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

Estimating the need for inpatient neonatal services: an iterative approach employing evidence and expert consensus to guide local policy in Kenya.

Universal access to quality newborn health services will be essential to meeting specific Sustainable Development Goals to reduce neonatal and overall child mortality. Data for decision making are crucial for planning services and monitoring progress in these endeavours. However, gaps in local population-level and facility-based data hinder estimation of health service requirements for effective planning in many low-income and middle-income settings. We worked with local policy makers and experts in Nairobi City County, an area with a population of four million and the highest neonatal mortality rate amongst counties in Kenya, to address this gap, and developed a systematic approach to use available data to support policy and planning. We developed a framework to identify major neonatal conditions likely to require inpatient neonatal care and identified estimates of incidence through literature review and expert consultation, to give an overall estimate for the year 2017 of the need for inpatient neonatal care, taking account of potential comorbidities. Our estimates suggest that almost 1 in 5 newborns (183/1000 live births) in Nairobi City County may need inpatient care, resulting in an estimated 24 161 newborns expected to require care in 2017. Our approach has been well received by local experts, who showed a willingness to work together and engage in the use of evidence in healthcare planning. The process highlighted the need for co-ordinated thinking on admission policy and referral care especially in a pluralistic provider environment helping build further appetite for data-informed decision making

Neonatal nasogastric tube feeding in a low-resource African setting - using ergonomics methods to explore quality and safety issues in task sharing.

BACKGROUND: Sharing tasks with lower cadre workers may help ease the burden of work on the constrained nursing workforce in low- and middle-income countries but the quality and safety issues associated with shifting tasks are rarely critically evaluated. This research explored this gap using a Human Factors and Ergonomics (HFE) method as a novel approach to address this gap and inform task sharing policies in neonatal care settings in Kenya. METHODS: We used Hierarchical Task Analysis (HTA) and the Systematic Human Error Reduction and Prediction Approach (SHERPA) to analyse and identify the nature and significance of potential errors of nasogastric tube (NGT) feeding in a neonatal setting and to gain a preliminary understanding of informal task sharing. RESULTS: A total of 47 end tasks were identified from the HTA. Sharing, supervision and risk levels of these tasks reported by subject matter experts (SMEs) varied broadly. More than half of the tasks (58.3%) were shared with mothers, of these, 31.7% (13/41) and 68.3% were assigned a medium and low level of risk by the majority (≥4) of SMEs respectively. Few tasks were reported as 'often missed' by the majority of SMEs. SHERPA analysis suggested omission was the commonest type of error, however, due to the low risk nature, omission would potentially result in minor consequences. Training and provision of checklists for NGT feeding were the key approaches for remedying most errors. By extension these strategies could support safer task shifting. CONCLUSION: Inclusion of mothers and casual workers in care provided to sick infants is reported by SMEs in the Kenyan neonatal settings. Ergonomics methods proved useful in working with Kenyan SMEs to identify possible errors and the training and supervision needs for safer task-sharing

Expectations for nursing care in newborn units in Kenya: moving from implicit to explicit standards.

Neonatal mortality currently accounts for 45% of all child mortality in Kenya, standing at 22 per 1000 live births. Access to basic but high quality inpatient neonatal services for small and sick newborns will be key in reducing neonatal mortality. Neonatal inpatient care is reliant on nursing care, yet explicit nursing standards for such care do not currently exist in Kenya. We reviewed the Nursing Council of Kenya 'Manual of Clinical Procedures' to identify tasks relevant for the care of inpatient neonates. An expert advisory group comprising major stakeholders, policy-makers, trainers, and frontline health-workers was invited to a workshop with the purpose of defining tasks for which nurses are responsible and the minimum standard with which these tasks should be delivered to inpatient neonates in Kenyan hospitals. Despite differences in opinions at the beginning of the process, consensus was reached on the minimum standards of neonatal nursing. The key outcome was a comprehensive list and grouping of neonatal nursing task and the minimum frequency with which these tasks should be performed. Second, a simple categorisation of neonatal patients based on care needs was agreed. In addition, acceptable forms of task sharing with other cadres and the patient's family for the neonatal nursing tasks were agreed and described. The process was found to be acceptable to policy-makers and practitioners, who recognised the value of standards in neonatal nursing to improve the quality of neonatal inpatient care. Such standards could form the basis for audit and quality evaluation

Effective coverage of essential inpatient care for small and sick newborns in a high mortality urban setting: a cross-sectional study in Nairobi City County, Kenya.

