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?

 

 

 

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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.

Noise


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.

#LanguageMatters


By Rosie Walker, Successful Diabetes and Anne.

DiabetesWe have both attended diabetes professional conferences and reflected on the language used about diabetes, for example, self-care is often labelled with words like ‘compliance’, patients are ‘suffering from diabetes’ and ‘poor’ is contrasted with ‘good’ control. These words carry a degree of stigma, or at the very least affect how people interact with those of us who have diabetes.   I have also blogged previously about the use of labels and stigma (check out #LabelsR4JamJars).

In other countries, most notably Australia, there has been a push to change the way language is used and Diabetes Australia have led the way in trying to eradicate words that are unhelpful when supporting people to live with diabetes and suggesting others. Their position statement ‘A new language for diabetes’ was drawn up by an eminent working group including clinicians, psychologists and of course, people living with diabetes. It is the basis for many events and presentations which quite literally ‘spread the word’ about language awareness and use in diabetes care. One such presentation was recently at the American Diabetes Association 2017 meeting in San Diego, where it was proposed that the USA might develop its own statement.

Inspired by attending that workshop and/or hearing about it through Australian diabetes advocate and blogger, Renza Scibilia, ourselves and Dr Partha Kar, Associate National Clinical Director for Diabetes in England, have decided to do something about this in the UK; working with people with diabetes, and also professionals and voluntary sector organisations, to create a UK statement that raises awareness of and promotes the best use of language in relation to diabetes and people living with it.

To start us off, we would like to hear your views:

What words or phrases do you think should be discouraged from use in referring to people living with diabetes, the management of their condition and/or diabetes care generally? Perhaps you could give us a list of your ‘top 5’ recommendations with alternatives?

To help you get started here is the Australian position statement

Please post your comments in the comments box below (if you would like to remain anonymous please say so in your comment and I will not post it openly on this site but will add your views to the debate).  You can also tweet us @anniecoops @successdiabetes using #Diabeteswords or #languagematters, by the end of July 2017.

You can also comment on other people’s ideas if you wish (politely of course!).

time to listenWe will be putting all the ideas together and will take all comments into account when drafting the statement.  The statement will be developed by a multi-disciplinary group but your voices can be heard.

Please contribute and also share this invitation as widely as you can – we would like to get the views of as many people as possible!

We will also be having a tweet chat on July 25th in the evening with @WeNurses using #WeMDT.  That should be a lively event so please put a place-holder in your diary!

Thank you!
Anne Cooper @anniecoops and Rosie Walker @successdiabetes

anniecoops diabetes

Fantasy Party Planning


Abracadabra

Abracadabra – I magic my own party!

I met some wonderful people this week. On weeks like this my job rocks; the chance to meet some really fantastic people who enrich my thinking and make life fun.

 

On the long journey home I was thinking about what it would be like if I could just put some of them in a room together what magic might happen! It was like one of those personal ‘dead or alive’ dinner party discussions – who would you select? But more importantly what could we achieve?

So, this blog is going to list some people who I would love to put in a room together to party! So how did I select my list? Each person has a set of unique super powers. Every single one of them I would think having coffee with them was a highlight of a day and finally I would just love to see what they would do if they were given a collective challenge.

The list order is alphabetically deliberately; there is no priority order and I know I will have missed some people, forgive me. Lists are written at a moment in time.

Here are where my party initiations are headed:

envelopeDeborah El-Sayed @Debselsayedd – Debs is someone to dream with. When we discuss ideas and make plans our conversations go to the most unexpected places. She’s is fun too and her parties are always the best ones, creative and expansive, in exactly the same way she thinks. She also makes things happen.

Emma Bearman @emmambearman – Emma is wonderful. I have never met anyone like her before. She is like a warrior, someone who gives part of her soul for her work on play in Leeds. Her passion is practically palpable and she would keep the party going with her energy (and play).

Hany Rizk @RizkHany – I went to a UX conference this week and his presentation blew me away. Hany is selected for his ability to make me think differently. I suspect he is also an ace UX designer. By the way he is also a super cool and from the Lebanon*. I think he brings values too.

Heather Henry @heatherhenry4 – this nurse is a super hero, who has taught me so much about asset based community development but she is also so determined and focussed. I use the story of Salford Dads and pub nursing as ways to describe an alternative way. Heather rocks.

