The health staff experienced many benefits from training and coaching on implementation of the new EENC guideline, including improved staff and mother satisfaction and health benefits for mothers and newborns. Patient satisfaction is closely linked to Quality of Care (QoC), which, according to the WHO, has two aspects: provision of evidence-based care by health workers and how care is experienced by patients [21]. In this study, the staff perceptions of clinical benefits and mothers’ positive responses to the new guidelines implies that QoC likely was perceived to have improved. The participants’ experience of mothers crying tears of happiness speaks to the rewards felt by the staff. The QoC model also emphasizes that improving QoC requires competent and motivated human resources as well as essential physical resources [21]. Targeting the competence of staff through coaching, as was conducted here, may be viewed as an individual-specific approach to improving quality of care. However, nursing practice is highly contextualized by the organization’s setting, intra-and inter-professional interaction, and multiple competing tasks [22]. This is also described in a study on health workers’ perceptions about what constitutes high-quality maternal and newborn care in rural Tanzania, where provision of care was perceived to be successful when things went as intended, when circumstances were predictable and the system was reliable [23]. At the same time, providing high-quality care likely motivates more women to seek health care [24], and a change in health-seeking behaviors. Mothers requesting EENC was observed by a few participants. A study from Finland on nurses’ experiences implementing new clinical guidelines found that patient awareness of the guidelines could help with successful implementation [25], similar to what was experienced here.
In our study, we found a challenge in the process of transitioning from learning to adopting and implementing EENC in the hospitals. The Normalization Process Theory (NPT) is a model that assists in explaining how new clinical guidelines become routinely embedded in health care practice [26]. According to NPT, a new routine is more likely to be sustained when staff understand the value, benefit, and importance of a new set of practices [22]. The staff experience of providing improved QoC might thus also have a positive influence on the implementation of EENC through positive effects on staff attitudes toward and personal commitment to the new guidelines [25]. For instance, in the study among birth attendants in Tanzania, observing a mother and baby to be in good condition was mentioned as a sign of having provided good quality care [23]. On the other hand, lack of outcome expectancy and motivation are found to be the main barriers to guideline implementation [27].
The participants’ emphasis on the importance of a conducive working environment resonates well with previous knowledge [25, 28, 29]. A qualitative study from Canada where administrators, nursing staff, and project managers were interviewed about factors influencing best practice guideline implementation found that leadership support, including provision of resources, was closely linked with positive staff attitudes and beliefs about the implementation [29]. Reports in this study that the number of midwives had been increased and that necessary equipment was in place after EENC had been implemented speaks to the management’s commitment to the intervention. In addition, participants expressed that collaboration with relevant departments, including Operation and Anesthesiology Units, Neonatal Care Unit, Post-Operative Wards, and Infection Control Department, was important. This again implies a coherent approach by management and is similar to the study from Canada where participants recognized interprofessional teamwork and collaboration as an important indicator for successful guideline implementation [29].
Although the staff spoke of few barriers to the implementation of EENC, some challenges, mainly related to cesarean births, were identified. Mainly, the participants talked about staff shortage as the primary challenge, which is a known barrier to successful improvement of health care practices [23, 28]. More specifically, participants shared experiences of having to leave mothers to themselves after cesarean births, interrupting skin-to-skin contact because of pressing work demands, especially during night shifts. Among birth attendants in Tanzania, the ability to stay close to the mother, both physically, to enable monitoring, and emotionally, was regarded as a sign of providing high-quality care. However, being the sole provider of maternal and newborn care in a health facility sometimes resulted in competing demands, which was perceived to result in untimely delivery of care [23]. According to NPT, the capability of nurses to implement a clinical guideline depends on its intrinsic workability and integration within the constraints of clinical practice [22]. Here, the new guidelines were perceived as saving staff resources. This was likely an important motivating factor for the staff to integrate EENC as the new routine.
