International Nurses Day 2022: Digital nursing and the role of the CNIO

“It’s the first question I always get when I introduce myself as a CNIO… “So what is that?” says Anna. And even being a long-established CNIO in a digitally mature organisation doesn’t change this. “People don’t always know what a CNIO does. Even today, I was up on one of our wards and I met one of the one senior staff nurses there. And I told her what I did, and she said “Oh, I didn’t know that we had one of those” recalled Simon.

But this applies at the top level of NHS organisations too. Sarah Newcombe commented “With Ruth May setting the expectation that there’s a CNIO at every organisation, I’ve certainly had a few chief nurses reach out to me saying, how do I get a CNIO? What will a CNIO do for me? What will they deliver?”

Almost all the CNIOs saw a challenge with the wide interpretation of the CNIO role across organisations. “I found that people were given the title of CNIO, but barely anyone knew what a CNIO should actually do.” said Jenny.

And with that uncertainty comes a real variety of responsibility, reward, and recognition. “At different trusts, CNOs have different positions within the trust. Very different banding, very different job descriptions, and very different expectations as to what you need to achieve. But NHS England are now looking at standardising exactly that” said Hayley. “There is still a lot of work to do – there is a massive variety of banding, responsibilities and level of input” agreed James.

And with that variation comes a question of fairness, of uncertainty on either role scope or pay. “You do see a lot of variation in how people are paid. What bands people are on,” said Jenny.

But the differences can also come down to what the role includes. “Many CNIOs had included the Clinical Safety Officer role, but lots of places are recognizing that’s a separate, full-time role in itself and advertising as such.” Hayley.  “We have a lot of differences across organisations, how the role is structured, funding, where the role sits” mentioned Sarah N.

And the discrepancy isn’t just limited to the role description, it can include the permanence of the role itself. “Leaders and executives need to make these digital posts substantive, because there’s still quite a lot of organizations out there where they’re put digital in, but they don’t make the posts substantive. So, when the deployment is complete, then the posts go. But actually, the deployment is the start of the journey, not the end” said Simon.

The team structure underneath the CNIO isn’t standardised either, but that looks to be changing. “Trusts do now recognise that CNIOs need a team around them to achieve great things. So lots of places now are going out for deputies” said Hayley.

The prevalence of the role has grown enormously. “When I came into post there were very few people who were in this post, I think I knew five or six, and now there’s dozens and dozens of people coming into CNIO posts” said Simon. And that’s as a result of this role changing, from a niche position at a few NHS Trusts, to far more standard. “I think organizations have realized that it’s not a nice-to-have, this is now core, you’ve got to have a CNIO, if you want to move at pace.” said James, “the number is of CNIO’s nationally has just exploded”

It’s not that this is necessary an entirely new role or career for nurses, it’s just not been this mainstream before. “There have always been nurses interested in technology and digital, but there’s never been a professional practice platform, it’s been quite hidden. But it’s now really seen as an acceptable career path which is really nice, having been on this journey for 20 years – it’s lovely to see it actually come to fruition” said Paula.

“At the London level for us, and beyond, they’re actually trying to define what is a CNIO, what is it that you need? What skillsets do you need and what training and development opportunities are there for you to aspire to that?” said Jenny. And this is work that’s being helped nationally, as well as regionally. “I think setting a clear strategy and vision nationally, across organisations, will help – to set expectations at an executive level” said Sarah N.

Whilst most of the panel had deep specialist knowledge before their move into digital, becoming a CNIO means they now have to look across all specialties. “I’m an ED nurse by background, I’d done 14 years of ED by the time I got this job, going through the ranks in a service and becoming an expert in that field. And now I’m straddling across everything – inpatient, outpatient, ED, maternity, AHPs. I think the breadth of it is where a lot of my learning had to be” said James

And it’s not just the variety of roles within nursing that CNIOs tend to represent. “We mustn’t forget pharmacists, therapists and midwives. Because they’re all passionate people that wants to see technology really giving patients a really good experience and keeping them safe” says Jenny.

Louise also sees the CNIO role as bringing the voice from across the different clinical professions.” One of the biggest recent changes is having a greater voice in clinical informatics for nursing, midwifery and AHP colleagues. Really getting people engaged and enabling a strong voice for the patient through those practitioners, working closely with our medical colleagues”

Anna came into the CNIO as an AHP, originally an ODP by clinical background. But she sees those differences as an asset – “AHPs see these things from totally different angles and bring different perspectives” she says, “and as a CNIO, you’ve got to have eyes for multiple things going on across the organisation.”

