Parental and Healthcare Provider Perspectives on the Care and Outcomes of Premature Newborns in Two Referral Hospitals in Southwestern Nigeria

Parental and Healthcare Provider Perspectives on the Care and Outcomes of Premature Newborns in Two Referral Hospitals in Southwestern Nigeria | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Parental and Healthcare Provider Perspectives on the Care and Outcomes of Premature Newborns in Two Referral Hospitals in Southwestern Nigeria Deborah Tolulope Esan, Ayodeji Olubunmi Ogunmuyiwa, Waliat Odunayo Ayinde, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7892012/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Preterm birth remains a leading cause of neonatal mortality and morbidity globally, with sub-Saharan Africa bearing a disproportionate burden. Preterm infants require specialized, high-quality care to improve survival and developmental outcomes. The quality of care in neonatal intensive care units (NICUs) of tertiary hospitals is critical; however, in low- and middle-income countries, challenges persist related to resource availability, clinical practices, and parental involvement. Understanding the perspectives of parents and healthcare providers is essential to identify gaps and improve care quality. Methods A qualitative study was conducted using in-depth interviews with both the parents of premature newborns admitted in the NICUs of the Federal Teaching Hospital Ido-Ekiti and the Ekiti State University Teaching Hospital and their healthcare providers. Purposive sampling was employed to recruit participants. Data collection occurred over a four-week period at each of the referral hospitals. Data was analyzed using content analysis, following a systematic four-step process. Results Twelve participants were recruited, 10 females and 2 males, ranging in age from 21 to 48 years old, who were members of 2 of the major ethnic groups in Nigeria: Yoruba and Igbo. Three main themes emerged: for the parents, the most important concern was the need for quality care, whereas for the providers, the most important concern was the challenges in providing quality care. Both groups considered equally important collaboration and communication between health care workers and the patients’ families. Both parents and healthcare professionals emphasized the importance of a well-equipped and safe physical environment, individualized care, and effective communication. Key challenges included staff shortages, inadequate equipment, and limited opportunities for parents to bond with their infants. Conclusion The study highlights the need for healthcare organizations to prioritize resource allocation, adequate staffing, and family-centered care approaches to improve the quality of care for preterm infants Premature infants quality of care neonatal intensive care unit healthcare providers parents’ perspectives referral hospitals qualitative study INTRODUCTION Despite advances in neonatal care, preterm birth remains a leading cause of neonatal morbidity and mortality worldwide (Cao et al., 2022). Preterm infants, born before 37 weeks of gestation, require specialized and high-quality care to improve survival and developmental outcomes. The quality of care provided in neonatal intensive care units (NICUs) of tertiary hospitals plays a critical role in determining these outcomes. Both healthcare providers and parents are central to this care process, influencing and experiencing the care delivered. Exploring their perspectives offers valuable insights into the actual care environment, challenges, and opportunities for improvement. Recent evidence highlights systemic challenges such as shortages of skilled staff, inadequate resources, and inconsistent adherence to clinical guidelines, which compromise care quality (Bayou et al., 2024). Furthermore, parental involvement and communication with healthcare providers are often limited, affecting parental satisfaction and infant well-being (Ketshabathupa, 2024). This study aims to assess the quality of care for preterm infants by integrating the viewpoints of healthcare providers and parents in two tertiary hospitals. Despite global efforts to improve neonatal care, significant challenges remain in the quality of care for preterm infants in tertiary hospital settings. Many facilities lack up-to-date clinical guidelines for preterm and low birth weight infants, and where guidelines exist, adherence is inconsistent (Bayou et al., 2024). Human resource challenges, including shortages of skilled staff, poor motivation, and inadequate supervision, further undermine care delivery. Beyond merely clinical difficulties, parental and provider experiences in LMICs are laden with emotional and logistical hardship. In Ghana, caregivers commonly struggle with insufficient information, limited education on their infants’ care, and a NICU setting they characterize as strange or intimidating, increasing anguish and hindering their ability to participate effectively to newborn care (Boadu et al.,2024). Nearly 56% of Tanzanian nurses who provided preterm care had never had any on-the-job training, and their understanding of topics like glucose and temperature monitoring was very lacking (Mwikali et al., 2023). Additionally, shortages of essential equipment, medications, and infrastructure are common (Bayou et al., 2024). Parents often report feeling excluded from care decisions and unsupported emotionally, which can increase stress and negatively affect infant outcomes (Ketshabathupa, 2024). Variations in care practices and outcomes across hospitals suggest the need for standardized quality measures and improved care approaches (Lee et al., 2022). Understanding these multifaceted issues from both provider and parent perspectives is essential to inform targeted interventions that enhance care quality and infant outcomes. Research Objectives To explore healthcare providers’ perspectives on the quality of care delivered to preterm infants in two tertiary hospitals, including challenges and facilitators. To investigate parents’ experiences and perceptions regarding the care and support received for their preterm infants. To identify systemic, resource-related, and communication barriers affecting the quality of care. METHODS Study Design This study employed a qualitative descriptive design to explore healthcare providers' and parents' perspectives on the quality of care for preterm infants. Participants and Setting The study was conducted in two tertiary hospitals with established Neonatal Intensive Care Unit (NICU) facilities: Federal Teaching Hospital Ido-Ekiti (FETHI) and Ekiti State University Teaching Hospital (EKSUTH). Participants included healthcare providers (neonatologists, nurses) involved in preterm infant care and parents caring for preterm infants admitted to the NICUs. Inclusion and Exclusion Criteria Healthcare providers (nurses and neonatologists) and parents were included if they were involved in the care of preterm infants admitted to the NICU at FETHI and EKSUTH. Participants were excluded if they were unwilling to participate in the study are excluded Sampling Technique Purposive sampling was used to recruit participants, as it allows for the selection of information-rich cases that can provide in-depth insights into the phenomenon of interest in this study to enhance robust and reliable conclusions. Sample Size Determination The sample size was determined by data saturation, which is the point at which no new themes or information emerge from additional data collection. Based on previous qualitative studies in this area, 12 participants from the research setting were used: three preterm parents (mothers); seven nurses, and two neonatologists. Data Collection Data collection occurred over a four-week period at each of the referral hospitals. For Federal Teaching Hospital, Ido-Ekiti, data collection was between November 1, 2021, and November 30, 2021, and between February 3, 2022, and March 5, 2022, for Ekiti State University Teaching Hospital . Data was collected through semi-structured interviews. Interview guides were developed based on the WHO quality of care framework and existing literature, covering themes such as clinical practices, resource availability, communication, parental involvement, and emotional support. Interviews were audio-recorded with consent, conducted in a private setting, allowing for open and confidential discussion and guided by category-specific questions. Participants completed demographic forms and were assured of comfort, confidentiality, and their right to withdraw. The first and the last authors, with extensive experience in qualitative research and healthcare studies, conducted the interviews. The researchers-maintained objectivity and acknowledged potential biases. Interviews lasted approximately 30-60 minutes, allowing for in-depth exploration of participants' perspectives and experiences. Recordings were stored securely and were only accessible to the research team. Data Analysis The interviews were coded and analyzed using NVivo 12 (QSR International), which facilitated the systematic organization, coding, and development of themes and subthemes from the transcribed data. Interviews were audio-recorded via tape recorder, transcribed verbatim, and analyzed using a content analysis approach (Craig et al., 2021; Krippendorff, 2018). This approach enabled the researcher to identify patterns, themes, and meanings in the data. The data analysis process involved four steps. First, data preparation ensured the accuracy and completeness of the transcribed interviews, which were then organized and formatted for analysis. Second, coding involved an inductive approach to identify concepts and themes emerging from the data, followed by focused coding to refine and categorize codes into broader themes and subthemes. Third, theme development involved identifying patterns and relationships in the data to develop themes, which were refined and defined through an iterative process. Finally, subtheme development further elaborated on the themes, providing a nuanced understanding of the data. Ensuring Rigor The rigor of this qualitative study was ensured through several measures (LaDonna et al., 2021). Firstly, data saturation was achieved by continuing data collection until no new themes or information emerged. Member checking was also conducted, where participants were provided with transcripts of their interviews to verify accuracy and ensure that their perspectives were captured correctly. Additionally, peer debriefing was undertaken, involving regular discussions with peers and experts in qualitative research to review the study's methodology, data collection, and analysis processes. An audit trail was maintained, detailing the research process, including data collection, analysis, and decision-making. Finally, reflexivity was practiced, where the researcher's own biases and assumptions were acknowledged and reflected upon throughout the study to minimize their impact on data collection and analysis. To ensure balance in analysis, the researcher, for instance, kept a reflexive journal in which, following each interview and coding session, personal thoughts, emotional reactions to the interviews, and potential assumptions were recorded. This allowed the researcher to critically reflect on how their background, beliefs, or expectations might influence interactions with participants or interpretations of the data. For example, when the researcher noticed a tendency to focus on negative aspects of hospital care, they revisited the data to ensure positive experiences were not underrepresented. Ethics Approval