Nurses’ knowledge, perceived challenges, and recommended solutions regarding premature infant care: A mixed method study in the referral and tertiary hospitals in Dar es salaam, Tanzania

Background There has been an increase in preterm birth of about 2% in a span of 14 years (2000–2014) mainly from Asia and Sub-Saharan Africa. Nursing care is very crucial and a lack of knowledge of health care providers is a contributing factor to morbidity and mortality. With the increasing number and investment of preterm infants towards attaining sustainable development goals (SDG) 3.2, nurses’ knowledge adequacy, challenges and solutions on their care needs to be affirmed. Methods A mixed method study was conducted between September 2020 to January 2021 in the neonatal units of four hospitals in Dar es Salaam. Self-administered structured questionnaire was used to assess adequacy of knowledge set at 50% or more for the three main domains 1) Essential newborn Care 2) Infection prevention and management 3) Special care and monitoring. A phenomenological design using a structured interview guide focused on challenges and recommended solutions in acquiring on-the- job training on the care of preterm infants. Quantitative data were analyzed using SPSS version 23 and qualitative data were thematically categorized. Results Out of 52 of nurses who participated and providing care to preterm infants; 48.1% came from a tertiary hospital, (84.6%) were females, only 28.8% aged more than 40 years and 23.1% had less than one year of experience. Overall, 55.8% of the nurses had never received on job training. Adequate knowledge among nurses was 94% on essential newborn care, 80.8% on infection prevention and management and 36.5% on special care and monitoring of preterm infants. Generally, immediate actions of helping baby breath (HBB) and cord care scored poorest. Components on special care and monitoring which had lowest scores included blood glucose monitoring, temperature monitoring and acceptable daily weight gain. Being more than 41 years old, a female nurse and working in the neonatal unit for at least 1–3 years were more likely to determine adequacy of knowledge on infection prevention and management. Lack of schedule and ways to identify those who require training were among the challenges mentioned in the focus group discussion. Conclusion The findings demonstrate an urgent need of instilling knowledge, skills and competences among nurses providing preterm care in our hospitals. Most nurses had not attended training on the care of premature infant. Special care and monitoring were most poorly performed. The recommended solutions included continuous medical education (CME) for all nurses through hospital and government commitment and encourage mentorship within and between hospitals. Nurses who are female, older than 41 years and those with 1 to 3 years of experience should be considered when planning for CME and mentorship program on infection prevention and management.


Abstract:
Background There has been an increase in preterm birth of about 2% in a span of 14 years (20002014) mainly from Asia and Sub-Saharan Africa. Nursing care is very crucial in these vulnerable infants and a lack of knowledge of health care providers is a contributing factor to morbidity and mortality. With the increase of preterm births, nurses' knowledge adequacy, challenges and solutions on their care needs to be affirmed. Objective Aim of the study was to assess the nurses' knowledge, its challenges and solutions on the care of premature infants. Material and Methodology A cross sectional study was conducted to determine adequacy of nurses' knowledge on the care of premature infants and phenomenological study design using focus group discussions explored on the perceived challenges and solutions in acquiring on job training. Adequacy of knowledge was set at correct response of 50% or more on each domain. Quantitative data were analyzed using SPSS Version 23 and qualitative data were thematically categorized and themes derived. Results 55.8% of the nurses had never received on job training. Adequate knowledge among nurses was 94% in essential newborn care, 80.8% in infection prevention and management and 36.5% on special care and monitoring. Being more than 41 years old, a female nurse and working in the neonatal unit for at least 1-3 years were more likely to determine adequacy of knowledge in infection prevention and management. The main challenge in acquiring knowledge was lack of scheduled on job training. Solution recommended was to increase number of trainings. Conclusion Most nurses had not attended training on the care of premature infant. Special care and monitoring was most poorly performed. One of the major challenge faced is not being able to attend training due to poor scheduling and the solution to this is have frequent trainings Recommendations: Training should be conducted on special care and monitoring of premature infants. Nurses who were female, older than 41 years and those with 1 to 3 years of experience should be considered when planning for mentorship program on infection prevention and management.

