Utilization of staff clinic services may vary by work station due to differences in work environments and stress levels. For instance, nurses working in high-stress areas such as emergency departments or mental health units may have different health service needs compared to those in less stressful environments.

The study reveals important socio-demographic factors associated with the utilization of staff clinic services at Parirenyatwa Hospital. While gender and age distributions are consistent with global trends, factors such as place of residence and work station highlight the importance of proximity and work environment in health service utilization. These findings are consistent with similar studies in the region, emphasizing the need for targeted interventions to address barriers and promote the utilization of health services among healthcare workers.

 

Quality of Services and Clinic Ratings

Only 2% of nurses rated the clinic services as quality, while 30% and 68% rated them as standard and moderate, respectively. Furthermore, 36% rated the clinic as poor, 64% as good, and none rated it as excellent. Similar studies, have often report mixed perceptions of healthcare service quality in resource-limited settings [12]. Inconsistent service quality is a common issue that can deter utilization of health services [13].

Key reasons for not using the clinic services include lack of readiness (16%), fear of stigmatization (14%), concerns about confidentiality (14%), perceiving no need (26%), lack of time (16%), and needing more awareness (14%). Similar barriers are found in other studies. For instance, the fear of stigmatization and confidentiality concerns are widely reported in healthcare settings across Sub-Saharan Africa [7]. Time constraints and perceived lack of need are also common barriers identified in healthcare utilization studies [14].

Only 14% believed their health information was kept confidential, 38% said no, and 48% were unsure. Concerns about confidentiality are prevalent in many studies, where mistrust in the healthcare system hinders service utilization. Efforts to enhance confidentiality practices are essential to improve service uptake [15].

About 34% reported that health information was used to patronize them, while 66% did not. Such experiences can significantly deter individuals from seeking healthcare, as highlighted in research another research, which reported that negative experiences with healthcare providers reduce trust and subsequent utilization [15].

Only 18% perceived clear benefits from accessing clinic services, 28% did not, and 54% partially saw benefits. Benefits cited included preventing health risks (40%), increased productivity (26%), ensuring a healthy environment (14%), and early detection of chronic illnesses (20%). The recognition of health benefits, such as early detection and productivity gains, is crucial for increasing service uptake. There is need to emphasize the importance of communicating these benefits effectively to encourage utilization.

 

Awareness and Utilization

Although all participants were aware of the staff clinic services, utilization rates varied, with acute illness treatment being the most frequently used service. However, services such as primary diagnosis, HIV testing, mental health support, family planning, and general medical check-ups were underutilized. Reasons for not utilizing some services included time constraints, concerns about result confidentiality, and fear of stigmatization. These findings are consistent with a study in Nigeria by Akinyemi on healthcare workers' health-seeking behavior. The study also found a significant association between the perceived benefits of staff clinic services and their utilization. Participants who found the services beneficial were more likely to utilize them, highlighting the influence of attitudes and perceptions on service uptake.

A significant finding of the study is the association between perceived benefits and utilization of staff clinic services. Participants who found the services beneficial were more likely to utilize them (p = 0.002). This highlights the importance of perceived benefits in influencing health service uptake. Similar trends have been observed in other studies, where positive perceptions of health services were linked to higher utilization rates [18]. The significant association between perceived benefits and service utilization emphasizes the need for targeted interventions to address barriers and promote the use of health services among healthcare workers.

 

Quality of Service

Participants' assessments of the clinic services showed significant differences. Quality services were rated by only 2% of the participants, standard services by 30%, and moderate services by 46% (p = 0.019). This indicates a general perception that the services are not of high quality. Similar studies in Nigeria and Kenya also reported that healthcare workers rated their staff clinic services as moderate to poor, citing inadequate resources and staffing as primary reasons for these perceptions [15].

When rating the clinic services, 22% of participants rated them as poor, 14% as good, and 64% as excellent (p = 0.043). This distribution suggests a polarized view, where a significant portion of users is dissatisfied with the services, while others find them adequate. A comparable study in South Africa found that ratings of clinic services were closely tied to the perceived responsiveness and professionalism of the staff, as well as the availability of medical supplies [18]. The mixed ratings at Parirenyatwa Hospital align with these findings, highlighting the importance of improving service quality to enhance user satisfaction.

The reasons for not utilizing some of the services provided were also significantly varied. The most common reasons included not seeing the need for the services (26%), not having time to go for screening (16%), and fear of stigmatization (14%) (p = 0.001). These barriers are consistent with findings from a study in Botswana, which reported that healthcare workers often avoided utilizing available health services due to similar reasons, including time constraints and fears about confidentiality [8].

Fear of stigmatization and concerns about the confidentiality of results were significant deterrents, with 14% of participants citing each as reasons for not using the clinic services. This is in line with studies conducted in Nigeria and Malawi, where healthcare workers expressed concerns about privacy and potential negative repercussions on their professional reputation if their health conditions were disclosed.

A notable 14% of participants indicated that they still needed to be made aware of the importance of the services. This points to a gap in effective communication and education about the benefits of utilizing the staff clinic. A similar issue was highlighted in a study in Uganda, where increased awareness and educational campaigns were found to significantly improve the utilization rates of staff clinic services [19].

The study at Parirenyatwa Hospital reveals several factors influencing the utilization of staff clinic services that are consistent with findings from similar studies in other regions. Key issues such as service quality, fear of stigmatization, confidentiality concerns, and the need for increased awareness are recurrent themes. Addressing these barriers through targeted interventions could significantly improve the uptake of staff clinic services, leading to better health outcomes for nurses. Enhancing service quality, ensuring confidentiality, and conducting awareness campaigns are essential steps to encourage higher utilization rates and improve overall healthcare delivery among healthcare workers.

 

Limitations of the study

The sample size for our study was relatively smaller than what would be required for the generalisation of the study findings. Similarly, we used self-reported satisfaction of the participants which increases the chances for social desirability bias. Future studies can consider using the mixed methods approach with a bigger sample to triangulate data and get a clearer picture on the subject matter.

 

CONCLUSION

In conclusion, nurses' utilization of clinic services is influenced by their attitudes, perceptions, and barriers to access. Despite high awareness, service utilization remains low for certain offerings. Efforts to increase utilization should address barriers such as concerns about confidentiality and stigma, while also emphasizing the perceived benefits of the services. Enhancing the quality of services and fostering positive employee attitudes can further promote utilization and improve overall healthcare outcomes among nurses.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

 

Conflict of interest  

The authors report no conflict of interest.

 

Authors’ contribution

Rumbidzai Marevesa: Development of the original draft

Maxwell Mhlanga: Review of the manuscript, data analysis and discussion.

 

Acknowledgements

We would want to acknowledge Management at Parirenyatwa Group of Hospitals for allowing us to carry out our research at their institution.

 

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

 

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by Izeos

TRANSFORMATIVE LEADERSHIP AND JOB SATISFACTION IN THE NURSING PROFESSION: A NARRATIVE REVIEW

Carla Rizzo ¹, Flavio Marti ², Luca Perrozzi ³*, Lucia Mauro ⁴

1. Complex Anesthesia, Resuscitation and Intensive Care Unit, IRCCS Hospital Physiotherapy Institutes, Rome (Italy).
2. Department of Health Professions AO San Camillo Forlanini, Master's Degree Course in Nursing and Midwifery Sciences, “Sapienza” University of Rome, San Camillo section, Rome (Italy).
3. Accident and Emergency and Specialist Surgery Department, A.O. San Camillo Forlanini, Rome (Italy).
4. Department of Surgical Sciences, Elective Surgery Block, A.O. San Camillo Forlanini, Rome (Italy).

*Corresponding Author: Luca Perrozzi, Department of Accident and Emergency and Specialist Surgery, Azienda Ospedaliera San Camillo Forlanini, C.ne Gianicolense 87, 00159 Rome (Italy). Email: lucaperrozzi@yahoo.it

Cite this article

ABSTRACT

Introduction: Healthcare organisations require optimal leadership to achieve goals and deliver high-quality services. Leadership is the ability to influence employee behaviour and beliefs and is an essential element of a successful organisation. Improving job satisfaction is a key objective in addressing the challenges related to achieving and maintaining quality standards, ensuring patient satisfaction and staff retention. Similarly, transformational leadership has positive effects on nurses' job satisfaction and promotes organisational wellbeing in the workplace.

Objective: The purpose of the review is to describe transformational leadership and job satisfaction in the nursing profession through a narrative revision.

Materials and methods: The bibliographic research was carried out between September 2022 and March 2024 by consulting databases such as PubMed, CINAHL, and PsycInfo, with time limits of 12 years and Italian and English language filters. All items deemed relevant have been stored and managed with the Zotero IT platform.

Results: 16 studies were examined: 1 comparative study, 5 descriptive correlational studies, 1 meta-analysis, 1 systematic review, 4 cross-sectional studies, 2 mixed method studies and 2 unspecified studies. The results of this study are consistent with transformational leadership theory, which highlights the leader's role in providing employees with supportive work environments that result in higher levels of job satisfaction and efficiency.

Conclusions: The skills of a transformative leader, such as the ability to listen, provide support, and promote fairness and recognition, are fundamental to increasing nurses' job satisfaction and sustaining environments with a high level of quality of care. Healthcare managers must protect the quality of work undertaken by staff, implementing strategies that can improve nurses' working conditions.

 

Keywords: Transformational Leadership; Job Satisfaction; Nurse; Work environment.

INTRODUCTION

Healthcare organisations are social systems in which human resources are the most important factor for the delivery of health care. Such organisations require optimal leadership to achieve goals and deliver high-quality services [1,2]. Leadership is the ability to influence employee attitudes and beliefs and is an essential element of successful and efficient organisations [3,4]. The current challenges of the health system require the presence of flexible and efficient managers [5] because the complexity of nurses' tasks requires complex leadership skills [6]. A wide range of studies have described the favourable outcomes of positive leadership, in particular, the transformational leadership style [7–9]. Transformational leadership motivates problem-solving and intellectual stimulation by influencing staff engagement in the organisation's mission. Such leaders stimulate nurses to use problem-solving strategies and provide patient care autonomously and responsibly [10]. Certain studies suggest that transformative leaders have positive effects on the wellbeing and job satisfaction of healthcare workers [4,11]. In addition, transformational leadership transforms nurses' goals and values for the benefit of the nursing profession [12] and work organisation and promotes team communication and collaboration, the work environment and organisational culture [13].

Work satisfaction, defined as “a pleasant emotional state that derives from the judgment of one's work or work experience” [14], is extremely important both for nursing managers and wellbeing of nurses in the workplace. Improving job satisfaction is a key objective in addressing the challenges related to achieving and maintaining quality standards, ensuring patient satisfaction and staff retention [15,16].

The more satisfied employees are, the more motivated they are to work and the greater the possibility of achieving the objectives, with an increase in productivity and quality. Job satisfaction cannot be overlooked if improving work performance is a priority of the organisation [17].

As part of the study, the authors described transformational leadership and staff job satisfaction, with the aim of synthesising the evidence that describes these aspects in the nursing profession.

Transformational leadership theorists indicate that leaders use socialised power to elevate and empower subordinates and provide the resources needed to achieve more than they thought possible in their work. Intrinsic motivation strategies support nursing autonomy, competence and relationship with others in the context of a mutually supportive environment to foster social and personal development at the service of the organisation's vision, mission, values, aims and objectives. In this way, subordinate nursing staff enjoy satisfaction in overcoming work challenges.

Nursing leaders must be proactive in recognising and addressing the job satisfaction needs of direct care nursing staff in order to maintain high-quality staff as well as the quality of patient care and healthcare environments [18].

 

Objective of the study  

The purpose of the review is to describe transformational leadership and job satisfaction in the nursing profession through a narrative revision of the literature.

 

MATERIALS AND METHODS

The bibliographic research was carried out from 1 September 2022 to 31 March 2024 by consulting the following databases: PubMed, Cinhal, and PsycInfo, with time limits of 10 years and Italian and English language filters. The research question was formulated according to the PICO method, as shown in Table 1.