and Consent to Participate This study was conducted following the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics and Research Committee of Federal Teaching Hospital Ido-Ekiti (FETHI) and Ekiti State University Teaching Hospital (EKSUTH) with ( Approval no. ERC/2021/10/29/657B and EKSUTH/A67/2022/02/003 ). Informed consent was secured from all participants before data collection. Participants were assured of confidentiality, anonymity, and the right to withdraw from study at any time without any consequences. RESULTS Overall, 12 participants: 3 mothers and 9 healthcare providers (7 nurses; 2 neonatologists). Ten were females and two were males (Table 1). Participants were between 21 and 48 years old. The participants were from two of the major tribes in Nigeria: Yoruba (10) and Igbo (2). Description of Participants Parents of Preterm Babies The 3 mothers were aged 21-38 years, all married, with 2 Christians and 1 Muslim. Two had tertiary education, and 1 had primary education. They gave birth at 28-32 weeks of gestation, and their babies stayed in the hospital for 3-8 days. Healthcare Providers The 9 providers were mostly female (7), aged 36-48 years, and all married. Four were Chi ef Nursing Officers, and 2 were Neonatologists. Seven had BNSC degrees, one has a masters, and one is a consultant. Eight were Christians, and 1 was Muslim. Six had formal neonatal care training. Themes Three main themes were identified: (1) Quality of Care, (2) Challenges in Providing Quality Care, and (3) Quality of Care, Collaboration, and Communication. Theme 1: Quality of Care Physical Setting Physical Setting: Parents and healthcare professionals emphasized the importance of a well-equipped and safe physical environment. Parents perceive the NICU environment as generally good, but some suggest improvements could enhance care quality. One parent noted, "The physical setting of the neonatal intensive care unit is okay in their quality of care" (Parent 1, EKSUTH). "The physical setting is very important because a good environment can facilitate improvement of health. A setting free from noise, hazards will promote the general well-being." (Parent 3, EKSUTH). “I think we are already giving quality care even if considering the fact that we don’t really have enough things instrumentally”. (Nurse 1. IDO) “I can't really say …the necessary things that we need to care or manage the babies are not available, we improvise some of the gadgets……we need an infusion fluid pump for them instead of Soluset or giving set, then a feeding pump too instead of just using an NG tube for them to feed them. The little ones we have, like two or three, are not functioning”. (Nurse 3. IDO) Healthcare Professionals' Role Parents appreciate the efforts of healthcare professionals, who play crucial roles in medication administration, monitoring, and health education. They recommended capacity building for healthcare professionals. "The healthcare professionals are trying to provide quality of care to my baby" (Parent 1, EKSUTH). “……. they (health care professionals) always come and give them medication,….. rub their body (infants) with oil with a pad and ……we should always breastfeed them." [Parent 2, EKSUTH] - "…….. (health care professionals) help to monitor the health of my baby by preventing infection, preventing malnutrition…" It can be better by ensuring that health care workers go for training" - [Parent 2, EKSUTH]. Health Education Most parents report receiving adequate health education, but one parent felt otherwise. "No, I was not health educated on the care, they only said that my baby is preterm, that is why she is in the incubator" (Parent 1, EKSUTH). “Yes, I was adequately health educated on the care in which they told me that “I should always breast feed my baby 24 hours, …. not rub silver bird on their hair because their body is not yet mature and …… not give other herbal medicine to the baby or other drugs except from the one they prescribe here for the baby " (Parent 2, EKSUTH). Rules and Regulations Parents are aware of NICU rules, such as handwashing and restricted visiting hours. A parent noted, "Yes, there are rules, they said that before giving them breast milk, we should always wash our hands" (Parent 1, EKSUTH). Another parent mentioned, "Only me and my husband are allowed to visit the baby" (Parent 2, EKSUTH). "Yes, there are rules, …offing of shoes, …. Hand washing before going and out of NICU, ……. Wearing hospital gowns when entering. …. Provision of aseptic techniques when caring for preterm babies. …… Washing of cup and spoon before expression of breast milk " (Parent 2, EKSUTH). Bonding Time Parents express concerns about limited bonding time with their preterm babies. A parent stated, "No, they don’t give me enough time to be with my baby" (Parent 2, EKSUTH). Theme 2: Challenges in Providing Quality Care Work Experience and Training Nurses have varying levels of experience and training, with some reporting inadequate formal training. when asked about formal training: "Yes, I have received formal training on neonatal care or preterm care" training (Nurse 1. IDO) "No" (Nurse 2, EKSUTH). Holistic Care Nurses emphasize the importance of individualized care, infection prevention, and monitoring. "…. depends on the condition of the babies, for like preterm babies, we do everything necessary for the baby " (Nurse 1, IDO). "Individualized care through feeding, changing of their diaper, position change, … assess the airway to see if nothing is blocking it. ……… try to suction, …… administration of oxygen to ease the breathing " (Nurse 1, EKSUTH). Lack of Personnel and Inadequate Facilities Nurses identify staff shortage, inadequate equipment, and training as significant challenges. "Lack of personnel because normally it should be a nurse to two babies, but there are not enough personnel at times" (Nurse 1, EKSUTH). " The equipment is not adequate because there are things that are necessary, such as the feeding pump and infusion pump. With the fluid pump to calculate the medication to be given will be easier " (Nurse 2, IDO ) "…….. issue of preterm baby is that they lack surfactant …… need incubator, the incubator we are using for them here some are obsolete, ……much patient to the ratio of the nurses is not okay" (Nurse 3, EKSUTH). "The facilities on ground now are not adequate for the care of preterm be, we need more’ -participant (Nurse 3, IDO) Protocols and Guidelines Nurses follow protocols like kangaroo care, exclusive breastfeeding, and infection prevention. "We encourage exclusive breastfeeding, and we ensure that the environment is free of infection to prevent nosocomial infection" (Nurse1, IDO). "……we try to do is to restrict the number of visitors that come in, …... maintain proper hygiene by hand washing, ………. change into our scrubs" (Nurse 1, EKSUTH). "We have to have more training because … research is ongoing, things are changing, so …. to go to training to be exposed to new things, to be able to practice it and to improve the quality of care of the preterm" (Nurse 3, EKSUTH). High Demand Nurses report that high demand hinders quality care due to staffing shortages. They highlighted various ways: "High demand hinders the quality of care because of the low availability of nurses" (Nurse 2, IDO). "If we do not give them quality care, it will hinder them from growing well, gaining weight, and most of them will not survive if quality health care is not rendered” (Nurse 2, EKSUTH). Theme 3: Quality of Care, Collaboration and Communication Work Experience and Training Neonatologists have extensive experience, but some report lacking formal training. Quality of Care Neonatologists emphasize the need for safe, timely, and evidence-based care. Quality care is essential for optimal outcomes. Quality of care starts from the antenatal period when a woman comes into the facility. "Preterm babies are high-risk babies and they require a high quality of care" (Neonatologist 1, IDO). "We prioritize safe and timely care, and follow evidence-based guidelines" (Neonatologist2, EKSUTH). "…… having the appropriate number of staff…. that improves quality of life and then the environment itself in terms of the facilities available will determine the quality of life the baby gets" (Neonatologist 2, EKSUTH). Collaboration Neonatologists highlight the importance of teamwork among healthcare professionals. "Care of a preterm is multidisciplinary, it involves different healthcare professionals" (Neonatologist 1, IDO). "Well, if we work together as a team, that can give us a good outcome, but each unit working along their own paths and not cooperating together " (Neonatologist 2, EKSUTH). "…. improving the care is based on ensuring safety in the environment of practice and of course collaborative efforts we cannot work in isolation and there is no amount of knowledge the doctors possess if the nursing care is not optimal the patient is going to suffer, if their environment is not convenient the patient is going] to suffer, so it's a collaborative work" (Neonatologist 1, IDO). Lack of Technologies Neonatologists report that inadequate equipment and technology hinder quality care. A neonatologist shared, "The place of technology is well established in managing newborns, fortunately for us, we tend to have few of these facilities" (Neonatologist 1, IDO). Family Involvement Neonatologists believe involving parents in care is essential for optimal outcomes. "Yes, definitely, medical practice can't ignore the opinion of the perspective of the parents as regards to the care of their babies" (Neonatologist 1, IDO). " …. new pattern of care now involves the parents of the baby" (Neonatologist 2, EKSUTH). Improvement Neonatologists suggest that advocacy and collaboration can improve quality care. Working with relevant stakeholders in the healthcare system, including philanthropists and non-governmental agencies, may change the face of care for preterm. "Generally improving the care is based on ensuring safety in the environment of practice and, of course, collaborative efforts" (Neonatologist 1, IDO). "….. good maintenance culture, those are some of the things that can prolong the life of whatever we have efficiency and effectivity" (Neonatologist 2, EKSUTH). DISCUSSION The physical setting of the NICU was perceived as generally good by parents, but some suggested improvements could enhance care quality. This finding is consistent with a study by Liu et al. (2020), which found that a well-designed NICU environment can improve patient outcomes and satisfaction. The importance of a safe and well-equipped physical environment is emphasized in the literature, with authors like Bayramzadeh & Aghaei (2021) highlighting its impact on patient safety and quality of care. In this study, both parents and healthcare professionals recognized the importance of a well-equipped and safe setting. Parents generally regarded the physical conditions as satisfactory but noted that improvements would further enhance care quality. This also aligns with global literature that underscores the impact of inadequate infrastructure on neonatal outcomes, especially in low-resource settings (Lawn et al., 2010; Moxon et al., 2015). Proper temperature regulation, infection control, and access to life-saving equipment like infusion and feeding pumps are critical for quality neonatal care (World Health Organization [WHO], 2016). This also aligns with global literature that underscores the impact of inadequate infrastructure on neonatal outcomes, especially in low-resource settings (Lawn et al., 2010; Moxon et al., 2015). Proper temperature regulation, infection control, and