Nursing Week 2019 poster gallery by St. Michael's Hospital

Using Responsive Behaviour Language and De-Escalation Strategies in the ICU to Improve Staff and Patient Safety Amanda Keating RN, BN St. Michael’s Hospital, Unity Health Toronto

FOCUS This project aligns with the following RNAO Best Practice Guidelines: • Preventing and Managing Violence in the Workplace • Delirium, Dementia, and Depression in Older Adults: Assessment and Care • Promoting Safety: Alternative Approaches to the Use of Restraints • Engaging with Clients who Use Substances

BACKGROUND

• Responsive behaviours, “… is a term that is often preferred by persons with dementia, mental health, substance use and/or other neurological disorders to describe how their actions words and gestures are a response to something important in their personal, social or physical environment.” (Alzheimer Society of Ontario, 2017) • Responsive behaviours, “…may have an identifiable pattern, such as occurring at a specific time of day, after a particular activity, or with a specific person.” (Wolf, Goldberg & Freedman, 2018) • Identifying the potential triggers of the behavior can lead to appropriate treatment, understanding the communication of the patient, and therefore decreasing the frequency of the behavior. • Medical Surgical Intensive Care Unit (MSICU) patients exhibit responsive behaviours and staff need more education to prevent and manage responsive behaviours in patients. • At St. Michael's Hospital (SMH), the Managing Responsive Behaviours (MRB) program, inclusive of tools and processes, has been implemented in all inpatient units but not in critical care areas. • The aim of this initiative is to develop and implement tools and processes to reflect the needs of MSICU patients exhibiting responsive behaviours.

PROCESS

Literature review and internal scan

TOOLS

Figure 1: MSICU MRB Algorithm

• Literature found was not often based on the critical care setting. • Reviewed existing tools and materials being used in other units throughout the hospital and assessed their applicability for MSICU’s patient population and nursing workflow. • Liaised with subject matter experts from other disciplines and units with regard to management strategies for responsive behaviours.

Assessment of knowledge gaps of MSICU staff

• Created a survey for MSICU RNs to identify knowledge gaps, areas of improvement, and learning needs of the staff. • Adapted the corporate algorithm in response to survey results, MSICU patient population, and MSICU workflow. • Adapted assessment and documentation tools from other units to one documentation tool that facilitates the identification of responsive behaviour risk factors, triggers, and allows for the tracking of behaviours and successful interventions.

Staff education

• An education presentation was created for staff RNs, on the topic of responsive behaviours and interventions to manage them. This presentation provided the opportunity to introduce the created algorithm and tool to the staff.

Pre- Survey

Figure 2: MSICU MRB Care Plan

• 48 completed surveys received, a response rate of 34%. • Survey consisted of multiple choice and free text answers.

Purpose • Identify learning needs of staff and provide education on the prevention, identification, and management of responsive behaviours in the MSICU.

Objectives: • Staff were knowledgeable and able to identify the majority of the interventions used for patients displaying responsive behaviours. • Staff identified that we have many assessment tools, but nothing to guide the staff on what the next steps are, or a clear pathway for management of this specific patient group. Staff requested an algorithm of interventions.

• Continue to provide education until completed with all full time and part time staff. • Finalize draft of algorithm and assessment/documentation tool. • Trial the use of both algorithm and assessment/documentation tool with patients with a history of, or current presentation of responsive behaviours. • An end-user survey will be given to the staff RN of the selected patients, to assess the usability of the algorithm and tool. • Based on results of end user survey, will make changes to the tool and algorithm. • During education sessions, staff requested for an alert sign or symbol for patients displaying responsive behaviours. The goal for this alert is to decrease the risk of behavioural events, and improve safety for staff who are not familiar with this patient. We may adopt 9CC’s current symbol, the “purple diamond”, to maintain consistency throughout the hospital. This symbol will be posted outside of the patient space, such as door to room, to alert all hospital staff to check with RN before entering room.

REFERENCES

PURPOSE & OBJECTIVES

• Conduct a literature review and internal scan of practices in other units. • Assess the gaps in staff knowledge about responsive behaviours. • Create tools for MSICU staff to facilitate the identification and management of responsive behaviours, and to develop patientspecific care plans.

• The MSICU tools were developed based on pre-survey results, review of existing SMH tools and review of literature. • Currently, education has been provided to 66 RNs, 47% of full time and part time staff RNs. • Staff education sessions have introduced the language of “responsive behaviours” into the unit practice. • Education sessions allow staff the opportunity to bring up questions about the presentation and concerns/suggestions with the algorithm and assessment/documentation tool.

NEXT STEPS

Development of tools to support MSICU practice

RESULTS

CONCLUSION

• The goal for use of these tools are to identify any patterns of behaviours, effective interventions, and assist in creating patient specific care plans. • “Because every patient is different and how the patient will respond to a given strategy is unknown, ongoing monitoring of the intervention’s effectiveness is imperative.” (Wolf et al., 2018)

• Alzheimer Society of Ontario. (2017). What are responsive behaviours. Retrieved from https://alzheimer.ca/en/on/We-canhelp/Resources/Shifting-Focus/What-are-responsive-behaviours • Hallett, N. (2018). Preventing and managing challenging behavior. Nursing Standard, 32(26), 51-63. • RNAO. (n.d.). Guidelines. Retrieved from https://rnao.ca/bpg/guidelines • Toronto Academic Health Science Network. (2016). Person Centered Language for Responsive Behaviours. 1-15. • Wolf, M. U., Goldberg, Y., & Freedman, M. (2018). Aggression and agitation in dementia. Continuum Journal, 24(3), 783-803.

ACKNOWLEDGEMENTS

Brigitte Delaurier RN, MN, CACCN (C) Cecilia Santiago RN, MN, CACCN (C) Melissa Guiyab RN, MN

Creating a Culture of Wellness and Positivity in the CVICU Arshia Najikhoie, Michelle Williams, Orla Smith Cardiovascular Intensive Care Unit, St. Michael’s Hospital, Unity Health Toronto

FOCUS • This project focused on the following recommendations from the Workplace Health, Safety, and Well-being of the Nurse Best Practice Guideline (BPG): • Recommendation 3.3 • Promote and support initiatives related to the physical and mental health and well-being of the nurse • Recommendation 3.4 • Organizations/nursing employers provide nurses with opportunities for personal, professional and spiritual development with regard to healthy work environments, professional competencies and work/life balance. • This project leveraged previous BPG work in the Cardiovascular Intensive Care Unit (CVICU) on health and wellness.

THEME 1

G R A T I T U D E

BACKGROUND • CVICU nurses care for critically ill patients, and manage high patient throughput from the operating room (OR) to the ward on a daily basis. • Nurses in the CVICU are interested in participating in health and wellness oriented activities. • Prior work indicated unit-based activities are preferred to offunit opportunities.

PURPOSE & OBJECTIVES

THEME 2 G I V I N G

• To engage nurses and the broader interprofessional team in a number of targeted activities to promote a culture of wellness and positivity in CVICU

B A C K

INTERVENTION/PROCESS • Wellness initiatives for CVICU staff were identified and coordinated between November 2018 – March 2019 • Our wellness initiatives were categorized as follows: • Expressing Gratitude • Giving Back • Self-Care

• In the month of November, the unit participated in 30 Days of Gratitude as part of the #YearOfCalm • A daily message was sent to staff from the Calm Mindful Living Calendar electronically and posted in the unit • “Inhale and think of something you are grateful for. Exhale gratitude. Repeat at last 5 times.” • A Gratitude Box was placed at the nursing station and staff were encouraged to make note of things they were grateful for at work. • Handwritten messages from the Gratitude Box were transformed into leaves on a tree which greets staff and families on entry into the CVICU. • In the month of December, we celebrated 10 Days of Holiday Heart. • Each staff member in the CVICU was assigned a number, and a random number was selected every day for 10 days to receive a gift.

• In the month of December, donations were collected for the following charities: • Daily Bread Food Bank • Over 400 lbs of food was collected • Shoebox Project • 19 boxes (each valued at ~$75) were donated to homeless and under-housed women in Toronto during the holiday season • In the month of March, the unit participated in a Period Poverty Drive. • With donations of cash and menstrual products, we created over 100 period packs for The Period Purse, a non-profit organization to support marginalized women who struggle to afford these necessities. THEME 3

S E L F -

C A R E

• Weekly TED talk series • Free access to the CalmHealth initiative for health care professionals, including meditation sessions • 10-minute mindfulness sessions in the unit • Night-time room bookings for exercise/yoga • Regular reminders about massage at work appointments

RESULTS

97%

• Nurses were invited to participate in a quick 5-item survey on use of the Calm App. • Among 28 respondents:

46%

Downloaded Calm App for personal use (n=13/28)

67%

Agreed or strongly agreed the Calm App promotes relaxation (n=18/27)

57%

64%

Reported use of the Calm App (n=21/28)

85%

Agreed or strongly agreed the Calm App alleviates feelings of stress (n=17/27)

• Nurses and other members of our interprofessional team (including students and physicians) were invited to participate in unit-based mindfulness sessions and complete a pre-post survey (n=27 surveys completed) • Session themes were as follows: • Self-compassion (5 mins 57 secs) • Marshmallows (11 mins 5 secs) • Kindness at Work (10 mins 58 secs) Feeling tense, nervous, restless, or anxious Before

• 70% responded somewhat or to a great extent • 30% responded not at all or very little

After

• 7% responded somewhat or to a great extent • 93% reported not at all of very little

Felt closely connected to the present moment (n=26/27)

Noticed thoughts come and go (n=23/27)

78%

Were aware of different emotions arising (n=21/27)

74%

Noticed physical sensations come and go (n=20/27)

RECOMMENDATIONS AND CONCLUSIONS

• Our wellness initiatives were well-received by nurses and members of the interprofessional team. • Short, unit-based mindfulness sessions are feasible and valuable during the workday. • We continue to plan and implement initiatives in the domains of gratitude, giving back, and self-care to support health and wellness.

FOR MORE INFORMATION

• • • •

www.calm.com www.dailybread.ca www.theperiodpurse.com www.shoeboxproject.com

ACKNOWLEDGEMENTS https://minoritynurse.com/5-ways-meditation-can-help-you/nurse-meditating-jpg/

We wish to acknowledge the interest, enthusiasm, and generosity of the staff in the CVICU.

Standardizing Transfer of Accountability from Post Anesthetic Care Unit to Inpatient Units Andrea Richards RN, BScN, Wendy Legacy RN, MSN, CNN and Theresa Baptiste-Bruno CLM St Michaels Hospital, Unity Health Toronto INTERVENTION/PROCESS

FOCUS Implementation of a standardized tool used during telephone Transfer of Accountability (ToA) between the Post Anesthesia Care Unit (PACU) and inpatient units • Recommendation 2.2: Use effective communication to share client information during care transition planning • Recommendation 3.2: Use standardized documentation tools and communication strategies for exchange of client information

• Stakeholder engagement, e.g., ToA Subcommittee • Pre-survey was distributed to elicit PACU RNs perspectives December 2018 -February • PACU Intrahospital TOA tool was developed using RNAO guideline for 2019 Transition of Care and National Association of Perianesthesia Nurses of Canada Standards of Practice

RESULTS

CONCLUSION

Pre-survey Results (n=19)

• A standardized tool allows for consistency during ToA. • Including the PACU RNs and other stakeholders in the development process improved the perceived level of satisfaction, ease of use and frequency of use of the ToA tool. • Although a more formalized process of evaluating the impact of the tool on ToA between PACU and inpatient units, RNs from inpatient units verbalized that ToA between the two areas has improved.

• Recommendation 4.2: Evaluate the effectiveness of transition planning on the continuity of care

BACKGROUND •

•

PACU did not have a consistent ToA tool with majority of staff using the PACU nursing documentation sheet as a guide during ToA. Current process poses risk to patient safety because of missed information PACU gives ToA to multiple units throughout the hospital multiple times during the day. Receiving inpatient units have inconsistent ToA practices with some units using unit-specific ToA forms and others did not.

Purpose: To improve patient transitions in care by standardizing the nursing transfer of accountability from PACU to inpatient units through the use of a ToA guide.

Process

Indicators

Outcome

Tracking of education attendance

In-services and one on one session with Standardized Tool .

Anecdotal feedback from the inpatient units

60% of PACU RN will use the ToA guide by March 31, 2019.

Post Implementation survey

50% increase in self-reported RN satisfaction with the ToA tool and

• Conduct a systematic evaluation of the impact of the tool on ToA between PACU and inpatient units. • Ongoing report and feedback to the ToA Subcommittee. • Conduct chart audits to assess documentation that ToA was done. • Expand the ToA tool to be used in Surgical Day Care and during PACU nursing ToA.

Level of satisfaction with the PACU-to-inpatient ToA tool

Data Collection Process

80% of RNs will be educated on NAPAN standards for PACU ToA

80% of PACU RNs will have documentation that ToA was done in their Nursing Notes by March 31, 2019

• ToA tool was trialed and edited based on RNs feedback • ToA tool initiated in PACU February 2019 - • RNs were given a copy of the tool • ToA tool was placed at various areas March 2019 where RNs give telephone ToA • ToA tool shared with ToA Subcommittee • Post-survey conducted

Post-survey Results (n=17)

PURPOSE & OBJECTIVES

Measures

RECOMMENDATIONS/NEXT STEPS

Pre- and post- surveys

Very satisfied somewhat satisfied Very and somewhat dissatisfied

88% 12% 0%

Very easy to use Somewhat easy to use Very and somewhat difficult

88% 12% 0%

Ease of use of the ToA guide

CONCLUSION

Level of improvement on communication between PACU and inpatient units

Feedback from inpatient units

Chart audit of Nursing Notes

Very improved Somewhat improved No improvement No response

47% 47% 0% 6%

All the time Sometimes Rarely and never

59% 41% 0%

Frequency of using ToA guide

REFERENCES American Society of Perianesthesia Nursing. (2016). Perianesthesia nursing standards practice recommendations and interpretive statements. Cherry Hill, New Jersey. College of Nurses of Ontario. (2019). Code of Conduct. Practice Standard. Retrieved from: http://www.cno.org/globalassets/docs/prac/49040_code-ofconduct.pdf Registered Nurses Association of Ontario (2014). Care transitions. Best practice guidelines. Retrieved from: http://rnao.ca/sites/rnaoca/files/Care_Transitions_BPG.pdf

ACKNOWLEDGEMENTS Nursing Practice and Education Professional Practice Mentor: Cecilia Santiago, RN, MN, CNCC(C) Karen D’ Souza, RN, BScN Lisa Manswell, RN, BScN Karen Keene, Clerical Assistance

Sustaining the Stop Harm and Prevent Violence Program: Staff-led debriefing Thomas Sawyer, RN BScN

St. Michael’s Hospital, Toronto, ON, Canada FOCUS Creation, implementation and evaluation of a debriefing tool for nursing staff to use. RNAO BPG: Workplace Health, Safety and Well-being of the Nurse Recommendation 3.1: Organizations/nursing employers provide ongoing training and education programs to ensure staff possess the knowledge to recognize, evaluate, and control or eliminate hazardous work situations. Workplace health and safety best practices be embedded/integrated across all sectors of the health care system.

RESULTS

INTERVENTION/PROCESS Figure 1: PDSA Activities and Milestones • Consult stakeholders (Corporate Health and Safety, Spiritual Care, Social Work and interdisciplinary team) • Staff complete pre survey • Focus groups with Charge RNs

Post Debrief Evaluation of Tool by Staff in Attendance: (n=8) 100% felt the tool provided a structured framework for the debriefing conversation to take place.

• Tool utilized after critical event identified by staff

Plan

88% felt the tool adequately prompted them to complete the Safety First event tracker. 75% felt the tool would help create a culture that supports, promotes and maintains staff well-being and safety.

75% felt using the tool would help create capacity for nurses to better support their colleagues in times of distress.

BACKGROUND Problem statement: Health care staff are more likely to be attacked than prison guards, police officers or bank employees. Increases in violence towards health care workers has led to a societal tolerance of violence in certain workplace settings. Gap in practice and/or opportunity for improvement: There is no consistency nor formal method to debrief as a clinical team after being involved in a critical incident on 9CC. Staff have indicated in previous violence de-escalation training sessions that they would benefit from the use of a debrief tool.

PURPOSE & OBJECTIVES Goal: • To introduce a debriefing tool to increase capacity of RN’s to engage in debriefing post critical incidents. Objectives: • Nursing staff engagement and participation in debriefing sessions. • Safety First reports and documentation demonstrate the use and application of structured debriefing strategies by staff. • Number/rate of reported employee safety events and debriefing sessions increase. • Application of Stop Harm and Violence de-escalation strategies and physical skills sustained at the unit level.

RECOMMENDATIONS/NEXT STEPS

Figure 3: Qualitative Comments from Staff

Act

Study

• Modify ORID debrief tool based on staff feedback

“Thanks for doing this important work. The idea of having more structured debriefs makes me feel more comfortable and confident to be working on 9CC.”

• Post debrief evaluation of tool • Review feedback from staff

Next Steps: • Review of debrief tool every 4 months to ensure staff feedback is acknowledged and refinements are made as necessary. • Ensure closed loop communication by forwarding explanation of how recommendations are being escalated based on staff feedback. Sustainability Recommendations: • Routine screening of patients who may be flagged due to responsive behaviours. • Encourage/promote Employee Assistance Plan to all staff. • Advertise resiliency workshops offered by the Learning Centre. • Continue to provide workplace anti-violence training to all staff.

REFERENCES International Council of Nurses. (2017). Position statement: Prevention and management of workplace violence. Geneva, Switzerland.

Figure 2: ORID Debrief Tool Overview

Objective

Reflective

Interpretive

“I think a debrief tool is a great idea!”

• Summarize the key points/facts of the critical incident. “Some people feel it’s the manager’s job or charge nurse who should lead a debrief but it can be led by any staff member.”

