2020 Nursing Week BPG Sustainability Virtual Poster Gallery

2020 Nursing Week BPG Sustainability Virtual Poster Gallery

Thank you to the 2020 BPG Nurse Champions!

• • • • • • • • • • • •

Ashnit Chhina, RN, Cath Lab – Cardiac Investigation Unit Guia Hernandez, RN, TNICU Lisa Manswell, RN, Perioperative Services Jacqueline Kong, RN, General Surgery, Gastro, ACS and Plastics Sunhee Jang, RN, CICU Jenelle Farrow, RN, TNICU Natalia Escalante Solana, RN, CICU Katherine Edmond, RN, Community Mental Health Services –FOCUS Program Elaine Selby, RN, Perioperative Services Winnie Leung, RN, Community Mental Health Services –STEPS Program Travis Edwards, RN, Inpatient Mobility Arpita Madan, RN, Inpatient Mobility

• Stephanie Rioux, RN, General Internal Medicine • Michael Panzarella, RN, Community Mental Health Services – Community Connections Program • John Edwards, RN, Trauma and Neurosurgery • Sabrina Parker, RN, Trauma and Neurosurgery • Domenic Tavares, RN, Oncology • Laxmi Devi, RN, Respirology • Caroline Vizl, RN, Respirology • Chris Carless, RN, Cardiology • Tsetan Dolkar, RN, Cardiology • Victoria McLean, RN, Palliative Care • Aysha Siddiqa Patel, RN, Palliative Care • Carla Gomez, RN, Inpatient Mental Health • Daniel Agbuis, RN, MS ICU

Building Confidence in eDocumentation Ashnit Chhina RN, BScN, MN Cardiac Catheterization Lab, St. Michael’s Hospital Recovery Destination

FOCUS • •

Facilitate the transition from paper to electronic nursing documentation in the Cardiac Catheterization Lab The Registered Nurses Association of Ontario’s (RNAO) Best Practice Guideline (BPG): Adopting eHealth Solutions: Implementation Strategies (2017) • Recommendation 1.10: Engage all stakeholders, • Recommendation 1.12: Prioritize efficiencies and user satisfaction • Recommendation 1.13: Comprehensive training

• •

•

Home

PURPOSE & OBJECTIVES The purpose of the BPG is to increase confidence in a new eDocumentation system among nurses in the Cardiac Catheterization Lab by: • Identifying areas of concern related to eDocumentation among nurses through a pre-survey • Implementing evidence-based interventions that address concerns raised by staff in the pre-survey

1. Identifying Nurse Champions • Three Superusers: received extra training in order to mentor colleagues during transition 2. Staff Engagement • TOA Working Group: Three Superusers and Recovery Room nurse 3. Process Planning • Workflow maps with staff pre-training and post-training 4. Hands-on Learning • Mock scenarios • Opportunities for additional training

Nursing Notes

Nursing Notes

XPER TOA Form

Prescription

Prescription

CARAT

Coronary Artery Diagram

Nursing Notes (if applicable)

Nursing Notes (if applicable)

Intraprocedure Record Inpatient Unit

XPER TOA Form Case Report Purple TOA Sheet (if provided)

Purple TOA Sheet (if provided)

Nursing Notes

Nursing Notes

Intraprocedure Record

XPER TOA Form

Case Report

Case Report

CD

CD

CARAT

Coronary Artery Diagram

MD Order Sheet

MD Order Sheet

Orange TOA Sheet

Orange TOA Sheet

Intraprocedure Record

XPER TOA Sheet

Case Report

Case Report

Cath Lab (Rm 1 & 2)

Other Hospital

CICU

Figure 1: Process planning; workflow map created during a group exercise

Figure 2: Comparison of current and new documentation using workflow map created through a collaborative staff effort The new eDocumentation system will increase efficiency in documentation.

The new eDocumentation system will increase the quality in patient care.

I am confident in my ability to accurately document during adverse events.

100%

100%

100%

90%

90%

90%

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INTERVENTION/ PROCESS

*NEW* Room 3 Documentation

Case Report

CIU (Recovery Room)

The Cardiac Catheterization Lab is in the process of implementing a new electronic nursing documentation system.

The current practice for nurses is paper documentation.

There will be a hybrid phase during the transition from “paper-only” to “electronic-only” as the new eDocumentation system is being implemented in each care area of the unit one at a time.

Through a literature review and an environmental assessment, the following concerns about the implementation of the new hybrid eDocumentation were: • Impact on Transfer of Accountability (TOA) • Time spent on documentation • Ease of use of the new system • Emergency scenarios

Current Documentation

Intraprocedure Record

BACKGROUND •

Post-Recovery Destination

0% Strongly Agree

Agree Pre-Interventions

Disagree Post-Interventions

Strongly Disagree

0% Strongly Agree

Agree Pre-Interventions

Disagree

Strongly Disagree

Strongly Agree

Post-Interventions

Agree Pre-Interventions

Disagree

Strongly Disagree

Post-Interventions

Figure 3: Pre- and post-intervention survey results that address concerns raised by staff with regards to eDocumentation

RESULTS • The response rates for pre- and post-interventions were 92% and 80%, respectively.

• There was a 22% increase in staff agreeing/strongly agreeing that implementation of the new system will improve efficiency in documentation.

• Upon completion of interventions, 89% of staff agreed that the new eDocumentation system will have a positive impact on the quality of patient care. Prior to the interventions, 58% agreed/strongly agreed that there will be an improvement in the quality of patient care.

• For emergency situations, 89% of staff agreed that they felt confident in documentation post-intervention, a 22% increase in comparison to the preintervention results.

• Both pre- and post-intervention, the mean, median and mode showed staff disagreed that the new eDocumentation system will increase workload.

• As per the mean, median and mode, staff agreed that their opinion was valued during the implementation of the new eDocumentation both preand post-intervention.

CONCLUSION • Staff expressed increased understanding of workflows and TOA during posttraining process planning session in comparison to pre-training session.

• Involving staff in activities including creation of workflow map and mock scenarios led to a more positive attitude towards the new eDocumentation system as verbally expressed by staff.

• A high staff turnover and anonymity created limitations of: • Inconsistency in the pre and post survey respondents • New staff unable to reflect on workflow impact

RECOMMENDATIONS/ NEXT STEPS • Continue to engage staff with feedback of hybrid documentation • PDSA cycles of workflow maps with staff during each phase of the transition (i.e. as each area of care transitions from paper documentation to eDocumentation)

REFERENCES Bani‐issa, W., et al. (2016). "Satisfaction of health-care providers with electronic health records and perceived barriers to its implementation in the United Arab Emirates." International Journal of Nursing Practice (John Wiley & Sons, Inc.) 22(4): 408-416.

Dunn, K. (2017). "Nursing Informatics Competency Program." Nursing Informatics Competency Program: 1-1.

George, N. M., et al. (2016). "Enhancing Prelicensure Nursing Students' Use of an Electronic Health Record." Clinical Simulation in Nursing 12(5): 152-158.

Nation, J. and V. Wangia-Anderson (2019). "Applying the Data-KnowledgeInformation-Wisdom framework to a Usability Evaluation of Electronic Health Record System for Nursing Professionals." Online Journal of Nursing Informatics 23: 1-1.

Registered Nurses Association of Ontario (2017). Adopting eHealth Solutions: Implementation Strategies. Toronto, ON: Registered Nurses Association of Ontario.

Schenk, E. C., et al. (2016). "RN Perceptions of a Newly Adopted Electronic Health Record." Journal of Nursing Administration 46(3): 139-145.

ACKNOWLEDGEMENTS My sincerest thank you to: All Cath Lab Staff Emily Kennedy, Clinical Nurse Educator Cardiac Catheterization Lab Kim Boswell, Clinical Leader Manager Cardiac Catheterization Lab Vanessa Durante, Corporate Nursing Education Manager

Start of Shift Huddles Guia Hernandez, RN Trauma Neuro Intensive Care Unit FOCUS The Start of Shift Huddles focuses on Wellness Activities to improve nursing well-being.

The Start of Shift Huddles aligns with the RNAO Best Practice Guideline: Healthy Work Environment: Workplace Health, Safety and Well-being of the nurse.

BACKGROUND

INTERVENTION/ PROCESS WHO •

All available staff including RN’s, CA’s, Clerical, RT’s & MD’s (optional)

WHAT •

Give staff a synopsis of what is the current state of TNICU

WHERE •

Nurses Station preferred

As indicated in the RNAO Healthy Work Environments Best Practice Guidelines, there is a need for a re-establishment of a sense of ‘holistic nursing’ practice and when there is a shared responsibility, this will facilitate the changes needed to help nurses achieve the necessary gains.

Based on a TNICU Staff engagement survey, psychological safety and workload stress drivers were ranked in the lower range A survey conducted in October 2019 for the purpose of this BPG indicated that morale was neutral.

• •

The Institute for Healthcare Improvement developed a Framework for Improving Joy in work.

A focus on joy is a step towards creating safe, humane places for people to find meaning and purpose in their work. This framework identified huddles as a time where teams could create ‘joy’ or pause for a ‘joyful’ moment.

PURPOSE & OBJECTIVES The overall aim of the Start of Shift Huddles is to: • Empower staff to have a voice • Help improve psychological safety • Increase staff communication and quality of information sharing • Create efficiencies • Increase staff accountability • Create a culture of collaboration and collegiality and a sense of community • Improve team and staff morale

WHEN • •

0750 hrs. &1950 hrs.

After receiving report and prior to visitation

HOW •

•

•

The charge nurse or clerical staff announce the start of shift huddle.

When everyone present, CN uses SHIFT HUDDLE TEMPLATE to conduct huddle If huddle warrants further discussion, information directed to CLM

RESULTS

CONCLUSION

• Initial feedback from Start of Shift Huddles is positive • More results will be determined after post- survey completed WHAT THE TEAM IS SAYING…

Huddles allow staff to be aware of issues, unit needs, and also recognize staff with their peers present. It is an effective management tool, one that can be used by staff to understand how things are working, and make quick changes to address issues or forestall potential problems.

“Start of shift huddles will be a great opportunity to bring the team together, give everyone the chance to feel involved and be a fun way to start the day! Can’t wait for them to begin!”

We work long hours, performing physical and emotional duties with focus on others. We should take 5-10 minutes out of our 720 minute shift to empower and focus on ourselves.

“ This BPG is great for communication especially during COVID, when communication constantly changes and staff need updates.”

Ultimately, even though finding time is challenging - huddles have proven to be valuable and beneficial for staff and patient care.

“With an ever changing patient load, it’s nice to know what the plan is for the shift going forward allowing us RTs to have proper equipment readily available as our department isn’t located near the ICU.”

RECOMMENDATIONS/ NEXT STEPS

Start of Shift Huddle Template

• Develop education session for staff and display reminders in the unit to attend the huddles.

• Engage the unit-based council to promote start of shift huddles • Continue to collect feedback on areas of strengths and needs of improvement • Conduct post-survey to measure changes in staff morale

REFERENCES

Barriers & Limitations • Acuity of unit and staff availability • Untimely admissions • Main focus of huddle is lost • Lack of interest

• Goldenhar, L.M., Brady, P.W., Sutcliffe, K.M. & Muething, S.E.( 2013).

Huddling for High reliability and situation awareness. BMJ Qual Saf. 22:899-906. doi:10.1136/bmjqs-2012-001467 • Halo Psychology (2019). Retrieved from https://www.halopsychology.com/2019/08/05/how-to-reap-thebenefits-of-psychological-safety.

• Kang, S. J. & Min, H.Y. (2018). Psychological Safety in Nursing Simulation. Nurse Educator. Vol.44.No 2. pp E6-E9.

• Perlo,J., Balik, B., Swensen, S., Kabcenell,A., Landsman, J., & Feeley, D. (2017). IHI Framework for Improving Joy in Work. Cambridge, Massachusetts: Institute for Healthcare Improvement.

• Shermont, H. et al. (2008). Meeting of the minds. Nursing Management.

39(8),38-44

ACKNOWLEDGEMENTS Elizabeth Butorac, Clinical Leader Manager, TNICU Maija Shannon, Resource Nurse, TNICU Caitlin Stanton, Resource Nurse, TNICU Susan Beswick, Evidence Based Practice Nursing Manager, Professional Practice

Increasing Health & Wellness Support in the Surgical Daycare Unit Lisa Manswell, RN, BScN, PAN (c) Surgical Daycare Unit, St. Michael’s Hospital

FOCUS This initiative focused on the following recommendations from the Workplace health, safety and wellbeing of the nurse, Best Practice Guideline (BPG): Recommendation 3.3: • Promote and support initiatives related to the physical, mental health and well-being of the nurse.

Recommendation 3.4: • Organizations/nursing employers provide nurses with opportunities for personal, professional and spiritual development with regard to healthy work environments, professional competencies and work/life balance.

Recommendation 4.1: • Organizations/employers engage in knowledge transfer activities that promote best practices regarding the health, safety and wellbeing of nurses.

BACKGROUND

INTERVENTION/ PROCESS ü Pre intervention Survey : 8 questions • Focused on staff perception of healthy work environments, current perception of health and wellness support in the unit and awareness of organizational resources available to support their personal health and wellness.

NEXT STEPS

RESULTS The following graphs illustrate both pre and post intervention survey results completed by the Surgical Daycare Unit team. The overall survey response rates were 90% (pre) and 84% (post).

Healthy Work Environments

ü Facilitated in-unit education huddles raising awareness of the importance for creating a healthy work environment, the benefits and impact on perioperative staff, patients and the organization.

Sustainability

ü Endorsed organizational resources offered to support employees’ own personal health and wellness including: • Workplace wellness website (SMH intranet) • Employee and Family Assistance Program (EFAP) • Annual resiliency workshop

"With all the new strategies, health & wellness is now at the forefront in the unit."

