Hospital News January 2024 Edition

Inside: From the CEO’s Desk | Long-term Care | Special Focus: Professional Development + Education

January 2024 Edition

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“I don’t think Doug Ford should be trusted with public health care.”

Listen to nurses.

When it comes to health care, this government has a lot to answer for. Underfunding the system is a direct cause of the nursing shortage, which led to 1,199 ER closures in 2023. Paying private clinics more than hospitals get for identical medical procedures is a misuse of taxpayer dollars. Defunding public health reduces health-care programming for entire communities.

Inadequate inspection of long-term care caused deaths that should never have happened.

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Contents January 2024 Edition

IN THIS ISSUE:

Inside: From the CEO’s Desk | Long-term Care | Special Focus: Professional Development + Education

Help on call for medical professionals

PROFESSIONAL DEVELOPMENT AND EDUCATION

22ND ANNUAL

January 2024 Edition

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12

FEATURED

Virtual reality’s role

Professional Development Education +

in nursing education Page 28 Part-time | Casual | Contract | Temporary Hospital Employees

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▲ Cover story: Virtual reality’s role in nursing education

28

JANUARY 2024 HOSPITAL NEWS 19

▲ 22nd Annual Professional Development + Education supplement

19 ▲ How SCOPE is diverting patients from EDs and easing family physicians’ workloads

COLUMNS Guest editorial ................4 In brief .............................6

14

From the CEO’s desk .....16 Nursing Pulse .................18 Long-term Care ..............38

▲ Too much paperwork is hurting physicians, and health care

Hyperthroughput operating rooms increase efficiency

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▲ Improving outcomes for CPR patients in the emergency room

16

Are Canadians suffering a

crisis of trust?

610 Applewood Crescent, Suite 103 Vaughan Ontario L4K 0E3 TEL. 905.532.2600|FAX 1.888.546.6189

www.hospitalnews.com Editor

Kristie Jones

editor@hospitalnews.com

Trust in Research Undertaken in Science and Technology Scholarly Network (TRuST) launched to combat growing trend of disinformation

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Denise Hodgson

denise@hospitalnews.com Publisher

Stefan Dreesen

By Mary Wells

stefan@hospitalnews.com

he rising trend of “fake news” came to prominence over the course of the COVID-19 pandemic as people turned to social media channels to read and distribute information that often fell far short of offering reliable information or verifiable data. The unchecked spread of misinformation led to serious harm for many individuals, especially those who decided to forgo scientifically proven treatments to combat the novel coronavirus.

It’s time we find ways to combat the growing tide of disinformation. We need governments, the research community, private industry, and citizens, to come together and create innovative policies and practices to ensure that existing and new technologies don’t come with unintended harms.

I doubt the engineers who first built those social media platforms were aware of how their products could one day be weaponized in campaigns of damaging – and deadly – misinformation. We need to find a way to bridge the gap between the people who design and build new technologies and the public who are the users of those technologies.

Here, at the University of Waterloo, we looked at several surveys that measured how Canadians’ trust in science, academia, health, technology and government has changed over the years. While there have been rel-

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atively few surveys measuring trust in science, the most consistent trend we’ve found is that trust in most institutions and individuals – especially the government – rose during the beginning of the pandemic but has since waned back to near pre-pandemic levels.

A report published in January by the Council of Canadian Academies, an Ottawa-based independent research organization, found that misinformation related to the spread of COVID-19 resulted in the loss of at least 2,800 lives and led to $300 million in hospital expenses over nine months of the pandemic.

Are Canadians suffering a crisis of trust across institutions? The data is troubling enough to spur me and some of my colleagues into action.

We cannot afford to sit on the sidelines and let the trust that Canadians have in science and academic institutions continue to erode. That’s why we created the Trust in Research Undertaken in Science and Technology Scholarly Network (TRuST), alongside my Waterloo colleagues, Nobel Laureate Donna Strickland and Canada Research Chair Ashley Mehlenbacher.

TRuST is the first multidisciplinary research network of its kind in Canada and aims to combat the growing trend of disinformation to better understand why some people deny, doubt or resist scientific findings and explanations.

Continued on page 6

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RN, PHD, CHE VP Professional Practice & Research & CNE, Ontario Shores Centre for Mental Health Sciences

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Publicist Health-Care Communications

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Monthly Focus: Gerontology/Alternate Level of Care/Rehab/ Wound Care/Procurement: Geriatric medicine, aging-related health issues and senior friendly strategies. Best practices in care transitions that improve patient flow through the continuum of care. Rehabilitation techniques for a variety of injuries and diseases. Innovation in the treatment and prevention of wounds.

Monthly Focus: Facilities Management and Design/Health Technology/Greening Healthcare/Infection Control: Innovative and efficient healthcare design, the greening of healthcare and facilities management. An update on the impact of technology, including robotics and artificial intelligence on healthcare delivery. Advancements in infection control in hospital settings.

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NEWS

Hyper-throughput operating rooms increase efficiency t Humber River Health (Humber), breaking new ground is the norm. The team, including staff and physicians, work tirelessly to improve processes and embrace new ideas. This innovative spirit is evident in their latest initiative: the Hyper-Throughput Operating Rooms, specifically designed for faster and safer anterior hip replacements. This approach is inspired by leading international healthcare practices and is a testament to Humber’s commitment to teamwork and excellence.

On December 21, the hospital celebrated the successful completion of its fourth Hyper-Throughput Operating Room pilot. This follows the success of the first pilot in October, showcasing Humber’s dedication to advancing healthcare, and how they are stepping up to find innovative ways to improve throughput and lower costs to address the growing demands of the provincial healthcare system.

“This truly was a collaborative effort, engaging the entire team throughout the planning process,” commented Jhanvi Solanki, Vice President of Clinical Programs. “Hyper-Throughput Operating Rooms break down each step within the process and evaluate its effectiveness – leaning out waste and introducing the concept of parallel processing has allowed micro changes to result in big time savings. We are proud to be doing our part to help the province tackle the surgical backlog.”

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HYPER-THROUGHPUT OPERATING ROOMS ARE NOT ABOUT SET NUMBER OF PROCEDURES PER DAY, BUT MORE SO ABOUT IMPROVING THE FLOW OF PROCEDURES AND LEANING OUT WASTES. Dr. Sebastian Rodriguez-Elizalde, Dr. Barry Cayen and Dr. Justin Chang, along with the Humber team, played a pivotal role in these pilot days. On November 24, Dr. Rodriguez-Elizalde performed an impressive 14 anterior hip replacements in just one day, setting a new standard in surgical efficiency without compromising patient safety in Canada. Drs. Chang and Cayen are also performing greater than typical volumes. Hyper-Throughput Operating Rooms are not about set number of procedures per day, but more so about improving the flow of procedures and leaning out wastes. The lessons learned from these pilot days are broadly applicable to all operating rooms. For example, the concepts of parallel and lean processing can help improve block utilization per day, per surgeon daily. This benefits the system at large because in many instances, this allows the surgeon to add an additional case to their lists.

“In a typical day, the orthopaedic surgeons and I will usually perform three to four surgeries per day in one operating room,” said Dr. Rodriguez-Elizalde. “Working with hospital

staff, we were able to effectively triple our surgical productivity through process improvements at the beginning and end of the surgeries. The most important element of innovation is ensuring there is a quality and patient safety framework.” All procedures are performed using navigation technology to ensure the utmost safety standards are met.

Intellijoint’s technology was critical to this effort, as it eliminates the need for intra-operative X-rays, while simultaneously reducing post-surgery complications and ensuring the highest level of safety. “As a local Ontario technology business, we are proud to work with hospitals like Humber River Health that are leading the nation in clinical and technological innovation,” says Armen Bakirtzian, Co-Founder and CEO of Intellijoint Surgical Inc. “Together, we have demonstrated how hospitals and innovators can collaborate in new and highly effective ways.”

These pilot Hyper-Throughput Operating Rooms have been transformative, setting an important example of how hospitals can use lean processing and teamwork to improve operational

efficiencies, while simultaneously reducing wait times and surgical backlog. Thanks to the parallel processes and the collective efforts of Humber staff, there was a marked decrease in total case time, operating room turnover, housekeeping, as well as set-up and takedown times.

Furthermore, patient outcomes were consistently exceptional; all patients bypassed the PACU, and there were no complications, with each patient being discharged that same day. There was even a reduction in garbage and linen usage, exemplifying the hospital’s commitment to sustainability. While recognizing that not all procedures can benefit from such high-throughput settings, the advancements made will continue to inform enhancements across the hospital’s operating rooms.

Looking ahead, Humber is working on transferring the learnings across as many surgical procedures as possible, marking another step in Humber’s journey of innovation. This initiative is about more than just surgical improvements; it is about reimagining healthcare possibilities, enhancing patient care, and making healthcare more accessible.

Humber River Health’s efforts are a shining example of what can be achieved when dedication meets innovation. The team’s relentless pursuit of better patient outcomes and their contribution to the community pave the way for a bright future in Canadian H healthcare. ■ JANUARY 2024 HOSPITAL NEWS 5

IN BRIEF

Few patients receive opioid agonist therapy after opioid overdose, despite benefits n the week following any hospital visit for an overdose, only one in 18 people with opioid use disorder begin a treatment known to be highly effective in reducing illness and deaths, according to new research in CMAJ (Canadian Medical Association Journal).

“These results highlight critical missed opportunities to prevent future mortality and morbidity related to opioid use, despite connection to health care for many patients in the days after a toxicity event,” writes Dr. Tara Gomes, a researcher at ICES and

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St. Michael’s Hospital, part of Unity Health Toronto, with coauthors.

Opioid use disorder (OUD) is a major public health issue, with an almost threefold increase in opioid-related emergency department visits between 2016 and 2021 in Ontario and a 32 per cent increase in related hospitalizations in Canada.

Opioid agonist therapy (OAT) is highly effective at reducing illness and deaths in patients with OUD. Using data from ICES, researchers looked at trends in OAT initiation rates for 20 702 emergency department visits and inpatient hospital admissions for opioid toxicity between

Continued from page 4

Crisis of trust?

TRuST will explore how engineers, scientists and researchers can find ways of embedding trust into the technologies that they are currently building. We hope that this can lead to further considerations of the intended, as well as the unintended consequences, of what those technologies can do.

It won’t be easy, but researchers and governments need to work together and think about how policy can help shape how we consider future technologies and online tools to prevent the spread of damaging misinformation.

New pharmaceuticals have to undergo rigorous study and clinical trials before they are brought to market. This is a measured approach that could be adopted when considering introducing new technologies into the wild. Before a company launches a new technological product into the marketplace, it could undergo a series of trials with a small group of people to identify whether any unintended issues come to light that could be addressed before allowing it to be expanded to more people.

Another approach could be for governments, in partnership with in-

dustry, non-profits and academia, to introduce a series of ethical standards that all technology companies would have to adhere to if they want to make their products available to the public.

This method builds upon the work that Waterloo professor and founding director of the Critical Media Lab, Marcel O’Gorman has done, alongside the innovation hub Communitech and the Rideau Hall Foundation, to create a set of guiding principles that advises governments, businesses and organizations to use technology for the good of humanity.

While these suggestions may appear to go against the grain of conventional thinking, we need to begin – and continue – this conversation of how to regain trust across science and technology.

We have already seen how the risks of avoiding this direct approach have created an environment of distrust toward researchers, scientists and policymakers in this post-pandemic period.

Tackling this challenge now is critical to ensure that future ideas and technological advances won’t suffer a similar H fate. ■

Mary Wells is the Dean of Engineering at the University of Waterloo.

6 HOSPITAL NEWS JANUARY 2024

January 2013 and March 2020. The median age of patients was 35 years, 65 per cent were male and 90 per cent lived in urban areas. Of the total visits, 29 per cent were from patients who had previously visited hospital for opioid overdoses, and 24 per cent had been dispensed OAT in the last year.

Only 4.1 per cent of hospital encounters for opioid overdoses led to OAT initiation within a week of discharge from hospital. Despite increased advocacy and publication of a 2018 national guideline recommending buprenorphine–naloxone as the preferred first-line treatment for OUD, there was no significant increase in OAT initiation rates. Studies show that risk of death is highest in the days following an overdose, and that patients are more likely to continue OAT if it is started in the emergency department, underlining the need for prompt initiation of treatment.

“Our research shows that there were substantial disparities in OAT

initiation rates, with potential barriers to prescribing for older patients, those with mental health diagnoses, and those in the lowest neighbourhood income quintile. Although OAT initiation rates have gradually increased since 2016, the release of the national OUD management guideline in 2018 was not independently associated with changes in this trajectory,” write the authors.

