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Background Missed nursing care undermines nursing standards of care and minimising this phenomenon is crucial to maintaining adequate patient safety and the quality of patient care. The concept is a neglected aspect of human resource for health thinking, and it remains understudied in low-income and middle-income country (LMIC) settings which have 90% of the global nursing workforce shortages. Our objective in this review was to document the prevalence of missed nursing care in LMIC, identify the categories of nursing care that are most missed and summarise the reasons for this. Methods We conducted a systematic review searching Medline, Embase, Global Health, WHO Global index medicus and CINAHL from their inception up until August 2021. Publications were included if they were conducted in an LMIC and reported on any combination of categories, reasons and factors associated with missed nursing care within in-patient settings. We assessed the quality of studies using the Newcastle Ottawa Scale. Results Thirty-one studies met our inclusion criteria. These studies were mainly cross-sectional, from upper middle-income settings and mostly relied on nurses’ self-report of missed nursing care. The measurement tools used, and their reporting were inconsistent across the literature. Nursing care most frequently missed were non-clinical nursing activities including those of comfort and communication. Inadequate personnel numbers were the most important reasons given for missed care. Conclusions Missed nursing care is reported for all key nursing task areas threatening care quality and safety. Data suggest nurses prioritise technical activities with more non-clinical activities missed, this undermines holistic nursing care. Improving staffing levels seems a key intervention potentially including sharing of less skilled activities. More research on missed nursing care and interventions to tackle it to improve quality and safety is needed in LMIC. PROSPERO registration number: CRD42021286897.

Background Tracking and understanding the progress and experiences of health workers and the outcomes of workforce decisions are essential for evidence-based workforce planning. In this scoping review, we aim to identify longitudinal studies that prospectively tracked healthcare professionals and that specifically focused on workforce issues such as career preferences, choices, and working conditions, and summarise the different approaches and methods used for tracking. Methods We searched MEDLINE, Embase, Global Health, PsycINFO, CINAHL, Education Resource Information Center (ERIC), EconLit and the Cochrane Library for articles published between 2000–2022 that longitudinally tracked doctors, nurses, midwives, physician associates/assistants. We further compared articles and conducted a back-and-forward citation search to identify longitudinal tracking studies which sometimes have multiple published articles . We developed a typology of the different tracking approaches, and summarised the major areas assessed and tracked by different studies. Results We identified and analysed 263 longitudinal tracking studies. Based on population recruitment and follow-up methods, we grouped studies into seven categories (cohort studies, multiple-cohort studies, baseline and data linkage studies, baseline and short repeated measure studies, baseline-only studies, data linkage-only studies and repeated survey studies). The majority of studies included used a cohort or multiple-cohort design ( n  = 180), and several others also used data linkage (n = 45) and repeated measure approaches ( n  = 24). Sixty-two studies recruited participants while they were students and followed them until they became the active workforce, and nearly half of the included studies started directly from the active workforce stage. Most of the included studies examined workforce issues including employment status, preference or intention (to leave/remain/migrate, specific speciality or location etc.), and work environment, however there was a lack of widely used measurement tools for workforce issues. Additionally, nearly 40% examined wellbeing issues and a subset (20%) examined physical health in the context of workforce-related issues. Conclusion We described a large number of different healthcare professional longitudinal tracking studies. In order for longitudinal tracking to contribute to effective workforce planning, we recommend employing a mix of cohort and data linkage approaches to collect data across the different stages of the workforce ‘working lifespan’, and using and continuing to test standardised measurement instruments to better capture experiences related to workforce and wellbeing.