CONCLUSION

76%

• Staff were unaware or not sure of the organizational resources available to support their own health and well-being.

• Participated in health and wellness initiatives.

• Nurses and support staff were interested in participating in unit-based health and wellness initiatives. ü Post intervention Survey: 7 questions

• To engage nurses and interprofessional team in several unit specific activities, to promote health and wellness in Surgical Daycare (SDC).

• To increase awareness of organizational resources available to support staff's personal health and wellness.

• Adopt unit-based wellness champion(s).

• Integrate SMH wellness coordinator.

ü Developed and implemented various unit initiatives to promote health and wellness in the workplace based on areas of interest disclosed in the pre intervention survey.

• The team felt that their health and wellness were not supported at work.

• To increase staff perception of health and wellness support in the workplace by 5 %.

• Continue promoting health and wellness activities for staff in the Surgical Daycare Unit.

• Transition BPG communication board into a workplace wellness board.

• The Day Surgery Unit team work in a busy and fast paced environment, managing high patient flows throughout the O.R., Interventional Radiology and Lithotripsy Units.

PURPOSE & OBJECTIVES

• Maintain concept of healthy work environments in Surgical Daycare and Perioperative Units.

•

To evaluate efficiency of knowledge transfer from education huddles.

•

Measure effectiveness of wellness initiatives.

•

Reassess staff perception of health and wellness support in the Surgical Daycare Unit.

92%

26%

• Are now aware of the organizational resources available to support their personal health and wellness.

• Increase in staff perception of health and wellness support in the Surgical Daycare Unit based on pre and post intervention surveys.

“The water challenge tracker card fits into my ID badge sleeve, which is easy to keep track of how many cups of water I’m drinking at work.”

"I loved all the activities and the prizes made things exciting."

ACKNOWLEDGEMENTS I wish to thank the Surgical Daycare Unit team for their positivity, support and enthusiasm during this BPG. Susan Beswick – Professional Practice Mentor Vasuki Paramalingam – CLM Wendy Legacy & Lory Lee – Unit Mentors

REFERENCES Carpenter, H., & Dawson, J. M. (2017). Evaluating perioperative nurses health, safety, and wellness. AORN Journal, 105(3). doi: 10.1016/s0001-2092(17)30116-3.

Registered Nurses’ Association of Ontario (2008). Healthy Work Environments Best Practice Guidelines: Workplace Health, Safety and Well-being of the Nurse: Toronto, Ontario.

Registered Nurses’ Association of Ontario (2011). Healthy Work Environments Best Practice Guidelines: Preventing and Mitigating Nurse Fatigue in the workplace: Toronto, Ontario.

Promoting a Positive Team Environment Through Knowledge of Effective Conflict Management Strategies Jacqueline Kong RN, BScN INTERVENTION

RESULTS

CONCLUSION

The purpose of this initiative is to promote and nurture a positive workplace culture through education on conflict management. Understanding the importance of personal conflict management styles and emotional intelligence were key factors in the success of this intervention.

Stage 1: Engage Self-Reflection Stage 2: Recognize Personal Conflict Management Styles Stage 3: Introduce Conflict Management Strategies Stage 4: Post-Intervention Reflection

Nurses completed the Workplace Interpersonal Conflict Scale before and after the intervention period.

BACKGROUND

Figure 2. TKI model looks at a person's level of assertiveness and cooperativeness when faced with conflict.

Pre-Intervention Conflict Score:

37.3 pts

Post-Intervention Conflict Score:

31.5 pts

It is important to recognize that conflict management strategies are circumstantial. Researchers have suggested that styles can be affected by levels of education, employment seniority, and the culture of a department (Başoğul and Özgür, 2016). On 16CCN, there is a fluidity of assertiveness and cooperativeness that allows nurses to adjust their styles depending on the situation. Most nurses self-report “collaboration” and “compromise” as their styles of choice. Staff were receptive to education and skill building that benefitted both their work and personal lives.

”

Under the stresses of a high-acuity workplace environment, it is important that individuals communicate effectively. Teamwork and collaboration is an ongoing process that requires effort and maintenance. Best patient care and professional development can be achieved through continuous sharing and application of new knowledge. Conflicts may be uncomfortable, but they are a natural part of our relationships. Understanding how to manage these interpersonal conflicts bolsters the capacity for staff to collaborate harmoniously.

OBJECTIVE Aim: Enhance staff knowledge on communication skills Measures: • Workplace Interpersonal Conflict Scale (WISC) • Wong & Law Emotional Intelligence Scale (WLEIS) • Thomas-Kilmann Instrument (TKI) Figure 1. Canadian's Approach to Conflict. Illustrates the 5 different conflict styles described by Thomas and Kilmann.

Competing

Collaborating

Compromising

Unassertive

“

It is not if we will have conflict, but how we deal with it.

Assertive

FOCUS

Avoiding

Accommodating

Note: A conflict score of zero is optimal in the ideal world.

Styles of 16CCN Nurses: Compromising 30% Avoiding 11% Collaborating 34% Accommodating 23% Competing 2%

RECOMMENDATIONS

16% improvement in perceived interpersonal conflicts Figure 4. “How often did you have a disagreement over your work?”

Results from one of the six WISC questions.

Never Uncooperative

Cooperative

Talk Conflict with O.B.E.F.A.

Opening – “I want to talk about…”

Behaviour – “When you do…”

Effect – “This happens…”

Feelings – “It makes me feel…”

Action – “What can we do to resolve this together…?” ~ Remember to Listen ~

Encourage open communication between staff Promote self-reflective exercises Have a neutral party available to mediate more difficult conversations Run simulations on an on-going basis to explore conflict management strategies

ACKNOWLEDGEMENTS

Almost Never

Education sessions included: • Discussion on staff survey findings and feedback • A personal assessment using the Thomas-Kilmann Instrument • Exploration of the five factors of Emotional Intelligence: self-awareness, self-regulation, social skills, empathy, and motivation • Utilization of I-statements through O.B.E.F.A. • A personalized lanyard card Figure 3. Front and back side of a lanyard card that staff received after their second education session.

This card reflects the “Avoidance” style, one of five personality styles.

• • • •

Style: The nonconfrontational approach.

Sometimes Often Very Often

Pre-Intervention

REFERENCES

Post-Intervention

Algonquin College of Applied Arts. (n.d.). MODULE FOUR: Dealing With Conflict. Retrieved from https://www.algonquincollege.com/healthandcommunity/preceptorship/module-four/module-fourdealing-with-conflict/

Figure 5. “I have a good understanding of my own emotions.”

Results from one of the 16 WLEIS questions.

On a scale of 1 (strongly disagree) to 5 (strongly agree).

Başoğul, C., & Özgür, G. (2016). Role of emotional intelligence in conflict management strategies of nurses. Asian nursing research, 10(3), 228-233.

Pro: Low stress. Good for de-escalating conflict. Gives the ability to focus on more important or urgent issues.

Managing and Mitigating Conflict in Health-care Teams. (2012). Retrieved from https://rnao.ca/bpg/guidelines/managing-conflict-healthcare-teams.

Psychometrics. (n.d.). Making Conflict Management a Strategic Advantage. Retrieved from http://psychometrics.com/conflict/

Con: Low assertiveness and dependability. Problems can fester and eventually worsen.

TIPS • Set priorities and delegate.

• Ask yourself… Are you “walking on eggshells”?

• Will postponing make matters worse?

Thank you to the staff of 16CCN Katherine Mansfield, Nurse Educator and Unit Mentor Susan Beswick, Evidence Based Practice Nursing Manager Joanne Bennett, Clinical Leader Manager

Thomas, K. W. (2008). Thomas-kilmann conflict mode. TKI Profile and Interpretive Report, 1-11.

Wong, C. S., Wong, P. M., & Law, K. S. (2007). Evidence of the practical utility of Wong’s emotional intelligence scale in Hong Kong and mainland China. Asia Pacific Journal of Management, 24(1), 43-60.

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2

3

Pre-Intervention

4

Post-Intervention

5

Wright, R. R., Nixon, A. E., Peterson, Z. B., Thompson, S. V., Olson, R., Martin, S., & Marrott, D. (2017). The Workplace Interpersonal Conflict Scale: An Alternative in Conflict Assessment. Psi Chi Journal of Psychological Research, 22(3).

Enhancing Interprofessional and Interdepartmental Capacity for Patients Experiencing STEMI: Leveraging the Role of the CICU Sunhee Jang, RN Cardiac Intensive Care Unit

FOCUS Enhancing Interprofessional and Interdepartmental Capacity for Patients Experiencing STEMI: Leveraging the Role of the CICU RN

BACKGROUND Currently there is varying practices in the Code STEMI activation and response process.

Nurses have identified a lack of confidence in initiating the activation call between EMS and the Cath Lab Interventionalist. The CICU RNs receive call from EMS or the sending facilitating with possible Code STEMI patients. The CICU RN patches the EMS call to the Interventionalist via a 3way call. The CICU RN listens to call and takes down details.

The Interventionalist will decide if the call is a Code STEMI and will indicate whether the RN should activate the Code STEMI team. CICU RNS have expressed concerns about possible trouble shooting any issues that may arise during these calls.

CONCLUSION

INTERVENTION/ PROCESS

RECOMMENDATIONS

RESULTS Four different confidence levels were combined into two separate groups. No/ slight confidence was the first grouping and moderate/ high confidence was the second grouping. The change in number of respondents who reported a moderate/ high confidence level to each question was measured from the pre- to the post-intervention survey.

The CICU nursing staff have varying years of experience; some have previous experience in the Cath lab environment while others do not. Different levels of experience has led to varying practices in how CICU RNs assist in the Cath lab.

CICU Code STEMI PRE/POST Survey

PURPOSE & OBJECTIVES The purpose of this BPG Initiative is to: 1. Standardize practices in the Code STEMI activation and response process.

2. Increase the comfort and confidence level of all CICU RNs in initiating the 3-way patch through with the Cath lab, EMS and/or ED teams.

3. Support understanding of the CICU RNs roles and responsibility during all components of a Code STEMI.

The initial goal was to improve nurses confidence by 10% on each question after intervention. A total of 6 mock Code STEMIs were performed. Through the post survey, it is clear that CICU RNs’ confidence level has increased in all domains. The results indicate that more training and practice is required to increase nurses confidence in trouble shooting technology during a Code STEMI activation. Overall, the results show that CICU RNs’ level of confidence has increased across all domains through the use of simulation.

• Simulation scenarios of potential Code STEMI phone calls were created using real examples and situations provided by experienced CICU nurses • Simulated a total of 6 mock Code STEMI calls in CICU which included in-the-moment education as questions arose as well as a debrief at the end of each simulation • Key participants in the simulations were less experienced CICU nurses • A total of 20 RNs participated in mock Code STEMI simulations

No confidence

Slight Confidence

Moderate Confidence

High Confidence

Pre

Post

Pre

Post

Pre

Post

Pre

Post

2. How confident do you feel when connecting 3 way calls (Interventionalist/RN/EMS) for a Code STEMI during the day shift?

13%

5%

33%

5%

25%

50%

29%

40%

3. How confident do you feel when connecting 3 way calls for a Code STEMI during the night shift?

25%

5%

21%

20%

33%

40%

21%

35%

4. How Confident do you feel when contacting the Cath lab 13% staff once 10% a 17% Code STEMI 5% activated?

29% 35%

42%

50%

5. How confident do you feel when trouble shooting during a Code STEMI activation? (i.e. dropping a phone call, unable to contact Cath lab staff, clarifying the Code STEMI protocol with the ED staff or residents, etc)

38%

15%

13%

30%

29%

20%

21%

35%

6. How confident do you feel when communicating directions to EMS staff (PCP or ACP)?

21%

5%

21%

30%

21%

35%

38%

30%

8%

5%

33%

15%

25%

50%

33%

30%

7. How confident do you feel with completing the current Code STEMI worksheet?

Question 2 shows the most improvement indicating that nurses felt more confident connecting the 3 way call between the Interventionalist, EMS and the nurse. Similarly, after the simulations, 75% of nurses reported feeling confident connecting 3 way calls for a code STEMI during the night shift. This 21% increase demonstrates a true change in comfort since there are fewer colleagues available to support each other during a night shift.

Question 5 shows the least improvement, indicating that the simulations did not result in a large increase in nurses’ confidence trouble shooting during a code STEMI activation. It was found that, in order to improve in this area, more training is required as many nurses still do not feel comfortable with it.

Overall, it is shown that nurses experienced improved confidence level across all questions.

• Establish Code STEMI activation training for newly hired nurses to ensure sustainability.

• Maintain frequent communication with and between CICU and Cath lab nurses • Provide on-going training and simulations to maintain confidence and learn changes as the code STEMI policy is updated

REFERENCES Frishman, W. (2007). Strategies for Reducing the Doorto-Balloon Time in Acute Myocardial Infarction. Yearbook of Medicine, 2007, 341–343. doi: 10.1016/s0084-3873(08)70216-5 Welsh, R. C., Travers, A., Huynh, T., & Cantor, W. J. (2009). Canadian Cardiovascular Society Working Group: Providing a perspective on the 2007 focused update of the American College of Cardiology and American Heart Association 2004 guidelines for the management of ST elevation myocardial infarction. Canadian Journal of Cardiology, 25(1), 25–32. doi: 10.1016/s0828282x(09)70019-4

ACKNOWLEDGEMENTS Susan Beswick, Evidence Based Practice Nursing Manager, Professional Practice Michelle Williams, Clinical Leader Manager, CICU

Improving Communication in the TNICU between Nurses and Physicians in the After Hours Jenelle Farrow, RN, BScN FOCUS

INTERVENTION/ PROCESS

To identify gaps in communication in the TNICU between Nurses and Physicians, and to integrate tools to streamline and improve communication.

