Experiences of inadequate interpersonal relationships regarding quality improvement and quality assurance in the Ministry of Health and Social Services in Namibia

ABSTRACT

Quality improvement and quality assurance in healthcare settings depend to a great degree on interpersonal relationships that enable effective communication and understanding between individuals. Poor interpersonal relationships between health professionals, patients or groups are considered detrimental to the achievement and sharing of common goals. This paper explored the experiences of managers and health professionals regarding the quality of health care delivery at the Ministry of Health and Social Services (MoHSS) in Namibia, using interviews and focus group discussions. The findings indicated negative attitudes by health professionals towards patients; poor communication among health professionals; lack of motivation and team work as well as resistance to change. It was concluded that most of the problems at MoHSS health care facilities are due to the lack of strong interpersonal relationships, either between patients and health professionals or between health professionals and management. The researchers recommend future research to document the views and experiences of private health providers and patients.

KEYWORDS:

• Interpersonal relationships
• quality assurance
• quality improvement
• communication
• health professionals
• Namibia

Introduction

Inadequate interpersonal relationships refer to the failure of- or lack of a strong bond- between two or more people (Stoetzer et al. 2009). Poor interpersonal relationships may impact negatively on the delivery of healthcare and services, and are viewed as being unfavorable to the achievement and sharing of common goals. Van Zanten et al. (2007) and Fong et al. (2005) established that a doctor’s communication and interpersonal skills encompass the ability to facilitate accurate diagnosis, counsel appropriately, give therapeutic instructions and establish caring relationships with patients. Whisman (2013) elaborated that good communication does not only produce positive interpersonal relationships, but leads to well-coordinated activities, helps regulate patients’ emotions, facilitates comprehension of medical information and aids in better identification of patients’ needs and facilitate quality improvement. Kourkoute and Loanna (2014) added that effective communication requires the abilities of health professionals to understand the patients’ experiences and expectations to minimize complaints and dissatisfaction.

Complaints about poor communication have surfaced in the print and electronic media, highlighting irregularities and patient dissatisfaction. McLaughlin’s and Kaluzny’s (2006) showed the presence of mistreatment and missed-treatment due to uneven quality of health care, bad interpersonal relations and poor communication between health care providers and clients. According to Simpson et al. (1991), it has been reported that most complaints from the public about medical services are not about competencies but about communication, adding that the majority of malpractice allegations arise from communication errors. At MoHSS-Namibia, challenges emanating from ineffective communication among health professionals and between recipients or healthcare users are evident. Simpson et al. (1991) further comments that serious communication problems are common in clinical practice. This yields persistent variations in the level of care provided, generating inconsistent results, inefficiencies, on-going mistakes, unacceptable service and poor health care outcomes (IOM 2004). An additional factor concerning communication is most health care facilities in Namibia is language barrier as not all patients or health professionals speak a common language.

The notion of quality improvement refers to continuous and ongoing efforts to measure improvements in efficiency, effectiveness, performance, accountability and indicators, by applying recognized methods and plans – such as ‘Plan-Do-Check-(Study)Act’ (PDSA) (Tews et al. 2008). Quality assurance refers to well-planned and systematised standards that are coordinated to support quality improvement in the health facilities. This is achieved by applying approaches and tools such as PDSA to monitor progress or evaluate and identify gaps to meet the expectations of the clients (Offei, Bannerman, and Kyeremeh 2004; Donabedian 1980; Palmer 1983). To achieve this purpose, several aspects need to be considered: for instance, effective communication and good interpersonal relationships as well as teamwork are vital components of QI to ensure quality health care delivery. In support of this, Ivancevich et al. (1997) reported that quality patient care can only be achieved through effective relationships and active involvement of health professionals in the planning and decision-making process. In this regard, it has been noted that there poor interpersonal relationships exist among healthcare professionals and between patients and healthcare professionals, which hinder quality healthcare delivery within the MoHSS facilities in Namibia. The poor interpersonal relationships amongst health professionals and between patients/families and the said medical professionals gave rise to the following question: ‘What are the experiences of managers and health professionals regarding quality of health care delivery in the Ministry of Health and Social Services in Namibia?’

This paper explores and describes the experiences of managers and health professionals regarding the quality of health care delivery in the Ministry of Health and Social Services in Namibia.

