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

Neonatal mortality has fallen more slowly than child mortality in the past twenty years in many low- and middle-income countries (LMICs) due to challenges with the provision of high quality care given the resource limited nature of such settings [1]. To improve neonatal survival, the provision of high quality care to small and sick is must improve [2]. Assisted feeding, often by nasogastric tube (NGT), is one of a set of interventions that form an essential package of facility based services. When fully implemented, feeding (oral or nasogastric) has the potential to substantially reduce neonatal mortality and morbidity, especially for low-birth-weight neonates [3]. NGT feeding is typically the formal responsibility of nurses. It is a time-consuming task that may need to be performed every two to three hours for small and sick babies [4]. In resource-limited settings, where the nursing workforce is severely constrained, components of the NGT feeding task may be only partly performed or completely missed, negatively impacting survival and early post-natal growth [5‐7].

Task shifting/sharing has been proposed as an approach for addressing health workforce shortages [8‐11]. However, despite the recent launch of task-sharing policies in Kenya, there are no specific guidelines that encompass task sharing between nurses and non-professional cadres in newborn units and no recognised ‘healthcare assistants’ within Kenyan public health facilities [12]. Anecdotal information suggests however, that nurses informally share tasks with untrained casual workers and babies’ family members. The safety and quality of care provided under such conditions is a major concern [13‐15]. How key neonatal nursing interventions are performed and shared, which components may be missed, and what safety issues need to be considered when performing and sharing tasks, remain undescribed in such settings.

Given the importance of NGT feeding, its time-consuming nature and the potential risk of serious consequences (for example aspiration) if incorrectly performed, it is imperative to consider safety in cases where it is shared. Our aim was, therefore, to explore this task in detail, gain preliminary information on how it is shared in Kenyan public hospitals and examine potential risks. This will provide preliminary data to conduct a larger study with a larger sample. Knowledge gained will inform discussions on whether and how this task could be formally and safely shared. We employed Ergonomics (or human factors and ergonomics, HFE) methods often helpful in unpacking complexities in the dynamics of task implementation processes.

The Human Factors and Ergonomics Society defines Ergonomics as “…the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.” [16] HFE methods have been traditionally used to improve quality and eliminate errors in various industries predominantly the aviation, nuclear, manufacturing and oil and gas industries [17]. In healthcare, HFE has the potential to make work practices simpler and therefore have a direct impact on the quality of care provided [18]. A number of studies have looked at how HFE methods can be used to gain insights into the dynamic nature of patient care, improve patient safety, analyse problems to generate solutions, calculate/predict risk levels as well as design solutions to mitigate medication administration errors. However, others argue that HFE methods are currently underutilised in healthcare in exploring issues of quality and safety [15, 19, 20].

In this study, we use Hierarchical Task Analysis (HTA) which is a flexible and structured technique to provide an exhaustive description of tasks in a hierarchical manner [21], and the Systematic Human Error Reduction and Prediction Approach (SHERPA) to describe the errors that might occur in each step of the HTA, the consequences, probability and criticality of such errors, and the remedial steps to be taken to reduce them [21, 22]. Healthcare Failure Mode and Effects Analysis (HFMEA) is a similar method to HTA and SHERPA and has also been used to identify potential failures and their causes before future services are provided and/or to improve current services. While both methods have the ultimate goal of improving patient safety, HFMEA has been shown to have validity challenges [23, 24]. SHERPA’s reliability and validity is consistently high, ranging between 0.65–0.9 and 0.74–0.8, respectively, and higher than other human error identification techniques [25‐27].

Understanding how humans interact with elements of a system, such as technologies, is important in designing fully functional, effective and safe systems [16, 20]. Patient safety, in the healthcare setting, largely depends on carefully thought out ergonomics of the workplace processes implemented during care provision [32]. HFE, in the healthcare setting, has mostly focussed on the design of medical devices and other aspects of Information Technology for health to increase patient safety and reduce prevalence of medical errors [19, 33]. The focus of HFE in the healthcare is now shifting towards improving human wellbeing through identifying ways to improve work processes and reduce workloads, especially for already resource constrained settings such as infant inpatient settings in LMICs, and more so in Kenya [20]. In this paper we focus on the nursing aspect of care provision in inpatient neonatal care settings in Kenya.

Outcomes of inpatient care for small and sick infants are highly dependent on nursing care, with better outcomes correlated with low patient to nurse ratios [34]. Meeting recommended nurse to patient ratios is still a challenge in most low- and middle-income countries, including Kenya, leading to some tasks being informally shared with unskilled personnel and the infant’s mother. The nature of care required to improve patient outcomes in neonatal settings is intricate and time consuming. In this study, we explore the complexity of performing NGT feeding, one of the many key tasks that nurses do while providing care to small and sick infants in inpatient settings [35]. Reported sharing, supervision and risk levels of the 47 tasks in NGT feeding varied widely in this study, despite SMEs coming from fairly similar care settings serving the poor and this could be suggestive of differences in perception and practice.

