Unpacking implementation: drivers of nurses´ utilization of the client service charter in a Tanzanian hospital

¹Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, P.O. Box 2 Mzumbe, Morogoro, Tanzania, ²Centre of Excellence in Health Monitoring and Evaluation, Mzumbe University, Dar es Salaam, Tanzania

^&Corresponding author
Godfrey Kacholi, Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, P.O. Box 2 Mzumbe, Morogoro, Tanzania

Introduction    

Patient-centered care is the foundation of effective healthcare, building trust, and satisfaction and ultimately leading to better health outcomes [1]. Recognizing this crucial role, the World Health Organization (WHO) established the Alma-Ata Declaration in 1978, laying the groundwork for strong primary healthcare systems globally [2]. However, the Astana Declaration, adopted in 2018, built upon this foundation by emphasizing empowering individuals and communities [3]. This shift reflects the evolving needs of healthcare delivery and highlights the importance of active participation in shaping health policies and plans that directly impact them [4].

To improve healthcare service quality, Tanzania, like many others, has adopted national guidelines, including the Client Service Charter (CSC) [5]. The Government of Tanzania, acknowledging the potential benefit of Client Service Charters (CSCs) as a tool for promoting a more client-focused approach throughout the public sector, introduced the concept in 2000 as part of a broader push to modernize public service delivery [6]. This initiative coincided with the Public Service Reform Programme (PSRP) launched in 1999 to implement the public service management and employment policy [7].

The successful implementation of CSC in healthcare is demonstrably linked to positive outcomes for patients and providers. Literature has shown that effective utilization of the CSC by health providers has been associated with higher patient satisfaction, fostering trust and encouraging adherence to treatment plans [5]. It is an undeniable fact that satisfied patients are more likely to return for follow-up care and adhere to prescribed medications, ultimately leading to better health outcomes [8]. It has always been the case that translating policy into practice can be challenging [9]. While publicizing new systems and tools for performance management is one thing, efficiently and effectively implementing them is another [10]. A 2005 CSC launched by Tanzania's Ministry of Health faced challenges that included limited distribution due to insufficient copies and a lack of formal implementation strategy, advocacy plan, and monitoring plan [5]. This may lead to health professionals, particularly nurses, being inadequately informed about the CSC's content or significance.

Nurses play a critical role in shaping the patient experience [11]. Their interactions with patients are often frequent and provide opportunities to build trust and rapport [12]. However, nurses themselves face challenges that can influence their ability to deliver high-quality service, such as heavy workloads, long hours, and demanding work environments, which can contribute to nurse stress and burnout [13], and potentially impact their ability to provide patient-centered care [14]. This study aims to address a gap in knowledge regarding the factors influencing nurses' utilization of the CSC in a Tanzanian hospital setting. Understanding these drivers is crucial for developing targeted interventions that can promote effective implementation of the charter and improve patient service quality. The findings can inform policy changes, training programs, and leadership strategies to create a more supportive environment for nurses to deliver care aligned with the CSC principles.

Methods     

Study design and setting: a cross-sectional research design was employed for this study. The study was conducted at Temeke Regional Referral Hospital, a 304-bed hospital serving the Temeke Municipality and neighboring areas in Dar es Salaam, Tanzania. As a secondary-level hospital within the Tanzanian healthcare system, Temeke Regional Referral Hospital manages a high patient volume, estimated between 1,800 and 2,000 daily. This includes general outpatients and inpatients seeking care across various services, such as reproductive, child, and mental health. Temeke Regional Referral Hospital is located in Temeke Municipal. The Municipal is part of the Dar es Salaam Region, with a population of approximately 1.6 million. This study was conducted from January to February 2023.

Study population and sampling: we recruited nurses employed at Temeke Regional Referral Hospital for at least six months before the study's commencement. This selection criterion ensured familiarity with the hospital policies and procedures. All nurse cadres meeting this experience requirement were eligible to participate. Their respective supervisors referred nurses who met the criteria to the Principal Investigator. A sample size calculation was performed to ensure the generalizability of our findings to the population of nurses at Temeke Regional Referral Hospital. Considering a target population of 222 nurses, a desired confidence level of 95%, a margin of error of 5%, and assuming a population proportion of 50% (as we have no prior information to suggest a strong bias towards either end of the spectrum), the calculated sample size was 133 nurses.

Data collection tool and procedure: an online survey method was employed to collect data from participants. Questionnaires were developed using Google Forms and distributed electronically. The questionnaire collected data on the characteristics of participants as well as individual and institutional factors affecting the utilization of CSC at the hospital. To ensure accessibility for all participants, the questionnaires were prepared in English, the primary language of instruction in Tanzania, and translated into Swahili, the first language of many participants. Before the main study, a pilot test was conducted using the translated questionnaires. This pilot involved a small group of Temeke Regional Referral Hospital nurses and served two key purposes. Firstly, it ensured that the content of the questionnaires was relevant, adequate, and worded for the target population. Secondly, it tested the effectiveness of the survey instrument in eliciting the information required to achieve the research objectives.

