Are you digitally ready?

The essence of the session I presented at #NIPEC18 today

Are you digitally ready?  I am hoping I am!

Maybe you are expecting a technical presentation; this is not that.  That’s because I actually believe that this whole agenda is about people.  Its not about a list of technical capabilities – its about how people respond to technology and its about everyone in this room, so how do you know if you are digitally ready?

First of all, for context, I would like to reflect back.

Its 1983 and I am a fresh faced student nurse. Much of the technology we have now didn’t even seem possible then.  We had no mobile phones and as a patient I was boiling my insulin syringe in a pan in the kitchen.

Over the decades since then I have assimilated technology into both my professional and my personal life, as I am sure you have too.

I have had no training in any of these things but I bank online, I order my meds online, I look loads up on google, I have an insulin pump and a Continuous Glucose Monitor.  I love the connections I gain on social media and I use this in both my social and professional life.

I feel I am digitally ready in many senses.

But what is it exactly that makes me so?

Here are the 5 characteristics that I think make me digitally ready:

The first is that I am change positive; that is I have a positive professional orientation towards change, seeing it as an opportunity rather than something to be avoided.  I like doing novel things.  I was the first complaints manager at our Trust, I was part of the team that set up NHS Direct, a nurse led telephone triage service and I think was one of the early nurses to work in an informatics role.  I experiment (safely of course) all the time, like I am experimenting today with you, presenting without slides.  You will have to let me know how it goes!

For me being change ready means exactly that, prepared to try new things, experiment and play.

I believe that all nurses need to be change positive as nursing as its taught today is unlikely to be the nursing of the future.  The pace of change is ramping up and technology is a large part of that, for example genomics and personalised medicine is likely to be come a reality in my lifetime.

I have already seen significant professional change. I used to be a staff nurse on a cadiology ward.  The only way we could do surgery on someone’s lungs was a large incision in someone’s chest.  It took days for them to recover.  It was painful. Now, today they can do this type of surgery using keyhole surgery. Think of the massive difference it makes.  It improves recovery but just think about the changes it makes to caring for these people!  It shifts the focus for nursing too.  And I predict it will be robotics next.

Being change ready is a good life skill as well as a professional skill too!

The second trait is Curiosity, when I mentor people I always advise them to remain curious.

Curiosity drives progress.  If we are not interested in ‘what if’ then things will always stay the same.

Curious people can be intimidating though – they challenge the status quo and make people feel uncomfortable.  I have often asked developers difficult questions about the art of the possible and hopefully driven better outcomes for patients as a result.  Its part of being able to see a wider perspective and to be able to see how technology and data can be used to a fuller strategic perspective.

So what am I currently curious about?  If we want to care for more people at home how can we lever technology to help?  I visited a brilliant care home near Coventry last week where these are using noise detectors in a large home to help to identify when things happen at night.  This increases rather than decreases privacy as it prevents the night staff having to actually go in to rooms at night for checks which in turn frees them up to support people who don’t sleep and focus on their ‘Wide awake club’ meaning care overall improves (and falls have reduced too).  I am interested in technology like Alexa and exploring how we can use it with patients.  Artificial intelligence too……. I could go on…… technology is a rich seam of interesting stuff for a curious person.

Curious people often have great imagination too and can describe how things might be, having conversations, visioning, and leading strategic change.

The third trait is a relentless focus on improvement.

I care deeply about the experience of people we care for, their carers and families.  This is fed from my own long term condition but everyone has the potential to empathise.

Sometimes the status quo is fine when you are on the right side of the service.  But it might be less so when you or your loved ones are unwell.  It changes the dynamic and you suddenly have what I call ‘real skin in the game’.

An example:

This week I received a letter from my GP.  It pointed out that I have a prescription for pre-filled insulin pens but I have no prescription for needles and it enclosed a  leaflet on how to give injections.  It concluded that they had set up an prescription for me to have needles.

What they failed to do was check my record.

The data they hold about me should have told them that I have an insulin pump.  I only use pens as a back up and rarely use them.  I have a box of 100s of needles prescribed 10 years ago that I have yet to use.

If the people focused hard on improvement using data they would have realised a number of things:

I am a pump user so don’t need many needles

I have had diabetes since 1979 and maybe sending me a leaflet about giving injections was slightly patronising (I suspect I have given more injections than the practice nurse).

