The themes generated from this study are as tabulated in Table 2. These are: inadequate management support, insufficient operational skills and knowledge or equipped learning, high workload and time constraints, health personnel readiness, dearth of enthusiasm for change, and accountability of the staff. A summary of these themes is also provided in the same Table 2.
Table 2
Summary of the themes and sub-themes
Category
|
Themes
|
Sub-themes
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Organisational factors
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Inadequate management support
|
Poor remuneration and lack of incentive
Unavailable practice guide and standard of practice
|
|
Insufficient operational skill and knowledge/equipped learning
|
|
|
Work overload and time constraints
|
|
Individual factors
|
Health personnel readiness
|
Need for self-discipline and interest
Dissatisfaction and discouragement of staff
|
|
Dearth of enthusiasm for change
|
|
|
Accountability of the nurses
|
|
Details of these themes and sub-themes are presented as follows:
Theme 1: Inadequate management support
The following two sub-themes emerged under this theme:
(a) Poor remuneration and lack of incentive
(b) Unavailable practice guide and standard of practice
(a) Poor remuneration and lack of incentive
Participants reported that their welfare was not being taken into consideration at all. As a result, they were not motivated to deliver quality healthcare services to the community because they are poorly treated by the government. Nurses expressed that the government must first make them happy and comfortable by paying their salaries and incentives in a timely manner. Additionally, the PHC facilities were not well equipped and therefore required a complete improvement from the government to strengthen the healthcare system. This would in turn enhance the quality of healthcare services. The following is an excerpt from the audio recordings:
“Advocacy, if they pay us very well we will implement it. Good remuneration is necessary because the welfare of the health personnel matters. You see the staff are not well taken care of, our welfare is poorly attended to so we can’t do better. I want to say that the nurses – the comfort of nurses – should also be taken into consideration (Nancy).”
“If the government do not participate enough to improve the remuneration of the staff in the healthcare centre there may be a challenge. A lot of constraints, a lot of compromises, we have from the government – from financing to human resources person, resources…most of these facilities you are seeing, we are not being supplied with anything. So most of the time we have to improvise… I think that is still a factor we can look into – incentive and encouragement (Iyabo)”.
(b) Unavailable practice guide and standard of practice
An unavailable practice guide and the standard of practice emerged as important, from the participants’ narrative in this study. Even though healthcare services were provided to patients in the community, the nurses reported that policies, standards of practice and practice guides which are key in delivery of high quality healthcare services in PCC, were lacking. The nurses stressed the need to improve PHC facilities by providing an evidence-based working practice for nurses. These strategies would enhance effective PCC implementation leading to improve the healthcare outcome to the community. Below are the excerpts from the interviews:
“The challenge I see is the need to provide a written document…it could be in form of poster that could be pasted on walls to remind somebody working, so when you are working you look and it reminds you of something (Rose)”.
“The design doesn’t actually allow for total client-centered care in such a way… things are muddled up together, we are addressing a lot of people together at the same time, such that we are not really client-oriented in our healthcare service (Mary)”.
“Then looking at the challenges we might say our knowledge bases are not the same so that might be a limitation to patient centered care in the primary health care system in Nigeria (Kola)”.
Theme 2: Insufficient operational skills and knowledge or equipped learning
The participants reported insufficient operational skills and knowledge of PCC as one of the barriers to implementing its strategies. It was observed that PCC knowledge and skill are associated with effective implementation to improve the quality of nursing healthcare service in the rural areas. They revealed the importance of knowledge on the PCC concept as an asset to be given from the government to professional nurses even after they have been employed in the healthcare system. Participants revealed that failure to keep updating with current knowledge, skills and learning was a challenge to them in not being able to implement PCC. The extract below from the transcript is evidence:
“There is no empowering people for knowledge… If government can provide something like a workshop or seminar I think that can help again to achieve patient-centered care, because if we are not orientated towards patient-centered care even we nurses might not do it the way we ought to do it, but if we are all orientated, if we know it and are familiar with the components, the approaches then we can do something (Wole)”.
“In terms of the technicality aspect of it, we might say Nigeria is still backward in the sense that when you are looking at the competence of the staff, the quality of service delivery to a client… we need more, adequate knowledge about patient-centered care (Kabirat)”.
“…the knowledge and the skills can hinder the utilisation of the patient-centered care concept… I want to say lack of knowledge about the client-centered care…you can’t practice what you don’t know…you are not aware you will not be able to use it (Kudira)”.
