Healthcare workers’ views on the use of continuous positive airway pressure (CPAP) in neonates: a qualitative study in Andhra Pradesh, India

Objectives, design and setting

The study had three objectives: 1) to explore the perspectives and experiences of healthcare workers on the use of CPAP in neonates in a middle-income country: 2) to identify what might help or hinder implementation of CPAP; and 3) to provide suggestions for what would be needed to improve the use of CPAP and further scale up in India and other middle-income countries.

To achieve these objectives, a qualitative study was conducted with healthcare workers from hospitals in Andhra Pradesh, India. Andhra Pradesh located in south east India, is the eighth largest state in India, covering an area of 160,205 km and with a population of 53 million [14]. The institutional delivery rate was 91.5% in 2015 (of which 38.3% were in government facilities), compared to the Indian average of 83% [15, 16]. The newborn mortality rate in 2015 was 28 /1000 live births, in line with the Indian average [16].

CPAP was introduced in neonatal units of government facilities in Andhra Pradesh from 2007, but most facilities started using CPAP from 2012 onwards (see Additional file 1 for details). The Indian Ministry of Health and Family Welfare recommends that CPAP should be used in tertiary centres (medical colleges) only. However, CPAP has also been introduced in level 2 facilities (district hospitals) in Andhra Pradesh following local initiatives, such as the donation of CPAP machines by wealthy entrepreneurs, and through the support of UNICEF within its broader programme of supporting the implementation of Special Newborn Care Units. UNICEF, in partnership with the state health authorities, developed clinical guidelines, organised workshops to train health care workers, and supportive supervision in hospitals to assist with the implementation of CPAP.

Sampling and recruitment

We used purposive sampling. We included two types of hospitals (district hospital, and medical colleges) and two types of healthcare workers (doctor and nurse) to ensure enough diversity of views. The inclusion criteria for hospitals were that they had to be from the government sector and that their neonatal unit(s) had to be equipped with CPAP machines (at least one conventional bubble CPAP machine). Moreover, we included hospitals from the north and south of Andhra Pradesh, and ensured the sample included district hospitals and medical colleges. We developed a sampling frame by contacting all neonatal units of Andhra Pradesh. Of the 19 hospitals identified as using CPAP, 15 healthcare facilities (eight district hospitals and seven medical colleges; seven hospitals from the north and eight hospitals from the south) were selected (see Additional file 1 for hospital characteristics). The inclusion criteria for healthcare workers were that they had to be working in the neonatal unit of the selected hospitals, clinically active, and providing CPAP care to their patients.

Focus group discussions (FGDs) were conducted with nurses to elicit norms and group-shared experiences of using CPAP in their neonatal units. Doctors were not available in sufficient numbers for FGDs without significantly disrupting clinical activities, so in-depth interviews (IDI) were conducted with this cadre.

The research team visited all hospitals included in the study. The time of the visit was agreed in advance with the Head of Department. On the day of the visit, one of the doctors working in the neonatal care unit was invited to take part in an IDI. All doctors agreed to participate in the study. Prior to the visit, the Head of Departments invited at least six nurses to take part in an FGD. We do not know if some nurses declined to participate as we did not request this information.

Data collection

Data collection took place between May and August 2016. Data were collected by two local female nurses experienced in social research and by a male paediatrician (JED) trained in qualitative research. JED’s research area of interest is the feasibility of using new technologies for child care in LMICs. Interviews were conducted in the participants’ health facilities. No one other than researchers and participants were present.

A topic guide was developed for FGDs and IDIs. The topic guide for FGDs was translated from English to Telugu, the local language of Andhra Pradesh, by the two local nurses who were fluent in both English and Telugu. The nurses conducted the FGDs in Telugu. JED was present during the FGDs and a debriefing was organised at the end of each FGD to discuss whether the topic guide needed to be amended, in light of new topics arising from the FGDs. The debriefings and the different amendments made iteratively to the topic guide jointly by JED and the two nurses ensured that the latter had a good understanding of the objectives of the study and that the topic guide was used in the best way to address the research questions, and consistently throughout the FGDs. The topic guides were used to ensure important aspects were covered but were used flexibly so participants could elaborate on other points that were important to them. The topic guide (Additional file 2) included the following domains: the experience of the healthcare provider, the perceived benefits and potential limitations of CPAP as an intervention to treat newborns with respiratory distress, the different aspects of CPAP and factors promoting or hindering the application of these, potential complications of CPAP, the type of support healthcare providers required to be able to use CPAP. All FGDs were audio-recorded, fully transcribed and translated from Telugu to English by one of the nurses who conducted the FGDs. All IDIs were conducted in English by JED, as all included doctors were fluent in English. IDIs were audio-recorded, and fully transcribed by JEDs.

No formal recommendation about corrective measures to address potential inappropriate use of CPAP was provided to participants. To avoid any concerns among participants that malpractice would be reported, we clarified in the consent process that clinical practice was not being assessed, and that recommendations arising from the study would be for all healthcare facilities in general and not for individual facilities. However, the research team provided informal clarifications at the end of the IDIs and FGDs when participants made specific requests.

