Gathara 2020

Original research
Missed nursing care in newborn
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009363 on 6 June 2019. Downloaded from http://qualitysafety.bmj.com/ on May 16, 2023 by guest. Protected by copyright.
units: a cross-sectional direct
observational study
David Gathara ‍ ‍,1,2 George Serem,3 Georgina A V Murphy,4
Alfred Obengo,5 Edna Tallam,6 Debra Jackson,7 Sharon Brownie,2,8
Mike English3,9
►► Additional material is Abstract under 5 years.3 A recent review by Bhutta

published online only. To Background Improved hospital care is needed and colleagues indicated that high-impact
view please visit the journal to reduce newborn mortality in low/middle-income
online (http://dx.d oi.org/10. low-cost interventions could avert more
countries (LMIC). Nurses are essential to the delivery of
1136bmjqs-2019-009363). than 71% of neonatal deaths with 82%
safe and effective care, but nurse shortages and high
patient workloads may result in missed care. We aimed
of this effect being attributable to facility-
For numbered affiliations see
end of article. to examine nursing care delivered to sick newborns and based care.4 However, quality of care for
identify missed care using direct observational methods. newborns in health facilities has been
Correspondence to Methods A cross-sectional study using direct- reported as poor in low/middle- income
Dr David Gathara, Public Health observational methods for 216 newborns admitted in six countries (LMIC).5 6 Most of these LMIC
Research, Kenya Medical health facilities in Nairobi, Kenya, was used to determine studies have focused on resource availa-
Research Institute–Wellcome which tasks were completed. We report the frequency
Trust Research Programme, bility and processes of medical care with
of tasks done and develop a nursing care index (NCI),
Nairobi 00100, Kenya; an unweighted summary score of nursing tasks done for little detailed information on the quality
D
Gathara@kemri-wellcome.org
each baby, to explore how task completion is related to and nature of care provided to sick
Received 21 January 2019 organisational and newborn characteristics. newborns by nurses.
Revised 16 May 2019 Results Nursing tasks most commonly completed were LMICs, especially sub-Saharan Africa,
Accepted 18 May 2019 handing over between shifts (97%), checking and where are also facing critical health workforce
Published Online First necessary changing diapers (96%). Tasks with lowest shortages with the global shortage esti-
6 June 2019 completion rates included nursing review of newborns
mated at over 7 million.7 In Kenya,
(38%) and assessment of babies on phototherapy (15%).
Overall the mean NCI was 60% (95% CI 58% to 62%), Wakaba and colleagues reported that
at least 80% of tasks were completed for only 14% public sector nursing densities ranged
of babies. Private sector facilities had a median ratio from 0.008 to 1.2 per 1000 population
of babies to nurses of 3, with a maximum of 7 babies across counties8 compared with an inter-
per nurse. In the public sector, the median ratio was 19 nationally suggested minimum health
babies and a maximum exceeding 25 babies per nurse. In workforce threshold of 4.5/1000 popu-
exploratory multivariable analyses, ratios of ≥12 babies
lation for doctors, nurses and midwives
per nurse were associated with a 24-point reduction in
the mean NCI compared with ratios of ≤3 babies per to achieve the Sustainable Development
nurse. Goals.9 Nurses in hospitals are vested
Conclusion A significant proportion of nursing care is with the responsibility of delivering inter-
missed with potentially serious effects on patient safety ventions prescribed by other providers
and outcomes in this LMIC setting. Given that nurses (doctors, nutritionists, and so on) in addi-
caring for fewer babies on average performed more of tion to providing nurse-initiated interven-
the expected tasks, addressing nursing is key to ensuring
delivery of essential aspects of care as part of improving
tions.10 In higher income countries there
quality and safety. is a growing body of knowledge on the
important contribution of nursing care in
hospitals to patient safety,11 outcomes and
care quality,12 with an association between
Introduction nursing shortages and care being delayed
Although progress has been made globally or omitted.13 This latter phenomenon
© Author(s) (or their
employer(s)) 2020. Re-use in reducing under- five mortality deaths has been described as ‘implicit rationing’,
permitted under CC BY. in the first 28 days of life (the neonatal ‘missed care’, ‘unmet nursing care needs’,
Published by BMJ. period) declined at a slower rate, particu- ‘care left undone’ or ‘task incomple-
To cite: Gathara D, Serem G, larly in sub-Saharan Africa.1 2 As a conse- tion’.14 Hereafter, we use the term missed
Murphy GAV, et al. quence, neonatal mortality contributes care to encompass all these terms. These
BMJ Qual Saf 2020;29:19–30. about 45% of mortality for children prior reports on missed care are based on
Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363 19

