CNIO Handbook

CHAPTER 1
CHAPTER 2
CHAPTER 3
CHAPTER 4
CHAPTER 5
CHAPTER 6
Sarah Hanbridge, CCIO, The Christie NHS Foundation Trust and Chair, CNIO Network

The value of nursing digital leadership

It's about two and a half years since I become a chief clinical information officer, meaning I very formally became the leader of digital nursing in a trust. But when I think about it, I've always been a champion of nurses leading digital change - I just didn't realise it.

I have always sought opportunities to improve the quality of care and, right at the start of my career, I saw that digitisation could be an important way of doing this. In the late 1990s, as a junior staff nurse, I was lucky enough to work in an organisation that was very forward thinking and which implemented an electronic patient record. I immediately saw how the quality of our nursing documentation improved after the transition from handwritten notes. I became convinced of the value of digital to nursing.

I also saw how important it was to empower nurses, midwives and allied health professionals to own digital change. I saw that only by providing colleagues with the required training and skills will digital solutions be fully incorporated into nursing practice.

The importance of digital tools

Fast forward to 2020, and I could never have predicted how important digital tools would have become to the provision of effective nursing care. During the pandemic, as it has become harder to deliver care face-to-face, remote monitoring has become even more important.

The pandemic has truly tested the nursing profession. But it has also helped us understand more than ever how digital can help us to do our jobs well and look after our patients to the best of our abilities.

Pre-Covid we had all lived and breathed the challenges of digitalisation. Then in a world of uncertainty during extremely difficult times, even previously sceptical nurses, midwives, allied health professionals and other clinicians turned towards digital solutions to ensure patients continued to receive health and social care.

Strong nursing leadership helped make this possible. I think it's fair to say that nurses are renowned problem solvers who bring solutions to the table. That's part of why I wanted to become a chief clinical information officer. I wanted to help bring the innovative thinking of nurses to the forefront and make sure it was central to new ways of working.

I see that as a big part of why nursing digital leadership is so valuable. It brings attention to the voices of frontline nurses, who are key to successfully introducing and implementing new healthcare models. That includes new digital models.

Listening and sharing

In my experience, transformation only happens by listening to people to understand what does and does not work. CNIOs do that listening work, and then make sure those views are taken into account when digital solutions are designed and implemented. We work collaboratively with other clinicians and with IT teams and developers to make sure solutions are safe, efficient and help support improvements in the quality of patient care.

Typically, the CNIO role doesn't come with the autonomy to make decisions single-handedly. Instead it's about influencing, about making relationships, about telling a convincing and persuasive story about what is required by frontline nurses.

Then, when a new solution is introduced, we make sure our colleagues have the training and support they need to use it to its full capacity.

I really believe that all the digital projects I've been involved in show the importance of that kind of leadership and input. One that springs to mind is a project I worked on at Salford Royal NHS Foundation Trust. I was a senior nurse programme manager for the Digital Control Centre - a programme using digital means to help more efficiently manage patients, staff and equipment.

Much of the Digital Control Centre work was about redesigning operational processes. But the only way that could work was if there was clinical engagement, and that's where I came in. I could liaise with staff to understand exactly what would work best.

We did a lot of pilots as part of the overall programme. I remember working with staff on some inpatient medical wards to explore the introduction of a task management process. The idea was to help advance understanding of capacity and demand, and support clinical safety.

Through those conversations with clinical staff we realised what the gaps were, what the bottlenecks were. And we gained a vision of what future iterations of the solution might look like. That's the invaluable contribution that can be made by CNIOs and other clinical IT leaders.

"Don't tell me about the software system"

During that programme, I started using a phrase I now utter all the time. "Don't tell me about the software system," I'd say. "Tell me about the people and the processes." That's what I'm interested in, and where I think I and other CNIOs can add value.

It's why I feel that it's important to keep building the numbers of CNIOs. But in the NHS the role of chief clinical information officer is still a relatively new one - let alone that of a chief nursing information officer. That means the idea of becoming a digital nurse leader can be daunting. You might know you want to ultimately become a CNIO but have no idea how to get there. Or you might have been appointed a CNIO and be seeking some support.

That's the whole purpose of the CNIO Network. It provides a buddying approach to mentorship and coaching for existing CNIOs while supporting the professional development of aspiring CNIOs. One of its major aims is to promote best practice, learning and collaboration.

