reflective practice in healthcare essay

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Reflective practice in health care and how to reflect effectively

Kiron koshy.

a Brighton and Sussex University Hospital

Christopher Limb

b Western Sussex University Hospitals, Worthing

Buket Gundogan

c UCL Medical School, University College London, London

Katharine Whitehurst

d Royal Devon and Exeter Hospital, UK

Daniyal J. Jafree

Reflective practice is a paper requirement of your career progression in health care. However, if done properly, it can greatly improve your skills as a health care provider. This article provides some structure to reflective practice to allow a health care provider to engage more with reflective practice and get more out of the experience.

Introduction

Reflective practice is something most people first formally encounter at university. This may be reflecting on a patient case, or an elective, or other experience. However, what you may not have considered is that you have been subconsciously reflecting your whole life: thinking about and learning from past experiences to avoid things that did not work and to repeat things that did. For example after tasting a food you do not like, you remember that experience, think about it, and when you next see that same food you know to avoid it. In medicine it is one of the best approaches to convert theoretical knowledge into practice.

As you progress through medical school and into foundation years as a doctor it becomes even more common. It is now expected to provide evidence of your reflections through your training on the ePortfolio and then throughout the rest of your professional life in revalidation. Hence, it is a good idea to get it right from the beginning.

First and foremost the biggest mistake you can make when reflecting is to treat it as a tick box exercise and a waste of time. With a bit of thought reflections can be a very useful tool in learning. Would you remember a generic case from a book? Would hanging all of those facts on a patient you have met make it more memorable? It allows you to recognize your own strengths and weakness, and use this to guide on-going learning. By reflection you will develop your skills in self-directed learning, improve motivation, and improve the quality of care you are able to provide.

What to reflect on

This can be anything.

Most reflections are on things that go wrong. These situations stay in one’s head and force us to begin to think about whether they could have done anything differently. For example:

Postoperative complications
Missed diagnosis
A dissatisfied patient
Failed procedure

However, reflecting on things that went well can often be more rewarding and be just as useful. It can build confidence and help you to repeat it again on another occasion. For example:

A well-managed cardiac arrest
An interesting seminar or conference
A patient thank you letter
A difficult but well performed procedure

Stages of reflecting

There are numerous models for reflections, but it is important to understand why you are asking each question and how that will help you to reflect 1 . This an integration of many concepts but the broad process is similar in all models: what happened, why does this matter and what are the next steps? 2

What, where, and who—the situation

Think about the situation in detail: What happened exactly and in what order, where were you at the time and who else was involved? What part did you have to play? What was the final outcome?

How did it make you feel—your emotional state

What was running through your head and how did you feel about it? Be honest with yourself: were you afraid, confused, angry or scared? If you can understand how you were feeling at the time it will help you put together why things happened as they did, and help you to recognize similar situations in the future.

Why did it happen—making sense of the situation

Now you have thought about the situation in greater detail, and probably recognized things that would have otherwise gone unnoticed, think about why things happened as they did. How did the situation, yourself, and others interact at the time. Did the situation go well or was there room for improvement?

Could you have done anything differently—critical review and development of insight

With the help of hindsight how would you have managed the situation differently? Think about what factors you could have influenced: is there anything you could have tried that may have improved the situation, or is there anything you did that was particularly important in the situation? It is easy to remember the things that you did not do and it is often the things that you did well that are forgotten.

What will you do differently in the future—how will this change your practice

This is arguably the most important stage in reflecting. You need to pull together everything you have thought of before to learn, change your own practice, and improve 3 . Do not only think about what you would do differently in that specific situation, but think whether you have thought of any transferable knowledge or skills you can utilize elsewhere. For example: if you reflect on a postprocedural complication do not only think of how you would manage this again but also how you would prevent it happening if you performed the procedure yourself! If you are a part of a well-led cardiac arrest do not think only of what you would do next to help, but also how you would lead an arrest in the future, or even how you would lead a team in any other situation!

Re-enforcement—what happens when you put this into practice

Test your reflections: When comparable situations happen again, do things change as you would expect them to? This is a chance to repeat the reflective cycle to refine and develop your understanding.

How to make the best use of reflective practice

As mentioned previously most people see reflective practice as a tick box exercise, but it does not have to be.

Over the next day take note of any interesting situations that arise. Later in the day try mentally reflecting, following this framework, and if you think any will be particularly useful to you write them down. If you try this for a week you will begin to see similar situations arising and how your reflective practice is positively affecting you.

Remember: you do not always have to learn only from your own experience; learn from others’ mistakes as well. Reflect on situations that you have witnessed to work out why things happened as they did, and how this can influence you.

It can be useful to take these reflections for peer or senior review: others may be able to draw light on things you have not noticed. This can allow you to recognize points for improvement and work on them. This can also be a useful learning opportunity for the other involved!

An example to put this into practice

I was involved in a patient confrontation; the patient was unhappy with her hospital stay and wanted to be discharged home. Unfortunately she required a package of care and so could not be discharged. I explained this and she returned to her bed. I was happy I had explained everything to her and continued with my other jobs.

Who, what, and why

I was involved in a patient confrontation; an elderly patient was unhappy with hospital stay and wanted to be discharged home. She was under our general surgical team for a head injury and observation after a normal CT head. She had been seen on our ward round and told that she was medically fit for discharge but still awaiting social services: her house had been reviewed and deemed unsafe so she was waiting for banisters to be installed. The issue was raised with me by chance as I was doing other things on the ward. I explained this to her and although she remained annoyed I was able to make her understand what the delay was and she returned to her bedside. She did not seek further clarification that day.

How did it make you feel

At the time I felt rushed and frustrated. I had a lot of other work to be done and this was distracting from that. She had already been told she was waiting for social services in the morning. I understood why this was difficult for her but did not think I would be able to do anything to help.

Why did it happen

The morning ward round was quite rushed and so our explanation was limited to telling her we were waiting for social services. I can understand from her point of view this may have meant very little, and so my explanation of what exactly we were doing may have relieved some frustration. Having been waiting up to this point, it is no surprise she continued to be angry but may have been accepting of this plan.

Could you have done anything differently

I think my explanation was very good, and the patient seemed happy with this, although I did not give a rough idea of how long this would take. It may have been useful to have spoken to the sister in charge to ask for what progress had been made to feed back to the patient. Also I did not ask her whether she was happy with this explanation: I may have been able to satisfy her frustration further by answering a few more questions or even recognize any other issues at home that may need addressing before discharge. Although the information given in the ward round was correct, it was not understandable to the patient. If this had all been quickly clarified in the morning, the patient would have been happy throughout the day and not caused a problem later on.

What will you do differently in the future

I think that the route problem in this situation was our explanation on the morning ward round. Furthermore, I am not sure how long such issues take to be addressed. To avoid a similar situation in the future I will speak to the other health care professionals on the ward to get a round idea of how long occupational interventions such as this and other community interventions take to start. This means when future patients are medically fit I can spend a moment in the morning informing them of what needs to be done and how long it may take. Hopefully this will allow me to address patient concerns early to avoid them becoming an issue when it is too late.

Re-enforcement

I will reflect on how future situations similar to this develop, looking for an improvement in the quality of my patient care.

Following a structure helps to focus a reflection: I am sure you will agree the learning points are much clearer from a good reflection!

Conclusions

To summarize, the benefits of reflecting are clear: it may be difficult to do initially, but through practice you will develop your own skills and become a better learner. Many structures are available so choose one what works for you. Reflective practice is an important part of your career progression on paper, but if done well, can greatly improve your skills as a health care provider.

Conflict of interest statement

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Published online 15 June 2017

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Reflective practice in health care and how to reflect effectively

Affiliations.

1 Brighton and Sussex University Hospital.
2 Western Sussex University Hospitals, Worthing.
3 UCL Medical School, University College London, London.
4 Royal Devon and Exeter Hospital, UK.
PMID: 29177215
PMCID: PMC5673148
DOI: 10.1097/IJ9.0000000000000020

Keywords: Career progression; Learning; Portfolio; Reflection; Reflective practice.

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Reflective writing style

Learning to write reflectively will equip you with the relevant ethical and analytical ability to benefit from your practical experiences. Reflection may be articulated differently, depending on whether you are speaking or writing about your experiences. There is no right or wrong way to write reflectively!

Reflective writing differs from standard academic writing in that it is more personal in nature. This means that you can use the personal pronoun “I” and talk about your own thoughts and feelings. It is important, however, not to be too casual or conversational. Reflective writing should include essential details, written directly and concisely. Clear examples are very useful. Deeper level reflective writing may also connect with the literature you have been reading, to support or even contradict what you have experienced.

Howatson-Jones, L (2010). Reflecting writing. In Reflective practice in nursing . Exeter; Learning Matters p. 120-121

Guided reflection

Guidelines for keeping a reflective diary/journal & writing up critical reflective incidents.

Keep a journal of experiences over the year.
Write up the journal entry/incident.
Below the entry write up your reflections / analysis notes of the situation.
Write up experiences the same day if possible.
Use actual dialogue wherever possible to capture the situation.
Make a habit of writing up at least one experience per work day/shift.
Balance problematic experiences with satisfying experience.
Challenge yourself at least once a day about something that you normally do without thought / take for granted.
Ask yourself 'why do I do that?' (i.e. make the normal problematic)
Always endeavour to be open and honest with yourself - find the authentic 'you' to do the writing.

Ask yourself these questions:

What did I learn from the situation?
In what way has it assisted my learning to be a health practitioner?
Could the situation have been better managed?

Johns (1992) & Carper (1978) in P. Palmer, S. Burns and C. Bulman, C., Reflective practice in nursing (1994). London. Blackwell Scientific Publications. p. 112.

Reflective Practice

Examples of reflective practice
Why use reflective practice?
When to use reflective practice
Some models of reflection
Writing reflectively
Recommended readings
Need help? This link opens in a new window

Superficial

Superficial (= descriptive reflection) non-reflectors

Reflection at this level is very basic – some would say it is not reflection at all, as it is largely descriptive! However the description should not just be of what happened but should include a description of why those things happened. Reflection at a superficial level makes reference to an existing knowledge base, including differing theories but does not make any comment or critique of them.

Example - Superficial reflection

Today I spent time with James (client) and his family on the ward. The family had a lot of questions about the rehabilitation process and wanted to know what was going to happen for James.

I wanted to reassure them that things were OK because I knew this was what they needed to know. I said that while it was difficult for anyone to know the rate of James’ improvement I could be sure that he would improve and that it was important for the family to keep hopeful about his future.

James’ father became angry and after raising his voice at me, telling me I was a “patronising little fool”, he stormed out of the room. James mother sat weeping beside his bed and I felt I had really stuffed things up for this family. I need to get some advice about how to handle angry families.

Medium (= dialogic reflection) reflectors At this level of reflection, the person takes a step back from what has happened and starts to explore thoughts, feelings, assumptions and gaps in knowledge as part of the problem solving process. The reflector makes sense of what has been learnt from the experience and what future action might need to take place.

Example - Medium reflection

Today I spent time with James (client) and his family on the ward. The family had a lot of questions about the rehabilitation process and wanted to know what was going to happen for James. I wanted to reassure them that things were OK because I remembered from a uni lecture by a carer that carers needed reassurance, information and hope for the future of the person they cared for. I said that while it was difficult for anyone to know the rate of James’ improvement I could be sure that he would improve and that it was important for the family to keep hopeful about his future.

James’ father became angry and after raising his voice at me, telling me I was a “patronising little fool”, he stormed out of the room. James mother sat weeping beside his bed. I felt confused and like I had done the wrong thing. I remembered from the same lecture about the emotional rollercoaster of caring for someone after a brain injury and how families could experience a range of emotional responses as they adjusted to their new reality.

I decided to ask James’ mother how things were going for the family and she started to open up about how she felt. She revealed that James’ accident had opened up longstanding conflict between her and her husband, and that she didn’t feel hopeful about anything. It seemed like a useful conversation.

Deep (= critical reflection) critical reflectors

This level of reflection has the most depth. This level of reflection shows that the experience has created a change in the person – his/her views of self, relationships, community of practice, society and so on. To do so, the writer needs to be aware of the relevance of multiple perspectives from contexts beyond the chosen incident – and how the learning from the chosen incident will impact on other situations.

For some critical reflective writing tasks it is expected that your writing will incorporate references to the literature - see Example - Deep reflection incorporating the literature below. Note that these are short excerpts from longer documents previously submitted for assessments (Permission granted by author).

