S6E5 Writing Case Studies Intro - Welcome to Stoma and Continence Conversations from Coloplast Professional. I'm Hannah, Ostomy Care Associate Education Manager at Coloplast. Working in specialist care, I know that stoma, bowel and bladder issues impact the lives of those you care for. This podcast is here to support your educational needs and help you in supporting your patients. You'll hear from fellow healthcare professionals and experts by experience, discuss the latest hot topics in the world of stoma, continence care and specialist practice. Hannah: Hello and welcome back to the podcast. We are bringing you another one of our Webinar Wednesday chats today, as Paul is joined by the wonderful Dr. Terri Porrett to talk about writing case studies. So let's get into it straight away. And first off, Terry explains why case studies are so important. I. Dr Terri: Well, I think case studies are really, really important Paul, and potentially more powerful than a formal article for publication. A case study is a snapshot of your clinical practice. It's either about a clinical challenge and how you've solved that for an individual patient. Or it's a snapshot of the challenges you are facing within your practice with workload, with getting people to understand the importance of things that you do. For example, I can remember back at the Homerton people saying to me, Terri, your team does an awful lot of telephone calls. You know, these are just social catch-up chats to your patients. No, these are really important clinical follow-ups and I put in one year in my annual report what I called, I didn't call it a case study, but it was, but it was what I called a snapshot of, this is what I achieved on one telephone check to a patient and I gave, obviously anonymised and it was a 75-year-old, I think eight weeks post-op. It was in the Summer, they had a loop ileostomy. This lady had issues already with a high output from her stoma, and we were now in the peak of summer and I knew there was a significant risk of her becoming dehydrated. As it was, during the course of this telephone chat, I found out that she had over one and a half litres output a day. Her GP had stopped prescribing her Imodium because he didn't think it was important, and that when she got out of the chair she felt really dizzy, postural hypertension. Okay, we dealt with all of that with the GP in the space of an hour. That prevented, as I could say, really clearly, this person falling at home, coming into casualty, being admitted to hospital, needing 24 hours IVs, we solved that with this, not really very important to our managers telephone check. So that was the power of a very simple case study showing one intervention that I did and ensuring that my managers understood the importance of these non-social ringing up for a little chat. These are clinical interventions on the telephone. People don't realise it. That one snapshot, no more issues. And actually, we then had dedicated telephone clinics put into our job plans to do all of these because they were so important. Paul: There’s so many points I almost wanna pull out from the things that you've said, and it really does highlight, you know, and again, it's that work thing people say, you know, your managers, so you're just doing a ‘social chat’. I remember one of the things that I was always taught as CNS was we never ‘chat’ with anybody. You know, we talk about that, the language to use and that sort of thing. And again, for the Apollo website, link is here on this webinar and we talk about how to talk about your service with managers because, a lot of time managers have absolutely no idea in what we do as CNSs. A lot of the time we are expensive numbers at the bottom of the spreadsheet, we are very, very expensive commodities. One of the things I would like to talk about, because we know that in the world at the moment, and it's only getting worse, workload for specialist nurses is just getting higher and higher and there's more demands on the service. There's more demands on each individual Clinical Nurse Specialist, and I'm not being overdramatic, but we've been hemorrhaging senior Clinical Nurse Specialists and they're not being replaced, we're finding it difficult to replace Clinical Nurse Specialists in any kind of specialty. And there's been a lot in the nursing press recently, and you look at Twitter, you look at all of those and you hear a lot of nurses talking about the anxiety and the negative impact of work left undone because there is just so much going on. Are case studies just, an added thing to that? Can it support with work left undone? Can you explain what work left undone actually is? Dr Terri: Well, Paul, everything you've said is so pertinent to the time at the moment and more relevant to me in my work outside of Coloplast as well as inside of Coloplast, because I have the privilege at the moment of being an RCN council member, and obviously the whole focus of the RCN at the moment is about the workforce wellbeing and retention of nursing staff. And what is really clear is that it's moral distress. So no nurse, no specialist nurse, no stoma care nurse goes to work each day going, do you know what? I'm gonna be horrible at work today and I'm gonna leave that undone and I'm not gonna do this, and I'm not gonna ring that patient who I told I was going to ring. Nobody goes to work like that, but that's the reality of how we leave