2018 Nursing Week: BPG Sustainability Virtual Poster Gallery

2018 Nursing Week BPG Sustainability Virtual Poster Gallery

Implementing Purposeful Rounding on Inpatient Nephrology/Urology Emily Sestito, RN and Christine O’Brien Kirch, RN

FOCUS •

BPG Topic: Improving Accountability and Patient Safety with Focused Hourly Rounding

•

RNAO BPG that aligns with our initiative: • • •

QUALITATIVE RESULTS

CURRENT STATE

• “Nurses and CAs working together”.

• “Team rounding was encouraged”.

• “More eyes can check the patients better and we can assist the patients better when they need it”.

• “More immediate care for patients who tend to wait to call”.

• “I like that two people go for rounds – improves safety if there is an emergency”.

Establishing Therapeutic Relationships: An intervention through which comfort, support and provision of care is facilitated Professionalism in Nursing – Accountability Preventing Falls and Reducing Injury from Falls:

CONCLUSION • Staff overall expressed an increasing sense of empowerment and team work when working overnight.

• Staff felt that patient safety was improved by implementing a consistent and formalized rounding practice.

BACKGROUND • Conflict arising between staff regarding who and when patient rounds should be completed on night shift. As a result patient safety is compromised as there is no consistent and reliable process outlined.

• Identified gap in process and opportunity for improvement: • Currently there is no formal rounding protocol to hold RN responsible for a consistent approach to hourly rounding. Furthermore, there is no documentation process to reflect hourly rounding.

• Purposeful (or intentional) Rounding has been successfully implemented on several inpatient units across the organization. This project is an opportunity to spread this initiative to the Inpatient Nephrology/Urology unit to support patient safety, and patient and staff satisfaction

PURPOSE & OBJECTIVES • To implement a standard practice of purposeful rounding (amongst CAs and RNs) that will improve patient safety by: • decreasing falls; • improving nurse/client therapeutic relationship; and • improving accountability.

Outcome measures: • 80% of RNs and CAs working on Inpatient Nephrology/Urology will receive education on the purposeful rounding initiative • 75% compliance with sign-up for purposeful rounding • 50% compliance with RNs documenting code status on the purposeful rounding sheet • 60% of RNs and CAs report overall satisfaction with the purposeful rounding initiative

INTERVENTION/PROCESS • Did a pre-implementation survey with RNs and CAs to learn about current informal rounding practices and to engage frontline staff in the process of developing the structured nightly purposeful rounding

RECOMMENDATIONS/NEXT STEPS RESULTS • 76% of RNs and CAs received training

• Developed and implemented an hourly nightly purposeful rounding format and sign up sheet, adapted from other St. Michael’s Hospital inpatient units, to improve accountability and assess sustainability: • All RNs and CAs will sign up for a rounding time before 2400 • Hourly purposeful rounds will be conducted between 2400 – 0500 • Staff will address the 4 P’s • Documentation will be on log sheet for each patient • Educated staff on expectation regarding the standardized purposeful rounding practice: • role definition of CA/ RN • explanation of the 4 P’s of intentional rounding • introduction to the new rounding documentation tool and format • Revised hourly nightly purposeful rounding sign up sheet once, based on feedback received from frontline RNs and CAs

Presence

Pain

Positioning

Proximity (of personal belongings)

• A pre-implementation survey of all staff demonstrated 50% were satisfied with the current informal rounding practice.

• A post-implementation survey was completed by 10 staff members and demonstrated that 60% were satisfied with Intentional Rounding.

• Will continue to monitor compliance through audit of Report Sheet • Will update Report Sheet based on recommendations from staff • Will strategize for improving distribution of workload during sign up

REFERENCES Registered Nurses’ Association of Ontario (2007). Professionalism in Nursing. Toronto, Canada: Registered Nurses’ Association of Ontario Massachusetts General Hospital, (2013). Hourly Safety Rounds, Blake 12 ICU . Accessed from: http://www.mghpcs.org/Innovation_Units/Documents/Blake12_HourlyRounding0613.pdf Mitchell, D., Lavenberg, J.G., Trotta, R. & Umscheid, C.A. Hourly Rounding to Improve Nursing Responsiveness: A Systematic Review. Accessed from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547690/ Harris, R., Sims, S., Levenson, R., Gourlay, S., Ross, F., Davies, N., Bearley, S., Favato, G. & Grant, R. (2017), What aspects of intentional rounding work in hospital wards, for whom and in what circumstances? A realist evaluation protocol. BMJ Open,7(1)

ACKNOWLEDGEMENTS Colleen Johns, Clinical Leader Manager, Inpatient Nephrology/Urology Colleen McNamee, Corporate Nursing Education Manager Marta Sliz, Administrative Coordinator, Nursing Professional Practice Donna Romano, Evidence-Based Nursing Practice Manager (interim) All the RNs and CAs who participated in implementation and evaluation of this initiative on the Inpatient Nephrology/Urology

Standardizing the Assessment and Management of Wound Care in the Family Health Team Amber Bala BScN (Hons) RN, Gail Sumagang BScN (Hons) RN Department of Family and Community Medicine

FOCUS

INTERVENTION/PROCESS

 Standardizing Wound Care Practices within the Family Health Team (FHT)

 Needs assessment survey done in January/February 2018  90% respondents participated in survey

 Current phase focusing on RNs

RN Confidence in Assessment, Description & Measurement of Wound

 Attendance at RNAO’s Wound Care Conference 2018

Extremely confident

Based on needs assessment survey, there is a clear need for standardized wound care within the FHT. What did we learn?

2

Very confident

3

Moderately confident

 RNAO BPG: Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational, and system outcomes, December 2013. Recommendation 11.1b

 Buy in from staff is key for support  Be the face of the cause – keep the team informed  Presenting a problem works best when you can present a solution

10

Slightly confident

9

Not at all confident

1 0

2

4

6

8

10

12

RECOMMENDATIONS/NEXT STEPS

BACKGROUND No “Gold Standard” to wound care provided. FHT addresses wound care in a different capacity compared to at the bedside because:  No FHT-specific wound care guidelines currently exist  Patients frequently see different clinicians with differing levels of knowledge, confidence, and experience in wound care  No consistency in wound care supplies between the 6 FHT sites  No FHT-specific wound care documentation tool currently exists The above information was gathered from a survey aimed at our nursing population within the FHT

PURPOSE & OBJECTIVES

• Education • Draft of PowerPoint presentation to present to RNs • Tentative dates of when to present information to RNs is planned

RN Confidence in Performing Wound Care

Extremely confident

• Draft of Patient Solutions Suite (PSS) documentation tool:

6

Moderately confident

11

Slightly confident 0 0

2

4

6

8

10

Pilot PSS wound care documentation tool at one site Provide education to all FHT RNs in all 6 sites PDSA results and subsequent PDSA cycle for MDs Involve interprofessional health care team members Post needs assessment survey after education delivery Continued advocacy by present champions, involve more RNs PSS documentation tool used for every wound care visit eLearning course for FHT RNs Standardize wound care supplies across all 6 sites Apply for BPG program 2018-2019

12

PSS Forms Used to Document Wound Care

REFERENCES Fletcher, J. (2007). Wound assessment and the TIME framework. British journal of nursing, 16(8), 462-466.