If not undertaken correctly, NGT feeding can have many serious consequences [36]. However, the greatest risks lie during NGT insertion, a task that precedes NGT feeding. Perforations and incorrect placement of the NGT can occur [37]. The task of NGT insertion was recognised solely as a professional role by the SMEs, undertaken only by qualified and competent personnel and was not the focus of this study. Findings from this study indicated that ‘moderate risk’ was the highest level of risk assigned to tasks during NGT feeding. None of the tasks was deemed of ‘high risk’ by either the researchers or the SME, suggesting considerable consensus. The tasks identified as ‘medium risk’ can be targeted for specific training and/or supervision efforts to reduce risk and increase safety during NGT feeding.

We noted that sharing was mostly reported to be with the mothers. There is growing appreciation of the importance of involving family members and patients in care management, so called patient-family-centred care, as it positively influences neonatal care [38]. In high-income countries, this concept of care has developed over the years, placing parents/family members at the centre of care provision and promoting individualised and tailored health care services. Previous studies have shown that 80–95% of families prefer this kind of care, especially when teaching and discussion on the care of the infant occur at the bedside. [39] This highlights the health benefits of involving mothers or other family members in care of children, including neonates and has led to the development of recommendations on integrating patient-family-centred care by the American Academy of Paediatricians [40‐42]. We also noted considerable heterogeneity in how sharing was reported by the experts. There were significant differences in the proportion of tasks reported as shared with either the mother, casual or students, despite the experts coming from fairly similar settings. Similar observations were also noted for reported supervision and risk levels of tasks. These differences could be due to the subjective nature of the perceptions and practice of task sharing by each expert in their respective settings and shows a gap in terms of clear and practical guidelines on how sharing of tasks should be implemented and which specific tasks should be shared, especially in the neonatal care context. One expert, for example, reported not sharing any of the tasks with the students, despite students being present in this setting, while the other expert (from the same setting) shared a considerable amount of tasks with the students (31.9%). We observed that some nurses were uncomfortable with or strongly opinionated against task sharing with students or other unqualified staff. These nurses often held policy or teaching roles that were somewhat removed from the real and practical frontline challenges in delivering nursing care in the context of limited human resources for health, among other challenges [43]. Anecdotal evidence, from other studies we are conducting in similar settings, also suggests that nurses tend to maintain a distinctive identity and therefore wield authority as to whom tasks can be shared with in their settings. This could explain why some experts will share tasks with the mother and not the students or the casuals, hence the heterogeneity in reported sharing proportions with the students, mothers and casuals. This shows a need for practical guidelines for task sharing currently not addressed in Kenya’s task sharing policy [12].

The use of HTA and SHERPA revealed the value of the HFE approach in eliciting these differences in perceptions that have direct effects on the quality and safety of NGT feeding. The involvement of mothers and unskilled personnel such as casual workers, in the provision of care for sick infants through task-sharing may help in ensuring that most, if not all the care that the neonate requires is provided. Tasks considered to be low risk can be reassigned to lower cadre workers within the neonatal setting, while high/medium risk tasks can be performed by the nurses; potentially managing the high workload that nurses have, especially in resource constrained settings like Kenya. In addition, nurses may have more time to provide the much needed critical care often associated with high/medium risk tasks. Those tasks reassigned should also be supervised in such a way as to reduce, if not eliminate, risks for undesirable outcomes during their implementation by the lower cadre. Careful consideration is necessary to ensure that the additional supervision responsibility on the nurses’ part does not become counterproductive. A delicate balance should be upheld to ensure that safety and quality of care is not compromised. Task sharing has the potential to help mitigate the health worker force shortages in LMICs, however, if undertaken without proper measures to ensure safety and quality, patient outcomes might be undesirable due to the potential likelihood of provision of low quality of care by whom the task is shared with. Therefore, provisions for standardised and detailed guidelines on training and supervision must be made for safe task-sharing and family-patient-centred care. Ergonomics methods have demonstrated to be useful in unpacking and understanding tasks in a way that can be applied to training and supervision needs, while at the same time highlighting focus areas of potential risks [18, 19]. During the course of the research, a novel way of annotating the HTA to show the task sharing and supervision was developed. This shows the flexibility of the method in being easily adaptable for new analyses.

