|Year : 2016 | Volume
| Issue : 1 | Page : 6-10
Behavior of health workers toward the implementation of clinical guidelines
International Union Against Tuberculosis and Lung Disease (The Union), Pune, Maharashtra, India
|Date of Web Publication||25-Feb-2016|
C/O - Mr Bijaya Ketan Samal, At-Pansapalli, PO - Bangarada, Via - Gangapur, District - Ganjam, Pin - 761 123, Odisha
Source of Support: None, Conflict of Interest: None
Background: The maternal health situation in the country always presents challenges before the overall health system in India. Implementation of clinical guidelines can bring uniformity and standards of treatment protocol, leading to better maternal health outcome. Objectives: To understand the attitude, behavior, and challenges faced by health workers with regard to the implementation of clinical guidelines and protocols in the domain of maternal health. Setting and Design: Different cadres of health care providers working at the district and block levels were selected conveniently with the permission of the State health administration. In addition, nursing and medical academicians were also included in the study. Materials and Methods: A pilot qualitative study in two districts of Assam was carried out. Different cadres of health workers such as Medical Officers (MO), Rural Health Practitioners (RHP), and Nurses working at the district and block levels were interviewed in-depth with the help of a semistructured interview schedule, which lasted for 26 days during May-July 2014. Results: The study elicited several pertinent issues related to the implementation of clinical guidelines, which include the introduction of clinical guidelines as a part of academic training, awareness about clinical guidelines, the commonest conditions for which clinical guidelines are used, challenges faced in accessing and implementing guidelines, and specific areas where clinical guidelines should be developed. Poor penetration of clinical guideline implementation was observed in the domain of maternal health care in the study area. Conclusion: Given the situation of maternal morbidity and mortality, the implementation of clinical guidelines appears rational.
Keywords: Clinical protocol, India, maternal health, reproductive health
|How to cite this article:|
Janmejaya S. Behavior of health workers toward the implementation of clinical guidelines. J Health Res Rev 2016;3:6-10
|How to cite this URL:|
Janmejaya S. Behavior of health workers toward the implementation of clinical guidelines. J Health Res Rev [serial online] 2016 [cited 2019 Oct 14];3:6-10. Available from: http://www.jhrr.org/text.asp?2016/3/1/6/175014
| Introduction|| |
Clinical guidelines or clinical protocols are a recommended set of principles meant for patient management. These are the documents that synthesize current evidence on how to most effectively organize and deliver health services for a given condition. Clinical guidelines help inform health care decision-making and can serve as the basis for policy, planning, evaluation, and quality improvement. The efforts to develop clinical guidelines date back to 1980, when a general consensus was reached in order to reduce variability in patient management and render medical care more appropriate. The need of such clinical guideline development was primarily felt owing to the following three factors: Rising health care costs, clinical practice variations, and inappropriate medical care. During recent times, there is a great degree of concern toward evidence-based clinical practice or evidence-based medicine (EBM), which is strongly linked to the introduction and proper implementation of clinical practice guidelines at all levels of health care: Primary, secondary, and tertiary. The concept of EBM encompasses both standard clinical guidelines, which deal with the methods and procedure for a particular medical condition, whereas the standard treatment guidelines deal with the rational use of medicines. Clinical guidelines are developed based on the clinical diagnostic criteria, therapeutic practice guidelines, and guidelines for management of diseases. Use of clinical guidelines in developed countries such as the United States of America, Europe, and the United Kingdom has been in vogue for several years. However, the pattern of usage of clinical guidelines in India is not like that in developed nations. In India, guidelines are developed by the Government and other pertinent professional bodies. These guidelines, in addition to guidelines developed by international agencies, are referred to in clinical practice by the health care workers in India.
The basic objective of this study was to understand the attitude, behavior, and challenges faced by health workers toward the implementation of clinical guidelines and protocols in the domain of maternal health.
| Materials and Methods|| |
A pilot qualitative study in two districts of Assam was carried out with the help of a semistructured interview schedule. The schedule consisted of questions pertinent to the introduction of clinical guidelines as part of academic training, awareness about clinical guidelines, the commonest conditions for which clinical guidelines are used, adherence to clinical protocols, challenges faced in accessing and implementing guidelines, and specific areas where clinical guidelines should be developed.