access to life-saving equipment like infusion and feeding pumps are critical for quality neonatal care (World Health Organization [WHO], 2016). Studies conducted in Sub-Saharan Africa have found similar results, linking poorer newborn outcomes and increased parental concern to overcrowding, a lack of incubators, and poor cleanliness (Washington, 2021; Tumukunde et al., 2024). Parental education is essential in empowering parents to participate effectively in the care of their preterm infants. Most parents in the study felt they were adequately educated about care routines, such as breastfeeding practices and hygiene. Parents appreciated healthcare professionals' efforts, highlighting their roles in medication administration, monitoring, and health education. This finding is supported by a study by Smith et al. (2024), which found that effective communication and education are critical components of high-quality care. However, some parents reported inadequate health education, which is consistent with a study by Jones et al. (2021), which found that parents often feel uninformed about their baby's care. This discrepancy reflects broader issues in communication and individualized support in NICUs. According to O’Brien et al. (2018), structured parental education is linked to improved neonatal outcomes and parental satisfaction. Health education must be consistent, culturally sensitive, and tailored to parents' needs and literacy levels. Despite recognizing the importance of bonding, parents expressed dissatisfaction with limited opportunities to interact with their infants. Bonding is not just emotionally beneficial. it also supports breastfeeding, neurodevelopment, and reduced parental stress (Feldman & Eidelman, 2003; Bieleninik et al., 2016). NICU policies should facilitate practices like kangaroo mother care and flexible visiting to enhance attachment and parental involvement. Competent neonatal care relies heavily on a skilled and well-trained nursing workforce. However, data from this study revealed disparities in training among nurses. Nurses identified staff shortage, inadequate equipment, and training as significant challenges. While some had received formal instruction in neonatal or preterm care. These discrepancies align with findings by Moxon et al. (2015), who noted that inadequate pre-service and in-service training among healthcare providers is a major bottleneck to improving neonatal outcomes in low- and middle-income countries (LMICs). Another study by Ndebele & Ndlovu (2023) corroborates the finding of this study, which found that staffing shortages and inadequate resources can compromise quality care. The importance of adequate staffing and resources is emphasized in the literature, with authors like Aiken et al. (2019) highlighting its impact on patient outcomes and nurse burnout. A lack of continuous professional development can lead to substandard care practices, particularly in dynamic and high-risk environments like NICUs. Therefore, structured and consistent training programs are essential for enhancing nurses' competencies and standardizing neonatal care (World Health Organization [WHO], 2016). Nurses emphasized the importance of individualized care, infection prevention, and monitoring. Despite systemic limitations, nurses emphasized the importance of holistic and individualized care tailored to each baby's condition. This finding is supported by a study by Lei et al. (2022), which found that individualized care can improve patient outcomes and satisfaction. The importance of infection prevention is also emphasized in the literature, with authors like Lim et al. (2019) highlighting its impact on patient safety. This also aligns with the principles of family-centered and developmentally supportive care, which emphasize adapting interventions to the infant’s condition to promote optimal health outcomes (Altimier & Phillips, 2016). However, the ability to deliver this level of care is often dependent on adequate staffing and access to functioning medical equipment, both of which were lacking in the observed settings. Another prominent barrier reported by nurses was the shortage of staff and essential neonatal equipment. These issues reflect broader health system inadequacies in many LMICs, where the nurse-to-patient ratio is frequently insufficient for safe neonatal care (Lake et al., 2017). The WHO recommends a ratio of 1:2 for critically ill neonates to ensure timely intervention and monitoring (WHO, 2016). The use of outdated or non-functional equipment further compounds the issue, placing neonates at increased risk of infection, undernutrition, and mortality (Bhutta et al., 2014). Despite environmental challenges, nurses reported adherence to important care protocols, including kangaroo mother care, infection control, and exclusive breastfeeding. This underscores the need for regular updates and refresher courses for clinical staff, enabling them to apply evidence-based protocols effectively and confidently (O’Brien et al., 2018). The issue of high patient demand and workload was a recurring theme. These observations are consistent with research showing that overburdened healthcare workers are less likely to provide thorough assessments, timely interventions, or adequate emotional support to families (Shields et al., 2019). Excessive workload can also lead to burnout, increased medical errors, and higher neonatal morbidity (Lake et al., 2017). Improving staff-to-patient ratios and reducing nurse fatigue are, therefore, critical to enhancing neonatal care quality. Neonatologists in this study recognized quality of care as central to the survival and development of preterm infants. They emphasized that such care must be safe, timely, and evidence-based, aligning with global definitions of high-quality care (WHO, 2016). This viewpoint aligns with Donabedian’s model of healthcare quality, which emphasizes structure, process, and outcomes as fundamental determinants of care quality (Donabedian, 1988). It also mirrors findings from Blencowe et al. (2019), who argued that improving neonatal outcomes requires consistent delivery of guideline-based interventions, especially in low-resource settings. Neonatologists further highlighted the influence of staffing levels and infrastructure on care outcomes. This supports the WHO’s position that appropriate workforce density and functional healthcare environments are prerequisites for quality maternal and newborn care (WHO, 2016). A major sub-theme that emerged was the critical role of interprofessional collaboration in improving care outcomes. Neonatologists viewed teamwork between doctors, nurses, and support staff as essential. Neonatologists highlighted the importance of teamwork among healthcare professionals. This finding is consistent with a study by Reeves et al. (2020), which found that effective teamwork can improve patient outcomes and satisfaction. The importance of collaboration and communication is emphasized in the literature, with authors like Leonard et al. (2019) highlighting its impact on patient safety and quality of care. This echoes the literature on collaborative practice models, which have been shown to reduce medical errors, improve patient safety, and foster comprehensive care in NICUs (Reeves et al., 2017). The Institute of Medicine (2001) also emphasized teamwork and communication as pillars of quality healthcare. Neonatologists further stressed that even the most knowledgeable clinicians are limited without collaborative support. This reaffirms the need for interprofessional respect and shared responsibility, as poor collaboration has been linked to delayed interventions and adverse neonatal outcomes (Lee et al., 2020). Neonatologists reported that inadequate equipment and technology hinder quality care, and was a persistent challenge. This shortfall limits the ability of clinicians to offer advanced and life-saving interventions such as mechanical ventilation, advanced monitoring, and surfactant administration, standard care in high-income settings. This finding is consistent with a study by Patel et al. (2022), which found that inadequate technology can compromise quality care. The importance of adequate technology is emphasized in the literature, with authors like Chaudhry et al. (2020) highlighting its impact on patient outcomes and healthcare efficiency. Studies by Moxon et al. (2015) and Bhutta et al. (2014) have shown that low-cost technologies, when adequately scaled, can significantly reduce neonatal mortality. Therefore, investment in neonatal technologies should be prioritized in efforts to improve the quality of care in Nigeria and similar LMICs. Parental involvement emerged as a vital, yet sometimes overlooked, component of quality care. Neonatologists acknowledged the evolving role of families in the NICU. This aligns with Family-Centered Care (FCC) principles, which emphasize the participation of parents in decision-making, caregiving, and emotional support (O’Brien et al., 2018). Studies have shown that FCC improves parent-infant bonding, enhances breastfeeding outcomes, and reduces parental stress (Gooding et al., 2011). Implementing the FCC requires changes in hospital culture and policies, such as flexible visiting hours, parental education, and kangaroo mother care, which have all been recommended by the WHO (2016). CONCLUSION Improving the quality of neonatal care requires a holistic approach that integrates environmental enhancements, workforce development, interprofessional collaboration, and meaningful parental involvement. Addressing infrastructural deficits, strengthening training programs, and fostering a collaborative, family-centered culture are critical steps toward improving neonatal outcomes, particularly in resource-constrained settings. These findings offer actionable insights for policymakers, healthcare administrators, and frontline providers working to advance neonatal care quality. Declarations Ethical Approval and Consent to Participate : This study was conducted following the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics and Research Committee of Federal Teaching Hospital Ido-Ekiti (FETHI) and Ekiti State University Teaching Hospital (EKSUTH) with ( Approval no. ERC/2021/10/29/657B and EKSUTH/A67/2022/02/003 ). Informed consent was secured from all participants before data collection. Participants were assured of confidentiality, anonymity, and the right to withdraw from study at any time without any consequences. The study was conducted in accordance with the principles of the Declaration of Helsinki, ensuring respect for participants' rights, welfare, and dignity. Consent for Publication: Not Applicable Availability of Data and Materials : The data supporting this study’s findings are available from the corresponding author on request. Competing Interests : The authors declare no competing interests. Funding: This research did not receive any grant from funding agencies in the public, commercial or not-for-profit sectors Author Contributions : DTE conceived and designed the study methodology, supervised the data collection and reviewed the initial draft of the manuscript. AOO analyzed the data and wrote the initial draft of the manuscript. WOA collected the data, analyzed the data and drafted the initial manuscript. BOO wrote the initial draft of the manuscript. AOO Analyzed the data and revised the manuscript. CGR analyzed the data and critically revised the initial draft of the manuscript. 