Materials and methods

A qualitative, exploratory, descriptive and contextual research design was used to explore and describe the experiences of managers and health professionals regarding quality health care delivery within the MoHSS facilities. This research design enabled the researcher to have an in-depth and holistic understanding of the phenomena (Burns and Grove 2009; Morse and Field 1996; Shaughnessy, Zechmeister, and Zechmeister 2003; Johnson, Onwuegbuzie, and Turner 2007). The participants in this study were managers and health professionals from different health facilities within the MoHSS who had broad knowledge and experience of quality health care delivery. Participants were selected purposively depending on their experience and knowledge about the study topic and by virtue of the position they occupied or their function in the health facilities (Creswell and Clark 2007).

Data collection and analysis

Twelve (12) individual interviews and five (5) focus group discussions (FGDs, comprising eight participants each) were conducted in Khomas (Windhoek), Kunene (Opuwo), Erongo (Swakopmund) and Omusati (Outapi) health facilities. The interview method was used as an exploratory and descriptive study for eliciting facts from the respondents (Brink, Van Der Walt, and Van Rensburg 2011). The FGDs approach was considered suitable for gaining a deeper understanding of the topic; generating new concepts and capturing diverse views by obtaining data directly from the participants as well as ensuring free group interactions and adequate responses (Merton, Fiske, and Kendall 1990; Krueger and Casey 2000; Morgan 1998). The sample size was supported by data saturation, which was reached when there was neither enough new information nor additional information generated and themes were repeating and no further coding was feasible (Fusch and Ness 2015; Babbie 2008). The following inclusion criteria were used to select participants:

• Professionally qualified doctors, nurses, pharmacists, social workers, environmental health officers and dentists working at the public health care facilities in the identified regions

• A member of the regional management team (RMT), Senior Medical Superintendent, Chief Medical Officer, Medical Officer, Regional Director, Matron, Nurse Manager

• A manager in a leadership position at MoHSS National level or Regional Health Directorate and expatriate health professionals who had worked in the MoHSS for more than three years.

Qualitative techniques were used to generate the themes and sub-themes in this study, which focussed on reading, re-reading, reducing and interpreting the data (Ulin et al. 2002; Creswell 2014). Audio tapes from the interviews and FGDs were transcribed and transferred to the computer for analysis. The transcribed data was further reduced into themes and sub-themes through coding and summarization of codes (Creswell 2014; Polit and Beck 2012). The data were sorted and organized to provide structure and simplified to extract meaning from the information collected (Polit and Beck 2012). The eight steps of Tesch’s coding technique were used to analysis the data (Creswell 2014; Tesch 1990). An independent coder, a specialist in qualitative research and the researchers identified the main themes and sub-themes through discussion and consensus.

The criteria of credibility, transferability, dependability and confirmability were used to ensure trustworthiness (Lincoln and Guba 1985; Holloway and Wheeler 2010; Polit and Beck 2012). Among the steps used to ensure credibility were debriefing meetings held with experts in the field, participants and management. Debriefing was used to evaluate the study by external persons during different phases to ensure its credibility (Leech and Onwuegbuzie 2008; Lincoln and Guba 1985; Maxwell 2004; Meriam 2001). The findings were derived from actual data collected at the health care facilities in relation to experiences of health professionals about the situations they were facing, which confirmed the credibility of the study. The results were also confirmed based on participants’ views, which can be compared to the findings of previous research conducted in similar contexts of health care.

Ethical considerations

Formal approval and permission to conduct the study was granted by Ethical Clearance Committee of the University of Namibia and the MoHSS. Permission was further sought from specific Health Regional Directors, Senior Medical Superintendents, Principal Medical Officers, and Nurse Managers in the regions where the study was conducted. Informed consent was obtained from each participant after being informed about the study, including the purpose and benefits of the study to persons and institutions (Polit and Beck 2012), as well as the right to participate freely without fear. The fundamental principles of respect, beneficence, justice, respect and dignity of the human were exercised throughout the research (National Health and Medical Research Council of Australia 2020). The benefits of the study were shared with the participants privacy and confidentiality were maintained (Reich 1995).