• How did this situation affect you emotionally?

• What is the meaning, central issue + pros/cons?

CONCLUSION •

Decisional

•

Future resolves/recommendations going forward.

• •

The modified ORID debrief tool was able to increase staff engagement and participation in debrief sessions after critical incidents. A majority of staff members surveyed felt more supported when using the debrief tool. Staff were adequately prompted to complete Safety First events and colleagues were encouraged to provide additional support to ensure event tracker completion.

Kingma, M. (2001). Workplace violence in the health sector: a problem of epidemic proportion. International Nursing Review. 48(3):129-30. Registered Nurses’ Association of Ontario (2008). Workplace Health, Safety and Well-being of the Nurse. Toronto, Canada: Registered Nurses’ Association of Ontario. Stanfield, R. B. (2000). The Art of Focused Conversation: 100 Ways to Access Group Wisdom in the Workplace. Canadian Institute of Cultural Affairs.

ACKNOWLEDGEMENTS Thanks to all the 9CC RNs, CAs & Allied Health, Mary Copeland (Clinical Lead Manager), Judy Pararajasingham (Clinical Nurse Educator), Ashley Skiffington (Professional Practice Mentor), Bill Ford (Spiritual Care Manager), nursing practice and education, RNAO. Contact information: sawyert@smh.ca

Improving Understanding and Embracing Gender Diversity Shantae Johns, RN BScN, Shannon Swift RN, MN St. Michael’s Hospital

PROCESS

FOCUS To enhance and positively impact the patient care experiences of transgender and gender non conforming patients in the MSICU

BACKGROUND Problem: ‘21% of trans identified individuals reported a lifetime avoidance of healthcare due to a fear of being misgendered, harassed, and discriminated by healthcare providers’ (TransPulse 2015).

“I’m really lost in regards to correct terminology and language”

“I have very limited knowledge in transgender medicine” “We would benefit from more education and training”

Figure 1. Quotes during staff discussion of “When it comes to healthcare, transphobia persists” (Globe and Mail 2018)

PURPOSE & OBJECTIVES Goal: To increase the knowledge and overall comfort levels of frontline staff providing care to transgender and gender non conforming patients in the MSICU by March 31st, 2019. Outcome Indicators: • Assessment and usage of preferred names and pronouns • Documentation on MSICU Kardex • Standardized language, staff confidence, and references to the Gender Identity Policy • Utilization of the Transgender Care Resource Binder

Plan Do Study

Act

RESULTS (CON’T)

Sustainability:

• Develop survey to assess knowledge base/ gaps • Consult and engage key stakeholders

• Encourage nurses to continue education and knowledge development by providing online resources and tools

• Survey review with community experts • Survey dissemination

• Encourage use of preferred names and pronouns in dialogue and use of designated areas on the kardex to document this information

• Analysis of data collected and comparison with initial predictions • Education targets identified • Development and execution of education plan using varying teaching and learning strategies/ modalities • Conduct post- survey to determine efficacy of the process • Develop recommendations and changes to care provision

Figure 2. PDSA Activities

Institutional/structural changes: Figure 3. The responses of staff in the MSICU in regards to their knowledge in hormone therapy and the healthcare needs of trans individuals Education targets: • Encourage sensitive dialogue through education huddles • Request for preferred names and pronouns of all patients • Familiarity with St. Michael’s Hospital’s Gender Identity Policy

RESULTS

CONCLUSION

Survey results n = 64

Most staff members reported the education huddles were helpful and insightful and they would apply the new knowledge to their daily practice.

• 50% of staff members identified they lacked knowledge and education • 58% identified they were apprehensive with dialogue because they did not want to offend • 24% of staff indicated they felt comfortable communicating in a sensitive manner • 85% reported it was appropriate to ask for pronouns

RECOMMENDATIONS/NEXT STEPS

There were mixed reviews on asking all patients for their preferred name and pronouns. The ‘My Story’ tool, and the unit kardexes are being updated to reflect preferred names and pronouns. A hospital committee with the assistance of patients and community experts is needed to analyze current practices which may inadvertently marginalize gender diverse individuals.

• Non gendered washrooms • Update Soarian Clinicals electronic record to reflect gender diversity • Practice changes in unidentified patients (Jane/John Doe) • Collaborative team effort to address and perform equity and sensitivity training for new hires

REFERENCES Benaway, G. (2018) When it comes to health care, transphobia persists. The Globe and Mail. Retrieved from https://www.theglobeandmail.com/opinion/article-when-it-comes-tohealth-care-transphobia-persists/ The 519 and Rainbow Health Ontario. (2016). Media Reference GuideDiscussing Trans and gender-diverse people. Retrieved from https://www.rainbowhealthontario.ca/wp-content/uploads/2016/01/MediaReference-Guide-Trans-and-Gender-Diverse-People1.pdf Trans Pulse (2015). Transgender People in Ontario. Retrieved from http://transpulseproject.ca/wp-content/uploads/2015/06/Trans-PULSEStatistics-Relevant-for-Human-Rights-Policy-June-2015.pdf

ACKNOWLEDGEMENTS Ellen Lewis, Mikita Patel, Ashley Skiffington, MSICU staff, Nursing Professional Practice

Improving Team Performance During Code Blues in CICU Dong Wei (Wendy) Xu RN, BScN, CCN(C), CNCC(C), Natalia Escalante Solana RN, BScN St Michaels Hospital, Unity Health Toronto

FOCUS To develop an interprofessional CICU Code Blue Response Team through improved team performance. Our initiative aligns with the following RNAO Best Practice Guideline: Developing and Sustaining Interprofessional Health Care: Optimizing patients/clients, organizational, and system outcomes.

BACKGROUND • The CICU is small ICU (n=10 beds) staffed by 6 nurses on days and 5 nurses on nights • Patients in the CICU often manifest cardiac arrhythmias which require urgent intervention. Life-threatening arrhythmias can result in cardiac arrest • It is unknown whether nurses in the CICU feel confident in their technical skills when responding to a cardiac arrest ("code blue") in the unit • Teamwork during codes has been shown to be affected by poor role clarity and non-effective communication 4

INTERVENTION/PROCESS Fig. 1: Overview of Timelines and Milestones • Literature review • Studied current process map November • Selection of measurement tool, development of survey.

• Dissemination of pre survey results • Unit huddles

• • February - • March •

April

Comments submitted with TEAM forms demonstrated critical reflections: • “Multiple interruptions to compressions” • “Resident not confident with pacing function” Nurses also identified cases when the team worked effectively: • “Well managed, excellent teamwork” • “Clear leadership from team lead”

• Pre intervention survey • In-unit mock codes December • Crash cart and defibrillator review

January

CONCLUSION

RESULTS (CON’T)

Fig. 3: Nurses’ Perceptions of Codes Pre and Post Interventions

Weekly knowledge review & quizzes Rapid-cycle SIM lab mock codes & in-unit mock codes SBAR communication teaching Post intervention survey

Before, n=24 After, n=20

• Dissemination of post survey results

• Each code and each patient present a different situation, so more data is required to see a true trend in TEAM scores. • The TEAM forms serve as good reflective tool to evaluate performance. As suggested in the literature, utilizing this form to debrief can help improve non-technical skills. 1 • Nurses’ perceptions appear more positive overtime. We suggest this is due to increased knowledge and insight into technical & nontechnical skills

RECOMMENDATIONS/NEXT STEPS • Document time of codes on TEAM forms to identify differences between day and night shifts. • More PDSA cycles based on the long term TEAM score trends and post-survey results. • Continued support for mock code blue training & ACLS certification.

RESULTS

REFERENCES

After every code blue in the unit, data was collected using the Team Emergency Assessment Measure (TEAM), developed by Cooper et al. (2010) 2. This tool allows responders to subjectively evaluate team performance, assessing topics such as communication, role clarity, and ability to adapt to change.

Cant R, Porter J, Cooper S, et al. (2016). Improving the non-technical skills of hospital medical emergency teams: The Team Emergency Assessment Measure (TEAM). Emergency Medicine Australia, 28, 641-646.

Cooper S, Cant R, Porter J, et al. (2010). Rating medical emergency teamwork performance: Development of the Team Emergency Assessment Measure (TEAM). Resuscitation, 81, 446-452.

Mahramus T, Penoyer D, Waterval E, Sole M, & Bowe, E. (2016). Two hours of teamwork training improves teamwork in simulated cardiopulmonary arrest events. Clinical Nurse Specialist, 284-290.

PURPOSE AND OBJECTIVES

Price J, Applegarth O, Vu M, & Price J. (2012). Code blue emergencies: A team task analysis and educational initiative. Canadian Medical Education Journal, 3 (1), e4-e17.

• To improve staff satisfaction on team performance during code blues in the CICU

ACKNOWLEDGEMENTS

• Perceptions regarding role clarity and team communication need to be explored in order to target interventions and build individual and team capacity to manage emergency situations • Research suggests that mock code training has a beneficial effect in team performance during emergency situations 3

Fig. 2: Team Scores during Intervention

Bar sizes normalized for response counts before vs. after

• To promote and sustain improved team performance through interprofessional collaboration Jan

Feb

Mar

Orla Smith, Clinical Leader Manager CICU & CVICU Michelle Williams, Clinical Nurse Educator, CICU & CVICU Ann Leung, Clinical Pharmacist, CICU

Standardized Pressure Injury Risk Assessment and Prevention Victoria Rams, RN, CNN(C)

Trauma Neurosurgery In-patient Unit, St. Michael’s Hospital, Unity Health Toronto

FOCUS Implementing standardized wound care pertaining to the evaluation of risk and prevention of pressure injuries (PIs) in a neuro-trauma population.

INTERVENTION/PROCESS Figure 1: Flow chart illustrating the introduction of the corporate-wide initiative

BACKGROUND Registered Nurses’ Association of Ontario (RNAO) has a guideline on Risk Assessment and Prevention of Pressure Ulcers RNAO Recommendation 1.2: “The client’s risk for pressure ulcer development is determined by the combination of clinical judgment and the use of a reliable risk assessment tool. The use of a tool that has been tested for validity and reliability, such as the Braden Scale for Predicting Pressure Sore Risk, is recommended. Interventions should be based on identified intrinsic and extrinsic risk factors and those identified by a risk assessment tool… Risk assessment tools are useful as an aid to structure assessment.”

2016: National Pressure Ulcer Advisory Panel (NPUAP) announce update in terminology from pressure “ulcer” to pressure “injury” to include both intact and ulcerated skin. NPUAP also suggest daily risk assessment for skin breakdown and plan of care.

Figure 3: PDSA cycle outlining the implementation and evaluation initiative

• Wound Care develops a standardized Prevention Plan (PP) Early 2018

• Evaluate gap in assessment and prevention planning of Pressure Injuries • Collaborate with Wound Care and RN Staff stakeholders

Plan Early November 2018

Late November 2018

• Conduct a refresher session re: PIs with RN staff and handout pre-survey • Educate Staff on Corporate Updates • Initiate 1:1 bedside sessions with RNs and review pressure points on at risk patients

• In-service with TN Inpatient RN staff on updates regarding Braden Scale assessment, introduction of Prevention Plan and review of PIs

• Corporate roll-out of updates on Soarian. Prevention Plan is to reflect Braden Scale assessment and flagged areas of concern and describes any involvement of the interdisciplinary team.

Figure 2: Braden Scale and Prevention Plan Tools implemented corporately Braden Scale found within initial or admission assessment tab. Completed qshift.

Currently: Trauma Neurosurgery (TN) Inpatient Unit completes Braden on Monday, Wednesday and Friday during day shift and lacks standardized documentation for a prevention plan.

• Evaluate results of audit and clarify with staff re: gaps in documentation • Conduct a post-survey • Address incomplete charting and barriers in implementation

Act

Study

• Audit Braden Scale and Prevention Plan documentation at three month intervals

RESULTS

Figure 4: Audit of TN Inpatient charts for Braden Scale and PP completion (n = 47 to 50)

Post-Survey Findings (n=21):  91% of staff RNs felt the Braden Scale and the PP tools useful for assessment and prevention of Pressure Injuries (PIs)  91% of staff RN felt confident educating family members on the risk and prevention of PIs

PURPOSE & OBJECTIVES

 Barriers identified in implementation of PP: “Behavioural/non-compliant patients, lack of pillows and mobility restrictions due orders”

Aim: Increase use of Braden Scale and implement a standardized Prevention Tool for Pressure Injuries on the TN Inpatient unit Achieve by April 2019: • 70% compliance rate of the Braden Scale tool completion • 60% compliance rate of Pressure Injury Prevention Plan completion • An increase in staff RN comfort in initiating a prevention plan for at risk patients with corporate updates

CONCLUSION Prevention plan found below Braden assessment. Completed qshift.

• Completion rate for Braden Scale tool was 95% - surpassed the objective goal of 70% and increased by 35% from initial rate • Prevention Plan Tool completion rate was on average 83% which surpassed the objective goal of 60% • Staff RN feel overall more comfortable with initiating and implementing a Prevention Plan as per survey responses

Key Success Factors • RNs found the placement of the Braden Scale and the Prevention Plan in the Initial Shift Assessment useful in prompting its completion • The percentage of at risk patients remained the same after the roll-out; flagging appropriate patients was maintained • Conducting 1:1 sessions with RNs for integumentary checks and review of proper documentation was conducive for adherence of prevention planning

RECOMMENDATIONS/NEXTSTEPS • Encouraging the interdisciplinary team in accessing the Braden Scale/Prevention Plan in Soarian • Addressing the barriers of initiating Prevention Plan, especially the mobility restrictions due to neuro-trauma patient population • Continuing audits and updating floor on compliance rate • Promoting different strategies every other month

REFERENCES 1) National Pressure Ulcer Advisory Panel (2016) Pressure Injury Prevention Points. Retrieved from: https://www.npuap.org/wp-content/uploads/2016/04/PressureInjury-Prevention-Points-2016.pdf 2) Ontario Neurotrauma Foundation, Spinal Cord Injury Ontario (2013) Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. Retrieved from: http://onf.org/system/attachments/168/original/Pressure_Ulcers_Best_Practice_G uideline_Final_web4.pdf 3) RNAO (2011) Best Practice Guidelines: Risk Assessment and Prevention of Pressure Ulcers. Retrieved from: https://rnao.ca/bpg/guidelines/risk-assessmentand-prevention-pressure-ulcers 4) Wounds Canada (2017) Prevention and Management of Pressure Injuries. Retrieved from: https://www.woundscanada.ca/docman/public/health-careprofessional/bpr-workshop/172-bpr-prevention-and-management-of-pressureinjuries-2/file

ACKNOWLEDGEMENTS Special thanks to Nursing Practice and Education for sponsoring this BPG initiative as well as the support of: • Wound Care Team: Katie Marinzel, CNS, Ting-Ting (Cecilia) Wan, OT and Janeth Velandia, NP • Mary Copeland, TN Inpatient CLM • Judy Pararajasingham, TN Inpatient Clinical Nurse Educator • Ashley Skiffington, RN, Professional Practice Mentor • All Staff RNs on the TN Inpatient Unit Contact Information: Victoria Rams, RN, CNN(C) Phone: (416) 864 - 5814 Email: ramsv@smh.ca

Professionalism in Nursing: Cell Phone Use by Staff in TNICU Vanessa Rozario-Roy, RN MScN(C) St. Michael’s Hospital, Unity Health Toronto

FOCUS

INTERVENTION/PROCESS

•

BPG Topic: Professionalism in Nursing: Cell Phone Use by Staff in TNICU

• Develop cell phone use ground rules for TNICU registered nurses to adopt

•

RNAO BPG: Healthy Work Environment (HWE) – Professionalism in Nursing

BACKGROUND • Nurses demonstrate values and attributes of professionalism when providing nursing care and collaborating with patients, nurse colleagues, other members of the health care team and nursing students (RNAO)

RESULTS

RECOMMENDATIONS/NEXT STEPS • Continue to collect patient/family feedback about staff using cell phones while working and share feedback with staff to reinforce the application of the ‘ground rules’

• Develop education session for RN and display posters in the unit to encourage appropriate use of cell phones while at work

• Continue to provide education to new hires re: cell phone use in the TNICU

• Conduct pre/post survey to measure staff’s awareness of the implications of cell phone use on personal health and well being and patient care

• Consider installing Apps like Checky (shows how many times you unlock your phone and your screen time) or AppDetox /Flipd (lets you set limits on the time you spend inside individual apps

Figure 2: Staff Pre-Survey

Figure 1: Poster Displayed in High Traffic Staff Areas in Unit

100 90 80 70 60 50 40 30 20 10 0

• Healthcare smartphone apps and multimedia resources are beneficial at the bedside; however, the increased use of cell phones and the negative affects on the users heath and wellbeing is a concern ( American Journal of Preventive Medicine, 2008) • Our patients deserve our full attention. This is impossible when our family and friends have perpetual access to us (AJN,2018). • There are almost 6 billion cell phone users in the world, with almost 86 gadgets for every 100 people (National Cancer Institute, 2011) • In 2011 the World Health Organization confirmed that cell phone use indeed represents a health menace, and classified mobile phone radiation as a carcinogenic hazard (Acharya, 2011)

14%

16%

19%

Disagree Agree

86%

84%

81%

Education increased Education increased Education increased my awareness of the my awareness of the my awareness of the negative effects of cell impact of cell phone impact of cell phone phone use on health use on use on quality of care and wellbeing professionalism

Figure 3: Staff Post-Survey

CONCLUSION

PURPOSE & OBJECTIVES

•

We live in a mobile, digital world and personal device use in the workplace cannot be completely avoided

• To explore TNICU nurses perceptions of the implications of using cell phones while working, and the impact on professionalism and personal health and wellbeing:

•

Health care providers need to balance responsibility to patients and to self (i.e. self-care in a manner that does not compromise patient care and personal health and well-being)

• Increase staff awareness of the implications of cell phone use while at work on how patients and families view the nurses professionalism

•

• Increase staff awareness of the implications of cell phone on their personal health and wellbeing

• Turn off notifications on your phone and If you have a smart speaker, put it to use - this helps keep the smart phone off your hands

Education is needed to raise awareness regarding the implications of cell phone use on personal health and wellbeing and professionalism

•

Cell phone use is a sensitive topic for staff and approaching it from a health and wellness perspective rather than punitive generated constructive discussions amongst staff

•

Management support is critical in monitoring and addressing cell phone usage amongst staff

REFERENCES •

American Nurses Association.(2011). ANA’s Principles for Social Networking and the Nurse. Guidance for Registered Nurses. Retrieved from https://www.nursingworld.org/social-networking.pdf

•

Acharya, J.P. (2013). A study on Some of the Common Health Effects of Cell Phones amongst College Students. Journal of Community Medicine & Health Education. Retrieved from http://www.omicsonline.org/a-study-of-the-common-health-effects-of-cellphones.