That's also the purpose of this Handbook. It brings together personal stories and learning from nursing digital leaders, sharing experience and expertise which will be useful to others interested in the field. You'll find it helpful whether you're new to a chief nursing information officer or allied health professional IT role, or whether you're considering progressing into such a role.

We also aim to further increase the profile and recognition of the CNIO role. Because as digital becomes more and more important to healthcare, so does strong nursing leadership in this area.

About the author: Sarah Hanbridge is chief clinical information officer of The Christie NHS Foundation Trust and chair of the CNIO Network, a role to which she was elected in July 2021. She has been a nurse for 26 years, involved in digital nursing nursing for much of that time, and took up her first formal digital nursing post in 2017.

CHAPTER 2

Jo Dickson, Chief Nurse, NHS Digital

Introducing the CNIO Role

The chief nursing information officer role is usually broad but, at its heart, it is about bridging the gap between technology and clinical practice. CNIOs should have a seat at the table when the clinical technology strategy is being set, and then through the procurement, planning and implementation stage of any new system. As CNIOs, we ensure the focus is on using technology to improve outcomes for patients and citizens.

What's it like starting out in a CNIO role?

If you're starting out in a CNIO role, you may be replacing an existing postholder or it may be an entirely new post for the organisation. You may also be a lone digital nurse, or you may be part of a team. It may be your first senior nursing role, which you've gained through previous digital experience, or you may already be a senior nurse and new to digital. These experiences are all slightly different.

When you're the first

Being the first CNIO for an organisation can feel like a daunting prospect. It's important to remember the positive aspects: that you have a fabulous opportunity to develop the role and to bring others along with you.

You will be able to set the agenda and direction, but it's likely others will try and point you towards meeting existing agendas. Instead, give yourself some time to decide what you want the priorities to be - and agree with your senior colleagues that this is the approach you'll be taking. You will have a more positive impact in the longer term, as well as getting personal satisfaction and a feeling that you are personally developing too.

If you're going solo

If you're the only digital clinical leader in your organisation, then the job can feel like a lonely one and really quite different to what most of us are used to as nurses.

The key thing to do in this situation is to form networks. In your own organisation, it's helpful to connect to other senior nurses. A good way to do this is by joining existing nursing collaboration groups (these will have different formats in different organisations). Although these colleagues will have different specialisms and interests, they too will have a focus on nursing strategy and workforce development.

If you are not directly reporting to your chief nurse/director of nursing, make sure that you meet with him or her in the early weeks in post and continue updating on progress. The digital nursing agenda should now be a key part of every chief nurse/director of nursing's portfolio, and he or she will be relying on you to help drive it forward.

Outside your organisation, there are plenty of opportunities to connect with fellow digital nurses. This includes via the Digital Health CNIO Network and via regional and sector-specific groups. There are also the likes of the Faculty of Clinical Informatics' nursing professional interest group, the BCS (Chartered Institute for IT) nursing specialist group, and the Royal College of Nursing eHealth forum.

If you're joining a pre-existing team

If you are lucky enough to be joining an existing team, this is likely to be multi-professional. That means it's important to link with clinical and non-clinical colleagues to determine who will lead on which aspects of the digital strategy. You don't want to step on each other's toes, but it's really important to make sure that all the clinical professions feel that their views are being heard. That means you may also be the identified lead for allied health professionals or other professional groups.

Who leads on what is likely to be based on individual interests and experience, but together the team will need to have input on areas such as research, clinical governance, digital clinical safety and patient/citizen involvement.

An important first step is to understand what has already been done - ask your colleagues to run you through progress over the past couple of years. Focus on what has gone well, but don't forget to ask about the lessons learned so that you can make improvements in future. Quality improvement is a key aspect of the CNIO role, and it needs to start early and continue always. You will then be able to gain a clear idea of what needs to be done in future, and will increase your understanding around stakeholder relationships (including with system suppliers), transformation and change activity within digital and across the wider organisation, and how involved your nursing colleagues already are in the digital agenda.

Be careful with how much you take on

It's hard to say no to things when you are new in post, but it's important not to take on too much - the danger is you won't be able to deliver, and that's really demoralising.

Be especially cautious of taking on work which could or should be done by others. Although it's tempting to 'fix' problems (especially for most nurses), you will get overloaded. The digital nursing agenda will be your key one, but it's important to recognise that you will also want to get involved in things which improve your knowledge and/or pique your interest. It is important to leave time to be able to do those things too, and if you've taken on too much work you won't have time to do so.