Example - Deep reflection

I started thinking about what was happening in this family and how James’ parents were both clearly distressed and may have been having difficulty supporting each other due to their own distress. James’ father’s abuse of me was possibly not a fair reflection on me but said a lot about how he was feeling. I wondered about his parent’s differing emotional responses and tried to put myself “in their shoes” to consider what it must be like for them. I could see that their questions and behaviours were driven by their extreme emotional states. They both needed an outlet for their emotions.

I also thought about what James needed from his parents to optimise his participation in the rehabilitation program and how I could support them to provide that. I knew I didn’t have the skills or confidence to provide the grief counselling they probably needed but I thought I could provide them with some space to share and acknowledge their grief and to suggest options for them to get further assistance in this area. I sat by his mother and said “This is really hard for you all isn’t it”. She responded with “so hard” and cried some more. We sat without talking for a while and when she was calmer I said “a lot of families find it helpful to talk with our social workers about how they are feeling when things like this have happened”. She agreed it would be good to talk and I helped her organise an appointment for the next day.

From the experience today I have learned that families don’t need superficial reassurance and that this can be perceived as patronising. It will be more helpful if I can acknowledge their emotional distress and fears and reassure them that their response – whatever it is – is normal and expected. If I show that I can cope with their distress I can assist them to get the support they need and this will be critical in getting the best outcome for clients like James.

Example - Deep reflection incorporating the literature

NOTE: These short excerpts are from longer documents previously submitted for assessments (Permission granted by authors). Also note the format of the in-text citations reflect this.

I needed to understand more about what resilience actually is, and whether it is learnable or inherent in a person’s personality. McDonald, Jackson, Wilkes, & Vickers, (2013) define resilience as the capacity to deal with “significant disruption, change or adversity” (p.134) and that in the workplace, adversity relates to the difficult or challenging aspects of the role. The authors identify traits associated with resilience such as “hardiness, hope, self-confidence, resourcefulness, optimism flexibility and emotional intelligence” (McDonald et al., p.134) and discuss how training programs have been established within the workplace to teach people these skills.

A plan for building resilience for my future role as a midwife would need to start now in order that positive patterns are embedded in my practice and everyday life. This would include activities discussed above as well as attempting to engage in habits of mindfulness on a day to day basis (Foureur, Besley, Burton, Yu, & Crisp, 2013).

Foureur, M., Besley, K., Burton, G., Yu, N., & Crisp, J. (2013). Enhancing the resilience of nurses and midwives: Pilot of a mindfulness-based program for increased health, sense of coherence and decreased depression, anxiety and stress. Contemporary Nurse: A Journal for the Australian Nursing Profession , 45 (1), 114-125.

McDonald, G., Jackson, D., Wilkes, L., & Vickers, M. (2013). Personal resilience in nurses and midwives: Effects of a work-based educational intervention. Contemporary Nurse: A Journal for the Australian Nursing Profession , 45 (1), 134-143.

It is vital to ensure a healthy work-life balance (Pelvin, 2010). Imbalances in professional and personal life can cause burnout (Fereday & Oster, 2010). Burnout increases with the incidence of family-work conflict (Jordan et al., 2013). Non work-related interests help reduce the risk of burnout; exercising, resting, leisure-time and self-pacing all assist in managing stress (Jordan et al., 2013; Mollart et al., 2013). Self-awareness and mindfulness positively affect our personal relationships and make valuable contributions to the professional workplace (van der Riet et al., 2015). Mindfulness also enables midwives to be totally present with women and their families (White, 2013). Keeping an up-to-date family diary has assisted in planning and pacing my study, work, personal and social activities.

Fereday, J., & Oster, C. (2010). Managing a work–life balance: The experiences of midwives working in a group practice setting. Midwifery, 26 (3), 311-318.

Jordan, K., Fenwick, J., Slavin, V., Sidebotham, M., & Gamble, J. (2013). Level of burnout in a small population of Australian midwives. Women and Birth , 26 (2), 125-132.

Mollart, L., Skinner, V. M., Newing, C., & Foureur, M. (2013). Factors that may influence midwives work-related stress and burnout. Women and Birth , 26 , 26-32.

Pelvin, B. (2010). Life skills for midwifery practice. In S. Pairman, S. Tracy, C. Thorogood & J. Pincombe (Eds), Midwifery: Preparation for practice (2 nd ed.). (pp. 298-312). Chatswood, NSW: Elselvier Australia.

van der Riet, P., Rossiter, R., Kirby, D., Dluzewska, T., & Harmon, C. (2015). Piloting a stress management and mindfulness program for undergraduate nursing students: Student feedback and lessons learned. Nurse Education Today , 35 , 44-49.

White, L. (2013). Mindfulness in nursing: An evolutionary concept analysis. J ournal of Advanced Nursing , 70 (2), 282-294.

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Last Updated: Nov 6, 2023 9:23 AM
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Reflective practice

Recognise, reflect, resolve: the benefits of reflecting on your practice.

Working in health and care is rewarding but it is also fast paced, and can be challenging and stressful at times. Creating the space to reflect on your practice, by yourself, with a colleague or as part of a group, can help you to deal with high levels of pressure and share lessons learned to strengthen the important bonds within and across teams.

This information outlines the benefits regular reflection can have on your practice and gives examples of some of the ways you can achieve reflective practice.

What is reflection?

Learn what we mean by 'reflection' and how you can use it to gain insight into your professional practice

Types of reflective practice

Learn about the different types of reflective practice available to you. Which you use will depend on the nature and scope of your practice, your activity and your learning style

Reflection and meeting your standards

Information on how reflection and reviewing practice is vital for meeting all of your standards

Reflective practice case studies and template

This section provides a summary of reflective models that can make your reflections effective and a template to guide your own activities

Reflective practice FAQs

This section answers some frequently-asked questions about reflective practice, like how to document your reflection

Reflection and Action Plan in Nursing Practice Essay

To find inspiration for your paper and overcome writer’s block
As a source of information (ensure proper referencing)
As a template for you assignment

Reflection on an Identified Practice Issue

Action plan.

Reflection is an essential part of the practitioner’s activity as it aims at stimulating the professional to improve the skills and learn how to deal with difficult situations (Eaton 2016). When reflection is applied, the practitioner becomes more experienced and confident of his/her abilities (Jasper 2006, Blair & Deacon 2015, Howatson-Jones 2016). A reflective person is open to communication in the way of gaining the best outcomes for the patients. Critical thinking is considered an inseparable part of reflective practice (Lillyman & Merrix 2012, Thompson & Pascal 2012). Inability to accept criticism may be an obstruction to reflective practice as it often presupposes admitting one’s fault and being ready to improve one’s methods. On the other hand, being too much critical is also bad as it undermines the practitioner’s confidence in his/her knowledge and skills (Ely & Scott 2007).

The reflective cycle proposed by Gibbs is considered one of the most efficient models (Ely & Scott 2007, Scaife 2010, Bulman. & Schutz 2013). It includes the following stages: description, thoughts and feelings, evaluation, analysis, conclusion, and action plan (Ely & Scott 2007, p. 187). I shall apply this model when describing my reflection on the mentioned practice issue. The type of knowledge informing the practice is personal experience (Freeman& Sturdy 2015).

Description

I noticed that two of my colleagues often neglected the rules of hand hygiene. They did not always wash their hands or change gloves when switching from one type of work to another. Sometimes they disrespected the hygiene requirements because of the lack of time (for instance, when there was a patient delivered by an ambulance, and there was no time to spare because the person’s life was in danger and every minute was crucial).

However, frequently such disregard took place when there was no hurry (for example, they did not wash their hands after using the bathroom). After a careful decision-making process, I decided to let the charge nurse know about the situation. However, I also warned my colleagues about my decision and asked them to be more responsible. My resolution gave them time to realize their mistakes before being invited to the charge nurse’s office and asked for the explanation of their behaviour. I also asked the charge nurse not to be too harsh on them but at the same time let them know that even a minor misconduct in a health service work may lead to damaging outcomes for the patients.

Thoughts and Feelings

As a health practitioner, my first concern was about the patients’ wellbeing and health. If a medical worker disregards the simplest hygiene requirements, he/she may disobey other rules which are much more crucial and the breaking of which may lead to dramatic outcomes for the people’s health. I felt rather disappointed and disturbed. I did not know how to find a way out of the situation which would satisfy all the stakeholders. I realized that the patients’ health is the first and foremost concern for me as a health practitioner. At the same time, I understood that I needed to maintain a good relationship with my colleagues. This situation frustrated and upset me. I had a feeling that my colleagues did not value the people’s lives to the necessary extent. I also had a hard time thinking that I would set them up by telling the charge nurse about the incidents.

The experience allowed me to make both positive and negative conclusions. I realized that I did a good thing when I noticed the situation and decided to take measures. My basic professional instinct is taking care of the patients, and in this case I was thinking about their health and wellbeing. On the other hand, I was disturbed because I was doing some harm to my colleagues by pointing out their wrong behaviour to the charge nurse. It would have negative outcomes on them. However, taking into consideration all the sides of the situation, I think I did the right thing. Maybe my colleagues will be punished, but they must not forget about their highest priority as healthcare practitioners. This case will teach them a lesson. I hope that they will be more considerate about their hygiene in future. Additionally, this minor case will teach them to be cautious about major cases. As a result, they will remember that someone’s health is in their hands, and they must conform to all the rules in order to provide the patients with the best care.

This situation taught me several lessons. First of all, it is vital to remember one’s responsibilities under any circumstances. Even though I did not want to hurt my colleagues, I was thinking of the patients’ welfare in the first place. I realize that as notice someone’s misbehaviour, other people might see mine. Therefore, this case taught me to be more cautious about the rules and obligations. Another thing I took from this issue is that it is necessary to keep on good terms with one’s colleagues. While I disapproved of some practitioners’ misconduct, I did not just go and report on them. I explained the situation to them and emphasized the significance of their correct behaviour. I did everything possible to maintain the favourable relationships with my co-workers.

There were two other resolutions I could have made. I could either tell my colleagues that I noticed their wrong conduct and ask them to stop, or I could complain to the charge nurse and not warn the people why she would have a conversation with them. In the first case, I would most likely earn the co-worker’s respect and hear a promise that such situations would never repeat. However, I could not be sure about their conscientiousness in future. In the second case, my colleagues would consider me a traitor who reported on them without explaining the situation. These two decisions are worse than the one I made because they only view the case under one angle. My resolution was the most suitable and included consideration of every side of the situation.

In future, if an identical situation occurs, I will develop a similar strategy. If I see any violations which may put the patients’ wellbeing under threat, I will let the authorities know about that, but at the same time, I will reveal my intentions to the colleagues involved. I believe that this is the most suitable way out of such practice issue. Patient’s health is my priority interest, but I also want to have good relationships with my co-workers.

Blair, E. & Deacon, A. (2015) A holistic approach to fieldwork through balanced reflective practice. Reflective Practice 16(3), 418-434.

Bulman, C. & Schutz, S., (eds.) (2013) Reflective Practice in Nursing , 5 th edn. Wiley-Blackwell, Chichester.

Eaton, C. (2016) “I don’t get it,” – the challenge of teaching reflective practice to health and care practitioners. Reflective Practice 17(2), 159-166.

Ely, C. & Scott, I. (2007) Essential Study Skills for Nursing . Elsevier, Edinburgh.

Freeman, R. & Sturdy, S. (2015) Knowledge in Policy: Embodied, Inscribed, Enacted . Policy Press, Bristol.

Howatson-Jones, L. (2016) Reflective Practice in Nursing , 3 rd edn. Sage, Los Angeles.

Jasper, M. (2006) Professional Development, Reflection, and Decision-making . Blackwell Publishing, Oxford.

Lillyman, S. & Merrix P. (2012) Nursing and Health Survival Guide: Portfolios and Reflective Practice . Routledge, London.

Scaife, J. (2010) Supervising the Reflective Practitioner: An Essential Guide to Theory and Practice . Routledge, London.

Thompson, N. & Pascal, J. (2012) Developing critically reflective practice. Reflective Practice 13(2), 311-325.

The Clinical Nurse Leader' Role: Risk Anticipator
Health History in the Genogram Presentation
Gibb's Reflective Cycle: Analysis
Hand Hygiene and Alcohol-Based Sanitizers
Reflective Practice Skills Analysis
Family Nurse Practitioners: Self Assessment Plan
Therapeutic Communication and Direct Care Nurse's Role
Advanced Practice Nurse: Roles, Pros and Cons
Advanced Practice Nurse's Skills and Duties
Reflective Learning and Nursing Burnout
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Article Contents

Introduction, ethics capability and ethics codes, objectives in revising the code of public health ethics in the usa, acknowledgements.

