Take the Resilience Challenge

There are many pressures in healthcare, all of which have an impact on people who work on the front lines. Resilience Challenge, a new interactive videogame, aims to raise awareness about these pressures.

http://game.resiliencecentre.org.uk/

In the early 2000’s, Safer Healthcare Now and other initiatives were launched to improve the 10% error rate in hospitals worldwide. After over a decade of research, and billions of dollars of funding, the error rate remains unchanged. So what went wrong? There are several perspectives on why patient safety hasn’t improved. These include a) we didn’t understand safety as a culture, not just individual errors b) we need to strengthen what goes right, not just eliminate what goes wrong, and c) we need better engagement between researchers and clinicians to makes sure that researchers are asking the right questions and clinicians are implementing the results.

Resilience Challenge is one way that researchers at in the Centre for Applied Resilience in Healthcare (CARe) at King’s College London are addressing these questions. We are studying how we foster organisational resilience in order to improve patient safety and support clinicians to provide high quality care. Organisational resilience is the ability of a system to adapt safely to pressures in healthcare. The Resilience Challenge videogame supports nurses, doctors, and healthcare professionals to explore this concept, and understand what it means in practice. Organisational resilience is not about individuals coping with poor working conditions; it’s about creating better environments in hospitals so that people can give great care.

The videogame is based on guiding a patient’s journey through the hospital safely. It combines comic book style visuals with accurate medical imagery to create an experience that is both familiar and imaginative. We want to engage with people from a broad range of backgrounds including healthcare students, professionals, and the public to understand the pressures healthcare providers face at work, and how organisations can support clinicians and safe decision-making. 

The Resilience Challenge is part of CARe’s wider work to inform policy about healthcare safety. The game is designed to raise awareness of the pressures on healthcare professionals and to start conversations about what can be done at an organisational level to support successful decision-making. CARe’s goal is to make healthcare systems work safely for everyone involved.

The Resilience Challenge was created through a collaboration between King’s College London’s Centre for Applied Resilience in Healthcare (CARe) and Karman Interactive, brokered and supported by the Cultural Institute at King’s.

Play the game, and please complete the survey at the end to support CARe’s research.

Learn more about our work here: http://resiliencecentre.org.uk/

 

All About That Base? Why Nursing Needs More Than Evidence

Evidence-based nursing. This is the focus of most of the modern nursing discourse (including this blog! Controversy ahead…). In all of nursing’s domains of practice, evidence-base is a hot topic, showing that we are up-to-date, safe, and professional.

There’s just one problem. Being ‘evidence-based’ does not mean nursing is any of these things.

Our profession has doubled down on evidence-based framing in recent years, in alignment with medical professionals. This is nothing new; nursing pioneers have long aligned nursing with aspects of the natural sciences and medical sciences in order to give nursing credibility[i]. I get the sense that nursing’s drive towards evidence is to appear credible alongside medicine, as much as it is to actually improve patient care.

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There are several reasons why evidence is not enough to form the basis of nursing knowledge:

  1. Evidence is not automatically right or good.

One only needs to say “Wakefield” and we know that scientific evidence can be flawed[ii]. While this is an extreme example, there are many published studies that are not rigorous or are clouded by conflicts of interest. Just because something has been studied or published does not make it accurate, safe, or useful.

  1. The knowledge to practice gap is slow.

Estimates vary, but we know it can be 10-17 years for knowledge to be translated into practice. Even then, it is extremely difficult to change nursing (or medical) practice, and have these changes last. And waiting 2 decades for changes in practice won’t serve our patients in the meantime.

  1. Standardization is not a good idea.

We know that evidence does not necessarily serve all people or populations. For example, when a study shows that an intubation technique works well in one setting, it does not mean it is safe for all settings. The idea that, if we standardize our care, we will improve patient safety, is fundamentally flawed[iii].

  1. In many cases, evidence does not exist.

How should nurses practice in the context of Zika virus? We are still learning this. There are patients with Zika who need care in the meantime, and we can’t wait until we have an answer to nurse them.

  1. Evidence is not ethically neutral.

Evidence is influenced by politics and economics, from start to finish. There are important issues which have not been researched because there isn’t funding available, or other issues are more politically attractive. Even when evidence is available, it can be difficult to fund or adopt; safe staffing ratios are a prime example. Greatest need does not always drive research priorities or implementation.