Data analysis

The thematic framework approach, a transparent matrix-based approach suited to applied research, was used to analyse the data [18]. The analysis was mainly inductive in nature. An initial list of codes was generated through line-by-line coding of a selection of the transcripts of the IDIs and FGDs (Additional file 3). Transcripts were read by a second researcher who independently generated another set of initial codes. Both researchers then agreed on an analytical framework comprising the most relevant codes, which was used to manually code the entire data set. Using matrices to display data relevant to each theme, further exploration and interrogation of the data identified similarities and differences across the dataset (Additional file 4). Through discussions with the whole research team, themes were further refined to provide clear descriptions and explanations. Five final themes were identified that reflect participants’ perspectives and experiences, and, relate to the use of CPAP in neonates.

Shortages of supplies, infrastructure, and staff mean CPAP is not always available and/or of the highest quality

Shortages of consumables and equipment and problems with infrastructure were common problems and had been experienced in all settings. Most participants reported shortages of specific consumables such as nasal prongs and respiratory circuits. Masks and equipment were sometimes available but in sizes ‘that are not suitable’ for preterm babies. Doctors from only two healthcare facilities reported that consumables were in good supply. Some doctors and nurses argued that additional CPAP machines were needed, because there were ‘not enough machines’ or many machines were broken. Although maintenance services were generally available, the service provided was often described as “not timely” and “not always effective”.

Shortages of staff was also a common problem reported in all interviews. Participants reported frequent ‘rotation’ of staff. When nurses trained in neonatal care were partially deployed in other wards, they lost ‘confidence’ and skills in the use of CPAP effectively. This was reported more in district hospitals than in medical colleges.

Most doctors and nurses had found it difficult to provide respiratory support with CPAP when they were facing these constraints, which were perceived as ‘compromising’ the care provided. Some doctors and nurses reported they could only provide standard care (oxygen and antibiotics), or had to use mechanical ventilation (which they considered as potentially harmful) when consumables and equipment for CPAP were insufficient. Others reported disinfecting and re-using consumables for CPAP, or modifying nasal prongs of inappropriate size, which they recognised was ‘not ideal’. The lack of a functioning X-ray machine was reported as problematic by some doctors because this meant pneumothorax could not be diagnosed. Half of the nurses reported that they had to sometimes (reluctantly) wean babies off CPAP too early to provide CPAP to newly admitted sick neonates. Staff from medical colleges had a higher caseload and were, overall, more concerned and had faced more of these problems compared to healthcare providers from district hospitals.

Poor organisational support hinders optimal implementation of CPAP and neonatal care

The way in which neonatal units are organised and run was reported by healthcare providers as being the cause of many of the constraints faced. Some doctors and most nurses believed they were not supported by the hospital management team or local authorities. In many cases, doctors and nurses described how their neonatal units were regarded as ‘external’ to the rest of the hospital or as distinct structures because they were under the authority of the National Health Mission, a federal government initiative aimed at improving neonatal health. The co-existence of two parallel authorities (the hospital management and the National Health Mission) created confusion about which authority was responsible for staffing and supplies, leading to major supply shortages and redeployment of staff reported above.

Healthcare providers feel powerless to provide better care for neonates

The struggle to provide care under ‘quite hectic’ circumstances and sometimes being ‘overwhelmed’ by patient numbers affected staff and made one doctor question ‘how can the sisters cope?’. There was a sense of ‘powerlessness’ expressed by most nurses and some doctors when faced with shortages of the basic supplies required for CPAP as well as by electricity “blackouts”. Some participants, particularly doctors, felt they were ‘overwhelmed’ by the number of cases requiring respiratory support. Working conditions were perceived as ‘stressful’ by some nurses, others described how they were ‘struggling’. Some nurses felt guilty for not being able to provide better care. Some nurses were afraid of harming neonates because of the need to reuse consumables.

Healthcare providers perceive CPAP as a beneficial intervention

Despite the constraints, almost all doctors and nurses mentioned that they ‘are still using CPAP’. Most doctors said that they would recommend it to colleagues from other healthcare facilities. The benefits of using CPAP in terms of preventing the ‘need for’ and the ‘complications of’ mechanical ventilation were recognised by most of the healthcare providers. Doctors and nurses highlighted that CPAP allowed efficient respiratory support for small neonates and reduced the use of mechanical ventilation. Moreover, not having to refer babies to a better equipped healthcare facility was seen as a major benefit of CPAP. Many doctors and nurses mentioned that fewer “referrals out” had been needed since they commenced using CPAP, and that they were better able to manage babies with respiratory distress in general. Organising referrals was difficult given the scarcity of ambulances, the need to convince parents to move to another distant facility, and because neonates were at risk of deteriorating during the transfer. Doctors reported that they had noticed a reduction in neonatal mortality in their units which they attributed to the use of CPAP. In terms of complications, all nurses and almost all doctors reported that they saw few complications when using CPAP, and that any harm caused to neonates was mainly related to the different constraints described above, rather than to CPAP itself.