Table 1. Research question formulated according to the PICO method

The following keywords were used: “transformational leadership”, “job satisfaction”, and “nurse*”. Within the study, all the articles that dealt with transformational leadership and job satisfaction in the nursing profession with a time limit of 12 years (from January 2012 to March 2024) were included in English and Italian. All articles written in other languages were excluded.

 

RESULTS

During the bibliographic research, the search string generated a listing of 223 articles on 3 different databases (PubMed, Cinhal, and PsycInfo) (figure 1).

 

Figure 1. “PRISMA Statement” flowchart[19].

 

All items were managed using the Zotero IT platform. After the duplicates were removed, 137 articles remained.  Selection by title and by abstract led to the exclusion of 109 articles. For the subsequent critical analysis, the 28 articles were read and evaluated in their entirety to identify and understand the content. On reading the full texts, 12 articles were discarded because they failed to comply with the inclusion criteria. A total of 16 studies were evaluated, broken down as follows: 1 comparative study, 5 descriptive correlational studies, 1 meta-analysis, 1 systematic review, 4 cross-sectional studies, 2 mixed method studies, 2 unspecified studies (see Table 2). Fifteen articles were published in English and one in Italian.

 

Evaluation of the quality of the studies

The articles were selected and evaluated using the checklists from “JBI Critical Appraisal Tools” [20]. A total of 16 articles were reviewed. To classify the studies in terms of quality, the overall score was calculated based on the number of "yes" answers. The included studies had at least 6 out of 10 of the items included in the checklists chosen by the authors of this study.

Table 2. Summary of results

DISCUSSION

The literature considered demonstrates that the transformational leadership style can positively influence job satisfaction in most of the included studies, regardless of the sample, the country, or the type of study chosen [21–34]. Only two studies do not describe a positive link between the variables analysed [35,36].

The results of this review highlight that the characteristics of a transformative leader – such as listening, support, fairness and recognition – are fundamental to increasing nurses' job satisfaction and creating environments with superior quality of care.

For example, the results of the systematic review by Specchia [31] and AbuAlRub and Alghamdi [34] emphasise that leaders who adopt a transformative style promote greater job satisfaction among nursing staff than those who adopt a transactional style. In fact, transformational leadership shows a significant and moderate correlation with job satisfaction (r = 0.45, p < 0.001), while transactional leadership shows a weak significant relationship with job satisfaction (r = -0.14, p < 0.01)[34]. In fact, the strength of transformational leaders is that they dedicate time to teaching and coaching nurses, focus on developing and improving their strengths, and provide advice for their professional and personal development [31].

These results are consistent with previous studies by Al-Hussami [37] and Bass [38]. These studies support the idea that nurses who worked with leaders who showed transformational leadership styles were more satisfied. In fact, these leaders taught and trained nurses, providing advice for professional development, treating them as individuals, listening to their concerns, and promoting their personal development[39].

Another issue concerns the correlation between transformational leadership, job satisfaction and the intention to leave work. For example, Labrague's study [26] shows how the transformational leadership of nursing executives influences nurses' job satisfaction and their intention to leave the profession despite the demographic characteristics (age, sex, sentimental situation, full time). Specifically, it differentiates toxic leadership from transformational leadership. Toxic leadership is significantly correlated with dissatisfaction at work (r = -0.19, p <0.001), absenteeism (r = 0.23, p < 0.001), psychological distress (r = 0.09, p < 0.05), organisational turnover intention (r = 0.11, p < 0.01) and professional turnover intention (r = 0.14, p < 0.001). Instead, transformational leadership is significantly related to job satisfaction (r = 0.37, p < 0.001), absenteeism (r = -0.13, p < 0.001) and the intention of organisational turnover (r = -0.08, p < 0.05). This underlines how important it is to educate leaders and nurse managers within healthcare facilities and develop behaviours that help and support staff. Indeed, maintaining a quality working environment has a significant impact on the retention of nurses and decreases the intention to leave the profession or nurse turnover.

In contrast, the results of the study by AbuAlRub and Alghamdi [34] indicate that the relationship between the transformational leadership style and the level of intention to stay at work was not statistically significant (r = 0.08, p = 0.14), so the transformational leadership style had no effect on the intention to stay at work.

Even if the results regarding intention to leave the profession are mixed, transformational leadership can provide supportive work environments that result in higher levels of job satisfaction and effectiveness [39]. In fact, by strengthening solid relationships with staff, transformational leaders understand the needs of nurses, they encourage staff to develop skills and autonomy in order to empower them to act.

The studies by Bohaman [23] and Choi [25] analysed the role that structural empowerment has in the relationship between job satisfaction and the transformational leadership style. Structural empowerment, in line with other previous research, [40–42] influences job satisfaction, organisational commitment[41], work commitment[43], lower levels of burnout and work stress [41] and turnover intentions[41,44]. This is due to the characteristics of the transformational leader, such as the ability to listen, inspire staff and stimulate individual and group skills. We can therefore state from these studies [23,25] that empowerment has a positive influence on job satisfaction.

In the study by Borman and Abrahamson [24], it emerged that nurses who worked for 5 or fewer years within the hospital had a statistically positive correlation with transformational and transactional leadership, while nurses who worked for 11 or more years did not have any type of significant relationship with any leadership style. For those who worked for 5 or fewer years, job satisfaction was mainly related to promotion opportunities, while for nursing staff of 11 or more years it had a stronger correlation for supervision. Therefore, leaders must understand the needs of their employees based on individual differences and their work experience.

The studies by McVicar and Laschinger [35,36] did not find a direct correlation between transformational leadership and job satisfaction. Roberts and Turner [36] highlighted how autonomy and distributive justice positively affect job satisfaction (0.503, p < 0.001; 0.272, p < 0.001). Within the study, the authors emphasise that autonomy represents a characteristic of transformational leadership, and distributive justice represents transactional leadership. It follows that, even if a direct relationship between the variables considered has not been found, autonomy represents one of the fundamental characteristics of the transformational leadership style. This implies that an increase in autonomy and distributive justice would increase job satisfaction.

Conversely, according to Brewer,[35] transformational leadership was not a significant predictor of job satisfaction. The variables with positive significant coefficients related to job satisfaction were organisational commitment, autonomy, tutor support and promotional opportunities. Considering job satisfaction as a dependent variable, a nurse who goes from a low organisational commitment value to a very high organisational commitment value is 12.6% more likely to be satisfied.

The Barlow meta-analysis [22] showed a very strong relationship between transformational leadership and job satisfaction: the aggregate result of the studies generated by the estimates of the size of the effect are more incisive and representative than the outcomes of individual studies examined. The study shows how transformational leaders stimulate and empower nurses to provide the resources needed to achieve greater results. In fact, staff intrinsic motivation strategies support autonomy, competence, and nursing relationships to create a mutually supportive work environment that promotes social and individual development at the service of the organisation's mission, values, and goals. In addition, the results report that the relationship between transformational leadership/job satisfaction has strengthened over time. The subgroup analysis showed that studies in the 21st century have stronger effects than studies in the 20th century. This can be explained by the identification of the Magnet design health and nursing excellence programmes, which notably increased in the 21st century [22]. Therefore, strategies must be implemented within hospitals today to increase the job satisfaction of nurses by assessing staff satisfaction on an annual basis and improving working conditions.

Another result to consider concerns the difference reported in various studies within the Barlow meta-analysis [45–47] between the greater satisfaction detected by nurses in indirect or mixed care (nurse administrators, specialised nurses) compared to staff engaged in direct care (ward nurses). This can be explained by the great shortage of nurses that is being experienced worldwide, which leads to greater workloads, work stress, burnout, intentions to leave the profession and turnovers that strongly affect job satisfaction. This is why nursing leaders are fundamental in order to understand and recognise the needs of their staff, to maintain a high quality of work, as direct care provides essential services for patients.

A study conducted in Italy by Morsiani[29] engaged focus groups to identify the main characteristics of a leader in relation to the achievement of satisfaction:

 

• Professional recognition. Job satisfaction depends on professional recognition, that is, giving value to the work of a nurse and expressing appreciation for the work of the staff.
• Fairness. Nursing leaders must adopt the same behaviour, be honest with all staff members and be objective about mistakes at work.
• Care of the individual. If a leader supports and listens to their staff, the latter will be more likely to experience job satisfaction. Often, the role of nurses, especially in Italy, is not recognised at a social and economic level. The first in the field who must defend the profession are precisely the leaders who must lead the profession to its emancipation, while maintaining relationships with other professionals. In fact, it is not a war between professions but an endeavour to enhance the value of the nursing profession.
• Support. Globally, the shortage of nurses impacts patient care, as the same care result must be achieved in the same time and with fewer human and material resources. Leaders should not put themselves on a different plane than nurses but should be present in the ward and help them in case of need. In addition, being present in the department is an opportunity to check the work of the staff and recognise what the errors may be within the care path and look for strategies to improve it.
• Listening. Being present also means knowing how to listen and understand the needs of the staff, such as shift scheduling and the difficulties encountered at work.
• Staff appreciation. The nursing manager must promote staff development by seeking to improve nurses, both individually and as a group. Training, feedback, and refresher courses are crucial tools to ensure that staff have greater autonomy and responsibility.
• Team development. Another important issue is teamwork. This study revealed the extent to which staff did not feel part of a work group. Teamwork is essential to ensuring collaboration, compensating for others' inadequacies, and sharing common goals and strategies to achieve patient satisfaction.

Therefore, there is scope for future studies employing a more rigorous research approach that would establish causal links between the variables considered and the appropriateness of generalising the results.

CONCLUSIONS

The review found that transformational leadership can have a positive influence on nursing job satisfaction levels. Therefore, nursing leadership assumes a fundamental role in influencing the perception that nurses have of their organisation. A leadership style that promotes nurses' autonomy, support, and empowerment can improve job satisfaction, organisational commitment, and nurses' intention to remain in their position while reducing emotional exhaustion [6]. This means that transformational leaders, through their stimulating and motivating behaviour, can induce changes in the psychological states of workers within organisations. In addition, some studies have shown how the adoption of the transformational leadership style can indirectly influence job satisfaction through the development and strengthening of nurses' sense of empowerment [23,25]. Within healthcare organisations, leadership plays a key role in providing effective and efficient care and translates into positive outcomes for professionals, patients and the work environment. It is therefore necessary to identify and fill the current gaps in the skills and abilities of nursing leaders through educational activities in institutions, underlining the importance of a two-way communication process and mutual trust between managers and nursing staff. The purpose of the review was to offer an overview of a current topic, as both job satisfaction and transformational leadership are two fundamental issues for the creation of a healthy and efficient work environment. Despite the fact that leadership quality and job satisfaction can be assessed using proven and generalizable measurement tools, few studies adopt such methods, and they thus fail to draw conclusions from the relationship between pertinent variables. For the future, the authors suggest conducting studies that can correlate transformational leadership and job satisfaction to obtain more generalizable results because these issues are based much more on empirical experience than on robust scientific evidence.

 

Limitations of the study

Although the research met the objective of this study, the review has limitations. For example, one of the limitations of a narrative review concerns the methodology itself; whereas a systematic review has a clear and obligatory a priori methodology, the narrative review approach lacks a research protocol. Another limitation is the interpretation bias of the results, which can bring to light only a part of the chosen topic. To confirm what has been described in this review, other studies are needed that can obtain certain, reproducible and generalizable results. In addition, the results that emerged from the other studies were evaluated by means of self-assessment questionnaires, which are frequently associated with response bias.

 

Funding

This study did not receive any form of funding.

 

Conflict of interest

The authors declare that they have no conflicts of interest associated with this study.

