Factors shaping good and poor nurse-client relationships in maternal and child care: a qualitative study in rural Tanzania

Nurses and midwives form a critical component of maternal and child health (MCH) services globally. They play a vital role in the delivery of primary health-care services related to pregnancy monitoring, delivery and postnatal care for women and newborns around the world [1, 2, –4]. In sub-Saharan Africa, nurses and midwives are often respected members of the community and provide advice and evidence-based information on a range of health issues, including care of newborns and young children [2‐4]. In the presence of sufficient, well supported, and competent nurses and midwives, 83 per cent of maternal deaths, stillbirths and neonatal deaths could be prevented [5‐7]. It is considered that competent nurses and midwives have the potential to increase client service uptake, continuity, and consequently improve health outcomes, such as increased breastfeeding initiation and duration, reductions in caesarean sections, maternal infections, postpartum hemorrhage, and preterm births [8]. Literature suggests that investing in nurses and midwives has the potential to yield a 1,600 per cent (16-fold) return on investment resulting from improved MCH outcomes [9].

Despite their critical role, there has been increasing clients’ dissatisfaction with nurses and midwives’ interpersonal and perceived technical competences within MCH care in the recent years [10‐19]. Perceived technical incompetence associated with skills, reliability, assurance, confidentiality, and patient engagement and, behavioral incompetence involving demeanor/attitudes empathy, communication skills/language, violation of client rights and respect, continue to obscure the positive value of nurses and midwives in the delivery of MCH interventions in Tanzania and elsewhere [10‐21]. Recent studies indicate that clients’ dissatisfaction with nurses’ interpersonal and technical aspect of care continues to erode client trust in formal healthcare system, service uptake, continuity and MCH outcomes [19‐23].

To address clients’ dissatisfaction, healthcare service governance instruments including policies, client service charters, health facility governance committees, complaints mechanisms and professional bodies have been emphasized in both high- and low-income settings but their effectiveness is not well-established. Consequently, political interventions such as employment termination remain the cornerstone of addressing this complex problem which further creates tension between clients and the politically pronounced ‘bad, lazy and incompetent’ nurses contributing to loss of providers’ morale [24, 25]. Competence based interventions focusing on provider communication skills and patient centered care and, patient literacy, information seeking, participation and questioning skills are often implemented on adhoc basis yielding unsatisfactory results. A major challenge with existing interventions documented in literature is the failure to address all the complexities of nurse-client relationships along the continuum of MCH care. Patient’s socio-economic fragility, literacy, and behaviours as well as providers’ competence and behaviours, and health system challenges particularly in rural contexts add to the complexity of nurse-client relationships. Rurality adds to the complexity of nurse-client relationships partly because of limited healthcare resources and infrastructures and the prevailing competition between informal and traditional systems which continue to impact uptake and continuity of formal MCH services [15, 23].This complexity necessitates targeted contextualized innovative solutions that places nurses and clients at the forefront as agents of change in optimizing intervention designs and implementation [26‐28]. A human centered design (HCD) is one of the innovative approaches to problem-solving that leverages insights from the end-users of services, and experiences in order to develop best-fit solutions that are rapidly prototyped and iteratively refined [26‐32]. HCD is considered to facilitate improvements in client, provider, and community satisfaction, as well as increased efficiency and collaboration in public health intervention development and implementation process [30‐32]. Furthermore, HCD may result in more successful and sustainable interventions compared to traditional problem-solving approaches in health care and public health [31]. HCD approach also embraces a system-wide outlook by considering interactions of factors at different levels and harmonizing individual interests to form collective interests when developing solutions [30‐32]. The aim of this study was to explore nurses and clients’ perspectives of factors shaping nurse-client relationships in MCH care. The findings of the study are expected to generate evidence to guide subsequent steps of HCD process that involve designing effective strategies for improving nurse-client relationships in Shinyanga, Tanzania.

