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Nyande FK, Ricks E, Williams M, Jardien-Baboo S. Challenges to the delivery and utilisation of child healthcare services: a qualitative study of the experiences of nurses and caregivers in a rural district in Ghana. BMC Nurs 2024; 23:177. [PMID: 38486259 PMCID: PMC10938804 DOI: 10.1186/s12912-024-01811-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/20/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Sub-Saharan Africa has one of the poorest child health outcomes in the world. Children born in this region face significant health challenges that jeopardise their proper growth and development. Even though the utilisation of child healthcare services safeguards the health of children, the challenges encountered by nurses in the delivery of services, and caregivers in the utilisation of these services, especially in rural areas, have contributed to poor child health outcomes in this region. AIM This study explored the experiences of nurses and caregivers in respect of the nursing human resource challenges to the delivery and utilisation of child healthcare services in a rural district in Ghana. METHODS Individual qualitative interviews were conducted with ten nurses, who rendered child healthcare services; nine caregivers, who regularly utilised the available child healthcare services; and seven caregivers, who were not regular users of these services. These participants were purposively selected for the study. Data were collected using individual semi-structured interview guides and analysed qualitatively using content analysis. Themes and sub-themes were generated during the data analysis. The Ghana Health Service Research Ethics Review Committee and the Nelson Mandela University's Research Ethics Committee approved the study protocol prior to data collection. RESULTS Three main themes emerged from the data analysis. Theme One focused on the shortage of nurses, which affected the quality and availability of child healthcare services. Theme Two focused on inexperienced nurses, who struggled to cope with the demands related to the delivery of child healthcare services. Theme Three focused on the undesirable attitude displayed by nurses, which discouraged caregivers from utilising child healthcare services. CONCLUSION Nurses contribute significantly to the delivery of child healthcare services; hence, the inadequacies amongst nurses, in terms of staff numbers and nursing expertise, affect the quality and availability of child healthcare services. Also, caregivers' perceptions of the quality of child healthcare services are based on the treatment they receive at the hands of nurses and other healthcare workers. In this respect, the bad attitude of nurses may disincentivise caregivers in terms of their utilisation of these services, as and when needed. There is an urgent need to comprehensively address these challenges to improve child healthcare outcomes in rural areas in Ghana. Relevant authorities should decentralise training workshops for nurses in rural areas to update their skills. Additionally, health facilities should institute proper orientation and mentoring systems to assist newly recruited nurses to acquire the requisite competences for the delivery of quality family-centred care child healthcare services.
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Affiliation(s)
- Felix Kwasi Nyande
- Department of Nursing, School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana.
| | - Esmeralda Ricks
- Department of Nursing Science, Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
| | - Margaret Williams
- Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
| | - Sihaam Jardien-Baboo
- Department of Nursing Science, Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa
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Page B, Irving D, Amalberti R, Vincent C. Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. BMJ Qual Saf 2023:bmjqs-2023-016686. [PMID: 38050158 DOI: 10.1136/bmjqs-2023-016686] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/07/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE The objective of this review was to develop a taxonomy of pressures experienced by health services and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies were developed from a review of observational studies directly assessing care delivered in a variety of clinical environments. DESIGN In the first phase, a scoping review of the relevant literature was conducted. In the second phase, pressures and strategies were systematically coded from the included papers, and categorised. DATA SOURCES Electronic databases (MEDLINE, Embase, CINAHL, PsycInfo and Scopus) and reference lists from recent reviews of the resilient healthcare literature. ELIGIBILITY CRITERIA Studies were included from the resilient healthcare literature, which used descriptive methodologies to directly assess a clinical environment. The studies were required to contain strategies for managing under pressure. RESULTS 5402 potential articles were identified with 17 papers meeting the inclusion criteria. The principal source of pressure described in the studies was the demand for care exceeding capacity (ie, the resources available), which in turn led to difficult working conditions and problems with system functioning. Strategies for responding to pressures were categorised into anticipatory and on-the-day adaptations. Anticipatory strategies included strategies for increasing resources, controlling demand and plans for managing the workload (efficiency strategies, forward planning, monitoring and co-ordination strategies and staff support initiatives). On-the-day adaptations were categorised into: flexing the use of existing resources, prioritising demand and adapting ways of working (leadership, teamwork and communication strategies). CONCLUSIONS The review has culminated in an empirically based taxonomy of pressures and an accompanying taxonomy of strategies for adapting in response to these pressures. The taxonomies could help clinicians and managers to optimise how they respond to pressures and may be used as the basis for training programmes and future research evaluating the impact of different strategies.
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Affiliation(s)
- Bethan Page
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Cicely Saunders Institute, King's College London, London, UK
| | - Dulcie Irving
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Rene Amalberti
- Foundation for Industrial Safety Culture, FONCSI, Toulouse, France
| | - Charles Vincent
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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Muinga N, Tuti T, Mwaniki P, Gicheha E, Paton C, Beňová L, English M. Evaluating the documentation of vital signs following implementation of a new comprehensive newborn monitoring chart in 19 hospitals in Kenya: A time series analysis. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002440. [PMID: 37910489 PMCID: PMC10619831 DOI: 10.1371/journal.pgph.0002440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
Multi-professional teams care for sick newborns, but nurses are the primary caregivers, making nursing care documentation essential for delivering high-quality care, fostering teamwork, and improving patient outcomes. We report on an evaluation of vital signs documentation following implementation of the comprehensive newborn monitoring chart using interrupted time series analysis and a review of filled charts. We collected post-admission vital signs (Temperature (T), Pulse (P), Respiratory Rate (R) and Oxygen Saturation (S)) documentation frequencies of 43,719 newborns with a length of stay > 48 hours from 19 public hospitals in Kenya between September 2019 and October 2021. The primary outcome was an ordinal categorical variable (no monitoring, monitoring 1 to 3 times, 4 to 7 times and 8 or more times) based on the number of complete sets of TPRS. Descriptive analyses explored documentation of at least one T, P, R and S. The percentage of patients in the no-monitoring category decreased from 68.5% to 43.5% in the post-intervention period for TPRS monitoring. The intervention increased the odds of being in a higher TPRS monitoring category by 4.8 times (p<0.001) and increased the odds of higher monitoring frequency for each vital sign, with S recording the highest odds. Sicker babies were likely to have vital signs documented in a higher monitoring category and being in the NEST360 program increased the odds of frequent vital signs documentation. However, by the end of the intervention period, nearly half of the newborns did not have a single full set of TPRS documented and there was heterogenous hospital performance. A review of 84 charts showed variable documentation, with only one chart being completed as designed. Vital signs documentation fell below standards despite increased documentation odds. More sustained interventions are required to realise the benefits of the chart and hospital-specific performance data may help customise interventions.
