Organisational learning culture in maternity units: A mixed-method study in rural district hospitals in KwaZulu-Natal, South Africa

Building organizational learning in health facilities is a health system strengthening strategy that has particular relevance for rural health workers (HWs) who may be geographically isolated without access to learning opportunities or specialist support. We present the findings of a mixed methods study exploring organizational learning in rural hospital maternity units. Data were collected from all cadres of HWs working in maternity units in 11 health facilities in two districts, including doctors, nurse managers, midwives and nursing assistants. A quantitative survey was conducted with all HWs using the validated Dimensions of Learning Organisation Questionnaire (DLOQ). We then conducted individual in-depth interviews with purposively selected HWs in each facility to explore their perceptions and experiences of learning, teamwork and leadership. We completed 116 DLOQ self-administered questionnaires and conducted 35 in-depth interviews. Strategic leadership scored highest on the DLOQ, with HWs reporting that managers provided opportunities for mentoring and learning. Doctors and nurse managers experienced team learning, leadership and communication more positively than midwives and nursing assistants. Learning was driven by senior doctors and managers, frequently taking a top-down didactic approach rather than employing reflection and dialogue. This is supported by low DLOQ scores for inquiry and dialogue and empowerment among nurses compared to doctors and managers. There is a need for shifts in learning approaches in maternity units from a didactic clinical focus to participatory dialogue and reflection, including interpersonal issues like respect and communication, and to ensure that all team members have access to learning opportunities. • Organisational learning in district hospital maternity units is sub-optimal • Learning opportunities for health workers often used a top-down didactic approach • Doctors and nurse managers had more positive learning experiences than nursing staff • A reflective learning approach is needed, recognising concerns of all health workers • Building learning culture in rural hospitals could improve respectful maternal care