Nursing workforce planning: are we just playing a numbers game?


calculator graphMost people who read the news in the UK are likely to have read recent articles that point to the possibility that there is a shortage of nurses[i][ii][iii]. In a time when we are talking about reconfiguring the way care is offered and moving care into people’s homes it is also well documented that we have an aging nursing workforce with particular concerns in community nursing.  In a report by the RCN in 2012, it was identified that almost 60% of the community nursing workforce could if they chose, retire in the next decade. Of course, it’s not just about the numbers of nurses who leave – it’s also the level of expertise that the system loses when these experienced nurses, who are likely to have up to 3 decades of experience, retire.

There are steps in place to try to attract nurses who were once registered but left the profession back into practice. This work is being led by Health Education England with a concerted public campaign to attract once registered nurses to undertake a period of updating to encourage them to return. You can read more about the campaign here.

Whilst workforce planning as a numbers game is important – we need to make sure we have an adequate flow of newly qualified nurses – what could be just as important is retaining those with the long years of experience to help to pass on their tacit knowledge and skills before they leave the profession through retirement.

Bearing this in mind a paper by Liebermann et al (2015) caught my eye. They discuss that, as well as adequately addressing the recruitment of new nurses, we also need to make sure we retain new entrants and encourage older nurses to postpone their retirement.

anne 1989 on wardI am now 51 and in the last year or so I have thought about the prospect of retirement more than ever in my life. I realise this is a natural progression, that looking forward is a good thing; I also recognise that if every one of my generation does this, there could be an inevitable skill gap. There are ways less experienced nurses can be supported to offer safe care such as decision support technology but even I (as a nurse with a passion for technology) know that this can never replace decades of practice experience. So what do we know about why it is that nurses seek to leave the profession early?

Liebermann et al undertook a longitudinal study via questionnaire that sought to understand what conditions were most likely to encourage nurses to stay, with a focus on the possible differences between younger and older nurses. In other words, do we need to do different things to encourage younger nurses to stick with nursing and for older nurses to encourage them to put off an early retirement?

In some ways the conclusions are not surprising – nurses need good management support to stay and to help them to keep up to the hard demands that nursing places on us. What is perhaps more interesting is that they found differences between the younger and older nurses. The researchers concluded that ‘supervisors [managers] should foster nurses’ expectation of remaining in the same job until retirement age by providing age-specific job resources’ (Liebermann et al 2015).

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

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

We know that a multi-generational workforce may require different leadership styles, so called ‘baby boomers’ may differ from ‘generation x’ or ‘millennials’, but do we equally need to look at what conditions keep nurses satisfied with their work conditions in this generational way too?

I think this is a fascinating thought that we may need to think about. So, it’s possible that any efforts we make to encourage people to stay in nursing, if we don’t understand the needs of particular generations, may fail. My final point is are we just addressing a numbers game, when we need to start to focus in some detail on how we can retain nurses, recognising that different generations may have different needs?

Liebermann SC., Muller A., Weigal M.,Wegge J (2015) ‘Antecedents of the expectation of remaining in nursing until retirement age’ Journal of Advanced Nursing doi: 10.1111/jan12634

With thanks to Dr Susan Hamer for bringing this journal article to my attention :0)

PS thanks to Ruth Auton for pointing out this paper from HEE http://hee.nhs.uk/wp-content/uploads/sites/321/2014/05/Growing-nursing-numbers-Literature-Review-FINAL.pdf

[i] http://www.theguardian.com/society/2014/dec/17/nhs-nurse-shortage-health-service-overseas

[ii] http://www.rcn.org.uk/newsevents/news/article/london/nursing-shortage-pmqs

[iii] http://www.telegraph.co.uk/news/nhs/11349403/AandE-units-will-be-forced-to-declare-nurse-shortages.html

‘You don’t know what you’ve got till it’s gone’


Dr R waves a filament triumphantly at me; ‘Ah, he says, we are normal’!