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Affiliation(s)
- Naomi Muinga
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Timothy Tuti
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Paul Mwaniki
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
| | - Edith Gicheha
- Rice360 Global Health Institute, Rice University, Texas, United States of America
| | - Chris Paton
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Lenka Beňová
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Mike English
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- Nuffield Department of Medicine, Health systems Collaborative, University of Oxford, Oxford, England
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Mbuthia D, Brownie S, Jackson D, McGivern G, English M, Gathara D, Nzinga J. Exploring the complex realities of nursing work in Kenya and how this shapes role enactment and practice-A qualitative study. Nurs Open 2023; 10:5670-5681. [PMID: 37221938 PMCID: PMC10333853 DOI: 10.1002/nop2.1812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 04/21/2023] [Accepted: 04/27/2023] [Indexed: 05/25/2023] Open
Abstract
AIM We explore how nurses navigate competing work demands in resource-constrained settings and how this shapes the enactment of nursing roles. DESIGN An exploratory-descriptive qualitative study. METHODS Using individual in-depth interviews and small group interviews, we interviewed 47 purposively selected nurses and nurse managers. We also conducted 57 hours of non-participant structured observations of nursing work in three public hospitals. RESULTS Three major themes arose: (i) Rationalization of prioritization decisions, where nurses described prioritizing technical nursing tasks over routine bedside care, coming up with their own 'working standards' of care and nurses informally delegating tasks to cope with work demands. (ii) Bundling of tasks describes how nurses were sometimes engaged in tasks seen to be out of their scope of work or sometimes being used to fill for other professional shortages. (iii) Pursuit of professional ideals describes how the reality of how nursing was practised was seen to be in contrast with nurses' quest for professionalism.
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Affiliation(s)
| | - Sharon Brownie
- School of Nursing, Midwifery & Public HealthUniversity of CanberraBruceAustralia
- School of Medicine & DentistryGriffith University, University DriveNathanQueenslandAustralia
- Centre for Health & Social PracticeHamiltonNew Zealand
| | | | | | - Mike English
- KEMRI Wellcome Trust Research ProgrammeNairobiKenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - David Gathara
- KEMRI Wellcome Trust Research ProgrammeNairobiKenya
- London School of Hygiene and Tropical MedicineLondonUK
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Imam A, Obiesie S, Gathara D, Aluvaala J, Maina M, English M. Missed nursing care in acute care hospital settings in low-income and middle-income countries: a systematic review. HUMAN RESOURCES FOR HEALTH 2023; 21:19. [PMID: 36918941 PMCID: PMC10015781 DOI: 10.1186/s12960-023-00807-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 02/23/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Missed nursing care undermines nursing standards of care and minimising this phenomenon is crucial to maintaining adequate patient safety and the quality of patient care. The concept is a neglected aspect of human resource for health thinking, and it remains understudied in low-income and middle-income country (LMIC) settings which have 90% of the global nursing workforce shortages. Our objective in this review was to document the prevalence of missed nursing care in LMIC, identify the categories of nursing care that are most missed and summarise the reasons for this. METHODS We conducted a systematic review searching Medline, Embase, Global Health, WHO Global index medicus and CINAHL from their inception up until August 2021. Publications were included if they were conducted in an LMIC and reported on any combination of categories, reasons and factors associated with missed nursing care within in-patient settings. We assessed the quality of studies using the Newcastle Ottawa Scale. RESULTS Thirty-one studies met our inclusion criteria. These studies were mainly cross-sectional, from upper middle-income settings and mostly relied on nurses' self-report of missed nursing care. The measurement tools used, and their reporting were inconsistent across the literature. Nursing care most frequently missed were non-clinical nursing activities including those of comfort and communication. Inadequate personnel numbers were the most important reasons given for missed care. CONCLUSIONS Missed nursing care is reported for all key nursing task areas threatening care quality and safety. Data suggest nurses prioritise technical activities with more non-clinical activities missed, this undermines holistic nursing care. Improving staffing levels seems a key intervention potentially including sharing of less skilled activities. More research on missed nursing care and interventions to tackle it to improve quality and safety is needed in LMIC. PROSPERO registration number: CRD42021286897.
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Affiliation(s)
- Abdulazeez Imam
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK.
| | - Sopuruchukwu Obiesie
- Centre for Evidence Based Intervention, Department of Social Policy and Intervention, University of Oxford, Oxford, UK
| | - David Gathara
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Jalemba Aluvaala
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Michuki Maina
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, S Parks Rd, Oxford, OX1 3SY, UK
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Imam A, Gathara D, Aluvaala J, Maina M, English M. Evaluating the effects of supplementing ward nurses on quality of newborn care in Kenyan neonatal units: protocol for a prospective workforce intervention study. BMC Health Serv Res 2022; 22:1230. [PMID: 36195863 PMCID: PMC9530438 DOI: 10.1186/s12913-022-08597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data from High Income Countries have now linked low nurse staff to patient ratios to poor quality patient care. Adequately staffing hospitals is however still a challenge in resource-constrained Low-middle income countries (LMICs) and poor staff-to-patient ratios are largely taken as a norm. This in part relates to limited evidence on the relationship between staffing and quality of patient care in these settings and also an absence of research on benefits that might occur from improving hospital staff numbers in LMICs. This study will determine the effect on the quality of patient care of prospectively adding extra nursing staff to newborn units in a resource constrained LMIC setting and describe the relationship between staffing and quality of care. METHODS This prospective workforce intervention study will involve a multi-method approach. We will conduct a before and after study in newborn units of 4 intervention hospitals and a single time-point comparison in 4 non-intervention hospitals to determine if there is a change in the level of missed nursing care, a process measure of the quality of patient care. We will also determine the effect of our intervention on routinely collected quality indicators using interrupted time series analysis. Using three nurse staffing metrics (Total nursing hours, nursing hours per patient day and nursing hours per patient per shift), we will describe the relationship between staffing and the quality of patient care. DISCUSSION There is an urgent need for the implementation of staffing policies in resource constrained LMICs that are guided by relevant contextual data. To the best of our knowledge, this is the first study to evaluate the prospective addition of nursing staff in resource-constrained care settings. Our findings are likely to provide the much-needed evidence for better staffing in these settings. TRIAL REGISTRATION This study was retrospectively registered in the Pan African Clinical Trial Registry ( https://pactr.samrc.ac.za/Default.aspx?Logout=True ) database on the 10th of June 2022 with a unique identification number-PACTR202206477083141.