To increase treatment initiation rates, they suggest institutional OAT training, creating OAT initiation protocols, promoting awareness of referral resources with outpatient addictions programs, and more.

A practice article illustrates the challenges of treating patients with multiple substance use disorders in hospitals, who often are experiencing undertreated withdrawal and pain.

“Initiation of opioid agonist therapy after hospital visits for opioid poisonings in Ontario” was published H December 18, 2023. ■

Scheduling for the future with artificial intelligence n health care, we plan for the unexpected. However, having the right number of staff working at the right time is a complex equation. When the ratio isn’t right, patients wait for care, which is stressful for them and the health professionals caring for them.

To better match physician coverage with patient demand, Fraser Health is partnering with Deloitte Canada to develop a physician scheduling tool that leverages artificial intelligence (AI) and machine-learning solutions to accurately forecast the waves in demand we see in the health system.

Having this intelligence is expected to improve the patient experience and reduce physician workloads.

The project is in the initial stages and is funded by a $1.5 million Scale AI award.

“We envision a tool that will bring in clinical profiles, along with sea-

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sonal events such as respiratory and influenza season, and perhaps even weather data, to more accurately predict how many patients will need care on any given day and match that demand with physician coverage,” says Sheazin Premji, Executive Director, Centre for Advanced Analytics, Data Science, and Innovation, Fraser Health.

The funding from Scale AI will allow the Fraser Health and Deloitte project team to develop three artificial intelligence models: two that leverage patient analytics from various electronic medical records to forecast volume demands coming to the emergency and medicine departments and assist leadership in pre-determining broader staffing requirements; and a third that takes the forecasted patient data and matches it with business rules, such as patient-physician ratios, to create a www.hospitalnews.com

IN BRIEF

Primary care lessons for Canada from OECD countries o improve primary care, Canada can learn from Organisation for Economic Co-operation and Development (OECD) countries with high rates of patients attached to primary care clinicians, write authors in an analysis in CMAJ (Canadian Medical Association Journal).

It is well known in Canada that there is a crisis in primary care, with about 17 per cent of people reporting that they were without a regular primary care clinician before the COVID-19 pandemic. The pandemic made the situation worse, with some family physicians retiring early, a situation common in other countries also.

The authors looked at nine countries where more than 95 per cent of people have a family doctor, primary care clinician or place of care, including France, Germany, New Zealand, United Kingdom, Denmark, Netherlands, Finland, Italy and Norway, and consider lessons for Canada.

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baseline schedule with advanced analytic capabilities to generate multiple scheduling scenarios.

“Fraser Health is undergoing a digital transformation to better serve patients,” says Jennifer MacGregor, Vice President of Digital Patient & Provider Experience. “We are grateful to ScaleAI for recognizing the value of partnering health care organizations with industry to find innovative solutions to everyday challenges.”

The Fraser Health/Deloitte collaboration ‘AI-Driven Physician Scheduling Solution and Workflow Optimization’ is one of nine Canadian health projects to receive $21 million in funding to pioneer the deployment of AI solutions.

The initiative promotes collaboration between hospitals and AI product and solutions providers to innovate further and accelerate the deployment of AI in H Canadian health care. ■ www.hospitalnews.com

Canada’s health spending was in the middle of the pack, although the percentage of health spending that was public was the lowest at 70 per cent, a figure unchanged since the 1990s.

Canada had similar numbers of family physicians per capita but the lowest number of total physicians per capita and spent less of the total health budget on primary care.

“Other countries have designed their system so that everyone has access to primary care. We need to do the same,” says Dr. Tara Kiran, a family physician at St. Michael’s Hospital, Unity Health Toronto and the Fidani Chair of Improvement and Innovation at the University of Toronto. “At the core, we need to guarantee access to primary care and increase how much we spend on it.”

Historical factors, such as physicians negotiating to remain autonomous at introduction of Medicare, have also affected Canada’s health system.

Key lessons for Canada: • Accountability – In countries with high rates of primary care attach-

ment, family doctors have stronger contractual agreements and accountability to government, insurers or both, whereas in Canada, they are private contractors with little system accountability. These countries also have more family doctors, or general practitioners, working in office-based, generalist practices compared with Canada, where many family doctors work in other parts of the system (e.g., providing emergency or hospital care) or in focused practice (e.g., sports medicine).

• Funding – A higher proportion of the total health budget should be spent on primary care. Medicare coverage in Canada could be extended to prescription medications, dental care and expanded mental health care to reduce the burden on physicians to provide care in these areas. Canada also needs more physicians per capita.

• System organization – Canada should move to a model where residents are guaranteed access to a pri-

mary care practice near their home and ensure that these practices are funded appropriately.

• Information systems – Practice efficiency can be improved and patient communications can be streamlined with online booking, secure messaging and a single patient health record accessible across Canada by patients and clinicians.

• Practice organization and physician payment – Governments and medical associations should shift primary care physicians to capitation or salary payments and away from fee for service, which is how most family physicians currently are paid in Canada. More organized after-hours care, fewer walk-in clinics and expanded roles for other health professionals can enable our primary care resources to be used more efficiently.

“These international examples can inform bold policy reform in Canada to advance a vision of primary care for H all,” the authors conclude. ■

New rule for emergency departments to safely reduce use of CTs after falls in older patients ow do emergency department staff determine whether older adults who have fallen need imaging?

A new decision rule will help emergency department physicians determine which older adults need imaging for head injuries, describes new research in CMAJ (Canadian Medical Association Journal).

With aging populations, emergency departments are managing an increasing number of older adults who fall; falling on level ground, like in one’s house, is a common cause of a brain bleed. Computed tomography (CT) of the head is commonly used to assess patients who have fallen, but sending every patient who has fallen for a head scan is inefficient and costly.

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“Overuse of CT in this population prolongs the emergency department visit, which has been shown to increase the rate of delirium while also diverting resources from other emergency patients,” writes Dr. Kerstin de Wit, Queen’s University, Kingston, Ontario, with coauthors from the Network of Canadian Emergency Researchers. “Furthermore, not all emergency departments have 24-hour on-site CT scanning facilities, meaning that some of these patients may be transferred to another centre.”

A team of emergency department physicians from across Canada and in the United States developed the Falls Decision Rule, which can be used to identify patients for whom it is safe to forgo a head CT to rule out intracranial bleeding after a fall. The researchers

included 4308 patients aged 65 years or older from 11 emergency departments in Canada and the US who visited the emergency department within 48 hours of falling. The median age was 83 years, 64 per cent were female, 26 per cent took anticoagulant medication and 36 per cent took antiplatelet medication, both of which increase the risk of bleeding.

The rule, which if used would avoid head CT in 20 per cent of the study population, can be applied to all older adults who have fallen, whether or not they sustained a head injury or can recall the fall.

This new rule complements the widely used Canadian CT Head rule, which applies to patients with disorientation, H amnesia or loss of consciousness. ■ JANUARY 2024 HOSPITAL NEWS 7

NEWS

Too much paperwork is hurting physicians, and health care

By Dr. Kathleen Ross ew of us look forward to administrative tasks. For physicians, however, relentless paperwork is actively eroding wellbeing and feeding into the ongoing health care crisis.

According to the Canadian Medical Association’s (CMA) most recent physician wellness survey, 60 per cent of respondents said that administrative burden was a direct contributor to burnout and worsening mental health.

Admin burden is not a single activity, but rather the culmination of system inefficiencies, complexities and a lack of interoperability between record-keeping systems. Together, they chip away at physicians’ time with patients, sap our energy and take away the focus on care – the reason we chose medicine.

Some administrative work will always be required in health care. Physicians need to document care provided and integrate results from specialists or clinic consultations into patients’ care plans.

But a report from the Canadian Federation of Independent Business (CFIB) found that 38 per cent of the 48 million hours physicians spend on

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administrative tasks is, in fact, unnecessary. Worse, red tape can delay patient care and contribute to moral injury as well as burnout among care providers.

Electronic Medical Records (EMRs) are one pain point. I was an early adopter, believing technology would reduce and streamline reporting. Instead, information duplication and redundancy has increased exponentially.

A task force on hospital report management in Ontario found that notifications of admissions, discharges and transfers, COVID-19 assessments and

other test results add up to millions of records every year. At the same time, the lack of interoperability between EMRs means doctors still have to chase information outside their own health authorities or specific areas of treatment, at times with a direct, negative consequence on patient outcomes.

Sorting through all of this comes at the cost of decreasing face-to-face time with patients during clinical hours, eroding access to care, or taking work home at the end of the day to complete on your own time, so-called “pajama time.”

Canadian first: New groundbreaking treatments for paediatric epilepsy patients pilepsy is the most common neurological condition in paediatrics affecting approximately one in one-hundred Canadian children.

For 11-year-old Makayla Douglass, epileptic seizures have been a part of her life since being diagnosed at the age of one. At its peak, Makayla would experience up to 30 seizures a day.

“Most of the seizure activity would happen in the evening and overnight hours,” explains mom, Jeannie Douglass. “She would go to sleep and then it would start, but then last summer it got so bad, she would have multiple seizures an hour throughout the night.”

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8 HOSPITAL NEWS JANUARY 2024

Makayla Douglass with her family.

The increased seizure activity was taking a toll on Makayla and her family, until she became the first paediatric patient in all of Canada to receive a new procedure called Radiofrequency Thermocoagulation, which took

place at Children’s Hospital at London Health Sciences Centre (LHSC).

Radiofrequency Thermocoagulation is a minimally invasive procedure that uses radio waves, through electrodes to heat and destroy tissue in the areas of the brain that have been identified as the source of seizure activity.

“We were able to implant electrodes directly into Makayla’s brain to determine where the seizure activity was coming from, which we concluded was in a deep area of the brain called the insula, an area that is difficult to access for a surgical procedure” says Dr. Andrea Andrade, Director of the Paediatric Epilepsy Program at Children’s Hospital, LHSC. Continued on page 10

Some physicians, tired of busy work and sacrificing their personal lives on the altar of medicine, are substantially reducing the number of hours they practise, or leaving the profession altogether.

Nearly half of physicians polled by the CMA said they were likely or very likely to reduce clinical hours – with those suffering psychological distress, not surprisingly, 1.4 times more inclined to do so.

Canada’s health care crisis is multifaceted. System reform will take time.

But reducing onerous, needless administrative tasks that are harming physicians is something we can do right now.

This work is underway in some provinces and territories. In Nova Scotia, a report that physicians were spending 100,000 hours writing sick notes prompted legislation prohibiting employers from requesting them.

Change is achievable on a national scale. The CMA’s working group on administrative burden is collaborating with regional medical associations and partner organizations to identify potential improvements and advocate for reform.

In partnership with MD Financial Management and Scotiabank, the CMA has also launched a $10-million Healthcare Unburdened Grant for projects to improve physician wellness by reducing their administrative burden. Recipients will be announced this spring.

Physicians enter medicine because we want to use our knowledge to care for others, not to get bogged down in paperwork. No one should feel they have no choice but to abandon the sector because of it. By naming the high toll admin burden takes on physicians and patient care, targeting solutions and collaborating to pull in the same direction, we can build efficiency into our health care system to give physicians the time they need with patients, as well as the time they need to H take care of themselves. ■ Dr. Kathleen Ross is a family physician in Coquitlam and New Westminster, B.C., and the president of the Canadian Medical Association. www.hospitalnews.com

SPONSORED CONTENT

Build strength and resilience with

Wellness Together Canada Online mental health resources and training designed for and by healthcare providers

By Wellness Together Canada tress and burnout rates continue to rise as healthcare providers work long hours supporting people across Canada through cold and flu season and beyond.

In response to the growing concern and need for mental health support, Wellness Together Canada has created a collection of dedicated mental health resources designed for medical professionals, healthcare practitioners and clinical support staff. Among these resources, is a free, online course called MindWell for Healthcare Workers that is designed to reduce stress and burnout, and increase personal wellbeing.

Resources and registration can be accessed on the Wellness for Healthcare Workers section of wellnesstogether.ca.

The next MindWell course starts on February 12, 2024.

“Being a healthcare provider is a demanding job, emotionally and physically,” says AnnMarie Churchill, Pres-

S

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ident and Lead Executive Officer at Stepped Care Solutions. “We see the need and want to offer resources that can help support healthcare providers with some of the daily challenges they face.”

Wellness Together Canada has partnered with MindWell to offer a short, four-week online training program designed by healthcare professionals for healthcare professionals to help reduce stress and anxiety, prevent burnout, and improve resilience.

The program offers flexible modules you can complete at your own pace, combined with live labs where participants meet online with their peers from across the country.

