I’ll show you mine, if you show me yours


Many years ago I learnt a very hard lesson. It’s about good intentions but still getting it wrong. We all like to think that our contribution to care is visible and valued by others but do we really take the time to understand the perspective of others who support patients and just as importantly what putting the patient at the centre really means?

NHS Direct

Three of these nurses worked at the site I did! It was a long time ago now!

My lesson is from the time when I worked at NHS Direct. It was a fantastic time we were breaking new boundaries and doing things across the country that hadn’t been done before. We were proud of our nursing assessment process. I was responsible for the technical system we used; not the algorithms, but the system functionality, that is how it works. We regularly referred callers to speak to or see the doctor in out of hours care. We were one of the first sites to integrate these services and we had a great relationship with the clinical leaders in that organisation. Providing seamless care was our aim across both organisations.

I was trying to develop a system whereby in our electronic referral to the doctor we included information about our assessment. The options were limited. We held a history of the full triage, all the questions asked and all the yes and no responses. Of course for a complex assessment this could be many many questions and as far as the nurses were concerned all of those questions were important, they all added weight to their referral. They were proud that they had done a comprehensive assessment, and wanted the doctors to see what they had done.

The doctors decided they didn’t want it- a stand off!

A difficult challenge to us at NHS Direct! I held firm. Surely they needed to understand why we had made the referral?

This went on for a while. We didn’t understand why they were so resistant, how could they refuse clinical information about someone we thought was ill enough for them to need to see them! Finally, in my wisdom, I decided I needed to find out more and persuaded one of the doctors to let me spend some time with them on a night shift. Arguably I should have done this earlier but, as you know, we all live and learn!

In the car in out of hours, in those days, the doctors were receiving referrals from the nurses directly and they only way they could view the referral was to print it off on a tiny portable printer. The doctor showed me what happened if he printed it off – ittoilet roll rolled out like an out of control Andrex* toilet roll….. Clearly not the communication that the nurses or I expected.

I learnt lots of things from this experience; a reminder of the need to listen, that we were not always the most important, that being proud can get in the way sometimes but most of all to stay focused on patients and their families. Fortunately I was able to put it right and improve what we did. We created a system where the nurses could create a short summary to transfer to the doctor; a better solution all round.

I think the lessons that I learnt then may be useful today too……

It is true to say that I really do feel that informatics is finally here to stay. Every meeting I attend everyone is talking about how important it is that everyone can see information about patients/citizens wherever they access services, that we need to reduce duplication and that this will contribute to a better patient experience. Sharing information is discussed as a fundamental enabler for service transformation. Excellent! I at least don’t have to have that debate any more.16571920_s

But then, I am rightly challenged on why do we have to ask for this now, why isn’t it here already? Surely if banking can do it we can? And so it goes on. I have worked with some of the most brilliant technical folk, they are so clever and awesome and I feel so lucky. They tell me that technically what we need, as an enabler for service transformation, can be delivered – so what’s stopping us besides money?

I am starting to wonder if the problem is similar to the one I faced at NHS Direct.

Everyone thinks that their part of any ‘record’ system is the most important, as did those nurses. There are many many conversations that loop round and round about standardisation of records, terms, datasets and about sharing agreements. But no one ever gives anything up. Equally the information governance debates centre on why not, rather than how can we, scaring the living daylights out of staff. And round we go. Although it’s never personal and it’s generally lovely people (most people in informatics are lovely 🙂 )the conversations loop round and round like a merry go round. I think we circle focused on our records and our contribution to care, as we did back at NHS Direct, rather than looking at the whole system and from the patients viewpoint.

I’ve started to wonder if, like I did at NHS Direct, we are looking at it from the wrong perspective. I think what many clinicians mean when they say a patient centred record is ‘my view of a patient centred record’. What’s more, I think portals, the current trend, is merely each group agreeing to share ‘my patient centred record’. Better than not sharing at all but perhaps an ‘I’ll show you mine, if you show me yours’ approach that doesn’t really focus on the patient at all. I’m not so naive as to think that we don’t need some specialty systems – intensive care is intensive care – but I still think we might have got some of the principles wrong!Sharing It leaves me wondering if informatics needs to embrace co-production in its fullest sense; that is getting patients/citizens to describe what they mean by a patient centred record in collaboration with the people who provide care and services and those clever IT folk. Once we start this conversation then perhaps we need to accept that we have to find a way towards this goal in a way that puts aside our existing professional and organisational perspectives. It may be that it’s simpler than we think? Perhaps it throws away the concept of organisational records? Maybe that’s too hard but worth thinking about surely? If we muster all our brains and hearts along with patients perhaps we could co-create a new picture of the future?

Is informatics ready for such radical approaches? So why is it that we haven’t already embraced them? I’m not sure but I suspect it’s cultural and a difficult one to crack! Informatics is more about analytical approaches and logic and not quite so often about hearts and minds. The nearest I have seen is the development of hack days but these tend to retain control in the technical domain.

