One way that this is changing is the expanding role of case management in healthcare. This can be done using patient navigators as well as a variety of healthcare professionals (nurses, social workers, physiotherapists, etc.). One of the biggest challenges to this is the that there is no formal profession for this, but the role can have significant impacts on patient outcomes and satisfaction. However, the National Case Management Network (NCMN) is trying to change that.

Recently I had the opportunity to meet with Joan Park (President) and Victoria Hadden (Project Manager, Communications). Currently in growth mode it is great to talk with them about communication and growth strategy. It was great to get the change to talk with them about all the work they are doing, and their upcoming conference.

Anyone that thinks their organization or unit could improve their patient experience through better case management should definitely check out their website and see learn from the organization.

This year I'm excited to be here on behalf of the Canadian Nurse's Association, for the Expert Commission. This means sitting down with the board, and speaking to the national assembly. Most importantly I'm here to listen and engage students, which is reassuring. It means that CNA is taking student's opinions seriously, they value and want input from nursing students. It is encouraging and I hope we can excite students to take up this opportunity and galvanizes students to continue to engage with professional associations throughout their career.

This morning I was able to sit down with the CNSA Board of Directors for brunch to talk about healthcare transformation on behalf of the Expert Commission. It was a great discussion and it was exciting to hear from some of the future change makers in our profession.

Over the next few days I will get the chance to speak with more students and engage a wider audience. I can't wait to continue to hear from more students and to hear the excitement and their thoughts on how to move the health of Canadians forward.

The Article: Cheerio, Laddie! Bidding Farewell to the Glasgow Coma Scale

Green, S. M. (2011). Cheerio, Laddie! Bidding Farewell to the Glasgow Coma Scale. Annals of emergency medicine, 58(5), 427-430. Elsevier Inc. doi:10.1016/j.annemergmed.2011.06.009

Big Idea:

The Glasgow Coma Scale was not originally intended to be a ubiquitous neurological scoring system. There is evidence to demonstrate the GSC is confusing, unreliable, and unnecessarily complex, and its manner of common clinical use is statistically unsound. Therefore we should consider using Simplified Motor Scales (SMS) that provide the same information, are easier to remember, are statistically derived and externally valid (p. 428)

Evidence:

This article is an editorial, so it is not primary research. The article references a number of other primary sources of evidence including recently published peer-reviewed literature from well respected journals. Referenced studies indicate the GSC has poor inter-rater reliability, it is not consistently remembered, there are different versions (usually outdated 12-point evaluations), it is inconsistent which prevents prognostic value (p. 428 par 1)

Quotable:

"It is time to abandon the Glasgow Coma Scale (GCS). As discussed below, this ubiquitous neurologic scoring system is confusing, unreliable, and unnecessarily complex, and its manner of common clinical use is statistically unsound." p. 427

"Some traditionalists will no doubt object to the blasphemy of "dumbing down" the GCS, but why tolerate pointless complexity?" p. 428

"The GCS is intellectually appealing to health care providers in that it creates apparent order out of disorder. It ambitiously tackles the enormous complexity of human neurologic response and organizes (oversimplifies) it into a tangible, appealing yardstick that cannot fail to impress with its seeming accuracy and precision. We want to believe that medicine can be this objective, and thus we tolerate the delusion." p. 429

So What?

This article was fascinating to me for two reasons. First, as a student I remember trying very hard to memorize the GCS and found it difficult, but thought I was the problem. Second, working in a simulation lab now I find it interesting to see how students do tend to want black and white answers. It is fascinating to step back and see the dialogue that happens in the literature as evidence evolves and researchers have to push for change, not an easy thing to do. As an educator I wonder how we make this apparent to students, since we have to mark them on something and they want very defined and specific answers, yet their knowledge will hopefully and should always be changing (read: evolving) with new evidence.

When you have an idea there are two things you can do, take action or do nothing. Most people with innovative ideas or thoughts on how to make things better choose the latter, because there are many reasons people come up with to not do anything. One of the things that holds people back is the fact that they can't do things perfectly or they think it won't be good enough.

