International Journal of Africa Nursing Sciences 18 (2023) 100569
Contents lists available at ScienceDirect
International Journal of Africa Nursing Sciences
journal homepage: www.elsevier.com/locate/ijans
The drivers and impediments of implementing the quality improvement
programmes at a government hospital in Eswatini: The registered
nurses’ perspective
Tinyiko Enneth Nkhwashu 1, *, Sophy Mogatlogedi Moloko 1, Mfanaleni Jimson Zikalala 2
Sefako Makgatho Health Sciences University, P.O. Box 142, MEDUNSA, Ga-Rankuwa 0204, South Africa
A R T I C L E I N F O
A B S T R A C T
Keywords:
Drivers
Impediments
Implementation
Quality improvement programmes
Registered nurses
Implementation of quality improvement programmes in health care institutions is considered a priority for health
institutions in improving the quality and safety of health care. The implementation of the programmes require
efforts from all levels of staff and may be influenced by factors at an individual and organisational level. The
purpose of this study was to describe and explore the drivers and impediments of the implementation of quality
improvement programmes at a government hospital in Eswatini.
A qualitative research design was used to explore and describe the drivers and impediments of implementing
quality improvement programmes at a government hospital in Eswatini. Non-probability, purposive sampling
was used to select the sample. Data were collected using face-to-face semi-structured interviews. Data analysis
was conducted following Tesch’s method.
The study identified human-related drivers as staff commitment and being appreciated and acknowledged. The
organisational drivers were buy-in from management, capacity building, and a Multidisciplinary team approach,
collaborations and partnerships. The human-related impediments were lack of ownership, resistance to change
and lack of motivation. In contrast, organisational impediments were the absence of a clear implementation
strategy, lack of leadership and management skills, lack of resources, poor reporting system and challenges from
the government.
Some significant drivers could be reinforced and challenges need to be addressed to facilitate the imple­
mentation of the programmes. Some of the human drivers and impediments were influenced by organisational
drivers and impediments. Therefore, reinforcing organisational drivers and correcting impediments could be
fundamental in enhancing the implementation of QIPs in the hospital.
1. Introduction
Improving the health outcome of the population is crucial for the
public health care system (Coles, Anderson, Maxwell, et al., 2020).
Implementing good quality health care can improve health outcomes;
thus, health and the quality and safety of health care are considered
priorities for governments, healthcare workers, and the public (Hill,
Stephani, Sapple & Clegg, 2020). These brought a need for formalisation
of the commitment by governments to improve the quality of the health
care system around the globe; consequently, a new body of knowledge
termed “quality improvement” was adopted (University Research
Council, 2016). Quality improvement (QI) is an intentional, systematic
application of specific methods to improve service delivery, to achieve
positive change. In health care, QI is defined as a rigorous systematic
process that emphasises continuous activities to achieve measurable
improvement of health outcomes, health system performance and pro­
fessional development, with the ultimate goal of improving the pop­
ulation’s health (Limato, Tumbelaka, Ahmed, et al., 2019).
Based on the Universal Health Coverage strategy, which stipulates
that people should be able to access quality health services, the Ministry
of Health has developed the National Health Sector Strategic Plan
2019–2023 as a build-up from the National Quality Management
* Corresponding author at: Gauteng College of Nursing, Ann Latsky Nursing Campus, Private Bag 40, Auckland Park, 2006, South Africa.
E-mail addresses: Nkhwashu.Tinyiko@gauteng.gov.za (T.E. Nkhwashu), sophy.moloko@smu.ac.za (S.M. Moloko), mzikalal@uniswa.sz (M.J. Zikalala).
1
Sefako Makgatho Health Sciences University, P.O. Box 142, MEDUNSA, Ga-Rankuwa 0204, South Africa.
2
University of Eswatini, Faculty of Health Sciences, Eswatini.
https://doi.org/10.1016/j.ijans.2023.100569
Received 18 July 2021; Received in revised form 19 March 2023; Accepted 15 April 2023
Available online 17 April 2023
2214-1391/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/bync-nd/4.0/).
T.E. Nkhwashu et al.
International Journal of Africa Nursing Sciences 18 (2023) 100569
Programme (NQMP) in 2010 in an endeavour to improve the quality of
health care in the country (Ministry of Health - Kingdom of Eswatini,
2019a). To align itself with this national initiative, and as a national
referral hospital of Eswatini, the selected government hospital has
embarked on extensive quality improvement (QI) initiatives. This is
crucial because the hospital is a key structure in the country’s healthcare
system, contributing about 31 per cent of all admissions made by gov­
ernment hospitals nationally (Ministry of Health - Kingdom of Eswatini,
2019a). With each department developing its QIPS as per need, the
hospital has adopted a decentralised implementation approach for its QI
programmes to monitor, measure and evaluate the quality of services it
provides (Booyens & Bezuidenhout, 2016).
By the year 2020, efforts have been made to capacitate registered
nurses by training them on various QI components so that they were
actively involved in the implementation of the programmes and the
Quality Management Approach to ensure that inputs are translated into
effective and high-quality service delivery (Ministry of Health, 2020).