 

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by OPI Napoli

Patients’ preferences, feelings, and benefits on Music-Based Intervention: A Pilot Study in COVID-19 Hospitalization

 

Alessio Pesce ¹, Francesca Lantieri ²

1. Department of Internal Medicine, Local Health Authority ASL2, Savona (Italy)
2. Department of Health Science, Biostatistics Unit, University of Genoa, (Italy)

* Corresponding author: Dr. Alessio Pesce, Department of Internal Medicine, Local Health Authority ASL2, Savona (Italy), Piazza Sandro Pertini n. 10, 17100 Savona, Italy.

Email: alessio.pesce@uniupo.it, ORCID: https://orcid.org/0000-0003-2702-4101

 

 

Cite this article

 

 

ABSTRACT

Introduction: COVID-19 patients survive in isolation with stringent measures of infection containment, leading to anxiety, fear, stress, loneliness, and depression. Music is recognized as useful to promote multiple health outcomes, including anxiolytic effects, pain-relieving, and relaxing effects that favour well-being and social interaction in healthcare settings.

Objective: This study aimed to determine the impact of a pre-recorded music-based intervention on the music perception in hospitalized COVID-19 patients. Music appreciation, evoked emotions, and self-reported effects were explored and compared before and after music-based intervention, also considering the gender of the patients.

Methods: This prospective study consisted of a pre-recorded music-based intervention administered to 272 patients hospitalized for COVID-19 by piping the music into rooms of inpatient medical area. Pre-recorded musical pieces of were selected by a music therapist considering specific formal and parametric characteristics, with the purposes of distraction, entertainment, relaxation, and emotional support. The patients’ opinions were collected using an ad hoc self-report questionnaire and a short data survey that followed the Consolidated Framework for Implementation Research (CFIR) guidelines.

Results: Music resulted to be the preferred entertainment activity during hospitalization by 84.6% of patients, with 96.6% of them expecting a positive effect and a very high grade of usefulness attributed to music before hospitalization and even higher afterwards. The music intervention significantly changed the patients’ perception of music from everyday life to hospitalization (p<0.0001). It proved successful in evoking pleasure and fun, which raised from 18.4% of everyday life to 41.1% during hospitalization. The usefulness of listening music to alleviate unpleasant feelings including anxiety, fear, loneliness, and low mood in COVID-19 disease, had a significant increase from 22.5% to 60.0% after the music intervention.

Conclusion: Music-based intervention, directed according to reference frameworks, provides self-reported social and emotional support in hospitalized patients for COVID-19.

Keywords: Covid-19, music therapy, emotions, hospitalization, music medicine

 

INTRODUCTION

Music represents an interdisciplinary topic, transversal to medicine and the human sciences. It constitutes a non-pharmacological intervention aimed at multiple health outcomes, including anxiolytic, pain-relieving, and relaxing effects that promote well-being, sleep quality and social interaction in healthcare settings [1-7]. Hospitalized patients with COVID-19 survive in isolation with stringent infection containment measures, which lead to anxiety, fear, stress, loneliness, and depression, even to the point of evoking obsessive thoughts; in the most severe cases they compromise the prognosis, increasing mortality and adverse events. Music-based interventions, therefore, can also be used in psycho-social need in COVID-19 patients [1]. To date, research protocols are available in the hypothesis that music can reduce anxiety, depression or improve the quality of life in COVID-19 patients [8]. Therefore, studies to explore patients’ perspectives and determine the effects of music-based intervention during hospitalization are needed to provide scientific evidence. Some authors [9] remark how essential the compatibility of musical pieces with people’s preferences is and how these may vary depending on expectations at a specific moment, health conditions, or the healthcare environment. A crucial aspect in music-based interventions is the proper selection of musical pieces. Listening to specific types/genres of favorite music or sounds is likely to have an emotional impact based on patients’ clinical conditions. Systematic reviews show that patients’ music background and listening habits have been drastically underestimated, reported in only 7.7% of the studies conducted [10]. Only about 25% of studies have explored patient feedback on musical [10]. Personality plasticity, cognitive-affective components [11] and the clinical conditions of patients, especially respiratory system efficiency and symptom aggravation, show a close correlation with music preferences [9], stated even before COVID-19 disease. Therefore, it is crucial to explore the in-patients’ music preferences, the utility that listening to music might have for them, and their feelings also in relation to COVID-19 before starting a music-based intervention. This knowledge would allow health and music professionals to personalize the intervention and be able to demonstrate important correlations between habitual musical preferences and attitudes with those experienced by the patient as a result of listening to music. The literature generally admits methodological weaknesses in music-based interventions [10,12]. There is a lack of scientific rigor in music selection, in the involvement of music experts, and in reporting and describing the music pieces used [12]. Furthermore, music has rarely been selected to achieve specific effects according to the reference frameworks [10,12]. The opportunity to identify music mechanisms of action would allow researchers to advance beyond basic questions about efficacy and begin to answer questions about how, why, and for whom an intervention works [12]. For these reasons, we applied a music-based intervention to in-patients affected by COVID-19 after pre-inquiring their music preferences and have administered a questionnaire to investigate their appreciation for music both before and after the intervention. The music-based intervention was selected by a music therapist and integrated according to guidelines and [13] a consolidated framework [14].

 

Objective

This study aimed to determine the impact of a pre-recorded music-based intervention on the music perception in hospitalized COVID-19 patients. Music appreciation, evoked emotions, and self-reported effects were explored and compared before and after the music-based intervention, also considering the gender of the patients.

 

MATERIALS AND METHODS

Sample Recruitment and Clinical Setting

All adult patients with COVID19 admitted to the COVID-19 inpatient medical area of the Italian hospital Santa Maria Misericordia (Local Health Authority ASL2, Savona), between May 18, 2020 and February 18, 2022 were recruited. The inclusion criteria were age 18 years or older, ability to understand, write and speak Italian, and written consent to the study. Patients with severe hearing and visual deficits, and with alterations of the state of consciousness, as assessed by the medical-nursing staff, were excluded. No exclusion criteria based on covid severity were applied. According to Italian rules at that period, no COVID-19 patient received visits from friends or family members during hospitalization. The study was conducted in accordance with the 1964 Helsinki Declaration and was approved by the Ethics Committee (May 18, 2020 – Protocol Number 10459); informed consent was obtained from all participants included in the study.

Study Design

This prospective study consisted of a pre-recorded music-based intervention and the administration of a questionnaire aimed at determining the perception of music in patients hospitalised for COVID-19, and their point of view on music listening in terms of their attitude toward music and the set of sensation associated to listening the music, during hospitalization, before and after the music intervention. Patients, upon their acceptance to participate in the study, were received an ad hoc self-report questionnaire and a short data survey, both in paper form. The questionnaire included 15 pre-treatment questions regarding the patients’ attitude toward music in their everyday life and in the hospital setting and 3 post-treatment questions to be answered after the music treatment. The patients were instructed to fill in in only the pre-intervention questions before the music treatment and to complete the rest of the forms only after the music intervention. The afternoon following admission, a single 90-minute length music-based intervention was introduced in the in-patient rooms via piped music. On the same day, following the musical presentation, the two data sheets were collected. Patients who agreed to participate to the study but refused the music-based intervention due to their choice or clinical worsening, were still invited to fill in Q1-Q15 and short data record at their convenience or after the improvement of their health conditions (Figure 1).

 

Figure 1. Flowchart of the study

Criteria for constructing the questionnaire

The present questionnaire was specifically constructed for this study to explore preferences, diffusion modes, utility, emotions evoked, and self-reported effects, also considering the gender, and to compare the point of view during hospitalization with what described by the patient after the music-based intervention. A preliminary questionnaire was constructed in 2013 and used for the first time on a sample of 55 patients to evaluate the point of view on habitual music listening and in hospitalization for cardiac catheterization [15]. The meaningful constructs, facade preferences and response categories that emerged from this previous study guided the initial design of the items for the present study. Based on this, an updated questionnaire was developed in 2020 following the adoption of the Consolidated Framework for Implementation Research (CFIR) to integrate a music-based intervention. According to the CFIR framework, to embody music into the hospitalization through piped music, it is necessary to explore the possibility of integrating music into the in-patient setting.
The purpose was to 1) understand the general appreciation and practical feasibility of the musical introduction, 2) explore the point of view of operators and patients to define the modalities of integration in the healthcare setting and 3) investigate listening preferences before the experimentation. To this aim, the updated questionnaire, preliminary to the present one, was submitted to all the 33 healthcare professionals and to a limited sample of 25 patients before the start of the experimentation. They were asked to give their opinion on the questionnaire and fill in two short surveys to assess the overall comprehensibility of the questionnaire and collect the suggestions from patients and health professionals, aimed at improving the form and content of the questionnaire. Based on scientific evidence from the literature [1-7,10,12], the frameworks on music selection, and the suggestions that had emerged from patients and operators in the preliminary investigation, the final questionnaire was declined and then submitted to the different sample of 267 patients of the present study, together with the short survey. The final questionnaire, specifically constructed for this study, consists of 18 questions. The questionnaire is structured in two sections, the first, pre-intervention, with the aim of exploring the patient’s habitual (8 questions, T0) and hospitalization perceptions (7 questions, T1) and the second to explore the patient’s experience after the music-based intervention (3 questions, T2). For questions 1 to 18 the participants can choose one of the predefined answers that best describes his or her point of view, with the possibility, for eleven of these questions, to enter open answers different from the predefined ones. Socio-demographic data (nationality, sex) were collected by the short data survey that was administered by a separate sheet and that include the overall evaluation of the questionnaire by the participant. This short survey also includes the pre-post opinions about the music intervention through 5 Point Likert Scale Questions (1: strongly disagree, 2: disagree, 3: neither agree nor disagree, 4: agree, 5: strongly agree).

Intervention

A pre-recorded music-based intervention was developed in the pre-experimental phase when the preliminary version of the questionnaire was developed. During this phase, musical genres of patients’ preference on admission were explored. A music therapist structured an intervention based on the opinions of 25 patients. The music-based experimentation was designed using specific theoretical frameworks for music selection [10] and reporting intervention quality guidelines [13]. Pre-recorded pieces of music were selected considering specific formal and parametric characteristics with the purposes of distraction, entertainment, relaxation, and emotional support. The selection criteria, declined through the intervention reporting checklists by Robb SL et al. [13] reported on the Equator Network are detailed in Table 1. The piped music was transmitted into the single room of patient participating to the study via a player and an amplifier located in a workstation isolated from the COVID-19 wards. Ceiling speakers were used to prevent contamination through portable music players/earphones and in consideration of the poor management of portable devices or musical instruments due to medical ventilation devices.

 

Table 1. Music-Based Intervention

Statistical Analysis

Categorical data are reported as counts (N) and percentages (%) with 95% confidence intervals (95%CI, binomial exact calculation). We applied the Cramer’s V test to investigate if the usually preferred genre of music (classical, Italian, foreign language, etc.) correlated with the preferences during hospitalization (Q3 vs Q13). Categorical variants were compared by Chi-square test or by Fisher’s exact test when more appropriate. In particular, the Fisher’s exact test was applied to explore if the emotional effects (relaxation, happiness, crave, etc.) were different between what expected in usual settings and what was expected during hospitalization (Q8 vs Q17). The Fisher exact test was also used to compare if patients enjoyed music and the reasons why they listened to music (the utility of the music in terms of kind of sensations achieved: amusement, relief, etc.) in the three settings: usual life vs what expected during hospitalization vs what actually felt during hospitalization (Q1 vs Q14 vs Q16, and Q7 vs Q12 vs Q18, respectively). These tests were confirmed by the Cochrane Q test to compare more than two groups for a binary outcome when considering only the two categorical “yes” or “no” answers. Also, the differences between females and males were investigated through the Fisher’s exact test, as well as the association between the genre of music preferred during the hospitalization and the emotional effect and the utility in terms of sensation achievement. Finally, the level of appreciation of music measured by the Likert questions was compared before and after the music intervention by the Wilcoxon test, while the correlation was estimated by Spearman’s rho; the differences between males and females were tested by the Mann-Whitney test. All tests were two tailed and considered significant with p-value (p) <0.05. Data were analyzed using 24.0 SPSS Software.

