Exploring quality of care in neonatal and paediatric inpatients

<p dir="ltr">Background: In neonatal care, planning and allocating the nursing workforce is particularly complex, as it involves balancing unpredictable fluctuations in patient numbers with varying levels of infant acuity. Although international guidelines recommend safe registered nurse (RN) to patient ratios, no national staffing guidelines are in place in Sweden, raising concerns about whether staffing levels adequately support safe and evidence-based care. Furthermore, advances in neonatal intensive care have partly been achieved at the cost of increased exposure to discomfort and pain, making effective pain management essential; yet clinical practices remain inconsistent. Another challenge in paediatrics and neonatal care is healthcare-associated harm (adverse events [AEs]), which can cause suffering, increased costs, and reduced quality of care. Even so, up-to-date systematic reviews on paediatric AEs are limited, and evidence on neonatal AEs in the Swedish context remains sparse, constraining the development of targeted preventive strategies and safety initiatives.</p><p dir="ltr">Aim: The overall aim of this thesis was to explore quality of care in neonatal and paediatric inpatients by evaluating nurse staffing structures, care processes, and clinical outcomes.</p><p dir="ltr">Methods: Studies I, II, and IV were observational cohort studies with longitudinal designs, built on two separate neonatal cohorts. The studies were conducted at a university hospital in Sweden, including three neonatal intensive care units. Study III was a systematic review of publications reporting AEs in inpatient paediatric settings. Across the studies, data were obtained from hospital registries, electronic health records, the national neonatal quality register, and bibliographic databases. In study I, RN staffing provision was compared with international recommendations, adjusting for both infant numbers and acuity. Study II explored the association between RN staffing levels and infant pain assessment outcomes. Study III synthesised research identifying paediatric AEs through manual record review and study IV investigated the incidence and characteristics of AEs among neonatal infants using retrospective record review with a Trigger Tool.</p><p dir="ltr">Results: In study I, RNs accounted for a median of 47% of bedside shift hours relative to nursing assistants. Across the 1,008 included shifts, 81% fell below international RN staffing guidelines, indicating frequent understaffing. Study II indicated that adequate RN staffing levels were associated with 70% higher odds of adherence to recommended pain assessment frequency among term infants. Adequate staffing was also associated with 63% lower odds of infant pain compared with major understaffing. Study III revealed considerable variation in reported AE rates. In studies using the Global Trigger Tool (or related Trigger Tool), the predicted proportion of admissions with at least one AE ranged from 3.8% to 53.8% in general care and from 6.9% to 91.6% in intensive care. In study IV, the overall AE rate was 240 AEs per 100 neonatal admissions, corresponding to 52% of the included infants. Of these events, 85% were considered preventable, and serious consequences were rare, with most adverse events assessed as related to nursing care.</p><p dir="ltr">Conclusions: Across the four studies, neonatal care was often delivered under RN staffing conditions below recommended levels, with measurable implications for quality of care. Adequate staffing was associated with more consistent pain management and lower levels of infant pain, highlighting the central role of nursing resources in protecting vulnerable newborns. The synthesis of previous research revealed substantial variation in reported AE rates, largely driven by methodological differences that limit comparability. Adverse events in neonatal settings were common and often preventable, indicating clear opportunities for improvement. Together, these findings underscore the importance of sufficient staffing levels and proactive safety initiatives to improve the quality of care.</p><h3 dir="ltr">List of scientific papers</h3><p dir="ltr">I. <b>Dillner P,</b> Göransson KE, Norman M, Unbeck M, Förberg U. Nurse staffing skill mix and acuity-adjusted provision ratios in Swedish neonatal care: A cohort benchmark study. International Journal of Nursing Studies Advances. 2026;10:100471. <a href="https://doi.org/10.1016/j.ijnsa.2025.100471">https://doi.org/10.1016/j.ijnsa.2025.100471</a></p><p dir="ltr">II. <b>Dillner P,</b> Unbeck M, Göransson KE, Norman M, Förberg U. Associations between nurse staffing and pain outcomes in neonatal care. [Manuscript]</p><p dir="ltr">III. <b>Dillner P*</b>, Eggenschwiler LC*, Rutjes AWS, Berg L, Musy SN, Simon M, Moffa G, Förberg U, Unbeck M. Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis. BMJ Quality & Safety. 2023;32(3):133-49. <a href="https://doi.org/10.1136/bmjqs-2022-015298">https://doi.org/10.1136/bmjqs-2022-015298</a></p><p dir="ltr">IV. <b>Dillner P,</b> Unbeck M, Norman M, Nydert P, Härenstam KP, Lindemalm S, Wackernagel D, Förberg U. Identifying neonatal adverse events in preterm and term infants using a paediatric trigger tool. Acta Paediatrica. 2023;112(8):1670-82. doi:10.1111/apa.16814. <a href="https://doi.org/10.1111/apa.16814">https://doi.org/10.1111/apa.16814</a></p><p dir="ltr"><br>* Shared first authorship.</p>