Experience of care of hospitalized newborns and young children and their parents: A scoping review

INTRODUCTION

Several global initiatives put parent involvement at the forefront of enabling children's well-being and development and to promote quality of care for newborns and hospitalized young children aged 0-24 months. Scanty evidence on mistreatment such as delays or neglect and poor pain management among newborns exists, with even less exploring the experience of their parents and their hospitalized young children. To address this gap, authors reviewed research on experience of care for hospitalized young children and their parents, and potential interventions that may promote positive experience of care.

METHODS

A scoping review of English language articles, guidelines, and reports that addressed the experiences of care for newborns and sick young children 0-24 months in health facilities was conducted. Multiple databases: PubMed, PROSPERO, COCHRANE Library and Google Scholar were included and yielded 7,784 articles. Documents published between 2009 and November 2020, in English and with evidence on interventions that addressed family involvement and partnership in care for their sick children were included.

RESULTS

The scoping review includes 68 documents across 31 countries after exclusion. Mistreatment of newborns comprises physical abuse, verbal abuse, stigma and discrimination, failure to meet professional standards, poor rapport between providers and patients, poor legal accountability, and poor bereavement and posthumous care. No literature was identified describing mistreatment of hospitalized children aged 60 days- 24 months. Key drivers of mistreatment include under-resourced health systems and poor provider attitudes. Positive experience of care was reported in contexts of good parent-provider communication. Three possible interventions on positive experience of care for hospitalized young children (0-24 months) emerged: 1) nurturing care; 2) family centered care and 3) provider and parental engagement. Communication and counseling, effective provider-parental engagement, and supportive work environments were associated with reduced anxiety and stress for parents and hospitalized young children. Few interventions focused on addressing providers' underlying attitudes and biases that influence provider behaviors, and how they affect engaging with parents.

CONCLUSION

Limited evidence on manifestations of mistreatment, lack of respectful care, drivers of poor experience and interventions that may mitigate poor experience of care for hospitalized young children 0-24 months especially in low resource settings exists. Design and testing appropriate models that enhance socio-behavioral dimensions of care experience and promote provider-family engagement in hospitals are required.

Nursing stakeholder identification guidelines for human resources for health and health workforce development: A scoping review

Aim

To investigate the existence of guidelines on the identification of nursing stakeholders as part of planning for human resources for health processes.

Background

Effective involvement of nursing stakeholders in planning and implementing human resources for health policies is strongly advocated by leading global bodies. Systematic identification of nursing stakeholders at an early stage is fundamentally important. Guidelines to support appropriate identification and inclusion of nursing stakeholders could support the active involvement of nurses and midwives in human resources for health planning processes at all levels.

Methods

We conducted a scoping review using the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for scoping reviews. We conducted a widely inclusive search for all types of records, including searches of bibliographic databases (PubMed, CINAHL, Scopus and Web of Science) and manual searches of selected websites and internet archives to identify grey literature, published in English since 2009. Search terms related to guidelines, stakeholder engagement and the health workforce.

Results

Of the 1058 potentially relevant sources identified, two studies met inclusion criteria. Both were guidelines produced by global bodies more than 12 years ago. Cochrane guidance on reporting ‘near‐empty’ reviews was followed, and eight additional sources meeting most of the inclusion criteria were identified and critiqued.

Conclusions

Guidelines regarding the process of nursing stakeholder identification specific to human resources for health planning processes are scarce and require updating. Critique of recent practices suggests considerable methodological variety and sub‐optimal identification of nursing stakeholders.

Implications for nursing and health policy

Nursing stakeholder engagement is an essential component of human resources for health planning processes, and the gap in literature points to a need for up‐to‐date guidance to ensure nurses’ active involvement.

Value of stakeholder engagement in improving newborn care in Kenya: a qualitative description of perspectives and lessons learned

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.

Informal task-sharing practices in inpatient newborn settings in a low-income setting-A task analysis approach

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.

Lessons from a Health Policy and Systems Research programme exploring the quality and coverage of newborn care in Kenya

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.

Developing recommendations for neonatal inpatient care service categories: reflections from the research, policy and practice interface in Kenya

Neonatal deaths contribute a growing proportion to childhood mortality, and increasing access to inpatient newborn care has been identified as a potential driver of improvements in child health. However, previous work by this research team identified substantial gaps in the coverage and standardisation of inpatient newborn care in Nairobi City County, Kenya. To address the issue in this particular setting, we sought to draft recommendations on the categorisation of neonatal inpatient services through a process of policy review, evidence collation and examination of guidance in other countries. This work supported discussions by a panel of local experts representing a diverse set of stakeholders, who focused on formulating pragmatic, context-relevant guidance. Experts in the discussions rapidly agreed on overarching priorities guiding their decision-making, and that three categories of inpatient neonatal care (standard, intermediate and intensive care) were appropriate. Through a modified nominal group technique, they achieved consensus on allocating 36 of the 38 proposed services to these categories and made linked recommendations on minimum healthcare worker requirements (skill mix and staff numbers). This process was embedded in the local context where the need had been identified, and required only modest resources to produce recommendations on the categorisation of newborn inpatient care that the experts agreed could be relevant in other Kenyan settings. Recommendations prioritised the strengthening of existing facilities linked to a need to develop effective referral systems. In particular, expansion of access to the standard category of inpatient neonatal care was recommended. The process and the agreed categorisations could inform discussion in other low-resource settings seeking to address unmet needs for inpatient neonatal care.

Exploring the space for task shifting to support nursing on neonatal wards in Kenyan public hospitals

BACKGROUND

Nursing practice is a key driver of quality care and can influence newborn health outcomes where nurses are the primary care givers to this highly dependent group. However, in sub-Saharan Africa, nursing work environments are characterized by heavy workloads, insufficient staffing and regular medical emergencies, which compromise the ability of nurses to provide quality care. Task shifting has been promoted as one strategy for making efficient use of human resources and addressing these issues.

AIMS AND OBJECTIVES

We aimed to understand the nature and practice of neonatal nursing in public hospitals in Nairobi so as to determine what prospect there might be for relieving pressure by shifting nurses' work to others.

METHODS

This paper is based on an 18-month qualitative study of three newborn units of three public hospitals-all located in Nairobi county-using an ethnographic approach. We draw upon a mix of 32 interviews, over 250 h' observations, field notes and informal conversations. Data were collected from senior nursing experts in newborn nursing, neonatal nurse in-charges, neonatal nurses, nursing students and support staff.

RESULTS

To cope with difficult work conditions characterized by resource challenges and competing priorities, nurses have developed a ritualized schedule and a form of 'subconscious triage'. Informal, organic task shifting was already taking place whereby particular nursing tasks were delegated to students, mothers and support staff, often without any structured supervision. Despite this practice, nurses were agnostic about formal institutionalization of task shifting due to concerns around professional boundaries and the practicality of integrating a new cadre into an already stressed health system.

CONCLUSION

Our findings revealed a routine template of neonatal nursing work which nurses used to control unpredictability. We found that this model of nursing encouraged delegation of less technical tasks to subordinates, parents and other staff through the process of 'subconscious triage'. The rich insights we gained from this organic form of task shifting can inform more formal task-shifting projects as they seek to identify tasks most easily delegated, and how best to support and work with busy nurses.