I think using data is an important part of improvement science.  But use it well. Focus on outcomes and do proper PDSA cycles.

I would love to know what outcome they expected when they sent me the letter.

Improving my injection technique might be the aim and I am grateful for that but they need to use the data in a better way.

Data is the lifeblood of improvement science.

If they wanted to make things better what outcome are they measuring? And how will they judge if they have made a difference.

Nurses who are digitally ready focus on service improvement informed by data!  I can’t stress strongly enough that a digital ready nurse understands the value of data and the contribution it makes to better outcomes.

My fourth point is resilience.  Its quite a trendy word right now so what exactly do I mean?

Resilient people keep trying.  They are bouncy and in this instance keep advocating for the technology no matter how many times they are shouted down or doors slammed in their faces. When you innovate using technology it doesn’t always go well but you have to keep adjusting, reframing until you get the best outcomes.

Its OK to say ‘That didn’t work did it?  Now how can we try to make it better?’  It takes a particular tenacity and resilience to safely fail and keep trying.  It’s a mind set.  I suppose another word for this might be an optimistic mindset.

I honestly think that technology and data create a great opportunity to make the lives of patients and nurses better.  But it’s a journey. Its not a one off.  It takes hard work, as an ongoing endless journey.

I have been in this space for 17 years and I have often felt like I was talking to myself.

Things are changing but digital nurses need to not fall over at the first hurdle but believe data and technology CAN make things better.

Finally trait five!

Networking and learning from each other.

I believe in stealing other peoples good ideas and building on them, if it improves care.  I don’t mean stealing patents, and those type of ideas, but I do mean the sort of mentality that looks around to see what other people are doing to see what you can learn!

Social media is one way of doing this.  Digital in this sense has created a whole new way of learning and communicating across the world.

Networks are a fantastic way to feed your curious traits, or your creative skills.  I urge you to connect and look around.  Are you well connected?  Do you have fantastic networks?

I am lucky that I am often these days asked to judge awards.  It shocks me how often nurses describe their projects to us and see them as unique, special – when in fact the trust in the next county or in NI or Scotland or wherever, are doing the same thing better!  Just think of the potential of networks when they are cumulative for the development of ideas.

Networks are generous spaces; if you don’t believe me take a look at the Fab NHS Stuff site where people are generously sharing their ideas.

So, finally – why do I think I might be digitally ready?

The five characteristics:

I am change positive, curious and relentlessly focussed on improving the experience of service users and importantly outcomes.  I am resilient, prepared to try new things and learn from others.

How are you digitally ready?

curiosity and my cat 🙂


Regeneration of self

93789758 - thick ropes on a deck of navy ships in the port of bergenI have a strong personal identity and all my worlds tend to collide in to each other with a distinct lack of clear boundaries.  I don’t mean I am boundary-less, more that I am Anne, the wife and mum, strands that are bound around identities as a worker, a nurse, a digital nurse, a patient, a friend, a pet owner, and someone who wants to try to leave the world a slightly better place when I go.  I see the many strands of me bound together like a strong rope.  I completely love working with people and gain huge amounts from comradeship and social contact, these too are strong elements of my rope.

So here I am having finally handed in my notice and technically moving away from my existing role as Chief Nurse at NHS Digital.  I am so proud to say what I do now, yet I am walking away from that title in May.  I am not sure how much of the rope needs to unravel as part of that process.

I am, I admit, a bit scared.

I know that I am not ready to stop working and think I have at least another decade where I want to do ‘stuff’.  I just can’t see yet what that means; what the new strands will be and how they will join my experiences and the other existing parts of my strong rope.  The thing is, I have worked since I was 16 years old; I only took 14 weeks off as maternity leave and I have had no other substantial periods of time off.  From the date I started work, to the day I finish this job will be 14,121 days.  Of those days, 12,892 of them have been working as a nurse. Those are big numbers.  No wonder my work identity is a strong component that runs through my life.

So, if now is a time for re-creating myself, I am worried that the rope may be bound too tightly.

