David Gathara: Quantifying nursing care done (or left undone)
Sick newborns require large amounts of nursing time, so what happens when nurses have to care for too many babies? By making direct observations of the care that is given this important new research identified how much care is missed. More care is missed when nurses have more babies to care for, showing the direct consequences of health care worker shortages.
I am David Gathara, I currently lead the nursing services research, but previously I have been co-leading part of the quantitative work on the Health Services that Deliver for Newborns.
My role within the Health Services that Deliver for Newborns has evolved over time. During the project in its early stages, I developed some of the proposals and materials. I started with quantitative work trying to understand the burden of disease for newborns, access for newborn care, the quality of care for the newborns and where they can access it.
I transitioned on to trying to appreciate how care is delivered within newborn units, more specifically to nursing. Appreciating how much nursing care is delivered and developing tools for measuring that, both directly but also trying to appreciate from a wider scope, from nurses’ perceptions. What nurses reported and their perceptions of missed care.
One of the major issues that Health Services that Deliver for Newborns is tackling, is trying to understand the contexts within which newborn care is delivered. By appreciating that, we hope we will be able to identify the challenges for delivering newborn care within these low-income settings where they have high mortality, high workload for nurses and limited nurse staffing. Using that evidence we hope to inform intervention designs that are more context relevant to solve some of the issues we picked up.
Missed care is a new concept that has come into place over a decade now. It often refers to the inability to provide the required nursing care, which can be a result of omission or delayed care. Evidence from high-income countries has illustrated that there is a strong link between care that is left undone or missed, and patient outcomes including mortality. Quality of care that is delivered to patients in hospital settings, but also in home care settings, has been linked to patient-centred outcomes, like patient experiences and how patients perceive the kind of care they receive from hospitals.
I think it is important, first because of the reasons I have just mentioned, and also in low and middle-income settings we have a different context. We have high patient workloads with limited nursing staff. The context is not perfect in terms of resources available for providing care. Appreciating how much care is delivered in our settings and some of the reasons that might be driving good quality care - meaning care that is being delivered or not being delivered - are very important when trying to appreciate and come up with interventions that are relevant for our setting.
We started by adaptating work on measuring missed care within Kenya, in newborn units. This work started off by developing the minimum standards required for nursing care provisions within the patient settings, in newborn units. Using these standards, we developed direct observation checklists based on tasks that can be directly observed. We took this forward using people that we trained to observe care as it was delivered within newborn units.
The challenges and the unique bit about this work is that different babies with different degrees of severity require different magnitudes of care. Different babies require different interventions and that poses a challenge in how you deal with different denominators of the required care. We developed a metric, which takes into account the varied denominators, that allows us to pool our findings across all the babies observed. This metric, we are calling it the ‘Nursing Quality of Care Index’.
The work we have done spans across six hospitals across the three different sectors: public, private and private-not for profit, for 260 babies. The key findings of this work is that only about 60% of the care that is required is actually delivered across all babies observed, and when you look at the public sector less than 50% of the care that is required is delivered. We have demonstrated that there is a strong association between the number of babies being looked after by one nurse and the care that they are able to deliver.
I think the implications of these findings point to one: we have identified tasks that are not being delivered and are directly linked to the outcomes of babies, like vital signs monitoring and feeds not being given. Also things that point to critical safety issues, interventions like oxygen or phototherapy not being properly delivered.
One of the main solutions that I see stemming from this work is that people have to come together as partners to increase the number of nurses providing care within newborn units. We cannot replace what nurses do, but even so we also need to provide mechanisms to support nurses, so that they can focus on more technical and critical things. This may include providing support staff, for instance the health care assistants that are used in high-income settings, but also might include revising the scope of practice for nursing. Since nurses have taken up a lot of responsibilities along the way and some of them are not really nursing tasks, that might provide a solution.
Moving forwards the research that needs to be taken into account: the methods that we have developed for direct observational work are much more difficult to deploy at skill, so we need to come up with approaches for measuring what nurses do, as care. More importantly, we need to focus on work that has not gained a lot of attention in low and middle-income settings.
This interview was recorded in December 2018