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Addressing the needs.
The Community of Neonatal Nursing Practice will address each of the identified gaps.
Standardized Curriculum
COINN works with countries to develop and utilize a standardized neonatal nursing curriculum. By standardization it is assured that each student is receiving education that include neonatal embryology, neonatal health assessment, neonatal pharmacology, and neonatal management. These topics are specific to the care of the small and sick newborns and their families. The neonatal nurse should also be trained as a researcher and leader in the field. A standardized curriculum across countries ensures that nurses are educated equally within the country context but would be able to travel from one country to another without additional education. This strengthens the workforce by allowing nurses to move from hospital to hospital, district to district, country to country with minimal retraining.
Neonatal Advanced Practice Education
The small and sick newborn and their families have unique problems and disease entities often not found at any other time in life. These include genetic abnormalities, errors of metabolism, cardiac defects, and more. These topics are often not discussed in other educational programs. Universities have asked for further neonatal training for their faculty from COINN. COINN has developed a 6-month Neonatal Nurse Fellowship Program that will help faculty acquire neonatal competencies and skills as well as, be certified as a Neonatal Nurse Fellow.
Faculty Clinical Preceptors
An evaluation of existing programs and working with universities another gap was noted to be consistent across countries and that is the need for clinical supervision. Clinical supervision is the time for the faculty to assess acquired knowledge and skills. To understand fully if a student is achieving the acquired knowledge and skills a consistent preceptor should be with the students in the clinical setting. A neonatal clinical preceptor is a new role for faculty. This role focuses on providing guidance to students while assisting them in skills acquisition and knowledge. Benefits of a consistent clinical preceptor:
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Improvement in communication within a multidisciplinary team.
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Improvement in skills acquisition.
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Student competency.
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Confidence in practice.
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Less turnover rate later as they are working in their roles (Shariff & Khademian, 2018).
Clinical Nurse Educator Role in Africa
COINN has further identified the need for training for new nurses in the neonatal unit. In studies done in Africa it has been found that the training to begin work in the neonatal unit was as short as 1 day up to maximum of 10 days in length. During this training most of the new nurses did not have a consistent preceptor and often learned several different ways to do the same task.
Gaps surrounding training in neonatal units include no training in small and sick newborn maladies and treatment, the need for consistency in training, and if they were trained there were too multiple preceptors. Nurses that are assigned to neonatal units in the US, UK, and high-income countries are given an orientation of 12-weeks to up to a year in length (Bischoff, 2018; Royal College of Nursing 2015). Survival of a neonate has been linked to the qualified neonatal nurse on duty (Hamilton, Redshaw & Tarnow-Mordi, 2007). Dabrow-Woods and Stegman (2020) noted that 50% of all practice errors are made by nurses not trained to in the nuances of the care of a sick patient. Furthermore, Dabrow-Woods and Stegman (2020) found that 65% of all errors were related to poor clinical decision-making skills. These skills are best acquired in a precepted training program.
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The need for small and sick newborn education, a new complex unit with equipment not encountered in school, and need for preceptors for the new employees led to poorly trained nurses (Dabrow-Woods & Stegman, 2020). Schnur (2020) recommended several interventions to help students and nurses. One was to use a standardized program to move the nurses from novice to competent and beyond. The second was use of a standardized program to allow the new staff time to adjust to the unit, acquire skills, and improve competency levels (Schnur, 2020). Students have said in other studies that when they have multiple preceptors they are confused as to the right way to care for a neonate. Matua, Seshan, Savithri, and Fronda (2014) demonstrated when a new nurse or student developed a relationship with one preceptor and felt part of the team they learned more and felt more confident about their practice. To mitigate the necessity for neonatal education, the need for consistency and too many preceptors, neonatal units in other countries have hired Clinical Nurse Educator (CNE). The role includes:
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Ensuring training of new staff.
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Documenting nurse competencies.
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Developing policies, procedures, and evaluating the ongoing staff educational needs.
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Preparing and training experienced neonatal nurses to act as preceptors for new trainees and students.
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Working with the faculty nurse preceptor to ensure all neonatal nursing students (neonatal nurse practitioner-NNP or equivalent and advanced neonatal nurse) will be placed with a prepared and experienced preceptor.
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Working with administration to develop policies, and procedures for neonatal tasks.
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Taking responsibility for training district level staff in small and sick care.
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Supervision of neonatal nurse competencies at the district level.
Specialization of Neonatal Nurses
In high income countries neonatal nurses are well organized and recognized. COINN’s position statement on what a neonatal nurse is states: “a nurse who specializes in the care of preterm and/or sick newborn infants and their families across the care continuum-hospital or community/follow up settings-during at least the neonatal period (first 28 days of life) to promote the best possible health outcomes.” (COINN, 2014). Without recognition of a specialty in neonatal nursing a nurse can be moved from unit to unit without preparation for that unit. Specialized nursing has demonstrated improved patient outcomes and less failure to rescue events (Kendall-Gallagher et al, 2011). Specialized nurses are safer for patients and demonstrate less errors (Kendall-Gallager & Blegen, 2009).
Sufficient Specialized Nurses to Care for The Small and Sick Newborn
In COINN’s work in many countries in Africa, similar to around the world it has been found that nurses do work based on the shift they work or the number of facility employees and not on the acuity of the small and sick newborns. In one country the unit was an 80 to 100 bed unit and it was staffed with five or six nurses during the day going down to five or less at night no matter what the census or acuity level. In high income countries staffing for neonatal units is done based on acuity and the recommendations from organizations such as the Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) and medical associations. In Africa there are no staffing recommendations. Amri et al (2020) looked at staffing in 35 countries and was able to demonstrate there was a significant association between nursing staffing and neonatal mortality (NM). When better staffing numbers existed, NM decreased. They demonstrated an increase of staff by 1% would decrease NM by 1%.