The course helps to: • Build resilience to bounce back faster from daily challenges • Protect and enhance overall wellbeing • Decrease stress to enhance personal performance at home and at work

“Self-care is central to maintaining mental health and plays a critical role in our ability to reduce the risk of chronic diseases, boost energy levels and improve quality of life,” says Churchill. “MindWell is designed to help our everyday heroes work on their own well-being and feel confident and capable, as they continue to care for the nation’s most vulnerable.”

Among participants who previously enrolled in the program: • 92 per cent were likely to recommend to colleagues • 86 per cent reported benefit to mental health and well-being • 92 per cent were satisfied with the training • 82 per cent reported improvement to stress management “Over the last three years, we’ve had more than 10,000 healthcare workers participate in our MindWell programs,” says Geoff Soloway, Founder and CEO of MindWell. “Participants

have told us that the training helped them alleviate stress and overcome feelings of wanting to give up on their careers.”

EACH DAY BRINGS NEW EXPERIENCES AND CHALLENGES Canadians across the nation continue to struggle to deal with the mental health impacts of financial uncertainty and complex challenges brought about by the long-term effects of the pandemic and global conflicts, among other things.

Wellness Together Canada is an online platform offering immediate mental health and substance use support for people of all ages, in every province and territory and in both official languages. The program provides free, 24/7 counselling support with little to no wait times.

If you or anyone you know is strugH gling, visit wellnesstogether.ca. Q JANUARY 2024 HOSPITAL NEWS 9

NEWS

Preventing psychological harm to healthcare workers

By Tegan Slot ot too long ago over a cup of coffee, I met a remarkable woman taking her hospital on a journey towards wellbeing. Like most hospitals across Ontario, they were suffering from the effects of the health and human resources crisis happening in the healthcare sector. The clinical care and support services teams felt burnt out. They were losing staff to early retirement, to professions where the demands were not as substantial, to short-term sick leave and long-term-disability. It was increasingly difficult to recruit new staff and those that started didn’t stay long.

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Health and human resources challenges are not unique to any one hospital; they are being experienced systemically across our healthcare system. The breadth and depth of the problem requires a collaborative, systems-driven solution to better support the wellbeing of our healthcare workers.

In November 2023, Public Services Health and Safety Association (PSHSA), and the Ontario Centres for Learning, Research and Innovation in Long-Term Care (CLRI) at the Research Institute for the Aging (RIA) jointly held a provincial workshop with the goal of preventing psychological harm in long-term care.

Continued from page 8

Paediatric epilepsy “From there, we placed electrodes in the insula structure and through a controlled temperature procedure called ablation, in which the tissue in the area was warmed up, we were able to remove parts of the area causing the seizures.”

The minimally invasive procedure was a success and reduced Makayla’s seizures by 70 per cent the first time.

Because it was so successful, the family opted to have the same procedure done a second time this past summer, which has resulted in Makayla being seizure free.

“It has given Makayla her life back,” says dad, Jeff Douglass. “It is incredible that we have this option here in London, it has changed our whole family and Makayla is happy and finally able to be a kid.”

The Radiofrequency Thermocoagulation was performed by using the ROSA One Brain, a state-of-the-art robotic arm, which was fully funded through donations to the Children’s Health Foundation. The ROSA is used in minimally invasive, robot assisted surgical procedures for epilepsy patients.

“This newer procedure, using the robotic arm, is less scary for patients 10 HOSPITAL NEWS JANUARY 2024

The Radiofrequency Thermocoagulation was performed by using the ROSA One Brain, a state-of-the-art robotic arm. and their families because it is all done through electrodes in a controlled manner. It is also minimally invasive with an amazingly fast recovery time, compared to an open skull surgery,” says Dr. Andrade.

It has been six months since Makayla underwent her second Radiofrequency Thermocoagulation procedure and she has not had a seizure since.

“It is still surreal, and we are sometimes wondering, will she have another one?” says Jeff. “But as each day goes by seizure free, we are looking into the future positively and happy for a bright H future for Makayla.” ■

Workers, employers and subject matter experts from across Ontario came together to share their knowledge, lived experiences and perspectives. Participants collaboratively identified workplace factors that lead to psychological harm, explored the root causes, and brainstormed solutions to mitigate risk.

Six key psychosocial factors were prioritized for discussion due to their prevalence in long-term care (LTC) and likelihood to contribute to psychological harm: 1. Workload management 2. Protection from moral distress 3. Organizational culture 4. Psychological protection 5. Psychological competencies and demands 6. Clear leadership and expectations Open, honest and heartfelt conversations ensued around staffing levels, funding models, complexity of care, job demands, worker competencies, communication, physical and cognitive abilities of staff and integration of psychological health and safety into overall workplace culture and work practices.

Solutions to complex issues in healthcare that contribute to recruitment, retention and overall worker wellbeing were explored at system, workplace and worker levels.

While the discussed topics apply directly to LTC, many are equally applicable to acute care and complex continuing care hospitals.

Today, my remarkable friend now has full Senior Leadership commitment and is a driving force for a care environment where worker wellbeing is prioritized at every level, throughout every department across multiple campuses. Her hospital is applying lessons learned from the workshop held this past fall to identify the root causes of psychological harm and find solutions tailored directly to the unique chal-

lenges and demands of clinical and non-clinical roles.

Beyond hospital-wide psychosocial factors, every job has unique factors that impact worker psychological health and wellbeing. By identifying job-based psychological risk, hospitals can: • Create awareness of psychological hazards and risk.

• Determine if existing control measures are adequate.

• Prevent injuries or illnesses through job design and planning.

• Develop safe work practices.

• Support job-orientation and onboarding practices.

Whether you start by seeking to understand the psychological climate across your hospital or take a job-based approach to identify factors unique to specific role profiles – the message is clear: Just start.

By taking a systematic approach to wellbeing, hospitals can manage stress in the workplace and attract and retain healthcare staff.

• As a senior leader, commit to creating and maintaining a psychologically safe workplace and provide the necessary resources to support worker wellbeing.

• As a clinical or non-clinical department leader, identify areas of operational opportunity, identify job factors impacting psychological health, listen for understanding and take action to prevent psychological harm.

• As a labour leader, support the workers’ right to know and to participate in a psychologically healthy and safe workplace.

Watch for the release of PSHSA’s report – Preventing psychological harm in long term care – root cause analysis and connect with us at workplacewellbeing@pshsa.ca to learn more about using a job-based approach H to preventing psychological harm. ■

Tegan Slot leads the Workplace Wellbeing team at PSHSA and takes a collaborative approach to health, safety and wellbeing solutions with a focus on cooperation, connections, and partnerships to achieve meaningful outcomes for public sector workplaces.” www.hospitalnews.com

Enhancing Patient Care Through Caregiver Inclusion

Different from visitors, family caregivers or essential care partners play an active role in providing physical, psychological and emotional support to a family member, partner or friend. Evidence shows that including essential care partners as part of the care team leads to improved quality of care and patient outcomes, improved working conditions for health professionals and less pressure and reduced cost on the health system.

Contact the Essential Care Partner Support Hub at ontariocaregiver.ca/essentialcarepartner for free expert guidance and evidence-informed resources to build or enhance an Essential Care Partner program.

NEWS

Help on call for medical professionals

Introduced during the pandemic, this support service became an invaluable resource for health care workers rapid response line for medical professionals with workplace-related health and safety questions and concerns has apparently been a long time coming, according to Vancouver Coastal Health Research Institute researcher Dr. Annalee Yassi. Together with other health care workers and researchers, Yassi led the medical Practitioner Occupational Safety and Health (mPOSH) initiative, which provides prompt dedicated support and guidance to medical professionals.

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“BEING ABLE TO CONNECT WITH A HUMAN BEING WHO CAN HELP ANSWER WORKPLACE QUESTIONS AND CONCERNS ALLOWS PHYSICIANS AND OTHER MEDICAL STAFF TO FEEL CARED FOR.” “Physicians are largely independent contractors and, before mPOSH was launched, they did not have a dedicated resource within the health care system where they could ask occupational health and safety ques-

tions with complete confidentiality,” says Yassi.

Innovation, community partnerships and a growing portfolio of services and patients have led to incredible advances in medicine, as

well as added layers of complexity within the profession. This was particularly true during the COVID-19 pandemic, when there was a high frequency of new health care policies that could sometimes raise further questions among health practitioners.

“There was a lack of consistent information surrounding workplace occupational health and safety concerns that may have impeded knowledge acquisition and understanding of policy changes in health care settings,” notes Yassi.

Ontario hospitals play critical role in Canadian health care advancements and innovation wenty Ontario research hospitals have been celebrated for their excellence in health research and for seeking to improve the delivery of health care in Canada. It’s a reminder of the vital role hospitals play in driving health care innovation and improving health care outcomes across Canada today.

Each year, Research Infosource Inc. releases a list of Canada’s Top 40 Research Hospitals, which is determined by total research spend by institute. Investments come primarily from philanthropy, government and industry, and support the innovative research activities at each organization.

“Ontario research hospitals play a tremendous role in driving health care innovation in Canada,” said Anthony Dale, President and CEO of the Ontario Hospital Association (OHA).

“Investments in hospital-based research have led to significant clinical advancements and improvements in

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the delivery of health care services.

Moving forward, as Canada’s population grows and ages, Ontario’s hospitals will play an anchor role in reimagining and redesigning health care services in their communities to meet this evolving need.”

Hospital-based research occurs at the intersection of patients, clinicians, clinician-scientists, and other researchers with linkages to universities, medical schools, and leading-edge biotech firms. Nowhere else are researchers as connected to patients or as involved in the delivery of care as in hospitals. In recent years, hospitals have made breakthroughs in areas such as kidney, respiratory and cardiovascular disease.

Ontario research hospitals attracted $1.82 billion in investment in 202122, an increase of 6.5 per cent over 2020-2021. This investment allows the sector to drive innovations that transform patient care and health care operations. Hospitals have also fos-

tered strategic partnerships through national networks to improve Canada’s clinical trials and pandemic preparedness.

Ontario’s research hospitals also attract and nurture scientific talent and contribute to Canada’s economic growth and prosperity. Since 2017-18, Ontario’s research hospitals have generated nearly 1,400 intellectual property disclosures and $162 million in commercialization revenue from more than 680 products, which are critical to strengthening the Canadian economy and competitiveness on a global scale.

“The OHA is proud of Ontario’s research hospitals for their contributions in improving health care delivery and health outcomes,” said Dale. “Moving forward, the OHA and its member hospitals will continue to play a leadership role in re-engineering hospital-based care so that scientific, technological and clinical breakthroughs are adopted.”

The following Ontario hospitals have been named among Canada’s Top 40 Research Hospitals for 2023: 1. University Health Network 2. Hospital for Sick Children 3. The Ottawa Hospital 4. London Health Sciences Centre/St. Joseph’s Health Care London 5. Hamilton Health Sciences 6. Sunnybrook Health Sciences Centre 7. Unity Health Toronto 8. Sinai Health 9. Centre for Addiction and Mental Health 10. St. Joseph’s Healthcare Hamilton 11. Kingston Health Sciences Centre 12. Children’s Hospital of Eastern Ontario 13. Baycrest 14. Women’s College Hospital 15. The Royal 16. Holland Bloorview Kids Rehabilitation Hospital 17. Bruyère 18. Hôpital Montfort 19. Trillium Health Partners H 20. Health Sciences North ■ www.hospitalnews.com

NEWS

RAPID PEER SUPPORT FOR MEDICAL PRACTITIONERS IN THE WORKPLACE mPOSH was launched at Vancouver Coastal Health (VCH) during the early days of the pandemic. It offered a confidential resource to medical practitioners who had questions related to exposures, had to be reached for contact tracing or wanted information on what to do if infected with COVID-19, along with return-to-work protocols following illness or exposure to a communicable disease.

Emails to mPOSH are triaged by medically trained individuals, including medical students, physicians and specialists, who would then aim to reply with a phone call or email within two hours.

Below is a sample of questions posed by mPOSH users: • “My partner has concerns about implications for our kids, etc. What do you recommend?”

• “I am a general practitioner working in the community. I have a question regarding the risk of exposure outside of work.”

• “I may have been exposed at work.

Can I still go out to Costco? Thank you for your hard work. This is very stressful.” mPOSH is well-integrated with VCH’s People Team, which supports

Around 50 per cent of physicians have experienced a physical or psychological safety event in their workplace, according to the findings of a Doctors of B.C. Engagement survey. prevention efforts and return-to-work plans for health practitioners, states Yassi. The mPOSH team also provides resources and collaborates with other B.C. health authorities, including Interior Health and Providence Health Care.