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So what are nurses to do?

I advocate a return to a comprehensive understanding of what makes up nursing knowledge. Carper wrote this paper in 1978[iv], and it’s still relevant and useful today.

Carper outlined that nursing has 4 kinds of knowledge:

  1. Art
  2. Science
  3. Ethics
  4. Experience

If we return to seeing nursing practice as a comprehensive body of knowledge, we can outline nursing work as being multidimensional. Evidence-based nursing has us leaning so heavily on science, that we lose the other factors in our conversations about nursing.

When we are supporting people with mental illness, we know that if we provide community supports, medication, and cognitive-behavioral therapies, we will have better outcomes than if we provide medication alone. This same logic can apply to how we use Carper’s types of knowledge.

We can form the basis of our practice with the art of nursing. We can say, no matter who I meet today, I will promote their dignity, or I will be caring, or whatever works in your practice. When we have a specific problem, such as acute kidney injury, we can use our scientific knowledge and our experience to provide expert care. We can advocate for vulnerable people because this is part of the ethics of nursing. These types of knowledge work together, and give us comprehensive nursing practice.

I think most nurses already integrate different types of knowledge in their practice. What we can change is how we talk about it. We can talk about how we apply different types of knowledge in our work. If we explain nursing knowledge in these domains, it may support nursing students to develop their practice. It may also be easier to talk about challenges, such as ethical dilemmas, when we move away from an overemphasis on evidence.

I believe in the vital role of evidence in nursing practice, as I am a nurse researcher, working to build our professional knowledge base. But I also see that we need more, and we can steer our professional conversation back to the multi-faceted knowledge that really makes up our base.


References

[i] Wuest, J. (1994). Professionalism and the evolution of nursing as a discipline: A feminist perspective. Journal of Professional Nursing10(6), 357-367.

[ii] Godlee, F., Smith, J., & Marcovitch, H. (2011). Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ342, c7452.

[iii] Learn more: http://resiliencecentre.org.uk/fact-sheets/safety-i-and-safety-ii/ Full disclosure- I am a member of the Centre for Applied Resilience in Healthcare.

[iv] Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in nursing science1(1), 13-24.

 

Domestic Violence and the ED: AENJ Hot Topic #FOANed

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Editor’s Note: In a second installment from newly appointed Associate Editor and author, Wayne Varndell presents a snapshot of a current political and social priority and how it relates to those working in Emergency Care. Periodically the Australian Emergency Nursing Journal intend to release a number of “Hot Topic” publications from recent and older journal issues as Free Open Access articles. Due to a dearth of high-quality free accessible literature to support nursing practice, Wayne will bring us a round-up each time a new “Hot Topic” release occurs. Once again by way of disclosure, no member of the editorial team receives any incentives from AENJ and these blogs are intended to promote quality evidence based nursing materials to a wider readership.


 

Authored by Wayne

Domestic violence is a pervasive, global problem of serious proportion. In Australia, the majority of dangerous, abusive and violent behaviour that occurs in the privacy of people’s homes is committed by men against women, with one woman dying per week.1 Men experience dangerous, abusive and violent behaviour, with one man every ten days dying in Australia.2 A study in Victoria found that deaths from intimate partner violence made up 2.3% and 12.9% (femicide and suicide, respectively) of the disease burden, and at the time of the report, intimate partner violence represented a greater disease burden than many well-known risk factors such as high blood pressure, smoking and obesity (Figure 1).3

 

Domestic violence graphFigure 1: Top eight risk factors contributing to the disease burden in women aged 15-44 years, Victoria, Australia, 2001.

As one of the primary health services, the emergency department is frequently used by those in a violent relationship, and is commonly seen as the first point of refuge. However, victims of intimate partner violence may be reluctant to disclose the violence unless asked directly by clinicians. Despite valid and reliable screening tools being available,4 routine screening for intimate partner violence in the ED setting is low, contrary to evidence suggesting that when asked directly, a significant number of victims disclose the violence.5, 6 While intimate partner violence against women has become more known and studied, more research and action is needed regarding male victims of intimate partner violence.