Remember there's no one best way to be a CNIO

As you start out as a CNIO, remember there is not one best way to do the role. It will depend on your own background and how much leadership or digital experience you already have.

Remember too that while some of the digital aspects of what you are doing might be new for you, you have lots of existing and transferable skills from your previous experience - and that's true whatever previous experience you have.

If you are coming into the role as an existing senior nurse with limited digital knowledge, make friends with colleagues in the IT/digital team. They will be keen to share their knowledge and experience with you, and it's a really good way to learn the 'language' of digital healthcare.

If this is your first post at this level but you have previous digital experience, then the relationships you will likely need to work on are those with other senior nurses and clinicians. This can feel difficult if you haven't done it before, but also because you are likely to be the one who has most digital knowledge. You'll need to be prepared to teach, and to encourage others' understanding and interest in digital, while developing these key peer relationships.

What skills do I need to flourish as a CNIO?

There are a number of key skills that I think you will need to succeed as a CNIO. Some you’ll have already, but all you’ll need to work on and develop.

  • Teamwork. You need to work as part of the team, to collaborate with and motivate others.

  • An authentic, credible style and a passion for improving clinical outcomes by using technology. This will often get you moving forwards even when times are most tough. It's important to have resilience and tenacity, as well as a pragmatic but can-do attitude.

  • A knowledge of your own limits. You need to know the boundaries of your own abilities, and to be able to ask for help.

  • An ability to make decisions. You'll need to be able to understand the issues facing colleagues and patients and be able to determine the best actions (sometimes without all the facts you would like).

  • Leadership. You need to be a good leader of others. Supporting and developing your colleagues is such an important part of the job of the CNIO. Some of my proudest moments as a CNIO have been seeing others develop into CNIOs (and other clinical leaders) themselves.

Don't forget development

The CNIO community is a vibrant and very giving one; in my experience, people will be generous with their time to support you and teach you. The benefit for them is that they will also learn from you.

There are digital nurses in all kinds of roles and across sectors, so make your networks big; include non-nurses and don’t be afraid to link up with digital clinicians working in different sectors, including in industry and outside the NHS.

Know you're part of a team that is continuing to grow

I was one of the first CNIOs in the UK and am very proud of that fact. What I'm more proud of though is that we have grown in number over the last 10 years and that we will continue to grow as a community of CNIOs and digital nurses. I'm proud too that we are now being recognised as an integral part of any healthcare team which is aiming to transform care through the use of technology. Good luck and keep in touch!

About the author: Jo Dickson is chief nurse at NHS Digital. She had a varied clinical background before moving into technology roles, and was previously chief nursing information officer at Leeds Teaching Hospitals NHS Trust and clinical informatics director at Nuffield Health. Jo is a past chair of the CNIO Network and a founding fellow of the Faculty of Clinical Informatics.

CHAPTER 3

Sarah Newcombe, CNIO, Great Ormond Street Hospital for Children NHS Foundation Trust

Back in 2015, Great Ormond Street Hospital for Children NHS Foundation Trust - a small but mighty specialist paediatrics trust - set a vision for its digital future. We were to introduce an electronic patient record (EPR): "An integrated system to be used by all staff, in all settings that will allow patients access in every interaction and hold the entire patient record."

I'd worked at the trust since 1997 and, when this announcement was made, I was working operationally but also on a project to introduce electronic observations to the organisation. That led me to being approached to join the procurement team for the EPR, and into months of Excel spreadsheets, understanding system build, system testing, site visits and networking.

When implementation of the system began, it soon became clear a chief nursing information officer was going to be important to success. I was appointed to the role in January 2018, during the groundwork phase of implementation - the go live date was set for just over a year later. I remember feeling excited about the challenge ahead but petrified of how I would lead the nursing workforce through this transformational change in such a short timeframe.

Three core values

In working on the implementation, I always had three core values in mind. The first was patient welfare: we needed to make sure that the introduction of an EPR didn't interfere with the safety of our care and, indeed, that it helped staff deliver the best possible care to our patients. The second was operational improvement. We needed to make sure that the EPR helped us deliver care more efficiently. The final was staff engagement, which as CNIO was and is a key part of my role.

I knew that clinical engagement was key to a successful implementation. Clinicians would be the ultimate users of the system and so they needed to be part of the journey, helping us build efficient workflows. The design of the system had to be intuitive to staff, to reduce not increase burden.