But as I learnt a long time ago listening and truly hearing are key to better solutions and I wait optimistically for the conversations to change.

*other toilet roll brands are available

Informatics skills – If you always do


‘If you always do what you have always done,

you will always get what you always got’

I see this everywhere, urging us to change; I am a bit bored with it to be honest but it does have an irritating ring of truth about it.

Nurse keyboardI’ve been thinking about the skills that nurses, midwives and health visitors need now and for the future over the last week, as a result of meeting 100s of nurses and talking to them about informatics. What I do know is that technology has already impacted on practice and I feel sure it will continue to do so. These days, as I only spend short rare periods on the ward, I often can’t use a piece of new equipment and have to ask someone to help. Informatics – that is both the use of information resources and technology – have an insidious impact on practice and increasingly are woven into the work we do with patients.

dream jobWhy is it then that we continue to write job descriptions (JDs) that could have been written 2 decades ago when I was a ward sister? They seem old fashioned and if they are trying to describe what nurses need to do they are dull, dull, dull. Nursing is one of the most exciting and diverse jobs I can think of yet if you go and pick up a vacancy on NHS Jobs and open the job description I suspect you might feel underwhelmed. In a competitive labour market surely we need to do better than this? These JDs are like a window into your organisations!

Two years ago I collaborated on a piece of work with Professor Dawn Dowding. We randomly sampled job descriptions taken from NHS Jobs on a single day and analysed them to look for the skills relating to informatics. I was yet again underwhelmed. You can see the full publication here (sorry its pay walled).

In a world where using information and technology are almost routine parts of our lives these JDs were shocking. Few referred to using information in a modern way although there were oblique references to some of these concepts. 16571920_sOne of the most powerful feelings I came away with was the rules driven Information Governance agenda with the focus on ‘thou shall not’ with no focus what-so-ever on how sharing information can improve safety. I am pleased that since then the Caldicott 2 review has corrected this perception but a quick scan on NHS Jobs reveals that this is still not evident in JDs.

Nursing is a modern profession. It is continually reshaping itself to meet the needs of the people we care for. Job Descriptions reflect how we see roles, how we recruit people with the skills to do the job and these in turn inform workforce plans that help us to educate the future workforce. We need modern nurses who are skilled users of information and technology to meet the challenges of the future. But if we always describe nursing in the ways often expressed in JDs, we will always get what we always got!

Here is a my take on a redraft – Nurse Draft JD – as an example of a more modern JD. I am not saying it is right, it was developed with my particular focus and was drafted before the 6Cs Compassion in Practice strategy but I believe it has the informatics skills woven through it, just like the use of information and technology are woven into practice. I just wanted to show how informatics could be described without asking for ‘Computer Skills’!!!!

We need to up our game.

technology future

 

Exploring New Territories


It was a usual morning with an early start at 6 o’clock to get the train from Wakefield to London. It was all pretty much typical, Costa coffee in hand and sat waiting patiently, shivering, on the station platform, as I always arrive early. As is also usual, I’m filling in those pockets of time with my Twitter feed on my beloved iPhone and I notice that the HSJ were announcing their first ’Social Pioneers’. As I do, I flick it open and the first thing I notice is a lovely picture of the lovely Teresa Chinn. Then as I scrolled down, there I was: gobsmacked – me a ‘Social Pioneer’?

I am passionate about how information empowers. Information can bring independence and create changes and shift in social order. So bringing information to nurses can enable them to improve their practice, see things in new ways, revolutionise and encourage improvement as well as spotlighting where things might not be right. For citizens, information can drive real change, be disruptive in creating new paradigms of systems and behaviours; I think that ‘Patients Like Me’ is one of the best examples I can think of that shows this; have a look at this story to see what I mean:

Frustrated ALS Patients Concoct Their Own Drug’ The Wall Street Journal, April 15th 2012

This powerful very short TedTalk from Stanley McChystal is about how having the confidence to open up information can make significant differences to what happens and illustrates my point too.

 

‘Information is only of value if you give it to the people who can do something with it’ Stanley McChrystal 2014

‘Sharing is power’ Stanley McChystal 2014

So what has this got to do with me being a ‘Social Pioneer’?

In around 2010 I discovered social media. I’m naturally curious and experimental so, curiosity prompted, I wander into social media. Wandering is a good description – I had little knowledge beyond being a Facebook user, no skills and little insight = scary!

What I discovered was a space that I think has huge potential for nurses but also those people who have health needs – it has the power to transform some aspects of how we use information.

What I also discovered amongst the nursing community was a reticence, anxiety and resistance and sometimes all of these things are still present. It frustrates me sometimes that I sense a lack of professional confidence about using social media and experimenting with its potential amongst many nurses. I also discovered people who I now realise are social pioneers, people with long term conditions and experiences of the health system that I started to follow and watch – I was amazed.