These nurses were nominated to become quality focus persons for the
hospital. Their responsibility was to support the implementation of QIPs
and empower other healthcare providers in the hospital (Ministry of
Health, 2020). With assistance from strategic partners, the Ministry of
Health in Eswatini has made some progress in implementing some QIPs
at different levels of health institutions in the country (University
Research Council, 2016:4). However, despite the implementation of the
QIPs, the health outcomes in Swaziland are below expectation, with an
estimated life expectancy of 53 years (Chowa, Espinola, Sullivan,
Mhlanga & Camargo, 2017). The outcomes are related to the challenges
in the healthcare system that hamper the effectiveness of healthcare
delivery due to a lack of attention to the production of high-quality
health services by some of the stakeholders (The World Bank, 2020).
Research revealed that QI requires the involvement of all stake­
holders in the healthcare system to succeed. It requires collaboration
between managers, administrative professionals, clinical workers, pa­
tients, caregivers, and researchers to improve processes and health
outcomes for patients/residents who need care (Singh, Wiese & Sillerud,
2019). Furthermore, QIP is viewed as a change process mainly centred
on people, with nurses seen as the main stakeholders of QIP because of
their fundamental role in caregiving (Alishaq & Alajmi, 2017; WHO,
2018). Therefore, for implementing QIPs, human factors like knowl­
edge, attitudes, perceptions, and values influence how the programme is
adopted and administered. In addition to human factors, other factors
are influencing the effective implementation of QI interventions and
strategies. These include contextual variables such as interactions
among the stakeholders, organisational structure, culture, and socioeconomic environment. However, despite the importance of QIPs in
improving health outcomes, competing for strategic priorities, lack of
leadership support, limited QI training, limited physician engagement,
inappropriate focus on interventions, and lack of recognition for QI were
found to affect the consistent implementation of QIPs negatively
(Quality improvement and Healthcare, 2020).
Consequently, affecting the outcome of the QI initiatives. QIPs must
be well implemented to improve health outcomes and employee work
experiences. Hence the motivation of the researchers to identify and
explore the drivers and the impediments of the implementation of QIPs
in the selected hospital (Wendwessen, Dereje & Gize, 2020).
3. Material and methods
3.1. Study design and setting
The study used a exploratory descriptive qualitative design to
explore and describe the drivers and impediments of the implement
implementation of quality improvement programmes at a government
hospital in Eswatini. The design enabled the researchers to enquire and
describe life experiences from the experiences of the healthcare pro­
viders involved in QI (Polit & Beck, 2017). The study was conducted at a
government hospital situated in the Hhohho region of Swaziland. The
hospital has 100 medical and paramedical staff, ranging from medical
specialists to interns, 258 nursing cadres, ranging from matrons to stu­
dent nurses and 233 support staff (Mbabane Government Hospital,
2011). With a bed occupancy of 500. The hospital is one of the in­
stitutions in the country in which extensive QIPs were being rolled out
and the country’s national referral hospital and a primary health care
facility for the surrounding community.
3.2. Study population and sampling procedure
The study population comprised eight registered nurses working for
at least one year up to fifteen years at the selected government hospital.
Purposive sampling or judgmental sampling allowed the researchers to
consciously pick specific participants who provided rich information on
the phenomenon, which needed to be studied (Mohajan, 2018). The
sample size was determined by the saturation of information which is
when data began to repeat itself (De Vos, Strydom, Fouche & Delport,
2016).
3.3. Data collection and analysis
Data were collected using in-depth face-to-face interviews, using a
semi-structured interview guide as a data collection tool. The interview
guide was developed in English, and all registered nurses were inter­
viewed in English as they were conversant with the language. An
audiotape recording device was used per the participant’s permission to
capture and preserve the data as accurately as possible (Creswell, 2013).
Raw audio recordings and field notes were transcribed verbatim into
Microsoft word files. The data were manually analysed using Tesch’s
method according to the following steps as suggested by Tesch in
Creswell (2013): the researchers carefully listened to the audiotaped
interviews and read transcripts to understand the whole picture con­
cerning the registered nurses’ perspectives, they then repeatedly
listened to the audiotape and read through the interview notes, writing
down ideas that emerged, that is, themes and sub-themes. A list of all
topics was made and then clustered similar topics together. This was
followed by the identification of major categories. Codes for similar
topics were created, and these were rearranged to see if they became
categories. The researchers then found suitable wording for these codes
and regrouped them into categories to indicate relationships, the re­
searchers drew lines connecting related categories, and the data was recoded again to develop more categories and sub-categories.
3.4. Measures to ensure trustworthiness
2. The purpose of the study
Trustworthiness was ensured throughout the study using Lincoln and
Guba’s framework (1985), which consists of five criteria (Polit & Beck,
2017). All the criterion was observed as follows: The ensured credibility
of the study through prolonged engagement when collecting data by
remaining in the field until data saturation was reached. Credibility was
also ensured by verbally paraphrasing the participant’s responses, and
they confirmed their responses. To ensure transferability, the re­
searchers used audiotape recording and field notes to transcribe data to
ensure that no information was missed, and the data was transcribed
verbatim. Confirmability was ensured by comparing the findings of the
The purpose of this study was to explore and describe the drivers and
impediments of the implementation of quality improvement pro­
grammes at a government hospital in Eswatini.