SURVEY RESULTS RNs who Attended Wound Care Class in Past 2 Years (n=25)

25

Morison, M., Ovington, L. G., & Wilkie, K. (Eds.). (2004). Chronic wound care: a problem-based learning approach. Mosby Incorporated.

23

20

Sibbald, R. G., Williamson, D., Orsted, H. L., Campbell, K., Keast, D., Krasner, D., & Sibbald, D. (2000). Preparing the wound bed-debridement, bacterial balance, and moisture balance. Ostomy/wound management, 46(11), 14-22.

15

Yes 24%

10 5

No 76%

         

5

Not at all confident

Achievement Aims: Identify knowledge gaps Incorporate evidence based information into practice Creation of standardized documentation tool Provide education to FHT RNs

3

Very confident

Goal: Standardize provision of wound care in the FHT in order to achieve better patient outcomes

   

CONCLUSION

3

ACKNOWLEDGEMENTS 1

0 RN No form/free Preassessment type

Other

Many thanks to Nursing Education & Practice for sponsoring this BPG initiative, our mentor Donna Romano RN, MSc, PhD, CPMHN(c) for guidance and encouragement, our DFCM Management Team (Jackie Chen , Nanette Lang, Bethany Kwok), our wonderful wound care working group, Lisa Miller for PSS support, and the SMH Wound Care Team for informational support

Transfer of Accountability for Maternity Patients Amy Burke, RN St. Michael’s Hospital

FOCUS •

•

Improving Transfer of Accountability (TOA) between nurses on Labour & Delivery and Postpartum/Combined Care units • Development and implementation of new standardized TOA checklist • Raising awareness of importance of TOA at bedside Promoting alignment with RNAO Best Practice Guidelines for Care Transitions, specifically: • Using standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions.

• Collaborating with the client, their family, and caregivers.

BACKGROUND • Opportunity to improve patient safety and patient experience, as well as better align to hospital policy, during Transfer of Accountability (TOA) between nurses.

• As per SMH hospital policy, 4 essential elements of TOA: 1) conducting TOA at the bedside 2) engaging patient and/or family (with patient’s consent) 3) performing safety checks 4) following a standardized format

OBJECTIVES • Develop a standard TOA checklist that is used by nurses for TOA at least 50% of the time by January 2018.

• Raise awareness for the importance of bedside TOA, with a focus on understanding the patient perspective.

METHODS (continued) 2. Staff nurse survey on usefulness of TOA checklist • Brief, online survey conducted January 2018. N=21 respondents.

3. Patient survey on experience of bedside TOA • Interviews conducted face-to-face at patient bedside, during February 2018. N = 21 respondents.

• Patients interviewed were stable, asked for consent and informed that results would be anonymized.

FINDINGS (continued)

CONCLUSIONS

Patient Experience Survey

TOA Checklist

• Overall, during the patient experience interviews, patients spoke enthusiastically about the amazing care they had received from nurses during their hospital stay.

Overall, how satisfied were patients with the way their care was transferred between nurses?

What aspects of bedside TOA did patients find valuable?

Knowing name and face of new nurse

Very satisfied

FINDINGS

Feeling safe

Somewhat satisfied

• 62% of nurses self-reported using the TOA checklist less than 50% of the time.

• Top 3 factors preventing nurses from using TOA checklist during report: • Prefer to use other parts of the chart for report: 76% • Feels like extra charting: 62%

Bedside TOA

Decreasing their anxiety

Very unsatisfied

Staff Nurse Survey

• Overall, nurses found the TOA checklist useful for improving patient safety, however it did not fit easily into their workflow.

• The majority of nurses were using the TOA checklist less than 50% of the time.

• The top 3 factors preventing nurses from using the TOA checklist were: preferring to use other parts of the chart for report, disliking the feeling of extra charting, and the checklist not being part of their regular routine.

Opportunity to ask questions

Somewhat unsatisfied

0%

50%

100%

Gaining a better understanding of their…

0% 20% 40% 60% 80% 100%

Above graphs show responses from Patient Experience survey conducted February 2018, N=21 respondents.

Comments from our patients regarding bedside TOA:

• Overall, the majority of patients were very satisfied with the way their care was transferred between nurses.

• The top 2 reasons why patients found beside TOA valuable were: 1. Knowing the name and face of their new nurse 2. Feeling safe in the knowledge that the appropriate health information had been transferred between the outgoing and oncoming nurse.

• We can learn from the patients’ suggestions on how their TOA experience could have been improved. Sometimes small changes can make a big difference for patients.

• Not part of regular routine: 48%

How useful is the TOA checklist sheet for improving patient safety?

How useful is the TOA checklist sheet for making nurses’ work easier?

“The most important thing is that information is transferred properly - and that should ideally happen in front of the patient so that they know it's happened.”

RECOMMENDATIONS/NEXT STEPS • Further investigation of how the TOA checklist could be adapted to integrate more seamlessly with the current nursing documentation workflow.

• Share results of patient experience survey with staff nurses.

METHODS 1. New TOA checklist for use during shift-to-shift and unit-to-unit TOA

Not at all useful Not so useful

Not so useful

Somewhat useful

Somewhat useful TOA Checklist •Developed iteratively with input and feedback from staff nurses •Paper checklist sheet routinely placed in all patient charts by clerk

“Bedside TOA is valuable because it covers important information, and leaves you knowing that you won’t have to tell the nurse the same things again.”

Not at all useful

Very useful

Very useful

Extremely useful

Extremely useful 0%

100%

0%

20% 40% 60%

Above graphs show responses from Staff Nurse Survey conducted January 2018, N=21 respondents.

“When you are a patient, you want to know as much about your health status as possible”.

Suggestions from our patients on how we could improve the TOA experience for them: • “Sometimes the nurses did not seem friendly to each other at TOA. This could be a bit unsettling.”

• “It would be helpful if nurses tried to talk more quietly during TOA in order to avoid disturbing the other patient(s) in the room”.