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Affiliation(s)
- Abdulazeez Imam
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya.
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Paediatrics, University of Nairobi, Nairobi, Kenya
| | - Michuki Maina
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Musitia P, Boga M, Oluoch D, Haaland A, Nzinga J, English M, Molyneux S. Strengthening respectful communication with patients and colleagues in neonatal units - developing and evaluating a communication and emotional competence training for nurse managers in Kenya. Wellcome Open Res 2022; 7:223. [PMID: 38708375 PMCID: PMC11066535 DOI: 10.12688/wellcomeopenres.18006.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 05/07/2024] Open
Abstract
Introduction: Effective communication is essential to delivering compassionate, high-quality nursing care. The intensive, stressful and technical environment of a new-born unit (NBU) in a low-resource setting presents communication-related challenges for nurses, with negative implications for nurse well-being, team relationships and patient care. We adapted a pre-existing communication and emotional competence course with NBU nurse managers working in Kenya, explored its' value to participants and developed a theory of change to evaluate its' potential impact. Methods: 18 neonatal nurse managers from 14 county referral hospitals helped adapt and participated in a nine-month participatory training process. Training involved guided 'on the job' self-observation and reflection to build self-awareness, and two face-to-face skills-building workshops. The course and potential for future scale up was assessed using written responses from participant nurses (baseline questionnaires, reflective assignments, pre and post workshop questionnaires), workshop observation notes, two group discussions and nine individual in-depth interviews. Results: Participants were extremely positive about the course, with many emphasizing its direct relevance and applicability to their daily work. Increased self-awareness and ability to recognize their own, colleagues' and patients' emotional triggers, together with new knowledge and practical skills, reportedly inspired nurses to change; in turn influencing their ability to provide respectful care, improving their confidence and relationships and giving them a stronger sense of professional identity. Conclusion: Providing respectful care is a major challenge in low-resource, high-pressure clinical settings but there are few strategies to address this problem. The participatory training process examined addresses this challenge and has potential for positive impacts for families, individual workers and teams, including worker well-being. We present an initial theory of change to support future evaluations aimed at exploring if and how positive gains can be sustained and spread within the wider system.
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Affiliation(s)
- Peris Musitia
- Health Service Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mwanamvua Boga
- Health Service Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dorothy Oluoch
- Health Service Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ane Haaland
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jacinta Nzinga
- Health Service Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Service Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Oxford Centre for Global Health Research, Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Service Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Oxford Centre for Global Health Research, Oxford, Oxford, UK
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Jepkosgei J, English M, Adam MB, Nzinga J. Understanding intra- and interprofessional team and teamwork processes by exploring facility-based neonatal care in kenyan hospitals. BMC Health Serv Res 2022; 22:636. [PMID: 35562721 PMCID: PMC9103056 DOI: 10.1186/s12913-022-08039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Within intensive care settings such as neonatal intensive care units, effective intra- and interprofessional teamwork has been linked to a significant reduction of errors and overall improvement in the quality of care. In Kenya, previous studies suggest that coordination of care among healthcare teams providing newborn care is poor. Initiatives aimed at improving intra- and interprofessional teamwork in healthcare settings largely draw on studies conducted in high-income countries, with those from resource-constrained low and middle countries, particularly in the context of newborn care lacking. In this study, we explored the nature of intra- and interprofessional teamwork among health care providers in newborn units (NBUs) of three hospitals in Kenya, and the professional and contextual dynamics that shaped their interactions. METHODS This exploratory qualitative study was conducted in three hospitals in Nairobi and Muranga Counties in Kenya. We adopted an ethnographic approach, utilizing both in-depth interviews (17) and non-participant observation of routine care provision in NBUs (250 observation hours). The study participants included: nurses, nursing students, doctors, and trainee doctors. All the data were thematically coded in NVIVO 12. RESULTS The nature of intra- and interprofessional teamwork among healthcare providers in the study newborn units is primarily shaped by broader contextual factors and varying institutional contexts. As a result, several team types emerged, loosely categorized as the 'core' team which involves providers physically present in the unit most times during the work shift; the emergency team and the temporary ad-hoc teams which involved the 'core' team, support staff students and mothers. The emergence of these team types influenced relationships among providers. Overall, institutionalized routines and rituals shaped team relations and overall functioning. CONCLUSIONS Poor coordination and the sub-optimal nature of intra-and interprofessional teamwork in NBUs are attributed to broader contextual challenges that include low staff to patient ratios and institutionalized routines and rituals that influenced team norming, relationships, and team leadership. Therefore, mechanisms to improve coordination and collaboration among healthcare teams in these settings need to consider contextual dynamics including institutional cultures while also targeting improvement of team-level processes including leadership development and widening spaces for more interaction and better communication.
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Affiliation(s)
- Joyline Jepkosgei
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya.
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mary B Adam
- AIC Kijabe Mission Hospital, Kijabe, Kenya
- Africa Consortium for Quality Improvement Research in Frontline Healthcare (ACQUIRE), Nairobi, Kenya
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
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Jepkosgei J, Nzinga J, Adam MB, English M. Exploring healthcare workers' perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals' newborn units. BMC Health Serv Res 2022; 22:172. [PMID: 35144594 PMCID: PMC8832787 DOI: 10.1186/s12913-022-07572-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits. METHODS This was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach. RESULTS Perceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors. CONCLUSION Our findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.
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Affiliation(s)
- Joyline Jepkosgei
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya.
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
| | | | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Wanyama C, Nagraj S, Muinga N, Tuti T, Edgcombe H, Geniets A, Winters N, English M, Rossner J, Paton C. Lessons from the design, development and implementation of a three-dimensional (3D) neonatal resuscitation training smartphone application: Life-saving Instruction for Emergencies (LIFE app). Adv Simul (Lond) 2022; 7:2. [PMID: 35012665 PMCID: PMC8744048 DOI: 10.1186/s41077-021-00197-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 12/22/2021] [Indexed: 11/16/2022] Open
Abstract
Neonatal mortality remains disproportionately high in sub-Saharan Africa partly due to insufficient numbers of adequately trained and skilled front-line health workers. Opportunities for improving neonatal care may result from upskilling frontline health workers using innovative technological approaches. This practice paper describes the key steps involved in the design, development and implementation of an innovative smartphone-based training application using an agile, human-centred design approach. The Life-saving Instruction for Emergencies (LIFE) app is a three-dimension (3D) scenario-based mobile app for smartphones and is free to download. Two clinical modules are currently included with further scenarios planned. Whilst the focus of the practice paper is on the lessons learned during the design and development process, we also share key learning related to project management and sustainability plans, which we hope will help researchers working on similar projects.
