|Year : 2018 | Volume
| Issue : 5 | Page : 412-419
Quality of service and associated factors in neonatal intensive care unit at Debre Berhan Referral hospital, Debre Berhan Ethiopia: A cross sectional study
Wassie Negash Mekonnen1, Alemnesh Mekuanint Desalegn2
1 Department of Public Health, College of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
2 Department of Nursing, College of Health Science, Debre Berhan University, Debre Berhan, Ethiopia
|Date of Web Publication||5-Sep-2018|
Wassie Negash Mekonnen
Department of Public Health, College of Health Science, Debre Berhan University, Debre Berhan
Source of Support: None, Conflict of Interest: None
Background: Neonatal Intensive Care Units (NICUs) are important units to maintain the health of newborns in hospitals. However, there are complaints about the quality of care in the NICU. Objective: The aim of this study was to assess the quality of services and associated factors in the NICU at Debre Berhan Referral Hospital. Materials and Methods: We conducted a cross-sectional study from January to June 2017 on a sample of 129 neonates. The data were collected through 5-point Likert scale questionnaire and observation and analyzed using SPSS version 20. In the meantime, bivariate and multivariate logistic regression was computed. We considered the level P < 0.05 statistically significant. Results: The maternal mean satisfaction score in the NICU was 77%. Majority (89%) of the respondents were satisfied with compassionate care and 85.5% with cleanliness of the compound. Half of the respondents, i.e., 53.5%, were dissatisfied with waiting time for card and test results. Equipment and drugs were not fulfilled in the NICU ward. The odds ratio of maternal satisfaction was higher among mothers who were satisfied with complaint procedures (adjusted odds ratio [AOR] = 13.8, 95% confidential interval [CI]: 4.48–42.38), those who were allowed to have visitors (AOR = 17.04, 95% CI: 2.83–102.4), and those who were satisfied with functionality and cleanness of toilet (AOR = 9.59, 95% CI: 1.19–76.87). Conclusions and Recommendations: The over all levels of maternal satisfaction were suboptimal. Mothers were highly satisfied with medication availability and cleanness of the hospital compound. Being satisfied with complaint procedure, allowed to have visitors, and satisfied with functionality and cleanness of toilet were the independent predictors.
Keywords: Debre Berhan Referral Hospital, Maternal satisfaction, Neonatal Intensive Care Unit, quality of service
|How to cite this article:|
Mekonnen WN, Desalegn AM. Quality of service and associated factors in neonatal intensive care unit at Debre Berhan Referral hospital, Debre Berhan Ethiopia: A cross sectional study. Med J DY Patil Vidyapeeth 2018;11:412-9
|How to cite this URL:|
Mekonnen WN, Desalegn AM. Quality of service and associated factors in neonatal intensive care unit at Debre Berhan Referral hospital, Debre Berhan Ethiopia: A cross sectional study. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Nov 30];11:412-9. Available from: https://www.mjdrdypv.org/text.asp?2018/11/5/412/240365
| Introduction|| |
Globally, every year, around 3.3 million babies die within their 1st month of life, and the proportion of under-five child deaths that are now in the neonatal period (the first 28 days of life) has increased in all regions of the world and is currently estimated at 41%. Of these deaths, over 90% occur in low- and middle-income countries. Moreover, one-third of all neonatal deaths occur in Sub-Saharan Africa. From 20 countries in the world with the highest risk of neonatal death, 75% are in Africa.
