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)

 

Advertisements

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?

 

 

 

A Nurse who has ‘Sold her Soul’?


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But what IS nursing?


Training_Queen's_Nurses-_District_Nurse_Training_at_the_Queen's_Institute_of_District_Nursing,_Guildford,_Surrey,_England,_UK,_1944_D23118

By Ministry of Information Photo Division Photographer [Public domain], via Wikimedia Commons

My husband often says to me ‘but what IS nursing?’. To be honest I struggle to answer his question without distilling my profession down to a set of tasks that don’t really get to the heart of it and I think that is an issue – we don’t actually know how to properly articulate what we do.

This poses a challenge when you are trying to implement electronic record systems to support the practice of nursing. Electronic systems respond well to lists and tables, check boxes and drop down lists. This is why electronic record systems meet our needs in terms of risk assessment and listing things but perhaps are less well able to respond to the more complex and less visible work of nurses.

Traditionally software systems are created based on what could be called ‘user requirements’. But if the users can’t clearly articulate what they need, then the developers will struggle to respond. In my experience nurses can describe a risk assessment form and probably paper forms they use but really struggle to describe the more complex aspects of what they do. The result? System developers develop task based record systems that drive nurses towards the less complex work and fail to record the more complex and less visible work of nurses.

The work by Davina Allen   – The invisible work of nurses: hospitals, organisation and healthcare (2014) – should start us to think more about how we describe the complex work we do but it’s a challenging conversation – complex and abstract and we are often too busy to engage. Allen says: ‘Nurses, it is argued, can be understood as focal actors in health systems and through myriad processes of ‘translational mobilisation’ sustain the networks through which care is organised.’

Perhaps it’s time to look again at the models of nursing we build systems on. Nursing care planning doesn’t do it for me, again it drives us to simplify and describe what we do merely as a set of tasks. Perhaps natural language processing is likely to offer more to nurses than we might think and we should engage with the developers of these type of solutions and resist the drive towards solutions that push us towards over simplification.

16571920_sI would argue that not everything we do can be entered as structured text of check boxes. If we do this pushes us towards task based thinking. We need better than this if we are to really recognise what nursing really is and build the electronic record systems nurses deserve.

Allen, Davina Ann 2014. The invisible work of nurses: hospitals, organisation and healthcare. New York: Routledge.

Vocation – the pull of the bedside


ward sisterWe have had a busy few weeks. We have recently had much sadness in our family and this weekend an aunt, who has been left with no direct children at 84, was admitted to hospital. Her lovely best friend (oh to have such long lasting friendships), and the family, have been doing our best with rounds of visiting, making sure she had things to talk about, and more importantly perhaps, eat; a round of prawn sandwiches on special request, a lovely fruit salad, a fruit jelly studded with raspberries. Another friend gave her a lovely leg massage. We are all generally trying to make her feel better.

But this blog isn’t about her care it’s about my instinctual response to being at the bedside again.

I just feel I know what to do to care. I instinctively understand how to make someone feel comfortable or perhaps, more importantly, when they are not. I knew that she needed her own things, that food when you feel poorly comes in small packages and when tears are close, it’s time to take a hand.

There was another lady in the bed beside us. She clearly couldn’t see very well so was often calling out but once you got close she could focus. Her hearing was better on one side than the other and she likes tea. I couldn’t stop myself going to help her. We didn’t talk for long but in a few minutes I learnt that she too had lost her son at 60, she liked to garden and grew tomatoes and she regretted some things about her life. I pulled her tea nearer and opened a bar of chocolate for her that we had brought.  It was ironic that we were interrupted politely by a nurse who closed the curtains and did a memory test with her in a very loud voice.  I know she doesn’t know what year it is.

Nursing badgeToday I suggested our aunt had a shower – she looked at me and said ‘Can I?’ We went to the horrible institutional shower room and I handed her the nice shower gel and shampoo I had brought. I asked her if she wanted me to wait outside having sorted a seat for her in the cubicle. ‘No!’ she exclaimed ‘You have seen all this many times before’ and I guess she was right. I know she enjoyed her shower and we put on skin lotion and hand cream afterwards. It is the first time she has been in her own clothes for 4 days!

The thing about the last few days is I strongly felt my urge and instinct to care. This wasn’t just because it was family; it was more than that. I know I only had one person to help and that I had the luxury of time but the satisfaction I felt was immense.  I feel drawn to it, as if it fits somehow.