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Affiliation(s)
- Conrad Wanyama
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya.
| | - Shobhana Nagraj
- Nuffield Department of Women's & Reproductive Health, Oxford, England
- The George Institute for Global Health, London, UK
| | - Naomi Muinga
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya
| | - Timothy Tuti
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya
| | | | - Anne Geniets
- Department of Education, University of Oxford, Oxford, UK
| | - Niall Winters
- Department of Education, University of Oxford, Oxford, UK
| | - Mike English
- KEMRI/Wellcome Trust Research Programme, Kenya Medical Research Institute, 197 Lenana Place, P.O Box 43640-00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jakob Rossner
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chris Paton
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Ray H, Sobiech KL, Alexandrova M, Songok JJ, Rukunga J, Bucher S. Critical Interpretive Synthesis of Qualitative Data on the Health Care Ecosystem for Vulnerable Newborns in Low- to Middle-Income Countries. J Obstet Gynecol Neonatal Nurs 2021; 50:549-560. [PMID: 34302768 DOI: 10.1016/j.jogn.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To critically assess and synthesize qualitative findings regarding the health care ecosystem for vulnerable (low-birth-weight or sick) neonates in low- to middle-income countries (LMICs). DATA SOURCES Between May 4 and June 2, 2020, we searched four databases (Medline [PubMed], SCOPUS, PsycINFO, and Web of Science) for articles published from 2010 to 2020. Inclusion criteria were peer-reviewed reports of original studies focused on the health care ecosystem for vulnerable neonates in LMICs. We also searched the websites of several international development agencies and included findings from primary data collected between May and July 2019 at a tertiary hospital in Kenya. We excluded studies and reports if the focus was on healthy neonates or high-income countries and if they contained only quantitative data, were written in a language other than English, or were published before 2010. STUDY SELECTION One of the primary authors conducted an initial review of titles and abstracts (n = 102) and excluded studies that were not consistent with the purpose of the review (n = 60). The two primary authors used a qualitative appraisal checklist to assess the validity of the remaining studies (n = 42) and reached agreement on the final 13 articles. DATA EXTRACTION The two primary authors independently conducted open and axial coding of the data. We incorporated data from studies with different units of analysis, types of methodology, research topics, participant types, and analytical frameworks in an emergent conceptual development process according to the critical interpretive synthesis methodology. DATA SYNTHESIS We synthesized our findings into one overarching theme, Pervasive Turbulence Is a Defining Characteristic of the Health Care Ecosystem in LMICs, and two subthemes: Pervasive Turbulence May Cause Tension Between the Setting and the Caregiver and Pervasive Turbulence May Result in a Loss of Synergy in the Caregiver-Parent Relationship. CONCLUSION Because pervasive turbulence characterizes the health care ecosystems in LMICs, interventions are needed to support the caregiver-parent interaction to mitigate the effects of tension in the setting.
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Nzinga J, Jones C, Gathara D, English M. Value of stakeholder engagement in improving newborn care in Kenya: a qualitative description of perspectives and lessons learned. BMJ Open 2021; 11:e045123. [PMID: 34193487 PMCID: PMC8246352 DOI: 10.1136/bmjopen-2020-045123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE Embedding researchers within health systems results in more socially relevant research and more effective uptake of evidence into policy and practice. However, the practice of embedded health service research remains poorly understood. We explored and assessed the development of embedded participatory approaches to health service research by a health research team in Kenya highlighting the different ways multiple stakeholders were engaged in a neonatal research study. METHODS We conducted semistructured qualitative interviews with key stakeholders. Data were analysed thematically using both inductive and deductive approaches. SETTING Over recent years, the Health Services Unit within the Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme in Nairobi Kenya, has been working closely with organisations and technical stakeholders including, but not limited to, medical and nursing schools, frontline health workers, senior paediatricians, policymakers and county officials, in developing and conducting embedded health research. This involves researchers embedding themselves in the contexts in which they carry out their research (mainly in county hospitals, local universities and other training institutions), creating and sustaining social networks. Researchers collaboratively worked with stakeholders to identify clinical, operational and behavioural issues related to routine service delivery, formulating and exploring research questions to bring change in practice PARTICIPANTS: We purposively selected 14 relevant stakeholders spanning policy, training institutions, healthcare workers, regulatory councils and professional associations. RESULTS The value of embeddedness is highlighted through the description of a recently completed project, Health Services that Deliver for Newborns (HSD-N). We describe how the HSD-N research process contributed to and further strengthened a collaborative research platform and illustrating this project's role in identifying and generating ideas about how to tackle health service delivery problems CONCLUSIONS: We conclude with a discussion about the experiences, challenges and lessons learned regarding engaging stakeholders in the coproduction of research.
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Affiliation(s)
- Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Caroline Jones
- Health Systems Research and Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - David Gathara
- Health Systems Research and Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Mike English
- Health Systems Research and Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, Oxford University, Oxford, UK
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Vincent CA, Mboga M, Gathara D, Were F, Amalberti R, English M. How to do no harm: empowering local leaders to make care safer in low-resource settings. Arch Dis Child 2021; 106:333-337. [PMID: 33574028 PMCID: PMC7982924 DOI: 10.1136/archdischild-2020-320631] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/27/2020] [Accepted: 01/24/2021] [Indexed: 11/05/2022]
Abstract
In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a 'portfolio' approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.