ACKNOWLEDGEMENTS My sincere thanks for the support of: Sharon Adams, RN, MN, PNC(C) Clinical Nurse Educator, Obstetrics & Gynecology Mary Murphy, RN, MN, Clinical Leader Manager Obstetrics/Gynecology/NICU Cecilia Santiago, RN, MN, CNCC(C) Nursing Practice Manager All the nurses and unit clerks on 15CC North and South.

Medical-Surgical Intensive Care Unit (MSICU) Best Practice Guideline (BPG): Assessment and Management of Lower Leg Venous Ulcers Anna Kha, RN, BScN St. Michael’s Hospital

FOCUS  MSICU adoption of the Registered Nurses Association of Ontario (RNAO) Best Practice Guideline (BPG) on Assessment and Management of Venous Leg Ulcers  Lower leg assessment and management of venous insufficiencies:  Adopt ankle brachial pressure index (ABPI) as a bedside assessment tool prior to the application of compression bandages  Using compression bandage wrapping as the Gold Standard for venous leg ulcers and venous insufficiency

BACKGROUND  Four years ago at RN education day in MSICU, the wound care team provided in-service on performing ABPI/ABI and compression for venous insufficiencies.  Patients presenting with venous insufficiencies, and venous ulcers requires better control of their edema  BPG Nurse champion will work with the wound care team to support the MSICU team in growing their knowledge and maintaining this skill set and enhancing patient care in MSICU Process Map

RECOMMENDATIONS/NEXT STEPS

RESULTS

PURPOSE & OBJECTIVES  Perform a comprehensive lower leg assessment  Identify venous insufficiency and leg ulcer clinical presentation  Helping colleagues feel more confident when caring for patients with venous insufficiency  Becoming more familiar with ABPI and compression bandages

Pre-Survey Questionnaires

 Attend St. Michael’s Hospital Level 4 Wound “Best Practices in Leg Ulcers management” class for more in-depth learning  Recruit mini-champions in MSICU to sustain the BPG  Keep up-to-date with new BPG recommendations  Provide review and education every 2 years

INTERVENTION/PROCESS  Informed MSICU staff of BPG Quality Improvement project through posters, emails, and presented at MSICU PACE Education Days  Created and emailed pre-survey questionnaires assessing nurses’ confidence in knowledge and skills application of ABPI and compression wrapping  Provided several in-service education sessions based on presurvey results  Reviewed post-survey questionnaire after in-service was assessed  Adopted and created the ‘Interpreting ABPI’ chart placed next to the compression bandages  Informed nurses of ABPI worksheet accessibility (located in filing cabinet) Interpreting Ankle Brachial Pressure Index* Chart ABPI Ranges

Information

Possible Cause of Ulcer

Type of Compression

>1.3

Calcified arteries

Diabetes

Incompressible arteries

0.8-1.25

Normal

Venous disease

High: 3040mmHg

Examples of therapeutic bandaging

Picture

Coban™ 2 (Elastic) 3M™ Canada Company, 2012.

0.6-0.8

Mild to Moderate PAD

Mixed venous and arterial

Moderate: 1520mmHg

Coban™ 2Lite (Elastic) 3M™ Canada Company, 2012.

Comprilan (Inelastic) BSN medical© ;2018.

Below 0.6

Severe PAD to critical ischemia

Arterial diseases

Compression not recommended Consider Vascular Surgery Consult

*A complete current and past medical health history must be considered Sources: Wounds Canada, 2006; RNAO, 2004; SMH Level 4 Wound Care, 2017; 3M™ Canada Company, 2012; BSN medical© ;2018.

CONCLUSION  The in-services on how to perform ABPI and Compression Bandages improved MSICU nurses’ confidence and comfort in performing these added skills

Post In-Service Questionnaires

REFERENCES  Burrows, C., Miller, R., Townsend, D., Bellefontaine, R., MacKean, G., Orsted, H., & Keast, D. (2007). Best practice recommendations for the prevention and treatment of venous leg ulcers: update 2006...reprinted with permission from Wound Care Canada. The Official Publication of the Canadian Association of Wound Care (2006; 4[1]:45-55). Advances in Skin & Wound Care, 20(11), 611621.  O’Meara, S., Cullum, N.A., & Nelson, E.A.. (2009). Compression for Venous Leg Ulcers (Review). The Chochrane Collaboration. Published by John Wiley & Sons, Ltd.  RNAO. (2007). Assessment and Management of Venous Leg Ulcers. RNAO Nursing Best Practice Guideline. Retrieved from http://rnao.ca/sites/rnaoca/files/Assessment_and_Mangement_of_Venous_Leg_Ulcers.pdf  Singer, A. J., Tassiopoulos, A., & Kirsner, R. S. (2017). Evaluation and Management of Lower-Extremity Ulcers. The New England Journal of Medicine, 377(16), 1559-1567. doi: 10.1056/NEJMra1615243  Society for Vascular Nursing. (2016). SVN Images. Retrieved from https://svnnet.org/resources/svn-images/  Sononet Professional Ultrasound Services for Primary-care Physician Offices.

(2010). ABI Worksheet. Retrieved from http://www.sononet.us/abiscore/documents/abi_sheets.pdf  St. Michael's Hospital. (2017). Level 4 Best Practices for Assessment and Management of Leg Ulcers. Wound Care Team.

ACKNOWLEDGEMENTS SMH Nursing Professional Practice Thank you to all of MSICU Staff for your interest and participations in this project!

Karen Wanamaker RN, MN, CLM MSICU Shannon Swift RN, MN, Nurse Educator MSICU Colleen McNamee, BPG CoP, Professional Practice Mentor SMH Wound Care Team and Janeth Velandia, NP

Lend a H.A.N.D. Ashley Mercer R.N. BScN St. Michael’s Hospital, Trauma/Neuro ICU FOCUS RNAO Best Practice Guideline • Workplace Health, Safety and Well-being of the Nurse.

Recommendations 2.0 and 3.1

BACKGROUND

INTERVENTION/PROCESS

RESULTS

Lend A H.A.N.D. Intervention

The tool is live and at this time, it has not yet been utilized. The debrief tool will be used to evaluate the RN’s experience raising a H.A.N.D.

H. = Help A. = Another N. = Nurse D. = Deliver Care

“Critical care professionals are exposed to serious occupational stressors such as: time pressure, reduced social support at work, excessive workloads, moral and spiritual distress related to ethical issues, uncertainty concerning patient treatment and high risk to develop negative emotional responses due to exposure to suffering and dying patients.”(Arrogante and Aparicio-Zaldivar, 2017).