Results and discussion

The data collection were conducted over a period of 2 weeks. The socio-demographic characteristics of the participants and their occupations are recorded in Table 1.

Table 1. Socio-demographic characteristics of participants.

Item	Count (n = 21)	%	Cumulative %
Age (yr.)
35–45	5	24	24
45- 55	13	62	86
55 >	3	14	100
Gender
Male	13	62	62
Female	8	38	100
Occupation
Deputy Permanent Secretary	1	5	5
Under Secretary	2	10	15
Directors	3	14	29
Pharmacist	1	5	34
Medical Superintendents	2	10	44
Principal Medical Officers	2	10	54
Health Programme Officers	3	14	68
Matron	4	19	87
Senior Personnel Officer	1	5	92
Other	2	10	100
Duration of work
2–5	6	29	29
5–10	8	38	67
10–20	5	24	91
20 >	2	9	100
Education attained
Primary	0	0	0
Secondary	0	0	0
Tertiary	17	17	17
Other	4	4	21

Data analysis generated one central theme and four (4) sub-themes regarding the experiences of the participants on quality of health care delivery in the MoHSS as indicated in Table 2.

Table 2. Themes and sub-themes.

Inadequate interpersonal relationships in terms of QI and QA	Negative attitudes among staff members and towards patients Poor communication among health professionals Lack of motivation and team work Resistance to change
Theme Sub-themes

The central theme was ‘Experiences of inadequate interpersonal relationships in terms of QI and QA in the MoHSS’. The four sub-themes that emerged were: Negative attitudes among staff and towards patients; Lack of effective communication; Lack of motivation and team work and Resistance to change.

Table 3 presents a summary of the experiences of managers and health professionals with regard to quality health care delivery in relation to interpersonal relationships.

Table 3. Summary of experiences of managers and health professionals on interpersonal relationships.

Sub-themes	Responses	Reason for the Choice
Negative Attitudes	Five participants indicated that health professionals have negative attitudes that results in them:	The following were some of the reasons stated as causes of the healthcare professionals’ actions:
	not greeting patients during consultations not introducing themselves prescribing medicines even before asking patients about their ailments	insufficient equipment and medical supplies workload burden inadequate knowledge and skills high patient volumes uncertainties about roles and responsibilities lack of resources and sources for help and support poor time management lack of leadership and management;
Lack of Motivation	Eight participants indicated that health professionals are demotivated.	The following were explanatory reasons for low morale:
		lack of leadership support shortage of staff workload burden unfavorable working conditions lack of employee wellness program inadequate Performance Management System lack of in-service training lack of incentive (especially for those serving in remote rural areas) bored team members (not challenged, not really interested) lack of skills and abilities in team members personal problems; and high staff turnover
Lack of effective Communication	Eight participants highlighted that poor communication and barriers in communication between health workers and patients/families do not only hinder provision of quality healthcare but results in mistakes or errors during diagnosis and treatment. One participant stated that nurses are being used as interpreters in addition to their professional roles.	The reasons for the above, amongst others, that were provided:
		personality conflicts lack of control and ownership un-prioritized, unplanned activities confusing roles
Resistance to Change	Three participants viewed change as good to improve healthcare delivery, but there would be/was resistance within the health settings.	• They argued that resistance is due to:
		lack of awareness and ill-communicated policies and guidelines resulting in ineffective implementation; inappropriateness and inconsistencies weak organizational culture rigid system that made it difficult for leadership to change the status quo lack of change management program

Interpersonal relationships are vital in communicating quality improvement initiatives and establishing strong relationships and rapport between health professional and patients or among groups sharing a common goal.

Sub-theme 1.1: Negative attitudes

Negative attitudes are a detrimental feature in quality health care and patient safety and result in negative behaviors displayed during interpersonal interactions between providers and patients. These behaviors are demonstrated as verbal or physical abuse or inappropriate communication with patients by health professionals or care providers; deficiencies in the availability of services, lack of privacy during patient care and unwillingness of providers to accommodate traditional practices (Mannava et al. 2015). This study revealed elements of patient neglect during treatment and care resulting from poor health care services. As indicated by the abovementioned researchers, neglect by doctors can lead to the death of a patient, as it did in this narration by one midwife in Gambia:

She was brought to the hospital on the 13th at around 9:00 am from another health centre. The doctor saw her and diagnosed hand-presentation. He [doctor] asked us [midwives] to observe her. No action was taken by the doctors up to the 15th late in the evening [48 hrs. later], when they took her to the theatre. He [doctor] first tried external cephalic version, which failed before a caesarean section was performed. The patient was wheeled dead from the theatre.