Original research
nurse surveys, only two have focused on newborn care Study sites and data collection
provision but within neonatal intensive care and they This study drew on earlier work that identified the
illustrate basic nursing care was missed with unex- facilities (n=31) providing inpatient newborn care for
pected rise in patient volume/acuity and interruptions 24 hours, 7 days a week (hereafter referred to as 24/7)
to respond to emergencies as the most common reason to the population of Nairobi.23 24 Among these hospi-
for care being missed.15 16 Similar findings have been tals 13/31 had more than 100 neonatal admissions
reported in the only study we identified from Africa annually and they provided care to over 96% of the
with the main nursing tasks left undone being comfort/ entire sick-newborn population accessing care within
talking to patients, educating patients and family and Nairobi County. These 13 facilities were considered
developing/updating nursing care plans/pathways.17 eligible for our study. We stratified these by workload
Authors of a recent systematic review recommended (newborn admissions per year ≤500 low; >500 high)
that researchers need to develop objective observa- and sector (the public, private not for profit, hereafter
tional methods for quantifying missed care to advance referred to as mission hospitals, and private for profit,
this field further.14 hereafter referred to as private hospitals). We purpo-
Our aims were therefore to explore the extent of sively selected six hospitals, two from each sector,
nursing care delivered to sick newborns in hospi- ensuring one high and one low workload facility in
tals in an LMIC, going beyond prior reports that each sector. Purposive selection of hospitals was used
have focused predominantly on medical aspects of as part of our aim was to span each sector to maximise
care,5 18 19 and develop and use direct observational variation in nurse to baby ratios and, because the
methods to identify and quantify the nature of missed proposed work was deemed potentially sensitive,
care in this setting. In doing this we had a secondary we required strong support of the hospital adminis-
objective to explore how nursing shortages may be tration. We used findings from a previous study that
directly impacting neonatal nursing care provision. explored the readiness of hospitals (their organisation
and resources) to provide a ‘structural quality score’
Methods and analysis for each facility to help characterise the six selected
This was a cross-sectional study using direct obser- facilities.24
vational methods to describe the essential neonatal
nursing care given to individual sick newborns in Study population and sampling strategy
Nairobi, Kenya. The study protocol is described in All newborns admitted within the newborn unit
detail elsewhere.20 in the six selected health facilities over the specific
study period formed the potential study population.
Establishing essential nursing care practices However, newborns who were at high risk of death
In earlier work Kenyan nursing experts and poli- within 12 hours, as defined by the clinician in charge
cymakers developed draft minimum standards for (extremely low birthweight babies, babies requiring
neonatal nursing care with recommendations on which frequent resuscitation), needing specialised care/treat-
tasks should be done and their frequency over 24-hour ment (eg, scheduled for surgery, requiring transfer
periods (see online supplementary table 1).21 Although for ventilation or with gross congenital malforma-
these standards were initially developed by a small tions) were deemed ineligible for ethical reasons and
group of stakeholders (n=12), they have since been as the draft minimum standards were not applicable.
presented to wider nurse expert stakeholder groups Newborns whose guardian or nurse declined consent
and representatives from Ministry of Health, training were excluded from the study.
institutions and development partners with interests Nurse staffing and routine activities may vary
in newborn health (Unicef, WHO) for validation and between weekdays and weekends and night and
were considered acceptable standards. These standards day. Care within newborn units is also often organ-
take account of three different levels of illness severity ised so that babies with different levels of disease
in hospitalised newborns with categories A: the most severity are in different ward sections/rooms.21 In each
acutely ill; B the moderately ill; and C the least ill. The hospital, a random sample of 12 shifts/time blocks of
nursing experts further agreed by consensus that if a 12 hours (144 observation hours per hospital) were
baby receives 80% or more of recommended nursing selected from within a 3-week period. We used strat-
care this would comprise a minimum threshold for ified random sampling to ensure we observed three
adequate nursing care delivered.21 Standards for provi- weekday day shifts, three weekday night shifts, three
sion of nursing care have generally been neglected and weekend day shifts and three weekend night shifts.
these are to our knowledge the first explicitly devel- Pilot data collection exercises confirmed it was logis-
oped for hospital care in Kenya. While these guidelines tically feasible for one observer to make direct obser-
were developed for the Kenyan context the absence vations of three babies located in adjacent cots in the
of reports in the literature of standards developed for same ward area for these 12 hours’ time blocks. Since
similar settings suggests they may have wider value as care within the newborn units is typically organised so
has been the case for clinical guidelines.22 that babies with similar disease severity (categories A,
20 Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363

Original research
B, C) are colocated in the same ward area, we there- the baby, taking vital signs or providing counselling)
fore used purposeful sampling to ensure that for each or documentation tasks (eg, recording of vital signs)
shift group (eg, the three weekday day shifts) one for which the observer checked nursing and medical
focused on observing category A babies, one focused records. Tasks are listed in table 3 and the observer
on category B babies and one focused on category C recorded if a task was done or not done by a nurse
babies with three babies who met the inclusion criteria (scored 0/1).
purposefully identified at the start of the 12 hours’ time Observations were stopped if a baby was discharged,
block for this purpose (online supplementary figure 1). transferred out of a section or changed condition and
The 12-hour periods were selected because they span became critically ill (when the minimum draft nursing
nursing shift change- overs and allowed observation standards did not apply). However, the data collected
of care round the clock. Detailed sampling and study up to the point of exit were used to readjust denomi-
procedures are provided in detail elsewhere.20 nators (see below). Similarly, if a baby’s care changed
but they remained in the same observation area, this
Data collection change was documented and the expected number of
Data were collected between 1 September 2017 and tasks revised. At the end of each 12-hour shift nursing
30 May 2018. We documented how often certain and medical records were reviewed for evidence of
nursing tasks (listed in table 3) were undertaken in a documentation tasks.
12-hour shift (07:00−19:00 or 19:00−07:00) using Observations were made by a nutritionist, considered
an observation checklist. The observers spent 1 week an appropriate cadre because they are familiar with
in the hospital before the 3-week period during which the hospital environment, equipment, care processes
12-hour shifts were randomly selected for observa- and medical language, and would be considered a
tion. The familiarisation period enabled observers to professional rather than an ‘outsider’. Moreover, we
learn the hospital environment and routines, introduce felt observing sick babies might be less distressing for
the study and gain consent from nurses. This 1-week a person with a health professional background. Using
familiarisation period also allowed the staff to become an observer who was not a nurse or clinician we felt
familiar with the observers aimed at reducing nurses’ might help overcome bias introduced by the observer
efforts to modify their behaviour (the Hawthorne relating their observations to their own standards of
effect). Team or task nursing was the commonly used practice or being influenced by shared professional
approach rather than primary nursing in provision of allegiances.
nursing to newborns. Therefore, over the 12 hours’
observation period, the care provided to three babies Sample size and analysis
was typically provided by multiple nurses. As such, the Our primary objective was to assess and quantify
baby to nurse ratio over a 12-hour shift was computed nursing care delivered to sick newborns and identify
by dividing the total number of babies admitted in missed care. As such, we based our sample size esti-
the unit with the number of nurses working during mations on the precision around proportions for indi-
the shift. For instance, if there were 30 babies in the vidual tasks reported as done (or not done). We esti-
newborn unit and three nurses were providing care mated that observing 216 babies (36 per hospital for
during a 12-hour shift, the resulting baby to nurse 12 hours) would provide denominators of 108, 216
ratio was 10 babies to 1 nurse. Majority of the nurses and 432 for the total number of times a task should
practising within newborn units are registered general be done (observed) assuming the task was required for
nurses trained at a diploma level (registered nurses) all babies and standards indicated the task should be
with no specialist training in newborn care. Within the done once, twice and four times per 24 hours, respec-
study hospitals, we did not observe significant varia- tively. Assuming a design effect of 2 to adjust for clus-
tion in the process of allocation of qualified nurses to tering of observed tasks within hospitals would allow
different levels of acuity based on training or years of us to report precision (95% CIs) around a statistically
experience. conservative proportion of 50% of expected tasks done
For each newborn selected for direct observation, of ±13.4%, 9.4% and 6.7%, respectively. The actual
the medical records were first reviewed and data on denominator for some tasks would, however, depend
the diagnosis, disease severity and any specific inter- on the patterns of use of specific interventions (eg,
ventions (eg, requirements such as phototherapy phototherapy, and see table 3) reducing our reported
or oxygen) were collected. This initial information precision. In the specific case of feeding, babies were
allowed the observer to determine the nature and often observed to have more than one type/route of
number of expected nursing tasks to be delivered for feeding as an option. In such cases, we pooled data
each baby based on their illness severity (category A, from different types of feeding (nasal gastric tube
B or C), the interventions they were receiving and the feeding, cup and spoon and breast feeding) so that a
nursing care standards. We categorised tasks as nursing/ baby was documented as fed if they were observed to
clinical tasks that require physical interaction with the receive feeds using one or more of the above routes at
baby or mother/family member (for instance, feeding the expected frequency.