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Ethics codes and reflective practice in public health

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Bruce Jennings, Ethics codes and reflective practice in public health, Journal of Public Health , Volume 42, Issue 1, March 2020, Pages 188–193, https://doi.org/10.1093/pubmed/fdy140

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In public health, acting ethically and fulfilling obligations to the public requires careful reflection and intentional decision making. This article discusses the role that an ethics code in public health can play in providing both an educational tool and a behavioral standard. It argues that maintaining public trust requires that public health personnel to live up to standards of professionalism in their conduct, and in order to do so they must have the capabilities necessary to cope in an ethically reflective manner with the pressures and decisions they face. The article illustrates this perspective by discussing the public health ethics code revision process currently underway in the USA.

In a policy-making and regulatory activity as complex as public health, acting ethically and fulfilling obligations to the public requires careful reflection and intentional decision making. The obligation to sustain the public trust and to promote the health and well-being of individuals and society as a whole not only pertains to governmental officials and civil servants, but also to those who practice public health in civil society and the private sector. Public health actions are based on evidence—both scientific observations as well as lived experience—but they are also based on what is valued in the professional culture of public health and what is valued in society at large. Public health decisions affect the health and well-being of diverse individuals, groups and communities. Social legitimacy and public trust are always essential to effective public health policies and programs, and hence to the promotion of the public’s health.

Ideals of human rights, individual liberty, social justice and equality, community, solidarity and the common good should guide public health policy and practice. In sum, possessing specialized knowledge and skill, providing service to the needs of others and respecting their rights, being entrusted with special powers and authority, and being committed to special ethical responsibilities in the use of that power are attributes that public health shares with other groups that are recognized as ‘professions’ in society today. At the same time, however, existing structures of power, coercion, discrimination and stigma also shape the policies and practices of all professions, including public health.

In this article, I begin by sketching a rather general perspective on the delimited, but still important, role that creating, updating and employing an ethics code can have over time as both an educational tool and a behavioral standard. I then attempt briefly to show how an appreciation of an ethics code as an educational tool has informed one public health ethics code revision process currently underway in the USA. Those working to reshape the US code of public health ethics and to bring it up to date have been intentional in providing both a form and a content for the code that will facilitate its educative value and effects.

Even this brief sketch of the situation of public health suggests how important it is for public health personnel to live up to standards of professionalism in their conduct; how vital it is that they have the capabilities necessary to cope in a robust and thoughtful manner with the pressures and decisions they face. A solid education in ethics is no less important for public health practitioners than excellent training in the health sciences and in the analytic techniques of health policy and management. The study of ethics includes conceptual refinement and clarification (normative ethics) and empirical studies of beliefs and attitudes in a diverse society (descriptive ethics). Both conceptual understanding and social–cultural acuity are essential in the professional practice of public health. The question is: How can social judgment and the ideals and standards of normative ethics be integrated within the structure of professional activity?

Historically, part of the answer to this question has been provided by formal, written codes of professional ethics. Of course, there are many ways of looking at the purposes served by professional codes of ethics, and different professional or occupational groups use the in different ways. Many scholars take a skeptical view of codes and focus on their status functions, while others focus on the substantive ideals and ethical commitments codes articulate. 1 I would like to bring these two perspectives into dialogue, recognizing the legitimizing and status conferring effects of public statements of ethical standards such as codes provide, but also acknowledging the philosophical validity of the norms codes often contain, especially when they assert duties of public service rather than merely the protection of professional self-interest. As a keen observer of professional ethics, Mark S. Frankel, argued: ‘A profession’s code of ethics is perhaps its most visible and explicit enunciation of its professional norms. A code embodies the collective conscience of a profession and is testimony to the group’s recognition of its moral dimension’. 2

Even from this point of view, today it seems clear that the promulgation of written codes of ethics alone is not sufficient to ensure professionalism in practice. More direct systemic, institutional, cultural and psychological influences shape the ethical conduct of public health professionals. These factors—such as racial prejudice and bureaucratic inertia and tunnel vision—must be addressed head on and met with strategic efforts at organizational change and the redistribution of power. Nonetheless, it is important for professions to take codes of ethics seriously. Undertaking the development or revision of code documents can and often does set in motion a healthy process of institutional self-reflection and sensitization. Once established on an ongoing basis, codes can play a meaningful part in promoting and sustaining a humane and respectful ethos of moral recognition and care in public health. They are not manuals or cookbooks to be mechanically followed, but their language and provisions can be a touchstone for ethical reflection and debate. By providing critical diagnosis and aspirational alternatives, codes can even address the structural and cultural factors that make the conduct of the field fall short of its own ideals and those of the broader society.

Sometimes codes take the form of credos, brief statements of principles and values. Other codes provide a lengthy list of propositions, often called ‘black-letter rules,’ stating prohibitions, obligations, standards of conduct or moral virtues the professional is expected to adhere to and exemplify. For example, the professional code of ethics produced by the American Medical Association in 1847 was a detailed account of the role and calling of physicians. 3 In medicine, such codes were considered quite important at the time because public trust was based on not only specialized training and knowledge but also on high ethical standards that set the professional group apart from competing service entrepreneurs. 4 The contrast between the history of medicine in America and public health suggests the importance of institutional and economic factors shaping the identity and norms of professions. 5 Organized public health activity came on the scene somewhat later and was a governmental entity for the most part, rather than a fee-for-service enterprise. Therefore the credibility and legitimacy of public health was not so consumer or market driven; it had no ‘clients’ to attract and satisfy. The police powers of the state underpinned the influence of public health, while the aura of professionalism (with its promise of both efficacy and trustworthiness) underpinned private sector medicine. During the first half of the 20th century, in both medicine and public health, as well as several other professional fields attracted by positive science and objectivity, an older emphasis on ethics receded in favor of technical expertise, competence and proficiency. However, by the 1970 and 1980s, a cultural backlash against virtually all forms of social authority and elitism, including the professions, led to challenges to monopolistic practices of the professions, challenges to the sufficiency of merely technical knowledge and expertise, and forced increasingly beleaguered professions to return to their ethical and service traditions. 6 One result was a proliferation of many new and revised professional codes of ethics during this period and a growing literature on professional ethics. 7

Many professional associations turn to codes of ethics or other official statements of ethical ideals, standards and rules in order to guide individual professionals who encounter the pressure to make decisions under conditions of uncertainty and who confront difficult choices among competing principles and values. However, no professional code of ethics interprets or applies itself, and none can do without the ethical discernment and capability of both individual practitioners and the organizations within which they work. 8 Ethical professionalism, in public health as elsewhere, is both a communal and an individual endeavor.

Overreliance on an ethics code understood as a set of black-letter rules, standards and obligations amounts to what might be called the ‘ethics manual’ fallacy. It is problematic for two reasons. First, it fails to give sufficient weight to the role of professional judgment in the interpretation of the rules of the manual. It aspires to, but in fact cannot, do without critical reasoning and understanding on the part of the professional rank and file; qualities which perforce must be cultivated somehow nonetheless. Indeed, when an ethics code is understood as merely an ethics manual in this way, it can even undermine critical reasoning in the profession because it promotes behavior that is legalistic, cautious and ethically narrow, if not unduly self-interested in relation to the professional status group.

To offset this tendency, in writing and in using professional codes of ethics it is important to combine proscriptive regulation with the promotion of moral learning, empathy, judgment and critical reasoning capacity. These can be named and called for explicitly within a code itself, of course. But what really matters is to supplement the code and surround it with an ethos of ongoing ethical dialogue within the profession so that ethical choices and challenges can become an everyday part of professional outlook and awareness. That is why, rather than focus on a code as an enforceable set of standards and rules only, I prefer to ask how a code can be an aspect of an ongoing process of ethics education and capacity building.

In what does an ethics education and capacity-building in public health consist? It is not for public health leaders and organizational executives alone. Ethics capacity building should strive for proficiency at all levels of activity and management. In the domain of ethics, at least, I think it is helpful to understand ‘proficiency’ as consisting of two components: macro-level reasoning skills and micro-level competencies.

There are four macro-level skills that should be noted here: (i) understanding the theoretical basis for ethical and political controversies in public health policy and practice; (ii) comprehending professional ethical norms and standards in public health; (iii) critically and systematically applying ethical theories and principles to practical decision-making issues in public health policy and practice; and (iv) being able to deliberate with peers and with the attentive public about the goals of public health measures and the values supporting those goals.

For their part, micro-level competencies come into play when a public health decision maker is operating in a situation of problem identification, assessment, choice of course of action and follow-up evaluation. The requisite competencies in this context are: (i) the ability to identify the ethical issues germane to the decision and to identify the specific values at stake in the decision; (ii) to assess the factual information available to the decision maker(s); (iii) to identify and reach out to involve the appropriate ‘stakeholders’ in the decision; (iv) to identify the options available to the decision maker; and (v) to consider the process for making the decision and the values that pertain to the process, such as transparency and inclusiveness.

In order to provide more detail concerning the possibilities of connecting a code of ethics with reflective practice and a quality improvement oriented process of ethics capacity building, I will briefly discuss the currently ongoing process within the American Public Health Association (APHA) to revise and update the public health code of ethics in informal use in the USA. In 2015 APHA convened a task force charged with revising, expanding and updating the code of public health ethics that had been adopted and promulgated in 2002. 9 In that year, for the first time, the largest public health association in the USA publicly stated the ethical expectations of the field, focusing on the ethical obligations of public health organizations. 10 The original authors of the 2002 code envisioned it as a living document that would change over time to accommodate and respond to shifts and innovations in the field. Mindful of such change in the intervening years, the 2015 task force intended to expand the document so that it encompassed not only the responsibilities of public health organizations but also individual practitioners as well.

The ethics code task force began with several important convictions concerning what a new code should contribute to the profession and practice of public health. It must explain—rather than merely assert—ethical standards and obligations for public health personnel and institutions. It should provide practical assistance with individual and collective decision making, especially in ethically challenging or ambiguous situations. The code should be concerned with both substantive ends (what ought to be achieved through public health policies and practices?) and with procedural means (how ought beneficial and just ends be achieved through public health policies and practices?).

In terms of ethical theory, the task force did not adopt a deductive approach based on covering principles of either a utility (i.e. health) maximizing sort or a rights-based orientation. We attempted to articulate the notion that justice pertains both to the outcomes of public health policies and practices and to the processes and procedures used to achieve those outcomes. Nor did we assert that health is the supreme value driving the practice of public health. Health promotion is one ethical pillar upon which public health rests, but it is not the only one. We adopted a more holistic and person-centered ideal (referred to as ‘human flourishing’) as our ethical touchstone in the code. This decision seemed in keeping with the epidemiological and intellectual orientation of our field, which is socially environmentally oriented and resists biological reductionisms of various kinds.

Regarding just process, the task force was guided by the notion that justice requires a deliberative and inclusive decision-making process in order to ensure that authority and power in public health is exercised in fair and productive ways. This in turn helps public health professionals and institutions maintain public trust and provides for a well-reasoned rationale, explanation and defense when public health measures are controversial and when the legitimacy of public health authority is called into question.

It is noteworthy, and unusual, that the revised US code begins with a short list of core values (as did its predecessor in 2002). These values are not states of the world that public health creates so much as they are preconditions for the possibility and success of public health, ethically considered. Here are the concepts and brief formulations used to articulate public health’s core values:

Fidelity and responsibility : The effectiveness of public health policies, practices and actions depends upon public trust gained through decisions based on the highest ethical, scientific and professional standards.

Health and safety : Public health personnel and organizations have an ethical responsibility to prevent, minimize and mitigate health harms, and promote and protect public safety, health and well-being.

Health justice and equity : Public health personnel and organizations have an ethical obligation to use their knowledge, skills, experience and influence to promote an equitable distribution of burdens, benefits and opportunities for health, regardless of an individual’s or a group’s relative position in social hierarchies.

Interdependence and solidarity : Public health personnel and organizations have an ethical obligation to foster positive—and to reduce or minimize negative—relationships among individuals, societies and environments in ways that protect and promote the flourishing of humans, communities, non-human animals and the ecologies in which they live.

Liberty : Public health personnel and organizations have an ethical responsibility to protect and promote a free and open society and respect the basic liberties of individuals.