“People ask me why you left nursing, you know, didn’t you miss it?” said Hayley “but I pull on my nursing experiences every day”

This view about nursing still being absolutely core was shared across the panel. “I still use my clinical and nursing knowledge on a daily basis” said Sarah N. “My favourite part is the engagement, being with nurses. Every day, I still love to be on the wards, just trying to understand what those challenges are, what they find hard, but also what they enjoy.”

And this is important; it’s not that they see themselves as having left nursing for informatics. “It’s not a role that just sits in health informatics, I wouldn’t want that. I’m a nurse and I am bringing the nurse to digital” said Lisa.

This perception may just be down to how relatively new the role is. “Hopefully this is a temporary thing – no one ever asks this question of matrons and other nurse leaders!” said Hayley.

A common theme was that, while half the CNIOs we spoke to did think of themselves as quite technical, absolutely none of them saw it as a requirement or even the most important part of their role.

Jenny tells the story of how she came from a very non-technical background. “When I was originally asked if I would like to be seconded into it a technical role, I said “no, I’m not the right person for this, I’m not at all technical, I don’t care how the widgets work, I just want to know it works and that it does what we need it to do for us as nurses to deliver our job.” And I was amazed at the response – they said, you don’t need to worry because we’ve got lots of that experience in the team already. What we want is for somebody to come into our team that is a nurse and knows what nurses want and can help us interpret that.” In fact, she found not being techy can be an asset, as you can be the person who asks the layman questions. “I started to hear people using a lot of abbreviations when talking about technology, and I started to say to “do you mind just telling me what you mean?”. After meetings, people would come up to me and say, I’m really glad you asked that because I was sitting there thinking, “I don’t know what they’re talking about!”

Louise’s view was that the other skills you bring are far more important. “One surprising thing I think is that you don’t have to be tech experts to do this role. It’s more about leadership and engagement” she said.

Even those who did consider themselves techie, didn’t think it was required for the role. “When my friends were out buying designer shoes, I was out buying the latest gadget” recalled Hayley “but we’ve got our experts in tech in our technical people, and I never profess to be technical. I always ask them to talk to me in layman’s terms.”

James also talked about a techie background, but he didn’t see it as a requirement “I was one of those who built my own computer when I was much younger, yes. But you don’t need to be a techie person to do this job. The thing that was required more than anything else was to be a senior nurse that carried the confidence of the organisation”

And even Paula, with a professional background in software as well as nursing, didn’t see it as essential. “I do see myself as a techie. But that’s a personal interest, not an organisational requirement”

The fact that you are now working across all different areas of nursing comes with a steep learning curve. James explains “I had to go and do shadowing shifts in outpatients, I had never worked there, not even as a student. And even now I’m not the expert in those areas. But I’m going to experts in that field and asking “What is it that you want in this area? How does this workflow work?” What I can bring is that I can do these things, I can make these things happen.”

Sarah N also had a steep learning curve, despite all her experience. “For the first 12 months it was one of the biggest challenges of my entire life., it was a real career change in many ways. But as you settle into the role, you realise actually you can do that, with your clinical knowledge and your clinical background.”

But James also reflected that this, in some ways, isn’t so different from other learning and development journeys that nurses go on. “It’s another specialism. Like ED is a specialism and ITU is a specialism – CNIO or digital is a specialism effectively. You could say and you need to know your product like you would know your patient presenting complaint or your pathophysiology in a particular clinical specialty. Whatever your product is, whether it’s Epic, Cerner, Allscripts doesn’t matter so much. But when you’re using it, you have to know it, to be credible.”

Many of our CNIOs hold very senior nursing roles – Associate or Deputy Director of Nursing – alongside the CNIO title. “I don’t think you can be a junior nurse going into a CNIO role. This is a senior nursing role that happens to focus on digital, not just a digital role” said James.

Simon specifically mentioned the need for management experience at the very least. “I think it is quite important to have had a management role or at least a senior ward role, because you need to know how to deal with people, work with people, deal with management. You need to understand the pressures of what’s going on in any organization in order to be able to translate what you’re doing into effective digital solution”

Part of that senior role can also include the professional and personal network it can bring. “It’s certainly helped that I was a known commodity in the organization” James added.