Original research
care index (NCI), at individual level for which the
denominator varies by diagnosis and case severity.
As indicated above during the development of the
minimum standards, local experts agreed that babies
receiving 80% or more of their expected care tasks
met a minimum threshold for adequate nursing care
delivered.21 We therefore created a binary variable
representing adequate nursing care delivered based
on whether babies’ NCI was 80% or more and report
the proportion of babies receiving adequate nursing
care delivered. In further analyses we use the NCI to
explore associations between this summary measure
of care delivered at the baby level with characteristics
of the hospital (sector), of the shift (the baby to nurse
ratio, categorised into <3 babies; 4–11 babies and
Figure 1 Nursing care index for each baby by number of babies per >12 babies per nurse) and of the baby (postnatal age
nurse across sectors.
categorised into ≤3 days; 3–7 days and 8–28 days,
birth weight categorised into ≤1499 g; 1500–1999
For our primary objective, we pool our data across g; 2000–2499 g; and ≥2500 g and severity category).
all babies observed and report as a proportion (with To define the baby to nurse ratio categories, the distri-
corresponding 95% CIs adjusted for clustering at the bution of data on baby to nurse ratio was used to
hospital level) the number of times a specific task was ensure a reasonable number of observations in each
observed as done divided by the number of times it was category. Linear regression was used to explore asso-
expected to be done. Some tasks (eg, vital signs moni- ciations between the NCI (dependent variable) and
toring) should be done on all babies irrespective of the these hospitals, shift and baby characteristics in unad-
severity of illness/severity category and so the propor- justed models. Multivariable models were built to
tions reported represent aggregate measures across all explore associations further using a stepwise forward
babies and severity categories (table 3). Other tasks selection procedure. Babies per nurse was included
(eg, intravenous fluid or oxygen monitoring) might a priori as an independent covariable in preference
only be required in babies in severity categories A and to hospital identity with which it is strongly associ-
B. Proportions reported therefore reflect performance ated in our data set. We therefore could not include
in such subgroups (with appropriate cluster-adjusted hospital identity in the regression models. We opted
CIs). to use baby to nurse ratio, while acknowledging that
In secondary analyses we created for each baby a this is also a proxy for sector (see figure 1) in our data
denominator based on the total number of expected set, as staffing ratios are a key parameter tracked and
nursing tasks that should have been delivered based reported in most missed care literature. To build our
on the standards and the number of interventions each multivariable model we used the Hosmer-Lemeshow
baby was receiving. This baby-specific denominator criterion of a likelihood ratio test (LRT) with p<0.2
was then used to determine a proportion of expected in the univariable analysis to identify possible covari-
tasks actually observed to be completed for each baby. able of interest. We added covariables starting with
This created a summary unweighted performance those with the strongest association in univariable
measure (all tasks given equal weight), the nursing analyses. LRTs (p<0.05) were used to determine
Table 1 Hospital characteristics by workload and availability of resources to provide care (structure index)
Annual newborn Structure index (score
Hospital Sector Cots admissions Annual total deliveries 0–100)* Mortality by sector†
Hospital 1 Mission 8 1438 6620 91 5.9
Hospital 2 Mission 15 160 1305 87 5.9
Hospital 3 Private 30 1816 2273 92 7.3
Hospital 4 Private 25 123 1398 91 7.3
Hospital 5 Public 21 1006 5457 81 16.5
Hospital 6 Public 15 299 6180 90 16.5
*Structure index comprised items from the following domains: infrastructure, laboratory services, hygiene equipment, safe delivery equipment and drugs
for mothers, resuscitation equipment for newborns in the delivery ward, essential equipment in the newborn unit, intravenous fluids and feeds in the
newborn unit and essential drugs in the newborn unit.24
†Crude inpatient neonatal mortality data estimates are based on study where 21% of the outcome data were missing and are therefore likely to be
biased.41

