At the end of many bumpy back road journeys in my 20+ years of global health practice was a welcoming nurse or midwife eager to share their successes and struggles in providing health care in some of the most remote places on earth. Working with few materials and without many things most of us would consider essential, they quietly went about the business of saving lives and improving health.
In many cases their heroic efforts are undocumented. Lack of supervision and objective feedback give few opportunities to improve, even if the desire is there. Despite wanting to provide high quality care, without assessment it is difficult to know if efforts to improve performance are effective. External regulation and accreditation programs rarely reach remote facilities and facilitative supervision is often lacking.
A basic tool to assess quality of care and performance could provide essential feedback to district level hospitals and rural health clinics. Many available tools assess the quality of care and capacity of various services for external stakeholders but few focus on the hospital as a whole and have limited use for internal quality improvement.
Recently, I had the privilege of working with an enthusiastic group of nurses in a large faith-based health service delivery system in Cameroon. Along with Meaghan Bradley, Secretary/Treasurer of the Global Nursing Caucus, and a team of enthusiastic MPH students we took on the herculean task of helping to develop hospital performance indicators for each service unit.
Over an 18-month period nurses mapped out all the services in the hospital, chose key measurement points, and developed performance indicators. Using the defined indicators nurses collected performance data and analyzed results. Since the process was participatory and driven by the assessment needs of the hospitals, personnel owned the process and felt empowered by the ability to objectively determine their performance and quality of care. As one midwife said “Because at first there was nothing in place to qualify our work, we were just excited with people saying that we are doing good work, that they enjoy our services, but there was nothing to measure it, there was no tool available, there was even no idea about the importance of that.” Objective assessment of the quality of care being provided pointed out gaps and allowed nurses to see where improvement was needed.
Objective assessment of care empowers nurses to document high performing areas, identify gaps, and make plans for improvement. Participating in assessment provides learning opportunities and fosters ownership of the results.
Contrary to what some might think, nurses in remote areas want to improve their practice but have few opportunities to build their capacity. Participatory assessment provides an objective way for nurses to measure performance and plan for improvement.
As we advocate for nurses to take up a voice in the global health conversation we need objective and rigorous methods to assess and document our efforts. Participatory performance assessment provides a basic, low-cost strategy to document successes and identify gaps. Empowering nurses to assess their performance is a vital first step in strengthening our voices.
Monita Baba Djara DrPH MS