This final article in our series on professionalism discusses nursing innovation. This is a Journal Club article and comes with a handout that you can download and distribute for a journal club discussion.
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This, the sixth and final article in a series on professionalism in nursing, highlights the importance of innovative thinking and practices. Topics covered include innovation in practice and how this links to professionalism, and the importance of embedding innovation in the undergraduate curriculum. The benefits and challenges of nurses becoming innovators are discussed, along with ways of supporting student nurses to become innovators. An outline of innovations in healthcare provides an understanding of how innovative practice can have a positive impact on patients and their care.
Citation: Creighton L et al (2022) Professionalism in nursing 6: the nurse as innovator. Nursing Times [online]; 118, 9.
Authors: Laura Creighton, Rosemary Peters and Alison Smart are lecturers in education; Gary Mitchell is senior lecturer in education; all at Queen’s University Belfast.
Innovation in nursing is the concept of coming up with ideas that are new and exciting, and using them to improve practice. Lachman et (2009) described it as “the application of creativity or problem solving those results in a widely adopted strategy, product, or service that meets a need in a new and different way. Innovations are about improvement in quality, cost-effectiveness, or efficiency”.
Innovation in nursing is the way forward to efficient, more-effective working practice. Sensmeier (2019) recognised that those who know the systems best work in them, stating that nurses are best suited to make innovative changes to existing nursing practice.
While innovation is about meaningful change, it is important to understand that it is not solely driven by inventions or new products; it can also mean making a slight adjustment to a current system, tool or policy, where it will have a positive effect on the service provided (Royal College of Nursing, nd). In nursing, innovation involves:
- Recognising challenges;
- Problem solving;
- Reflecting on practice;
- Implementing change.
In modern healthcare settings, nurses are encouraged to question current practice and find solutions to enhance performance. Healthcare is ever-changing and it is the duty of health professionals to embrace change and apply evidence to their practice. Hulks et al (2017) found that effective management is important in embracing change and challenging working conditions. Managers should give staff the time to reflect on practice and work collaboratively in a nurturing environment to solve problems and enhance the performance of their team.
De Bode (2021) researched the role of the nurse as innovator during the Covid-19 pandemic and commended the innovative work of nurses in reinventing practice to suit the complex needs of patients. In response to the pandemic, nursing staff were redeployed to unfamiliar practice settings and their existing skills were enhanced so that they could practise in these areas. One example of innovative and compassionate practice during the Covid-19 pandemic in Brazil was using latex gloves filled with warm water to mimic a loved one holding the hand of patients in critical care when visiting was not permitted (Spocchia, 2021).
Adhering to professional standards
It is the professional duty of nurses to be innovative in their practice. The Nursing and Midwifery Council (NMC)’s (2018) Code states that nurses should:
- Prioritise people;
- Practise effectively;
- Preserve safety;
- Promote professionalism and trust.
These standards of professionalism form the foundations of nursing practice in the UK. Innovation in healthcare should exist within the stipulations of the professional role and must be based on evidence-based practice.
Innovative practice can involve improving current work methods in line with the NMC’s standard of prioritising people, which focuses on:
- The effective delivery of care;
- Meeting the specific needs of individuals;
- Working collaboratively;
- Always acting in the best interests of people.
Improving systems in the clinical environment means care can be delivered more effectively.
Nurses must provide evidence-based care. Innovative practice should be based on research and implemented in line with workplace policies.
“Florence Nightingale is perhaps the most well-known nursing innovator”
Nurses must work in accordance with their levels of competency. The nature of innovation lends itself towards creative thinking, questioning methods and solving problems. Practitioners should recognise their own limitations and act within safe parameters.
Promoting professionalism and trust
Nurses must uphold the reputation of the profession and make sure public trust is maintained. It is important to relate to this when implementing new processes and practices, such as through risk assessment, auditing and quality assurance.
Innovation in nursing is the way to achieve efficient, more-effective working practice. Sensmeier (2019) recognised that those who work in the systems know them best, stating that nurses are best suited to make innovative changes to existing nursing practice.
Benefits of innovation
The benefits of encouraging and embedding innovation into undergraduate and registrant nursing include:
- Patients and service users receive high-quality evidence-based care, meaning they benefit from the most current and safe care available;
- Whereas, traditionally, the nursing role was often viewed as the ‘handmaid’ to other professions, nurses are now educated to degree level and higher, know how to search for the most current literature and are more confident advocates for patient care. Embedding innovative thinking enables nurses to apply these skills to achieve improvements in nursing practice;
- The soaring cost of healthcare, made worse by the Covid-19 pandemic (King’s Fund, 2022), means financial pressures on the NHS are set to grow. However, while cost can be a deterrent to innovation, there are many innovative and creative ideas that are cost effective, such as education tools for the prevention of chronic disease that reduce the cost of ongoing treatment;
- Innovation in nursing creates a sense of pride for the profession, as an achievement for one nurse is seen as an achievement
for all. This raises morale and, in turn, can lead to greater creativity through role modelling.