Many of the CNIOs talked about being the connection between nursing and informatics, with a foot in both camps. “My technical team can do the technical build, but I’m able to bridge the conversation. I am the translator between the technical team and the clinical team,” said James. This view was echoed by Simon. “We’ve managed to create a culture where we have a really close relationship with our technical side, so we’re acting as a bridge now between the between the clinical side bedside, clinical nursing, but also helping the technical side for the system, build, configuration. So we can act as interpreters for both sides.”

While you might think this would lead to cultural clashes, this way of working has been embraced. “My favourite thing is definitely the nursing informatics team. They are the most amazing people, and we have great fun, amazing conversations. They’re highly skilled, highly talented, just wonderful people. And  I’m really, really proud of them and all that we’ve achieved as a collective” said Louise.

And being a nursing voice in informatics brings real benefit to nurses on the wards. Jenny explains that “previously people out in the wards felt things were being “done to them”, technology was given to them and it doesn’t work, it doesn’t do what we want it to do. They wanted somebody that could be that nursing voice and I’ve stayed true to that – I’ve always stuck with what the brief, to be the nurse, to be the voice of nursing and patients”.

“When you’ve done that sort of trust-wide implementation with a big bang EPR, everyone just associates you with that piece” says Sarah “But actually there’s now more about that innovation, having that vision of what what’s the possible.”

And even the work that involves the EPR isn’t just about the EPR. “I do a lot of work in the core EPR but that is the data that feeds our business reporting” said James.

The isolation of the role within any one organisation was noted by several of the panel. “It can be very lonely at first, because quite often the organization you’re working with don’t understand what the role is, what you’re trying to achieve and even the purpose of it,” said Hayley.

But this seems to be more than balanced by the community of CNIOs and digital nurses nationally.

“One massive thing for me has been the networking with other CNIOs” continued Hayley, adding some of the direct benefits this can bring. “We’ve realised that we were reinventing the wheel – for example, we’re all writing safety cases for the same technology”

And there’s a comradery from the change that CNIOs are going through together. “I think I’m really lucky to be part of the group of CNIOs I am now because we’re a bit on the crest of a wave,” said Lisa.

Even for experienced nurses, the CNIO network stands out. Lisa added that “I’m used to be in part of national and regional networks. But I have never been involved in anything so friendly and such a lovely and supportive place to be part of as this CNIO network. I’ve always believed that you should look out and not just in, so I’ve always looked for networks, but I’ve never been part of one that was as massive as this.”

Sarah N cautions that, while the networks are amazing, it’s not automatically offered to you “You have to be able to access those networks, you have to go looking. And I think if you don’t know where to start, that is one of the challenges for some people.”

But Louise’s advice is that this shouldn’t discourage you. “There’s some great people out there, so connect with the people who are already doing it. Don’t worry if you haven’t been involved previously, there are plenty of opportunities for development and learning.”

Anna’s advice is to leverage that help “Just remember that there are people there to help, people out there that might have already done it. It’s about lessons learned, learning from other people so that you can do it better. Look for people that are mentors and try and see if they can help you in your journey.”

Louise also encourages mentoring. “Alongside looking at new education opportunities and broadly getting involved, do also try to get a mentor. There are people that are already in digital leadership roles in nursing, at all levels” she advises. And James speaks from personal experience – “I’ve had some very fortunate mentorship in this as I’ve grown up”

The national leadership, and the regional groups too, seem to have helped with the community and coordination discussed above. “We’ve got regional CNOs now that Natasha Phillips has implemented, which is great in bringing the regional teams together,” said Hayley.

“Working with Natasha and her team at national NHSE level, gives you better insight in terms of population health, how we use data to make a difference, and how we can support each other“ said Sarah N, herself CNIO for the London region. And Louise agrees, “I think it’s really very helpful having a national CNIO, and the ‘What Good Looks’ Like framework will enable us to have that common language and common mission at the same time.”

And it’s not just that these national and regional roles are important for nurses themselves, but for the wider importance of digital nursing. “This now puts nursing right up there, alongside Chief Medical Information Officers” said Sarah N.

