Nursing & parental perceptions of neonatal care in Central Vietnam: a longitudinal qualitative study

In Vietnam significant progress has been made towards the achievement of reducing the under 5 mortality rate in line with the UN Millennium Development Goals (MDG 4) and the subsequent Sustainable Development Goals (Goal 3), both seeking to eradicate health inequalities and strengthen country progression though social, economical and environmental targets [1, 2]. Despite being ranked as a ‘poor’ country by the Human Development Index (116/188) [3], Vietnam’s health indicators are better than expected for a country with low income per capita [2]. Since 1990, the under 5 mortality rate in Vietnam has declined from 58 per 1000 live births to 24 per 1000 [4]. In contrast, however, neonatal mortality has decreased slowly throughout this time and still accounts for nearly three-quarters of all infant deaths [5], with large variation seen between different districts within the same province [6]. Given that infant mortality remains a significant public health issue in Vietnam, newborn care has undergone rapid expansion during the past decade [4]. All provincial hospitals now have neonatal units, although with varying resources [7]. To achieve further progress in this area, however, the knowledge, skills and systems of the neonatal workforce need to be understood, as translation and implementation of appropriate knowledge into practice remains a global health problem [6]. This is particularly significant in low and middle income settings where there is little evidence to support the notion that practices which work well in one country will work well in another [8]. Empowering the local health care workforce through knowledge and skills training is essential to ensure relevance and feasibility of the training process. In neonatal care, the nursing team play a major role in the delivery of care, constituting the largest professional group amongst the health care workforce working with newborns [9]. Nursing staff have the greatest contact with patients and their families, therefore having the greatest potential for preventative education to reduce infant mortality [9].

Nursing in Vietnam has made many advances in the past decade, including a growing recognition of an expanded nursing role following a name change from ‘Implementer of Doctors Order’ (‘Y tá’) to ‘nurse’ (‘diệu dương’) [10]. There remain significant issues however, despite the development of a national examination following graduation [9], as there are shortages of qualified faculty, a lack of teaching resources and no standardised nursing procedures [11]. There is a lack of research into the impact of nursing provision and education in Vietnam in all areas, but in particular in neonatal nursing where staff are often sent from other specialities within the hospital and receive no specific neonatal training. Without specialist knowledge in newborn care, further reductions in neonatal mortality have been hard to achieve. To address this, funding was successfully sought in 2013 to implement a structured neonatal nursing programme over an 18 month period in one pilot hospital in Vietnam. The programme, led and coordinated by Canterbury Christ Church University (CCCU), was implemented on a bi-monthly basis with experienced neonatal nurse lecturers from the UK teaching classes covering aspects of neonatal care such as thermoregulation, respiratory assessment and developmental care. Following completion of the education programme, we explored whether there were any changes in the attitudes and perceptions of the neonatal nurse participants towards their role and the role of the parents of the infants with whom they worked, at defined time points over 18 months. We also explored the parents’ perceptions to determine any changes in family experience as the nurses gained experience. This paper focuses specifically on the outcomes of this research, the first of its kind in Vietnam.

A total of 83 individuals participated in the study over 3 time points, including the same 16 nurses and 67 different parents at each time point (T1: 21 parents T2 & T3: 23 parents, respectively). As is typical for nursing in this setting, all participants were female. Results will be presented by group.

The aim of this study was to explore changes in the perceptions and attitudes of nurses and parents towards their experiences in the neonatal unit following a neonatal nursing education intervention in a single neonatal unit in central Vietnam. The study has some limitations. As interview methodology remains a fairly new concept in Vietnamese culture, our approach encountered some cultural differences which meant we did not always achieve the depth of information in our responses that we had envisaged, despite piloting the interview schedules. Demographic information was also not collected from parents, making it difficult to explore whether their experience may have been impacted by previous experience or length of stay. It is also important to note parent participants interacted with nurses who had taken part in the study alongside with a number who had not. Our parental findings are therefore based on their overall experience on the neonatal unit. What we have shown, however, is that neonatal qualitative research in middle income countries can be achieved through international partnership. The results of our interviews highlight many interesting changes in the responses over three time points. For nurses, this included changes in their perception of the nursing and parental role, and a growing awareness of ethical issues and challenges communicating sensitive information with parents and professional standards. For parents these changes included a growing sense of wanting more participation in their infants’ care through information sharing about their baby’s condition, practical advice around baby care, a growing awareness of ward practices which affect their engagement and satisfaction with care, and an increase in positive feedback for nurses.

These results provide insight into the culture of neonatal nursing in one unit in central Vietnam, and its continuing practice changes following an educational intervention. For nursing staff, a growing sense of professional identity can be seen through their increased confidence to interact with the medical team, their support of parents, and their pride in the care they provide and the unit in which they work. Whilst a growing number of nurses reported that parents should support them in their work, this could reflect an increase in awareness of the extent of their nursing role in developmental care, pain management, and symptom recognition and management. It may also be reflective of a growing belief in the ability of parents to provide care for their own infant during admission. For parents, the gradual increase in wanting more involvement in their infant’s care may reflect the nurses’ perceived expanding role. Parents wanting and potentially gaining more involvement in their infants’ care could promote awareness of practicalities which hinder their ability to do so. The difficulties in communication with parents that nurses reported is consistent with the parental responses that they gain most of the information about their baby’s condition from the doctors along with the decrease in reported information sharing and updates. An area for future training may therefore include communication skills training for nurses on how to communicate effectively with parents, thereby improving both nursing and parental experience.