work on many days going, do you know what, I didn't get enough time. I wanted to spend more time with that patient talking about A or B, I wanted to ring. I'll have to do that tomorrow, but I really would've preferred to ring this patient today. And you leave work with a real sense of dissatisfaction with the quality of the work that you've given. Being able to document is quite therapeutic for yourself in writing down what you couldn't do, that in itself helps. But I don't know if you've heard of Dr. Phil Hammond. He's a GP, but he's also on the radio and he writes books about the NHS, and he refers to a thing called the National Institute of Good Enough ‘NIGE’. Okay, because specialist nurses, the NHS, it's all we've got to be striving and delivering an excellent, exemplary service all of the time, and sometimes good enough is okay. We are doing the fundamentals of our care, we're keeping patients safe. And sometimes in the situations throughout Covid and now catching up from Covid and with reduced staff, it's okay to be NIGE. Okay, so sometimes the National Institute of Good Enough is okay. But what I would say is that documenting what you haven't been able to do, either at the end of a day or do, I used to like at the Homerton doing snapshots, which were small collections of data, mainly because I didn't like having to collect lots of data all of the time, and you know what I'm like with a spreadsheet, not good! So I would do a snapshot. I'd go, right this week we are gonna measure blah. So one week we measured how many phone calls we got into the service with queries from GPs, from other doctors, from consultants, from patients, that we had to answer and respond to. Then I did, if we didn't do telephone calls, I documented just one call that I did out of eight this particular day to patients, and we've already discussed that. So I would do a snapshot of in this week, these are the things that either myself as an individual nurse specialist or the team of stoma care and colorectal nurse specialists were not able to achieve and with the provisor patients were safe. But this was not an exemplary service, and if this is a snapshot of just one week but this is what happens every week. So work left undone is the things that actually we normally don't measure because we're frightened to say, I didn't do this, and then get some well-meaning manager, start performance managing us because why didn't you do this? Or we need to write a Datix because you didn't do this. So I think it's work left undone is the challenge for nursing across the board at the moment. I think, you know, when you look at the challenges on a daily basis for ward-based staff with the number of vacancies, bank and agency staff, they are constantly not being able to do what they want to do for their allocated patients. So I think it's really important to think of this as advocacy. If we don't tell our managers in a considered snapshot case study type of way, what we can't deliver for our patients, we are not advocating for them, we're not advocating for ourselves, and we're not advocating for our service and our patients. And as nurses, we do like to crack on quite a bit with the, I'm the patient's advocate. Well, this kind of work, although not directly patient-facing, is advocacy. Advocacy for the service that those patients are getting. So I think it's really, really important. And as you mentioned with the Apollo website, part of the reason that Apollo came into being, to give people the tools and the confidence to be able to advocate for different aspects of their service. So not just, this is my job plan, but this is snapshot of issues that my service is experiencing. Paul: Brilliant. And I think again, there's one thing there that I'd like to almost pull out. I mean, it is, it's that fear. And I always used to explain it that 100% one day is gonna be less than 100% the next. Every day I go to work, I always give a 100%, but what is a 100% one day, potentially is gonna be 80% the next day because of extrinsic factors that are completely out of my control. Yeah, and you've mentioned that, you know, we've mentioned managers quite a lot here, but obviously there are different audiences, the case studies, and you know, you mentioned that you did these snapshot in time things at the Homerton. And again, when I talk to nurses, nurses think of case studies, hopefully you know, you've changed their mind already, but what do you actually, once you've done this case snapshot, once you've done that case study, once you've had a really interesting experience, you've managed a situation really well, something's come up. It's the first time you might have had Caput Medusa and or anything like that, and you go, oh, this was absolutely brilliant. What do you do with those case studies? What sort of impact can they have? Where do you send them? Because obviously we don't want 'em just to sit in a folder on someone's desktop because they're not doing anything when they're sitting in that folder. Dr Terri: So I think you've got to be really clear when you're documenting something. Am I documenting this case study, which doesn't have to be two and a half thousand words referenced, and you know, referring to best practice. It can be a documentary case study. Is this for internal use for me to present a case for an improvement within my staffing or my service or whatever? Or is this for external readers to learn