Inclusivity . Public health personnel and organizations have an ethical responsibility to be inclusive of, transparent to and accountable to the public at large.

Identifying and cultivating ethical best practices is a reflective and dynamic endeavor. Whatever the specific content of public health policies and practices may be in particular communities at any given time, public health would be adrift without these values orientations or if it were practiced in the absence of public trust, in a society lacking in solidarity and individual liberty, in a closed and discriminatory, excluding way, and if they did not actually sustain health and safety in the long run. Therefore these are core or ‘constitutive’ values for public health. This observation is not purely theoretical since these ethical values are not inherent in human society as such and rarely, if ever, arise spontaneously. They are historically contingent, fragile and require concerted, purposive activity to sustain. The motivating logic behind identifying such core values in a code of ethics is as follows: If the profession of public health takes its meaning and reason for being from these bio-social states of affairs, then it follows that its activities should be conducted in ways that sustain and foster these core values rather than in ways that ignore or undermine them.

Moreover, the notion that an ethics code and a surrounding ethos of moral learning or ethics education go together is reflected in the revised US code by the importance placed on professional judgment and the need to interpret general ethical norms in light of particular circumstances. Following Frankel, one may distinguish among three basic types of professional ethics codes: the ‘aspirational,’ the ‘educative’ and the ‘regulatory’. 11 The US code falls into the educative category. In keeping with this, the task force included in the code a section on the process of judgment. In reflecting on the best way to formulate this section, it used the following thought experiment: ‘If you were a public health professional deliberating in a leadership staff meeting with policy makers, or in a community forum where policy options are under debate, what basic ethical questions should be asked in any adequate deliberation, not matter what else was discussed? What questions would you identify, such that if none of them were discussed at all, you would reasonably feel that ethics had not been taken seriously?’

The draft US code identifies eight questions that should always be part of any deliberation or debate—implicitly or, better, explicitly—before a proposed public health intervention is undertaken: (i) ‘Would the action being considered be ethically wrong even if it were to have a good outcome?’; (ii) ‘Would the proposed action be demeaning or disrespectful to individuals and communities even if it benefited their health?’; (iii) ‘Have we done what is reasonable to offset the potential harms and losses that the public health requirements impose on individuals and communities?’; (iv) ‘Is it reasonable to expect, based on best available evidence and past experience, that the proposed action would achieve its stated health goals?’; (v) ‘Would the proposed action demonstrate good stewardship and deserve the trust that the public has invested in public health personnel?’; (vi) ‘Would the proposed action demonstrate that public health personnel are using their power and authority judiciously and with humility?’; (vii) ‘Would the proposed action withstand close ethical scrutiny and be justified by valid reasons that the general public will understand?’; and (viii) ‘In deciding on a proposed action, have all potentially affected stakeholders had a meaningful opportunity to participate, and, if not, is there ethical justification for not involving them?’

The final section of the revised US code is the most situation-specific and concrete. It uses a well-established classification system of 12 functional domains of public health management and practice, which includes activities such as community health surveillance and assessment, enforcement of public health laws, and measures to increase access to health and social services. 12 The code offers a set of prescriptive ‘should’ statements regarding ethically significant actions and decisions that often arise in each functional domain. A brief explanatory commentary accompanies each statement concerning what a public health professional or organization should do and how (in accordance with what fair and due process) their legal and professional judgment and discretion should be exercised.

Public health personnel and organizations should strive to provide accessible information about public health issues and functions to the public, including but not limited to political leaders, health care providers, affected populations and communities. Knowledge is a necessary (but insufficient) input into building healthy homes, workplaces and communities. Imparting accurate and accessible information requires that public health personnel and organizations use a variety of communication techniques and teaching methods, remaining sensitive to the diverse audiences they must reach. Doing so helps public health personnel meet their goals of protecting the health and safety of individuals and fostering the health of communities.

Ethical policies and practices to inform and educate the public about public health issues and functions should:

Attend to the needs of diverse audiences : Public health organizations serve individuals and communities that vary with respect to demographic characteristics, social and cultural factors, familiarity with public health, and health status. Ensuring that information and education about public health issues and functions are tailored to the needs of various audiences is critical to meeting the obligations of health and safety, justice and equity, and inclusivity.

Engage individuals and communities in the development of individual and collective solutions to public health issues : The process of informing and educating the public about public health issues and functions should include messages and processes that empower individuals and communities to participate in the development of healthy communities. Recognition of the interdependence of health and the solidarity needed for solutions to public health problems should be clearly communicated to the public.

‘Public health practice, research and organizations cannot protect the public’s health and perform their ethical obligations to society unless a well-trained, competent and well-motivated workforce exists as a resource to support them. Ultimately society as a whole must support this vital resource and provide the education and public funding necessary for its maintenance. Nonetheless, the field of public health itself and public health organizations must also do their part to maintain a competent workforce. This domain of public health function has ethical significance because ethical goals of public health cannot be met unless the work of public health is well done.

Ethical policies and practices to maintain a competent public health workforce should:

Provide adequate institutional and professional support to enable competent performance : In public health, as in other fields, there is a strong connection between an individual’s competent actions and the context within which a professional practices. Public health leaders and organizations should recognize the nature and significance of supportive context and make arrangements for individual public health personnel to be adequately supported, for without this competent performance is not a reasonable ethical expectation.

Think broadly and creatively about educational and training needs : It is important to be aware of ‘real-world’ environments and communities in which public health personnel work and how that affects their effective competence. Training should also be provided in the area of communications skills and political acumen related to public health work. Finally attention should be paid to often underutilized educational models such as apprenticeships and mentoring.

Note that the language just quoted from the first draft of the new code document is not final at the time of this writing and may be changed when the code is officially published. I quote these draft passages here simply to provide a flavor of tone that the task force tried to set in providing ethical guidance on practices within these functional domains. The draft code is currently undergoing wide review within the networks and sections of the APHA, among a broad range of stakeholder groups, and interested individuals, academics, researchers and practitioners. The document will be revised in light of comments received and then will work its way through another round of review before it is adopted in some form. Using its ideas and concepts creatively to vivify ethical awareness in the field will be our ongoing task and challenge.

When thinking of ethics, many first think of regulation, supervision and formal enforcement. Regulation, supervision and formal enforcement play their part in ensuring that professional conduct meets high ethical standards, to be sure, but these matters should be handled by duly authorized agencies and organizations. The revised code the APHA has been working on in the USA—like many others around the world—is not intended to be a disciplinary or regulatory document. 13 Its only authority is the force of conscience and reasoned argument. Its influence, if it has any, will come about because the normative ethos of the public health profession is receptive to such authority and because the moral imagination of the profession is broad enough to embrace the possibility of a better, more just society, as well as a healthier one.

This article is based on a Keynote Presentation delivered to the Workshop on Building Competency and Capability in Public Health Ethics and Law, held at the Royal Society of Medicine in London on 18 January 2018. I wish to thank colleagues at the workshop for their comments and discussion, in particular A.M. Viens, John Coggon and Farhang Tahzib from whose ongoing work on ethics capacity building in public health I have learned a great deal. I should also like to thank two anonymous reviewers for the Journal of Public Health for their helpful comments on an earlier draft of this article.

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Study Skills

Reflective practice toolkit.

Introduction

What is reflective practice?

Everyday reflection
Models of reflection
Barriers to reflection
Free writing
Reflective writing exercise
Bibliography

Reflective practice

Reflective practice is the ability to reflect on one's actions so as to engage in a process of continuous learning.

- Donald Schon

Imagine that you come home at the end of a really bad week where everything possible has gone wrong. When you walk in the front door you are confronted with a time machine which can take you back to Monday morning so you can live the whole week over again. You use this opportunity to think about everything that went wrong and what you could do (if anything) to correct things as well as trying to repeat the things that you have done right. It may not seem like it but this is reflective practice - the act of thinking about our experiences in order to learn from them for the future. In real life you probably don't have access to time travel but you can still work towards being a reflective practitioner. We can all undertake activities to think about our experiences, learn from them and develop an action plan for what we will do next.

Reflective practice was something which developed in disciplines such as teaching, medicine and social work as a way to learn from real life experiences. People in these areas would think about encounters with their students, patients or clients, how these worked and what lessons they could take away. Over time many other areas have adopted the principles of reflective practice, including universities. You can use reflection when studying, for example when preparing group work or when working on assignments. It is also useful beyond academia when you are applying for jobs, as part of a professional qualification or just as a way of thinking about your role.

Although a definition of reflective practice has been included above this is only one part of a larger process. Reflection is a very personal thing and different people will define it in different ways. It is important to remember that there is no one 'correct' way of defining what reflection is or how it should be done as a lot of this will depend on your own circumstances.

Think about ... Definitions

Take a few minutes to think about what reflective practice means to you. There is no right or wrong answer to this question and your answer will depend on many factors and your own background. Keep this definition in mind as you read through the rest of the resource.

Why reflect?

You can practice reflection during your education, within the workplace or as part of your general personal wellbeing. It has many benefits at both a personal and professional level and can help you to focus on planning for future experiences.

So what are the main benefits of reflection?

When you're studying you are likely to be very involved in your work and achieving academic success. It can be easy to become too focused on your work in this situation but reflective practice allows you to look at the bigger picture. Undertaking regular reflection, for example once a term, can help you to think about your goals for studying and your plans for the future.
It can help with the issue of 'self-talk'. We all have a little voice inside our heads which reminds us of all the things we could have done differently in certain situations. Reflecting on an experience can help to put this voice to use as we learn from what we have done and move forward.
It gives you areas to improve on or develop. Whether you are a student or in the workplace you will find that you are constantly being asked for ways in which you can develop your knowledge and skills. Undertaking reflections can help you to think about areas that you can work on as well as what you are doing well.
Students are often asked to reflect as part of their assignments or coursework. Your tutor may give you an exercise where you have to think about a topic in relation to your own experiences or you may have to reflect on something as part of a general essay question.
Reflection can help you to be more creative and try new things. It's very easy to get stuck in a rut and it can be helpful to think about what you are doing and why you are doing it. This can help to spark new ideas and ways of thinking.
Human nature means that we all make assumptions about people and situations. Taking a step back and reflecting can help you to challenge some of these assumptions and see things from a new perspective.
Reflection is a key part of emotional intelligence - the ability to understand and remain in control of our emotions. This is a useful skills to have both for our own wellbeing and when working with others.
It helps to maintain a healthy work/life balance by offering a defined process for thinking things through. Hopefully you can learn from them and move on rather than dwelling on what happened.

How to reflect

Now you understand the benefits of being reflective how do you actually go about doing it? There is no one magic formula to follow and you will find that what works for your peers might not work for you. Some people find reflecting out loud works for them whilst for others it's something private. You can be really organised and regularly write your reflections down or you can do it as and when you can. It's best if you can reflect regularly as this will help you get into the habit and you will be able to build on what you learn.

The easiest way to get started with reflection is to ask yourself some of the following questions about the experience you want to reflect on. As you look at the questions think about how you might record your answers, for example in a reflective journal, so that you can remember them in the future.

Reflective questions transcript [Word]
Reflective questions transcript [PDF]

This section has introduced the concept of reflective practice and what you might use it for. As we move through this resource you will be encouraged to think about how you might make reflection work for you and how you can become a reflective person in your everyday life.

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Reflection and reflective practice in health professions education: a systematic review

Reflections
Published: 23 November 2007
Volume 14 , pages 595–621, ( 2009 )

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Karen Mann 1 ,
Jill Gordon 2 &
Anna MacLeod 3

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The importance of reflection and reflective practice are frequently noted in the literature; indeed, reflective capacity is regarded by many as an essential characteristic for professional competence. Educators assert that the emergence of reflective practice is part of a change that acknowledges the need for students to act and to think professionally as an integral part of learning throughout their courses of study, integrating theory and practice from the outset. Activities to promote reflection are now being incorporated into undergraduate, postgraduate and continuing medical education, and across a variety of health professions. The evidence to support and inform these curricular interventions and innovations remains largely theoretical. Further, the literature is dispersed across several fields, and it is unclear which approaches may have efficacy or impact. We, therefore, designed a literature review to evaluate the existing evidence about reflection and reflective practice and their utility in health professional education. Our aim was to understand the key variables influencing this educational process, identify gaps in the evidence, and to explore any implications for educational practice and research.

