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Innovation in nursing practice: a means to tackling the global challenges facing nurses, midwives and nurse leaders and managers in the future

2011; Wiley; Volume: 19; Issue: 2 Linguagem: Inglês

10.1111/j.1365-2834.2011.01241.x

1365-2834

Robert McSherry, Mary Douglas,

Global Health and Surgery

Generally ‘Innovation’ is defined as a new method and/or practice device. ‘Practice’ is regarded as ‘a practising; habit or custom, repeated action for gaining skill, the resulting condition of being skilled, knowledge put into action and the exercise of a profession’ (Collins 1986). Collectively we would define the term Innovation in Practice (IiP) as the encouragement of professionals to utilize their acquired knowledge and skills to creatively generate and develop new ways of working, drawing on technologies, systems, theories and associated partners/stakeholders to further enhance and evaluate practice. Innovation in practice is imperative in order to improve patient safety and quality care; IiP does not and will not occur in isolation requiring investment, support and resource allocation from managers, leaders and governments. Boyd (2011) a recognized authority on IiP makes claims to ‘leaders and managers to see innovation not as a gift, but a skill that everyone in the organization can master’. Boyd (2011a) further argues that IiP also requires Innovation in Management which is founded on three primary principles. ‘Creating innovative competencies, allocating resources to innovative projects, and managing an innovative pipeline from idea to market launch’ (Boyd 2011). The National Health Service (NHS) ‘Institute for Innovation and Improvement’ (2011) state innovation is about doing things differently or doing different things to achieve large gains in performance. It is a myth that most innovations come from laboratories, policy makers or senior leaders. Most innovations, whether in the public sector or the private sector, come from staff working within those organisations. Similarly the NHS ‘National Innovation Centre’ (2011)‘works nationally and internationally with innovators in industry, academia and the NHS to speed the development and diffusion of healthcare technology innovations’. Taking both the NHS Institute for Innovation and the Improvement and National Innovation Centre (2011) overviews of innovation into account, it is evident that as suggested by Gibson and Kelly (2010)‘innovation is about change and organizations and individuals tend to resist change’. Furthermore is it realistic and indeed optimistic to expect nurses and midwives working at the frontline to innovate and change practice, given the enormous challenges they face in the future? Without nurses and midwives, health and social care would come to a standstill because ‘nurses and midwives are fundamental to high-quality healthcare. There is hardly an intervention, treatment or healthcare programme in which we do not play a significant part’ (Department of Health (DoH) 2010a). A truly global, indisputable acknowledgement and testimony of the facts that nurses and midwives ‘play a key role in determining the quality of health and social care and enabling people to make choices, and in public heath, health promotion, and illness prevention – crucial elements of future health care – but they cannot build this capital unaided’ (DoH 2010b P32). Despite the recognition of the fact that nursing and midwifery is a highly complex, demanding profession requiring knowledgeable, skilled and critical thinkers and doers coupled with huge amounts of dedication, commitment and hard work (Brechin 2000). However, regardless of this recognition, there is a growing perception reported in the news and media (Telegraph, Smith, 2010, The Guardian, Boseley, 2009, Nursing Times 2009), that the quality of nursing is diminishing and that nurses and midwives sometimes don’t care or are lacking in compassion to care (Firth-Cozen & Cornwell 2009). This unsatisfactory image and growing public perception is surely a misconception originating from a small minority that cannot and should not be allowed to affect the majority of nurses and midwives who deliver safe, confident, competent and compassionate quality care. In trying to eradicate the misperceptions above, nurses and midwives need to be also mindful of the fact, that globally the future of nursing will be challenged by major economic crisis, climatic disasters, changes in healthcare politics/policies and societal factors where rationing, spending reviews, efficiency savings and resource allocation are the thing of the future and not the past. Nurses, midwives and nurse leaders and managers like other public sector workers and professions will need to ensure the professionals are developed and sustained. Sustainability at the frontline of care delivery will only occur by educating and training nurses and midwives to unlock the potential associated with IiP. Liberating nurses and midwives to embrace innovation will undoubtedly be difficult because ‘providing high quality care for patients will always be a key priority for nurses; but so often doing the “day job” can become all consuming, we can lose sight of the fact that part of the job is to identify and deliver improvements’ (NHS Institute for Innovation and Improvement 2010). Liberating nursing and nurses/midwives to innovate and enhance practice through transformation and change will not and does not occur in isolation. Successful and sustained innovation and change(s) in practice as suggested by McSherry and Warr (2008, 2010), Bettencourt (2010) and Gibson and Kelly (2010) requires organizations like the NHS and individuals working within to create the following: an organizational culture and working environment founded on ensuring a sound vision, strategy, goals and insightfulness of people to generate and evaluate ideas, make links and network with external partner companies/stakeholders in developing