In addition to these services, mPOSH promotes and offers important information about COVID-19 vaccination, monitors exposures to

other infectious diseases, including tuberculosis, and connects health care professionals with workplace violence supports.

Another significant mPOSH mandate is to analyze anonymised data and do research to develop resources and guides that can address identified gaps in health care settings. For example, mPOSH tracks violent incidents, as well as addresses the need

among medical staff for respirator fit-testing to reduce the risk of exposure to transmissible diseases in the workplace.

“We see the role of mPOSH as one of advocating for medical staff,” says Yassi. “So long as it continues to be beneficial to medical practitioners and the health sector, our hope is to continue offering this service long into the H future.” ■

Made-to-order diagnostic tests may be on the horizon McGill researchers demonstrate potential for on-the-spot 3D-printed tests cGill University researchers have made a breakthrough in diagnostic technology, inventing a ‘lab on a chip’ that can be 3D-printed in just 30 minutes. The chip has the potential to make on-the-spot testing widely accessible.

As part of a recent study, the results of which were published in the journal Advanced Materials, the McGill team developed capillaric chips that act as miniature laboratories. Unlike other computer microprocessors, these chips are single-use and require no external power source – a simple

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paper strip suffices. They function through capillary action – the very phenomena by which a spilled liquid on the kitchen table spontaneously wicks into the paper towel used to wipe it up.

“Traditional diagnostics require peripherals, while ours can circumvent them. Our diagnostics are a bit what the cell phone was to traditional desktop computers that required a separate monitor, keyboard and power supply to operate,” explains Prof. David Juncker, Chair of the Department of Biomedical Engineering at McGill and senior author on the study.

At-home testing became crucial during the COVID-19 pandemic. But rapid tests have limited availability and can only drive one liquid across the strip, meaning most diagnostics are still done in central labs. Notably, the capillaric chips can be 3D-printed for various tests, including COVID-19 antibody quantification.

The study brings 3D-printed home diagnostics one step closer to reality, though some challenges remain, such as regulatory approvals and securing necessary test materials. The team is actively working to make their technology more accessible, adapting

it for use with affordable 3D printers. The innovation aims to speed up diagnoses, enhance patient care, and usher in a new era of accessible testing.

“This advancement has the capacity to empower individuals, researchers, and industries to explore new possibilities and applications in a more cost-effective and user-friendly manner,” says Prof. Juncker. “This innovation also holds the potential to eventually empower health professionals with the ability to rapidly create tailored solutions for specific needs right at the H point-of-care.” ■ JANUARY 2024 HOSPITAL NEWS 13

NEWS

How SCOPE is diverting patients from EDs and easing family physicians’ workloads

By Kaitlin Jingco ith busy emergency departments (EDs) during respiratory illness season and the shortage of access to primary care in Ontario, family physicians can find themselves in tricky positions when patients come in needing referrals to specialty care.

There are two options, Dr. Nadine Laraya, a family physician in Toronto’s west end, explains. The first is to search through their networks and even the internet for a specialist, call around trying to connect with a specialist, then make a case as to why the referral should be accepted – a process that can take up to 45 minutes. The second option is to send the patient to the hospital for the ED to handle.

“Our days are so jam-packed,” says Laraya. So, when the former option is chosen, it can mean pushing appointments, skipping your lunch break and ending the day late. When the latter is chosen, while it saves the busy family doctor time, “it really clogs up the emerg.”

Neither option is ideal. That’s where Seamless Care Optimizing the Patient Experience, or SCOPE, comes into play.

SCOPE is a virtual program that provides family physicians with a single point of access to resources and system navigation. So, when they need to make a referral, they simply contact SCOPE’s nurse navigator, who is an expert on hospital and community programs and can quickly pinpoint where the patient can go to get the care they need in the timeliest manner.

Since SCOPE launched in 2012, 91 per cent of family physicians who are registered with the program said it has improved timing of consultations, and an estimated 82 per cent of calls that would have led to ED visits were diverted.

“I feel like we are a bridge,” says Nisha Benning, the SCOPE nurse navigator for West Toronto, based out of St. Joseph’s Health Centre. “Our

Photo credit: Eduardo Lima

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Nisha Benning. health care system in Ontario is very complex and challenging, and it can be an administrative burden for primary care physicians. It is my main job to take that on for them.”

With administrative burden being cited as a key cause of record-level burnout among physicians, Laraya says having Benning on her side is “a win.”

“Things in the hospital are constantly changing,” says Laraya, who felt so strongly about SCOPE that she became the program’s primary care lead in West Toronto. “It’s helpful for us to have someone whose finger is on the pulse of all of that so we’re not learning the hard way in having to make multiple referrals in multiple places before we can get our patient to see someone.”

Dr. Laura Pripstein, a family physician who also uses SCOPE’s services, echoes Laraya’s sentiments.

“I love SCOPE,” she says. “I can’t imagine going back to working as a primary care physician without SCOPE.” Pripstein, who works with Dorothy Wedel, the nurse navigator for Downtown East Toronto based out of St. Michael’s Hospital, says SCOPE has been especially helpful for aging patients, as her nurse navigator has a strong understanding of home and community care options, as well as under-housed patients.

“For my clients who are more street-involved, there’s stigma,” she says. Out of fear of judgement, some may even avoid getting help altogether, so decreasing the interactions needed to get the appropriate care through SCOPE “has been a game changer.”

“It’s such a wonderful feeling,” says Benning, knowing the impact she and her SCOPE colleagues are having on patients and the primary care provid-

ers who are registered with SCOPE. Thinking about how she diverts patients away from busy EDs and into the care they need, she adds, “It’s very rewarding.”

And while they’re all advocates for SCOPE, Benning, Pripstein and Laraya all have the same recommendation for its improvement: that SCOPE grows.

There are about 15,000 family physicians in Ontario, and just 2,681 of them are registered with SCOPE. Currently, through SCOPE’s nurse navigators, those registered have access to internal medicine, medical imaging and home and community care services. Mental health navigation is being implemented and explored in various regions.

“I hope they expand the specialty groups that are involved and add more numbers,” says Pripstein. “I think that H would make things a lot better.” ■

Kaitlin Jingco works in communications at Unity Health.

14 HOSPITAL NEWS JANUARY 2024

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NOMINATE A NURSING HERO!

2024 19th Annual Hospital News

NURSING HERO AWARDS Celebrating Canada’s Nurses and Their Contributions Along with having their story published, the winner also will take home: CASH PRIZES: 1st PRIZE $1,500 2nd PRIZE $1000 3rd PRIZE $500 Have you been inspired, encouraged or empowered by an employee or a colleague?

Have you or your loved one been touched by the care and compassion of an outstanding nurse?

Do you know a nurse who has gone above and beyond the call of duty?

Hospital News will once again salute nursing heroes through our annual National Nursing Week (May 7th to 13th) contest.

Nominations can be submitted by patients or patients family members, colleagues or managers.

Please submit by April 6 and make sure that your entry contains the following information: • Full name of the nurse • Facility where he/she worked at a time • Your contact information • Your nursing hero story Please email submissions to editor@hospitalnews.com or mail to: Hospital News, 610 Applewood Crescent, Suite 401, Vaughan, ON, L4K 0E3

If you do not recieve confoirmation within 24 hours of emailing your nomination, please follow up at editor@hospitalnews.com or by telephone 905.532.2600 x2234.

FROM THE CEO’S DESK

Caring for the people who care for our patients

By Dr. Frank Martino s we begin a New Year, I reflect upon the exceptional dedication of staff, physicians and volunteers across Ontario hospitals who spend time away from their families every holiday season to ensure patients receive the care that they need. At a time when many hospitals are continuing to recover from the impacts of the pandemic, it’s more important than ever that we take care of those who take care of our patients.

While senior health executives juggle many priorities, I have no doubt that one near the top of every hospital CEO’s list is staff and physician health and wellbeing. It certainly is for me.

Our people are the heart of our hospitals and the recent pandemic served as a stark reminder that we need to be doing all we can to support team members in the workplace. A healthy and engaged workforce is not only critical to the delivery of safe, quality patient care today, but a catalyst for growing the health care workforce of tomorrow.

As hospitals work to address the impacts of health human resource challenges being felt across the province, the question on everyone’s mind is, what steps are we taking to retain the valued health care professionals that are currently working in the system, while also encouraging a new generation to commit to the professions we need in the future?

At Osler, we’re looking ahead and addressing this priority in several ways through enhanced wellness programming, growth opportunities, formal and informal recognition programs, strategic partnerships, and thoughtful recruitment campaigns. Other strategies include providing development and sponsorship opportunities for staff, developing pathways for clinical externs, implementing alternative models of care, and enhancing processes that help improve the flow of patients through our hospitals. To date, staff and physician response has been positive, reinforcing that we’re moving in the right direction, and we’re confident that the cumulative effect of

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these strategies will have a positive impact. Moving forward, it is imperative that we continue to listen to the voices of our staff and physicians to help ensure we are nurturing and supporting them in this truly noble calling.

What we’re doing outside our walls to support team members is just as important as what’s happening inside our walls. As a family physician, I’m proud of the growing partnerships we continue to nurture with primary care and our Ontario Health Team partners.

Our community care colleagues play such a significant role in supporting wellness in our communities, and in preventing unnecessary hospital visits and admissions. Working together, we can ensure patients are receiving the best care in the right place at the right time, and by the right caregivers across the entire system.

As we work to address the wellness needs of our team members, we are focused on providing inspiring work experiences for those entering the health care profession. As Osler partners with Toronto Metropolitan University to open a new School of Medicine in Brampton in 2025, we’re acutely

Dr. Frank Martino, President & CEO, William Osler Health System aware that we have an exceptional opportunity to ensure this new workforce is inspired to pursue their careers in our hospitals and in our communities.

Osler’s Academic Practice Partnership with Humber College is also advancing nursing education, scholarship, and research between the two institutions.

Our health system is as good as the people who work within it. Let’s do everything in our power as senior leaders to ensure we’re taking the necessary steps to sustain the valued talent within our hospitals, communities, and schools so that Ontarians continue to receive the H best care today and into the future. ■

Dr. Frank Martino is President & CEO, William Osler Health System.

Improving outcomes for CPR patients in the emergency room

By Olivia Lavery adie McClure, a Clinical Resource Nurse in the St. Michael’s Hospital emergency department, says resuscitating patients using CPR can be physically and emotionally challenging.

“When you pour your heart into a resuscitation and have done everything you can and the patient still doesn’t make it, there is always the question of what could I have done better.”

A new study is aiming to answer that question directly.

The Measurement and Improvement of Cardiac Arrest Resuscitation in the Emergency Department (MICARE) study uses sensors placed on

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patients to take in second-by-second data about CPR quality. The sensors analyze everything from the rate and depth of chest compressions to the amount of time a patients goes without receiving chest compressions. The data is ready for review and analysis immediately following a patient case.

Although CPR quality has been studied for in-patients at St. Michael’s in the past, this study is the first of its kind in Canada to look at emergency department CPR. The St. Michael’s team leading hope to expand to other hospitals and provide training for other teams to implement similar programs.

Dr. Garrick Mok, an emergency physician and Deputy Chief of the Emergency Department, and his study co-lead Samuel Vaillancourt, Director of Quality Improvement for the ED,

say the study is offering clinicians valuable information about how they can optimize patient outcomes.

“We have learned a lot from the initial cases on common trends we are seeing in our CPR performance,” says Mok. “This will help us drive change to improve care for our patients. The old adage ‘you can’t improve what you don’t measure’ is very true in these cases.”

Because sensors are already placed on patients in cardiac arrest, applying the study doesn’t delay treatment in critical situations. The data collected is anonymized, meaning patients can’t be identified based on the information the teams use to debrief.

Mok says about 100 patients a year will come into the department needing www.hospitalnews.com

NEWS

Continuing medical education at Ornge

By Justyn Aleluia n the world of Critical Care Paramedicine, there is always something new to learn – whether on the job or in a classroom. Ornge consistently supports Continuing Medical Education (CME) programs to ensure paramedics and clinicians can provide the highest quality of care to patients.

For the past few years, Ornge has been developing and updating its approach to CME to continually meet the needs of both learners and the organization.

Traditionally, CME has required large groups of paramedics to gather once per year for four days of classroom learning. This past year, Ornge launched a revamped approach to CME, called Continuing Professional Development (CPD). In this updated program, Ornge paramedics and clinicians can connect with educators on a more decentralized level. It leverages the expertise from our frontline paramedics, physicians, and asynchronous learning.