Interruption of skin-to-skin contact after cesarean births, a concern which was shared by several participants, is problematic for various reasons. Firstly, skin-to-skin contact following cesarean births was reported by mothers in the US to have a calming effect, both for themselves and their newborns. Mothers also expressed that they felt empowered and experienced increased confidence in their maternal role, even in a highly medicalized setting [30]. This is echoed in our study firstly because mothers were calmer when receiving skin-to-skin contact after cesarean births, focusing more on their babies than on medical issues. Secondly, skin-to-skin contact is known to increase milk production [31]. A common reason for not performing EBF is a perception that the milk is insufficient [32, 33]. At the same time studies show that perceived milk insufficiency in most instances is alleviated by proper counselling by health staff [34]. In a study across 11 provinces in Viet Nam, the odds of pre-lacteal feeding (during the first 3 days after birth) after cesarean births compared to vaginal births was significantly greater [35]. Despite the great importance of EENC after cesarean births, staff shortages seemed to reduce QoC in this area. This was likely the main reason why several respondents considered it a challenge that many women could choose cesarean births. This is also recognized by the WHO in new guidance on non-clinical interventions specifically designed to reduce unnecessary cesarean births [36] and warning that medicalization of normal child birth may overburden front-line health workers [21].
One suggestion for improving learning outcomes was that all staff should be able to attend the coaching and training by national or provincial trainers. It was argued that it might be harder to convince health staff to follow guidelines and implement new routines if they had not received direct training. In a systematic review assessing successful interventions for promoting professional behavior change in healthcare work, Johnson and May (2015) observe that participants must have a clear impression that what they are asked to do makes sense and that their responses (changed practice) measure up to the expectations of external observers (i.e. audit and feedback) [37]. Further, in complex interventions, confidence in authoritative sources and agreement on criteria by which their credibility can be assessed is essential [26]. In a study from Kenya, one main barrier to guideline implementation was that not all health staff members were trained, resulting in a lack of knowledge and skills to apply the guidelines in general [38]. Although we found that it is not feasible to organize the training to all relevant staff at a hospital, there would be some improvements needed in some hospitals such as the selection of training participants (e.g., leadership, training skills) and ongoing coaching by provincial trainers and supervisors.
There were advantages to in-house training. For instance, there is the chance to influence management protocols in the case of disagreements with hospital authorities. This personal involvement will likely increase motivation for training and for the implementation to succeed [39]. At the same time, Johnson and May (2015) showed that interventions reinforcing modified peer group norms by emphasizing the expectations of an external reference group (in this case supervisors or management) offer the best chances of success [37]. As such, the staff perception that challenges due to skepticism and misconceptions faced at the beginning of the implementation now seemed to have ceased in part speaks to the importance of peer group norms for behavioral change.
Some participants expressed that there was not much practice during the training. Such impressions indicate that the training may not have adequately addressed the intent of the guidelines, which emphasize that at the end of on-site coaching, staff should demonstrate proficiency in new routines [10]. This conclusion is further supported by the literature, since meta-analyses show that successful behavior change interventions commonly incorporate new practice norms through experience [37], and resonate well with a new model developed by WHO for more on-the-job capacity development [10]. Learning experiences seem to be more lasting when participants are motivated to learn [40]. In this study, some health staff members who received training had many years of experience working with birth attendants. Adult learners are often more interested in practical learning than theory and want to learn exactly what is relevant to their work [40]. At the same time, although practice was not included in the initial training, the staff experienced the benefits and barriers of implementing EENC through their subsequent work. A recent study exploring facilitators and barriers to guideline implementation in Ethiopia indicated that continuous monitoring, evaluation, and mentorship were critical elements in the integration of the guideline into the system of the hospital [41].
The main advantage of the study was the use of individual in-depth interviews, which made it possible to gain deeper and more detailed insight into the experiences and attitudes of the health staff. The study also had some limitations. First, due to cost and time constraints, we visited only one province and one municipality out of 63 provinces/municipalities, which limits the generalizability of the findings. Second, there was no triangulation of data through use of other data collection methods, such as observation, to validate our findings. In this study the researchers were not permitted to interact with mothers. Therefore, comments about the mothers and reference to their experiences were from the provider perspective. Third, language was a barrier for direct communication between the researcher and interviewees [42]. Fourth, the interpreter was employed in the A&T offices, which could have created bias. The interpreter had a good understanding of the program, and thus translated the content well. However, using an interpreter affiliated with A&T might have made the participants less willing to disclose negative views about the training. While the inclusion of different staff groups working at different levels might enhance the transferability of findings, the apparent successful implementation of EENC in Viet Nam and lack of significant barriers reported suggest that the findings may have limited transferability to settings with more profound challenges in maternal and newborn care.
In conclusion, health staff reported improved staff and mother satisfaction, and health benefits for both the mothers and newborns from EENC after receiving training and coaching using the WHO approach. An approach to develop competencies, with a focus on practical training and coaching, should be promoted to form, reinforce and sustain recommended practices of health staff.