Settings and design
Different cadres of health care providers working at the district and block levels were selected conveniently with the permission of the State health administration. In addition, nursing and medical academicians were also included in the study.
All the individual interviews were conducted at the respondents' respective health facilities after seeking written informed consent. Each interview lasted for about 1–1.5 h. All the interviews were audio-recorded after obtaining consent for doing so from the respondents. The interviews were conducted with the help of a semistructured interview schedule that lasted for 26 days during May–July 2014. In total, 36 interviews were carried out: 15 Medical Officers (MOs), 3 Rural Health Practitioners (RHPs), and 18 nurses. In addition, 4 interviews were conducted from 2 medical and 2 nursing academicians.
The audio-recorded files were transcribed in Microsoft Word 2010, developed by Microsoft, USA. The transcribed data were coded into different groups and themes were identified. The themes thus identified underwent thematic analysis. Based on this thematic analysis, a final report was prepared. No statistical analysis was carried out in this study.
| Results|| |
In this pilot qualitative study, several enquiries were made to the nursing and medical personnel to capture their experiences, ideas, needs, and challenges on the usage of clinical guidelines/protocols in the domain of maternal health. In response to the academic introduction of clinical guidelines, 3 (2 general nurse and midwife (GNM) and 1 RHP, N = 36) health providers denied having been introduced to any of the clinical guidelines as part of their academic training, 19 (10 MOs, 8 nurses, and 1 RHP, N = 36) health providers did not respond to it and 14 (5 MO, 8 Nurses, 1 RHP, N = 36) health providers reported to have been introduced to one or more clinical guidelines. [Table 1] enlists the name of clinical guidelines and protocols introduced as part of academic training, as reported by different cadres of health workers.
|Table 1: Names of the guidelines introduced as part of academic training as reported by health care providers|
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Two (1 GNM and 1 RHP, N = 36) health providers did not know about any clinical guidelines, 10 (6 MOs and 4 nurses, N = 36) providers did not respond when they were asked whether they know about any clinical guidelines and the rest 24 (9 MOs and 15 nurses, N = 36) health providers were aware of one or more clinical guidelines. When asked to name a few guidelines they are familiar with, 2 (2 MOs, N = 36) could not name a single guideline, whereas 34 (12 MOs, 3 RHPs, and 19 nurses, N = 36) health providers named one or more guidelines. The names of these guidelines that are familiar to different cadres of health workers are listed in [Table 2].
Twenty (7 MOs, 2 RHPs, and 11 nurses, N = 36) health providers could not respond about the source of guidelines and 16 (7 MOs, 1 RHP, and 8 nurses, N = 36) mentioned the source of the clinical guidelines. Most of them mentioned Government institutions; 1 mentioned a non-governmental organization (NGO) that has imparted the training, and 1 other health provider mentioned the internet. When asked about relevant training received, 20 (8 MOs, 2 RHPs, and 10 nurses, N = 36) health providers could not respond to the query, one MO denied having received any training, while 15 (4 MOs, I RHP, and 10 nurses, N = 36) mentioned that they received training; however, only 2 MOs could name the types of training they received, which were hand washing and Skilled Birth Attendance (SBA).
When asked about accessibility of guidelines, 20 (8 MOs, 2 RHPs, and 10 nurses, N = 36) could not respond, 2 nurses said that they do not have access to any guidelines, and 14 (5 MOs, 1 RHP, and 8 nurses, N = 36) said that they have access to clinical guidelines.
When the effort was made to know how many health providers refer to clinical guidelines and protocols in their clinical practice, 19 (10 MOs, 2 RHPs, and 7 nurses, N = 36) did not respond, 15 (5 MOs, 1 RHPs, and 9 nurses, N = 36) said that they refer to clinical guidelines, 1 nurse told that she does not feel like referring to guidelines, and another nurse said she does not have any experience in referring to clinical guidelines.