RESULTS

Analyzed Sample and Baseline patients’ characteristics

Two hundred and seventy-two patients met the eligibility criteria, however five refused to participate in the study, declining the proposal because they did not want to answer the questions on the questionnaire. Among the participating patients, two refused the music-based intervention after answering the first questions of the questionnaire; one due to clinical aggravation and the other due to the need for rest. The flowchart of the study is depicted in Figure 1. Patients were mostly Italian (94.4%), 59.6% were males. For 95.1% of the participants, the questionnaire had a good (66.8%) or complete intelligibility (28.3%). Only 4.9% believed that the questions were fairly comprehensible. Answers regarding the usual everyday life are described in Table 2 (Q1-Q8). Usually, patients listened to music to get a pleasant distraction (69.7%) or to relieve from negative feelings (22.5%) and what achieved from listening to music was relax (41.6%) or leisure (18.4%).

 

Table 2. Habitual listening to music

Preferences specific to the hospitalization

Most of patients at the time of hospitalization would have preferred listen to music (84.6%) rather than other activities such as reading, watching TV, etc. Accordingly, the patients declared they would like to listen to music during hospitalization (95.5%), granting that it would have a positive effect on them (96.6%), mainly through piped music (93.3%), and without any distinction in administration time (85.4%) (Table 3 Q9-Q15). The genre of music habitually listened highly correlated with the one desired during hospitalization (Cramer’s V = 0.928, p<0.0001), with only 6 patients preferring a genre of music different from the one usually preferred.

Table 3. Views on music listening during hospitalization.

Perceptions experienced after music-based intervention

Answers given after the music treatment are reported in comparison with answers given before the treatment (Table 4). Patients who appreciated listening to music increased from 93.6% of the everyday life, to 95.5% in their perception of hospitalization, and up to 98.5% after hospitalization (Q1, Q14 and Q16), although the latter percentage is slightly inflated by the fact that two patients who didn’t habitually like music refused the music treatment and therefore did not answer to the post treatment questions (Table 4). These differences reached the statistical significance when comparing “yes” vs “I do not know” across the three periods (the only two “no” answers were missing at the post treatment, Cochran’s Q= 13.0, df=2, p=0.0015). According to the high percentage of patients declaring that they liked music, the degree of usefulness attributed to music was very high both before and after hospitalization (median= 4 in both, on a score from 1 to 5) (Table 4). There were high and significant correlations between the two (Spearman’s rho=0.631, p<0.0001) and difference between the two periods did not reach the statistical significance (Wilcoxon Signed Ranks Test Z = -1.821, p=0.0687), although 23 patients gave a score below 4 before hospitalization (8.6%, two patients scored 1, one scored 2 and 20 scored 3), who reduced to only 9 patients giving a score of 3 (3.4%). The emotional effects usually conveyed by music were significantly different from those conveyed during hospitalization (Q8 vs Q17, p<0.0001), with happiness falling from 17.2% to 8.7% and excitement from 9.4% to 0, while amusement/entertainment raised from 18.4% to 41.1% (Table 4). Also, the reasons why the patients listened to music changed from the usual habits to the idea the patients had about hospitalization and to what they have actually perceived during the hospitalization (Q7 vs Q12 vs Q18, p<0.0001): pleasant distraction went from 69.7% to 55.8% to 38.7%, while relief went from 22.5% to 35.2% to 60.0% (Table 4). Only 80 patients chose the same reasons for the three periods, mostly (90.0%) desired music for pleasant distraction.

 

Table 4. Perceptions experienced after music-based intervention.

Not surprisingly, the music treatment was appreciated especially by the patients who preferred listening to music rather than other activities such as reading, watching TV, etc.: all the 266 patients that had declared they would have liked listening to music appreciated the treatment, while 4 patients out of 39 that would have rather preferred other entertainment activities were then not sure about the music treatment (p<0.0001). However, the patients who preferred other activities were mainly satisfied by the music treatment. Finally, there were some differences between males and females (Table 5). In particular, males tended to habitually listen to music more than females (96.2% vs 88.0%, p=0.0161) and through different playback sources (p<0.0001), in particular males preferred radio and females preferred television. Females usually tended to listen to music more to get a pleasant distraction, achieving relaxing sensations while males more to get relief from negative feelings (p<0.0001), achieving leisure (p<0.0001). Of note the answers specific to hospitalization showed, at opposite, that females were more expecting to get relief, while males were more expecting to get a pleasant distraction (p<0.0001), a trend confirmed at the post treatment evaluation (p<0.0001).
Females rated the utility of listening to music slightly less than males as for their hospitalization expectance (p=0.0330, Mann-Whitney test), but without any difference at the post treatment evaluation, when at opposite their appreciation was even higher than those by males, although not significantly different (Table 5).

Table 5. Gender Differences to questionnaire responses

DISCUSSION

This pilot study aimed to determine the impact of a pre-recorded music-based intervention on music perception in patients hospitalized for COVID-19. This study, in line with others [16], describes an almost total appreciation for music in everyday life. The COVID-19 patients included in this study liked music even more in the perspective of hospitalization, with a further increase in the overall liking after the music-based intervention. Particularly, this observation emerged in females with a 99.1% of appreciation and a reduction from 6.5% to 0.9% of undecided/negative answers after the treatment. This implies that the musical listening confirmed and exceeded the usual expectations towards music, particularly in females, who showed a slightly lower preference for music than males in their habitual life. This observation provides support for the importance of music presence during hospitalization and potential benefits in COVID-19 patients. This study also shows that habitual preferences are closely related to those in the in-patient setting and should therefore be considered in order to direct music-based interventions [10,12-14]. The preference for Italian pop music reflects the cultural and musical background of the participants, considering their Italian origins and the high average age. Regardless of the usual musical medium, and in line with other studies [22], participants preferred piped music in the in-patient setting, while only 0.7% and 4.9% of them liked live music or music via earphones, respectively. It is conceivable that piped music represents a socially accepted medium in the care setting and that live music may represent an unrealistic novelty, especially given the restrictions and isolation during hospitalization. However, it must also be considered that the use of medical devices such as masks or helmets for ventilation makes it difficult or impossible to set up a system of music diffusion via earphones. Likewise, there are further complications in the hygienic handling of diffusion devices/music instruments in a COVID-19 environment, which must ensure minimal contamination of surfaces by microorganisms [23]. These limitations might have mitigated, in fact, the clear preference for piped music. The habitual listening to music was shown to find its place in numerous daily life activities (during free time, sports, or work). Similarly, the patients were willing to enjoy music at any time during hospitalization, being the preferred entertainment activity in hospital compared to other proposals, such as reading, watching TV, or taking drugs to relax. This may suggest the possibility to extend music not only to the in-patient rooms but also to the corridors, to the rooms used for clinical care services, and to the common spaces. The experimental intervention impacted the perception of the effects attributed to music. Feelings of pleasure and enjoyment were experienced by more than double the participants compared to the usual condition. Not surprisingly given the patients’ situation, happiness and joy decrease from 17.2% to 8.7% and the exciting/energizing effect was not perceived by anyone post-intervention. Similarly, the reasons that motivated the patients to listen to music were significantly different between everyday life, the hospitalization perspective, and the post intervention. The usefulness of listening music to alleviate unpleasant feelings including anxiety, fear, loneliness, and low mood had a significant increase after the music intervention. Furthermore, the degree of usefulness experienced with the intervention was greater than that usually perceived, even if the very high level of appreciation already in everyday life did not allow us to detect a statistically significant increase. No participant experienced little or no benefit from the intervention. The pre-recorded music was specifically designed according to general patient preferences and frameworks for entertainment and mood improvement, considering the need for emotional support in disease. In the literature, for example, it has been widely demonstrated that musical rhythms between 60 and 80 bpm or the use of musical instruments that are tuned to A432(Hz) can assist physical and emotional relaxation with a decrease in sympathetic nervous system activity, thus decreasing adrenergic activity, neuromuscular arousal, cardiovascular and respiratory rhythms, tension, metabolic rate, gastric acidity, motility, and sweat gland activity [10]. In this study, in line with findings in the literature, the effects of music listening can be traced back to the rationale with which the music was selected [10]. In fact, music selected to promote distraction, relaxation, entertainment and emotional support predominantly elicited relaxation and pleasure, recognised to distract, and alleviate unpleasant feelings such as anxiety, fear and stress. To confirm this, sadness, melancholy, love, nostalgia, and pride were evoked to a limited extent by listening to music. These findings support the directionality of the music-based intervention according to specific frameworks. Scientific rigour in music selection, the involvement of music experts, and the use of reporting guidelines can determine specific listener-perceived effects and allow for adequate replicability of the intervention. These data are in line with other studies that suggest that music-based intervention induced greater satisfaction and compliance in the patient pathway [18]. Awareness and recognition of the usefulness of music by the patient can in fact mitigate the decision-making processes of care and self-care. Structural changes can improve the environment and even encourage interaction between operators and patients [24]. However, economic, and organizational aspects must be considered in order to integrate this kind of service. In this study, the design of a piped intervention based on pre-recorded music tracks, according to scientific frameworks, required limited costs for the music setting by a professional and the copyright licenses, given that the in-patient area already had ceiling-mounted audio diffusion media. Also considering that the use of the music playback devices avoided any risk of infection from contamination, the safety of the intervention, in addition to the cost-effectiveness, was evident. Other studies have already amply demonstrated the benefits in terms of cost-effectiveness in multiple contexts and with different music playing methods [25,26].

CONCLUSION

This pilot study explored in-patients’ preferences, utility that comes from music, usages, and expectation from the effect of music in COVID-19 patients, before and after music-based intervention, and was carried out in response to a lack of studies in the literature and methodological weaknesses of publications. In this study, music was the most welcome activity during the hospitalization. The experimental intervention, directed according to reference frameworks, significantly impacted on the utility, on the evoked emotions, and on the self-reported effects of music during hospitalization for COVID-19. This result provides support for the intervention with pre-recorded music as an integrated standard in treatment protocols to meet the need for social and emotional support in hospitalized patients for COVID-19 and possibly in similar settings of hospitalization in isolation.

Limitations

It was not possible to recruit patients younger than forty years of age. This made it impossible to evidence some generational differences between the participants. A similar consideration regards the lack of heterogeneous in nationality. In addition, participants could not enjoy parental visits during their hospital stay due to COVID-19 restrictions, limiting the comparison with the more general situation of parental social support. Other clinical variables such as anxiety levels, loneliness in the healthcare relationship [27,28], psycho-physical distress and respiratory complications, which could have impacted the perception of the music experienced, were not considered. In the literature, there is ample evidence that patients with high levels of anxiety and distress obtained greater benefit from music [1,3,6,18,29-32], so although the aim of this study was not to measure changes in health outcomes, a correlation between high levels of psycho-physical distress on admission and musical perceptions related to the need to alleviate unpleasant feelings is likely. Preferences, beliefs, and attitudes towards the different genre of music, also in the context of socio-demographic characteristics should lead future study. The catchiness, use of melody, rhythm, and ease to understand of lyrics should be explored as well. Future randomised controlled trials using the same framework should be considered, to determine its effects on healthcare outcomes in multiple populations with similar needs for social and emotional support. The appropriate use of music may also be aimed at improving recovery time and reducing the need for medication to treat COVID19-induced psycho-physical distress [1,33,34]. Hopefully future studies will consider patients’ perceptions as a crucial factor in determining the specific psychophysical effects of music. Based on this knowledge it will be possible to structure, implement and systematically replicate music in healthcare environment.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.

 

Conflict of interest

The authors report no conflict of interest.