The emergency department is for many people, the first and often continuing point of medical assistance and safety. Intimate partner violence remains one of the greatest disgraces in Australia. Through increased awareness, screening and early intervention it can be dramatically improved. The Australasian Emergency Nursing Journal is pleased to provide open-access to essential content on ways and means to improve identifying and responding to victims of intimate partner violence within the ED setting:

 

References

  1. White Ribbon. Why is the work of White Ribbon important? 2015 [cited 2015 November]; Available from: http://www.whiteribbon.org.au/white-ribbon-importance.
  2. Dutton, D. and Nicholls, T., The Gender Paradigm in Domestic Violence Research and Theory: Part 1—The Conflict of Theory and Data. Aggression and Violent Behavior, 2005. 10(6): p. 680-714.
  3. Victorian Health, The health costs of violence: Measuring the burden of disease caused by intimate partner violence – a summary of findings., Department of Human Services: Victoria.
  4. Rabin, R., Jennings, J., and Bair-Merritt, M., Intimate partner violence screening tools. American Journal of Preventative Medicine, 2009. 36(5): p. 439-445.
  5. Schimanski, K. and Hedgecock, B., Factors to consider for family violence screening implementation in New Zealand emergency departments. Australasian Emergency Nursing Journal, 2009. 12: p. 50-54.
  6. Ramsden, C. and Bonner, M., An Early Identification and Intervention Model for Domestic Violence. Australasian Emergency Nursing Journal, 2009. 5(1): p. 15-20.

 

Why Nurses Need to be Politically Active

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Follow Jennifer on Twitter @JJackson_RN

Editor: It is with great pleasure that Injectable Orange welcomes back guest author Jennifer Jackson. In this post Jennifer implores us, as nurses, to take an active interest in politics, as it really does impact right down to our capacity to provide care and treatment. This is a very timely post, as many of our junior doctor colleagues throughout the UK are in the midst of a political struggle around threats to their contractual provisions. In my home state we have seen major threats to senior doctor contracts and significant cuts to nursing jobs. The medical profession are often galvanised in their political missions to preserve the integrity and entitlements of their profession. Unfortunately nursing often seems to rely on unions or figureheads to represent our professional interests and often feel disempowered or disinterested by the politics of healthcare. Jennifer offers a call to action – stand up and be counted as a profession #NursesUnite.

Voters cartoon

Why Nurses Need to be Politically Active – Jennifer Jackson

After a thesis-writing hiatus, I’m back for more discussion about professional issues in nursing! First on my list is nursing and politics. We are about to have a federal election here in Canada, which is promising to be one of the most interesting and important elections in a long time. In most countries, there are many opportunities to vote and be part in the political process. This blog post will look at some reasons why nurses need to be politically active, and what political action in nursing can look like.

It is a great thing to be able to participate in a general election. The ability to have women, Indigenous persons, and Persons of Colour vote are fairly recent historical developments. There are fragile democracies around the world, where people are fighting to have political rights. Many people have devoted their lives to the support of these rights, and I think we do them a great disservice if we take our democratic power for granted.

I also believe that voting and political engagement DO make a difference. If we look to the Greek meaning of democracy, demos refers to the people, while –cracy is government, meaning the government of the people. Our political opportunities, such as voting, give each person a voice in what happens in our systems. Whether you are male or female, rich or poor, rural or urban, you have an equal vote in how your country and your municipality are run.

It is great to encourage general political participation, and there are lots of reasons that nurses can benefit from voting and being politically active. Political activity is as old as the nursing profession. Florence Nightingale developed the world’s first graphs, and showed them to the British Parliament, convincing politicians to continue funding her work in Crimea. There is a legacy in health care that is the result of political activity, and nurses can continue these efforts today.

Here are my top 3 reasons why nurses need to be politically active:

  1. Politics can change the work we do.

Political factors can have a substantial impact on what type of work we do as nurses, because of the impacts on society. A prime example? Texting and driving. Laws were enacted in Canada to decrease distracted driving, and there have been fewer car accidents as a result. This means fewer trauma codes, fewer ICU admissions, fewer fatalities. Laws and political decisions impact care we need to provide as nurses. As nurses, we can ask ourselves, who is coming through our doors? What could be done to address preventable illness and injury?

