Missed nursing care in newborn units: The need for improvements in nursing workforce in LMICs

By Dr. David Gathara

Improved hospital care is needed to reduce newborn mortality in low- and mid-income countries (LMICs). Nurses are essential to the delivery of safe and effective care. In hospitals, they are responsible for initiating and delivering interventions as well as coordinating care provided by other professionals (e.g doctors, nutritionists); but nurse shortages and high patient workloads may result in missed care. Sick newborns require continuous high-level care over multiple days, predominantly from nurses, and are especially likely to suffer detrimental consequences of missed care.

Using direct-observational methods, we examined nursing care delivered to 216 sick newborns who were admitted in six health facilities across the public, mission and private sectors in Nairobi, Kenya, in an effort to identify nursing tasks done (or left undone).

We observed great variation in task completion with omission of nursing tasks that might directly influence the baby’s outcome, such as feeding, monitoring of vital signs and appropriate use of interventions like fluids and oxygen. This highlights potentially critical safety and patient well-being issues. Aggregating nursing tasks done per baby, average task completion was 60% (95% CI 58 – 62) with at least 80% of essential tasks completed for only 14% of babies. Private sector facilities had a median ratio of three babies to nurses, with a maximum of seven babies per nurse. In the public sector, the median ratio was 19 babies per nurse, with a maximum exceeding 25 babies per nurse. In exploratory analysis, ratios of ≥ 12 babies per nurse were associated with a 24% increase in missed care when compared with ratios of ≤ three babies per nurse. Our results suggest that the high levels of missed care observed in the public sector are most likely related to the very high baby to nurse ratios found in public hospitals (figure 1).

Figure 1: Nursing care index for each baby by number of babies per nurse across sectors

As part of a wider programme of work, we observed that nurses’ time is often taken up by tasks that are not necessarily core to the nursing role. Examples include clerical tasks such as organising patient files, receiving telephone calls and billing, collecting supplies from stores and ward cleaning, including baby cots and equipment. These non-patient facing activities take up a significant amount of their time. There are opportunities to refocus nursing practice on skilled tasks for which they are specifically trained and re-assign some tasks to other workers.

In higher income countries there is a growing body of literature that demonstrates that missed care is associated with low nurse staffing ratios and poorer patient safety, poorer care quality and worse patient outcomes. Similar data have been lacking from LMICs and our studies are some of the first to report and explain this link. We propose that the absence of studies quantifying the link between nursing shortages and the quality of hospital care in LMICs results in nurses’ contribution being undervalued. As a result, shortages in nursing and throughout the wider workforce are not addressed and undermine the nurses’ ability to deliver quality care.

While our data illustrate how nursing shortages contribute to missed care of ill babies, there are probably important effects of such high workloads on the nurses themselves, including their own perception of failing to meet the standards of care they aspire to as professionals. The exhaustion and burnout that are also potential consequences are important detrimental effects on the emotional and psychological well-being of nurses and on the sustainability of this crucial workforce.

Improving quality of care and its contribution to newborn survival clearly demands an expansion of the nursing workforce, potentially complemented by additional human resource investments that allow nurses to operate as skilled providers. Failure to address critical workforce issues will mean that missed care remains common and undermines efforts to deliver high-impact, low-cost interventions for small and sick babies. The highlighted gaps in care underscore the urgent need for system strengthening to support quality improvement initiatives and to increase neonatal survival, while also indicating the need for further research on service redesign that focus on nursing.

Read the original journal article, Missed nursing care in newborn units: a cross-sectional direct observational study, here.

About the Author

David Gathara is a health systems researcher currently leading work on nursing services research aimed at developing indicators, tools and approches for evaluating the quality of nursing care delivered in hospitals. He also co-leads the Health Services that Deliver for Newborns programme of work whose focus is understanding the burden, need and access of newborn care services as well as evaluating the quality of newborn care services. He holds a Master of Science in Epidemiology from the London School of Hygiene and Tropical Medicine and a PhD from the University of Amsterdam. Since joining KWTRP in August 2008, his research work has spanned a range of disciplines including, clinical trials, evaluation of quality of care within hospitals and exploration of the application of various statistical methods (propensity score analysis, multi-level models and statistical process control) to routine data. David played a key role in development, database design and setting up the Clinical Information Network - a pragmatic research database collecting patient level data from all paediatric admissions from 14 county referral hospitals and aims at improving use of information in policy and practice. He has broad interests’ in the use of epidemiology to monitor disease trends, interventions effects, identify quality of care gaps and the use of this data for effective decision making although with a bias on how human resources for health more specifically the nursing workforce influences the quality of care provided. His future work aims at developing human resource interventions as well as optimising approaches for nursing care provision.

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