Original research
Results
Table 2 Characteristics of babies observed
Data were collected from six hospitals spanning
n (%) public, private and mission sectors. Of the 13 hospi-
Characteristic n=216
tals that met our inclusion criteria as possible study
Shift of observation hospitals, we identified six hospitals to be included
Weekday day 59 (27.3) in the study. One medium-sized private hospital (657
Weekday night 54 (25.0) annual admissions) declined to participate in the study
Weekend day 50 (23.1) citing hospital policy on access of medical records and
Weekend night 53 (24.5) patient privacy, a replacement hospital with similar
Neonatal care category characteristics was identified from the remaining seven
A (severe illness) 69 (31.9) hospitals. No refusals from families/caregivers were
B (moderate severity) 75 (34.7) reported. The annual neonatal workload for these
C (stable) 72 (33.3) hospitals ranged from 123 to 1438 newborns admitted
Gender per year while the annual total deliveries ranged from
Male 122 (56.7) 1398 to 6620 births. In a previous study, we assessed
Female 93 (43.3) the availability of basic infrastructural resources for
Age categories (days) providing care (structure index) in accordance with
≤2 49 (23.0) Kenyan guidelines.24 The availability of basic infra-
3–7 80 (37.6) structural resources was considered at least good
8–28 84 (39.4) (>80%) in all six hospitals and varied from 81% to
Pooled birth weight categories (kg) 92%. The two mission hospitals were heterogeneous,
<1.4 70 (32.6) one was more similar to a private hospital while the
1.5 to <1.9 50 (23.3) other had staffing ratios and workloads similar to
2.0 to <2.4 22 (10.2) those in public hospitals. A summary of hospital char-
≥2.5 73 (34.0) acteristics is presented in table 1.
Baby:nurse ratio A total of 216 babies were observed (described in
1–3 babies/nurse 84 (39.1)
table 2 and online supplementary table 2 for hospital-
4–11 babies/nurse 50 (23.3)
specific results) against a direct observation checklist
with an equal number of babies (72) in each sector.
≥12 babies/nurse 81 (37.7)
The majority of the babies were aged less than 7 days,
Type of delivery
61% (129), while 33% (70) and 59% (126) weighed
Spontaneous vaginal delivery 81 (37.9)
<1500 g and were born via caesarean, respectively. Of
Caesarean section 126 (58.9)
those delivered via caesarean section, 42% (53/126)
Assisted vaginal delivery 7 (3.3)
were from the private sector. The primary reasons for
Primary diagnosis at observation
admission were prematurity/low birth weight 43%
Premature, LBW 92 (42.6)
(92), respiratory distress syndrome 19% (42) and
Respiratory distress syndrome 42 (19.4) severe jaundice 11% (24). There were relatively equal
Jaundice 24 (11.1) numbers of observations across the sample stratifying
Birth asphyxia 17 (7.9) variables (sector, neonatal care category and nursing
Neonatal sepsis 9 (4.2) shift). A baby was only observed for one 12-hour shift
Meconium aspiration 7 (3.2) and not in any subsequent periods.
Hypoxic ischaemic encephalopathy 5 (2.3) In table 3, we present the proportions when specific
For observation/accommodation 8 (3.7) expected tasks were observed to be completed by
Other 12 (5.6) nurses using data pooled across all babies observed.
LBW, low birth weight. The tasks most commonly completed by nurses were
nursing care handing over for babies between shifts
(97%), checking and, where necessary, changing
whether additional factors added to the model should diapers (96%), checking eyes for damage from photo-
be retained in a final model. In a linked exercise, the therapy, turning of babies on phototherapy (91%)
and supporting mothers practising kangaroo mother
LRT was also used to examine whether babies per
care (91%). The least done tasks included nursing
nurse be included as a continuous or categorical vari-
review of newborns (38%), cord care (38%), turning/
able. All analyses were conducted using the statistical repositioning (38%), cleaning eyes and checking for
analysis software STATA V.13. discharge/infection for babies on phototherapy (38%),
Written informed consent was sought from both oxygen saturation monitoring (34%) and skin assess-
mothers and nurses while hospital management teams ment for babies on phototherapy (15%). Of the vital
provided permission to conduct the study in the signs, oxygen saturation (required six hourly for
hospitals. babies on oxygen or in category A or B) was the least