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T.E. Nkhwashu et al.
International Journal of Africa Nursing Sciences 18 (2023) 100569
study with existing literature. Description of the methodology used in
the study, verbatim transcription of interviews, data analysis and liter­
ature control ensured the dependability of the study. The researchers
ensured authenticity by reporting the experiences, views, language, tone
and feelings as the registered nurses expressed them in their context.
Table 2
Themes and subthemes.
Ethical approval for the study was obtained from the Sefako Mak­
gatho Health Sciences University’s Research and Ethics Committee
(reference number SMUREC/H/119/2018:PG), and permission was
sought from the Ministry of Health’s Swaziland National Health
Research Review Board (NHRRB) and the Hospital. All registered nurses
signed informed consent forms before undertaking the research. Par­
ticipants wishing to withdraw during the study would have been
allowed to freely withdraw as participation was voluntary. Registered
nurses’ rights to justice, autonomy, anonymity, privacy and confiden­
tiality were respected.
1. Human-related drivers
1.1. Staff commitment
1.2. Being appreciated and acknowledged
2.1. Buy-in from management
2.2. Capacity building
2.3. Multidisciplinary team approach, collaborations
and partnerships
3.1. Lack of ownership
3.2. Resistance to change
3.3. Lack of motivation
4.1. Absence of clear implementation strategy
4.2. Lack of leadership and management skills
4.3 Lack of resources
4.5. Poor communication and reporting system
4.6. Challenges from the external environment
–economy, government policies
3. Human-related
impediment
4. Organisational-related
impediment
far:
P1: “Whatever is in our power and ability to change, we as nurses with the
support staff and everyone involved works hard to address the issue. We
are committed to meet the quality standards.”
P6: “Well, for me, I have resorted to doing things the normal way. Do my
best with the current situation. With whatever I am given, I try to provide
the best care to the patient the best way I can. So I do my best with what I
am provided with.”
4. Results
Eight registered nurses participated in the study. Three were females,
and five were males. The age of the registered nurses ranged between 24
and 42 years. Four participants had more than five years of work
experience, with the highest being ten years. The other four had work
experience of one year to five years. All participants, except one, had
some experience either currently serving or previously served as a
departmental representative to the hospital’s quality management team
(see Table 1).
Four themes emerged from the data analysis, as shown in Table 2.
The themes were human-related drivers, organisational-related drives,
human-related impediments and organisational-related impediments.
4.1.2. Being appreciated and acknowledged
Some participants indicated that being appreciated by the quality
focal person encourages and drives them to continue doing their best in
terms of quality. Scheduling meetings for presenting performance on
quality improvements, awarding good performance and feedback
mechanisms were some of the activities that provided some form of
acknowledgement and encouragement to the nurses.
4.1. Human-related drivers
P1: “It feels good to be commended when you have done things correctly.
You see. So let it be a norm to encourage us. Even in this challenging state
of things, we continue to put effort because we are being appreciated”.
P3: We have a quality office in the hospital, they give us feedback from
time to time on how we are performing. They also acknowledge good work
by some of us.
P4: Every month, we meet and present what we are doing, and QIPs are
included. In that meeting, we were awarded for our efforts towards
quality improvement. That encourages us to give quality care.
4.1.1. Staff commitment
The results showed that registered nurses and other support staff
were putting in some effort towards implementing the QIPs in the hos­
pital. Participants acknowledged improvements in the quality and
standards of nursing practices in other departments because they were
committed to the programmes. However, they did confess that their
commitment and effort sometimes were not enough and could only go so
Table 1
Demographic characteristics of the participants (n = 8).
Sex
Subthemes
2. Organisational-related
drivers
3.5. Ethical considerations
Participant
Themes
Age
(yrs.)
Work
experience in
hospital
Experience in relation to QIPs
Current departmental nurse
focal person for quality
Current departmental nurse
focal person for quality, 2 years
Newly appointed departmental
nurse focal person for quality, 4
months
Currently departmental nurse
focal person for quality, 4
months
Former departmental nurse
focal person for quality 2016,
for 1 month
Current departmental nurse
focal person for quality, for 3
past years
None
Departmental representative to
the hospital’s Quality
Management Team
1
F
38
10 yrs.
2
F
40
08 yrs.
3
M
33
09 yrs.
4
M
42
08yrs
5
M
24
05yrs
6
F
26
03yrs
7
8
M
M
29
31
02yrs
04yrs
4.2. Organisational-related drivers
4.2.1. Buy-in by top management
Some participants mentioned that top management had shown some
form of buy-in and involvement towards the QIPs by setting up the
structures needed to implement the QIPs. The management established
an institutional quality office, which assisted in the reduction of the
over-reliance on external quality bodies like the Council for Health
Service Accreditation of Southern Africa (COHSASA) for quality moni­
toring and evaluation services. The quality office worked hard to ensure
that QI is a continuous daily exercise in the hospital. Moreover, partic­
ipants mentioned the fact that management and the quality office should
play active leadership roles for the effective implementation of the QI
programmes:
P1: “So I feel like the top management people must be at the forefront. It
must be them who are proactive in these QIPs because if these can be
implemented, there can be a difference.”