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Reflective Practice in Health Professions Education

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Acknowledgements

We acknowledge with thanks the contribution to the conduct of this study by the Society of Directors of Research in Medical Education. Thanks also to Drs. Kevin Eva and Joan Sargeant for their helpful feedback.

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Mann, K., Gordon, J. & MacLeod, A. Reflection and reflective practice in health professions education: a systematic review. Adv in Health Sci Educ 14 , 595–621 (2009). https://doi.org/10.1007/s10459-007-9090-2

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Published : 23 November 2007

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DOI : https://doi.org/10.1007/s10459-007-9090-2

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Published: 26 August 2024

Solid health care waste management practice in Ethiopia, a convergent mixed method study

Yeshanew Ayele Tiruneh 1 ,
L. M. Modiba 2 &
S. M. Zuma 2

BMC Health Services Research volume 24 , Article number: 985 ( 2024 ) Cite this article

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Metrics details

Introduction

Healthcare waste is any waste generated by healthcare facilities that is considered potentially hazardous to health. Solid healthcare waste is categorized into infectious and non-infectious wastes. Infectious waste is material suspected of containing pathogens and potentially causing disease. Non-infectious waste includes wastes that have not been in contact with infectious agents, hazardous chemicals, or radioactive substances, similar to household waste, i.e. plastic, papers and leftover foods.

This study aimed to investigate solid healthcare waste management practices and develop guidelines to improve solid healthcare waste management practices in Ethiopia. The setting was all health facilities found in Hossaena town.

A mixed-method study design was used. For the qualitative phase of this study, eight FGDs were conducted from 4 government health facilities, one FGD from each private health facility (which is 37 in number), and forty-five FGDs were conducted. Four FGDs were executed with cleaners; another four were only health care providers because using homogeneous groups promotes discussion. The remaining 37 FGDs in private health facilities were mixed from health professionals and cleaners because of the number of workers in the private facilities. For the quantitative phase, all health facilities and health facility workers who have direct contact with healthcare waste management practice participated in this study. Both qualitative and quantitative study participants were taken from the health facilities found in Hossaena town.

Seventeen (3.1%) health facility workers have hand washing facilities. Three hundred ninety-two (72.6%) of the participants agree on the availability of one or more personal protective equipment (PPE) in the facility ‘‘ the reason for the absence of some of the PPEs, like boots and goggles, and the shortage of disposable gloves owes to cost inflation from time to time and sometimes absent from the market’’ . The observational finding shows that colour-coded waste bins are available in 23 (9.6%) rooms. 90% of the sharp containers were reusable, and 100% of the waste storage bins were plastic buckets that were easily cleanable. In 40 (97.56%) health facilities, infectious wastes were collected daily from the waste generation areas to the final disposal points. Two hundred seventy-one (50.2%) of the respondents were satisfied or agreed that satisfactory procedures are available in case of an accident. Only 220 (40.8%) respondents were vaccinated for the Hepatitis B virus.

Hand washing facilities, personal protective equipment and preventive vaccinations are not readily available for health workers. Solid waste segregation practices are poor and showed that solid waste management practices (SWMP) are below the acceptable level.

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Healthcare waste (HCW) encompasses all types of waste generated while providing health-related services, spanning activities such as diagnosis, immunization, treatment, and research. It constitutes a diverse array of materials, each presenting potential hazards to health and the environment. Within the realm of HCW, one finds secretions and excretions from humans, cultures, and waste containing a stock of infectious agents. Discarded plastic materials contaminated with blood or other bodily fluids, pathological wastes, and discarded medical equipment are classified as healthcare waste. Sharps, including needles, scalpels, and other waste materials generated during any healthcare service provision, are also considered potentially hazardous to health [ 1 ].

Healthcare waste in solid form (HCW) is commonly divided into two primary groups: infectious and non-infectious. The existence of pathogens in concentrations identifies infectious waste or amounts significant enough to induce diseases in vulnerable hosts [ 1 ] If healthcare facility waste is free from any combination with infectious agents, nearly 85% is categorized as non-hazardous waste, exhibiting characteristics similar to conventional solid waste found in households [ 2 ]. World Health Organization (WHO) recommends that appropriate colour-coded waste receptacles be available in all medical and other waste-producing areas [ 3 ].

Solid waste produced in the course of healthcare activities carries a higher potential for infection and injury than any other type of waste. Improper disposal of sharps waste increases the risk of disease transmission among health facility workers and general populations [ 1 ]. Inadequate and inappropriate handling of healthcare waste may have serious public health consequences and a significant environmental impact. The World Health Organization (2014) guidelines also include the following guidance for hand washing and the use of alcohol-based hand rubs: Wash hands before starting work, before entering an operating theatre, before eating, after touching contaminated objects, after using a toilet, and in all cases where hands are visibly soiled [ 4 ].

Among the infectious waste category, sharps waste is the most hazardous waste because of its ability to puncture the skin and cause infection [ 3 ]. Accidents or occurrences, such as near misses, spills, container damage, improper waste segregation, and incidents involving sharps, must be reported promptly to the waste management officer or an assigned representative [ 5 ].

Africa is facing a growing waste management crisis. While the volumes of waste generated in Africa are relatively small compared to developed regions, the mismanagement of waste in Africa already impacts human and environmental health. Infectious waste management has always remained a neglected public health problem in developing countries, resulting in a high burden of environmental pollution affecting the general masses. In Ethiopia, there is no updated separate regulation specific to healthcare waste management in the country to enforce the proper management of solid HCW [ 6 ].

In Ethiopia, like other developing countries, healthcare waste segregation practice was not given attention and did not meet the minimum HCWM standards, and it is still not jumped from paper. Previous study reveals that healthcare waste generation rates are significantly higher than the World Health Organization threshold, which ranges from 29.5–53.12% [ 7 , 8 ]. In Meneilk II Hospital, the proportion of infectious waste was 53.73%, and in the southern and northern parts of Ethiopia, it was 34.3 and 53%, respectively. Generally, this figure shows a value 3 to 4 times greater than the threshold value recommended by the World Health Organization [ 7 ].

Except for sharp wastes, segregation practice was poor, and all solid wastes were collected without respecting the colour-coded waste disposal system [ 9 ]. The median waste generation rate was found to vary from 0.361- 0.669 kg/patient/day, comprising 58.69% non-hazardous and 41.31% hazardous wastes. The amount of waste generated increased as the number of patients flow increased. Public hospitals generated a high proportion of total healthcare waste (59.22%) in comparison with private hospitals (40.48) [ 10 ]. The primary SHCW treatment and disposal mechanism was incineration, open burning, burring into unprotected pits and open dumping on municipal dumping sites as well as in the hospital backyard. Carelessness, negligence of the health workers, patients and cleaners, and poor commitment of the facility leaders were among the major causes of poor HCWM practice in Ethiopia [ 9 ]. This study aimed to investigate solid healthcare waste management practices and develop guidelines to improve solid healthcare waste management practices in Ethiopia.

The setting for this study was all health facilities found in Hossaena town, which is situated 232 kms from the capital city of Ethiopia, Addis Ababa, and 165 kms from the regional municipality of Hawasa. The health facilities found in the town were one university hospital, one private surgical centre, three government health centres, 17 medium clinics, and 19 small clinics were available in the city and; health facility workers who have direct contact with generating and disposal of HCW and those who are responsible as a manager of health facilities found in Hossaena town are the study settings. All health facilities except drug stores and health facility workers who have direct contact with healthcare waste generation participated in this study.

A mixed-method study design was used. For the quantitative part of this study, all healthcare workers who have direct contact with healthcare waste management practice participated in this study, and one focus group discussion from each health facility was used. Both of the study participants were taken from the same population. All health facility workers who have a role in healthcare waste management practice were included in the quantitative part of this study. The qualitative data collection phase used open-ended interviews, focus group discussions, and visual material analysis like posters and written materials. All FGDs were conducted by the principal investigator, one moderator, and one note-taker, and it took 50 to 75 min. 4–6 participants participated in each FGD.

According to Elizabeth (2018: 5), cited by Creswell and Plano (2007: 147), the mixed method is one of the research designs with philosophical assumptions as well as methods of inquiry. As a method, it focuses on collecting, analyzing, and mixing both quantitative and qualitative data in a single study. As a methodology, it involves philosophical assumptions guiding the direction of the collection and analysis and combining qualitative and quantitative approaches in many phases of the research project. The central premise is that using qualitative and quantitative approaches together provides a better understanding of the research problems than either approach alone.

The critical assumption of the concurrent mixed methods approach in this study is that quantitative and qualitative data provide different types of information, often detailed views of participants’ solid waste management practice qualitatively and scores on instruments quantitatively, and together, they yield results that should be the same. In this approach, the researcher collected quantitative and qualitative data almost simultaneously and analyzed them separately to cross-validate or compare whether the findings were similar or different between the qualitative and quantitative information. Concurrent approaches to the data collection process are less time-consuming than other types of mixed methods studies because both data collection processes are conducted on time and at the same visit to the field [ 11 ].

Data collection

The data collection involves collecting both quantitative and qualitative data simultaneously. The quantitative phase of this study assessed three components. Health care waste segregation practice, the availability of waste segregation equipment for HCW segregation, temporary storage facilities, transportation for final disposal, and disposal facilities data were collected using a structured questionnaire and observation of HCW generation. Recycling or re-using practice, waste treatment, the availability of the HCWM committee, and training data were collected.

Qualitative data collection

The qualitative phase of the data collection for this study was employed by using focus group discussions and semi-structured interviews about SHCWMP. Two focus group discussions (FGD) from each health facility were conducted in the government health facilities, one at the administrative level and one at the technical worker level, and one FGD was conducted for all private health facilities because of the number of available health facility workers. Each focus group has 4–6 individuals.

In this study, the qualitative and the quantitative data provide different information, and it is suitable for this study to compare and contrast the findings of the two results to obtain the best understanding of this research problem.

Quantitative data collection

The quantitative data were entered into Epi data version 3.1 to minimize the data entry mistakes and exported to the statistical package for social science SPSS window version 27.0 for analysis. A numeric value was assigned to each response in a database, cleaning the data, recoding, establishing a codebook, and visually inspecting the trends to check whether the data were typically distributed.

Data analysis

Data were analyzed quantitatively by using relevant statistical tools, such as SPSS. Descriptive statistics and the Pearson correlation test were used for the bivariate associations and analysis of variance (ANOVA) to compare the HCW generation rate between private and government health facilities and between clinics, health centres and hospitals in the town. Normality tests were performed to determine whether the sample data were drawn from a normally distributed population.

The Shapiro–Wilk normality tests were used to calculate a test statistic based on the sample data and compare it to critical values. The Shapiro–Wilk test is a statistical test used to assess whether a given sample comes from a normally distributed population. The P value greater than the significance level of 0.05 fails to reject the null hypothesis. It concludes that there is not enough evidence to suggest that the data does not follow the normal distribution. Visual inspection of a histogram, Q-Q plot, and P-P plot (probability-probability plot) was assessed.

Bivariate (correlation) analysis assessed the relationships between independent and dependent variables. Then, multiple linear regression analysis was used to establish the simple correlation matrices between different variables for investigating the strength relationships of the study variables in the analysis. In most variables, percentages and means were used to report the findings with a 95% confidence interval. Open-ended responses and focused group findings were undertaken by quantifying and coding the data to provide a thematic narrative explanation.

Appropriate and scientific care was taken to maintain the data quality before, during, and after data collection by preparing the proper data collection tools, pretesting the data collection tools, providing training for data collectors, and proper data entry practice. Data were cleaned on a daily basis during data collection practice, during data entry, and before analysis of its completeness and consistency.

Data analysis in a concurrent design consists of three phases. First, analyze the quantitative database in terms of statistical results. Second, analyze the qualitative database by coding the data and collapsing the codes into broad themes. Third comes the mixed-method data analysis. This is the analysis that consists of integrating the two databases. This integration consists of merging the results from both the qualitative and the quantitative findings.

Descriptive analysis was conducted to describe and summarise the data obtained from the samples used for this study. Reliability statistics for constructs, means and modes of each item, frequencies and percentage distributions, chi-square test of association, and correlations (Spearman rho) were used to portray the respondents’ responses.

All patient care-providing health facilities were included in this study, and the generation rate of healthcare waste and composition assessed the practice of segregation, collection, transportation, and disposal system was observed quantitatively using adopted and adapted structured questionnaires. To ensure representativeness, various levels of health facilities like hospitals, health centres, medium clinics, small clinics and surgical centres were considered from the town. All levels of health facilities are diagnosing, providing first aid services and treating patients accordingly.