Variables and measurements: the utilization level of the CSC was the dependent variable in this study. A yes/no question was used to measure this: do you regularly refer to the CSC guidelines in your interactions with patients? This study considered "regular" to be a frequency where the service provider consults the CSC document at least once daily. This study investigated the influence of two factors on nurses' use of the CSC in their daily practice. The first set focused on individual factors, including nurses' knowledge, perceptions, interests, and time pressures. The second set examined institutional factors, such as the accessibility of the CSC guidelines, leadership commitment to the CSC's principles, accountability and incentive structures related to the CSC, training, and support provided by the CSC, and the overall organizational culture. Nurses' responses to survey items exploring factors affecting CSC utilization were measured using a 5-point Likert scale. The scale ranged from 1 (strongly disagree) to 5 (strongly agree), with 3 representing a neutral position. The mean was calculated from each item of the dependent variables. A mean score above 2.5 on a survey item indicated factors that facilitate using the CSC. Conversely, a mean score below 2.5 indicated factors hindering CSC utilization.

Data management and analysis: data was extracted from the Google Form and downloaded as a Microsoft Excel file. To ensure data security, this file was saved in a password-protected location accessible only to the investigator. The file was named using a unique version number to facilitate tracking and potential future updates. Before data analysis, a thorough data cleaning process was undertaken. This involved verifying the accuracy and completeness of the information collected from participants. The data was then carefully structured to ensure seamless import into the statistical software program. The cleaned data was exported from the Excel file and imported into IBM SPSS version 16.0 for analysis. Descriptive statistics were employed to summarize the data, including calculating frequencies, proportions, and means.

Ethical considerations: the study adhered to ethical research principles to protect participants' rights and well-being. At the outset, participants were provided with a clear explanation of the study's purpose, data collection methods, and how their information would be used. This informed consent process ensured that participants made voluntary choices about their participation. Furthermore, participants were assured of their right to withdraw from the study at any point without penalty. Finally, the study maintained participant confidentiality by anonymizing all data and adhering to strict data security protocols.

Results     

Demographic information of study participants: the study recruited 133 nurses at Temeke Regional Referral Hospital (Temeke RRH) in Dar es Salaam, Tanzania. The average participant age was 46 years old. Most participants (75.9%, n=101) were female. Nurses from the maternal ward made up the largest group (33.8%, n=45), with a very small number from the outpatient department (OPD) (0.8%, n=1). In terms of demographics, most participants were single (55.6%, n=74) and held diplomas in nursing and midwifery (44.4%, n=59). Notably, over half (55.6%, n=74) had less than one year of work experience (Table 1).

Utilisation level of client service charter: a survey was conducted to see how often healthcare providers refer to the CSC guidelines when interacting with patients. The results showed that most (62.1%) participants did not consult CSC for work-related purposes at least once in the past half year.

Individual-related factors influencing utilization of the client service charter: to understand how individual nurses use the CSC Guideline of 2018, this study examined four key factors: nurses' knowledge of the guidelines, their perceptions and attitudes towards them, and the time pressures they face. The study found that nearly all participants (97.7%, n=130) expressed a positive perception (users believe the charter was relevant to their specific roles and situations within the hospital), and a strong majority (90.2%, n=120) were aware of the charter. Encouragingly, a vast majority (96.2%, n=128) indicated a keen interest in using the CSC. Limited time emerged as a significant barrier, with a large majority (84.6%, n=112) of participants reporting difficulty finding time to review the CSC regularly (Table 2).

Institutional factors influencing the utilization of the client service charter: an overwhelming majority (93.9%, n=125) reported the absence of a designated committee specifically responsible for overseeing the implementation of the CSC at the hospital level. Interestingly, despite the limited accessibility of the CSC, most participants (72.1%, n=96) felt that the hospital management encourages staff to follow the charter in service provision. The study found that over three-quarters (78.2%, n=104) of participants did not possess a copy of the CSC, either in hard or soft copy format. More than half (61.7%, n=82) of participants indicated a lack of regular training opportunities to refresh their knowledge of the CSC. An even greater majority (84.3%, n=112) reported the absence of incentive or recognition programs for staff who consistently uphold the CSC principles (Table 3).

The charter´s-related factors influencing its utilisation: the study examined how different charter features affect how hospital staff use them. The vast majority (nearly 80%) said the language of CSC was clear and easy to follow. Additionally, most participants (almost 98%) were satisfied with the current format and length of the guidelines. However, there was a mixed response regarding the charter. While two-thirds felt the charter content was up-to-date and aligned with its goals, a significant portion (over 73%) found the charter itself too long to read comfortably (Table 4).

