Improving immediate neonatal care within Kenyan hospitals.

Project Overview

Kenya has a high neonatal mortality, at 22 per 1000 neonatal deaths, and is among the ten worst performing countries in sub-Saharan Africa. Insights from recently completed ethnographic research on nursing care within Kenyan newborn units suggest that poor inter-professional and inter-departmental communications in the early peri-partum phases of care may be a significant factor in adverse neonatal (and maternal) outcomes although this was not the focus of these studies. These preliminary observations align with evidence that different departments (eg maternity and newborn units) and different professionals (eg nurses and doctors) often work in isolation instead of as clinical teams. Disruptions and miscommunication then often characterise the care pathway followed by a newborn resulting in poor quality of care and medical errors. Addressing these issues will require moving beyond specific technical skills training to tackle broader organisational issues that contribute to poor neonatal outcomes.

The proposed DPhil will begin to explore where improvements might most usefully be made in the organisation of immediate newborn care within Kenyan district hospitals. The DPhil would look particularly at what interventions should be delivered in the delivery unit, with particular attention being paid to care at the time of a pre-term birth and how interventions might be bundled together. Ideas around critical care pathways could be of interest and how these might influence who takes responsibility for which aspects of immediate care and how the specific contextual issues of Kenyan hospitals might influence this. Work would extend to include the transfer for babies requiring ongoing care to the neonatal care wards and how this might be better managed within low-resource settings which have particular challenges with unavailability of highly skilled workers. Work might be usefully be complemented by a systems thinking approach as the journey a sick newborn makes may span several hospital locations (delivery units, theatres and newborn units (NBU)), teams and sub-cultures through the course of immediate neonatal care.  For a system to function, there must be synergy, interdependence and accurate and timely transmission of patient information between the sub-systems and different professional cadres along this patient journey.  As well as identifying needs for additional resources or technologies the DPhil may also therefore draw on specific theories around team, inter-professional and inter-personal communication as evidence on patient safety from high income countries suggests that inadequacies in these are major factors contributing to procedural mistakes in acute care.

To address the challenges outlined above the student will initially spend time identifying useful literature and develop a solid theoretical basis for subsequent empiric work. Drawing on this literature the student will develop a proposal for empiric work to be conducted in Kenya where considerable work already engages with county (district) hospitals. Empiric work might employ process mapping, a technique thatuses health-workers’ local knowledge to describe the management of care as a series of consecutive steps (sometimes recursive and including activities, staff roles and interactions etc) that usefully reveal both physical and spatial journeys and how communication of vital patient information is transferred within and between teams. This early work would consider how to integrate appropriate interventions into the process of care. Such work could progress to include capture of quantitative data on processes (eg. time taken for specific care transitions or cohort studies to assess important health indicators such as babies’ temperature on arrival to NBU). Work could also include detailed ethnographic observation of the important neonatal care sub-systems in hospitals spanning normal working days, nights and weekends with perhaps focused observations of the transitions between teams / sub-systems. The latter might include observing the behaviours and interactions that comprise the daily communication and taken for granted world of staff routines and handovers/offs and the context in which this occurs. Complementary data from interviews or focus group discussions could also provide valuable data. Overall the aim would be to identify critical areas / strategies for improvement in immediate neonatal care in Kenyan hospitals and other LMIC

Background references:

  1. Process mapping: https://www.bmj.com/content/341/bmj.c4078
  2. Inter-professional work: https://qualitysafety.bmj.com/content/qhc/13/suppl_1/i85.full.pdf & https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000072.pub3/full & https://www.sciencedirect.com/science/article/pii/S0277953617302009?via%3Dihub & https://www.sciencedirect.com/science/article/pii/S0277953612003450?via%3Dihub
  3. Neonatal care in LMIC: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60792-3/fulltext & https://adc.bmj.com/content/100/1/42 & https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1056-0
  4. Neonatal transitions https://www.resuscitationjournal.com/article/S0300-9572(15)00341-X/fulltext

Training Opportunities

The purpose of this DPhil is to equip the student with an understanding of the organisational and social factors that influence the use of essential interventions and quality of immediate neonatal care in LMIC as part of foundational training in clinical and health services research. Time will be spent learning and conducting literature reviews and identifying and exploring different theories and methods that then inform study designs. There will be opportunities to develop further links to the Oxford Healthcare Improvement team as this work develops (https://www.oxfordhealth.nhs.uk/oxford-healthcare-improvement/about-us/our-team/). The student will be expected to lead the design of studies based on their skills and interests and will then learn by developing a detailed proposal to satisfy the requirements of scientific and ethical review. Where necessary appropriate training in research methods will be provided (eg. in qualitative or quantitative data collection and analysis) and there will be opportunities for engaging with a wider body of researchers in Oxford and Kenya conducting health systems research.  It is anticipated that during the course of the DPhil and primarily linked to the collection of primary data up to 6 months may be spent in Kenya based at the Nairobi offices of the KEMRI-Wellcome Trust Research Programme (www.kemri-wellcome.org).   

Theme

Tropical Medicine & Global Health

Admissions

Project reference number: 992

Funding and admissions information

Supervisors

Name Department Institution Country Email
Professor Mike English Tropical Medicine Oxford University, Nairobi KEN menglish@kemri-wellcome.org
Dr Charles Roehr Newborn Services, Women's Centre, John Radcliffe Hospital Oxford University Hospitals' Trust GBR
Dr Jacob McKnight Tropical Medicine Oxford University, Nairobi KEN jacob.mcknight@ndm.ox.ac.uk

There are no publications listed for this DPhil project.