I saw the huge untapped potential that I believe social media offers us. Yes, it breaks down boundaries and flattens hierarchies, but it also has the real potential to change the very nature of the power based relationship between systems and people. I also believe it still has untapped public health potential but it has to move beyond broadcasting to achieve the possible.

So in 2010 I decided that one of the things that was needed were some role models in nursing that showed what could be achieved and as no one else (other than a few notable exceptions like Teresa @agencynurse and a few other pioneers) were taking that on, I decided that I would. If I was to show the power of social media I needed to ‘show’ it, not just point at it; doing presentations about social media is one thing but living it is another. So my ambition was to be a good role model for nurses in social media. That’s when the real pioneer journey began. My delight on being identified as a social pioneer was partly to do with feeling that it was evidence that I had, at least partly, achieved some of what I had set out to do.

In my journey I also discovered a very eclectic diabetes community and I am proud to say that I have also been part of that, making I hope, a contribution based largely on my 35 years of living with type 1 diabetes but of course combined with my other skills and knowledge. I have written with another social pioneer – @parthakar (whom I have never met in real life but know that I will 🙂  )  about the use of social media in the professional interface between professionals and patients – this would never have happened without Twitter. Here it is:

‘A New Dawn: the Role of Social media in Diabetes Education’

pionee signpost

Famous signpost with directions to world landmarks in Pioneer Courthouse Square, Portland, Oregon

That’s why the word ‘pioneer’ was the part that gave me the most satisfaction when I read the piece in the Nursing Times and Health Service Journal supplement. I was also cited alongside many people I greatly admire – each has made a unique and significant contribution. I was delighted that the write up picked up some of the very things I was trying so hard to do, rather than just my level of frenetic activity! That’s exactly what I set out to do, to start to chart the new territory of social media for patients and nurses and other people who are part of the big NHS and social care extended family and I hope I am a little part of an enduring story.

FlorenceI also came to realise that being called a ‘pioneer’ gave me great satisfaction for other reasons; I have always taken on roles in leading (and sometime ‘bleeding’) edge environments; complaints management in 1990 (listening to complaints then was not what it is now), NHS Direct, the National Programme for IT and informatics is still, in its own way, pioneering. There is also the point that nursing has a strong history of pioneers like Mary Seacole and Florence Nightingale – fantastic role models.

So on Wednesday I celebrated with a very large piece of cake!

Anne Cooper – ‘Social Pioneer’ – who would have thought it! Now where is the next territory to explore?

So that’s enough about me (a very self-indulgent blog this week AnnieCoops!): A very big thank you to everyone who was kind enough to nominate me (you know who you are), the Nursing Times and Health Service Journal and the lovely judges: Jenni, Andrew, Shaun and Emma. But also I couldn’t be social without conversations and it is those people who increasingly have the confidence to share, debate, support and push conversations in social media that I need to thank. Your conversations, blogs, video blogs inspire me, help me to grow and learn, support me and enable me to see new futures – thank you.

Cake

 

 

The highs and lows of being a patient


roller coasterI’ve had a very mixed day today, you know, one of those ones where it’s a bit like a roller coaster, up and down and all around – I’ve been to clinic and it wasn’t all good news. To make it worse the good news came first and then the pricking of the bubble 😦 but I guess on balance it was OK in the end.

For those of you who know little about Diabetes I had a clinic appointment and was waiting for a test result called HbA1c. It’s a test that helps you to understand how well you have managed your diabetes over the previous 2-3 months (you can read more about it here). As I had been trying very hard to improve my diabetes management I was looking forward to seeing how well I had achieved this aim. But it wasn’t good news 😦Diabetes

My result was actually higher than I have ever had before and I just don’t understand why. I also have slightly raised blood pressure which has persisted for a year or so. Regarding my BP my lovely consultant, Dr R, wants me to take more tablets but I want to try losing some weight first but we agreed a middle way; a 24 hour BP recording to see what is really going on.

I was despondent. I need to lose weight – for the BP (and also for me) – but that complicates my overall management and I honestly don’t understand why my HbA1c is so high.

This is where the experience turned around – Dr R, is simply a star. Now you need to understand that I suspect I’m not an easy patient, particularly for the nurses, but probably also for the docs. I try so hard to be a ‘good’ patient but I also know that I’m a Yorkshire lass who has a reputation for calling a spade a shovel at times of pressure and clinic = pressure. I also, of course, can smell patronising behaviour from a long distance and my response isn’t always as gracious as it should be, despite my efforts.superstar

I am pleased to report that Dr R handled me and my need for help with skill and aplomb. We have a plan and, more, we are going to manage it using email and technology. It seems that he has heard my pleas for less ‘clinic’ and more remote help and responded with a positive optimistic and helpful outlook. I certainly didn’t feel patronised or told off, he just made to feel like they were going to help me to get to the bottom of my issue. I feel sure with a bit more effort on my part and with his insight and skill we can sort this out. It was the first time I have ever really come away feeling like I had a clear ‘plan’.