A pre-survey was conducted with staff, as well as small huddles and one on one conversations with Nurses and Physicians. With stakeholder input and feedback the following communication tools were created and implemented in January 2020. TNICU volunteers placed the Bedside Check-in sticker at the top of every flowsheet.

The After Hours Non-Urgent List was placed on a clipboard at the nurses station close to the Charge RN.

This initiative aligns with the RNAO Best Practice Guideline recommendations entitled: Developing and Sustaining Interprofessional Healthcare 10.0 Competent Communication 10.1 Organizations can support interprofessional care through enhanced communication by: a. Establishing effective communication processes and tools to support collaboration and communication teams b. Standardizing documentation and encouraging information sharing c. Create a culture that promotes regular formal and informal communication among team members

Bedside Check-in Completion 40% 35% 30% 25%

Feburary

20% 15%

28%

FIGURE 1

0% 0 of 3

PURPOSE & OBJECTIVES To develop after hours communication tools in the Trauma and Neurosurgery Intensive Care Unit.

• 3 points of bedside MD Check-In’s (~1600, ~2100, ~0630) with 60% compliance of 2 or more check in’s completed by June 1, 2020 • Implement an after-hours non- urgent list with 65% post survey result ‘somewhat’ or ‘very’ satisfied • Reduction of calls to on-call MD through the night related to non urgent issues as reported on post survey • 80% satisfaction with departmental communication in the 2020 Staff Engagement survey Bedside check-in’s prior to handover was a process not always happening.

The goal of a bedside check-in is to address issues, keep orders up to date, ensure effective and accurate information for TOA between Nurses and Physicians, and decrease order entry clean up for Physician on call.

1 of 3

2 of 3

3 of 3

Bedside Check-in Completion 40% 35% 30% 25%

FIGURE 2

March

20% 15% 10%

33%

35%

2 of 3

3 of 3

Bedside Check-in

21% 11%

5% 0%

Studies have shown: Effective communication and understanding of a patients treatment plan are crucial for successful implementation and completion of patient care.

To narrow the focus, we decided to concentrate on the after hours (~16000700) in the TNICU as resources during these times significantly decrease.

26%

• Send post surveys to RN’s and MD’s to gain insight on use and effectiveness of the After-Hours Non-Urgent list • Continue to highlight the availability and purpose of the list • Orient new staff on the Bedside Check-in sticker and focus on creating ‘checking in’ prior to handover and during night rounds an expectation • Continue check-in audits and provide updates during Safety Huddles • Follow up with results of 2020 Staff Engagement Survey and satisfaction with departmental communication

14%

5%

0 of 3

Inadequate or incorrect information jeopardizes patient safety and the continuity of care.

Bedside Check-in

32%

10%

BACKGROUND In the 2019 Staff Engagement Survey, departmental communication was identified as an area we would like to focus on improving in the TNICU. Although it was reported as 71.7% satisfaction, we felt that number could be higher.

RECOMMENDATIONS/ NEXT STEPS

RESULTS

1 of 3

February 2020: 58% of 2-3/3 check ins documented March 2020: 68% of 2-3/3 check ins documented exceeding target of 60% compliance k

Staff comments on the After Hours Non-Urgent List: “I really like that we have an informal communication tool to use for non-urgent issues!” RN “I like when the nurses use the non urgent list. It has helped reduce calls re: non urgent issues through the night” MD “I think the list is a really good idea. People have to utilize it more” RN

REFERENCES Anthony, M. K. and G. Preus. 2002. “Models of Care: The Influence of nurse Communication on Patient Safety.” Nursing Economics 20(5):209-15 RANO (2013) Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes. http://rnao.ca/sites/rnaoca/files/DevelopingAndSustainingBPG.pdf Sharma S, Hashmi MF, Friede R. Interprofessional Rounds in the ICU. [Updated 2019 Oct 11] In: SatPearls [Internet]. Treasure island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507776/

CONCLUSION

ACKNOWLEDGEMENTS

• Bedside check in audits showed that check in’s improved over the course of two month’s • It is beneficial to patient care and TOA to have the most up to date orders and any issues addressed- ensuring MD checks in at bedside before handover is paramount • Based on RN’s and MD’s feedback, they generally like the Non-Urgent list, but wish it was utilized more

A big thanks to: Dr. Uriel Trahtemberg, TNICU Maija Shannon, Resource Nurse, TNICU Elizabeth Butorac, Clinical Leader Manager, TNICU Susan Beswick, Evidence Based Practice Nursing Manager, Professional Practice

Compassionate End of Life Care in the CICU: Implementation of the 3 Wishes Program Natalia Escalante Solana RN, BScN, CCN(C) Cardiac Intensive Care Unit FOCUS

INTERVENTION/ PROCESS

To improve the resources available to support patients and families at end of life through the implementation of the 3 wishes program.

This project aligns with the following RNAO Best Practice Guideline: “Supporting and strengthening families through expected and unexpected life events”.

Nov 2019

• • • •

Conducted literature search Connected with stakeholders Posted engagement materials around the unit Adapted survey from the literature

Dec 2019

• • • •

Conducted pre-survey Analyzed results Created resource binder Created supply cart

Jan 2020

• Shared results of survey and gathered feedback • Began delivering in-service to RNs • Had first 3 wishes moment in the unit

BACKGROUND • Death in an ICU setting can be a dehumanizing experience resulting in depression, anxiety and post-traumatic stress disorder for surviving family members. In addition, it can lead to vicarious trauma and compassion fatigue in healthcare providers.

• RNs in CICU perceive they do not have the resources needed to support patients and families at end of life as evidenced by the survey conducted in the unit.

• Implementation of the 3 wishes program can provide nurses with resources to support patients and families during end of life.

• Informal interviews with family members and unit staff point at satisfaction with this initiative.

RECOMMENDATIONS/ NEXT STEPS • PDSA cycles to modify the 3 wishes resources available in the unit.

• Interventions to address communication skills and comfort level when addressing end of life wishes with patients and families.

• Targeting the barriers nurses encounter when asking patients and families about end of life wishes.

Feb 2020

Azoulay, E., Pochard, F., Kentish-Barnes, N., Chevret, S., Aboab, J., Adrie, C., ... & Fassier, T. (2005). Risk of post-traumatic stress symptoms in family members of intensive care unit patients. American journal of respiratory and critical care medicine, 171(9), 987-994.

• In-service for RNs continued • Changes to supply cart informed by RN feedback

PURPOSE & OBJECTIVES

RESULTS

• To implement the 3 wishes program as a nurse-led initiative in CICU.

The initial survey distributed in the unit had an 80% response rate (n=26).

• To explore potential barriers and facilitators to the implantation of this program.

CONCLUSION

REFERENCES

• The 3 wishes program has been shown to make the dying process more personal (3) and has a positive impact on nurses and physicians by facilitating meaningful end of life care.

• By implementing the 3 wishes program in CICU, we can offer resources for the RNs to better support patients and improve the quality of end of life care we provide.

RESULTS (CON’T)

Cook DJ, Swinton M, Toledo F, Clarke FJ, Rose T, Hand-Breckenridge T, Boyle A, Woods A, Zytaruk N, Heels-Ansdell D, Sheppard RD. Personalizing death in the ICU: The Three Wishes Project. Ann Intern Med 2015;163:271279. doi:10.7326/M15-0502

• Implementation of 3 wishes began in January. By February 75% of the RNs in the unit had received an in-service detailing how the 3 wishes program works and how to implement it in CICU. • 60% of the families who experienced death in CICU in February were offered 3 wishes.

• Some of the wishes carried out include thumb prints, photos and playing the patient’s favorite music.

Neville TH, Agarwal N, Swinton M, Phung P, Xu X, Kao Y, Seo J, Granone MC, Hjelmhaug K, Hainje J, Pavlish C, Clarke FJ, Cook DJ. Improving end of life care in the intensive care unit: Clinician’s experiences with the 3 Wishes Program. J Palliat Med 2019. doi: 10.1089/jpm.2019.0135 Sabo, B. (2011). Reflecting on the concept of compassion fatigue. Online journal of issues in nursing, 16(1).

ACKNOWLEDGEMENTS Michelle Williams, Clinical Leader Manager, CICU & CVICU

Photograph of patient holding his daughter’s hand. Taken February 2020

Involving persons in client centered care: Getting off to the right start Katherine Edmond, RN; Nicole Kirwan, Clinical Leader Manager; Madeline Ritts, RN Community Mental Health, The FOCUS team FOCUS

INTERVENTION/ PROCESS

• RNAO BBG: Person-and Family-Centred Care (2015) Recommendation 1.2: Build empowering relationships with the person to promote the person’s proactive and meaningful engagement as an active partner in their health care.

• How can we increase collaboration with our clients at FOCUS and empower clients to take and active role in care planning?

• How do interprofessional mental health clinicians engage clients after the client is admitted?

• How can interprofessional mental health clinicians establish person-centred care and promote recovery during the initial client contacts?

Client consultation in standardizing the intake meetings

-Client control

Degrees of client’s power

-Delegated power -Partnership

-Placation

Degrees of tokenism

-Consultation -Informing

BACKGROUND Home

New referral is assigned to clinician

Intake visit occurs at…

Community Inpatient unit Clinic

PURPOSE & OBJECTIVES

What’s happening during these visits

?

-Therapy

Literature review -client centered care planning

Increase reported staff confidence and incorporate principles of recovery orientated practice and person-centred care into all first visits with FOCUS clients.

Illicit client feedback on:

• Relevance of involvement in their care • Experience of first visit with the FOCUS team

No power

-Manipulation

Client Interviews (9)

RECOMMENDATIONS/ NEXT STEPS

RESULTS

Focus groups (2) with case managers (13)

Second literature review -Client intakes

• Two Focus groups with clinicians, total of 13 staff participated • Nine client interviews “I will let the client kind of decide where “I didn’t hear a the conversation will judge or a lawyer go” and I am on this -Clinician “build CTO” trust” (community “To have the client -Clinician treatment order) have the -Client information is “essentially like client centered” my production -Clinician manager” “I needed a big -Client help at that moment and I was like suffocating.”

-Client

“I didn’t like to be told to take medication” -Client

“work as a team and hope to work together” -Clinician

CONCLUSION • Overall, clients reported a positive experience.

Process measures:

Long term

• Identify key messages to be communicated to all newly referred clients • Develop process map for new intakes to the team • Develop intake materials requested by staff

• Create training session emphasizing client centered care and recovery orientated practice • PDSA cycle following a client’s experience with intake process

• Provide a booster training session three months after the first session.

• Create a competency based assessment for a simulation new intake visit.

REFERENCES

• Clinicians/Case managers expressed feelings of uncertainty around the new intake procedure • Staff incorporated person-centered care principles into their practice during new intakes

Ottawa Charter for Health Promotion: First International Conference on Health Promotion Ottawa, 21 November 1986. Retrieved from https://www.healthpromotion.org.au/images/ottawa_charter_hp.pdf

Key success factors were:

Mental Health Commission of Canada. (2015). Guideline for Recovery Orientated Practice. Retrieved from https://www.mentalhealthcommission.ca/sites/default/files/201607/MHCC_Recovery_Guidelines_2016_ENG.PDF

• Case managers having the chance to compare approaches and learn from each other • Gleaning valuable client feedback about their intake experience Insights:

Next Step: Develop education session

Short term

Grim, K., Rosenberg, D., Svedber, P., & Schon, U.K.,(2016). Shared decision-making in mental health care –A user perspective on decisional needs in community-cased services. International journal of qualitative studies in health and well-being 11 30563.

10.3402/qhw.v11.30563

• Case managers were doing better than they thought they were.

• Number of clinicians that attend focus groups • Number of clients interviewed

Immediate

• Clients recognized when their initial intake wasn’t ideal, and reflected on their role in the process.

Registered Nurses Association of Ontario. (2015). Person-and Family Centred Care.

Retrieved from https://rnao.ca/bpg/guidelines/person-and-family-centred-care.

ACKNOWLEDGEMENTS With gratitude and appreciation to: Madeline Ritts, team lead Nicole Kirwan, Clinical Leader Manager Murray Krock, Director, Nursing Practice and Education.

This project would not have been possible without the support and participation of the FOCUS team staff and clients. Thank you!

Professionalism in Nursing: Peer to Peer Mentorship Elaine Selby RN Perioperative Services FOCUS

RECOMMENDATIONS/ NEXT STEPS

PURPOSE & OBJECTIVES

Establish a peer-to-peer mentorship program in the Regional Anaesthesia Room for newly hired nurses, inclusive of an orientation pathway.

Mentorship is:

To develop a clear and comprehensive peer-to-peer mentorship program and orientation pathway.

Create a 6 week Pathway

“A reciprocal and collaborative learning relationship between two, sometimes more, individuals with mutual goals and shared responsibilities for the outcomes and success of the relationship”.

RNAO BPG Recommendations: • Recommendation 2.1: Being open-minded and having the desire to explore new knowledge • Recommendation 2.2: Asking questions leading to the generation of knowledge and refinement of existing knowledge • Recommendation 2.4: Being committed to lifelong learning • Recommendation 3.5: Recognize personal capabilities, knowledge base, and areas for development

• Identify skills to be completed weekly • Debrief at the end of each shift

Measures • Create a set of competencies • This can be used as a guide for learning

Week 4

• New hires will complete the competencies • Demonstrate their preparedness to work independently upon 6 week completion

Week 5

Week 6

• Epidural blood patch • Vetting next day’s OR list for patients • Calling Booking Office with add-on’s or removals • How to select a patient for regional room • Pre-op triaging  blood work, medication stickers, etc.