A very small proportion (8.5%) of the 47 NGT feeding tasks were reported as often missed by the majority of the SMEs in this study. Contrary to the commonly used missed care definition however, and while fully aware of the risk of incorrect implementation of NGT feeding tasks, the SMEs did not consider a task as missed if it was performed by unskilled persons (casuals or mothers). Therefore, despite NGT feeding being an important aspect of care for sick neonates, nurses may often, knowingly, miss parts of the process or delegate to unskilled personnel. This can have significant effects on the recovery time and outcome of the infant [29, 44, 45]. Missed nursing care for sick infants has also been reported in other settings and is often related to support and comfort care [44]. Similarly, in this study we found that screening the bed/cot for privacy, talking to the infant and thanking the infant/mother were some of the tasks related to psychosocial elements of care that were reported as often missed by majority of the SME members.

This study has both strengths and limitations. We used two small groups of SMEs to unpack the complex nature of NGT feeding. Engaging SMEs in discussions on the selected aspects of NGT feeding implementation showed that there was an established implicit understanding of the task. These experts were chosen based on their experience rather than aiming to have a representative sample of care providers in public sector hospitals. The use of SMEs and involvement of small groups of experts in ergonomics methods research is the norm and is valued due to its efficiency in enabling in-depth focus on specific performance issues [21, 22]. The sample size may not be sufficient and lacks power statistically with regard to the task sharing aspect of the study. Our aim for doing this, however, was to gain a preliminary understanding of the norms and practices of task sharing in the SMEs’ care settings, and as part of ongoing work to understand the tasks done by nurses to inform future work on task sharing and measuring the work done by nurses [46]. These findings should therefore be interpreted with caution. We plan, in the near future, to share findings from a larger study exploring task sharing in neonatal settings in different hospitals in Kenya using a larger sample size. SME discussions were conducted in groups, which may have led to biased responses of individual experts when reporting on norms within their facilities and convergence of opinions. Furthermore, the provision of two experts from each of the four facilities in SME2, suggests they should not be thought of as independent respondents. Nonetheless, we report high heterogeneity in responses from individual experts in sharing, supervision and risk levels for NGT feeding. Further exploring the origins of the observed heterogeneity would have provided a better explanation to the observations, we, however, did not do this. Almost twice as many tasks were reported as highly supervised as those deemed as of medium risks, whether this increased demand for supervision had implications on the nurses’ workload was not further explored. Some tasks, such as ‘Insert syringe to tip of NG tube’ and ‘Pour feed into the syringe’ under the sub-goal ‘Perform NGT feeding’ were reported as often missed by minority of the SMEs yet the subsequent tasks were reported as never missed by all SMEs. This introduces some ambiguity given that the tasks are performed in sequence. One cannot, for example, ‘Allow the feed to flow by gravity’ if they missed pouring the feed into the syringe in the first place. Some of the noted discrepancies can best be disambiguated through observations. Observational work is often used to complement HTA in ergonomics methods, we plan, in future detailed reports, to share findings from in-depth ethnographic and other methods to explore missed care in Kenya.

To our knowledge, this is the first application of HFE methods to neonatal care research and healthcare in a low-resource setting. A significant number of systems used to report patient safety dwell on analysis of adverse events after they occur, however, there is a shift to focus more on proactive and progressive systems that enable identification of system weaknesses before tragic outcomes and thus avoiding failure modes [47]. Among such methods include HFMEA and HTA/SHERPA. In this study however, we chose to use HTA and SHERPA given our expertise and experience with the methods and their flexibility in their implementation across different teams. HFE methods have previously been shown to be valuable in highlighting patient safety issues during care provision [15, 19, 20]. In our setting, local researchers and SMEs found the methods engaging and easy to grasp [27, 48]. The SMEs welcomed the use of HFE to better understand and articulate the complexity of tasks that hitherto had been a form of implicit knowledge in Kenya making it difficult to share tasks or have standards that comprehensively guide task sharing. This positive experience is contrary to previous reports that healthcare professionals usually have an initial scepticism for these methods [49].

Sharing tasks with lower cadre workers or even with a patient’s family in low-resourced healthcare settings may help ease the pressure of high workloads and nursing shortages. However, little is known about how task-sharing might impact safety and quality of care, particularly for neonatal patients where informal task-sharing seems common and not standardised. The novel use of HTA and SHERPA in this study to analyse NGT feeding in a low income neonatal setting revealed the value of these methods to describe the complexity and elicit quality and safety concerns in preforming routine nursing tasks. Our findings could lead to targeted, evidence-based local policy on reorganisation of tasks and detailed training and standard guidance for NGT feeding in neonatal care in LMIC as part of efforts to improve quality of care and reduce neonatal mortality. More widely HTA could help to formalise approaches to task sharing as well as identifying the training needs for non-professional carers, whereas SHERPA could help to assess the risks associated with sharing tasks. Together, these methods offer a way to help improve mortality rates in low-resource intensive settings.