Southern Ethiopia - Gwent Health Link

Health Centre 2

First impressions, March 2008: ‘Health Centre 2 is a number of long, low rise buildings set in dusty grounds with some native trees for shade. A broken motorbike lies abandoned in the grounds. There is a central covered courtyard with seating for patients waiting for the several clinics located in the rooms leading off the courtyard. Other clinical areas have benches under veranda type shelter. Health Centre 2 is situated on the outskirts of the village and reached by turning off the main tarmac road and travelling a short distance on a dusty, unmade road in reasonable repair. Buildings are in reasonable condition and comprise two treatment rooms, one delivery room (with three couches), one first stage room, antenatal clinic and a number of other inpatient and outpatient rooms plus offices and store rooms. Some rooms would benefit from painting. They are all quite sparsely furnished and there is no linen on couches or inpatient beds. The mattress cover on the bed in the first stage room doesn’t fit, leaving the end third of the mattress exposed. Privacy may be an issue as curtains and screens seem in short supply. There are no screens between the three couches in the labour room’. 

(Observation notes, March 2008)

Use of equipment: staff reported that they were using the equipment given and found it very helpful. Although laboratory staff were not using the centrifuge provided by the Link as they already had a functioning centrifuge, other items of laboratory equipment were seen to be in use. Throughout the visit members of staff in all areas of the Health Centre were observed correctly using resources provided by the Gwent team, for example: alcohol gell for hand disinfection; the glucometer for glucose testing; plastic aprons and gloves were available for use in the delivery room; neonatal resuscitation bag and mask; disposable ventouse suction cups for delivery. There were however some clinical areas in which equipment given should/could have been available for use, but was not, for example there was no blood pressure monitoring cuff and stethoscope in the medical outpatients’ clinic. Equipment and books were found to be locked in the store room for ‘safe keeping’ when they could have been available for use in clinical areas. A demonstration was given at the time of delivery of the oxygen concentrator (November 2007) but staff at this visit reported that the oxygen concentrator had not been used as they did not know how to do so.

Cleaning materials: The Health Centre seemed to be more organised and most areas were cleaner than observed at the visit in November 2007. There were however areas requiring better attention, for example a used scalpel blade remained in a bowl in the delivery room for two days and the walls of some clinical areas, particularly the first stage labour room looked particularly grubby. Floors and beds were essentially clean and although sinks were often dusty and seemed stained, those in use were generally clear of blood and waste. Cleaners reported that they regularly used the buckets, mops and bleach purchased at the last visit and there was evidence of this. Observation of the washing area showed soiled linen being soaked in large bowls provided by the Gwent team and the supply of bleach was considerably diminished. Cleaners were able to describe the amount of bleach used. Public lavatories were marginal in their cleanliness and one additional lavatory near a patient waiting area was very offensive. Cleaners are not employed overnight or on Sundays. A reliable water supply is an ongoing difficulty for Health Centre 2, to the extent that patients should be charged for a glass of water to take medication. The erratic water supply sometimes impacts on the ability to keep areas clean but a poor standard of cleanliness can also be due to lack of awareness/attention to detail. Empty boxes and items of unused equipment, including two cans of fuel for a motor cycle, were seen to be ‘stored’ in clinical areas thereby creating a hygiene and/or safety risk for patients and staff. It was disappointing to observe that the resuscitation area with IV giving set and oxygen concentrator, set up in November 2007 with full demonstration of its use, had been dismantled.

Staff training – retention and use of skills: The midwife who attended the midwifery skills workshop in November 2007 had left the Health Centre to train as a health officer so it was not possible to assess his application of skills learnt. A laminated ‘hand washing’ chart given at the workshop was found to be lying on top of a dusty cupboard in the delivery room rather than being displayed near the sink. ‘Blue tack’ was adhered to the back of the chart as possible evidence of display at one time. Other charts/teaching aids that would have been of benefit on display were found tidily stored in a locked cupboard. The donated midwifery books could not be found. Staff reported that all women deliver in lithotomy position so it would appear that the midwife who attended the midwifery skills workshop in November had been unable or unwilling to pass on/apply the skills learnt or perhaps was unable to assimilate the ‘new’ methods in his practice. Similarly the need for privacy in labour did not appear to have been heeded as there were no screens separating the three beds in the delivery room, although it was reported that one could be ‘borrowed’ from elsewhere in the Health Centre if needed. One laboratory technician from the Health Centre was in Awassa participating in the laboratory skills workshop run by the Gwent team at the time of the visit and it may be possible to follow up his learning at the next visit. Members of the Gwent team led small group and individual teaching sessions on emergency surgery, resuscitation and emergency obstetrics/midwifery skills. Assessment of understanding was undertaken by observing staff demonstrate/teach colleagues. Most were quick to gain skills. Retention of knowledge and application of skills in clinical practice on a longer term basis can take place at the next and/or subsequent visits to Health Centre 2.

Review of ‘teaching log’: Health Centre staff reported that they shared knowledge and skills with each other and that a record was kept of staff training however it was hard to obtain evidence of this beyond the verbal report. The ‘teaching log’ left by the Gwent team in November was very difficult to find and was eventually located under a pile of papers in a store room/office. There was one entry only in the teaching log – ‘25/1/2000EC, safe delivery’.

Use of computers and e-learning materials; computer skills testing: The two computers provided by the Gwent team in November 2007 were installed in a small office. The office was locked but key access and use of the computers was said to be non problematic. Staff reported that they frequently accessed the computers and used the teaching materials. Those interviewed said they valued the learning resources and looked up information relating to patient conditions. Testing computer literacy showed varying degrees of competency. Most were able to access the e-learning packages from the icons on the desk top and worked their way through the given exercise with reasonable confidence. Examination of the computer logs showed daily use but the installed tool does not specify type of use. A training log book has now been attached to the computers to record reason for use. Certainly staff were keen to attend for individual training despite the busy clinics and numbers of patients waiting to be seen. The computers were correctly shut down and covered with a protective cover, essential in such a dusty environment. The printer was not functioning but a member of the Gwent team rectified this during the visit.

Patient perceptions: Patients interviewed at the Health Centre gave quite positive reports. Although waiting times were said to be very long, in some instances requiring a return visit in the afternoon if there were too many to be seen in the morning clinic, patients reported that staff were good to them and their privacy was respected. One group interviewed said that staff ‘worked hard and did their best’. Health Centre staff were certainly observed being kind to patients, for example, when advice was being given to the father of one small boy with severe malnutrition, but there was little evidence of ‘nursing care’ per se of those who were inpatients. Community representatives were invited to comment on the Health Centre at the joint meeting. They stated that there were too many patients for the number of staff and too few resources. The community would like the Health Centre upgraded to a hospital with more resources and staff training to minimise the need for transfer. Transportation of patients was also said to be very difficult. The community stated that they were very supportive of the Health Centre and staff but suggested more communication/joint working.

Staff perceptions: Staff were generally satisfied working in Health Centre 2 but said that it was very busy and did not have enough resources for the number of patients. They reported that the equipment and training provided by the Gwent team was very useful and they valued the ongoing support.

Student perceptions: There were no students on placement in Health Centre 2 in March 2008 but two newly qualified clinical nurses were informally interviewed, one of whom had spent time there as a student. This nurse reported that she hadn’t observed a great deal of change since her student placement about twelve months previously. Both nurses liked working in Health Centre 2, citing a friendly atmosphere and young colleagues as reasons, but both said they would prefer to work in a referral hospital.