Expectations for Nursing Care in Newborn Units in Kenya: Moving from Implicit to Explicit Standards

Analysis BMJ Glob Health: first published as 10.1136/bmjgh-2017-000645 on 21 March 2018. Downloaded from Expectations for nursing care in newborn units in Kenya: moving from implicit to explicit standards Georgina A V Murphy,1,2 Gregory B Omondi,2 David Gathara,2 Nancy Abuya,2,3 Jacintah Mwachiro,2 Rose Kuria,4 Edna Tallam-Kimaiyo,4,5 Mike English,1,2 On behalf of the Nursing Tasks Advisory Group To cite: Murphy GAV, ABSTRACT Omondi GB, Gathara D, et al. Neonatal mortality currently accounts for 45% of all child Key questions Expectations for nursing care mortality in Kenya, standing at 22 per 1000 live births. in newborn units in Kenya: Access to basic but high quality inpatient neonatal services What is already known about this topic? moving from implicit to explicit for small and sick newborns will be key in reducing ► Access to essential inpatient services with adequate standards. BMJ Glob Health neonatal mortality. Neonatal inpatient care is reliant on nursing care for small and sick newborns will be 2018;3:e000645. doi:10.1136/ key if progress is to be made in reducing neonatal bmjgh-2017-000645 nursing care, yet explicit nursing standards for such care do not currently exist in Kenya. We reviewed the Nursing mortality in low- and middle-income countries. ► Although the performance of key nursing tasks is Handling editor Seye Abimbola Council of Kenya ‘Manual of Clinical Procedures’ to identify tasks relevant for the care of inpatient neonates. An expert described in detail in nursing manuals, there are Received 13 November 2017 advisory group comprising major stakeholders, policy- currently no agreed written standards to guide the Revised 29 January 2018 makers, trainers, and frontline health-workers was invited delivery of nursing care for neonatal patients in Accepted 30 January 2018 to a workshop with the purpose of defining tasks for Kenya. which nurses are responsible and the minimum standard ► Instead, standards are implicitly defined as with which these tasks should be delivered to inpatient historical practice norms that vary, often quite neonates in Kenyan hospitals. Despite differences in markedly, from one facility to the next. opinions at the beginning of the process, consensus was What are the new findings? reached on the minimum standards of neonatal nursing. ► An expert group comprising major stakeholder The key outcome was a comprehensive list and grouping organisations, policy-makers, nursing trainers, and of neonatal nursing task and the minimum frequency frontline workers spanning private and public sectors with which these tasks should be performed. Second, a http://gh.bmj.com/ can work together, respecting the challenges of simple categorisation of neonatal patients based on care varying contexts, to reach consensus on defining needs was agreed. In addition, acceptable forms of task minimum standards of neonatal nursing care. sharing with other cadres and the patient’s family for the ► Levels of dependency of neonatal patients were neonatal nursing tasks were agreed and described. The defined with the recognition that different patients process was found to be acceptable to policy-makers may require different standards of care depending and practitioners, who recognised the value of standards on the severity of their condition and dependency on September 29, 2021 by guest. Protected copyright. in neonatal nursing to improve the quality of neonatal on nursing care. inpatient care. Such standards could form the basis for audit and quality evaluation. 1Centre for Tropical Medicine repeated and often multiple interventions and Global Health, Nuffield INTRODUCTION delivered 24 hours a day, and their condition Department of Medicine, can change rapidly. Good outcomes for this University of Oxford, Oxford, UK The need to reduce neonatal mortality has 2Health Services Unit, KEMRI become a priority internationally, with the patient population are, therefore, particularly – Wellcome Trust Research Sustainable Development Goal (SDG) three dependent on nursing care. Programme, Nairobi, Kenya targeting to reduce mortality to 12/1000 live The WHO has helped lead efforts to set 3Nairobi City County births or lower.1 In Kenya, substantial efforts standards for neonatal care, including recent Government, Nairobi, Kenya 4 4 indicators on all aspects of peripartum care. Ministry of Health, Nairobi, will be needed to reduce the current neonatal Kenya mortality of 22/1000 live births to reach this A number of these indicators touch on quality 5Nursing Council of Kenya, SDG target by 2030. Access to basic but high of the nursing process; many of these implic- Nairobi, Kenya quality inpatient neonatal services for small itly require high quality nursing care provi- Correspondence