So, the two-week pilot has flown by!
With most of my time being spent sitting in a corner of the ward observing the nurses and asking “Ki koro?” which means “what are you doing?” in Bengali.
I’m working with nurses on two wards in the MSF hospital in Kutupalong, Bangladesh, where we’re using a specially developed smartphone app to gather data on everything nurses do during during a shift.
I remembered why I love nursing, the interactions and care you provide to the patients; your colleagues; and the fact that every day is different
My questions are not only to prompt them to record and time their different tasks, but also so I can learn more about what they are doing and how.
During the pilot stage of this project we can still develop the app the nurses record their work on, making any necessary changes. During the pilot we have three aims:
- Make the app as easy to use as possible
- Capture all the tasks the nurses are conducting
- Ensure the data entered is as close to reality of the situation as possible. This means nurses are able to enter tasks and information as accurately as possible. What we don’t want is for nurses to start substituting one task for another or guessing what task in the app another task comes under. Mistakes are inevitable, but we want the nurses to feel they are able to enter everything they are doing, as precisely as they are doing it.
The aim of the project overall is to get a deeper understanding of humanitarian nursing, and to hopefully be able to use the data we gather to inform guidelines of optimal nursing levels in humanitarian settings, where conditions can be very different than in highly resourced Western hospitals.
Getting to know you...
Luckily the nurses’ enthusiasm continues and they seem happy with my presence on the ward. Our conversations, although still about the app and the research, now start to become more social and I learn where everyone’s from, if they’re married, if they have children, why they like nursing, as well as their likes and dislikes. This is what I really love about MSF, being able to spend time with the local staff and really getting to know them.
When I tell them I’m single they tell me they can find me a husband...
The team has started teaching me more Bengali and they tell me little bits of history about the area. They say that I have to go to the beach, as it is the longest beach in the world. More amusingly, when I tell them I’m single they tell me they can find me a husband.
Getting to know the app
But, back to sitting on the ward and observing, thinking about our three aims. One of the first things I notice is that some nurses are struggling to remember where to find certain tasks in the app.
The app actually includes 19 main tasks (Table 1) with 46 sub-tasks, so it’s not surprising that in the first few days they are struggling.
Another reason why a pilot is so useful is that it allows the nurses to become more familiar with the app. I decide to create a kind of cheat sheet of flowcharts which I called “Tasks and where to find them” (Figure 2 and 3). I couldn’t believe I hadn’t thought about it for the training, yet another reason to love pilots, they give you time to realise anything you may have forgotten and put it right.
I also remembered why I love nursing, the interactions and care you provide to the patients; your colleagues; and the fact that every day is different. All of this is great for encouraging people to become nurses, not so great when you are trying to record what nursing is.
Lost in translation?
The sheer variety of tasks our teams were completing, coupled with language barriers and the fact that in general everyone does things a little bit differently made the two weeks very eventful.
I found out that the translation of the app’s interface, which I had spent hours doing with a translator, was far from perfect. I’d written out the questions back in my flat in London. Although I felt I’d been thinking about the context at the time, it really isn’t until you are in place that you can really understand it and how it can affect what you’re doing.
The key is to keep things simple.
Looking at the text I’d written for the app’s interface, I had used long sentences and hadn’t always picked the most obvious words to describe things. This meant I couldn’t help but giggle when I found out that the nurses were understanding translation of “Were you interrupted?” as “Were you bored?”.
I’d noticed they hadn’t been answering the ‘interrupted’ question, even when they clearly had been, so I asked Helal (nurse supervisor for the paediatric department) if he thought there was something wrong.
Helal had a real insight into the nurses and how they worked, the cultural difference and the purpose of the data collection.
Helal explained the direct Bengali translation I needed was “Did something move into the middle of your path?”. I felt a little better at not having got that one perfect, but still took the Bengali translation out of the app, leaving just the English and then made big signs with the correct translation on and stuck them to the nursing stations.
"A brilliant test for me and the app"
Then one morning I found the nurses discussing or debating how best to fill out the app when it came to administering medication.
One nurse felt that if she had entered “Administering drugs to many patients” and one patient needed cannulating, that cannulating should be included as part of the administering drugs, as if the patient wasn’t cannulated the drugs couldn’t be administered.
The other nurse felt that the “Administering drugs to patients” task should be marked as started, but incomplete, then the cannulation task should be completed before “Administering drugs to one patient” could be done. The point was that they were both right.
What an example like the cannulation task comes down to is what we want the data to show. Knowing what you want from the data is really important. It’s at moments like these, and there were several, that I had to remember that the aim of our data collection was to know the variety, frequency and duration of different nursing tasks, in order to be able to outline a day in the life of a humanitarian nursing team.
All this meant that the drug administration and cannula tasks should be logged in the way that the second nurse explained it, as it was actually three separate tasks, even though they were all linked to the same purpose. So, I explained this and both nurses understood.
This was a brilliant test for me and the app. I learned that I need to make the aims of the data collection as clear as possible; that I need the nurses to understand the steps they need to take on the app to achieve that aim; and that we need consistency. So, a few extra training sessions flowed.
The other lesson I learnt was that some concepts just don’t translate. ‘Missed nursing care’ is an error of omission, referring to ‘any aspect of required patient care that is omitted (either in part or in whole) or delayed’ (Kalisch, 2009, p1510).
As a nurse in the UK, there were always tasks I didn’t manage to complete, either partially or fully, and so I would hand these over to the nurses on the next shift.
In the app we had an “end of shift” survey asking nurses to outline anything they had not managed to complete and why. Normally missed care is because of an increase of patients or patient severity, a lack of equipment or communication, meaning it’s generally a system failure and not a nursing failure.
I love pilots as well as nursing! Bring on the roll out!
And this is how I explained it in the training sessions. That from this information we can learn what is leading to tasks being delayed or omitted, and look for solutions. But I noticed the nurses were always entering that there weren’t any tasks they weren’t able to fully complete.
When I asked and observed them they generally didn’t have much to note, but on the few occasions when there was something, for example a piece of equipment was broken or a patient was difficult to cannulate, they would go out of their way to get it done, borrowing equipment from another ward or asking a nurse known for being able to cannulate difficult patients to come and help, even if the next medication round wasn’t until after their shift had finished.
Tea and insight
During all these lessons Helal was incredible. I actually put in a task specifically for him called “Working on the study” as I was constantly booking meetings with him and offering to take him for tea and then cheekily talking about the app.
He had a real insight into the nurses and how they worked, the cultural difference and the purpose of the data collection. Bringing all of this together he gave priceless comments on how best to organise the app.
So, with several lessons learnt and a mere 43 changes made to the app, I realised I loved pilots as well as nursing! Bring on the roll out!