There are a few key steps I took which made the task of implementation feel more manageable, and which I'd recommend to any nursing colleague supporting a similar project.

  • Create a team: Creating a team of nursing informaticians was the single best thing I did. Members had diverse backgrounds, skills and experience. That meant we were able to build an EPR that was tailored to the range of people in the organisation and the range of work they do: the different pathways and workflows, and also different levels of expertise in digital systems. We appointed a huge number of subject matter experts, who advised us on how the specific workflows in which they and their colleagues were involved should be reflected in the EPR. This has been important in making the most of clinical decision support functionality within the system. We've ensured the EPR supports clinicians in applying best practice in specific areas of care, but also that it allows diversion from that when clinical judgement requires. It means we avoid clinicians becoming fatigued by alerts about deviations from best practice that are in fact entirely justified.

  • Learn from others: I spent time making friends with both national and international colleagues who had travelled the journey before. These relationships definitely played a part in the success not only of the EPR implementation but with my development as a CNIO. The CNIO Network was a particularly important part of building these relationships and sources of support.

  • Take the opportunity to review how care is provided: Before we implemented our EPR, we had several different ways of documenting the same information. I saw the implementation as an opportunity to rethink this, and create new ways to care - introducing an EPR shouldn't just be about digitising existing ways of working. We, for instance, created some functionality we call Essence. This is a means of entering a brief description of what a clinical note is about: it only takes 30 seconds and is up to 156 characters, a bit like a tweet. It means that any clinician looking through a patient's record can quickly understand which clinical notes are relevant to current care - rather than having to open all of them and read through they can judge the most relevant from the summary.

  • Take every opportunity to communicate with clinical colleagues about the implementation: I invited myself along to every clinical meeting that existed across the trust to talk about the journey, where we were to date, and what we needed from the teams. I wanted the EPR to be at the forefront of everyone's minds and for everyone to understand that the system was theirs - to use and to shape. We weren't introducing a system to people, but introducing a system with them.

  • Focus on change management: This project was the single biggest transformation the trust had been through. There are challenges to leading a huge programme of change. The logistics of bringing an entire organisation on this journey, at the same time as staff are facing the normal day-to-day challenges, were far from easy. We appointed change managers to help here. They were trained to support the system design but more importantly the adoption and longer-term optimisation. When working on an EPR project, the go live is of course the main focus but there is so much important work that happens afterwards, once people have actually started using it. Sometimes it's only then that you see how a workflow or patient pathway can be best represented on the EPR. Having operational teams feel they had ownership of the EPR, and could shape it over time, was a key part of our success.

  • Get training right: We familiarised staff with the system by giving them basic sessions on how it worked and tip sheets. We didn't train them to use the system fully, because we knew that you only really learn how to use an electronic patient record when you actually start using it in practice.

The system went live over the 2019 Easter weekend. We went with a big bang launch, so the EPR was live everywhere across the trust. It was one of the highlights of my career - seeing months of work come into fruition in front of your eyes was fantastic.

Running the implementation

It was such a big transformation that, as an organisation, we ran the implementation as though we were confronting a major incident. This enabled staff to bring any issues directly to the implementation team to either be actioned or support given.

As a nursing leadership team we created what we called SWAT teams - small groups of experts who were dispatched to help with some of the more complicated process in the new EPR. Blood administration was an example: when we knew that someone had ordered blood, a SWAT team was dispatched to go and help the staff through the process using the EPR.

With all that said, my advice is to make an EPR go live a celebration. It's one of the few times the whole organisation will come together to support a transformational change. The success of an EPR implementation goes beyond just putting the system in. For some clinical teams, the true value was only seen later, in the form of opportunities to improve services and continually improve the care we deliver. It is at this point that patients, families and staff start to experience the deeper benefits that digital transformation can bring.

"With all that said, my advice is to make an EPR go live a celebration. It's one of the few times the whole organisation will come together to support a transformational change."

Benefits

One big area of benefit is the availability of data. With all information being held in the electronic patient record, and the knowledge that it is robust information, we’ve been able to create clinical dashboards. These give staff an understanding of where things are going well and where they are going less well. This in turn means that we can standardise and improve clinical workflows.

I’m always working to engage my clinical colleagues in making best use of the system, helping encourage a curiosity about it can be used to the maximum possible benefit. Once that seed is planted - and nurtured within individual clinical teams - staff can start to use data to drive change themselves.