P2: “I think the management is very involved because the officer we have
was brought here by the Ministry of Health. And was accepted by the
hospital management, allocated an office to show that they were involved.
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International Journal of Africa Nursing Sciences 18 (2023) 100569
Moreover, they appointed some managers for the quality programme like
nurses, and doctors. So they are greatly involved.“
the more experienced staff were more resistant to the changes that came
with the implementation of QIPs. Some participants also complained
about the change of the hospital nurse focal person as having a negative
effect on the implementation of the QIPs. They minced no words in
expressing how the previous nurse focal person was better than the
current one, as verbalised below:
4.2.2. Capacity building
According to the participants, there has been a considerable effort
put by the Ministry of Health, the hospital and other partners into ca­
pacitating registered nurses and other hospital staff regarding QIPs and
quality in general. Extensive orientation, in-service training and work­
shops were provided for the hospital staff regarding the programmes.
Some of the information was shared during the scheduled QIP meetings
hosted by the Quality Office of the hospital.
P1:“…there has been a change in personnel. As much as there was that
negative attitude towards the (previous) nurse focal quality officer, but
the person was a hard worker.”
P2:“…there is some resistance from others, and it is difficult to do the
quality programme if there is resistance from the other staff…Change is
very difficult…if you are used to doing things this way and then suddenly
you are told to do things systematically. It is difficult; it is change.
P2: “When the quality improvement programme was rolled out, there was
training specifically for nurses, for orderlies, for doctors….The training
was on how to structure our quality projects and how to go about it.”
P4:“…they (QIP) were just theoretical until we had some on-job training.
So they came to present to us on how to form…to come up with a QIPs.”
P6:“…So I got on board just to learn more about the QIP. I even went for
the QMS (quality management system) workshop.”
4.3.3. Lack of motivation
Some participants expressed that they lack the motivation to adopt
QIPs as a daily routine. They acknowledged that they only focus on
quality improvement when it is time for audits to get good credits. One
of the reasons mentioned as the course for lack of motivation was low
remuneration.
4.2.3. A multidisciplinary team approach, collaborations, and partnerships
A multidisciplinary approach was adopted by most departments for
the implementation of the QIPs, out of which the formidable depart­
mental multidisciplinary teams (MDTs) enhanced the implementation of
the programmes in the various departments. Participants reported that
these MDTs were made up of nurses, doctors, laboratory personnel, or­
derlies and many other cadres, both professional and lay.
Some departments like Voluntary Counseling and Testing (VCT) had
also seen effective partnerships with other institutions, mainly nongovernmental organisations (NGOs). These organisations provided
technical assistance and support and other resources for the initiation
and up-keep of the QIPs in these departments.
P7 “… we lack those kinds of things that can motivate us, drive us all
along to practice quality, not only focus when we are expected to be
audited so that we can get marks. But to be our daily basis. Something that
is a routine.”
P1 “So currently, the staff is not motivated. They would tell you plainly
that their salaries are just too low.“
4.4. Organisational-related impediments
4.4.1. Absence of a clear implementation strategy
The participants indicated a lack of management strategy regarding
the implementation of QIPs in the hospital. Participants argued that the
management of the hospital is seen pushing for ISO certification of the
hospital, whilst leaving behind the implementation of the QIPs, yet the
latter should be strategic (systematic) means to get to accreditation.
P4:“…we are an MDT working in collaboration with the other team
members. So you find that things are easy…Yah! That is the benefit of
working as a team…we are working with many partners, the NGO’s; they
would come now and again to make follow-ups on the programmes that
they are supporting.”
P8: “And also the multidisciplinary approach because there was a meeting
for doctors, nurses and orderlies being involved. So it helped create that
atmosphere that whatever we are doing, it is not just for one cadre but for
everyone.
P1: “…you feel like we are leaving behind things. Like, when we get to the
workshops, you get a sense that we are rushing for ISO accreditation so
that we have this and that. And as somebody who is now informed about
the prerequisites for accreditation, you know that you need a clear
strategy for implementation.”
P6:“…I went to the QMS workshop. That is when I got to understand that
we are just joking. Certification is far from us, very far from us …”
4.3. Human-related impediments
4.3.1. Lack of ownership
It was reported that some registered nurses did not own up to the
responsibilities for the challenges and successes of the QIPs. Instead,
they left it to the respective departments’ nurse quality focal persons to
solely drive the programmes. They still believed that quality manage­
ment is the sole responsibility of the quality office, and they did not
realise that they are in charge of making these programmes effective.
4.4.2. Lack of leadership and management skills
Participants indicated a lack of leadership and management skills,
firstly among top management and then the nurses themselves,
regarding the programmes. This resulted in registered nurses not being
given time by their ward managers to engage in QI activities. Some had
no quality-related meetings for months. They lamented that some
registered nurses also limit their practice to bedside activities and shun
their leadership roles in QIPs and their implementation.
P3:“… Forcing it down does not do much for this institution and the
clientele. Some nurses are lagging, dragging their feet, and not taking
responsibility for anything.“
P8:“… people do not see this thing from the perspective of improving the
department, but they see it as an initiative for an individual, the quality
focal person.”