Looking back at the first interview of Nursing Ideas with Doris Grinspun I cringe a little bit. I recorded it with my Macbook at the time and you can hear the laptop fan spin up when it got a bit to hot. The we bite at the time was pretty rough around the edges, there are also typos and bad grammar in almost every post. If I was a teacher and had to grade Nursing Ideas I would have given myself a D- if I was feeling a bit generous. Today, I'd probably say it is up to a B-. This may because I try to be a harsh critic to my own work, but also because I see a lot of ways I can improve it. From sound, editing, lighting, web design, layout and the list goes on, there are all sorts of other things I want to change. However, Nursing Ideas has always been my sandbox. A place that I could experiment try things out and hopefully make something that was interesting.

While I may not have everything the way I want. I am always trying to find small ways to improve. Today I'm happy to say one of the things I've been thinking about is updating some of the branding. The original nursing ideas logo was a bad drawing I sketched out on my computer so I'd have something. It was sloppy, but it could work. Recently I finally took the time and invested in a new logo. As I begin to speak to more organizations, publish more articles, and help produce more podcasts for other organization I want to have a brand and site that reflects the quality of people I work with and interview. I have another logo I can use that reflects the older logo, which will be used for a few promotional items I'm working on and podcasts. However, in print and affiliation this is the logo that I'm planning to use for branding Nursing Ideas.

I hope you like it, but more importantly I want to thank you. Thank you for watching and commenting on videos, for sharing videos and telling friends. Nursing Ideas was never meant for me and I can only hope that others get something from it. Hopefully this new logo helps improve the looks of the site. I want you to know I do take it seriously and plan to continue to work on improve the site, recording more podcasts and creating more content.

Accepting that piece of paper was a great honour, but there were a few parts that to me were more exciting. First, seeing my classmates accept their degrees. I was privileged to sit in class with the leaders of nursing that will spread out from that hall and begin to change the face of healthcare. Second, I got to see the new Bachelors of Science in Nursing be awarded to students I had taught, for better or worse, but hopefully better. From stressed out and tired in the lab to well groomed, composed and beaming with pride they made it through the difficulties of a nursing degree. They have every right to be proud.

While it was a great night to celebrate there are two things that I took away from the night. Sitting in the giant hall of a few hundred if not close to a thousand people I realized that only a few handful needed to be there for me. I saw faces of friends, faculty and family that supported me through my education. They are the reason I was being handed a degree. Through tough nights and long weeks they supported me. The best part of accepting that degree was recognizing the incredible role they all played in me getting it.

The other piece that struck me relates to the lack of magic or secret power that comes with that degree. There is no special textbook, no answer key we now are allowed to look in. While we have all just endured a great deal of stress and a large workload it is hardly over, if anything it is just beginning. To me this is what continuing education is all about. Two or three letters rarely give you much power, except if a license is required. However, they do bring a small amount of respect and a large bit of responsibility.

Now we have to start to create the plans for the next semester or chapter of our lives. We have to see the opportunities and the challenges that most need our attention. There will be no rubric  to follow, no teacher giving us constructive criticism. We only have the knowledge we gathered and the ability to learn. Hopefully that preparation will be enough, hopefully it will help us support those around us.

To all those of you who graduated this year, whether a diploma, degree or graduate studies. Congratulations, you deserve to celebrate! Once you are finished I'm excited to see what lies next, the challenges you will take on and the difference you will make.

The Article: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Big Idea:

Increased interest in implementation science has lead to a number of different theories about how to turn research into practice behaviours. However, each one is a bit different and leaves out key elements. This study was done to compare the different theories, identify overlap between the theories and merge them to close the gaps caused by using only one theory for implementation.

Evidence:

They used a snowball sampling approach to find published theories that have been tested to identify their strengths and what parts of the theory supports implementation. Then they try to link the different theories together by grouping and relabeling things that were redundant or overlapping and pulling appart ideas that were trying to cover unique underlying concepts.

Quotable:

"some estimates indicate that 2/3rds of organizations' efforts to implement change fail." p. 2

The 5 constructs:

- Intervention

- Outer Setting

- Inner Setting

- Individual Characteristics

- Process

So What?

This paper is extremely useful when planning to implement new research and engaging health systems in change behaviours. The constructs presented in the paper help provide useful perspectice and strategies for enabling better implementation and sustained changes.

I would highly recommend this to educators, managers and directors looking to implement change. Students may also find this paper useful for nursing leadership and organizational classes. Nursing leaders and researchers may also benefit from reading this paper for talks on change and ensuring their messaging and research include these valuable perspectices.

