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Bringing craft knowledge to the surface

Anne Marie Rafferty, CBE, FRCN, is professor of nursing policy and former dean of the Florence Nightingale faculty of nursing and midwifery at King’s College London, U.K.

As one of the keynote speakers at CNA’s biennial convention, she will share her views on emerging health-care trends and what must happen for nurses to get ahead of the care curve. Canadian Nurse asked her to provide a glimpse into her presentation.

Apr 02, 2018
Anne Marie Rafferty
Phil Weedon

You’ve said nurses have a key role to play in responding to health-care trends such as managing chronic diseases, the aging population, multimorbidities and shifts in technology. How prepared are nurses?
The trends point to increasing demand for the skills and capabilities that are the DNA signature of nurses: communication, coordination and managing complexity. Interpersonal skills — high-level cognitive and team-working skills — are what employers want across the board, and these are at a premium in the 21st century across the world of work.

This is good news for nurses, who excel in these areas, and it means we already hold an evolutionary advantage in the ecosystem of health care. But at the same time, demand is intensifying from patients with multimorbidities (both mental and physical), which is creating hot spots that challenge the resilience and capacity of our health systems to respond effectively. As nurses we need to be better prepared for the higher level cognitive and organizational decision-making that this complexity demands. We shall need to “tech-up” with decision-making tools, use support from artificial intelligence in digital health and combine e-solutions with hands-on care. Doing these things, which requires an investment in education, will position nurses as digital leaders. We need to ensure we are at the forefront of designing such tools and not just engaged in their delivery.

You have strongly supported having a well-educated nursing workforce in your country. In what ways can such a workforce help manage the trends?
Education is the best insurance policy against uncertainty and for building a robust skills base and resilience for the future. Evidence from our 2014 retrospective observational study, “Nurse Staffing and Education and Hospital Mortality in Nine European Countries,” demonstrates consistently better outcomes when nurses are educated to the baseline of a bachelor’s degree. This work was something of a breakthrough, since previous evidence had been drawn from the U.S. and provoked the criticism that different contexts could challenge the applicability of those findings to other jurisdictions. Our study invalidated this criticism by demonstrating that, regardless of how health-care systems were funded or organized, better educated nurses delivered better outcomes for patients.

Given the fast-paced, even frantic, world of health care, we need to intensify investment in higher order skills and education, not dilute them by dumbing down education. This means investing in high-quality content knowledge, creative modes of delivery and in savoir faire, craft knowledge and how to get things done. We also need ways to continually learn in clinical and social microsystems, which can translate into better outcomes for patients. First-order problem-solving skills and creativity need to be built into the learning process. But to succeed in this, nurses need to be part of a culture and infrastructure that supports such learning. I think we are accomplished at building the base, but less so at the upper storeys and cognitive levels or in providing the space to learn and consolidate learning in the workplace.

In Canada, governments, health-care leaders and the public are calling for greater use of interprofessional teams. What has been your experience of such teams in the U.K.?
In the U.K. we have been embedding interprofessional education in our curricula across the health disciplines at the undergraduate level for decades, but the challenges of coordinating curricula across different professional groups are tremendous. My sense is that this is not where the focus needs to be; instead, it needs to be carried over into the workplace where most professionals are working together and in teams. Creating a pull-through into the post-qualification level is vital. In the U.K. there is so much churn in the system that the sense of “team-ness” can be fragile, partly because doctors are no longer attached to particular specialists and nurses are moved around wards. There is no patterning in rotas or shifts across professions. Teams today need to learn to work with transience and fragmentation and to free-form quickly and make decisions under those conditions — hence, the emphasis on acquiring interpersonal, high-level cognitive and interdisciplinary 21st century skills.

How would you rate the collaboration between nurses with degrees and nurses with diplomas in the U.K.?
I’m not sure we have much sense or evidence of the success of intra-professional collaboration across the different segments of the professions, but I think it depends on how well led the teams are. Good teamwork relies upon strong leadership. I think a lot depends on that and, frankly, environments are so pressurized and tough that having many people on your side — watching your back and covering for your blind spots — is something most colleagues would value more than the label they bear.

What strategies would you recommend to help Canada’s nurses advocate for better health policies?
In terms of how collaboration can affect advocacy, I would take a leaf out of Obama’s playbook and say, “Yes We Can.” We can draw on our collective strengths and commonalities and use that as the launch pad for lobbying and advocacy at every level.

I think sometimes nurses see a gulf between what they do in their day job and what influencing at the political and policy level means. I don’t see a gulf; rather, I see synergy between them.

The theme of the CNA convention — From Insights to Impact: It Starts with Nursing — speaks to nurses by recognizing the insights generated through their everyday practice. The trick is to harvest and harness these insights by converting them into gold in terms of their impact for patients — which means moving from what to how.

As with innovation, this does not happen by magic. It needs a process to make it happen — to organize and mobilize it. Doing so relies on a social process, but time, space and strategies are also needed to move knowledge and people forward — in other words, an infrastructure and investment to pull it off. Handovers and huddles provide positive meeting points for knowledge exchange and learning. But as quality improvement studies show, while we are great at identifying areas for improvement and even implementing solutions, the learning component is often the weakest link. So we need to map and engineer these processes consciously into our practice.

What would that look like?
It does not mean adding yet another item onto the to-do list; rather, it means bringing the knowledge to the surface — the craft knowledge we already have stocked and squirrelled away — and then using that to pan for gold.

Part of that gold consists in the stories we tell and exchange in clinical practice. Storytelling is how we make sense of the world. Nurses are often powerful storytellers, even though they may not realize it. Storytelling is also a skill that can be learned and taught, and it’s important that nurses learn how to tell a good story. Along with synthesizing evidence, it is a powerful tool for turning insight into something with a policy impact. Perhaps CNA could create a mechanism to help nurses craft the case for policy change. After all, politicians and policy-makers are human, too, and respond as we do to the human drama in stories from our practice on the front line.

But how much more powerful it would be if all nurses were to tell the same story. Joining with colleagues and building a united front and coalition of support by reaching out to patients, doctors, NGOs and civil society would strengthen the voice and turn up the volume in communicating with policy-makers. Building a shared platform for advocacy would bring not only strength in numbers but a spectrum of positions from which to engage with policy-makers. As I’ve said, policy-makers are human, and we can use our very human skills and talents to connect with them and empathize with their point of view. Empathy is one of our greatest assets, and we must use it strategically to advocate for better health policies and outcomes for patients.