•

Effects of using Mobile phones too much. (2011). National Cancer Institute. Retrieved from http://www.cancer.gov/cancertopics/factsheet/Risk/cellphones

•

How your Smartphone can affect your well-being. (2014). Association for Psychological Science. Retrieved from https://www.psychologicalscience.org

•

Cellphones in the hospital: (2018). Can staff use them for personal reasons? Retrieved from https://healthydebate.ca/2018/11/topic/cellphones-in-hospital)

•

Bartholomew,K. (2018). Not so smart: Cell phone use hurts our patients and profession. American Journal of Nursing. Retrieved from https://www.journals.lww.com

ACKNOWLEDGEMENTS Liz Butorac: Clinical Leader Manager TNICU. Jenna Moulder: Clinical Nurse Specialist TNICU. Ashley Skiffington: Evidence Based Practice Nursing Manager. TNICU Registered Nurses. Nursing Practice and Education Committee.

Managing and Mitigating Conflict in Health-Care Teams Sidra Nadeem, RN & Hussein Jaffer, RN St. Michael’s Hospital (Unity Health Toronto)

Conflict is inevitable in any work environment due to differences in perceptions, goals, needs, and ideas. Healthcare teams are particularly vulnerable to conflict in today's increasingly stress‐laden work environment where professional relationships can be threatened by different sources of conflict (RNAO, 2012). Learning to manage conflict is crucial in maximizing productivity and improving team functioning and cohesiveness. Research indicates that high levels of conflict in healthcare teams is correlated to poor quality of work and an increase in errors with patient safety. It also plays an important role in our personal lives which can cause emotional and moral stress resulting in negative relationships with friends and family (Almost et al., 2016).

CURRENT ISSUE AND GAPS Unresolved conflict on the unit

Poor use of conflict resolution strategies (e.g., many unit changes/ inconsistencies; gossiping)

Staff participation at two educational sessions: 1. In-Service Session I: • Awareness and recognition of the different conflict management styles through the Thomas-Kilman Conflict Mode Instrument (Figure 2) was understood and applied to case-based scenarios 2. In-Service Session II: Competing Avoiding • Staff members were involved in reviewing steps and strategies in managing conflict on Collaborating the unit (Figure 3 & 4) • A decision-making algorithm was created for navigating workplace conflict. Staff Compromising Accommodating members were also provided a pocket guide to keep with the steps and strategies Figure 2: Thomas-Kilman Conflict Mode Instrument discussed in resolving conflict PLAN

COMMUNICATE

Poor attempt to resolve conflict (e.g., lack of appropriate communication style)

Harbouring negative feelings/attitudes toward colleague(s)

Figure 1: The current process of conflict management on the unit

PURPOSE & OBJECTIVES To improve 7CCS staffs’ understanding and awareness on different conflict management strategies by 50% as a foundation to help us feel empowered to navigate through difficult situations in the workplace by March 2019. • To identify the current corporate resources in handling different types and sources of conflict on the unit • To strengthen staffs’ self-awareness of conflict management styles that promote self-reflective practice and enhances a culture of inclusiveness • To engage team members in developing strategies and interventions which emphasizes effective communication skills to manage conflict

RESOLVE

Describe your concerns; use “I” language and handle conflict sooner

Identify the issue and take time to reflect

 Non-directional; cyclical  Non-constructive approaches Creating poor working relationships/lack of teamwork

RESULTS

INTERVENTION

BACKGROUND

Brainstorm for possible solutions and provide suggestions

Figure 3: Potential steps and technique involved with effective conflict management

Assessment of Staff around Conflict 1. I have good understanding of the different conflict management styles 2. I am aware of the resources at St. Michael’s Hospital to give me the tools and knowledge to work in difficult situations 3. During a conflict, I have a strong awareness of my feelings and emotions 4. I believe this BPG will create change around the perception of conflict on the unit? 5. I see myself using the education, tools and interventions provided to manage conflict?

RECOMMENDATIONS/NEXT STEPS Agree

Neutral

Disagree

PRE

POST

PRE

POST PRE

POST

40%

92%

35%

25%

20%

96%

30%

50%

80%

92%

15%

79%

21%

86%

11%

Table 1: Survey results to show the comparison of pre-survey (n=20) and postsurvey results (n=28) of unit in-service education sessions • To demonstrate compliance and willingness to participate, the attendance at the in-service sessions was 83% of the total Cardiology staff (i.e., nursing staff, allied health staff, etc.)

CODE OF CONDUCT My commitments under the St. Michael’s Hospital Code of Conduct are: I am committed to the highest standards of conduct in my relationships with my colleagues, patients, volunteers and visitors. I understand it is essential that my actions always reflect the St. Michael’s mission and values, demonstrate ethical leadership, and promote a work environment that upholds the St. Michael's Hospital commitment to providing compassionate patient care. I know the hospital will have great trust and confidence in my conduct as an employee, and I will always act in a manner to preserve that. St. Michael’s Hospital Code of Conduct (2015)

Figure 4: The 3-F Framework to engage in assertive communication

FACT

7CCS Charter RESPECT

We treat and respect each other with consideration, compassion and empathy. We carry our conversations and interactions with dignity and regard for each other’s beliefs, values, cultures, and backgrounds. This demonstrates our appreciation and commitment to work with ethical conduct. TEAMWORK We commit to working together in a cooperative and coordinated effort to ensure that our patients’ safety and needs are always prioritized. Together we continue to foster a culture that embraces interprofessional collaboration by engaging in shared decision-making process. PROFESSIONALISM & ACCOUNTABILITY We take pride and ownership in the work we do that is reflective in our knowledge, skill, and judgement in order to meet our professional standards. We interact with team members, patients, and families that resonates with our corporate mission and values. HONESTY & EQUITY We are mindful of our words and actions in creating a safe, constructive, and open communication space to appropriately address conflict. We create fairness and transparency in our workplace to allocate tasks and responsibilities based on individual’s role and capacity.

FEELING

• Describe the behaviour of what the other person is doing that is having a negative impact • "I noticed..." • Express your feelings and point of view clearly and calmly. Avoid generalization with “you…” • “I feel…”

• Invite the other person to share perspective and their solutions • “I would like to/prefer…” or FAIR “let’s find a solution that works REQUEST for both of us…”

Figure 5: Staffs’ feedback and input was gathered in the creation of a unit-based Code of Conduct

CONCLUSION • By attending the unit-based in-service sessions, team members were able to engage in open, transparent and constructive dialogue that addresses issues around conflict. o Based on the results, there was an increase in staffs’ awareness of the resources available at St. Michael’s Hospital to deal with conflict management o Staff indicated that the strategies developed will help team members engage in effective and assertive communication to promote empathy and consideration towards each other o The Code of Conduct will support staff in day-to-day decision making and help create an environment that improves the standard of conduct acceptable to all o The tools and education sessions provided are some preliminary interventions in helping team members feel empowered to navigate through difficult situation in workplace

To further influence practice, leaders and managers should be aware of the antecedents to conflict and develop interventions that support the needs of the healthcare staff to ensure sustainability a) They can assist staff in handling and guiding crucial in-themoment conversations through leading debriefing sessions b) Unit leaders can motivate staff attendance and promote conflict management workshops offered by the organization c) Integrate unit in-service sessions and unit-based interventions in the new hiring package

2. Ongoing participation in educational programs and/or training on conflict resolution strategies that focuses on enhancing emotional intelligence are fundamental for healthcare providers (Cox, 2018) a) Incorporating role playing exercises that engages staff in sharing experiences and strengthening communication skills b) Encouraging regular reflective journaling can facilitate heightened self-awareness to find meaning in experiences for self-improvement

REFERENCES Almost, J., Wolff, A. C., Stewart‐Pyne, A., McCormick, L. G., Strachan, D., & D'souza, C. (2016). Managing and mitigating conflict in healthcare teams: An integrative review. Journal of Advanced Nursing, 72(7), 1490-1505. Cox, K. M. (2018). Use of emotional intelligence to enhance advanced practice registered nursing competencies. Journal of Nursing Education, 57(11), 648-654. Registered Nurses of Ontario. (RNAO). (2012, September, 12). Best practice guideline: Managing and mitigating conflict within health-care team. Retrieved from https://rnao.ca/sites/rnao-ca/files/Managing-conflict-healthcare-teams_hwe_bpg.pdf Thomas,K. W.,& Kilman, R. H. (1974). Thomas-Kilman conflict mode instrument. Xicom: Tuxedo, NY

ACKNOWLEDGEMENTS We would like to acknowledge and thank the following individuals who provided support and consultation in this project: • • • • •

Victoria Buczek, RN, MN, Clinical Leader/Manager Kimberly Tan, RN, MN, Unit Educator Ashley Skiffington, RN, MEd, Evidence Based Practice Nursing Manager Christopher Law, CHRL, CMP, Leadership and Organization Consultant Diana Crawford, MSc, CMP, Leadership and Organization Consultant

For further information, please contact: Sidra Nadeem: nadeems@smh.ca Hussein Jaffer: jafferh@smh.ca

Supporting Early Pregnancy Loss in the Emergency Department: Continuation and Stability Sarah Martin, Ray Howald, Kate MacWilliams St. Michael’s Hospital, Toronto, Ontario, Canada

BACKGROUND • Women access the ED for a variety of reasons when experiencing a miscarriage • In 2016, ED had 2,803 visits of women experiencing a miscarriage, or bleeding in early pregnancy (Approximately 7 per day!) (source: Decision Support Services) • From women experiencing a miscarriage in the Emergency Department, we know… • Loss not acknowledged, but dismissed • Perceived lack of discharge education • Lack of clarity regarding follow up • Experiences of marginalization

FIRST YEAR ACTIVITIES

SECOND YEAR ACTIVITIES

RECOMMENDATIONS / NEXT STEPS

• Stocked Discharge Materials

• Continued partnership with 15CC, Spiritual Care, Social Work

•

Distribute staff education slides via ED weekly email update

•

Engage ED Physicians in the project

• Created Miscarriage Resource Binder, including policies, tools and contact information that is readily accessible in the ED

•

Finalize the medication discharge information for Misoprostol and Methotrexate

• Restocked and labeled discharge information

•

Resurvey staff to assess for change in comfort levels

•

Continue to engage operational stakeholders with the results of last year’s staff survey (ie. creation of outpatient gynecology clinic for follow up, continued education opportunities)

• Hosted Pregnancy and Infant Loss Network Compassionate Care Workshop • Updated Perinatal Bereavement policy and checklist for application in the ED • Met with Pathology regarding policy and procedure • Survey of 100 ED Staff, including RNs, MDs, Clericals, Social Work, and Pharmacy, helped define the issue through a survey of 100 ED staff

• Engaged with multiple services to verify and harmonize policies, procedures for miscarriage in the ED

REFERENCES

RNAO BPG: Care Transitions 1.1 Assess the client’s current and evolving care requirements on admission, regularly throughout an episode of care, in response to a change in health status or care needs, at shift change and prior to discharge. 1.3 Assess the client for physical and psychological readiness for a care transition. 1.5 Assess the learning and information needs of the client, their family and caregivers to self-manage care before, during and after a transition. 2.1 Collaborate with the client, their family and caregivers and the interprofessional team to develop a transition plan that supports the unique needs of the client while promoting safety and continuity of care. 3.1 Educate the client, their family and caregivers about the care transition during routine care, tailoring the information to their needs and stage of care.

AIM To continue last year’s efforts to improve the care provided to women and families who experience a miscarriage (pregnancy loss at <20wks) throughout their stay in the Emergency Department (ED), on discharge and when transitioning back to the community.

• Regular ED Staff education huddles • Implemented Butterfly sign to signify loss

• To create a Miscarriage Policy binder

• Improve staff comfort/confidence • Reduce number of improperly disposed fetal remains

• Pregnancy & Infant Loss Network – Sunnybrook Hospital. (n.d.). Retrieved from https://pailnetwork.sunnybrook.ca/ • Provincial Council for Maternal and Child Health. (2017, March 31). Early Pregnancy Loss in the Emergency Department. Retrieved from http://www.pcmch.on.ca/health-careproviders/maternity-care/pcmch-strategies-and-initiatives/earlypregnancy-loss-emergency-department/

OBJECTIVES

• To lead education huddles for staff with the learning objectives:  Define different types of pregnancy/infant loss  Identify where to find resources  Understand practical application of Perinatal Bereavement Checklist and requisitions  Review management of fetal remains  Identify where to find discharge information  Explain how to provide supportive care

• MacWilliams, K., Hughes, J., Aston, M., Field, S., & Moffatt, F. W. (2016). Understanding the Experience of Miscarriage in the Emergency Department. Journal of Emergency Nursing, 42(6), 504-512.

• Registered Nurses’ Association of Ontario. (2014). Care Transitions. Retrieved from https://rnao.ca/sites/rnaoca/files/Care_Transitions_BPG.pdf

SUCCESSES! • Staff are utilizing discharge materials • Over 80 ED have been trained on the ED Miscarriage Policy, resources and tools! • Staff are using the butterfly sign to communicate a loss

ACKNOWLEDGMENTS We wish to graciously acknowledge and thank the following for their support throughout this work: Murray Krock, Director of Nursing Practice and Education; our Partners, including 15CC, Spiritual Care and Social Work; and the ED staff.

Improving General Internal Medicine Heart Failure Client’s Care Transition: Delivering Effective Education Using the Teach-Back Approach Tamara A. Lewis, RN

St. Michael’s Hospital, Unity Health Toronto, Ontario

RESULTS

FOCUS

INTERVENTION/PROCESS

Improving GIM HF Client’s Care Transition Through Education Using The Teach-back Approach

RN education sessions on HF & the Teach-Back Approach Teach-Back Checklist

HF Education Package

NURSING TEACH-BACK QUESTIONS ON HEART FAILURE EDUCATION: DO EACH SHIFT (Patient’s Kardex) RECIPIENT OF TEACHING

DAY 0

 Recommendation 3.1: Educate client, family and caregivers about care transition during routine care, tailoring information to needs and stage of care.  Recommendation 3.2: Use standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions.  Recommendation 3.4: Coach the client on self-management strategies to promote belief in their ability to look after themselves on care transition.

BACKGROUND

HF Education and Use of "Teach-Back"

 Patient  Caregiver Name

ADMISSION • •

Date

Time

Initial

Barriers to Learning

SYMTOMS

HEART FAILURE / SYMPTOMS / NOTIFICATION PARAMETERS (CORE MEASURE)  Patient  Caregiver Name

• • •

Overview: Heart Failure Video (Channel 75) Tell me in your own words what the words “heart failure” mean to you. Tell me which heart failure symptoms you remember.

Optional Questions You May Ask  Patient  Caregiver Name

• •

Tell me the symptoms you would call in to your doctor or healthcare provider. How will eating too much salt make your symptoms worse?

DAILY WEIGHT AND ACTIVITY

DAILY WEIGHTS / DRY WEIGHT / ACTIVITY (CORE MEASURE)  Patient  Caregiver Name

• • • •

Do you have a scale at home? Tell me how you will weigh yourself each day? When will you notify your doctor/provider? Tell me how would you know if you are pushing too hard when doing activities?

Optional Questions You May Ask  Patient  Caregiver Name

• •

 The objective is to provide effective client education that equips and empowers patient/family/caregivers to successfully engage in self-management of their condition once discharge to their respective community settings.

RN engages patient in HF education daily

15 10

Can you recall when to notify your MD regarding your weight? Tell me how you will be active at home every day?

DIET AND MEDICATIONS

 Patient  Caregiver Name

• • • • •

Name a seasoning to avoid. Tell me how you will limit your fluids each day. Tell me two foods high in salt. Can you tell me the name of your water pill? Can you tell me the name of your BP/heart pills

RN uses the Teach-Back approach to re-enforce HF education daily

Optional Questions You May Ask  Patient  Caregiver Name

• • •

Name two frozen liquids that count as fluid. Name a side effect of your Beta blocker (BP or heart pill). Name a side effect of your ACE Inhibitor (BP or heart pill).

• •

What is your family doctor’s name? Tell me the date and time of your scheduled follow-up appointment after discharge Tell me what zone you are in if you have gained >3lbs and have swelling in your feet today. If you are in the green zone, what does this mean?

DISCHARGE READINESS

FOLLOW-UP APPOINTMENT/SYMPTOMS (CORE MEASURE)  Patient  Caregiver Name

Initials

Unit HF Board

• •

Signature

Initials

Always

Sometimes Never** RN Responses

Patient education using Teach-back approach

n=36, * RN had never directly cared for HF a client on GIM, **HF package distributed by previous RN

CONCLUSIONS  Over a three month period (January-March 2019) 36 RNs were re-educated on heart failure and strategies for effective teaching using a Teach-Back approach. During that period 33 patient were admitted to GIM with a primary diagnosis of Heart Failure. Only 2 patients completed a patient satisfaction survey regarding the HF education they received during their admission and gave positive reviews.