Reference:

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. a, & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation science, 4, 50. doi:10.1186/1748-5908-4-50 - 

Be You:

 

 

It is easy to look at a leader or colleague and think, “Wow, I’d really like to be like her/him.” I have had my fair share of those thoughts, and sometimes I still do. When I start to think that way, though, I try to stop myself. I try to stop others who say similar things about me, too (e.g. “I wish I could do that like you,” etc.).

No one else sees the world exactly like I do. My vision reflects my knowledge, skills, experiences, and beliefs. Likewise, no one else sees the world exactly like you. You bring your own flare to the universe and to those around you. Stop wasting your time trying to be like others. Find yourself; be you. That’s the “sweet spot” of passion and contribution – no matter who “you” are.

 

While I do agree that you should not spend your time trying to be someone else that does not mean you cannot change or evolve. I find I am constantly looking at others and seeing things that I wish I could do better, but as Joni Watson points out there is little value to wishing to be someone else. Instead a simple shift in perspective can make all the difference. Ask yourself, what is it about them that I admire?

When you stop to simply wish to be something you are not you can start to focus on what you want to be. If you see a great nurse, don't "wish you were a great nurse". Think about what makes them great, then make a plan to develop those skills. Did they do a fantastic assessment? Did they prioritize and organize there day well? Usually what makes others is great is a skill. It isn't genetic although it might be hard to identify what the secret sauce was, but be sure that there is generally something you can learn to emulate it.

Once you can recognize what it is you can then start to focus on learning to improve your skills. Did a speaker at a conference give a great speech? I'm willing to bet that it was not their first speech, and it was not the first time they delivered it. That excellent execution of a skill is almost always based on practice, preparation and constant refinement of a skill. No matter what that skill is you likely have the required IQ, it is more a matter of deciding what skills you want to dedicate your time to cultivate.

When I saw this device, the Bruin Biometrics Sub-Epideral Moisture Scanner I was intrigued. Being able to identify pressure ulcers at an even earlier stage would be very interesting. Then I remembered technology still does not address behaviour. Therefore, the device would only really use if it did mean that health care providers were better implementing pressure ulcer prevention protocols.

For those of you who don't know a pressure ulcer is a breakdown of the skin and vascular tissue to to a lack of circulation. It is usually caused by mobility, moisture and friction issues. It is now considered a preventable illness and has very serious risks to a patient. The reason they are considered preventable, is often with simple interventions such as regular turning of patients, changing moist bedding, and reducing friction they can be reduced and prevented. The reality though is healthcare providers need the knowledge and the time to actually do this.

Regarding this device, my thought is this. It would be fantastic, but the increase cost to purchase and train staff may lead to a tighter budget that increases staff load and actually prevents them from taking the time to implement the measures to reduce and prevent pressure ulcers. This is not a guarantee, but often with technology we think about the potential and not the limitation.

I think with all technology we need to remember what IMPACT a device will have. Does it help with the required behaviour or is it just impacting marginally around the behaviour. Where would the better spend in money be for patients.

When I was taking my BScN we were all just trying to keep our heads above water. Get the courses finished, the assignments in and being sure not to hurt anyone in clinical practice. When you are at that type of thought level there is very little time for mind growth, you just shove in information, get it back out on the exam, and keep going. Hoping that something will be left by the end of that 4 years. I know I felt somewhat surprised when I passed my nursing license, I didn't feel different, but apparently I knew a lot more than 4 years previous.

One thing that I noticed too is that despite not always being able to come up with the right answer to my preceptors question, meaning I had to go look it up or double check, I often got along very well with patients. Somehow I could often work with patients that had refused to have other men care for them or had "fired" certain staff from caring from them. Now, I'm no patient whisperer, when you are student you often just have more time to spend with the patient, to be more human, more humane with them. Today, while watching a video with Dean Ornish (one of my heros) and Deep Chopra (a person I rarely cared to pay attention to) I realized why what I spending time with patients had such a big impact on them.

Community is a way of providing peace of mind. Peace of mind, happiness, joy and other positive emotions influence the way we feel and change our physiology. Negative emotions hurt us too. People say that hospitals can be risky places to be, because of injury, but what about the way we are treated? If my parents or sister wakes me up I can be a less than pleasant person, if I heard an alarm going for 5 minutes I'd lose my mind, let alone all day. What does the hospital environment and the way we rush around and ignore our patients do to their physiology?

