Abstract
Roughly translated from Plato’s The Republic, the English language proverb states ‘Necessity is the mother of invention’. However, invention is only part of the process we currently refer to as innovation. The necessity in the quotation in our case is due to the universal challenges to healthcare provision across the globe, namely increasing demand because of a rising burden of chronic disease and limited resources, now more than ever. It is against this context and the challenges of doing ‘innovation’ that this special edition sits, with a series of papers, and their related commentaries, exploring both the why and how of nursing innovation.
Innovation is seen as a process comprising a series of interlinked, and at times overlapping processes, which encompass adoption, implementation, sustaining, spreading and scaling. In a policy brief from the World Health Organization (Nolte et al., 2018) the key components that define innovation include novelty, added value and discontinuous change. This novelty is potentially frightening, or challenging to the status quo, and therefore we need courageous nursing leaders (see the perspective piece) and courageous nurses who are not afraid to argue against standard practice and to suggest a new way.
Innovation was amongst four key topics discussed at the International Council of Nurses’ Congress 2019 (International Council of Nurses, 2019). The American Nursing Association has their ‘Ignite Nursing Innovation’ scheme (American Nursing Association, 2020), with support and funding for nurse innovators. The UK Royal College of Nursing has specific resources to support innovation in nursing (Royal College of Nursing, 2020) both recognising nurses' pivotal role in healthcare and the contribution they can make to the process. From a policy perspective, England’s National Health Service (NHS) Long Term Plan (NHS, 2019) talks about innovation in two ways: one very clearly from a clinical research perspective and accelerating new technologies; the other as innovation being delivered by frontline clinicians skilled up with quality-improvement methodologies.
This capacity to use quality-improvement methodologies helps address the final component of innovation, in so much that as innovations are implemented, we also have to recognise that they must deliver improvement. The Institute for Healthcare Improvement (IHI) Triple Aim is useful to consider at this stage (IHI, 2020), with the three domains being:
improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of healthcare.
The collection of papers in this issue starts to look at projects that span these aims and a range of contexts and countries reflecting the global nature of nursing and the challenges it faces.
Using the broader definition as a process rather than a moment of inspiration, we can see that innovation has much in common with knowledge mobilisation: the creation or mobilising of knowledge in different forms to make an impact on policy or practice. When we talk about knowledge, we recognise more than the codified knowledge of books and papers. Aristotle (translation republished 2000) describes three approaches or forms of knowledge: episteme, techné and phronesis. Episteme refers to the scientific learning on a subject, techné the craft or art, and phronesis refers to wisdom. The wisdom of nurses in understanding the contexts of health and the skills of delivering complex care are forms of knowledge that we don’t always preference and yet should be valued. This ability for nurses to understand their practice and incorporate others’ experiences into that process are at the core of many of the papers.
Macduff et al. use the topic of anti-microbial resistance (AMR) to explore methods that allow or enhance the ability of nurses to be ‘innovative’. ‘Innovation in nursing being an ongoing response to a process of dialogue between practice ‘as is’ and practice ‘as it should be’. Using methods drawn from outside the immediate discipline of nursing, a common theme that we will return to in other papers, Macduff et al's work to enhance the dialogue through visual methods that help express existing (implicit) knowledge in the nursing workforce and express this in a way that could be shared (explicit). Through this reflective process Macduff et al. explore the relationship between imagination and innovation, as we imagine nursing as it could be.
Wolstenholme et al. expand the sources of knowledge beyond ‘just’ nurses to include all those involved in the commissioning and delivery of services, and using methods drawn from design uses visual methods to ensure all participants can contribute their knowledge equally. Design also provides a structured problem-solving approach that has been used in industries outside of nursing for years. These methods have been increasingly used to support innovation in the form of both quality-improvement and practice development in healthcare, as evidenced by their use in many of the papers in this issue, and more broadly (Chamberlain et al., 2015). Through structuring reflection supported by visual and design methods, innovations in service provision were developed with both service providers and users, these innovations had credibility created through the methods that transparently involved all stakeholders.
