Table 3 Barriers and enablers to implementation phase of stages of change model [study ID]
Barriers | Enablers |
|---|---|
Poor recording and extraction of clinical information Poor quality of information in medical records and collected information (3) | Good recording and extraction of clinical information |
Data collection divided between numerous workers (3) Non-motivated data collector (3) | High level of qualifications/experience of data collector and appropriate training (2,3) |
Audit meetings as a “blaming exercise” Audit meetings are a “blaming exercise” (2) run as a formal meeting where there is a fear of blame and punishment among attendees (fear of being judged/punished for findings; confidentiality not respected; afraid to tell story; may lie to protect oneself) (2,3,6,8,9) Case notes with deficiencies from medical doctors were not audited (“it’s not fair, only cases of midwives are audited, they have never chosen cases of the bosses. They do errors too”) (6) | Audit meetings as a “learning” exercise Audit meetings are run in an informal non-punitive learning environment which provides the opportunity for interaction, discussion and sharing of ideas about changing practice (2,7,8) |
No local clinical leadership Audit only works when the one leader—Head of Department— is present. When s/he is not there no one else takes initiative, there is poor attendance at meeting and attendees are not motivated to participate as felt recommendations would not be implemented (4,8) | Local clinical leadership is crucial Local leadership (e.g. Head of Department) is a strong facilitator of clinical audit/maternal death review implementation and traditional hierarchical relationships may be an enabler. This occurs when the head of the hierarchy encourages a multidisciplinary approach and promotes staff acceptance of need to conduct audit (2,3,8,9) |
Audit meetings are uni-professional Traditional medical hierarchies prevent the establishment of a multidisciplinary audit team. This excludes hospital managers and midwives/nurses who are then not motivated to take part in the audit (3,5,8) | Audit meetings are multi-professional Involvement of the whole multidisciplinary team was felt to motivate staff and promote implementation across the health system (2,7,9) |
Poor communication of audit findings and feedback | Good communication of audit findings and feedback |
Lack of feedback of recommendations to staff who did not participate, including management (3,6,8) | Findings and recommendations need to be communicated across the health system (2,3) |