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Affiliation(s)
| | | | - David Gathara
- Health Services Unit, KEMRI-Wellcome Trust, Nairobi, Kenya,London School of Hygiene & Tropical Medicine, London, UK
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Rene Amalberti
- Foundation for an Industrial Safety Culture, Toulouse, France
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust, Nairobi, Kenya .,Oxford Centre for Global Health Research, Nuffiled Department of Medicine, University of Oxford, Oxford, UK
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Bolan N, Cowgill KD, Walker K, Kak L, Shaver T, Moxon S, Lincetto O. Human Resources for Health-Related Challenges to Ensuring Quality Newborn Care in Low- and Middle-Income Countries: A Scoping Review. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:160-176. [PMID: 33795367 PMCID: PMC8087437 DOI: 10.9745/ghsp-d-20-00362] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND A critical shortage of health workers with needed maternal and newborn competencies remains a major challenge for the provision of quality care for mothers and newborns, particularly in low- and middle-income countries. Supply-side challenges related to human resources for health (HRH) worsen shortages and can negatively affect health worker performance and quality of care. This review scoped country-focused sources to identify and map evidence on HRH-related challenges to quality facility-based newborn care provision by nurses and midwives. METHODS Evidence for this review was collected iteratively, beginning with pertinent World Health Organization documents and extending to articles identified via database and manual reference searches and country reports. Evidence from country-focused sources from 2000 onward was extracted using a data extraction tool that was designed iteratively; thematic analysis was used to map the 10 categories of HRH challenges. FINDINGS A total of 332 peer-reviewed articles were screened, of which 22 met inclusion criteria. Fourteen additional sources were added from manual reference search and gray literature sources. Evidence has been mapped into 10 categories of HRH-related challenges: (1) lack of health worker data and monitoring; (2) poor health worker preservice education; (3) lack of HW access to evidence-based practice guidelines, continuing education, and continuing professional development; (4) insufficient and inequitable distribution of health workers and heavy workload; (5) poor retention, absenteeism, and rotation of experienced staff; (6) poor work environment, including low salary; (7) limited and poor supervision; (8) low morale, motivation, and attitude, and job dissatisfaction; (9) weaknesses of policy, regulations, management, leadership, governance, and funding; and (10) structural and contextual barriers. CONCLUSION The mapping provides needed insight that informed new World Health Organization strategies and supporting efforts to address the challenges identified and strengthen human resources for neonatal care, with the ultimate goal of improving newborn care and outcomes.
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Affiliation(s)
- Nancy Bolan
- Office of Global Health, University of Maryland School of Nursing, Baltimore, MD, USA.
| | - Karen D Cowgill
- University of Washington Department of Global Health, Seattle, WA, USA
| | - Karen Walker
- The George Institute for Global Health, Newtown, Australia
| | - Lily Kak
- U.S. Agency for International Development, Washington, DC, USA
| | - Theresa Shaver
- Social Solutions International, Inc., Washington, DC, USA
| | - Sarah Moxon
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Bechange S, Gillani M, Jolley E, Iqbal R, Ahmed L, Bilal M, Khan IK, Yasmin S, Schmidt E. School-based vision screening in Quetta, Pakistan: a qualitative study of experiences of teachers and eye care providers. BMC Public Health 2021; 21:364. [PMID: 33593327 PMCID: PMC7885518 DOI: 10.1186/s12889-021-10404-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 02/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background Visual impairment in children is a significant public health problem affecting millions of children globally. Many eye problems experienced by children can be easily diagnosed and treated. We conducted a qualitative study with teachers and optometrists involved in a school-based vision screening programme in Quetta district of Pakistan to explore their experiences of training, vision screening and referrals and to identify factors impacting on the effectiveness of the programme. Methods Between April 2018 and June 2018, we conducted semi-structured in-depth interviews with 14 teachers from eight purposefully selected schools with high rates of inaccurate (false positive) referrals. Interviews were also conducted with three optometrists from a not-for profit private eye care hospital that had trained the teachers. Interviews were audio recorded and professionally transcribed. NVIVO software version 12 was used to code and thematically analyze the data. Results Findings suggest that the importance of school-based vision screening was well understood and appreciated by the teachers and optometrists. Most participants felt that there was a strong level of support for the vision screening programme within the participating schools. However, there were a number of operational issues undermining the quality of screening. Eight teachers felt that the duration of the training was insufficient; the training was rushed; six teachers said that the procedures were not sufficiently explained, and the teachers had no time to practice. The screening protocol was not always followed by the teachers. Additionally, many teachers reported being overburdened with other work, which affected both their levels of participation in the training and the time they spent on the screening. Conclusions School-based vision screening by teachers is a cost-effective strategy to detect and treat children’s vision impairment early on. In the programme reviewed here however, a significant number of teachers over referred children to ophthalmic services, overwhelming their capacity and undermining the efficiency of the approach. To maximise the effectiveness and efficiency of school-based screening, future initiatives should give sufficient attention to the duration of the teacher training, experience of trainers, support supervision, refresher trainings, regular use of the screening guidelines, and the workload and motivation of those trained. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10404-9.
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Affiliation(s)
- Stevens Bechange
- Sightsavers Pakistan Country Office, Plot 3-A, Street 7, Sector G-10/2, Islamabad, Pakistan.
| | - Munazza Gillani
- Sightsavers Pakistan Country Office, Plot 3-A, Street 7, Sector G-10/2, Islamabad, Pakistan
| | - Emma Jolley
- Sightsavers - United Kingdom, 35 Perrymount Road, Haywards Heath, West Sussex, RH16 3BW, UK
| | | | - Leena Ahmed
- Sightsavers Pakistan Country Office, Plot 3-A, Street 7, Sector G-10/2, Islamabad, Pakistan
| | - Muhammed Bilal
- Sightsavers Pakistan Country Office, Plot 3-A, Street 7, Sector G-10/2, Islamabad, Pakistan
| | - Itfaq Khaliq Khan
- Sightsavers Pakistan Country Office, Plot 3-A, Street 7, Sector G-10/2, Islamabad, Pakistan
| | - Sumrana Yasmin
- Sightsavers Pakistan Country Office, Plot 3-A, Street 7, Sector G-10/2, Islamabad, Pakistan
| | - Elena Schmidt
- Sightsavers - United Kingdom, 35 Perrymount Road, Haywards Heath, West Sussex, RH16 3BW, UK
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 12/24/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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17
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English M, Nzinga J, Irimu G, Gathara D, Aluvaala J, McKnight J, Wong G, Molyneux S. Programme theory and linked intervention strategy for large-scale change to improve hospital care in a low and middle-income country - A Study Pre-Protocol. Wellcome Open Res 2020; 5:265. [PMID: 33274301 PMCID: PMC7684682 DOI: 10.12688/wellcomeopenres.16379.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 01/25/2023] Open
Abstract
