Under the SSKIN

Since W2tQ started almost 15 years ago a collection of 250 draft posts have gathered (virtual dust). Many are probably empty - half-baked ideas - with no clear title (reminder - of the contents).

In nursing there are (thankfully) constant reminders, one being: the need to strike a balance between the person, being least restrictive, assumed mental capacity, best interests and high quality care delivery.

Revisiting the threshold concepts, h2cm and deprivation of liberty safeguarding draft paper brings recollection of a draft post and the lesson:

In many nursing situations you cannot assess what you cannot see.

In Nursing Times 29.11.11 a Nursing Practice comment item was titled:

“Compulsory training would help every HCA spot moisture lesions” 

Denise Elson, points to the SKIN (Surface, Keep moving, Incontinence and Nutrition) bundle as a set of very useful principles, and further refined to SSKIN:

SSKIN - Surface: Skin inspection: Keep moving: Incontinence: Nutrition

The Tissue Viability use the principle of SSKIN:

• Surface: make sure you're on a supportive surface 
• Skin inspection: check it isn't discoloured or sore 
• Keep moving: change your position often 
• Incontinence: keep clean and dry 
• Nutrition: eat healthily and drink frequently ( https://www.plymouthhospitals.nhs.uk/tv-sskin )

As a reflective exercise, if needed, think about SSKIN within h2cm - Hodges' model. Not just the physical (SCIENCES) focus but how these relate to the INTRA-INTERPERSONAL, SOCIAL, POLITICAL and the SPIRITUAL. We will revisit this using h2cm.

On the blog's 15th anniversary 20th April, I'll also try and put some numbers together.

Whitlock, J., et al. (2011) Using the skin bundle to prevent pressure ulcers. Nursing Times; 107: 35, 20-23.

See also:
Tissue Viability Society

Report: Personalised Health and Care 2020 - National Information Board

individual
INTERPERSONAL : SCIENCES

humanistic ------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

group

self-help, self-care, person-centredness, personalised care	task-centredness, administration, time, processes, events, data capture
"Patients told to go online in radical NHS reform"	"Government withholds 35m nursing technology fund"

Report: Personalised Health and Care 2020. National Information Board. November 2014.
https://www.gov.uk/government/publications/personalised-health-and-care-2020

Sources:

The Times, Patients told to go online in radical NHS reform. 13 November 2014. London. p.1.

The Nursing Times, Government withholds 35m nursing technology fund. 12 November 2014. p.2.

NT: Nurses urged to use checklists to reduce human error in practice

Last month Nursing Times included an item on checklists, highlighting work by the WHO in perioperative nursing and the 'Patient Safety First' campaign. Following surgery's lead is the realisation that similar checklists have the potential to improve communication and team working in other areas such as nutrition, situational awareness and pressure ulcer care.

Checklists are ubiquitous in our day-to-day lives, the dividend for using them is fairly obvious. What is less obvious is the fact that checklists alone are dead bureaucratic adornments. Checklists are animated by situations and thinking, reflective individuals in those situations. As Lomas reports there is a need to stop at an agreed key point in the patient pathway and ask the critical - checklist - questions. In team work this co-ordinated acknowledgement to complexity is essential for comprehensive, consistent and safe care.

What is interesting here is the emphasis on human factors. While checklists undoubtedly have a demonstrated - proven - role to play in safety, situational awareness is not a product of checklists alone. There is a need for learning and for the cultivation of cognitive lists. While human memory is fallibility incarnate - hence the role for checklists - there is also the need for skilled, knowledgeable professionals with the required communication and observational skills. The need for nurses to further develop observational skills has also been highlighted over recent months.

So as checklists are checked and logged: prepare a space for the mental checklist that is Hodges' model. The model is situated, person-centered and one of the original purposes was to help bridge the theory - practice gap. Try doing that with a checklist: alone

Clare Lomas, Safety checklists could cut 'human error' in clinical practice, Nursing Times, 106, 3, 26 January 2010, p.2.

Nursing management consultants & being optically challenged

Being somewhat optically challenged at present (need new glasses!) I have nonetheless managed to sort some old papers. I came across a more recent news item from the Nursing Times 8 September, p.3 by Sally Gainsbury. What use is late news?

I raise this now because public sector health finance provides the impetus, so this subject is perpetual motion. It is also reported ongoing by HSJ. I refer to this not to take sides, but to acknowledge that politically there is a need to make decisions and find the required £20bn efficiency savings. The news line reads:

DH told 1,500 district nurses could go with no damage to patient care

The item focuses on a report for the DoH produced by McKinsey management consultants. The government has distanced itself from the reports recommendations, but the need for action remains. The Nursing Times news item includes two clocks (with the total nursing time available depicted as 1 hour) that break down the time spent on patients on general medical wards and community wards. While this is just one aspect of a report of more than 100 pages, the findings are of great interest. ...

GENERAL WARD: 15 mins Physical care; 10 mins Psychosocial care; 35 mins non-patient care.
COMMUNITY NURSES: 17 mins Antenatal activities; 13 mins Postnatal; 27 mins npc; 3 mins other and classes.
I have not worked on a general or mental health ward for a long time, but I was surprised to see the time spent on patient being less on the wards than the community - 25 minutes v. 30 minutes. There are challenges in comparing different clinical areas, but I would have thought travel, administration - including paper and e-record data entry would impinge much more on community. On mental health wards there has been an effort to free nurses to nurse - with protected time? So pause for thought there - but only for a moment....

