Keywords

Quality; Nursing services; Gaza hospitals; Neonatal intensive care unit

Introduction

The Neonatal Intensive Care Unit (NICU) constitutes a therapeutic environment appropriate for the treatment of the newborn (NB) in a serious condition. The fragility of these NBs, the increasing implementation of high-risk procedures and the low tolerance to medication errors are some of the concerns of nursing professionals working in the NICU [1]. The infant mortality rate among Palestine refugees was 18.2 per 1000 live births; 17.1 in the West Bank and 19.6 in Gaza Strip [2]. This reflected significantly increase in neonatal mortality from 12 per 1000 live births in 2008 to 20.3 per 1000 live births in 2013 [3]. Also, twothirds of neonates deaths occurred within the neonatal period, mostly during the first few days of life [4].

The nurse is responsible for implementing care that valorizes the physical, mental and social development of the NB [5]. Assessing the quality of services provided by nurses is crucial and, therefore, nurses are challenged to maintain and improve their quality of care [6]. Therefore, to build an image and maintain competitive advantages, successful organizations recognize the significance of continuously delivering quality services [7]. According to World Health Organization (WHO), detailed quality of care protocols and “job aids” for almost every aspect of care have improved quality and also shifted more care to the responsibility of skilled neonatal nurses, particularly concerning addressing infection prevention, feeding support, use of intravenous fluids, and safe oxygen use with careful tracking of oxygen saturation levels and follow-up services [4].

NICUs are important units to maintain the health of newborns in hospitals. The movement for quality in health services is today a need incorporated into the management of various interrelated areas [8]. This ensures safe service with excellence. In this perspective ensuring healthcare quality is understood as a multiprofessional task. Indeed, it is widely known that healthcare quality is not achieved through professional nursing practices alone. Moreover, professional nursing practice cannot be underappreciated or made invisible in the efforts to achieve healthcare quality [9].

As essential references for nurses' performance, they provide parameters for service quality assessment. In agreement with some authors, service quality below the standard level is considered contrary to the knowledge developed in nursing care practices and the theoretical framework of nursing [10]. Various approaches to quality assessment and quality improvement of 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 [9-11]. In this context, the international council of nursing attempt to define quality standards for nursing care, presented six categories of descriptive statements: patient satisfaction; health promotion; prevention of complications; well-being and self-care; functional readaptation and nursing care organization. Aiming to explain the nature and the different aspects of social mandates in nursing, the descriptive statements are, for patients, the assurance of quality nursing care, and for nurses they are a common reference and guide for professional practice performed with excellence [9].

The findings and recommendations of this study could add value to nursing profession globally and in Palestine partially in following areas: in practice, this study could provide suggestions to hospital policy makers to improve practices and management of neonates. Also, it could help in improve quality of nursing services. In education field, study will serve as the basis for review of neonatology curriculum in pre-services and in-service trainings in medical and nursing education. In research field, this study could build body of knowledge based of many researches, and may inspire for further researches. Also, in nursing care, this study may provide a way of proper compliance of neonatal care protocol in neonatal units, these issues will improve rates of neonatal morbidity and mortality.

With the progress and validation of an instrument to determine the nurses' perception of the activities that contribute to nursing care quality, it was admitted that it is "possible to collect data and transform them into essential information for effective management and make the nursing team aware of the need to improve the services provided [12]. When performing the literature review in many of countries such as: Brazil and Portugal [13] the investigations related to the quality of nursing care were found to be limited, which justifies the development of this study. In agreement with some authors were include Natalia Eiro Yuri and Daisy Maria Rizatto Tronchin, it was believed that it was very important to obtain data related to the perception of nurses involved in the provision of nursing care. Programs and actions to improve quality require changes in services and depend largely on the commitment and dedication of nursing professionals [14]. The availability of information regarding the quality of nursing care provided in NICUs is insufficient. Therefore, the study aimed to assess the quality of nursing services provided at NICUs at governmental hospitals in Gaza Strip.

Materials and Methods

Study design The study adopted the quantitative, descriptive cross-sectional design.

Study population

The target population of the study consisted of all the nurses were working in the NICUs of governmental hospitals (Shifa Medical Complex, Nasr Pediatric Hospital, Al-Aqsa Hospital, Nasser Medical Complex, El-Emaraty Hospital and the European Gaza Hospital) in Gaza Strip during the period of data collection, it consisted of 220 nurses who are employee as full time and have experience more than two years.

