What makes a nurse a good caregiver?  

Identifying the drivers of staff nurse behaviors to improve the quality of health care 

From the US to sub-Saharan Africa, there is growing recognition that in healthcare facilities it is not just the quality of infrastructure or the level of training that counts – the behavior of staff plays a critical role in health outcomes for patients.

Giving birth in a facility, rather than at home, is a positive choice that increasing numbers of women are making in India’s Uttar Pradesh state. Yet rates of neonatal and maternal mortality remain stubbornly high. Poor institutional healthcare at the time of labor and delivery is undoubtedly one of the main causes. But improving the way providers deliver care first means understanding their behaviors.

In Uttar Pradesh, it is staff nurses who bear primary responsibility for women in labor, from the moment they arrive at a health facility until after the baby is born. Many interventions to improve nursing practices focus on training. But when it comes to managing labor and delivery, nurses don’t always make use of their enhanced knowledge and skills. What could be the reasons for this surprising gap between what nurses know and what they do?

To answer that question and find ways to improve neonatal and maternal health outcomes, Surgo Foundation drew on innovative research methods from the behavioral sciences, the private sector, and academia to systematically investigate the full range of factors – external and internal – that drive nurses’ practices.

We discovered that nurses face a heavy workload and are blamed for any negative outcomes of labor and delivery, even though important factors, like the mother’s antenatal healthcare, are outside their control. They must often deal with unsupportive doctors and disrespectful patients and families. Many nurses try to cope with the stress by taking shortcuts, rather than carefully following the procedural steps they learned in training. When faced with decisions about what’s best for the mother and baby, they may choose the option that seems least likely to get them in trouble with their supervisors, or to anger the woman’s family, instead of doing what is best for the mother and baby.

We also found that nurses often underestimate the significance of common risk factors such as anemia, and they fail to refer difficult cases to senior staff or a better-equipped hospital. Once the immediate stress of the birthing process is over, they often become inattentive, instead of ensuring that the mother remains at the hospital for 48 hours, is monitored for post-delivery complications, and receives help with breastfeeding.

Our holistic approach revealed why current efforts are not fully closing the “know–do” gap among nurses. For example, training them to use protocol checklists has proved ineffective, perhaps because practical tools don’t address the internal factors of stress and risk perception that drive nurses’ behavior.

What might be the solutions? Adequate staffing, supplies, and infrastructure are necessary but not sufficient to motivate nurses to do the right thing. Our findings suggest that changes are needed across the system, from better accountability mechanisms within the health facility to helping families understand the nurse’s expertise and role. Above all, it is crucial to address the internal drivers of the nurse’s behavior, such as her self-confidence and risk perception, with the right messages, tools, and supportive supervision. Together, these approaches could significantly improve clinical practices and close the gaps in quality of care for women giving birth in Uttar Pradesh, and they could be applied to improve primary healthcare around the world.