Emergency patient transport by nurses in selected rural areas in Botswana

Primary care must connect emergency care services to communities through communication, transportation, and referral channels for integrated people-centered service delivery. Patients with acute care need frequently access the healthcare system via lower-level regional clinics or remote rural health posts. The mixed-methods research study utilized an exploratory sequential design, in three phases, guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model of work system and patient safety.Phase one utilized a qualitative descriptive approach, semi-structured interview with a purposive convenience sample of 26 registered nurses from four remote, isolated rural health districts in Botswana. The study explored nurses' experiences with emergency transportation of patients from rural health posts and clinics to the higher-level clinics and hospitals for further management.The interviews' content and thematic analysis were conducted using a combined deductive and inductive coding procedure. The two main themes that emerged under 'person' are: infringement of the scope of practice and violation of professional conduct; three subthemes were identified, including practicing outside the scope of practice, inadequate knowledge, and skills, and restricted from making decisions. The themes that emerged under the organization include ineffective clustering of health care facilities, lack of support, and poor communication between health facilities. Four subthemes identified under lack of technology and tools, included lack of transport, lack of equipment, shortage of medications, and inadequate and inefficient use of time as a resource. The central theme that emerged under the environment concerns working under highly deplorable conditions. Phase two utilized the Delphi technique for item generation and establishing content validity guided by the Systems Engineering Initiative for Patient Safety (SEIPS) Model. The items were generated and synthesized from an extensive literature review and the qualitative descriptive study exploring nurses' experiences in rural emergency patient transportation. The initial item pool consisted of 84 items.This Delphi study utilized purposeful sampling to recruit experts from various specialists in emergency medicine, trauma surgery, trauma, emergency nursing, nurses, paramedics, and emergency medical technicians. A two-round modified Delphi method with experts was used to generate additional items and validate the content. Sixteen experts were invited to participate in both rounds. In the first Delphi round, 29 items were accepted for the final item set, 12 items were revised, 17 new items were added, and 26 items yielded a content validity index (CVI) of <0.8 and were thus eliminated; therefore, 58 items remained for analysis in phase two. In round two of the Delphi phase, 56 items were accepted for the final item set, one new item was added, and one (1) new item yielded a CVI of <0.8 and thus eliminated; therefore, the final item set for a scale to measure effective rural emergency patient transport (RET) in rural health facilities consisted of 58 items.Phase three of the study evaluated the psychometric properties of 58 items scale, using a cross-sectional study design among a sample of 302 nurses in rural clinics and health posts undertaking emergency patient transport in four health districts. The RET total Cronbach Alpha value was 0.980. A categorical principal components analysis identified three components explaining 63.35 % of the total variance. The factors, technology, tools, personal knowledge and skills, and organization accounted for 27.32 %, 18.15 and 17.88% of the total variance, respectively. The reliability of the three factors, as determined by the CATPCA's default calculation of the Cronbach Alpha, was 0.960, 0.946, and 0.956, respectively, indicating that the variables from each factor correlate. The perceived ineffective emergency transfer of patients was associated with work system shortfalls. The work system needs to be balanced and consider the requirements of the various stakeholders involved in the processes for optimal performance of patient transport. the findings from the present study offer a preliminary instrument to measure effectiveness of rural emergency transport (RET) and can be used to better understand and improve clinical practice.