When asked about clinical conditions for which the guidelines are referred, 21 (10 MOs, 2 RHPs, and 9 nurses, N = 36) providers did not respond and 15 (5 MOs, 1 RHP, and 9 nurses, N = 36) have mentioned the clinical conditions in which they refer to guidelines. [Table 3] lists the commonest clinical conditions in which guidelines and clinical protocols are referred.
|Table 3: Commonest clinical conditions in which guidelines are referred to|
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When asked about the purpose of referring to clinical guidelines 23 (9 MOs, 2 RHPs, and 12 nurses, N = 36) did not respond, 13 (5 MOs, 1 RHP, and 7 nurses, N = 36) providers mentioned reasons for referring to clinical guidelines. Moreover, 29 (15 MOs, 3 RHPs, and 9 nurses, N = 36) health providers did not respond when asked about the benefits of referring to clinical guidelines and 7 (1 RHP and 6 nurses, N = 36) health providers agreed that they get benefits from referring to guidelines.
“I do refer clinical guidelines for training people not for clinical management.” [Obstetrics and Gynecology (O & G) specialist, District Headquarter Hospital]
“To rule out confusion regarding dosage” (GNM, Community Health Center)
“To store vaccine” (ANM, Sub Center)
When asked about challenges faced by the health providers in implementing clinical guidelines, 29 providers did not respond, 5 (3 MOs, 1 RHP, and 1 nurse, N = 36) health providers agreed that they did not have any challenge and 2 providers mentioned the reasons for being challenged.
“Guidelines are not customized” (MO, State Dispensary)
“Difficult as guidelines are not translated in regional language” (GNM, Community Health Center)
When asked about the need for developing specific clinical guidelines, 19 (8 MOs, 1 RHP, and 10 nurses, N = 36) providers did not respond, 4 (2 MOs, 1 RHP, and 1 nurse, N = 36) said that there is no need for developing new guidelines as the current guidelines are sufficient. On the other hand, 13 (5 MOs, 1 RHP, and 7 nurses, N = 36) providers suggested new guidelines; however, the suggestions were in the line of routine clinical practices, not specific ones. Development of guidelines on oligohydramnios and protocols for surgical intervention of Post Partum Hemorrhage (PPH) are the prominent suggestions.
“There are guidelines on medicinal management of PPH but no guideline on surgical management of PPH so there should be guideline on surgical management of PPH.” (O and G Specialist, District Headquarter Hospital)
“There should be guideline on Oligohydramnious.” (O & G Specialist, Private Hospital)
Furthermore, 4 academicians, 2 each from the medical and nursing fraternities, were interviewed in-depth about their ideas, experiences, and suggestions regarding the implementation of clinical guidelines and protocols in the area of maternal health. The first medical academician is of the opinion that clinical guidelines should be introduced in the medical education system. National Institute of Clinical Excellence (NICE), Royal College of Obstetrics and Gynecology (RCOG), and American College of Obstetrics and Gynecology (ACOG) guidelines may not be suitable in the Indian context. He added that it is difficult to break the guidelines. He named a few organizations involved in guideline development, such as RCOG and ACOG, and urged the involvement of Indian authors in developing guidelines. The second medical academician emphasized ground-level implementation of guidelines. She reiterated that guidelines are of no use if not properly implemented at the ground level. She attributed poor monitoring by the health department as an important factor for the poor ground-level implementation.
One of the first nursing academicians commented on guidelines as per the following quote:
“Guidelines are useful but in spite of having these guidelines providing quality nursing care is not possible because of some problems. Guidelines could be tool for standard quality care, suppose during training period they could learn everything in concordance to the guideline, e.g., how to involve community. We are providing everything through theory side, but we can't control on practical side.” (Nursing Tutor)
Similarly, the second nursing academician opined that:
“We do follow INC guidelines, those staff working at PHCs at this district but regarding their service I am not concern. Teaching is different and service is different, I can't comment on it.” (Nursing Tutor)
When asked about the current medical and paramedical curriculum dealing with guidelines and clinical protocol, the first medical academician said that presently the Federation of Obstetricians and Gynaecologists of India (FOGSI) and RCOG guidelines are referred to for teaching purposes. Guidelines developed by the government of India are also referred to, but those are mainly for the health services and are not suited to the requirements of medical colleges. The second medical academician agreed to use RCOG and ACOG guidelines for teaching purposes. The nursing academician mentioned the incorporation of National Rural Health Mission (NRHM) guidelines in the nursing syllabus; however, she was not sure of any government program-related guidelines or the fitting of the same into the nursing syllabus. The second nursing academician said that guidelines are part of nursing education and that the tutors have undergone SBA training, hence they can inculcate the same as part of nursing education. When specifically asked about referring to guidelines while imparting education, only 1 nursing academician responded and said that guidelines have been there for 4 years but need to be reviewed.