 

Authors’ contribution

Dr. Alessio Pesce: Conceptualization, Methodology, Writing- Original draft preparation, Visualization, Investigation, Validation, Writing- Reviewing and Editing.
Department of Internal Medicine, Local Health Authority ASL2, Savona (Italy), Piazza Sandro Pertini n. 10, 17100 Savona, Italy. Tel: +39 340 7114674. E-mail: alessio.pesce@uniupo.it; ORCID: https://orcid.org/0000-0003-2702-4101
Dr. Francesca Lantieri: Software, Data curation, Visualization, Investigation, Supervision, Validation, Writing- Reviewing and Editing.
Department of Health Science, Biostatistics Unit, University of Genoa, Italy, via Pastore 1, 16132 Genova, Italy. E-mail: f.lantieri@unige.it; ORCID: https://orcid.org/0000-0002-8923-0165

 

Acknowledgements

We want to thank the staff of the Internal Medicine department at the dedicated Covid-19 hospital in Albenga, and Dr. Letizia Ceravolo for revising the English-language manuscript.

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by OPI Napoli

Effectiveness of nursing intervention in short-term hospitalization for patients suffered from borderline personality disorder and self-harm. A narrative literature review

Antonino Calabrò¹, Federica Ilari², Lorenzo Rizzo³, Alessia Lezzi⁴, Simone Zacchino⁴, Pierluigi Lezzi⁵, Giovanni Maria Scupola⁶, Marta Fanton⁷, Roberto Lupo⁶, Elsa Vitale^8*

 

1. Psychiatry Unit, Nuovo Ospedale Degli Infermi, Biella, Italia
2. Department of Translational Medicine, University of Eastern Piedmont, Biella, Italy
3. Eating Disorders Cente, Villa Eèa Cooperative Città Azzurra, Bolzano, Italy
4. Associazione Nazionale Italiana Tumori, Lecce, Italy
5. Neurology Unit, Vito Fazzi Hospital, Local Health Authority (ASL) Lecce, Italy
6. Department of Emergency Medicine, San Giuseppe da Copertino Hospital, Local Health Authority Lecce, Italy
7. Azienda ospedaliera nazionale SS. Antonio e Biagio e Cesare Arrigo, S.C. Cardiologia, Alessandria, Italy
8. Department of Mental Health, Local Health Authority (ASL) Bari, Italy

*Corresponding Author: Elsa Vitale, Department of Mental Health, Local Health Authority (ASL) Bari, Italy. E-mail: vitaleelsa@libero.it; ORCID: 0000-0002-9738-3479.

 

 

Cite this article

 

ABSTRACT

Introduction: Personality disorder sufferers with severe self-harm and experience long psychiatric hospitalizations have complex mental health conditions and are at risk of suicide. When the symptoms of emotional instability are combined with self-harm, the resulting crisis often becomes difficult for patients and caregivers to manage. To improve care during these crises, the Dutch Multidisciplinary Guideline for Personality Disorders designates “brief admission” (BA) hospitalizations as an ameliorative intervention.

Objective: To describe the effectiveness of short hospitalization nursing care for people with borderline personality disorder and who practice self-harm, compared to ordinary hospitalization. Methods: A narrative review was conducted through the Embase and CINAHL databases, the selected articles had to answer the following research questions: “what are the observable benefits of short-term hospitalization on patients with borderline personality disorder?”; and “what are the benefits compared to short hospitalization operators?”.

Results: Seven studies were selected. The results show that BA was perceived as an effective nursing intervention, which promoted the patient’s self-determination and self-care. This helped increase confidence in daily life and allowed people to maintain their daily routines, work, and relationships by decreasing long hospitalizations and increasing patient compliance. There has also been benefit from the staff, who report an improvement in work quality.

Conclusions: This type of hospitalization has developed in Northern European states. BA has never been tested in the Italian healthcare sector. It would be appropriate and desirable, given the results obtained, to experiment with this procedure also in Italy to obtain specific feedback regarding the relationship of short-term hospitalization with our National Health Service. It is hoped that this research can be a stimulus in this sense.

Keywords: Borderline Personality Disorder, Nursing Management, Brief Admission, Patient Experiences, Self-Harm, Short-term hospitalization.

Cite this article

 

INTRODUCTION

Borderline Personality Disorder (BPD) is the most common personality disorder observed in clinical settings and within societies around the world. This disorder is characterized by various elements: a set of unstable and changing interpersonal relationships; emotional instability which often manifests itself with sudden attacks of anger; poor impulse control associated with self-harm; identity disorders [1]. The prevalence of people with borderline personality disorder in general and clinical psychiatric populations is approximately 4% and 20%, respectively. Approximately 75% of patients with borderline personality disorder attempt suicide and 10% succeed in their attempt [2]. Self-harm is part of the signs and symptoms of BPD and is the act of harming oneself voluntarily but without a conscious or declared suicidal intention (non-suicidal self-harm ANS) [3].
It is a very common phenomenon widespread especially among young people, in fact, it is also a major health care problem among both outpatient psychiatric patients and those in hospital care, with incidence rates of 55% and 65%, respectively. When the subject with BPD practices recurrent acts of self-harm, it is due to his inability to express his own internal suffering, he attacks his own body because he has the impression that by doing so, he will calm down. This becomes difficult to manage both for the patients themselves but above all for the healthcare personnel who deal with them [2]. Patients with borderline personality disorder are followed in both outpatient and hospital settings. Treatment typically begins with community services with day care and individual and/or group psychotherapy, depending on the individual [4].
When the behavior of these individuals becomes dangerous to their health, treatment may sometimes be necessary. interruption of outpatient treatment, preferring hospitalization in a psychiatric ward to ensure good protection for the patient. However, unplanned or long-term hospitalization for these patients without a clear treatment structure is very often associated with clinical and functional decompensation [5]. Hospitalization has been shown to have limited value, with often a failure to eradicate ideas. aimed at anti-conservative actions, with the development of possible negative side effects such as the beginning of a period of regression and the continuous need for repeated hospitalizations over time [6].
The Dutch Multidisciplinary Guideline for Personality Disorders [7] recommends short-term hospitalization as a treatment and crisis management approach for people with borderline personality disorder. Similarly, the National Institute for Health and Clinical Excellence (NICE) Clinical Guideline [8] for patients with borderline personality disorder mentions the development of autonomy and the promotion of individual choice as key factors for this type of treatment. Patients should be actively involved in finding solutions to their problems even during a crisis, as this allows them to gain experience in managing the crisis and to develop a certain autonomy regarding the decisions to be made at that moment [4].
Early hospitalizations and preventive interventions have made it possible to positively change the subsequent clinical course of individuals with borderline personality disorder. It was soon noticed that preventive psychiatric hospitalizations for such patients led to significantly greater agreement between healthcare professionals and patients on the treatment they would have liked to undertake and thanks to this type of intervention many patients who took part experienced the control over one’s own care. Following this model, to support patients with borderline personality disorder, a specific crisis intervention called “brief admission” (short hospitalization or BA) was developed [2]. With the advent of the new diagnostic and statistical manual in 2014 (DSM V), the new perspectives of this disease have also changed, and therefore also the treatments. Since then a new path has been started, therefore few review studies have been found one of these is by Helleman et,[4] al. who subsequently conducted the experiments that were introduced. With this article we want to raise awareness and bring out new perspectives for the treatment of this pathology

 

Purpose

To describe the effectiveness of short hospitalization nursing care for people with borderline personality disorder and who practice self-harm, compared to ordinary hospitalization.

 

MATERIALS AND METHODS

On the day 04/11/2023 with the support of the staff of Biomedical Library Foundation in Biella, Italy, a bibliographic search was conducted within the Embase and CINAHL Complete databases.

 

Search strategy and keywords used

A narrative review of the literature [9] was conducted following the methodology reported in the ‘Scale for the Assessment of Narrative Review Articles’ (SANRA) [10]. The following research questions were formulated:

1. What are the benefits of short hospitalization for patients suffering from BPD?
2. What are the benefits compared to short-term hospitalization operators?

To conduct the literature search, a research question was previously outlined using the P.I.O. framework (Table 1), search strings were subsequently created on biomedical databases such as Embase and CINAHL, using the Boolean operators “AND” and “OR” to interconnect the following keywords: Borderline Personality Disorder, Emotionally unstable personality disorder, Injuries, Self-Inflicted, short hospitalization, brief hospital, Nursing Staff, Hospital, Nursing Outcomes, Nursing Management.

Table 1. The PIO methodology assessment.

Inclusion and Exclusion criteria

All original studies, attributable to primary resources, relevant to the research question illustrated were included. Only references written in English published in the last 15 years were taken into consideration.
However, secondary studies were excluded. Also excluded were all those references such as collections of abstracts, oral dissertations, and those quotes for which it was not possible to find the written “full text” version through the library circuit of the “Virtual Library for Health – Piedmont” (BVS – P).
Literature selection method: From the results of the searches carried out on the databases, a total of 128 bibliographical references were included. The results obtained were analyzed by two evaluators independently, by title and abstract, to identify relevant articles. The selected studies were found in full text format, read critically and the relevant ones were included in the review.
Extrapolated variables; the following data were extrapolated from the included studies: title, authors; study design; study context; mode; results and conclusions and listed in chronological order.

RESULTS

The bibliographic search revealed 128 references, of which 24 in CINAHL Complete and 104 in Embase. After a selection by reading the title and abstract, 96 articles were excluded. The articles initially included were 32; after removing the double 18s, 15 full text articles remained. The results were analyzed by two evaluators independently and read critically; after removing secondary studies, 7 articles were selected, respectively: 5 articles in Embase and 2 articles in CINAHL Complete.

Study selected

Below are the synoptic table 2 summarizing the selected articles.

Table 2. Studies selected in the present review.