Nurses working less than 2 years have the least compassion satisfaction, the least burnout and the lowest secondary trauma.

Nurses working 2-5 years have some of the highest compassion satisfaction, tied with nurses working greater then 10 years. Nurses 2-5 years have the second highest burnout scores, second only to nurses working 5-10 years. They have the lowest secondary trauma scores.

Nurses working 5-10 years have the highest burnout scores compared to any other demographic and the second highest secondary trauma scores.

Nurses working greater than 10 years have some of the best compassion satisfaction scores, some of the lowest burnout scores and some of the lowest secondary trauma scores.

Most at risk nurses are nurses working 5-10 years in relation to burnout and secondary trauma scores and are falling in their compassion satisfaction scores.

Nurses most in need of compassion satisfaction boosts are nurses working less than 2 years. (PROQOL, Version 5, 2009).

PURPOSE & OBJECTIVES To create a unit wide culture of support, team work, and to foster excellence in critical care resiliency regardless of years of experience.

To achieve a streamlined, algorithmic approach to managing the most common stresses a TNICU RN can experience.

To create a framework any nurse can trust. If activated, help will arrive and the RN’s stressful situation will be managed quickly, effectively and supportively.

To identify the TNICU’s most at risk nurses using a Pre and Post Intervention survey measuring Compassion Satisfaction, Burnout and Secondary Trauma known as PROQOL Version 5 2009.

CONCLUSION Although the tool has not yet been utilized, there have been many instances that nurses have said “I could have raised a H.A.N.D. during….situation” or “I almost raised a H.A.N.D.” Hopeful, that this will be a valued resource once the unit has practiced this intervention and can trust it works and will always be available.

RECOMMENDATIONS/NEXT STEPS Focus on sustainability: New Hires will receive training on the “Lend a H.A.N.D.” intervention upon arrival to the TNICU. Ongoing promotion of the Lend a H.A.N.D. tool in staff meetings and huddles and through interaction with staff one on one.

REFERENCES Arrogante,J., Aparicio-Zaldivar, E., 2017.Burnout and health amount critical care professionals: The mediational role of resilience. Intensive and Crit. Care Nursing 42, 110-115.

Professional Quality of Life Scale:Compassion satisfaction and compassion fatigue (ProQol) Version 5, (2009).

ACKNOWLEDGEMENTS Ellen Lewis, CLM TNICU; Corinne Risling, Educator TNICU Donna Romano, Evidence Based Practice Interim Manager & The Interdisciplinary Team in the TNICU

Transfer of Accountability from Outpatient to Inpatient Settings Anna Karpenko RN, Ekaterina Mikhelson RN & Irene Pryshlak RN St. Michael’s Hospital

FOCUS

RN SURVEY OF TOA NEEDS

RESULTS

SUSTAINABILITY

Transfer of Accountability (ToA) from outpatient to inpatient settings

1. Is there a standardized ToA tool on your unit?

2. Is there a clear process of transferring accountability when you transfer a patient to an admitting unit/ER? 3. Is there a proper place to document patient condition and needs before transferring a patient to another unit?

4. Do you feel confident that you transfer all information when giving verbal ToA? 5. Do you think a standardized ToA tool will help to ensure the safe transition of patient care during transfer from outpatient to inpatient settings?

As our tool is still in the initial piloting process, we currently are not able to present any results. We anticipate to have our final result and revised tool by March 2019.

•

•

The ToA tool has been used a number of times in both Positive Care and Marotta Specialty Clinics

Barach P. Handover: improving the continuity of patient care through identification and implementation of novel patient handover processes in Europe. Project website, 2015. Available from: http://www.handover.eu/index.html

INTERVENTION/PROCESS

•

So far, the feedback revealed the tool has provided great structure and form to aid the transfer of patients from the clinics to admitting units

Eggins S, Slade D. Communication in Clinical Handover: Improving the Safety and Quality of the Patient Experience. Journal of Public Health Research. 2015;4(3):666. doi:10.4081/jphr.2015.666.

•

Positive verbal feedback has been received from the receiving floor RNs ie. 16CC & ER

Tregunno, D., Jeffs, L., Hall, L. M., Baker, R., Doran, D., & Bassett, S. B. (2009). On the Ball. JONA: The Journal of Nursing Administration, 39(7/8), 334-339. doi:10.1097/nna.0b013e3181ae9653

RNAO Best Practice Guideline • Care Transitions • Professionalism in Nursing • Collaborative Practice • Person Centered Care

BACKGROUND The Problem • Lack of consistency in ToA practices among Specialty Clinics RN

Why is it an Issue?

• Ineffective communication is a well-recognized contributor to patient harm in hospitals (Barach, 2015).

• Ineffective ToA can lead to wrong treatment, delays in medical diagnosis, life-threatening adverse events, client complaints, increased health care expenditures, increased hospital length of stay and litigation (Tregunno, 2009).

PURPOSE & OBJECTIVES Goal •

To develop a standardized approach to ToA from outpatient clinics to acute settings through the development and implementation of a ToA Tool that can be added to the patient medical record

What were you hoping to achieve?

•

To develop a ToA tool that is tailored to Specialty Clinics

•

To improve the effectiveness and coordination of communication among nurses

•

To support safe, effective care practices and efficient flow of patients from Specialty Clinics to inpatient units

1. A RN ToA Tool was created for proper transfer of patients from outpatient clinics to acute settings

2. A definition key was developed on the reverse side of the tool to allow a better understanding and standardized approach of the expectations for completing the tool.

Audits will be preformed on a quarterly basis

• The paper ToA tool will be incorporated into the electronic medical record • Integration of ToA tool will support a consistent approach to handovers • Connect with senior management to organize a “TOA awareness” month at regular intervals to encourage clinics to collect new data and update or improve their processes as necessary

CONCLUSION Up to date

REFERENCES

RECOMMENDATIONS/NEXT STEPS • Modify the handover tool as needed • Incorporate the ToA tool into unit-based orientation program • Implement this tool into other Specialty Clinic areas ie. Breast Cancer Centre • Apply findings to other transitional care points across the larger organization through collaboration with Transfer of Information Working Groups and practice councils

Contact Information/Acknowledgements 4CC Specialty Clinics: 416-864-6060 ext.: 2732 Anna Kacikanis - Clinical Leader Manager

Interprofessional Family Communication Tool in the Trauma and Neurosurgical Intensive Care Unit Chantel Barry, BScN, RN, CNN(c) St. Michael’s Hospital

FOCUS

INTERVENTION/PROCESS

RESULTS

RECOMMENDATIONS/NEXTSTEPS

RNAO BEST PRACTICE GUIDELINE

1. Development Required several meetings, revisions and PDSA Cycles to ensure buy-in

Individual component completion varied, but the overall compliance rate was 15%

The next step is to revise the tool based on recently gathered staff feedback: • Kardex should have a “Family Communication” subheading for ongoing updates • Ongoing Communication should be accounted for on the 24-hr task chart rather than a stand-alone tool to increase compliance

Developing and Sustaining Interprofessional Health Care: Optimizing patient, organizational and system outcomes. Recommendation 10.1 was utilized to inform this initiative.