Study setting

This research carried out at main six NICUs in different Governorates of the Gaza Strip were including Al Shifa Medical Complex (SMC), Nasr Pediatric Hospital (NPH), Al-Aqsa Hospital (AH), Nasser Medical Complex (NMC), El-Emaraty Hospital (EH) and the European Gaza Hospital (EGH).

Period of the study

Data collection started in May 2019 and continued until mid-July 2019. Data entry, analysis and writing the final report continue to September 2019.

Sample and sampling

The study population was 220 nurses in six hospitals. Fifty percent of the those nurses were recruited to the study by simple random method according to their distribution in six governmental hospitals and have the eligibility criteria. The sample consist of 110 nurses who are working in NICUs in governmental hospitals as following; 30 from Shifa Medical Complex (SMC), 23 from Nasr Pediatric Hospital (NPH), 21 from Nasser hospital, 13 from Al- Aqsa Hospital (AH), 14 from European Gaza Hospital (EGH) and 9 from El-Emaraty Hospital (EH).

Eligibility criteria

Participants of this study were chosen according to the inclusion criteria. It include all the nurses who are working in NICUs in governmental hospitals, who are employees as full time and have experience more than two years.

Instrument of the study

Forty one items structured interviewer questionnaire was constructed by the researchers after reviewing by a scientific committee in our country. The questionnaire included two parts, the first part was allocated to collect information regarding sociodemographic characteristics of the participant nurses, it included sex, age, address, the hospital, educational level, experiences in NICU by years and occupation “practical nurse, registration nurse or supervisor nurse”, where the second part was allocated to gather information about quality of nursing care. It consist of forty one items classifies and eight domains. The domains are pain and stress domain, family-centered care domain, infection and inflammation domain, clinical nursing care practice domain, quality and safety domain, respiratory and ventilation domain, ethics domain, and professional issues in NICU nursing domain.

Validity and reliability

Content validity was included 7 experts. The comments of experts were considered and modifications needed to be were done accordingly. The internal consistency reliability was statistically computed and Cronbach’s alpha was over 0.7 which is acceptable value for the reliability of the tool.

Data collection

Data were collected by the researchers through face to face an interviewed questionnaire with nurses who work in NICUs in the selected six governmental hospitals. A consent form was added in front of each questionnaire and ask the participants nurses to freely participate in the study. The average time for filling the questionnaire was 15-20 minutes.

Data management and data analysis

The collected data were entered into the computer software "Statistical Package for Social Sciences" SPSS program version 20 and analyzed after coding of the questions and then cleaning of the entered data. Numerical data were expressed as means and standard deviations. Qualitative data such as: gender, educational level and local of residence were expressed as frequency and percentage. The ANOVA was used for examining for significance at level (0.05).

Ethical considerations

A permission was obtained from the Ministry of Health to conduct the study at the governmental hospitals. Also a consent form was requested and signed by each participant which indicated that the participation was voluntary and to emphasize the confidentiality of the information and the right to refuse participation or withdraw at any time.

Results

Socio-demographic characteristics of participants

The total of participants was 110, (60%) of them were males. Regarding the distribution of participants according to their hospital, 30 (27.3%) from SMC, 23 (20.9%) from NPH, 21 (19%) from NMC, 13 (11.8%) from AH, 14 (12.7%) from EGH and 9 (8.2%) from EH. The distribution of participants according to their occupation, most of them were registered nurses 83 (75.4%), 19 (17.3%) were a practical nurses and 8 (7.3%) work as a supervisor nurse. Classification of them according to the age by years, address, educational qualification, and experience of participants in the NICU as shown in Table 1.

Table 1: Sample distribution according to socio-demographic data.

Mean score of nurse’s perception about the quality of nursing care

Forty-one items distributed in eight domains to assess the quality of nursing care were answered correctly. Briefly, the total quality of nursing care in NICUs was 75.8%. The average of the domains associated of quality of nursing care in six hospitals were descendingly as following: infection and inflammation (78.6%), respiratory and ventilation (76.8%), safety (76.2%), clinical nursing care practices (76.2%), ethics (75.6%), pain and stress (75%), family-centered care (74%), and professional issues in NICU nursing (73.6%) as shown in Table 2.