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Ketshabathupa, B. (2024). Socio-economic and psychological challenges experienced by caregivers of babies admitted at Princess Marina hospital neonatal intensive care unit Gaborone, Botswana (Doctoral dissertation, The University of Zambia). Krippendorff, K. (2018). Content analysis: An introduction to its methodology. Sage Publications. Kuhnly, J. E. , & Dokken, D. L. (2018). Family-centered care in the NICU: A literature review. Advances in Neonatal Care, 18(3), 183-192. LaDonna, K. A., Artino Jr, A. R., & Balmer, D. F. (2021). Beyond the guise of saturation: rigor and qualitative interview data. Journal of Graduate Medical Education, 13(5), 607-611. Lake, E. T. , Staiger, D. , Edwards, R. R. , Smith, J. G. , & Rogowski, J. A. (2017). Nurse staffing and neonatal intensive care unit infection rates. JAMA Pediatrics, 171(8), 747–754. Lawn, J. E. , Mwansa-Kambafwile, J. , Horta, B. L. , Barros, F. C. , & Cousens, S. (2010). ‘Kangaroo mother care’to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology, 39(suppl_1), i144-i154. Lee, S. K. , O’Brien, K. , O’Connor, M. , & Himelreich, J. (2020). Family-integrated care in the neonatal intensive care unit: a systematic review and meta-analysis. The Lancet Child & Adolescent Health, 4(4), 265–280. Lei, L. P. , Lin, K. P. , Huang, S. S. , Tung, H. H. , Tsai, J. M. , & Tsay, S. L. (2022). The impact of organisational commitment and leadership style on job satisfaction of nurse practitioners in acute care practices. Journal of nursing management, 30(3), 651-659. Leonard, M. , Graham, S. , & Bonacum, D. (2019). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 18(5), 346-354. Lim, J. H. , Ahn, J. W. , & Son, Y. J. (2019). Association between hospital nurses’ perception of patient safety management and standard precaution adherence: A cross-sectional study. International journal of environmental research and public health, 16(23), 4744. Liu, Y. , Liu, J. , & Zhang, Y. (2020). The impact of NICU design on patient outcomes and satisfaction: A systematic review. Journal of Perinatology, 40(10), 1430-1438. Moxon, S. G. , Lawn, J. E. , Dickson, K. E. , Simen-Kapeu, A. , Gupta, G. , Deorari, A. ,. . . & Bhutta, Z. A. (2015). Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy and Childbirth, 15(Suppl 2), S7. Ndebele, N. C. , & Ndlovu, J. (2023). The Impact of Staffing Moratoria on the Delivery of Quality Health Care Services in the Department of Health. African Journal of Governance and Development, 12(2), 120-140. O’Brien, K. , Robson, K. , Bracht, M. , Cruz, M. , Lui, K. , Alvaro, R. ,. . . & Lee, S. K. (2018). Effectiveness of Family Integrated Care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial. The Lancet Child & Adolescent Health, 2(4), 245–254. Patel, S. N. , & Patel, R. N. (2022). Impact of technology on healthcare: A systematic review. Journal of Healthcare Engineering,. Reeves, S. , Pelone, F. , Harrison, R. , Goldman, J. , & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (6), CD000072. Shields, L. , Zhou, H. , Pratt, J. , Taylor, M. , Hunter, J. , & Pascoe, E. (2019). Family-centred care for hospitalised children aged 0–12 years. Cochrane Database of Systematic Reviews, 3, CD004811. Smith, C. M. , Horne, C. E. , & Wei, H. (2024). Nursing practice in modern healthcare environments: A systematic review of attributes, characteristics, and demonstrations. Journal of Advanced Nursing, 80(9), 3481-3498. World Health Organization (WHO). (2016). Standards for improving quality of maternal and newborn care in health facilities. WHO. Table Table 1. Study Participants’ Characteristics (n = 12) Characteristics Description Parents of Preterm Babies Gender All Females Age in years 24.3 (21–38) Marital Status All married Religion 2 Christian, 1 Muslim Educational Level 2 Tertiary, 1 Primary Gestational Age 28 – 32 weeks 28weeks 2 32weeks 1 Hospital Stay in NICU 1-3 days Healthcare providers Gender 7 Females, 2 Males Age in years 41+ (36–48) Marital Status All married Religion 8 Christian, 1 Muslim Educational Level All Tertiary (7 BNSc, 1 MNSc, 1 Consultant) Designations 7 Nurses, 2 Neonatologists Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7892012","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":552058447,"identity":"8dee1f7b-52da-4e29-9eb8-b4393e65be48","order_by":0,"name":"Deborah Tolulope Esan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABD0lEQVRIiWNgGAWjYDCCAzxgEsL52AAV5SFWC+NMkrUw8xKjhe9478HHFTV3GPj5Dz97bLvDJrFfuoHxwds2hjx5B+xaJM+cSzY8c+wZg+SMNHPj3DNpiTPnHGA2nNvGUGx4ALsWgxs5ZpINbIeBDAYz6dy2w7kbbiSwSfO2MSRubMCh5f4boJZ/hxnszx//Jm0J1LL/RgL7b7xabvCYSTa2AW1hyDGTZgTZIpHAxgzSMh+H9yXP5CUbNvYd5pG4kVMm2XsmrX7GjcRmyTnnJBI34AyxswcfNnw7LMfff3ybxM8dNsb8M5IPfnhTZpM4H4fDYAA5IhhBaiUYDA7g14IFyBOwZRSMglEwCkYMAAAMQmLjZBMMQQAAAABJRU5ErkJggg==","orcid":"","institution":"Bowen University Iwo","correspondingAuthor":true,"prefix":"","firstName":"Deborah","middleName":"Tolulope","lastName":"Esan","suffix":""},{"id":552058448,"identity":"9bb535ef-0cd8-49f2-a586-17284759cfc6","order_by":1,"name":"Ayodeji Olubunmi Ogunmuyiwa","email":"","orcid":"","institution":"Lagos State University Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ayodeji","middleName":"Olubunmi","lastName":"Ogunmuyiwa","suffix":""},{"id":552058449,"identity":"59c8c748-668b-4a9b-8748-4e461c9bab5b","order_by":2,"name":"Waliat Odunayo Ayinde","email":"","orcid":"","institution":"Afe Babalola University","correspondingAuthor":false,"prefix":"","firstName":"Waliat","middleName":"Odunayo","lastName":"Ayinde","suffix":""},{"id":552058450,"identity":"92f014fa-a0e8-4023-8a93-9ccc8c72963d","order_by":3,"name":"Blessed Obem Oyama","email":"","orcid":"","institution":"Afe Babalola University","correspondingAuthor":false,"prefix":"","firstName":"Blessed","middleName":"Obem","lastName":"Oyama","suffix":""},{"id":552058451,"identity":"43908c01-bfa1-4766-be38-6780a1d87ecf","order_by":4,"name":"Adetunmise Oluseyi Olajide","email":"","orcid":"","institution":"Ladoke Akintola University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Adetunmise","middleName":"Oluseyi","lastName":"Olajide","suffix":""},{"id":552058452,"identity":"3bfc1235-96df-47a8-b447-426fae15bf78","order_by":5,"name":"Carlos Guillermo Ramos","email":"","orcid":"","institution":"University of California","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Guillermo","lastName":"Ramos","suffix":""}],"badges":[],"createdAt":"2025-10-18 08:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7892012/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7892012/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97249823,"identity":"a0c3f318-87a8-4c0f-a75f-a05e45aa00d7","added_by":"auto","created_at":"2025-12-02 13:13:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":917340,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7892012/v1/d7069080-04fe-4eba-9d71-97ff5d49ad1e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eParental and Healthcare Provider Perspectives on the Care and Outcomes of Premature Newborns in Two Referral Hospitals in Southwestern Nigeria\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDespite advances in neonatal care, preterm birth remains a leading cause of neonatal morbidity and mortality worldwide (Cao et al., 2022). Preterm infants, born before 37 weeks of gestation, require specialized and high-quality care to improve survival and developmental outcomes. The quality of care provided in neonatal intensive care units (NICUs) of tertiary hospitals plays a critical role in determining these outcomes. Both healthcare providers and parents are central to this care process, influencing and experiencing the care delivered. Exploring their perspectives offers valuable insights into the actual care environment, challenges, and opportunities for improvement. Recent evidence highlights systemic challenges such as shortages of skilled staff, inadequate resources, and inconsistent adherence to clinical guidelines, which compromise care quality (Bayou et al., 2024). Furthermore, parental involvement and communication with healthcare providers are often limited, affecting parental satisfaction and infant well-being (Ketshabathupa, 2024). This study aims to assess the quality of care for preterm infants by integrating the viewpoints of healthcare providers and parents in two tertiary hospitals.\u003c/p\u003e\n\u003cp\u003eDespite global efforts to improve neonatal care, significant challenges remain in the quality of care for preterm infants in tertiary hospital settings. Many facilities lack up-to-date clinical guidelines for preterm and low birth weight infants, and where guidelines exist, adherence is inconsistent (Bayou et al., 2024). Human resource challenges, including shortages of skilled staff, poor motivation, and inadequate supervision, further undermine care delivery. Beyond merely clinical difficulties, parental and provider experiences in LMICs are laden with emotional and logistical hardship. In Ghana, caregivers commonly struggle with insufficient information, limited education on their infants’ care, and a NICU setting they characterize as strange or intimidating, increasing anguish and hindering their ability to participate effectively to newborn care (Boadu et al.,2024). Nearly 56% of Tanzanian nurses who provided preterm care had never had any on-the-job training, and their understanding of topics like glucose and temperature monitoring was very lacking (Mwikali et al., 2023).\u003c/p\u003e\n\u003cp\u003eAdditionally, shortages of essential equipment, medications, and infrastructure are common (Bayou et al., 2024). Parents often report feeling excluded from care decisions and unsupported emotionally, which can increase stress and negatively affect infant outcomes (Ketshabathupa, 2024). Variations in care practices and outcomes across hospitals suggest the need for standardized quality measures and improved care approaches (Lee et al., 2022). Understanding these multifaceted issues from both provider and parent perspectives is essential to inform targeted interventions that enhance care quality and infant outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eTo explore healthcare providers’ perspectives on the quality of care delivered to preterm infants in two tertiary hospitals, including challenges and facilitators.\u003c/li\u003e\n \u003cli\u003eTo investigate parents’ experiences and perceptions regarding the care and support received for their preterm infants.\u003c/li\u003e\n \u003cli\u003eTo identify systemic, resource-related, and communication barriers affecting the quality of care.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"METHODS ","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a qualitative descriptive design to explore healthcare providers\u0026apos; and parents\u0026apos; perspectives on the quality of care for preterm infants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in two tertiary hospitals with established Neonatal Intensive Care Unit (NICU) facilities: Federal Teaching Hospital Ido-Ekiti (FETHI) and Ekiti State University Teaching Hospital (EKSUTH). Participants included healthcare providers (neonatologists, nurses) involved in preterm infant care and parents caring for preterm infants admitted to the NICUs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare providers (nurses and neonatologists) and parents were included if they were involved in the care of preterm infants admitted to the NICU at FETHI and EKSUTH. Participants were excluded if they were unwilling to participate in the study are excluded\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling Technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to recruit participants, as it allows for the selection of information-rich cases that can provide in-depth insights into the phenomenon of interest in this study to enhance robust and reliable conclusions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size Determination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was determined by data saturation, which is the point at which no new themes or information emerge from additional data collection. Based on previous qualitative studies in this area, 12 participants from the research setting were used: three preterm parents (mothers); seven nurses, and two neonatologists.