I 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.

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!

So 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 🙂

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.

What 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.

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.

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!

It’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:

I 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!