In 2009, the Federal Ministry of Health (FMOH) of Ethiopia with support of the United Nations International Children Economic Fund and with technical assistance from Ethiopian Pediatric Society piloted the newborn corner in 100 health facilities (50 health centers and 50 hospitals) in the country. In addition to these, various approaches to quality assessment and quality improvement of the Neonatal Intensive Care Unit (NICU) services have been proposed over time. From various approaches, many of them focus on the availability of essential infrastructure, equipment, written procedures and treatment protocols. Evidence shows that even when all the necessary structural components are available, the quality of care may still be poor unless appropriate use of available resources to ensure effective case management., Defining what is truly meant by quality health care is controversial. In 1966, Donabedian introduced the conceptualization of quality components that has formed the basis of many, if not most, modern models of health-care quality. He described quality as having three principal components: structure, process, and outcome. Structure refers to the attributes of the settings in which care is provided. It includes such elements as resources, staff, and equipment. Process covers all aspects of delivering care and is related to the interaction within and between practitioners and patients. Outcome focuses on the end result or the effect of the care provided., Many factors could be connected to the poor quality of NICUs. One of these is lack of support, or a delayed response, from the authorities in the provision of essential health commodities for the NICU. Sometimes, the hospital management appeared not to recognize the NICU as a separate unit from pediatric services and denied the necessary and critical support it needs. In addition, lack of continuous upgrading or updating of knowledge and skill in the management of newborn care since the initial training together with workload of the nurses is mainly due to shortage of trained NICU nurses added with shortage of equipment and supplies., Environmental conditions are directly related to patient safety, health, and comfort. A clean, hygienic environment with continuous supplies of clean water and electricity, good sanitation, and safe waste disposal are the basis of appropriate care of patients, for carrying out all procedures and interventions and for controlling infection.
The impact of light and noise on health and well-being has been a major focus of the study for many researchers in the field of neonatal studies.,
Each NICU should have incubator or unit with radiant heating, ventilator and neonatal continuous positive air pressure (CPAP) driver with humidifier, syringe/infusion pumps, resuscitation, blood gas analysis, phototherapy, noninvasive blood pressure measurement, transillumination by cold light, portable X-rays, ultrasound scanning, expression of breast milk, and transport (including mechanical ventilation), and also, there must also be access to a 24-h laboratory service orientated to neonatal service needs. Likewise, NICU should have 1:1 to 1:2 nurse-to-patient ration. According to Donabedian quality measurement model, the outcome components are very crucial. Early outcomes are associated with clients' satisfaction. In regard to the study conducted in Gondar, 67.1% of the study participants were satisfied with the overall nursing care services. Moreover, in the study conducted in Jimma University Specialized Hospital, out of 40 admitted patients included in the study, 55% were satisfied with the food services of the hospital, 60% were dissatisfied with the visiting hours of the hospital, and about 39% of respondents said that they were not satisfied with the information provision about the hospital and service processes. In a study conducted in Tanzania on the quality of neonatal health care, 90.6% of mothers were not satisfied with the amount of time spent by the doctors in seeing their babies. Despite the availability of these pieces of information related with quality of NICU services, there is no enough published study on quality of care provided by NICU so far, as to the researchers' knowledge. Hence, this study assessed the quality of care provided at the NICU in Debre Berhan Referral Hospital (DBRH) with regard to various components of structure, process, and outcome domains within the context of quality.
| Materials and Methods|| |
Study design, study period, and study area
Institutional-based cross-sectional study design was undertaken from January to June 2017. In addition, the study was conducted at DBRH, which is found in Debre Berhan Town, Ethiopia. The Hospital is classified into different departments, NICU being run under the Department of Pediatrics. The neonatal ward is reported to be able to accommodate as many as 20 patients. Average census is 2–6 NICU patients daily and 50–70 patients/month and some more. There are, on average, 600–840 annual admissions. The NICU is covered by one pediatrician, one general practitioner, and 15 nurses, within this five being trained nurses. Currently, the unit is one of the NICUs in the country.
All mothers of the neonates admitted to DBRH.
Selected mothers of the neonates admitted to the NICU at DBRH during the study periods.
The study included mothers of neonates who were admitted to the NICU and stayed for >2 days.
Sample size determination and sampling procedures
The actual sample size for the study was computed using single-population proportion formula. With an assumption of 50% of mothers of the neonates been satisfied with quality of services in NICU, 5% marginal error, and 95% confidence level, the sample size calculated was 384.16; after adjusting these for sample size total population, the final sample size was 129.