In low and middle-income countries (LMIC) general hospitals are important for delivering some key acute care services. Neonatal care is emblematic of these acute services as averting deaths requires skilled care over many days from multiple professionals with at least basic equipment. However, hospital care is often of poor quality and large-scale change is needed to improve outcomes. In this manuscript we aim to show how we have drawn upon our understanding of contexts of care in Kenyan general hospital NBUs, and on social and behavioural theories that offer potential mechanisms of change in these settings, to develop an initial programme theory guiding a large scale change intervention to improve neonatal care and outcomes. Our programme theory is an expression of our assumptions about what actions will be both useful and feasible. It incorporates a recognition of our strengths and limitations as a research-practitioner partnership to influence change. The steps we employ represent the initial programme theory development phase commonly undertaken in many Realist Evaluations. However, unlike many Realist Evaluations that develop initial programme theories focused on pre-existing interventions or programmes, our programme theory informs the design of a new intervention that we plan to execute. Within this paper we articulate briefly how we propose to operationalise this new intervention. Finally, we outline the quantitative and qualitative research activities that we will use to address specific questions related to the delivery and effects of this new intervention, discussing some of the challenges of such study designs. We intend that this research on the intervention will inform future efforts to revise the programme theory and yield transferable learning.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - Grace Irimu
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | - David Gathara
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- Health Services Unit, KEMRI-Wellcome Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Fitzgerald L, Gathara D, McKnight J, Nzinga J, English M. Are health care assistants part of the long-term solution to the nursing workforce deficit in Kenya? HUMAN RESOURCES FOR HEALTH 2020; 18:79. [PMID: 33081790 PMCID: PMC7576771 DOI: 10.1186/s12960-020-00523-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 10/09/2020] [Indexed: 05/24/2023]
Abstract
This commentary article addresses a critical issue facing Kenya and other Low- and Middle-Income Countries (LMIC): how to remedy deficits in hospitals' nursing workforce. Would employing health care assistants (HCAs) provide a partial solution? This article first gives a brief introduction to the Kenyan context and then explores the development of workforce roles to support nurses in Europe to highlight the diversity of these roles. Our introduction pinpoints that pressures to maintain or restrict costs have led to a wide variety of formal and informal task shifting from nurses to some form of HCA in the EU with differences noted in issues of appropriate skill mix, training, accountability, and regulation of HCA. Next, we draw from a suite of recent studies in hospitals in Kenya which illustrate nursing practices in a highly pressurized context. The studies took place in neo-natal wards in Kenyan hospitals between 2015 and 2018 and in a system with no legal or regulatory basis for task shifting to HCAs. We proffer data on why and how nurses informally delegate tasks to others in the public sector and the decision-making processes of nurses and frame this evidence in the specific contextual conditions. In the conclusion, the paper aims to deepen the debates on developing human resources for health. We argue that despite the urgent pressures to address glaring workforce deficits in Kenya and other LMIC, caution needs to be exercised in implementing changes to nursing practices through the introduction of HCAs. The evidence from EU suggests that the rapid growth in the employment of HCA has created crucial issues which need addressing. These include clearly defining the scope of practice and developing the appropriate skill mix between nurses and HCAs to match the specific health system context. Moreover, we suggest efforts to develop and implement such roles should be carefully designed and rigorously evaluated to inform continuing policy development.
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Affiliation(s)
| | - David Gathara
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacob McKnight
- Nuffield Dept. of Medicine, University of Oxford, Oxford, UK
| | | | - Mike English
- NDM, University of Oxford, Oxford, UK
- Health Services and Research Group, KEMRI-Wellcome Trust, Kenya Medical Research Institute/Wellcome Trust Research Programme, PO Box 43640, Nairobi, 00100 Kenya
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English M, Strachan B, Esamai F, Ngwiri T, Warfa O, Mburugu P, Nalwa G, Gitaka J, Ngugi J, Zhao Y, Ouma P, Were F. The paediatrician workforce and its role in addressing neonatal, child and adolescent healthcare in Kenya. Arch Dis Child 2020; 105:927-931. [PMID: 32554508 PMCID: PMC7513261 DOI: 10.1136/archdischild-2019-318434] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine the availability of paediatricians in Kenya and plans for their development. DESIGN Review of policies and data from multiple sources combined with local expert insight. SETTING Kenya with a focus on the public, non-tertiary care sector as an example of a low-income and middle-income country aiming to improve the survival and long-term health of newborns, children and adolescents. RESULTS There are 305 practising paediatricians, 1.33 per 100 000 individuals of the population aged <19 years which in total numbers approximately 25 million. Only 94 are in public sector, non-tertiary county hospitals. There is either no paediatrician at all or only one paediatrician in 21/47 Kenyan counties that are home to over a quarter of a million under 19 years of age. Government policy is to achieve employment of 1416 paediatricians in the public sector by 2030, however this remains aspirational as there is no comprehensive training or financing plan to reach this target and health workforce recruitment, financing and management is now devolved to 47 counties. The vast majority of paediatric care is therefore provided by non-specialist healthcare workers. DISCUSSION The scale of the paediatric workforce challenge seriously undermines the ability of the Kenyan health system to deliver on the emerging survive, thrive and transform agenda that encompasses more complex health needs. Addressing this challenge may require innovative workforce solutions such as task-sharing, these may in turn require the role of paediatricians to be redefined. Professional paediatric communities in countries like Kenya could play a leadership role in developing such solutions.
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Affiliation(s)
- Mike English
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya .,Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | | | - Fabian Esamai
- Department of Paediatrics and Child Health, College of Health Sciences, Moi University, Kenya, Eldoret, Kenya
| | | | | | - Patrick Mburugu
- Department of Paediatrics and Child Health, School of Medicine, Jomo Kenyatta University of Africulture and Technology, Nairobi, Kenya
| | - Grace Nalwa
- Department of Paediatrics and Child Health, Maseno University, Maseno, Nyanza, Kenya
| | - Jesse Gitaka
- Directorate of Research and Innovation, School of Medicine, Mount Kenya University, Thika, Kenya
| | - John Ngugi
- Department of Paediatrics and Child Health, Kenyatta University, Nairobi, Kenya
| | - Yingxi Zhao
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Paul Ouma
- KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Fred Were
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
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Nabwera HM, Wright JL, Patil M, Dickinson F, Godia P, Maua J, Sammy MK, Naimoi BC, Warfa OH, Dewez JE, Murila F, Manu A, Smith H, Mathai M. 'Sometimes you are forced to play God…': a qualitative study of healthcare worker experiences of using continuous positive airway pressure in newborn care in Kenya. BMJ Open 2020; 10:e034668. [PMID: 32792424 PMCID: PMC7430418 DOI: 10.1136/bmjopen-2019-034668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE: To explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up. DESIGN AND SETTING: A qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya. PARTICIPANTS: Healthcare workers in the newborn units providing CPAP. PRIMARY AND SECONDARY OUTCOME MEASURE: Facilitators and barriers of CPAP use in newborn care in Kenya. RESULTS: 16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available. CONCLUSION: CPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use. ETHICS: This study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.
