Where is your change preference?

figure headSometimes life throws you an opportunity to explore something new or even explode things you thought you knew. Often you think you know what enthuses you but then you surprise yourself; I once surprised myself white-water rafting in the Ottawa River – I was like the figure-head on the front of a ship, holding on bravely – but I digress! This time it was a new opportunity to explore and expand some knowledge.  As part of my Florence Nightingale Foundation Burdett Scholarship I have been very lucky to spend some time at Roffey Park  and a few weeks ago I was there looking at change management.

So we looked at a number of theoretical change models. That was interesting enough; I knew some and was less familiar with others. Then the interesting bit started, we tried putting them along a scale according to what I have termed humanist > mechanistic approaches. What I call humanist are what is termed ‘relational’ where enabling techniques like World Café, Future Search and Appreciative Inquiry have their place. At the opposite end of the spectrum was more mechanistic project management type approaches, that are less messy and are organised in a more logical flow led by theorists such as Lewin and to a degree Kotter; they have a more linear and analytical style with techniques like business process mapping and lean methodology. Of course the scale is not a scientific one and it is matter of personal interpretation and perspective.


I had a sudden moment of clarity. The process of learning led me to think about my personal preferences and how I liked to think about change. I discovered that although I see that different approaches have different strengths and weaknesses, I had a personal preference for the type of approach to change that I liked to be involved in. I also saw that not only had I personal preference for any approach to change, that I worked in organisations that equally had a culture with a leaning towards an approach, and finally that there was an opportunity for discomfort and tension in this.

BridgesMy favourite model was a new one to me and is a model called ‘Transition Management’ based on the work by William Bridges. It refocuses change into transition, which is the psychological transition and reorientation required in response to change. I loved the idea that before we can transition we need to address endings and then we inevitably experience a neutral zone, a period of chaos and an in-between time. Then the process of renewal starts. I loved the language of this model. Words like: endings, relationships, resistance, disorientation, beginnings and new identity. If you want to know about Bridges have a look at this article here.

Gant chartSo, I like a particular approach to change but I work in an area that clearly can’t use that approach, you can’t introduce new software using appreciative inquiry – you need good Gantt charts plenty of them! If you work in the large scale programmes I work in you are nobody if you don’t have a Gant chart or a RAG status!  But I survive there despite my preferences – I had to think hard about why!

My conclusion was that I am able to see that its appropriateness that matters most and having people around who have the skills to use the right approach. Organisational development people are not one-trick ponies they need to be able to work out what is the best way and then use it. I’m just glad that with my preferences for relational models of change I work with some great people who have skills at the other end of my change spectrum – It made me think about difference and value it even more!

At a time where there is a need for unprecedented change in the NHS, understanding our personal preferences and leanings as well as the embedded culture of organisations and their almost instinctive responses to the need for change has to be important learning.

standing out from crowd

The importance of partnership and mutual respect

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

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

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

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

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

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

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

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

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

Seasonal gifts of learning

2013 14Well another year is almost coming to a close. I quite like the sense of endings and new beginnings, although I confess that these days I’m much less of a party animal and am much more likely to see the end of year out in a quiet and hopefully thoughtful way, with a bit of feasting maybe and looking forward!

lightbulbThis last year has been a great one for me (#Annies50th) but it has been also stressful and frantic, with new jobs, extensions at home and a fantastic exploration of the social media world. One of the things that this digital world has been great for, second only to the amazing people I have met both virtually and increasingly face to face, is for learning; that is expanding my thinking, sometimes blowing a hole in my previous ideas. It’s been a wonderful exploration, that I hope will continue.

So my gift to you are the three (almost 4) TED talks that have made the most impact on me, along with a couple of Vimeos.

The first is a TED talk that I first saw this year while I was on my Organisational Development Practitioner Programme. I have watched it many times since. The talk is about perspectives, how life is made up of overlapping stories of contrast and truth – and is well worth the 20 minutes. It’s a stunner and worth a reflection for all leaders and healthcare practitioners:

Chimamanda Ngozi Adichie: The danger of a single story

The second is Brene Brown, after my last blog I was pointed back at her talk about vulnerability.  This is about humanity and our acceptance of vulnerability.  Again for Healthcare Professionals (but everyone too) its worth a listen.

