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!

Have you ever been so scared that you feel sick?

This reflection was prompted by a conversation a group of nurses were having on Twitter.  We chatted about how much responsibility we had shouldered when we were students.  I can remember taking charge of a ward as a third year student on nights; it wasn’t uncommon where I trained back in the 1980s.  Although this wasn’t what made me scared I am glad that this no longer happens.Anne 1986

These conversations took me back to when I had first qualified.  Essentially there is only one day’s difference between being a student, and wearing a staff nurse’s uniform; one day in white and the next day in blue.  Perhaps if I had stayed at the hospital I had trained at it would have been easier; it was a small hospital so everyone knew me and would have known I was as green as grass, even though I was competent – I had, after all, just passed my finals.

But that isn’t what happened to me.  I moved from a very small district hospital (we had 8 wards in total) to St James’s Hospital in Leeds.  At the time it was the subject of the ‘Jimmy’s’ programme, one of the first hospital ‘fly on the wall’ documentary and was notorious as the largest hospital in Europe; I couldn’t have gone to a more different place.  My first job was as a staff nurse on a 6 bedded coronary care unit, with 6 telemetry channels; I loved it.  I love acute work but I liked the fact the patients were awake unlike in ITU.  But of course it was a pressurised environment.  The sister at the time was amazing but she left within a few weeks of my arrival and in what seemed like no time at all I was rostered to be ‘in charge’ on nights.ECG

Just to put this in context, the nurses on the CCU only had the support of house officers at night.  The house officers often looked to the nurses for guidance and advice – in my situation I really felt exposed and it was like the blind leading the blind.  I really hope this would never happen now!

I can vividly remember driving down the motorway to go on my nightshift feeling really sick, gripping the steering wheel hard, and praying that nothing would happen. Life isn’t like that though is it?

It can’t have been my very first shift but not much later (I was still at the feeling sick stage) I turned up for work and took handover from another staff nurse, Pete (I wonder where he is now).  I will never forget what happened next.

We took handover in the middle of the unit – we could see all the beds.  While we were handing over Pete had given a gentleman a bottle, he couldn’t pass urine in bed and Pete had assessed that he was well enough to stand to try to pass urine into a bottle.

We completed the handover and Pete left the unit, leaving me with a (then) nursing auxiliary.  He had just left, we were moving towards the curtained bed and there was this almighty crash.  The man had arrested, face down on the floor, wrenching out his heparin pump in the process and of course this was bleeding.  What followed taught me what I was capable of; not flapping and taking practical steps to do the best I could to save the man’s life.  The crash team were prompt but we couldn’t save him.

The next part is why I remained scared for quite a long time.  I had never told anyone that someone had died before.

This gentleman’s wife, not an hour before had been visiting her husband; apparently everyone thought he was doing very well.  She must have left the hospital worried – he was on CCU after all – but reassured too, he was alive and well when she left him.  When she got home the phone was ringing.  It was me; please could she come back to the hospital?Old phone

We didn’t have a relative’s room; we used the sister’s office on the adjacent ward to break bad news.  I can see the room now, blue carpet, brown furniture, big desk; not an ideal space to do what I had to do.  I did the best I could carefully explaining that her husband had died.

I didn’t expect what happened next.  The lady grabbed me by my uniform, around my neck and thrust me up against the wall.  She screamed that she didn’t believe me and what had I done to him?  I remember my surprise and being scared as I was on my own and she was really very upset.

I must have sorted it out somehow and I know I will have tried to do that as well as I could but those moments that happened around 26 years ago are still quite vivid.  I know there has to be a first time for everything but I am honestly not sure I was ready or that I got the help I needed afterwards.

I learnt to cope, I know that I used to be able to be relied on in a crisis (I suspect it’s still true but untested of late) but I do feel I learnt the hard way.  But why is it important and what did I learn? It taught me to make sure newly qualified nurses are given proper support and preceptorship.  It taught me how resilient I am.  I am not fazed by breaking bad news anymore and it no longer makes me feel so sick, although it’s always something I find challenging – but that’s normal.

But I remained scared for quite a long time – so scared I used to feel sick!  Have you ever been so scared you feel sick?