The source population is <10,000, that is, we had only 180 neonates within 3 months; by taking the previous year data and this year monthly average patient flow. Due to this reason, we adjusted the calculated sample size using correction formula and adding 5% nonresponse rates:
n = n
1 + n
1 + 384
By adding 5% nonresponse rates, n = 123 + 6, i.e., n = 129.
Sampling and data collection technique
The researchers employed convenience sampling technique. Mothers whose neonates admitted in the NICU were interviewed successively in all working time. In this way, the calculated samples were achieved in the time boundary. In the meantime, all mothers were interviewed during discharge. Further, the researchers used structured questionnaire to collect relevant data. Reviewing related literatures was a very important part of the process in this regard. Five nursing students were actively participated to collect the pertinent data.
Data processing and analysis
The collected data were checked for completeness, accuracy consistency, and clarity first and then entered into a computer using Epi Data 3.1 and transferred to SPSS version 20 (IBM, Armonk, NY, USA). After completion of data entry, it was cleaned before analysis. Then, the survey data were analyzed using frequency, mean, median, proportion, and standard deviation. Logistic regression analysis was carried out. Bivariate analyses were done to see the presence of associations between independent and dependent variables. Then, to control confounding variables, multivariate logistic regression analyses were carried out. Odds ratio was used in determining the association between variables. During the analysis, P < 0.05 at 95% level was considered as there is significant association between variables.
| Results|| |
Sociodemographic characteristics of the study population
A total of 127 participants were participated on the study with a response rate of 98.4%. Among these, 111 (87.4%) of the mothers were married. The mean age of the respondents was 28.14 (+5.574) years. About 53(41.7%) of respondents had first visit to the hospital and 74(58.3%) had two or more visits [Table 1].
|Table 1: Sociodemographic characteristics of the study participants in Neonatal Intensive Care Unit: Debre Berhan Referral Hospital, Debre Berhan, Ethiopia, 2017 (n=1127)|
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Maternal satisfaction with services
Majority of respondents, 106 (83.4%), were either satisfied or very satisfied by cleanness of NICU ward. Those participants who were both very satisfied and satisfied with staff consent before the onset of any clinical procedure were 94 (74%). Among all respondents, 100 (78.8%) were either very satisfied or satisfied by their baby health progress. About half of the respondents 64 (50.4%) were satisfied or very satisfied with knowing how and where to present their complaints.
Nearly two-third of the respondents 81 (63.7%) were either very satisfied or satisfied by cleanness and functionality of toilet and shower. From those who got the laboratory services in the hospital, 115 (91.2%) of the respondents were either very satisfied or satisfied. About 113 (89%) of the respondents were either very satisfied or satisfied with availability of prescribed medications in hospital pharmacy. Those respondents 93 (73.3%) were either satisfied or very satisfied by ward quietness. About two-third of respondents 86 (67.7%) were either very satisfied or satisfied by NICU ward ventilation. By clear explanations of tests, procedures, and treatments, mothers who either very satisfied or satisfied were 88 (69.3%). About one-third of respondents 49 (38.6%) were either very dissatisfied or dissatisfied by adequate treatment for child [Table 2].
|Table 2: Maternal satisfaction with services given in Neonatal Intensive Care Unit: Debre Berhan Referral Hospital, 2017 (n=127)|
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The overall maternal satisfaction
The maternal mean satisfaction score with services given in the NICU ward was 3.8 in 5-Likert scale, which is equivalent to 77%. Nearly half of the respondents, 59 (46.4%), were both very dissatisfied and dissatisfied to get necessary information using direction indicators. Among respondents, 68 (53.5%) mothers were both very dissatisfied and dissatisfied with waiting time for card and test results.
About 26 (20.5%) of the mothers were either dissatisfied or very dissatisfied with the functionality and cleanness of shower and toilet. A large number of respondents 113 (89%) were either very satisfied or satisfied with staff respect and compassion. Nearly one-third of the respondents 39 (30.7%) were either very dissatisfied or dissatisfied with water and food provided by the hospital [Table 3].
|Table 3: Overall maternal satisfaction in Neonatal Intensive Care Unit: Debre Berhan Referral Hospital, 2017 (n=127)|
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Structural components of quality of service (associated with inputs)
NICU ward had eight rooms. these rooms used for various purposes like. for isolation, for Kangaroo mother care, and for mothers waiting. There were two rooms with a bath and a toilet for health provider and neonates' care-taker. The remaining rooms consist of coordinator office and duty rooms for nurses.