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CPR. Care providers perform CPR for two minutes at a time before switching off with a colleague. He hopes that collecting data will not only help patients, but the physicians, nurses and other members of the health care team treating them.

“It is extremely tiring to do CPR for two minutes,” says Celine Callender, a Co-Clinical Nursing Educator. “The quality of our compressions is so important, and it’s important to communicate that you are tired so someone can relieve you. Poor CPR is just as bad, if not worse, than no CPR.” If the study data shows that CPR quality flags before the end of those two minute rotations, teams can adjust to switch off more frequently.

Farah Warsi, a nurse and Co-Clinical Nursing Educator, says the sensors can even provide opportunities for real-time coaching to ensure providers

“It allows paramedics who are working a shift who might have some down time between calls or are working on a slow day, to connect with educators who can run them through training,” says Brad Baumber – Manager of Paramedic Education and Development at Ornge, “it promotes the concept of micro learning instead of dumping all the information on them at once.”

All paramedics have the opportunity to enhance and develop specific skills, catered to the demographic they service. For example, paramedics at one base may experience more paediatric calls and staff may opt to improve skills in that area though CPD. This year, Ornge focused on educating about high-risk deliveries within the transport environment, but the program touches on many more areas of learning – everything from newborns to end of life care.

In the past few years, Ornge has invested heavily in training to create

medium to high fidelity training spaces at every one of our bases. In its first full year of service, paramedics completed one day of simulation focused on adult patients, one day focused on paediatrics, at-base training, asynchronous learning, and a Transport Medicine Physician ride-along. Ornge continues to update the program’s curriculum based on analytics from learners within the program.

“At first, the CPD model for each calendar year was planned out, but

Photo credit: Eduardo Lima/Unity Health Toronto

are achieving the correct depth and rate of compressions in patient cases.

Mok credits a number of people for bringing the study to life, including the St. Michael’s Cardiac Arrest Committee led by Dr. Natalie Wong and Dr.

Olivia Lavery works in communications at Unity Health. www.hospitalnews.com

EXPLORING ORNGE’S ADVANCED PARAMEDIC EDUCATION PROGRAM AND ITS DEVELOPMENT.

Katharine Allen, the Unity Health simulation team, emergency department leadership, and Zoll, the company that design the sensors.

“It has truly been a team effort to H get this started,” says Mok. ■

this year we decided to organize only 65 to 75 per cent of the content and leave the rest open to be self-directed. If someone needs to brush up on a certain skill, they can self-identify and learn the skill individually,” Baumber explains.

Ornge carefully selected paramedics to be Clinical Practice Leads (CPL) for the program. CPLs work at all bases to deliver learning activities in settings such as classrooms, simulation, practice-based preceptorship, and peer-topeer mentoring. They are relied on to be leaders, coaches, role models, and teachers and are entrusted with guiding learners through their continued education.

“Sometimes crews go out on challenging calls, and when they come back, they now have the opportunity to connect with CPLs to debrief and learn based on their experiences on call,” says Baumber.

The revamped program is exceptionally important to Ornge’s operations and to its patients. Ornge services all of Ontario’s many diverse communities, including those that are remote who rely on Ornge to provide them access to the highest quality of care. The CPD program prepares frontline staff to appropriately react to the various environments they might find themselves in – a skill crucial to upholding health equity on H Ontario. ■

By Justyn Aleluia, Communications Intern at Ornge.

JANUARY 2024 HOSPITAL NEWS 17

NURSING PULSE

RNAO fellows find solutions to fill gaps, advance care and improve outcomes

By Victoria Alarcon ith more than 500 fellows, the Registered Nurses’ Association of Ontario’s (RNAO) Advanced Clinical Practice Fellowship (ACPF) program has reached new heights over the last two decades. Refreshed in 2022, the program now provides opportunities for RNs and NPs to develop their knowledge, skills and expertise in four different fellowship streams, each with an overarching goal to meet a need or fill a gap within a specific workplace or organization. With the support of their organization, a mentor and RNAO, hopeful fellows submit proposals for projects that: lead change in evidence-based nursing practice; promote equity in nursing and health; advance health and wellbeing; and/or support improvements in long-term care. If a proposal meets the criteria for acceptance within one or more of these four streams, the fellow’s organization will receive funding of $15,000 for a 450-hour fellowship (12 weeks full time or 20 weeks part time). With this funding, plus the organization’s own funding, organizations can cover for a fellow’s absences, while they take time away from work to participate in the program.

RN Cyndy Ocampo is just one* of the hundreds of engaged RNs and NPs who have completed ACPFs. This glimpse of what she has accomplished, and the impact she has had on her workplace, may just inspire you to explore your own fellowship.

Photo credit: Stef+Ethan

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LOOKING AT RETENTION AND RECRUITMENT FROM A DIFFERENT LENS For Cyndy Ocampo, the hardest part of the nursing crisis has been seeing colleagues leave, one by one.

“It’s sad to see your colleagues go, especially if you’ve invested (time in) a relationship with them,” says the clinical performance analyst at Toronto’s Spectrum Health Care, a Best Practice Spotlight Organization® (BPSO®)

For 23 years, the Registered Nurses’ Association of Ontario (RNAO) has inspired RNs and NPs to lead targeted projects that support organizational and personal growth on the road to better care. Cyndy Ocampo (above) took advantage of the association’s Advanced Clinical Practice Fellowship (ACPF) to learn more about what she could do as a nursing leader to support staff during the height of the COVID-19 crisis. that provides home care services so clients, especially seniors, have the choice and confidence to receive care at home.

During the height of the pandemic in early 2021, there was higher-than-average turnover because COVID-19 restrictions forced part-time nurses to leave and choose only one employer.

In addition, growing patient workloads increased staff burnout. “Before COVID, (nurses) would see an average of 10 patients a day, maybe up to 15 or 16. During COVID, they were seeing more than 20 patients,” she explains. As a result, Spectrum Health Care, like many other home care providers, would have to decline referrals because of staffing issues.

The resulting frustration and a desire to find a solution inspired Ocampo to apply for a fellowship that would focus on retention and recruitment. The stream she chose emphasizes the development of leadership skills, knowledge and expertise in specific areas of

education, management, research and policy.

Ocampo wanted to learn what she could do as a nursing leader to support staff during a crisis. “(The solution) needed to come from the leadership perspective,” she emphasizes.

When her ACPF was confirmed in September 2021, she quickly completed an environmental scan to understand the retention and turnover issues at her organization. She learned that nurses with up to five years experience made up close to half of the nursing team and those with more than 16 years made up only 16.5 per cent. In her research, she noted that recruiting more nursing staff may offer a quick fix, but it does not solve staff retention.

From her scan, she also learned that staff sought more support and coaching from management. “(Nurses) left to go elsewhere – to a hospital or longterm care – because there was more support for them there,” she says, add-

ing that new hires working in the community felt alone or not part of a team.

Given her findings, Spectrum Health Care created new nursing leadership roles and began hiring for positions like clinical educators, nursing directors and nursing supervisors.

Nurses in these roles would provide staff support that included regular staff check-ins. They would also meet staff at their patients’ homes, if they needed guidance with a certain skill. In addition, they changed the way they approached their mandatory three-week orientation for new hires. Instead of mandating that orientation be conducted in person only, online orientation also became an option. “We needed to be more flexible, so we offered more online education and they could complete it when they could,” she says.

The team culture has changed for the positive and Ocampo can see it.

To ensure the new strategies are working, she interviews current and new staff to find out what management can do better. “We ask the new hires if this is the job they were expecting, what can we improve on, what their favourite part of the job is and where we can help.”

Since completing her fellowship earlier this year, Ocampo says she has grown stronger. “It has helped me become a better leader,” she notes. Before the fellowship, she thought the focus should be entirely on the patient, but now she sees that staff need support and resources too. “If you’re taking care of your staff, it ultimately leads to patient satisfaction.” *PLEASE NOTE: This article is condensed from an article that featured the stories of three ACPF fellows. For more on the other fellows, read the full article in the Spring-Summer 2023 issue of RNJ.RNAO.ca, the digital publication of the Registered Nurses’ Association of Ontario (RNAO). The full article is also available in the online “nursing” section of Hospital News. Inquiries about the program can be directed to RNAO’s ACPF project co-ordinator, Erica D’Souza at H edsouza@RNAO.ca ■

Victoria Alarcon is communications officer/writer for the Registered Nurses’ Association of Ontario (RNAO), the professional association representing registered nurses, nurse practitioners and nursing students in Ontario.

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PROFESSIONAL DEVELOPMENT AND EDUCATION

22ND ANNUAL

Professional Development Education +

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JANUARY 2024 HOSPITAL NEWS 19

PROFESSIONAL DEVELOPMENT AND EDUCATION

Internship supports advancement of health informatics knowledge gnes Leung and Tram Nguyen were excited for a new professional development opportunity.

The two nurses are participating in a first of its kind internship at UHN – a joint endeavour between the Clinical Informatics and Collaborative Academic Practice (CAP) teams.

Agnes and Tram will use their experience as point-of-care nurses to support programs and work that bridge the informatics and clinical spheres, including the Epic Essential Skills program, which recently rolled out for inpatient nurses.

Epic Essential Skills, a joint initiative between the Clinical Informatics

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team and CAP, uses a data-driven approach to improve end-user satisfaction with UHN’s new health information system (HIS) from Epic through the delivery of tailored, in-person upskilling sessions.

In addition, Agnes and Tram will support the newly-formed Epic Nursing & PSW (personal support workers) Clinical Documentation Working Group (ENPCD). That group has a mandate to improve the work lives of nurses and PSWs by streamlining Epic documentation and workflows, along with other clinical informatics initiatives including work to improve barcode medication compliance rates across UHN.

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Tram Nguyen, (L), and Agnes Leung are UHN nurses who are part of a new internship that is serving as an important step towards the continued advancement of health informatics knowledge in the clinical setting to promote quality of care.

“Working through the pandemic definitely pushed me to look for and pursue new development opportunities,” says Agnes.

“With the evolution of technology and its influence on the health care system, I believe that nursing roles are also rapidly changing, so it’s crucial to have nurses actively involved in this change process, and not in the backseat.”

AIMING TO INCREASE CLINICAL INFORMATICS CAPACITY WITHIN NURSING Tram echoes that sentiment.

“Last year, when UHN transitioned its health information system from EPR to Epic, it demonstrated a desire to move towards improving patient safety and care,” Tram says. “Working at the bedside has given me insight into the current nursing workflow and processes, but also the challenges faced by frontline staff.

“As a former interim Advance Practice Nurse Educator at the Toronto Western Hospital for the Orthopedic

and Combined Surgical Unit, I bring a lens as a nurse from the frontline, but also from nursing practice.”

This internship is an important step towards the continued advancement of health informatics knowledge in the clinical setting to promote quality of care at UHN. “One of the aims of the internship is to increase clinical informatics capacity within nursing, given the central role our new health information system plays in nursing documentation and practice,” explains Jillian Chandler, Manager, UHN Clinical Informatics.

Karen Martin, Executive Director, Nursing and Health Professions Practice & Chief Practice Information Officer at UHN, says “we’re very excited about this partnership.

“Our nurses highly value opportunities for developing new knowledge, testing innovations and advancing patient-centered practice,” Karen says.

“These will all be enhanced by this internship and the presence of Agnes H and Tram, our new interns.” ■

This article was submitted by UHN News.

20 HOSPITAL NEWS JANUARY 2024

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PROFESSIONAL DEVELOPMENT AND EDUCATION

Simulation training trains staff to de-escalate situations new virtual reality (VR) simulation training program with a mental health focus at The Hospital for Sick Children (SickKids) is empowering staff to effectively de-escalate situations that can lead to harm for patients, families and practitioners.

Visiting a hospital can be a stressful experience at the best of times. When difficult situations arise, it is important that health-care providers feel equipped to put theory into practice and effectively navigate escalating tensions and emotions.

When a person is faced with a challenging situation, it can quicky escalate when an intense rise of emotions impacts their ability to cope. These escalating circumstances are often saturated with complexities and nuances that demand a unique training approach that is incredibly hard to

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replicate but is essential to ensuring health-care providers feel equipped to put theory into practice and effectively navigate the escalating tensions and emotions.

The VR training, developed within the Literacy Pillar of the Mental Health Strategy led by Laila Strazds, Education Project Manager, is unique in that it allows staff, in a simulated scenario, to practice responding to a patient interaction that follows a pattern of escalation (baseline, escalation, crisis, and recovery).