What is Teach-back?  Teach-back is a research-based health literacy intervention that improves patient-provider communication and patient health outcomes (Schillinger, 2003).  Education is delivered in a supportive and caring way, allowing the patient/care-giver or family member to explain in their own words what they understand they need to know or do to effectively manage their condition in the community.  It is not a test or quiz of patients, but an evaluation of the providers ability to effectively relay important information for a client’s successful self management of their condition.

Surveys / follow-up call / questionnaire geared to evaluate if:  Clients received CHF package while in hospital  Clients received education on CHF from RN while in hospital  Client's satisfaction with the education received on HF while in hospital  Client’s understanding of HF self management  Clients received follow-up appointment to CHF clinic within 1 month of discharge Audits/Analysis:  HF package distribution rate  HF education initiation and use (Soarian charting)  HF education Teach-Back checklist utilization  HF 30-day readmission rates

N/A*

Signature

Systematic reviews report clients who receive pre- and postdischarge education on care, treatment, medications and ADLs have favourable post-transition outcomes such as reduced readmission rates, adverse drug events and increased client and family satisfaction (RNAO, 2014).

The goal of the GIM HF Care Transition initiative is to reduce the readmission rate for GIM HF clients by 30% from a yearly average of 38.7% to 20% by December 2019 through effective teaching during clients hospital stay, facilitated by use of a standardized HF education package and a Teach-Back Checklist

MEDICATION / SALT / FLUID LIMITATION (C0RE MEASURE)

Heart failure (HF) is a chronic condition that is associated with acute exacerbations, and frequent 30-day readmissions on average 21.0% (HQO, 2016). Frequent HF exacerbations lead to poor quality of life and increased risk of mortality.

PURPOSE & OBJECTIVES

RN distributes "HF Education Package"

Distribute C HF Package on admission (or within 48hrs) START Heart Failure Education

Number of RNs

RNAO Best Practice Guideline: Care Transition

RECOMMENDATIONS/NEXT STEPS

 Teach-Back is being incorporated in nursing undergraduate practice. While this terminology may be foreign to RNs >10yr out of nursing school, the concept was not new and was informally being implemented in their nursing practice. Key Success factors  Two RNs committed to continuing to champion and serve as a resource on the unit for fellow colleagues.  1 Consolidating nursing student took the initiate to solicit a role as student BPG HF champion.

Building Sustainability:  Continue to recruit RNs to act as champions and mentors to RNs less confident in ability to engage patient in HF education.  Create e-module on HF education using the Teach-Back approach to be view by all new hire during orientation to unit and subsequently every ~2years.

REFERENCES Canadian Institute for Health Information. (2012). All-Cause Readmission to Acute Care and Return to the Emergency Department. Health Quality Ontario [HQO]. (2016). Transition between Hospital and Home. Registered Nurses 'Association of Ontario. (2014). Clinical Best Practice Guidelines: Care Transitions. Schillinger D, Piette J, Grumbach ... (2003). Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy. Arch Intern Med. 163(1):83–90. doi:10.1001/archinte.163.1.83

ACKNOWLEDGEMENTS

Aisha Muslim RN, Phyllis Nugent RN and Shirley Bells RN Clinical Nurse Educator for your support during the implementation of the “HF education utilizing teach-back approach” initiative Avleen Buttar, nursing student, for your bravery and inspiring commitment to education All GIM RNs and staff for your continued commitment to evidencebased practice

Engaging Clients in the Emergency Department Who Use Opioids Monique Harding RN BScN CPMHN(C), Stephanie Lucchese RN BScN CPMHN(C) St. Michael’s Hospital, Unity Health Toronto

RECOMMENDATIONS/NEXT STEPS

FOCUS

RESULTS

•

The focus of the project was to increase engagement with clients who use opioids in the Mental Health Emergency Service Area (MHESA)

• 100% of full-time and part-time RNs in MHESA received naloxone kit training between February 8th – March 10th, 2019

•

Universal screening questions to be incorporated into secondary assessments forms in MHESA

•

The RNAO Best Practice Guideline used to guide this initiative is Engaging Clients who Use Substances (RNAO, 2015)

• Post survey results show a vast improvement in familiarity with the take home naloxone kits and comfort levels when teaching patients how to properly use the kits

•

Education provided to new hires regarding safe opioid use and naloxone kits during orientation to MHESA

•

Naloxone kit roll out was initiated in Fall 2018 in the ED, MHESA staff were trained in naloxone administration

•

The PowerPoint presentation used during the education sessions and the updated community addiction resources will be added to the shared electronic drive so that staff can access them at any point should they want to review it

•

MHESA RNs to obtain further education through the “Opioid Overdose Prevention, Recognition and Response” education session offered by Toronto Public Health for their staff who work at the municipal Safe Injection Sites

Pre-Naloxone Training

BACKGROUND • There is a rise in opioid use that has contributed to an increase in opioid related deaths in Canada (Fischer, Vojtila & Rehm, 2018)

(Government of Canada, 2018)

PURPOSE & OBJECTIVES

• In the first half of 2018, there were 2,066 opioid-related deaths, 94% were accidental (Government of Canada, 2018)

Aim: By March 15th 2019, improve staff knowledge and comfort level with educating clients who use opioids about safe opioid use and using home naloxone kits.

• In 2017, there were: • 704 opioid-related ED visits in the Toronto Central LHIN • 7764 opioid related ED visits in Ontario • 1265 opioid related deaths in Ontario

INTERVENTION/PROCESS • Survey was sent to MHESA RN staff to assess their comfort level with working with clients who use opioids

REFERENCES Post-Naloxone Training

•

Fischera, B., Vojtilaa, L., Rehma, J. (2018). The ‘fentanyl epidemic’ in canada – some cautionary observations focusing on opioid-related mortality. Preventative Medicine, 107, 109-113. doi: 10.1016/j.ypmed.2017.11.001

•

Government of Canada. (2018). Opioid related harms in Canada [PDF file]. Retrieved from https://www.canada.ca/content/dam/hcsc/documents/services/publications/healthy-living/infographic-opioid-relatedharms-december-2018/infographic-opioid-related-harms-december-2018.pdf

• Data obtained between Dec 6th – Dec 21st, 2018

•

The original survey results identified a gap in staff knowledge and staff reported low comfort levels regarding opioid overdose and the use of naloxone kits

•

Ontario Agency for Health Protection and Promotion. (2018). Opioid-related morbidity and mortality in Ontario. Retrieved from https://www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx#/tre nds

•

Education sessions were provided to staff on the following: • Safe opioid use • How to recognize opioid overdose • The use of nasal and intramuscular naloxone kits • Universal screening questions for substance use

•

Registered Nurses Association of Ontario. (2015). Engaging Clients who use Substances. Retrieved from https://rnao.ca/sites/rnaoca/files/Engaging_Clients_Who_Use_Substances_13_WEB.pdf

•

• (Government of Canada, 2018)

Post-Survey: Staff were re-issued the original survey to assess if there was an improvement in their familiarity of naloxone kits and teaching patients how to use the kits after the education training A comparison of the new results to the original data (Pre and Post) was analyzed and completed by March 30, 2019

CONCLUSION •

MHESA had no standardized protocol to screen clients for opioid use

•

There was a surprisingly high number of staff who did not feel comfortable discussing safe opioid use with clients

•

Staff reported they found the education helpful because many were not aware of the contents in the naloxone kits

ACKNOWLEDGEMENTS Special thanks to the MHESA RNs, Ifat Witz (Clinical Leader Manager), Tasha Penney (Clinical Nurse Educator), Ashley Skiffington (Evidence Based Practice Nursing Manager) and the entire Nursing Professional Practice team for their support with this project.

Communicating with your MS Care Team: A Guide to MS Care at St. Michael’s Hospital Sheryl Clarke, Registered Nurse

St. Michael’s Hospital

FOCUS RNAO BPG: Establishing Therapeutic Relationships • •

RESULTS (CON’T)

INTERVENTION/PROCESS

Patient Needs Assessment: How often do you contact the MS clinic for the following concerns?

Review current pathways of communication

Advancing communication that is purposeful, goal directed and in the best interest of the patient Fostering communication that is responsive to concerns at any stage of the patient care journey and of the relationship

RECOMMENDATIONS/NEXT STEPS • Develop information guide based on results of surveys • Engage stakeholders in the development process

Fig. 3: Online Responses (n=30)

Review volume of email & telephone contacts then group according to most frequent type of inquiries

Fig. 4: Paper Based Responses (n=113)

• Engage St. Michael's Patient Education Specialist • Distribute the guide to patients and stakeholders to review

100% 90% 80% 70%

Develop and distribute patient information needs assessment survey

• Patients who have a complex disease, are required to have complex treatment protocols and have contact with multiple health care providers require clear and concise communication • The multidisciplinary approach to care for patients with MS necessitates communication with several offices, clinics, support staff, nurses, physicians and allied health • There is currently no standard printed communication for the patient which outlines the MS clinics processes • Internal and External reviews revealed incongruence in patient expectations and realities of clinic practice which caused frustration for patients • The gap in information regarding the processes of the MS Clinic presents an opportunity for improvement

PURPOSE & OBJECTIVES • To provide clear, consistent information that meet patient needs • To provide direction on processes that impact care • To enhance patient care continuity • To improve patient satisfaction and experience • To enhance patient ability to self-direct care

50% 40%

Very Often

30%

Sometimes

10% 0%

Develop and distribute staff survey

Assemble results of patient and staff surveys to inform next step

Patient Needs Assessment: What information should we include in a handout for patients? Fig. 1: Online Responses (n=40)

Rarely

CONCLUSION

RESULTS Fig. 2: Paper Based Responses (n=113) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

• Patients and families have expressed a need for information materials • The survey data explains the type of information patients and their families would like to receive • Data supports a frequency of contact for information specific to Medication related matters, Symptom management, and Appointment booking processes

Yes No Unsure Skipped

• Develop and distribute evaluation survey to patients and staff to assess whether the guide met patient information needs and to obtain feedback on content from staff and stakeholders

Often

20%

Medications Symptoms Appointments Emotional supports Transportation Vaccination-Immunization Test results Money problems/finances Other healthcare… My medical records… Letters [ work, school,… Disability insurance forms Other reasons why you…

BACKGROUND

60%

• Engaging all members of the healthcare team can be challenging due to varying ideas of what information should be provided to patients • Patients and families need an information guide to be developed • Evaluation of the content of the guide will determine whether it meets patient education needs, and is uniform with clinical practice

Never skipped

REFERENCES RNAO. (2014). Establishing Therapeutic Relationships. Retrieved from https://rnao.ca/bpg/guidelines/establishing-therapeutic-relationships RNAO. (2015). Person and Family-Centered Care. Retrieved from https://rnao.ca/sites/rnao-ca/files/FINAL_Web_Version_0.pdf Greene, S. M., Tuzzio, L., & Cherkin, D. (2012). An initiative toward advancing the contribution of the nurse-client therapeutic relationship on system outcomes, practice, and clinical outcomes. A Framework for Making Patient-Centered Care Front and Center. The Permanente Journal, 16(3), 49–53. Sorenson, Per Coelberg., Giovannoni, Gavin., Montalban, Xavier., Tahlheim, Christoph., Zaratin, Paola., & Comi, Giancarlo. (2018). The Multiple Sclerosis care unit. Multiple Sclerosis Journal. 1-10. K Zissman,Keren, Lejbkowicz, Izabella, and Ariel Miller. (2012). Telemedicine for multiple sclerosis patients: assessment using Health Value Compass. Multiple Sclerosis Journal. 18(4) 472-480 .

ACKNOWLEDGEMENTS

Credit and acknowledgement to MS Clinic Nurses, Gabriela Escobar, who arranged the content and posted the surveymonkey links, and along with Sandra Fletcher; collated the raw data, and provided several revisions on the appearance of the data; and to Ashley Skiffington for ongoing guidance and evaluation on each step of the process.

Using Experience Based Co-Design to Engage Clients and Staff in Identifying Priorities for Improvements in Care in a Residential Withdrawal Management Service (Detox) Samantha Boumeester, RN, BScN, HonBA St. Michael’s Hospital, Unity Health Toronto

PROJECT OVERVIEW 



To utilize experience-based co-design principles to improve the experience of residential withdrawal management service (WMS) for clients who use substances This project was informed by the RNAO BPG on Engaging Clients Who Use Substances (2015) recommendations 5.3, 6.4, and Accreditation Canada Standards for Substance Abuse and Problem Gambling (2015) guidelines 1.0, 2.0, 7.0, 13.0, 15.0.

BACKGROUND 



Since the inception of withdrawal management services, service users have not been involved in identifying change ideas for improvement St. Michael’s Hospital Withdrawal Management Services will be combining services with the University Health Network (Ossington WMS- detox) in a new facility located at 333 Sherbourne This provides a unique opportunity for service users to be involved in program development, change and innovation

INTERVENTION/PROCESS

Plan Do

To engage key stakeholders of St. Michael’s Hospital WMS- detox regarding the services provided



To develop a list of change ideas that can be used to improve clinical services



To create a sustainable way to have key stakeholders involved in service changes

RECOMMENDATIONS/NEXT STEPS

 10 of 15 staff were surveyed (100% completion rate from full-time and part time staff)  25 clients were surveyed  8 clients participated in 1:1 filmed interviews for the creation of an Experience Based Co-Design video

Next steps: • Share EBCD film with staff and clients • Continue to work on actionable items list

Staff Survey Responses Using Likert Scale (Strongly Agree to Strongly Disagree) 50% of staff thought that the WMS was a welcoming environment, 50% strongly disagreed

• Engage key stakeholders • Provide feedback from literature review to staff and service users • Introduce program information pamphlet and clients rights and responsibilities

90% of staff thought that the WMS was an unsafe environment for clients 90% of staff felt that clients did not have enough access to group therapy 80% of staff felt that current medication policies did not meet the needs of the clients

Sustainability • Continue bi-annual staff retreats • Monthly meeting with BPG Champion and CLM to discuss progress, updates, and work on actionable items list • Post actionable service improvement ideas within staff office as a check-list • Utilize film for new staff trainings and across the addictions service to get buy-in for engaging clients in their care and program development • Create a “Quality Corner” for staff to provide suggestions for service improvement

Client Survey Responses Using Likert Scale (Strongly Agree to Strongly Disagree) + Yes/No 100% of clients agreed that the intake process at WMS was welcoming

Study

• Conduct client surveys • Conduct staff surveys • Conduct 1:1 client interviews and video record for creation of film

Act

• WMS staff retreat – introduced bi-annually • Data collected from surveys to inform next steps for program development • Creation of film to be used for staff training purposes and getting buy-in for service change • Service restrictions eliminated; all old service restrictions removed

REFERENCES

72% of clients felt that the current treatment referral package did not meet their needs 88% of clients reported there were not enough groups run at WMS to support their recovery 60% of clients reported their mental health needs were not addressed while in WMS 72% of clients reported they would want access to infectious disease screening while at WMS

PURPOSE & OBJECTIVES 

• Conduct literature review on leading practices in WMS services • Consult key stakeholders

RESULTS

IMPLICATIONS  The model of experience based co-design was widely accepted with positive feedback as a sustainable way to engage clients who use substances in the development and change of services that they use.  Our goal to engage clients who use substances in identifying priorities for program improvements within the WMS was achieved  It was quite difficult to engage clients while staying at the WMS as they were at a very vulnerable stage (either in withdrawal, trying to access various services, have had prior negative interactions with health care providers and did not want to participate)  Through the surveys and 1:1 interviews the following actionable ideas for service improvement have been developed: • 36 short-term ideas • 19 medium-term ideas • 14 long-term ideas

Accreditation Canada Standards (2015). Substance Abuse and Problem Gambling. Version 10. Registered Nurses Association of Ontario (2015). Engaging Clients Who Use Substances. Retrieved from https://rnao.ca/sites/rnaoca/files/Engaging_Clients_Who_Use_Substances_13_WEB.pdf The Point of Care Foundation (2013). Experience Based Co-Design Toolkit. Retrieved from https://www.pointofcarefoundation.org.uk/resource/experience-basedco-design-ebcd-toolkit/

ACKNOWLEDGEMENTS Special thanks to:

Nicole Kirwan, Clinical Leader Manager, Community Mental Health and Addictions Murray Krock, Director, Nursing Practice and Education Vanessa Chavez Prieto, Corporate Nursing Education Manager Katherine Cooper, Medical Media, Photography and Video Production All staff and clients at SMH WMS who participated and provided feedback for this BPG project.

Managing Responsive Behaviours on the Inpatient Mobility Unit Olga Krasik, RN

St. Michael’s Hospital, Unity Health Toronto

FOCUS

INTERVENTION/PROCESS

BPG topic: Managing Responsive Behaviours

RESULTS

CONCLUSION

Graph 1: Survey results

• 100% of surveyed staff stated that they found the care plan useful, and saw themselves using it. • In-services promote capacity building among RNs and CAs in caring for patients with RB. • RB care plan improves communication about the needs of these patients and promotes patient centered care.. • Further evaluation is needed to determine the long term impact of the RB care plan on patient care.

Figure 1: Flow diagram of timeline and deliverables

RNAO BPG: Caregiving strategies for older adults with Delirium, Dementia and Depression

Survey Responses Pre and Post Intervention

• Staff learning needs assessment December • Pre survey distribution 2018

+ 29%

+ 17%

9 8 7 6

Pre Intervention

Post Intervention

BACKGROUND Orthopedic patients can exhibit responsive behaviours (RB) due to delirium, dementia, or other cognitive impairments. Some patients with RB are assigned a constant care (CC) provider. Patient’s RB and requirement for constant care need to be assessed, managed and documented. Currently, there is no individualized care plan for orthopedic patients exhibiting RB.