Original research
Table 3 The number of expected tasks as per neonatal nursing guidelines and the proportion of these tasks completed by domain and
type
Required for Frequency Expected tasks assuming
all babies in 24 hours 12 hours’ observation shifts
observed in a according to and adjusting for category/ Tasks done,
Domain Task type Task 12-hour shift standards* interventions (n) n (%) 95% CI
Nursing/clinical General nursing Handing over nursing care between shifts Yes 2 216 210 (97.2) 87 to 99
tasks Nursing review of newborns Yes 2 216 83 (38.4) 16 to 67
Baby cleaned No 1 126 83 (65.9) 43 to 83
Linen changed No 1 126 70 (55.6) 26 to 81
Nurse attends ward round† No 1 75 64 (85.3) 21 to 99
Checking and changing diaper as required Yes 8 216 207 (95.8) 87 to 99
Communication to parent Yes 1 216 105 (48.6) 30 to 67
Handwashing/scrub‡ Yes 2 216 200 (92.6) 67 to 99
Cord care where required No 1 110 42 (38.2) 17 to 65
Temperature monitored§ Yes 4 216 127 (58.8) 20 to 89
Respiration monitored§ Yes 4 216 107 (49.5) 16 to 83
Pulse monitored§ Yes 4 216 122 (56.5) 19 to 88
Oxygen saturation monitored§ No 4 144 49 (34.0) 9 to 72
Turning done as required Yes 8 216 81 (37.5) 13 to 71
Feeding three hourly as required No 8 180 126 (70.0) 58 to 80
Phototherapy care Clean eyes and check for discharge/infection No 4 34 12 (35.3) 11 to 71
Eye pad changed No 2 34 12 (35.3) 12 to 69
Skin assessment¶ No 4
Skin assessment 1 34 19 (55.9) 27 to 81
Skin assessment 2 34 5 (14.7) 1 to 68
Check eyes for damage from phototherapy¶ No 4
Check eyes for damage 1 34 31 (91.2) 53 to 99
Check eyes for damage 2 34 19 (55.9) 26 to 82
Turning/positioning done¶ No 6
Turning/positioning done 1 34 31 (91.2) 48 to 99
Oxygen therapy Oxygen regulated 76 61 (80.3) 36 to 97
care Check nostril tube position¶ No 8
Check nostril tube position 1 75 61 (81.3) 60 to 93
Intravenous fluids Fluids regulated as required** No 2 21 16 (76.2) 11 to 99
Intravenous Cannula flushed before giving intravenous No 2 126 51 (40.5) 7 to 86
treatment treatment††
KMC Counselling and supporting mother to initiate and No 2 32 29 (90.6) 57 to 99
continue with KMC
Supervision of the mother for correct KMC No 2 32 24 (75.0) 31 to 95
practice
Documentation Documentation Clinical nursing review Yes 2 216 107 (49.5) 22 to 77
tasks Planned care Yes 2 216 140 (64.8) 20 to 93
Vital signs Yes 2 216 154 (71.3) 22 to 96
Treatment documented No 2 150 146 (97.3) 90 to 99
Ward round recommendations No 1 75 55 (73.3) 44 to 91
Phototherapy documentation No 2 31 19 (61.3) 18 to 92
Summary of feeds intake No 2 180 137 (76.1) 33 to 95
Oxygen therapy No 2 76 57 (75.0) 43 to 92
Health talks/parent communications‡‡ Yes 2 216 53 (24.5) 6 to 63
Charting of fluids administered No 2 66 60 (90.9) 73 to 97
Turning/positioning Yes 2 216 59 (27.3) 6 to 67
*For instance, for tasks with a frequency of 2 in 24 hours we would observe one task in a 12-hour shift.
†Only one doctors ward round was expected in 24 hours.
‡At first contact with patient only since it was difficult to establish a denominator since handwashing should be done before each time the nurse makes contact with the patient.
§Monitoring done as per draft neonatal nursing guidelines.
¶Tasks have multiple sub-items.
**During the observation shift or when fluid was running, evidence for an attempt to regulate the rate.
††For twice daily medication, we would observe two tasks in 24 hours.
‡‡Health talks/parents are supposed to be continuous; however, we are interested in at least two sessions in 24 hours (one during the day and one during the night shift).
KMC, kangaroo mother care.

Original research
Table 4 Mean nursing care index and proportion of babies with adequate nursing care delivered
Proportion of babies
with adequate
nursing care delivered
Mean (SD) nursing care index (NCI≥80%)
Overall Nursing/clinical tasks Documentation tasks n/N (%)
Shift of observation
Weekday day 61.9 (57.4–66.3) 63.6 (59.4–67.9) 57.5 (49.9–65.2) 9/59 (15.3)
Weekday night 58.5 (53.6–63.4) 58.1 (52.4–63.9) 59.3 (54.4–64.2) 6/54 (11.1)
Weekend day 62.9 (58.1–67.7) 64.1 (58.9–69.4) 59.9 (53.9–65.9) 7/50 (14.0)
Weekend night 58.2 (52.9–63.5) 59.6 (54.0–65.3) 54.5 (48.2–60.7) 9/53 (17.0)
Neonatal care category
A (severe illness) 63.3 (58.8–67.8) 61.2 (56.3–66.0) 67.8 (62.4–73.2) 16/69 (23.2)
B (moderate severity) 60.0 (55.8–64.3) 61.6 (56.8–66.3) 55.6 (50.6–60.7) 12/75 (16.0)
C (stable) 57.9 (54.2–61.7) 61.5 (57.6–65.3) 50.4 (45.1–55.6) 3/72 (4.2)
Baby:nurse ratio
1–3 babies/nurse 72.9 (69.8–75.9) 73.7 (70.2–77.3) 71.3 (67.4–75.1) 27/84 (32.1)
4–11 babies/nurse 61.1 (57.3–64.9) 62.1 (58.1–66.1) 59.1 (52.8–65.3) 3/50 (6.0)
≥12 babies/nurse 47.0 (43.9–50.1) 48.4 (44.9–51.8) 43.0 (38.5–47.4) 1/81 (1.2)
Sector
Mission 64.8 (61.5–68.0) 65.2 (61.6–68.9) 64.0 (59.7–68.2) 9/72 (12.5)
Private 73.9 (71.2–76.6) 74.6 (71.2–78.0) 72.7 (69.8–75.7) 22/72 (30.6)
Public 42.4 (40.0–44.8) 44.4 (41.3–47.4) 36.6 (31.8–41.5) 0/72 (0.0)
NCI, nursing care index.
done, 34% (49/144), but pulse, respiratory rate and with category C babies (mean documentation-specific
temperature monitoring (required for category A, B NCI 50%; 95% CI 45% to 56%). To explore the
and C babies) were also done on fewer than 60% of proportion of babies receiving a minimum threshold
occasions. For documentation tasks, treatment and of adequate nursing care delivered, we applied our
fluid administration were the most documented, 97% previously defined cut-off of ≥80% of the required
and 91% of the episodes, respectively, while the least nursing tasks per baby being done. Overall, 14% (95%
documented tasks were turning (27%) and communi- CI 10% to 20%) of the babies received a minimum
cation with the parent (25%). Online supplementary threshold of adequate nursing tasks done by this crite-
table 3 describes in detail the number of expected tasks rion. While none of the babies in the public sector met
as per neonatal nursing guidelines and the proportion this criterion, 31% (22) and 13% (9) of the babies in
of these tasks completed by neonatal care categories the private and mission sectors achieved this threshold,
and hospital sector. The median number of expected respectively. Although suboptimal, higher proportions
tasks (effective denominator) per baby was 23 (IQR of babies who were sicker (category A, 23% (16)) and
20–28, minimum and maximum 16 and 44, respec- where staffing ratios were 1–3 babies per nurse (32%
tively). For all 216 babies observed, the mean NCI was (27)) were observed to receive minimum threshold of
60% (95% CI 58% to 62%; range 24–96) (table 4). adequate nursing care (table 4).
Variations in the NCI became apparent when obser-
vations were stratified by the sector and day/time of Hospital and baby characteristics associated with mean
observation as well as by baby-specific characteristics NCI
(eg, clinical category) and by the baby to nurse ratio Initial univariable analyses suggested that a lower NCI
on the whole ward at the time of the observations. For was associated with a baby having a weight ≥1500
example, higher proportions of care were done in the g, higher baby to nurse ratios on a shift (a 26-point
private sector (mean 74%; 95% CI 71% to 77%), in reduction in mean NCI when there were ≥12 babies
the 1–3 babies per nurse category (mean 73%; 95% per nurse compared with 1–3 babies per nurse) and
CI 70% to 7%), and among sicker babies—category observations made in the public sector compared with
A (mean 63%; 95% CI 59% to 68%). A generally the mission sector (22-point reduction in the mean
similar pattern was observed if nursing/clinical tasks NCI) (table 5). Meanwhile a higher NCI was associated
and documentation tasks were considered separately with a postnatal age >8 days and care in the private
with a suggestion that more documentation tasks were sector. In the multivariable analysis that included
done for category A babies (mean documentation- baby to nurse ratio but excluded sector babies, age,
specific NCI 68%; 95% CI 62% to 73%) compared neonatal care category and baby to nurse ratio were