P1: “..it is frustrating me because the decision-maker does not seem to
understand what we are about as nurses. Attending meetings becomes
difficult, especially between working in shifts and everything that is going
on”.
P8: “Without nurses being strengthened, especially on the issue of lead­
ership and management, we will fail. It is not just about the bedside
nursing, but about putting the systems in place to make sure that what is
needed for the bedside nursing is there.”
4.3.2. Resistance to change
Participants described resistance towards implementing QIPs based
on the challenges that came with a change in general. The resistance was
towards the leadership of the quality focal persons and a work envi­
ronment that does not foster smooth change. It was noted that some of
4.4.3. Lack of resources
Participants complained about the lack of supplies, a situation that
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International Journal of Africa Nursing Sciences 18 (2023) 100569
has persistently been prevailing in the hospital. Most of the difficulties
they raised arose from problems in the organisation, especially the lack
of equipment and supplies. Participants also expressed their concerns
about the hospital’s infrastructure, which does not provide for the
required setting for proper implementation of the QIPs. Staff shortage
was also described as a problem for implementing QIPs in the hospital
resulting in tiredness and burnout among the staff.
them committed to the course of their implementation despite the many
challenges they encounter. The nursing profession is the backbone and
has long given itself to better the quality of care given, even way before
quality became a national responsibility (Liu, Luo, Haase et al., 2020;
Poortaghi, Ebadi, Salsali, et al., 2020). Furthermore, giving quality
health care that reaches high standards is an ethical responsibility of
health care professionals, especially nurses.
Appreciation by rewarding good performance and recognition for
effort made in implementing the QIPs through scheduled meetings and
feedback encouraged registered nurses in this study to continue working
hard towards quality improvement. The finding is similar to a study in
Ethiopia, where staff recognition was a predictor for continuous quality
improvement (Wendwessen, Dereje & Gize, 2020). In Uganda, recog­
nising nurses’ contributions to improving the quality of work enhanced
nurses’ feelings of self-worth and confidence (Okaisu, Kalikwani,
Wanyana and Coetzee, 2014). Furthermore, In Indonesia, meaningfully
recognising the nurses’ contributions and leadership role to improve the
work environment so that quality improvement work in primary health
care enhanced nurses’ feelings of self-worth, confidence, and respect
(Limato, Tumbelaka, Ahmed, et al., 2019). Such initiatives showed that
the management of the hospitals understood that for the QI plan to be
effectively implemented in the hospitals, any form of disrespect, disre­
gard, and non-appreciation towards the staff, had to be promptly
addressed.
Complimentary to the study finding, stand-up meetings and depart­
mental meetings were common platforms for providing feedback in the
United States of America (Singh, Wiese, & Sillerud, 2019). Feedback
from managers and staff was necessary to ensure that quality improve­
ment initiatives were implemented appropriately and to plan on ad­
justments and changes based on the feedback (Singh, Wiese & Sillerud,
2019). Furthermore, feedback with increased intensity of support has
been recognised as an essential facilitator when implementing QIPs and
effective in helping to incorporate improvements into practice (Hill,
Stephani, Sapple & Clegg, 2020).
The Western Sussex Hospitals and NHS Foundation Trust (2020)
argue that despite the enthusiasm that nurses must be engaged and drive
the implementation of the quality improvement programmes, organ­
isational commitment and support within a culture that promotes nurseled QI change is needed. At an organisational level, this study revealed
that buy-in of QIPs by top management, capacity building and multi­
disciplinary team approach, collaborations and partnerships were the
drivers for implementing the QIPs. Establishing a quality assurance of­
fice to ensure continuous implementation of quality improvement ini­
tiatives in this study shows buy-in, commitment and acceptance of QIPs
by management. The commitment is further revealed by the efforts
made to ensure that registered nurses are capacitated in QIPs. Orienta­
tion sessions, training workshops and meetings were common platforms
used for capacity building. Similar to the study findings, training was the
most frequently used method of capacity building, resulting in signifi­
cant improvements in QI outcomes (Hill, Stephani, Sapple & Clegg,
2020). Training clinicians on effective quality improvement practices is
critical to the future of healthcare; hence, the provision of opportunities
for individual and team-based QI training is a crucial attribute of the QI
program (Quality improvement and Healthcare, 2020). Lynn (2017)
further alluded that preparation for QI should begin as early as the initial
nurse training and education and also continue post-registration into
practice if nurses are to meaningfully contribute to QI as part of their
clinical practice.
The findings of this study revealed that some departments had used
various levels of collaboration and partnerships in the implementation
of the QIPs. Inter-professional/inter-cadre and inter-departmental col­
laborations were the main approaches that were adopted. The involve­
ment and collaboration between multidisciplinary teams enhanced the
implementation of the QIPs. Hill, Stephani, Sapple and Clegg (2020)
found collaboration and communication to be necessary for the effective
implementation of quality improvement initiatives, mainly where there
P1: “… when it comes to the lack of work equipment and supplies, the
situation is bad…For example, quality speaks even to the infrastructure,
and as somebody who is now informed about the pre-requisites for
accreditation, you know that you need this and that. For instance, in my
workstation, the roof is falling.”
