Nursing: Missed care in newborn units

Michaela Mattias Alferes is a 24 year old nurse who works in for the ministry of health in Maunhambo Health Post around 2 hours drive from Milange. She has received training by Save the Children in January 2017. The training focuses on emergency care to deal with obstetric complications and best practice to ensure safe delivery of babies, reduction in maternal mortality. According to Michaela there are about 110 deliveries per month in this area. “Our number one challenge for the next year is to reduce infant and maternal mortality to zero. This is the government’s aim and we want to achieve this. We have made great progress in reducing deaths – when this clinic first opened we had many every year, this year, fortunately we have only had 2. But that is still 2 families with children growing up without their mother. A child shouldn’t grow up without their mum.” She tells. Zambézia province in the central region of Mozambique presents many of the worst indicators related to child development. 64% of children in the province are likely to experience deprivation in two or more basic needs including health, education, sanitation and water. Across the province 46% of infants under five years of age are chronically malnourished and the infant mortality rate is the highest in country with 205 deaths per 1,000 births. Save the Children implements a holistic programme which combines health and early learning education programmes. We train, equip and support community health and education workers as well as existing health centres. With this programmes Save the Children has reached 3,071 children under 5 children and 1,002 pregnant women.

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Improved hospital care is needed to reduce newborn mortality in low/middle-income countries (LMIC). Nurses are essential to the delivery of safe and effective care, but nurse shortages and high patient workloads may result in missed care. We aimed to examine nursing care delivered to sick newborns and identify missed care using direct observational methods.


A cross-sectional study using direct-observational methods for 216 newborns admitted in six health facilities in Nairobi, Kenya, was used to determine which tasks were completed. We report the frequency of tasks done and develop a nursing care index (NCI), an unweighted summary score of nursing tasks done for each baby, to explore how task completion is related to organisational and newborn characteristics.


Nursing tasks most commonly completed were handing over between shifts (97%), checking and where necessary changing diapers (96%). Tasks with lowest completion rates included nursing review of newborns (38%) and assessment of babies on phototherapy (15%). Overall the mean NCI was 60% (95% CI 58% to 62%), at least 80% of tasks were completed for only 14% of babies. Private sector facilities had a median ratio of babies to nurses of 3, with a maximum of 7 babies per nurse. In the public sector, the median ratio was 19 babies and a maximum exceeding 25 babies per nurse. In exploratory multivariable analyses, ratios of ≥12 babies per nurse were associated with a 24-point reduction in the mean NCI compared with ratios of ≤3 babies per nurse.


A significant proportion of nursing care is missed with potentially serious effects on patient safety and outcomes in this LMIC setting. Given that nurses caring for fewer babies on average performed more of the expected tasks, addressing nursing is key to ensuring delivery of essential aspects of care as part of improving quality and safety.

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