Southern Ethiopia - Gwent Health Link

Findings and analysis of evidence, March 2008 visit

As highlighted, sample sizes are small and measurement uncomplicated, therefore simple ‘number counts’, description and examples best portray the evaluation findings to date. The field notes and visit reports of members of the Gwent team were reviewed for evidence of progress against elements of the stated aims and outcomes of the project. Feedback from Ethiopian colleagues was also considered against the agreed aims. Findings from each Health Centre are reported separately under the headings ‘first impressions’; ‘use of equipment’; ‘cleaning materials’; ‘staff training – retention and use of skills’; ‘review of the teaching log’; ‘use of the computer and e-learning materials; computer skills testing’; ‘patient perceptions’; ‘staff perceptions’; ‘student perceptions’. For the purpose of this report, the ‘results’ described for each Health Centre are indicative rather than absolute. A full account of observations and evidence is available on request.

Health Centre 1

First impressions, March 2008: ‘Health Centre 1 is a group of low rise buildings set in spacious but undeveloped grounds. Each building is divided into rooms of varying size. These are in a reasonable state of repair but would benefit from cleaning and painting. Paths between the various areas of the Health Centre are unmade and small mounds of earth are piled up near the buildings and broken equipment lies discarded in the grounds. There is a small, covered seating area with benches for patients near the clinical rooms and an additional bench under a tree at the entrance. The Health Centre is located on the outskirts of the village. Roads within village 1 have a tarmac surface but the access road to the Health Centre is unmade and in a very poor/rough condition making the journey particularly uncomfortable for ill patients and labouring women. The Health Centre has two treatment rooms, one delivery room with two couches and an antenatal clinic. The mattress cover of one delivery couch is badly torn and both couches are antiquated. There is also an inpatient area and other rooms used as office space, or storage, or additional clinical space. Rooms are sparsely furnished and beds and couches devoid of linen. Windows in treatment rooms are ‘blacked out’ to some extent but there are no curtains. There are screens in some rooms’.

(Observation notes, March 2008)

Use of equipment: Staff reported that equipment was being used and there was evidence that it was available in clinical areas, for example, blood pressure monitoring cuffs and stethoscopes and laboratory equipment were seen to be in appropriate clinical locations. A neonatal resuscitation mask was found to be dirty, regrettably providing obvious evidence of use. Staff were observed correctly using a range of equipment. Books and CD Roms were in the ‘library’ area and posters on ‘obstetric emergencies’, provided in November 2007 were visible on the walls. However, there were also large boxes of unused surgical instruments locked in the store cupboard and IVI giving sets and fluid were not readily available for use in the emergency admissions area. Health Centre staff reported that the oxygen concentrator had not been used as they did not know how to do so. A member of staff had been given a demonstration when the oxygen concentrator was provided, however it was reported that this member of staff no longer worked at Health Centre 1. Some equipment was being used that was not stored correctly, for example blood pressure monitoring cuffs and stethoscopes were observed lying around on desks, not replaced in protective cases. Some equipment (for example, surgical instruments) was not sterilized when it should have been. In contrast to some clinical areas, the laboratory was found to be particularly clean and tidy with equipment provided by the Link stored and used correctly.

Cleaning materials: Cleaning materials provided in November had been used. During the visit there were two deliveries. The delivery room was seen to be well washed down afterwards using bleach. There was an observed improvement in the overall cleanliness of the Health Centre since November 2007 but also areas to be addressed, for example, ensuring soap and water is available at every sink and removing unused/obsolete/broken equipment and cardboard boxes ‘stored’ in treatment rooms. Cleaners do not work on Sundays or overnight leaving areas potentially unclean during this time.

Staff training – retention and use of skills: A member of staff from the Health Centre attended the Link’s midwifery skills training workshop in November 2007. The workshop programme contained teaching sessions on the advantages of an upright position in labour and how episiotomy should not be a ‘routine’ procedure. The staff member reported that he had put into practice what he had learnt at the workshop and described using a manoeuvre for a case of shoulder dystocia. He also reported assisting women to give birth using more upright positions rather than being placed in lithotomy. Episiotomy was said to be performed as necessary only, not as a matter of routine and an examination of delivery records confirmed this. A member of the Gwent team was able to assess this person’s knowledge and skills through further teaching and discussion. She was also able to observe him teaching others and confirm that his skills were good. These examples indicate that the workshop had a positive influence on this midwife’s practice.

In November 2007, the laboratory was provided with a haematocrit centrifuge and other essential equipment and trained by a member of the Gwent team in its use. They were also instructed in record keeping. Laboratory staff were observed using some of the equipment, for example glucose meters and found to be doing so correctly. Correct laboratory records had been made, thus demonstrating the effectiveness of the training and learning. Laboratory staff were however unable to use the haematocrit centrifuge as they did not have any capillary tubes.

Review of the ‘teaching log’: A review of the teaching log was disappointing. Although a book to record teaching/training sessions had not been provided, a member of staff had attended the midwifery skills workshop in November and been introduced to the principles of teaching/learning and teaching logs and had a copy of an outline format for recording training sessions. The person concerned reported that colleagues had been taught the skills he learnt on the workshop but the training had not been documented. It would be fair to assume that some training had taken place as the individual was a very willing and able course participant, but there was no record of this beyond verbal assurances. In any case, the ‘teaching log’ had not been implemented.

Use of the computer and e-learning materials; computer skills testing: The computers were located in a dusty room but were covered with appropriate plastic covers. Access to the computers was said by staff to be quite difficult. The visiting Gwent team experienced this when having to wait some time for the room key holder to be found. The one printer was located in a separate office and there were reports from staff that the printer too was difficult to access. There were problems with the functioning of both computers and monitors that a Gwent team member was able to partially rectify, only after some considerable time and effort. Electricity supply to Health Centre 1 can be erratic, again inhibiting use of the computer. Computer training sessions were restricted during the visit because of a power cut and a verbal assessment of computer skills therefore needed to be undertaken instead of the practical exercise. This assessment identified that staff had varying levels of skill, learned in college/university. The questionnaire designed to assess use of the computer (see appendix 7) highlighted that some staff appear to use the computer regularly for accessing e-learning materials and apply this knowledge to patient care. However the power cut during the visit resulted in limited opportunity to use the tool to check familiarity with the e-leaning materials (see appendix 8). Health Centre staff cited lack of access to the room prevented them from using the computer. The computer logs record sporadic use of the computers.

Patient perceptions: The representative of the Women’s group reported that there had been an improvement in staff attitude with staff more supportive of patients and also an improvement in the cleanliness of the Health Centre. It was difficult to determine the time period for the change but her views were repeated by community representatives in the joint Health Centre/community/Woreda/Link meeting. Waiting times were said to be long and certainly patients were observed to be waiting all morning/afternoon. The women interviewed while waiting for antenatal clinic said that although there was no screen in the room the door was closed and their privacy was respected.

Staff perceptions: Staff perceptions of the Health Centre were obtained through informal, opportunistic interviews with the midwife, a pharmacist, laboratory technician and three clinical nurses. Other feedback was given at group staff meetings and through discussion during the various ‘tours’ of the Health Centre. Overall, staff reported that they were happy with the improvements and were very pleased with the equipment provided. They appreciated the ongoing support of the Gwent team.

Student perceptions: Health Centre 1 is not a current placement for students as there is no accommodation. There are plans to build student accommodation however and members of the Gwent team were shown the proposed site.