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

Never, ever back off a challenge! Update on Florence Nightingale Foundation Scholarship

It’s a few months now since I was given my Florence Nightingale Burdett Trust Leadership Scholarship – I’m starting to feel the pressure, yes, I actually have to do something (!) but this week I started to work on how I might add some value through my project.

social media networkI knew I wanted to think more about social media and how professionals behave alongside the public in these digital spaces; I am keen that we recognise the potential for social media, as well as the usual rules that we seem to need to establish, in terms of ‘you must do this’ but more usually ‘you must never do this!’.

I want to interview new people who may not usually get heard in the health space, this includes people who use health services but also those outside the sector. It was this in mind that I travelled to Plymouth Plymouth 2to see Steve Wheeler (@timbuckteeth). I have known about Steve for a while and follow his blog, which almost always makes me think. It was a real privilege to meet him – to put it into context his blogs get massive numbers of reads and comments and his following on Twitter is almost 20,000.

This is how Steve describes himself on Twitter:

‘Web 2.0 researcher, author of The Digital Classroom, Associate Professor of learning technology, Associate Professor of learning technology in the Faculty of Health, Education and Society, at Plymouth Universityinternational speaker, disruptive activist.’

Steve, amongst his many research interests, is interested in Web 2.0 social technology. Steve’s blog is called ‘Learning with e’s’.

I had a long chat to Steve about my scholarship and what I was interested in. Essentially I am interested in trying to help health professionals make the most of the opportunities that social media presents, not just for professional development but also to work with patients and citizens.

Steve has some interesting views about social media and how we interact with it. He is generous and knowledgeable. I made the mistake of asking him how he would tackle the questions I was asking and he came back as quick as a flash – ‘make a video documentary’ – he says. I paused for about 20 seconds and said ‘I’m going to do that’.

Steve Wheeler 1

So here we are. I have no video equipment and no experience of audio-visual ‘stuff’ but there is nothing I like more, than a challenge. It made me reflect on myself as a person and why I always end up with the strangest jobs and doing the things everyone says won’t work, or are too hard – I like it that way 

So I will be going back to Plymouth at some point to video Steve and to put down on record my exploration of social media for my scholarship – putting the output on YouTube seems fitting somehow.

My very great thanks to Steve, Pam (@pam007Nelmes) who arranged the meetings for me and the delightful Ray, Professor of Informatics also at Plymouth (@rjonesplymouth) for his insights and looking after me

If you want to try a taster of Steve’s blogs try this one on digital tribes – I promise it will make you think too.

PS – There is still time to apply for a Scholarship – look here and why not have a go – its a fantastic opportunity!

#NHSChangeDay pledge – ward dashboards and dictation

NHS+Change+Day_logo_calendar_png_5_____On NHS Change Day I committed to make more effort to visit front-line services that were using technology with an increased effort to understand the issues they face and to learn from them.

In a national role it is easy to feel disconnected from the front-line.  I already work an occasional shift on a ward, which certainly keeps me grounded, but in my role I am expected to have a really wide understanding of things related to informatics and in truth it’s a real challenge; not only do you have to keep up with the technology, which is going so fast, but also a wide understanding of how care is delivered.  I understand that I will never know everything about all of this and I never offer views about things I genuinely don’t understand, preferring instead to try to network people together who do know, but it is nevertheless essential that I have a broad understanding.  My visits are an attempt to make sure I increase my awareness and am genuinely doing my best to represent the profession in the wide ranging discussions I get involved in – I like to evidence my conversations where I can.

technology future

I arranged a visit to Northumberland Tyne and Wear NHS Foundation Trust.   angel of the northI had a great day – everywhere I have ever been to visit has always made me really welcome and North Eastern folk are renowned for their friendliness and hospitality.  I had to drive for 2 ¼ hours to reach the site but this was eased a little buy having to drive past the Angel of the North which I love.

There were two things they were showing me:

The first was the ward dashboard.  This is a great project.  The word dashboard implies something that shows performance against some targets, theirs is so much more than that.  They have moved the concept on a step and the dashboard is more of a knowledge centre.  They do have a screen that shows the key targets for them where they are using the Royal College of Psychiatrists ‘Accreditation for In-patient Mental Health Services’ (AIMS). These standards are a key quality improvement driver for them – you can read more about AIMS here:

The interesting thing for me about what they have done is they have gone beyond using the dashboard as just displaying performance and turned it into a knowledge centre.  There are many resources that staff can use that can help them to do the best quality work; evidence based assessment scales, forms, pathways – in fact a really useful resource for staff arranged in a central location that is kept up to date and fresh – I really liked it.