It's an example of how EPR-related work doesn't stop with a go live. It's a journey but one that it's a privilege to be on.

About the author: Sarah Newcombe is chief nursing information officer at Great Ormond Street Hospital for Children NHS Foundation Trust. She joined the organisation in 1997 as a staff nurse. In 2012, she became the clinical lead for the implementation of electronic observations at the trust. She has been CNIO since January 2018.

CHAPTER 4

Louise Hicks, CNIO and Director of Development, Barts Health Trust

One of the very first things I ever did in clinical informatics was to build a team of outstanding people.

In 2015, shortly after becoming director of development at Barts Health, an informal steering group of nurses who - like me - wanted to make sure the nursing voice was heard in digital projects was formed.

A few years later, I'd formally add the chief nursing information officer role to my responsibilities. But the importance of teamwork has never changed.

Getting a clinical informatics project off the ground, and then running effectively, can never involve only one person. It needs involvement across all clinical user groups (each of which may have slightly different needs and priorities) as well as across the IT side (both the internal IT staff and those working vendor-side). It needs, in short, teamwork.

Negotiation and trust

For me, that means that personal leadership style is key to success in the CNIO role. I'm very committed to collaboration, participation, and facilitation that enables an understanding of where everyone's coming from. I like to build on the strengths of a team and create a strong user voice, bringing people together through engagement and towards a shared goal. Helping teams to be truly empowered in their digital development and journey is also important to sustained outcomes, growth of talent, and the satisfaction of team members.

That probably sounds like it's straight out of a textbook. But all I'm really saying is that success in the CNIO role is about how you negotiate with people and how you build collaborative trust. It's about making sure that teamwork is inclusive and builds understanding across all domains of the health informatics world. That way, you get the best out of the technical and clinical aspects of people's skills and responsibilities.

I have expertise in, and a strong passion for, the development of outstanding care, nursing practice, the NHS, and organisational development and transformation. I'm not an IT technical expert but the NHS Digital Pioneer Fellowship and further training and development have really helped to expand my skills, critical thinking and system knowledge. The Digital Health CNIO Network, Summer Schools and regional CNIO groups have also been fabulous sources of rich information. So over the years I've developed skills in health informatics and recognise the opportunity to bring together a multi-professional team and enable a shared perspective on the digital solution. It makes a real difference to adoption if the patient and user voice are part of the team and early co-design - bringing in creative ideas and positive momentum and a satisfaction in the work. Really understanding what matters to everyone as part of the programme team is essential. By working and learning together, we get the best possible outcome.

The importance of identity

We have built an excellent clinical informatics team at Barts Health as part of a programme we call "We Connect". Having a brand and team identity has been a positive motivator. The progamme is recognised across our group of hospitals, not just for digital transformation but for an energising approach to teamwork and change implementation methods.

The CNIO role is a lovely combination of clinical insight, health informatics and the ability to enable people to want to come on board. It's about the ability to collaborate to enable often large-scale change and digital transformation, to reduce unwarranted variation and simultaneously achieve positive quality improvement. The core is engaging people at the heart of the development and raising the profile of health informatics, as well as bolstering digital competence and capability among fellow clinicians.

Negotiation skills are important in working with the team and wider workforce. Making sure the changes and developments really reflect excellence in the clinical workflow and are clinically led is crucial. Listening to teams, understanding what they need and then helping them to get it is important. Getting people involved early helps get a good balance between generic and specialist requirements and enables a seamless design. Building a wider team including super-users, digital champions and ambassadors does much to extend knowledge, skills and involvement and they are a fabulous positive energy and resource for wards and services. When people are part of the solution and can share in the improvement it all changes for the good.

That informal steering group created back in 2015 has grown to become a formal nursing informatics infrastructure. We have a nursing informatics officer at each of our four main hospital sites, a deputy and a lead informatics nurse, and then hundreds of super users. I report into the chief nursing officer, meaning informatics is central to nursing at the trust and have a close working relationship with the CIO and CCIO. The collective clinical informatics leadership team has a strong bond and the support has been truly amazing.

Our teams played a huge part in successful implementation of the electronic prescribing and medicines administration (EPMA) project back in 2021 and designed new functions and workflows right through the complexities of covid waves. This has built on our earlier implementation work, enabling digital development in nursing across the whole Barts Health Group. We have EPMA pharmacists and digital midwives, a growing allied health professionals informatics group, and medical clinical informatics leads too. We're all continuously working together with our clinical systems and IT colleagues to enhance outcomes for our patients and our communities.