No set time frame New hires felt unprepared Week 2

• Admission of pre-op patient, Signing patient into OR • Regional Room pause, TOA • Review aseptic technique, IV access / blood draw • Spinal anatomy & assisting with spinal block • One day orientation with Educator

• Independent – Commonly used drugs in Regional Room • Upper extremity blocks • Arterial line refresher • Review of Ultrasound basics • Distinguish between SDA and DS admission

REFERENCES

Mentor RN’s felt frustrated Week 3

Longer orientation time

Academy of Medical-Surgical Nurses. (2012). AMSN mentoring program: mentor guide. Retrieved from https://www.amsn.org/sites/default/files/documents/p rofessional-development/mentoring/AMSNMentoring-Mentor-Guide.pdf

•

Canadian Nursing Association. (2018). Certification mentorship toolkit: Commit to excellence. Retrieved from https://www.cna-aiic.ca/-/media/cna/pagecontent/pdf-en/certification-mentorshiptoolkit.pdf?la=en&hash=D4AC6F9492E3127580BEBA5 1622D890CF66F509B

•

NYSORA. (2020). Techniques. Retrieved from https://www.nysora.com/techniques/

•

Registered Nurses’ Association of Ontario, (2014).

Clinical Best Practice Guidelines: Professionalism in Nursing. Retrieved from: https://rnao.ca/sites/rnaoca/files/Professionalism_in_Nursing.pdf

RESULTS “to promote professional growth and development through evidence based practice”

“a much needed resource to help our new staff feel competent”

CONCLUSION ACKNOWLEDGEMENTS

Difficulty recruiting new staff • Lower extremity blocks • Health teaching and the pre-op patient (Popliteal catheter, reinforcement of analgesic post-op) • Seek out opportunities for observation & learning • Milestone - Independently admitting, blocking, and transferring patient with minimal supervision from preceptor

• • Milestone – Independently admitting, blocking and transferring a patient • Stocking towers and carts • Checking crash cart • Narcotic count and ordering of more narcotic • Inputting daily stats and future stats

BACKGROUND

Week 1

• Regular evaluation of the pathway

Outcomes

INTERVENTION/ PROCESS

In the Regional Room, there were no mentorship or orientation standards in place for newly hired nurses.

• With each newly hired nurse, a PDSA cycle will be completed based on evaluation and feedback from mentor and mentee

• Epidural Neuraxial procedures • Combined spinal epidural • Adjunct upper extremity blocks

Thank you to all the staff in the Regional Room and the following individuals: Comfort Zone

Orientation Pathway / Binder

Evidence Based

Intentional Approach

Care Experience

• Lory Lee, Clinical Nurse Educator • Vasuki Parmalingam, Clinical Leader Manager • Susan Beswick, Evidence Based Practice Nursing Manager

Youth Appropriate Substance Use Screening and Brief Intervention for Early Psychosis Intervention Service Winnie Leung, RN, BScN, CPMHN (C) Community Mental Health FOCUS

TOOLS

PURPOSE & OBJECTIVES

Fig. 4

Fig.3

Substance use screening, assessment, and brief intervention that matches client’s stage of change is important • Most prevalent substance choices: Cannabis (42%), Alcohol (29%) • Youth are open to discuss their substance use when it is approached with an open and non-judgmental approach • Youth respond well to concrete, tangible harm reduction strategies

Purpose • To identify and implement a standardized substance use screening assessment in an EPI program • To implement brief interventions for substance use counselling

RNAO Best Practice Guidelines Engaging Clients Who Use Substances: 1.1 - Screen all clients to determine whether they use substances 1.2 - Determine the level of support required for clients who use substances 3.0 - Use brief interventions to collaborate with clients identified as at risk for or experiencing a substance use disorder

Objectives • Focus group with case managers to identify current practice • Collect data on prevalence and choice of substance use • Identify screening tool relevant to youth population • Identify brief intervention appropriate to STEPS client population

Key success factors • Early Stakeholder involvement improves buy-in • Utilize subject experts and literature review to guide practice • Short and numerous PDSA cycles allow processes to evolve quickly • Roll with resistance, explore challenges and potential solutions at each PDSA cycle

BACKGROUND STEPS for Youth Program • Community mental health Program – Early Psychosis Intervention (EPI) • Psychiatrist, 4 case managers, 1 team leader, 70-80 clients • Youth 14-35 years old experiencing first episode psychosis (FEP) • Intensive case management services (i.e. goals including: education, employment, housing, relationships, symptom management, finances, substance use counselling) Prevalence and Relevance • 1 in 3 youth ages 16-29 report current cannabis use in Canada • 60% of clients experiencing FEP in Ireland have used cannabis in the 12 months prior to presenting to treatment services • Ongoing cannabis use following FEP are associated with greater number of relapses and longer admissions in hospitals

STEPS client admission

Case manager asks clients if in past 6 months substance use caused functional impairment at intake

High risk

Advice re: moderation Match intervention based on readiness for change

RECOMMENDATIONS/ NEXT STEPS Act • Develop resource package for youth appropriate referrals • Assessment tool available electronically for outreach visits • Offer pre-treatment substance use engagement group for clients in precontemplative stage • Screening with CUDIT + AUDIT tools

Problematic substance use flagged at weekly roster review based on clinical judgment

Use contemplation circle (Fig. 7)

Plan • Literature review on substance assessment tools for youth and potential challenges • Consult subject experts: DBT therapist, NP on addictions and MH services

• • Fig.5

PDSA Cycle 1 • All clients completed initial screening (Fig. 1, Fig. 2) • 50% of case managers completed CUDIT with 1 client • Successes: framing assessment as standardized care, open ended questions, non-threatening, non-judgmental • Challenges: Assessment tool unavailable on outreach visits

RESULTS

MAYBE 0%

UNKNOWN 15%

YES 27%

Substance choice (N=72) Vaping 3%

Alcohol 29%

Other 16%

Cigarette s 10%

Low risk NO 58%

•

Incorporate substance use screening at weekly roster review to inform program development Incorporate standardized substance use screening tool for all new client intake for standardized care Offer on-going substance use engagement groups periodically based on prevalence, substance choice, and client identified priorities Monthly update at team meeting to encourage team to practice ongoing substance use assessments and brief intervention

Cannabis 42% Fig. 1

1. Adamson S, Kay-Lambkin F, Baker A, et al. (2010) An improved brief measure of cannabis misuse: The Cannabis Use Disorders Identification Test – Revised (CUDIT-R). Drug Alcohol Depend 2010 2. Ayonrinde, O. (2019) Cannabis Contemplation Circle. Queens University 3. Bush, K. Kivalahan, D.R., McDonell, M.B., et al. (1998) The AUDIC Alcohol Consumption Questions (AUDIT-C): An effective brief screening test for problem drinking. Arch Internal Med. (3): 1789-1795.

4. Canadian Consortium for Early Intervention in Psychosis (CCEIP). (2019). Cannabis Use Tear Pad. 5. Madigan, K., Brennan, D., Lawlor, E., Turner, N., Kinsella, A., O’Connor, J. J., … O’Callaghan, E. (2013). A multi-center, randomized controlled trial of a group psychological intervention for psychosis with comorbid cannabis dependence over the early course of illness. Schizophrenia Research, 143(1), 138–142.

6. Registered Nurses’ Association of Ontario (RNAO). (2015). Clinical Best Practice Guidelines: Engaging clients who use substances. (March), 1–118.

7. Rudzinski, K., McGuire, F., Dawe, M., Shuper, P., Bilsker, D., Capler, R., … Fischer, B. (2012).

Brief Intervention Experiences of Young High-Frequency Cannabis Users in a Canadian Setting.

Contemporary Drug Problems, 39(1), 49–72.

RESULTS CONTINUED

Do • Conduct focus group to identify current practice • Collect data on prevalence and choice of substance use for all clients • CUDIT tool selected, assess 1 client per case manager in 2 weeks

Substance use problematic in past 6 months? (N = 72)

Administer substance use screening tool for in depth assessment if appropriate

•

Fig.7 5

REFERENCES

Study • Analyze initial screening results • Challenges identified • Lack of youth appropriate referrals post-screening • Addressing client readiness for change No

Yes

Inform of risk due to FEP Menu of options (including referrals)

INTERVENTION/PROCESS

Reassess every 8 weeks (Roster review)

DESIRED STATE

CONCLUSION

Fig.2

PDSA Cycle 2 • AUDIT tool was added based on client identified substance choices • 75% of case managers completed CUDIT (Fig.3) and AUDIT (Fig. 4) with clients including 1 new intake • Youth appropriate referrals package developed (Fig. 5) • Readiness for change assessed with Cannabis Contemplation Circle (Fig.7) • Parent and youth appropriate harm reduction visuals made available (Fig. 6) • Pilot Cannabis engagement psychoeducational group implemented with positive feedback • Successes: E-tool provided easier access to assessment • Challenges: Psychotic symptoms, minimal insight, limited rapport, dual-diagnosis

Fig.6

ACKNOWLEDGEMENTS Thank you for your guidance and support with this initiative: Murray Krock, Director Nursing Practice & Education Nicole Kirwan, Clinical Lead Manager Deane O’Leary, STEPS team leader John Nguyen, STEPS OT Joram Muzones, STEPS RN Nicole Etherington, STEPS SW Keith Hansen, Nurse Practitioner MH & Addictions Maria Ricardo, DBT therapist, Covenant House Dr. Oyedeji Ayonrinde, Queens University Researcher

Improving the Provision of Care through Communication: Clinical Assistant to Registered Nurse Reporting on Patient Care Travis Edwards, RN, BScN St. Michael’s Hospital, Unity Health Toronto, Toronto, ON FOCUS

INTERVENTION/ PROCESS

• Establish a structured reporting system resulting in improved care coordination through effective communication between Clinical Assistants (CAs) and Registered Nurses (RNs).

Informal discussions and questionnaire administered to CAs and RNs on 4 Bond & 9 South to better understand their reporting needs

RESULTS continued • 95% compliancy rate with the use of CA worksheet

• In your experience, what information do you need reported to you from the CA? (what information do you need handed off to you) • What information do you need reported to you from the RN in order to complete your job?

• When is the best time for you to receive information from CA’s?

• When is the best time for provide information to the CA’s?

• What is currently working? What is not working?

• Increase continuity of care and patient safety.

• Reduce delay in the delivery of care during shift exchange.

BACKGROUND • Communication on Inpatient Mobility between CAs and RNs is inconsistent, resulting in incomplete data during transfer of accountability (TOA). The use of ineffective communication patterns has adversely affected continuity of care between CAs and RNs. This provides opportunities for improvement in coordination and continuity of care.

BOWEL MOVEMENTS FOLEY OUTPUT

INTEGUMENTARY CHANGES

• End of shift reporting compliance remains inconsistent and continues to be a challenge. Anecdotal accounts of RNs reveal that although end of shift reporting does not always happen, patient care information is being passed throughout the shift.

CONCLUSION • Staff engagement and surveying revealed the widespread acknowledgement that communication is important in the provision of patient care. In light of this, reports remain consistent that not all staff are engaging in the established reporting system, which has resulted in a low compliance rate.

VOIDING Figure 1.2 – Created CA worksheet for tracking patient care

• Barriers to effective communication are a direct result of occupied staff on a busy surgical unit.

RESULTS

• Lack of standardization and structure, healthcare complexity and contrasting communication styles were identified as barriers to effective communication (Foronda, MacWilliams, McArthur, 2016).

• Formalized surveys revealed important information regarding staff perceptions on communication (pre-survey)

COGNITIVE CHANGES

• Currently there is no formalized reporting system between CAs and RNs.

FOOD (ORAL) INTAKE

REFUSAL OF CARE

RNAO BPG RECCOMENDATIONS • 2.1 - Use effective communication to share client information among members of the interprofessional team during care transition planning.

• 3.2 - Use standardized documentation tools and communication strategies for clear and timely exchange at care transitions Figure 1.1 – Results of data from informal questionnaire with RN’s regarding required information to be reported from CA

• 3.3 - Obtain accurate and complete client medication information on care transition • 4.3 Evaluate the effectiveness of communication and information exchange between the client, their family and caregivers and the health-care team

PURPOSE & OBJECTIVES • Understand staff perceptions and reporting needs to improve communication between Clinical Assistants and Registered Nurses • Ascertain current satisfactory rates of communication between CA’s and RN’s • Streamline current Clinical Assistant communication tool • Establish a structured reporting system between Clinical Assistants to Registered Nurses

Table 1: Results from administered surveys for RN and CA related to perception on communication and responsibility RN Communication is important when it comes to patient care 100% Room for improvement in communication 94% Communication between RNs and CAs is currently good 75% Report is always received (RN) or given (CA) at the end of 48% shift about patient care Clinical Assistants responsibility to report information to 72% the Registered Nurses Standardized tool would help improve communication 90% between CAs and RNs

CA 100% 91% 63% 91% 82%

•

More tick boxes and details than previous sheet, less writing

•

Included ‘RN Checklist’, a reminder checklist of information for the CA’s to report to the RN at the end of shift.

• Education provided to CAs to better understand nursing perspective on reported patient care

• In the future, a continued effort will need to be made to improve the implementation of this system, as feedback from Registered Nurses has revealed the desire for a structured CA to RN reporting system.

RECOMMENDATIONS/ NEXT STEPS • Integrate CA to RN reporting system into CA New Hire Orientation package for future sustainability • Continued presence of managerial and RN support

73%

Results were categorized accordingly and guided the creation of a new CA care worksheet.

Purpose of sheet was to limit amount of time it took CAs to complete and fill worksheet for next shift which would result in additional time to be focused on patient care.

• Positive feedback from Clinical Assistants showed that the updated worksheet has been easier to use, resulting in an increase in time available to focus on patient care.