“I don’t know if it was a conscious decision” said Hayley “Originally, I was getting involved just as an intensive care nurse, and I ended up being the nurse lead for the implementation of a localised EPR. When they advertised the role of the CNIO, absolutely I was interested, interested in the role, but it was quite a big bit of a jump for me in terms of banding, but my boss at the time really encouraged me”

Lisa tells a similar story “My journey to digital was an accident” she said. “I was on the periphery of the implementation of our e-observations very much from the perspective of getting what we needed as nurses to support our patients, but not the digital end per se.” But that accidental start led to her falling in love with the role. “By the time the ADN post came out with CNIO in the title… nobody else was getting that job. That job was mine, I actually wanted it. And that was quite a journey, from being “Why would I want that?” to “that’s absolutely nobody else’s job but mine”.

This seems to be a common thread. “I hear a lot of this from CNIOs – people tend to fall into the role,” said Hayley.

Sometimes it’s direct interaction with the need for digital that began the journey “I was head of nursing for corporate projects working on standardising paper processes for documentation, streamlining everything we had. And it really shocked me. We collected a paper document from every single ward for every single thing they did, we laid it out across the floor and found that we had 97 discharge processes and 20 odd fluid charts. And that’s when I started thinking, how could we actually build this into the system going forward,” said Jenny.

James tells a similar story. “We were doing the go-live for Cerner, I was there as the Matron not the IT person. I got to be involved in the updates, and became the lead for Emergency Services, and then the CNIO job came up and it went from just in the ED space to across everything”

Lisa explains the link “I’m associate director of nursing for patient safety, as well as being chief nursing information officer. But the two link because a future for improving patient safety is absolutely entwined with digital, because that’s how we close a lot of the gaps.”

Louise also sees a firm link with quality improvement. “My role was in development (and still is), so the thing that really attracted me to digital was the opportunity to be able to use that, to explore technology for nursing education and quality improvement. If you’d asked me this even 10 years ago, I wouldn’t have expected to be doing this, but it’s so stimulating, it’s so amazing.”

And Anna’s journey came from transformation, and she credits the experience and skills she brought from there. “I started off in transformation, and there you’ve got to work with a lot of people from different backgrounds within the health setting, working on various projects. Watching nurses work the way they have to, no one questioned why there was a lot of duplication – what shocked me was the effort nurses and HPS have to do with some of these processes. So bringing digital to those projects meant that we were able to streamline the work that they were doing.”

“I took a secondment to be a EPR trainer, and I loved that whole training and engaging people, then took on a role, to be a systems designer within the IT team. I did a little bit of a business workflow re-engineering systems design, and that’s when I fell in love with technology and digital” said Paula, who then ended up going far deeper into a technical career. “I’ve had an unusual career structure, including eight years working for two different suppliers. I learned to code, through to being an engineering manager running the software team, which was fascinating.”

Sarah N said that “on reflection, I think digital has been part of my whole career. I’ve been nursing 30 years, originally in intensive care, but I really stepped into digital was when I moved into more of an operational role. I realised we didn’t have the tools we needed, and I implemented the solution – where I won the Digital Pioneer Award for Digital Leadership. Our organization announced that they were looking to implement a trust wide EPR. And for that they required a CNIO, and I was approached to apply.”

And Simon’s time in digital now spans two decades. “I actually had my first digital role in about 2001, 2002. We were one of the first ICUs to use a dedicated patient workload systems, and I was asked if I would take over, and that flowered into procuring an updated system, hardware, training – everything. From there I moved into electronic blood transfusion processes, which timed with transitioning as an organisation into an EPR. Then in 2016 we applied for a Global Digital Exemplar programme, the organisation created the CNIO role and it just seemed a natural progression”

Put yourself forward and find ways to be part of digital. “Just get involved in the change” advises Hayley.  And Lisa agrees, “I’d say absolutely do it, if you already have a passion for it then that’s brilliant”

And do not be held back by any fear of the technology. “I think the tech is such a small part – it’s the change management side of the role and that engagement and being having a vision for what you want to improve” says Hayley. Anna adds that “it’s important to embrace it and to not be shy of it. You do not have to be an expert in an area, it’s just having that drive, the zeal to work within that digital space”

Louise suggests a simple stepping stone. “If you’re wanting to get involved, you can dip your toe in the water by being a super user, get the training to do that, and build your confidence”. And it’s even better to anchor this off your existing interests. Louise added that “if there’s something you’re passionate about, get in touch with your CNIO and make yourself known because there are plenty of opportunities”

There’s also a lot of people you can turn to and learn from online. “Twitter is massive for digital, and the networks are so supportive, all across the country, and you can see the next generation of CNIOs coming through” said Lisa.

