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Neonatal Nasogastric Tube Feeding In A Low-Resource African Setting – Using Ergonomics Methods To Explore Quality And Safety Issues In Task Sharing
Date Posted: 26/Nov/2018
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.
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.
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.
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.
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, 6, 7].
Task shifting/sharing has been proposed as an approach for addressing health workforce shortages [8, 9, 10, 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, 14, 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, 26, 27].
Task analysis
Quality and safety
Nasogastric tube feeding
By Gregory B. Omondi, George Serem, Nancy Abuya, David Gathara, Neville A. Stanton, Dorothy Agedo, Mike English and Georgina A. V. Murphy
Source: BMC Nursing 201817:46©  The Author(s). 2018
Received: 30 May 2018 Accepted: 31 October 2018 Published: 16 November 2018

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