But the other thing that happened also made me very happy indeed. Sometimes, as a patient, when you give feedback it’s really hard to see whether anyone is taking you seriously. The place where I receive my care is a struggling Trust. On the recent staff survey only just over half of the staff said they would recommend it as a place for their friends and family to be cared for and they were in the worst 20% scores for all trusts for some of the measures. The diabetes centre is fairly new, build from charitable monies but when I got there today the reception area was closed, shuttered and unmanned for the second time – I suspect a sign of the underlying cracks in the system.Pressure

I also know they have a problem with workload and they need to think about how they can do things differently but I think they feel like they under siege; torn and burdened.

But I discovered that they do listen; Dr R is a gem. I spoke to him last time in clinic about how difficult it is to get an appointment and how I didn’t think I need to physically be with him in the same room and surely we could use different ways to communicate? I also subsequently pointed him at my blog about a ‘Year of Care’ – see here.

Well, well, well; he was bursting to tell me his news as soon as I walked into the room and he brought a massive smile to my face – they are going to start a service improvement initiative to do exactly what I suggested, finding 20 patients from each of the 3 hospitals who would like to try to work with the team in new ways, using email and technology, to see if it works! I couldn’t have been prouder. I just hope of course that it is better for everyone and that includes saving some money but they are going to do this properly, with proper measures to assess the impact – my little heart swelled with pride.Computer stethescope

I also persuaded him (I hope 🙂 to look at how these patients could connect with each other using social media; I offered to run some sessions for those patients who were interested – you never know it might help them to be better connected as it has done for many of the people with diabetes that I chat to on Twitter, using #DOC and #ourD. It seems I have volunteered myself to help and am delighted to do so.

So, today was a day of highs, too high a HbA1c and a great one of feeling good that I might be helping to support making things better even if it’s in a very small way. Dr R promises me that they will write this all up when they are done and I can’t wait to see the outcome.

Are you a patient who has a good idea? Why don’t you try offering it up to see what people make of it? You never know you might have one of the solutions everyone is looking for!idea

The importance of partnership and mutual respect


knowledgeI think I’m probably a ‘knowledge worker’. I didn’t know anything about being a knowledge worker until I got a new brilliant boss who has the brain the size of a small planet. Once she got to know me and how I did my work she told me I was a knowledge worker and one who capitalised on networks, building relationships and connecting people. The work on knowledge workers and the role in how we organise work is quite interesting but it isn’t the focus of this blog – if you want to read a little bit more then there is a link here to work by Rheinhardt et al (2011).

One of the downsides of being a knowledge worker, along with the need to be up on your game at all times, is it can be quite lonely – you sit at the edge of most groups; your role is to move around and bring and take knowledge. It’s true that I am often not a central member of a team; I move in and out and hopefully add value along the way.network

Working as a nurse in informatics means that my role is often to act as a translator between IT folk and nurses; I have to have enough knowledge to be able to explain the perspective of the other group and work hard to bring the groups together, as I know that if people from technical backgrounds work more closely with the clinical and patient communities then the success of any project is more likely or it is more probable that a better solution will be found. It’s also a bit like a facilitator of co-production! If you want to know more about this I recommend this video. The need to see it from both sides is essential and the knowledge worker uses knowledge to facilitate learning and understanding from both perspectives.

Unfortunately in informatics it leads to seeing both the best and the worst of people. Over the last few weeks I have become frustrated by how people blame others about lack of progress. I have worked with some brilliant IT people; clever, caring and dedicated to working to make health services better, their drive to do the right thing sometimes shocks me, even now after 10 years of working with them. Clinical staff are not the only ones who care. Of course nurses are like this too, most nurses strive to do the best that they can and improve and I have witnessed this many times in the last 30 years.
Why is it then that I still hear one group blaming the other for a problem?

  • ‘The IT staff don’t understand us and what we do!’
  • ‘IT just give us the kit and walk away – they never listen’
  • ‘The nurses are not interested in IT really because they will never engage’
  • ‘Nurses never come to our meetings’

What I see is that all these things are true. But there is a risk that if we continue to blame we fail to recognise that the single most important thing that we need to do is learn to work productively together; for nurses that means making the IT folk your friends and listening to their ideas and plans and for the IT folk, it’s respecting nurses and helping them to understand the potential of IT.  Why not go out with a district nurse if you want to understand or get down onto those wards?

The boundaries that seem to exist are not real but I am getting exhausted climbing over the wall between nurses and IT!

partnershipSo my piece of knowledge that I’m trying to share is that if we are going to innovate using technology the relationship between clinical staff and technical staff needs to change to one of partnership, mutual respect and trust. It’s the only way we can do this.