Participants were also asked about the contributors of good nurse-client relationships. Looking across transcripts, contributors of good nurse-client relationships were mainly the opposite of contributors of poor nurse-client relationships. For instance, nurse and clients’ contributors were mainly related to their good behaviors and actions that transpire during physical therapeutic interactions within MCH clinics and good outcomes after such interactions. Good behaviors, attitudes, and actions of nurses cited to contribute to good relationships included those related to good reception of the client, expressing care, good communication, better services, ongoing support, friendship and trust, and positive reputation within the community. During therapeutic interactions, good reception by a nurse was said to be characterized by exchanging greetings, introducing oneself, addressing worries, offering hope, asking what the problem is and promoting equality. Furthermore, expression of care was said to be characterized by nurse’s willingness and readiness to help, promoting clients’ rights, closeness to clients, showing interest in clients’ concerns and cooperation. Moreover, good communication was said to be characterized by nurses’ good and soft language, positive body language, calmness, avoidance of harshness and harassment, listening, consensus building/shared decision making and being able to speak a local language. Likewise, better healthcare services were characterized by nurses’ timeliness of care, correct treatment, good counseling and post-care instructions, and friendly services. After therapeutic interactions, nurses’ confidentiality of patient information, continued friendship and continued communication and support surfaced as shaping good nurse-client relationship. These good nurses’ behaviors and actions were cited to increase client’s satisfaction with both interpersonal and technical quality of care consequently constructing good therapeutic relationships.

Although nurses’ positive behaviors and actions dominated as shaping good relationship, clients’ good behaviors, attitudes and actions were also mentioned. For instance, during therapeutic interactions, clients’ timely arrival to the clinic, client’s positive attitude and trust towards nurses, adherence to instructions, good communication, openness and understanding what services they deserve, and thankfulness were cited as shaping good nurse-client relationship. After the interaction, clients’ satisfaction with care/absence of complaints, friendship beyond MCH clinics often accompanied with gifts and promoting goodness of nurses in the community were cited as shaping good nurse-client relationship. Some participants commented:

[Good relationship] occurs when you receive the patient well, how you introduce yourself and offer medical services. At the end of the day, you build friendship, you stay connected and she may call you if she has a problem. It occurs when the client becomes satisfied with your services, and you may become like family friends. She may even bring you gifts because you offered good care (Nurse, Health Centre)

What I know is that a good relationship between nurses and clients is shaped by three things. First is trust between client and nurse, meaning a client has high trust towards a nurse. Second, confidentiality meaning nurse keeps patient information confidential. Third, willingness and readiness of a nurse to leave all other things to offer care to the client, hospitality and treating the client like a king. If are done, there will always be good relationship between a nurse and client” (Client, Dispensary)

This study was conducted as the first step of the ongoing HCD intervention to co-design an intervention package for improving nurse-client relationships in MCH care in rural Tanzania. Ideally, to address the contributors of poor nurse-client relationship, a consideration of an innovative approach that brings nurses and MCH clients together as partners in the intervention design and evaluation process need to be made. It is for this reason, HCD approach is being embraced because it is considered to facilitate improvements in client, provider, and community satisfaction and increased efficiency and collaboration in public health intervention development and implementation process [27‐32]. Furthermore, HCD is considered to result into more successful and sustainable interventions when compared to traditional problem-solving approaches in health care and public health in general [27‐32]. Melles, Albayrak and Goossens [32] recently proposed that the implementation of HCD in healthcare need to focus on developing an understanding of the people facing a particular challenge and their needs and engaging the stakeholders from early on and throughout the design process and embracing a system-wide approach by considering interactions of factors at different levels and harmonizing individual interests to form collective interests when developing solutions to the identified challenges. Consequently, we first sought to generate an understanding of the factors shaping poor nurse-client relationships to guide future steps of HCD process. Therefore, the study was conducted with an overarching question, ‘what are the contributors of poor nurse-client relationship in MCH care that could form the basis for co-designing effective interventions?'

