Knowledge Natter Q&A with Nicola Lakeman

Our Knowledge Natter’s feature friendly and informal discussions with our knowledgeable champions and those who are empowered by quality improvement in their work; from veterinary surgeons, to veterinary nurses, receptionists or members of management and Quality Improvement. 

In this Q&A, Lou Northway, clinical lead RVN at RCVS Knowledge, spoke to registered veterinary nurse, Nicola Lakeman, whose team have been named Knowledge Champions.

Louise Northway:

I'm absolutely delighted today to be speaking to a very influential Registered Veterinary Nurse, Nicola Lakeman, who I'm sure many of you already know. Nicola and her team were named Knowledge Champions in 2021, for their absolutely amazing work around canine aural cytology. Plymouth Veterinary Group, which is an IVC Evidensia practice, alongside CVS Small Animal Team, were jointly awarded practice champions for their separate ear cytology audits.

Plymouth Veterinary Group created guidelines for performing cytology on patients presenting with ear pathology, utilising the whole team's skillset to improve patient journey for a common and often persistent presentation. The application showed a bottom-up approach, increasing training, utilising the Registered Veterinary Nurse skill sets and demonstrating strong evidence that their changes led to an overall decrease in the number of antibiotics prescribed. As you can hear, a really positive project all round. Hi, Nicola. Thank you so much for joining us today.

Nicola Lakeman:

Hi, thank you.

Louise Northway:

I've got so many questions I want to ask you. I think we'll get cracking with, where did your inspiration for this particular project come from?

Nicola Lakeman:

Well, I'm going to say, it wasn't inspiration as such, it was an arm twisting, because I actually did it as a project for one of my modules. I completed the Advanced Vet Nurse Practioner Masters Degree at Glasgow University. For the Quality Improvement module we had to write a protocol. After a few lunch and learns in practice, I decided to write a protocol on ear cytology.

The module for university was just to write a protocol, it wasn't implemented. But I thought, "You've just done all this CPD, just spent all this time writing your protocol. There's no point doing CPD unless you then take it and run with it and do stuff with it." So yeah, we implemented it in practice. We got some of the other nurses, the nurses that were interested and wanted to do it, we got them, got some CPD on board. We got some sponsorship for it and went from there, really.

Louise Northway:

Amazing. Did you have to get any new equipment? How did you do your training with the team that wanted to get involved?

Nicola Lakeman:

The pharmaceutical company that did the initial CPD, we went back to them and said, "This is what we really want to do. Could you help?" And they actually came to the practice with multiple microscopes.

Louise Northway:

Woo hoo!

Nicola Lakeman:

Yes, they were amazing. And we did a session upstairs in the office, so lots of different work stations. And we all looked down the microscope and we could see whatever it was that we could see. We could talk between each other and confer. It was a real group CPD lab session, for me it was great fun. So yeah, using the pharmaceutical company, it sounds awful using them, but we did, just to get that training on board. But also, because we did the training together, it helps that team bonding sort of thing. But it also creates standardisation, which I think is really important.

The standardisation would then occur, that we all were looking for the same thing. We all know what the same thing looks like. Our microscope, in practice isn't that good. And I'm going to say most people are a bit like, "Oh, our microscope's a little bit rubbish." We got the guys in to service it. They were like, "Yeah, it's absolutely fine." I'm like, "Please, can you show us how to look after it properly?" So, we did that.

We actually did so well with our cytologies and making sure we were booking them out properly and all the rest, that our clinical director was actually like, "Would you like a new microscope? Because you've done so well." We got a new microscope and it's even got a little tablet on the top, so we can take digital pictures of what we see and then that can be attached to clinical histories, so there's a visual record. Because I think that's quite important for those sorts of things.

Louise Northway:

Yes, because you could really think of that idea as well for things like wounds. If someone sees a post-op check back three times and you have to interpret clinical notes, it's very difficult. Whereas a photograph is so handy and helpful, isn't it?

Nicola Lakeman:

Yes, definitely. Dentals as well. Any dental procedures just take pictures before and after so you can show clients. It's excellent.

Louise Northway:

Did you and your team have that, "Why haven't we done this before," moment?

Nicola Lakeman:

I think everyone does at some point, don't they? They're like, "Oh why didn't I think of that?" And I think that's what I love about Quality Improvement. And you say to people, "We need to do quality improvement," it doesn't mean you weren't good to start with. 

Improving means you weren't that good and now you're getting better. I think loads of practices are already really, really good. They just don't realise that they're doing it and had a name put to it as such and they're doing it already. I think anything that encourages other nurses, other vet practices to do it, yes, go for it.

Louise Northway:

Oh, it's like music to my ears listening to you there. So how did you go about collecting your data?