This statement is not different from the experiences in MoHSS, as stated that

 … in some health facilities, patients were complaining that they are not even greeted; health workers don’t [sic] introduce themselves; sometimes they just prescribe even before asking patients what is wrong with them, ah … there is poor customer care. (Participant 3)

This view was further shared by McCabe, (2004); Jangland, Gunningberg, and Carlson (2009) and Gilmartin and Kerrie (2008) in Norouzinia et al. (2015) who said that most research studies have reported poor nurse-patient relationships, resulting in a poor quality of health care. Research studies have analyzed other issues related to these negative attitudes towards patients and identified a variety of contributing factors, such as insufficient equipment and medical supplies and heavy workloads as well as inadequate knowledge and skills (WHO 2015; Respectful Maternity Care Charter – White Ribbon Alliance 2020). In this study, staff shortages and an increase in workloads were viewed as the main causes of negative attitudes, in addition to insufficient equipment and medical supplies, as emphasized by one participant:

 …  …  … .. Doctors don’t have time and are ever busy with their patients. (Participant 4)

Sub-theme 1.2: Lack of motivation and team work

Worldwide, motivation is one of the most complex and intense topics in many health care systems, with debates focusing on searching for strategies to retain and attract essential skills to enhance quality health care delivery. It is a management approach that encourages desired behavior among healthcare teams to achieve common goals based on ‘ … the set of forces that initiate behaviour and determine its form, direction, intensity and duration and a reward system that encourages quality work’ (Johnson and Scholes 2002). Motivation is one of the critical components in human resources planning. It has been proven that motivated and educated health workers increase morale, which contributes to quality health care delivery, noticeable effectiveness, and efficient service (Dieleman et al. 2006). A study by Iipinge et al. (2006) proposes that recognition of hard work and non-financial rewards could be used as incentives to attract and retain health workers to serve in the rural areas, while remaining in the public health sector. This study revealed several of the factors believed to be demoralizing health professionals in the Namibian MoHSS, such as inadequate equipment, insufficient materials and medical supplies as well as a heavy workload due to the shortage of health professionals. Participants further stated that staff shortage and increased workload was resulting in exhaustion and burnout, anxieties and frustrations due to long waiting times, inadequate equipment and materials.

‘I think they are no longer motivated because of the number of staff which is on the ground. The staffs are really exhausted, they are really  … really overworked; even you try to implement a reward system, in house arrangement to reward those who have done well; at least those ones are motivated. There is just not even time to sit down with your people and discuss because of the pressure and demand from the patients, you are so few … You try to satisfy the patients’ need [s]. As a result, you are left with little to take care of other things. (Participant 5)

One participant indicated that they experience unfavorable working conditions, which decreases staff morale.

… the other thing maybe is also the improvement of condition of service for the staff members that in my opinion can also eh  … add value; people will be more motivated if, their condition of service is improved. (Participant 6)

Research has shown that creating an environment where employees have leisure activities and are recognized for hard work has the potential of improving morale and patient care. Some of the participants suggested intensifying the wellness programs to alleviate stress and encourage staff to work hard after a time of leisure.

 … we need really that wellness to be healthy, have a health mind, fresh mind to be able to read the policies and understand them. You need that time but you don’t have that time most of the time is … I may say for me after my observation, every one of the health worker is overworked and is burnt out. So, I can’t blame them why you didn’t read what I gave you to read yesterday … the little time you have … . if you are tired, the mind is tired just to sleep maybe and then wake up to go for work again tomorrow morning and deal with 200 hundred or five hundred patients and you have a family, your children’s homework to attend to. (Participant 8).

Another participant further complained that they have no sufficient time to discuss and give feedback on critical issues concerning patients.