The hospital and surgical centre found in the town provide advanced surgical service, inpatient service and food for the patients that other health facilities do not. The HCW generation rate was proportional to the number of patients who visited the health facilities and the type of service provided. The highest number of patients who visited the health facilities was in NEMMCSH; the service provided was diverse, and the waste generation rate was higher than that of other health facilities. About 272, 18, 15, 17, and 20 average patients visited the health facilities daily in NEMMCSH: government health centres, medium clinics, small clinics, and surgical centres. Paper and cardboard (141.65 kg), leftover food (81.71 kg), and contaminated gloves (42.96 kg) are the leading HCWs generated per day.

A total of 556 individual respondents from sampled health facilities were interviewed to complete the questionnaire. The total number of filled questionnaires was 540 (97.1) from individuals representing these 41 health facilities.

The principal investigator observed the availability of handwashing facilities near SHCW generation sites. 17(3.1%) of health facility workers had hand washing facilities near the health care waste generation and disposal site. Furthermore,10 (3.87%), 2 (2.1%), 2 (2.53%), 2 (2.1%), 1 (6.6%) of health facility workers had the facility of hand washing near the health care waste generation site in Nigist Eleni Mohamed Memorial Comprehensive Specialized Hospital (NEMMCSH), government health centres, medium clinics, small clinics, and surgical centre respectively. This finding was nearly the same as the study findings conducted in Myanmar; the availability of hand washing facilities near the solid health care waste generation was absent in all service areas [ 12 ]. The observational result was convergent with the response of facility workers’ response regarding the availabilities of hand washing facilities near to the solid health care waste generation sites.

The observational result was concurrent with the response of facility workers regarding the availability of hand-washing facilities near the solid health care waste generation sites.

The availability of personal protective equipment (PPE) was checked in this study. Three hundred ninety-two (72.6%) of the respondents agree on the facility’s availability of one or more personal protective equipment (PPE). The availability of PPEs in different levels of health facilities shows 392 (72.6%), 212 (82.2%), 56 (58.9%), 52 (65.8%), 60 (65.2%), 12 (75%) health facility workers in NEMMCSH, government health centres, medium clinics, small clinics, and surgical centres respectively agree to the presence of personal protective equipment in their department. The analysis further shows that the availability of masks for healthcare workers was above the mean in NEMMCSH and surgical centres.

Focus group participants indicated that health facilities did not volunteer to supply Personal protective equipment (PPEs) for the cleaning staff.

“We cannot purchase PPE by ourselves because of the salary paid for the cleaning staff.”

Cost inflation and the high cost of purchasing PPEs like gloves and boots are complained about by all (41) health facility owners.

“the reason for the absence of some of the PPEs like boots, goggles, and shortage of disposable gloves are owing to cost inflation from time to time and sometimes absent from the market is the reason why we do not supply PPE to our workers.”

Using essential personal protective equipment (PPEs) based on the risk (if the risk is a splash of blood or body fluid, use a mask and goggles; if the risk is on foot, use appropriate shoes) is recommended by the World Health Organization [ 13 ]. The mean availability of gloves in health facilities was 343 (63.5% (95% CI: 59.3–67.4). Private health institutions are better at providing gloves for their workers, 67.1%, 72.8%, and 62.5% in medium clinics, small clinics, and surgical centres, respectively, which is above the mean.

Research participants agree that.

‘‘ there is a shortage of gloves to give service in Nigist Eleni Mohamed Memorial Comprehensive Specialized Hospital (NEMMCSH) and government health centres .’’

Masks are the most available personal protective equipment for health facility workers compared to others. 65.4%, 55.6%, and 38% of the staff are available with gloves, plastic aprons and boots, respectively.

The mean availability of masks, heavy-duty gloves, boots, and aprons was 71.1%, 65.4%, 38%, and 44.4% in the study health facilities. Health facility workers were asked about the availability of different personal protective equipment, and 38% of the respondents agreed with the presence of boots in the facility. Still, the qualitative observational findings of this study show that all health facility workers have no shoes or footwear during solid health care waste management practice.

SHCW segregation practice was checked by observing the availability of SHCW collection bins in each patient care room. Only 4 (1.7%) of the room’s SHCW bins are collected segregated (non-infectious wastes segregated in black bins and infectious wastes segregated in yellow bins) based on the World Health Organization standard. Colour-coded waste bins, black for non-infectious and yellow for infectious wastes, were available in 23 (9.6%) rooms. 90% of the sharp containers were reusable, and 100% of the waste storage bins were plastic buckets that were easily cleanable. Only 6.7% of the waste bins were pedal operated and adequately covered, and the rest were fully opened, or a tiny hole was prepared on the container’s cover. All of the healthcare waste disposal bins in each health facility and at all service areas were away from the arm’s reach distance of the waste generation places, and this is contrary to World Health Organization SHCWM guidelines [ 13 ]. The observation result reveals that the reason for the above result was that medication trolleys were not used during medication or while healthcare providers provided any health services to patients.

Most medical wastes are incinerated. Burning solid and regulated medical waste generated by health care creates many problems. Medical waste incinerators emit toxic air pollutants and ash residues that are the primary source of environmental dioxins. Public concerns about incinerator emissions and the creation of federal regulations for medical waste incinerators are causing many healthcare facilities to rethink their choices in medical waste treatment. Health Care Without Harm [ 14 ], states that non-incineration treatment technologies are a growing and developing field. The U.S. National Academy of Science 2000 argued that the emission of pollutants during incineration is a potential risk to human health, and living or working near an incineration facility can have social, economic, and psychological effects [ 15 ].

The incineration of solid healthcare waste technology has been accepted and adopted as an effective method in Ethiopia. Incineration of healthcare waste can produce secondary waste and pollutants if the treatment facilities are not appropriately constructed, designed, and operated. It can be one of the significant sources of toxic substances, such as polychlorinated dibenzo-dioxins/dibenzofurans (PCDD/ PCDF), polyvinyl chloride (PVC), hexachlorobenzenes and polychlorinated biphenyls, and dioxins and furans that are known as hazardous pollutants. These pollutants may have undesirable environmental impacts on human and animal health, such as liver failure and cancer [ 15 , 16 ].

All government health facilities (4 in number) used incineration to dispose of solid waste. 88.4% and 100% of the wastes are incinerated in WUNEMMCSH and government health centres. This finding contradicts the study findings in the United States of America and Malaysia, in which 49–60% and 59–60 were incinerated, respectively, and the rest were treated using other technologies [ 15 , 16 ].

World Health Organization (2014:45) highlighted those critical elements of the appropriate operation of incinerators include effective waste reduction and waste segregation, placing incinerators away from populated areas, satisfactory engineered design, construction following appropriate dimensional plans, proper operation, periodic maintenance, and staff training and management are mandatory.

Solid waste collection times should be fixed and appropriate to the quantity of waste produced in each area of the health care facility. General waste should not be collected simultaneously or in the same trolley as infectious or hazardous wastes. The collection should be done daily for most wastes, with collection timed to match the pattern of waste generation during the day [ 13 ].

SHCW segregation practices were observed for 240 rooms in 41 health facilities that provide health services in the town. In government health centres, medium clinics, small clinics, and surgical centres, SHCW segregation practice was not based on the World Health Organization standard. All types of solid waste were collected in a single container near the generation area, and there were no colour-coded SHCW storage dust bins. Still, in NEMMCSH, in most of the service areas, colour-coded waste bins are available, and the segregation practice was not based on the standard. Only 3 (10%) of the dust bins collected the appropriate wastes according to the World Health Organization standard, and the rest were mixed with infectious and non-infectious SHCW.

Table 1 below shows health facility managers were asked about healthcare waste segregation practices, and 9 (22%) of the facility leaders responded that there is an appropriate solid healthcare waste segregation practice in their health facilities. Still, during observation, only 4 (1.7%) of the rooms in two (4.87%) of the facilities, SHCW bins collected the segregated wastes (non-infectious wastes segregated at the black bin and infectious wastes segregated at yellow bin) based on the world health organization standard. The findings of this study show there is a poor segregation practice, and all kinds of solid wastes are collected together.

In 40 (97.56%) health facilities, infectious wastes were collected daily from the waste generation areas to the final disposal points. During observation in one of the study health facilities, infectious wastes were not collected daily and left for days. Utility gloves, boots, and aprons are not available for cleaning staff to collect and transport solid healthcare wastes in all study health facilities. 29.26% of the facilities’ cleaning staff have a face mask, and 36.5% of the facilities remove waste bins from the service area when 3/4 full, and the rest were not removed or replaced with new ones. There is a separate container only in 2 health facilities for infectious and non-infectious waste segregation practice, and the rest were segregated and collected using single and non-colour coded containers.

At all of the facilities in the study area, SHCW was transported from the service areas to the disposal site were transported manually by carrying the collection container and there is no trolley for transportation. This finding was contrary to the study findings conducted in India, which show segregated waste from the generation site was being transported through the chute to the carts placed at various points on the hospital premises by skilled sanitary workers [ 17 ].

Only 2 out of 41 health facilities have temporary solid waste storage points at the facility. One of the temporary storage places was clean, and the other needed to be properly cleaned and unsightly. Two (100%) of the temporary storage areas are not fenced and have no restriction to an authorized person. Temporary storage areas are available only in two health facilities that are away from the service provision areas.

Observational findings revealed that pre-treatment of SHCW before disposal was not practised at all study health facilities. 95% of the facilities have no water supply for hand washing during and after solid healthcare waste generation, collection, and disposal.

The United States Agency estimated sharp injuries from medical wastes to health professionals and sanitary service personnel for toxic substances and disease registry. Most of the injuries are caused during the recapping of hypodermic needles before disposal into sharps containers [ 13 ]. Nearly half of the respondents, 245 (51.5%), are recapping needles after providing an injection to the patient. Recapping was more practised in NEMMCSH and surgical centres, which is 57.5% and 57.5%, respectively. In government health centres, medium clinics, and surgical centres, the recapping of used needles was practised below the mean, which is 47.9%, 48, and 43.8%, respectively. This finding was reasonable compared to the study findings of Doylo et al. [ 18 ] in western Ethiopia, where 91% of the health workers are recapping needles after injection [ 18 ]. The research finding shows that there is no significant association P-value of 0.82 between the training and recapping of needles after injection.

Focus group participants ’ response for appropriate SHCWMP regarding patients ’ and visitors ’ lack of knowledge on SHCW segregation practice

“The personal responsibilities of patients and visitors on solid HCW disposal should be explained to help appropriate safe waste management practice and maintain good hygiene .” “Providing waste management training and creating awareness are the two aspects of improving SHCW segregation practice.” “Training upgrades and creates awareness on hygiene for all workers.”

Sharp waste collection practices were observed in 240 rooms in the study health facilities, and 9.2% of the rooms used disposable sharp containers.

Sixty per cent (60%), 13.3%, 8.24%, and 15.71% of the sharps containers in NEMMCSH, government health centres, medium clinics, and small clinics, respectively, were using disposable sharps containers; sharps were disposed together with the sharps container, and surgical centre was using reusable sharp collection container. All disposable sharps containers in medium and small clinics used non-puncture-resistant or simple packaging carton boxes. 60% and 13.3% of the disposable sharps containers in NEMMCSH and the government health centre use purposefully manufactured disposable safety boxes.

Needle sticks injury reporting and occurrence

A total of 70 injuries were reported to the health facility manager in the last one year, and 44 of the injuries were reported by health professionals. The rest of the injuries were reported by supportive staff. These injuries were reported from 35 health facilities, and the remaining six health facilities did not report any cases of injury related to work; see Tables 2 and 3 below.