P7:“…the staffing that is human resource, it is a problem. It is a factor
that is affecting us… Yah, we have burnout, so you cannot deliver when
you are tired.”
4.4.4. Poor communication and reporting system
The lack of hospital QI meetings and the absence of departmental
planning meetings in the wards were all cited by participants as a
challenge to the communication and reporting of QI matters in the
hospital. A registered nurse will attend the QI meeting representing the
unit; however, there is no platform available to communicate the in­
formation from the QI meeting to the colleagues in the ward.
P1: “So even if someone attends the QIPs meetings because there is no
proper reporting system that nurse will come back from the meeting and
just shelves the minute book. So at the end of the day, whatever was learnt
from the meeting remains with that individual.“
P6: “The only people with information are the focal persons. Like in my
unit, we do not even have those monthly meetings that other units have, so
it is tough for you to try and get everyone together and dispense the
information.”
4.4.5. Challenges from the external environment – economy, government
policies
The study revealed that the implementation of QIPs in the selected
hospital is grossly affected by the external environment, mainly its
dependence on the government. Some participants noted that some
departments like the Voluntary Counseling and Testing (VCT) depart­
ment enjoyed more attention from the government and the strategic
partnering organisations because they render services that are in line
with government priority areas. This leaves some departments feeling
neglected and disadvantaged when it comes to receiving government’s
support in many areas, including their QIPs:
P6: “We depend on government for everything, and our government is not
at a financial state where it can support the programme.”
P8: “…the challenge is it is working for the government. The government
is working on minimum standards. There is usually no money. But, in this
department, the VCT, we have achieved a lot ever since this quality
programme started because VCT is a priority project and receives a lot of
support.“
5. Discussion
The results revealed some improvements in the quality of nursing
practice and care in the wards where registered nurses were making
some effort and committed to the implementation of the QIPs. Mahomed
and Asmall (2017) affirm that increased effort from staff members is
required for effective implementation and sustainability of quality
improvement. Moreover, regardless of the health system challenges,
when the registered nurses are put in front for implementing quality
exercises, it results in high levels of commitment towards the effective
implementation of the QIPs. QIPs came as hope for addressing long­
standing concerns about the quality of care RNs ought to deliver, making
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International Journal of Africa Nursing Sciences 18 (2023) 100569
are regular QIPs meetings with leaders as part of multidisciplinary
teams. Nurses perceived the collaboration formed through respect and
respect in all its professional applications as valuable and essential for
successful collaborative team dynamics (Davies, Lyons & Whyte, 2019;
Western Sussex Hospitals and NHS Foundation Trust, 2020).
Despite the collaboration formed in other departments, some regis­
tered nurses did not own up to the QIPs, and there were challenges in
managing the changes that came with the implementation of the pro­
grammes in the hospital. The findings indicate a need for a paradigm
shift or changes towards how QIPs are viewed in general to effectively
implement the QIPs in the hospital. QI is part of the nursing sector, and
registered nurses should take ownership, responsibility, accountability
and the authority to act to become effective in their role in implementing
the QIPs in the hospital (De-Kock, 2017). Furthermore, nurses must take
ownership of their QI problems rather than denying their existence. The
absence of local ownership has a detrimental effect on any quality
endeavour (Bastemeijer, Boosman, Van Ewijk et al., 2019). When RNs
meet a challenge to meet QI goals and targets, the blame should not
always be shifted to uncontrollable circumstances like financial con­
straints, staff shortage, and the government’s failure to provide a
favourable environment that supports the implementation of QIPs. The
registered nurses should take responsibility and ownership for their
failure or achievements in implementing the QIPs.
According to Liu, Luo, Haase, et al. (2020), frontline healthcare staff,
like RNs, hold an imperative role in implementing change in healthcare
settings. They have major oversight responsibilities for QI initiatives and
are often the first to report difficulties, problems and obstacles when
delivering health care or implementing any initiative. Challenges could
be viewed as one side of the factors that influence the implementation of
any change programme, the other side being the drivers, hence the need
for change management strategies to handle the challenges (Zwane,
2019; Rosbergen, Brauer, Fitzhenry et al., 2017). However, change is
often difficult when health professionals are connected to old ways of
doing things, consequently viewing quality improvement as an unre­
lated program that is not integral to what they are doing (BMJ, 2020).
Singh et al. (2019) assert that implementing new QIPs and change ini­
tiatives can be challenging. The authors further allude that it is common
for every organisation to fear change.
Healthcare institutions need to align themselves and be committed to
adopting necessary changes to implement quality-enhancing pro­
grammes successfully (Himelstein, 2016). It is noted that organisational
factors do influence the capability to enhance the adoption of quality
improvement initiatives. These factors may include: the exemplary
leadership, culture, infrastructure, and governance in place to embrace
change (Unity Point Healthcare Organization, 2018). Addressing these
factors is essential for healthcare institutions so that workers are not
more stressed and frustrated due to challenges in professional practice
emanating from organisational problems, rather than putting effort to­
wards quality programmes. An organisation may have beautiful quality
improvement strategies on paper, but dismally fail to translate them into
practice because of poor or lack of implementation processes and
structures (Ovretveit, Dolan-Branton, Marx, et al., 2018; Squires, Aloi­
sio, Grimshaw, et al., 2019).