The second part of my visit was fascinating; first of all I want to tell you a story:

Imagine you are a community psychiatric nurse and you have just visited a psychotic patient.  They have complex needs and you leave their home and you know need to document the visit, it’s Friday and if anything happens over the weekend you want your notes to be available in the electronic system.  You pull your small car around the corner into a safe parking place and pull out your laptop.  You know you can connect but it’s a bit of a struggle, you have to turn around in your seat to open the lid of the laptop.  It takes your around 45 minutes to key in the information and you sigh with relief, stretch out and close the laptop down when you are finished.


This is a real situation for many mobile staff.  Access to electronic systems has improved, so has equipment but inputting information into most devices in a car is a real challenge.

In NTW they were finding that clinical staff were regularly spending significant portions of their working day typing clinical documentation, in fact they were often spending longer documenting than actually seeing the patient.  Nurses are not always the best typists and the time taken to type into records can be laborious and was creating inefficiencies in the way they used their time.

The trust came up with an innovative way to try to tackle this problem – dictation – and it works! So the nurse now has a Blackberry into which she/he dictates a summary of the visit.  The recording is sent immediately to a dictation team who enter the information in draft form into the record.  By the time the nurse gets back to her home or base all she/he has to do is to check and authorise the entry.  It takes around 8 minutes for a long entry but many take less.  The results are impressive.

I spoke to a fantastic CPN who showed me how she worked.  She told me that it is difficult at first, dictation of records is not a skill nurses are taught and it feels strange but they developed some prompt sheets and a way of working that means they soon gain confidence.  Hannah, the CPN, had managed to save so much of her time that she had taken on extra duties assessing referrals to reduce waiting times – she was a really impressive nurse!

These images show an average day before and after dictation (the red is admin time, green patient time and yellow travel) for another CPN.  Its sampled days and not averaged but still gives an impressive perspective:

before dictationafter dictation

This is just a pilot for NTW, they have more work to do to see if they can make this work efficiently and at scale, but it really got me thinking.  I have done some web-surfing and nearly all of the work that has been done in dictation is for doctors in acute settings and concerns off-shoring of dictation but it could really make a difference for lots of community nurses too.  It demands that we develop new skills and ways of working but the early results in NTW are very impressive and worth exploration.

My visit achieved exactly what I had hoped for – my thinking has changed and I have new ambitions for the way electronic records could operate.  Thank you to all the staff at NTW NHS Foundation Trust who generously gave up their time for me – I am very grateful.

Have things improved since 1993?

Can you remember what you were doing in 1993? I can – I failed to get the job I thought I really, really wanted.  What was the job? It was the out-patient services manager in a very large acute hospital.  I wanted the job because I wanted to make things better.  I had been handling complaints for a little while and by far the greatest number seemed to be about out-patients; the out-patient manager and I had a great relationship but we never seemed to be able to make things ‘better’.  He was retiring and I wanted to ‘have a go’!

Waiting room


In 1993 the Patients Charter was published and we had a big push on reducing waiting times in clinics and starting using bar coding to record how long patients spent waiting.  We even tried using some computer modelling to try to improve things but I’m not sure we really made any difference.  I looked at  complaints data for 2011-12 and 27% of complaints were still about out-patients .  It started me wondering if we were making any real improvements and are we tackling the right issues?

How do I know that we didn’t improve things?  First of all, my experience of clinics, as a patient, has barely changed since I first entered the healthcare system in 1979.  Clinics are still the same in 2013 as 1979, with the possible exception that I am more likely to be seen more promptly.  But I’m not sure this is what people who attend are really most concerned about.