I think I need to face a period of letting go.  I can’t be the same thing forever and it’s time for change, hopefully in a good way.  Then I need to face up to some new choices and new directions.  It should be the most exciting time, but the truth is I am already having sleepless nights, not worrying exactly, its more of a nagging anxiety about letting go.

I guess it’s normal, but I am finding the waiting time excruciating. I am terrible at endings and this one seems a mighty big one!  I usually ignore them and sort of slide into the next thing, avoiding goodbyes. I would prefer it to happen now with no extended waiting times. But patience and preparation are the name of the game right now, finishing things too.

I hope to blog about my new adventures, assuming they come to pass and want to get my writing juices flowing again, so my apologies for the self indulgent blog.

If you have made some major life changes in retirement, let me know and send me some words of encouragement and your tips!  I feel sure this is a common life stage problem!


“Since when,” he asked,
“Are the first line and last line of any poem
Where the poem begins and ends?”
Seamus Heaney


Poem by Sophie Sabbage, The Cancer Whisperer,  Thank you.


Cassandra and Nursing Terminology

Cassandra1I was once told I was like Cassandra.

I had to go and look up what on earth that meant. If you don’t know the story of Cassandra, she was cursed by the God Apollo who gave her the power of prophecy but when she refused his seduction he spat in her mouth, so people didn’t believe what she told them. She could speak prophecies that no one believed. In modern use her name is used to indicate someone whose accurate prophecies are not believed by those around them.

As I am getting nearer the end of my career I again feel a similar frustration about some of the things I see in nursing and my inability to help others to see what I can see. Perhaps I am not wise enough to speak prophecies, nor clever enough to explain what I think I see, but I do not seem to be able to explain my views to other nurses so that they take what I am saying seriously.

What is it I can see?

Many years ago, when I worked on wards, in the morning, at the end of a night shift, if the night had been uneventful for a patient we would write ‘Slept well’ in the patient’s record. In those days it was recorded in a Kardex system, on paper. I know that most of the information I recorded will have never been looked at again, it will have disappeared into the paper record and have added no value as time passed. Its half- life will have deteriorated very quickly. In the brave new digital world, data that we enter in record systems does not decay in the same way; data maintains its value and potentially has value beyond that of the individual’s care. The emergence of big data, machine learning and artificial intelligence (AI) mean that everything we record has the potential to be re-used.

This means that nursing must get serious about data quality.

If we don’t do this, we will be making decisions based on poor quality information. As Professor Alison Leary (@Alisonleary) says #GIGO or ‘garbage in, garbage out’. Sometimes this might not matter but in the future when we are using information for clinical decision support, for example, it might matter a great deal.

39321270 - folder and stethoscope (clipping path included)I also believe that merely ensuring that the data we enter is accurate and timely is only part of the story. We must get serious about information standards and the way we express what we do through a standard nursing terminology. What sorts of things do I mean? We need standards for how we record a patient’s weight across systems, as it could be used to calculate a dose of a medication. We need to ensure we consistently record nursing observations such as pressure ulcers, so we can measure improvement and compare across systems/organisations. We need to ensure we express care requirements in a standard way so that when we communicate across organisational boundaries and don’t lose meaning.

We need national nursing information standards that we can apply across all professional practice that will enable us to measure nursing outcomes, compare performance, share information and, for the future, provide data that will support accurate AI.  A wonderful informatics nurse called Anne Casey wrote about some of this in an RCN paper ‘Making Nursing Visible’ (I can’t find the date of publication, but the review date is set at 2014). Anne’s paper is still true today and indeed I can see an even greater imperative. We need to do this for the whole profession; if we continue to believe that each organisation is a digital island, with its on special requirements and its own way of recording nursing practice, we will fail to capitalise on the potential data offers nursing.  Exactly how many versions of a fluid balance chart do we need to create?

The doctors are much further on with this agenda and indeed the Allied Health Professional Community too are making progress. In nursing a small number of senior nurses have more vision, usually where electronic nursing records are becoming more mature. They can see the power of structured data about nursing. The trouble is we need to do comprehensively across the profession and we need to agree standards before we digitise, so we can embed those standards and terms in the systems from the start.