Nicola Lakeman:

Oh, so for those that don't know, I'm a clinic nurse and I love doing clinics basically, that's my job. And one of the things I find with consulting is you have to be able to reflect on what you do. How else do you know you're getting better at something? I'm very good at pulling off information from the computers. I use our practice management system really well to do certain things. Since we've been part of a corporate group, I'm not allowed to have my weird and wonderful things on the computer. But my clinical director is actually really, really good at making predictive text things.

As long as we have an item and it's booked out, I can search for something. There is a microscopy ‘A’ fee on our computer system, which is what we decided our ear cytology was going to be. It's really easy to search for it. It's just a case of knowing how your practice management systems work and how you can pull that information off. Anything that makes your life easy is always good, because you're more likely to do it.

Louise Northway:

That's fascinating. I completely agree, collecting data can be quite difficult if your system isn't set up. But you can make it simple by doing things manually yourself as well. Just not probably for your particular project but tally charts and things like that just to tick off when something's being done.

Nicola Lakeman:

Yes, definitely.

Louise Northway:

And so you implemented your new regime and you started collecting your data. How did you share the outcomes from cycle one with your team and what were their reactions like?

Nicola Lakeman:

Well, as with most things in veterinary practice, I think this is a really good lesson to share with all people that try and implement things or start new projects. We started this in 2017, so four years ago. And for the first year, despite me going, "Please recommend aural cytologyies, please do this." Nothing really happened. It took quite a long time for all the things I'd put into place to actually start fitting into place. I think with some of the team it just took a little bit of time to remember it. Some people just needed a little bit more confidence in using the microscope and then once they'd done it a few times they could really run with it. It took a good year before we actually started seeing anything happening. And then once it did, you feed those results back, it just snowballed, it really, really did.

Louise Northway:

Yes, and I bet from the clients' perspective as well, it was a much more... Well, a quicker result wasn't it for the client to know what was wrong with their pets. They didn't have the normal delay. It was more efficient too.

Nicola Lakeman:

Yes, I mean hand on heart, some of the ear cytologies weren't done within the time of the consultation. But I'm going to say the majority of clients are more than happy to go home and we would phone them and say, "The vets actually recommended an ear cleaner rather than their antibiotic, because we have yeasts present rather than bacteria. Did you just want to pop up and get some more ear cleaners and go from there?"

Louise Northway:

Yes, such a brilliant service. And what would you say to nurses who think, "Oh, I would actually really like to do this myself," how would you recommend they go about talking to their line managers?

Nicola Lakeman:

Well, because every practice is slightly different and what I think worked really, really well with this practice, it was a team project. We tend to find with quite a lot of clinical audits and QI, the few that are really interested can be very vet led with some things. But this really involved the whole team. It involved the receptionists and how they communicated with the clients to start with, setting owner expectations, the vets communicating, the nurses being utilised to do what they want to do. I think from the perspective of nurses or other team members wanting to implement things, is to think who is this for? Is it a team thing? Who's the best person to talk to? I think it's important to remember that your ANAs, your students and your receptionists are as important for quality improvement as the veterinary surgeons are or the RVNs. It's a team thing and getting your team behind you helps keep your motivation up. It really helps those bonds that you have within the practice and that's when you succeed the best, I think.

Louise Northway:

Yeah, I completely agree. I have the same experiences sharing outcomes with the team when we have made improvements. It's really motivating for everybody. And then they start thinking, "What can I do? What can I change? What can I improve?"

As you say, then it snowballs and we want lots more snowballs broadly in the profession.

Nicola Lakeman:

Yes.

Louise Northway:

Along the way it was largely a really positive project, but did you encounter any issues?

Nicola Lakeman:

Like I said, it took us a good year before we did anything and I think it could very easily have not... Well, just failed really. It was just me going, "Come on, come on." Nagging, really. I'm quite good at that.

Louise Northway:

That's a top tip for tonight. Nag everybody.

Nicola Lakeman:

Just like the equipment not working, ironing that out, and raising everyone's confidence in using the microscope. I'm not going to say competence, because I think all of them are competent using the microscope. They just haven't got that confidence.

We all remember or have been in a position where we ask someone to look at something under the microscope and they're like, "Oh, I think it's this but I'm not too sure." You have to Google the picture of something just to have a little look or you go get someone else, don't you? Just to have a little look. I think all of my nurses are competent in doing it. We just needed to build their confidence a lot more. So yeah, we did have a few hurdles and I'm not going to say it was completely an utterly smooth process, and it did take a lot of time. But I think we got there in the end. That's important, I think.

Louise Northway:

Yes, small bumps in the road are all part of it really, aren't they?

Nicola Lakeman:

Yes.

Louise Northway:

Sometimes you will try a certain way of doing whatever you are doing, it doesn't work out, so you just have to redirect a little bit.

Before you did this particular project, what do you think your team's opinion of QI was and how do you think it's changed now?