PS Shhhh: Dear nurses – I always find that cake is helpful when you want to have a difficult conversation with IT 🙂  I make a mean Victoria Sponge 🙂 Cake

The best thing? Nurses spend more time at the bedside!


NHS+Change+Day_logo_calendar_png_5_____This is the last of my posts relating to my pledge for last year’s NHS Change Day, where I wanted to put more effort into visiting frontline services.  My last visit during the year was to meet the informatics team and lead informatics nurse at Liverpool Heart and Chest Hospital NHS Foundation Trust.

A few facts first about the hospital; it’s one of the largest specialist heart and chest hospitals in the UK, providing specialist services in cardiothoracic surgery, cardiology, respiratory medicine including adult cystic fibrosis and diagnostic imagingIn 2012 the Trust was rated as the top performing hospital for “overall patient care” in the Care Quality Commission’s National Inpatient Survey for the sixth year running and was awarded the HSJ ‘Provider of the Year’ award in 2012.  The hospital is sited with a number of other NHS providers on the same site but as soon as I walked through into the main entrance I was impressed, not just by the environment, although this was modern and welcoming, but also by the staff who were all amazingly friendly and helpful.

Penguin outside entrance to Liverpool Heart and Chest Hospital

Penguin outside entrance to Liverpool Heart and Chest Hospital

It was a long walk through the hospital to the Trust HQ – sited in portacabins outside the main building.  The reason why?  The HQ had been converted into a great new ward facility!

The Trust deployed the AllScripts electronic patient record system in June 2012.  I met the incredibly enthusiastic Lyndsey, the nursing lead for informatics and she took me to the wards where I met front-line staff and saw the hardware they were using on the wards.  There seemed to be no lack of equipment but Lyndsey explained that the nurses were keen to move towards more flexible mobile technology – tablets – a trend that I am hearing from lots of different places.  Nurses don’t want to be tethered to desktops or even laptops – they want to be able to hold the technology in their hands at the bedside.

The deployment at LHCH was a big-bang deployment and I reflected on the courage and leadership that will have taken from the whole informatics team.  They managed the risks well, they used champions from the front line, 10% of staff were trained as champions (a significant commitment from the Trust), and Lyndsey and the CCIO worked really hard to make sure safety was paramount.  They also made it clear that they had been well supported by their supplier, AllScripts, which is also great to hear.

team

I was impressed by the evidence of clinical leadership and respect that I observed.  Lyndsey was no nurse leader hidden away in an informatics department.  She knew nearly all the staff we met on the wards and was clearly liked and respected – after all she is one of them.

I asked a ward sister what she thought was the best thing about the deployment and her answer was – ‘It’s great.  The nurses spend more time at the bedside! I don’t see nurses sat at the nurses station writing up their notes because they do this with the technology with the patients’.  A great answer that gives me hope.

The Trust’s journey doesn’t end here though.  Dr Mark Jackson, Director of Research and Informatics took up his portfolio fairly recently.  It was a pleasure to meet him too.  His background in research means that he places high value on the understanding that can be gained through information and the opportunities that a new electronic record system can create.  I think he will be looking to make best use of the data assets they are building.

Overall this experience was a fitting and optimistic end to my 6 visits during 2013.  What did I learn in Liverpool?  That optimistic and clear clinical leadership definitely makes a difference in informatics.  I saw very little paper in the Trust.  But there was also a little jangling worry too.  As I was leaving the ward I saw a Fax machine – ‘What’s that?’ says I.  Apparently its the only way the local community nursing provider will take referrals – it sort of made me want to howl with frustration!  I suspect the Trust staff feel the same 🙂16571920_s

So #NHSChangeDay2013 for me is done, but not done!  I have gained so much understanding through my visits that I am using in my national role that I am determined to continue to visit sites! Volunteers for a visit are welcomed!

Informatics: What is Nursing ‘Clinical Content’?


I wrote the content of this post some time ago because I realised that I was having many conversations about what I understood as ‘clinical content’ but many people didn’t know what I was referring to, except if they worked in informatics.  It took me ages to ‘get it’ but increasingly I realise this is a very important part of the future if we are going to develop electronic patient records.Record keeping nurse

So, imagine the scenario, you are a newly qualified nurse and you have had a couple of days on the ward and at last you are sent to assess a newly admitted patient.  You pick up all the documentation and forms and off you go.  I am confident that those pieces of paper would affect the information you collect.  They are clinical content.

Clinical content refers to the components of nursing records that:

1     Structure care processes and;

2     Provides information at the point of care that supports clinical decision making.

Examples include:

1     Templates (for data collection – supporting nursing to make high quality assessments),

2     Risk assessment frameworks (to bring evidence to care processes for example PU risk assessment)

3     Care pathways (to support clinicians in making optimal decisions about care plans with patients).

They may also include alerts and warnings, where professionals’ attention is brought to a particular aspect of a patient’s condition for example an allergy.

Why is clinical content important?