 … there is not even time to sit down with your colleagues to discuss because of pressure and demand from the patients, you are so few to satisfy the patients’ need[s], as a result, you are left with little to take care of other needs. (Participant 6)

Participants perceived that poor quality service is an effect of low motivation in healthcare facilities. Several studies, involving a number of researchers, such by Mutale et al. (2013) and Tynan et al. (2013) stated that health worker motivation has the potential to affect the quality of health services. It has been recognized that low health worker morale can severely undermine demand for health services and may lead to wastage of resources and the loss of the limited number of workers. Participants have previously suggested a number of solutions; such as reward benefits for outstanding performance; intensifying wellness programs to alleviate stress; incentives; bush allowance (risk compensation); transport allowance; free rural accommodation and education for health providers’ children as well as television/radio sets (Bailit Health Purchasing, LLC 2002).

There was consensus amongst participants that unplanned activity that result in confused roles, and which are not prioritized, do not only because tension amongst healthcare workers, but also delay the provision of quality health care services, due to undefined or unintegrated functions and ambiguities. One respondent expressed this as ‘ … too many things’ and ‘ … things not going well’. Various reasons for this were unearthed during the study, as referred to by a participant,

 … sometimes we as a hospital don’t have control over, when it comes to capital project that is at the level of the ministry. So, we have no direct control on ensuring that we … we are starting, initiating, and completing capital projects to comply with what is stated in the recommendations of eh … eh … QI project. (Participant 4)

In summary: Vagueness in core functions of QA as well as the absence of methods and measures of quality improvements might result in deficiencies and the inability to maintain quality standards.

Sub-theme 1.3: Lack of effective communication

Reflecting on methods of verbal and non-verbal communication, the findings of the study with regard to the challenges most frequently expressed at the majority of health care facilities, highlighted language barriers, since not all patients or health professionals are able to speak a common language. Good communication promotes good teamwork, high levels of satisfaction by both patients and health providers and a reduction in workload and stress in the work environment. It also promotes adherence to treatment, since patients will be willing to return for follow-up visits. Studies have indicated that failures in both teamwork and communication amongst health professionals and between them and their patients, is one of the main factors contributing to medical errors and adverse events and consequently, in the reduction in the quality of the care (Martins et al. 2014; Bagnasco et al. 2013). Several studies, such by the Canadian Patient Safety Institute (2020); Morey et al. (2002); Jeff, Gustafson, and Beaubien (2005); WHO (2009) have specifically singled out that strong teamwork increases patient safety and decreases the number of medical errors and burnout as health professionals are able to tackle cases as a unified team.

Analysis of this study’s data indicated that poor interpersonal communication derives not just from lack of teamwork, but additionally from language barriers, lack of motivation, beliefs and values as well as resistance to change. Language barriers result in poor communication, omissions and delayed treatment, medical errors, near-misses, and unsafe conditions in primary care (Smith et al. 2017). In addition, the study revealed that there were no interpreters at health care facilities but interpretation was done by nurses, beyond the scope of their practice, in those cases where doctors do not understand the language spoken by patients and vice versa.

 … nurses had to interpret in cases where the patients did not understand the language spoken by the health professional. (Participant 1)

The study revealed that the most common method of communication between patients and health professionals was through spoken word, during face-to-face contact; however, no method was available to communicate with deaf patients. Non-verbal communication includes sign language and the movement of body parts (facial expression, hands, lips, shoulders, and neck). Each one of these communication methods being used had advantages and disadvantages that influenced effectiveness of communication. McLaughlin and Kaluzny (2006) stated that ineffective communication and poor coordination are among contributing factors to poor health care services.

A further, complicating factor is that most medical officers (MOs) in the health facilities are expatriates who therefore do not speak local languages and are unable to communicate effectively with patients. The resulting difficulties during consultations were mentioned by one participant.

 … expatriate doctors are not able to do everything that is expected to be done by the medical officer (MO) and nurses are often assigned to interpret beside their scope. (Participant 2)

In this regard, it was found that most clinicians are unable to communicate effectively in English, which is the official language spoken in Namibia in addition to eleven (11) other local languages. Given the complexity of the healthcare system and the information being transmitted on daily basis, the language barrier becomes a serious challenge in the provision of health care services. This was evidenced in previous studies too; that the language barrier is a significant problem in healthcare processes, especially among non-English speaking health professionals. It affects medical terminologies as well, especially in written communications by specialists (Solet et al. 2005). As a result, effective communication skills of health professionals are vital for effective health care provision: to gather information, facilitate accurate diagnoses, appropriate counseling, providing therapeutic instructions for effective care and treatment (WHO 2015; Van Zanten et al. 2007; Fong et al. 2005; Duffy et al. 2004).