January 2019

• In services educating staff on RBs and management strategies as well as documentation for constant care • RB care plan roll out

• Audit of Soarian charting FebruaryMarch • Audit of care plan tool compliance 2019 • Continued in services FebruaryMarch • Championing use of care plan 2019

RECOMMENDATIONS/NEXT STEPS

2 1 0

Knowledge about RBs out of 10 Comfort Level Working with Patient Exhibiting RBs out of 10

Legend: Knowledge Scale: 0 = no knowledge to 10 = extremely knowledgeable Comfort Scale: 0 = very uncomfortable to 10 = extremely comfortable

I could immediately tell the patient’s name

The care plan is eyecatching, colourful, and easy to use

The care plan helped me quickly identify what I could do to help the patient

Table 2: Care plan Initiation Compliance Week

PURPOSE & OBJECTIVES

Number of patients exhibiting RBs 0

Feb 4-10

Feb 11-17

Feb 18-24

Aim: To improve communication amongst staff and family about the needs of patients exhibiting responsive behaviours (RB), and to build capacity amongst staff in caring for these patients.

Feb 25-Mar 3

Mar 4-10

Mar 11-17

Care plan use not applicable

Evaluation Measures

Indicators

Data Collection

Mar 18-24

Mar 25-31

Process

80% of RNs will be educated on common management strategies and required documentation

Tracking of Education Attendance

60% of patients who demonstrate RB will have an individualized care plan by March 31, 2019

Audit of individualized care plan

60% of patients with a CC provider will have the appropriate Soarian documentation by March 31, 2019

Audit of Soarian documentation

Table 1: Aim and Objectives

Outcome

50% increase in self-reported RN Pre and post surveys knowledge of and confidence in working with patients exhibiting RB

% completion

Graph 2: Soarian Constant Care Charting Compliance Rate

Located at the patient’s bedside Patient centered

Interprofessional Individualized

80%

Address RB care plan in bedside TOA Modify care plan based on staff feedback Share and celebrate results Identify and build capacity for champions Implement the BPG into new-hire training by the clinical nurse educator

REFERENCES •

Number of patients exhibiting RBs with a care plan

Jan 28-Feb 3

Figure 2: Responsive Behaviours Care Plan

• • • • •

• • •

Martin, L. S., Gillies, L., Coker, E., Pizzacalla, A., Montemuro, M., Suva, G., & Mclelland, V. (2016). An Education Intervention to Enhance Staff Self-Efficacy to Provide Dementia Care in an Acute Care Hospital in Canada. American Journal of Alzheimer's Disease & Other Dementiasr, 31(8), 664-677. Alberta Health Services (2016, March). Responsive Behaviours. Retrieved from https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-srs-responsivebehaviours.pdf. Alzheimer society of Canada (2017, August 11th). What are responsive behaviours. Retrieved from https://alzheimer.ca/en/on/We-can-help/Resources/ShiftingFocus/What-are-responsive-behaviours Interior Health. Accommodating and Managing Responsive Behaviours: PIECESABC Tool. Retrieved from https://www.interiorhealth.ca/sites/Partners/SeniorsCare/DementiaPathway/MiddleD ementiaPhase/Documents/PIECES-ABCtool.pdf

ACKNOWLEDGEMENTS This initiative was funded by the generous support of the Piera Cardella Scholarship at St. Michael’s Hospital Many thanks to the staff of Inpatient Mobility Unit for your contributions, Mary Van Impe for your support, Cecilia Santiago and Shawna McIntyre, and Ines De Campos for your mentorship and leadership, Michelle Rawlings for your design expertise, Nursing Practice and Education for the opportunity to participate in the BPG initiative

Responsive Behaviour in Trauma and Neurosurgery Intensive Care Unit Oscar Cahyono RN, Vasuki Paramalingam RN, MSN, CNCC (C) and Cecilia Santiago RN, MN, CNCC(C) St. Michael’s Hospital, Unity Health Toronto Toronto, ON, Canada

FOCUS

Topic: caregiving strategies for patients exhibiting responsive behaviour with potential constant care requirement post critical care discharge RNAO BPG: caregiving strategies for older adults with delirium, dementia and depression • Recommendation 1.1: maintain a high index of suspicion for the prevention, early recognition and urgent treatment of delirium • Recommendation 1.3: initiate standardized screening methods to identify risk factors for delirium on initial and ongoing assessments

BACKGROUND • Trauma & Neurosurgery Intensive Care Unit (TNICU) transfers patients with responsive behaviour to constant care rooms on 9CC ward • Pre-intervention, 55% of 9CC ward RNs perceived that less than 50% of ICU-transferred patients were appropriate for the constant care rooms • There has been no constant care criteria guideline for TNICU, decisions to transfer patient to constant care rooms are based on RNs’ subjective opinions • Only <10% of TNICU RNs were familiar with the term “responsive behavior” • While 95% of TNICU RNs perceived that responsive behaviours, alleviating and precipitating factors are always included during Transfer of Accountability (TOA), 60% of 9CC ward RNs stated that these information are relayed by TNICU RNs during TOA only sometimes • 9CC ward RNs suggested TNICU RNs to discuss pain medication/sedation (name, dose and time) during TOA from TNICU to 9CC

INTERVENTION/PROCESS October – December 2018

• Pre-intervention surveys sent to TNICU (n=56)and 9 CC ward (n=45)RNs • Peer to peer interviews with TNICU RNs (n=25) to assess opinions on constant care • Chart audits on ticket to ward completion rate

Figure 3: 9CC ward opinions on ICU-transferred patients appropriateness for constant care rooms post-intervention (n=38) 0-25% 25-50% 50-90%

January – February 2019

• Educated TNICU RNs using PowerPoint based on survey results • Presented current state and BPG plan to address issues to: • TNICU and 9CC UBCs • Constant Care/Managing Responsive Behaviour Committee • Stickers applied to kardexes and ticket to ward sheets to address issues

• Post-intervention surveys to assess changes post roll out • Chart audits for ticket to ward completion rate for patients with responsive behaviours March 2019 • PowerPoint presentations to update TNICU RNs on progress • Emails sent to 9CC ward RNs for BPG project update

90-100% 0%

10%

20%

30%

40%

50%

Figure 4: TNICU frequency of discussion on responsive behaviour with 9CC ward post-intervention (n=38) Always Often I don't know

Figure 1: arrow showing changes made to ticket to ward sheets

10%

20%

30%

40%

50%

Figure 5:TNICU RNs awareness of responsive behaviour post-intervention(n=54) Agree Neither Disagree 0%

Figure 2: arrow showing changes made to patient kardexes

CONCLUSION • We met our objective of building assessment of responsive behaviours and need for constant care on existing ICU documentation and communication tools. Staff has been using Ticket to Ward sheets consistently • This process of change has resulted in observed: • improvement in awareness of responsive behaviours in TNICU • improvement in communication of responsive behavior between TNICU and 9CC ward • Further evaluation is needed to assess the impact of the communication tools in improving the transition of TNICU patients to 9CC ward constant care rooms • TNICU has not been transferring significant number of patients with responsive behaviour to 9CC ward • To be revisited in three months

RECOMMENDATIONS/NEXT STEPS

Sometimes Never

PURPOSE & OBJECTIVES

Goal: • To improve quality of communication during TOA regarding responsive behaviour and patient’s need for constant care Objectives: • To increase staff knowledge about responsive behaviours and assessment of constant care need when transferred to 9CC ward • To build assessment of responsive behaviours and need for constant care on existing ICU documentation tools • To evaluate completion of tools Measures: • ≥ 60% of 9CC RNs state that >50% of ICU-transferred patients are appropriate for constant care • ≥ 60% of 9CC RNs state that TNICU RNs often/always speak about responsive behaviours with related precipitating and alleviating factors • ≥ 60% of TNICU RNs are aware of the term “responsive behaviour” • 75% of the patient with responsive behaviours will have Ticket to Ward sheet completed • 100% integration of stickers on kardexes, ICU flowsheet and Ticket to Ward sheet by September 2019

RESULTS

10%

20%

30%

40%

50%

60%

70%

80%

Figure 6: Completion of responsive behaviour section of TOA by TNICU RN 100%

• Integrate temporary stickers to kardexes and ticket to ward sheets • Incorporate the term “responsive behavior” in TNICU documentation (i.e. TNICU flowsheet) • Make “constant care” e-module part of new TNICU RN orientation • Recruit unit champions to continue to educate and support staff on responsive behaviour • Continue to update Constant Care/Managing Responsive Behaviour Committee regarding constant care and responsive behavior related documentation in Trauma/Neurosurgery Program

REFERENCES Registered Nurses’ Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care (2nd ed.) Toronto, ON: Registered Nurses’ Association of Ontario

95% 90%

ACKNOWLEDGEMENTS

85% 80% 75%

Jan.26 - Feb. Feb. 3 - 9 2 (n=4) (n=2)

Feb 10-16 Feb. 17-23 Feb.24-Mar. (n=3) (n=7) 2 (n=2)

Mar.3-9 (n=2)

Mar.10-16 (n=3)

Mar.17-23 (n=2)

• • • • •

TNICU and 9CC RNs TNICU and 9CC UBCs Constant Care/MRB Committee Nursing Practice and Education Elizabeth Butorac, TNICU CLM

Improving Understanding and Embracing Gender Diversity in the Emergency Department Mallory Harris, RN, BScN, BScK St. Michael’s Hospital

FOCUS RNAO BPG: Embracing Cultural Diversity in Healthcare: Developing Cultural Competence

BACKGROUND • An Ontario study (Bauer et al., 2014) found that transgender and gender nonconforming people faced significant barriers to accessing emergency care  52% reported negative interactions with ED healthcare providers

INTERVENTION/PROCESS

c. Standard of Practice

a. Staff Survey

•

• Created and circulated staff survey to gain an understanding of barriers and facilitators to care and perceived comfort and knowledge of gender diversity • Over X number of ED staff completed the survey

Initiated multiple PDSA cycles to determine a standard of practice for consistent identification and communication of preferred name and/or preferred pronouns

Figure 1: Respondent Roles

 29% reported an unmet healthcare need in the past year

d. Gender-neutral Signage

 50% of transgender presenting to the ED in their felt gender reported negative experiences

•

• A recent article in the Globe and Mail shared the patient experience of a transgendered female accessing three downtown Toronto emergency departments, including “downtown hospital known for treating Toronto’s LGBTQ community and its more marginalized communities”

RESULTS •

• To improve the transgender and gender nonconforming patient experience within the Emergency Department (ED) and to ensure every patient that accesses our department feels safe, secure, and can receive the urgent care they are seeking

2. To implement a standardized way to identify and communicate preferred name and/or pronouns; and 3. To update the emergency department with gender neutral signage to support an inclusive space

(1) staff education around cultural diversity, population specific language and terminology, recognizing access barriers and healthcare concerns; (2) developing a Standard of Practice (SOP) to ensure preferred name and/or preferred pronouns are identified and communicated across the multidisciplinary healthcare team; and (3) updating the emergency department with inclusive, gender-neutral signage throughout the space.

•

Implement gender inclusive bathroom signs throughout the emergency department

•

Conduct post education survey to re-assess staff knowledge and comfort levels with transgender and gender nonconforming patient populations

•

Create a standard of practice (SOP) for identifying and communicating preferred name and/or pronouns

•

Chair monthly Pride committee meetings to focus on continuing diversity education and inclusivity training.

•

Advocate for inclusive gender option in Soarian (male, female, other, unknown)

REFERENCES

AIM

1. To provide staff education to improve terminology, language, and comfort when caring for this patient population;

Request, design and implement gender-neutral signage throughout the emergency departments physical space to promote inclusivity

Figure 2: Hesitations in addressing LGBTQ populations

“I suppose I should have predicted that transphobia would follow me into every aspect of my life, but I naively assumed that having the correct name and gender on my health card would protect me.”

OBJECTIVES

A multi-facet approach to embrace gender diversity includes:

RECOMMENDATIONS/NEXT STEPS

 21% reported a lifetime avoidance of the ED due to fear of discrimination and/or harassment

• Her experience is recounted through vivid descriptions of multiple negative and inappropriate interactions with both clinical and nonclinical staff

CONCLUSION

80% of clinical and non-clinical staff participated in mini education huddles  Staff report feeling more comfortable with terminology and addressing transgender and gender nonconforming healthcare needs

b. Education • Provided clinical and non-clinical staff with mini education huddles and Trans101 educational booklet to improve understanding of terminology and language when addressing transgender and gender nonconforming patients

•

Established a Pride Committee with bi-monthly meetings  Current focus: educational blitz and staff activities during pride month (June 2019)

•

Created, printed, and circulated Trans101 booklet as an ED reference guide and resource to staff

Bauer, G., Scheim, A., Deutsch, M., & Massarella, C. (2014). Reported emergency department avoidance use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of Emergency Medicine, 63(6), 713-720. Benaway, G. (2018, July 20). When it comes to health care, transphobia persists. The Globel and Mail. Retrieved from: https://www.theglobeandmail.com/opinion/article-when-it-comes-to-health-caretransphobia-persists/ Giblon, R & Bauer G. (2017). Health care availability, quality, and unmet need: a comparison of transgender and cisgender residents of Ontario, Canada. BMC Health Services Research, 17:283. Houssayni, S & Nilsen, K. (2018). Transgender Competent Provider: Identifying Transgender Health Needs, Health Disparities, and Health Coverage. Kansas Journal of Medicine, 11(1), 15-19.

ACKNOWLEDGEMENTS We would like to graciously acknowledge and thank the following for their support throughout this project: ★ Kate MacWilliams – ED Clinical Nurse Specialist ★ Ashley Skiffington - Professional Practice Nurse Mentor ★ Melissa McGowan - ED Research Education Coordinator ★ SMH ED staff

Person-Centered Care Standards for the Support and Care of Transgender Clients in the CIBC Breast Centre Michaela McCrady, RN, BScN, Marta Bisiker, RN, BScN, Ekaterina Mikhelson, RN, MN, Anna Kacikanis, RN, MN, St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS Establish standards, clinic guidelines, and multidisciplinary approach for CIBC Breast Centre staff on the support and care of transgender clients RNAO BPG: Person- and Family Centered Care • Recommendation 1.3: Listen and seek insight into the whole person to gain an understanding of the meaning of health to the person and learn their preferences for care • Recommendation 2.1: Develop a plan of care in partnership with the whole person that is meaningful to the person within the context of their life • Recommendation 6.2: Design an environment that demonstrably improves the person’s experience of health care

PURPOSE & OBJECTIVES Goals: Improve the patient experience • Increase/expand staff knowledge of the transgender community, and improve person-centered care by providing a professional, sensitive, and holistic approach

RESULTS

RECOMMENDATIONS/NEXT STEPS (CON’T) Post Survey: Staff Response

Figure 4: Examples of Waiting Room Signage

100% of Breast Centre staff found strategies from Learning Sessions helpful 100% of Breast Centre staff felt the information was relevant Overall increase in knowledge in providing transgender care

INTERVENTION/PROCESS • 30 multidisciplinary Breast Centre staff completed pre-survey assessing current approach and knowledge in providing care to transgender patients

BACKGROUND No current standard approach to care of transgender clients in the CIBC Breast Centre resulting in: • Patient and staff dissatisfaction • Lack of follow-up from the transgender community Transgender clients are about 70% less likely to be screened for breast cancer compared to the cisgender patient population at St. Michael’s hospital (Gajic, 2019) Figure 1: Process Map of the Current/Pre-State

Figure 3: Comments from Staff

• Resulted in a resounding need for Learning Sessions on transgender care • After extensive literature reviews and interviewing an NP with expertise in the area of gender identity, we presented 6 Learning Sessions • Learning Sessions were approx. 15 min long and provided evidence based support for the multidisciplinary team Figure 2: Slides from the Learning Session

CONCLUSION • Staff were very receptive and learning sessions resulted in group discussions with many voicing concerns and opinions on this topic • Staff found the learning sessions relevant, helpful and contributed to an increase in knowledge about transgender care

RECOMMENDATIONS/NEXT STEPS • Adapting the Breast Centre referral form to include whether a patient is transgender and what pronouns and name they prefer • Hanging LGBTQ-friendly posters and signage in Breast Centre, indicating a trans-friendly environment • Updating the Breast Centre website to reflect transgender and LGBTQ inclusivity

Figure 5: Example of Washroom Signage

REFERENCES Available upon request

ACKNOWLEDGEMENTS CIBC Breast Centre Staff Ashley Skiffington, RN, Med, Professional Practice Mentor Nursing Practice and Education Sue Hranilovic MN, NP-PHC, ACRN

Improving Nurse Health and Safety in the NICU Manev Shokar, RN, BSc, BScN St. Michael’s Hospital

FOCUS

PURPOSE

INTERVENTION (CON’T) 2. Monthly Health Lifestyle Themes and Lifestyle Wellness Challenges

BACKGROUND

• To increase awareness of health and safety issues amongst nurses in the NICU • To encourage and increase nurse participation in healthy lifestyle sessions, such as fitness programs

Promote and improve nurse health and safety in the NICU through educational and recruitment strategies. Injury and decreased quality of life: Nurses in the NICU may be at risk for injuries specific to their specialty nursing duties, such as moving heavy equipment including: infant beds, infant warmers, instrument carts and resuscitation equipment and repetitive bending over cribs (Stichler, Feiler, & Chase, 2012). Demanding work schedules: Nurses work long hours and long stretches of workdays without a day off, which prevents them from addressing their own health needs, particularly the need for rest, exercise and other stress reduction activities (Geiger-Brown et al., 2004 & RNAO, 2008).