Study description

The first article is a study conducted through interviews, using Giorgi’s descriptive phenomenological methodology: Experiences of patients with borderline personality disorder with the brief admission intervention: A phenomenological study; published in International Journal of Mental Health Nursing in March 2014 [11]. The researchers’ overall objective was to describe the lived experiences of patients diagnosed with borderline personality disorder during the brief admission. A total of seventeen patients participated in the present study, which was conducted between January 2011 and August 2012. Patients were included according to the following criteria: individuals receiving public mental health services in the Netherlands; sufficient understanding of the Dutch language; diagnosis of borderline personality disorder according to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria; ability to sustain an interview; prior experience with brief admission; neither age nor gender were considered. Instead, patients who met the following criteria were excluded: substance abuse; persons who presented fear that the interview would be recorded. Data were collected through interviews lasting between 45 and 75 minutes each, structured following a common pattern and based on clinical experience and a review of relevant Helleman literature. Data saturation was reached when no new meaning units were mentioned after interviews were conducted with 15 participants. Interviews with participants were audio recorded and transcribed verbatim. The meaning units in the transcripts were then identified and analyzed to reveal current problems and patterns following the steps described by Giorgi. Thematic analysis of the interviews revealed the effectiveness of four units of meaning of short hospitalization from the patients’ perspective: the organization of the short hospitalization; the quality of contact with a nurse; the regaining of free time in daily life; and the personal value this type of intervention acquired for patients. These units of meaning formed the essential structure of the experience. Patients also reported that the quality of contact with a nurse is the most important thing. Nurses should therefore be aware of the meaning and value of their relationship with patients with borderline personality disorder considering the strong interpersonal hypersensitivity of such individuals.
The second article is an interview study focusing on qualitative analysis of patients’ experiences: Individuals’ experiences with brief admission during the implementation of the brief admission skåne RCT, a qualitative study; published in Nordic Journal of Psychiatry Nordic [6]. The researchers’ overall objective was to detect possible limitations and strengths of brief admission and what were the reasons for requiring or conversely not requiring this type of admission. A total of 8 patients participated in the present study. Patients were included according to the following criteria: meeting at least three criteria for a diagnosis of borderline personality disorder; having been admitted to a psychiatric hospital for acute care for at least seven days or having presented to a psychiatric emergency room at least three times in the past six months; having recently performed acts of self-harm and/or recurrent suicide attempts; and age ≥18 years to 60 years. In contrast, patients were excluded if they met the following criteria: no regular contact with outpatient psychiatric services; somatic disorder or need for medication management that contributes significantly to the inclusion criteria (e.g., if self-harm occurs only during episodes of hypoglycemia in a diabetic person or in someone with substance-induced psychosis); homeless persons.
Data were collected through interviews conducted at the Lund psychiatric clinic, their duration was between 20 and 45 minutes each, and all interviews were conducted following a common pattern. The interviews with the participants were audio-recorded and transcribed verbatim. The units of meaning in the transcripts were then identified and analyzed to reveal current problems and patterns. From the thematic analysis of the interviews, it can be stated that the elements of short hospitalization most valued by the participants were the organization and routine of the ward. This is contrasted with the statements of some patients who reported that they had problems with some negative attitudes of the staff. Regarding the reasons reported for requesting short hospitalization, effective prevention of impulses aimed at self-harm, ending social isolation, creating a daily routine, and having an alternative to excessively long hospitalizations and mandatory hospitalizations emerged. Reasons for not requesting short hospitalization, on the other hand, are fear of rejection and difficulty in deciding the degree of severity of personal problems.
The third article is an interview study focused on qualitative analysis of nurses’ experiences: Brief admission (BA) for patients with emotional instability and self-harm: nurses’ perspectives person-centered care in clinical practice; published in International Journal of Qualitative Studies on Health and Well-being [12]. The researchers’ overall objective was to describe the experiences of nurses working with BA related to patients with emotional instability and self-harm. A total of 8 nurses participated in the present study. Purposive sampling was used to recruit participants. The only criterion that was followed to include the nurses was that they worked, during day shifts, within the selected psychiatric clinic, in the ward where the short hospitalization was taking place. Interviews with participants were audio recorded and transcribed verbatim. Units of meaning in the transcripts were then identified and analyzed to reveal current problems and patterns. Thematic analysis of the interviews revealed four main themes related to nurses’ experiences: providing safety and continuity, promoting relationship as caring time, shifting the focus to inpatient health, and empowering the patient. In addition, nurses reported that this new approach to hospitalization had several positive effects.
The fourth article is an interview study focusing on qualitative analysis of patients’ experiences: Brief admission for patients with emotional instability and self-harm: A qualitative analysis of patients’ experiences during crisis; published in International Journal of Mental Health Nursing [2]. The researchers’ overall goal was to answer the following research questions: what are patients’ experiences during brief admission? What do patients think are the key components of ‘brief admission? What improvements are considered relevant by patients? Purposive sampling was used to recruit participants, starting with contact with those who had most used short admission. A total of fifteen patients participated in the present study. Patients were included according to the following criteria: possessing a documented clinical history of emotional instability (mainly problems with emotion regulation and impulse control, borderline personality disorder); prior experience with brief admission; whether the patient had recently performed acts of self-harm and/or recurrent suicide attempts; neither age nor gender were taken into account. Instead, patients who had a primary diagnosis of psychotic disorder or depressive disorder were excluded.
Data were collected through interviews conducted at participants’ outpatient units, their duration ranged from 13 to 51 minutes each (mean = 31 minutes), and all interviews were conducted following a common pattern and structured based on a review of previous research. Interviews with participants were audio recorded and transcribed verbatim. The units of meaning in the transcripts were then identified and analyzed to reveal current problems and patterns following the steps described by Giorgi. Thematic analysis of the interviews revealed four themes related to patients’ experiences: “it is a break when life gets difficult”; “it is comforting to know that there is help”; “it encourages taking personal responsibility”; and “it is helpful to see problems from a different perspective.” Four themes also described key components: “a clear treatment plan,” “a smooth admission procedure,” “a friendly and welcoming approach from staff,” and “daily conversations.” Finally, three themes described areas for improvement: “feeling guilty for requesting short hospitalization,” “room occupancy problems,” and “differences in staff competence.” Overall, the results indicate that short hospitalization constructively supports patients with emotional instability and self-harm during a period of crisis.
The fifth article is a study conducted through inductive and qualitative interviews, uses hermeneutic phenomenological methodology and is inspired by Ricoeur’s theory of interpretation: A Brief Breathing Space: Experiences of Brief Admission by Self-Referral for Self-Harming and Suicidal Individuals with a History of Extensive Psychiatric Inpatient Care; published in Issues Ment Health Nurse [13]. The overall goal of the researchers was to detect the main characteristics as well as pre-expectations and reflections on potential improvements and adaptations of short hospitalization through patients’ personal experiences during their BA. A total of seven patients participated in the present study. Patients were included if they had met the following two criteria: prior experience of short admission; having been admitted to a hospital ward for psychiatric care for at least one hundred and eighty days in the 365 days prior to short admission.
Data collection was carried out through interviews conducted at patients’ homes or within psychiatric clinics in Helsingborg, Lund or Malmo between September and October 2018. All interviews were conducted following a common pattern. Interviews with participants were audio recorded and transcribed verbatim. The units of meaning in the transcripts were then identified and analyzed to reveal current problems and patterns. From the thematic analysis of the interviews, it can be said that the patients experienced the short hospitalization as a worthy antidote to the loss of control in dealing with self-injurious and suicidal instincts; moreover, the relief of not being continually interviewed reduced to some extent the negative feelings of fear in seeking help and care from health care personnel. Contrast this, however, with the statements of some patients who reported how brief hospitalization could offer the help and protection needed in times of mild crisis, but how it was of little help in the face of a more severe crisis.
The sixth article is a study conducted through interviews, using the descriptive qualitative method: Experiences of how brief admission influences daily life functioning among individuals with borderline personality disorder (BPD) and self-harming behavior; published in Journal of Clinical Nursing [14].
The researchers’ overall goal was to explore the experiences of how brief admission affects daily life functioning among individuals with borderline personality disorder and self-injurious behavior. Purposive sampling was used to recruit participants. A total of sixteen patients participated in the present study, which was conducted between November 2020 and January 2021. Patients were included according to the following criteria: diagnosis of borderline personality disorder; experience of brief hospitalization; whether the patient had recently performed acts of self-harm; neither age nor gender were considered. Instead, patients who met the following criteria were excluded: being admitted to a hospital at that time. Data collection was carried out through interviews conducted at the location chosen by each participant, their duration was between 15 and 90 minutes each, and all interviews were structured and conducted following a common pattern.
Data saturation was reached when no new meaning units were mentioned after interviews were conducted with 13 participants. Interviews with participants were audio recorded and transcribed verbatim. The meaning units in the transcripts were then identified and analyzed to reveal current problems and patterns. From the thematic analysis of the interviews, it can be stated that short hospitalization was perceived as a functioning nursing intervention that promoted self-determination and self-care, helping to increase control over one’s everyday life. In addition, short hospitalization made it easier for people to create or maintain a daily routine, employment and social relationships.
The seventh article is a naturalistic study with repeated measures (pre-test and post-test): Patient-Initiated Brief Admission for Individuals with Emotional Instability and Self-Harm: An Evaluation of Psychiatric Symptoms and Health-Related Quality of Life; published in Issues in Mental Health Nursing. Aim was to evaluate how symptoms of anxiety, depression and health-related quality of life (HRQoL) change after patient-initiated brief admission (PIBA), in patients in crisis with increased risk of self-harm. One hundred and thirteen patients were recruited from a Stockholm psychiatric clinic between 2016 and 2020. Upon admission and discharge, patients completed the Hospital Anxiety and Depression Scale (HADS) and the EuroQoL-5 Dimension Questionnaire (EQ-5D). Two outpatient psychiatric clinics and two psychiatric hospital departments in Stockholm specializing in BPD and anxiety disorders were involved initially.
During the 4-year intervention period (2016-2020), a reorganization was performed, and four additional outpatient units were included. By minimizing exclusion criteria and involving only inpatient and outpatient adult psychiatric units specializing in BPD, our patient sample is considered representative of the patient population of these units. One of the units had two patient rooms dedicated to PIBA, while the other unit had one room dedicated to PIBA. Inclusion criteria were as follows: (1) clinical history and current symptomatology of emotional instability (mainly problems with emotion regulation and impulse control) and a history of self-harm and (2) at least one previous period of inpatient care. Of the 145 patients who had PIBA contracts during the intervention period, 113 (78%) gave oral and written informed consent to participate in the study. The results obtained among the 113 patients with PIBA contracts, 57% (n = 64) used PIBA at least once during the study period.
There was a significant decrease in symptoms of anxiety and depression, as reflected in the HADS score, after the first hospitalization, with a medium effect size. Significant reductions in both anxiety and depression symptoms were also observed after subsequent hospitalizations. Combining the two subscales of the HADS, the results showed a large effect (d = 0.75) on the total burden of psychiatric symptoms. This result was confirmed in the analysis of the EQ-5D dimension “anxiety/depression,” with a large reduction (d = 0.72) in symptoms. The HRQoL of the participants increased significantly, with a large effect as measured by the EQ-5D VAS and a mean effect as measured by the EQ-5D index. and analysis of each dimension of the EQ-5D index showed that only the “Anxiety/depression” dimension was significantly decreased (except for “Habitual Activities” in the third admission to PIBA). This specific EQ-5D result was consistent with the changes in anxiety and depression symptoms in the HADS.
The potential reasons for the absent effect on the “Mobility” and “Self-care” dimensions could be due to low levels of symptomatic load in these areas. Moreover, they were not the primary indication for PIBA. The decrease in the “Habitual Activities” dimension was not significant for the first, second, and fourth admissions to PIBA. This could be an area for improvement and show the need to further educate health care providers on helping patients with behavior activation and helping self-help regarding initiating their daily activities. Almost all participants (95.2%) described PIBA as a constructive intervention. The importance of getting quick help when psychiatric symptoms worsen. The results of this study also reported high ratings (M = 9.02 out of 10) regarding the approach from staff, which aligns with previous studies of PIBA [11,12] in which a friendly and welcoming attitude from health care providers was described.
Based on this, our hypothesis is that PIBA is cost-effective and efficient in terms of utilization. The overall purpose of PIBA is to provide a patient-initiated time-out in a safe environment when a crisis is imminent, the patients in this study, in which most had been diagnosed with a disorder that was previously considered “difficult to treat”, stated that PIBA fulfills its stated purpose.

 

DISCUSSION

The objective of this review was to describe published studies on the effectiveness of short hospitalization nursing care for people with borderline personality disorder and who practice self-harm, six studies were identified of which 6 are qualitative [2,6,11–14] and one quantitative [15].
The thematic strengths found by the patients are summarized in these 4 macro areas identified by Helleman [6] and common to other authors: were: 1 Structure and routine, 2 Positive staff attitudes, 3 The experience of self and 4 Negative staff attitudes.

1. Structure and routine: Patients reported value in knowing that a BA was available to them and experienced it as helpful in regaining basic sleep and eating routines, getting respite from the demands at home, and creating meaning safety. The fact that they could be sure that there would be daily conversations reportedly created a feeling of safety. Even just knowing that BA was a possibility was mentioned as something important, even if it wasn’t used. The reported perception was that the BA had prevented them from self-harming and attempting suicide. However, self-harm treatment was not perceived as the focus of BA. Rather, BA’s role was to meet basic needs by providing “rest from real life” by letting go of daily duties or overthinking to do something.
2. Positive attitudes from staff: Patients also reported positive attitudes from staff. A warm welcome at the start of the BA is “more important than people think”. The experience of being listened to, taken seriously and feeling responsible for their health was perceived as building their confidence. The operators ensured daily conversations, which led to feelings of greater safety.
3. The experience of the self: main objective of the BA, during admission the responsibility for managing current crises is in the hands of the participants themselves. This was mostly described as a positive experience: patients were able to take control of their situation, self-determine (taking medications not from nurses but self-managed), keep personal items, sense of independence and integrity, all in one protected environment where discussion is always possible.
4. Weaknesses noted by patients were linked to: From the staff as lack of knowledge about BA, negative attitudes about BA expressed in front of patients, which created an unwelcome and unsafe feeling and lack of time. Lack of time was another factor. This made them feel rejected, which in turn increased distress and negative thoughts.