  1. We can represent the interests of the nursing profession.

Most nurses are experiencing, or have experienced a period where there have been health care cutbacks. Wage freezes, working without a contract, decreases to hospital funding, strikes- most of us have been there. Nurses can follow these funding decisions directly to their impact on patient care, because of our role providing patient care. When we vote, we elect people who will make budgeting decisions. We can vote for people who will support our job security, and adequate funding for health care. We can also reinforce the importance of the nursing profession by contacting politicians to share information and let them know that nurses vote. Political activity gives nurses an opportunity to represent and advance our professional values.

  1. We can advocate for our patients.

For me, the most important reason to be politically active is because politics is a means for nurses to advocate for patients. Advocacy is very important for nurses because social justice is a core value of the nursing profession. When we work in clinical settings, we can help one patient at a time, and this work is central to our profession. When we vote, sign a petition, or participate in a political event, we can potentially help thousands of people at a time. Political activity takes the work of nurses from being a discreet event in one setting, and raises it to a societal level.

A lot of the social determinants of health can be impacted through political decisions. Nurses can help to protect health care access for vulnerable populations. An example of this is refugees. In Canada, funding was cut to refugee health care programs. An outcry from multiple professions took the case to the Supreme Court of Canada, where the decision was overturned. This is an example of when political action was effective to advocate for a vulnerable population.

So what can we do?

There are many ways nurses can be politically active.

Some suggestions include:

  • VOTE! (Especially on October 19 if you are Canadian).
  • Encourage your friends to vote, too!
  • Call or email your elected representatives, and tell them about an issue that matters to you.
  • Engage with a political party or organization on social media, and share information with your followers.
  • Actively participate in your nursing union or association.
  • Join a protest or demonstration.
  • Write a letter to the editor about an issue in your community.
  • Run for a political position or office- can be anything from your local union chapter to a federal seat in parliament.
  • Talk about politics with your coworkers, friends, and neighbors. Encourage them to get involved too, even if they have different views.

Other resources include:

Samara, a non-partisan organization dedicated to improving political participation.

Vote Compass, to help you determine whom you should vote for on election day.

Nursing union and association election resources

United Nations, Department of Political Affairs

 

These are just a few of the ways that nurses can be politically active. I encourage you to use political activity as part of your nursing practice, to advocate for our patients and our profession!

 

Why “Soft Skills” Matter

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Follow Jennifer on Twitter @JJackson_RN

Injectable Orange Editorial: So the call went out on Twitter for eager bloggers to share their words via injectableorange.com and Jennifer replied… big time. This post is the second in what we are hoping to be a series of regular guest posts focussing on professional communication and the so-called “soft skills” of nursing. Enjoy.Slide1

In this blog, I examine professional development, and other non-clinical aspects of nursing. It is important to illustrate why these skills matter for nursing, and why you should care about these issues. To understand this effectively, it is helpful to talk about the pillars of the nursing profession; this gives us a framework. In this post, I talk about how nursing is structured, and how soft skills fit into this structure, and why it is important for you.

We all love some excitement. Many nurses love the adrenalin rush of participating in a Code Blue or other high-intensity scenario. There are a multitude of psychomotor skills required in these events, and it gets your blood pumping to be in the middle of a critical situation. Today, I am here to advocate for a different type of essential nursing skill: soft skills. I believe that these skills are integral to nursing, and are among the most important abilities that a nurse can have at the bedside.

Soft skills, or non-clinical skills, or non-technical skills, refer to skills that are above and beyond the psychomotor tasks that nurses complete. They have been loosely defined as skills that enhance interpersonal interaction. Examples of soft skills are communication, advocacy, critical thinking, and interpersonal skills. It is important to see these skills as a distinct, and learnable part of nursing. All nurses can work to improve their soft skills, and in turn their nursing practice. In this post, I will cover 3 distinct reasons why soft skills matter: they connect domains of nursing practice, they express different kinds of nursing knowledge, and they make a difference for patients (and employers!). We’ll also explore what do to next.