PROCESS • • • • •

PLAN • • •

Identify health and safety concerns of nurses in the NICU Consult key stakeholders

•

Introduce monthly health lifestyle themes Introduce Wellness Challenges Conduct In-service

ACT

STUDY

Conduct nurse surveys Observe participation in lifestyle challenges Visual surveillance for usage of safety in the NICU strategies

• • •

Continue to encourage nurse participation in health and wellness programs Ccontinue monthly themes Use data to inform next steps

Figure 3: Board set up of Monthly Lifestyle Theme and Step Challenge

INTERVENTION

1. In-Service • PowerPoint “Improving Nurse Safety in the St. Michael’s NICU”

Nurse Participation in Weekly Fitness Programs 70% 60% 50% 40% 30% 20% 10% 0%

Figure 4: Graph displaying nurse participation in Fitness Programs, n=20. Participation

“According to the Canadian Labour and Business Centre (2002), three strategies are recommended for improving work environments:

75% of nurses work 4-5, 12-hour-shifts per week 90% of nurses get less than 5 hours of physical activity/week

1. initiatives related to the physical work environment (appropriate equipment and training availability); 2. initiatives related to the physical health of the employee (fitness and weight loss programs); and 3. initiatives related to mental health/stress/psychosocial concerns (stress management programs, and programs to deal with family and workplace issues)” Case study by Lamontagne (2002) • Conducted at Seven Oaks General Hospital in Winnipeg, Manitoba • Implementation of a wellness program • Initial impact showed employees’ change in lifestyle behaviours, improved employee morale, high participation rates in wellness programs and improved communication between staff and managers

65% of nurses eat non home cooked meals 3-4 times/week

Figure 5: Healthy Lifestyle Survey results, n=20.

How confident are you in your understanding of… Prevention of lower back pain techniques (NICU specific)

Figure 6: Pre & Post Health & Safety Presentation Results

Musculoskeletal injuries arising from NICU specific tasks (ex: bending over cot) Proper posture while moving equiptment in the NICU

After Before

Where equiptment should be placed by the bedside in the NICU

Figure 2: Improving Nurse Safety in the NICU PowerPoint Presentation slides.

• About half of the nurses (n=18) pointed out to anecdotal evidence of changes in lifestyles. Ex: change in the lifestyle of some nurses who started walking to work instead of driving or taking the bus, or those who started exercising on a regular basis. • High participation rates for the weekly step challenge (~60%) could indicate a strong level of support for the challenge and overall satisfaction with it. • The process changes resulted in increased understanding of workplace safety issues in the NICU, including musculoskeletal injuries, prevention of lower back pain and proper posture while moving equipment. • The monthly fitness programs call for the undertaking of a scientific study involving nurses and examining changes in fitness and lifestyle. The study can rely upon a control group in order to isolate program impacts. After the completion of the study, it should offer some indication of impact of wellness activities on health and lifestyle. • Some NICU nurses expressed some concerns about the fact that night shift workers were being left out of most health and wellness activities, and their overall workload was such that it made it difficult even for day shift nurses to participate in the activities.

RECOMMENDATIONS/NEXT STEPS

RESULTS

Figure 1: PDSA Cycle.

RNAO Health, Safety and Wellbeing of the Nurse (2008) states:

CONCLUSION

4 6 Scale 1-10

• Consider Mental Health of nurses as topic of nurse wellbeing - Holding Small Group Learning Activities focused on management of patient/family aggression and reducing distress • Create a web-based module based on in-service PowerPoint • Consider a organizational based approach to workplace health promotion: “establish and integrate a sustainable program of activities that reflect the employees and the organization on a variety of issues, ex: factors that affect employee well-being and voluntary health practices” (RNAO, 2008).

REFERENCES

Canadian Labour and Business Centre. (2002). Twelve Case Studies on Innovative Workplace Health Initiatives: Summary of Key Conclusions. Canadian Labour and Business Centre: Ottawa, ON. Geiger-Brown J, Trinkoff AM, Nielsen K, Lirtmunlikaporn S, Brady B, & Vasquez EI. (2004). Nurses’ perception of their work environment, health and well-being: a qualitative perspective. American Association of Occupational Health Nurses Journal. 52(1)16-22. Lamontagne F. (2002). Case Study: Seven Oaks General Hospital. Canadian Labour and Business Centre: Ottawa, ON Registered Nurses’ Association of Ontario (2008). Workplace Health, Safety and Well being of the Nurse. Toronto, Canada: Registered Nurses’ Association of Ontario. Stichler, J.F., Feiler, J.L., and Chase, K. Understanding risks of workplace injuries in labor and delivery. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2012; 41: 71–8.

ACKNOWLEDGEMENTS Mary Murphy

Ashley Skiffington

Preventing and Mitigating Nurse Fatigue on General Internal Medicine (14 CC)

Magetta Vincent RN, BScN; Shirley Bell RN, Clinical Nurse Educator; Kim Grootveld BScOT, MScQIPs, CLM; Susan Camm RN, BScN, MHSc, CLM

St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS

PROCESS

To optimize and sustain a delivery model of care between Registered Nurses (RNs) and Clinical Assistants (CA's) by implementing a buddy system and daily huddle process to help prevent and mitigate staff fatigue on 14CC.

1. Needs Assessment

BACKGROUND

• Interviews (n =60) RNs & CAs • Face to face (n = 80) )RNs CAs • Pre-survey (n = 103) RNs and 34 CAs

• Staffing and workload are complex issues that cannot be remedied with simple ratios or predictive needs (RNAO, 2011)

2. Engaged Stakeholders

• Health care fatigue may significantly interfere with functioning and may persist despite periods of rest (RNAO, 2011) • This work aligns with the RNAO Best Practice Guideline (BPG) entitled Preventing & Mitigating nurse fatigue in Health Care (2011) • General Internal medicine(14CC) is a 78 bed high acuity unit with 123 RNs and 43 CA’s. Based on feedback from staff:  Staff weren’t aware when coworkers were overwhelmed and needed assistance or when coworkers were available to give us support when needed  All staff were trying to master their our own complex work assignments  With increasing medical acuity and physical and psycho-social needs of our patients, we must ensure we have effective strategies to decrease staff fatigue

• Met with coworkers to address the vision for our unit: a supportive, inclusive environment where everyone feels motivated to come to work • Revisited delivery model of care used in the past • Explored how the team can use huddles to improve communication and address challenges affecting workload 3. Education • Booster sessions provided for RNs and CA's

Promote a sense of teamwork and improve communication through the development of a daily 5-10 minute staff huddle and assigned buddy system.

Indicators

Methods

Frequency

• Group emails, staff meetings, unit walk abounds and one on ones

Huddle compliance Manual audits target 98% by April 2019

Weekly

Buddy system compliance target of 98% by April 2019

Weekly

Manual audits

RNs and CAs attitudes Interviews and perceptions towards Survey huddles and buddy system Table 1. Indicators

Pre-Survey Interview Date: October 26th, 2018 Post-Survey Interview/focus groups Date: March 10th and March 14th

“A new buddy system is key to reducing stress”

“This buddy system helps us support each other and provide better quality care” “I feel safe raising issues” “We can learn from each other”

Table 2. Buddy system compliance

DATE

• Staff reported improved satisfaction and wellness with the new buddy and huddle process.

Our huddle process is designed to improve communication and support teamwork.

• Staff reported feeling like a part of the team.

Figure 2. Huddle on GIM

4. Awareness Campaign

MEASURES

People are reporting an improvement in teamwork and support with the same amount of staff.

Figure 1. Audit of buddy system

RESULTS

OBJECTIVE

CONCLUSION

RESULTS (CON'T)

# of CAs # of CAs /CAs # of RN/CA # of RN/RN working not using not working working as a team as a team the buddy as a team Buddy team work buddy system team

March 9

March10

March11

March12

March13

March14

March 15

Table 3. Registered Nurse and Clinical Assistant perceptions and attitudes pre and post buddy system and huddle implementation

Improved staff satisfaction and wellness Improved unit teamwork Staff that feel supported and motivated at work

Pre-Survey

“It Improve patient care, staff satisfaction and wellness”

RECOMMENDATIONS/NEXT STEPS

Post-Survey .

Agree

Disagree

Agree

• 14CC met and surpassed huddle and buddy system compliance targets.

Disagree

• Share the survey and audit results with Educator /CLMs and stakeholders • Conduct interviews/focus group sessions with RN’s and CAs to explore how to sustain the huddle and buddy system processes in practice • Continue to conduct weekly audits to measure compliance and share the audit results with staff at each staff meeting • Incorporate allied health teams into daily huddles • Provide a electronic board for staff to visualize the information . captured in the daily huddles and where they can list any concerns • Next PDSA cycle begins September 2019

REFERENCES 98%

100%

95%

100%

88%

12%

100%

The buddy system is so important when I feel overwhelmed”

“This certainly reduced my stress” “The huddles helped me understand my partner’s assignment and plans for the shift”

Registered Nurses Association of Ontario. (2011). Preventing and mitigating nursing fatigue in health care: Best practice guidelines. Retrieved from http://rnao.ca/sites/rnaoca/files/Care_Transitions_BPG.pdf

ACKNOWLEDGEMENT General Internal Medicine RNs & CAs Aisha Muslim RN ,BScN Nursing Practice and Education Ashley Skiffington, Evidence Based Practice Nursing Manager

Advanced Care Planning: Nursing Leading the Way Cathy Wilson, RN, CCHN(C) St Michael’s Hospital, Unity Health Network FOCUS To increase the knowledge and comfort level of the nurses in the Family Health Team (FHT) so that advanced care planning (ACP) becomes part of routine care for patients over the age of 70. To increase the number of documented end of life conversations and substitute decision makers (SDMs) or power of attorney (POAs) for personal care documented in the patients cumulative patient profile (CPP) in the electronic medical record (EMR).

BACKGROUND Seniors (65 years and older) are the fastest growing age group in Ontario. By 2041, it is projected that 25% of Ontario’s population will be 65 years or older, almost doubling from 3 million seniors in 2016 to 4.6 million seniors. (Aging with confidence: Ontario’s Action Plan for Seniors). Currently in the Family Health Team we do not have a standardized approach for RNs to incorporate ACP into routine visits. Large numbers of seniors are receiving care within the FHT without documentation of a SDM or POA on their chart. Nurses are well positioned within the FHT to enhance the care of seniors by having the discussion with patients about end of life care and improving the documentation of SDM/POAs. Figure 1: EMR Search of Patients 70+ with a documented POA

PURPOSE & OBJECTIVES • To incorporate ACP into the routine care of patients over the age of 70 • To increase the number of documented SDMs/POAs for personal care and advanced care plans to 10% of this population by December 2019 • Help to raise awareness in supporting individuals to make informed decisions that align with their end of life desires • Documentation of ACP encourages communication between the patient and their chosen SDM/POA. The hope is that these wishes will be followed and that caregiver burden is reduced if decisions need to be made

RESULTS • Based on the new process, RN saw 25 patients for an ACP discussion

•

Presentation at UBC to discuss the successes and ease of increasing the documentation of SDM/POA and advanced care plans

•

Completion of a seniors preventative health assessment form to be used by RNs to help facilitate the ACP discussion

•

Presentation of the success of this initiative to the FHT’s Seniors Strategy Committee.

•

Identify an RN champion at each site to help continue this initiative

•

RNs to start the ACP discussion with patients to see first hand the patient satisfaction from this discussion

•

BPG Nurse Campion to present this initiative to the FHT medical staff at one of their monthly meetings to introduce this change in RN practice

• 24 new SDM/POAs were documented in the chart in the CPP section of the EMR • 25 new advanced care directives were documented in the chart as a special note • 2 DNR forms were completed

Figure 3: Patient qualitative narratives (semi-structured interviews)

INTERVENTION/PROCESS

REFERENCES

Figure 2: Process map representing future state Providers refer patients to RN

RECOMMENDATIONS/NEXT STEPS

CONCLUSION • ACP and documentation of SDM/POA’s can be completed by the RNs in the FHT • Patients were receptive and expressed gratitude when the discussion of ACP was raised with them

End of life Planning Canada. Who Will Speak for You? 2016. www.elplanning.ca. 12 December 2018. Government of Ontario. Aging with Confidence. Plan Update. Toronto: Government of Ontario, 2016. Document. Registered Nurses' Association of Ontario. Professionalism in Nursing. 01 10 2015. Document. 15 November 2018.

• No one refused to have advanced care discussion with the RN • A gap exists in the holistic care that we currently provide and RNs can fill that gap to help provide patient centred care across the entire life span • A key factor for success in this initiative is the long-term therapeutic relationship that the RN has established with patients in the FHT

ACKNOWLEDGEMENTS Lorna McDougall, NP, St. Michaels Academic Family Heath Team Sarah Nestico CNS, St. Michael’s Academic Family Health Team Linda Jackson, Executive Director, St. Michaels AFHT Jacqueline Chen CLM Nanette Lang CLM Nursing Practice and Education

Supporting our Colleagues Experiencing Distress Debbie Snatenchuk, RN; Shannon Swift, RN St. Michael’s Hospital, Unity Health Toronto

FOCUS Identify areas of need in regards to supporting our colleagues experiencing distress in the Medical/Surgical Intensive Care Unit (MSICU).

INTERVENTION/PROCESS Fig 1. Activities associated with each Plan, Do, Study, Act (PDSA) step

RESULTS 58% (n=180) of staff in the MSICU responded to the survey

• 66% of the staff did not know the term “Second Victim” • 82% of the staff had witnessed/experienced an unanticipated

• Witnessing/experiencing an adverse event in the MSICU can

• 57% of the staff felt personally responsible for a

• The term “Second Victim” was first used in 2000, based on

• 42% of the staff felt that they could not obtain adequate

error/adverse event

lead to profound personal and professional consequences

support

research that was conducted with physicians who experienced emotional distress after an adverse event (Tamburri,2017)

CONCLUSION

• Research estimates that 50% of all healthcare providers are

• A majority of staff working in the MSICU had

a ‘Second Victim” at least once in their career (Yao & Fei, 2018)

and from that number, only 25% are interested in using EAP (Employee Assistance Program)

PURPOSE

• A majority of staff seek support from colleagues and family

• To understand the percentage of individuals in the MSICU who

who are not trained in crisis management and counseling

have experienced distress

• To identify areas where staff seek support and areas that may be needed for support

OBJECTIVES • 90% of staff will be aware of the term “Second Victim” and the stages of recovery

• Increase staff awareness of resources that are presently available to them

other in a time of need.- “It’s OK not to be OK!”

• Develop an infrastructure that supports emotional first aid (supportive debriefing within 24 hours, peer support, hospital support, professional support)

• Create a wellness check list for staff at the end of their shift - UBC

REFERENCES •

“Call for Solutions” (2012). Implementation of the "Second Victim" Support Program: RISE. Maryland Patient Safety Center, 2012.

•

Edrees, Het al. (2016). Implementing the RISE Second Victim Support Programme at the Johns Hopkins Hospital: a Case Study. BMJ Journal, 6(9), 1–25.

•

Glauser, W, et al. (2016). Many Hospitals Don't Do Enough to Support Health Care Workers after an Adverse Event. Healthcare Quarterly, 21(23), 1–10.

•

Scott, S.D. (2011). The Second Victim Phenomenon: A Harsh Reality of HealthCare Professionals. Patient Safety Net, 1–8.

•

Scott, S.D. (2016). Designing a Second Victim Support Program: Assessment Worksheet/Planner. Health Care for You, 1–8.

•

Tamburri, L.M. (2017). AACN of Critical Care. Creating Healthy Work Environments for Second Victims of Adverse Events, 366–374.

•

Yoo, Lindsay, & Mengdi Fei. (2018). The Second Victim: Supporting Healthcare Providers Involved in Medication Errors. Hospital News, 41.

witnessed/experienced an unanticipated adverse event

• 50% of staff felt personally responsible for an adverse event

Victim”

• Foster/train staff to understand, talk, and support each

adverse event/medical error/or injury to patient

BACKGROUND

• To measure staff’s level of knowledge of the term “Second

RECOMMENDATIONS/NEXT STEPS (CON’T)

Fig 2. Reported feelings associated with distress

• The term “Second Victim” is a relatively new term for staff

RECOMMENDATIONS/NEXT STEPS • Educate staff on Second Victim/stages/recovery – ongoing • Create buzz word “Second Victim” - no one should suffer in silence – ongoing

• Develop a healthy safe zone/place for staff to receive support - Wellness Room for staff

ACKNOWLEDGEMENTS Ashley Skiffington, Evidence Based Practice Nursing Manager (Professional Practice Mentor) Ellen Lewis, Clinical Leader Manager, MSICU (Unit Mentor) Shannon Swift ,Clinical Nurse Educator, MSICU (Unit Mentor)

Promoting Utilization of the Online Patient Education Portal and Patient Oriented Discharge Summary (PODS) Elizangela Do Rosario, Melissa Darbyson, Emily Sestito, Ian Barrett St. Michael’s Hospital

FOCUS

INTERVENTION/PROCESS

Promoting utilization of online patient education portal and patient oriented discharge summary (PODS) on Nephrology and Urology patients on 8CS.