Build your rope team

During the We Connect nursing programme, I was reminded of a presentation I'd heard several years before. When we were implementing our Cerner EPR, we went as a team over to their headquarters in Kansas for a conference. One of the speakers was Erik Weihenmayer, the first blind person to reach the summit of Mount Everest.

His inspiring presentation introduced us to the idea of a rope team - the people who are with you as you adventure; who will save you from falling. It was an idea that really stuck with us as a nursing informatics team. Any time we implement a new digital project, we're really clear about who is on our  rope team. As we began to implement the EPMA project, I received a postcard from one of the teams involved. It was a picture of climbers on a rope team. There was something really nice about that - about people feeling they were part of a team in which everyone had one another's backs and sharing that same adventure.

Our team has expanded over time and there is a strong core of people who have really developed nursing informatics. We continue to integrate health informatics in everyone's day, helping others to take their careers forward through the likes of fellowships, mentorship, coaching, our What Good Looks Like Strategy, and shared decision-making councils. They are true health informatics ambassadors and signal the very best of nursing and its impact. I am proud to work with such an amazing team of professionals.

Louise Hicks is CNIO and director of development at Barts Health Trust, one of the largest NHS trusts in England, and a visiting professor at City University of London. She became CNIO at Barts in 2019, having initially joined the trust as an improvement and transformation programme director. Louise previously worked in higher education and in clinical practice, of which she has over 40 years' experience.

CHAPTER 5

Dione Rogers, CNIO, Barking, Havering and Redbridge University Hospitals NHS Trust

It's fair to say I've had a varied nursing career. I qualified in 1994 and have held clinical roles and management ones. I started taking an interest in digitally-supported healthcare over 10 years ago when I discovered a love for data and how it can drive improvements for patients and staff.

I moved into my first chief nursing informatics officer post in 2019, when the trust I was working for at the time was procuring an electronic patient record. Since then, I have completed the Florence Nightingale Foundation's Digital Leadership Scholars programme and started an MSc in data analytics and artificial intelligence. I tell you that to prove that as a new or potential CNIO you already have a set of skills to bring to the role - and those you don't have you can learn!

One key area in which you will have pre-existing skills, though ones that may need developing further in the context of the CNIO role, is clinical safety.

Essentially this is risk management, and as clinicians we do this daily. The design of systems, how they are applied into practice and how data can be used to drive clinical safety are all components of the CNIO role. At times there will be a need to say no to an idea that has been deemed safe on a formal risk assessment but which would be a risk if applied to a certain department or patient group.

I experienced this when rolling out a task-based system. The functionality was sound but when it was used by the on-call team it posed a patient risk of duplicate tasks due to not having a scheduling function. It was however suitable for the hospital at night team. The understanding of how areas work and how certain systems impact on those areas is a critical skill to develop.

Top tip: Learning about general risk management is beneficial if this is a gap in your knowledge. (The aviation industry has some great examples – which is always good to hear!)

Digital clinical safety

So how do we define clinical safety in the context of digital? This is covered in the Digital Clinical Safety Strategy, published in September 2021. It is an essential and insightful read and aligns well with the The NHS Patient Safety Strategy.

I particularly like this simple definition:

"Digital clinical safety is about making sure the technologies used in health and care are safe, and then using those technologies to improve patient safety."

Technology is changing patient safety by moving healthcare from a reporting culture to one of prevention. Personalised medicine, predictive medicine, and technology-supported diagnostics are just some of the domains working to prevent negative outcomes.

The relationship between digital innovation and clinical safety is well documented. Improving sepsis detection, alerting to patient deterioration, and improved access to specialist teams are a few I have personally seen improve patient outcomes.

Shared care records help to improve communication between healthcare communities and remote monitoring is helping keep more patients at home during the pandemic.

It is essential to understand technology alone is not responsible for these improvements. People, processes, and organisational culture are all equally important. The role of the CNIO in my opinion is to ensure the systems are fit for purpose, do not increase patient safety risks, and are successfully implemented so as to gain full benefits in practice.

Digitisation however can present some risks. Access to electronic data can lead to concerns about data breeches and confidentially. An essential part of the CNIO role is to support a culture of information safety through training, audit and learning lessons. Another area is data quality: does the information in different systems match up, can we trust it and how do we use this to improve patient outcomes?