Introduction
Premature infants are prone to complications like respiratory distress syndrome and infection.
These are one of the main causes of mortality among these infants (1).
Approximately 1 million out of 15 million born prematurely globally die each year due to complications associated with preterm birth (2) With preterm birth rates on the rise (2)  Some of the factors linked to inadequate care provided is health worker shortages which is compounded by a lack of specific knowledge and competencies (4) In Northern Tanzania, prematurity was the most common cause of mortality in low birth weight infants (5) but causes of these mortality was not determined including quality of care.
There is a link between adequate care provided in relation to adequate knowledge among health care providers. Nurses are the backbone care providers for these infants their knowledge needs to be ascertained.
The main aim of this study was to assess nurses' knowledge on the care of premature infants in 3 main domains, essential newborn care, infection prevention and management and special care and monitoring. This study also aimed at Determining factors associated with their knowledge.
Further exploring their challenges and solutions in acquiring this knowledge was of importance. Study population were all nurses who worked in the neonatal unit in these hospitals and those that specifically took part in caring for these premature infants.

Methodology
The study was conducted between September 2020 to January 2021

Quantitative study design
Sample size was acquired using kish leslie formula with 69% proportion of nurses with adequate knowledge on preterm care then using formula for finite population using population size we got 52.
Those excluded from the study are nurses who declined consent to participate. Data was collected using a self-administered questionnaire (S1) with the tool adopted from a study done in Masindi Uganda (6) which later modified using the Tanzanian Neonatal national guideline of 2019. A pilot was done and questionnaire corrected.
With the assistance of a selected nurse in each respective hospital, consecutive sampling was done until sample size was attained.
Data was entered and cleaned in SPSS Version 23. The dependent variables were knowledge on three main domains: 1. Essential newborn care 2. Infection prevention and management and 3.
Special care and monitoring. The independent variables were sociodemographic factors (age, gender, cadre), institutional factors (either working in the regional hospital or the national hospital), level of education, years of experience, and when was the last training/workshops on preterm care attended. Frequency tables were generated to determine the social demographic distribution of the nurses. Ranges were generated in the variables of age and years of experience.
The questions were computed and each question was graded as 1 and 0 and dichotomized as correct and incorrect responses respectively. For each of the themes, nurses were judged to have adequate knowledge if they responded correctly more than 50% of the questions in each domain.
Chi-square or Fischer's test p-value was used for the categorical variables against adequate and inadequate knowledge in each domain to determine association factors and any p-value of < 0.05 in logistic regression was determined as statistically significant in the association of nurses' knowledge in the care of preterm newborns.

Qualitative study design
Focus group discussions (FGD) were done after the completion of the quantitative data collection.
Nurses eligible for the FGD were those with experience of a year and more in the neonatal unit caring for premature infants. Purposive-homogenous sampling was done. The number of FGD was held based on saturation attainment. The aim was to conduct FGD in both the national hospital and regional hospital in order to get their experiences based on the 2 different levels of hospital. From the regional hospital, the hospital with most nurses with inadequate knowledge in special care and monitoring was selected. Two FDG were done, one was conducted in Temeke regional referral hospital and the other at MNH, Upanga with a total of 6 participants in each FGD.
Interview guide was adapted from a study by Campbell et al (7) then modified to suit the objectives of this study (S2) Recordings were transcribed and with the assistance of an expert in qualitative data analysis, the transcribed notes were read several times to determine codes using the codebook created. The    Knowledge on special care and monitoring provided to the premature infants was poorly responded in the following questions; 19% knew how to do blood glucose monitoring within the first 24 hours after delivery, temperature monitoring in the preterm newborn with less than 1500 g weight with 25% of the nurses having a correct response and Only 29% of the nurses knew the acceptable daily weight gain. (Fig 3)

General experience in acquiring knowledge
The nurses felt that there is need to know more about how to use the equipment at work.
"…knowledge that we need most is how to operate the machines (i.e. concentrator) that are brought. We are not taught how to use them. They just show us the parts.
The only thing we understand is when it doesn't bubble but we don't know how to operate them…" (P2 Temeke RRH) Main source of knowledge is through learning from one another.
"…We usually hold CME whereby one is assigned a topic based on standard operating procedures (SOP) or guideline to teach each other in our departments…" (P2 MNH, Upanga)

Perceived challenges
While at work, both in the regional and national hospital, lack of equipment/ resources was common.
"…For instance, when a newborn is brought in sick you will find that one bed can have two or even three or even four babies…" (P2 Temeke RRH) "…in these coming months of January and February we expect an increase in delivery of newborns and with the understaffing issue at hand, it becomes a big challenge …" (P1 MNH, Upanga) While acquiring knowledge, the selection process was thought to be an obstacle.
"…When it comes to deciding who goes for training, it's the task of the in-charge nurse of the ward. But the issue isn't with just the in-charge nurse, the issue is the number of nurses that could be released to go for training…" (P2 MNH, Upanga)

