 I'm David Gadar. I currently lead the nursing services research but previously have been co-leading part of the quantitative work on the health services that deliver for newborns. My role within the health services that deliver for newborns has evolved over time. I joined the project in its early stages. I developed some of the proposals and materials started off with the quantitative work time. Time to understand the burden of disease for newborns, access for newborn care and the quality of care for the newborns who actually access it. And then transition on to trying to appreciate how care is delivered within newborn units, more specifically to nursing, appreciating how much nursing care is delivered, developing tools for measuring that both directly but also time to appreciate from a more wider scope on nurses' perceptions or what we often refer to nurse reported perceptions of mist care. One of the major issues that the health services that deliver for newborns is tackling is trying to understand the context within which newborn care is delivered and by appreciating that we hope we will be able to identify the challenges for delivering newborn care within this low income settings where the high mortality settings, high workload for nurses, limited nurse staffing and using that evidence inform interventions designed that are more context relevant to solve some of the issues we pick up. Mist care is a new concept that has come into place in over a decade now and often refers to the inability to provide the required nursing care and that can either be as a result of omission or delayed care. And evidence from high income countries has actually illustrated that there is quite a strong link between care that is left and done on mist and patient outcomes including mortality, quality of care that is delivered to patients but also in hospital settings but also in home care settings and has also been linked to patient centered outcomes like patient experiences and how patients perceive the kind of care that they receive from hospitals. I think it's important first because of the reasons that I've just mentioned but for our kind of setting and low and middle income setting I think we have a different context we have high patient workloads with limited nursing staff the context is not perfect in terms of the resources available for providing care so appreciating how much care is delivered in our settings and some of the reasons might be driving good quality care meaning care is being delivered or not being delivered are very important in trying to appreciate and come up with interventions that are very relevant for our setting. We've recently backed on undertaking work on measure in mist care within Kenya in newborn units and it's work that started off by first developing the minimum standards required for nursing care provision within the inpatient setting newborn units and then using these standards we developed direct observation checklists based on tasks that can actually be directly observed and then took this forward using people that we trained to actually observe care as it was being delivered within newborn units. The challenges and the unique bits about this work is that babies with different degrees of severity actually require different manchutes of care and different babies require different interventions and that poses a challenge with how do you deal with the different denominators of the required care and we developed a metric which takes into account the varying denominators that allows us to pull our findings across all the babies observed and so this metrics we calling it the nursing quality of care index and the work that we've done spans across six hospitals both across the three different sectors public, private and private not for profit and for 216 babies. The key findings from this work is that only about 60% of the care that is required is actually delivered across all babies observed and when you look at the public sector less than 50% of the care that is required is delivered We've demonstrated a strong association between the number of babies being looked after by one nurse and the care that they are able to deliver. I think the implications of these findings is that the point to one we've identified tasks that are not being delivered that are directly linked to the outcomes of babies things like vitro science monitoring and feeds not being given, not being delivered but also things that point to critical safety issues like interventions not like oxygen or phototherapy not being properly delivered. One of the main solutions that I see stemming from this work is that people have to come together as partners to increase the number of nurses providing care within new born units cannot replace what nurses do but even so we also need to provide mechanisms for supporting nurses so that they can focus on more technical and critical things and that might include providing support staff for instance healthcare assistants that are used in high income settings but also might include revising the scope of practice for nursing and since nurses have taken up a lot of responsibilities along the way and some of them are not really nursing tasks and that might provide a solution. Moving forward the research that needs to be taken into account is the methods that we've developed for direct observation work are much more difficult to deploy at scale we need to come up with approaches for measuring what nurses do at scale but more importantly is focusing on work that has not gained a lot of traction in low and middle income settings.