Change(s) implemented: • Knowledge of patient education websites was promoted by one on one teaching with nurses as well as email, and in-services by patient education staff • Patient education website links will be highlighted on the discharge papers by clerical and nurses • Poster with websites were displayed in patient rooms

BACKGROUND

• A previous quality improvement study at St. Michael’s Hospital found patients prefer education material that is easily accessible and available in a variety of formats (Yang, Johns, Thomas, & Zeynalova, 2013) • This work was informed by the following recommendations from the Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline (BPG) entitled Person and FamilyCentred Care (2015): • Recommendation 1.2: Build empowering relationships with the person to promote the person’s proactive and meaningful engagement as an active partner in their health care • Recommendation 2.2: Engage with the person in a participatory model of decision making, respecting the person's right to choose the preferred interventions for their health • Recommendation 5.1: Educate health care providers at a minimum on the following attributes of person and family centred care to improve the person’s clinical outcomes and satisfaction with care

PURPOSE & OBJECTIVES

CONCLUSION • There was a 40% increase of nurses who gained knowledge of our online website educational portal • The number of website traffic increased from December to January according to the website monitoring statistics • Utilization of PODS from Urology service were at 100% • The key success factors in this project were engaging our mentors and key stakeholders

RECOMMENDATIONS/NEXT STEPS • Send surveys to patients to establish if when they were discharged the nurses mentioned the websites • Add the websites on the appointment cards given to patients upon discharge

Fig 1. Poster displayed in patient rooms

RESULTS Pre Education Staff Knowledge

• To sustain the changes in practice we need to perform audits of the discharge summaries to ensure the websites are being highlighted

REFERENCES Post Education Staff Knowledge

Purpose: To increase knowledge and use of our online patient education websites through patient teaching, and updating the patient oriented discharge summary Objectives: • To increase staff knowledge as indicated by a pre and post education survey • To increase patient education website traffic as indicated by website monitoring statistics • To evaluate patient satisfaction and knowledge as indicated by telephone surveys

RESULTS (CON’T)

Thomas, E. N. (2017). Knowledge is Power. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5337670/ Registered Nurses’ Association of Ontario. (2015). Person and Family-Centred Care. Retrieved from https://rnao.ca/sites/rnaoca/files/FINAL_Web_Version_0.pdf

Pre Education Website Usage

Post Education Website Usage

ACKNOWLEDGEMENTS • Anthea Iskander, Quality Improvement Analyst, Quality Improvement Implementation • Tedi Brash, Consumer Health Info, Coordinator Health Info and Knowledge Mobilization • Ashley Skiffington, Evidence Based Practice Nursing Manager .

Supporting Clients on Home Anticoagulation Therapy in the VTE Clinic Emmi Wang RN, BScN and Irene Pryshlak RN

4CC Specialty Clinics, St. Michael’s Hospital, Unity Health Toronto FOCUS

Pre-Process: Current State Pre-state

To standardize documentation and educational material to support clients on home subcutaneous (SC) anticoagulation therapy in the venous thromboembolism (VTE) clinic.

Hematology client requiring SC anticoagulation home therapy.

RNAO Best Practice Guideline (BPG): Professionalism

RN or other HCP provides client education

 1.5: Using information or evidence from nursing and other disciplines to inform practice  5.2: Assisting the client with their learning needs

Problem 1

Problem 2

No standardized teaching tools. No discharge evaluation or consistent documentation.

A written order from the MD is not always provided if a 1st dose is to be administered.

RNAO BPG: Client Centred Learning  1.4: Develop documentation tools to support effective communication of client centered learning

Literature findings: • Problems with injection technique are prevalent in outpatient SC therapies. Adequate client care and education are crucial and should be optimized (Mengiardi, 2011). • Client self-injection will be less costly to the health care system than using home care nurses (Wells et al., 1998).

Objectives: • To create and implement standardized documentation and education tools for HCPs • To obtain positive feedback on education provided from 80% of clients

• Tool is under review by key stakeholders (Dr. Lim and Dr. Tseng) • Positive verbal feedback was received from HCPs who reviewed the resource or trialed it during client home SC anticoagulation teaching • Anticipate evaluation results available by April 2019

This package consists of: 1. 2. 3. 4. 5. 6.

Standardized documentation form Patient teaching material Drug information sheet from Thrombosis Canada Tracking sheet for injection sites How to obtain a sharps container in the community Patient satisfaction questionnaire for feedback

Wells, P. S., Kovacs, M. J., Bormanis, J., Forgie, M. A., Goudie, D., Morrow, B., & Kovacs, J. (1998). Expanding eligibility for outpatient treatment of deep venous thrombosis and pulmonary embolism with low-molecularweight heparin: A comparison of patient self-injection with homecare injection. Archives of Internal Medicine (1960), (16), 1809. doi: 10.1001/archinte.158.16.1809

Frequency of individual HCPs coming across clients on SC anticoagulation therapy in their practice 7 6

Slightly comfortable 25%

5 4 3

ACKNOWLEDGEMENTS

HCPs that believe having a standardized documentation form for education provided will be beneficial

100% Yes

1 0

• Revise tool as needed based on stakeholder feedback • Post-implementation survey of staff HCPs at 3 months and 6-12 months • Collect feedback from clients via post-teaching questionnaire

Mengiardi, S., Tsakiris, D. A., Lampert, M. L., & Hersberger, K. E. (2011). Drug use problems with self-injected low-molecular-weight heparins in primary care. European Journal of Clinical Pharmacology, (2), 109. doi: 10.1007/s00228-010-0956-5

8 Moderately comfortable 42%

RECOMMENDATIONS/NEXT STEPS

REFERENCES

HCPs' self-reported comfort in providing home SC anticoagulation therapy to patients

Not comfortable 25%

Having created standardized documentation and educational materials, we will enhance professionalism in nursing and improve client centred learning.

Sustainability • Quarterly audits of usage of package for the first year and gather feedback • Connect with management to facilitate additional education opportunities e.g., In-service from Hematologist • Include in unit orientation binder

We surveyed a total of 12 staff in our clinic (MD/RN/Student). The majority of sampled staff feel they would benefit from having standardized documentation and education tools.

PURPOSE & OBJECTIVES • To promote consistency in education provided to clients • To facilitate consistent and complete documentation post-teaching • To provide effective client centred learning

By creating and implementing a home anticoagulation therapy teaching package, we have corrected the two problem clouds we identified in our preprocess state.

INTERVENTION/PROCESS

Very comfortable 8%

Goal of BPG initiative:

Implementation has started

Delay in carrying out health teacher/administering 1st dose

BACKGROUND Problem: There is a lack of consistency in documentation and the education provided to clients by health care professionals (HCP) in the VTE clinic.

Client discharged to self-care with shortterm clinic follow-up

Post-Process: Desired State

Less than Once a week Twice a week >twice a week once a week

Daily

RESULTS & CONCLUSION n=12

We have not yet reached the evaluation and sustainability stage.

Dr. Lim and Dr. Tseng, Hematology Ekaterina Mikhelson, Unit Mentor 4CC Specialty Clinics

Improving effective communication of patient care plan on the Respirology Unit Jessie Chiu, RN & Britney Lepp, RN St. Michael’s Hospital, Unity Health Toronto

BACKGROUND “These documents (Kardex) play extremely important roles in supporting day-to-day nursing practice... some of them are collaboratively constructed to convey important patient care information within a shift, or across multiple shifts … they are an integral part of clinical care.” (Crabtree et al., 2009) In literature by Lee et al. (2016): • Inadequate communication during transfer of accountability creates an opportunity for adverse events • Incomplete, inaccurate and forgotten information can generate ambiguities between outgoing and incoming healthcare providers

RECOMMENDATIONS/NEXT STEPS

RESULTS

INTERVENTION/PROCESS • Audits of Kardex completion rates (n=35) • Staff survey usage of Kardex and inputs on how to Investigation improve the Kardex (n=13) Stage

• Revision of Kardex (Multiple PDSA Cycles) Intervention

Evaluation

Figure 3. Pre and Post implementation staff survey on usage of Kardex.

Figure 4. Identified barriers from staff survey on the usage of Kardex.

Other barriers : • Accessibility • Outdated information on Kardex

• Post implementation audits on Kardex completion rates (n=8) • Pots implementation Staff Survey on usage of the Kardex

REFERENCES Crabtree, C., Howard, P.B. and El-Mallakh, P. (2009).The care and outcomes management plan and Kardex: A design for improving documentation of nursing plan of care and patient outcomes. Journal of Healthcare Information Management, 23(1), 50-55. Lee, S., Phan, P., Dorman, T., Weaver, S. and Pronovost, P. (2016). Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. BMC Health Services Research, 16, 254. doi: 10.1186/s12913-016-1502-7.

PDSA Cycle 1 Figure 1. Process Map to identify gaps in practice

FOCUS

Registered Nurses’ Association of Ontario (2014). Care Transitions. Toronto, ON: Registered Nurses’ Association of Ontario.

Our initiative aligns with the RNAO Best Practice Guideline (BPG) Care Transitions: • Use effective communication and standardized documentation tools to share client information at care transitions • Healthcare professionals engage in continuing education to enhance the specific knowledge and skills required for effective coordination of care transitions

Figure 5. Kardex audits after revised version 1 during PDSA Cycle 1.

The aim of the initiative is to improve communication of patient information through a standardized patient care plan (Kardex) that is specific to the Respirology floor. Original Version of Kardex Revised Version 2 of Kardex

Figure 2. Different version of Kardex from different PDSA cycle

PDSA Cycle 2

Revised Version 1 of Kardex

PURPOSE & OBJECTIVES

• To increase the completion rate of all sections in the Kardex by 10% by April 2019 • To increase RN usage of the Kardex

• Further investigation is required to determine ways to increase staff usage of the Kardex; which will include addressing the barriers identified by staff • Engage with staff to determine if further revision of the Kardex is required. Once finalized, the Kardex will be sent to Medical Media to be officially recognized as the Respirology Unit Kardex. • Continue to engage staff by role modeling behavior and by embedding Kardex usage practice during TOA to ensure sustainability

CONCLUSION • Barriers to effective use of the Kardex were identified, with workload and time being the primary barriers • An increase of 10% in completion rates was found for the revised Kardex; determined through Kardex audits • 33% of staff stated that they have increased their usage of Kardex since the rollout of the revised Kardex; with 66% of staff stating their usage has remained similar • There was overall satisfaction in Kardex revisions

ACKNOWLEDGEMENTS Nursing Practice and Education Respirology Unit Mentors: Barb Hooper and Sarah Sweetman Professional Practice Mentor: Cecilia Santiago 6 Bond Respirology Unit Staff RNAO

Preventing Hypotension in Hemodialysis Patients Kristin Albuquerque RNM BScN; Charina Villar RN; Wen Jin RN, BScN, CNeph(C) St.Michael’s Hospital: Unity Health Toronto

FOCUS

PURPOSE & OBJECTIVES

Goal: Development and implementation of a tool to assist nurses with preventing hypotension during hemodialysis treatments.

Goal: Prevent hypotension during treatment by limiting IDWD • 5 out of 11 patient identified with UFR >13ml/kg/hr will see improvement • Objective: Improve communication between patients and registered nurs es using principles of motivational interviewing

RNAO BPG: Strategies to Support Self-Management in Chronic ConditionsCollaboration with Clients • 1.1a Nurses establish rapport with clients and families. • 1.1c Nurses establish a written agenda for appointments in collaboration with the client and family, which may Include: • 1.1d Nurses consistently assess client’s readiness for change to help determine strategies to assist client’s readiness for change to help determine strategies to assist client with specific behaviors. • 1.2e Nurses encourage clients to use monitoring methods (RNAO, 2010) •

BACKGROUND

Current State Process Map

5. Health care provider may advise patient fluid restriction but patient may not be ready for change

1.Patients gain >3kg of fluid weight between treatments

4. Unable to get patient to dry weight due to hypotension and nurse reports issue to MD

2. Requires faster fluid removal rate during treatment

3. Decrease in intravascular volume causing hypotension SBP<90mmHg

• • • • •

Gaps in Practice No set guidelines on managing blood pressure and fluid removal during dialysis implemented on the unit Patients receive mixed messages from nurses and HCP they encounter Nurses and patients may not realize the consequences of persistent intra-dialytic hypotension and are more fixated on fluid removal. Especially if the patient is asymptomatic. Nurses may be unsure of their role in supporting behavioral change in patient

Method: Provide tool to nurses to motivate patients adhere to fluid restrictions

INTERVENTION/PROCESS

Motivational Interviewing Tool

Patient Name : __________ Objective Risk Factors: Review last 6 treatments. (Chart Review). • Dry Weight _________ • Average Weight Gain ______________ • Max: UF rate/Kg/h_________ (>13) • Max Weight Gain_________ • Number of tx unable to attain dry weight • (>1 kg) ________ (>30%) • Number of treatments with Hypotension - (90 mmHg)_________ - (> 40%) • Patient Physical Symptoms: • Shortness of breath □ • Cramps □ • Dizziness □ • Fatigue □ • Other □

Subjective Information • On a scale of 1 to 10: How important is it to restrict your fluid intake to approx 1L/day ? - 1 = not important and 10 = very important • On a scale of 1 to 10: How ready are you to make changes to your lifestyle to reduce the amount of fluid intake? - 1= not ready and 10 very ready • Would reduced fluid intake cause you hardship? • Would less fluid intake address your symptoms before/during /after dialysis? • What additional information do you need to make the change? • f you tried to reduce you fluid intake, what would it look like for you? • Is there anything we can do to help you?

Desired State Process Map

Patients consistently gain 3-5kg of fluid weight between treatments

Nurse educates patient on risks and consequences of fluid overload and hypotension during dialysis using educational material provided in unit

Nurse uses motivational interviewing tool to assess why patient has increase IDWG and use tool to set goals with the patient

Patients will take completed tool home to review and one copy will be on patient chart

Nurse will follow up with patient in future tx to assess how patient is coping with maintaining appropriate fluid gain

RESULTS The tool was informally presented to the staff and their feedback was collected . Quotes from staff: • "it’s a good tool, but It just takes too much time to complete" • " Patients don’t understand concept" • "I like idea of motivating my patient to control fluid intake rather than just telling them to drink less" • The tool was also trialed to a number of patients in our focus group Quotes from patients • "I know nurse that I have to drink less but my food is just too spicy" • "I have to take so many medications during the day it is hard to swallow with just a drop of water" • "I don't understand why I'm heavy I don’t drink" • • CONCLUSION • Summary Statement • • Fluid restriction is a major change in a patient's life and is hard to • accomplish with just using a single tool. It requires extended time, • persistence and desire for change. •

What did you learn? • How to use motivational interviewing in our practice • Limitations of motivational interviewing • Some patients are not willing to change • Staff are not willing to use the tool because it is time consuming • Language and cognitive barriers in patient population What were key success factors? • Patient's readiness for change • Less complications during treatment motivates patient to adhere

RECOMMENDATIONS/NEXT STEPS Next steps • Use feedback from stakeholders to revise motivational tool and reduce the amount of questions asked • Implement a pre-screen for change and only implement tool if the patient is willing to change • Continue to encourage patients who struggle with reducing fluid intake using principles of motivational interviewing Ideas/strategies to help sustain the changes in practice • Develop an in-service to educate staff on integrating motivational interviewing in practice

REFERENCES Heershap, A., Fox, C., Dharlyn, D., Tagpis, F., Romero, J., Pringle, T., … Infante, S. (2018). The interdisciplinary team and the patient: Working together to achieve buy-in for a UF rate less than 13 mL/Kg/Hr. Nephrology Nursing Journal, 45(5), 485-488. Russell, C.L., Cronk, N.J., Herron, M., Knowles, N., Matteson, M.L., Peace, L., & Ponferrada, L. (2011). Motivational Interviewing in Dialysis Adherence Study (MIDAS). Nephrology Nursing Journal, 38(3), 229-236. Registered Nurse Association of Ontario (2010). Strategies to Support Self-Management in Chronic Conditions-Collaboration with Clients. Toronto, Canada: Registered Nurses Association of Ontario.

ACKNOWLEDGEMENTS Kevin Barlow RN, MN, CNeph(C),Clinical Nurse Specialist – Hemodialysis Fiona Harrington RN, MN, Clinical Leader/Manager – Hemodialysis & Apheresis Vanessa Chavez Prieto RN, CAPM, MN, BPG CoP, Professional Practice Mentor

Increase Utilization of a Standardized Assessment Tool for COPD Karin Bogad RN, BScN, Nanette Lang CLM, Sarah Nestico CNS Department of Family and Community Medicine

FOCUS Figure 1: Overview of COPD

INTERVENTION/PROCESS

RESULTS

1. EMR data pull and subsequent chart audit to confirm how many COPD patients there are at the Health Centre at 80 Bond 2. List the strengths, weaknesses, and time taken to complete the two different COPD assessment tools Figure 2: Process to Identify Patients for RN COPD Assessment Total number of patients with • 169 COPD diagnosis

BACKGROUND No standard process for RN involvement in COPD care at Health Centre at 80 Bond • There are two different COPD assessment tools (checklist and stamp) and neither are used by the nurses at the Health Centre at 80 Bond • Each family practice site has its own way of managing patients with COPD • Lack of standardization between the 6 family practice sites

Patients with COPD and no pneumococcal vaccine

Table 1: COPD Checklist Evaluation

2. Provide feedback on the usability of two different COPD assessment tools (checklist and stamp) currently on the electronic medical record (EMR)

1. Share findings with nurse colleagues at UBC meeting

Strengths

Weaknesses

Time to Complete

2. Modify COPD checklist to increase usability

• Easy to access on EMR • Has direct links to resources • Has section for RN comments

• Title • Wording of some questions • No examples of SABA, LAAC & LABA • No POA question

• 20-30 minutes

3. Meet with MRPs to review a way to identify COPD patients for RN assessment 4. Trial different methods for follow-up (phone, in- person, and on-line

REFERENCES

Table 2: COPD Stamp Evaluation • 50

Patients seen in last year, contact information up to date, not palliative

Strengths

• 26

• 6 patients agreed to come into clinic for COPD assessment (3 checklists completed and 3 stamps completed)

• Has education section • Has follow-up plans section • Has list of referrals • Space for RN comments in each section

• 20 patients declined RN COPD assessment

PURPOSE & OBJECTIVES 1. Create a role for RN to be involved proactively in COPD care

RECOMMENDATIONS/NEXT STEPS

Weaknesses • Takes longer to access on EMR • No direct link to resources • Cannot be completed in one visit • Some questions need to be reworded • Change sequence of some questions • No POA question

Time to complete • 45+ minutes

CONCLUSION • Based on feedback gathered, the COPD checklist is the preferred tool for RN COPD assessments • Challenges: encouraging COPD patients to come to clinic for assessments (large homeless population, individuals who do not consider COPD a priority due to social determinants of health and individuals who have a self-reported adequate knowledge base)

• Gracia, C., Leong, N., Bowler, K., Rodrigues, A. & Lee, G. (2017) RN COPD Patient Education Stamp. Toronto, Canada: St. Michael’s Hospital Academic Family Health Team, Sumac Creek Health Centre • Jaeranny, S. & Rodrigues, A. (2017). SMH COPD PostDischarge Checklist. Toronto, Canada: St. Michael’s Hospital Academic Family Health Team, Quality Improvement Committee • Registered Nurses’ Association of Ontario (2005). Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD). Toronto, Canada: Registered Nurses’ Association of Ontario. • Registered Nurses’ Association of Ontario (2010). Nursing Care of Dyspnea: the 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD). Guideline Supplement. Toronto, Canada: Registered Nurses’ Association of Ontario

ACKNOWLEDGEMENTS Department of Family and Community Medicine Professional Practice Mentor :Ashley Skiffington

Transfer of Accountability and Hourly Rounding on Inpatient Mental Health Katelynn Greenough RN, BScN

St. Michael’s Hospital, Unity Health Toronto FOCUS

Creation, enhancement, and implementation of new tools to promote safety in the inpatient mental health unit (17CC).