My feetBut I know the truth, I may have passed the filament test and in Dr R’s eyes be ‘low risk’ but my feet are far from normal, in fact they feel odd. I just know there has been a change and it’s not a good feeling. They use a filament, a small, thin, soft piece of plastic, to test sensation on the feet of people who have diabetes. ‘Can you feel that?’ is their phrase. Over the last 5 years or so I have noticed a real difference in my feet. I can’t always feel sensations like I once could and they get sore and give me a terrible burning sensation if I walk a few miles – I suspect its neuropathic pain. It’s not so bad that I need to do anything in particular but I know it’s not as it was – I think I have early sensory neuropathy.

I’ve had type 1 diabetes for more than 30 years, to be precise 34 years and 9 months. I’m well and although not as fit as I would like to be I’m active and doing OK. The trouble is I also know it’s a bit like walking a tightrope; diabetes can just nudge you off balance at any time for no seemingly rational reason.

My feet 2012 in Italy

My feet 2012 in Italy

Feet are funny but massively important parts of you. I seem to have hypersensitive feet; it’s always been a thing that irritates me that I can’t wear the beautiful toe post sandals. I just can’t tolerate the bit between my toes. On the plus side I am not, and have never been, a smoker and I do look after my feet, they are treated to lovely foot cream at bedtime almost every day and I am very careful these days about being barefoot (although I still do it, I mean, after all you need to feel the sand between your toes).

A diabetic foot is what it’s called – not the toe post sandals part, that’s just me – but the risk that people with diabetes have, the risk of complications of ulcers that don’t heal and amputations. You are warned about the risks; your feet are precious and the risks are related to good control. However, beyond 50 years of having diabetes of the so called ‘medallists’ only 39% of people are free of problems with their feet – yep that’s right: 6 in 10 people had some symptoms of neuropathy according to the study by Sun et al (2011). (Great study by the way – if you are interested in what happens to people with diabetes over time but not for the faint hearted with diabetes). I think that’s a lot. At clinic they risk assess you against criteria a little bit like this.

But that’s all well and good.

I am 51 and not 101.

I want to wear fashionable and sexy shoes – that usually means heels.

There is not a healthcare professional in the land who thinks that is OK; I have been advised to wear ‘sensible’ shoes. I rebel and I refuse. My wardrobe is full of suitably unsuitable shoes……

flat pumpsBut this summer has proved different. It is with sadness that I report that I feel myself slipping into the comfortable shoes abyss – I even bought some wide shoes this week; it makes me sad.  Here they are my little (wide) black walking pumps.

I know that many people have issues with their feet and for many different reasons and I empathise. My compromise solution is to wear comfort for walking and heels for all else. So if you see me slipping on a pair of wide pumps you know why – I’m walking somewhere and trying to keep my fitbit steps up! The truth is I’m a middle aged woman with diabetes who is watching out for her feet. And for all doctors, podiatrists and nurses; please remember we are people who want to express ourselves through our footwear like many other people, give us a break for as long as we can hobble in the shoes!

I will be wearing suitably unsuitable sexy heels for as long as I can 🙂

My favourite suitably unsuitable shoes :)

My favourite suitably unsuitable shoes 🙂

The other thing is, numbers are about other people aren’t they? But the uncomfortable truth is that they are about you and me too.

Footnote: I wrote a blog for the lovely @whoseshoes about my mother in law and her shoes and you can read it here

The title of the blog is from the wonderful song by Joni Mitchell – thank you to Pete, @swelldiabetes for reminding me!

 

 

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

 

 

My response to NMC and the revised Code


The Nursing and Midwifery Council in the UK is consulting in a second round on ‘The Code: standards, performance and ethics for nurses and midwives’.  This round of consultation follows a 6 month consultation on revalidation and links a revised code to the revalidation process.

The Code is the foundation of good nursing and midwifery practice, and a key tool in safeguarding the health and wellbeing of the public.

Since the last drafting of the Code social media has become an increasingly prevalent part of modern society; not just for nurses but also for the public they serve. As such, I am grateful that there is a reference to social media in the re-drafted code – it is important that the regulator and the professions recognise the emerging need for digital professionalism, that is the need for principles of personal and professional nursing practice to be applied in a digital space.

You can see the draft code here

This blog post contains the consultation feedback I will be offering in relation to point 114 relating to social media.