Original research
Table 5 Univariable and multivariable models for the association of mean NCI with baby and hospital characteristics
Model 1: univariable associations Model 2: multivariable associations
2
Coefficient 95% CI P value R Coefficient 95% CI P value
Gender
Male Ref 0.003
Female 1.99 −2.84 to 6.81 0.418
Birth weight (kg)
<1.4 Ref 0.026
1.5 to <1.9 −7.75 −14.23 to −1.28 0.020
2.0 to <2.4 −3.37 −11.92 to 5.17 0.440
≥2.5 −3.84 −9.68 to 2.01 0.200
Age (days)
≤2 Ref 0.061 Ref
3–7 −0.16 −6.34 to 6.02 0.959 1.78 −3.06 to 6.64 0.469
8–28 8.82 2.70 to 14.95 0.005 7.46 2.55 to 12.36 0.003
Nursing shift
Day 0.013
Night −4.03 −8.79 to 0.73 0.100
Neonatal care category
A (severe illness) Ref 0.015 Ref
B (moderate severity) −3.25 −9.09 to 2.59 0.274 −4.27 −8.78 to 0.23 0.063
C (stable) −5.34 −11.23 to 0.56 0.076 −7.65 −12.29 to −3.02 0.001
Baby:nurse ratio
1–3 babies/nurse Ref 0.406 Ref
4–11 babies/nurse −11.79 −16.65 to −6.92 <0.001 −11.49 −16.26 to −6.73 <0.001
≥12 babies/nurse −25.89 −30.13 to −21.65 <0.001 −24.41 −28.64 to −20.17 <0.001
Sector
Mission Ref 0.556
Private 9.13 5.21 to 13.05 <0.001
Public −22.40 −26.32 to −18.49 <0.001
NCI, nursing care index.
identified as associated with the NCI based on the LRT Discussion

(p=0.005). In this multivariable model, a baby being The aim of this study was to quantify nursing care
in category C was associated with an 8-point reduction tasks that can be observed that were delivered to sick
in mean NCI when compared with category A babies, newborns and identify missed care (tasks done or left
and when there were ≥12 babies per nurse or 4–11 undone) within a set of Kenyan newborn units. Task
babies per nurse this was associated with a 24-point completion varied greatly overall and across hospital
and 12-point reduction in NCI when compared with sector and newborn illness severity category. We observed
shifts when there were 1–3 babies per nurse. A post- omission of nursing tasks that might directly influence
natal age >8 days was associated with a 7-point higher the baby’s outcome, for instance, feeding, monitoring
NCI when compared with babies aged ≤2 days. of vital signs and appropriate use of interventions like
fluids and oxygen. This highlights potentially critical
The strong apparent relationship between NCI
safety issues, although our study was not designed to
measured for each baby and the baby to nurse ratio
explore the effects on patient outcomes. These specifi-
of the shift being observed was further explored in a
cally missed tasks are likely to be compounded by indi-
simple scatter plot (figure 1). This demonstrates the
rect effects of missed care linked to poor communica-
strong relationship between sector and baby to nurse tion between nurses and patients and among teams of
ratio and thus the relationship between sector and carers.25 Communication with and education of mothers
NCI apparent in univariable analysis. In the private or caregivers, such as explaining the baby’s illness and
sector the median ratio was 3 babies to 1 nurse with management and teaching them how to safely feed
a maximum ratio of 7 babies to 1 nurse. In the public their baby, was provided on less than half the occasions
sector the median ratio was 19 babies to 1 nurse with expected. These aspects of missed care may adversely
a minimum of 10 and a maximum exceeding 25 babies affect mothers’ experience of care and influence babies’
per nurse. early recovery and longer term maternal- neonatal