Solutions to the perceived challenges
Those that are related to work, on job training for every newly employed staff was recommended.
"…Those who are new to the assigned ward either newly employed or just a volunteer or even a doctor, they should undergo an on job training on how to care for the preterms…" (P5 MNH, Upanga) When it came to improving knowledge, learning from other nurses was advocated in both the regional and national hospital "…Amongst the nurses at our workplaces can teach one another about something new they learned…"(P1 Temeke RRH)

Discussion Essential Newborn care
In our study most of the nurses (94%) had adequate knowledge in essential newborn care unlike the study done in Masindi Uganda whereby only 41.9% of nurses had adequate knowledge (6).
This would be explained by the fact that 45% of the nurses, which was the majority number from the study in Uganda, were mainly those from outpatient and did not do daily inpatient care for newborns. Overall in our study, there was low knowledge on step wise management of help baby breath (HBB) algorithm which was consistent in the study done in Uganda where 21.9% of the nurses had the knowledge (6). In our study 55.8% of the nurses had also not had the privilege to attend any training on premature infant care due to the COVID pandemic prohibition of social gatherings. This would explain the low level of knowledge in HBB algorithm which is usually provided through training by CCBRT every six months. All newborns at birth need simple care which includes the help baby breath protocol which is sufficient for 80-90 % of the time when done appropriately.

Infection Prevention and Management
80.8% of the nurses had adequate knowledge on infection prevention and management in our study compared to the study from Uganda, 13.3% (6). Umbilical cord care by ensuring the use of a clean blade when cutting the cord as means of prevention of infection was the most poorly answered question in this domain. Whereas in the study done in Uganda this similar question had a better response with 72.1% having a correct response (6). While the study from Ethiopia, 61% of the nurses had a correct response (8). In a cross-sectional study with an observational component including 6 sub-Saharan African countries including Tanzania showed that 94% of the health care workers used a clean blade to cut the cord (9). Despite cord care having the poorest response, the practiced care is known by many health care workers. In our study the poor response might be explained by the fact that initial cord care, which was what the question was assessing, is provided by labor ward nurses and the midwife. In our study the nurses who participated were mainly neonatal nurses, who didn't practice daily initial cord care

Special Care and Monitoring
In our study, 36.5% of the nurses had adequate knowledge of special care and monitoring. While in a cross-sectional observational study done in Pakistan, 46%-54% of the nurses in the neonatal unit performed vital signs monitoring as required (10). This study didn't assess knowledge directly like in our study so comparability with our study is questionable. The results from our study would be explained by the fact that nursing staff ratio to number of infants is low. Regular and scheduled monitoring becomes a challenge when few nurses are available to provide care. Vital signs monitoring in neonates is the most integral part of their care whereby in modern medicine, continuous vital signs monitoring is being preferred instead of intermittent monitoring (11). It is known that trends in vital signs can predict some of the complications that the preterm newborns are at risk of such as sepsis, NEC, brain injury, BPD, and even mortality. This emphasizes the importance of constant monitoring of vital signs.
Among the poorly answered questions was the monitoring of blood glucose with 19.2% of the nurses having correct responses. This is very crucial in the management of premature infants because impaired glucose control in very preterm newborns has been associated with an increase in morbidity, poor neurologic outcome, and even mortality. This has enabled studies done to compare continuous glucose monitoring which was found to be better in terms of glucose control than intermittent monitoring (12). Findings in our study could be due to the inability to frequently monitor random blood glucose due to inadequate supply of strips. This limits the practice of frequent monitoring.
Monitoring of temperature in those premature infants with weight less than 1500g was not well known with only 25% of the nurses having the correct response. Lack of adequate nursing staff might contribute to lack of proper monitoring. This might also be due to the availability of continuous temperature monitoring for premature infants placed on a servo machine. This might not be the case for every premature infant admitted to the neonatal unit. Only the high-risk premature infants are placed under the servo machine and every preterm irrespective of being high risk or not needs monitoring. Newborns who are at risk of hypothermia are those with very low weight and those with low gestational age at the time of birth. This has a detrimental effect on their neurodevelopment or even leads to death (13). The importance of proper temperature monitoring in these premature infants and the need to improve knowledge should be prioritized.
About 28.1% of the nurses knew acceptable daily weight gain of the premature infant despite being a daily routine practice done in the neonatal unit. Weight monitoring is crucial since it is an indicator of the energy intake and expenditure (internal heat loss through basal metabolism and physical activity) and enables one to decide on how to intervene when there isn't adequate weight gain i.e. the use of parenteral nutrition. Poor growth during admission in the neonatal unit has been linked to poor neurodevelopmental outcomes (14). So there is a need to emphasize the proper daily weight monitoring to ensure proper action is put in place.