Nicola Lakeman:

I'm going to say, we've been part of the Practice Standard Scheme since it began, because we're a hospital, we were a hospital accredited beforehand. So that part of clinical governance and QI has always been there. But I think it was very much something that the vets did in order to tick the box for the Practice Standard Scheme checklist. I think now that we've done a project which has the  whole team involved rather than just a few individuals that, like you said, they just want to be more involved. They want to do something, the receptionists want to do something to do withclient satisfaction and those sorts of things. They're like, "Oh, we could do this, we could do that." I think having a project which is very team orientated has made quite a difference.

Louise Northway:

And it's really fun as well, isn't it?

Nicola Lakeman:

I think it is, yeah!

Louise Northway:

When you hear clinical governance, you think to yourself, "Gosh, that sounds quite serious."

Nicola Lakeman:

Yes.

Louise Northway:

And of course elements of it are, but actually the projects within Quality Improvement can be really fun and engaging. And I think it always explodes all the ideas, you have one little thing you think you might do and then, "Oh, we could do this." And like you mentioned a moment ago with the client care team, if clients are complaining, what themes are they complaining about? What is it specifically and what can we do to improve things? You've done this project, which you've got an award for, so congratulations again.

Nicola Lakeman:

Thank you.

Louise Northway:

Get my QI pompoms out for you all. What aspirations do you and your team have for the future? What's next?

Nicola Lakeman:

We've got a few in the pipeline that we're already doing. We've been looking at blood pressure monitoring, differences between using a doppler and an osscilometric, and patient outcomes. My surgical nurses will do blood pressure before they do the surgical stuff. I don't do any surgical stuff. They do blood pressure before and we've been looking at how many of those are hypertensive, what are the outcomes, what happens? That's something that we're doing currently. Bigger picture, as you already said, our practice is part of IVC Evidensia, so we already run a journal club in our practice to help that evidence-based knowledge and talking about what evidence is out there. But we've been looking at opening our journal club to other practices. 

There's a million ways to do something. Talking to other practices, so IVC, we are really looking at opening a journal club for all nurses. There are nurses that work on their own. Who do they get to talk to about Quality Improvement and evidence-based medicine? We really want to create more of a community so we can share QI ideas. I'd love it if someone in one practice has done an audit and they've written a protocol and they give it to another nurse in another practice. You don't have to worry about writing these protocols or creating these spreadsheets. That's why Ilove RCVSKnowledge with their Canine Cruciate Registry. It's already there for you so you can put it into place. I think we really need to share a lot more and hopefully we can do that.

Louise Northway:

That's lovely. An inclusive learning collaborative environment with everybody.

Nicola Lakeman:

Yes.

Louise Northway:

I think that's so important. And we forget when you work in a busy practice like you and I do, you take for granted, don't you, as you say, having someone to talk to in a team with lots of team members to share experiences with and there will be nurses and vets who are two-man bands, so to speak, who may be missing out on having that influence. It's a really, really positive thing if we can do more collaborative journal clubs.

I wish I was down your way. You're a little bit far away from me, for me to drive down. To finish off Nicola, what words of advice do you have to any veterinary professionals listening?

Nicola Lakeman:

I'm going to say I don't think there's a right or a wrong way for Quality Improvement. And I'm going to say most of you are doing it already, you just don't realise you're doing it. And just because someone suggests something, it doesn't mean you're not doing well already. Just start small, just start with something really easy.

I tell you what's really good from a nurse consulting point of view, it tells you what the answers are. For those nurses that are looking at post-op surgical sites and you're a bit, "Ooh, I don't know what to do with that, should I get a vet involved? Should I..." Score it and have a protocol in your practice. If it scores above a one, then you get a vet involved, or if it scores above a two get a vet involved. If it's a one (normal) or a two (abnormal no treatment) then you're fine. It gives you guidelines, it gives you structure for what you can do. Start small, but that's brilliant about QI, it's inclusive and everyone can do it.

Louise Northway:

Yes, every single person. Just so everyone knows, Nicola is referring to the National Audit of Small Animal Neutering. And that is a spreadsheet that you can download from the RCVS Knowledge website on which you can record your patient's data and then submit your audit data at the end of every month to RCVS Knowledge. And that will be benchmarked against all the other practices in the UK, so we all know how we're doing. It's a really good thing to get involved with. Very straightforward, very simple, and a very good place to start. 

Nicola, thank you so much for spending some of your day with me today. I really appreciate it. You're an inspiration to us all. How many more awards and strings to your bow do you need? You're amazing.

Nicola Lakeman:

Thank you.

Louise Northway:

And your team is awesome too, so thank you so much. 

Award winners are named as RCVS Knowledge Champions and will receive a plaque for the practice, badges for you and your team if applicable, and £250 prize money to spend how you wish. More details are available at here