BACKGROUND LITERATURE The quality of communication largely influences families perception of overall care provided (Peigne et al., 2011) TNICU FAMILY SATISFACFTION SURVEYS Reviewed TNICU Family Satisfaction Surveys from previous two years RN’s and MD’s scored average or less 12% and 33% respectively in communication related areas Families identified a need for more consistent and frequent communication from the Interprofessional Team stating:

2. Components of the tool At Time of Admission Communication • Family Presence with 2 hours of Admission • Acute Phase Introductions • ICU MD Introductions

Continue to focus on sustainability by doing bi-monthly audits New hires will have orientation training regarding the use of the Interprofessional Family Communication Tool

Ongoing Interprofessional Communication • Bedside Communication • Family Meeting within 5 days of admission 2. Formatting • Tool exists as a sticker on the back of the Nursing Flow Sheet • Colourful sticker on the front of Nursing Flow Sheet to prompt completion 3. Dissemination Presented the tool to all health disciplines and outlined objectives, expectations as well as how to fill out the tool NOT APPLICABLE

“There needs to be improvement in how to contact family when someone is admitted – more timely …”

4. Implementation Huddles, emails and discussion regarding “GO LIVE” date

“…would have liked the family conference so that we would know what happened in the operation room and what to expect…”

PURPOSE/OBJECTIVES There is currently no streamlined approach for Interprofessional Family Communication in the TNICU To implement an Interprofessional Family Communication Tool in the TNICU to streamline the team’s approach to communication as a strategy to improve family satisfaction (reflected in Family Satisfaction Surveys) TARGET GOAL: 15% compliance by Audit #1 25% completion rate by second month of project implementation Increase MD and RN Family Satisfaction Scores by 5% over 2 months in communication related areas

REFERENCES CONCLUSION The Interprofessional Family Communication Tool has reached the target goal of 15% compliance by Audit #1 Staff have claimed that “if nothing else, the Reminder Sticker serves as a tool on rounds to remember to communicate with families” and that “team members are engaging with families more readily since the tool was implemented”

Peigne, V., Chaize, M., Falissard, B., Kentish-Barnes, N., Rusinova, K., Megarbane, B., ... & Georges, H. (2011). Important questions asked by family members of intensive care unit patients. Critical care medicine, 39(6), 1365-1371 Reader, T. W., Flin, R., Mearns, K., & Cuthbertson, B. H. (2007).

Interdisciplinary communication in the intensive care unit. British journal of anaesthesia, 98(3), 347-352.

ACKNOWLEDGEMENTS Through implementation, we are able to identify members of the team who require more encouragement/education regarding family communication Further study is required to identify if increased compliance rates translate to increased Family Satisfaction Survey scores in communication related areas

Ellen Lewis, TNICU Clinical Leader Manager Corinne Risling, TNICU Clinical Nurse Educator Donna Romano, Evidence Based Practice Nursing Manager

Standardizing Advance Care Planning Assessment with Cystic Fibrosis Patients Jessie Kar Yan Chiu, BScN., RN, Erin Cuaresma, BScN., RN & Grace Appiah- Kubi, BScN, RN St. Michael’s Hospital Respirology Department, Specialized Complex Care

BACKGROUND Cystic Fibrosis (CF) is a life-limiting congenital disease, with most patients dying at a young age of progressive lung disease. Lung transplantation offers hope for many but may not occur.

The dual objectives of maintaining hope for transplantation while simultaneously preparing for end of life is a great challenge for patients, families and staff (Braithwaite et al., 2011).

RECOMMENDATIONS/ NEXT STEPS

INTERVENTION/PROCESS

Pre- intervention and investigation stage

• Chart Audit • Patient Survey (Previous BPG 2016-17): • 97% of patients have not talked to CF Team about ACP • Only 5% of patients have knowledge of what ACP is

Intervention

• ACP Brochure – final edition submit to literacy specialist • In-service education with Staff RN & SW • Distribute ACP Brochure on admission • SW to see patient 3-5 days after distribution of brochure • Documentation on shared drive excel sheet

• Multiple PDSA cycles in creating brochure.

• Continuous feedback from MD, RN & SW via one-on-one conversation.

• Literacy Specialist to approve language on brochure.

• No standardized approach on initiating “The Talk”.

• “The Talk” can be considered a “taboo”.

• Patient’s end-of-life wishes might not be addressed, which could result in poor communication prior to their death.

• In a study with 20 CF patients records, only 15% of patients had a do-not-resuscitate order agreed to more than 1 week prior to death. (Philip et al., 2008).

• Majority of patients have NO Advance Care Planning (ACP)

Braithwaite, M., Philip, J., Tranberg, H., Finlayson, F., Gold, M., Kotsimbos, T., Wilson, J.. (2011). End of life care in CF: Patients, families and staff experiences and unmet needs, Journal of Cystic Fibrosis, 10, 253-257.

Hospice Palliative Care Ontario (2017). Speak Up Advance Care Planning Workbook Ontario Edition. Retrieved from www.advancecareplanning.ca

RESULTS Current State

PURPOSE & OBJECTIVES • Improve awareness and knowledge on ACP and resources available to ALL Cystic Fibrosis patients, families and staff.

• Improve initial and follow up assessment and communication of patient’s wish on ACP.  To continue to have 100% completion of initial ACP assessment on admission.  To have 100% staff participation in education session on standardized ACP assessment ( utilization of brochure during admission) by May 2018.  To have at least 70% compliance rate on documenting & follow up status on shared folder excel sheet by May 2018.  To have 70% patient having conversation on ACP with social worker by August 2018.

• Next steps: • Sustaining the practice by imbedding new practice into routine practice.

• Spread to outpatient clinic as part of the annual assessment.

REFERENCES

FOCUS RNAO BPG: End-of-life Care During the Last Days and Hours • Comprehensive, holistic assessment of Advance Care Planning (ACP) on Admission (1.3, 1.4).