In support of these views, Aghabarari, Mohammadi, and Varvani-Farahani (2009); Aghamolaei and Hasani (2010) emphasized that good communication can yield positive outcomes including reduced anxiety, guilt, pain, and disease symptoms Moreover, it can increase patient satisfaction, acceptance, compliance, and cooperation with the medical team, and improve physiological and functional status of the patient; it also has a great impact on the treatment provided for the patient (Aghabarari, Mohammadi, and Varvani-Farahani 2009). As previously mentioned, participants revealed that there was no provision to cater for deaf patients, a situation that can accelerate mistakes or errors during treatment. Ineffective communication and poor coordination are among the contributing factors to poor health care services (McLaughlin and Kaluzny 2006). In substantiating this view, Ivancevich et al. (1997) suggest that ‘ … [t]o maximize disease control, patients must participate effectively in their medical care’.

Sub-theme 1.4: Resistance to change

There are various reasons that lead to resistance to change; for example, personality attributes or organizational context, an irresponsive structure, an unconducive working environment. In addition, inappropriate or lack of communication stifles the change that provides direction and which encourages people to actively participate in or accept change, such as improvement programs. In the Namibian MoHSS, there is anxiety and restlessness about these issues and resistance to the introduction of quality improvement programs, as these are perceived as additional work.

 … some people perceived quality improvement as different programme, additional to what they are currently doing and many people do not see it as integral to what they are doing. (Participants 6)

The participants indicated that the MoHSS had a rigid system that made it difficult for leadership to change the status quo. This was due to a lack of change management and resistance to change. They suggested that health professionals are connected to old ways of doing things and therefore they view quality improvement as an unrelated program that is not integral with what they are doing.

Individual or group will resist, they will always say now we have done it this way many years ago, we didn’t do that, what are you telling us; because they have done it so many times when you bringing new ideas it will take time to change the mind, it requires a strategic approach. If you simply issue guidelines, issue standards, these are the standards or circular whatever go and do it, not many people will change. (Participant 2)

Resistance to change reflected through negative attitudes and ineffective communication, results in poor understanding of policies and guidelines at MoHSS. Tanner (2015) states that ‘ … [s]sometimes it is not what a leader does, but it is how she/he does it that creates resistance to change; and undue resistance can occur because change is introduced in an insensitive manner or at an awkward time’.

Conclusion and recommendations

Interpersonal relationships are among the vital mechanisms that create a conducive health care environment, given the constant need for the exchange of information. Our data suggests that most of the problems within Namibia’s MoHSS health care facilities are due to the lack of strong interpersonal relationships, either between patients and health professionals or, between health professionals and management. This was reflected by the accounts of participants who revealed weaknesses in interpersonal communication, which leads to lack of understanding of the common values, negative attitudes, as well as poor quality of care. Quality improvement requires establishing guidelines for good relationships among health care teams and patients. On this basis, MoHSS is urged to keep abreast of change and develop a robust and systematic approach that facilitates change management and quality improvement at the health care facilities.

This study describes the experiences and challenges encountered by health professionals in their quest to deliver quality healthcare in the busiest referral and district hospitals in four regions of Namibia. It should be stressed that as the study did not include a representative sample of health facilities, there might be some quality aspects excluded which might reflect similarities and differences among different settings. This study focused on public health care facilities and did not consider private health care facilities. Their inclusion might have identified quality practices that could have benefitted the public health sector. Due to financial constraints and time, the views of community members (patients / families) could not be captured, hence the notion of quality healthcare was not investigated from the perspective of patients and or their families. It would be interesting to consider the views of managers and health professionals from the private health sector, as well as patients who are recipients of private health care services. The researcher recommends that future research document the views and experiences of private health providers and patients.

Acknowledgements

We are highly indebted and grateful to all managers and health professionals who participated in the study and willingly shared valuable information that enable understanding of the quality of health care delivery within the MoHSS facilities.

Disclosure statement

No potential conflict of interest was reported by the author(s).