In the end, it will involve trying something new, and that can be scary. Jenny recalls that “I think you have to sometimes take a leap of faith in yourself and really go for it. Somebody had faith in me when they said that they didn’t need me to be a technical person, because otherwise I would never have considered this role”

Paula explains that “It’s not necessarily all just about nursing documentation or nursing, nurses can play a wider part in the digital and technology agenda. We have a skillset for running wards, making decisions and risk-based assessments. We’re used to dealing with timelines, we bring different thought processes to the table. We have a whole skill set that we don’t necessarily recognise as being transferable skills.”

Simon also thinks that some of the wider skills that nurses can develop can be excellent foundations for digital roles. “Having things like project management, process or QA training is really good, because it means that when you’re looking at implementing or trying to understand how clinical workflows work, it gives more of an understanding of what impact those changes may have, and the dependencies of those changes.”

Jenny saw a major change when she successfully applied for a DigitalHealth.London Digital Pioneer Fellowship.  “I just thought it was a great opportunity, I really enjoyed it. A lot of it is around networking, meeting people with other roles within healthcare and hearing about their experiences, we all learned so much from one another. The second part was about being able to have permission and time to focus on a specific piece of digital work, because we’re so busy all the time.”

But this doesn’t have to be outside your organisation. Jenny explains that at St George’s “we have allowed people to be seconded over. So if clinical people are interested in digital, we can bring them over into our department for six months to spend time with us, you can dip your toe in and have a go.”

And it doesn’t need to be that big a commitment. Sarah suggests that you can “reach out to your informatics teams. We’re quite lucky, most organisations have an informatics team now. Spend some time with them, even if it’s just for a few hours, to try and understand what those roles might be, but also look for opportunities to get involved with projects. There’s lots going on out there that does need nursing input”

And CNIOs, and digital nurses in general, love when they get that extra engagement from nurses interested in technology. Hayley says that “one of the most exciting parts of the role is someone coming to me saying, look, I’ve got an idea, what technology out there is that to help me? Or I’ve got this piece of technology I want to implement, how do we go about it?

Most of our panel reflected on the need to formalise the education programmes for digital nursing, from the very beginning of a nurse’s education – taking digital nursing into the very mainstream of nursing.

Jenny’s suggestion is that “technology should be embedded pre-reg, as part of the curriculum. I’d love to have students coming in as part of their placements in the organisation, so they can start thinking quite early on. Not only how technology is going to enable them to do their job, but even that it could be a career pathway going forward.” Sarah sees a similar challenge. “What are we teaching in universities about digital at the moment – sadly the answer is “not a lot”. It’s not necessarily about the specific type of EPR. It’s, it’s more about how do you document digitally? Why is data important? How will data benefit my patients?”

And this doesn’t just stop when nurses qualify. Lisa believes that “we need to start preparing our junior nurses for digital roles now. And so now we’ve got a digital development nurse posts in our teams at all levels, at (band) five, six, seven, and eight, so we’ve got that whole career structure for people. And that wasn’t there for me. So I think it’s about that career structure, but nationally there is a real drive to put that in too.”

Sarah sees this as needing formal recognition too. “I think we also have to look at accreditation and appropriate nursing qualifications. So that digital nursing is recognised by the NMC in the same way that other types of specialties are.”

And Jenny reflected on what this means as an entire career path. “Further on, in the nursing career pathway very often you think, as a nurse, do I want to go into leadership and management, or into education and training, or research, or become a nurse specialist. There’s are all those traditional routes, but now we need to add technology, because it’s so important”

But there are signs of change coming here too, with new roles that Sarah is introducing at GOSH. “I’m excited that we have been talking about Advanced Clinical Practice roles for digital, which is a new concept, we’ve not had them before. We’re in early conversations, but they could raise the profile and provide a pathway for nurses to get into digital roles and then subsequently into CNIO roles. Because at the moment, having done it, it’s a very big leap from an operational role, even at a senior operational level, into an informatics role.”