RNAO BPG: Care Transitions (2014) • • •

Recommendation 2.2 Recommendation 3.2 Recommendation 4.2

BACKGROUND Transfer of accountability (ToA) involves communication between clinicians and patients during care transition. Engaging patients in ToA improves patient satisfaction and transparent care delivery (Holly & Poletick, 2013). Communication breakdown in the form of inaccurate or missing information has been linked to adverse events and patient safety risk (Holly & Poletick, 2013). Critical information is often missed without the use of a standardized format (Chaboyer, et al., 2016). A new tool was created using IPASS (Ransom B, & Winters K, 2018) to standardize ToA on 17CC. Hourly rounding (HR) by nursing staff supports patient safety, recovery, and engagement. HR ensures that patient care needs are more readily identified and met which reduces patient anxiety (Shin & Park, 2018). The current HR tool on 17CC was modified to help clarify policy expectations and to support ease of use for the nursing staff.

PURPOSE & OBJECTIVES To promote patient safety in the inpatient mental health unit (17CC) by implementing standardized ToA and HR tools. • Increase RN compliance with structured ToA and patient engagement by 70% • Increase RN knowledge with HR expectations by 100% • Increase RN satisfaction with modified HR tool by 85%

PROCESS / INTERVENTION PDSA Cycle 1

December 2018- February 2019 ToA tool (2 of 2) and HR tool implemented, tested and evaluated using surveys and RN feedback

24-Hour ToA tool was tested by 4 RNs for 2 weeks. RNs found tool not meeting workflow of 12 and 8 hour shifts RNs prefer ToA tool formatted to be used per shift Shift ToA tool further modified based on RN feedback HR tool was modified based off on RN feedback

Figure 1: Hourly Rounds Tool

2. Staff surveys and interviews • ToA surveys (n =31) conducted to measure: staff knowledge of ToA processes, satisfaction with current ToA tools, and comfort level in engaging patients at ToA • HR surveys (n= 30) conducted to measure: staff knowledge of HR policy expectations and satisfaction with current HR tool • Face-to-face interviews (n=17) conducted to understand current barriers with ToA and HR processes 3. Staff education • Refresher education created and delivered to staff on ToA & HR processes as per policy with ongoing coaching on new tools 4. Development of new ToA tool for Mental Health 5. Modification of current HR tool

Table 1: Transfer of Accountability Survey (n = 18)

ToA real-time observation audits conducted (n=44) to measure compliance with ToA tool and patient engagement

Random chart audits (n= 84) conducted to measure compliance with ToA process

Education provided helped to clarify ToA processes Shift report ToA tool helps to standardize ToA ToA consent stickers are effective for the kardex Safety checks are listed and accessible on tool Patient engagement strategies were provided and references are accessible to staff ToA and HR processes are linked

Table 2: Hourly Rounding Survey (n=17) Post surveys (n=18) conducted to measure knowledge and satisfaction with new ToA/HR tools Modified HR tool currently being approved through medical records

• •

Disagree

89%

Neither agree/ disagree 11%

67% 78% 72% 89%

11% 11% 11% 11%

22% 11% 17% 0%

•

67%

22%

11%

•

• 0%

•

• Agree

Disagree

Bedside ToA increased following staff education Staff knowledge around ToA processes and satisfaction with ToA tool increased as a result of the project Standardized shift report increased significantly following the implementation of new ToA tool Majority of staff agreed that patient engagement strategies and references were accessible; however, patient engagement at ToA only moderately increased. It was observed during audits that patient engagement was affected by consent provided, which may partly account for moderate increase Overall, the new ToA tool for mental health ensures that critical information is communicated in a standardized way at care transition points Staff knowledge around HR processes increased following education and implementation of modified tool 41% of staff agreed hourly rounds tool was user friendly, while 35% of staff neither agreed nor disagreed. The aim was 85% indicating that further education about using the tool may be needed Overall, modified HR tool reinforces policy expectations as it relates to HR processes and documentation

Education provided helped to clarify HR process

82%

Neither agree/ disagree 18%

Policy statement on modified tool helped to increase RN expectation of process Time change helps coincide with ToA and shift change RN satisfaction with modified HR tool

82%

18%

RECOMMENDATION / NEXT STEPS

71%

18%

11%

41%

35%

24%

• •

Survey Items

• 0%

Table 3: Audit of ToA Processes

February PDSA Cycle 1 (n = 14 reports) March PDSA cycle 2 (n = 30 reports)

Figure 2: ToA Tool

Agree

Survey Items

Month

1. Environmental scan

Concept maps created for both ToA and HR Policies, procedures, and best practices reviewed Visited an external inpatient mental health unit to observe ToA practices and resources

March 2019

Post surveys completed with RN feedback to modify tools

METHODS • • •

PDSA Cycle 2

CONCLUSION

RESULTS

Initiated at bedside 9/14 (64%) 25/30 (83%)

Patient Completed Conducted safety check engagement in with consent structured format 14 /14 12/14 4 /14 (100%) (85.7%) (1 on pass) (28.5%) 30/30 27/30 16/30 (100%) (90%) (53%)

Use ToA tool

•

4 / 14 (28.5%)

REFERENCES

20/30 (67%)

•

1. 2. 3.

*Audits conducted in Ward and ACU (Days, Evenings, and Nights) **February audits completed before education ***March audits completed after education

Staff Verbal Feedback “Patient location is easier to identify with the modified HR tool”

•

Barriers to patient engagement at ToA should be further explored Further patient education will focus on importance of participating in ToA to increase their engagement Ongoing staff education on the importance of utilizing standardized tools to promote safety should be considered Ongoing evaluation and auditing of ToA/HR processes to assess practices and provide feedback to staff is highly recommended Identified practice gaps and barriers should be assessed and solutions provided to support best practices

Chaboyer, W., McMurray, A., Marshall, A., Gillespie, B., Roberts, S., Hutchinson, M., Botti, M., McTier, L., Rawson, H. & Bucknall, T. (2016). Patient engagement in clinical communication: an exploratory study. Scandanavian Journal of Caring Sciences (565-571) Holly, C. & Poletick, E. (2013) A systematic review on the transfer of information during nurse transitions in care. Journal of Clinical Nursing (23) 2387-2396 Shin, N. & Park, J. ( 2018). The effect of intentional nursing rounds based on the care model on patient’s perceived nursing quality and their satisfaction with nursing services. Asian Nursing Research (12) 203-208 Registered Nurses Association of Ontario (2014). Care Transitions. Toronto ON: Registered Nurses’ Association of Ontario. Retrieved from http://rnao.ca/sites/rnao-

ca/files/Care_Transitions_BPG.pdf

“Shift Report ToA tool helps to keep my day organized”

“The education really helps to identify policy”

“I’m glad the use of professional judgment comes into play”

“The ToA tool helps me to identify my safety checks during shift change”

ACKNOWLEDGEMENTS Clinical Leader Manager: Ifat Witz BA(Hon), MA, CHE Clinical Nurse Educator/ Unit Mentor: Tasha Penney RN, MN, CPMHN(C) Professional Practice Mentor: Cecilia Santiago RN, MN, CNCC(C) Medical Media: Marcelo Siles Nursing Practice and Education

Multidisciplinary Coordinated Care Plan in the Positive Care Clinic (PCC) Liza Abraham, B.A., RN, BScN, Rachel He, RN, BScN, Ekaterina Mikhelson, RN, MScN St. Michael’s Hospital, Unity Health Toronto FOCUS

Figure 1: Coordinated Patient Care Plan Template

INTERVENTION/PROCESS

Develop and implement a Multidisciplinary Coordinated Care Plan for HIV patients with complex needs

•

• RNAO BPG: Person-and-Family Centered Care

• •

Next Steps

Plan

Conduct a process map to identify gaps Consult key stakeholders Conduct staff surveys

• Post survey has been sent out to collect feedback from all team members on how to use the Coordinated Care Plan for patient care

 Recommendation 6.1: Promote a holistic and patient centered approach to improve quality of care, patient experience and engagement in care  Recommendation 6.2: Collect continuous feedback from the patient and utilize this feedback to make improvements at all levels of the health system

• •

•

Act

Based on staff feedback, what do we change, keep or improve? Weekly team meeting

•

• Weekly multidisciplinary team round to discuss patients with complex needs, which has started on April 1st, 2019

Create coordinated patient care plan template used for patients with complex needs Introduce this template to team members and trial with real patients

• Concerns raised at 1st meeting; how to maintain engagement of complex patients who have tendency to ‘no show’ to appointments i.e. implement follow-up process

BACKGROUND

Sustainability

HIV patients with complex medical and psychosocial needs are assessed by multidisciplinary care team in the Positive Care Clinic.

•

Study

Conduct staff post surveys

Incoming Patient

Nursing Assessment

MD Assessment

Pharmacy Counseling

SW Assessment Dietitian Assessment

Referral to Psych or other specialists if needed

Each disciplinary assessment is valuable, but where is it being tracked? How do we know what’s been done, what’s to be done, what’s a priority

Patient’s follow-up visit (in 1-6 months)

PURPOSE & OBJECTIVES Goals • • •

To improve communication among a multidisciplinary team To enhance patient experience and achieve optimal patient care To improve clinical efficiency and reduce work duplication

Objectives • •

RECOMMENDATIONS/NEXT STEPS

To implement a Coordinated Patient Care Plan Weekly multidisciplinary team round

Staff Survey (n=12, Physician, Psychiatrist, Pharmacist, Social Worker, RN & Dietitian)

RESULTS •

Coordinated patient care plans were created and used for HIV patients with complex needs.

•

Comments from RNs : “It made sense for me to see exactly what was most recently done at a glance. Very useful to see what the other disciplines had done, without having to go back into Soarian or flip through the chart”.

•

Comment from MD Specialist: “It was a better use of time to see what had been completed. Anything there warranted a quick glance to see what still needed to be done and if it required follow up or input”.

•

Comment from Pharmacist: “It was good to know who is doing what”.

 10 out of 12 are only sometimes or rarely aware of patient assessment or intervention done by other team members.  11 out of 12 are only sometimes or rarely able to easily find the multidisciplinary documentation for the patient.  12 out 12 agree it is very important or important to have a coordinated care plan for patients with complex needs.  11 out 12 think it would be useful to have the most recent multidisciplinary update on patient’s chart before the visit.  10 out 12 think patients and team members will benefit from having the patient care plan

CONCLUSION • Introducing a new tool in a well-established clinic could be challenging • Key success factors: Communication & team collaboration

• Communication • Support & engage staff • Become a part of Standard of Care

REFERENCES Registered Nurses’ Association of Ontario (2015). Person and Family Centered Care. Toronto, ON: Registered Nurses’ Association of Ontario. Retrieved from https://rnao.ca/bpg/guidelines/person-andfamily-centred-care Van Dongen JJJ, Van Bokhoven M, Daniels R, Van der Weijden T, Emonts W, Beurskens A. Developing interprofessional care plans in chronic care: a scoping review. BMC Family Practice. 2016; 17:137

ACKNOWLEDGEMENTS Anna Kacikanis CLM in Specialty Clinic Dr. Kevin Gough Program Director in Positive Care Clinic Myrle Du Cille, Grace Wozniak & Emmie Wang, RN Jordan Lewis, Social Worker Deborah Yoonge & Mark Naccarato, Pharmacist Nursing Practice and Education

Debrief Process for TNICU: F.A.S.T. Discussion Lidia Yamane, RN

St. Michael’s Hospital, Unity Health Toronto RECOMMENDATIONS/NEXT STEPS

FOCUS

INTERVENTION/PROCESS

RESULTS

Creation and implementation of a Debrief Tool and Process for TNICU staff members.

 Phase 1: • As this may be unfamiliar at first, either CNS, or Social Work will facilitate the debriefs. They can act as role models for future facilitators and help staff with familiarizing and encouraging the practice of debriefs

Pre-Implementation:

• Continue promoting and normalizing the debriefing experience

A preliminary survey was sent out to explore the unit’s needs and perception of debriefs after critical incident (n= 47). • 100% agreed that there should always be debriefs after identified critical incidents with 68% strongly agreeing. • Identified Triggers for Debriefs: 1. Ethical Dilemmas 2. Challenging patient or Family 3. Code Blue 4. High Acuity Admissions 5. Other: organ donations, withdrawal of young patients • Barriers identified: • 98% identified Workload or Time • 43% Lack of Qualified Facilitator

• Identify “debrief advocates’ and provide formal training to champion debriefers in Group Crisis Intervention and Critical Incident Stress Management

RNAO BPG: Healthy Work Environments- Workplace Health, Safety and Well-Being of the Nurse  1.0: Organizations/nursing employers create and design environments and systems that promote safe and healthy workplaces  3.1: Organizations/nursing employers provide ongoing training and education programs to ensure staff possesses the knowledge to recognize, evaluate, and control or eliminate hazardous work situations

BACKGROUND Debriefing after a critical event refers to a gathering of key players and having a discussion and review of events. It allows for reflection and evaluation of team performance after an event. Post- event debriefing has been recommended by the American Heart Association (AHA) as it has been recognized for improving both system and team performance by providing feedback and learning opportunities. As well, it also has the potential to address the psychological impact or feelings associated with responding to critical events.

• During this period, charge nurses will be trained to recognize when there’s a need for debriefs and ‘novice debriefers’ will be trained in how to facilitate a debrief. A debrief tool, called F.A.S.T Discussion, with prompting phrases is available which anyone can use to help with facilitating  Phase 2: • Champions will begin facilitating debriefs Figure 1: Debrief Process

Post-Implementation: Currently 40% of staff have attended an in-service on the process of debriefing and the use of the F.A.S.T Discussion tool. There have been 4 debriefs conducted since going live on Feb. 11 with a total of 21 participants. • Debrief #1: Code Blue and Ethical Dilemma • Debrief # 2: Organ Donation • Debrief #3: Ethical Dilemma • Debrief #4: Formal debrief with CLM, Ethics, and SW

Compassion fatigue and burnout are high in health care. Burnout has been known to have a negative impact on individuals and their work and nurses are at high risk of burnout (Gagangeet, 2016). Through the mechanism of debriefing, burnout and health care related stress can be addressed. Debriefs can improves opportunity for resilience, provide validation from peers and normalize feelings.

Debriefs were well received, the debrief tool was utilized in 2/4 of debriefs and recommendations were sent to CLM for all debriefs.

Although the benefits of debrief are known, there is a lack of debriefs after critical events in the TNICU. We sought to address this issue by developing a debriefing process after identified critical events to support staff.

CONCLUSION

PURPOSE & OBJECTIVES

• Overall, the aim of the BPG which was to create a debrief process was achieved however, we have not reached the target of having debriefs after 50% of identified critical incidents

To develop a debriefing process and to increase number of debriefs conducted after identified critical incidents by 50%.

• A key successful factor was creating an interdisciplinary approach to debriefing

• Creates a culture and practice that supports, promotes, and maintain staff health, well-being and safety • Supports staff with successful transitions to returning to work Figure 2: Debrief Tool

• Address specifically ethical dilemmas and moral distress-either through the means of ethics education or re-introducing grand ethic rounds

REFERENCES Copleand, Darcy & Liska, Heather. (2016). Implementation of a Post-Code Pause: Extending Post-Event Debriefing to Include Silence. Journal of Trauma Nursing(23): p58-64. 10.1097/JTN.0000000000000187 Clark, Ruth & Mclean, Christopher. (2018). The professional and personal debriefing needs of ward based nurses after involvement in a cardiac arrest: An explorative qualitative pilot study. Intensive and Critical Care Nursing. 47. 10.1016/j.iccn.2018.03.009. Gangangeet, Sandhu; Colon, Jose; Barlow, Dawn; Ferris, Donna. (2016). Daily informal multidisciplinary intensive care unit operational debriefing provides effective support for intensive care unit nurses. Dimensions of Critical Care Nursing. 35(4):175–180. DOI: 10.1097/DCC.0000000000000190 Rose, Stuart & Cheng, Adam. (2018). Charge nurse facilitated clinical debriefing in the emergency department. Canadian Journal of emergency Medicine (20): 781-785. https://doi.org/10.1017/cem.2018.369 The Alfred. (2015). The Alfred ICU FAST-PAGE guide to debriefing. Retrieved from: https://docs.google.com/document/d/1Gq4v_urxiMV9HpX0LR8q3LGKeo60YKHo8 yDUJ1RH9bg/edit

ACKNOWLEDGEMENTS • • • •

Liz Butorac, CLM & Jenna.Moulder, CNS Stacey H and Patrycja B - Social Workers BPSO- Nursing Practice & Educators TNICU staff, Unit Based Council (UBC)