  •  Safety

If we collect consistent evidence based information and use this to deliver care we can improve safety, for example, well structured and common handover documents as patients move across the systems can help to maintain continuity of care and avoid safety incidents.

  • Sharing

If we are to enable sharing of records with patients, attention to clinical content will make sure we document in open and transparent ways that enable people to understand the record.

  • Expertise of workforce

We know that the experience in the nursing workforce is set to fall as the older more experienced nurses leave the workforce. Good quality and evidence based clinical content can be used to guide staff through care processes and build their nursing knowledge and expertise.

  • Efficiency

Implementing electronic systems does not always make work more efficient on its own and only by judicious professional review can we make sure that the paper systems converted to electronic are robust and not wasteful.

  • Improving quality

Providing staff with the best information at the point of care helps to make sure that patients receive high quality evidence based care. It also allows us to robustly review our performance in a structured way; for example, we need to be able to measure pressure ulcer incidence. In order to understand how we might be able to improve and to investigate if we are outliers from a performance perspective we need to be able to compare ourselves with others, so we need data collection that is common. This leads us to conclude that common data collection templates should be important.

  • Information overload

In the new information age there is almost too much information available for staff to integrate into their practice. Well governed and managed clinical content can help staff to be as up to date as possible.

Is Clinical Content just about electronic records?
Clinical content is commonly referred to as a component of electronic records but actually all record keeping systems have a component of clinical content. If you visit any ward or department you are likely to find assessment frameworks and templates for collecting information, as well as possibly local standardised care plans. Sometimes these have strict governance applied but paper records have a tendency to proliferate, for example, in one city they found that they had around 600 pieces of paper to be used in nursing records.
Why should we be concerned about this? Doesn’t the system work we have now work?
As the world we work in becomes more and more electronic so nursing is likely to evolve to catch up with the world around us. We can of course just turn our pieces of paper into electronic versions of the same, but this would represent a huge missed opportunity. Experience of implementing electronic records in the US shows that just making paper electronic, while a low complexity approach, adds the lowest value in terms of quality, efficiency and safety. We have a huge opportunity to improve things but we need to grasp this now, and we need professional leadership to make it happen.

Isn’t this about IT and, therefore, not a professional issue?
This is definitely not about IT. When any clinician starts using a new system it will come as an empty vessel, a bit like a show home. In order to make it useful, and contribute its potential, it needs clinicians to make it work for them through adding high quality well governed content. Also professionals need to work out how it will work for them, to continue with the show home analogy they need to make sure the sofa fits into the room and that the colours match.

Why don’t systems come with content already in place?
Some systems will come with some content from the system supplier or a third party. If anyone takes this content they are likely to find that it perhaps is not fit for their organisation (most content is from the US) and requires a lot of review to make it fit for purpose.

Should we be developing our own content now?
It is a good idea to start to develop nursing content and to streamline existing records now even if you are not planning an electronic record. If this is done carefully it can ease the way forward for implementing electronic records. The downside of this is that it is expensive and time consuming and if every organisation has to do this alone it may represent large sums of NHS funds. Nursing is already behind the curve professionally; the medical profession is already making strides forward to enable standards such as discharge summaries to be used across the service. Nursing has a tremendous track record of innovation and with good leadership clinical content development could contribute to other priorities such as QIPP and the productive initiative.

What needs to happen to make this a reality?
The first step is senior clinical leadership and ownership by the profession. In order for this to happen we need to be clearer about why this is important and what any activity can offer.
Governance, ownership and risk will be key issues to be explored.

So next time you fill in an assessment form, complete a nursing record or perform an admission assessment or discharge – you are using clinical content.  It’s too important to ignore!

medical records

#NHSchangeday 3 reflections – Record Keeping


NHS+Change+Day_logo_calendar_png_5_____On #NHSChangeday I committed to visiting front-line services – back to the floor if you will – to make sure I had the widest understanding possible of the challenges people face and how informatics could help. I have enjoyed my #nhschangeday activities so far. Over the last couple of weeks I have also visited Barts Health NHS Trust and Leeds and York Partnership NHS FT.

medical recordsWhat have remained with me, since these visits, are some thoughts about record keeping.

When I do my clinical practice on the wards I work on an elderly rehabilitation ward.  I find the documentation on the ward a real challenge.  Each patient has an A4 folder for the nursing record and to my eye is full of assessment forms and I struggle to work out exactly what needs to be done for any one patient.  For me an essential purpose of the record is to enable the best communication so that anyone supporting the patient’s needs can quickly understand how they can help.  I thought it might be just me but after a CQC visit recently the trust, as part of their action plan, is doing lots of work to revise their nursing documentation.

Barts was interesting, as a large university hospital and for me personally it is a more familiar environment than many of the other places I have visited so far. They have a large Electronic Patient Record deployment and I was impressed by their informatics strategy – it is ambitious and focussed on sharing. I was, however, quite surprised to see how little structured nursing documentation it seemed to contain.  It may be that I just went to the wrong places (it’s a big place) but in terms of consistent nursing content across different areas of the hospital that’s not what I saw or heard and I suspect this is part of their plans and the journey they are travelling – I hope so.