Organizationally: Mixing BA with acute hospitalizations was a challenge for patients in BA when they found themselves relatively stable compared to other hospitalized patients. This led to worries about irritating others, feelings of guilt for trying to use BA preventively. It has been noted that having only one room, within an acute ward, undermines the entire purpose of the BA as the risk of being left alone during the crisis and without support from providers is very high.
The quantitative study by Eckerström [15] analyzes the aspects of anxiety/depression and quality of life through two scales, the first Hospital Anxiety and Depression Scale (HADS) and the second EuroQoL-5 Dimension Questionnaire (EQ-5D). The data collected validates those of previous studies for anxiety and depression, a significant decrease in symptoms of anxiety and depression, as reflected in the HADS score, after the first hospitalization. Significant reductions in anxiety and depression symptoms were also observed after subsequent hospitalizations. Combining the two subscales of the HADS, the results showed a large effect (d = 0.75) on total psychiatric symptom burden. This result was confirmed in the analysis of the EQ-5D dimension “anxiety/depression”, with a large reduction (d = 0.72) in symptoms. These findings match the results of a previous study, which included 15 patient respondents who reported that BA helped them overcome suicidal thoughts, depressive symptoms, and emotional distress [12]. The quality-of-life results highlight that nearly all participants (95.2%) described BA as a constructive intervention, the importance of receiving rapid help when psychiatric symptoms worsen. The results of this study also reported high ratings regarding the staff approach. Patients who have experienced both BA and regular hospital care describe the latter as old-fashioned, as patients have to wait until they get worse to receive treatment and demonstrate their need for help with self-harm as already demonstrated by Lindkvist’s study [13].
In reference to the second research question “What are the benefits compared to short-term hospitalization operators?” Eckerström’s study [12] aims to describe the experiences of nurses working with BA in relation to patients with emotional instability and self-harm, through interviews. The data that emerged also confirms from the nurses some data already collected by the patients from a care perspective such as: provides safety and continuity; direct access to the patient, without going through official channels Emergency, urgency and acceptance department (DEA), Mental Health Center (CSM) has improved communication between operators and patients, reducing misunderstandings that sometimes arise when communications are filtered through different nurses and doctors. Know what you both expect from the contract.
Furthermore, nurses described their new responsibility as challenging because they had to support patients with nursing interventions rather than medications or monitoring alone. In this sense the improvement of the patient-nurse relationship leads to a greater understanding of the person behind the patient, which was mostly described in a positive way.
Promoting person-centered care led to a demonstration of nurses’ confidence in their patients’ abilities fostered a positive relationship in which patients began to act more constructively, leading to mutual respect and a more balanced relationship. However, such in-depth reporting was painful because it became too close to the patients. BA gave nurses the mandate and the possibility to focus on nursing care, making the best use of those concepts of empathy that belong to us.

 

CONCLUSIONS

The objective of this review was to describe published studies on the effectiveness of short hospitalization nursing care for people with borderline personality disorder and who practice self-harm. Considering what was assessed in the discussions, we can affirm that short hospitalization is the best nursing intervention in terms of effectiveness and results obtained in the treatment of the population taken into consideration. The aspects of greatest interest that have the best outcomes are: quality of the patient-nurse relationship, the regaining of free time in daily life, the awareness of support for quality and duration of care, the management of self-harming and suicidal instincts, the promotion of self-determination and self-care, the maintenance of valid social relationships in the family and in the working world, the increase in the perception of security.
Undoubtedly within our review we took into consideration the critical issues that emerged such as: organizational factors, patients in BA admitted to emergency facilities, lack of staff training.
Nurses should therefore be aware of the meaning and value of their relationship with patients suffering from borderline personality disorder considering the strong interpersonal hypersensitivity of such subjects.
Short-term hospitalization was born and developed within the psychiatric wards and healthcare facilities of Northern European states, where nowadays it very often represents the most used treatment for the care of people with borderline personality disorder, as well as all the complications that this diagnosis brings. As regards the situation in our country, however, there are no studies that deal with this topic. In Italy, in fact, short hospitalization has never been experimented with, despite the effectiveness demonstrated by the results obtained from this treatment. Given the modest number of studies that we have analyzed for this type of hospitalization, it would be appropriate and desirable to experiment with this procedure also in Italy to have specific feedback regarding the relationship of short hospitalization with our National Health Service.
It is considered appropriate to continue and stimulate research into this topic, given the few studies on this subject present in the literature, as the topic we have discussed is one with a strong social impact.

 

Strengths and limitations

The strengths of the study are: original argument on a developing topic which has demonstrated excellent results, from the research carried out the presence of only one revision carried out by Helleman 2014 at the beginning of the process, 2014 subsequently no other revisions were found. It is believed to be an important contribution for the scientific community to be able to make known a patient-centered care model and consequently to be able to implement it in other contexts as well.
The limits are specific to narrative reviews: poor reproducibility of the research, little specificity.
Furthermore, the study was self-financed which led to a search of a few databases and the possibility of downloading full texts.

 

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

Author Contributions

All Authors equally contributed.

 

Acknowledgments

Authors thank all the staff of Biomedical Library Foundation in Biella, Italy.

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[4] Helleman M, Goossens PJJ, Kaasenbrood A, Van Achterberg T. Evidence Base and Components of Brief Admission as an Intervention for Patients With Borderline Personality Disorder: A Review of the Literature: Evidence Base and Components of Brief Admission as an Intervention for Patients With Borderline Personality Disorder. Perspect Psychiatr Care 2014;50:65–75. https://doi.org/10.1111/ppc.12023.

[5] Liljedahl SI, Helleman M, Daukantaité D, Westrin Å, Westling S. A standardized crisis management model for self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder: The Brief Admission Skåne randomized controlled trial protocol (BASRCT). BMC Psychiatry 2017;17:220. https://doi.org/10.1186/s12888-017-1371-6.

[6] Helleman M, Lundh L-G, Liljedahl SI, Daukantaité D, Westling S. Individuals’ experiences with brief admission during the implementation of the brief admission skåne RCT, a qualitative study. Nord J Psychiatry 2018;72:380–6. https://doi.org/10.1080/08039488.2018.1467966.

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by OPI Napoli

Online Learning Method in COVID-19 Pandemic: The Perspectives, Opportunities, and Challenges of Nursing Students in Aceh, Indonesia: An Exploratory Descriptive Study

 

Cut Husna¹, Riski Amalia^1*, Ahyana¹

 

¹ Department of Medical and Surgical Nursing, Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia, 23111.

Corresponding author: Ns. Riski Amalia, S.Kep., M.Kep. Teungku Tanoh Abee Street, Kopelma Darussalam, Universitas Syiah Kuala, Banda Aceh, Indonesia, 23111. Orcid: https://orcid.org/0000-0002-3004-0455. Email: riskiamalia@usk.ac.id.

 

 

Cite this article

 

 

ABSTRACT

Introduction: The Covid-19 virus pandemic caused a significant impact on communities’ life and their activities throughout the world. The Covid-19 pandemic also had a significant effect on the education system in Indonesia and requires all teaching and learning activities for students to be carried out by virtual or online learning method.

Aim: This study was to explore online learning methods’ perceptions, opportunities, and challenges in the COVID-19 pandemic among nursing students.

Method: A descriptive explorative study was implemented with a cross-sectional design. The study was conducted on 276 nursing students in Aceh, Indonesia. The data were collected using a 5-point Likert scale and the standardized Online Learning Perception Scale (OLPS) and Opportunities and Challenges Online Learning (OCOL) questionnaires. The reliability test of the questionnaires were indicated by Cronbach alphas of 0.89 and 0.90, respectively.

Result: The study results showed that 50.4% of the nursing students have positive perceptions about the online learning method, 51.4% of the students believe that online learning offers high opportunities, and 50.4% of students think that the online learning method is highly challenging. It showed more than 50% of the students have significant on the positive perceptions, high opportunities, and challenges in learning method.

Conclusion: The positive perception, high opportunities, and challenges towards online learning methods among nursing students is the result of a study that proved the benefits of online learning methods which can be used as an alternative for students to achieve learning goals, especially during the COVID-19 pandemic. Positive perceptions from students towards online learning methods can be encouragement and strength for one of the online-based learning methods and could also be proven by the high opportunities and challenges students in this online learning method.

Keywords: Perception, opportunities, challenges, students, online learning

Cite this article

 

INTRODUCTION

The COVID-19 outbreak in December 2019 has significantly impacted communities’ life and activities. The SARS-CoV 2 causes COVID-19 has become an epidemic and causes the foremost crucial number of deaths worldwide. The COVID-19 generated more than 80% of infected people developed mild to moderate illness with symptoms such as fever, dry cough, fatigue, and severe symptoms such as chest pain, loss of speech, and shortness of breath, and recover without hospitalization [1]. It has also impacted all aspects of human life globally, including economic, education, health, medical needs and services, and social crises [2].
The impact of the COVID-19 pandemic on education is also prominent. The government policy to carry out physical and social distancing as a health protocol required by the World Health Organization has mandated that all teaching and learning activities carried out at home (school from home) [2]. The health protocol intended to minimize physical contact to break out the virus’s chain. Learning media through distance learning with online media (in-network) is a method used to achieve learning competencies during this pandemic [3].
Online learning that has been widely applied for years is back in the spotlight during the COVID-19 pandemic. Before the pandemic, e-learning had not received much attention due to the perception that face-to-face learning was more effective than online methods. The COVID-19 pandemic has made swift changes and forced the learning system to be online to reduce the gaps due to the lockdown situations [4-7]. They aimed to achieve student competencies through critical thinking, creative thinking, collaboration, and communication. Critical thinking directs students to solve problems in the learning process. Creativity thinking is having high creativity and reasoning and seeing a situation from various sides or perspectives, changing textual learning to be contextual using multiple sources in society. Then, collaboration is an activity to work together in their future lives, and finally, communication means conveying ideas and thoughts quickly, clearly, and effectively [8]. The online learning method needs determination and ability from the user, including the students must be perspicuity, dependability, stimulation, attractiveness, and usability and innovation. The study also proved that stimulation and attractiveness is an online learning method that significantly affects students’ satisfaction during the COVID-19 pandemic [9].
Furthermore, an online class-based curriculum is more flexible and convenient for students. The use of online learning platforms in teaching and learning was more effective and efficient; however, some challenges may occur in online learning, especially in the practice of lab skills [5,7]. Online learning also offers some opportunities for the students. The students could access appropriate and accessible data and information, master the use of information and technology tools, access education anywhere, seek and learn new knowledge virtually through textbooks and print media that affect the role of lecturers in delivering learning materials [4].
Based on the primary sources conducted with several students of the Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia, as an area severely damaged during the 2004 tsunami with the condition of being very prone to natural disasters unstable geographical conditions. The students explained that the online learning method is beneficial in time management, transportation costs, and autonomy in the learning process. However, some students dominantly showed that they were confused in the laboratory skills conducted online and preferred face-to-face laboratory learning, experienced boredom, and sometimes lacked concentration during the online learning process. Furthermore, other students mentioned that the opportunities in the online learning methods might develop creative ideas, such as making learning media; video, role play, demonstration, leaflet, booklet, and several other assignments. It also motivated them to self-learn by accessing digital learning resources, enhancing their discussion skills, and using online meeting platforms, such as Zoom meeting applications and Google classroom. The challenges during online learning include the lack of internet connection, application systems, electrical power, computers or android devices, and environmental factors. This online learning challenge is supported by Gumede & Badriparsad [11] mentioned that there are concerns about the transition from face-to-face lectures to online learning systems and the need to adapt adequately to online learning methods such as devices and data availability. The objective of the study was to explore three parts about online learning methods among nursing students: Perceptions, opportunities, and challenges in the COVID-19 pandemic.

 

METHOD

Study Design

This study design was a descriptive explorative to explore the perceptions, opportunities, and challenges of the online learning method in the COVID-19 pandemic in nursing students.