robust structures and systems for sharing and communication of information. Boyd (2011) like McSherry and Warr (2008, 2010) indicates that excellence in practice and innovation requires ‘leadership teams [that] must take the responsibility for training and development, recruitment, and reward systems that elevate the innovation’. For nurses and midwives to become sound innovators and entrepreneurs in the future (The Nursing and Midwifery Council (NMC) (2008)‘ The Code: Standards of conduct, performance and ethics for nurses and midwives, NMC, London) their education and associated roles and responsibilities must be aligned to contracts of employment and job descriptions which, reflect and support them in leading innovation in practice. Professional bodies responsible for reviewing and commissioning nursing roles of the future should also ensure clarity concerning career pathways, educational requirements along with incorporating where and how innovation and enterprise will be recognized and rewarded. However whilst acknowledging that innovation in practice is complex, challenging and rewarding, successful and sustained innovation as argued by Gibson and Kelly (2010) regardless of the size, requires support and resources. ‘Every successful organization began as a nimble, innovative start up with the ability to grow-correct and quickly adapt to the needs of its customers’ (Gibson & Kelly 2010). The provision of quality nursing care across the world started the journey in this way. Today nursing and midwifery and associated providers of services by the nursing profession play a vital and pivotal role in the development, delivery and sustainability of huge, varying and dynamic healthcare markets and systems across the globe. To innovate and change within these organizations requires support and the utilising of the various toolkits or frameworks to aid the process and evaluate the impact of change. Innovation requires vision, structure, strategy and engagement with associated partners and stakeholders to evaluate the impact of care and services in order to improve care and services. ‘The introduction by the United Kingdom government into the NHS of the “NHS Quality, Innovation, Productivity and Prevention” (QIPP) framework’ (DoH 2010c) is designed ‘to support innovation in our clinical practice and develop pathways that improve effectiveness and enhance the patient experience as well as providing value for money’. The challenge for nurses, midwives and nurse leaders and managers is in using the QIPP framework to support quality and governance initiatives’ in the future. Encouraging nurses and midwives to innovate, share and disseminate the findings will be imperative in the drive to improving the imagery of nursing, the quality of nursing and in maintaining patient safety along with achieving efficiency and effective savings. Within this edition of the Journal of Nursing Management the importance of innovation in nursing practice is welcomed and brought to the fore along with devising strategies and frameworks for establishing and or evaluating the impact of change. Jones and Griffiths' ‘Back to the floor Friday (BtfF): an evaluation of a leadership initiative to improve patient care’ highlights the importance of senior nurse leaders and managers keeping in touch with the reality of day to day practice. Jones participatory action research study offers insightful ways of how nurse managers and leaders may encourage and support innovation in practice by engaging with nurses and midwives working on the frontline. Locke et al. in evaluating the impact of introducing administrative assistants to support the workload of ward managers, focuses on the issue of innovation and increasing effectiveness. Findings from this study make interesting reading and provide evidence of how workload redistribution can support increased quality of care by enabling ward managers to spend less time on administrative tasks thus having increased time to spend with patients and leading staff. The next four papers address care pathways and processes, and their value and contribution in supporting innovation and effectiveness in clinical practice. The phenomenological study by Dee and Endacott conducted in a hospice inpatient unit, provides us with a timely reminder of how care pathways although created to ensure minimum standards of care need to be understood and implemented with a clear understanding of the patients journey and safeguards that the care given is appropriate. The study identifies the essential need to ensure that staff using the care pathways receive the appropriate communication skills training and that there is an opportunity for nurse managers to take the lead in educating staff around the reasons for use of the pathway. In contrast, Rafter and Kelly in describing the initiation of a telemedicine stroke intervention and treatment programme within a community hospital articulates the positive impact on patient care that can be achieved where strong nursing leadership provides clear vision, motivation and a practice framework to introduce an exciting new innovation in practice. Although acknowledging that programme development takes considerable time and is extremely challenging, the resultant improved scope, quality and speed of stroke treatment is a major improvement for patients alongside the enhanced role of the nurse. Stahl and colleagues set out to investigate how nurses and physicians view the transfer of health information in documentation and perceptions of using a nationally standardized electronic health record. They conclude that although overall professionals offer positive perceptions to electronic health records, challenges are inherent in capturing a holistic overview where much additional information concerning psychosocial health and family function is not documented but passed from individual to individual. Globally, there is an increasing use of Process based work-flow models in healthcare. Using a