Occasionally there need to be workarounds, the concept of deviating from the intended use, that may need a full risk assessment and logging on the risk register. It is important to understand clinical safety to ensure the impact and likelihood of potential harms. Workarounds can also lead to positive outcomes in the form of enhancement requests to the developers.

Top tip: I would recommend setting 30 minutes aside each week to read or learn a new digital skill (so that equates to 21 hours of learning per year). You will soon become an expert and understand the digital language.

Clinical safety standards and clinical safety officers

There are formal clinical safety standards that apply to digital systems. The one that applies to the use of health systems is DCB0160: Clinical Risk Management – its application in the deployment and use of health IT systems. (It is supported by the related standard for the application of clinical risk management in the manufacture of health IT systems, DCB0129.)

Evaluating the use of a system against DCB0160 is the job of the trust's clinical safety officer (CSO). This is a named individual who is responsible for ensuring the safety of a Health IT System in that organisation through the application of clinical risk management.

The individual has to be a suitably qualified and experienced clinician who holds a current registration with a professional body; has to be knowledgeable in risk management; and is responsible for ensuring clinical risk management processes are followed.

Top tip: Arrange to spend some time with a clinical safety officer from your organisation or form elsewhere. It is always good to see the practical application.

To CSO or not to CSO?

So do you need to qualify as a clinical safety officer if you are a CNIO? There is no definitive answer to this currently. The Faculty of Clinical Informatics has produced recommendations for a CCIO which states this should be a desirable qualification.

There is not a CNIO standard at present. Some employers would like to combine the role and others have a separate CSO. I am not currently a qualified CSO – however, becoming one is on my personal development plan. Traditionally organisations have one or two CSOs but there can be more. Some organisations outsource the role to skilled professionals.

Being the CSO as the CNIO has a risk of becoming so time consuming the other elements of the role may be compromised. So it may be best that it is not seen as the duty of the CNIO, but that the skills of a CSO are useful for a CNIO to have.

Top tip: If you're applying for a CNIO role, check whether the CSO aspect is also part of it. If it is, discuss the percentage of the role that will be allocated to safety sign off.

Becoming a CSO

There are currently two parts to becoming a CSO. The first is to complete the eight e-learning modules, which can be accessed for free by anyone with an NHS email address. Once someone has passed these modules, he or she can move onto what is called the foundation course. This involves direct teaching.

Once complete, you are a certified CSO. You also receive 14 continuing professional development (CPD) points.
You can find out more about the training on the course's page on the NHS Digital website.

Top tip: Spaces on the course are limited so agree whether being a CSO is a part of your CNIO role and, if it is, include it in your personal development plan as an essential course. Then apply for funding and book a place in plenty of time. Remember too to book out time to complete the e-learning at a pace you are comfortable with.

About the author: Dione Rogers is chief nursing informatics officer at Kettering General Hospital NHS Foundation Trust (to March 2022) and at Barking, Havering and Redbridge University Hospitals NHS Trust from April 2022. She qualified as a nurse in 1994 and has held clinical roles in stroke, haematology, respiratory, rehabilitation and acute care as well as general, operational and project management roles.

CHAPTER 6

Melanie Robertson, CNIO, South Tyneside and Sunderland NHS Trust

Differing approaches to informatics

The CNIO role is often seen as a link between nurses working clinically and the IT department, but in my case it also involves being a link between two recently merged trusts covering acute and community services.

The previous organisations had taken very different approaches to informatics. One had an electronic health record (EHR) used for all nursing documentation, with care planning having been completed electronically for around 20 years.

The other trust had a 'best of breed' style, using a number of smaller systems for specific tasks. Large parts of the nursing documentation, including care planning, had remained on paper.

The two organisations merged in April 2019, and a decision was made to implement the EHR across the entire trust. That implementation was relatively straightforward and on the whole was well received, but two large groups of nurses coming together to work on common documentation did highlight areas where work was required.

Care planning was the noticeable aspect where refinement was needed. The nurses who were new to electronic care planning spotted imperfections in the use of the system. Those who had used it for many years had often just learnt to work around those imperfections - but in so doing, it meant care planning wasn't always as effective as it could be.