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection occurred over a four-week period at each of the referral hospitals. For Federal Teaching Hospital, Ido-Ekiti, data collection was between November 1, 2021, and November 30, 2021, and between February 3, 2022, and March 5, 2022, for Ekiti State University Teaching Hospital\u003cstrong\u003e.\u003c/strong\u003e\u0026nbsp; \u0026nbsp;Data was collected through semi-structured interviews. Interview guides were developed based on the WHO quality of care framework and existing literature, covering themes such as clinical practices, resource availability, communication, parental involvement, and emotional support. Interviews were audio-recorded with consent, conducted in a private setting, allowing for open and confidential discussion and guided by category-specific questions. Participants completed demographic forms and were assured of comfort, confidentiality, and their right to withdraw. The first and the last authors, with extensive experience in qualitative research and healthcare studies, conducted the interviews. The researchers-maintained objectivity and acknowledged potential biases. Interviews lasted approximately 30-60 minutes, allowing for in-depth exploration of participants\u0026apos; perspectives and experiences. Recordings were stored securely and were only accessible to the research team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviews were coded and analyzed using NVivo 12 (QSR International), which facilitated the systematic organization, coding, and development of themes and subthemes from the transcribed data. Interviews were audio-recorded via tape recorder, transcribed verbatim, and analyzed using a content analysis approach (Craig et al., 2021; Krippendorff, 2018). This approach enabled the researcher to identify patterns, themes, and meanings in the data. The data analysis process involved four steps. First, data preparation ensured the accuracy and completeness of the transcribed interviews, which were then organized and formatted for analysis. Second, coding involved an inductive approach to identify concepts and themes emerging from the data, followed by focused coding to refine and categorize codes into broader themes and subthemes. Third, theme development involved identifying patterns and relationships in the data to develop themes, which were refined and defined through an iterative process. Finally, subtheme development further elaborated on the themes, providing a nuanced understanding of the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnsuring Rigor\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe rigor of this qualitative study was ensured through several measures (LaDonna et al., 2021). Firstly, data saturation was achieved by continuing data collection until no new themes or information emerged. Member checking was also conducted, where participants were provided with transcripts of their interviews to verify accuracy and ensure that their perspectives were captured correctly. Additionally, peer debriefing was undertaken, involving regular discussions with peers and experts in qualitative research to review the study\u0026apos;s methodology, data collection, and analysis processes. An audit trail was maintained, detailing the research process, including data collection, analysis, and decision-making. Finally, reflexivity was practiced, where the researcher\u0026apos;s own biases and assumptions were acknowledged and reflected upon throughout the study to minimize their impact on data collection and analysis. To ensure balance in analysis, the researcher, for instance, kept a reflexive journal in which, following each interview and coding session, personal thoughts, emotional reactions to the interviews, and potential assumptions were recorded. This allowed the researcher to critically reflect on how their background, beliefs, or expectations might influence interactions with participants or interpretations of the data. For example, when the researcher noticed a tendency to focus on negative aspects of hospital care, they revisited the data to ensure positive experiences were not underrepresented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted following the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics and Research Committee of Federal Teaching Hospital Ido-Ekiti (FETHI) and Ekiti State University Teaching Hospital (EKSUTH) with (\u003cstrong\u003eApproval no. ERC/2021/10/29/657B and EKSUTH/A67/2022/02/003\u003c/strong\u003e). Informed consent was secured from all participants before data collection. Participants were assured of confidentiality, anonymity, and the right to withdraw from study at any time without any consequences.\u003c/p\u003e"},{"header":" RESULTS","content":"\u003cp\u003eOverall, 12 participants: 3 mothers and 9 healthcare providers (7 nurses; 2 neonatologists). Ten were females and two were males (Table 1). Participants were between 21 and 48 years old. The participants were from two of the major tribes in Nigeria: Yoruba (10) and Igbo (2). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParents of Preterm Babies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 3 mothers were aged 21-38 years, all married, with 2 Christians and 1 Muslim. Two had tertiary education, and 1 had primary education. They gave birth at 28-32 weeks of gestation, and their babies stayed in the hospital for 3-8 days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealthcare Providers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 9 providers were mostly female (7), aged 36-48 years, and all married. Four were Chi ef Nursing Officers, and 2 were Neonatologists. Seven had BNSC degrees, one has a masters, and one is a consultant. Eight were Christians, and 1 was Muslim. Six had formal neonatal care training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree main themes were identified: (1) Quality of Care, (2) Challenges in Providing Quality Care, and (3) Quality of Care, Collaboration, and Communication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 1: Quality of Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhysical Setting\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhysical Setting: Parents and healthcare professionals emphasized the importance of a well-equipped and safe physical environment. Parents perceive the NICU environment as generally good, but some suggest improvements could enhance care quality. One parent noted,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;The physical setting of the neonatal intensive care unit is okay in their quality of care\u0026quot; (Parent 1, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026quot;The physical setting is very important because a good environment can facilitate improvement of health. A setting free from noise, hazards will promote the general well-being.\u0026quot; (Parent 3, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think we are already giving quality care even if considering the fact that we don\u0026rsquo;t really have enough things instrumentally\u0026rdquo;. (Nurse 1. IDO)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I can\u0026apos;t really say \u0026hellip;the necessary things that we need to care or manage the babies are not available, we improvise some of the gadgets\u0026hellip;\u0026hellip;we need an infusion fluid pump for them instead of Soluset or giving set, then a feeding pump too instead of just using an NG tube for them to feed them. The little ones we have, like two or three, are not functioning\u0026rdquo;. (Nurse 3. IDO)\u003cstrong\u003e\u003cem\u003e\u003cbr\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealthcare Professionals\u0026apos; Role\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParents appreciate the efforts of healthcare professionals, who play crucial roles in medication administration, monitoring, and health education. They recommended capacity building for healthcare professionals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;The healthcare professionals are trying to provide quality of care to my baby\u0026quot; (Parent 1, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;\u0026hellip;. they (health care professionals) always come and give them medication,\u0026hellip;.. rub their body (infants) with oil with a pad and \u0026hellip;\u0026hellip;we should always breastfeed them.\u0026quot; [Parent 2, EKSUTH]\u003c/p\u003e\n\u003cp\u003e- \u0026quot;\u0026hellip;\u0026hellip;.. (health care professionals) help to monitor the health of my baby by preventing infection, preventing malnutrition\u0026hellip;\u0026quot; It can be better by ensuring that health care workers go for training\u0026quot; - [Parent 2, EKSUTH].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth Education\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost parents report receiving adequate health education, but one parent felt otherwise.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;No, I was not health educated on the care, they only said that my baby is preterm, that is why she is in the incubator\u0026quot; (Parent 1, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Yes, I was adequately health educated on the care in which they told me that \u0026ldquo;I should always breast feed my baby 24 hours, \u0026hellip;. not rub silver bird on their hair because their body is not yet mature and \u0026hellip;\u0026hellip; not give other herbal medicine to the baby or other drugs except from the one they prescribe here for the baby \u0026quot; (Parent 2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRules and Regulations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParents are aware of NICU rules, such as handwashing and restricted visiting hours. A parent noted,\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026quot;Yes, there are rules, they said that before giving them breast milk, we should always wash our hands\u0026quot; (Parent 1, EKSUTH).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother parent mentioned,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Only me and my husband are allowed to visit the baby\u0026quot; (Parent 2, EKSUTH).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026quot;Yes, there are rules, \u0026hellip;offing of shoes, \u0026hellip;. Hand washing before going and out of NICU, \u0026hellip;\u0026hellip;. Wearing hospital gowns when entering. \u0026hellip;. Provision of aseptic techniques when caring for preterm babies. \u0026hellip;\u0026hellip; Washing of cup and spoon before expression of breast milk \u0026quot; (Parent 2, EKSUTH).