When the medical academician was asked about the adherence of clinical guidelines, he urged that there be proper support in terms of infrastructure, manpower, drugs, and continuous monitoring as well. Similarly, the nursing academician responded to the adherence of clinical guidelines as per the following quote:
“All guidelines need to be adhered and followed, e.g. administration of uterotonics is there, but our hospital set up is not at par, because of which students could not get proper exposure to the standard guidelines. We are teaching partograph but the in hospital they could not plot all partograph every time, in hospital there are many cases. We can improve the compliance to guideline through trainings. Authority should pressurize to health staff to adhere to the guidelines. Presently academic institutes do not have any role in the health services thus we can't do anything towards the adherence to the guidelines at the field level.” (Nursing Tutor).
| Discussion|| |
A mixed response regarding the implementation of clinical guidelines could be observed among different cadres of health workers serving at different levels of health care. Although many of the questions were not responded to by the MOs, they had more experiences, awareness, and concerns regarding the implementation of clinical guidelines compared to the other two cadres of health providers (RHPs and nursing cadre). Many of the health care providers reported about the academic introduction of clinical guidelines, but were skeptical, as it is mostly textbooks that are being followed in nursing and medical colleges rather than clinical guidelines. However, studies emphasize the introduction of standard treatment guidelines, essential medicines and rational use of medicines, in addition to diagnostic skills, in the undergraduate medical curriculum. The reported common clinical conditions for which guidelines are referred to by the health care providers are available on the NRHM portal, which should preferably be accessed for patient management as and when required. In addition, standard treatment guidelines for treatment of common and specific conditions are also available on the NRHM portal.
Moreover, many challenges are being encountered while implementing clinical guidelines. In many health care settings, the implementation of clinical guidelines is generally fragmented and inconsistent.,,, Various factors including lack of training of the health care providers in quality management, lack of awareness of the details of the guidelines, and the lack of acceptance of the given recommendations by those involved in the process of care are some of the major challenges in the implementation of clinical guidelines in health care settings., Furthermore, clinical guidelines are recommendations on appropriate management of people with specific diseases and are based on the best available evidence that help health care professionals; however, guidelines do not replace their knowledge and skills. Again, guidelines may not be applicable to all patients because of individual social, psychological, and economic differences. A wide range of contextual factors at the individual, institutional, and system levels often coexist and pose additional challenges to guideline implementation and use.
Given the challenges in the implementation of clinical guidelines and as reported by different cadres of health workers, one of the most important strategies to make the implementation of clinical guidelines successful is to make planning concurrent rather than consecutive to guideline development so that the recommendations are clear and useable, target users are primed for adoption, and their needs, preferences and insight on contextual factors can inform implementation planning. Language has been reported as an important barrier in accessing guidelines, hence steps need to be taken in order to develop guidelines in multiple languages. Similarly, concerns have been raised regarding the adherence of clinical guidelines that requires simultaneous health system development, including among other factors infrastructure, health human resource, logistics and supply chain, essential drugs, and supplies.
| Conclusion|| |
Implementation of guidelines may seem little cumbersome in many health care settings owing to several obvious factors; however, implementation should not be avoided based on these criteria. Implementation can bring standards and uniformity throughout the medical fraternity and health care setting. However, individual idiosyncrasies need not to be forgotten while adopting clinical protocols. Often adoption of clinical guidelines creates a clash between rational approach and empirical approach which should preferably be opted considering the best of patient's interest. Hence, despite the obvious difficulties in the implementation of clinical guidelines, the adoption of them should be established across the health system. Moreover, given the situation of maternal morbidity and mortality, implementation of clinical guidelines appears rational. Hence the necessary arrangement should be made at the health system level for effective utilization of clinical guidelines in the area of maternal health in India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]