Generally, QI is now valued and viewed as fundamental for a
healthcare institution’s role in giving their services. There are escalating
calls for hospitals to embark on an extensive range of QI programmes,
which arise from internal and external factors (Liu, Luo, Haase, et al.,
2020). This ought to be aimed at integrating quality improvement
practices into the daily practices of nursing care (Robert, Sarre, Maben,
et al., 2020; Wattrus, 2017). This integration also hinges on a clear
strategy that is multi-facet in approach to quality improvement of health
care services and further integration of quality improvement pro­
grammes with increased ICT (Information and Communication Tech­
nology) applications for enhancing the turnaround time (Agarwal &
Ganesh, 2017). This study showed that there were challenges in inte­
grating QIPs into the daily routine due to unclear integration strategies
from managers, heavy workload, and obsession with routine work by
registered nurses. Without long-term strategic commitment, expecting
people to find time for their second job (QI) is unrealistic, and there is
growing recognition that this needs to change” (NHS Improvement,
2019; West, 2016). According to Lynn (2017), QI also needs to be fully
integrated into the Nursing Council’s scope for nursing practice so that
nurses learn about it. It should be incorporated into all aspects of nurses’
professional identity – into vision and values at the national and local
levels. Moreover, preparation for QI should begin as early as the initial
nurse training and education and continue to post-registration practice if
nurses are to meaningfully contribute to QI as part of their clinical
practice.
The findings in this study showed that time attributed to partici­
pating in QI activities like attending meetings or any other things
outside routine work was just not there, especially in the wards. How­
ever, evidence shows that some leaders have recognised that QI yields
better quality of healthcare and productivity; hence they have decided
to make sure that time for QI is made mandatorily available (Care
Quality Commission, 2018). Some managers did not view QIPs as
important hence they do not afford registered nurses time to engage in
QIPs. The managers did not provide good leadership towards the
implementation of the QIPs. They were focused on staff completing
routine work and not integrating QIPs into the routine. According to
Drew and Pandit (2020), management, leadership, and QI are separate
yet intertwined. Therefore, it may be argued that effective and efficient
implementation of QI initiatives calls for a more leadership mindset than
a managerial one. This is also important when considering the man­
ager’s leadership role of motivating and supporting staff members is a
critical element to a successful quality-improvement process since
frontline staff interact with clients daily (Singh, Wiese & Sillerud, 2019).
The hospital generally suffered from a persistent lack of equipment
and supplies, and the infrastructure did not meet the quality standards.
The situation affected the implementation of QIPs negatively. Persistent
barriers to implementing the QIPs lead to consistent poor performances
(Hlatshwayo, 2019; Kingdom Of Eswatini Vulnerability Assessment
Committee, 2018). As a result, consistent poor results from any initiative
have the potential to render nurses hopeless and helpless. Bayer and
Baykal (2018) stated that the work environment and position had a
bearing on the quality perceptions of health care workers. However, the
state of the hospital in which these improvements are implemented may
pose many challenges to RNs, which in turn affected the implementation
of the quality programmes. Therefore, RNs were helpless towards their
challenges, which affected the QI programmes. Nurses generally make a
difference as they practise, and, as importantly, what they fail to do,
hence ought to be adaptive as stated by Rafferty, Busse, Zander-Jentsch
(2019), who suggested that nurses need to be effective to address
problems and make changes in their unit with limited resources.
The number of staff members in the hospital was not sufficient for
routine health care, and the implementation of the QIPs resulting in
burnout of the available staff. Hence nurses perceive inadequate staffing
as a major cause of deterioration in the quality of hospital care in the
current healthcare system. There is a worldwide market for health
personnel. However, the market is skewed being influenced by the
global disparities in the economic inequalities, mostly remuneration of
workers and delivery of care, instead of by health needs and the burden
of the disease (McPake, Maeda, Araújo et al., 2013 in Portela, Fehn,
Ungerer et al., 2017). Moreover, other factors like civil unrest, the
outbreak of new diseases, economic crisis and the resulting social
problems all culminate in healthcare professionals leaving their posi­
tions due to work overloaded in care institutions, especially in devel­
oping countries (Portela, Fehn, Ungerer et al., 2017). Dogan and Kaya
(2004) in Bayer and Baykal (2018) noted that personnel shortage is one
of the three most significant hindrances to Total Quality Management
(TQM) in hospitals. It was also grossly highlighted that doctors regar­
ded, particularly the number of nurses and auxiliary personnel insuffi­
cient, to ensure the continuity of quality care (Bayer & Baykal, 2018).
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International Journal of Africa Nursing Sciences 18 (2023) 100569
Shihundla, Lebese and Mahutla (2016) found that a high patient-nurse
ratio caused nurses’ burnout and job dissatisfaction. As observed in
this study, burnout and job dissatisfaction left nurses with powerlessness
and moral distress. Hence nurses perceive inadequate staffing as a major
cause of deterioration in the quality of hospital care in the current health
care system.