CPAP enables nurses to work independently

Almost all doctors and nurses referred to CPAP as an ‘easy procedure’ or that they could ‘operate the machine with ease’. Because of the perceived technical simplicity of applying CPAP, most nurses and some doctors felt that trained nurses could initiate CPAP ‘independently’. This is in sharp contrast to mechanical ventilation which required doctors to be present. Nurses were confident and felt satisfied that they ‘do not need doctors to operate CPAP’ and that ‘we nurses operate the machines on our own…without the help of doctors’. Allowing nurses to be more independent in providing advanced care to neonates was reported to, at least partially, resolve the bottleneck caused by lack of availability of doctors.

Main findings

To the best of our knowledge, this is the first study to explore the perceptions and experiences of healthcare workers from a middle-income setting about their use of CPAP in neonates, and the factors affecting implementation of CPAP in newborn care units in such settings. Healthcare providers working in neonatal units in this study faced several constraints that hindered the implementation of CPAP. Shortages of staff, equipment, consumables and a non-supportive work environment meant that healthcare providers could not always provide CPAP when they knew it was needed for a baby, nor could they provide the level and quality of care they would have liked to. Providing care under these circumstances can leave staff feeling “powerless”. But despite such constraints, healthcare providers recognised the potential of CPAP as a life-saving treatment. Using CPAP was perceived as technically straightforward and it allowed nurses to provide advanced care to neonates “independently of doctors”, which is particularly helpful given the shortage of other trained specialist staff at neonatal units in district and tertiary level healthcare facilities.

Staff shortages were explained by the feeling that the management teams in government hospitals tend to not perceive neonatal care units as akin to intensive care units in terms of staffing requirements but consider that the nurse-patient ratio can be the same as for the general paediatric wards. Other studies in low and middle-income settings have identified similar situations, where staff report that there are too few healthcare workers in place to manage babies who require CPAP and to ensure suitable regular monitoring is provided [19]. The global Every Newborn Action Plan to reduce neonatal mortality, emphasises that availability of human resources and sustainable supply chains for medical products are major bottlenecks to the provision of quality inpatient neonatal care [20]. The Indian Newborn Action Plan also recognises that quality of care in hospitals is affected by a lack of human resources [21]. The findings of this study further highlight the need to address staff, as well as consumables and equipment shortages when new care packages such as CPAP are introduced and/or scaled up in a country.

Healthcare providers reported that there were problems regarding the organisational structure related to recruitment, management, and supply of consumables and equipment. Most neonatal units in India have been established by the federal government under the National Health Mission but are located within hospitals under the jurisdiction of state governments. Because the responsibilities of both authorities in this setting are unclear to many healthcare providers and managers, there can be problems with allocation of budget, human resources, consumables and equipment. The World Health Organization recommends that every health facility should have enough managerial and clinical leadership to foster an enabling environment, including a supportive environment for the staff, to improve the quality of newborn care [22]. Our findings provide an illustration of the impact on working conditions of the lack of leadership and organisational capabilities in health service.

The fact that healthcare workers recognised CPAP as a new evidence-based treatment option for babies with neonatal distress and are enthusiastic about using CPAP was surprising but similar findings were reported from South Africa [23]. Moreover, in terms of CPAP allowing nurses to be more independent, studies from Fiji and Ghana also reported that nurses could competently administer CPAP in the absence of doctors [6, 19].

Limitations of the study

This study includes the perspectives of both doctors and nurses using CPAP in neonates. A female nurse fluent in the local language and experienced in interviewing healthcare workers facilitated the FGDs with nurses to obtain rich and detailed information. However, it was not possible to interview hospital managers, state health authorities, nor maintenance technicians, whose perspectives would also be valid and would add another dimension to the data, because of time and resources constraints. Purposive sampling was used to recruit a range of junior and senior doctors, nurses with different level of experience, and staff from two levels of care. However, nurses were selected by the Head of Department, which may have introduced selection bias. Finally, this study only sought to explore the experiences and perceptions of healthcare workers about the use of CPAP, and not to assess their knowledge and skills, which may also impact on optimal use of CPAP.

Implications for practice and further research

India has shown a strong commitment to reducing neonatal mortality over the last decades. Availability of advanced neonatal care services has increased through major investments by the government; 602 special newborn care units have been established and more will be implemented in the future [24]. However, there are also concerns about the quality of care provided in these units. This study illustrates what is needed to introduce and scale-up an additional care package such as CPAP care in this context. Availability and quality of CPAP rely not only on “the machine” being there but on a complete enabling environment including trained staff, consumables, maintenance, and ability to diagnose and manage complications of CPAP use in neonates. Staff motivation to use new technologies is high. But, policy makers and managers should be aware that staff motivation could be adversely affected in the long term if constraints in the working environment are not addressed satisfactorily. These include staff training and a better staff-patient ratio. Efforts should also be put in place to improve the integration of neonatal units with the rest of the hospitals, better organization particularly in terms of providing regular supplies of consumables, and strengthening accountability through monitoring and supportive supervision. Operational research should investigate the quality of CPAP use, particularly the knowledge and skills of the staff using CPAP, and the impact of the introduction and scale-up of CPAP on important clinical outcomes such as neonatal mortality, and adverse events.