“When there’s a mental health crisis, it’s a very high stakes, complex situation. We need to practice, but historically there hasn’t been a great way to do this,” says Dr. Sasha Litwin, Emergency Department Physician and contributor to the design of the project. “Virtual reality makes for an immersive practice setting that gives

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people the chance to test things out, see what works, and learn – so when it happens, which it does often, we’re ready.”

PUTTING THEORY INTO PRACTICE Escalations can take on many different forms, from a rise in the volume of their voice, to hitting or breaking things or harming themselves or someone else. A main indicator of an escalating circumstance is when, for a variety of reasons, someone is unable to self-regulate and get themselves out of that state. The uniqueness of each situation presents distinct challenges for health-care providers to respond in a supportive, trauma-informed way.

“The biggest offering of this technology is the interaction, whether you’re a novice or a trained person” says Robert Chatwin, a Child and Youth Counsellor who was part of a pilot group to provide feedback during the development phase of the training tool. “It creates a psychologically safe environment for you to see instantly the ramifications of your choice –often times you only get that instant feedback from real experience.”

The roughly 20-minute simulation immerses care providers in the fictional story of a 13-year-old non-binary youth named Caden who was

brought into the Emergency Department by their mother for suicidal risk and self-injury. Different variations of the story are presented based on how the learner chooses to respond to Caden at each of the 13 interaction points. The program follows the four escalation levels to help staff practice critical decision-making, collaborative problem-solving, and emotional awareness and regulation at each level of an escalation. It was designed to incorporate equity, diversity and inclusion features, like prompting the use of Caden’s correct pronouns to avoid misgendering.

“We come into each case with the expectation that we’ll provide the best care possible,” says Dr. Jabeen Fayyaz, Director of the Simulation Program (SimKids) and Emergency Department Physician. “This VR training allows all learners across disciplines to build their confidence in handling an escalating circumstance, ultimately allowing us to focus on providing our patients the care they deserve in the best possible way, customized to their need.”

The VR training will start being used in early 2024, starting with staff who are Crisis Prevention Institute (CPI) certified, and later integrated into a larger de-escalation program offered through the SickKids Learning H Institute. ■ www.hospitalnews.com

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PROFESSIONAL DEVELOPMENT AND EDUCATION

Getting nurses working:

Sunnybrook makes strides with internationally educated nurses

By Marie Sanderson my Son gently applies bandages to a patient’s face as they chat about his excitement of returning home to see family after his hospital stay. Her job as a registered nurse in Sunnybrook’s Ross Tilley Burn Centre is a long way from Seoul, South Korea, where Amy started her career in nursing.

Amy is just one example of an internationally educated health care worker helping to meet human health resource demands in Ontario. Sunnybrook’s Internationally Educated Nurse (IEN) Pathway helps to support cultural integration, language proficiency and skills development for these team members, with a dedicated group of interprofessional staff guiding and coaching those enrolled.

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Nurses who have studied and are certified abroad must successfully meet requirements established by the College of Nurses of Ontario (CNO) before working as a nurse in the province. The Supervised Practice Experience Partnership is a partnership between CNO, Ontario Health and approved organizations like Sunnybrook, offering substanial supervised practice experience, and is woven into the hospital’s unique pathway.

“Sunnybrook’s pathway is a roadmap for internationally educated nurses, leveraging their specialized skills and expertise, and enabling workforce integration in the Canadian healthcare setting. And the impact is significant, supporting career development, quality patient care and our healthcare system at a time of great need,” explains

Amy Son pictured at Sunnybrook Health Sciences Centre

Photo credit: Kevin Van Paassen, Sunnybrook

Tracey Das Gupta, Director of Interprofessional Practice at Sunnybrook.

Opportunities include providing healthcare work experience in unreg-

ulated roles, like observer and patient support provider, while at the same time covering gaps in human health resources needs. Further opportuni-

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24 HOSPITAL NEWS JANUARY 2024

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ties include expanded clinical extern roles and, ultimately, recruitment into nursing roles.

Sunnybrook has 174 internationally educated nurses currently on the pathway, and 115 people have been hired into nursing roles at the hospital. For participants, some of the highlights include career coaching, interview preparation, mentorship and language proficiency support.

“The support of Sunnybrook has made the world of difference in my career,” says Amy, who says working at Sunnybrook was her dream job. “For me, every patient interaction is an opportunity to make a positive impact.

I’m truly committed to enhancing the lives of others throughout my nursing career.”

Amy recently received the Joan Lesmond Internationally Educated Nurse of the Year Award from the CARE Centre for Internationally Educated Nurses, which is presented to a registered nurse who has overcome challenges to achieve their Ontario nursing license.

Photo credit: Kevin Van Paassen, Sunnybrook

Amy Son cares for a patient in Sunnybrook’s Ross Tilley Burn Centre In addition to her frontline nursing role, Amy serves as a safety coordinator for the Ross Tilley Burn Centre and Tory Trauma Program, engaging in quality enhancement projects. She

also participates in remote teaching to nursing students in South Korea and is an Expert Nurse Mentor for the CARE Centre for Internationally Educated Nurses.

“In Canada, nursing unites professionals from around the world, sharing a common goal of providing high quality care to patients,” adds H Amy. ■

Marie Sanderson is a Communications Advisor at Sunnybrook Health Sciences Centre.

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JANUARY 2024 HOSPITAL NEWS 25

PROFESSIONAL DEVELOPMENT AND EDUCATION

Blanche River Health recruits internationally trained registered nurses

By Dan Strasbourg hinking outside the box has yielded great results in efforts to recruit Registered Nurses (RNs), according to Jorge VanSlyke, President and CEO, Blanche River Health (BRH).

“Like hospitals across Canada, the chronic shortage of clinicians has tested our ability to recruit and retain health care providers, such as RNs,” she said. “Our Human Resources department challenged themselves to attract internationally trained nurses to our area, and as a result, four of the seven new RNs hired since July, 2023 were trained abroad.”

According to Debra Schenk, Manager, Human Resources at BRH, leveraging programs for internationally trained professionals was key to tapping into the international labour market.

“If employers want to stand out, they need to understand and deliver what future employees value most,” she said. “For many internationally trained medical professionals, that means experiencing a smooth immigration process.”

BRH Human Resources Generalist Lisa Poeta leveraged two government programs to support the hospital’s efforts.

“The Labour Market Impact Assessment (LMIA) program gives employers the green light to hire internationally trained workers, while the Rural and Northern Immigration Pilot (RNIP), provides immigration support to those who move from abroad to work in participating Canadian communities,” she said.

Anju Devassy worked as a Registered Nurse in India for five years before deciding to join her extended family in Canada.

After arriving on a student Visa in 2020, she secured a job as a Personal Support Worker with the goal of continuing her career as a Registered Nurse. Blanche River Health provided her with the opportunity to complete

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the College of Nurses of Ontario’s 140-hour Supervised Practice Experience Program, a requirement in order to become eligible to practice nursing in Ontario.

“The supervised practice I received at Blanche River Health was much appreciated and helped me transition to documentation standards commonly used in Ontario,” said Devassy, who accepted a position as a Registered Nurse in July, 2023. Her husband and daughter have joined her in Kirkland Lake. “I also appreciate the support I have received from the BRH Human Resource team to help me transition to life in Canada.”

The RNIP program is now supporting her family’s efforts to secure permanent residency.

In the past two months, three more foreign-trained RNs joined

Blanche River Health, including Oge Okafor from Nigeria and Surbhi from India.

Okafor participated in the RNIP, and she is grateful for the support she received.

“I hold a Masters degree in Nursing, backed by five years of experience,” she said. “I obtained my Ontario nursing license from the Philippines, and needed a temporary work Visa to get my career started in Canada.

I’m grateful for the RNIP program, which not only helped fast-track my temporary work Visa, they are still supporting me as I work through my application for permanent residency.”

Upon arrival to their new homes, Blanche River Health offers support from settling in, making connections with community supports, and ob-

taining a Social Insurance number, to opening Canadian bank accounts and making sure they are prepared for Canadian winters.

“I was born and raised in the Philippines before moving to China and then Canada” said VanSlyke. “I understand how daunting it can be to start over in a new climate, with new food, new entities to register with, and few familiar faces to help me navigate everything.”

She also recognizes that supporting newcomers helps root their families in the community, which is essential in retaining the talent the hospital attracts.

To this end, the Human Resources team at BRH has partnered with local multi-cultural groups that foster connections with other newcomers and provides annual memberships so new employees can tap into cultural and social events. The team also partners with local Chambers of Commerce to leverage programming and tap into local resources while providing in-depth onboarding packages with information and resources on local services and amenities.

According to VanSlyke, this personal touch, coupled with government programs that remove barriers to recruiting internationally trained health care professionals, can have a positive impact on addressing chronic shortages of clinicians, as evidenced by Blanche River Health’s recent successes.

“While we applaud and fully support the various programs to support local health care professionals, demand outpaces the supply right now, and tapping into the international market is another great way help fill that need,” she added.

If you or anyone you know is interested in employment at Blanche River Health, please contact us at careers@blancheriverhealth.ca or (705) 567-5251 Ext. 3204. For further details about our job opportunities, please visit our website H blancheriverhealth.ca ■

Dan Strasbourg is the Public Relations & Fundraising Lead at Blanche River Health.

26 HOSPITAL NEWS JANUARY 2024

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COVER

Virtual reality’s role in nursing education: Strengthening empathy in therapeutic communications

By Christine Vogel ow do you gauge if someone is dangerously anxious? In Canada, suicide rates among young girls have climbed to double that of boys. In the U.S., they’re at their highest point in 80 years, so that the U.S. Preventive Services Task Force now recommends routine anxiety screenings for children and adolescents as well as adults.

Every patient care interaction offers the potential to be a behavioral-mental health encounter, but not every

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health provider knows how to connect with patients and ask tough questions in a tactful way to get truthful answers. They may be reluctant to seem intrusive, especially with patients they rarely see. It’s hard enough to dig into a friend’s emotional state. Yet anxiety sufferers may avoid follow-up care if they perceive their healthcare providers as unsympathetic or dismissive.

Nurses on the frontline of patient care often do not feel adequately prepared to deal with “difficult” con-

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IMMERSIVE VIRTUAL REALITY SIMULATIONS CURATED FOR NURSING EDUCATION OFFER LOW-RISK TRAINING OPPORTUNITIES FOR HIGH-ACUITY COMMUNICATIONS THAT IMPROVE THE NURSE-PATIENT RELATIONSHIP versations due to a lack of education in effective communication skills, according to research into the role of empathy in healthcare. This lack of confidence can create additional stress in an already high-pressure role, and become a contributing factor to leaving the profession, with nearly a third of nurses in a recent McKinsey survey considering leaving their direct patient care role within a year.

Moreover, a shortage of clinical placements and preceptors for student supervision is also hindering many nurse learners from gaining exposure to the diverse array of human conditions and challenging conversations they need in order to reach comfort levels. A U.K. survey reported 70 per cent of early career and student nurses feeling they have missed vital learning experiences.

Assessing someone’s level of distress is not the only communication mine-

field for nurses to navigate. An equally fraught encounter is around end-oflife issues. Many nurse learners have never had direct exposure to death and are uneasy in conversations. They may fill pauses with unnecessary chatter, or be oblivious to appearing cold and uncaring if they remain silent.

They may also unintentionally dredge up their own past or present grief while helping patients facing mortality.

The inability to have frank conversations around sensitive issues such as poverty, homelessness, physical safety, or other social determinants of health can also become an impediment to care. The quality and frequency of meals and the type of shelter may be directly connected to the patient’s complaint, but eliciting details can require tact and patience on the nurse’s part.

Nurses who can better understand the backstory to a patient’s condition will be better equipped to offer solutions. www.hospitalnews.com

FILLING THE GAP IN CLINICAL TRAINING SITES I taught students for a dozen years as a nurse educator. Providing a wide variety of safe and effective opportunities for practicing skills in high-acuity situations that can be difficult to predict or simulate is a huge challenge, especially when placements for clinical rotations are in tight supply.

Today, immersive virtual reality (VR) simulations are helping supplement instruction gained from in-person clinical rotations, as nursing colleges like the University of Manitoba and Ontario’s Sheridan College are experiencing. VR training platforms built specifically for nurses can offer learners the opportunity to gain practice in treating patients in an interactive and risk-free learning environment.

VR scenarios can help nurse learners develop their clinical judgment and problem-solving capabilities by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

Interactive VR simulations are also transforming how nursing students

learn to communicate with patients around anxiety, depression, self-harm, and other uncomfortable topics like drug use, end-of-life decisions, and stages of grief. As noted in a study published in 2021 in Nurse Education Today, highly realistic scenarios equip learners to provide compassionate, effective treatment while avoiding the limitations and risks associated

with real-world – and scarce – clinical learning environments.