This week a number of things happened that reminded me of all of this.  While the media is alight with stories of 111, I have been thinking of more commonplace things.  Out-patient clinics are important places.  People’s lives are irrevocably changed in them; people are given life changing news, sometimes good and sometimes not so good and on occasions down right devastating.  For me all clinic visits provoke anxiety and an institutionalised behaviour where I sometimes surprise myself.  I become very compliant no matter what staff do, say or how they behave.  Over the last few years, perhaps with increasing age I have been a bit more confident with the medical staff but I admit I’m scared of the reception staff.  In addition I have never ever heard a doctor or nurse say ‘I’m so looking forward to clinic today’ – in fact this week a middle ranking doctor told me he hated being in clinic.  I’m not sure if he is unusual or not.

This week this brilliant inspired posting on Patient Opinion reminded me of all of this – clearly I am not alone.  Please follow this link and read this feedback:

The same week that I read this I also tripped up over a blog by a medic that I really liked.  He was reflecting on the experience of withdrawing money in India from a bank and compared this to the admission process here at home – I think he has a point and what’s more it also applies to many types of out-patient clinic.  I have stopped asking for the ‘one-stop-clinic’ where I can get everything done too – I just suffer the shuffle from one waiting chair to the next.

Another blogger @mandyhall84 also describes her experiences here:

A lot of people visit out-patients – if I’ve got this right from the HSCIC information, there were around 6.5 million visits to out-patients in 2011/12 – that’s a big number. A review of issues relating to ‘appointments’ on Patient Opinion show a mixed bag of excellent to poor bell



In all the time I have had diabetes I have never met another person with diabetes or a pump in the clinic area.  I believe there is great scope for improving things and using at least some clinics in different ways to support patients.  I feel confident that if the new modern out-patient staff had vision they would consider using a co-production approach to reviewing how we deliver these services – maybe they are?  Perhaps it’s just my personal experience, and I don’t like to generalise, but finally I would like to leave you with this paper by John Launer, whose writing I greatly admire:

Why are we still getting it so wrong?

waiting chairs

Co-production and hope

Sometimes being so active online is a challenge – the amount of information that is thrown at me in various media is huge and it’s difficult to keep focussed and sift out those things I need to remember in a way that is more than passing interest. This specific blog is to help me to do that – to focus in on two things that I think are important that have struck me over the last week; the first is the parable of the blobs and squares and the second is the importance of young people and hope (my blog also includes paperclips!)Paperclips

The Parable of the Blobs and Squares
The parable of the blobs and squares was brought to me through the fabulous #leaders4leeds and specifically @smclrk . It really made me think about the concept of institutionalisation and how we treat and care for patients as well as how we resolve issues and consult with communities. By institutionalisation, in this context, I mean we force, through absence of choice, people who come into contact with our services to behave in a particular way. As a result they are less likely to choose or adopt any other approach or behaviour – as a result we may fail to capitalise on their knowledge, expertise and creativity.parable of blobs and squares

You can watch the short video that explains about blobs and squares here:

You see when I am a patient I’m quite blobby; I don’t like to be processed like a sausage and I suspect that because of what I know and what I do for a living I feel quite blobby to the people who help me too. It’s not unusual for a nurse or doctor who doesn’t know me to quite quickly ask me ‘can I ask what you ‘do’?’ – I suspect despite my best efforts to conform I can be quite challenging and blobby.
But then our systems are often set up to be very square and sometimes when I’m at work I’m square too. We are often forced into designing processes that feel inflexible to the receiver; my clinic appointments often feel like this but conversely I have been responsible for clinics too and sometimes it feel impossible to do anything else other than design them as processes and in the way we do.

The parable of the blobs and squares points to different way to try to resolve the problems we face – that is co-production. The concept includes employing more ‘blobby’ people who can work across the interface between the square organisation and those people who have the needs that we need to meet – known also as boundary spanners. bridgeSo, for example, I wonder if clinics would look the same for patients with long term conditions like diabetes if we were to co-design them with patients…… I for one would be lobbying for perhaps more group orientated and social spaces. When I think back to the time I got my pump although my lovely Diabetes Specialist Nurse went through all the technical parts of learning to use the pump I would have loved to meet someone who was already a pump user. My only contact with those people has been online on Twitter. I see this as a real missed opportunity to build expertise amongst patient and perhaps more resilience and less dependence.

