“I train and mentor, they take them”: A qualitative study of nurses' perspectives of neonatal nursing expertise and its development in Kenyan hospitals

Abstract Aims and Objectives Neonatal inpatient care is reliant on experienced nursing care, yet little is known about how Kenyan hospitals foster the development of newborn nursing experience in newborn units. Design A Qualitative ethnographic design. Methods Face to face 29 in depth interviews were conducted with nurses providing neonatal care in one private, one faith based and one public hospital in Nairobi, Kenya between January 2017 and March 2018. All data were transcribed verbatim, coded in the original language and analysed using a framework approach. Results Across the sectors, nurses perceived experience as important to the provision of quality care. They noted that hospitals could foster experience through recruitment, orientation, continuous learning and retention. However, while the private hospital facilitated experience building the public and faith‐based hospitals experienced challenges due to human resource management practices and nursing shortages. Conclusion Health sector context influenced how experience was developed among nurses. Implications Nurturing experience will require that different health sectors adopt better recruitment for people interested in NBU work, better orientation and fewer rotations even without specialist nurse training.

workforce. The data for this paper are derived from a broader ethnographic study exploring nurses' perceptions of what constitutes "quality care" in the neonatal unit. This paper focusses on experience, its importance in facilitating nurses' ability to give quality inpatient care to sick newborn babies and how different hospital contexts (public, faith based and private) facilitate or constrain the nurses' acquisition of experience. The research question was therefore "how does one acquire experience in and how does your work environment facilitate the process?"

| Design and study setting
This study was a qualitative ethnographic study in three hospitals from public, private and faith-based offering 24-hr inpatient care for sick newborns in Nairobi, Kenya. This is because Kenya operates a pluralistic health sector with care services being provided by the Government (public), private for profit and private not for profit (herein referred to as faith based) institutions (Chuma & Okungu, 2011). The public sector gives approximately 50%-60% of the health services, while the remaining health services are provided by the private and faith-based sectors (Ministry of Health, 2013;Population & MEASURE/DHS+, 2005). This study was undertaken in the Newborn Units (NBUs, the inpatient neonatal care wards) of one public, one faith based and one private hospital, in Nairobi County, Kenya. Table 2 summarizes the key characteristics of NBUs in the study hospitals.
The study adopted a qualitative ethnographic design (Creswell & Poth, 2017). After obtaining permission from top hospital administrators and NBU ward managers, the primary author created rapport with nurses working in the NBUs by sharing with them a detailed information sheet regarding the study prior to consenting them. It was between January 2017 and March 2018, when twenty-nine in-depth interviews using an interview guide were also conducted with nurses who were purposively sampled providing neonatal care, 10 in the public, 8 in the faith based and 11 in the private hospital. All except 3 interviews were digitally recorded using an audio digital recorder. The three interviewees did not consent to be recorded. All available nurses during the study period in the hospital were eligible for participation and except in the private hospital, all available nurses in the public and faith based were interviewed after voluntary consenting. Twenty-eight interviews were conducted in English while one was conducted in Kiswahili, Kenya's national language. the first author was a PhD student undertaking her research and had no prior knowledge of the nurses.
The findings have been reported using the SRQR checklist. "See Supplementary File 1".
The research received ethics clearance certificate number SU-IRB 0060/16/3555 and participating hospitals as well as County Department of Health. All participants were provided written informed consent before participation in interviews.

| Data analysis
Analysis began by open coding to understand quality from nurses' perspectives. Initial codes were generated from the research objectives, but additional codes were developed iteratively as they arose from observation and an initial careful reading of the transcripts. Using Nvivo 10 software for management, we coded the data in their original language and translated into English where necessary (Castleberry, 2014). Emerging themes were discussed across co-authors while credibility was ensured through feedback to the nurses for sense checking; thirdly, the researcher made presentations in various local forums where feedback was received and incorporated working. The themes identified and presented in this paper are recruitment, orientation, continuous leaning and retention.

| Demographic characteristics of the participants
Twenty-nine nurses were interviewed, most of whom were aged between 30-39 years and more than half had received training at diploma level. In Kenya, nurse training institutions offer programs at three levels: certificate, diploma, degree (BScN) and Masters (Msc) in nursing. A masters takes two years, a BScN involves 4 years of training followed by a 1-year internship; a diploma requires 3 years of training while a certificate in nursing can be gained after two and a half years of training but do not involve internship (MoH, 2012). A higher diploma can be gained by nurses who have a basic diploma who have worked for at least two years and involves one year of further study. Diploma level and degree level training involve 2 and 4 weeks of specific training in neonatal care, respectively. Six of the nurses in the private hospital were trained to degree level and one had a Masters. This contrast to the faith-based hospital where only one nurse had been trained to degree level and the public where there were no nurses in the NBU with degree level training. Table 3 summarizes demographic characteristics of the study sample.