from either a novel or challenging clinical situation and the solution that I found for managing it? So I think there are multiple uses for this, but actually you have to be really clear before you start. Because if we are writing for our peers to learn from a clinical situation, we need some photographs probably. So as you're writing, you know, before you write the case study, as you are experiencing this clinical situation, you have, we need photos for this. This is going to show what I'm doing, this is going to show what the problem is. So I think that be very clear at the beginning and don't be put off by case study. Cause when I think of case study, I think of when I was doing my Masters and degree and I think, oh it's really formal, it's a significant word count. It has a significant kind of heading or it's kind of key headings and the format, you've got to write it. And externally for publication, yes, there is more rigor to the format. You know, many can be one page. Many case studies can make fantastic posters at conferences, so be clear of what the reason for them is. And internal case studies, just to make a point, can be really, really short. I mean, literally two paragraphs can be a snapshot case study, allowing a manager or non-clinical person to understand a problem in a more real-world way. Paul: And I think that's it. It's making people understand or putting things in a format that is appropriate to the listener, to the person that is receiving it. So if we are talking annual reports, and I remember, you know, Terri you taught me how to do an annual report and you know, you literally ground it into me what should be included. And when you're sending out an annual report, send it to every man and his dog, including their secretary if they have one, it doesn't matter, literally do it to the inbox. And you are sending it to the finance guys. Don't just send out a generic email. Actually say, you know, I'd like you to pay special attention to page eight to nine. You know, where you put down how much stock and how much you know, stock we've received from, you know, pens, papers, Post-Its, all of those sorts of things. We've saved you money, because as Clinical Nurse Specialists, as part of the service, we talk to private companies, they give us all this stock and that sort of thing, so we've saved you that much money. Now you've mentioned, you know, you have different receivers of these case studies, and you've mentioned things like the snapshot that like you did, that brilliant one where you said of the telephone call that you've done, you know, that two paragraph thing. Which then leads me to that question is, what should be included? Is there, you know, a one kind of framework that fits all? Or if you're doing something to one type of stakeholder, do some sort of format or you know, inclusion, what to include? Dr Terri: Okay, so if we think internally and we think about things that we're going to put, we are gonna put in an annual report or some kind of letter or statement to our managers about making some kind of improvement or to the service or for them to understand a specific challenge to the service that they need to support us to rectify. As we spoke earlier, it's about who is your audience? So it's an internal audience, it's an external audience. What are the key things you want them to understand? So I used to practice, and I'm sure all of you do, and we deliver a service and you think if this was my Mom or my Brother or my Dad, this is how I would want them to be treated. I always used to look at these snapshots as my more informal, not double-blind, randomised control, whatever. My more informal way to allow whoever I want to influence. If it could be the Chief Nurse, it could be the Finance Officer, it could be the Commissioning Lead for the community, whoever it is that you are wanting to influence, to change or improve your service. You want them look through your eyes in the same way as you. We want them to understand if this was your Mom or Dad, would it be good enough? Because that's how our minds think. And I think there is an opportunity to give people an emotional kind of view of what it is like to face-to-face care for somebody because I think, you know, unless you're in a patient-facing role, it's hard sometimes not to see this as transactional, as numbers on the spreadsheet a tariff of, you know, what the service can claim for and the income it can generate. But also I think, and as Professor Allison Leary talks a lot about, you think it's expensive to hire or to have pay an expert like me or another expert, specialist nurse, and this quote from with the oil refinery fires, you think it's expensive to hire me because I'm an expert to put these out? Have a go with somebody who's not an expert and see how much it costs you! It's that kind of vision. And there's areas and some example articles and texts on the Apollo website Paul, that with work written by Professor Leary, where she does identify the importance of identifying work left undone. If we think in our own lives, we go somewhere for a service. I go to have my car serviced. And if when I pick it up they haven't done something, but they haven't told me they haven't done it. It's not okay for me on the receiving end, but also for that service because it might be something safety-critical with my car and they've not told me and fixed it. So, you know, if we put ourselves