to and sick newborns will be key if progress is to sion. High income countries, such as the UK 2 3 Dr Georgina A V Murphy; be made. Sick newborns require continual have produced valuable detailed guidance murphygina@ gmail. com supportive care and observation, with on neonatal nursing.5 6 Equivalent standards Murphy GAV, et al. BMJ Glob Health 2018;3:e000645. doi:10.1136/bmjgh-2017-000645 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2017-000645 on 21 March 2018. Downloaded from ratios as high as 15:1 have been previously described. Key questions Such ratios are in extreme contrast to the internation- Recommendations for policy ally recommended ratios of newborns to nurses of: 4:1 for basic or continuing care; 2-3:1 for stable babies ► Minimum standards of neonatal nursing care could be used as benchmarks for quality evaluation across private and public sector requiring intervention; and 1:1 for high-dependency 11 facilities. care. Quality of care for neonatal patients varies widely ► Highly practical operational research priorities were identified, between health facilities and across sectors (private and these included the need to identify/design more structured nursing public) in terms of their structural capacity to provide notes (cardex) and better tools to document nursing observations care and indicators of the process of care. Although, to facilitate more rapid, accurate, and informative documentation indicators capturing key nursing processes are typically and communication between nurses and with other professionals lacking. as part of improving quality of care. ► Clearly defining expectations of neonatal nursing care may Identifying key neonatal nursing tasks support discussions on the role of different health worker cadre We began by trying to identify nursing standards docu- in providing neonatal care, task-shifting policy, neonatal nursing training needs, and setting appropriate nurse to patient ratios. ments in Kenya by reaching out to experts, the Ministry of Health, and the Nursing Council of Kenya (NCK). The only document that emerged as being relevant was the NCK ‘Manual of Clinical Procedures’.12 The manual do not currently exist in many low-resourced setting, applies to all areas of nursing and is a key reference text including Kenya. for nurse training institutions in Kenya. While the manual To complement these ongoing international efforts to offers detailed standard operating procedures on many define standards for and indicators of care for small and nursing procedures, it does not offer guidance on how sick newborns, we set out to consider specifically defining often tasks should be done nor by whom. Instead, such minimum standards of neonatal nursing care in Kenya. operational decisions are made at each facility and are In doing this, we aimed to initiate a discussion on explicit often implicitly rather than explicitly defined. We are not nursing care standards. We aimed to provide locally aware of the availability of such neonatal nursing stand- agreed benchmarks that can support evaluations of the ards from any sub-Saharan African countries. quality of inpatient neonatal nursing care. Drawing on this manual, medical and nursing team members identified tasks relevant for inpatient neonatal EXPLORING STANDARDS OF NEONATAL NURSING IN KENYA care and organised these into domains (eg, vital signs The setting and monitoring, oxygen treatment, etc). We sought to Nursing care within the newborn unit is predominantly present these to an expert advisory group for more provided by registered nurses. Diploma and degree level detailed consideration. registered nurses receive 2 and 4 weeks of training in http://gh.bmj.com/ newborn care, respectively. Since 2012, a specialist 1 year Expert advisory group post-basic training in neonatal nursing was approved We constituted an expert advisory group (n=12; see by the Nursing Council of Kenya; however, the number Nursing Tasks Advisory Group in the author list below) of nurses trained so far at national level is only approx- made up of individuals responsible for: delivery of imately 100 nurses. Thus, the vast majority of nurses neonatal care in major public and private hospitals; providing neonatal care in Kenyan hospitals learn their neonatal nurse training; and child health and nursing on September 29, 2021 by guest. Protected copyright. skills during practice, where there are no nurses with services policy in the Ministry of Health and a County specialist neonatal nursing qualifications. Nurse training Government. This group also included major nursing and practice in Kenya is regulated by the Nursing Council stakeholder groups, the National Nurses Association of of Kenya (NCK). The National Nurses Association of Kenya and NCK. These members of the expert

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