| Nurses views on experience
When the nurses participating in the study were asked for their thoughts on what constitutes quality care in the NBU, nearly all mentioned a nurse's experience as a key component of the provision of quality neonatal care. Some of the nurses spoke about experience in terms of "having worked with babies before" and "being comfortable in role" attributes which could be seen as "competent" nursing (Benner, 1982). Others spoke more specifically about the ability to Despite the nurses' views that recruitment was an important step in facilitating the delivery of quality nursing care, it was only in the private hospital that the participants said that nurses were recruited specifically to the NBU and prior experience with newborns was specified as a requirement: …For staffing standards, one of our minimum standards is that s/he must have worked with newborns before… Private 03 Although the nurses ideally spoke of the need to recruit nurses with prior NBU experience and interest, practically those from the public and faith-based hospitals said that nurses were recruited generally without specifying their previous experience or interest in working with newborns. Irrespective of how the nurses ended up in the NBU, the participants across the sectors described three processes that they perceived as important in creating an experienced nurse. These were orientation; continuous learning; and retention.

| Orientation
The orientation process was used to introduce the nurses to their environment, an induction onto the ward. However, from observations what was covered in orientation differed across settings. In While all the participating nurses emphasized the importance of a period of orientation, some of the nurses (4/10) in the public sector hospital said that they had started working on the NBU with no orientation. They perceived that their lack of orientation had been due to staff shortages and the lack of processes to ensure systematic implementation. One of the nurses who had not received orientation and was starting as a novice in the NBU environment said that she had experienced frustration as she did not know where to get equipment and medications and she had to refer to charts on the wall to conduct routine tasks such as how to calculate feeds and medications:

| Continuous learning (CL)
Following on from orientation, around half of the nurses from each hospital mentioned that opportunities for continuous learning were important for acquiring neonatal nursing-specific skills. In the private hospital attendance at CL sessions was mandatory as attendance formed part of their nursing performance reviews.
Attendance at CL sessions was not mandatory in either the public or the faith hospitals but attendance at such sessions was taken into consideration when a nurse applied for long-term training opportunities and for promotion. It was observed nurses in both public and private attend CMEs on Kangaroo Mother Care and resuscitation, respectively. However, during the three months of observation in the faith-based hospital no opportunities to attend CL sessions were observed.
While ideally, all three hospitals had different opportunities for continuous learning, in practice few nurses in the public or faith-based hospitals were able to take up these opportunities. This was attributed to staffing shortages on the ward making it difficult to attend: CMEs are there but due to shortage we don't get time to attend… Public 08 In the faith-based hospital, one nurse mentioned that they (junior staff) were not given the opportunity to attend training, instead a member of senior management would attend the sessions and subsequently give occasional updates to those who had not been able to attend: Retention of experienced nurses varied. In the public hospital, it was observed that there was a tendency to carrying out frequent change overs (rotation) of staff except for the ward in charge and the deputy. These changeovers were described by most nurses as a hospital strategy to enable nurses to gain experience across different service areas. However, its frequency was described as too often, a strategy that was being used to deal with staffing shortages across wards. It is these frequent change overs that were described by all ten nurses as counterproductive and demotivating: I train and mentor, they take them…I am frustrated and tired…who has time to waste on nurses who will be taken elsewhere after a few months… Public 03 For the private and faith based, retention challenges which were not common were described as being a result of the desire for nurses to pursue other growth opportunities. Two nurses in the private described the opportunities available for pursuing a degree in nursing as they continued with work as a strategy that helps them stay. However, given opportunities in the national government run hospital they could leave: …Okay, the opportunity to upgrade to a degree while still on payroll is a plus because then we tend to stay on… however, if I get greener pastures in a parastatal, I would leave….