Brené Brown: The power of vulnerability

The third is Susan Cain; for me this TED talk is about understanding others and taking at deeper look at myself.  I am definitely not introverted; I love people and always think out loud with others.  In fact I’m terrible on my own, a weakness I know.  Watch Susan Cain  to think about yourself and how you connect to others but also and probably more importantly how to value difference.

Susan Cain: The power of introverts

Now a couple of Vimeo videos:

The first I have mentioned in a blog before.  I remain convinced that in the future co-production, sharing, integration, and social responsibility will become the most important things we do.  This video by explains why co-production helps:

The Parable of the Blobs and Squares

The final Vimeo video is from the wonderful @wenurses where they created a celebration of why people are proud to nurse. It is important that as a profession we keep our identity and be proud.  Its been a difficult year but this video gives a sense of what we have and how strong we are:


Finally I would like to wish anyone who reads this a happy, healthy and successful 2014.

happy new year

Post Script

There was another TED talk that I considered including but its not for the faint hearted.  This talk by Philip Zimbardo is about why nice people might turn ‘bad’.  It contains some hard hitting images.

Philip Zimbardo: The psychology of evil

The hardest thing to say out-loud

It’s not very often I’m asked to talk about having Type 1 Diabetes – I’m usually in some nursing or informatics forum or talking about social media – but a few weeks ago I was delighted to be able to go to talk to a group of MSc nursing students in Nottingham. I had a great time. I came away with a real feeling of optimism for the profession. I hope they enjoyed it – some of them are likely to read this and I have no doubt they will tell mDiabetes sugare…..

While I was telling my story something strange happened, something cathartic and afterwards I realised I had never said some of the things I said to this group out loud, in fact when I said them I could almost feel the group do a sharp intake of breath, a moving back, a sitting up straighter; I don’t know, something shifted, moved as if they started to really listen.
So what was this revelation that I made? Difficult as it is for me I have decided to write it down.

Moving homeIn 1989 we moved house. It was the first time I had ever moved and I found the whole experience exhausting. We started early and finished late, running around, packing, unpacking and dealing with problems. I remember that I probably didn’t stop for food but my husband’s Mum made us some tea (that’s dinner in the North – just in case I am confusing you), I suspect I didn’t eat so much of it, as I was so tired – too tired to eat. I remember we hadn’t had chance to assemble the actual bed so we fell exhausted onto our mattress on the floor of our new bedroom. I woke up some hours later with paramedics in the room and no idea why they were there or indeed where I was.

It transpired that I had had a hypoglycaemic attack (a very low blood glucose) and I hadn’t woken up, caused I suspect, by my acute tiredness and lack of eating. I had fitted, a full blown seizure, and it was the scariest thing you can imagine. My poor poor husband had called an ambulance – I had been in a full-blown non-epileptic seizure, with loss of consciousness and convulsions and he was also very scared – it wasn’t one of the things I had warned him about!

Home - I didn't let it happen the second time we moved to this house.

Home – I didn’t let it happen the second time we moved to this house.

I can’t describe how this feels even now. I am someone who likes to be in control and to think that I was in a state whereby I didn’t know what had happened still makes me feel frightened. When people talk about avoiding hypoglycaemia at all costs, even when it means poorer control and all of the things that go with that, I completely understand.

This is hard to say out loud. I have no idea why. I fit at night if my blood glucose is low and if I am so exhausted that I don’t wake up. Why do I find that so hard to say? I think I know why and it’s the reason why I am writing this down.

Even though this is still hard to say – ‘I fitted’ – it wasn’t actually this that created the tension in the room with the students – so what on earth was it? When I fitted I was incontinent of urine and I wet the bed. I used exactly those words – ‘I wet the bed’. The room felt different and they were listening to me in a different way.

There are some things that still feel taboo, that carry a stigma and I think that having ‘fits’ is one of them and that I have internalised this based on my experiences and society around me during my lifetime. Internalized stigma is felt within the person with the condition and reflects their feelings, thoughts, beliefs and fears about being different (Muhlbauer, 2002). The fact that the students seemed unfazed by this confession was counter-balanced by what happened when I said that I had ‘wet the bed’. It wasn’t just me that noticed – there was someone with me on that day who commented afterwards, independently, ‘Did you notice what happened in the room when you said you had been incontinent of urine?’ I don’t know what made me say it – I had never said it out loud to anyone before – not even to my other half. So here we seem to have another social taboo, one that I had internalised.