Table 2: Distribution of the sample according to nurses perception about quality of nursing care in NICUS in Gaza strip.

The association between the quality of nursing care among nurses and their socio-demographic characteristics

There was statistically significant differences in the mean of pain, stress and family-centered care domains according to nurses address of residences, where the participants who live in North Gaza and Middle zone were lower quality of nursing care than those who live in Khan-Younis and Rafah Governorates P-value (0.003,0.032) as shown in Table 3. In the other hand the other domains weren’t statistically significant differences according to nurses address of residences because of P-value more than 0.05.

Table 3: Mean difference in the domains related to their address.

According to educational level, there was significant difference in the average of ethics domain, where the nurses of diploma have lower average in comparison of those with bachelors and master (P: 0.040) as shown in Table 4. The quality of the participants have diploma is lower than there have bachelor's and master's degrees, while other variables are not significant with educational level because of P-value more than 0.05.

Table 4: Mean difference in the ethics related to their education level.

Discussion

This study was conducted to assess the quality of nursing services in the NICU at Gaza Strip. The study discovered that the nurses mean quality of nursing services given in NICU was 3.8 in 5-Likert scale, which is equivalent to 75.8%. This result is consistent with the study conducted at Debre Berhan Referral Hospital, Ethiopia 77% [15]. This similarity might be due to almost of the nurses taken educational and training courses that will improve the practice interventions in NICU.

Adherence of infection prevention and control protocol is one of the main issues that reduce of complications and neonatal mortality. The study showed that the mean of infection and inflammation domain was 78.6%. The result is consistent with another study conducted by Eljedi and Dalo that explained 79% [16]. The similarity between those studies is result all the nursing team have good knowledge and practice of hand washing and applying the main infection prevention guideline.

The study discovered that the mean of safety application was 76.2%, this result is inconsistent with another study showed 68% of health care professionals reported that they recapped, broke or bent used needles before disposal [17]. In this study hospitals' sharps containers were available, so there was not need to recap needles.

Regarding to family centered care, the hospitalization of neonates for a long period made parents and the family feel anxious and stressed [18]. The quality of nursing care according to family-centered care was 74%. This finding is inconsistent with another study showed that most nurses apply family centered care principles (93%) [19]. This clear difference between the two studies is due to work pressure and a shortage of nurses in Gaza hospitals corresponding to the standard number of patients in NICUs. This shortage of nurses number pushed them to focus on the children's health status and neglected family centered care. The international ratio in the NICU was 1:1 but this ratio wasn’t achieved in governmental hospitals in Gaza, where the ratio is 1:4.

Regarding to pain and stress, the neonates often require repeated invasive needle-related procedures throughout their hospitalization. Reducing neonates' pain during medical and nursing procedures is important. High-quality synthesized evidence demonstrates analgesic effects of three pain management strategies: breastfeeding; skin-to-skin care, also referred to as kangaroo care; and small amounts of sweet solutions [20]. In this study the quality of nursing service of pain and stress was 75%. This finding is inconsistent with another study conducted by Willeia et al. showed that nurses acknowledged of pain neonates' and the importance of pain control to minimize children's development risks, the pain was primarily evaluated by behavioral indicators, such as weeping, facial mimics, and motor activity [21]. This statistically significant difference is due to the irregularity in applying the neonatal protocol in NICUs of Gaza hospitals, which focuses on administering sedative drugs before any painful medical procedure, and also as a result of work pressure.

Conclusion

There wasn’t significant differences between the quality of nursing services average according to socio-demographic variables such as: gender, age, experience in NICU and occupation. But there was statistically significant difference in family-centered care average according to nurses address of residence, where the participants in North Gaza and Middle zone have less quality of nursing care than those in Khan-Younis and Rafah Governorates. This result could by attributed to that the nurses who live in Northern Gaza and Middle zone are working in hospitals of high work pressure and full of patients “SMC and NPH”, while those who live in Khan- Younis and Rafah Governerates are working in hospitals of less work pressure and few of patients “EGH and NMC”. The working in hospitals of less work pressure and fewer patients give more chance and time for nurses to provide the best services and good quality regarding the family centered care.

