Endings, Beginnings and Being Scared


ward sister

It’s a big deal.  I have worked in the NHS since 31st January 1983, when I first started my nurse training.  I have also been in a salaried role since I was 16 years old.  I have never had a sabbatical and only took 14 weeks off work when I had my son, returning and expressing milk everyday on the midwifery unit at the hospital where I worked so I could continue to give my son breast milk.  I have worked hard, chosen difficult roles and never been afraid to volunteer or do extra.

I have some regrets.  It was impossible to stay at the bedside back then and influence things at a more senior level.  I am of the ‘Management Generation’, where nurses moved in to management if they wanted to be involved in a wider range of things and, as I saw it, have an influence on how things were ‘done’ for patients.  There are lots of my generation like this.  It’s sad because we are castigated for not staying at the bedside and, as I have said in blogs previously, accused of selling our souls.  I was ambitious but all I ever wanted to do was make the biggest difference I could.  I also know I was a good bedside nurse, because patients often told me.

best way to prediuct the future

I hope I have made some difference.  In the last three decades I have always done new jobs; a complaints manager before there were any, setting up NHS Direct, moving into nursing/clinical informatics.  That’s one of the reasons its been hard; being one of the first is often harder than following someone else.  I have given as much support and help to others as I can, even when it was difficult.

Now those times are finished, and I have set myself adrift.

I no longer have a ‘proper’ job and for someone like me that is a big deal.  I think I probably have around 10 more years of career left, at 55 that seems reasonable. I am fed up of being a slave to a job, although I have been very lucky in the roles I have had.  My ex-boss says I had earned autonomy (I think he means he never really knew where I was or what I was doing!!) but clearly, I still needed to deliver what the organisation was paying me to do.  I loved my job, but the timing was right to go; plus, its someone else’s turn to do something with the role.  I don’t want to be the person everyone wishes would get out of the way!

So, I am forging out a new path and I am discovering the things that seem to be the things that make me ‘tick’.  I want to rediscover my voice and use it well. I am increasingly interested in the experience of patients and how we make sure their voices are heard, especially in the digital space.  I haven’t finished in informatics yet where, in particular, I would like to do something about the gender divide.  Its better than it was 20 years ago but I still feel that we have some way to go.

It appears that I need a cause, something to drive me on, so that’s what I am focusing on doing – working out what makes me tick.

I will be doing some work to keep the wolves at bay and feed my family.  As is usual with me though its far from straight forward.  So the trendy way of describing this is a portfolio career.

I will do a small amount of independent work.

I have also decided to join a tiny (a small number of staff compared to NHS Digital) fledgling social enterprise called Ethical Healthcare Consulting.  Why would I want to take huge sums of money from the NHS, working as a consultant? The NHS that has fed me, paid for my house and educated me in the last decades?  This way, as part of a community interest company we can aim to try to put something back and to do some good, whilst bringing our expertise back to the NHS and without making huge profits.  I see us as sitting just outside and alongside the NHS in values and ambitions.

I will also be working with the glorious mHabitat team and trying to help the Leeds Care Record team to deliver the Person Held Record WITH the people of Leeds.

What else, I am not so sure.  The diary isn’t full but that is perhaps good for now.  There is a house to reclaim as mine, new chickens to bring to the garden.  There are books to read and blogs to write.  I have never had a greenhouse and I want to grow tomatoes and blooms like my Granddad did.

DSCN0244

Exciting, I guess.  But bloomin scary too!  Wish me luck!

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Indelible marks for #70nursebloggers


After 34 years I can still remember her. Why is it that some people we care for seem to make an indelible mark on our memory?

She was the wife of a patient. I worked in Scarborough so lots of older people came on holiday, lots and lots of them; seeking sunshine, the Spa and the long line of  slot machines, ice cream and bingo on the front. They came in droves when the sun came out, despite the continued chill of the North Sea. Of course some of them became unwell.

He had chest pain. An older gentleman. He was tall, upright and smart.

She in contrast was tiny, like a little bird. I can’t remember where she came from but she had a strong accent, possibly Eastern European. She seemed very exotic.

I was a nearly qualified third year student, close to my finals and, as a result, was allowed to work on the three bedded coronary care unit that was part of the male medical ward.

