Fieldset
Innovation: A day in the life of a humanitarian nursing team – More observations

Any decision is only as good as the information it’s based on. British nurse Josie and her team are running an innovative new project to gather information on how nurses work in humanitarian emergencies – to ultimately help MSF save more lives.

A nurse treats a five-month-old for pneumonia at the MSF hospital in Kutupalong

Working “lates” (1:30-10pm) in the hospital are not quite as relaxing as the “earlies” (5:30am to 1pm) were, but the observations are going well.

The data from my observations of the nursing teams here in Bangladesh is going to supplement the data from our smartphone app, so it’s vital to get a complete picture of what a humanitarian nursing team actually does.

Luckily, I’ve managed to observe each nurse participating in the study carrying out important nursing tasks – e.g. taking vital signs and administering medication – at a variety of times.

This is really important to ensure that the results from the observation are as true to the real situation as possible.

Holding back

The observation has actually been much harder than it sounds, or at least than I thought it would be. There is a need to be really focused on what’s going on while holding back any reaction you may have.

It’s amazing what you learn when you’re just observing.

After years of working as an MSF nurse on the wards, supporting nursing teams to provide the best possible care to their patients, as well as being a generally loud and outspoken person, it’s really hard not to get involved.  

But not reacting is actually really important for the research, as anything I say that could lead to change in the nurses’ behaviour could affect the results and reduce their validity.

So, for now, I’m biting my tongue.

Unintended consequences

It’s amazing what you learn when you’re just observing.

For example, the nurses take vital signs for all patients at 6am and for critical patients hourly or as frequently as needed. That’s quite typical of other hospitals.

However, when ward round starts at 8:30am the nurses take all the vital signs again on behalf of the doctors. From a UK nurse perspective, this is unusual and means that the ward round generally takes longer.

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A mother sits with her child, who is recovering from burn injuries, at MSF's hospital in Kutupalong
A mother sits with her child, who is recovering from burn injuries, at MSF's hospital in Kutupalong

I tried to subtly ask why the nurses were taking patients’ vital signs on rounds: It seems that a previous international doctor had asked the doctors doing the rounds to take patients’ vital signs as a way to maintain the skill.

This is a good idea in practice, but in reality, the nurses have ended up taking them and it has increased the time the ward round is taking.

There may be other reasons as well that I wasn’t able to find out, as I wasn’t able to get too involved. However, this is a classic example of the unintended consequences that can occur from simple ideas being put into place and then not following their impact.

International staff, especially, come and go from humanitarian projects so frequently that it can be hard to keep note of why things are done the way they are. And, as I mentioned in my previous post, with such cultural diversity in the medical team it means that there are so many different ways to do the same thing.

The sapling nursery

During the period when I was doing “lates” in the hospital, I was lucky enough to have a second visitor, Cesc, the study lead.

With this being my first quantitative nursing study, not a day has passed without me messaging Cesc. And, because I’m five hours ahead of the UK, he has actually been waking up to a pile of Whatsapp messages and emails for the last six weeks!

But, having people like Cesc onboard is what the Sapling Nursery (MSF’s innovation fund) is all about – having experts in the team that are available.

Studies can be so tricky and technical, and you can often find yourself questioning yourself and your methods.

Being able to talk things through with someone who could conduct a study in their sleep is amazing.

Ukihya is a beautiful location with the house surrounded by rice paddies. where they end there is then thick jungle-like vegetation with tall palm trees often covered in hundreds of birds.

Cesc arrived and I took him straight to the hospital to meet the team.

Like Vicky, the nursing advisor, he thanked the nurses for their incredible work and dedication and started the two-week count down.

Going off-ward

It was great to be able to show Cesc the things I’d been describing and talk through the ideas we had on the ward.

One of these ideas was developing a spaghetti diagram of the tasks nurses need to leave the ward to complete, and where they have to go.

Both Cesc and I were really interested to see how much time nurses were spending off the ward and how much of that time was necessary and unnecessary.

For example, it’s necessary to leave the ward to go to the bathroom. However, it might be unnecessary to leave the ward to collect equipment, as the equipment could already be on the ward.

I found the observation of time away from the ward really exciting. Although, that excitement soon faded when I found myself timing how long it took to get to each location. And I didn’t have to do it just once, or twice, but three times and on three separate days at three different times of the day.

Still, it did amuse the staff watching me walk in and out of the ward for three days.

However, just like the observation, you cannot just do it once and assume that is how it happens every time. So, to ensure we have a time as close to the reality as we can get it under the circumstances of the study, I did it three times and will then take an average of those three times.

A tour of Ukihya

While Cesc was here I also thought I should show him a little of the local area.

So, one morning before we started our late shift, we did a small tour around Ukihya, where the international staff house is.

Ukihya is a beautiful location with the house surrounded by rice paddies. where they end there is then thick jungle-like vegetation with tall palm trees often covered in hundreds of birds.

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Chillies drying near the MSF staff house in Cox's Bazar
Chillies drying near the MSF staff house in Cox's Bazar

So, we took a stroll and saw the chillies drying in the sun and families catching fish out of their large ponds, weighing them ready to sell at the market.

We then headed to the market to buy piyaju.

Piyaju are deep-fried balls of lentils that are served with raw onions and cucumber. They are my favourite Bangladeshi snack.

Piyaju are also sold just outside the hospital, which means that I know they will be hot and fresh at 10:30am.

By week three of my stay here, I had already frequented the piyaju stand so often that the staff knew me by name and started preparing my order (three bags of 10 piyaju – one for each ward and the international team) as soon as they saw me at the entrance of the hospital.

So, I couldn’t let Cesc leave without trying them.

Then we quickly popped to buy some of the incredibly soft and colourful Bangladeshi fabric, before heading back to the house to start work ahead of my final late shift of observing the nurses. 

Next week will be our final week of data collection on the nursing app, so I’ll be spending the week double-checking we have all the information we need before I leave the following Monday.

I can’t believe how fast the last seven weeks have gone!