I recommend the Parable of the Blobs and Squares to you.
My second major thought this week is the importance of ‘hope’. It feels like there is negative pressure across the whole system at the moment – sometimes so much so that it feels scary. Hope makes it possible to lead and to see a vision of how things can be better and is vital if we are to cope with the challenges we all face.
Hope can come from unexpected places or at unexpected times but I see a pattern emerging for me and how I might be able to stay focussed on building hope. You may recall from my previous blog about the Florence Nightingale Foundation Conference how I was struck by @ruthcarnall who talked about emerging leaders and how we had a responsibility to help them to grow and lead? This week I also witnessed a young person who shone hope across nursing – Molly Case’s poem ‘Nursing the Nation’ at the RCN Congress 2013 had ‘hope’ written all over it.
I also found another group of inspiring young leaders this week who again gave me great hope. Have you heard of the #StC Paperclip challenge? You can read about it here:Paperclip challenge

This is a brilliant and brave idea led by a group of nurses that again gave me optimism and hope. Watch the video and be inspired!

My son also gives me hope. He is young dedicated and passionate about what he does. He doesn’t get everything right but then I didn’t either and I had to learn to be the best I could be – in fact I’m still learning actively!

 So I can see sparkling and shining lights of hope in the system and they are often linked to young people. I am going to make sure I give as much help and support to young people in our system as I can; Hopethey need the chance to make a difference and the confidence to challenge the status quo. I will be trying to support and mentor as many of them as I can!

“Only in the darkness can you see the stars” Martin Luther King Jnr
“The best way to not feel hopeless is to get up and do something. Don’t wait for good things to happen to you. If you go out and make some good things happen, you will fill the world with hope, you will fill yourself with hope.” Barack Obama

Is digital enough?

Twitter is fantastic as a place to have great conversations that wouldn’t be possible without this digital space – I love it – but again today I had another fantastic Tweetup, that is a face-to-face meeting with someone I first met on Twitter. It seems to me that as my twitter relationships evolve I instinctively want to make the effort to meet the person face-to-face. For me, it seems that for the required depth of some of the relationships, digital just isn’t enough. So what happened today was a little bit of face-to-face magic with @smclrk where I learnt so much and started to form a relationship that I hope will endure, that Twitter conversations alone would never have achieved.

This led me to think about some of the debates about using technology to deliver care – is digital enough? Many readers of this blog are likely to have read my earlier blog ‘To Whom it May Concern’ – it’s one of my most popular postings – and are likely to note that I seem to be advocating less face-to-face and more digital. Similarly Roy Lilley’s (@roylilley) blog for the KingsFund ‘It’s crept up on us’ is saying similar things; we need to recognise that in the world we know today surely technology has a greater role and place. I whole heartedly agree but I find the debates that this generates distracting and extremely frustrating.

The trouble is it sometimes feels like we are looking for a silver bullet, or a single direct approach or solution to the complex challenges we face in delivering care in a changing economic and societal landscape – in truth there is no one solution. complicatedSo why then do commentators persist in saying you can never replace face-to-face with technical solutions, implying that advocates of technology are saying this is the single way? I have never heard any advocate of new ways of using technology or innovation say that this is the case! What they do say is that for some processes (ordering repeat prescriptions for example) or transactions (a query about diabetes control from an experienced patient via email) technology can play a part.

When I went to work at NHS Direct in 1999 I remember being told by other nurses that you can’t care for patients over the telephone. 9184840_sI think this debate is past us now with lots of care being delivered using the telephone; but this is also not without its controversy, if I ever tweet or talk about my personal desire for telephone consultations someone will comment or question to say that I ‘don’t understand’ and that we should always use face-to-face and my heart sinks. I have never said or suggested that we could completely replace face-to-face care. As a person with a long term condition I can say for me that technology can have a role that will improve the quality of my life and (maybe) reduce the cost burden of my multiple hospital visits but equally I need to see my Diabetes Specialist Nurse sometimes for a different sort of conversation that cant be achieved on the phone or via email.

So, is digital enough? I say that it isn’t, and never will be, but it must have a role. Like my experience on Twitter some remote digital relationships are enough but for some, face-to-face is the way to go. My suspicion is that digital will have an increasing role in healthcare but it will never replace the dialogue that we have as human beings who occupy the same room. My plea is can we be balanced in our approach to adoption of new approaches to delivering services using new technologies that may improve the quality of life for some people?