Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement.

BACKGROUND:The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY:We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS:Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning

Generation of reactive oxygen species in relevant cell lines as a bio-indicator of oxidative effects caused by acid mine water

Reactive oxygen species (ROS) production and resultant oxidative stress (OS) has been implicated as a pathway of toxicity in animal species exposed to pollutants. The gills of aquatic animals and the liver and kidneys of mammalian species are specific cellular sites of toxicity. Oxidative effects of acid mine drainage effluent (following passive and active treatment) impacting a natural stream were assessed using selected cell lines. Levels of pollutants such as heavy metals in acid mine drainage (AMD) effluent can be quantified following treatment, but it is unknown whether this is associated with equivalent reduction in toxicity. ROS production by AMD untreated (U) and after treatment (T) was quantified in a fish gill cell line (RTgill-W1) and in two mammalian cell lines (C3A human liver and Vero monkey kidney). ROS production was determined using the oxidant sensitive fluorogenic probe, 2′, 7′-dichlorofluorescein diacetate (DCFH-DA) following exposure to U and T, AMD water. Treatment of AMD water caused reduction in levels of Al, Zn, Fe, Si and Mn while levels of Cr, Cu, Ar and Hg remained unchanged. A dose-dependent increase in ROS production was observed for U and T. ROS formation decreased from 14% to 4.5%, 16.4% to 7.2% and 25.3% to 17.7% in the RTgill-W1, C3A, and Vero cell lines exposed to 100% AMD water, U and T. The presence of Mn and/or other ions in treated water and subsequent ROS formation indicates that water could still be toxic to cells and requires further processing. The DCFH-DA assay in several cell lines can be used to rapidly bio-monitor quality of AMD water related to formation of ROS and subsequent cellular effects. However, cut-off levels for cellular toxicity must be established to ensure safety of this water for aquatic animals and for animal and human consumption.Keywords: acid mine drainage, bio-monitoring, DCFH-DA, reactive oxygen specie

Generation of reactive oxygen species in relevant cell lines as a bio-indicator of oxidative effects caused by acid mine water

Reactive oxygen species (ROS) production and resultant oxidative stress (OS) has been implicated as a pathway of toxicity in animal species exposed to pollutants. The gills of aquatic animals and the liver and kidneys of mammalian species are specific cellular sites of toxicity. Oxidative effects of acid mine drainage effluent (following passive and active treatment) impacting a natural stream were assessed using selected cell lines. Levels of pollutants such as heavy metals in acid mine drainage (AMD) effluent can be quantified following treatment, but it is unknown whether this is associated with equivalent reduction in toxicity. ROS production by AMD untreated (U) and after treatment (T) was quantified in a fish gill cell line (RTgill-W1) and in two mammalian cell lines (C3A human liver and Vero monkey kidney). ROS production was determined using the oxidant sensitive fluorogenic probe, 2′, 7′-dichlorofluorescein diacetate (DCFH-DA) following exposure to U and T, AMD water. Treatment of AMD water caused reduction in levels of Al, Zn, Fe, Si and Mn while levels of Cr, Cu, Ar and Hg remained unchanged. A dose-dependent increase in ROS production was observed for U and T. ROS formation decreased from 14% to 4.5%, 16.4% to 7.2% and 25.3% to 17.7% in the RTgill-W1, C3A, and Vero cell lines exposed to 100% AMD water, U and T. The presence of Mn and/or other ions in treated water and subsequent ROS formation indicates that water could still be toxic to cells and requires further processing. The DCFH-DA assay in several cell lines can be used to rapidly bio-monitor quality of AMD water related to formation of ROS and subsequent cellular effects. However, cut-off levels for cellular toxicity must be established to ensure safety of this water for aquatic animals and for animal and human consumption.OTI is grateful to the Schlumberger Stichting Fund, The Netherlands for a fellowship. The National Research Foundation and the Department of Paraclinical Sciences (University of Pretoria) are acknowledged for research funding [Project number: V027-12].http://www.wrc.org.zaam2017AnatomyParaclinical Science

The Elephant Queen: Can a nature documentary help to increase tolerance towards elephants?

