6209 Examining nursing care provision through direct observations of newborn care in resource-constrained Kenyan neonatal units

Abstract

<h3>Objectives</h3> In resource-constrained Low Middle-Income Countries (LMICs) one nurse may be responsible for care of 20 or more babies.¹ This study examines nursing care provided on 8 high-dependency neonatal units in Kenya and examines the relation with such extreme levels of nurse staffing. <h3>Methods</h3> Using direct bedside observations of care and a structured checklist, we identify whether expected care is provided to a newborn, by whom and which critical components of care are missed completely. We used the nursing care hours per patient shift to determine the average nursing time per patient per 12-hour shift as a measure of nursing input. We examine how this measure of nurse input is associated with overall care provision using descriptive analysis and multilevel modelling to adjust for confounding. <h3>Results</h3> We conducted 1,848 hours of observations on 154 12-hour nursing shifts, observing the nursing care provided to 597 babies in 8 neonatal units. Nursing input as an absolute maximum ranged from 19.2 to 72.0 minutes per newborn on a 12-hour shift (assuming no personal breaks, equivalent to 5 to 25 times the workload of a comparable high-resource setting). On average, nurses in these units only provided 34% of all expected care, much care was either completely missed (34% overall) or informally delegated (32% overall) to caregivers and nursing students. Almost 100% of nasogastric tube feeding was carried out by caregivers with limited supervision who missed critical steps such as checking if the tube was in place about 50% of the time. Nursing students carried out 40% of intravenous medication administration and 80% of vital signs measurements. Nurses provided a greater proportion of care to unstable babies. In such extreme contexts, the level of nurse staffing inputs was not associated with nurse-delivered care (B-co-efficient: -0.011, 95% CI: -0.065 to 0.044 with adjustment for clustering). <h3>Conclusion</h3> Qualified nurses manage to deliver only 1/3rd of expected care in high-mortality Kenyan neonatal units; informal task shifting to caregivers and mothers and subconscious triage so that nursing time focuses on technical tasks and sicker babies’ result. We found no association between staffing inputs and nurse-delivered care, perhaps because in all settings staffing ratios were so inadequate. However, the frequency of truly missed and informally delegated care is likely to impact safety and quality of babies care and such intense work environments likely adversely impact staff themselves. Major efforts must be made to improve nurse staffing in these and similar settings. <h3>Reference</h3> Imam A, Obiesie S, Aluvaala J, Maina JM, Gathara D, English M. Identifying gaps in global evidence for nurse staffing and patient care outcomes research in low/middle-income countries: an umbrella review. <i>BMJ Open</i> 2022 Oct 1;<b>12</b>(10):e064050.