First of all it is important to point out that the code is also supported by NMC guidelines relating to social media that can be found here:

This is the current draft wording in The Code:

‘114. You must ensure that you use social networking sites and other forms of electronic communication responsibly and in-line with our guidance, in particular by not referring to employers, colleagues or past or current people you have cared for’ (page 19)

Of course the use of social media is also governed by other parts of the code, for example:
Maintain clear professional boundaries (page 7)
Uphold the reputation of your profession (page 8)
Be open and honest and act with integrity (page 8)
You must respect people’s right to confidentiality (page 10)

The main issue that concerns me relating to point 114, and what I consider to be responsible professional digital behaviours, is the draft wording ‘not referring to employers’. I do not see how this is needed as part of the code. Social media platforms often allow professionals to include details of their employer in a profile statement and indeed LinkedIn (a widely used social media platform) allows the use of an on-line CV where past and previous employment is cited. If nurses and midwives are also following the other parts of the code detailed above then the addition of ‘employer’ in this list seems overly restrictive.  I do not understand why nurses and midwives are unable, should they wish to do so, give details of where they work, in an open and transparent society.

I would propose that more appropriate wording could be:

‘You must ensure that you use social networking sites and other forms of electronic communication responsibly and in-line with our guidance, in particular by respecting the confidence of colleagues or past or current people you have cared for’

I would also recommend a subsequent review of the guidelines for use of social media by nurses who are skilled and understand the medium to take account of the emerging use of digital media in supporting patients, for example school nurses who are using Facebook to support young people and the use of social media for providing peer connections for patients with long term conditions.

If you would like to make your voice heard as part of the consultation – whether you be a member of the public or a professional – you can do so here:

These is my personal consultation feedback, as a registrant, and may not be the view of my employer.

social media network

On being a ‘hard done to’ bottom


Learning is a funny thing isn’t it? – The things you remember and then those things you don’t. I’ve had my learning muscles tested recently as part of my Organisational Development Practitioner Programme which I chose to do as part of my Florence Nightingale Foundation Burdett Leadership Scholarship. My instinct was right, by the way, there is much useful learning in OD for people interested in leadership. I know that some of the theories passed me by and weren’t retained in my pooh bear sized brain but some things have stuck and some of the systems thinking from this week has definitely stuck; it’s all about tops, bottoms and middles.

organisationsThe theory is quite simple; people in organisations adopt very predictable patterns of behaviour and that breaking out of these is what we need to do before we can really achieve but of course changing behaviours is a real challenge for all of us. Systems thinking is from work by Barry Oshry that explains that organisations are broken down into ‘Tops’, ‘Middles’ and ‘Bottoms’ and that each of these, naturally as part of a system, moves back to unhelpful behaviours that create many of the organisational issues we face. This week we did the organisational workshop to experience the system workings of organisational life in a way designed to magnify these natural and unhelpful behaviours that manifest in the worlds of Tops, Middles and Bottoms; before you say you are never a ‘Top’ etc we all occupy these roles at one time or another, they do not necessarily reflect organisational status (but they might). I had great fun 🙂

The process of allocation to a role in the workshops was random and I was delighted to find myself as a ‘bottom’. That’s where the fun started! I have to say that although in my role I wasn’t unhelpful nor was I as focussed at first as I should have been and I did revert to the behaviours that Oshry would have predicted, for me this was to withdraw to almost a playful space. I was experiencing true ‘bottomness’.

Those of you who have done the organisational workshop will understand significance of this picture :)

Those of you who have done the organisational workshop will understand significance of this picture 🙂

Oshry predicts that people will revert to an unhelpful behaviour and unless we can break from this we will perpetuate the same issues over and over again. Tops at times of pressure suck up responsibility and become ‘burdened’. Middles slide into the middle between tops and bottoms and become weak and ‘torn’. Bottoms hold higher ‘ups’ responsible and become ‘oppressed’. Oshry also explains that Customers also fall into a pattern of unhelpful behaviour where they become ‘righteously done-to’.

Sure enough, as the great workshop panned out, all of these behaviours were exhibited. My bottomness centred on a feeling of no one telling me anything and therefore I didn’t know what I was supposed to be doing so along with my mates we had a grand old time – playfulness as withdrawal.

Oshry goes on to explain that we chose how we behave and that these patterns do not need to persist – we can chose to be different.

Partnership is the key and changing and transforming our relationships can stop these behaviours and stop recreating the organisational patterns.

