 My name is Jake McKnight and I lead the ethnographic elements of the HSDN project. I spend a lot of time in the actual newborn units trying to understand nurses and having long-form interviews with them where we ask them questions about what it is to be a nurse, what they do on a daily basis, and the jobs and tasks which make up their daily role. The particular problem we're interested in is that the nurses are so critical to care for newborns in these types of settings. There are very few doctors and the time the doctors spend with babies is very short, whereas with nurses, they're there for most of the care that's delivered comes through the nursing. The nurses are responsible for ensuring that the baby is clean and fed, kept warm, which is crucial, and also that they get their medications on time. Those things sound quite simple, but if you've got 40 or so babies who are all screaming and all need attention, then of course there's lots of strains on nurses' time, and our job was to look at these particular questions and see how nurses make priorities about what to do with very limited resources. We use ethnographic methods in our research, which means that we spend a great deal of time trying to understand the local culture and practice. Ethnographic methods generally come from anthropology. Traditionally, that meant moving to a culture that you didn't understand and not many people knew about and learning the language and really understanding cultures and routines and rituals and these kinds of things. It's used much more so in this type of environment in public health, where you have what could be considered a subculture. You've got newborn unit nurses who operate according to their own rules and routines and some might say inward-facing in that they look to each other for guidance, and so understanding that you really need to embed yourself within that department and understand how things work. We use these methods because we're part of a group and we're a multi-method group, so the other researchers in the team tend to use more statistical or more quantitative measures to understand where the weaknesses are and to get very much a numbers-based view of what's going on in these wards, but that doesn't account for everything. That will explain what's going on, but it sometimes doesn't help you understand why things are happening in the way that they do. So ethnographic methods are very good for understanding these why questions and why it is that nurses do what they do. What I can tell you about nurses working in these kinds of environments is that they're very, very busy in a way that you can barely fathom if you're an NHS nurse, for example. Some of the things will be very familiar, actually, but just the scale of them is what makes it so difficult. So, for example, a nurse working in the newborn units that we studied might have to sometimes look after 40 children, 40 really sick children, whereas the maximum kind of ratio that you might deal with in the NHS or in another developed economy is perhaps four to one. So there's a tenfold increase in what they're asked to manage just in clinical terms. In addition to that, nurses are busy outside of their working environment. They may have other businesses, they may be the major earner for their families and so they may have lots of dependents who are looking to them for their own education or food. The very basics of living in Nairobi at this time is a very expensive city. And then they travel to work and it may take an hour and a half to get across the city as well so that they arrive tired and then they're faced with this extremely high ratio and in a built environment which doesn't really lend itself to newborn unit nursing. And so everything about it is kind of an extreme relative to what we might see here. And of course they end up quite exhausted by this and so they've got a limited amount of attention and potentially get very worn down and the phrase they often use is burnt out. I think the first thing that we really need to consider is alleviating some of these obvious pressures. The ratio is just unfair. It's unfair to the children in the unit and to the nurses who work there. So we could really do a lot with that ratio for one. But then some of the simple things, they call the beds on the wards the King James beds and I asked why and they said all those beds are as old as the King James Bible and they're rusted and clearly not fit for purpose. So there's some very simple material things. But then beyond that I think the whole nursing profession has had quite a hard time in Kenya lately. There's been a series of strikes and scandals and I think perhaps trying to increase the motivation of nurses working there give them some new resources and training which might help raise them up and of course this human resource, this help that they so desperately need to get the job done and to feel like they are actually being good nurses and lending the care that these children need. With regard to what research still needs to happen I've got to say that we've been extremely lucky today and that we've had such a great opportunity to understand the context of newborn unit nursing in Nairobi. We really richly understand the context and the institutions involved what it is to be a nurse at this time and some of the larger figures. We know the need that's there for nursing. We know that there's very few hospitals responsible for the vast percentage of overall through the health system. There's a real bottleneck around three or four facilities. This research has really built a foundation for us to build a new intervention on. So in terms of the next research we really just need to take this opportunity to design a new intervention and to implement it.