• Raise awareness in supporting individuals and families to make informed decisions that are consistent with their beliefs, values and preferences in the last days and hours of life (1.4 2.1, 2.2, 3.4, 4.2, 5.1, 5.3, 5.4 ).

• Key to collaborate & involve the interprofessional team in finalizing the ACP brochure and in follow-up assessment.

• Engage the support of patients and family.

• Liase with resources from the Patient and Family Education Library.

Desire State

 60% Full time and Part time staff participated in education session.  Pending feedback from Literacy Specialist .  Patient feedback on the brochure from patient survey and Patient Family Advisory Board.  Chart Audit on admission assessment on Soarian.  Chart Audit on utilization of shared drive excel documentation and number of distributed brochure.

CONCLUSION  There is an increase in completion of admission assessment on ACP by RN, however we continue to work on increasing patients’ awareness by:  Standardizing the assessment and follow up assessment.  Providing patient with accessible information on ACP.  Increasing communication between patient and health care team.  Normalizing “the talk” by standardizing the initialization of the topic( not only at end of life) .

Philip, J.A., Gold, M., Sutherland, S., Finlayson, F., Braithwaite, M. & Kotsimbos, T. (2008). End-of-life Care in Adults with Cystic Fibrosis.

Journal of Palliative Medicine, 11(2), 198-203.

Registered Nurses’ Association of Ontario (2001). End-of-life care during the last days and hours. International Affairs & Best Practice Guidelines.

Sawicki, G.S., Dill, E.J., Asher, D., Sellers, D.E. & Robinson, W.M. (2008).

Advance care planning in adults with cystic fibrosis. Journal of Palliative Medicine, 11(8), 1135-1141.

Speak Up Ontario Advance Care Planning Workbook http://www.speakupontario.ca/

ACKNOWLEDGEMENTS Nursing Practice and Education Mentor: Donna Romano Unit Mentors: Wendy Cheuk & Sarah Sweetman Respirology Chief Physician: Dr. Elizabeth Tullis Social workers: Annie Thomas & Anne Culligan 6 Bond Advance Care Planning QI Team 6 Bond Nursing Staff Cystic Fibrosis PFAB Group Piera Cardella Scholarship Nomination

Integrating Smoking Cessation Practices among Cancer Patients Criselda Diaz Gonzales RN, Maria Laylo RN, Khushdeep Parhar RN, Rosemarie Rivera RN MN, Charmaine Mothersill RN MN CLM

BACKGROUND

NEXT STEPS

METHOD

A review of the literature shows that smoking among cancer patients continue to be a problem since up to 20% continue to smoke after a cancer diagnosis.

It is essential that patients have access to smoking cessation counselling, support, and treatment because smoking reduces the effectiveness of cancer treatments, exacerbates chemotherapy and radiation side effects, increases the risk of developing a second primary cancer, and increases cancer recurrence.

In the St. Michael’s Hospital (SMH) Medical Day Care Unit (MDCU), several challenges to its smoking cessation support for cancer patients were identified:

• Only 131 out of 3,637 patients were screened for smoking from January to December 2017.

• The screening tool used provided inadequate information about patients’ smoking habits and motivation to quit.

• There was a lack of confidence among staff in assessing, counselling, and advising patients about smoking cessation.

• There was no standard referral process in place.

• The interprofessional team was unaware of smoking cessation resources available in the hospital and community.

An environmental scan was conducted to identify the strengths and challenges in current smoking cessation practices and resources.

A process map was developed which shows that nurses will use the SMH Smoking Cessation Assessment Form, provide advice and information pamphlet to patients, and refer consenting patients to the SMH Smoking Cessation Program.

A new patient education pamphlet was developed in collaboration with patients and the interprofessional team.

ASK Enhanced Screening & Assessment Tool

ADVISE Patient Education Tool

ACT Streamlined Referral Process

Sustainability Strategies • Report the number of new patients, their smoking status, and whether smoking cessation referral is initiated during daily rounds • Perform regular audits to determine whether nurses are screening, assessing, and referring patients to smoking cessation programs

REFERENCES An education session was delivered to each participant and a post-intervention questionnaire was conducted to evaluate the staff’s knowledge and confidence is smoking cessation practices and treatments after the education session.

RESULTS To align current smoking cessation practices with RNAO Best Practice Guidelines Integrating Tobacco Interventions into Daily Practice and Cancer Care Ontario’s practice recommendation of using Brief Interventions by implementing:

Figure 1. Pre-Intervention Questionnaire Results

A baseline questionnaire was conducted to evaluate the interprofessional staff’s knowledge and confidence in smoking cessation practices and treatments.

The above findings suggest that assessment, staff education, and referrals to smoking cessation programs need to be addressed in order to improve smoking cessation support in the MDCU.

PURPOSE & OBJECTIVES

• Evaluate whether patients are being assessed and referred to smoking cessation programs • Evaluate whether interventions improve smoking cessation rates among cancer patients • Develop a Smoking Cessation Initiative Toolkit to help other units initiate a smoking cessation process • Raise awareness for physicians regarding new smoking cessation process in Medical Day Care Unit • Evaluate the effectiveness of the Smoking Cessation Pamphlet in increasing patient’s knowledge of smoking cessation resources

Participants The staff (n=19) included Registered Nurses, Nurse Practitioners, Social Workers, Registered Dietitians, Pharmacists, and clericals.

Individual and small group education sessions were facilitated as a 15-minute PowerPoint presentation.

Findings Post-intervention questionnaire responses (Figure 2) revealed a significant increase in participants’ knowledge and confidence level in smoking cessation practices in comparison to the pre-intervention questionnaire responses (Figure 1).

Overall, patients found the content of the Smoking Cessation Pamphlet easy to understand and provided useful information about signs and symptoms of nicotine withdrawal and resources available.

Evans, W.K., Truscott, R., Cameron, E., Peter, A., Reid, R., Selby, P., et al.

(2017). Lessons Learned implementing a province-wide smoking cessation initiative in Ontario’s cancer centres. Current Oncology, 24(3). e185-e190.

Figure 2. Post-Intervention Questionnaire Results Questionnaire Indicators 1) Screening patients who currently smoke 2) Providing patients with information about the benefits of smoking cessation 3) Providing patients with advice on how to quit smoking 4) Providing education about smoking cessation programs and resources 5) Providing information about pharmacological and non-pharmacological interventions for smoking cessation

CONCLUSION Staff education was essential to support the implementation of smoking cessation practices.

Involving the interprofessional team was key to the success of the uptake of new smoking cessation process.

Liu, J., Chadder, J., Fung, S., Lockwood, G., Rahal, R., Halligan, M., et al.

