Southern Ethiopia - Gwent Health Link

Health Centre 3

First impressions, March 2008: ‘Health Centre 3 is set in very pleasant, well tended gardens creating an atmosphere of relaxation, particularly welcome after a very uncomfortable journey as the Health Centre is located approximately one mile outside the village and is reached via an unmade road in an extremely poor state of repair. The road to the village itself is also unmade for some considerable distance and in poor repair, making access for patients very difficult and uncomfortable. The main clinic and inpatient areas are set around attractive gardens so that patients can sit/lie on the grass while waiting to be seen. Seating is also available on the veranda outside each clinic room. A large reception area is at the entrance and stores and a washing area located in additional buildings elsewhere in the grounds. Health Centre 3 has a number of rooms for both in and outpatient services as well as storage and administration. Some screens and curtains are evident but not in every room. There is no screen between the two beds in the delivery room and the beds look very clinical. Inpatient beds are covered with a clean blanket. Health Centre 3 does have access to a car when it is not being used by the local Woreda Health Council which owns it, but patient transfer is still problematic, not least because of the very poor state of the roads’.

(Observation notes, March 2008)

Use of equipment: Staff reported using all the equipment provided in November 2007. Members of the Gwent team were proudly shown photographs displayed on the office wall of Health Centre 3 that depicted staff using various items of equipment. Ambu bags, gloves, masks and goggles for delivery and the oxygen concentrator were identified as being particularly useful. Blood pressure monitoring cuffs and stethoscopes were observed to be in use in the antenatal clinic and emergency treatment room; two others were said to be non functioning. Laboratory staff were observed using the urine strips and glucose meters. The centrifuge and haemometer were reported to be working well. Some spare/duplicate equipment was seen to be correctly locked in the store cupboard but some items, for example a proctoscope and a chest drain, could have been made available for quick access in the minor injuries/emergency clinic. The oxygen concentrator was observed to be functioning and reported to have been used on one occasion.

Cleaning materials: All areas of Health Centre 3 were generally clean and tidy although some sinks lacked soap and there was surplus equipment and empty cardboard boxes inappropriately ‘stored’ in some clinical rooms. The laboratory was noted to be particularly dusty and fairly cluttered with unnecessary/non functioning equipment and rubbish. Cleaners were observed using mops and buckets and wearing heavy duty gloves provided by the Gwent team. They were observed cleaning surfaces, doors and windows, not simply mopping floors and washing down delivery beds after use. The public lavatories were observed to be cleaner than at the visit in November. All staff in Health Centre 3 were said to be responsible for the cleanliness of their own clinical area and while this was not instigated by the Gwent team, provision of cleaning materials should maximise the positive benefits of responsibility and pride in a particular clinical area. The cleaning staff spontaneously and publicly thanked the Gwent team at the staff meeting for the cleaning materials and equipment provided.

Staff training – retention and use of skills: Training provided was said to be very helpful, particularly resuscitation skills. An example was given of how staff in Health Centre 3 had been able to use the manoeuvres taught by the Gwent team at the previous visit to assist a woman with a difficult breech birth to achieve a positive outcome for mother and baby. Further evidence for this was documented in the Health Centre diary which records: ‘12/06/2000 …it was difficult to remove the child but with UK manoeuvres removed the child’. A staff member concerned also volunteered this information at an informal interview. An examination of delivery records showed that many women had an episiotomy to assist birth. Discussion with a staff member confirmed that contrary to the teaching on the midwifery skills workshop, episiotomy was the norm, particularly for primigravid women. This staff member had not attended the workshop so presumably the information had not been assimilated and/or passed on. Workshop participants had been introduced to teaching skills but it appears more work needs to be done with Ethiopian colleagues on teaching and training methods to ensure they have the knowledge, skills and confidence to teach/share information with others. Books provided at the last visit were out on display in the small computer room. Staff were said to be able to take books home and a record of this kept but such records were not seen. Members of the Gwent team conducted individual and small group training during the March visit and were able to assess learning during these sessions by asking staff to demonstrate skills to each other. There was a marked enthusiasm for learning with staff staying on beyond normal working hours to access the emergency skills and computer training.

Review of ‘teaching log’: It was disappointing to find that the teaching log had not been implemented since its introduction at the midwifery skills workshop in November 2007. While staff reported that there was no scheduled training per se in the Health Centre, opportunities were taken at the handover period to discuss new/unusual cases. There is a limited record of this in the work diary, for example: ‘22/06/2000 – discussed about EPI, drugs and individual patients seen’. It was also reported verbally that the midwife attending the midwifery skills workshop in November had used the teaching and clinical skills acquired at the workshop to demonstrate to colleagues the management of shoulder dystocia. Lack of training materials were said to limit teaching opportunities but there was a definite sense of wanting to initiate a learning culture in Health Centre 3.

Use of computers and e-learning materials; computer skills testing: One monitor was not functioning, possibly due to a blown bulb caused by fluctuations in electricity supply. This was rectified during the visit. Examination of the computer logs provided evidence that the computers were used daily. Evaluation questionnaires showed that most staff had basic computer skills with a few quite proficient. Most had learnt these skills in college while undertaking professional qualifications. Some staff were able to access the e-learning materials installed by a member of the Gwent team during the November visit and gave examples of how they had used these to improve their knowledge of patient care. All staff were keen to improve their skills with individual training and returned several times during breaks in clinical duties to complete the skills training package. A training log book was left to monitor and record rationale for computer use and access of the e-learning packages.

Patient perceptions: Verbal reports from community representatives at the joint meeting echoed the informal group interview with patients. Feedback regarding the Health Centre and the services provided were positive overall however the community would like the Health Centre upgraded to hospital status with more staff, resources, funding and staff training to better meet the needs of the local community and to minimise referral elsewhere. Transportation for patients was reported to be very difficult. There were verbal reports also from community representatives that women have begun to attend Health Centre 3 more frequently for antenatal care and some then return for delivery. It was good to observe during the visit in March, a woman being brought to Health Centre 3 by a traditional birth attendant when labour was too prolonged, thus providing one example of a positive interface between the Health Centre and traditional community practice. There was a good outcome for both mother and baby. A member of the Gwent team observed the care of the woman and was able to teach/advise on basic ‘nursing’ care, taking and recording observations and allowing the woman to remain more upright to facilitate the delivery of a very large baby. Health Centre staff were also observed providing care to a young girl with a deep gash to her forehead and badly swollen eye. The dressing was changed gently and staff wore gloves provided by the Gwent team at the previous visit. This observation was in keeping with reports from an informal group interview with patients in which they said that staff treated them well and respected their privacy.

Staff perceptions: Informal interviews with staff found that they enjoyed working in Health Centre 3. Strong management, team work and responsibility for a given area were cited as positive attributes. One staff member had experience of working in a different Health Centre but preferred Health Centre 3.

Student perceptions: Students are placed in Health Centre 3 for clinical experience however there were no student nurses or student midwives available to meet with at the time of the visit. A group of four third year laboratory technician students were interviewed as a group and reported that Health Centre 3 was a good placement for learning as they could experience a full range of ‘routine’ tests and procedures. The equipment provided for the laboratory and staff was also said to benefit the students’ learning experience. The students described a good atmosphere and said staff were supportive of them. They also commented on the large number of students trying to gain experience – an issue particularly noticeable during the November 2007 visit when fifteen student midwives were placed in Health Centre 3 to gain experience in antenatal care. There was also opportunity to interview a newly qualified clinical nurse who compared Health Centre 3 very favourably to the Health Centre she had experienced as a student; ‘better management and better resources’ were cited as reasons for the preference.