Background We argue implementation research pays insufficient attention to time. We were prompted by learning gained from the Harnessing Innovation in Global Health for Quality Care (HIGH-Q) programme to explore implementation through time as an analytical lens. Time directly underpins how individuals, teams, and organisations adopt and sustain new practices, yet existing frameworks primarily reference it indirectly. We propose that considering time as a multi-dimensional construct is relevant to the science of implementation in complex systems and to promoting its thoughtful practice. Arguments HIGH-Q research involved coordinated ethnographic, quantitative and interventional studies of workforce enhancements in hospitals already benefiting from long-term neonatal technology and quality improvement support. Findings made it clear how time scarcity constrains improvement and use of new technologies in low-resource environments. New clinical technologies such as continuous positive airway pressure require time of users directly and indirectly linked to new cognitive and coordination work. Tasks compete for scarce time resulting in prioritisation, while time is needed for skill development, reflection, and team adaptation. Conceptually we suggest the following: (1) time functions as a finite and negotiable resource that must be deliberately allocated to new practices, without creating temporal space, change efforts risk displacing existing essential work; (2) “hidden time” is required for reflection, collaboration, management and internalisation of new routines—activities rarely acknowledged in project planning; (3) time is an expression of value, reflecting what actors prioritise and the moral or organisational meaning attached to the allocation of effort; (4) healthcare work is governed by temporal structures—shifts, schedules, and social norms—that may hinder flexibility and adaptation; (5) maintaining “time in reserve” supports resilience and psychological recovery in stressful environments, yet interventions may erode this capacity; and (6) implementers’ own time investments are frequently omitted when characterising interventions, despite being crucial for sustainability. Conclusions Viewing implementation through the prism of time exposes hidden constraints and misalignments between expectations, timelines and real-world conditions. Time in its multiple manifestations should be explicitly examined alongside theories of change and implementation frameworks to help understand why interventions in complex systems succeed or fail, especially where personnel and resources are already scarce.

Background Nursing practice is a key driver of quality care and can influence newborn health outcomes where nurses are the primary care givers to this highly dependent group. However, in sub-Saharan Africa, nursing work environments are characterized by heavy workloads, insufficient staffing and regular medical emergencies, which compromise the ability of nurses to provide quality care. Task shifting has been promoted as one strategy for making efficient use of human resources and addressing these issues. Aims and objectives We aimed to understand the nature and practice of neonatal nursing in public hospitals in Nairobi so as to determine what prospect there might be for relieving pressure by shifting nurses’ work to others. Methods This paper is based on an 18-month qualitative study of three newborn units of three public hospitals—all located in Nairobi county—using an ethnographic approach. We draw upon a mix of 32 interviews, over 250 h’ observations, field notes and informal conversations. Data were collected from senior nursing experts in newborn nursing, neonatal nurse in-charges, neonatal nurses, nursing students and support staff. Results To cope with difficult work conditions characterized by resource challenges and competing priorities, nurses have developed a ritualized schedule and a form of ‘subconscious triage’. Informal, organic task shifting was already taking place whereby particular nursing tasks were delegated to students, mothers and support staff, often without any structured supervision. Despite this practice, nurses were agnostic about formal institutionalization of task shifting due to concerns around professional boundaries and the practicality of integrating a new cadre into an already stressed health system. Conclusion Our findings revealed a routine template of neonatal nursing work which nurses used to control unpredictability. We found that this model of nursing encouraged delegation of less technical tasks to subordinates, parents and other staff through the process of ‘subconscious triage’. The rich insights we gained from this organic form of task shifting can inform more formal task-shifting projects as they seek to identify tasks most easily delegated, and how best to support and work with busy nurses.