(2016). Smoking behaviours of current cancer patients in Canada. Current Oncology, 23(3),201-203.

Registered Nurses’ Association of Ontario. (2017). Integrating tobacco interventions into daily practice. Clinical Best Practice Guidelines.

Retrieved from: http://rnao.ca/sites/rnaoca/files/bpg/FINAL_TOBACCO_INTERVENTION_WEB.pdf

ACKNOWLEDGEMENTS We would like to thank the Medical Day Care Unit staff, Quality Improvement Lead, Dr. Hicks, Clinical Leader Manager, Charmaine Mothersill, Clinical Educator, Rosemarie Rivera and BPG mentor, Donna Romano for supporting us in this project. Special thanks to Haematology and Oncology patients who participated in this project.

Developing Resilience in the Cardiac Catheterization Lab Debby Law, RN, BScN & Galina Bolsakov, RN St. Michael’s Hospital

FOCUS Prevent and mitigate nurse fatigue through developing resilience in the Cardiac Catheterization Lab (Cath Lab).

Explore the current level of stress in staff and expand the team resilience to reduce staff fatigue.

Utilize the RNAO BPG Preventing and Mitigating Nurse Fatigue in Heath Care, Recommendation 7.2 to inform our initiative.

INTERVENTION/PROCESS

RESULTS: PEER TO PEER INTERVIEW

CONCLUSION Unit huddle attendance increased from 54% to 72% in 2 months.

Staff Survey

Initial feedback from staff indicates unit huddle improves overall communication in the Cath Lab.

N = 12 (RNs & Technicians)

Require more time to measure the full effectiveness of the unit huddle in improving team resilience and decreasing burnout.

Explored the level of fatigue and team cohesiveness in staff.

RECOMMENDATIONS/NEXT STEPS

BACKGROUND Research (Rushton, Batcheller, Schroeder, & Donohue, 2015) showed healthcare staff working in high-stress areas reported high level of burnout.

Contributions to staff’s fatigue in the Cath Lab includes: • Increased number of sick calls • Increased staff turnover rate • Insufficient communication among staff • Increased workload • High patient acuity • Unpredictable events

Peer-to-Peer Interview N = 19 (RNs & Technicians) Identified the stressors that contribute to causing burnout and sought suggestions from staff.

• 3 main factors () that can lead to staff burnout were identified by 19 staff.

• We introduced a Unit Huddle to address the communication gaps in the Cath Lab.

RESULTS: UNIT HUDDLE • To increase the number of attendance during unit huddle to an average of 80% by March 31st, 2018.

PURPOSE & OBJECTIVES To understand staff’s fatigue level at workplace and identify the areas to improve team resilience by utilizing Plan Do Study Act (PDSA) cycles.

Improve sustainability of the unit huddle by introducing a fun contest between staff, Huddle Leaderboard (see photo), to promote attendance.

Cath Lab Unit Huddle Attendance from January to March 2018

Unit Huddle Implemented a daily team meeting with all staff to disseminate information (i.e. patient flow and staffing) in the unit to improve communication and promotes team resilience in the Cath Lab.

Conduct follow-up survey to determine the effectiveness of the unit huddle and changes in team resilience in 6 months.

REFERENCES Cusack, L., Smith, M., Hegney, D., Rees, C. S., Breen, L. J., Witt, R. R., … Cheung, K. (2016). Exploring environmental factors in nursing workplaces that promote psychological resilience: constructing a unified theoretical model. Frontiers in Psychology, 7 (600). DOI: 10.3389/fpsyg.2016.00600 Provost, S. M., Lanham, H. J, Leykum, L. K., McDaniel Jr, R. R., & Pugh, J. (2015).

Health care huddles: managing complexity to achieve high reliability.

Health Care Management Review, 40(1), 2-12. DOI: 10.1097/HMR 0000000000000009 Registered Nurses’ Association of Ontario. (2008). Preventing and Mitigating Nurse Fatigue in Health Care. Toronto, ON: Registered Nurses’ Association of Ontario.

100%

Rushton, C. H., Batcheller, J., Schroeder, K., & Donohue, P. (2015). Burnout and resilience among nurses practicing in high-intensity settings. American Journal of Critical Care, 24(5), 412-420. DOI:10.4037/ajcc2015291

80%

Traynor, M. (2017). Critical Resilience for Nurses: An Evidence-based Guide to Survival and Change in the Modern NHS. New York: Routledge.

60%

ACKNOWLEDGEMENTS RESULTS: STAFF SURVEY • 12 staff completed the survey and more than half of the staff (54.7%) experienced moderate to high level of fatigue from the workplace.

40%

20% Attendance (%)

28-Mar

26-Mar

24-Mar

22-Mar

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0%

27-Jan

Photo: Huddle Leaderboard

• Staff rated their team cohesiveness as slightly below average at 45.8 on a 100-point scale.

25-Jan

Linear (Attendance (%))

We would like to thank Nursing Practice & Education for their sponsorship in this BPG initiative, Clinical Leader Managers Kim Boswell and Victoria Buczek for their leadership support.

Emily Delaney and Kamala Persad-Ford for their contribution, and the CIU staff and medical team for their participations in the process.

Intentional Rounding for Falls Prevention on Inpatient Mobility Denis Aleynikov RN; Lory Lee RN, MN; Vasuki Paramalingam RN, MN St. Michael’s Hospital, Toronto, Ontario, Canada

FOCUS

INTERVENTION/PROCESS

• Reducing falls related to elimination, “Full bladder falls”, on Inpatient Mobility (Orthopedics) • Identify current falls rates, causes for falls, and the distribution of falls during shift • Increase patient safety

• Analyzed current state via chart reviews and Safety & Learning Events: number of falls, falls by service, time of falls, and cause of the fall

• RNAO Best Practice Guideline supporting focus: • Preventing Falls and Reducing Injury from Falls (4th edition)

• Provided teaching to Registered Nurses and Clinical Assistants via faceto-face sessions regarding intentional rounding at night

CONCLUSION • Intentional rounding for falls prevention was accepted by staff with enthusiasm with a high compliance rate

• Conducted 30 interviews with staff to obtain understanding the current process for falls prevention and strategies

• One “Full bladder fall” in February was related to not following closely the protocol of intentional rounding

• Implemented intentional falls rounding at night starting January 2018

BACKGROUND • Falls and fall injuries can impact a patient’s quality of life and can trigger a series of negative and compounding effects (RNAO, 2017) • Nurses and other health care providers can implement evidence-based falls prevention initiatives to reduce costs related to falls (RNAO, 2017) • From April 2016 – September 2017 (18 months), there were 107 falls on Inpatient Mobility, equating to roughly 6 falls per month, 1 fall a week.