Then last week I had a great experience going to visit a forensic mental health ward.  Other than it being a great learning experience for me, I am a general nurse with limited mental health experience, the record keeping took my breath away; reams and reams of narrative, with a few structured forms.  I know this is likely to reflect the different cultures between the more assessment orientated general and nursing and mental health but the contrast was stark!

The Nursing and Midwifery Council Record Keeping Guidance states that record keeping is an integral part of nursing and midwifery practice.  There are two key reasons for good quality record keeping; the first to ensure the delivery of safe and effective care and the second as a legal record of the care delivered.  It is an essential asset if we are to deliver care across teams and organisational boundaries, making sure that patients don’t experience a ‘bumpy ride’ as they transfer care across individuals, teams and services.  We also need good records for audit and research so we can assess outcomes and look at the contribution that nursing makes to the care of people.  The RCN produced a document relating to this called ‘Making Nursing Visible’ which makes the point that if we have accurate electronic nursing records we can measure the impact of nursing practice on patient outcomes.

Over the last year record keeping has continued to be debated with many people seeing nurses being burdened by data collection systems.  We need to find ways to make sure information is collected once, at the point of care, and used many times for other purposes, with the patient’s permission if it is required.

But the diversity of types and content of records is alarming.  I have been listening to people talking about a standard language for nursing records for a few years and we never seem to make any progress; I’m not convinced that it isn’t a holy grail.16571920_s

So what can we do?  We know that nurses like narrative and see record keeping as a burden rather than a task they want to do.  We know that we have to cope with the diversity of nursing settings that I continue to see when I visit sites.  I’m not sure I know the answer but I do know that nurses and midwives need to be the ones who step up to meet this challenge.  The worst thing that we can do is let someone tell us how to ‘do’ our record keeping and what we should be recording and how.  We also are unlikely to be able to continue with paper record keeping in many settings.  Compromise is also likely to be part of any solution – a willingness to focus on the patient rather than the history and culture of nursing and finally to accept that perhaps we need to change.

Informatics can help if nurses engage to make sure that systems are implemented well, with good clinical content that focuses on patients and working in partnership both with patients but also the multi-disciplinary team.  It’s a leadership challenge for nurses with many people walking away from this issue in the past and as a result we often end up with systems that do not reflect what our patients or we need.

There are also emerging technologies on the horizon that might help. The developments in the field of Natural Language Processing is likely to enable us to be less focussed on drop down boxes and radio buttons but it will still mean we have to seek agreement over the use of some aspects of our record keeping.  Barts Health are starting to explore and take steps on this journey. It may mean we talk less about ‘forms’ but may mean we need to think about the language we speak in, the words we use to describe particular aspects of care and that when, for example, we say ‘Pressure Ulcer, Grade 3’ we all mean the same thing.  I think this is still about standards but perhaps different to the conversations we have had so far  – I’m looking forward to watching this story unfold.

Computer stethescope

#NHSChangeDay pledge #2 Visit to Liverpool Community Health Trust


Continuing my change day pledge to visit front-line services, to better understand their use of technology, I had an inspiring visit to Liverpool Community Health NHS Trust. The day started well with the friendliest people I have experienced in a while as soon as I got off the train – and I thought we were chatty in Yorkshire!

LiverpoolIt’s a long time since I worked in a community setting, although I have often worked with community teams. District nursing was a dream for many of us in the 1980s when we qualified but roles were rare and didn’t come up often. With the increasing need to care for more patients in their homes and meet people who have complex needs through multiple long term conditions, community nursing is becoming a priority and we need creative teams with great leaders who can think through new ways of doing things.

Liverpool Community NHS Trust provides more than 60 different healthcare services and employs around 3,500 staff. Each year, on average, staff deliver care to:
• 52,000 people as outpatients within treatment rooms;
• 125,000 patients to our four Walk-in Centres;
• 51,000 sexual health service user visits;
• 250,000 visits to patients in their own home;
• 480,000 Immunisations and Vaccinations;
• 50,000 Community Equipment items delivered;
• 34,000 Wheelchair service items delivered.

You can find out more about the Trust here:

The first part of my visit was to meet Gemma an impressive district nurse. I found her inspiring because of her commitment to make technology work for patients. They are using EMIS on mobile devices such as laptops and tablets to manage the community nursing team’s work. Gemma showed me how referrals are received and booked for a visit by a nurse for assessment. The system looked easy to use and ‘clean’. The trust has ambitious targets that all the clinical field staff have mobile devices by September 2013 and that this will enable them to increase the number of contacts per clinician per day. None of this could be achieved without supportive passionate IT teams and I also met Kathy, a transformation manager who has the ambition to make the trust’s targets a reality, despite them being stretching. It’s sometimes easy to forget the technology teams who work so hard to support clinical innovation. I am hoping the central nurse technology fund might be able to help teams like these move faster to realise these benefits for patients.
The team are also part of a collaborative that is making the ‘redbook’ electronic. Shortly before or after a baby is born, parents are given a Personal Child Health Record (PCHR). In England, this usually has a red cover and is often called “the red book”. This is a way of keeping track of a child’s progress. Another brilliant piece of work; you can watch a video about the e-redbook here.

