'But you have to start somewhere….': Nurses’ perceptions of what is required to provide quality neonatal care in selected hospitals, Kenya [version 2; peer review: 2 approved]

Background: Kenya has one of the highest rates of neonatal mortality in the world at 22/1,000 live births. Improving the quality of newborn care would greatly improve survival rates. There is an increasing consensus that strong health systems are key to achieving improved health outcomes. However, there is significantly less agreement on what to strengthen in low and middle-income countries such as Kenya. As nurses are the main caregivers in many inpatient settings, efforts aimed at improving the quality of facility care for sick newborn babies need to take into account nurses views and opinions. Our intent in this paper is to describe the current state of the nursing environment and what would be required to improve the quality of those environs from nurses’ perspectives. Methods: Between January 2017 and March 2018, we collected data through non-participant observations, unsolicited conversations and review of admission registers. We also conducted 29 individual in-depth interviews with nurses working in the newborn units (NBU) of a public sector hospital (n=10), a private sector hospital (n=11) and a faith-based hospital (n=8). The interviews were digitally audio recorded, transcribed verbatim and, together with observation notes, analysed using thematic content analysis. Results: Nurses as frontline care givers and intervention intermediaries, irrespective of their work contexts, have similar aspirations, needs and expectations from the health systems of how they should be supported to provide quality inpatient care for newborns. These are about the structure of the work environment, especially human resources for health, and the consequences of inadequate structure. They are also about how care is organised and systems that respond to emergencies. Conclusion: Interventions and investments to improve quality need to be directed towards experienced based co-design where we listen to the problems that nurses experience.