qualitative critical incident technique Kontio et al. identifies relevant process-related, managerial and clinical incidents. This study identifies the importance of decision makers taking such incidents into account when designing information systems and process-information content. A key theme in reviewing contribution to the QIPP agenda is the challenge of introducing innovation in clinical practice and through structure and processes increasing effectiveness to enhance the patient experience. Randle and Clarke investigate perceived factors affecting compliance with infection control guidance and conclude that change was driven by senior managers who intervened and took responsibility for implementation. An important observation in this article is that as a result, infection control nurses themselves reported that they felt that they had more authority as a consequence of these changes and that they too could enforce change. The authors conclude that change achieved as a ‘top-down’ approach can be effective but long term success relies more on engagement, empowerment and a comprehensive approach which addresses barriers to compliance. Another approach to measuring quality of patient care is to view quality from the patients’ perspective. Frojd et al. explore the patients’ perception of quality care by means of a large scale questionnaire survey to 2734 inpatients. In seeking to identify areas in need of quality improvement this study offers insight in to the importance of the role of the nurse manager. As the authors point out, nurse managers could play a more active part in measuring quality of care and in using results from such measures to develop and improve quality. As efficiency savings and the economic crisis affects healthcare the increased use of agency and temporary staff in many settings raises concern regarding the level of risk associated with professional competencies and the need for robust policies and strategies to ensure safe, quality patient care. Hennerby and Joyce report a study on the implementation of a competency assessment tool for registered general nurses working in acute paediatric settings. The study observes that attention to the human factor associated with change is pivotal and that change itself is reliant on the support of middle managers and those at the operational level. Suhonen and Paasivaara in their study of human capital related to project success in health care work units report that three main factors related to project success are management of enthusiastic culture; management of regeneration and management of emotional intelligence. George and Haag-Heitman identify the contribution that nursing peer review can make to quality and safety in healthcare. They conclude that the meaningful use of peer review at all levels of nursing will support quality and safety, thus assure positive outcomes for patients, families and society. Levenstam and Bergbom present the Zebra index, which is a development of the authors’ previously published Zebra Patient classification system, and suggest that the index allows nurse managers to follow changes in nursing care over a period of time and can explain why two similar units with the same number of staff per patient can have a totally different workload situation. Hauck, Griffin and Fitzpatrick use a descriptive correlational study design to explore the relationship between perceptions of structural empowerment and anticipated turnover among critical care nurses. The study shows that an inverse relationship exists between nurses’ perception of their access to opportunity, information, support and resources, and their perception of the possibility of voluntarily terminating their current position. In the final paper in this issue, Parsons and Cornett remind us of the need for sustainability following innovation in practice. ‘Magnet’ recognition is a marker of distinction for many healthcare organizations. However, as Parsons points out, ‘sustainability may require a different looking glass’, and concludes that whereas achieving magnet status is work well done; this is only the first step. The challenge will be to ensure sustainability, maintain excellence standards achieved and further develop practice over time. ‘Those unwilling to change are often left behind’ (Gibson & Kelly 2010) and those willing to change are sometimes often left unrewarded, unrecognized and disheartened because the achievement was not rewarded, recognized and or celebrated. Innovation in Nursing Practice as outlined in this edition of the Journal of Nursing Management is happening and making significant contributions to improving the imagery and quality of nursing care. For some nurse leaders and managers and governments the speed of innovation in nursing practice is not at a fast enough speed to accommodate the enormous global challenges facing nursing’s future. On a positive note nurses and midwives should be commended for the fact that they are engaging with fellow professionals, partners and stakeholder to advance innovation in nursing practice. However nurse leaders and managers need to reflect upon how they are facilitating and enabling this to occur and to offer support and resources to ensure innovation in nursing practice remains viable and sustainable. Frontline nurses and midwives need to continue to explore and unlock the potential of innovation in enhancing quality and demonstrating impact and outcomes of care and intervention as the future is dependent on their ideas, creativity and willingness to engage with change. Finally the editors would like to personally thank and acknowledge all the contributors, fellow professionals, stakeholders and partners for demonstrating that Innovation in Nursing Practice is happening. We would strongly recommend nurse leaders and managers to continue the Innovation in Nursing Practice journey by offering support and resources in the future. Innovation in Nursing Practice does not and will not happen in isolation.