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Affiliation(s)
- Helen M Nabwera
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jemma L Wright
- Paediatrics Department, Betsi Cadwaladr CHC, Wrexham, UK
| | - Manasi Patil
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Fiona Dickinson
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pamela Godia
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Judith Maua
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Mercy K Sammy
- General Paediatrics, Gertrude's Garden Children's Hospital, Nairobi, Kenya
| | | | - Osman H Warfa
- Neonatal, Child and Adolescent Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Juan Emmanuel Dewez
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Florence Murila
- Paediatrics and Child Health, University of Nairobi School of Medicine, Nairobi, Kenya
| | - Alexander Manu
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Smith
- Maternal and Newborn Health, International Health Consulting Services Ltd, Liverpool, UK
| | - Matthews Mathai
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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21
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Ndiaye S, Bosowski J, Tuyisenge L, Penn-Kekana L, Thorogood N, Moxon SG, Lissauer T. Parents as carers on a neonatal unit: Qualitative study of parental and staff perceptions in a low-income setting. Early Hum Dev 2020; 145:105038. [PMID: 32311647 DOI: 10.1016/j.earlhumdev.2020.105038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/28/2020] [Accepted: 03/31/2020] [Indexed: 11/12/2022]
Abstract
UNLABELLED Aim To determine parents' experiences on a neonatal unit in a low-income country, how they and staff perceive the role of parents and if parents' role as primary carers could be extended. BACKGROUND A busy, rural district hospital in Rwanda. Rwandan neonatal mortality is falling, but achieving Sustainable Development Goal target is hampered by trained staff shortage. METHODS Qualitative thematic content analysis of semi-structured interviews with 12 parents and 16 staff. RESULTS Parental concerns were around their baby's survival, stress and discharge. They were satisfied with their baby's care but feared their baby may die. Mothers described stress from remaining in hospital throughout baby's stay, providing all non-technical care including tube or breast feeds day and night, followed by kangaroo mother care until discharge. They expressed loneliness from lack of visitors, difficulty finding food and somewhere to sleep, financial worries, concern about family at home, and were desperate to be discharged. Staff focused on shortage of nurses limiting technical care, ability to educate parents and provide follow-up. Neither groups thought parents' role could be extended. CONCLUSION Staff, including senior management, were mainly focused on increasing nursing numbers. Parents' concerns were psychosocial and about coping emotionally with their baby's care and practical concerns about inpatient facilities, particularly lack of food and accommodation and absence from home. Staff preoccupation with nurse numbers made them concentrate on medical care, but parental issues identified are more likely to be provided by experienced mothers, allied health professionals, mothers' groups or community health workers.
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Affiliation(s)
- S Ndiaye
- London School of Hygiene and Tropical Medicine, London, UK
| | - J Bosowski
- London School of Hygiene and Tropical Medicine, London, UK
| | - L Tuyisenge
- University Teaching Hospital of Kigali, Rwanda
| | - L Penn-Kekana
- London School of Hygiene and Tropical Medicine, London, UK
| | - N Thorogood
- London School of Hygiene and Tropical Medicine, London, UK
| | - S G Moxon
- London School of Hygiene and Tropical Medicine, London, UK
| | - T Lissauer
- Imperial College Healthcare Trust, London, UK; University of Rwanda, Rwanda.
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Omondi GB, Murphy GAV, Jackson D, Brownie S, English M, Gathara D. Informal task-sharing practices in inpatient newborn settings in a low-income setting-A task analysis approach. Nurs Open 2020; 7:869-878. [PMID: 32257274 PMCID: PMC7113512 DOI: 10.1002/nop2.463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 01/10/2020] [Accepted: 02/03/2020] [Indexed: 11/20/2022] Open
Abstract
Aim To describe the complexity and criticality of neonatal nursing tasks and existing task-sharing practices to identify tasks that might be safely shared in inpatient neonatal settings. Design We conducted a cross-sectional study in a large geographically dispersed sample using the STROBE guidelines. Methods We used a task analysis approach to describe the complexity/criticality of neonatal nursing tasks and to explore the nature of task sharing using data from structured, self-administered questionnaires. Data was collected between 26th April and 22nd August 2017. Results Thirty-two facilities were surveyed between 26th April and 22nd August, 2017. Nearly half (42%, 6/14) of the "moderately critical" and "not critical" (41%, 5/11) tasks were ranked as consuming most of the nurses' time and reported as shared with mothers respectively. Most tasks were reported as shared in the public sector than in the private-not-for-profit facilities. This may largely be a response to inadequate nurse staffing, as such, there may be space for considering the future role of health care assistants.
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Affiliation(s)
| | - Georgina A. V. Murphy
- KEMRI‐Wellcome Trust Research ProgrammeNairobiKenya
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Debra Jackson
- Faculty of HealthUniversity of TechnologySydneyNSWAustralia
| | - Sharon Brownie
- School of MedicineGriffith UniversityNathanQldAustralia
- PRAXIS ForumGreen Templeton CollegeUniversity of OxfordOxfordUK
| | - Mike English
- KEMRI‐Wellcome Trust Research ProgrammeNairobiKenya
- Nuffield Department of MedicineUniversity of OxfordOxfordUK
| | - David Gathara
- KEMRI‐Wellcome Trust Research ProgrammeNairobiKenya
- Aga Khan University HospitalNairobiKenya
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23
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English M, Gathara D, Nzinga J, Kumar P, Were F, Warfa O, Tallam-Kimaiyo E, Nandili M, Obengo A, Abuya N, Jackson D, Brownie S, Molyneux S, Jones COH, Murphy GAV, McKnight J. Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya. BMJ Glob Health 2020; 5:e001937. [PMID: 32133169 PMCID: PMC7042598 DOI: 10.1136/bmjgh-2019-001937] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 11/02/2022] Open
Abstract
There are global calls for research to support health system strengthening in low-income and middle-income countries (LMICs). To examine the nature and magnitude of gaps in access and quality of inpatient neonatal care provided to a largely poor urban population, we combined multiple epidemiological and health services methodologies. Conducting this work and generating findings was made possible through extensive formal and informal stakeholder engagement linked to flexibility in the research approach while keeping overall goals in mind. We learnt that 45% of sick newborns requiring hospital care in Nairobi probably do not access a suitable facility and that public hospitals provide 70% of care accessed with private sector care either poor quality or very expensive. Direct observations of care and ethnographic work show that critical nursing workforce shortages prevent delivery of high-quality care in high volume, low-cost facilities and likely threaten patient safety and nurses' well-being. In these challenging settings, routines and norms have evolved as collective coping strategies so health professionals maintain some sense of achievement in the face of impossible demands. Thus, the health system sustains a functional veneer that belies the stresses undermining quality, compassionate care. No one intervention will dramatically reduce neonatal mortality in this urban setting. In the short term, a substantial increase in the number of health workers, especially nurses, is required. This must be combined with longer term investment to address coverage gaps through redesign of services around functional tiers with improved information systems that support effective governance of public, private and not-for-profit sectors.
