Explaining the uptake of paediatric guidelines in a Kenyan tertiary hospital – mixed methods research

BMC Health Services Research

Mike English⁷  Jim Todd⁶  Migiro Santau¹  Dejan Zurovac³  Dorothy Mbori-Ngacha⁵  Christopher Maina²  Harrison Kihara²  David Gathara⁷  Alexandra Greene⁴  Grace W Irimu⁷ 

[1] Division of Child Health, Ministry of Health, Nairobi, Kenya;Kenyatta National Hospital, P.O. Box 20723–00202, Nairobi, Kenya;Center for Global Health and Development, Boston University, Boston, MA 02118, US;Child Health, University of Dundee, Dundee, UK;Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, P.O. Box 19676–00202, Nairobi, Kenya;London School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK;P.O. Box 43640–00100, Nairobi, Kenya

关键词: Complex adaptive system;    Hospital leadership;    Mixed methods research;    Performance;    Implementation;    Guidelines;    Ethnographic;    ETAT+;   

Others  :  1133277
DOI  :  10.1186/1472-6963-14-119

 received in 2012-12-17, accepted in 2014-01-30,  发布年份 2014

【 摘 要 】

Background

Evidence-based standards for management of the seriously sick child have existed for decades, yet their translation in clinical practice is a challenge. The context and organization of institutions are known determinants of successful translation, however, research using adequate methodologies to explain the dynamic nature of these determinants in the quality-of-care improvement process is rarely performed.

Methods

We conducted mixed methods research in a tertiary hospital in a low-income country to explore the uptake of locally adapted paediatric guidelines. The quantitative component was an uncontrolled before and after intervention study that included an exploration of the intervention dose-effect relationship. The qualitative component was an ethnographic research based on the theoretical perspective of participatory action research. Interpretive integration was employed to derive meta-inferences that provided a more complete picture of the overall study results that reflect the complexity and the multifaceted ontology of the phenomenon studied.

Results

The improvement in health workers’ performance in relation to the intensity of the intervention was not linear and was characterized by improved and occasionally declining performance. Possible root causes of this performance variability included challenges in keeping knowledge and clinical skills updated, inadequate commitment of the staff to continued improvement, limited exposure to positive professional role models, poor teamwork, failure to maintain professional integrity and mal-adaptation to institutional pressures.

Conclusion

Implementation of best-practices is a complex process that is largely unpredictable, attributed to the complexity of contextual factors operating predominantly at professional and organizational levels. There is no simple solution to implementation of best-practices. Tackling root causes of inadequate knowledge translation in this tertiary care setting will require long-term planning, with emphasis on promotion of professional ethics and values and establishing an organizational framework that enhances positive aspects of professionalism. This study has significant implications for the quality of training in medical institutions and the development of hospital leadership.

【 授权许可】

   
2014 Irimu et al.; licensee BioMed Central Ltd.

【 图 表 】

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