Jane was the lead for this. It was starting to be daunting with all these impressive leads presenting!

Sheena is a passionate speech and language therapist and what was most striking about Sheena was her patient focus. Quietly spoken but with a real passion for improving things for patients. Despite information governance challenges Sheena has managed to create a service where they Skype patients for a SLT session. It’s beautiful in its simplicity and she could tell us of real benefits for young people but also those who are geographically remote. I was impressed. We had a really pragmatic conversation about how to make an iPad stand up so the camera was in the right place to give the best picture – it’s not always the big things that matter.

Finally, they showed me something that is dear to my heart; an ambitious city wide project to empower citizens to take more control of their own health called the Mi project. They aim to use technologies to support people to take more responsibility and stay well. You can see more here:

Inspiring leadershipI am really grateful for the Trust for giving me such an inspiring experience and would like to thank Ian and Kathy for looking after me but also Bernie Cuthel, CEO and Helen Lockett, Executive Nurse, for taking the time to meet me and the whole team for making me welcome. They are an ambitious, inspiring and lively organisation – just like I found Liverpool to be. I had more friendly faces and chats with strangers than I remember in any city for a good while! Thank you Liverpool!

Nursing Informatics Study tour to Chicago


Sometimes I think I am just the luckiest person. Chicago 2013I love the NHS and nursing; and working in informatics is exciting and challenging. When I was 18 and embarked on my career I never imagined it would take me all over the world but last week I was so privileged to escort a group of NHS nurse leaders to look at informatics in Chicago, USA.

The study tour was arranged by HIMSS who do an amazing job of supporting nurses who have an interest in informatics as well as their wider activities.  The trip was part of a year long plan of activities in the UK – we have also had free open webinars and a summit to discuss the approach taken to technology in nursing in the US.  You can read more about HIMSS here.

The experience and background of the nurses in the group was broad – mental health, general nursing, midwifery and education were all represented along with commissioning and those with a leadership role in informatics.  They were competitively selected from around 35 applications – there were 9 nurses in the group.  The group also represented the 4 countries of the UK.Nearly all the nurses

This isn’t everyone but its nearly all the people from the trip

The experience proved an interesting one.  The following are my key learning points:

1  Where is the UK compared to the US in informatics development?

I am not sure whether I am reassured or disappointed that I didn’t see anything that surprised me.  Certainly in hospital settings the nurses are using more record systems but they face the same challenges as we face at home.  They still talk about the challenge of clinical content/records and the time it takes nurses away from patients.  The scale of investment, however, is very different.  IT is not seen as an add-on but as an essential part of their business and in some areas it has led to significant improvements.  I will blog more about this when I have the presentations from each site.  The nursing informatics teams in each organisation were much bigger than I see in the UK – with some teams of 10 staff, all nurses!patient call system

Mobile working in its many forms is also a matter of debate for them but in the new build organisations we visited they have invested in much better infrastructure leading to more potential for mobile working.

2  The importance of governance and quality improvement

All of the sites we visited were Magnet Hospitals and this was noticeable and I couldn’t fail to be impressed. The staff were happy in their organisations with some directly expressing how they stayed working at that hospital because they loved working there.  If you don’t know about Magnet hospitals you can read more here.

What was particularly inspiring about this for informatics was how the governance structures of magnet hospitals had ensured that nurses were empowered to positively affect the decisions taken about informatics.  On one site the informatics lead was responsible to the nursing professional practice committee.  It makes perfect sense to me – a positive way of governing and empowering those who use the technology.

The same is true of improvement activities – they were driven through professional groups rather than management with great success.

More about shared governance here.

Different philosophies

Although I noted the similarities in the implementation of technology in the sites we visited there was also a major different in how they viewed patients/service users.  We asked many questions about patient access to records, information ownership and patients’ involvement in services; it was clear from the responses that in the UK we are much more focussed on patients and their involvement. In some areas (not all) the care was very medicalised and neither the patients nor the nurses seemed to be centre stage!

Over the next couple of weeks I will also write up some comments about each of the sites we visited.

A big thank you to HIMSS who were superb but also the brilliant nurses on the trip who asked many searching questions and worked hard to understand what they saw and heard.  I also confess to laughing until I cried on some occasions – there is no better company than nurses!

I also enjoyed Chicago very much; I have never been to a friendlier city.  It is also a beautiful place.Trump tower

Trump International Tower, Chicago