Jenni Middleton @nursingtimesed – all parties need someone who can communicate with insight, wisdom, style and flair and that is what Jenni can do. Unusual for me to chose a journalist but Jenni is a real pro and she also has great style. All parties need someone with style!

Lance Gardner @LanceAACltd – selected for his creativity and his clear focus and insights into doing the right thing, the right way. No half-way measures for Lance, if it’s not done right he doesn’t do it. He’s also a trail blazer. Lance has a non-flashy way of working that I really admire.

Linda Whalley – Linda is a colleague. She is a great thinker and worth having alongside you but she is also one of the wittiest people ever. She has a way of seeing situations and people that is unique, wise and funny.

Lindsey Fallow @betabetic – what a treat Lindsey is to know. I don’t know anyone else quite like her. She is clever, wise, unafraid and has a groundedness about her that makes me feel safe. I don’t know anyone who has so many life challenges who remains so positive and un-beaten. She is just incredible.

Mark Davies @markpricedavies – ah Dr Mark. One of my favorite doctors. Mark is fun to be with but he is also a good person to think with, he will bring new ideas that others haven’t thought of. He also has a fearlessness about his persona, a non-traditionalist.

Mary Dixon-Woods @marydixonwoods – I’ve never met Mary (I would love too) but every party needs a professor and researcher and Mary is the one I admire most. She, too, is someone who is pushing boundaries and looking at things in new ways. I used one of her emergent research approaches in my MSc and my tutor thought I was being a bit alternative – which I consider to be an admirable thing! I will maybe meet her in real life one day.

Maxine Craig @maxine_craig – Maxine understands people like no one else I know. A deep meaningful insight into people and organisations wrapped in a beautiful soul. She is also so restful to spend time with! She will keep the party grounded and well.

Pete Thomond @petethomond – Pete is very special. I love the way he thinks – there are no blocks and barriers in Pete’s mind and his conversations reflect that. I guarantee at the party he would be an ideas generator, someone who asked interesting questions and could see the connections between ideas and concepts.

Rachael Dunscombe @UKpenguin – Rachael is in theory an IT person but when I look and see her that’s not what I see! I see someone who has so much insight into a wide range of things, not for her just pure IT but real breadth and depth! A linker of things…. Someone who I want to meet more in future.

Rob Webster @NHS_robW – Rob for me represents values. He is clear about his and would make certain we were clear about ours. He is also wise; his life and work have made him so.

Roz Davies @roz_davies – Roz is a very beautiful person. I don’t know anyone else who so consistently lives the values they express. She is someone who it’s cool to hang out with to explore values and find deeper meaning. Never under estimate her!

Simon Norris @simon_Norris – Simon is a creative if ever I knew one. His optimism is what strikes me though and his values. You would be surprised about where conversations with Simon go. Another value driven person. I love great UX designers too, they are the ones that bring IT alive for people.

Steve Wheeler @timbuckteeth – I don’t know anyone else like Steve. An academic but he is uber cool and another thinker. He is also a rebel I think. I admire rebels with values. They make me feel braver.

Susan Hamer @dollyblue3 – selected for her determination but also her incisive brain. She knows the right thing to do and does it regardless of what people think. She can be out-spoken but you will need to be at this particular party! She will help you to take an idea apart and work out what to do and bring evidence into play.

Teri Porritt @gbtpo – Teri is unstoppable. She is values driven and has so many facets to her professional persona. Peel away the layers and you will find many beautiful things that she brings to the party. Energy is the most obvious one, but you will also find a photographer inside!

Victoria Betton @victoriabetton – Victoria is another creative soul but one who can do serious business. She takes ideas and just makes them happen, like magic. Another values driven person who takes risks and walks the walk.

So how will this party go? I have no idea! But it won’t be boring that’s for sure! What ideas would we create and solutions could we find? What would we make happen?

I’ve no idea but I know that each one of these people brings gifts to my fantasy party. In writing my list I realised that there are some common themes: values, passion and the ability to think with me, play out through thinking – thought expanders.

I am grateful that all of these people have played some sort of role in my life from making me think differently to making me laugh out loud! Now let’s get on with this party!

Anne

47426673 - superhero kid at home. christmas holiday concept

Post Script: Writing this I kept on thinking of other people I couldn’t miss off (I am sorry if you are one! You will all know who you are I hope) and it was a great exercise in making me feel incredibly lucky.

*Correction:  I had originally thought Hany was from Germany but he is actually from the Lebanon – sorry Hany!