Limitations of the Study

This study had several limitations; first: many independent factors that may affect the quality of nursing care weren’t study. Hereafter, further studies are recommended to exclude potential confounding factors. Secondly, we did not have all the NICUs nurse's team in governmental hospitals. To better understand such effects, taking all the nursing teams with a large sample size is recommended. Thirdly, the nature of cross-sectional design which limits the causal effect relationship.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

Acknowledgments

The General Directorate of Human Resources Development in the Palestinian Ministry of Health and the NICUs at governmental hospitals are appreciated for their cooperation and giving us this opportunity to conduct the study. Also, we are grateful to all the mothers who participated in this study.

References

1. Alton M, Mericle J, Brandon D (2006) One Intensive Care Nursery’s Experience with Enhancing Patient Safety. Adv Neonatal Care 6: 112-119.
2. Ministry of Health (2016) Annual Health Report, Gaza Strip. Palestine.
3. Berg MM, Madi HH, Khader A, Hababeh M, Zeidan W, et al. (2015) Increasing neonatal mortality among Palestine refugees in the Gaza Strip. PLoS One 10: 8.
4. World Health Organization (2012) Recommendations on Interventions to Improve Preterm Birth Outcomes Highlights and Key Messages from the World Health Organization, Geneva.
5. Aita M, Snider L (2003) The art of developmental care in the NICU: A concept analysis. J Adv Nurs. 41: 223-232.
6. Zhao SH, Akkadechanunt T, Xue XL (2009) Quality nursing care as perceived by nurses and patients in a Chinese hospital. J Clin Nurs 18: 1722-1728.
7. Chahal H, Kumari N (2012) Service quality and performance in the public health-care sector. Health Mark Q 29: 181-205.
8. Dias AO, Martins EA, Haddad MC (2015) Instrument for assessing the quality of Rapid Response Team at a university public hospital. Rev Bras Enferm 67: 700-707.
9. Portugal. Ordem dos Enfermeiros (2012) Conselho de Enfermagem. Padroes de qualidade dos cuidados de enfermagem: enquadramento conceptual e enunciados descritivos.
10. Stallings-Welden LM, Shirey MR (2015) Predictability of a professional practice model to affect nurse and patient outcomes. Nurs Admin 39: 199-210.
11. Portugal. Ministerio da Saude (2012) Direcao-Geral de Saude. Plano Nacional de Saude 2012-2016: Eixo Estrategico - Qualidade em Saude.
12. Rodrigues AV, Vituri DW, Haddad MC, Vannuchi MT, Oliveira WT (2012) The development of an instrument to assess nursing care responsiveness at a university hospital. Rev Esc Enferm USP 46: 167-174.
13. Fradique MJ, Mendes L (2013) Effects of leadership in improving the quality of nursing care. Rev. Bras. Enferm 10: 45-53.
14. Yuri NE, Tronchin DM (2010) Quality of maternal-child health care at a University Hospital, according to the nurses' perspective. Rev Esc Enferm USP 44: 331-338.
15. Mekonnen W, Desalegn A (2018) 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 11: 412-419.
16. Eljedi A, Dalo S (2014) Compliance with the National Palestinian Infection Prevention and Control Protocol at Governmental Paediatric Hospitals in Gaza Governorates. Sultan Qaboos Univ Med J 14: 375-381.
17. Hutin Y, Hauri A, Chiarello L, Catlin M, Stilwell B, et al. (2003) Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bull World Health Organ 81: 491-500.
18. Cockcroft S (2012) How can family centred care be improved to meet the needs of parents with a premature baby in neonatal intensive care? J of Neonatal Nurs 18: 105–110.
19. Cooper LG, Gooding JS, Gallagher J, Sternesky L, Ledsky R, et al. (2007) Impact of a family-centered care initiative on NICU care, staff and families. J Perinatol 27: 2.
20. Johnston C, Barrington KJ, Taddio A, Carbajal R, Filion F (2011) Pain in Canadian NICUs: have we improved over the past 12 years? Clin J Pain 27: 225–232.
21. Martins SW, Dias FS, Enumo SRF, Paula KMP (2013) Pain assessment and control by nurses of a neonatal intensive care unit. Rev Dor 14: 21-26.