Accidents or incidents, including near misses, spillages, damaged containers, inappropriate segregation, and any incidents involving sharps, should be reported to the waste-management officer. Accidental contamination must be notified using a standard-format document. The cause of the accident or incident should be investigated by the waste-management officer (in case of waste) or another responsible officer, who should also take action to prevent a recurrence [ 13 ]. Two hundred seventy-one (50.2% (CI: 45.7–54.6) of the respondents agree that satisfactory procedures are available in case of an accident, while the remaining 269 (49.8%( CI: 45.4–54.3) of respondents do not agree on the availability of satisfactory procedures in case of an accident, see Table 4 below. The availability of satisfactory procedures in case of an accident is above the mean in medium clinics, which is 60.8%. 132(24.4%) of the staff are pricked by needle stick injury while providing health services. Nearly half of the respondents, 269 (49.8%), who have been exposed to needle stick injury do not get satisfactory procedures after being pricked by a needle, and those who have not been stung by a needle stick injury for the last year. 204 (37.8%) disagree with the presence of satisfactory procedures in the case of a needle stick injury. In NEMMCSH, 30.2% of the research participants were pricked by needle stick injury within one year of period, and 48.8% of those who were stung by needle stick injuries did not agree upon the presence of satisfactory procedures in case of needle stick injuries in the study hospital. 17.9% and 49.5%, 24.1% and 60.8%, 7.6% and 50% of the respondents are pricked by needle sticks, and they disagree on the availability of satisfactory procedures in case of accidents, respectively, in government health centres, medium clinics, small clinics, and surgical centre respectively.

One hundred seventy-seven (32.7% (CI:29.1–37) respondents were exposed to needle stick injury while working in the current health facilities. One hundred three (58.1%) and 26 (32.9%) needle stick injuries were reported from WUNEMMCSH and medium clinics, which is above the mean. One hundred thirty-two(24.7% (95%CI:20.7–28.1) of the respondents are exposed to needle stick injury within one year of the period. Seventy-eight(30.2%), 17 (17.9%), 19 (24.1%), 15 (16.3%), 3 (18.8%) of the staff are injured by needle sticks from NEMMCSH, government health centres, medium clinics, small clinics, and surgical centre staffs respectively within one year of service.

The mean availabilities of satisfactory procedures in case of accidents were 321 (59.4% (CI:55.4–63.7). Out of this, 13.7% of the staff is injured by needle sticks within one year before the survey. Except in NEMMCSH, the mean availabilities of satisfactory procedures were above the mean, which is 50%, 60%, 77.2%, 66.3%, and 81.3% in NEMMCSH, government health centres, medium clinics, small clinics, and surgical centres respectively.

Table 5 below shows that Hepatitis B, COVID-19, and tetanus toxoid vaccinations are the responses of the research participants to an open-ended question on which vaccine they took. The finding shows that 220 (40.8%) of the respondents were vaccinated to prevent themselves from health facility-acquired infection. One hundred fifty-six (70.9%) of the respondents are vaccinated to avoid themselves from Hep B infection. Fifty-nine (26%0.8) of the respondents were vaccinated to protect themselves from two diseases that are Hep B and COVID-19.

Appropriate health care waste management practice was assessed by using 12 questions: availability of colour-coded waste bins, foot-operated dust bins, elbow or foot-operated hand washing basin, personal protective equipment, training, role and responsibility of the worker, the presence of satisfactory procedures in case of an accident, incinerator, vaccination, guideline, onsite treatment, and the availability of poster. The mean of appropriate healthcare waste management practice was 55.58%. The mean of solid health care waste management practice based on the level of health facilities was summed and divided into 12 variables to get each health facility’s level of waste management practice. 64.9%, 45.58%, 49%, 46.9%, and 51.8% are the mean appropriate health care waste management practices in NEMMCSH, government health centres, medium clinics, small clinics, and surgical centres, respectively. In NEMMCSH, the practice of solid healthcare waste management shows above the mean, and the rest was below the mean of solid healthcare waste management practice.

Healthcare waste treatment and disposal practice

Solid waste treatment before disposal was not practised at all study health facilities. There is an incineration practice at all of the study health facilities, and the World Health Organization 2014 recommended three types of incineration practice for solid health care waste management: dual-chamber starved-air incinerators, multiple chamber incinerators, and rotary kilns incinerators. Single-chamber, drum, and brick incinerators do not meet the best available technique requirements of the Stockholm Convention guidelines [ 13 ]. The findings of this study show that none of the incinerators found in the study health facilities meet the minimum standards of solid healthcare waste incineration practice, and they need an air inlet to facilitate combustion. Eleven (26.82%) of the health facilities have an ash pit to dispose of burned SHCW; the majority, 30 (73.17%), dispose of the incinerated ash and burned needles in the municipal waste disposal site. In one out of 11 health facilities with an ash pit, one of the incinerators was built on the ash pit, and the incinerated ashes were disposed of in the ash pit directly. Pre-treatment of SHCW before disposal was not practised at all health facilities; see Table 6 below.

All government health facilities use incineration to dispose of solid waste. 88.4% and 100% of the solid wastes are incinerated in WUNEMMCS Hospital and government health centres, respectively. This finding was not similar to the other studies because other technologies like autoclave microwave and incineration were used for 59–60% of the waste [ 15 ]. Forty-one (100%) of the study facilities were using incinerators, and only 5 (12.19%) of the incinerators were constructed by using brick and more or less promising than others for incinerating the generated solid wastes without considering the emitting gases into the atmosphere and the residue chemicals and minerals in the ashes.

Research participants’ understanding of the environmental friendliness of health care waste management practice was assessed, and the result shows that more than half, 312(57%) of the research participants do not agree on the environmental friendliness of the waste disposal practices in the health facilities. The most disagreement regarding environmental friendliness was observed in NEMMCSH; 100 (38.8%) of the participants only agreed the practice was environmentally friendly of the service. Forty-four (46.3%), 37 (46.8%), 40 (43.5%), and 7 (43.8%) of the participants agree on the environmental friendliness of healthcare waste management practice in government health centres, medium clinics, small clinics, and surgical centres, respectively.

One hundred twenty-five (48.4%) and 39(42.4%) staff are trained in solid health care waste management practice in NEMMCSH and small clinic staff, respectively; this result shows above the mean. Twenty-seven (28.4%), 30 (38%), and 4 (25%) of the staff are trained in health care waste management practice in Government health centres, medium clinics, and surgical centres, respectively. The training has been significantly associated with needle stick injury, and the more trained staff are, the less exposed to needle stick injury. One hundred ninety-six (36.4%) of the participants answered yes to the question about the availability of trainers in the institution. 43.8% of the NEMMCSH staff agreed on the availability of trainers on solid health care waste management, which is above the mean, and 26.3%, 31.6%, 31.5%, and 25% for the government health centres, medium clinics, small clinics, and surgical centre respectively, which is below the mean.

Trained health professionals are more compliant with SHCWM standards, and the self-reported study findings of this study show that 41.7% (95%CI:37.7–46) of the research participants are trained in health care waste management practice. This finding was higher compared to the study findings of Sahiledengle in 2019 in the southeast of Ethiopia, shows 13.0% of healthcare workers received training related to HCWM in the past one year preceding the study period and significantly lower when compared to the study findings in Egypt which is 71% of the study participants were trained on SHCWM [ 8 , 19 , 20 ].

Three out of four government health facility leaders, 17 (45.94%) of private health facility leaders/owners of the clinic and 141 FGD participants complain about the absence of some PPEs like boots and aprons to protect themselves from infectious agents.

‘ ‘Masks, disposable gloves, and changing gowns are a critical shortage at all health facilities.’’

Cleaners in private health facilities are more exposed to infectious agents because of the absence of personal protective equipment. Except for the cleaning staff working in the private surgical centre, all cleaning staff 40 (97.56) of the health facilities complain about the absence of changing gowns and the fact that there are no boots in the facilities.

Cost inflation and the high cost of purchasing PPEs like gloves and boots are complained by all of (41) the health facility owners and the reason for the absence of some of the PPEs like boots, goggles, and shortage of disposable gloves. Sometimes, absence from the market is the reason why we do not supply PPE to our workers.

Thirty-four (82.92%) of the facility leaders are forwarded, and there is a high expense and even unavailability of some of the PPEs, which are the reasons for not providing PPEs for the workers.

‘‘Medical equipment and consumables importers and whole sellers are selective for importing health supplies, and because of a small number of importers in the country and specifically, in the locality, we can’t get materials used for health care waste management practice even disposable gloves. ’’

One of the facility leaders from a private clinic forwarded that before the advent of COVID-19 -19) personal protective equipment was more or less chip-and-get without difficulty. Still, after the advent of the first Japanese COVID-19 patient in Ethiopia, people outside the health facilities collect PPEs like gloves and masks and storing privately in their homes.

‘‘PPEs were getting expensive and unavailable in the market. Incinerator construction materials cost inflation, and the ownership of the facility building are other problems for private health facilities to construct standard incinerators.’’

For all of the focus group discussion participants except in NEMMCSH and two private health facilities, covered and foot-operated dust bins were absent or in a critical shortage compared to the needed ones.

‘‘ Waste bins are open and not colour-coded. The practice attracts flies and other insects. Empty waste bins are replaced without cleaning and disinfecting by using chlorine solution.’’ “HCW containers are not colour-coded, but we are trying to label infectious and non-infectious in Amharic languages.”

Another issue raised during focus group discussions is incineration is not the final disposal method. It needs additional disposal sites, lacks technology, is costly to construct a brick incinerator, lacks knowledge for health facility workers, shortage of man powers /cleaners, absence of environmental health professionals in health centres and all private clinics, and continues exposure to the staff for needle stick injury, foully smell, human scavengers, unsightly, fire hazard, and lack of water supply in the town are the major teams that FGD participants raise and forwarded the above issue as a problem to improve SHCWMP.

Focus group participants, during the discussion, raised issues that could be more comfortable managing SHCWs properly in their institution. Two of the 37 private health facilities are working in their own compound, and the remaining 35 are rented; because of this, they have difficulty constructing incinerators and ash removal pits and are not confident about investing in SHCWM systems. Staff negligence and involuntary abiding by the rules of the facilities were raised by four of the government health facilities, and it was difficult to punish those who violated the healthcare waste management rules because the health facility leaders were not giving appropriate attention to the problem.

Focus group participants forwarded recommendations on which interventions can improve the management of SHCW, and recommendations are summarised as follows:

“PPE should be available in quality and quantity for all health facility workers who have direct contact with SHCW.” “Scientific-based waste management technologies should be availed for health facilities.” “Continuous induction HCW management training should be provided to the workers. Law enforcement should be strengthened.” “Communal HCW management sites should be availed, especially for private health facilities.” “HCWM committee should be strengthened.” “Non-infectious wastes should be collected communally and transported to the municipal SHCW disposal places.” “Leaders should be knowledgeable on the SHCWM system and supervise the practice continuously.” “Patient and client should be oriented daily about HCW segregation practice.” “Regulatory bodies should supervise the health facilities before commencing and periodically between services .”

The above are the themes that FGD participants discussed and forwarded for the future improvements of SHAWMP in the study areas.

Lack of water supply in the town

Other issues raised during FGDs were health facilities’ lack of water supply. World Health Organization (2014: 89) highlights that water supply for the appropriate waste management system should be mandatory at any time in all health service delivery points.

Thirty-nine (95.12%) of the health facilities complain about the absence of water supply to improve HCW management practices and infection prevention and control practices in the facilities.

“We get water once per week, and most of the time, the water is available at night, and if we are not fetching as scheduled, we can’t get water the whole week”.

In this research, only those who have direct contact have participated in this study, and 434 (80.4%) of the respondents agree they have roles and responsibilities for appropriate solid health care waste management practice. The rest, 19.6%, do not agree with their commitment to manage health care wastes properly, even though they are responsible. Health facility workers in NEMMCSH and medium clinics know their responsibilities better than others, and their results show above the mean. 84.5%, 74.5%, 81%, 73.9% and 75% in NEMMCSH, Government health centres, medium clinics, small clinics, and surgical centres, respectively.

Establishing a policy and a legal framework, training personnel, and raising public awareness are essential elements of successful healthcare waste management. A policy can be viewed as a blueprint that drives decision-making at a political level and should mobilize government effort and resources to create the conditions to make changes in healthcare facilities. Three hundred and seventy-four (69.3%) of the respondents agree with the presence of any solid healthcare waste management policy in Ethiopia. The more knowledge above the mean (72.9%) on the presence of the policy is reported from NEMMCSH.

Self-reported level of knowledge on what to do in case of an accident revealed that 438 (81.1% CI: 77.6–84.3%) of the respondents knew what to do in case of an accident. Government health centre staff and medium clinic staff’s knowledge about what to do in case of an accident was above the mean (88.4% and 82.3%), respectively, and the rest were below the mean. The action performed after an occupational accident revealed that 56 (35.7%) of the respondents did nothing after any exposure to an accident. Out of 56 respondents who have done nothing after exposure, 47 (83.92%) of the respondents answered yes to their knowledge about what to do in case of an accident. Out of 157 respondents who have been exposed to occupational accidents, only 59 (37.6%) of the respondents performed the appropriate measures, 18 (11.5%), 9 (5.7%), 26 (16.6%), 6 (3.8%) of the respondents are taking prophylaxis, linked to the incident officer, consult the available doctors near to the department, and test the status of the patient (source of infection) respectively and the rest were not performing the scientific measures, that is only practising one of the following practices washing the affected part, squeezing the affected part to remove blood, cleaning the affected part with alcohol.