 

Population and Sample

This study was conducted from September to October 2020. The populations were all the nursing students at the Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia who had been studying from years of 2016-2019 (year of academic entry) at both the academic and professional education stages. The sampling method was consecutive sampling totalling 276 students.

 

Instruments

The perception questionnaire used was the standardized Online Learning Perception Scale (OLPS) from Wei & Chou (2020), and Opportunities and Challenges Online Learning (OCOL) questionnaires. The reliability test of the questionnaires using Cronbach alpha of 0.90 and 0.89, respectively. The researchers developed Opportunities and Challenges Online Learning (OCOL) questionnaires based on a literature review. It was validated for face validity and content validity using content validity index (relevance, clarity, and brevity) by three experts from the Faculty of Nursing at Universitas Syiah Kuala, Banda Aceh, and fulfilled the validity test requirements. For the face validity aimed to investigate the cultural relevance, understanding of meaning, logical flow, grammar, and composition of the newly developed items [1]. The OLPS and OCOL questionnaires consisted of 5-points Likert scale: strongly agree (5), agree (4), doubtful (3), disagree (2), strongly disagree (1). The OPLS consisted of 23 positive statements and the OCOL questionnaires (opportunities and challenges online learning method) consisted of 24 positive statements. The binary categories have been decided by using mean score for OPLS into 2 categories: positive and negative peceptions. Morever, the OCOL questionnaire also divided into 2 categories: high and low opportunities and challenges online learning method.

 

Data Collection

The preparatory stage of data collection includes completing the administration process and approval from the Dean of the Faculty of Nursing at Universitas Syiah Kuala, Banda Aceh, Indonesia. The researcher collected the data by recruiting the eligible respondents: all students of the class 2016-2019 (four batches) in the academic and professional stages using online learning in the COVID-19 pandemic. The data is kept confidential by coding the respondents. The respondents signed the written informed consent form using an online platform. Next, the respondents who agreed to involve in this study were sent a link to fill out the online questionnaires. The questionnaire was checked for completeness. The researchers would like to thank the respondents who have participated in the study.

 

Data Analysis

Descriptive analysis in this study uses the mean, standard deviation, frequency, and percentage of perceptions, opportunities, and challenges of online learning methods for nursing students. Data were analyzed using the statistical package Statistical Program for Social version 23.0 (IBBM Corp., Armonk, New York, USA).

Ethical consideration

This study is consistent with the Declaration of Helsinki. The study has been approved by the local Ethics Committee in Indonesia (Research Code: 113003080620; Decision Date: July 21, 2020).

RESULTS

The population in this study was both the nursing students of academic and nurses’ profession stages of Faculty of Nursing, totally 667 students. By using consecutive sampling, 276 students were conducted in this study. The results of this study consisted of demographic data of the respondents, perceptions about online learning, and opportunities, and challenges online learning method in COVID-19 pandemic are explained as follow (Table 1, 2, 3, 4)

 

Table 1. Characteristics of the respondents (n = 276)

Table 1 showed the average age of the respondents was 20.44, with a standard deviation of 1.56. The majority of respondents were female (91.7%).
Then, most respondents had only been studied for a year or started in 2019 (27.5%), and 94.2% of the respondents had online learning experiences. The biggest obstacle in online learning methods was internet access (25.1%).

 

Perceptions, opportunities, and challenges online learning method in COVID-19 Pandemic

Student’ perception, opportunities, and challenges about online learning method among nursing students in Faculty of Nursing are shown in Table 2.

Table 2. Perceptions, opportunities, and challenges of nursing students about online learning method in COVID-19 pandemic (n = 276)

Table 2 showed 50.4% of respondents have positive perceptions of online learning in COVID-19, 51.4% believe that online learning methods offer high opportunities, and 50.4% think that online learning is highly challenging.

The details of each item for OPLS and OCOL questionnaires were presented in Tables 3, 4, and 5 as follow:

 

Table 3. Online Learning Perception Scale (OLPS) of nursing students about online learning method in COVID-19 pandemic (n = 276).

 

Table 4. The opportunities of nursing students about online learning method in COVID-19 pandemic (n = 276).

 

Table 5. The challenges of nursing students about online learning method in COVID-19 pandemic (n = 276)

DISCUSSION

This study explores the opportunities and challenges of online learning methods during the COVID-19 pandemic in nursing students. The results showed that more than half of the respondents have positive perceptions of online learning (50.4%). This finding is supported by several statement items indicating a positive impact of online education on students, namely the availability of various learning resources, available time and place, reducing pressure during exams and assessment, and increasing student creativity in creating learning media. Meanwhile, nearly half of the students show negative perceptions (49.6%) of online learning. The nursing students mentioned that online learning requires high internet data or fees, and internet access is limited for those living far from urban areas due to environmental factors and electrical powers. Besides, the interaction with lecturers and other students is minimal. They found it challenging to understand the learning delivered by lecturers and other students during activities in online education.
The finding concerning the students with negative perceptions (49.6%) on the online learning method aligns with Zhafira et al. (2020), who argued that students need to have learning methods to motivate themselves to achieve their learning goals. The online lecture system is still perceived as a breakthrough or a new paradigm in teaching and learning activities because students and lecturers do not need to attend class. They only rely on an internet connection to conduct learning activities from faraway places [13]. Furthermore, also supported by the results of the study stated that several problems in online learning method in the COVID-19 pandemic such as technological factors, mental health, time management, and the balance between life and education. The study results also reported that the students are dissatisfied with the online learning experience due to distraction and reduced focus, psychological problems, and management issues [14].
The study conducted by Khan et al [6] showed that most of the students positively perceive the online learning system in the pandemic to maintain the educational process; however, there are several challenges, such as internet quality, digital information technology literacy, and economic conditions related to internet fee. However, the study results by reported that a different view of online learning activities in terms of soft skills do not be achieved, such as the face-to-face learning method in the class. Then, a study conducted by Kulal & Nayak [16] also revealed that students feel comfortable with the online learning process with support from educators. Yet, they could not provide a traditional classroom learning atmosphere because of technical problems and lack of training, impacting the ineffectiveness of online classroom learning by educators.
The world of education around the globe must process faster adaptation in the face of the COVID-19 pandemic by switching to online learning models to accelerate opportunities in facing the era of industrial revolution 4.0 as part of digital technology transformation [17-19]. Furthermore, Gurel and Tat[16] stated that opportunity is a situation or condition relevant for an activity that is positive and fun and has advantages and forces that encourage an action to occur.
This study shows that most respondents (51.4%) believe that the online learning method offers high opportunities. The COVID-19 pandemic crisis provides opportunities for lecturers to develop pedagogical innovations and create digital-based teaching curricula. One of which is that academics could teach and guide students in accessing e-learning technology and apply techniques that could design various flexible online programs to increase students’ competence in problem-solving, critical thinking, and adaptability skills [20]. Furthermore, the previous study also mentioned that the students agree with the benefits and are very satisfied with their learning experience by using online learning methods [21]. However, the online learning method needs additional financial burden due to fully online learning, namely cost to access and cost to acquire equipment [22].
The study results also show that more than half of the students (50.4%) found the online method in the COVID-19 pandemic is highly challenging. The forms of online learning challenges faced by students during the COVID-19 pandemic were internet access (25.1%), learning interactions (21.0%), learning facilities (17.9%), learning media (14.0 %), methods (13.3%), and learning materials (8.8%). Fearnley & Malay [23] stated positive developments in students’ readiness for online learning. However, the results of Yaseen et al [25] research found challenges during online education, including concerns about the technological competence of lecturers and students, increased assignments, privacy issues, social inequality when activating videos, communication disorders due to internet network constraints, unable to assess student body language and soft-skills during the learning process, student absenteeism due to internet disconnection, ethical considerations due to increased plagiarism during assignment creation, online video skills laboratory and use of virtual laboratories not suitable as a substitute for practical demonstration. However, there are opportunities for reform in the learning process, although online learning is still not considered the best alternative to studying on campus [26].
Internet access for online-based learning is critical during the COVID-19 pandemic. The government’s policy to reduce the spread of the COVID-19 virus or COVID-19 disease through physical and social distancing has shifted the offline to online learning method. The development of information technology impacts an increasingly effective learning process using computer-based technology. Media and technology adopted as facilitation in open and distance learning are also challenge the willingness to use learning models from students’ perspectives [27]. Furthermore, in the digital era and the COVID-19 pandemic, educational institutions are increasingly promoting online learning, resulting in a shift from traditional face-to-face classes (offline) to distance learning (online) [28]. However, especially for the laboratory skills competencies, almost all the students mentioned that they are more satisfied with face-to-face than the online learning methods [29]. However, especially for the laboratory skills competencies, almost all the students mentioned that they are more satisfied with face-to-face than the online learning methods. This study results follow the statement by Muflih et al. (2021) which reported that the students expressed mixed feelings about online learning, and most of them supported face-to-face classroom learning. They are pessimistic about learning professional skills and core competencies online.

 

Conclusion and Recommendations

The online learning method is highly relevant and applied worldwide during the COVID-19 pandemic. The pandemic has altered the order of a community’s lives in various aspects of life, including education. The existence of physical and social distancing policy with the obligation to learn from home has required online learning. The online learning methods provide several benefits, such as reducing the risk of COVID-19 transmission, increasing information and technology (IT) mastery skills, improving time management, and motivating students to learn independently.
Meanwhile, the opportunities for online learning methods in the COVID-19 pandemic are also significant, and the nursing students believe that online learning offers them high opportunities. These opportunities include using IT facilities, improving experiences in the learning process, enhancing creativity, allowing for critical and innovative thinking, providing opportunities to access learning resources, such as e-books, e-journals, e-libraries, and e-education, and enhancing self-management skills in time management in the process of completing requirements. Furthermore, the online learning methods are also highly challenging for nursing students during the COVID-19 pandemic. The challenges are internet access, internet data or fee, learning platform facilities, electrical power, environmental problems (natural and non-natural disturbances), and time constraints.
This results study provides feedback for the policymakers to prepare feasibly and good online learning platforms, internet facilities, costs, and IT personnel who could ensure the sustainable use of this online method. The governments may improve the online learning method through increasing internet access, learning media, methods used, learning materials, learning interactions, and learning facilities.

 

Study Limitations

The study only focuses on a descriptive exploratory. A cross sectional design was not conducted hence it can not explore the factors associated with others several online learning methods.

Conflict of interest

The authors declare no potential conflict of interests with respect to the research, authorship, and/or publication of this article.

Funding

This research did not receive any specific grant from funding agencies.

Authors contribution

Author 1: Dr. Ns. Cut Husna, S.Kep, MNS, Nursing Lecturer at the Faculty of Nursing, Universitas Syiah Kuala, Aceh, Indonesia. Contribution type: conception, design, supervision, fundings, materials, data collection and/or processing, analysis and/or interpretation, literature review, writing, and critical review. Email: cuthusna@usk.ac.id ; ORCID: https://orcid.org/0000-0002-6283-4209

Author 2: Ns. Riski Amalia, S.Kep, M.Kep, Nursing Lecturer at the Faculty of Nursing, Universitas Syiah Kuala, Aceh, Indonesia. Contribution type: analysis and/or interpretation, literature review, writing, and critical review. Email: riskiamalia@usk.ac.id ; ORCID: https://orcid.org/0000-0002-3004-0455

Author 3: Ns. Ahyana, S.Kep, MNS, Nursing Lecturer at the Faculty of Nursing, Universitas Syiah Kuala, Aceh, Indonesia. Contribution type: conception, design, supervision, literature review, and writing. Email: ahyana@usk.ac.id ; ORCID: https://orcid.org/0000-0001-6750-5052

 

Acknowledgment

The author would like to thank all respondents, the Nursing Students Universitas Syiah Kuala for their willingness and fully participation in this study, also to the Institute for Research and Community Service Universitas Syiah Kuala-Darussalam; the Dean of the Faculty of Nursing, the Nursing Ethics Committee Nursing Faculty Universitas Syiah Kuala which has fully assisted and facilitated in this study.

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