Thinking about community - providers will no doubt vary in the way (district) nursing teams are organized, the location of their bases and how that impacts average journey times. Districts also vary in the way the population is distributed, especially those neighbourhoods were social and economic deprivation is higher and need may be increased.

This is why access to GIS (geographical information systems) by team managers and members is crucial and should not just be some esoteric academic and intelligence artifact. While we should not under estimate the potential use of GIS to inform inpatient care, it is community services that are best placed to benefit from improved intelligence, planning and decisions.

There is a long thread here and the politicians of all parties know it leads into the forest ....

For example, much can be read in a single word "... McKinsey found that only 15 minutes was on the "physical care" of patients while the remaining 10 minutes went on "psychosocial" care, such as talking to patients." I hope that 'only' does not suggest that talking to patients is 2nd best, even though basic nursing care is the factor in the news regarding public perception of the quality of nursing care. This is a constant problem as we move to outcomes. Are we going to have patients saying - "The physical care was excellent, but I felt like I was in a religious retreat. Nobody hardly spoke, explained anything." Patient education, self care, staying well, the effective use of medication and treatment ... is predicated on psychosocial engagement.

What is also very troubling is that cost savings might mean detrimental changes in the skill-mix; the ratio of qualified to health care assistant staff. Some of the best 'natural' nurses I have worked with and work with today are dedicated HCAs. They have a major role and contribution to make, but if safety gains are to be maintained and improved upon then 'safe' skill-mix is critical.

Given the present demographic, 'nurses' are not new to cuts. In the public sector cuts are part of that perpetual motion I mentioned at the start. What frustrates is working on the holistic care mosaic to produce something that is safe, effective, quality care; then as we come to finally add the threads - clinical supervision, PDP, health IT, outcome measures, public engagement we have to unravel and start again.

Image source used with permission and thanks: D L Ennis. Visual Thoughts http://dlennis.wordpress.com/

W2tQ and the Nursing Times Awards 2009

Welcome to the QUAD has entered the Nursing Times Awards -

As they say - nothing ventured....

A big thank you to all W2tQ visitors over the past three years.

Nursing Times: Safety ytefaS :semiT gnisruN

This weeks Nursing Times includes an article by Liz Owen 'Improving compliance with the C. difficile root cause analysis tool' (2009). The piece includes a section that highlights* the importance of reflection, which together with action planning underpins the concept of root cause analysis (p.16).

There are three references in particular cited: Murphy (2002) in relation to the infection and prevention team giving leadership to staff committed to reducing health care associated infections (HCAI) rather than accepting sole responsibility for HCAI. This also entails capturing the 'hearts and minds' of staff (Shapiro, 2003) completing the root cause analysis tool (p.16). Amongst many interesting points - it was found that there were unexpected benefits too (Glanfield, 2003) notably - strengthened relationships and improved attitudes.

This reminds me of affordances in human-machine interfaces and the use of technology more generally. As Owen and others show whatever we call these unexpected outcomes they are by definition unexpected, or not readily accessible to our initial perception and reasoning. Owen found that clinical engagement and leadership proved central in this project. Is there a way to foresee more of the 'unexpected' whether barriers or benefits?

Before being able to engage with others we need to be aware and able to -

reflect on our own hearts and minds.

A coherent team with the inevitable chaotic-creative outliers that (just 1 or 2....) personalities bring might just help us see around the corners - an additional key asset to safety...

Murphy, D.M. (2002) From expert data collectors to interventionists: Changing the focus for infection control. American Journal of Infection Control; 30: 120-132.
Shapiro, A. (2003) Creating Contagious Commitment. Hillsborough, NC: Strategy Perspective.
Glanfield, P. (2003) Towards sustainable change and improvement. In: Pickering, S.P. (ed) Clinical Governance and Best Value. London: Churchill Livingstone.
Owen, L. (2009) Improving compliance with the C. difficile root cause analysis tool. Nursing Times; 105: 16, early online publication.
*even if that is just a subtitle?

Nursing Times and mind mapping: All my slides are packed, I'm ready to go...

This Saturday I leave for the Society for Philosophy and Technology Conference in Charleston, SC. Still awaiting news regards funding with £200 gratefully received thus far.

I'm really looking forward to this, not just being able to contribute, but listening to the other presentations. Must admit that after the weather here in the UK, warmer climes will be most welcome.

The past week's Nursing Times included a feature on mind mapping in research. I haven't checked the full paper, but in NT noticed two references to Buzan (1997 and 2003).

I'm keen to differentiate h2cm from mind mapping, even though of course there are a lot of similarities.

I wonder if Hodges' model gets a mention in the full paper? If not then of course other people realise h2cm isn't about mind mapping!

The reason why I ask (beyond the obvious) is that for many people models of nursing are old-hat. When were they really in fashion? The 80s...

When did Buzan's mind mapping arrive? I think 'Use your Head' aired on TV in the 70s, early 80s...? My Library thing includes books written by Buzan in the 80s and one or two from the 70s.

Maybe it really is time to move on?

So looking forward to the (relaunch of) semantic web Community too!