Our findings unmasked a range of factors shaping poor nurse-client relationships in MCH care. Nurses’ behaviors, attitudes and actions that portray poor reception and hospitality upon client’s arrival to the facility constructs poor relationships. Likewise, nurses’ failure to express care and concerns towards the clients and their suffering, poor communication in terms of abusive, and unfriendly language, and even the harsh tone, negativity towards clients and poor services dominated as the main drivers of poor relationship. However, expressing positive behaviors, attitudes and actions emerged to fuel positive relationships. At the heart of poor behaviors, attitudes and actions was the concern that nurses’ dissatisfaction with working conditions, remuneration and poor motivation as well as associated mental instability impacts how they construct relationships with their clients. Most of these findings are not novel. A large body of literature have always linked poor provider–client relationship with providers’ behaviors, attitudes, and actions in Zimbabwe [13], Malawi [12, 20], Tanzania [14, 17, 23], Kenya [16], Iran [18], Spain [19], Australia [36] and Ghana [37]. For instance, a systematic review of 81 articles, 68% of which were from Africa by Mannava et al. [20] indicated that positive nurses’ behaviors including expression of care, respect, sympathy and helpfulness construct good relationship while negative attitudes including verbal abuse, rudeness and poor communication not only constructed poor relationship but also reduce client healthcare seeking and health outcomes. This indicates that interventions that promote positive nurses’ behaviors, attitudes and actions manifesting during therapeutic interactions in MCH forms an important partway to improving nurse -client relationships, client healthcare seeking behaviors and health outcomes. It is also important to note that similar findings have also been reported by Isangula [23] when examining trust in doctor- client relationship in a similar setting. Meaning, promotion of positive behaviors, attitudes, and actions, need to extend beyond nurses to other healthcare providers who interacts with clients across MCH service points within healthcare facilities.

While most literature have focused on providers’ behaviors, attitudes and actions that fuel poor nurse-client relationships in health care, for instance [18‐23] and [36‐39], there appears to be paucity of literature focusing on clients’ contributors of poor nurse-client relationships. Consequently, most of the existing interventions -whether governance instruments, competence -based or political- prioritize or lays blames to providers (nurses included) as the prime source of poor provider-relationships in therapeutics encounters [17‐25]. However, the finding of this study indicate that clients have a notable contribution to poor nurse-client relationships. A tendency of clients being ‘much know’ meaning they often ‘instruct’ nurses what to do, late attendance, non-adherence to established procedures at the facility, negative attitudes towards nurses, poor communication, inadequate education and awareness, poverty, hurrying and forcing to receive certain services, dissatisfaction with care, faith in traditional healers and unstable mental health emerged as contributors. These findings point to a suggestion that attempt at improving nurse-client relationships need interventions that not only focus on nurses but also clients’ behaviors, attitudes, and actions as well as improving client’s awareness on health issues, process of care and health service purchasing power.

One issue that need close examination is a tendency of nurses citing clients as ‘much know’. This is complex problem and may be reflecting deeper issues of medical knowledge custodianship and the prevailing power-dynamic between nurses and clients. On the one hand, medical providers are often considered the custodians and reliable sources of ‘correct’ medical knowledge and practices. However, some research indicates clients often consider easiness of accessibility of medical information at the risk of inaccuracy and non- reliability [40‐42]. A recent evidence synthesis study [41] indicated that clients “tend to prefer the Internet for the ease of access to information although they continue to trust providers because of their clinical expertise and experiences. Receiving medical information from internet sources for example may mean that nurses like other medical providers may be challenged as clients are becoming more and more empowered through other sources of medical information. This imply that empowering clients by facilitating easy access to information about medical topics should be approached with care since they may access incorrect information that could negatively impact their therapeutic interactions with medical providers in healthcare settings.

On the other hand, citing clients as ‘much know’ may portray the prevailing power dynamics between nurses and clients. The education disparity between nurses and clients noted in this rural setting (see demographic information) may contribute to feelings of superiority or authoritarian tendency among some nurses. Therefore, some nurses may resist accommodating clients’ insights and preferences on the treatment process. This may also indicate limited understanding of the value of client participation in decision making as part of promotion of client-centered care among some nurses. It is important to note that power-dynamics and poor engagement of clients in treatment decision making has been reported as common in the study settings and other low-income healthcare settings [20‐23]. Consequently, some authors encourage nurses to focus on working with the clients through power sharing and negotiation rather than being preoccupied with doing everything to them without engagement [43, 44]. Some authors recommend adapting the traditional approaches to provider–client and communication in therapeutic settings to and optimize client engagement in health decision making as a means of minimizing the negative impact of client access to health information through non-medical sources [43]. This approach is expected to result into client empowerment, partnership, client-centered care and shared decision making which positively impact healthcare seeking and outcomes [42, 44].