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Affiliation(s)
- Mike English
- Health Services Unit, KEMRI – Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, Oxford, Oxfordshire, UK
| | - David Gathara
- Health Services Unit, KEMRI – Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacinta Nzinga
- Health Services Unit, KEMRI – Wellcome Trust Research Programme, Nairobi, Kenya
| | - Pratap Kumar
- Institute of Healthcare Management, Strathmore University Strathmore Business School, Nairobi, Nairobi Area, Kenya
- Health-E-Net Limited, Nairobi, Kenya
| | - Fred Were
- Department of Paediatrics, University of Nairobi, Nairobi, Nairobi, Kenya
| | - Osman Warfa
- Neonatal, Child and Adolescent Health Unit, Kenya Ministry of Health, Nairobi, Kenya
| | | | - Mary Nandili
- Neonatal, Child and Adolescent Health Unit, Kenya Ministry of Health, Nairobi, Kenya
| | - Alfred Obengo
- National Nurses Association of Kenya, Nairobi, Kenya
| | | | - Debra Jackson
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Sharon Brownie
- Griffith University Menzies Health Institute Queensland, Nathan, Queensland, Australia
| | - Sassy Molyneux
- Health Systems and Research Ethics, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, Oxford, UK
| | - Caroline Olivia Holmes Jones
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
- Department of Health System and Research Ethics, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Jacob McKnight
- Center for Tropical Medicine and Global Health, University of Oxford Centre for Tropical Medicine, Oxford, UK
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McKnight J, Nzinga J, Jepkosgei J, English M. Collective strategies to cope with work related stress among nurses in resource constrained settings: An ethnography of neonatal nursing in Kenya. Soc Sci Med 2020; 245:112698. [PMID: 31811960 PMCID: PMC6983929 DOI: 10.1016/j.socscimed.2019.112698] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 12/21/2022]
Abstract
Kenyan neonatal nurses are asked to do the impossible: to bridge the gap between international standards of nursing and the circumstances they face each day. They work long hours with little supervision in ill-designed wards, staffed by far too few nurses given the pressing need. Despite these conditions, a single neonatal nurse can be tasked with looking after forty sick babies for whom very close care is a necessity. Our 18-month ethnography explores this uniquely stressful environment in order to understand how nurses operate under such pressures and what techniques they use to organise work and cope. Beginning in January 2015, we conducted 250 h of non-participant observation and 32 semi-structured interviews in three newborn units in Nairobi to describe how nurses categorise babies, balance work across shifts, use routinised care, and demonstrate pragmatism and flexibility in their dealings with each other in order to reduce stress. In so doing, we present an empirically based model of the ways in which nurses cope in a lower-middle income setting and develop early work in nursing studies that highlighted collective strategies for reducing anxiety. This allows us to address the gap left by prevalent theories of nursing stress that have focused on the personal characteristics of individual nurses. Finally, we extend outwards from our ethnographic findings to consider how a deeper understanding of these collective strategies to reduce stress might inform policy, and why, even when the forces that create stress are alleviated, the underlying model of nursing work may prevail.
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Affiliation(s)
- Jacob McKnight
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | | | | | - Mike English
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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25
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Tsiachristas A, Gathara D, Aluvaala J, Chege T, Barasa E, English M. Effective coverage and budget implications of skill-mix change to improve neonatal nursing care: an explorative simulation study in Kenya. BMJ Glob Health 2019; 4:e001817. [PMID: 31908859 PMCID: PMC6936475 DOI: 10.1136/bmjgh-2019-001817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/31/2019] [Accepted: 11/10/2019] [Indexed: 11/14/2022] Open
Abstract
Introduction Neonatal mortality is an urgent policy priority to improve global population health and reduce health inequality. As health systems in Kenya and elsewhere seek to tackle increased neonatal mortality by improving the quality of care, one option is to train and employ neonatal healthcare assistants (NHCAs) to support professional nurses by taking up low-skill tasks. Methods Monte-Carlo simulation was performed to estimate the potential impact of introducing NHCAs in neonatal nursing care in four public hospitals in Nairobi on effectively treated newborns and staff costs over a period of 10 years. The simulation was informed by data from 3 workshops with >10 stakeholders each, hospital records and scientific literature. Two univariate sensitivity analyses were performed to further address uncertainty. Results Stakeholders perceived that 49% of a nurse full-time equivalent could be safely delegated to NHCAs in standard care, 31% in intermediate care and 20% in intensive care. A skill-mix with nurses and NHCAs would require ~2.6 billionKenyan Shillings (KES) (US$26 million) to provide quality care to 58% of all newborns in need (ie, current level of coverage in Nairobi) over a period of 10 years. This skill-mix configuration would require ~6 billion KES (US$61 million) to provide quality of care to almost all newborns in need over 10 years. Conclusion Changing skill-mix in hospital care by introducing NHCAs may be an affordable way to reduce neonatal mortality in low/middle-income countries. This option should be considered in ongoing policy discussions and supported by further evidence.
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Affiliation(s)
| | - David Gathara
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jalemba Aluvaala
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Timothy Chege
- Institute of Healthcare management, Strathmore University, Nairobi, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, Centre for Geographic Medicine Research Coast, Nairobi, Kenya
| | - Mike English
- Health Services Unit, KEMRI - Wellcome Trust Research Programme, Nairobi, Kenya.,Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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26
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Gathara D, Serem G, Murphy GAV, Obengo A, Tallam E, Jackson D, Brownie S, English M. Missed nursing care in newborn units: a cross-sectional direct observational study. BMJ Qual Saf 2019; 29:19-30. [PMID: 31171710 PMCID: PMC6923939 DOI: 10.1136/bmjqs-2019-009363] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND 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. 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. RESULTS 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. CONCLUSION 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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Affiliation(s)
- David Gathara
- Public Health Research, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya .,Nursing and Midwifery, Aga Khan University School of Nursing and Midwifery East Africa, Nairobi, Kenya
| | - George Serem
- Public Health Research, KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Alfred Obengo
- National Nurses Association of Kenya, Nairobi, Kenya
| | - Edna Tallam
- Registration and Licensing, Nursing Council of Kenya, Nairobi, Kenya
| | - Debra Jackson
- Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Sharon Brownie
- Nursing and Midwifery, Aga Khan University School of Nursing and Midwifery East Africa, Nairobi, Kenya.,School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
| | - Mike English
- Public Health Research, KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya.,Department of Paediatrics, University of Oxford, Oxford, UK
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