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Table 3 Challenges with the monitoring task and charts

From: Using a human-centred design approach to develop a comprehensive newborn monitoring chart for inpatient care in Kenya

Challenge

Description and examples

Challenges relating to chart design

 Multiple charts

Participants reported that several charts exist in the wards that collect similar information leading to duplication of information and possibly transcription errors.

Current charts that collect feed/fluid prescription and observation data include:

1. Fluid chart

2. Feed chart

3. Weight chart

4. Temperature chart – Respiratory rate, Oxygen saturation, pulse

5. Treatment sheet - feed/fluid prescription

6. Doctors notes – feed/fluid prescription

7. Nursing cardex – may have vitals as well as other notes

* In some hospitals, the feed chart also has vital signs

 Different ways of filling the same fields

Different ways of filling the same fields make it difficult to interpret what has been recorded and compare between health workers or hospitals; for example, where one uses a plus sign to indicate urine output, could it be interpreted to mean more urine was present? Or, where a tick is used, does that imply the presence of urine in the baby’s diaper or that urine output was assessed?

 Improvisation due to missing fields

Inadequate fields on forms leading to improvisation; for example, users adding additional columns on the chart or writing over space designated for other fields.

 Difficult to fill charts

Limited space to write values – small boxes for filling pulse on temperature charts

Current temperature graphs are difficult to fill

 A mismatch between units on charts and available equipment

Example: temperature scale in Fahrenheit while thermometers show the temperature in centigrade

 Different charts to write related information

Participants felt that for proper feed and fluid monitoring, prescription information should be on the same chart as monitoring information as opposed to having the prescription in the doctor’s notes or the treatment sheet.

 Charts do not support workflow

The charts were not designed to support the order nurses follow while carrying out their tasks. For example, they typically bundle tasks; take vital signs measurements before giving feeds or fluids while some charts listed the feed/fluids before the vital signs.

General monitoring challenges

 Interprofessional communication

Poor interprofessional communication was reported as a challenge to monitoring by both nurses and doctors as well as between junior and senior professionals within the cadres.

 Knowledge deficit

Both doctors and nurses felt that less experienced health workers such as interns lacked knowledge in prescribing (particularly for low birth weight babies) and identification of problems (for example out of range values) possibly due to their limited experience.

 Staff shortage

Nurses felt that staff shortage was a barrier to the proper documentation. Related to this, some hospitals reported that mothers were involved in feeding babies and filling feed monitoring charts

 Charts shortage

The participants reported an inadequate supply of charts

 Misplaced charts

Nurses reported that in many cases, monitoring charts would either be placed at the bedside or at the nursing station in a pile which sometimes led to charts being misplaced.