Difference in knowledge among the nurses
Nurses who were older than 41 years of age were 2.3 times more likely to have adequate knowledge on infection prevention and management compared to those who were less than 30 years old. This was similar to a study done in Mosul whereby nurses aged 40-49 years had more knowledge on general care of premature infants compared to the younger nurses (15).
Nurses at the national level were 0.35 less likely to have adequate knowledge in infection management compared to those in regional referral hospitals. The study done in Uganda showed those who work on a higher level of the hospital were 1.1 times more likely to have adequate knowledge in infection management (6). This was inconsistent with our study where more nurses from the regional hospital had adequate knowledge. The nurses in the regional hospitals that participated in this study did care for both premature and term infants so they were aware of proper cord care which was the most poorly responded question in the national hospital. Prevalence of cord sepsis among premature infants is not known currently. This cannot be linked with the knowledge the nurses from the national hospital have in respect to cord care in premature infants.
Females nurses were 3.2 times more likely to have adequate knowledge in infection prevention and management compared to male nurses. This could be explained by the high numbers of female nursing staff compared to the males.
Nurses that worked for 1-3 years were 2 times more likely to have adequate knowledge in infection prevention and management compared to those with more years of experience. This could also be explained by the fact that the nurses with less years of experience in neonatal ward were updated on current cord care available since they were recently from school.

Experience, challenges and solutions in acquiring knowledge among nurses
Based on the qualitative part of the study, the general experience in acquiring knowledge is based on their learning needs when caring for the premature infants and the sources of knowledge available for them. The learning needs stated by the nurses is knowing how to operate the equipment at work and being up to date on the management of premature infants. Their main source of knowledge while at work was fellow nurses and doctors.
These findings were similar to those found in the Indian study (7). When considering about training, perhaps in house mentorship should be considered and strengthened in the neonatal ward.
This will contribute to better care for these infants (18).
In our study, challenges that were perceived by the nurses were those related to work which included understaffing, work overload, and lack of equipment at work. This was consistent with the study done in India by Campbell et al. (7). These factors affect the overall care the preterm newborns receive.
Challenges perceived while acquiring knowledge included not having a standard selection process for those attending training, this being similar to a study by Campbell et al (7). In the quantitative data from this study most of the nurses had not attended any training on premature infant care and this could be explained by the poor selection process and lack of on job training plan.
As part of the solution to the challenges faced, it was suggested that senior nurses and doctors should be tasked to teach other nurses. Team work among health care workers has been seen as an integral part in providing care (16). In terms of challenges faced while working some of the solutions implicated were the availability of on job training for every new employee and to have a training schedule that will allow all nurses to attend. According to WHO's a new roadmap on human resources to ensure all newborns survive and thrive, on-the-job training has been suggested as one of the strategies for improvement (17). All these findings were similar to the study by Campbell et al. (7). This study was done before the implementation of the Newborn Essential Solutions and Technologies (NEST 360) program in Dar es Salam which is currently in place to ensure training on how to manage newborns using the current technology not forgetting the basic care.

Strength of the study
Using quantitative data, we captured the inadequate knowledge in special care and monitoring while the added component of the qualitative part of the study was able to highlight challenges in acquiring knowledge and suggested solutions to these challenges.

Study limitations
1. In the public health center in Dar es Salam only the regional and national hospitals had neonatal intensive care units. The number of employed nurses working in the NICU from all 4 hospitals was approximately 54 at the time of the study. The sample size is too small with lack of a standard tool to assess knowledge, so enable the generalizability of the data becomes a challenge.

2.
A study that has both cross sectional and observational component should be done based on assessing premature infant care to ascertain adequate care provided rather than making this assumption with only assessment of knowledge.
3. After FGD, transcripts were not returned to participants for comments and correction. The participants of the FGD were not able to provide feedback on the transcripts for verifying accuracy and clarification of results. There was a possibility of missed out information.
Although the practice of verification of transcripts is still questionable and might not add any value to the data.