A Nurse who has ‘Sold her Soul’?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Practicing what I preach – role modelling and social media

This blog is a bit of an experiment :0)

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

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

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

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

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

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

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

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


Thank you so much xxx

Thank you so much xxx

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

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.




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