Private 08
Nurses who expressed a desire to leave attributed it to a desire to earn a higher salary: …Salaries here are soo small, but again you will be told that even what we charge our patients is little…so, we work as we look for better job opportunities… In the Kenyan context, although all nurses employed by the public and private sector are required to renew their license every three years, each health sector has its own nursing practice and workforce management system (Wakaba et al., 2014;Waters et al., 2013). Whereas in the public sector nurses are recruited and managed centrally by the County department of health, the faith based and private sectors have hospital-based recruitment and management system. There is also a diversity on how different counties plan for and manage their nursing workforce (Wakaba et al., 2014). Findings from this study have shown that nurses who start working in the NBUs in the faith based and public hospitals are likely to be "novices" in that environment (although potentially "expert" in other areas of clinical care) but in the private they are already at least competent. In public and faith based, there are few opportunities for a nurse to develop "expertise" except through practice as there is little CL. While the nurses in the faith based might have the opportunity to become "experts" through continuous practice (although not CME), this is not the case for the public as these nurses are moved across different departments in the hospital.
There is some evidence from low-and middle-income countries (LMICs) in the accountability literature to show that nurses posted as facility managers gain managerial experience through on job training, supportive supervision from their managers and peer learning (Nyikuri, Tsofa, Tsofa, Barasa, Okoth, & Molyneux, 2015). There is also anecdotal evidence to suggest that nurses gain experience in LMICs through attachment, internship and volunteer schemes in private owned clinics and hospitals as well as in government-owned hospitals. However, no studies were found on how nurses move from being novice to expert in their clinical role and to our understanding, this study is unique in exploring the role of hospitals in LMICs in developing nursing experience for quality care. Previous research in the USA, Australia, UK and Finland has shown that nurses develop substantial knowledge of the strengths and weaknesses of hospital systems through experience (Debono & Braithwaite, 2017;Johnson, 2015;Nielsen, Lasater, Lasater, & Stock, 2016 (Moxon et al., 2018). At the ward and hospital levels, nursing leaders need to anticipate dynamism in nurses personal interests and goals and give a positive environment that supports them to decrease nursing turnover rates (Spivak, Smith, Smith, & Cynthia Logsdon, 2011). A study to understand registered nurses (RNs)' decisions to remain or leave their workplaces in two private hospitals in Kenya showed that among other factors, feelings of non-appreciation due to lack of the professional development opportunities and poor remuneration influenced their turnover (Mbuthia, Brownie, Brownie, & Holroyd, 2017).
Benner's theory was found to be useful in curriculum development in education institutions (Altmann, 2007). Considering the stages in acquiring expertise as outlined in Benner's theory, more purposeful strategy is argued for developing expertise and therefore quality of NBU nursing care. The lessons gained from this process can be applied to other specialized parts of hospitals. At present most HRH focus is on production of numbers but not on expertise, the global debate needs to include expertise.

| Limitations
These study findings are limited; firstly, the study was conducted in a small number of places in one city, but it offers detailed work and triangulation of interviews and observations. Secondly, the authors did not start out by looking at expertise but emerged as an important finding and so interviews and observations did not consider mentorship and supervision on the job but offers insights into area for new research.

| CON CLUS ION
Nurses as the backbone of the healthy system globally and in Kenya consider experience in caring for sick newborns as a key aspect in delivering quality care. Benner's theory is useful in understanding how to begin to cultivate and nurture experience. Nurturing experience will require that different health sectors adopt better recruitment for people who wish to work in NBU, better orientation and fewer rotations as key things even without specialist nurse training.

| RELE VAN CE TO CLINI C AL PR AC TI CE
These findings are relevant in the clinical practice as they bring to the fore the need for hospitals to support nurses in their efforts to deliver quality care.
First, the findings in this study point to the factor that no matter the sector of practice, nurses perceive that experience is important to their ability to give quality care. Experienced nurses are more likely to be confident to take care of patients as they are comfortable in making clear patient care decisions.
Second, experience in important for nurses to develop positive attitude in the workplace and to guide and nurture it among novices. Third, nurturing experience is an essential and paramount for hospital work environments that are keen on supporting nurses give quality care. This study has identified that health managers need to adopt better recruitment for people who wish to work in NBU, better orientation and fewer rotations as key things even without specialist nurse training.

ACK N OWLED G EM ENTS
I acknowledge all the nurses who allowed me to be part of their lives on the ward by observing daily routines and interactions. I am especially grateful for the time they took to participate in interviews as well as in informal discussions.

CO N FLI C T O F I NTE R E S T
The author(s) declare that they have no conflict of interests.

AUTH O R S ' CO NTR I B UTI O N S
MN was responsible for conceptualization of the idea, data collection, analysis and write up of initial draft. PK, CJ and ME gave overall support in the analysis and critique of the final paper.

E TH I C S A PPROVA L A N D CO N S E NT TO PA RTI CI PATE
The research received ethics clearance from the Strathmore University and KEMRI certificate no. KEMRI/SERU/CGMR-C/SU-IRB 0060/16/3555 and was also approved by the three participating hospitals as well as Nairobi City County department of Health.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from KEMRI-Wellcome Trust but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are, however, available from the authors upon reasonable request and with permission of KEMRI-Wellcome Trust.