FlorenceI don’t see many people listening; it’s a complicated story that uses strange words such as terminology and classification systems. Nurses who might understand are often still at the margins of the profession; nursing who work in informatics are increasingly sought but still do not have high status, unlike in the US where they seem to value nurses with informatics experience more highly and the presence of a Chief Nursing Information Officer (CNIO) is much more common.

This is not a technology issue, it’s a nursing one. Whether we chose NANDA or the International Classification of Nursing Practice (ICNP), or another system, do nurses have the vision to see that we need standards, so we can look at outcomes, share data and in future use it for AI.

Do we understand that the data we record may contribute to the future care of other patients beyond the patient we are caring for now, unlike my ‘Slept well’ notes of the past?

I hope so, I hope that for once my prophecy; that nursing is not taking this agenda seriously and may be leaving it too late, will not come true. I have been trying unsuccessfully for years to get the profession to listen.  I think Florence Nightingale with her interest in data would have seen the need for a standard nursing terminology.

Let me know if you are interested in this agenda. I’m not sure what we can do but more voices might make a difference #nursingterminology

Links/further reading:

Why use ICNP?

CNC – Overview: Nursing Interventions Classification (NIC)

What is nursing diagnosis and why should I care?

What is Deep Mind Health?




Putting people at the heart of digital #PDDigital17

11845107 - circuit board with in heart shape patternHaving a good digital idea isn’t enough. Good ideas are all well and good but only if they solve a real problem. Knowing what problems people face in terms of their health and care can take real insight – a deep understanding of issues that are complex and very personal.  It’s also true that listening alone isn’t enough.

It’s possible if we don’t change the way we create digital solutions and we continue to create an environment where we go straight to what we believe is the solution then we may miss the point.  That’s where co-production could help but if we are not careful this term can become diluted and misused. I recommend reading this blog by Mark Brown to read a little bit more about what I mean. As Mark says ‘it’s really, really hard’. We talk about user research in digital but that’s just a type of listening hard and for me still doesn’t cut it.

So, what can we do to make more of a difference?

people-drive-digital#PDDigital set out to explore this idea believing that putting people at the heart of digital would have a positive influence on the use of digital and social for good in health and care.  #PDDigital stands for ‘People Drive Digital’. Drive in this context is a very important word: putting people at the centre isn’t enough. We need to really focus on the concept that people who use services have skills and insights that are unique and are assets in their own right. We need to break down the barriers between people who use services and professionals who work on solutions. It’s about partnerships and recognising where good ideas really come from and creating environments where they can thrive.

Co-production in a digital space means that we respect where these assets lie and #PDDigital has unearthed some great examples of solutions that have been developed in this way. But there is a problem still. Getting people with good ideas to the stage where their ideas can take flight and become real solutions is difficult.

giantlogo1This year the founders of #PPDigital, Victoria Betton, Roz Davies and myself have decided to bring #PDDigital closer to the other people that matter; the technical people who have great skills and entrepreneurs looking for fab ideas. We will be at the GIANT Health Event 2017 aiming to have new conversations with different people aiming to illuminate the importance of those ideas that arise at the heart of what really counts; the ideas and challenges faced by real people. We hope that by talking about the idea that the real insights are held by patients, carers and professionals caring directly for people, we have the best chance of making a digital difference.

Please come and join us at GIANT if you are interested in our ideas. We welcome everyone and we look forward to having some great conversations.

A Nurse who has ‘Sold her Soul’?

cropped-nursing-badge-e1398349876516.jpgWhen I was 26 I decided that I wanted to do a different nursing role and I became a research nurse for a programme that aimed to develop an quality of life assessment tool. I don’t think you can do much more patient centred work than this but despite that my father-in-law told me that I had ‘sold my soul’ and all ‘proper’ nurses were at the bedside and I was wasting the money that had been invested in my training. This was an ongoing debate between us but essentially I ignored him. This wasn’t the last time similar things would be said to me in my career. Later when I went to help to set up the NHS Direct service I was told by other nurses that I had ruined my career and I would never get another job. It was clear to me that for my father-in-law and for these other people the professional identity of a nurse was firmly uniformed and at the bedside.

I recently read an interesting paper that seeks to understand issues of professional identity for medical professionals who have adopted a managerial leadership role. This strikes me as in many ways like a nurse who has moved into new professional contexts away from the bedside. I thought it would be interesting to use the framework identified in this work for personal reflection on my career and professional identity as a nurse, manager and informatics specialist. Be prepared! If you read the whole paper I found it a hard read, reaching as it does into sociology and organisational theory.