NICU had three incubators, four phototherapies, four warmers, 15 cylinders for oxygen, and one concentrator oxygen check available. However, the ward does not have pulse oximetry, exchange transfusion, umbilical catheter, tray dressing set, stand infusion double hook, single head high intensive phototherapy unit, vinyl-coated 1.5 m measuring tape, examination light mobile, and CPAP. Generally, the NICU ward fulfills only 15 (65.2%) of equipment out of 23 which are considered as standard by FMOH. Regarding with pharmacy service and medicine availability, 72.2% of medicine were available in the hospital pharmacy. Similarly, laboratory tests should be available as the Ethiopian Ministry of Health Standards; only 81% of the tests were available in the NICU. However, laboratory tests such as blood chemistry and culture and sensitivity tests of any fluid were not available in the laboratory of the hospital.
The other important resources in the NICU are human resources. Associated with it, there were one pediatrician, two general practitioners, and 15 nurses in the NICU (DBRH).
Factors associated with maternal satisfaction at the Neonatal Intensive Care Unit ward, Debre Berhan Referral Hospital
In binary logistic regression analysis, about 36 variables were tested for the presence of association with maternal satisfaction. From these variables, being asked consent and permission before any clinical procedure, access of ways to presenting complaints to concerned bodies, being allowed to have visitors, functionality and cleanness of toilet, quietness of the ward, clear explanation about procedures and medications, perceived adequate treatment obtained, and information gained easily using indicator were found to be significantly associated with maternal satisfaction with services in the NICU ward at P < 0.05. In our study, there is no significant association between demographic characteristics and mothers' satisfaction.
To control confounding variable which have P < 0.25 in binary logistic regression analysis were entered into multiple logistic regression analysis. Among these variables, access of ways to presenting complaints to concerned bodies, being allowed to have visitors, functionality and cleanness of toilet, quietness of the ward, clear explanation about procedures and medications, and information gain easily using indicator were the independent predictors of maternal satisfaction with services in the NICU ward at P < 0.05. From these variables, those who were satisfied with complaint procedures were 13.8 times more likely satisfied with services given in the NICU than those who were not satisfied complaint procedures (adjusted odds ratio [AOR] = 13.8, 95% confidential interval [CI]: 4.48–42.38).
Those who were satisfied with being allowed to have visitors were more likely satisfied with services given in the NICU than their counterparts (AOR = 17.04, 95% CI: 2.83–102.4). Similarly, those who were satisfied with functionality and cleanness of toilet were more satisfied (AOR = 9.59, 95% CI: 1.19–76.87). In addition, those who were satisfied with quietness of the ward were more likely satisfied with the services given in the NICU ward as compared to who were not satisfied with quietness of the ward (AOR = 10.31, 95%, CI: 1.15–221.9). Moreover, those who were satisfied with information gained easily using singe indicator were more likely satisfied with the services given in the NICU than those who were not satisfied with information gained easily using indicator (AOR = 5.16, 95%, CI: 1.51–17.6) [Table 4].
|Table 4: Association between variables with maternal satisfaction in Neonatal Intensive Care Unit: Debre Berhan Referral Hospital, 2017|
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| Discussion|| |
This study was conducted to assess the quality of services and associated factors within the NICU at DBRH. The study discovered that the maternal mean satisfaction score with services given in NICU was 3.8 in 5-Likert scale, which is equivalent to 77%. This result is higher than the study conducted at Wolaita Sodo University Teaching Hospital, Ethiopia (54.2%), at Gondar University Teaching Hospital, Ethiopia (67.1%), and at Jimma University Specialized Hospital, Ethiopia (67.2%).,, This difference might be due to the difference of clients: A study conducted at Wolaita Sodo University was in outpatient department (OPD). Likewise, studies conducted at Jimma and at Gondar were in inpatients in the medical pediatric ward, which affect the clients' expectation about their outcome. The patients at medical and pediatric ward are not as critical as the patients at NICU. It might also be due to the difference in data analysis; in our study, data were treated as continuous data and reported as mean score. However, others considered the data as categorical which implies that patients with neutral feeling were considered as not satisfied. It could also be due to time variations; the study in Jimma, Wolaita Sodo, and Gondar were done 2 years back. Hence, the level qualities of services are time sensitive.
