I had originally intended this post to be a sort of overview of our current projects, an answer to the unspoken question of what all we’ve been working on in Malawi during these past months. But when I sat down to write, the phrase in the title kept rattling around my head.
What do we do when it’s not working?
It’s a question that has actually been forming in my mind since Week 1. Not the cheeriest of things to think about, but definitely something that has become an increasingly salient issue during our time at St. Gabe’s.
You see, we arrived loaded with potentially life-saving technologies- including two devices that Nkechi and I helped design ourselves. In the warm glow of the OEDK and the BRC, our solutions seem to address pressing global health needs almost perfectly.
Unfortunately, the real world is a great deal messier than life inside the hedges. We arrived at St. Gabriel’s to discover, almost immediately, that two of our star technologies were being underutilized. Morphine Tracker and Data Pall, the brainchildren of previous summer interns (1), have not been updated regularly since last September. Also, although the hospital’s Rice bCPAP (2) is functional, and there is one nurse and a foreign doctor who are trained in its use, this life-saving device is not always used. We remain unsure to what extent this is due to lack of training, and how much is simply that there aren’t as many babies as we imagined who can benefit from the device at this particular hospital.
I’m not going to lie, it was tremendously disheartening to see our beloved technologies in have not been used as much as we anticipated. However, I have a semi-ridiculous combination of optimistic and Type A tendencies, and thus was not content to just mope about the problem. Instead, we have been using these setbacks in order to take a step back and reevaluate. So what do we do when it’s not working?
Here are the answers so far:
- Don’t assess blame.
BTB was not being unrealistic by sending us here. Nor are the St. Gabriel’s staff shortsighted for not using our devices to the extent that we originally thought that they would. We just haven’t yet arrived at an optimal solution. Playing the blame game represents a lack of generosity towards all members of this program. Moreover, anger is not a productive emotion. People can sense your frustration, hindering collaboration. End Yoda rant.
- Ask questions. Even hard ones. To everyone.
In our very first week here, we launched ourselves into this process with Morphine Tracker. Not only did we learn more about the palliative care nurses’ opinions on the software, but we also asked nurses about the record-keeping practices. We asked the HIV clinic’s data manager about differences between palliative care and the highly successful ART (3) program. Upon doing this, we’ve learned that a lot of things that initially seemed rather counterintuitive actually play an important role in the palliative care system. As our internship has progressed, we’ve developed closer ties to people throughout the hospital. They’ve had good times with us- teaching Chichewa, sharing jokes, playing pool at the hospital cafeteria, even sharing meals- and they’ve seen us buckle down and work- doing everything from the unglamorous tasks of paperwork and pills to becoming flies on the wall in order to get a better ideas of how things (and people) work here. As the weeks have progressed, our message has come across loud and clear: the BTB interns care about St. Gabe’s. We’re here to learn, and we want more than anything to help the staff treat patients successfully.
And lo and behold, because we’re starting to understand and continuing to care, people have responded with refreshing honesty. We ask why Morphine Tracker or the bCPAP aren’t being appropriately utilized, and people are willing to give their two cents without being offended or afraid of retribution. In this way, we’ve learned that hard questions require solid foundations of trust and sincerity. - Focus dually on people and systems
Call me biased, but Morphine Tracker is a pretty great system: easy to use, and addressing a vital need that (as far as I know) no other program in Africa is addressing in quite the same way. Unfortunately, the few people who knew how to use this tool left palliative care around the same time (either for work on another ward, or for a different hospital altogether). This is kind of a freak occurrence for a ward that usually boasts relatively low turnover, but it still illustrates an important truth about medical technologies: implementation requires both a decent system, and a team of rock stars to champion it. In response to the discovery of this dual nature of tech implementation, we’ve both redesigned elements of Morphine Tracker and put an emphasis on training people to use it. A huge part of this training actually isn’t that technical- it instead focuses on discussions within Hospice about why this will improve their jobs and increase quality of care to patients. This approach to education acknowledges the tremendous role of personal agency in creating sustainable change (4). Even if our database remains less than perfect, the idea of having people who are knowledgeable and enthusiastic should translate to better outcomes in the future.
- Remove as many barriers to use as possible
To do this for Morphine Tracker, we’ve adopted a three-pronged approach. First, we have altered the tool itself to better suit current needs. This has involved labeling parts of the database more intuitively, changing the charts types to facilitate use for quarterly reports to the Ministry of Health and donors, and redesigning paper records to include the information needed for Morphine Tracker.
Secondly, we’ve been talking about Morphine Tracker with doctors, clinicians, nurses, and other team members- even those outside of palliative care. The hope is that by making Morphine Tracker a name that is recognized hospital-wide, support for its use will increase. Time will tell on that part, I suppose.
Thirdly, we are working to ensure that training for Morphine Tracker is as sustainable as possible. If the Morphine Tracker ‘experts’ are sick, on holiday, or take a new job, people should still have the opportunity to learn. This training should be independent of the BTB internship schedule as well, allowing people to develop skills or just answer a question in the quickest way possible. To do this, we have written a user manual, something that was previously not available for the program. This picture-heavy manual features a hefty FAQs section, and will be left behind in hard copy and digital edition. On top of that, we’re currently developing video tutorials, giving people the option to learn or refresh on Morphine Tracker at any point to come.
- Smile!
Yeah, it stinks when things don’t completely go as expected. But that’s life: life in a hospital, life in Malawi, life in engineering, I suppose. After a particularly challenging day, I love to unwind by having a dance party with neighborhood kids or making some pancakes for dinner (5). But even just walking around the Family Centered Care Unit, I find that it helps tremendously to smile! Smile at the nurses and clinicians, smile at Nkechi, smile at the patients. Everyone here is working towards the same goal of alleviating suffering and preserving human dignity: isn’t that something that deserves a few pearly whites?
(1). http://malawi.blogs.rice.edu/2014/07/28/morphine-tracker/
(2). http://www.rice360.rice.edu/bubbleCPAP
(3). Antiretroviral therapy, the current standard of care for patients who are HIV+.
(4). Holy buzzwords, Batman! Sorry about that.
(5). Which I’m sure my mom is super happy about.