So here it is I will try to summarise what I see as the key points from the paper. I have taken the key conceptual points but not dived into the full conceptual framework (I suspect that would be a PhD!).

13971283 - two halves of the paper masks on a wooden backgroundThe paper ‘Hybrid Manager- Professionals’ Identity Work: the Maintenance and Hybridization of Medical Professionalism in Managerial Contexts’ (McGivern et al 2015) concludes that there are two types of storylines that are used around medical managerial roles i.e. roles when a doctor adopts a managerial role in addition to that of a medic. The article used comparable data from three studies of organisational change in the NHS and used identity theory work in order to create a new classification framework.

The first role identified is doctors who are described as ‘incidental hybrids’, those who find themselves in positions of management responsibility but do this through a sense of responsibility or duty. They are likely to maintain strong personal professional identity, continuing to see themselves principally as part of their professional group, managing the same traditional professional individual and group norms. They usually position themselves in these roles in a transitory way often by obligation. These types of clinical managers usually represent and protect institutionalised professionalism. They seek to align themselves to their professional identity and group first and may down play the managerial aspects of their role. They are likely to adopt a ‘representation’ position in relation to their profession.

In contrast, ‘willing hybrids’ are those professionals who have adopted and integrated a broader professional identity earlier in their careers or later in response to professional identity challenges; they have thought through the breadth of professionalism and see it extending beyond that of the traditional model and have embraced this identity. They have a different professional narrative to a traditional one, often formed by mentors and role models, where they have identified and sought to resolve professional identity conflicts and embrace the hybrid role. An example of this might be the tension between the attention to a single patient versus the needs of a population, weighing up the collective good versus individual need or where there is a need for professionals to align themselves with managers rather than seeking purely a professional allegiance. Willing clinical managers often position themselves as a professional elite seeing the management of others and/or services as a more challenging role. These are professionals who have embraced a permanent hybrid state. They are likely to be misaligned with traditional models of professionalism by engaging with others outside of the traditional professional hierarchy, for example managers, to the extent that others may accuse them of ‘moving to the dark side’.

I found this article to be really thought provoking making me reflect on my role in relation to nursing professionalism and my career.

Through my career I have sought managerial roles where the impact of what I do extends beyond that of individual patients and have been accused in the past of having ‘sold my soul (to management)’ and yet I still feel firmly placed in a nursing professional context. I think I have managed to reconcile my adopted roles and integrate these with my professional identity. Early in my career I admired nurses who were visible change agents, doing new things and leading us to new thinking. My move to being a hybrid professional came reasonably early in my career.

My extension of thinking around the contribution of nursing and the broader professional agenda was influenced by people in novel and innovative roles. Two examples spring to mind: Alison Kitson  who I met in the late 80s/early 90s when she was working on standards of care I so wanted to work on similar creative and innovative work. Similarly, in the early 1990s I went to Leicester Royal Infirmary and met Helen Bevan (@helenbevan) who was then leading innovative service improvement initiatives I can remember wanting exactly that job. It’s funny but I now know Helen and although my visit is very memorable to me I know she can’t remember it! Finally in the early 2000s I was very inspired by Maxine Craig (@maxine_craig) who was a nurse who had already taken a step towards a realignment of her professional identity and I was in awe of the improvement work she was doing and again I remember thinking I really wanted her job!  Of course I never did get any of those service improvement roles despite trying – sometimes its being in the right place at the right time!

I still feel hurt when others make the observation that I am ‘no longer a real nurse’ as in my reflection of professional and personal identity I believe that it is possible to both be a nursing professional but one whose role extends beyond that of direct patient care. I see this accusation as similar to those who accuse doctors in management as having moved to the ‘dark side’.

My reflection is that nurses who work in informatics or technology roles also have adopted hybrid professional roles where there is the necessity to blend professional identity and influence change at scale, including influencing what we might consider to be out-dated and old-fashioned professional nursing practices.