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBonding Time\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParents express concerns about limited bonding time with their preterm babies. A parent stated,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;No, they don\u0026rsquo;t give me enough time to be with my baby\u0026quot; (Parent 2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 2: Challenges in Providing Quality Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWork Experience and Training\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses have varying levels of experience and training, with some reporting inadequate formal training. when asked about formal training:\u003c/p\u003e\n\u003cp\u003e\u0026quot;Yes, I have received formal training on neonatal care or preterm care\u0026quot; training (Nurse 1. IDO)\u003c/p\u003e\n\u003cp\u003e\u0026quot;No\u0026quot; (Nurse 2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHolistic Care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses emphasize the importance of individualized care, infection prevention, and monitoring.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u0026hellip;. depends on the condition of the babies, for like preterm babies, we do everything necessary for the baby \u0026quot; (Nurse 1, IDO).\u003c/p\u003e\n\u003cp\u003e\u0026quot;Individualized care through feeding, changing of their diaper, position change, \u0026hellip; assess the airway to see if nothing is blocking it. \u0026hellip;\u0026hellip;\u0026hellip; try to suction, \u0026hellip;\u0026hellip; administration of oxygen to ease the breathing \u0026quot; (Nurse 1, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLack of Personnel and Inadequate Facilities\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses identify staff shortage, inadequate equipment, and training as significant challenges.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Lack of personnel because normally it should be a nurse to two babies, but there are not enough personnel at times\u0026quot; (Nurse 1, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u003cem\u003eThe equipment is not adequate because there are things that are necessary, such as the feeding pump and infusion pump. With the fluid pump to calculate the medication to be given will be easier\u003c/em\u003e\u0026quot; (Nurse\u003cem\u003e\u0026nbsp;2, IDO\u003c/em\u003e)\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u0026hellip;\u0026hellip;.. issue of preterm baby is that they lack surfactant \u0026hellip;\u0026hellip; need incubator, the incubator we are using for them here some are obsolete, \u0026hellip;\u0026hellip;much patient to the ratio of the nurses is not okay\u0026quot; (Nurse 3, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026quot;The facilities on ground now are not adequate for the care of preterm be, we need more\u0026rsquo; -participant (Nurse 3, IDO)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProtocols and Guidelines\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses follow protocols like kangaroo care, exclusive breastfeeding, and infection prevention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;We encourage exclusive breastfeeding, and we ensure that the environment is free of infection to prevent nosocomial infection\u0026quot; (Nurse1, IDO).\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u0026hellip;\u0026hellip;we try to do is to restrict the number of visitors that come in, \u0026hellip;... maintain proper hygiene by hand washing, \u0026hellip;\u0026hellip;\u0026hellip;. change into our scrubs\u0026quot; (Nurse 1, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026quot;We have to have more training because \u0026hellip; research is ongoing, things are changing, so \u0026hellip;. to go to training to be exposed to new things, to be able to practice it and to improve the quality of care of the preterm\u0026quot; (Nurse 3, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHigh Demand\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNurses report that high demand hinders quality care due to staffing shortages. They highlighted various ways: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;High demand hinders the quality of care because of the low availability of nurses\u0026quot; (Nurse 2, IDO).\u003c/p\u003e\n\u003cp\u003e\u0026quot;If we do not give them quality care, it will hinder them from growing well, gaining weight, and most of them will not survive if quality health care is not rendered\u0026rdquo; (Nurse 2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme 3: Quality of Care, Collaboration and Communication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWork Experience and Training\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatologists have extensive experience, but some report lacking formal training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuality of Care\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatologists emphasize the need for safe, timely, and evidence-based care. \u0026nbsp; Quality care is essential for optimal outcomes. Quality of care starts from the antenatal period when a woman comes into the facility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Preterm babies are high-risk babies and they require a high quality of care\u0026quot; (Neonatologist 1, IDO).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026quot;We prioritize safe and timely care, and follow evidence-based guidelines\u0026quot; (Neonatologist2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026quot;\u0026hellip;\u0026hellip; having the appropriate number of staff\u0026hellip;. that improves quality of life and then the environment itself in terms of the facilities available will determine the quality of life the baby gets\u0026quot; (Neonatologist 2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCollaboration\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatologists highlight the importance of teamwork among healthcare professionals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Care of a preterm is multidisciplinary, it involves different healthcare professionals\u0026quot; (Neonatologist 1, IDO).\u003c/p\u003e\n\u003cp\u003e\u0026quot;Well, if we work together as a team, that can give us a good outcome, but each unit working along their own paths and not cooperating together \u0026quot; (Neonatologist 2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u0026hellip;. improving the care is based on ensuring safety in the environment of practice and of course collaborative efforts we cannot work in isolation and there is no amount of knowledge the doctors possess if the nursing care is not optimal the patient is going to suffer, if their environment is not convenient the patient is going] to suffer, so it\u0026apos;s a collaborative work\u0026quot; (Neonatologist 1, IDO).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLack of Technologies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatologists report that inadequate equipment and technology hinder quality care. A neonatologist shared,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;The place of technology is well established in managing newborns, fortunately for us, we tend to have few of these facilities\u0026quot; (Neonatologist 1, IDO).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFamily Involvement\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatologists believe involving parents in care is essential for optimal outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot;Yes, definitely, medical practice can\u0026apos;t ignore the opinion of the perspective of the parents as regards to the care of their babies\u0026quot; (Neonatologist 1, IDO).\u003c/p\u003e\n\u003cp\u003e\u0026quot; \u0026hellip;. new pattern of care now involves the parents of the baby\u0026quot; (Neonatologist 2, EKSUTH).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImprovement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatologists suggest that advocacy and collaboration can improve quality care. Working with relevant stakeholders in the healthcare system, including philanthropists and non-governmental agencies, may change the face of care for preterm.\u003c/p\u003e\n\u003cp\u003e\u0026quot;Generally improving the care is based on ensuring safety in the environment of practice and, of course, collaborative efforts\u0026quot; (Neonatologist 1, IDO).\u003c/p\u003e\n\u003cp\u003e\u0026quot;\u0026hellip;.. good maintenance culture, those are some of the things that can prolong the life of whatever we have efficiency and effectivity\u0026quot; (Neonatologist 2, EKSUTH).\u003c/p\u003e"},{"header":"DISCUSSION ","content":"\u003cp\u003eThe physical setting of the NICU was perceived as generally good by parents, but some suggested improvements could enhance care quality. This finding is consistent with a study by Liu et al. (2020), which found that a well-designed NICU environment can improve patient outcomes and satisfaction. The importance of a safe and well-equipped physical environment is emphasized in the literature, with authors like Bayramzadeh \u0026amp; Aghaei (2021) highlighting its impact on patient safety and quality of care. In this study, both parents and healthcare professionals recognized the importance of a well-equipped and safe setting. Parents generally regarded the physical conditions as satisfactory but noted that improvements would further enhance care quality. This also aligns with global literature that underscores the impact of inadequate infrastructure on neonatal outcomes, especially in low-resource settings (Lawn et al., 2010; Moxon et al., 2015). Proper temperature regulation, infection control, and access to life-saving equipment like infusion and feeding pumps are critical for quality neonatal care (World Health Organization [WHO], 2016).\u003c/p\u003e\n\u003cp\u003eThis also aligns with global literature that underscores the impact of inadequate infrastructure on neonatal outcomes, especially in low-resource settings (Lawn et al., 2010; Moxon et al., 2015). Proper temperature regulation, infection control, and access to life-saving equipment like infusion and feeding pumps are critical for quality neonatal care (World Health Organization [WHO], 2016). Studies conducted in Sub-Saharan Africa have found similar results, linking poorer newborn outcomes and increased parental concern to overcrowding, a lack of incubators, and poor cleanliness (Washington, 2021; Tumukunde et al., 2024).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; Parental education is essential in empowering parents to participate effectively in the care of their preterm infants. Most parents in the study felt they were adequately educated about care routines, such as breastfeeding practices and hygiene. Parents appreciated healthcare professionals' efforts, highlighting their roles in medication administration, monitoring, and health education. \u0026nbsp;This finding is supported by a study by Smith et al. (2024), which found that effective communication and education are critical components of high-quality care. However, some parents reported inadequate health education, which is consistent with a study by Jones et al. (2021), which found that parents often feel uninformed about their baby's care. This discrepancy reflects broader issues in communication and individualized support in NICUs. According to O’Brien et al. (2018), structured parental education is linked to improved neonatal outcomes and parental satisfaction. Health education must be consistent, culturally sensitive, and tailored to parents' needs and literacy levels. Despite recognizing the importance of bonding, parents expressed dissatisfaction with limited opportunities to interact with their infants. Bonding is not just emotionally beneficial. it also supports breastfeeding, neurodevelopment, and reduced parental stress (Feldman \u0026amp; Eidelman, 2003; Bieleninik et al., 2016). NICU policies should facilitate practices like kangaroo mother care and flexible visiting to enhance attachment and parental involvement.