Again, the underutilised power of nurses’ knowledge in the Risling and Risling paper is highlighted. The contribution of the paper being a call to arms that nurses are perfectly positioned to reintegrate nursing informatics, into everyday nursing. No better examples of this are seen in the implementation of electronic patient records (which anecdotally) appear to be largely a top down process, not drawing on the best practice of either implementation or design, and not valuing the expertise of the workforce in knowing why they do what they do already. Risling and Risling use, once more, a user-centred design approach, this time drawn explicitly from the field of computer science. Through supporting nurses to use these methods and the correct language to communicate across disciplines, more effective innovative relationships are enabled.
Elegantly, the Hardiman et al. paper shows there is, in fact, another way. Using a practice-development derived approach, in conjunction with more traditional engagement with IT providers, they developed, with front line nurses as the key stakeholders, a system that not only served the technical requirements but also acted as a driver for person-centred care. Once more mobilising the expertise of nurses through a technical system that worked for rather than against nursing phronesis, wisdom.
The next two papers are similar in focus: Kaufman et al. show that through allowing the complete exploration of what, at first, appeared to be a straightforward question about a technological solution, the broader contextual issues around training and policy are just as important – if not more than – the interface of the technology. This is the context of healthcare where nurses hold a monopoly of experience. This paper also reminds us that even where there is a technological solution, if delivered well, it serves to enhance rather than replace the key component of the nurse–patient interaction.
The Martin et al. paper shows that innovation in the form of technology (digital communications) brings its own challenges as well as opportunities. Technology allowed the young people in the study to ask questions they wouldn’t raise face-to-face with service providers; however, it also created expectations that the service was not yet set up to meet. This created a mismatch in expectations, with the young people expecting the same level of 24-hour service that they can receive from other services (banking, information) outside of healthcare. Sometimes it is only through trying out solutions (prototyping in the design parlance) we can learn more about unexpected outcomes of innovation. This can be done at a range of levels with ‘thought experiments’, cardboard cut outs, or small tests of change as described by the plan-do-study-act approach in quality-improvement methodologies.
The final paper, Andrews et al., proposes a structural response to how to enable this innovation through collaboration.
A number of papers have suggested that the use of methods from outside of nursing is in itself innovative. Several papers have used the methods of design (user centred, experience based). Andrews et al. describe a collaboration bringing together the best of nursing knowledge and clinical engineering methods. Involving nurses in the process allowed for the contextual understanding of not only technical care but pathways and environment. The paper also highlights similarities between the problem-solving approaches of both engineers and nurses. They cite the double diamond approach of the UK Design Council, which has four phases: discover, define, develop and deliver. Each two sections describe a divergent and convergent phase of investigation and can align with the iterative nursing process of assess, plan, intervention, evaluation. Where design methods can strengthen the innovation from nurses is in the visual and tangible methods that help make the intangible knowledge and know-how of nurses tangible and allows new knowledge to emerge.
The paper and its commentary cite a growing movement across the globe of organisations that are recognising the value of this partnership. From England’s National Institute for Health Research Devices for Dignity programme, to examples from the USA including the Mayo Clinic’s Centre for Innovation and the Kaiser Permenante Garfield Innovation Centre. There are also similar centres in New Zealand, such as Good Health Design. What this geographically diverse set of initiatives has in common is that they all offer opportunities for these disparate forms of knowledge, the episteme, techné and phronesis, to be harnessed into delivering meaningful and measurable change for the citizens who use our health and social care services.
The Accelerated Access Review (Wellcome Trust, 2016), a document explicitly setting out how best to access innovation for the benefit of patients and to improve healthcare efficiency, states: ‘patients and citizens are active partners in research and innovation. Their diverse experiences and expertise underpin decision-making at all stages’ (National Voices, 2016, p. 4).
The collection of papers contained in this edition make a strong case that nurses represent equally diverse experiences and so should be supported in contributing to this national and international priority. The closing Perspectives piece by June Andrews reminds us all that leadership, courage and innovation go hand-in-hand and are needed for change. This special edition represents only a snapshot of the work that is being carried out by nurses in the name of innovation. We look forward to seeing nurses’ roles and contributions to this ambition grow from strength to strength.