Background Data from High Income Countries have now linked low nurse staff to patient ratios to poor quality patient care. Adequately staffing hospitals is however still a challenge in resource-constrained Low-middle income countries (LMICs) and poor staff-to-patient ratios are largely taken as a norm. This in part relates to limited evidence on the relationship between staffing and quality of patient care in these settings and also an absence of research on benefits that might occur from improving hospital staff numbers in LMICs. This study will determine the effect on the quality of patient care of prospectively adding extra nursing staff to newborn units in a resource constrained LMIC setting and describe the relationship between staffing and quality of care. Methods This prospective workforce intervention study will involve a multi-method approach. We will conduct a before and after study in newborn units of 4 intervention hospitals and a single time-point comparison in 4 non-intervention hospitals to determine if there is a change in the level of missed nursing care, a process measure of the quality of patient care. We will also determine the effect of our intervention on routinely collected quality indicators using interrupted time series analysis. Using three nurse staffing metrics (Total nursing hours, nursing hours per patient day and nursing hours per patient per shift), we will describe the relationship between staffing and the quality of patient care. Discussion There is an urgent need for the implementation of staffing policies in resource constrained LMICs that are guided by relevant contextual data. To the best of our knowledge, this is the first study to evaluate the prospective addition of nursing staff in resource-constrained care settings. Our findings are likely to provide the much-needed evidence for better staffing in these settings. Trial registration This study was retrospectively registered in the Pan African Clinical Trial Registry ( https://pactr.samrc.ac.za/Default.aspx?Logout=True ) database on the 10th of June 2022 with a unique identification number-PACTR202206477083141.

Background Advanced practice providers (APPs), including physician assistants/associates (PAs), nurse practitioners (NPs) and other non-physician roles, have been developed largely to meet changing healthcare demand and increasing workforce shortages. First introduced in primary care in the US, APPs are prevalent in secondary care across different specialty areas in different countries around the world. In this scoping review, we aimed to summarise the factors influencing the development, recruitment, integration, retention and career development of APP roles in hospital health care teams. Methods We conducted a scoping review and searched Ovid MEDLINE, Ovid Embase, Ovid Global Health, Ovid PsycINFO and EBSCOhost CINAHL to obtain relevant articles published between Jan 2000 and Apr 2023 that focused on workforce management of APP roles in secondary care. Articles were screened by two reviewers independently. Data from included articles were charted and coded iteratively to summarise factors influencing APP development, recruitment, integration, retention and career development across different health system structural levels (macro-, meso- and micro-level). Results We identified and analysed 273 articles that originated mostly from high-income countries, e.g. the US ( n = 115) and the UK ( n = 52), and primarily focused on NP ( n = 183) and PA ( n = 41). At the macro-level, broader workforce supply, national/regional workforce policies such as work-hour restrictions on physicians, APP scope of practice regulations, and views of external collaborators, stakeholders and public representation of APPs influenced organisations’ decisions on developing and managing APP roles. At the meso-level, organisational and departmental characteristics, organisational planning, strategy and policy, availability of resources, local experiences and evidence as well as views and perceptions of local organisational leaders, champions and other departments influenced all stages of APP role management. Lastly at the micro-level, individual APPs’ backgrounds and characteristics, clinical team members’ perceptions, understanding and relationship with APP roles, and patient perceptions and preferences also influenced how APPs are developed, integrated and retained. Conclusions We summarised a wide range of factors influencing APP role development and management in secondary care teams. We highlighted the importance for organisations to develop context-specific workforce solutions and strategies with long-term investment, significant resource input and transparent processes to tackle evolving healthcare challenges.

World Patient Safety Day 2025 is dedicated to \"Safe Care for Every Newborn and Every Child\". In this Perspective, we highlight how parents, relatives, and the community, through observation and communication with healthcare workers, can become full partners in the safety of newborns and children, preventing harm at home, on the ward, and throughout the health system.

Summary Points * Antibiotics that are well absorbed after oral administration are available, and the best current evidence suggests they are safe and effective for many conditions. * Belief in the superiority of intravenous antibiotics is widespread among health professionals and patients, but it is not supported by good evidence. Expanding the evidence base will provide patients and clinicians with further reassurance in specific situations, but reasons for the belief in the strength of intravenous therapy also need to be understood and addressed. * Trials expanding the evidence base might follow noninferiority designs, based on the precedent of widespread intravenous use. For many indications, the theoretical reasons for preferring intravenous therapy are not strong, and the risks of intravenous therapy are well established. It would be more logical for many indications to regard oral antibiotics as the default position and require trial designs to test the superiority of intravenous therapy. * Clarity regarding the harms and benefits of intravenous antibiotics is needed. There is potential to change global clinical practice for the better, reducing health care costs and minimizing harm to patients.