BACKGROUND: Effective coverage requires that those in need can access skilled care supported by adequate resources. There are, however, few studies of effective coverage of facility-based neonatal care in low-income settings, despite the recognition that improving newborn survival is a global priority. METHODS: We used a detailed retrospective review of medical records for neonatal admissions to public, private not-for-profit (mission) and private-for-profit (private) sector facilities providing 24×7 inpatient neonatal care in Nairobi City County to estimate the proportion of small and sick newborns receiving nationally recommended care across six process domains. We used our findings to explore the relationship between facility measures of structure and process and estimate effective coverage. RESULTS: Of 33 eligible facilities, 28 (four public, six mission and 18 private), providing an estimated 98.7% of inpatient neonatal care in the county, agreed to partake. Data from 1184 admission episodes were collected. Overall performance was lowest (weighted mean score 0.35 [95% confidence interval or CI: 0.22-0.48] out of 1) for correct prescription of fluid and feed volumes and best (0.86 [95% CI: 0.80-0.93]) for documentation of demographic characteristics. Doses of gentamicin, when prescribed, were at least 20% higher than recommended in 11.7% cases. Larger (often public) facilities tended to have higher process and structural quality scores compared with smaller, predominantly private, facilities. We estimate effective coverage to be 25% (estimate range: 21-31%). These newborns received high-quality inpatient care, while almost half (44.5%) of newborns needed care but did not receive it and a further 30.4% of newborns received an inadequate service. CONCLUSIONS: Failure to receive services and gaps in quality of care both contribute to a shortfall in effective coverage in Nairobi City County. Three-quarters of small and sick newborns do not have access to high-quality facility-based care. Substantial improvements in effective coverage will be required to tackle high neonatal mortality in this urban setting with high levels of poverty

EWPD Constraints on Flavor Symmetric Vector Fields

Electroweak precision data constraints on flavor symmetric vector fields are determined. The flavor multiplets of spin one that we examine are the complete set of fields that couple to quark bi-linears at tree level while not initially breaking the quark global flavor symmetry group. Flavor safe vector masses proximate to, and in some cases below, the electroweak symmetry breaking scale are found to be allowed. Many of these fields provide a flavor safe mechanism to explain the t tbar forward backward anomaly, and can simultaneously significantly raise the allowed values of the Standard Model Higgs mass consistent with electroweak precision data.Comment: Matches version published in JHE

A constitutive model for cytoskeletal contractility of smooth muscle cells

The constitutive model presented in this article aims to describe the main bio-chemo-mechanical features involved in the contractile response of smooth muscle cells, in which the biochemical response is modelled by extending the four-state Hai–Murphy model to isotonic contraction of the cells and the mechanical response is mainly modelled based on the phosphorylation-dependent hyperbolic relation between isotonic shortening strain rate and tension. The one-dimensional version of the model is used to simulate shortening-induced deactivation with good agreement with selected experimental measurements. The results suggest that the Hai–Murphy biochemical model neglects the strain rate effect on the kinetics of cross-bridge interactions with actin filaments in the isotonic contractions. The two-dimensional version and three-dimensional versions of the model are developed using the homogenization method under finite strain continuum mechanics framework. The two-dimensional constitutive model is used to simulate swine carotid media strips under electrical field stimulation, experimentally investigated by Singer and Murphy, and contraction of a hollow airway and a hollow arteriole buried in a soft matrix subjected to multiple calcium ion stimulations. It is found that the transverse deformation may have significant influence on the response of the swine carotid medium. In both cases, the orientation of the maximal value of attached myosin is aligned with the orientation of maximum principal stress

What capacity exists to provide essential inpatient care to small and sick newborns in a high mortality urban setting? - A cross-sectional study in Nairobi City County, Kenya.

INTRODUCTION: Appropriate demand for, and supply of, high quality essential neonatal care is key to improving newborn survival but evaluating such provision has received limited attention in low- and middle-income countries. Moreover, specific local data are needed to support healthcare planning for this vulnerable population. METHODS: We conducted health facility assessments between July 2015-April 2016, with retrospective review of admission events between 1st July 2014 and 30th June 2015, and used estimates of population-based incidence of neonatal conditions in Nairobi to explore access and evaluate readiness of public, private not-for-profit (mission), and private-for-profit (private) sector facilities providing 24/7 inpatient neonatal care in Nairobi City County. RESULTS: In total, 33 (4 public, 6 mission, and 23 private) facilities providing 24/7 inpatient neonatal care in Nairobi City County were identified, 31 were studied in detail. Four public sector facilities, including the only three facilities in which services were free, accounted for 71% (8,630/12,202) of all neonatal admissions. Large facilities (>900 annual admissions) with adequate infrastructure tended to have high bed occupancy (over 100% in two facilities), high mortality (15%), and high patient to nurse ratios (7-15 patients per nurse). Twenty-one smaller, predominantly private, facilities were judged insufficiently resourced to provide adequate care. In many of these, nurses provided newborn and maternity care simultaneously using resources shared across settings, newborn care experience was likely to be limited (<50 cases per year), there was often no resident clinician, and sick babies were often referred onwards. Results suggest 44% (9,764/21,966) of Nairobi's small and sick newborns may not access any of the identified facilities and a further 9% (2,026/21,966) access facilities judged to be inadequately equipped. CONCLUSION: Over 50% of Nairobi's sick newborns may not access a facility with adequate resources to provide essential care. A very high proportion of care accessed is provided by four public and one low cost mission facility; these face major challenges of high patient acuity (high mortality), high patient to nurse ratios, and often overcrowding. Reducing high neonatal mortality in this urban, predominantly poor, population will require effective long-term, multi-sectoral planning and investment