Original research
bonding.25 26 Interprofessional and intraprofessional suggests nurses have to engage in ‘sub-conscious triage’
communication is likely undermined by, for example, when the volume of work is overwhelming33 as well as
poor documentation and inability of nurses to engage with wider literature reporting that nurses often prior-
in medical rounds. Both may adversely affect the team- itise medical or technical interventions at the expense
work that is critical to providing safe, effective care in of social and relational aspects of care.25 New technolo-
high-pressure clinical environments.27 28 gies are widely felt to offer great promise for improving
In our secondary analysis we developed a measure newborn outcomes but are most likely to be used in the
that aggregated all the (observable) tasks done per baby, sickest babies. Their introduction may further increase
the NCI. The mean proportion of expected tasks done time spent on this group to the neglect of babies who
per baby was 60% overall. The threshold recommended are apparently less ill, potentially putting this group at
by local experts representing minimum threshold of risk of deterioration, or delay to their recovery. More-
adequate nursing care delivered was rarely achieved over, these technologies still require human resources to
(14% babies). The NCI varied in association with sector support their use and could potentially exacerbate the
being highest in the private sector. However, there was general problem of missed care in settings with critical
a strong association between sector and the number of workforce deficits. While our data illustrate the extent
babies that each nurse was caring for. No babies were of missed care taking the perspective of the baby, there
observed in the private sector when there were >7 are also likely to be important effects on nurses them-
babies per nurse while no babies in the public sector were selves of such high workloads and their own perception
observed when there were <10 babies per nurse. Failure of failing to meet professional expectations of care. The
to take account of this dramatically different nursing exhaustion and burnout that are potential consequences
workload could, mistakenly we believe, be interpreted are important detrimental effects on the emotional and
as suggesting that nurses generally perform better in the psychological well- being of nurses34 and on sustain-
private sector. Focusing on the number of babies per ability of this crucial workforce.
nurse, our findings suggest this strongly related to the The gaps in care we highlight underscore the urgent
proportion of tasks completed (NCI). Our model suggests need for system strengthening to support the nursing
a 24% reduction in the NCI when there was 1 nurse per workforce in LMIC and for quality improvement initia-
12 or more babies compared with 1 nurse to up to 3 tives and research on service redesign to focus on nursing.
babies. We believe that the relationship between staffing As part of a wider programme of work, we observed
levels and care received also mediates the apparent effect that nurses’ time is often taken up by tasks that are not
of shift timing on NCI (with care at night scoring lower necessarily core to the nursing role. Examples include
than in the days). The obvious implication is that to clerical tasks such as organising patient files, receiving
improve quality of care, it is imperative that workforce telephone calls and billing, collecting supplies from
deficits are addressed. These findings contribute to the stores and ward cleaning of baby cots and equipment.
growing body of evidence linking inadequate staffing These non-patient-facing activities take up a significant
and missed care. Studies undertaken in Sweden,29 across amount of their time.33 Opportunities therefore exist to
Europe30 and in England13 have reported associations refocus nursing practice on skilled tasks for which they
between staffing and nursing care left undone. Addition- are specifically trained and reassign some tasks to other
ally, the number of patients per nurse and the number of workers. Such approaches may enhance the professional
nursing care hours per patient-day have been associated status of nurses and make most efficient use of human
with missed care.31 32 However, most of this literature is resources through, for example, specific forms of task
based on data from nurse surveys of self-reported missed sharing. In HICs healthcare assistants support nursing
care and are from high-income country (HIC) settings. care provision by undertaking non-technical tasks.35 36
While improving nurse numbers is key, our data illus- In LMICs, including Kenya, task sharing/shifting from
trate considerable variation in the NCI with the same doctors to clinical officers (physician assistants) and
nurse to baby ratios (figure 1). This suggests there is nurses has been implemented to support care provi-
also some potential for improving care by learning what sion for HIV, tuberculosis and non- communicable
steps nurses take in some settings to achieve high perfor- diseases.37 38 However, delegation of some tasks to a
mance despite significant challenges through efforts to supportive cadre needs careful consideration to ensure
study ‘positive deviants’. adequate supervision and patient safety.39 Furthermore,
Additional findings from our secondary analysis it should be clear that addressing the nursing workforce
suggest that babies who were more severely ill (category deficit is the first priority which may be complemented
A) received higher levels of nursing care (8% higher NCI) by introducing support workers.
compared with stable babies (category C) in the adjusted Our results need to be interpreted in light of the
multivariable analysis. We hypothesise that nurses may following limitations. The use of direct observational
feel stable babies are out of danger and hence priori- methods limited the nursing tasks assessed to those
tise care provision to babies who are perceived to be at that can be observed and we might have underes-
higher risk of death. These findings are consistent with timated the magnitude of tasks done (or not done).
parallel ethnographic work conducted by our team that Interestingly, we did note that care was sometimes

