The health workforce conundrum for burn care in Uttar Pradesh, India: a qualitative exploration

Figures & data

Figure 1. Schematic representation of the process of developing subthemes and major themes.

Table 1. Study participants: healthcare workers in burn units and primary health centre.

Health workforce	Gender	Total experience (in years)	Experience in burns (in years)
Burn Unit
Plastic surgeon
Faculty – Plastic surgery	Male	20	20
Faculty – Plastic surgery	Female	9	9
Faculty – Plastic surgery	Male	10	10
Senior Resident (Plastic surgery – MCh* student)
Senior Resident	Male	3	3
Senior Resident	Female	2	2
Senior Resident	Male	3	3
Senior Resident	Female	2	2
Intensive care
Faculty – Intensivist, Burn ICU*	Female	10	2
Junior Residents
Junior Resident – Psychiatry, on burns counselling	Female	2	2
Junior Resident – Burn ICU	Female	1	1
Rehabilitation practioners
Physiotherapist – Burn unit	Male	20	20
Physiotherapist – Burn unit	Male	24	14
Nursing cadre
Nursing in-charge – Burn Unit	Female	29	9
Nurse – Burn ICU	Female	1	1
Nurse – Burn ICU	Male	1	1
Nurse – Burn ward	Female	1	1
Nurse – Burn ward	Female	16	12
Staff Nurse – Burn ward	Male	1	1
Other staff
ICU technician – Burn ICU	Male	7	1
Dresser – Burn unit	Male	3	3
Dresser – Burn unit	Male	9	9
Multi-Purpose Worker – Burn unit	Male	8	4
Primary Health Centre
Medical officer (doctor)	Male	12	–
ANM* Supervisor	Female	20	–
ANM	Female	3	–
ANM	Female	3	–
ANM	Female	16	–
ASHA* Facilitator	Female	4	–
ASHA Facilitator	Female	6	–
ASHA	Female	15	–
ASHA	Female	15	–

*MCh – Master of Chirurgiae, ICU – Intensive Care Unit, ANM – Auxiliary Nurse Midwife, ASHA – Accredited Social Health Activist.

Table 2. Themes and sub-themes.

Theme	Software/ Hardware	Sub-themes
Dynamics within multidisciplinary burn teams	Software	Team dynamics Importance of multidisciplinary team and teamwork. Complex relation, power, and normative hierarchy Doctors as team leaders, but divergent view on agency. Non-involvement of non-doctor cadres in decision making. Role confusion among nurses and other cadres. Mutual respect, appreciation and trust are important. Contribution to saving lives – a big motivation. Plastic surgery residents’ dilemma Interest, aspiration, and training discordance. Low motivation for acute burn, but high for burn surgery.
	Hardware	Employment contract and incentives Differential nature of employment, salary, and incentives. Involuntary posting in burn unit. No clarity on job description. Need to refine plastic surgery training Structure of residency training – no uniformity on burns component. Training need and gap for acute burn care.
Dynamics between health workers and patients	Software	Ambivalent satisfaction and motivation Patients’ and their family’s trust, expectations, and respect. Contribution to saving and improving lives. Responsibility sharing, mutual respect. Appreciation of good work. Complex clinical and non-clinical challenges Clinical and emotional challenges of dealing with patients and caretakers. Low motivation of patient and family.
	Hardware	Workforce Shortage and training challenges Shortage of staff require multi-tasking and task shifting. Lack of defined and specific training package for burn care. Pre-service training not sufficient for burn care. Need for comprehensive training Complete training package for burns. Induction training before posting. Soft skills training and psychological safety. On the job capacity building and mentoring.
Dynamic between health facilities (burn unit and overall health systems)	Software	Front-line workers’ confusion Front-line workers overworked, need additional incentives for extra work. Balancing routine work and special assignment. Lack of orientation. Keen to support referral, community-based rehabilitation.
	Hardware	Disconnect between peripheral health centres and burn units Delayed referral from peripheral facilities. Health workforce and infrastructure gaps. Training gap among primary health care and front-line workers. Improved infrastructure and addressing staff shortages.

Table 3. Themes and supporting quotes.

Themes	Supporting quotes
Dynamics within multidisciplinary burn teams	I feel so hectic (exerted) in this (burn) ward for the last six months, so I asked my ward in-charge to switch me to another ward, or some other emergency ward, because I want to sincerely care for the patient. I want to do work with freedom. I don't want to follow someone's orders. R4, Nurse Here, burn care has a major component. I am from different part of country; we don't see this many burn patients in those part of country. There are many factors to that but in the main MCh (plastic surgery residency) curriculum, it depends upon the area from where we're doing the training. Coming to plastic surgery, everyone has their own interest. R19, Plastic surgery resident doctor If the government or the hospital administration provides some set of protocols or guidelines in form of paper or online which the nurses can follow freely without asking anyone, then I would have clarity about my scope of practicing or my limit. I just want to know our scope to providing care to the patient. R4, Nurse
Dynamics between health workers and patients	In my opinion, whether it's the burn unit or its staff, a training or upgradation type of programme should run at regular intervals of time. Like, even if one is familiar with everything, then too, there should be a programme with refresher point of view. Like a kind of continuous review going on, new people learning things by observation, and the experienced ones are getting a refresher or recapitulation. R14, Multi-purpose worker Some patients really bring tears to my eyes when they narrate their ordeals. That makes me wish and pray to the Almighty, again and again, that may this patient get alright as soon as possible, if not by my hands, by anybody's hands, but please make him recover fast and send home healthy. R17, Dresser The training should cover all the aspects. The critical care people should explain nutrition and fluid management to them. A three-day workshop should be conducted by the critical care people, on fluid management and on how to decide the antibiotic, how to control the fluid, we should explain things regarding dressings. R1, Intensivist
Dynamics between health facilities (burn unit and overall health systems)	Medical college affiliated community centres are there, for example, we have this centre near XYZ. Now, if they associate our rehabilitation team, physiotherapist, occupational therapist with these people, once a week, or as per their schedule and the time available accordingly, at least they can go and guide the patients. R18, Physiotherapist If it is major injuries, we will not do any procedures as such. Patient comes and if we feel that this injury is major or it is a major burn injury and we cannot cure it. Here, we don’t have so much facility here, we try to see the patient in the ambulance itself and refer. C9, PHC medical officer Till now I have not come across any people with burn case. If I get such report, immediately we will call 102 ambulances, we will directly take them to the place where burn unit, we have that facility that ambulance will directly take them to the same department which they need. C1, ASHA facilitators

Figure 2. Human Resource for Health (HRH) action framework for health workforce in burns.