Simplifying documentation

For me, the care plan is the most important aspect of the nursing process. If we don't have a plan our success is purely down to chance. If we don't identify a goal or outcome how do we even know that we have succeeded? How can we compare the outcomes of our care with our peers, whether in the same organisation or beyond? Making sure the same care plans are used consistently helps reduce variation - everyone works to the same goals and the same outcomes, which improves patient care.

To make documentation and care planning work for nurses, and ultimately benefit patients, we need to make assessments and plans as easy to complete as possible. That includes using digital systems. As CNIO, I'm therefore currently undertaking a review of care planning across our trust.

The staff nurses who use the documentation on a regular basis are best placed to say what needs to be improved in the current system and to review and comment on suggested changes. On that basis I set up a project steering group with representatives from both hospital sites and a range of staff roles, including staff nurses in band 5 and 6 roles from a range of medical and surgical specialties, ward managers, matrons and IT.

The three key areas for improvement

The group met to debate experiences of using electronic care plans. It became clear there were three key areas for improvement:

  • How we use the electronic care planning system. Traditionally, we have used our care planning system to record and evaluate whether standards of care - support with hygiene, for instance - has been delivered. That's meant nurses have had much less time to actually use the care plan functionality, and means we've never used the software's ability to evaluate a patient's care against a care plan.
  • The number of plans. We currently have 150 care plans. Some are automatically digitally activated for a patient but, if a nurse needs to add an additional plan, he or she has to search through the full list of plans. You either have to scroll through to try and find the one you need, but the names aren't always as clear as they might be, or search. While nurses who have used the system for a while have got used to these imperfections, those who are new to the system pointed out that this was really challenging.
  • Training. It was felt specific training should be offered to nurses to make sure they were comfortable with how the digital care planning setup worked, as well with the general clinical practice around care planning.

I have also connected with fellow CNIOs and digital nurses to discuss the care planning. Via the Digital Health CNIO Network Discourse, I've understood that this planning is challenging for many nurses, regardless of whether a digital of a paper-based system is used. The issue is often one of time. I can therefore see that while digital working can help, there is also a practice issue - and that, as CNIO, I may need to look beyond the informatics element to truly transform care planning in the trust.

The organisation currently has around 150 separate care plans. Even though these can be completed digitally, there are so many that it is difficult for nurses to select between them and know the right one to use in the right situation. Our steering group has now identified around 30 subjects on which we think we need to focus plans, and we have 'subject experts' working on these.

We have also reviewed a different process for evaluating care plans within our EHR. This will place a greater emphasis on evaluating the care that has been given against the care that has been planned. There is the ability to do this within the care planning software, but we've nor previously used it. My plan is to pilot using it across a couple of wards to see if we might be introduce its use consistently.

What has been really important to my work so far on this project has been having the support and direction from the senior nursing, midwifery and allied health professional team. Around the time the trust merged, I was working as a nurse consultant in an operational role and giving what other time I had to the CNIO role. At that point, the CNIO reported into the IT team.

The benefits

The merger made the CNIO role more important still and so, with agreement, it moved to be part of the trust's corporate senior nursing team reporting directly to the director of nursing. This meant I could support the team in understanding the importance of digital nursing, and the opportunities it provides, but also that I could understand the nursing priorities for the organisation. The team also offers me real support in implementing changes, like those to care planning.

The shared decision making approach with the steering group has also been very important. Feedback of clinical staff as the end users of the technology has led to some excellent and well received improvements in our electronic health record. I remember one particular example when we'd introduced an assessment for patients who were at risk of self-harm or falls and needed one to one nursing care, or to be in a bay where a nurse was always present. The idea was that, on a two-hourly basis, staff would record what support and interactions had been provided.

In conversations with teams, we heard that these assessments were typically completed by healthcare assistants - and clashed with the intentional care rounds they were completing. So we moved the document in the EHR so it sat within the care round checklists. By doing that, we moved from 20-30% completion of the assessment to around 90%.

We are fortunate that our EHR can be adapted to the way in which we work: we don't just have to use a one-size-fits all, off the shelf setup. We can build and edit documents and assessments in a way that we find useful. The shared decision making process will help ensure that any changes we make to the digital care planning process enable nurses to provide good quality, safe care, in an efficient and secure way.

About the author: Melanie Robertson is chief nursing informatics officer and cancer lead clinician at South Tyneside and Sunderland NHS Foundation Trust. She initially took on CNIO responsibilities in 2018, reporting to the IT team. In February 2020, the role moved to report to the director of nursing. Melanie has been a registered nurse since 1994.

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