Table 2: Results from administered surveys for Registered Nurses only (Post Implementation) Agree Neutral Disagree Communication has improved between CAs 50% 38% 12% and RNs Currently satisfied with the communication 71% 21% 7% between CAs and RNs Important end of shift information about 33% 46% 28% patient care is received in a itimely manner Still room for improvement in communication 88% 13% 0% between CAs and RNs

REFERENCES Registered Nurses’ Association of Ontario, (2014). Clinical Best Practice Guidelines: Care Transitions. Retrieved from: http://rnao.ca/sites/rnao-ca/files/Care_Transitions_BPG.pdf Foronda, C., MacWilliams, B., & McArthur, E. (2016).

Interprofessional communication in healthcare: An integrative review. Nurse Education in Practice, 19, 36-40. https://doi.org/10.1016/j.nepr.2016.04.005

ACKNOWLEDGEMENTS A special thanks to Shawna Singh (CLM) and Peter Le (Resource Nurse) for their collaboration and support in making this project possible.

Nursing comfort in pain management of patients with substance use disorders Arpita Madan , RN; Keith Hansen, NP INTERVENTION/ PROCESS

FOCUS Therapeutic relationships of nurses and patients with substance use disorders within the context of pain management.

Emphasized focus on Opiate and Opioid substances.

Pre- Survey: Conducted amongst nurses on 4Bond and 9CS to clarify relevance of topic, nursing sentiment on current practices and questions/concerns that could be addressed with some key results: •

BACKGROUND • What is the problem?

Due to limited education regarding the topic of substance use and harm reduction as well as lived negative experiences of nurses on the unit with this client population, the gap between nurses’ comfort and appropriate pain management is widening.

• Why? - Acuity and high turnover of patients - Time constraints - Behavioural challenges displayed by patients - Compassion fatigue • Evidenced by?

- Paper survey conducted on the unit amongst RNs. - Observations of negative patient/RN interactions surrounding pain control.

- Multiple interviews conducted with RNs on unit, Peer support specialist and Addictions team NP.

PURPOSE & OBJECTIVES Increase nursing comfort around assessment of pain and implementation of pain management for patients with substance use disorders/addictions.

Create better understanding about function of Addictions Team.

Emphasize Harm Reduction theories and practices that will benefit patients currently using Substances.

Utilise pre-existing Best Practice Guidelines and their recommendations regarding substance use disorders and nursing practice in relation to them.

• • • •

72% Strongly agreed that this subject matter is relevant 56% agreed or strongly agreed that they had experienced difficulty developing therapeutic relationships with patients with substance use disorders 48% felt only sometimes supported by existing resources 80% experienced helplessness/frustration 56% experienced compassion fatigue

RESULTS

RECOMMENDATIONS

n = 22 Online surveys completed, with the following select results.

1. Do you feel more comfortable addressing pain management for patients with substance use disorders post this session?

2. Which sub-topic did you find most useful?

Focused educational session created in collaboration with Addictions NP Keith Hansen regarding substance use disorders and concurrent pain management with the following sub-topics: 1. Barriers to Therapeutic 5. Functions of use/Functions with relationships Pain 2. Harm Reduction vs Abstinence 6. Cravings and Withdrawal based theories 7. Opiate Deficit and Loss of 3. Understanding Compassion Tolerance Fatigue and resources to 8. Opiate replacement mitigate treatments used by Addictions 4. Clinical Diagnostic criteria and team, functions of Addictions methods. team.

Conduction of Education Session: Skills Day 1 - Topics 1,2 and 3 by BPG Champion and Topics 4-8 by NP Keith Hansen from the Addictions Team.

Skills Day 2 - Topics 1-8 by BPG Champion due to scheduling conflict for NP. Post - Survey: Online post survey sent to Attendees (n=44) of Skills day 1 and 2, Post Survey questions included questions regarding organization of material, relevance of topics and post-session sentiment related to future pain management of patients with Substance use disorders.

2. Planned debrief sessions with the unit team when dealing with challenging patient scenarios.

3. Educational session regarding pain management and substance use disorders on an annual basis with Addictions team during skills day.

4. Possible future implementation of a Opiate withdrawal tools.

REFERENCES

Preparation of Education session: Research was conducted over a 3 month period regarding Substance use disorders and concurrent pain management issues.

Important findings in research included: Themes of Reciprocal Mistrust, Lack of accurate knowledge about substance use and harm reduction, Compassion fatigue, Moral distress and Desire to minimize risks amongst others, rank high in barriers faced by nurses to developing therapeutic relationships with substance use clients. (5) Qualitative interviews conducted with Peer support specialist, Addictions NP and MD, Floor RNs and RNs working closely with substance use clients.

1. Information package for new hires as well as for students consolidating on the unit.

It was a lot of information but presented in a way that wasn’t overwhelming and the flow from each sub topic was very intuitive

Great presentation! I really liked how practical advice was given on how to establish trust with your client, and about how to educate your client about PICC lines.

It's such a relevant aspect of nursing especially at St Michael's, I feel like I learned a lot

CONCLUSION ➡ Nurses on the unit are enthusiastic to fill their knowledge gaps when presented in a structured manner. ➡ Support systems that are available throughout the hospital need to be reinforced amongst the staff. ➡ Necessary to engage RNs within a task oriented educational focus using specific examples - the unit is extremely busy with high turnover and thus in-services should be frequent and highly specific. ➡ Compassion Fatigue and Helplessness rank extremely high in barriers expressed by RNs to therapeutic relationship building and pain management ➡Nurses response to the education session showed the need for continuing (and possibly mandatory) opportunities for knowledge building in regards to Substance use, Harm reduction strategies and pain management.

1. Addiction and Substance use Treatment Options. (n.d.). Retrieved from https://ontario.cmha.ca/harm-reduction/ 2. Blum, C., (September 30, 2014) "Practicing Self-Care for Nurses: A Nursing Program Initiative" OJIN: The Online Journal of Issues in Nursing Vol. 19, No. 3, Manuscript 3.

3. Elizabeth Zelvin ACSW, CSW, CASAC & Diane Rae Davis PhD, CSW (2001) Harm Reduction and Abstinence Based Recovery, Journal of Social Work Practice in the Addictions, 1:1, 121-133, DOI: 10.1300/J160v01n01_09 4. Engaging clients who use substances . (2015, March). Retrieved from https://rnao.ca/sites/rnaoca/files/Engaging_Clients_Who_Use_Substances_13_WEB.pdf 5. Hardill, K. (2019). That Look That Makes You Not Really Want to be There: How Neoliberalism and the War on Drugs Compromise Nursing Care of People Who Use Substances. Witness: The Canadian Journal of Critical Nursing Discourse, 1(1), 13–27. doi: 10.25071/2291-5796.15 6. Maté, G. (2018). In the realm of hungry ghosts: close encounters with addiction. Toronto: Vintage Canada.Hawk, M., Coulter, R.W.S., Egan, J.E. et al. Harm reduction principles for healthcare settings. Harm Reduct J 14, 70 (2017). https://doi.org/10.1186/s12954-017-0196-4 7. Mendes, A. (2014). Recognising and combating compassion fatigue in nursing. British Journal Of Nursing (Mark Allen Publishing), 23(21), 1146. https://doi.org/10.12968/bjon.2014.23.21.1146 8. Registered Nurses’ Association of Ontario. (2017). Crisis intervention for adults using a trauma-informed approach: Initial four weeks of management (3rd ed.). Toronto, ON: Author.

9. Registered Nurses’ Association of Ontario. (2015). Engaging Clients Who Use Substances. Toronto, ON: Registered Nurses’ Association of Ontario.

10.Registered Nurses’ Association of Ontario. (2009) Supporting Clients on Methadone Maintenance Treatment. Toronto, Ontario. Registered Nurses’ Association of Ontario.

ACKNOWLEDGEMENTS Sincere thanks extended to Keith Hansen, Addiction team Nurse Practitioner, for sharing his wealth of knowledge and experience to enhance understanding while preparing for the education session.

Shawna Singh (CLM) and Peter Le ( Resource Nurse) for support and technical assistance.

Improving communication about patient care on internal medicine Stephanie Rioux, RN, BScN; Shirley Bell RN, Clinical Nurse Educator; Kim Grootveld BScOT, MScQIPs, CLM; Susan Camm RN, BScN, MHSc, CLM General Internal Medicine, St. Michael’s Hospital, Unity Health Toronto FOCUS The Internal Medicine, Geriatric and Stroke unit is an acute care inpatient unit that consists of 78 beds. Our patient population has a high level of varying needs. Strong communication is essential to provide optimal patient care and staff wellbeing during Care Transitions.

In order to optimize care, Clinical Assistant (CA) to Clinical Assistant Transfer of Accountability (TOA) had been implemented and sustained since January 2020.

The goal was to implement a streamlined TOA reporting system between the CAs in order to improve workflow, time management and overall communication.

INTERVENTION/ PROCESS Intervention Communication Board

TOA Worksheet

CA to CA TOA Process

Description Created a communication white board in the high observation “locked unit” to identify staff assignments, falls risk and behaviour risk patients Simplify and clarify TOA worksheets with most important information needs for CAs, based on CA TOA survey, 1:1 discussion and focus groups Develop workflow for CAs to give effective, timely TOA to oncoming CA

RESULTS

RECOMMENDATIONS/ NEXT STEPS

 CA to CA TOA completion rate increased to 100% by week #2  CA to CA TOA reporting time decreased by 42% during PSDA cycle 1  Balance outcomes resulted that we also improved workflow for RNs and CAs

Next steps will involve PDSA Cycle #2, where CAs complete a written report of the oncoming TOA worksheet to assist in ease of transfer of information to following CA. Due to large volume of patients each CA is assigned, our CAs identified this strategy as something to aid them in giving effective and efficient TOA.

Graph 3: TOA Completion Rates

Additionally, continuation to reinforce the importance for CAs to touch-base with the RN at the start of the shift for any information changes or updates related to patient care is needed, as this is something that is getting missed as reported by our RNs

Currently, there is a literature gap with minimal published research on CA TOA or reporting

We will continue with routine check in and progress updates for both CAs and RNs to identify compliance/completion rate and if there are any new barrier to providing timely, concise and accurate TOA.

CA to CA TOA Process: ACTT

BACKGROUND Preliminary Clinical Assistants’ survey revealed: •28.6 minutes to receive TOA from the Registered Nurses (RNs) •Maximum time reported is up to 1 hour to complete TOA from RNs •36.8% of CAs always receive report from prior CA and 42% sometimes receive TOA or touch base with prior CA

PROCESS MAP

Arrive

• Arrive ready to go at start of shift • Grab your assigned TOA sheet

THE BIG PICTURE Connect

TOA

Touch Base

• Connect with the off going CA for assignment

Graph 2: TOA Reporting Time Outcome (minutes)

• Address 4 keys points 1. Mobility 2. Care Needs 3. Behaviour 4. Diet • Touch base with appropriate RN for additional information or updates related to patients care

Indicator or Measure

Process Indicator

AIM & OBJECTIVES The aim of the CA to CA TOA is to implement a streamlined TOA process to reduce TOA time by 25% from 28 minutes to 21 minutes and to have 100% compliance of CA to CA TOA by March 15, 2020.

See figure 1: Indicators and Measures

Outcome Indicator Balance Measure

 637 hours saved in a year, which goes back to our patients to help them with their needs and overall health and wellbeing

New admissions and/or transfers?

TOA will initially be conducted as RN to CA

Figure 1: Indicators & Measures

Reduction in time spent for CAs to receive information on patient care needs leads to more time available for direct patient care  A 15 minute reduction per CA per day leads to 12.25h extra time available for patient care over a week

REFERENCES Glynn, D., Saint-Aine, R., Gosselin, M., Quan, S. & Chute, J. 2017.

The role of unlicensed assistive personnel in patient handoff.

Nursing 2017 Graph 3: Balance Measure Outcomes

Description

Howard, K & Becker, C. 2016. Moving change of shift report to the bedside for UAP. Nursing 2016

• Percentage of CAs completing TOA • Percentage of CAs utilizing updated TOA worksheet • CA Communication Lead completing Communication Board

Registered Nurses Association of Ontario. (2014). Care Transitions : Best practice guidelines. Retrieved from: https://rnao.ca/bpg/ guidelines/care-transitions

• CA to CA TOA Compliance • Reduction in CA to CA TOA time • Improved workflow for RNs and CAs • Improved time management for RNs and CAs

ACKNOWLEDGEMENTS 14CC Clinical Assistants & Registered Nurses Nursing Professional Practice and Education Cecilia Santiago, Nursing Practice Manager, Professional Practice

Implementing a Standardized Fall Risk Screening Process in Community Mental Health Care in the Community Connections Program Michael Panzarella, RN, BN, H.BSc St. Michael’s Hospital, Unity Health Toronto Current State: Currently, Community Connections does not

FOCUS • Community Connections is an Intensive Case Management program consisting of 7 case managers of various disciplines (RN, OT, SW) providing a variety of biopsychosocial services to adults experiencing significant mental and physical health challenges in the community or home setting

RESULTS

have a fall risk assessment screening tool in place

• Continue to assess new clients admitted to the program and screen for falls risk • Connect with developer of Edmonson Psychiatric Falls Risk assessment tool for permission to use • Create job aids for staff • Store assessments in Fall Assessment Binder and revisit on a monthly basis

Desired Future State:

• RNAO BPG related to topic: Preventing Falls and Reducing Injury from Falls.

REFERENCES

PURPOSE & OBJECTIVES

1. Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., ... & Shekelle, P. G. (2004). Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Bmj, 328(7441), 680.

2. Edmonson, D., Robinson, S., & Hughes, L. (2011). Development of the Edmonson psychiatric fall risk assessment tool. Journal of psychosocial nursing and mental health services, 49(2), 29-36.