When I was a nursing student, I had clinical rotations in mental health yet lacked exposore to dealing with issues such as drug addiction, homelessness, and suicidal thoughts. As a graduate student, I found myself inadequately prepared to support patients grappling with these now prevalent societal

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challenges. I struggled to find the right words to use with patients, and hesitated to inquire about their emotional well-being, unsure of my place in doing so. And in dealing with mortality, I had to learn to tamp down the natural inclination to tell hurting people “it’s going to be okay,” which gives false hope, or “I understand,” which can imply agreement.

Continued on page 36

PROFESSIONAL DEVELOPMENT AND EDUCATION

Promoting academic teaching and applied research oyal Victoria Regional Health Centre (RVH) and York University signed a Memorandum of Understanding (MOU), further deepening the two organizations’ joint commitment to improve health outcomes for patients and train the next generation of caregivers and researchers.

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and push past what has always been done so we can offer better care for our patients, their families, our community, and region. This partnership opens the door for us to ‘imagine the possibilities’ as York University’s faculty and TEAM RVH grow in their own knowledge and skills through a variety of opportunities.”

“WE CHALLENGE AND PUSH PAST WHAT HAS ALWAYS BEEN DONE SO WE CAN OFFER BETTER CARE FOR OUR PATIENTS, THEIR FAMILIES, OUR COMMUNITY, AND REGION.” “At RVH, we ask questions to promote new learnings, ideas, research and discovery,” says Gail Hunt, RVH President and CEO. “We challenge

RVH and York have a rich history of collaboration. The partnership has provided real-world educational opportunities for York’s nursing and

RVH President and CEO Gail Hunt (left) and York University President and Vice-Chancellor Dr. Rhonda Lenton sign Memorandum of Understanding to promote collaboration in academic teaching and applied research. allied health students. In 2023 alone, RVH has onboarded and provided clinical student placements for 70 students, both in groups and for one-toone preceptor models.

In addition, 32 York nursing students (from the York/Georgian College partnership) are finding both employment and valuable experiential education opportunities during their year in our Clinical Extern program.

Under the new MOU, RVH will continue these clinical placements and experiential learning, as well as increase collaboration for development of research capacity and opportunities in the areas of: • Mental health • Healthy aging and seniors’ care • Family, community, home, and urgent care medicine • Maternal, child, infant and adolescent health, and development 30 HOSPITAL NEWS JANUARY 2024

• Rehab sciences • Disease diagnostics, treatment, control, and prevention • New health technologies, such as digital health and artificial intelligence Members of TEAM RVH will also benefit greatly from the partnership through the organizations’ shared networking, resources, mentorships, continuing education and professional development.

“On behalf of York University, we are delighted to explore collaborative opportunities with RVH,” says York University President and Vice-Chancellor Rhonda Lenton. “By leveraging our combined expertise and pooling our strengths in research and education, I am certain that we can improve health outcomes and make important contributions toward high-quality, sustainable, inclusive, and accessible health care for the communities we H serve.” ■ www.hospitalnews.com

Studies have shown that patient satisfaction goes up by 2.5%, and staff turnover can plummet over 8 percentage points (from 16.7% to 8.1%), when certified nurses are increased by 60% in an acute care unit.1 Further studies indicate that healthcare facilities will see a 2% decrease in the odds of mortality and failure to rescue for every 10% increase in certified nurses.2 Research has also found significantly lower rates of falls in units with two

or more geriatric-certified nurses,3 with average length of hospital stay reduced by one day after a 6% increase in certified nurses.4

Nurses committed to high practice standards The CNA Certification Program says this is all possible because specialty certification confirms that a nurse’s practice is consistent with national standards.5 Certified nurses are committed to an advanced standard of professional competence, and this is directly correlated with improved patient outcomes, such as fewer central-line-related infections in surgical ICUs.6

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CNA certification is effective, studies say

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Increasing the number of CNA-certified nurses improves recruitment and retention, and leads to safer patient care, research shows.

RSES A

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CNA Certification Offers Proven Path to Better Workplaces and Patient Care

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CERTIFIED

Health-care facilities that offer CNA certification, and encourage nurses to pursue it, are able to retain and attract nursing talent. CNA offers a voucher system, where workplaces can pay for their staff to pursue specialty certification (valid for 1 year, minimum 15 exam registrations required).

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To help retain and attract the best nurses for your organization, contact the CNA Certification Program at certification@cna-aiic.ca.

1

Craven, H. (2007). Recognizing excellence: Unit-based activities to support specialty nursing certification. MedSurg Nursing, 16, 367-371.

2

Kendall-Gallagher, D., Aiken, L. H., Sloane, D. M., & Cimotti, J. P. (2011). Nurse specialty certification, inpatient mortality, and failure to rescue. Journal of Nursing Scholarship, 43, 188-194. doi:10.1111/j.1547-5069.2011.01391.x

3

Lange, J., Wallace, M., Gerard, S., Lovanio, K., Fausty, N., & Rychlewicz, S. (2009). Effect of an acute care geriatric educational program on fall rates and nurse work satisfaction. Journal of Continuing Education in Nursing, 40, 371-379. doi:10.3928/00220124-20090723-03

4

Nelson, A., Powell-Cope, G., Palacios, P., Luther, S. L., Black, T., Hillman, T., . . . Gross, J. C. (2007). Nurse staffing and patient outcomes in inpatient rehabilitation settings.

Rehabilitation Nursing, 32, 179-202.

5

Straka, K. L., Ambrose, H. L., Burkett, M., Capan, M., Flook, D., Evangelista, T., . . . Thornton, M. (2014). The impact and perception of nursing certification in pediatric nursing.

Journal of Pediatric Nursing, 29, 205-211. doi:10.1016/j. pedn.2013.10.010

6

Boyle, D. K., Cramer, E., Potter, C., Gatua, M. W., & Stobinski, J. X. (2014). The relationship between directcare RN specialty certification and surgical patient outcomes. AORN Journal, 100, 511-528. doi:10.1016/j. aorn.2014.04.018

PROFESSIONAL DEVELOPMENT AND EDUCATION

Project BETTY is enhancing the way skills training is delivered in hospitals or 20 years, Canadian Surgical Technologies and Advanced Robotics (CSTAR) at London Health Sciences Centre (LHSC) has driven innovation in research, simulation and training the health care providers of today and tomorrow.

Bringing Education and Technology to You, a mobile simulation training program also known as Project BETTY, is the latest innovative educational program developed through CSTAR. Project BETTY’s goal is to bring simulation training directly to clinical areas to make skills training more accessible to hospital staff. Instead of booking time off and rearranging schedules to attend off-site training, frontline workers can participate in the training without leaving their unit.

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The 15-30 minute-training sessions are focused on developing hands-on skills to address patient safety challenges such as transfers and mobility, catheterization and the recognition of a deteriorating patient.

“We’ve hired many new nurses in the past few years, and because of COVID-19, we had to switch from in-person training to virtual training,” said Stephanie Ayres, Director of Education at LHSC. “The focus of Project BETTY is to provide more of those hands-on training experiences that are so important.”

The training has not only been helpful for newer hires; it has also created opportunities for experienced staff to build on their skillsets and incorporate evolving best practices.

“Best practice standards change all the time,” said Liz McGowan, a clinical educator and one of Project BET-

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32 HOSPITAL NEWS JANUARY 2024

THE TRAINING HAS NOT ONLY BEEN HELPFUL FOR NEWER HIRES; IT HAS ALSO CREATED OPPORTUNITIES FOR EXPERIENCED STAFF TO BUILD ON THEIR SKILLSETS AND INCORPORATE EVOLVING BEST PRACTICES. TY’s lead instructors. “Having handson practice is invaluable as opposed to simply reading about a new policy or procedure. We can actually be there to guide staff through scenarios together.”

Funding from the Skills Development Fund – an Employment Ontario program funded in part by the Government of Canada and the Government of Ontario – was instrumental in hiring staff and purchasing equipment for Project BETTY. Since its launch in May 2023, the program has trained over 800 staff members, putting it over halfway to reaching its goal of over 1,500 trainees in the first year.

“As hospitals and health care facilities evolve to meet the needs of patients in our modern world, it is great to see training methods for staff evolve as well,” said Rob Flack, MPP for Elgin-Middlesex-London. “The $500,000 investment from the Skills Development Fund Training Stream has given the Canadian Surgical

Technologies and Advanced Robotics (CSTAR) team at London Health Sciences Centre an opportunity to lead the way with Project BETTY. Training is more efficient, reaching a greater number of staff members and ultimately, improving care for patients.”

Clinical educators are often focused primarily on teaching nurses, explained McGowan, but because Project BETTY’s educators operate as a mobile simulation team, they have been able to reach a broader range of staff members and help other members of the interdisciplinary care teams to solidify their roles within the simulations.

The convenience and effectiveness of the training is leading to expansion with plans underway to create new training modules for wound care and other requested topics. The programming and evaluation methods have also been designed to be shared with H other health-care organizations. ■ www.hospitalnews.com

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PROFESSIONAL DEVELOPMENT AND EDUCATION

Leadership program brings together team members from across clinical areas

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34 HOSPITAL NEWS JANUARY 2024

Photo credit: UHN

inda Ahn and Sarah McDermid-Flabbi have learned leading is not about having all the answers.

Members of different health professions in different UHN hospitals, the pair were among about 100 participants who recently completed the Leadership Accelerator for Clinical Leaders. The group took part in workshops, learning groups, assessments and a leadership panel over the sixmonth course, which is part of UHN’s commitment to driving a high-performance culture.

One of the sessions was on coaching. Its lessons surprised both Linda and Sarah, and still resonate.

“Coming from a clinical background, I pride myself on being solution-driven, giving advice, offering recommendations,” says Linda, a registered dietitian who joined UHN in 2001 and is now an Operations Lead in Allied Health at Toronto Western Hospital. “But I learned that’s not always the best way to help.

“I learned to slow down, ask more questions, be more curious. By understanding more of the issue someone on your team is facing, you can help them find solutions and empower them.”

Those sentiments are echoed by Sarah, a registered nurse with UHN since 2014 who worked as an advanced practice nurse educator (APNE) in the Emergency Department at Toronto General Hospital from April 2020 until earlier this month, when she moved to UHN’s Peter Munk Cardiac Centre as the Nurse Lead developing the Nursing Clinical Coach and Mentorship Program.

“It was a lightbulb moment,” she says of the session on coaching. “I had always looked at my role as a fixer, someone who had to have answers to everyone’s questions to have value, to be a go-to person.

“Being more inquisitive, asking people about their challenges and possible solutions from their perspective, engages them more in their work. I ask different questions because of that module – it was a total game-changer.”

“I’ve built a lot of relationships at UHN that make me want to stay here,” says Sarah McDermid-Flabbi, Nurse Lead developing the Nursing Clinical Coach and Mentorship Program at UHN’s Peter Munk Cardiac Centre. “This program fostered those relationships and built new ones, and it’s opened my mind to different ways of thinking, different ways to lead.”

THE GOAL OF THE LEADERSHIP ACCELERATOR FOR CLINICAL LEADERS WAS TO OFFER TAILORED DEVELOPMENT TO INDIVIDUALS WHO HAVE SHARED AN INTEREST IN ADVANCING TO LEADERSHIP ROLES IN UHN CLINICAL AREAS TO GROW THEIR LEADERSHIP CAPACITY, AND ULTIMATELY BUILD THE LEADERSHIP BENCH STRENGTH OF THE ORGANIZATION. The program, which celebrated its graduation on Monday, Oct. 30, aligns with the new UHN Leadership Competency Framework approved by Executive Leadership Forum in April of this year.

“We want to strengthen the leadership skills that are most important to delivering impact across the organization,” says Sheila O’Brien, UHN’s Executive Vice President of People & Culture.

“Our goal is to enhance the leadership capabilities of our employees because we know that effective leadership in health care is directly linked to improved patient outcomes, better organizational performance and enhanced employee engagement,” she says.

The goal of the Leadership Accelerator for Clinical Leaders was to offer tailored development to individuals who have shared an interest in advanc-

ing to leadership roles in UHN clinical areas to grow their leadership capacity, and ultimately build the leadership bench strength of the organization.

In April of this year, Linda, Sarah and others identified by their leaders as potential participants, were notified

by UHN People & Culture about the program, including the time commitment, topics covered and learning objectives. Classes – virtual and in-person – and the related homework were done in addition to continuing their full-time job.

“I was very excited and intrigued,” Linda says of the original email, adding that “it was a real confidence boost” and “I felt valued” to know her managers and director were recommending her for the program.

