Specialized neonatal nursing skill development and nursing implementation initiatives in NICU

<p><strong>BACKGROUND</strong></p><p>Years of armed conflict, natural disasters, a pandemic, and restrictive social policies targeting women have made Afghanistan one of the world’s most complex humanitarian crises. In 2015, Afghanistan reported a high estimated neonatal mortality rate of 22 per 1,000 live births. Of these deaths, approximately three-fourths occur within the first week of life, highlighting this period as the most critical for neonatal survival.</p><p></p><p>Médecins Sans Frontières (MSF) supports Boost Provincial Hospital in Lashkargah, Helmand Province, Afghanistan. MSF supports a 78-bed Neonatal Intensive Care Unit (NICU), with patients separated into inborn, outborn, and tetanus rooms.</p><p></p><p><strong>METHODS</strong></p><p>Between 2023 and 2025, the NICU team undertook sustained efforts to improve the quality of nursing care in a high-volume NICU. These efforts included nursing practice changes, implementation initiatives, improvements to supplies and biomedical equipment, specialized training, remote neonatal nursing implementer support, and ongoing bedside mentorship.</p><p></p><p>The NICU nursing team conducted three cohorts of the 13-week TEMBO Newborn Care (NC) course, consisting of self-paced online modules followed by classroom sessions with remote and in-person facilitation. All nurses also received annual Helping Babies Breathe training. An essential neonatal nursing skills logbook was introduced for all nurses to track practice of key competencies, including neonatal assessment, breastfeeding support, cord care, safe medication administration, nasogastric tube insertion and maintenance, and related skills. Monthly key topics, standard operating procedures (SOPs), and skills were reinforced through direct bedside mentoring.</p><p></p><p>Infection prevention and control (IPC) was strengthened through daily hygiene rounds observing hand hygiene, cleaning and disinfection of equipment, waste segregation, breastmilk safety, and peripheral intravenous catheter monitoring. Each night shift designated an IPC focal nurse to conduct hygiene observations.</p><p></p><p>A systematic admission checklist was implemented for all new NICU admissions, including caretaker welcome messages, ward orientation, visitor policy explanation, hygiene kit distribution, and support for postnatal care visits. Daily health promotion messages focused on breastfeeding, hygiene, kangaroo mother care (KMC), and maternal nutrition.</p><p></p><p>A standardized NICU patient file was introduced, including an admission chart, treatment plan, neonatal early warning signs, fluid and feeding prescriptions and monitoring, medical and nursing notes, and weight curves. Nursing quality indicators, such as chart audits and patient identification monitoring, were reviewed monthly.</p><p></p><p><strong>RESULT</strong></p><p>In 2024, the NICU faced significant operational challenges, including a bed occupancy rate of 135%, with an average of 492 neonatal admissions per month and approximately 2,267 deliveries per month in the maternity ward. Despite these constraints, the Newborn Care course achieved high uptake, with 80% of NICU nurses (35 of 44) completing the training. Nurses reported the training to be highly relevant and beneficial to their practice. One nurse stated, “Completing the NC course, I learned more important knowledge and skills for working in NICU than in my previous general training.”</p><p></p><p>Overall neonatal mortality in the NICU appeared to decline in 2024 compared to the pre-implementation period in 2022.</p><p></p><p><strong>CONCLUSION</strong></p><p>The implementation of specialized neonatal nursing training and best-practice measures had a positive impact on staff performance and contributed to improved quality of care in the NICU. The combination of structured nursing implementation measures and hands-on leadership fostered best nursing practices and a positive learning culture, supporting the development and maintenance of specialized neonatal nursing competencies over time.</p>