3. Heslop, K., Wynaden, D., Bramanis, K., Connolly, C., Gee, T., Griffiths, R., & Al Omari, O. (2012). Assessing falls risk in older adult mental health patients: a Western Australian review. International journal of mental health nursing, 21(6), 567-575.

4. Loorand-Stiver, L. Falls Prevention Strategies in Adult Outpatient or Community-Based Mental Health and/or Addiction Programs [Environmental Scan issue 35]. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2012.

5. Registered Nursing Association of Ontario [RNAO]. (2017). Preventing Falls and Reducing Injury from Falls, Fourth Edition. Retrieved from https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries.

6. Stubbs, B. (2011). Falls in older adult psychiatric patients: equipping nurses with knowledge to make a difference. Journal of psychiatric and mental health nursing,18(5), 457-462.

7. Wynaden, D., Tohotoa, J., Heslop, K., & Al Omari, O. (2016). Recognising falls risk in older adult mental health patients and acknowledging the difference from the general older adult population. Collegian, 23(1), 97102.

Outcome Indicators

AIM: To develop and implement a standardized tool that all staff can use to screen for falls risk regardless of health discipline

RECOMMENDATIONS/ NEXT STEPS

•

80% of community mental health caseworkers report feeling confident to implement screening tool and associated interventions

•

Overall amount of falls in community decreases to less than 20%

INTERVENTION/ PROCESS

BACKGROUND • Falls are expensive! Costing an estimated $8.7 billion/per year and the average length of stay is approximately 22 days.

• Falls can lead to other complications: Hip Fractures, Head Injuries, Permanent Lifestyle Change or Disability, and Psychological Changes (i.e..

“Fear of Falling”).

• Average age of a psychiatric fall ~55-56 years old.

• 46/90 (51%) of the Community Connections clients are over the age of 50 • 18/90 (20%) of clients have experienced one or multiple falls within the past year

ACKNOWLEDGEMENTS

• Community Connections clients have multiple risk factors such as:

KEY LEARNINGS • Buy in is easier to achieve when you can demonstrate a need using data or clinical situations • Quality improvement initiatives require a lot of time and multiple revisions • What makes sense to one discipline may not make sense to another… standardized education and training is important

Special thanks to: Deane O’Leary, Team Leader Community Connections and STEPS for Youth Program Nicole Kirwan, Clinical Leader Manager, Mental Health and Addictions Vanessa Durante, Corporate Nursing Manager, Professional Practice Carolyn Ziegler and Kaitlyn Merriman, Health Sciences Library Christopher Uranis , MHESA & the Canadian Mental Health Association All staff and clients from the Community Connections Program

Intentional Rounding with an Interprofessional Team John Edwards RN, BScN, RMT Trauma Neurosurgery In-Patient Unit, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON FOCUS

INTERVENTION/ PROCESS

Increasing intentional rounding compliance to improve patient safety and satisfaction on 9CC.

• Interprofessional quality huddles and 1:1 coaching to refresh staff on IR. • Reorient staff, patients and patient families to IR posters in patient rooms.

• Update sign up sheet to include weekends.

• Build quality improvement board to keep unit updated on current state and improvements.

• Implement interprofessional day and night IR champions.

RNAO BPG: Preventing falls and reducing injury from falls.

Recommendation 5.3: Implement rounding as a strategy to proactively meet the person’s needs and prevent falls.

BACKGROUND Intentional Rounding (IR) is a structured process wherein a health care provider goes to patients’ bedsides at standard times throughout a shift with the goal of proactively anticipating, identifying and meeting patient care needs.

Interprofessional quality huddles were introduced week 6 and 7. Average night time IR compliance at 92% post intervention. All falls resulted in mild or no harm.

CONCLUSION • • • •

“RN’s can get overwhelmed with tasks and IR is Interprofessional quality huddles were introduced week 6 and 7. Weekend IR rolled out week 10. Average day time IR compliance rate at 82% post intervention.

“No one followed up with the results of the last rollout.”

– Allied Health

Aim: To increase day time IR compliance from 25% to >80% and roll out day time weekend IR while maintaining night time IR compliance >80% resulting in an overall decrease in falls by Mar 31/20.

• Implement IR documentation in Soarian.

• Examine timing of day time IR related to reported falls.

• Examine call bell wait times.

Sustaining our success:

Figure 1: Qualitative comments from staff pre-intervention

PURPOSE & OBJECTIVES

RECOMMENDATIONS/ NEXT STEPS

Figure 2: Day time results of compliance audits vs reported falls

The issue: 9CC had the second highest fall rate in the hospital in 2014/15. Post IR rollout our fall rate dropped by 30%. Since the roll out, compliance among staff has waned. This increases the risk for falls, especially on days where compliance is particularly low.

“We honestly weren’t sure if rounding was still a thing.”

– Allied Health

Learnings: • Small actions can have a big impact on positive patient care.

• High turn over can result in practices being lost in one generation if they are not embedded in the onboarding process.

• Closing the information loop by reporting QI results back to participating staff is CRITICAL to the sustainability of QI projects.

RESULTS

Interprofessional Collaboration is the process in which various professional disciplines deliver care synergistically to positively impact health care outcomes.

scheduled during breaks when we’re short.” – RN

Figure 3: Night time results of compliance audits vs reported falls

“I like it a lot! Feels like they haven’t forgotten me. I get the help I need.” - Patient

Day time IR compliance increased by 57% post intervention.

Weekend IR was successfully rolled out.

Night time IR compliance increased by 8% post intervention.

Falls rate remains below corporate target.

Figure 4: Qualitative comments from patients and families postintervention

“I really don’t need anything but if I do I just wait because I don’t want to bother anyone.”

- Patient

“Makes us feel less lonely. We get lonely in here.” - Patient

• Maintain interprofessional day/night IR champions.

• Unit Based Council to continue IR audits.

• Include IR during unit onboarding and in the 9CC standards of care.

• Include IR as part of corporate onboarding.

• Continual support for teamwork training by expert coaches; role clarity; and strong team leadership.

REFERENCES Akuamoah-Boateng, K., Wiencek, C., Esquivel, J., DeGennaro, G., Torres, B., Whelan, J. (2019).

RAMPED-UP: The Development and Testing of an Interprofessional Collaboration Model. Journal of Trauma Nursing, 26(6), 281-289.

Hicks, D. (2015). Can rounding reduce patient falls in acute care? An integrative literature review.

MedSurg Nursing, 24(1), 51-55.

Hutchings, M., Ward, P. & Bloodworth, K. (2013). ‘Caring around the clock’: a new approach to intentional rounding. Nursing Management, 20(5), 24-30.

Registered Nurses’ Association of Ontario. (2017). Preventing Falls and Reducing Injury from Falls (4th ed.). Toronto, ON: Author.

Vestergaard, E. & Nørgaard, B. (2018). Interprofessional collaboration: An exploration of possible prerequisites for successful implementation. Journal of Interprofessional Care, 32(2), 185-195.

ACKNOWLEDGEMENTS Trauma and Neurosurgery In-Patient Staff, Patients, & Families IR Champions: Sandra Chambers CA, Theresa Cook NP, Janet Katsouris RN, Jess Pacquing RN, Verity Tulloch PT Mary Copeland, Clinical Leader Manager Judy Pararajasingham, Clinical Nurse Educator Vanessa Durante, Corporate Nursing Education Manager

Improving Best Practices with the Use of Physical Restraints Sabrina Parker, RN, BScN, BScH Trauma-Neurosurgery Inpatient Unit, St. Michael’s Hospital, Unity Health Toronto FOCUS & BACKGROUND

INTERVENTIONS & PROCESS

Patients on the Trauma & Neurosurgery inpatient unit often exhibit responsive behaviors and safety risks to themselves and others. Physical restraint use was common.

Education Focused Interventions • In-services for Registered Nurses (RNs) & Clinical Assistants (CAs) on physical restraint safety • 1-on-1 teaching sessions for RNs & CAs on how to use quick release and D-ring tie for soft limb restraints

RESULTS

• Continue obtaining stakeholder feedback • Mini Physical Restraint Decision-Making Algorithm cards to be distributed to RNs & CAs • Weekly Audit to be performed by day shift charge RN • Trauma-Neurosurgery Inpatient Standards of Care now includes physical restraint information

Physical Restraints Decision-Making Algorithm • Guides staff on how to safely and legally use physical restraints

REFERENCES

Figure 4. The number of patients with physical restraints post-interventions

Figure 1. Pre-Intervention Assessment of Physical Restraint Use

Interprofessional focus group findings revealed staff had a limited understanding of physical restraints and legal requirements on their use. They also expressed there are communication barriers that prevent them from entering and obtaining orders.

Lack of orders and documentation can lead to unsafe & extended use of physical restraints, miscommunication regarding clinical status, an inability for patients to transition out of constant care or acute care, and serious legal implications for staff.

AIM STATEMENT To improve the safety of physical restraint use by March 2020 as determined by: • 50% increase in valid restraint orders • 50% increase in Soarian documentation by RNs

Figure 2. Physical Restraint Decision-Making Algorithm

Physical Restraint Request Form • Request form is flagged in the patient’s chart by the RNs to remind doctors (MDs) to enter or renew the physical restraint order • MDs see the flagged request form during morning rounds and enter the order at this time if it was missed earlier Figure 3. Physical Restraint Request Form

RECOMMENDATIONS & SUSTAINABILITY

Figure 5. Valid Orders & RN Soarian documentation within 24hrs for patients on physical restraints post-interventions

CONCLUSION Physical restraint safety can be facilitated by on-going education, decision-making and communication focused interventions. The quality improvement initiative resulted in: • 25% increase in valid restraint orders • 60% increase in Soarian documentation by RNs • 13% decrease in physical restraint use

Akbas, M., Oztunc, G., & Torun, S. (2019). Nurses’ Knowledge, Attitudes and Practices towards the Use of Physical Restraints and their Affecting Factors: A Multi-Centre Cross-Sectional Study. International Journal of Caring Sciences, 12(2), 1023.

Eskandari, F., Abdullah, K. L., Zainal, N. Z., & Wong, L. P. (2018). The effect of educational intervention on nurses' knowledge, attitude, intention, practice and incidence rate of physical restraint use. Nurse education in practice, 32, 52-57.

Government of Ontario (2015). Mental Health Act, R.S.O. 1990, c. M.7.

Retrieved from https://www.ontario.ca/laws/statute/90m07 Government of Ontario (2017). Patient Restraints Minimization Act, 2001, S.O. 2001, c. 16. Retrieved from https://www.ontario.ca/laws/statute/01p16 Government of Ontario (2018). Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A. Retrieved from https://www.ontario.ca/laws/statute/96h02 Hevener, S., Rickabaugh, B., & Marsh, T. (2016). Using a decision wheel to reduce use of restraints in a medical-surgical intensive care unit. American Journal of Critical Care, 25(6), 479-486.

Kaya, H., & Dogu, O. (2018). Intensive care unit nurses’ knowledge, attitudes and practices related to using physical restraints. International Journal of Caring Sciences, 11(1), 61-70.

Registered Nurses Association of Ontario (2012). Promoting Safety: Alternative Approaches to the Use of Restraints. Retrieved from https://rnao.ca/bpg/guidelines/promoting-safety-alternativeapproaches-use-restraints Schmidtke, S., & Iverson, L. (2018). Reducing Use of Restraints through Education on Alternatives. Medsurg Nursing, 27(3), 157-159.

St. Michael’s Hospital (2014). Alternatives to the Use of Physical Restraints.

Toronto, Canada.

ACKNOWLEDGEMENTS Special thank you to all 9CC staff, Mary Copeland (CLM), Cecilia Santiago (Professional Practice Mentor), Judy Pararajasingham (Clinical Nurse Educator), Alison Barker (OT), Harsha Babani (OT), Allison Rinne (OT), Kirsty Nixon (NP), Sarah Marshall (NP), Heather Perry (NP), Stephanie Lucchese (CNS), Constant Care Working Group, and the RNAO

Cannabis and Cancer: Addressing the Gaps to Improve Patient Care Domenic Tavares, RN, BScN Oncology FOCUS Best Practice Guideline: Person & Family-Centered Care (Registered Nurses Association of Ontario, 2015).

•Recommendation 2.2: Engage with the person in a participatory model of decision making, respecting the person’s right to choose the preferred interventions for their health, by sharing information to promote an understanding of the available options for healthcare so the person can make an informed decision.

BACKGROUND Since legalization in 2018, cannabis use has increased with 18% of Canadians reporting use in the last three months versus 14% prior to legalization. The largest growth of new users are above the age of 45 with these groups more likely to use it for medical purposes with or without a prescription. Historically, cannabis use has elicited strong, polarizing views on its efficacy in managing cancer and related side effects. While there is a growing body of research, conflicting information remains.

A survey of 926 patients with cancer noted that 74% reported an interest in education about cannabis with only 15% stating they received information via their healthcare providers (HCPs) which is their preferred source.

However, nurses and other HCPs report a lack of knowledge to confidently address cannabis use in their practice. As it becomes more accessible, patients may be receiving information from unreliable sources which may impact their oncological treatment and care. This has necessitated a need for the outpatient medical day care unit to address current gaps in our education, assessment practices and referral processes in order to improve patient care.

PURPOSE & OBJECTIVES 1. The aim is to increase nursing and allied health knowledge and understanding of the use of cannabis in cancer care to at least 80% by March 31, 2020 2. The aim is to develop and implement an assessment tool for cannabis use among new malignant oncology and hematology outpatients in order to increase consistency of assessments of cannabis use to 90% by March 31, 2020

METHODS Phase 1: Assessment of current state Survey • N = 16/19 (nurses & allied health) • Exploring the attitudes and perception of staff towards cannabis use in cancer care, current knowledge level and learning needs • Survey findings drove interventions Semi-structured interviews • N = 2 assessment nurses, 2 pharmacists, 1 dietician, 1 MD • Small working group was formed to collect further data and reflect on current assessment and referral practices

METHODS CONT.

