Categorizing and assessing comprehensive drivers of provider behavior for optimizing quality of health care

Abstract

Inadequate quality of care in healthcare facilities is one of the primary causes of patient mortality in low- and middle-income countries, and understanding the behavior of healthcare providers is key to addressing it. Much of the existing research concentrates on improving resource-focused issues, such as staffing or training, but these interventions do not fully close the gaps in quality of care. By contrast, there is a lack of knowledge regarding the full contextual and internal drivers-such as social norms, beliefs, and emotions-that influence the clinical behaviors of healthcare providers. We aimed to provide two conceptual frameworks to identify such drivers, and investigate them in a facility setting where inadequate quality of care is pronounced. Using immersion interviews and a novel decision-making game incorporating concepts from behavioral science, we systematically and qualitatively identified an extensive set of contextual and internal behavioral drivers in staff nurses working in reproductive, maternal, newborn, and child health (RMNCH) in government public health facilities in Uttar Pradesh, India. We found that the nurses operate in an environment of stress, blame, and lack of control, which appears to influence their perception of their role as often significantly different from the RMNCH program's perspective. That context influences their perceptions of risk for themselves and for their patients, as well as self-efficacy beliefs, which could lead to avoidance of responsibility, or incorrect care. A limitation of the study is its use of only qualitative methods, which provide depth, rather than prevalence estimates of findings. This exploratory study identified previously under-researched contextual and internal drivers influencing the care-related behavior of staff nurses in public facilities in Uttar Pradesh. We recommend four types of interventions to close the gap between actual and target behaviors: structural improvements, systemic changes, community-level shifts, and interventions within healthcare facilities.

Fig 1. Framework for Unpacking Provider Practices (UPP).

The framework outlines the complex set of factors influencing facility outcomes via the clinical practices of staff.

Fig 2. Pipeline showing the main components of the Providers Outcomes Pathway (POP) to develop interview guides and scenarios for the decision-making game.

For the full Providers Outcomes Pathway used, see S1 Fig.

Fig 3. Sample decision-making game scenario.

The text was played via speaker to participants, who selected one answer. This scenario investigated the focus areas ‘Stress and coping mechanisms’ and ‘Reluctance of patients’ (see Fig 4).

Fig 4. The 12 focus areas identified as likely to drive critical behaviors of staff nurses in facilities.

These 12 factors were selected out of 17 found in total, based on the frequency with which they occurred in facility-based immersion interviews.

Fig 5. Excerpt from the Providers Outcomes Pathway (POP), showing the pathway from key causes of maternal and neonatal mortality to behaviors within the facility.

As next steps, these behaviors were compared to insight from immersions, which were then linked to focus areas examined in detail in the decision-making game (see S1 Fig for the full pathway).

Fig 6. Contextual influences on staff nurse drivers of behavior and associated coping behaviors, as distilled from immersions and responses to decision-making game scenarios.

Fig 7. Program and staff perception of the nurse role.

Programs and staff nurses perceive the role of the nurse differently, resulting in a gap between program expectations and actual behaviors.

Fig 8. Summary of suggested recommendations and priorities to improve nurse quality of care within facilities.