I was always wary of getting too close to families but she was all alone. No family nearby. No other visitors but her. It was before open visiting but we used to let her come and go.

She seemed to take a shine to me. She used to chat ten to the dozen and sometimes I just couldn’t keep up.

Eventually their hotel or b&b booking must have finished because she moved into a room we had for relatives. She asked me daily to go and have tea with her. She wanted to read my tea leaves! I wasn’t sure about this at all!

Eventually I relented and we had tea. She tipped my china tea cup up and looked inside.

She said: I see a place, it’s name starts with ‘L’, I can see money, not riches but enough. She looked up at me, with pale blue eyes and said I can see a tall dark stranger and you will marry him within the year.  I thought she was so sweet; I hugged her and went off to my early shift.  I also thought she was a little bit strange and had a little laugh to myself!

Eventually they went home together. He recovered and I hope he did well.

The other girls had quite a laugh at her predictions. I had no boyfriend and what place started with an ‘L’?

18 months later, I was married to my now husband and living in a little tiny house – 10 Leeds Road.  I smile now. Perhaps my memory has gone awry!

One of the best things about nursing are those people we are lucky enough to meet along the way. We are part of some of the most difficult parts of their lives and we must leave our own marks on their memories but they leave their indelible marks on us too.

Sent from my iPad

Sorting out the information ‘Wheat from the Chaff’


16571920_sFor the last decade, or so it seems, in my professional technology life, we have been talking about the holy grail of interoperability. So, what on earth does that mean? I’m basically a non-techie and my understanding of interoperability is that we can send information around the system, from one place to another, and when it sets off it doesn’t lose any meaning as its transferred and arrives with its meaning intact. In other words, the information is available and understood by the person that receives it and this is as the sender intended. Standards are key to making this happen and at last this is starting to happen. Have a look at the PRSB and Interopen.
Wow, I mean that means we can share information using standards and free up information that have traditionally been effectively locked behind electronic walls.

Freeing up information to flow around the system comes with some issues and in our endeavours to make it flow I am not sure we have thought through some of the consequences of all this data arriving at the point of care, in a multi-professional context, that centres around the care of an individual person.

Back in the olden days, when I was a ward sister and subsequently investigating complaints, I was often faced with large piles of paper notes about an individual patient. They were hard to plough through. There were some tricks that everyone used to use to get to the essence of what had been happening to a patient.  At the back of the notes there were, usually in reverse date order, a set of correspondence between different doctors; an admission referral, a discharge summary, letters from clinic and so it went on. That’s where you started to get the best picture, a timeline, of what had been going on.

I know that we are working on standards that provide similar summaries of episodes of care which is brilliant. They will provide a much-needed way of navigating a person’s care in a timeline.

The challenge comes for those areas and professions who may be less practiced and used to summarisation; nursing for example.
hydrantThere is a risk that all this machine processable information will flow into records (maybe alongside information sent by patients too) and we won’t be able to see the wood for the trees! Imagine if you had to review every piece of information in one of those fat sets of paper notes and you were on a busy MAU. It will be like the quote from Mitchell Kapor: ‘Getting information of the internet is like drinking from a fire hydrant’. How will we ever know what is important and what can be left?
Some professionals already have solved this problem or at least started to do so. GPs, the most experienced Health Care Professionals in using electronic records, already understand the value of summaries and lists but these operate in one environment only.

How are we going to prevent this information that will be flowing around systems becoming overwhelming? How will we make it so that clinical staff do not feel the need to review every piece of information? Where will we stand if we fail to review once piece of information amongst the many?

It seems to me that we might need to think about a longitudinal record for a citizen and stop seeing records as a patchwork of systems connected by standards. If we fail to summarise, to prioritise, and to recognise that everyone can’t read everything, how are we going to sort out the most useful information from the most mundane? How can machine processing help us (or can it)? How will we share the piles of data across all the professions?

What I do know is that this affects the way nurses and probably others need to think about the way we keep records. If we don’t we will drown in a deluge of electronic information and potentially be no better off than we are today.

Perhaps we can just let the citizen take responsibility for the timeline? But that probably won’t work for everyone.

What do you think? Have I got this all wrong?

39321270 - folder and stethoscope (clipping path included)

 

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!

saltburn

“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.

poem

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.