‘Partnership

A relationship in which we are jointly committed to the success of whatever project, process or endeavour we are in.’

Partnership 2We can chose to be part of what he describes as the ‘side show’ where we make up stories about it and evaluate others as malicious, insensitive and incompetent or we can take the centre ring and have understanding and empathy for others, staying focussed on the best outcome and take a wider view where you take into account the perspective of others. Tops should take a position where they focus on developing responsibility throughout whole organisation. Middles should maintain independence of thought and act in service of the whole system. Bottoms should take responsibility not only for their thing but also for the whole thing.

I think I recognise Oshry’s organisation in many places I have been in my career, where ‘stuff’ happens and I also recognise my own unhelpful behaviours in those he describes. I can also adopt some of the more helpful behaviours that move to a better position of partnership. If you ever get chance to do the organisational workshop I would recommend you jump at it; it certainly fits with my experiential model of learning.

There is no way I will forget being a hard done to bottom and also the need to stop those old behaviours developing, even without thought, and I will try to take a more helpful partnership position.

You can find out more about the organisational workshop and Barry Oshry here and here.

Nursing, research, knowledge and practice


knowledgeI had a really interesting Twitter conversation yesterday.  It was about research and evidence, stemming from a conversation where I said I would be unlikely to attend a research conference. I suspect that I am now also going to appear very stupid although I am not sure I am – I know I can synthesize information and indeed reach robust conclusions from information presented to me – but I often find understanding research papers challenging.

I find the way many research papers are written impenetrable. They use language where I have to look up the research terminology to enable me to understand. And I just don’t get it – surely passing on the knowledge is the single most important thing that you have to do? Research that adds little value as its meaning is lost in complex and obfuscated language is also adding less value than a well written and clear piece of research?  That is, of course, assuming the research is well constructed, undertaken, analysed and presented!

I know I can understand the evidence, after all I scored well at University having done a systematic review and I actually enjoyed my dissertation once I got going but some of the research papers just do not hold my attention if I have to work too hard to find and evaluate the meaning.
There are materials around that can help – I came across this blog by Calvin Moorley, that is clearly written and helpful but understanding these things isn’t necessarily the answer. This assumes research papers are well articulated and clear – but often in my experience they are not!

magazinesAlmost everything we do in nursing should be based on knowledge – that is the critical space between experience and applied evidence. The speed at which new evidence and materials comes available is also a challenge – how can I possibly keep up to date in all the areas of nursing practice that I am interested in, and synthesise it with my existing knowledge?

When I started writing this blog I went to explore some evidence to see what I could find to illustrate points but I found some good stuff, stuff I didn’t know, and I could understand, but I would never have found had I not been writing this blog! It’s impossible to be on top of the whole evidence base and live and work! It would be a full-time job 😦

So what does it all mean? Well, I think this is now about nursing knowledge management; an area of practice that we discuss little in nursing but I believe is increasing in importance. Benner describes the development of skills through novice to expert but in 2014 the ability to practice at expert level taking account of new emerging evidence is challenging.  We need knowledge workers to help us find meaning from new emerging areas of research.

There are some bright spots on the horizon. The recent find of the Evidently Cochrane blog site has encouraged and motivated me to be more engaged with research. The knowledge management part is taken care of, studies assessed and evaluated on my behalf in order that I can assimilate the research evidence quickly and develop knowledge in my practice. For example, I have always been cynical about risk assessment, always feeling that perhaps it wasn’t quite doing what it intended to do, and up pops my friends at Cochrane bringing my attention to this work that was debated on a great @wenurses chat recently – you can see the chat here. Another example of taking evidence and using a twitter chat to increase nursing knowledge.  I also value highly the KCL Policy+ that is published regularly, aimed at current areas of policy focus for nursing.

So what does this all mean? It means that researchers need to write research findings in an accessible way that can be quickly turned into knowledge by practitioners and we need more knowledge brokers like the brilliant Cochrane people who work hard to help everyone access new evidence. Writing in simple accessible language is not dumbing down, in fact I think it’s much harder to write clearly in non-technical jargon so perhaps that’s the real reason research papers are often difficult to understand – writing simply and well is much too hard! The Cochrane site aims to translate evidence in to meaningful understanding for everyone and thank goodness I found it!knowledge 2