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Missed nursing care in newborn units: a cross-sectional direct observational study
  1. David Gathara1,2,
  2. George Serem3,
  3. Georgina A V Murphy4,
  4. Alfred Obengo5,
  5. Edna Tallam6,
  6. Debra Jackson7,
  7. Sharon Brownie2,8,
  8. Mike English3,9
  1. 1 Public Health Research, Kenya Medical Research Institute–Wellcome Trust Research Programme, Nairobi, Kenya
  2. 2 Nursing and Midwifery, Aga Khan University School of Nursing and Midwifery East Africa, Nairobi, Kenya
  3. 3 Public Health Research, KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
  4. 4 Global Health, Bill and Melinda Gates Foundation, Seattle, Washington, USA
  5. 5 National Nurses Association of Kenya, Nairobi, Kenya
  6. 6 Registration and Licensing, Nursing Council of Kenya, Nairobi, Kenya
  7. 7 Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
  8. 8 School of Medicine, Griffith University Faculty of Health, Gold Coast, Queensland, Australia
  9. 9 Department of Paediatrics, University of Oxford, Oxford, UK
  1. Correspondence to Dr David Gathara, Public Health Research, Kenya Medical Research Institute–Wellcome Trust Research Programme, Nairobi 00100, Kenya; DGathara{at}


Background Improved hospital care is needed to reduce newborn mortality in low/middle-income countries (LMIC). Nurses are essential to the delivery of safe and effective care, but nurse shortages and high patient workloads may result in missed care. We aimed to examine nursing care delivered to sick newborns and identify missed care using direct observational methods.

Methods A cross-sectional study using direct-observational methods for 216 newborns admitted in six health facilities in Nairobi, Kenya, was used to determine which tasks were completed. We report the frequency of tasks done and develop a nursing care index (NCI), an unweighted summary score of nursing tasks done for each baby, to explore how task completion is related to organisational and newborn characteristics.

Results Nursing tasks most commonly completed were handing over between shifts (97%), checking and where necessary changing diapers (96%). Tasks with lowest completion rates included nursing review of newborns (38%) and assessment of babies on phototherapy (15%). Overall the mean NCI was 60% (95% CI 58% to 62%), at least 80% of tasks were completed for only 14% of babies. Private sector facilities had a median ratio of babies to nurses of 3, with a maximum of 7 babies per nurse. In the public sector, the median ratio was 19 babies and a maximum exceeding 25 babies per nurse. In exploratory multivariable analyses, ratios of ≥12 babies per nurse were associated with a 24-point reduction in the mean NCI compared with ratios of ≤3 babies per nurse.

Conclusion A significant proportion of nursing care is missed with potentially serious effects on patient safety and outcomes in this LMIC setting. Given that nurses caring for fewer babies on average performed more of the expected tasks, addressing nursing is key to ensuring delivery of essential aspects of care as part of improving quality and safety.

  • health services research
  • nurses
  • patient safety
  • quality measurement
  • standards of care

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  • Contributors DG, ME and GAVM designed the study with contributions from AO, ET, DJ and SB. DG and GS were responsible for the coordination and supervision of data collection. DG and ME wrote the initial draft manuscript with substantial and critical input from all coauthors. All authors read and approved the final version of the manuscript.

  • Funding This work was supported by the Health Systems Research Initiative joint grant provided by the Department for International Development, UK (DFID), Economic and Social Research Council (ESRC), Medical Research Council (MRC) and Wellcome Trust (grant number MR/M015386/1). ME is supported by a Wellcome Trust Senior Research Fellowship (No 097170).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Scientific and ethical approval for this study was granted by the Kenya Medical Research Institute Scientific and Ethics Review Unit.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available upon reasonable request.

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