To all the students out there, remember this. You will learn it all in time. You will eventually know all the cranial nerves, what they do and how to test each one. You will know the indications, contraindications and potential interactions of the drugs you come to use on a regular basis. But more importantly never forget that you are caring for another person, and if you can make them feel valued they will feel better. If you can make them feel cared for and love you will improve their health.

For those of you who missed it, Google Health was a personal health record (a place to track your health information) that launched a few years ago and Google recently decide to slowly shut down.

Now what I mean by the first statement I made is that Google got greedy, and they forgot how the internet was built. They know how the internet works, but they forgot that the internet was build by passionate individuals using their spare time to develop, code and grow sites of their interest. Unfortunately, their approach to Google Health was an corporate or private development style of development. They tried to work with hospitals, insurance agencies and a few other businesses and focused on trying to bring in their health information rather than really trying to work on the user interface and generating a market for users to track their health.

What I mean by this is what Walt Mossberg talked about at TEDMED. Google should have focused on pushing the technology companies, the engineers and developers that are making consumer devices to adopt standards and practice that allow users to aggregate their personal health information.

Slowly we are seeing devices, some of which I have bought and love, that are emerging that allow users to track their health (sleep, weight), fitness (blood pressure, speed), diet (calorie count) and exercise (running, biking) and the list is growing. This is the data the people are slowly starting to build, collect and become passionate about.

I think that Google should have capitalized on aggregating this type of information first in the PHR, or at least in equal parts. Sure it is fascinated, especially as a healthcare professional, the records we keep on patients, and the fancy labs and tests we order. But that is not what our patients need to see and learn about. They need to get better at monitoring their diet, doing more exercise and connecting the dots with their symptoms. Clearly PatientsLikeMe is the leader in the disease focus of PHR, but I think this is the same problem as our healthcare systems (world wide), we focus on disease not health.

If we can get patients passionately monitoring their personal health data, and start to pair that with the medical knowledge and insights we have into their disease, then we will have a useful PHR.

This means that I now commute from downtown to this lovely building, where I work on the third floor. I work in the Nursing Resource Centre, which is a large clinical simulation area where I work with students on skills related to their clinical practice.

So far the majority of my work has been focused on medication calculations working in small groups. In the next few weeks as classes begin this will transition to working with students on more traditional skills like bed baths, catheterization, etc. I am not an instructor, in the sense that I teach a specific course. Instead my job is to work with students in the lab on skills they need support in to build on what they have learned in class.

This fall I will be working a few days a week in this job and continuing to work on some consulting projects. Hopefully this will allow me more time to post to Nursing Ideas, but thought you might like to know what I am personally up to these days. In the future most personally related posts are kept on my blog at RobertFraser.ca/Wordpress

I am going to go on a mission. A mission to focus and significantly decrease the number of apps I currently have by looking at redundancy and prioritizing. I probably don't need 9 exercise apps. I do like testing them, but still if I want to have a hope of using them I need to consolidate, use one reliable way.

The lofty goal will be 7 (plus or minus 2), there is something magical about that number, but also scientific. There is research that backs up that cognitively this is about how much we can remember at any given time. Hence, a 7 digit phone number. I am not sure if I will be able to get there, but I'm going to try and drill down towards it. Even if I don't come close making progress will most certainly help to reduce the clutter.

At the very minimum, even if I am unable to limit myself to seven I do want to make these pages (which I will eventually link here):

• 7 Essential iPhone Apps from a Nurse
• 7 Essential iPad Apps from a Nurse

The Apps my change over time, but I'm going to let you know the absolute must-have's that I would not dare to part with, because the long list I have currently would not do anyone very much good.

Some of the best lessons are:

• Constantly review progress - this prevent embarrassment, provides motivation, prevents problems becoming big problems, and allows you to say when something is done
• It has to be safe to tell the truth - people need to be able to speak their mind and share their ideas
• Communication should not mirror the organizational hierarchy - everyone needs to be able to have a conversation and the same level of respect and worth
• People and how they function is more important than ideas - if people do not act on ideas than they do not mean much
• Do not let success mask problems - not one or group is perfect, especially when things are going well it is important to have an accurate assessment of what is working well and needs to be fixed

There are a lot of other great lessons in there, but these are just a few highlights. Hopefully you will enjoy it too. Always great to learn from other fields and see how you can bring it back to your workplace.he