Urinary incontinence is a really common condition affecting more women than men. If you simply google ‘stigma urinary incontinence’ you will find a plethora of articles about it. So, it seems that some topics are still hard to discuss. Writing this down is hard and it feels difficult to say; I feel that I might be judged as different and that this might mean people treat me differently.
tabooI have not experienced a seizure, or indeed urinary incontinence, for years now, mainly through improved control, because of my beloved insulin pump, and through more care and diligence around testing. But the fact is that it has taken me almost 15 years to say the words out loud make me feel sad. Many people live with conditions such as incontinence and as a result of the stigma attached to this do not report it to healthcare professionals who may be able to help. My hope in writing this down is that it helps to create conversations about some of these taboo topics that impact on so many people lives.

To find out more about urinary incontinence here is the link to the NHS Choices webpage.

Muhlbauer S. 2002. Experience of stigma by families with mentally ill members. Journal of the American Psychiatric Nurses Association 8:76-83.

Perceived Weirdness Index and Leadership

Sometimes I think I can be seen as being a bit eccentric and to be honest I quite like it; although it doesn’t mean I am fond of being the centre of attention. I often feel on the edge of things, not quite mainstream, sometimes it’s fun, other times it’s lonely. But is my eccentricity something that can be a help?who are you

I have been studying the practice of Organisational Development (OD) recently as part of my leadership scholarship and am learning lots of things that I think have equal applicability in a leadership space. OD practitioners use the concept of ‘self as instrument’, understanding that any intervention has an impact and think carefully about how they act, think and do – their presence. I think leaders could usefully think like this too. I started to wonder if my perception of ‘self’ and my presence might be something to do with how I affected things around me. Presence can be thought about as impact created by personal appearance, manner, values, knowledge, reputation, and so on. So, if ‘self’ is important in leadership interventions, is my possible eccentricity an advantage or a disadvantage?

There is a fascinating idea first described by Halafin (1976) called the ‘Perceived Weirdness Index’ (PWI) that I came across exploring the OD literature. Your PWI may make you more or less effective as a change agent. The PWI is a spectrum of behaviours with a ‘sweet spot’ where you are not in the mainstream of the organisational culture but just weird enough to be at the edge, the theory being that if your PWI is just like everyone else’s you are less likely to be successful at effecting change as you are absorbed into the organisational culture but if you are in the ‘sweet spot’ then you can be more effective as a change agent.pwi

Are the people who you think are change agents just a bit weird? Where do you think your PWI score is in your workplace? How different are you? All very interesting thoughts!

odd one out

How to make a good idea great

ideaI love it when I have a great idea; I want to offer a unique contribution in life that makes things better for people but I don’t know about you, I often find out that something I thought was a great idea has already been thought up by someone else.

It’s hard to identify truly unique ideas, especially in health where many of us are thinking as hard as we can about how we can do it better. I spend a lot of time with people who are enthusiastically thinking up plans and ideas about really important things. But there is one thing that struck me recently – why do people not ask around and join up with other people who may also have thought up the same idea, make the idea great?

 “The whole is greater than the sum of its parts.” Aristotle


Sometimes it’s about self-confidence, the confidence it takes to ask. I see much great work going on and I spend many hours trying to connect people together. I see people struggling with the same issues as their neighbours in other hospitals, communities, homes and work. I think we need to work harder at connecting, at liberating ideas and allowing them to be solved by networks and communities.

For once I’m not just talking about the power of social media – I mean literally talking to each other. I don’t believe anyone needs permission to find collaborators and to share. Why do we persist in thinking in organisational silos?

So, my musings for the last couple of weeks lead me to the conclusion – we need to get out more!

So, if you have a great idea:

  • Talk to as many people as possible about your idea;
  • Look around and find out if anyone is working on the same idea or problem, the internet (and twitter) make this so easy!
  • Has someone already had your idea – can you elaborate their idea and make it even more fabulous?
  • You don’t need permission to chat to other people – go on, seek out networks and communities;
  • Ignore hierarchy – good ideas come from everywhere and your idea may well be the unique one everyone is looking for; and
  • Don’t be afraid to share – my grandma used to say you will always get back more than you give.

DreamsAll those nurses and midwives out there that I meet – go and talk to your neighbours; wards, hospitals, communities and never be afraid to keep dreaming new dreams.

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