Background The UK’s health and care system is increasingly dependent on international recruitment to fill workforce gaps. In 2022–2023, nearly half of new Nursing and Midwifery Council (NMC) registrants were internationally educated nurses and midwives (IENs), with most coming from non-EU countries such as India, the Philippines, and Nigeria. While European Union (EU) nurses played a substantial role in NHS recruitment during the early 2010s, Brexit and subsequent immigrant policy changes contributed to a decline in EU recruit and a shift toward non-EU sources. This shift highlights the importance of understanding the differing experiences of EU and non-EU IENs. This scoping review explores recent literature on IENs’ experiences in the UK, with attention to similarities and differences between these groups. Methods We searched Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, EBSCOhost CINAHL, and Web of Science for peer-reviewed articles that explored the experiences of IENs in the UK between 2010-2024. Three reviewers screened articles for eligibility, and data were charted and coded thematically. Results Thirty-three studies met inclusion criteria. We identified eight key themes: (1) migration motivation, (2) registration processes, (3) workplace adaptation, (4) deskilling and recognition, (5) discrimination, (6) job satisfaction, (7) social integration, and (8) coping and support. IENs frequently migrated in search of better professional opportunities but encountered complex processes. Many struggled to adapt to the workplace, with non-EU IENs more likely to report deskilling, limited recognition of prior experience, and visa-related restrictions. Discrimination was a persistent issue, particularly for Black and non-EU IENs, leading to poor job satisfaction and career progression. EU nurses, while previously benefitting from automatic qualification recognition, increasingly reported marginalisation following Brexit. While some IENs reported receiving good support from their employers and managers, others described inconsistent or absent support, and many relied heavily on religion or informal peer networks, especially from shared cultural or national backgrounds. Conclusion IENs in the UK face diverse barriers spanning regulation, professional adaptation, social integration, and discrimination. These challenges vary by region of origin, particularly between EU and non-EU IENs. As international recruitment continues, tailored and sustained action is needed to improve IENs’ integration, retention, and wellbeing.

Background As healthcare facilities in Low- and Middle-Income Countries adopt digital health systems to improve hospital administration and patient care, it is important to understand the adoption process and assess the systems’ capabilities. This survey aimed to provide decision-makers with information on the digital health systems landscape and to support the rapidly developing digital health community in Kenya and the region by sharing knowledge. Methods We conducted a survey of County Health Records Information Officers (CHRIOs) to determine the extent to which digital health systems in public hospitals that serve as internship training centres in Kenya are adopted. We conducted site visits and interviewed hospital administrators and end users who were at the facility on the day of the visit. We also interviewed digital health system vendors to understand the adoption process from their perspective. Semi-structured interview guides adapted from the literature were used. We identified emergent themes using a thematic analysis from the data. Results We obtained information from 39 CHRIOs, 58 hospital managers and system users, and 9 digital health system vendors through semi-structured interviews and completed questionnaires. From the survey, all facilities mentioned purchased a digital health system primarily for administrative purposes. Radiology and laboratory management systems were commonly standalone systems and there were varying levels of interoperability within facilities that had multiple systems. We only saw one in-patient clinical module in use. Users reported on issues such as system usability, inadequate training, infrastructure and system support. Vendors reported the availability of a wide range of modules, but implementation was constrained by funding, prioritisation of services, users’ lack of confidence in new technologies and lack of appropriate data sharing policies. Conclusion Public hospitals in Kenya are increasingly purchasing systems to support administrative functions and this study highlights challenges faced by hospital users and vendors. Significant work is required to ensure interoperability of systems within hospitals and with other government services. Additional studies on clinical usability and the workflow fit of digital health systems are required to ensure efficient system implementation. However, this requires support from key stakeholders including the government, international donors and regional health informatics organisations.