Table 1

Mapping the strengths and challenges of an LRS NBU and taking a systems perspective based on personal observations and prior research (‘invisible’ issues in italic text)

DomainExamples of strengthsExamples of challenges
Patients/mothersFamilies are highly motivated, are often keen to engage in care once their confidence is built (eg, feeding support and monitoring) and mutually supportive groups including ‘expert’ mothers whose babies have been on the ward the longest. These groups may form especially in hospitals where mothers are resident. Enabling mothers with good information on their baby can help promote continuity of care as they become the bridge between different teams and helps foster the global movement towards family-centred careMay initially be overwhelmed by baby’s illness and have to mobilise resources to supplement those of the hospital (eg, purchasing drugs, feeds and diapers)
Levels of literacy and numeracy may limit sharing of care if this is not well designed
Power differentials linked to socioeconomic, educational and cultural factors may undermine relationships between families and staff
StaffMany retain a strong vocational commitment to ‘service’ and some experienced nurses have clearly dedicated themselves to NBU work. Committed staff can be champions of safe, high-quality care.
Despite resource problems some wards have teams that provide each other with critical social and emotional support—this can be a foundation for further team-based improvements
Staff have considerable knowledge about how the local system works and where key challenges lie, they may have important links to the local community and may be able to mobilise wider support for improvement efforts
Low staff numbers with high workloads can result in burnout that reduces engagement in improvement efforts
Some leaders have not received training in or may lack an appetite for leadership roles
Frequent staff turnover
Ancillary staff may have poorly defined roles and responsibilities, may be poorly trained (eg, in infection prevention) and little may be invested in their supervision
Fear of blame or confrontation may prevent discussion of mistakes or safety issues
Interprofessional rivalries may undermine communication, relationships and teamwork
Tasks, technology and toolsIncrease in availability of basic equipment (eg, pulse oximetry, Continuous Positive Airway Pressure, CPAP)
Increased access to smartphones or computers and so to knowledge and links with other professionals
Considerable innovation already occurring to make efficient use of resources (eg, through task sharing or safe reuse of consumables)
Team has often developed routines that prioritise the most critical tasks to focus on when under extreme time pressure
Wards may be supplied with the wrong tools (eg, adult drug formulations) or receive new staff with minimal training or experience
Staff struggle with poorly designed ‘everyday’ tools, for example, treatment and nursing observation charts inherited unchanged from adult wards
Established routines may suit staff but not optimise patient outcomes and be hard to change
Adding new technologies gives the impression of more advanced care (giving professionals greater status) but may increase workloads for some staff and so may not improve outcomes
TeamsTeamwork and respectful communication are highly valued by staff and families
The importance of practical experience and learnt skills is recognised in a team not just qualifications or professional cadre
Staff can go out of their way to offer practical or emotional support to other staff and caregivers
There is little obvious reward or recognition of individuals’ efforts to sustain quality services
Practical skills are often developed by individual trial and error, limited attention is paid to coaching and mentorship
Traditional professional hierarchies and poor leadership practices undermine team performance
Environment and working conditionsBasic infrastructure may be available
Many ‘work-arounds’ have been developed that overcome long-standing challenges
Relatively small investments/changes can produce substantial benefits
Mothers of babies recognise how challenging things are for staff and are often very positive and grateful when they are well cared for
The physical space is often poorly suited to needs of NBU (eg, power outlets, oxygen systems)
Inadequate attention is paid to basic infection control and staff and family needs (eg, adequate toilets)
Overcrowding undermines effective care
Little support is provided to staff and families who may experience emotional distress
OrganisationThere is emerging recognition that safety is reputationally critical and a key part of quality improvement
Some senior staff have gained knowledge and skills in how to work within existing local and political systems to effect change
Effective leadership can inspire shared goals and a sense of ‘mission’ despite challenging environments
There is often a feeling that senior management are only concerned about quality for appearances sake so quality and safety activities are conducted ‘just to tick boxes’
Local leaders have limited control of spending or resources limiting their ability to make changes
Hospitals may rely for equipment on donations making it hard to execute a plan for improvement
Hospital leadership may create a fear of being blamed for poor outcomes so there is an unwillingness to acknowledge errors
  • LRS, low-resource settings; NBU, Newborn Unit.