Discussion     

This study sought to assess factors that influence the utilization of the CSC Guideline of 2018. Interestingly, the study found that most participants (over 62%) don't refer to the CSC guidelines regularly. Healthcare workers in Tanzania, like many worldwide, face heavy workloads and limited time [15]. The time constraints faced by healthcare workers in Tanzania could be a significant barrier to adopting the CSC guidelines, as they may not have time to dedicate to lengthy reading materials.

Although study participants expressed an interest in using the CSC was deemed relevant to their situations and duties, access to the charter in hard or soft copy was a challenge. This shows that the national guidelines dissemination approach looks limited in reaching and informing potential end users. Healthcare professionals who are seeking to fulfill their commitments may be frustrated by the lack of a readily available and centralized access point for guidelines [16]. The study identified a well-written CSC using clear and understandable language in a user-friendly format. However, while the charter's comprehensiveness is valuable, its length could challenge staff to absorb and readily reference fully. This might hinder the consistent application of the charter. The empirical literature has shown that bulky guidelines and policies limit the ability of already overburdened health professionals to refer to and utilize the guidelines regularly [17]. Addressing the perceived bulkiness of the charter, creating concise summaries or user-friendly formats offers a practical solution to encourage regular use and consistent application of the charter.

Despite leadership support for the CSC, the hospital lacks a dedicated team to specifically and solely oversee its day-to-day execution. The results raise a concern that hospital staff may not fully understand the Quality Improvement Team's role in ensuring the CSC is implemented, including client satisfaction. According to [18], one of the core aspects of Quality Improvement Teams is ensuring client satisfaction with healthcare services. This may involve overseeing the implementation of the CSC, which outlines the standards of care patients can expect. Quality Improvement Teams act as the governing body for quality improvement initiatives within the hospital [19].

The current study identified a lack of regular training to refresh staff's knowledge of the CSC. This could be because the initial focus might have been solely on implementation, potentially overlooking the importance of ongoing staff education and negatively affecting the utilization of the charter. Studies have shown that information retention weakens over time, and regular training opportunities function as a form of reinforcement, mitigating knowledge decay and promoting sustained learning [20,21]. Refresher training keeps health workers' knowledge fresh and ensures they can consistently deliver the promised level of service [22].

The study revealed an absence of dedicated incentive or recognition programs that encourage staff to consistently uphold the CSC principles by using the charter. Implementing recognition programs to uphold CSC principles is undoubtedly vital. As urged by [23], this positive reinforcement could strengthen the desired behaviors, demonstrably motivating staff to deliver exceptional service as outlined in the charter consistently. Undoubtedly, intrinsic rewards significantly influence employee motivation, ultimately boosting their performance [24].

Strengths and limitations of the study: this study addresses a gap in knowledge by investigating the factors affecting nurses' use of the CSC in a specific Tanzanian hospital setting. This can provide valuable insights for improving CSC utilization within that context. While focused on a specific setting, the study's findings may have broader relevance to other hospitals in Tanzania or healthcare facilities in other countries facing similar challenges with staff adherence to service charters. However, the study is limited to the sample size of nurses surveyed, potentially affecting the findings' generalizability to other hospitals. The study's focus on a single Tanzanian hospital limits the generalizability of the results to other hospitals or healthcare settings, even within Tanzania. Factors influencing CSC use might vary depending on the specific context. The study may rely on self-reported data from nurses regarding their use of the CSC. This can be susceptible to social desirability bias, where participants might under-report instances where they don't adhere to the CSC.

Conclusion     

Our study identified low utilisation of the CSC among nurses. Several factors contributed to this include limited accessibility of the CSC in both physical and digital formats, time constraints faced by nurses, hindering their ability to review the charter, insufficient opportunities for ongoing staff training on CSC principles, absence of incentive or recognition programs to motivate adherence to the CSC: and the perceived length or complexity of the CSC document itself. To address this shortcoming, the strategies should include developing a comprehensive plan to ensure wider distribution of the CSC by using a user-friendly digital version of the CSC, accessible through the hospital intranet or a mobile app for easy access and reference; developing a shorter, bulleted point summary of the CSC's key principles for quick reference during busy shifts; integrate regular training sessions on the CSC into existing staff development programs; integrate adherence to the CSC into performance evaluations to incentivize its application; and empower the hospital Quality Improvement Team to oversee the implementation of CSC at the hospital level.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final manuscript.

Acknowledgments     

We would like to extend our gratitude to the management of Temeke Regional Referral Hospital and to all the participants in this study.

Tables     

Table 1: demographic information of study participants (n=133)

Table 2: individual-related factors influencing utilization of the client service charter (n=133)

Table 3: institutional factors influencing the utilization of the client service charter guideline

Table 4: the charter´s-related factors influencing its utilisation (n=133)

References