Very few studies have performed qualitative research in this area; however one study in particular carried out qualitative interviews with 198 parents of infants who were hospitalised within the first month of life in Cambodia, Malaysia, Laos and Vietnam, and explored perceived barriers to newborn care [21]. Results highlighted that parents had low levels of satisfaction with their neonatal experiences, with parents from one unit in Hanoi, Vietnam, specifically (n = 48) citing issues such as availability of medications, privacy, cleanliness and staff demeanour as areas which negatively impacted their experience. A small number of parents in our study highlighted hygiene as an issue affecting their satisfaction, although this was often directed towards other parents on the unit rather than the unit itself. The positive appraisal of staff in our own study is in contrast with the results from Martinez et al. This could be attributed to limitations in that the infants of the parents interviewed were still inpatients in our study, and therefore the parents may have felt uncomfortable criticising the providers of their infants care; alternately, it could reflect a change in the attitudes of the nursing personnel towards parents following training in family-centred care. Martinez et al. also conducted surveys with 212 health care providers, exploring their perceptions of barriers in providing care. The surveys undertaken with health care providers in Vietnam (n = 63) highlighted a lack of nursing staff as a concern to providing more aggressive treatment on the neonatal unit [21]. While this was reported by nurses in our study, we also found that parents felt that there should be more staff to help mothers care for their infant. Reports by the nurses that parents should help support them to care for the infants also suggests a need for more nursing support on the neonatal unit. Health care providers cited a lack of staff training as impacting the provision of neonatal care in the study by Martinez et al. [21], which is emphasised by our own study in which the nurse highlight their sense of pride from their training through increased knowledge, impact upon practice and improved infant care. This suggests that implementing an educational intervention can build staff confidence, lead to an increased sense of professional identity, and help nursing staff to perform their role. A systematic review of motivation and retention of health workers in developing countries found that career development, educational opportunities and recognition from managers were major motivational themes [22]. The Human Development Report from the United Nations suggests better job opportunities through education and development could result in a more engaged workforce who are more efficient, helping in turn to maintain and raise the standards of their care as a source of pride [23]. This area requires further research to determine whether a more educated and motivated nursing workforce may facilitate a reduction in infant mortality.

The majority of research undertaken in the neonatal context in Vietnam focuses on causes of infant mortality and morbidity [4, 5, 24, 25], implementation and outcomes of community-based interventions [8, 26, 27] and the knowledge base of health care staff [6, 7]. The results from these studies collectively suggest that knowledge transfer and resulting practice change may be hugely important factors in reducing infant mortality. Identification of areas of knowledge improvement such as infection control, symptom recognition and temperature control are highlighted across many of the studies. Whilst our study does not directly assess the knowledge of the staff, it suggests an increasing sense of professionalism accompanying an expanding understanding of the extent of the neonatal nursing role. Further research is therefore required with the nurses in our own study group to determine the degree of knowledge acquisition, and whether the content of the educational training impacts upon their attitudes and opinions of neonatal care. Similarly assessment of retention of knowledge is critical, as decreasing competence over time is a concern [28]. In order to effect changes in practice, teaching and learning needs to be maintained over a sustained period of time to ensure clinical currency. Recent studies have shown that this is feasible and successful. Thukral et al. evaluated an educational programme with newborn care providers in resource limited settings in India and Kenya through satisfaction surveys, multiple choice examinations, objective structured clinical exams (OSCEs) and confidence assessments [29]. Shrestha et al. successfully examined changes in knowledge and practice after a care of the newborn intervention with nurses in maternity, emergency and delivery units in India [28]. Development of effective baseline and outcome measures is required to formally assess the nurses in our own study for future intakes of staff into the education programme, and if the interventional model is shared with other local hospitals.

Despite the lack of research into parental experiences in neonatal care in Vietnam and surrounding similar countries, the results from our study suggest that the needs of parents who have an infant in the neonatal unit are universal and not impacted by the country or it’s economic standing. Parents reporting a desire for more information and more participation reflect interview studies with parents from many developed countries such as the UK, USA and Australia; [30‐33] the main difference being that parent outcomes are arguably better defined, measured and studied in developed countries. Further research into parental experiences and outcomes (such as stress, anxiety, post-traumatic stress, depression) may help us to understand more about the parental experience and how to support them in countries such as Vietnam. This may ultimately impact upon infant mortality and morbidity, as negative prior experience of neonatal care served as a barrier to parents accessing care for future infants in the study by Martinez et al. [21] More positive parental experience may therefore result in parents being more willing to access neonatal care for subsequent babies, potentially helping to improve infant outcomes in developing countries.

This study has highlighted that the introduction of an educational intervention can produce short term effects upon both nursing and parental experience of neonatal care in one unit in central Vietnam. Further research is required to determine the long term impact of the intervention, the ability of nurses to translate knowledge into clinical practice through assessment of nursing knowledge and competence, and the impact and needs of parents. Understanding more about these factors will allow us to continue to improve the experiences of parents and nurses and highlight how these areas may contribute towards the reduction of infant mortality and morbidity in Vietnam.