Theme 3: Work overload and time constraints
Work overload and time constraints emerged as a theme from the data. Participants reported excessive workload as one of the major hurdles to implementing PCC in the healthcare service in PHC settings. It was further mentioned that nurses faced a lot of physical and psychological stress due to the shortage of nursing staff in the PHC system. In addition, the nature of the environment and the workload made the quality of their nursing health care to be poor and the patients were not allowed to make decisions in the care process. This means that the current working environment in the rural PHC setting is not conducive for nurses to practice PCC. Related interview extracts below are evidence:
“Bureaucracy or let me put it that way, that is, if there are too many things to be done… If you have a lot to do like you have over 50 clients and it’s only you. If you have enough hands you can easily practise PCC (Sadia)”.
“So for an individual if the work load is bulky and we are busy, it may not be easy for us to follow PCC approaches and practise it (Joy)”
“If we nurses must practise this concept – our timing is very important because honestly we have a very large number of patient to attend to within a short period of time (Mary)”
Theme 4: Health personnel readiness
Health personnel readiness emerged as a theme with two sub-themes as follows:
(a) Need for self-discipline and interest
( b) Dissatisfaction and discouragement of staff
(a) Need for self-discipline and interest
Participants identified self-discipline, interest and laziness as some of the hurdles to the implementation of PCC. It was further mentioned that for the PHC system to implement PCC, it would be crucial for nurses to develop enthusiasm with self-discipline in order not to continue undermining its potential to improving the quality of health care. The quotes below are a reflection:
“Laziness on the part of we, the nurses, to engage with patients…Interest is also important; some may not have interest in it like that…so lack of interest is a factor.... (Jide)”.
“Lack of self-discipline, due to problems from government…because there are some things you can do, there are some things that you have knowledge of doing... (Kemi)”.
( b ) Dissatisfaction and discouragement of staff
Several participants who reported dissatisfaction and discouragement of the staff during interviews further expressed that underpaying rural nurses coupled with lack of incentives, lack of work balance, limited opportunities for career development and poor management of PHC resulted in poor healthcare service delivery. All these were mentioned to contribute to nurses’ dissatisfaction and discouragement. As a result, delivery of quality healthcare services using PCC was negatively impacted. These extracts below are evidence:
“…if we have facilities and if it is not that the work is so much that five people are supposed to do it and only one person is doing it, definitely if there is division of labour, definitely nurses will adopt the method, it is a very good method and it will help nurses to know their patient better if there is improvement in the health of the patient… (Eunice)”.
“There is an average amount of clients we are expected to see in the health facility, for example in the immunisations section let me use that as a standard, we are expected to see just about 30 or 40. Just a facilitator, as I am expected to see 15 so if we are only two we are expected to see 30 people effectively but do you know we have people coming in tons of about 80 daily? (Winnie)”.
Theme 5: Dearth of enthusiasm for change
Dearth of enthusiasm for change was reported by the participants during the data collection stage. It was also reported that the majority of the nurses were resistant to change. This prevalence among nurses was identified as a concern regarding PCC implementation. This is a potential consequence that contributed to the ineffective use of PCC. However, the readiness of the nurses to embrace change would enhance the healthcare outcome of the patients and improve healthcare service because nurses as individuals can promote PCC. These changes have the potential to increase the readiness to change among nurses and influence organisational interventions to promote PCC and the well-being of the healthcare providers which would inevitably lead to the high quality healthcare services needed. The extract below asserts this:
“I have seen what it could be so I know that many nurses are resistant to change that is the very first thing… there is this challenge of people not ready to change (Ade)”.
“If you want to change the whole world you cannot change the whole world but you will realise that you, yourself, need to be changed – that’s where to start… (Mariam)”.
“Human beings naturally are resistant to change. The challenge I foresee is in the ability of the nurses to change their practice from what we have been practising since (Yinka)”.
Theme 6: Accountability of the nurses
Participants reported professional accountability. It was expressed as taking responsibility for action by upholding the holistic standards on quality healthcare service of patient care as well as maintaining competency. The nurses further stated that it was important to ensure that the patient’s interest was always considered first through collaboration and involvement in the decision making process. The nurse earned the patient’s trust by sharing their thoughts willingly. The extract below is the evidence:
“I’m saying that using a client centered approach will help to take the possible preventive measure we can take…nurses will benefit in the sense that when you do something very well you feel good about yourself, that you have done this very well. You know that it helps you to feel fulfilled at the end of the day (Detan)”.
“Primary health care facilities will be a better patronised place, if the community sees that the nurses respect and value their involvement in their work (Elizabeth)”.