\u003c/p\u003e\n\u003cp\u003eCompetent neonatal care relies heavily on a skilled and well-trained nursing workforce. However, data from this study revealed disparities in training among nurses. Nurses identified staff shortage, inadequate equipment, and training as significant challenges. While some had received formal instruction in neonatal or preterm care. These discrepancies align with findings by Moxon et al. (2015), who noted that inadequate pre-service and in-service training among healthcare providers is a major bottleneck to improving neonatal outcomes in low- and middle-income countries (LMICs). Another study by Ndebele \u0026amp; Ndlovu (2023) corroborates the finding of this study, which found that staffing shortages and inadequate resources can compromise quality care. The importance of adequate staffing and resources is emphasized in the literature, with authors like Aiken et al. (2019) highlighting its impact on patient outcomes and nurse burnout. \u0026nbsp;A lack of continuous professional development can lead to substandard care practices, particularly in dynamic and high-risk environments like NICUs. Therefore, structured and consistent training programs are essential for enhancing nurses' competencies and standardizing neonatal care (World Health Organization [WHO], 2016).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Nurses emphasized the importance of individualized care, infection prevention, and monitoring. Despite systemic limitations, nurses emphasized the importance of holistic and individualized care tailored to each baby's condition. This finding is supported by a study by Lei et al. (2022), which found that individualized care can improve patient outcomes and satisfaction. The importance of infection prevention is also emphasized in the literature, with authors like Lim et al. (2019) highlighting its impact on patient safety. This also aligns with the principles of family-centered and developmentally supportive care, which emphasize adapting interventions to the infant’s condition to promote optimal health outcomes (Altimier \u0026amp; Phillips, 2016). However, the ability to deliver this level of care is often dependent on adequate staffing and access to functioning medical equipment, both of which were lacking in the observed settings. Another prominent barrier reported by nurses was the shortage of staff and essential neonatal equipment. These issues reflect broader health system inadequacies in many LMICs, where the nurse-to-patient ratio is frequently insufficient for safe neonatal care (Lake et al., 2017). The WHO recommends a ratio of 1:2 for critically ill neonates to ensure timely intervention and monitoring (WHO, 2016). The use of outdated or non-functional equipment further compounds the issue, placing neonates at increased risk of infection, undernutrition, and mortality (Bhutta et al., 2014).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Despite environmental challenges, nurses reported adherence to important care protocols, including kangaroo mother care, infection control, and exclusive breastfeeding. This underscores the need for regular updates and refresher courses for clinical staff, enabling them to apply evidence-based protocols effectively and confidently (O’Brien et al., 2018). The issue of high patient demand and workload was a recurring theme. These observations are consistent with research showing that overburdened healthcare workers are less likely to provide thorough assessments, timely interventions, or adequate emotional support to families (Shields et al., 2019). Excessive workload can also lead to burnout, increased medical errors, and higher neonatal morbidity (Lake et al., 2017). Improving staff-to-patient ratios and reducing nurse fatigue are, therefore, critical to enhancing neonatal care quality.\u003c/p\u003e\n\u003cp\u003eNeonatologists in this study recognized quality of care as central to the survival and development of preterm infants. They emphasized that such care must be safe, timely, and evidence-based, aligning with global definitions of high-quality care (WHO, 2016). This viewpoint aligns with Donabedian’s model of healthcare quality, which emphasizes structure, process, and outcomes as fundamental determinants of care quality (Donabedian, 1988). It also mirrors findings from Blencowe et al. (2019), who argued that improving neonatal outcomes requires consistent delivery of guideline-based interventions, especially in low-resource settings. Neonatologists further highlighted the influence of staffing levels and infrastructure on care outcomes. This supports the WHO’s position that appropriate workforce density and functional healthcare environments are prerequisites for quality maternal and newborn care (WHO, 2016).\u003c/p\u003e\n\u003cp\u003eA major sub-theme that emerged was the critical role of interprofessional collaboration in improving care outcomes. Neonatologists viewed teamwork between doctors, nurses, and support staff as essential. Neonatologists highlighted the importance of teamwork among healthcare professionals. This finding is consistent with a study by Reeves et al. (2020), which found that effective teamwork can improve patient outcomes and satisfaction. The importance of collaboration and communication is emphasized in the literature, with authors like Leonard et al. (2019) highlighting its impact on patient safety and quality of care. This echoes the literature on collaborative practice models, which have been shown to reduce medical errors, improve patient safety, and foster comprehensive care in NICUs (Reeves et al., 2017). The Institute of Medicine (2001) also emphasized teamwork and communication as pillars of quality healthcare. Neonatologists further stressed that even the most knowledgeable clinicians are limited without collaborative support. This reaffirms the need for interprofessional respect and shared responsibility, as poor collaboration has been linked to delayed interventions and adverse neonatal outcomes (Lee et al., 2020).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Neonatologists reported that inadequate equipment and technology hinder quality care, and was a persistent challenge. This shortfall limits the ability of clinicians to offer advanced and life-saving interventions such as mechanical ventilation, advanced monitoring, and surfactant administration, standard care in high-income settings. This finding is consistent with a study by Patel et al. (2022), which found that inadequate technology can compromise quality care. The importance of adequate technology is emphasized in the literature, with authors like Chaudhry et al. (2020) highlighting its impact on patient outcomes and healthcare efficiency. Studies by Moxon et al. (2015) and Bhutta et al. (2014) have shown that low-cost technologies, when adequately scaled, can significantly reduce neonatal mortality. Therefore, investment in neonatal technologies should be prioritized in efforts to improve the quality of care in Nigeria and similar LMICs.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Parental involvement emerged as a vital, yet sometimes overlooked, component of quality care. Neonatologists acknowledged the evolving role of families in the NICU. This aligns with Family-Centered Care (FCC) principles, which emphasize the participation of parents in decision-making, caregiving, and emotional support (O’Brien et al., 2018). Studies have shown that FCC improves parent-infant bonding, enhances breastfeeding outcomes, and reduces parental stress (Gooding et al., 2011). Implementing the FCC requires changes in hospital culture and policies, such as flexible visiting hours, parental education, and kangaroo mother care, which have all been recommended by the WHO (2016).\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eImproving the quality of neonatal care requires a holistic approach that integrates environmental enhancements, workforce development, interprofessional collaboration, and meaningful parental involvement. Addressing infrastructural deficits, strengthening training programs, and fostering a collaborative, family-centered culture are critical steps toward improving neonatal outcomes, particularly in resource-constrained settings. These findings offer actionable insights for policymakers, healthcare administrators, and frontline providers working to advance neonatal care quality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e:\u0026nbsp;This study was conducted following the principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics and Research Committee of Federal Teaching Hospital Ido-Ekiti (FETHI) and Ekiti State University Teaching Hospital (EKSUTH) with (\u003cstrong\u003eApproval no. ERC/2021/10/29/657B and EKSUTH/A67/2022/02/003\u003c/strong\u003e). Informed consent was secured from all participants before data collection. Participants were assured of confidentiality, anonymity, and the right to withdraw from study at any time without any consequences. The study was conducted in accordance with the principles of the Declaration of Helsinki, ensuring respect for participants' rights, welfare, and dignity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u0026nbsp;\u003c/strong\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e: The data supporting this study’s findings are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e: The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research did not receive any grant from funding agencies in the public, commercial or not-for-profit sectors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e: DTE conceived and designed the study methodology, supervised the data collection and reviewed the initial draft of the manuscript. AOO analyzed the data and wrote the initial draft of the manuscript. WOA collected the data, analyzed the data and drafted the initial manuscript. BOO wrote the initial draft of the manuscript. AOO Analyzed the data and revised the manuscript. CGR analyzed the data and critically revised the initial draft of the manuscript. All authors approved the final draft of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e We sincerely acknowledge the commitment of the healthcare workers and the mothers who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAiken, L. H. , Sloane, D. M. , Ball, J. , Bruyneel, L. , Rafferty, A. M. , \u0026amp; Griffiths, P. (2019). Nursing workforce for new-born care: Quality of care and patient safety. Journal of Nursing Management, 27(3), 532-541. \u003c/li\u003e\n\u003cli\u003eAltimier, L. , \u0026amp; Phillips, R. M. (2016). The Neonatal Integrative Developmental Care Model: Advanced Clinical Applications of the Seven Core Measures for Neuroprotective Family- centered Developmental Care. Newborn and Infant Nursing Reviews, 16(4), 230\u0026ndash;244. \u003c/li\u003e\n\u003cli\u003eBayou, N. B. , Tesfaye, B. H. , Alemu, K. , Worku, A. , Tadesse, L. , Bekele, D. ,. . . \u0026amp; Nigatu, T. G. (2024). Systematic review of the quality of care provided to sick children in Ethiopian health facilities. Journal of Global Health, 14, 04243. \u003c/li\u003e\n\u003cli\u003eBayramzadeh, S. , \u0026amp; Aghaei, P. (2021). Technology integration in complex healthcare environments: A systematic literature review. Applied ergonomics, 92, 103351. \u003c/li\u003e\n\u003cli\u003eBhutta, Z. A. , Das, J. K. , Bahl, R. , Lawn, J. E. , Salam, R. A. , Paul, V. K. ,. . . \u0026amp; Walker, N. (2014). Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? The Lancet, 384(9940), 347\u0026ndash;370. \u003c/li\u003e\n\u003cli\u003eBieleninik, Ł. , Ghetti, C. , \u0026amp; Gold, C. (2016). Music therapy for preterm infants and their parents: a meta-analysis. Pediatrics, 138(3), e20160971. \u003c/li\u003e\n\u003cli\u003eCao, G. , Liu, J. , \u0026amp; Liu, M. (2022). Global, regional, and national incidence and mortality of neonatal preterm birth, 1990-2019. JAMA pediatrics, 176(8), 787-796. \u003c/li\u003e\n\u003cli\u003eChaudhry, B. , Wang, J. , \u0026amp; Wu, S. (2020). Impact of health information technology on quality of care. Journal of Healthcare Management, 65(4), 261-274. \u003c/li\u003e\n\u003cli\u003eCraig, S. L. , McInroy, L. B. , Goulden, A. , \u0026amp; Eaton, A. D. (2021). Engaging the senses in qualitative research via multimodal coding: Triangulating transcript, audio, and video data in a study with sexual and gender minority youth. International Journal of Qualitative Methods, 20, 16094069211013659. \u003c/li\u003e\n\u003cli\u003eDonabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743\u0026ndash; 1748. \u003c/li\u003e\n\u003cli\u003eFeldman, R. , \u0026amp; Eidelman, A. I. (2003). Skin-to-skin contact (Kangaroo Care) accelerates autonomic and neurobehavioral maturation in preterm infants. Developmental Medicine \u0026amp; Child Neurology, 45(4), 274-281. \u003c/li\u003e\n\u003cli\u003eGooding, J. S. , Cooper, L. G. , Blaine, A. I. , Franck, L. S. , Howse, J. L. , \u0026amp; Berns, S. D. (2011). Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Seminars in Perinatology, 35(1), 20\u0026ndash;28. https://doi. org/10. 4300/JGME-D-21-00752. 1. \u003c/li\u003e\n\u003cli\u003eJones, R. A. , Newburn, M. , \u0026amp; Baird, K. (2021). Parents\u0026apos; experiences of care in neonatal units: A systematic review. Journal of Neonatal Nursing, 27(3), 153-162. \u003c/li\u003e\n\u003cli\u003eKetshabathupa, B. (2024). Socio-economic and psychological challenges experienced by caregivers of babies admitted at Princess Marina hospital neonatal intensive care unit Gaborone, Botswana (Doctoral dissertation, The University of Zambia). \u003c/li\u003e\n\u003cli\u003eKrippendorff, K. (2018). Content analysis: An introduction to its methodology. Sage Publications. \u003c/li\u003e\n\u003cli\u003eKuhnly, J. E. , \u0026amp; Dokken, D. L. (2018). Family-centered care in the NICU: A literature review. Advances in Neonatal Care, 18(3), 183-192. \u003c/li\u003e\n\u003cli\u003eLaDonna, K. A., Artino Jr, A. R., \u0026amp; Balmer, D. F. (2021). Beyond the guise of saturation: rigor and qualitative interview data. Journal of Graduate Medical Education, 13(5), 607-611.\u003c/li\u003e\n\u003cli\u003eLake, E. T. , Staiger, D. , Edwards, R. R. , Smith, J. G. , \u0026amp; Rogowski, J. A. (2017). Nurse staffing and neonatal intensive care unit infection rates. JAMA Pediatrics, 171(8), 747\u0026ndash;754. \u003c/li\u003e\n\u003cli\u003eLawn, J. E. , Mwansa-Kambafwile, J. , Horta, B. L. , Barros, F. C. , \u0026amp; Cousens, S. (2010). \u0026lsquo;Kangaroo mother care\u0026rsquo;to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology, 39(suppl_1), i144-i154. \u003c/li\u003e\n\u003cli\u003eLee, S. K. , O\u0026rsquo;Brien, K. , O\u0026rsquo;Connor, M. , \u0026amp; Himelreich, J. (2020). Family-integrated care in the neonatal intensive care unit: a systematic review and meta-analysis. The Lancet Child \u0026amp; Adolescent Health, 4(4), 265\u0026ndash;280. \u003c/li\u003e\n\u003cli\u003eLei, L. P. , Lin, K. P. , Huang, S. S. , Tung, H. H. , Tsai, J. M. , \u0026amp; Tsay, S. L. (2022). The impact of organisational commitment and leadership style on job satisfaction of nurse practitioners in acute care practices. Journal of nursing management, 30(3), 651-659. \u003c/li\u003e\n\u003cli\u003eLeonard, M. , Graham, S. , \u0026amp; Bonacum, D. (2019). The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care, 18(5), 346-354. \u003c/li\u003e\n\u003cli\u003eLim, J. H. , Ahn, J. W. , \u0026amp; Son, Y. J. (2019). Association between hospital nurses\u0026rsquo; perception of patient safety management and standard precaution adherence: A cross-sectional study. International journal of environmental research and public health, 16(23), 4744. \u003c/li\u003e\n\u003cli\u003eLiu, Y. , Liu, J. , \u0026amp; Zhang, Y. (2020). The impact of NICU design on patient outcomes and satisfaction: A systematic review. Journal of Perinatology, 40(10), 1430-1438. \u003c/li\u003e\n\u003cli\u003eMoxon, S. G. , Lawn, J. E. , Dickson, K. E. , Simen-Kapeu, A. , Gupta, G. , Deorari, A. ,. . . \u0026amp; Bhutta, Z. A. (2015). Inpatient care of small and sick newborns: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy and Childbirth, 15(Suppl 2), S7. \u003c/li\u003e\n\u003cli\u003eNdebele, N. C. , \u0026amp; Ndlovu, J. (2023). The Impact of Staffing Moratoria on the Delivery of Quality Health Care Services in the Department of Health. African Journal of Governance and Development, 12(2), 120-140. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien, K. , Robson, K. , Bracht, M. , Cruz, M. , Lui, K. , Alvaro, R. ,. . . \u0026amp; Lee, S. K. (2018). Effectiveness of Family Integrated Care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial. The Lancet Child \u0026amp; Adolescent Health, 2(4), 245\u0026ndash;254. \u003c/li\u003e\n\u003cli\u003ePatel, S. N. , \u0026amp; Patel, R. N. (2022). Impact of technology on healthcare: A systematic review. Journal of Healthcare Engineering,. \u003c/li\u003e\n\u003cli\u003eReeves, S. , Pelone, F. , Harrison, R. , Goldman, J. , \u0026amp; Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (6), CD000072. \u003c/li\u003e\n\u003cli\u003eShields, L. , Zhou, H. , Pratt, J. , Taylor, M. , Hunter, J. , \u0026amp; Pascoe, E. (2019). Family-centred care for hospitalised children aged 0\u0026ndash;12 years. Cochrane Database of Systematic Reviews, 3, CD004811. \u003c/li\u003e\n\u003cli\u003eSmith, C. M. , Horne, C. E. , \u0026amp; Wei, H. (2024). Nursing practice in modern healthcare environments: A systematic review of attributes, characteristics, and demonstrations. Journal of Advanced Nursing, 80(9), 3481-3498. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). (2016). Standards for improving quality of maternal and newborn care in health facilities. WHO. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Study Participants\u0026rsquo; Characteristics (n = 12)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 536px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eParents of Preterm Babies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eAll Females\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eAge in years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e24.3 (21\u0026ndash;38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eAll married\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eReligion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e2 Christian, 1 Muslim\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eEducational Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e2 Tertiary, 1 Primary\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eGestational Age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e28 \u0026ndash; 32 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003e28weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003e32weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eHospital Stay in NICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e1-3 days\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 536px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 536px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealthcare providers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e7 Females, 2 Males\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eAge in years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e41+ (36\u0026ndash;48)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eMarital Status\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eAll married\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e8 Christian, 1 Muslim\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eEducational Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003eAll Tertiary\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(7 BNSc, 1 MNSc, 1 Consultant)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 277px;\"\u003e\n \u003cp\u003eDesignations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 259px;\"\u003e\n \u003cp\u003e7 Nurses, 2 Neonatologists\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Premature infants, quality of care, neonatal intensive care unit, healthcare providers, parents’ perspectives, referral hospitals, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-7892012/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7892012/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePreterm birth remains a leading cause of neonatal mortality and morbidity globally, with sub-Saharan Africa bearing a disproportionate burden. Preterm infants require specialized, high-quality care to improve survival and developmental outcomes. The quality of care in neonatal intensive care units (NICUs) of tertiary hospitals is critical; however, in low- and middle-income countries, challenges persist related to resource availability, clinical practices, and parental involvement. Understanding the perspectives of parents and healthcare providers is essential to identify gaps and improve care quality.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA qualitative study was conducted using in-depth interviews with both the parents of premature newborns admitted in the NICUs of the Federal Teaching Hospital Ido-Ekiti and the Ekiti State University Teaching Hospital and their healthcare providers. Purposive sampling was employed to recruit participants. Data collection occurred over a four-week period at each of the referral hospitals. Data was analyzed using content analysis, following a systematic four-step process.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTwelve participants were recruited, 10 females and 2 males, ranging in age from 21 to 48 years old, who were members of 2 of the major ethnic groups in Nigeria: Yoruba and Igbo. Three main themes emerged: for the parents, the most important concern was the need for quality care, whereas for the providers, the most important concern was the challenges in providing quality care. Both groups considered equally important collaboration and communication between health care workers and the patients\u0026rsquo; families. Both parents and healthcare professionals emphasized the importance of a well-equipped and safe physical environment, individualized care, and effective communication. Key challenges included staff shortages, inadequate equipment, and limited opportunities for parents to bond with their infants.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study highlights the need for healthcare organizations to prioritize resource allocation, adequate staffing, and family-centered care approaches to improve the quality of care for preterm infants\u003c/p\u003e","manuscriptTitle":"Parental and Healthcare Provider Perspectives on the Care and Outcomes of Premature Newborns in Two Referral Hospitals in Southwestern Nigeria","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 06:37:41","doi":"10.21203/rs.3.rs-7892012/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba4c9a40-390e-4d2f-8bbc-3444581ee5e9","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-02T06:37:41+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 06:37:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7892012","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7892012","identity":"rs-7892012","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}