into a position like that when we were on the receiving end of a service and something doesn't get done, how can that service improve if you and the person that don't say, we didn't have time on this occasion to, but if you bring it in next week, we will change that tire because it's… do you understand? So I think if we just try and put this rather than this formality of business cases and business plans, think about what it would be like for us on the receiving end of the service that didn't do everything it said it was going to do, and the issue it might cause me and more cost it might cause me. And then we can write in a way because we have that understanding, like we want our managers to understand, well, if this was my Mom, if this was my Dad, is it good enough? We need to reflect on the challenges of not reporting what we don't do, and it's significant. If we don't get people to understand what we don't do we are really having, we'll have a problem trying to then present the argument of why we need to increase headcount or change the times of our clinics or whatever, because we haven't, we've glossed over that bit. As nurses, we have a duty of candor, so we have to say when it's not going tip top. Okay. And we have to say, you know this happened actually, we found this out and we stopped A and B happening. But it was by luck. That could have been, we have to highlight this because that could have been the serious clinical incident for that patient. Paul: I think that's, it's amazing you know, you spoke there about fear and I think for a lot of nurses, we do a really good job, we love thinking that we do a really good, we love telling people that we do a good job. But I, sometimes I think we get afraid of saying, actually we are not that good at X, or this couldn't happen because of Y, I tried, but I just couldn't. And actually vocalising that in the form of a case study and that sort of thing, hopefully is empowering and saying, you know, yes, we need to speak up for our service, but at the end of the day we also speak up for the patients as well. And if we didn't have a service, what would happen to them? And I think as you said, case studies are a phenomenal way and a powerful way to do that. And I love the fact that you said, you know, it doesn't have to be reams and reams, it's not 2000 words, it can be two paragraphs. It's however, the format to put that case study through is almost dependent on the situation. So like you said, you know, sometimes, yeah, pictures are absolutely fantastic, but sometimes it's not appropriate and it's just words, it's breaking it down. So I love the fact, I say there is no golden template for a case study. And Terri, you're gonna love my last little bit. Okay, my last question to you. Okay. I wanna see that smile when I say, Terri, what are your top tips for writing case studies? I know, I know. I had to put Terry's top tips in! Dr Terri: Okay. First of all, my top tip is do not overcomplicate or overthink an internal case study. Okay, a case study that you are using a snapshot for your argument. Don't overthink it. Don't overcomplicate it. This is not a randomised control trial, nobody expects it to be. The second thing is be really clear of who you're writing to, cause quite often it will be a specific person or a group of people that you need for them to understand a particular, so be really clear who your audience is. Okay. The third thing I suppose is get a not, so I always used to test out a lot of things I'd written in my annual report on my Brother, my Brother’s not medical at all. And I've said to him, can you understand what I'm saying here? Because most of my audience that I was trying to inform and change things weren't medical. So if my Brother could get it, I knew that they would understand what I'm saying. And if he'd say, I don't understand that word. And why is that important? I knew I had to write more to explain those things. My top tip would be get somebody who doesn't know your service inside out, like you to read it and go, yeah, I get exactly in those two paragraphs. I get what you're saying. Okay. So I think that's three. Four is, as Paul said, once you've written an annual report or a snapshot, email it to whoever it is you, you need to email with a personal covering letter, a personal covering email to each of them so that you are, and you are telling them in your email why they are so important and can directly impact on the improvement of patient care. So if you make somebody feel, okay, all I've gotta do is say yes to that and I'm going to, I'm gonna make all, I'm gonna improve things for patients. People really like that. Really like that. And the fifth thing I would say is once you've done one, do more cause they are really, really powerful and they can be short and sweet and really targeted and it saves you doing a million and 1 business cases! So that's Terri's top tips! Hannah: So there you go, case studies aren't so boring after all! Thanks to Dr. Terri Porrett for taking the time to chat with Paul. We've put together a handout to go alongside this episode, and it's available in the show notes for you to download right now. Thank you for listening to Stoma and Continence Conversations, and we'll be back with another episode for you next week. Outro - Stoma and Continence Conversations is brought to you by Coloplast Professional. To learn more, visit www.coloplastprofessional.co.uk