Original research
documented as done when this was not corroborated contextually relevant standards. We observed great
by our observations, suggesting observations may variation in task completion with potentially impor-
be more accurate than record review. Observations tant implications for patient well- being and safety.
might be influenced by observer bias and are at risk Aggregating nursing tasks within babies, average
of Hawthorne effects. We developed through exten- task completion was 60%. Our exploratory analysis
sive piloting a highly structured checklist and provided suggests a strong relationship between the high levels
careful training to help overcome these limitations of missed care observed and the high baby to nurse
in addition to a 1- week familiarisation period for ratios found especially in the public sector. Improving
observers in each hospital before the start of formal quality of care and its contribution to newborn survival
observations. We did not evaluate interobserver vari- clearly demands an expansion of the nursing work-
ability within the main study. A study team member force, potentially complemented by additional human
and the four observers recruited did train together resource innovations. Failure to address critical work-
on the observational methods over a 1-week period force issues will mean missed care remains common
during which we evaluated the observers’ performance and undermine efforts to deliver high- impact, low-
against the study team member as the reference. Similar cost interventions for small and sick babies. While
evaluations were conducted for 2 days in each hospital the focus of our work was newborn units in one city
during the 1-week familiarisation period before start our wider experience suggests similar challenges are
of the actual data collection. In these training exer- faced on paediatric and other hospital wards in Kenya
cises observers demonstrated >95% concordance with and probably many other African settings. Our data
the observations of the study team member. During therefore lend support to initiatives highlighting the
data collection there were weekly supervision visits to critical role nurses play in care provision such as the
ensure consistency in data collection and adherence to ‘Nursing Now campaign,’ a global campaign aiming
study standard operating procedures. to improve health by raising the profile and status of
We purposefully selected a relatively small sample of nursing worldwide.40
hospitals in one city that varied by sector and work-
load (annual admissions 106–1319) and excluded the Author affiliations
1
sickest babies from our sample. This selection limits Public Health Research, Kenya Medical Research Institute–Wellcome Trust
Research Programme, Nairobi, Kenya
the generalisability of our findings although extremely 2
Nursing and Midwifery, Aga Khan University School of Nursing and Midwifery
sick newborns are a minority on the wards we studied. East Africa, Nairobi, Kenya
Despite the small number of hospitals studied, we feel 3
Public Health Research, KEMRI/Wellcome Trust Research Programme, Nairobi,
the inclusion of different sectors with different organi- Kenya
4
Global Health, Bill and Melinda Gates Foundation, Seattle, Washington, USA
sational capacities provides useful insights on the nature 5
National Nurses Association of Kenya, Nairobi, Kenya
and magnitude of missed care. The very different baby 6
Registration and Licensing, Nursing Council of Kenya, Nairobi, Kenya
to nurse ratios found in the private and public sectors 7
Nursing and Midwifery, University of Technology Sydney, Sydney, New South
do, however, preclude our ability to explore any effect Wales, Australia
8
School of Medicine, Griffith University Faculty of Health, Gold Coast,
that the sector may have on our missed care measures
Queensland, Australia
and we make the assumption that it is baby to nurse 9
Department of Paediatrics, University of Oxford, Oxford, UK
ratio that is the major determinant of missed care. As a
result, the findings of our exploratory analyses must be Contributors DG, ME and GAVM designed the study with
interpreted very cautiously although they are consis- contributions from AO, ET, DJ and SB. DG and GS were
responsible for the coordination and supervision of data
tent with wider literature on the association between collection. DG and ME wrote the initial draft manuscript
nurse staffing and missed care. The NCI we used may with substantial and critical input from all coauthors.
also be criticised for not taking account of the relative All authors read and approved the final version of the
manuscript.
importance of some tasks (all are given equal weight).
It does, however, have the advantage of being intu- Funding This work was supported by the Health Systems
Research Initiative joint grant provided by the Department for
itive and easily understood and is based on tasks an International Development, UK (DFID), Economic and Social
expert panel proposed were all relevant to achieving a Research Council (ESRC), Medical Research Council (MRC)
minimum standard of care while the allocation of task- and Wellcome Trust (grant number MR/M015386/1). ME is
specific weighting values could itself be very contested supported by a Wellcome Trust Senior Research Fellowship
(No 097170).
and has not to our knowledge been attempted in prior
Competing interests None declared.
work on missed nursing care.
Patient consent for publication Not required.
Conclusion Ethics approval Scientific and ethical approval for this study
was granted by the Kenya Medical Research Institute Scientific
Our work addresses an important gap in the global and Ethics Review Unit.
literature on quantifying the care delivered by nurses Provenance and peer review Not commissioned; externally
using direct observational methods. To the best of peer reviewed.
our knowledge, this is the first such study in a low- Data sharing statement Data are available upon reasonable
resource setting and it drew on development of local, request.

Original research
Open access This is an open access article distributed in 18 Gathara D, Opiyo N, Wagai J, et al. Quality of hospital
accordance with the Creative Commons Attribution 4.0 care for sick newborns and severely malnourished children
Unported (CC BY 4.0) license, which permits others to copy, in Kenya: a two-year descriptive study in 8 hospitals. BMC
redistribute, remix, transform and build upon this work for any
purpose, provided the original work is properly cited, a link Health Serv Res 2011;11.
to the licence is given, and indication of whether changes were 19 Reyburn H, Mwakasungula E, Chonya S, et al. Clinical
made. See: https://creativecommons.org/licenses/by/4.0/. assessment and treatment in paediatric wards in the north-east
of the United Republic of Tanzania. Bull World Health Org
ORCID iD
2008;86:123–39.
David Gathara http://orcid.org/0000-0002-0958-0713
20 Gathara D, Serem G, Murphy GAV, et al. Quantifying
nursing care delivered in Kenyan newborn units: protocol
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Original research

Missed nursing care in newborn

►► Additional material is Abstract under 5 years.3 A recent review by Bhutta

Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363 19

20 Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363

Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363 21

care index (NCI), at individual level for which the

22 Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363

Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363 23

24 Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363

Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363 25

identified as associated with the NCI based on the LRT Discussion

26 Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363

Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363 27

28 Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363

Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363 29

30 Gathara D, et al. BMJ Qual Saf 2020;29:19–30. doi:10.1136/bmjqs-2019-009363

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