Barriers to innovation
As with any set of benefits there come challenges. Kelly and Young (2017) outlined some of the challenges of innovating in healthcare, which include:
- Limited funding budgets;
- Increasing demand on resources;
- Ever-mounting pressure on the front line;
- Rising expectations of the public.
Much of this has escalated during the Covid-19 pandemic. As an example, in the early waves of it, older people with multiple comorbidities were reluctant to present to hospital when needed (Baggio et al, 2021); foregoing healthcare can lead to patients becoming more unwell and needing higher levels of care for longer periods, putting a further strain on resources.
We propose that some of the challenges to innovation experienced by nurses at a personal and professional level are:
- Understaffing, leading to nurses feeling overworked and undervalued, which can result in their creativity being stifled;
- Lack of encouragement or support from colleagues;
- Lack of knowledge as to how to implement innovations or creative ideas, such as who to ask or how to gain funding (Nesta, 2019).
Supporting nurses to innovate
Motivation, encouragement, knowledge and support can help people achieve a goal (Creighton and Smart, 2022). The same is true with creative ideas and innovation in healthcare. A positive and supportive environment will allow creativity and innovation to flourish; Box 1 suggests a reflection activity to help nurses with this.
Box 1. Reflecting on an achievement
Think of a time when you have achieved something. This could be receiving good grades, passing a driving test, winning an award, or completing a sporting achievement, such as running a marathon.
- What was your motivation?
- How did the people around you react or treat you?
- What were the barriers you encountered along the way to achieving your goal?
- How did you feel once it was achieved?
- What advice would you give someone else trying to achieve the same thing?
Putting innovation into practice
Innovation in nursing practice does not have to be complex to benefit patient care. Florence Nightingale is perhaps the most well-known nursing innovator. During the Crimean War in the 1850s, her response to the high mortality rates among wounded soldiers was to provide them with clean water, medical equipment, fruit and a clean environment (McDonald, 2020). This simple innovation decreased death rates from 60% to <5% (Karimi and Alavi, 2015).
Among more recent examples of simple nurse-led innovations that have improved patient care is the End PJ Paralysis campaign (endpjparalysis.org). This began in the UK in 2017, and has now become a global movement, after evidence showed that older hospital patients could spend up to 97% of their day sitting or lying down (Brown et al, 2009). These findings were alarming because, after only 10 days of bed rest, older adults can lose 1kg of muscle mass and almost 20% of their strength (Evans, 2010).
Low physical activity and bed rest have also been associated with serious adverse clinical outcomes, such as thrombosis or pressure injury (Pavon et al, 2020). The End PJ Paralysis campaign raised awareness of these issues and called for hospital wards to support their patients to change out of their pyjamas into their own clothes and get out of bed during the day (Crabtree et al, 2021). The impact of this innovative approach, which led to older hospital patients being more active during the day, was substantial: evaluation of the campaign showed a notable reduction in falls, pressure injuries and days spent in hospital across the UK (Stephenson, 2018).
A nurse-led innovation that has improved quality of life for people living with a learning disability is the Just A Minute (JAM) Card (jamcard.org). JAM Cards allow people with a learning disability, autism or communication barriers to tell others they need ‘just a minute’ in a discreet and simple way. People with other conditions, such as dementia, have also expressed how the JAM Card can make life easier, particularly when paying for items at a shop, using public transport or becoming lost in a familiar place (Mitchell et al, 2020).
Another nurse-led innovation in the field of learning disability nursing relates to a short illustrative book Am I going to Die? that helps people with a learning disability to understand about their illness and dying so they can make sense of what is happening to them or someone they know who is ill (Hollins and Tuffrey-Wijne, 2009). People with a learning disability are at higher risk of premature death, but research shows that they are often not fully aware of their prognosis, commonly due to poor communication (Adam et al, 2020); resources such as this innovative book can help them to understand what is happening.
Recently, there has been an increase in digital innovations in healthcare. One nurse-led example is a digital programme to support children’s emotional wellbeing and resilience. The Embers the Dragon programme (embersthedragon.co.uk) consists of learning resources that can be used for children of pre-school age to enhance their emotional resilience at an early stage of development, facilitated by a range of professionals. An early evaluation of the pilot programme showed 69% of children who completed the programme said they were more likely to talk to a trusted adult about their emotions and wellbeing as a result (Selby and Allabyrne, 2021).
Another nurse-led innovation in the care home sector resulted in a medication app (TracA D) that led to reductions in prescriptions of antipsychotic medications for people living with dementia (Royston et al, 2016). In addition, in nursing education, gamification is a new innovative digital approach that has been used to support student knowledge and uptake of influenza vaccination (Mitchell et al, 2021). Innovations such as these have demonstrated that nurses can play a leading role in the development and implementation of innovative healthcare practices.
“Innovation in nursing is the way forward to efficient, more-effective working practice”
Supporting innovation in undergraduate nurses
Manalo (2020) recognised that individuals should be prepared for work in the 21st century by obtaining skills in critical thinking, problem solving and innovation. This view supports embedding problem-based learning into the teaching of undergraduate nurses, encouraging higher-level thinking, thinking outside the box, taking a solutions-focused approach and reflecting on outcomes.