So, I suspect, this weekend I have been reminded of the meaning of ‘vocation’ the strong draw, almost a summons, to occupation. Sometimes I wonder if I’m kidding myself, if perhaps I have just been lucky to find something I like to do so much, but this weekend has reminded me that its more visceral than that.

As I was leaving the ward the two ladies in the beds opposite said to me ‘you were lovely with that lady – you should be a nurse’ and I smiled, and said ‘thank you’, after all what a huge compliment and wondered to myself what had dragged me away from the bedside all those years ago.

anne 1983

Practicing what I preach – role modelling and social media


This blog is a bit of an experiment :0)

lead by exampleDespite not really setting out with any grand intentions in mind, I was identified as a Social Pioneer by the Nursing Times in 2014, mainly for both my promotion of engagement with people with long-term conditions on Social Media but also for my work with professionals in encouraging and role modelling.

I believe that in a modern society nurses should be digitally competent and have a high level of digital professionalism in order to:

‘uphold the reputation of your profession at all times. You should display a personal commitment to the standards of practice and behaviour set out in the Code. You should be a model of integrity and leadership for others to aspire to. This should lead to trust and confidence in the profession from patients, people receiving care, other healthcare professionals and the public.’ (Extract from the Code, NMC 2015)

I try hard to do this at all times and aspire to role model digital behaviours. Here are some examples of how I try to do this:

  • I work hard at holding professional conversations at the same time as maintaining a balance of being human and authentic.
  • I try to help others if they seem to be struggling.
  • I add value through adding content and materials that further nursing.
  • I share my knowledge of social media and have worked with NHSIQ to produce a simple film for practitioners – see here.

As part of my nursing revalidation I need to collect feedback about my practice.

It would be really brilliant if you could leave a comment for me below that I can use to further reflect for my professional portfolio!

Constructive feedback from anyone is welcomed, not just other nurses. Feedback from patients and students is particularly welcomed.

anniecoops

Thank you so much xxx

Thank you so much xxx

Passing on the baton


passing the batonFor any of you who know me today, you might find this hard to believe, but I was often picked for the 4×4 100m relay team at school. OK – I wasn’t the first choice, probably the fourth – but, hey, chosen I was, and I learnt how to pass the baton.

For those of you who have ever run in relay you might remember being taught how purposeful that baton passing on needs to be; a process of firmly slapping the baton into the hands of the recipient, so they know they have got it and they can confidently stretch and run to the end of their leg. As I was often the second or third to run I was both the ‘receiver’ and ‘passer’ of the baton. Being passed the baton as efficiently and effectively as possible with no margins for error is a learnt skill and although my speed might not have always been what they hoped I don’t remember having a problem with baton passing.

So here I am many years later reflecting that now is the time to start to think about my baton passing technique in earnest again but it’s a slightly different race.

I was always ambitious and serious. Even when I was a student nurse, I secretly wanted to be the nursing officer or manager because I believed that way I had more influence over what happened to patients. I was shrewd, I knew that managers wielded the power to make a positive difference. I then went on to make some less orthodox choices, still related to trying to change things, and in many ways that’s how I ended up in informatics, I believed (and still do even more so) that information and technology can help citizens and patients for good.belt and badges

But I find myself at a time in my career when I’m thinking differently about the future, having conversations with friends saying things like ‘I have one big job left in me’, talking in ways I have never spoken before, as if the end is in sight. Sounds dramatic? Feels it too and slightly scary.

Perhaps its natural progression as I gaze forwards to times when I have more time to choose what I do and where I give my time and effort to making a difference in other ways – I don’t mean not working but I do mean working in different ways.

What I know is that this means I need to brush up on baton passing on again. If I hold any knowledge and skills how can I pass them on; how can I baton pass without taking my eye off the forwards race and still keep running as fast as I can?

I have written about eldership before and my thoughts keep coming back to the same thoughts. How can I help the people picking up the race beyond me? How can I make sure we don’t stall and drop any batons?

Supporting and investing in leaders of the future is what I need to do but it’s not always easy.  Broach a conversation about succession planning and people gaze at you as if you are giving up, rolling over and lack ambition – I’m not and I don’t. What I am doing is adjusting my focus, making sure I pass my baton on. Informatics is still hard, the hardest gig I have ever had, in a profession that, in the main, still seems to kick back against it despite predictions that digital is part of the future of health. So I’m focussed on finding the nursing digital leaders who I can pass the baton on to, but it’s a long time since I’ve passed any batons so I may be a bit clumsy at first but I will improve so watch out… I could be passing the baton to you! 😉hand waiting for baton