RECOMMENDATIONS/ NEXT STEPS

Phase 4: Audit and Feedback (in progress) A.Survey - Evaluate staff knowledge and perceptions of cannabis use in cancer care post education B. Focus group on assessment tools – feedback on usefulness of tools

1.

• • •

RESULTS Pre-Survey: • 60% noted an increase in interest since legalization • Average knowledge level of 3.5 • 100% of staff wanted education session Education Sessions: Supportive Care Rounds: February 12, 2020 1. Qualitative narrative:

2. Survey data: • Education sessions still in progress • Post-education survey to be done and analyzed in future of project

CONCLUSION

Phase 3: Implementation of education • Module developed on learning needs • 2 x 1 hour sessions (in progress) • Case studies to assess knowledge & implementation of assessment tools

2. Completion of assessment tools: • Screening tool in Soarian after feedback on draft • Sustainability: audits of screening tool completion

3. Development of streamlined authorization/referral process 4. Development of patient education materials

REFERENCES

Phase 2: Development of assessment tools • Assessment tools developed for concise and consistent data collection

Current state of medical daycare unit:

Completion of education sessions: 8 more nurses, 2 allied health Feedback to identify future learning needs Sustainability: new staff orientation and quarterly focus groups to look at new research

There are a number of gaps within our center that must be addressed. The lack of education of staff and assessment practices may lead to potential negative outcomes for our patients. There are contraindications, drug interactions and potential chemotherapy interactions that patients may not be aware of. It is also important to note that in other cases, the harmbenefit ratio must be considered as research in cannabis is still lacking but a percentage of patients express positive symptom management outcomes from use.

The education sessions appear to be useful in increasing staff knowledge and confidence in the preliminary phase. The screening tool also has received positive reviews. However, there are limitations to what can be drawn from this narrative data. Further data from a survey and focus groups will be gathered once the education sessions have been completed and the assessment tools are put into action.

Clark, C. (2018). Medical Cannabis: The Oncology Nurse’s Role in Patient Education About the Effects of Marijuana on Cancer Palliation. Clinical Journal of Oncology Nursing,22(1). doi:10.1188/18.cjon.e1-e6.

Health Canada. (2018). Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids. Retrieved from https://www.canada.ca/content/dam/hc-sc/documents/services/drugsmedication/cannabis/information-medical-practitioners/information-health-careprofessionals-cannabis-cannabinoids-eng.pdf.

Pegram, S. A., Woodfield, M. C., Lee, C. M., Cheng, G., Baker, K. K., Marquis, S. R. & Fann, J. R. (2017). Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use. Cancer, 123(22), 4488 – 4497. doi: 10.1002/cncr.30879. w Registered Nurses’ Association of Ontario. (2015). Person- and Family-Centred Care.

Toronto, ON: Registered Nurses’ Association of Ontario.

Statistics Canada. (2019). National Cannabis Survey 1st Quarter 2019. Retrieved from https://www150.statcan.gc.ca/n1/daily-quotidien/190502/dq190502a-eng.htm.

ACKNOWLEDGEMENTS Erin M’Larkey, Registered Dietitian Dr. Jonathan Ailon, Internal Medicine Charmaine Mothersill, Clinical Leader Manager, Oncology Vanessa Durante, Corporate Nursing Education Manager

Patient Centred Learning for Patients with G-tubes Caroline Vizl, RN; Laxmi Devi, RN 6 Bond Respirology BACKGROUND

INTERVENTION/ PROCESS

NEXT STEPS

Post Survey Results 6

• Determined current process of G-tube management in CF patient population • Engaged key stakeholders PHASE 1 • Created survey to assess RN confidence level in g-tube management and education

Current Cystic Fibrosis (CF) population who have g-tubes: 22 out of 300+ Current process in place outlines nurses responsibilities centering around teaching, however there are no resources to support teaching and the existing discharge checklist is vague and uninformative. This has caused a gap in nursing knowledge regarding discharge teaching on g-tube care and management in the CF population, particularly among new RNs on 6Bond.

5

4

3

• Conducted literature review • Created staff education slides regarding g-tube care and management PHASE 2 • Created “Cystic Fibrosis and G-Tubes” discharge booklet

FOCUS In order to tackle the outlined problem, the BPG “Facilitating Patient Centered Learning” was utilized.

Specifically recommendations regarding: Use a universal precautions approach for health literacy to create a safe, shame- and blame-free environment Use plain language, pictures and illustrations to promote health literacy Tailor your approach and educational design by collaborating with the client and the interprofessional team

PHASE 3

o

• Created post survey to reassess RN confidence level in g-tube management and education after receiving education on the topic • Received feedback on discharge booklet from patients and unit nurses • Finalized “Cystic Fibrosis and G-Tubes”

o

o

FINDINGS Respirology nurses were surveyed on their self rated knowledge and confidence regarding management and discharge teaching on g-tubes, before and after receiving education on the same topic.

PURPOSE & OBJECTIVES Increase nursing staff confidence in providing patient education in Gtube care and management by 40% (from 40% to 80%) in order to ensure safer transition to self-care.

Create a new checklist and education package for patients discharged with new g-tubes.

Use “Cystic Fibrosis and GTubes” as needed and assess effectiveness

Pre Survey Results 9 8

Ensure sustainability by involving Clinical Nurse Educator

2

1

0

Question 1

Question 2

Strongly Disagree

Question 3 Disagree

Question 4 Agree

Question 5

Question 1: I feel confident I have the knowledge, skill and judgement required to provide safe nursing care to patients with new or existing g-tubes Question 2: I understand my responsibilities when providing nursing care to a patient with a new or existing g-tube Question 3: I feel prepared to provide nursing care to patients with new or existing gtubes Question 4: I feel that I have all the resources necessary to discharge my patient home with a new g-tube Question 5: I feel confident when providing patient education regarding at-home gtube management

CONCLUSION Based on our initial survey results, 70% of nurses felt they had the knowledge, skill and judgment to safely provide g-tube care. However, only 40% of them felt confident in providing discharge teaching. A factor in this is a lack of resources to support patient teaching.

7 6 5

After providing an education “refresh” for our nurses to clarify roles, responsibilities, and required care 100% rated they either ‘agreed’ or ‘strongly agreed’ that they understood their responsibilities and felt confident in providing discharge instruction to patients going home with gtubes.

4 3 2 1 0

Question 1 Question 2 Strongly Disagree

Question 3 Question 4 Question 5 Disagree Agree Strongly Agree

Incorporate education into onboarding process for new hires

Strongly Agree

Additionally 100% felt they had they necessary resources to discharge their patients home with a g-tube with the addition of “Cystic Fibrosis and GTubes” booklet.

REFERENCES Commonly asked questions about G-tubes. (2019, July 21). Retrieved January 30, 2020, from https://torontoadultcf.com/nutrition/commonlyasked-questions-about-g-tubes Garrison, C. (2018). Enteral feeding tube clogging: What are the causes and what are the answers? A benchtop analysis. Nutrition in Clinical Practice, 33(1), 147-150. DOI: 10.1002/ncp.10009 Lord, L. (2018). Enteral access devices: Types, function, care and challenges. Nutrition in Clinical Practice, 33(1), 16-38. DOI: 10.1002/ncp.10019 Registered Nurses’ Association of Ontario (2012). Facilitating Client Centred Learning. Toronto, Canada: Registered Nurses’ Association of Ontario.

Tsang, A., Gillijam, M., Kelly, E., & Tullis, E. (2002). Home gastrostomy feeding. A manual for physicians, nurses and dietitians. Revised (2013).

Unity Health Network. 2016. Care of Enterostomy Feeding Tubes Policy.

ACKNOWLEDGEMENTS Barb Hooper, Clinical Leader Manager, Respirology Sarah Sweetman, Resource Nurse Nida Irshad, Clinical Nurse Educator Vanessa Durante, Corporate Nursing Education Manager

Using Mindfulness Techniques to Mitigate Mental Fatigue in an Adult Acute Care Setting Chris Carless, RN & Tsetan Dolkar, RN Inpatient Cardiology Unit, St. Michael’s Hospital FOCUS • Many stressors were identified among healthcare workers that contributed to fatigue. CNA’s factsheet on fatigue reported that fatigue affects healthcare worker’s judgment, increases risk of making errors, increases falls/ injuries and affects continuity of care. Fatigue leads to moral distress and impaired coping abilities for nurses.

• Currently we have limited intervention techniques in place on the inpatient cardiology unit and there are no practice guidelines on managing fatigue in our workplace.

RESULTS

PURPOSE & OBJECTIVES The aim of “Using mindfulness techniques to mitigate mental fatigue in an adult care setting” was to reduce the level of fatigue experienced by inpatient cardiology staff by 5% by the end of March 2020.

Objectives • To introduce mindfulness practice to frontline staff.

• To promote and sustain the practice of mindfulness resulting in reduced mental fatigue among frontline workers.

INTERVENTION/ PROCESS 1. Assessment • Two different surveys were carried out among Cardiology staff during the initial phase of our BPG. • The first survey assessed the nurses and clinical assistants perception of fatigue and the symptoms they experienced (n=16).

• Another training cycle to reinforce and solidify the concepts • Submit a proposal to medical media to create pamphlet for quick reference on the unit • Have a weekly practice on mindfulness • Attach a handout/ pamphlet to the Workstation on Wheels • Encourage staff to practice the mindfulness based interventions.

Symptoms of fatigue experienced among staff (N=16) 90 80 70 60 50 40 30 20 10

REFERENCES

0

BACKGROUND • Mindfulness is a way of living with a greater attention and intention, and with less judgment. The goal of mindfulness techniques is to empower individuals to respond to situations consciously rather than automatically.

• Mindfulness meditation is known to alleviate stress, anxiety, burnout and enhance resilience among healthcare professionals.

• There are an increasing number of studies showing the effect of mindfulness practices on the human brain and its physiological benefit, for example reduction in symptoms linked to cardiovascular disease and cancer.

NEXT STEPS

• The second survey (The Chalder Fatigue Scale) assessed the mental and physical fatigue among three different categories of healthcare workers: Nurses, Clinical Assistants and other Health disciplines (n=24). It was noted that nurses experienced a higher level of fatigue then the other two groups of staff.

2. Intervention • The initial introduction to mindfulness session began on the 30th of January and ran until the 9th of March. Using a 10-minute session, each staff member was trained in four mindfulness exercises and a short chair yoga flow. The session took place on the unit, in a central charting room.

3. Tools • A poster on “Mindfulness - What’s in it for me?” was designed and posted on the unit bulletin board, quality board and in the washroom to draw staff’s attention on our initiative.

• A handout featuring the mindfulness interventions was developed and distributed during the educational session for easy reference.

Narrative data from participants: • “ I found it very useful, especially the breathing exercises when I am overwhelmed...”

• “ I think it is very powerful and useful initiative because we tend to get so busy without taking a minute...Mindfulness intervention help you teach relaxation, being in a moment and help improve patient care” • “I felt relaxed, it gave me an idea of what to do when I am stressed ...I use it mostly at home” • “It helps to relax rather than lash out, take a few breaths and it relaxes you...chair yoga is nice, I like it” Overall Findings: • Most staff reported feeling positive about the initiative but had difficulty remembering the details of training.

• Some reported not having enough time to perform the intervention during work, or not feeling that work was the appropriate venue for this practice.

CONCLUSION • It is not easy to sustain lifestyle and/or work habit changes in a short period of time.

• It is important to create awareness among staff on the impact of fatigue on both an individual and unit level.

• Mindfulness practices remain underutilized in healthcare teams despite potential benefits.

• Mindfulness practices are both achievable and worthwhile, even with limited resources.

• It is possible to design a program on daily mindfulness practice but it is hard to measure the effect of this training on healthcare worker’s mental health in a short span of time.