Our study was in line (77.9%) with other study conducted in Jimma clients' satisfaction with health service deliveries at Jimma University Specialized Hospital.
Our study showed that majority of the respondents, 106 (83.4%), either satisfied or very satisfied by cleanness of NICU ward. This is higher than a study conducted in OPD at Wolaita Sodo Teaching Hospital (49.2%) and at Jimma University Specialized Hospital (76.7%)., This difference might be due to good efforts made in DBRH and also might be due to the time difference (the study at Wolaita Sodo Teaching Hospital was done 2 years back, or it might be due to low patient flow in the NICU as compared to other wards).
In this study, 113 (89%) of respondents were either very satisfied or satisfied with the availability of prescribed medication in hospital pharmacy. This is better than the study conducted in Wolaita Sodo (63.7%) and Jimma (55%)., This difference might be due to the fact that in NICU, there are separate pharmacies and supplies as compared to other wards.
This study showed that 88 (69.3%) of the mothers were either very satisfied or satisfied, by clear explanations of tests, procedures, and treatments. The finding in the present study is slightly higher than the one conducted in Wolaita Sodo. With regard to the instructions given by the doctor on investigations/prescriptions, 64.8% responded as “satisfied.” This difference might be because there are improved services in DBRH.
In this study, access of ways to presenting complaint procedures (AOR = 13.8, 95% CI: 4.48–42.38), being allowed to have visitors (AOR = 17.0, 95% CI: 2.83–102.4), functionality and cleanness of toilet (AOR = 9.5, 95%, CI: 1.19–76.87), quietness of the ward (AOR = 10.3, 95%, CI: 1.15–221.9), clear explanation about procedures and medications (AOR = 6.5, 95%, CI: 1.19–35.24), and information gain easily using indicator (AOR = 5.1, 95%, CI: 1.51–17.6) are significantly associated with maternal satisfaction with services given in the NICU. However, other studies conducted at Jimma, Wolaita Sodo, and Gondar do not significantly associated.,, This difference may be because our study showed that it is the true association. Or difference in data analysis logistic regression in the earlier studies.
This study showed that some of the basic equipment for NICU such as pulse oximetry, exchange transfusion, umbilical catheter, tray dressing set, stand infusion double hook, single head high intensive phototherapy unit, vinyl-coated 1.5 m measuring tape, mobile examination light, and CPAP were not available in the NICU ward of DBRH. Similarly, medications such as digoxin injection, dopamine, hydrocortisone, dexamethasone, and plasil are not available as the WHO recommendations. Moreover, laboratory investigations such as blood chemistry, serum glutamic oxaloacetic transaminase/aspartate aminotransferase, serum glutamic pyruvic transaminase/alanine aminotransferase, bilirubin direct and total, blood urea nitrogen, creatinine, random blood sugar/fasting blood sugar, cholesterol, total protein, albumin, electrolytes test (sodium, potassium, chloride, phosphorus, calcium), and culture were not done., These may be due to the limitation of resource (shortage of budget) or negligence and/or give less attention for NICU by planners and practitioners of the hospital.
In the present study, the ratio of nurse to patient in the NICU was found to be up to 1:10, which is far from the Recommendation given by British Prenatal and Medical; Association maximum of 1:2. This differences might be due to the difference in the level of development and setups of the hospital.
We would like to extend our thanks to Debre Berhan University, College of Health Science, for providing approval of the research and providing material while conducting this research. Our gratitude goes to our data collectors for their effort to bring quality data. Finally, we would like to say thank you for our study participants for their genuine answers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]