15350566 - people-puzzle isolated on a whiteI can also see how this is challenging and why professionals with these blended professional identities seek to join a new professional tribe, where the issues of professional identity management and norms can be more safely explored. These tribes also create alternative role models and mentors. I feel that this is emerging in the informatics community where they have even selected to embark on a journey of professionalisation.

who are youMy conclusion is that I have a tendency toward being a willing hybrid who elected to adopt a role that seeks to combine professional identity to a specialist informatics role. I believe that it is possible to hold the values of patient driven care at a population level beyond that of meeting the needs of an individual patient.

The paper discusses in more detail the impact of hybrid professionals and identity work and I recommend it as reading in particular for those who find themselves in non-traditional professional roles.

Thanks to Pete Thomond (@pete.Thomond) , Managing Director, CleverTogether, for bringing this paper to my attention but also for his analysis of the paper which helped to form my reflections.

I believe that the phrase ‘Once a nurse, always a nurse!’ is true but it is possible to adopt a hybrid professional identity; these hybrid roles, that push the boundaries of traditional professionalism, create the climate for professional tensions that lead to change, modernisation and improvement.

Wrapping presents

30561685 - piles of presents  doodle heaps of gift boxesMy husband’s family are great at wrapping presents; they have the art of disguising the real content of a parcel down to a tee. Even gifts of cash for grandchildren come in large boxes. That way you never can be sure what’s beneath the wrapping paper.

I think feedback is a lot like this. When people give feedback about their care experiences they often have thought carefully how to wrap up, carefully, what they want to express. They give it as a gift – most often they say because they don’t want the same thing to happen to someone else, or they want to express thanks for an event that surpassed their expectations. They carefully wrap the gift in the words. It’s hard to choose how to express those words – just like carefully wrapping a present.

I’ve blogged before about how often services respond to these ‘gifts’. I think it’s often a response to the size of the parcel, when in fact they need to open the gift more carefully, examine what is inside and look at it with fresh eyes, irrespective of the wrapping.

It’s cliched maybe to say feedback is a gift but that is exactly what I believe. If we were to consider more carefully what people were saying and hear what they were expressing it would help us to focus on what we might need to do better, or what we are good at.

To do this we need to be able to unpick what feedback means; tune in to the real messages and focus on ‘what next?’.

presents 2For me that’s the real beauty of Care Opinion. It creates a perfect place for this to happen. The feedback is volunteered not sought, so its wrapping is most carefully expressed. The giver of the gift really wants it to make a difference and wants staff to hear what they have to say.  So, working with feedback in teams seems to me to be a no-brainer and that’s exactly what Care Opinion are seeking to do.

I know that if I was still a ward sister I would want to receive those gifts and would be anxious to look carefully at what was inside rather than just reacting to the size of the parcel.

I am delighted to have been asked to be a Non-Executive Director for Care Opinion and I will continue to help them create ways that people can offer the gift of feedback and work on how the service and individuals respond.


I am often so very naive.  I know I am supposed to be an adult, who even has some semblance of a brain, but I am a marketer’s dream.

notificationsI have never considered social media noise before; never thought about how all the notifications were competing for my attention and how often I had got in to checking my phone.  It’s worse if I’m not focussed, so I can go all day at work and never look but one hint of a moment of boredom or procrastination and I’m there.  Cats and kittens always work…..

It was a presentation by Hany Rizk @Rizkhany last week that brought this in to sharp focus by showing this video.  I recommend that you watch it through to the end:

Also look at the website Time Well Spent

It got me thinking about how I manage my personal time and how I need to find some quieter spaces.  Hany managed to persuade me that I need to use settings better to manage my notifications and even switch off my phone (gulp).  I know, most of you are thinking; ‘where has she been????’

noiseI work in an environment where digital tools are seen as part of the future in the way we support health and well-being and I started to wonder how health related digital tools could compete with the existing noise.  How can we build tools that use notifications etc in a positive way, a way that enhances health related behaviours?  How can we compete with the noise of giants like Facebook and Instagram?  We need to think like Marketers!

If we are to build new digital tools that are successful and fit in with people’s lives we need to consider the noise that we create and how its positioned alongside the existing cacophony of social media.

I wonder who is thinking about that as they design new health tools.  I hope some clever people are!

52287225 - concept for mobile apps, flat design vector illustration.