Health facility workers’ understanding of solid health care waste management practices was assessed by asking whether the current SHCWM practice needs improvement. Four hundred forty-nine (83.1%) health facility workers are unsatisfied with the current solid waste management practice at the different health facility levels, and they recommend changing it to a scientific one. 82.6%, 87.4%, 89.9%, 75%, and 81.3% of the respondents are uncomfortable or need to improve solid health care waste management practices in NEMMCSH, government health centres, medium clinics, small clinics, and surgical centres, respectively.

Lack of safety box, lack of colour-coded waste bins, lack of training, and no problems are the responses to the question problems encountered in managing SHCWMP. Two Hundred and Fifty (46.92%) and 232 (42.96%) of the respondents recommend the availability of safety boxes and training, respectively.

Four or 9.8% of the facilities have infection prevention and control (IPC) teams in the study health facilities. This finding differed from the study in Pakistan, where thirty per cent (30%) of the study hospitals had HCWM or infection control teams [ 21 ]. This study’s findings were similar to those conducted in Pakistan by Khan et al. [ 21 ], which confirmed that the teams were almost absent at the secondary and primary healthcare levels [ 20 ].

The availability of health care waste management policy report reveals that 69.3% (95% CI: 65.4–73) of the staff are aware of the presence of solid health care waste management policy in the institution. Availability of health care waste management policy was 188 (72.9%), 66 (69.5%), 53 (677.1%), 57 (62%), 10 (62.5%) in NEMMCSH, Government health centres, medium clinics, small clinics, and surgical centre respectively. Healthcare waste management policy availability was above the mean in NEMMCSH and government health centres; see Table 6 below.

Open-ended responses on the SHCWM practice of health facility workers were collected using the prepared interview guide, and the responses were analyzed using thematic analysis. All the answered questions were tallied on the paper and exported to Excel software for thematic analysis.

The study participants recommend.

“appropriate segregation practice at the point of generation” "health facility must avail all the necessary supplies that used for SHCWMP, punishment for those violating the rule of SHCWMP",

“waste management technologies should be included in solid waste management guidelines, and enforcement should be strengthened.”

The availability of written national or adopted/adapted SHCWM policies was observed at all study health facilities. Twenty eight (11.66%) of the rooms have either a poster or a written document of the national policy document. However, all staff working in the observed rooms have yet to see the inside content of the policy. The presence of the policy alone cannot bring change to SHCWMP. This finding shows that the presence of policy in the institution was reasonable compared to the study findings in Menelik II hospital in Addis Ababa, showing that HCWM regulations and any applicable facility-based policy and strategy were not found [ 22 ]. The findings of this study were less compared to the study findings in Pakistan; 41% of the health facilities had the policy document or internal rules for the HCWM [ 21 ].

Focus group participants have forwarded recommendations on which interventions can improve the management of SHCW, and recommendations are summarised as follows.

‘‘Supplies should be available in quality and quantity for all health facility workers with direct contact with SHCW. Scientific-based waste management technologies should be available for health facilities. Continues and induction health care waste management training should be provided to the workers. Law enforcement should be strengthened. Community healthcare waste management sites should be available, especially for private health facilities. HCWM committee should be strengthened. Non-infectious wastes should be collected communally and transported to the municipal SHCW disposal places. Leaders should be knowledgeable about the SHCWM system and supervise the practice continuously. Patients and clients should be oriented daily about health care waste segregation practices. Regulatory bodies should supervise the health facilities before commencing and periodically in between the service are the themes those FGD participants discussed and forward for the future improvements of SHCWMP in the study areas.’’

The availability of PPEs in different levels of health facilities shows 392 (72.6%), 212 (82.2%), 56 (58.9%), 52 (65.8%), 60 (65.2%), 12 (75%) health facility workers in NEMMCSH, government health centres, medium clinics, small clinics, and surgical centres respectively agree to the presence of personal protective equipment in their department. The availability of PPEs in this study was nearly two-fold when compared to the study findings in Myanmar, where 37.6% of the staff have PPEs [ 12 ].

The mean availability of masks, heavy-duty gloves, boots, and aprons was 71.1%, 65.4%, 38%, and 44.4% in the study health facilities. This finding shows masks are less available in the study health facilities compared to other studies. The availability of utility gloves, boots, and plastic aprons is good in this study compared to the study conducted by Banstola, D in Pokhara Sub-Metropolitan City [ 23 ].

The findings of this study show there is a poor segregation practice, and all kinds of solid wastes were collected together. This finding was similar to the study findings conducted in Addis Ababa, Ethiopia, by Debere et al. [ 24 ] and contrary to the study findings conducted in Nepal and India, which shows 50% and 65–75% of the surveyed health facilities were practising proper waste segregation systems at the point of generation without mixing general wastes with hazardous wastes respectively [ 9 , 17 ].

Ninety percent of private health facilities collect and transport SHCW generated in every service area and transport it to the disposal place by the collection container (no separate container to collect and transport the waste to the final disposal site). This finding was similar to the study findings of Debre Markos’s town [ 25 ]. At all of the facilities in the study area, SHCW was transported from the service areas to the disposal site manually by carrying the collection container, and there was no trolley for transportation. This finding was contrary to the study findings conducted in India, which show segregated waste from the generation site was being transported through the chute to the carts placed at various points on the hospital premises by skilled sanitary workers [ 17 ].

Observational findings revealed that pre-treatment of SHCW before disposal was not practised at all study health facilities. This study was contrary to the findings of Pullishery et al. [ 26 ], conducted in Mangalore, India, which depicted pre-treatment of the waste in 46% of the hospitals [ 26 ]. 95% of the facilities have no water supply for handwashing during and after solid healthcare waste generation, collection, and disposal. This finding was contrary to the study findings in Pakistan hospitals, which show all health facilities have an adequate water supply near the health care waste management sites [ 27 ].

Questionnaire data collection tools show that 129 (23.8%) of the staff needle stick injuries have occurred on health facility workers within one year of the period before the data collection. This finding was slightly smaller than the study findings of Deress et al. [ 25 ] in Debre Markos town, North East Ethiopia, where 30.9% of the workers had been exposed to needle stick injury one year prior to the study [ 25 ]. Reported and registered needle stick injuries in health facilities are less reported, and only 70 (54.2%) of the injuries are reported to the health facilities. This finding shows an underestimation of the risk and the problem, which was supported by the study conducted in Menilik II hospitals in Addis Ababa [ 22 ]. 50%, 33.4%, 48%, 52%, and 62.5% of needle stick injuries were not reported in NEMMCSH, Government health centres, medium clinics, small clinics, and surgical centres, respectively, to the health facility manager.

Nearly 1/3 (177 or 32.7%) of the staff are exposed to needle stick injuries. Needle stick injuries in health facilities are less reported, and only 73 (41.24%) of the injuries are reported to the health facilities within 12 months of the data collection. This finding is slightly higher than the study finding of Deress et al. [ 25 ] in Debere Markos, Ethiopia, in which 23.3% of the study participants had encountered needle stick/sharps injuries preceding 12 months of the data collection period [ 25 ].

Seventy-three injuries were reported to the health facility manager in the last one year, 44 of the injuries were reported by health professionals, and the rest were reported by supportive staff. These injuries were reported from 35(85.3%) health facilities; the remaining six have no report. These study findings were better than the findings of Khan et al. [ 21 ], in which one-third of the facilities had a reporting system for an incident, and almost the same percentage of the facilities had post-exposure procedures in both public and private sectors [ 21 ].

Within one year of the study period, 129 (23.88%) needle stick injuries occurred. However, needle stick injuries in health facilities are less reported, and only 70 (39.5%) of the injuries are reported to the health facilities. These findings were reasonable compared to the study findings of the southwest region of Cameroon, in which 50.9% (110/216) of all participants had at least one occupational exposure [ 28 , 29 ]. This result report shows a very high exposure to needle stick injury compared to the study findings in Brazil, which shows 6.1% of the research participants were injured [ 27 ].

The finding shows that 220 (40.8%) of the respondents were vaccinated to prevent themselves from health facility-acquired infection. One Hundred Fifty-six (70.9%) of the respondents are vaccinated in order to avoid themselves from Hep B infection. Fifty-nine (26%0.8) of the respondents were vaccinated to protect themselves from two diseases that are Hep B and COVID-19. This finding was nearly the same as the study findings of Deress et al. [ 7 ],in Ethiopia, 30.7% were vaccinated, and very low compared to the study findings of Qadir et al. [ 30 ] in Pakistan and Saha & Bhattacharjya India which is 66.67% and 66.17% respectively [ 25 , 30 , 31 ].

The incineration of solid healthcare waste technology has been accepted and adopted as an effective method in Ethiopia. These pollutants may have undesirable environmental impacts on human and animal health, such as liver failure and cancer [ 15 , 16 ]. All government health facilities use incineration to dispose of solid waste. 88.4% and 100% of the wastes are incinerated in WUNEMMCSH and government health centres, respectively. This finding contradicts the study findings in the United States of America and Malaysia, which are 49–60% and 59–60 are incinerated, respectively, and the rest are treated using other technologies [ 15 , 16 ].

All study health facilities used a brick or barrel type of incinerator. The incinerators found in the study health facilities need to meet the minimum standards of solid health care waste incineration practice. These findings were similar to the study findings of Nepal and Pakistan [ 32 ]. The health care waste treatment system in health facilities was found to be very unsystematic and unscientific, which cannot guarantee that there is no risk to the environment and public health, as well as safety for personnel involved in health care waste treatment. Most incinerators are not properly operated and maintained, resulting in poor performance.

All government health facilities use incineration to dispose of solid waste. All the generated sharp wastes are incinerated using brick or barrel incinerators, as shown in Fig. 1 above. This finding was consistent with the findings of Veilla and Samwel [ 33 ], who depicted that sharp waste generation is the same as sharps waste incinerated [ 33 ]. All brick incinerators were constructed without appropriate air inlets to facilitate combustion except in NEMMCSH, which is built at a 4-m height. These findings were similar to the findings of Tadese and Kumie at Addis Ababa [ 34 ].

Barrel and brick incinerators used in private clinic

Strengths and limitations

This is a mixed-method study; both qualitative and quantitative study design, data collection and analysis techniques were used to understand the problem better. The setting for this study was one town, which is found in the southern part of the country. It only represents some of the country’s health facilities, and it is difficult to generalize the findings to other hospitals and health centres. Another limitation of this study was that private drug stores and private pharmacies were not incorporated.

Conclusions

In the study, health facilities’ foot-operated solid waste dust bins are not available for healthcare workers and patients to dispose of the generated wastes. Health facility managers in government and private health institutions should pay more attention to the availability of colour-coded dust bins. Most containers are opened, and insects and rodents can access them anytime. Some of them are even closed (not foot-operated), leading to contamination of hands when trying to open them.

Healthcare waste management training is mandatory for appropriate healthcare waste disposal. Healthcare-associated exposure should be appropriately managed, and infection prevention and control training should be provided to all staff working in the health facilities.

Availability of data and materials

The authors declare that data for this work are available upon request to the first author.

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Acknowledgements

The authors are grateful to the health facility leaders and ethical committees of the hospitals for their permission. The authors acknowledge the cooperation of the health facility workers who participated in this study.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Yeshanew Ayele Tiruneh

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L. M. Modiba & S. M. Zuma

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Dr. Yeshanew Ayele Tiruneh is a researcher of this study; the principal investigator does all the proposal preparation, methodology, data collection, result and discussion, and manuscript writing. Professor LM Modiba and Dr. SM Zuma are supervisors for this study. They participated in the topic selection and modification to the final manuscript preparation by commenting on and correcting the study. Finally, the three authors read and approved the final version of the manuscript and agreed to submit the manuscript for publication.

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Tiruneh, Y.A., Modiba, L.M. & Zuma, S.M. Solid health care waste management practice in Ethiopia, a convergent mixed method study. BMC Health Serv Res 24 , 985 (2024). https://doi.org/10.1186/s12913-024-11444-8

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Reflective practice in health care and how to reflect effectively

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