Knowledge, perception, and practice of standard operating procedures among health care workers in primary health centers in a Southern state, Nigeria

INTRODUCTION

Standard operating procedures (SOPs) for health workers are powerful tools in Primary Health Care (PHC). It is a basic tool that makes a physician’s extension possible.^[1] SOP is a document that clearly defines who does what, where, how, and why, in a step-wise protocol.^[2,3] It’s a written protocol for the classification of disease conditions and subsequent identification of relevant procedures for such disease management in the absence of a doctor by an authorized non-clinician health worker. SOP is the basic tool being used for the training of Community Health Extension Workers (CHEWs), and it’s the tool they are expected to use in the management of patients. Its use by the CHEWs is expected to enhance the accuracy of “diagnosis” and the provision of good treatment.^[4] Knowledge transfer within an organization is important; however, the actual transfer of knowledge within organizations remains a source of concern for management.^[5] If operating procedures and policies are not laid out in writing in a clear and concise manner, management spends unnecessary time explaining processes to members of an organization.^[6] There is a compelling argument for the transfer of both explicit and tacit knowledge through SOPs, whose goal is to allow all parties involved in an organization to be aware of specific rules and guidelines.^[7,8] The SOP users are reminded that while conformance to a specific, static standard is desired, quality is a moving target.^[9] Therefore, SOPs must constantly evolve and act as written work processes that support and guide people on the way an activity is undertaken^[10] and eliminate variation in work performance caused by different people completing the same work processes in different ways.^[11] It’s vital to any organization that staff are utilized to the highest possible standard.^[12] This can often be jeopardized with the implementation of new procedures and policies or with the hiring of new staff. Having identified SOPs as key tools for the standardization of processes through the internal transfer of knowledge within an organization, an investigation into the role of knowledge management will be conducted with an emphasis on examining the role of SOPs as knowledge management tools.^[13]

MATERIALS AND METHODS

RESULTS

A total of 162 respondents participated in the study. This represented a response rate of 83.9%.

The level of knowledge of SOPs among health workers was assessed, and the result revealed that the overall mean knowledge score was 18.01 ± 3.39, and out of the 162 respondents, 55 (34.0%) had poor knowledge, scoring less than the mean score, while 107 (66.0%) demonstrated good knowledge, scoring from the mean or higher. Most of the respondents defined SOPs as guidelines for all PHC workers (84%) and believed that they should be used by all PHC workers (87.7%). Respondents identified providing guidelines (87.7%) and standardizing patient care (87.7%) as the primary purposes of SOPs. Respondents overwhelmingly disagreed that SOPs replace healthcare provider decision-making (84%) or delay treatment (93.8%). Most believed SOPs should be used daily (90.1%), and it benefits all patients (96.9%) [Table 1].

Not being trained to use SOPs was significantly (p < 0.05) associated with their usage, with respondents who agreed that they had not been trained to use SOPs being less likely to use them daily, with only 50.0% reporting daily use, compared to 92.9% of those who disagreed. Difficulty in understanding SOPs was significantly (p < 0.05) associated with their usage, with respondents who found SOPs difficult to understand being less likely to use them daily, with 55.6% reporting daily use, compared to 92.9% of those who disagreed [Table 2].

DISCUSSION

The study revealed that for the overall knowledge of SOPs, more than half (66%) of the respondents had good knowledge of SOPs, which is in keeping with a study conducted in Primary Health Centres in Ekiti, South West Nigeria^[4] where the 81.1% of the respondents had good knowledge of SOPs. This study in Ekiti^[4] also, revealed that regular utilization of standing orders is low and there is a need to educate workers on its importance. This contrasts with our study, which showed that the majority (90.1%) recognize daily SOP use, ensuring a consistent practice of use of SOPs. Another study reported that the selected workers (100%) had high knowledge of Standard Precautions as a concept in the health care system.^[16]

The study showed overall, health care workers (63.6%) hold positive views about SOPs, recognizing their benefits in patient care, safety and workload management. This finding corroborates a similar study, which revealed that clinical practice guidelines improved patient management outcomes and quality of care.^[17] Our study found that 79.6% workers agreed that SOPs contain all necessary drugs needed to treat common diseases. The findings were in concordance with another study^[4] where 80.5% responded similarly.

This shows that the positive attitude exhibited by the health workers suggests they are receptive to SOPs and this can encourage adherence to SOP and its utilization. This was in contrast with a study^[18] which showed slightly over half (52.8%) responded to be non-compliant to SOPs, unlike ours, which showed 54.3% of good attitude of the respondents towards SOPs. The majority of the respondents (90.1%) did not believe SOPs make consultations easier; this may be due to the lack of integration of SOPs into daily practice to reinforce a positive attitude in the health workers.

In our study, 83.3% had access to copies of SOPs and 95.3% admitted to daily usage of it, while 98% had a copy with them, and 62.3% admitted they used it regularly, as reported.^[4] However, challenges persist with respondents feeling that the lack of updated copies (27.8%), overwhelming patient load (17.3%), and limited training toward its use (12.3%) could affect their practice of using SOPs when attending to patients.

Our study reveals that training and retraining of health workers (p < 0.001), difficulty understanding SOPs (p < 0.001), and concerns about wasting time (p < 0.001) significantly impact SOP usage and are the main factors affecting the use of SOPs. This corroborates a study^[4] which found that time spent on one client was a significant determinant towards the usage of SOPs among primary health workers in Ekiti. Another study^[19] found that while SOPs were perceived to be valuable, they were frequently misunderstood, and there was no one overseeing their practice, which is in line with our finding that lack of senior supervision also negatively affects SOP adherence significantly (p < 0.05).

The limitation of the study was due to the self-administered method of our questionnaire administration; the response rate was reduced as some copies were not filled out, and some were missing, which could not be retrieved. We did not meet the required sample size. The strength of the study was that it provides hypotheses for future studies in this area, which has hitherto received little attention amongst the concerned populace.

Application of the findings in this study can directly lead to improvements in the acceptance and rightful practice of SOPs in centers where it is lacking.

CONCLUSION

The study revealed that knowledge of SOPs amongst health workers is mostly good, and attitude and perception were mostly positive amongst the health workers, but most of the workers felt that SOPs are difficult to understand and waste time in attending to patients, and this has affected the usage of SOPs in healthcare centers.