Bernstein, S. (2019). Being Present Mindfulness and nursing practice. Nursing 2019. Retrieved on January 14, 2020 from Nursing 2019, vol 49-issue 6 pp. 14-17 Botha, E., Gwin, T., & Purpora, C. (2015). The effectiveness of mindfulness based programs in reducing stress experienced by nurses in adult hospital settings: a systematic review of quantitative evidence protocol. JBI Database of Systematic Reviews and Implementation Reports, 13(10), 21-29. doi; 10.11124/jbisrir-2015-2380 Caldwell, J. A., Caldwell, L., Thompsom, L. A., & Lieberman, H. R. (2019). Fatigue and its management in the workplace. Neuroscience and Biobehavioral Reviews, 96, 272–289. doi.org/10.1016/j.neubiorev.2018.10.024 Canadian Nurses Association. (2012). Nurse fatigue [factsheet]. Retrieved from https://www.cna-aiic.ca/-/media/cna/pagecontent/pdf-en/fact_sheet_nurse_fatigue_2012_e.pdf?la=en&hash=CF6B0942E8C1C16C96A60067860C9CA2E8C280B5 Fiorito, R. (2017). 12 Chair Yoga Poses For Stress. Pure Wow, Retrieved on January 11th 2020, from https://www.purewow.com/wellness/chair-yoga-poses Fletcher, E. (2020). Guided Morning Exercises-Ziva Meditation. You Tube. Retrieved on January 11, 2020, from https://youtu.be/-L6CE9HxF1k Howland, L.C., & Bauer-Wu, S. (2015). The mindful nurse, American Nurse Today, 10(9). Retrieved from https://dev01.americannursetoday.com/mindful-nurse/ Masters, E.(2009). Chair and Drive Time Yoga for Nurses. Scrubs. Retrieved on January11th 2020, from https://scrubsmag.com/chair-and drive time yoga-for–nurses/ Riet, P. V. D., Levett-Jones, T., & Aquino-Russell, C. (2018). The effectiveness of mindfulness meditation for nurses and nursing students: An integrated literature review. Nurse Education Today, 65, 201–211. doi: 10.1016/j.nedt.2018.03.018 Registered Nurses Association of Ontario. (2014). Managing and mitigating fatigue: tips and tools for nurses. Retrieved December 16, 2019, from https://rnao.ca/sites/rnao-ca/files/RNAO_ToolKit_2012_rev4_FA.p Registered Nurses Association of Ontario. (2011). Preventing and mitigating nurse fatigue in healthcare: Healthy work environments best practice guideline. Retrieved December 16, 2019, from https://rnao.ca/sites/rnaoca/files/Preventing_and_Mitigating_Nurse_Fatigue_in_Health_Care.pdf Robins, J. L., Kiken, L., Holt, M., & McCain, N. L. (2014). Mindfulness: an effective coaching tool for improving physical and mental health. Journal of the American Association of Nurse Practitioners, 26(9), 511–518. https://doi.org/10.1002/23276924.12086 Stewart-Weeks, L. (2018). 1-Minute Mindfulness Exercises. Psych Central. Retrieved on December 18, 2019, from https://psychcentral.com/blog/1-minute- mindfulness-exercises/

ACKNOWLEDGEMENTS We would like to acknowledge and thank the following individuals: Susan Beswick, Evidence Based Practice Nursing Manager Marta Sliz, Administrative Coordinator for Nursing Practice and Education Kimberly Tan, Clinical Nurse Educator, Heart and Vascular Program Victoria Buczek, Clinical Leader Manager, Heart and Vascular Unit Kamala Persad-Ford, Registered Nurse, Cardiac Investigation Unit Jennifer Trieu, Care & Transitions Facilitator, Cardiology

Standardizing the Approach to Pain Management in Patients with Advanced Dementia within a Palliative Care Setting Aysha S. Patel RN, BScN & Victoria McLean RN, BScN, CHPCN(C) FOCUS

PURPOSE & OBJECTIVES

• BPG Topic = Standardizing the Approach to Pain Management in Patients with Advanced Dementia Within a Palliative Care Setting • RNAO BPG = Delirium, Dementia, and Depression in Older Adults: Assessment and Care, Second Edition

Workflow

Purpose

PATIENT ARRIVES ON UNIT

• To standardize the approach to pain management for patients with advanced dementia, in PCU, who are unable to self-report, by implementing a validated assessment tool

DO THEY MEET PAINAD CRITERIA? • History of advanced dementia • Unable to self-report

Objectives

BACKGROUND In the Palliative Care Unit (PCU) at St. Michael’s Hospital (SMH), the pain experience of patients with advanced dementia, who are unable to self-report, is not met with a standardized approach

PCU RN Current State Survey

Yes: •ESAS •PAINAD on occasion •Comment: “Recently, we had a patient with advanced dementia and we used PAINAD. This was an effective tool to manage the pain of this patient.”

DOCUMENTATION • Complete PAINAD Scale Qshift and PRN • Complete IP/CADD Assessment if intervention is required

INTERVENTION/ PROCESS

Do •Pilot in PCU January 10 – March 6, 2020 (8 weeks) •Update stakeholders via bullet rounds and email

RESULTS PCU RN Post-Implementation Survey

Study •Post-implementation survey, small group discussions •Measure compliance and quality by reviewing health records

Yes: • PAINAD Scale

Compliance: Health Record Review Depression

Untreated/ Undertreated Pain Agitation and Delirium

Refusal of Care

RNAO BPG Practice Recommendations • Assess older adults with dementia for pain using a population specific, validated pain assessment tool (e.g. PAINAD Scale) • Monitor older adults with dementia for pain, and implement pain reduction measures

• Future integration into Electronic Health Record • 2020 Nursing Week BPG Sustainability Poster Gallery Walk Event • Submit poster abstract to present at 2020 International Congress on Palliative Care

Burns, M., & Mcilfactrick, S. (2015). Palliative Care in Dementia: Literature Review of Nurses’ Knowledge and Attitudes Towards Pain Assessment. International Journal of Palliative Nursing, 21(10), 479–487. doi: 10.12968/ijpn.

2015.21.8.400

Literature Review Sleep Disturbance

• Align with other Unity Health Palliative Care Units to standardize practice across organization

REFERENCES

Act •Revise process as necessary Figure 1 – PAINAD Scale

• Annual practice review at Palliative Care Council

IDENTIFY PATIENT ON KARDEX

• Improve nursing knowledge and skill related to pain management of the target population

Plan •In-service education sessions •Design PAINAD Scale to allow integration into health record •Create workflow

• Monthly health record review to measure compliance with feedback to staff

RECOMMENDATIONS/ NEXT STEPS

• Implement PAINAD Scale to assess and treat pain in target population

Issue

SUSTAINABILITY

Jansen, B. D. W., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., Mcilfactrick, S. J.,Parsons, C. (2016). Nurses Experiences of Pain Management for People with Advanced Dementia Approaching the End of Life: A Qualitative Study. Journal of Clinical Nursing, 26(910), 1234–1244. doi:10.1111/jocn.13442 Paulson, C. M., Monroe, T., & Mion, L. C. (2014). Pain Assessment in Hospitalized Older Adults With Dementia and Delirium. Journal of Gerontological Nursing, 40(6), 10–15. doi: 10.3928/00989134-20140428-02 Registered Nurses Association of Ontario. (2016). Delirium, Dementia, and Depression in Older Adults: Assessment and Care, Second Edition. Retrieved Nov. 13, 2019, from https://rnao.ca/sites/rnao.ca/files/bpg/RNAO_Delirium_ Dementia_Depression_Older_Adults_Assessment_and_Care.pdf

ACKNOWLEDGEMENTS Cecilia Santiago, Nursing Practice Manager Norman Dewhurst, Clinical Leader Manager Sheila Deans-Buchan, Nurse Practitioner Susan Beswick, Evidence Based Practice Nursing Manager

Implementing the Braden Scale and Prevention Plan on the Inpatient Mental Health Unit Carla Gomez, RN Mental Health, St. Michael's Hospital, Unity Health Toronto FOCUS To implement the Braden Scale and Pressure Injury Prevention Plan on the Inpatient Mental Health Unit 17CC.

RNAO BPG: Assessment and Management of Pressure Injuries for the Interprofessional Team (2016)

INTERVENTION/ PROCESS  Literature review completed

CONCLUSION

RESULTS Braden Scale completion audit results from November 1, 2019 to February 25, 2020

 Process map and pre-survey conducted to identify practice and knowledge gaps and assess confidence levels in nurses  In-service Education Sessions completed with nurses

Recommendation 1.2: Assess risk for developing additional pressure injuries and use a valid and reliable pressure injury risk assessment tool Recommendation 2.2: Develop a pressure injury plan of care Recommendation 5.2: Assess health-care professionals’ knowledge, attitudes, and skills related to the assessment and management of existing pressure injuries before and following educational interventions

 Audits conducted to assess compliance rates

• Nurses have voiced that the implementation of the Braden Scale tool and prevention plans have strengthened their assessment skills.

 Post-survey completed by RNs to determine if there was an increase in their knowledge and confidence in assessing pressure injury risk and creating pressure injury prevention plans.

RECOMMENDATIONS/ NEXT STEPS • Braden Scale reminder to be added to the Unit Documentation Reminder Sheet.

• Braden Scale Score sticker to be added to the patient care plans.

• Individuals with mental health illnesses can have a higher incidence of poor physical health (Melamed et al. 2019).

• Mental health patients have a higher rate of diabetes and obesity which can affect mobility and activity (Norton et al, 2017).

• In 2019, the Mental Health Unit did not use a standardized tool to assess for pressure injury risk.

OBJECTIVES • To increase the completion of Braden Scale assessment and pressure injury prevention plans for Mental Health patients within the first 8 hours of admission.

• Increase staff knowledge and confidence levels when assessing for pressure injury risk.

• The Braden Scale assessment tool and prevention planning intervention were implemented on the inpatient mental health unit to assess patients’ risk and prevent pressure injuries.

• The completion of Braden Scale assessments have increased by approximately 82% on the inpatient mental health unit.

BACKGROUND

• Mental health conditions can lead to inadequate nutritional intake, stupor, mental inactivity and a reduced response to stimuli, thereby increasing pressure injury risk (Woodbury & Hougton, 2004).

• Individuals with mental health illnesses are at risk of developing pressure injuries due to a higher incidence of poor physical health.

• Braden Scale assessment and prevention techniques will be included in nursing orientation for newly hired nurses.

• Audits will be completed quarterly to determine compliance

Process Map – New current state

Post-Survey Results 92.86% of RNs feel extremely confident or very confident completing a Braden Scale assessment after in-session education – an increase of 75% 35.72% of RNs feel extremely confident or very confident treating level 1 and level 2 pressure injuries – an increase of 25.01% 57.14% of RNs feel very confident recognizing level 1 and level 2 pressure injuries – an increase of 22.14%

REFERENCES Canadian Institute for Health Information. (2016). Hospital Harm Improvement Resource: Pressure Ulcer. Retrieved from https://www.ehealthsask.ca/services/resources/Resources/PSA-17-18-03- Preventing-PressureUlcers-in-Acute-Care.pdf Melamed, O.S., Fernando, I., Hahn, M.K., LeMessurier, K.W., Soklaridis, S. & Taylor, V.H. (2019).

Undering engagement with a physical health service: a qualitative study of patients with severe mental illness. The Canadian Journal of Psychiatry, 64(12), 872-880.

Norton, L., Afalavi, A., Ho, C., Johnston, D., Mark, M., Moffat, S., O’Sullivan-Drombolis, D. & Parlow, N. (2017). Best practice recommendations for the prevention and management of pressure injuries. Wounds Canada. Retrieved from: https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/172-bprprevention-and-management-of-pressure-injuries-2/file

ACKNOWLEDGEMENTS Cecilia Santiago RN, MN, CNCC (C) Tasha Penney RN, MN, CPMHN(C) Ifat Witz BA (Hon), MA, CHE

Engaging Patients and Families during their stay in MSICU Daniel Agbuis, Cecilia Santiago, Shannon Swift, Fionna Yau St. Michael’s Hospital, Unity Health Toronto FOCUS

PRE-INTERVENTION RESULTS

INTERVENTION/ PROCESS

Pre-intervention results led to the creation of tools that incorporate family needs and preferences while also guiding RNs to include family engagement interventions in their plan of care.

To develop a standardized protocol to assist RNs in responding to patient and family needs throughout their stay in the MSICU.

BACKGROUND There is a lack of organization and standardization in the processes surrounding family engagement in the ICU. This results in decreased capacity and confidence of RNs to support patient and family needs and a lack of adequate engagement and involvement in their plan of care.

The objective of this protocol is to promote positive partnerships with family members in meeting their particular needs and wishes. The purpose is to assist RNs to prioritize family engagement and to serve as a guide to complete family engagement interventions.

Unfortunately, due to the COVID-19 pandemic, family members and visitors were prohibited from visiting during the implementation phase of my project. As a result, this project has taken a hiatus and will resume once families are permitted to return.

Prior to the pandemic, the following were completed: • bedside education and engagement with nurses about the tools and their role in promoting family engagement • presentations with social workers and spiritual care providers about the tools and their utility in family engagement.

As a result, patient and family needs are often overlooked and their needs are not given adequate priority. The tools introduced in this project will assist RNs to incorporate family engagement in their nursing routines

OBJECTIVES

RECOMMENDATIONS/ NEXT STEPS

SUPPORTIVE CARE ALGORITHM Patient admitted to MSICU for 048 hours

Advocate for family meeting

NO

Proceed to 4896 hour protocol

Clinical triggers?

YES Patient still in MSICU 48-96 hours?

YES

YES

NO

Anticipated discharge in 12 hours?

Proceed to 48-96 hour protocol

NO

Next steps: • Trialing the use of the checklist on the flow sheet while continuing to receive feedback from frontline staff on its usefulness • Continue to engage in active education with staff • Refer staff to tip sheets posted around the unit and at each bedside SUPPORTIVE CARE CHECKLIST • Gain feedback from family members on how this new protocol has helped meet their personal preferences during their stay in the ICU • Algorithm will guide clinical decision making on family engagement interventions. • Audit algorithm and checklist use and relate to amount of family • Checklist compartmentalizes family engagement interventions into chronological meetings arranged time periods relative to the patient’s admission length.

• Relate audit results to patient and family satisfaction scores on • Checklist is placed on the patient’s flow sheet for daily documentation. patient/family survey post discharge, once sophisticated systems are in • Clinical triggers are circumstances that increase the patient’s risk of mortality. If any place to gather such information of these are present, the clinician is urged to advocate for a family meeting to discuss goals of care with the family.

REFERENCES

D/C protocol YES

Advocate for family meeting

NO

Proceed to >96 hour protocol

Clinical triggers?

Huffines, M., Johnson, K. L., Smitz Naranjo, L. L., Lissauer, M. E., AnnMichelle Fishel, M., DÂ, A. H. S. M., … Smith, R. (2013). Improving Family Satisfaction and Participation in Decision Making in an Intensive Care Unit.

Critical Care Nurse, 33(5), 56–69.

ACKNOWLEDGEMENTS YES Patient still in MSICU >96 hours?

YES

Anticipated d/c in 12 hours?

NO

D/C protocol Advocate for family meeting Discuss disposition with ICU team

Follow up with family

• Nursing Practice and Education for funding this project.

• Mentors: Cecilia Santiago, Shannon Swift, Fionna Yau and Ellen Lewis for their continued support of my professional development and allowing me the opportunity to take on this project in the MSICU. • MSICU colleagues for their involvement in evidence-based initiatives to promote family engagement in the MSICU. D/C protocol after 14 days of admission