UNIVERSITY OF KWAZULU-NATAL AN ANALYSIS OF QUALITY IMPROVEMENT BY NURSES AT A SELECTED TERTIARY HEALTHCARE FACILITY IN RWANDA BY ANTOINETTE BATUNGA 2017 AN ANALYSIS OF QUALITY IMPROVEMENT BY NURSES AT A SELECTED TERTIARY HEALTHCARE FACILITY IN RWANDA Dissertation submitted in fulfilment of the requirements for the Master’s degree in Nursing Administration in the School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa. BY Antoinette BATUNGA 212540750 SUPERVISOR: Dr Jane KERR March 2017 Declaration I, Antoinette BATUNGA declare that this research dissertation titled “An analysis of quality improvement by nurses at a selected tertiary healthcare facility in Rwanda” and under supervision of Dr. Jane Kerr is my original work, and all resources and materials that have been used or quoted have been indicated and acknowledged by means of reference. Antoinette BATUNGA Dr Jane KERR DATE DATE i Dedication This dissertation is dedicated to my beloved family for psychological, physical, social support and love that was given throughout this course which enabled me to complete the course successfully. ii Acknowledgements First and foremost my thanks to the almighty God for his gift of good health that enabled me to go through this course successfully. Special thanks to Col. Dr. Ben Karenzi for the sponsorship he gave and the financial support that enabled me to complete the course successfully. My sincere gratitude to my supervisor Dr. Jane Kerr for her professional guidance, knowledge on research, her motherly love and support towards achieving this document, despite other commitments she had. My sincere appreciation to the academic and support staff of Nursing Department of the University of KwaZulu - Natal, for the knowledge, encouragements, and all the support provided that made me grow academically. Their contribution to my knowledge will always be remembered. Special thanks to Mr. Harerimana Alex for his physical, psychological and academic support while in need, despite all other commitment he had. Your assistance was highly recognised. My thanks go to the administration of the selected hospital for allowing me to collect data for my research project. My thanks to Muraraneza Claudine, Kanimba Justine and Basinga Vivianne for Psychological, social, and academic support that they gave me which was of great importance to the completion of my course. My appreciation to all the participants who agreed to participate in the study of my project willingly, their contribution was of great importance in the quality improvement regarding the services rendered at the selected hospital. My thanks to the UKZN ethical committee for the ethical clearance provided which permitted me to carry out my research study. My thanks to Dr Ndatinya, Dr Ngoboka Jean Paul for information and academic support provided your support was highly appreciated. iii My sincere gratitude to the Rwanda Ministry of Education for giving me permission to conduct my research study. iv Abstract BACKGROUND: Improving and maintaining the quality of care in healthcare institutions is not easy and has become a continuous challenge. Though quality improvement continues to be a global issue, the Government of Rwanda, guided by its Vision 2020, has made significant progress in the health field, especially in providing accessible quality care and services to all Rwandan citizens. Furthermore, the Rwanda Ministry of Health, through its 2015 health policy, has introduced a number of interventions to improve quality of care, such as promoting customer care, ongoing training and capacity building of the staff in the health sector, and decentralising health care infrastructures. A number of constraints have been noted which hinder effective quality improvement, such as shortage of human and material resources. It has become important to analyse quality improvement by nurses at a selected tertiary healthcare facility in Rwanda. Purpose of the study: The purpose of this study was to analyse quality improvement by nurses; in order to develop guidelines for nurses on effective quality practices at a selected tertiary healthcare facility in Rwanda. Methodology: A concurrent mixed methods approach (quantitative and qualitative), was used in this study. Data were collected by the researcher over a two month period. In a quantitative approach, data were collected using a checklist to conduct an audit of quality improvement activities by nurses and purposive sampling was used to identify 13 quality improvement documents in 11 units/departments. In a qualitative approach, data were collected from registered nurses and patients who were seeking healthcare services at the time of data collection. Interview guides were used. Purposive sampling was used to identify 15 registered nurses; and 17 patients for the qualitative data collection and 12 nurse managers and experts in guideline development to participate in guideline development process. Quantitative data were analysed using SPSS version 23, while qualitative data were analysed using thematic content analysis. Nominal group technique was used to develop guidelines for nurses to improve the quality of care at the selected facility. Findings: Out of 11 departments from the selected hospital, the majority (90.9 %) of departments had incident reporting documents. Seventy-two per cent of departments reported having an audit tool for measuring the quality of care that was available and accessible to users. It was found that 36.6 % had a copy of quality policy document; 18.2% reported having registration books for complaints, however it was found that these complaints books were not v used on a daily basis. Furthermore, it was noted that only 18.2% of departments had a copy of the quality action plan. Concerning annual quality report findings indicated that of 11 departments, none had a copy of the annual quality report. Findings from qualitative data in this study revealed a number of factors related to quality improvement, which were grouped into three categories: organisational resources, managerial roles, and customer care. Regarding the organisation resources, a number of subthemes emerged in this study: lack of materials and equipment, shortages of nurses and doctors, lack of guidelines to guide nurses on improving the quality of nursing care and lack of sufficient drugs in the hospital pharmacy (reported by both nurses and patients). Construction and renovation of buildings has been happening which has reduced congestion for patients. Regarding managerial role, factors that hindered quality improvement were nurses’ resistance to change, lack of knowledge concerning quality improvement, lack of supervision, and lack of health education for patients. Regarding customer care, patients were dissatisfied with the lack of sufficient drugs, long waiting times, lack of sufficient beds and rooms. Although a number of challenges were reported that hinder quality of care, patients appreciated effective performance and care from their healthcare workers that increased their satisfaction with the quality of care provided. Proper explanations and orientation made it easy for patients to seek healthcare services in the different departments and pharmacy turn around time has improved. It was also noted that nurses recognised that career development and support was helping them to improve the quality of care. Based on the findings from this study, quality improvement guidelines for nurses have been developed for the selected tertiary hospital where this study was conducted. Recommendations: Increase in-service training on quality improvement to raise employees’ knowledge and skills levels. Emphasise proper staffing and staff management of employees to avoid work overload in some units. Reduce waiting times and provide sufficient essential drugs in the hospital pharmacy reducing the need for patients to buy drugs from private pharmacies. Remedy lack of equipment and materials to enable nurses to work in a suitable environment. Conclusion: Despite challenges faced by the healthcare facility, there has been remarkable progress in quality improvement through response to needs in human and material resources. Improvement of quality care is a cornerstone in the health of the population of Rwanda. Keywords: Quality improvement, Quality of care, Standards of care, Patient Satisfaction. vi Table of Contents Declaration .................................................................................................................................. i Dedication .................................................................................................................................. ii Acknowledgements .................................................................................................................. iii Abstract ...................................................................................................................................... v Table of Contents ..................................................................................................................... vii List of Annexures ..................................................................................................................... xii List of Figures ........................................................................................................................ xiii List of Tables ........................................................................................................................