Literature in low- and middle-income countries suggest that availability of healthcare resources (enough providers, medicines and medical equipment) is essential in creating smooth environment where provider–client relationships can be established and sustained [23]. This partly explain why a range of health system factors emerged in this study appears to impact how nurse-client relationships are constructed within MCH care. Inadequate resources (medicines, medical supplies and equipment), infrastructures, financial resources and nursing workforce, poor human resource for health management practices, and inadequate policy implementation emerged to create frequent tensions and frictions among clients and nurses consequently impacting their relationships. Inadequate resources for instance may influence negative nurses’ behaviors and attitudes towards clients [20]. Relatedly, inadequate resources limit nurses’ capacity to utilize the full potential of her expertise and create blames and conflicts with clients who miss specific services due to lack of resources [17‐23, 45]. It is important to also note that inadequate resources may create tensions between nurses and clients due to prevailing politicization of medicine where politicians often make promises of quality and free MCH care to clients contrary to what facilities could actually offer [23, 45]. A study of providers in Tanzania [45] indicated that politicians make promises of free health service to pregnant women when the healthcare facilities have limited budget to ensure availability of resources to meet these political commitments. Consequently, the nurses and other providers carry the burden and become the targets of attacks and abuse by unsatisfied/angry clients who are not happy with inadequate resources for healthcare services and are often considered corrupt [45]. This is evidenced by an incident described by one of our participants where a nurse was physically abused by the client for the healthcare facility not having the POP (see above).

Most importantly, lack of patient trust towards health facilities and healthcare providers and high faith in traditional medicine emerged to contribute to poor nurse-client relationships. While similar findings have been previously reported in a similar setting with respect to doctor- patient relationships [23], it may be that nurses’ behaviors, attitudes and actions portraying poor hospitality and non- expression of care as well as concerns of inadequate resources in formal healthcare system pushes clients to have higher trust and faith in informal practices [23]. Furthermore, conducting a study in a rural region with wealth traditional practices that appears to compete with formal western care may explain high preference to traditional healers [23]. An important finding was the absence of an independent agency for gathering, processing and sharing clients and nursing feedbacks within healthcare system. This emerged as important because of many concerns of dysfunctional suggestion box system in terms of lack of education among clients, delay in working on suggestions and lack of feedback to the people who offered complaints. Similar challenges have been detailed previously in a similar setting [23]. What these findings points to is that efforts to improve nurse client-relationship requires combination of interventions that not only seek to promote positive behaviors among nurses and clients but also ensuring availability of resources, nurse workforce management practices and building confidence and faith of community members towards formal western care.

Taken together, all these findings indicate that there may not be a single best fit solution that could be employed to strengthen nurse-client relationships. This is because such relationship is impacted by complex factors operating at the level of nurses themselves, clients, and health system. This may explain why a combination of intervention were proposed. First, those focusing on nurses such as awards and recognition, continued professional development, peer to peer learning and mentorship including pairing good and experienced nurses with bad and inexperienced nurses in service delivery and using nursing platforms (meetings, conferences, workshops etc.) to insist on personal devotion and adherence to nursing professional and work ethics. Most of these suggestions have been proposed in previous literature [17‐23]. For instance, Kumbani et al. [20] proposed strengthening workforce development, including training in communication and counselling skills as a pathway to improving nurses’ behaviors and attitudes as attempt to improve maternal health services and outcomes in Malawi. Second, those focusing on clients including education and community sensitization and insisting on good behaviors and attitudes towards nurses on different platforms. Third and final, those focusing on health system including improving service quality and working conditions, increasing and better management of nursing workforce, improving remuneration and incentives, extended mentorship, improving complaints mechanisms and strengthening nursing school’s student screening and nursing curriculum. It is important to note that most of these suggestions are among the key recommendations of studies on provider–client relationships in low- and middle-income countries[36‐39, 46]. Underemphasis on the role of improving provider-client relationships in health care and inadequate funding may have contributed to less implementation of most of these suggestions.

The factors shaping poor nurse- client relationships appear to extend beyond nurses to both patients and healthcare system and facilities. These results may inform the design of new initiatives and the policies that support them in order to strengthen interpersonal relationships in health care settings more broadly. Therefore, implementation of effective interventions for addressing identified factors considering feasibility and acceptance to both nurses and clients using novel strategies such as HCD could pave the way for employing good nurse-client relationships as a tool for improving performance indicators and health outcomes within MCH care.