The reality of neonatal nursing work in Kenya and implications for quality and safety: Direct observation of tasks and time utilisation.

BACKGROUND: Little is known about how nurses working in care settings affected by remarkably high workloads and workforce constraints manage their work and time to deliver needed care. OBJECTIVE: This study aimed to characterise nursing workflows and examine time allocated to care in high mortality, intermediate care Kenyan neonatal units. DESIGN AND METHODS: Using 'shadowing' as a time and motion technique, we directly observed 1-2 nurses per 12-hour shift in 8 Kenyan county hospitals. We used an Activity Log Sheet to document their activities during the shift and thematic content analysis of observation notes to classify and group tasks performed. In a second phase, we documented the time spent on specific critical tasks and instances of multi-tasking and care interruptions. RESULTS: We directly observed 499 person-hours over 36 day shifts and 15 night shifts. A typical day and night shift had a median of 38 (25-47) and 32 (18-44) babies respectively with a median nursing hours per-patient per-shift of 0.9 (0.5-1.2) hours. We recorded 1891 task episodes comprised of 36 different tasks that we grouped into eight workflow domains. Most tasks involved: direct patient care (37 %) or indirect patient care (23 %) with communications, documentation and reporting, staff or student supervision and mentorship, interruptions, personal breaks, and rest less frequently performed tasks. Nurses commonly devoted up to 20 minutes even to critical tasks while continuing to multi-task and managing more than 2 instances of interruptions during a newborn caring task. CONCLUSIONS: Kenyan neonatal nurses perform direct and indirect patient caring tasks while grappling with demanding housekeeping, administrative, and clinical teaching and mentorship roles under extremely limited time availability. Time allocated even to complex tasks is minimal and rarely given full focus, threatening patient safety. Our findings highlight opportunities to redistribute basic non-clinical roles for enhanced patient and caregiver experience. Even so, nurse staffing must be substantially improved.