Connecting Domains of Nursing Practice

It is important to consider how the nursing profession is structured. Nurses have 4 distinct domains of practice: clinical, administrative, educational, and research. Each of these areas is united by the fact that we all use the nursing process. While the bulk of nursing takes place in the clinical domain, each of these domains is essential. They reflect how nurses create professional knowledge (research), learn professional knowledge (educational), apply professional knowledge (clinical), and foster the creation/learning/application of professional knowledge (administrative). Side note: this is why we should refer to nurses by their domain of the profession, such as “clinical nurse” instead of staff nurse, frontline nurse, bedside nurse etc. It ties the role directly back to its pillar of the profession. Each domain is a leg of our table, and is essential to having a robust nursing profession. It is important to know how the profession is structured, so you can map where your role lies, and how you relate to other roles within the profession. This is not a hierarchy- it is an understanding that we are different but that we are all on the same team.

However, each domain is also different. You can discuss backwards regression analyses in research and progression of mobilization in clinical practice. So how do we talk to each other? Soft skills. We use interpersonal and communication skills to connect between domains of practice, and share our insights and our challenges. This is important because clinical nurses may have a great suggestion for new nursing research initiatives. Nurse educators may inform nurse administrators about a need for advocacy around educational funding. Our soft skills can break down barriers and strengthen the integration of our domains of practice, making nursing practice easier for all of us.

Expressing Different Kinds of Nursing Knowledge

In addition to having different domains of nursing practice, we also have different kinds of nursing knowledge. These kinds of knowledge cross all 4 domains of practice, and represent how nurses understand their profession. Carper’s landmark article outlined that nursing knowledge is categorized as art, science, ethics, and experiential knowledge. Chinn and Kramer later added social justice or emancipatory knowing as a fifth type of nursing knowledge.

Domains of Practice Types of Nursing Knowledge
Clinical Art
Administrative Science
Research Ethics
Education Experience
Social Justice

Everything we do is multidimensional, or it would not be nursing. Our unique types of knowing are expressed through soft skills, in everything that we do. Let’s take an IV insertion, which is a bread-and-butter psychomotor skill. While you get your supplies to put in the IV, you grab a hot pack- your experiential knowledge tells you your patient might be a hard poke, and your science knowledge tells you that heat will help this situation. While you prepare your supplies, you comfort the patient and explain the procedure. That’s the art of nursing. This patient may need a PICC line, but could be high risk for IV drug use- the ethics and social justice of nursing. One commonplace procedure; 5 types of nursing knowledge.

So how do we express our different types of nursing knowledge? You guessed it, soft skills. Nursing runs on this complex integration of knowledge; however, a lot of it can happen internally and it is not seen or recognized by others. When we can articulate what we are doing, using our nursing knowledge as a framework, we demonstrate the full range of nursing. This will increase the appreciation and respect for our profession.

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Soft Skills Make a Difference for Patients (and Employers!

No matter where we work, nurses make a difference for patients. When you ask patients what makes the biggest impact to them during a hospital stay, nursing communication ranks consistently as one of the most important factors. In my experience as a clinical nurse, I found that many people placed emphasis on psychomotor skills. I remember the days of being a student and saying, I need an IM and an IV start! However, if we really want to make a difference for patients, we need to have good soft skills too. Research has demonstrated that communication makes a huge impact for patients, and is the most important aspect of being a health care leader. In light of this, we need to consider soft skills as seriously as any other type of nursing skill.

Increasingly, employers care about soft skills. Now that patient experience is a common measuring point in hospitals (whether it should be or not- this is reality), administrative nurses are hiring clinical nurses for personality instead of experience or background. I have heard this stated by many nurse managers- “We will teach them everything they need to know during orientation. What I need is someone to be part of our team.” If you are looking to score your nursing dream job, you need to demonstrate that you have strong soft skills. To see how to write a resume that does this, see this post.

So Now What?

Soft skills are an essential part of nursing, across all domains of practice and types of nursing knowledge. So what does a nurse do about this? Treat soft skills the same way as you would any other skill. Practice, seek out resources, ask for advice, and participate in continuing education. It is reasonable to ask your colleague, how can I improve at IV insertion? It is also completely reasonable to ask, what are some ways to communicate with a family that is grieving? You wouldn’t put in an IV without learning about it first, and the same logic applies to soft skills too. Consider soft skills an integral part of how you nurse and how you talk about the nursing profession. You will see great benefits for yourself, and also for your patients.

I will continue to explore soft skills and nursing in this blog, so stay tuned! In the meantime, how have soft skills impacted your nursing practice?