“I read through the topics outlined and realized I wanted to learn more about all of it to know if I’m doing things right, or there’s a better way. It all looked very relevant to my day-today work.” www.hospitalnews.com

PROFESSIONAL DEVELOPMENT AND EDUCATION Photo credit: UHN

Sarah says she saw the email inviting her to join the program as “an olive branch to grow as a leader and grow in my own development.

“It also puts into perspective that people see the work you do, and see your potential.”

From May through October, participants – some already in UHN clinical leadership roles such as supervisors and leads, others who aspire to their first people leadership role – completed six modules. Among the topics were “Essentials of Leadership,” “Making Meetings Work,” “The Coaching Habit” and “Navigating Conflict.”

“In designing the program, we wanted to ensure it was aligned to our new UHN Leadership Competency Framework to help participants understand not only what it means to be a leader but also the unique leadership behaviours that our most effective leaders at UHN demonstrate each and every day,” says Alyssa Roebuck, Senior Advisor, Leadership Development with People & Culture.

Alyssa leads all of UHN’s current leadership programs, including Emerg-

“I read through the topics outlined and realized I wanted to learn more about all of it to know if I’m doing things right, or there’s a better way,” Linda Ahn, Operations Lead in Allied Health at Toronto Western Hospital, says of the invitation last spring to participate in the six-month Leadership Accelerator for Clinical Leaders. “It all looked very relevant to my day-to-day work.”

ing Leaders, and works closely with Jessica Marangos, Senior Director, Talent and Learning, to set the future direction of UHN’s Leadership Strate-

gy. In the coming years, it will include new development programs for leaders at all levels in the organization, and an integration of the new UHN Leader-

ship Competency Framework into how UHN executes key recruitment, talent management and rewards processes and programs for leaders.

Continued on page 36

The Bridging Educational Grant in Nursing (BEGIN) program provides eligible Ontario bridging students with tuition reimbursements of up to $10,000 per year.

New enrollees can choose to work in four priority sectors:

Spaces are limited.

Apply today.

Hospitals, Primary Care, Long-Term Care or Home and Community Care.

Learn more at begin.werpn.com

*Eligible PSW-RPN students can receive a tuition and mandatory ancillary fee reimbursement of up to $6,000 per year (maximum of $15,000 over three years). Eligible RPN-RN/PSW-RN students can receive a tuition and mandatory ancillary fee reimbursement of up to $10,000 per year (maximum of $30,000 over three years). BEGIN participants who demonstrate financial need may also qualify for additional funding of up to $5,000 per year.

PROFESSIONAL DEVELOPMENT AND EDUCATION Continued from page 29

Virtual reality’s role GAINING CONFIDENCE THROUGH VR SIMULATIONS Through VR, nursing students can practice developing emotional intelligence and essential skills in empathy, communication, assessment, and intervention, both for evaluating care options and for delivering upsetting news about health status.

VR simulations can be customized to meet nursing curriculum and learning objectives with diverse patients across the lifespan with a wide array of conditions, from recognizing symptoms to selecting interventions and evaluating outcomes. VR encourages experimentation by allowing learners to hone soft communication skills – using verbal and non-verbal cues that convey empathy such as high-level listening, receptive body language, eye contact, honesty, clarity, and even purposeful silence – as well as hard skills like administering a Patient Health Questionnaire (PHQ-9) for depression screening, or the Gen-

eralized Anxiety Disorder (GAD-7) assessment, all in a safe and controlled environment.

For example, a nursing student may assess medication side effects for a child recently prescribed methylphenidate for treating ADHD and be required to tailor explanations to both the boy and his concerned mother. Other scenarios could require the nurse learner to evaluate and provide reassurance to a middle-aged man experiencing his first anxiety attack, or a young woman with worsening depression, or grief-stricken family members confronted with endof-life decisions for a parent. Within the simulation, the patient and companions ask realistic and emotional questions, challenging the learner to build their communication skills.

A 2023 Pennsylvania College of Technology study looked specifically at how full immersion VR simulation can help nurses gain confidence in their communication skills and feel more comfortable in dealing with anxiety-prone patients and improve their

MCC 360:a key part of quality assurance programs across the country MCC 360, a multi-source feedback and coaching program, helps physicians improve their communication, collaboration, and professionalism. The program gives physicians insights into their practice by providing feedback from those who matter most – their patients, colleagues and co-workers – and supports their development with one-on-one coaching.

Organizations across Canada, including hospitals and provincial colleges, are incorporating MCC 360 into their quality assurance programs because of the: • Insightful report collating qualitative and quantitative feedback collected from patients, colleagues, and co-workers for each physician • One-on-one coaching options that fit respective organizational needs and help physicians constructively understand the feedback and build an action plan • Dedicated, bilingual customer service to support the program, administrators and participants • Research behind MCC 360 and its status as a Health Standards Organization Leading Practice Eighty percent of participants self-reported in a survey that they made practice changes based on the feedback and coaching. Through the program, physicians also earn CPD credits from the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada. MCC 360 offers organizations meaningful, in-practice assessment and support of physicians to further develop their CanMEDS roles, which have been shown to improve patient outcomes. Learn more at www.mcc.ca/mcc360

own self-care techniques. Being able to review performance, receive real-time feedback on both wording and tone and delivery, and continue to practice is essential in building confidence for nurses to feel better prepared for therapeutic communications and, ultimately, avoid burnout.

CULTIVATING COMPASSION THROUGH VR Virtual reality is paving the way for more compassionate and patient-centered healthcare. New research out of Taiwan even concludes that virtual reality communication simulations “should be arranged as early as possible in fundamentals of nursing practice courses.”

Couldn’t we all benefit from improving our ability to navigate difficult con-

versations and become more confident in asking people about their feelings – and explaining our own? After nearly every incident of mass violence, we hear that the perpetrator exhibited warning signs of instability. Unfortunately, those in close proximity often lack the knowledge or skills to manage such indicators, while the sufferer may fear repercussions for seeking treatment.

Enhancing communication regarding anxiety, grief, and drug use could contribute to a better world, similar to how individuals acquire skills in cardiopulmonary resuscitation (CPR), the Heimlich maneuver, and administering naloxone for opioid overdoses.

VR simulations offer this potential for no-risk practice in recognizing danger signals and facilitating open discussions about problems and issues – and H revealing solutions. ■

Christine Vogel, MSN, RN, CHSE, CHSOS, is a lead nurse educator at UbiSim (www.ubisimvr.com), where she is actively engaged in designing, piloting, and evaluating evidence-based immersive virtual reality (VR) simulations for nurse learners. Her career spans more than 25 years in the field of nursing, including over 12 years of experience within nursing academia. She may be contacted via email at christine. vogel@ubisimvr.com.

Continued from page 34

Leadership program “Our aim was to provide participants with an experience that would equip them with essential leadership skills that can be put into practice right away, whether as an individual contributor or as a leader,” Alyssa says.

Alyssa says one of the great aspects of the program was the ability for participants to connect – and re-connect – with each other in the in-person sessions, which were a shift from the virtual world everyone has grown so accustomed to over the course of the pandemic.

“The energy in those sessions was truly rewarding to see, and as we look towards future programs, we recognize the value that those connections bring,” Alyssa says.

Linda and Sarah say completing the program has strengthened their connection and commitment to UHN.

Both add that it was invaluable to meet and work with colleagues from other health professions and different sites across the organization, relationships that will be beneficial on the leadership path.

“I’ve built a lot of relationships at UHN that make me want to stay here,” Sarah says. “This program fostered those relationships and built new ones, and it’s opened my mind to different ways of thinking, different ways to lead.”

Linda says the program is “worth every minute of your time” because it lets you study different leadership skills and styles, something that she found very aspirational.

“It reinforces why I’ve been with UHN for this many years,” Linda says.

“It shows that the organization values people and will invest in them to be H the best they can be.” ■

This article was submitted by UHN News.

36 HOSPITAL NEWS JANUARY 2024

www.hospitalnews.com

LONG-TERM CARE NEWS

First-of-its-kind network supports faster adoption of technology in long-term care he Coordinated Accessible National (CAN) Health Network, a leading national initiative focused on accelerating Canadian innovation in health care, announced the launch of its Long-Term Care Innovation and Scaling Network. This new network, led by Ottawa-based Bruyère, is designed to enhance the quality of life for long-term care (LTC) residents and operators, by introducing innovative, Canadian-made technology solutions to address LTC’s most pressing challenges.

The CAN Health Network is a federally funded organization that works directly with the country’s leading health care operators (referred to as Edges) to identify their biggest challenges and match them with Canadian-made technology solutions. It provides Canadian companies with access to real health care environ-

T

“THIS PARTNERSHIP HAS SIGNIFICANT POTENTIAL TO ENHANCE THE CARE EXPERIENCE FOR THE MORE THAN 200,000 CANADIANS THAT CALL LTC HOME AND THEIR LOVED ONES.” ments where they can implement their market-ready solutions, gain valuable feedback from end-users, and scale across the Network and beyond.

Bruyère, a founding Edge in the CAN Health Network, is a large health care employer providing specialized hospital and long-term care in Ottawa. Bruyère will lead the CAN Health LTC Innovation and Scaling Network, bringing proven Canadian technology solutions to the more than 2,000 LTC homes in Canada.

Canadian companies working with the CAN Health Network will now

be able to bring their solutions faster into long-term care homes that need them most.

The global pandemic highlighted several challenges facing the health care sector, including in long-term care: from staffing shortages, infection control, and PPE, to funding constraints and rising acuity of residents.

“The Can Health Network, by creating connections between Canadian companies with proven solutions and Canadian LTC homes, enables us to play an important role in addressing the challenges facing long-term care,”

said Guy Chartrand, President, and CEO, Bruyère.

“This partnership has significant potential to enhance the care experience for the more than 200,000 Canadians that call LTC home and their loved ones.” “The launch of the longterm care network is a major milestone for the CAN Health Network, and further builds momentum for Canada to lead the new health care economy,” said Dr. Dante Morra, Chair, CAN Health Network. “Through this partnership with Bruyère, one of our leading Edges, we will introduce top Canadian solutions to LTC to address some of its most pressing challenges and support Canadian companies by helping them scale these solutions across the country.”

The CAN Health Network is powered by its Edges – 31 leading health care organizations across the country.

Since its inception in 2019, the CAN

UPCOMING EDITIONS FEBRUARY 2024

MARCH 2024

APRIL 2024

FEBRUARY FOCUS: Gerontology/ Alternate Level of Care/Rehab/Wound Care/Procurement:

MARCH FOCUS: Facilities Management and Design/Health Technology/Greening Healthcare/Infection Control:

APRIL FOCUS: Healthcare Transformation/ eHealth and EHR/Mobile Health:

Geriatric medicine, aging-related health issues and senior friendly strategies. Best practices in care transitions that improve patient flow through the continuum of care. Rehabilitation techniques for a variety of injuries and diseases. Innovation in the treatment and prevention of wounds.

Innovative and efficient healthcare design, the greening of healthcare and facilities management. An update on the impact of technology , including robotics and artificial intelligence on healthcare delivery.

Advancements in infection control in hospital settings.

Annual Wound Care Supplement

Annual Infection Control Supplement

Advertising Booking Deadline January 26th Material Deadline January 30th For more info email advertising@hospitalnews.com

Advertising Booking Deadline February 23rd Material Deadline February 27th For more info email advertising@hospitalnews.com

38 HOSPITAL NEWS JANUARY 2024

Programs and initiatives that are transforming care and contributing to an effective, accountable and sustainable system including virtual care. Innovations in electronic/digital healthcare, including mHealth and the Electronic Health Record (EHR).

Annual E-Health Supplement & Special Focus Anesthesiologists

Advertising Booking Deadline March 22nd Material Deadline March 25th For more info email advertising@hospitalnews.com

www.hospitalnews.com

LONG-TERM CARE NEWS

Health Network has completed 54 commercialization projects, with 48 innovative Canadian companies.

“We are proud to work with the country’s leading health care providers, that include long-term care homes and home care,” said Dr. Morra. “As these Edges run commercialization projects with top technology solutions, that success can now be shared and scaled across the long-term care network.”

The CAN Health Network recently welcomed the Yukon Hospital Corporation as its latest Edge, which will bring cutting-edge health technology to the Yukon, and improve access to care for remote communities. To learn more about the CAN Health LongTerm Care Innovation and Scaling Network, visit: https://canhealthnetwork.ca/innovation-and-scaling-netH work. ■

www.hospitalnews.com

JANUARY 2024 HOSPITAL NEWS 39

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