Promoting innovative practice in undergraduate nursing education empowers students to take ownership of their own learning and development, and enables them to become critical and analytical thinkers, which will benefit them in their nursing careers. Students are able to blend theory with practice and use knowledge from evidence-based learning to create solutions to problems in clinical areas.
To meet the ever-changing needs of clinical practice, it is that vital nurse educators prioritise education about innovation to enable future nurses to flourish as innovators. In September 2020 at Queen’s University Belfast, we brought innovation to life for undergraduate student nurses through Dragons’ Den-themed tutorial workshops, which challenged year-one students to think creatively about ways they might contribute to future innovations in practice.
This was done as part of our undergraduate module, Professionalism in Nursing, which explores the NMC’s Code and how to apply it to practice. One of the classes is on innovation, and students take part in group problem-solving activities. The key is not to discuss the problem, but to create a solution to a gap in practice or a problem.
Box 2 describes an activity we came up with for students to do in their tutorial to encourage them to think of improvements that could be made. Each class voted for the best idea and a grand final in the style of Dragons’ Den was held; judges included the head of school, director of education and nursing field leads.
Box 2. Encouraging student innovation: student exercise
- During a clinical placement, or in your time in university, did you identify any problems that needed solving or areas that need to be enhanced?
- How would you do this?
- Describe what process you would follow, the potential cost and the rationale behind why it is needed
- Do some research to see if the solutions already exist. If not, your creativity has led you to become an innovator in nursing
The students had to do a one-to-two-minute elevator-style pitch of their idea and the best teams won prizes. Never did we imagine that our first-year students, who had undertaken just one clinical placement, would come up with such fantastic ideas. Some of the students’ ideas were already in practice, unknown to them, but they still enjoyed and benefited from the creative process. The top innovations were:
- Pre-placement familiarisation/orientation visits for students;
- A cultural awareness app to help ensure patients’ cultural and spiritual needs are met in the care environment, such as dietary requirements, contact point for religious or spiritual matters and end-of-life care;
- Equipment that uses colours and pictures to engage children with having their vital signs taken, by providing an element of play so it is less difficult or distressing for them.
The winning project was the orientation pre-placement visit for students. The rationale was that all students get nervous before placement and this is partly due to having a fear of the unknown. The students proposed that there are questions only other students can answer and some questions that, as educators, we had not even thought of providing information on. This was further highlighted during the Covid-19 pandemic, as online teaching and support meant students felt less prepared and more anxious about going out into practice. The university decided to adopt the idea but, as it was conceived during Covid-19 restrictions, videos were used instead of in-person visits. These are recorded by students after a placement, providing information and advice for students coming into those settings. This turned out to be a positive experience for both faculty and students.
Other ongoing innovation projects involving students and staff included the development of a Makaton (Makaton.org) programme for students to learn how to communicate with patients and clients using symbols, signs and speech. Patients who can benefit are those who use Makaton to communicate, such as people with learning disabilities or cognitive difficulties, or those who are non-verbal communicators.
Comments from the winning students after taking part in the project are shown in Box 3. The success of this project means, we will continue to run the innovations workshop for our February and September student intakes.
Box 3. What the winning students said about their experience
“Taking part in the innovations project was energising and enlightening. As a group, we admit we appreciated the competitiveness, though we found it inspiring to hear of other ideas across the cohort. The innovations project offered us a sense of pride and accomplishment. Our idea, known as student familiarisation, came about after a long video call together. We understood from the beginning that we wanted our idea to positively impact other student nurses, current and future.
“Together, we began considering what issues we have faced so far on our nursing journey and uncovered the agreement on feeling unorganised before attending clinical placements. Once this issue was established, our group began to think about how we could make a change, which is what led us to student familiarisation. The main concept of this innovation is to alleviate anxiety before placements, allowing students to feel prepared.
“We are delighted that we won the innovations project – knowing our idea has been taken onboard by the School of Nursing and Midwifery here [at Queen’s University Belfast] is an overwhelming achievement. The project has certainly educated us. We now appreciate that, often, it only takes one small idea to make a difference and anyone can do this. This has provided us with great confidence, and we intend to carry on forming more positive innovations in the future as nurses.”
Source: Creighton and Smart (2021).
There are many benefits of nurses being innovators, as well as barriers and challenges to progress. The profession faces huge challenges in terms of staffing, resources and resilience, with Covid-19 resulting in one of the greatest periods of adversity experienced in modern nursing. In response to the pandemic, nurses have had to adapt, and we can only hope that this has led to a workforce of creative and forward-thinking innovators.
- It is the professional duty of nurses to be innovative in their practice
- Innovation involves the adoption of a problem-solving mindset
- Undergraduate nurses need support to be innovators
- There are both benefits and challenges involved in embracing innovation
- Innovation in clinical practice can lead to enhanced patient care
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