Conflict between humans and elephants is one of the more complex examples of human‐wildlife conflict, a key challenge for wildlife conservation. While interventions exist to separate humans from elephants, few exist aimed at bringing the two species closer together. This study assesses if a natural history film, The Elephant Queen (TEQ), makes communities living around elephants more tolerant of conflict with elephants. Questionnaires and interviews were conducted before and after seeing the film screened on a mobile cinema in Southern Kenya. A double robust ordinal regression analysis using 357 matching specifications to measure the effect size of viewing TEQ on the six criteria identified as being drivers of tolerance of a wild animal by the Hazard Acceptance model. This study found that students aged between 16 and 18 gained knowledge (mean effect size = 0.27) and affection (mean effect size = 0.17) towards elephants and felt the benefits of elephants more keenly (mean effect size = 0.26) following viewing TEQ. Community members aged between 16–80 also gained knowledge (mean effect size = 0.21) and saw the benefits of elephants (mean effect size = 0.15) but felt the costs of living with elephants more profoundly after viewing TEQ (mean effect size = −0.11). After 90 days a follow‐up survey also showed a significant increase in community “affection” towards elephants (mean effect size = 0.11), however the costs, benefits and knowledge gained had been reduced to a statistically insignificant level compared to baseline. Our results suggest that natural history films can serve as a valuable tool in inspiring young minds. When shown to an adult audience, changes were more nuanced and some of the changes were short lived (<3 months). Read the free Plain Language Summary for this article on the Journal blog

Predicting Nitrate-N leaching under different tillage systems using LEACHM and NTRM

Two simulation models LEACHM-N and NTRM were used to estimate nitrate-nitrogen (NO3 –N) leaching in a sandy loam soil under no-till (NT), reduced tillage (RT), and conventional tillage (CT) practices, for conditions with residue (R) and without residue (NR) in undisturbed soil columns. LEACHM-N generally overestimated NO3 –N mass below 0.4 m in RT and CT treatments. However it underestimated NO3 –N concentration ([NO3 –N]) measured immediately after fertilizer application, particularly at the lower depths, showing a deviation of up to 50%. LEACHM-N overpredicted [NO3 –N] in the top 0.2 m soil layers in all treatments. Overall, model predictions were within one standard deviation of observed data. NTRM performed well at depths below 0.4 m, but underpredicted NO3 –N movement at shallower depths. No significant differences were shown among tillage and residue treatments by NTRM. Both models still require improvement to accurately predict [NO₃ –N] in the soil

Quantifying nursing care delivered in Kenyan newborn units: protocol for a cross-sectional direct observational study

In many African countries, including Kenya, a major barrier to achieving child survival goals is the slow decline in neonatal mortality that now represents 45% of the under-5 mortality. In newborn care, nurses are the primary caregivers in newborn settings and are essential in the delivery of safe and effective care. However, due to high patient workloads and limited resources, nurses may often consciously or unconsciously prioritise the care they provide resulting in some tasks being left undone or partially done (missed care). Missed care has been associated with poor patient outcomes in high-income countries. However, missed care, examined by direct observation, has not previously been the subject of research in low/middle-income countries.The aim of this study is to quantify essential neonatal nursing care provided to newborns within newborn units. We will undertake a cross-sectional study using direct observational methods within newborn units in six health facilities in Nairobi City County across the public, private-for-profit and private-not-for-profit sectors. A total of 216 newborns will be observed between 1 September 2017 and 30 May 2018. Stratified random sampling will be used to select random 12-hour observation periods while purposive sampling will be used to identify newborns for direct observation. We will report the overall prevalence of care left undone, the common tasks that are left undone and describe any sharing of tasks with people not formally qualified to provide care.Ethical approval for this study has been granted by the Kenya Medical Research Institute Scientific and Ethics Review Unit. Written informed consent will be sought from mothers and nurses. Findings from this work will be shared with the participating hospitals, an expert advisory group that comprises members involved in policy-making and more widely to the international community through conferences and peer-reviewed journals

Quantifying nursing care delivered in Kenyan newborn units: protocol for a cross-sectional direct observational study

In many African countries, including Kenya, a major barrier to achieving child survival goals is the slow decline in neonatal mortality that now represents 45% of the under-5 mortality. In newborn care, nurses are the primary caregivers in newborn settings and are essential in the delivery of safe and effective care. However, due to high patient workloads and limited resources, nurses may often consciously or unconsciously prioritise the care they provide resulting in some tasks being left undone or partially done (missed care). Missed care has been associated with poor patient outcomes in high-income countries. However, missed care, examined by direct observation, has not previously been the subject of research in low/middle-income countries.The aim of this study is to quantify essential neonatal nursing care provided to newborns within newborn units. We will undertake a cross-sectional study using direct observational methods within newborn units in six health facilities in Nairobi City County across the public, private-for-profit and private-not-for-profit sectors. A total of 216 newborns will be observed between 1 September 2017 and 30 May 2018. Stratified random sampling will be used to select random 12-hour observation periods while purposive sampling will be used to identify newborns for direct observation. We will report the overall prevalence of care left undone, the common tasks that are left undone and describe any sharing of tasks with people not formally qualified to provide care.Ethical approval for this study has been granted by the Kenya Medical Research Institute Scientific and Ethics Review Unit. Written informed consent will be sought from mothers and nurses. Findings from this work will be shared with the participating hospitals, an expert advisory group that comprises members involved in policy-making and more widely to the international community through conferences and peer-reviewed journals

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