This study revealed poor communication of QI-related information
from the operational to executive management levels. The departments
and the hospital lacked systems that guide the dissemination of QI in­
formation, hence the poor implementation of the programmes. Good
communication promotes good teamwork, high levels of satisfaction by
both patients and health providers, and reduced workload and stress in
the work environment (Rosen, DiazGranados, Dietz, et al., 2018).
Economic environments and financial challenges are becoming a
greater risk to the existence and growth of healthcare organisations.
Therefore, a quality improvement that would enhance financial and
operational efficiency in healthcare institutions is essential to thriving in
an increasingly complex environment (Unity Point Healthcare Organi­
sations, 2018). However, healthcare institutions need to be robust
regarding quality improvement projects that need to be undertaken
considering the project’s cost-effectiveness, time, and priority. In this
study, it was noted that the country’s ailing economy had crippled the
government’s fiscal state thus, negatively affecting the implementation
of the QIPs in the hospital. This situation has significant challenges like
poor procurement processes of pharmaceuticals and supplies, dilapi­
dated structures, slow, tedious recruitment and replacement of staff; all
of which are done at the government level also prove to be an unfav­
ourable environment for public healthcare facilities to improve the
quality of their services (Ministry of Health Kingdom of Eswatini,
2019b).
implementation of quality improvement programmes at the selected
government hospital, the following were recommended regarding to
further research, nursing education, nursing practice and management.
Recommendations for further research
• More research should be done on the experiences of RNs concerning
quality improvement issues, and it must involve all government
hospitals in the country.
• Research is needed to evaluate structural and managerial processes
and other factors that influence quality-related issues in the hospital
or nationally.
Recommendations for the nursing practice and management
• Hospital management needs to strategise and review the imple­
mentation of the QIPs periodically.
• Hospital management needs to prioritise corrective measures to
persistent problems, namely: supply of resources, insufficient staff­
ing, inadequate and dilapidated infrastructure, all of which are the
cornerstones of any quality project.
• The Ministry of Health has to review its human resource structures
regarding staff recruitment in the hospital and procurement and
supply chain policies.
• The Eswatini Nursing Council may assign specified continuous pro­
fessional development (CPD) points to quality-related material each
nurse has to acquire each year of licensure.
Recommendations for nursing education
• More time should be allocated for in-service training, workshops,
and continuing education for RNs towards implementing quality
improvement programmes for better service delivery and quality
nursing care.
• More RNs should be trained as health care quality specialists, espe­
cially for middle and high-level management.
• The training for nursing management should include healthcare
quality improvement initiatives.
• Nurse Managers should be educated, skilled and committed to
quality improvement management.
6. Conclusion
The findings revealed the human and organisation-related drivers
and impediments for the implementation of the QIPs. Therefore, the
researchers conclude that there were significant factors that could be
reinforced because they contributed positively to the implementation of
the QIPs. On the other hand, some challenges/impediments need to be
addressed because they do not favour the effective and efficient imple­
mentation of the programmes. The findings show that much has been
done to enhance the implementation of QIPs in the hospital. However,
the problems faced by RNs also have a significant influence on the ex­
ercise. For the programmes to be effective, they need focus, commit­
ment, and adherence to the institutional policy by the registered nurses.
It is worth noting that some of the organisational factors influenced
human-related drivers and impediments. Being appreciated and
acknowledged for the efforts made encouraged the RNs to implement
the QIP, while a shortage of resources, staff and low remuneration might
have resulted in burnout and lack of motivation. Therefore, reinforcing
the organisational drivers and correcting strategic challenges could be
fundamental in enhancing the implementation of QIPs in the hospital.
Author contributions
The project was conducted to fulfil the requirement of the master’s
degree qualification. The project leader was MJZ a masters student, TEN
promoter, respectively. The student under supervision was involved in
conceptualisation, data collection, analysis, report writing and drafting
of the manuscript. TEN and SMM augmented the literature search and
refined the manuscript and the Grammarly technique done by SMM.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
7. Limitations
The researchers identified some restrictions that may affect the
generalizability of the findings of this study (Shantikumar, 2018). Rich
information that could have given more light, especially on the initial
phases of the programmes in the selected hospital, was lost to RNs who
were promoted to Nurse Manager Positions and were not participants in
this study. The study was limited to one hospital, and generalising to the
whole country might not be possible as different results may be obtained
from other hospitals.
Acknowledgement
We gratefully acknowledge the following individuals who have
played an important part in this article. Sefako Makgatho Health Sci­
ences University’s Research and Ethics Committee (SMUREC) ensuring
that the study comply with the ethical requirement for conducting
research. Ministry of Health’s Swaziland National Health Research Re­
view Board (NHRRB) for granting permission to conduct the study. The
Registered nurses from the hospital for agreeing to take part in the study.
Dr T.E Nkhwashu, Sefako Makgatho Health Sciences University, for your
immense contribution, guidance and supervising of the whole project.
8. Recommendations
Based on the findings of the drivers and the impediments of the
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International Journal of Africa Nursing Sciences 18 (2023) 100569
Mrs. M Moloko, Sefako Makgatho Health Sciences University, for your
assistance in literature search, refining the manuscript and the Gram­
marly technique coaching in the study. Mr M.J Zikalala, Sefako Mak­
gatho Health Sciences University, for collecting data from the
participants, analysing and writing the report.
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