• Lack of a standardized approach to falls prevention RNAO BPG Recommendation: •

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

PURPOSE & OBJECTIVES • Decrease the number of “Full bladder falls” • Raise awareness and staff’s knowledge of current factors leading to falls on Inpatient Mobility • Implement focused intentional rounding on Inpatient Mobility • Maintain 80% compliance rate of performing intentional rounding

RECOMMENDATIONS/NEXT STEPS

• Reviewed and compared completed intentional rounding sheet to falls incidents to assess effectiveness of intervention

RESULTS • Decreased falls rates in February 2018 by 40% and March 2018 by 67% • There were no falls related to elimination "Full bladder falls" in January and March

• Conduct monthly huddles with staff to update regarding fall rates, factors causing falls, and intentional rounding compliance • Continue assessing completed intentional rounding sheet • Implement Falls board to provide visual update of the current monthly falls rate

• Significantly decreased the number of falls before the shift change • High compliance rate (over 80%) with signing intentional rounding sheets

REFERENCES Registered Nurses Association of Ontario. (2017). Clinical Best Practice Guidelines: Preventing Falls and Reducing Injury from Falls. Retrieved from http://rnao.ca/sites/rnao-ca/files/bpg/FALL_PREVENTION_WEB_120717.pdf

ACKNOWLEDGEMENTS

Special thanks to: Inpatient Mobility Registered Nurses and Clinical Assistants Colleen McNamee, Corporate Nursing Education Manager

Transfer of Accountability between Post-anesthesia Care Unit to Inpatient Mobility Jennifer Wong, RN, BScN St. Michael’s Hospital, Toronto, Ontario, Canada

•

To utilize a standardized transfer of accountability (TOA) tool for information sharing between Inpatient Mobility RNs PACU RNs To increase effective communication to further promote patient safety

• •

RNAO Best Practice Guideline focus: Care Transitions • • Recommendation 2.2: Use effective communication to share client information among members of the interprofessional team during care transition planning • •

Recommendation 3.2: Use standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions

•

Pre-survey conducted to 4B/9CS nursing staff to identify strengths and weaknesses of current TOA practice Rough draft of TOA tool created from template of PACU TOA tool used on 16CC Individual education sessions were completed Implementation of TOA tool initiated in February

Pre-survey qualitative data from staff: “Patient arrives not as described in report”

“Inconsistencies and information is missed”

4Bond 90% 80%

60%

• •

Figure 1: First draft of TOA tool

Inefficiencies in TOA between nurses results in repetition, duplication, and omission of client information (RNAO, 2014) The use of structured tool reduces loss of data and improve retention of information received (Ong & Coiera, 2011) Sedated patients arriving from recovery room are vulnerable to communication breakdown potentially leading to postoperative complications and even death (Krimminger et al., 2018) Employee frustration caused by lack of consistency in communication of key information (Krimminger et al., 2018) The 2016-2017 BPG champions initiated the work on developing a TOA tool for PACU and inpatient mobility The 2017-2018 BPG work aims to advance the PACU-inpatient mobility TOA initiative

•

To modify the Post-anesthesia Care Unit (PACU)-inpatient mobility TOA tool To implement continuous cycles of changes and evaluate impact of changes that result in improvement to TOA tool compliance

• •

50%

47%

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20%

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30%

27% 18%

REFERENCES

0% Feb. 15 - 22 (n=27)

Feb. 23 - Mar 1 (n=28)

Mar 2 - Mar 8 (n=28)

Mar 9 - Mar 15 (n=31)

Mar 16 - Mar 22 Mar 23 - Mar 30 (n=36) (n=22)

•

Ongoing feedback obtained from nursing staff Currently in the process of implementation of last TOA tool draft

•

9CS 100% 90% 80% 70% 60% 50% 40%

20%

17%

73%

57%

38%

14%

10% 0% Feb 15 - 22 (n=6) Feb 23 - Mar 1 (n=9)

Mar 2 - Mar 8 (n=7)

Krimminger, D., et al. (2018). A Multidisciplinary QI Initiative to Improve OR-ICU Handovers. American Journal of Nursing, 118(2), 48-59.

Ong, M.S., & Coiera, E. (2011). The Joint Commission Journal on Quality and Patient Safety, 37(6), 274-284.

Registered Nurses’ Association of Ontario. (2014). Care transitions. Clinical Best Practice Guidelines. 1-88. Retrieved from http://rnao.ca/sites/rnaoca/files/Care_Transitions_BPG.pdf

ACKNOWLEDGEMENTS

33%

30%

Figure 2: Final draft of TOA tool

• •

Figure 3: Compliance Audit with cycles of change

•

•

Continue to implement continuous cycles of changes and audit TOA tool completion Multidisciplinary involvement essential to sustain TOA process and staff satisfaction Connect with PACU CLM and Clinical Nurse Educator to obtain feedback on tool Educate RNs to roll out tool on both PACU and inpatient mobility Barcode form number on tool to make tool a permanent part of patient’s record Ongoing staff feedback and revise tool

18%

10%

OBJECTIVES •

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54%

Include tool in post-op admit package

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•

100%

Email from CLM

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•

Majority of the staff liked overall template of the tool Easy to use and had necessary relevant information when obtaining TOA A number of staff placed tool with Kardex resulting in compliance audit issues Staff preferred for PACU RNs to use TOA tool to ease flow of report

RECOMMENDATIONS/NEXT STEPS

BACKGROUND

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“No structure”

70%

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Include tool in post-op admit package

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CONCLUSION

RESULTS

INTERVENTION/PROCESS

Email from CLM

FOCUS

Mar 9 - Mar 15 (n=11)

Mar 16 - Mar 22 Mar 23 - Mar 30 (n=7) (n=8)

Figure 4: Compliance Audit with cycles of change

Special thanks to…

Vasuki Paramalingam, Clinical Leader Manager Lory Lee, Clinical Nurse Educator Cecilia Santiago, Professional Practice Mentor All the 4B/9CS nurses Nursing Practice and Education

Promoting Staff and Patient Safety With the Use of Seclusion Joram Muzones, RN, BScN St. Michael’s Hospital, Toronto, ON, Canada

FOCUS

INTERVENTION/PROCESS

Phase 1

• Learning needs assessment  Seclusion Use Questionnaire & ongoing staff engagement • Environmental scan  Data collection on the current use of seclusion • Identified that staff needed education on the current restraint policy

Phase 2

• Ongoing draft of seclusion procedure • Development of: (1) Seclusion Decision Making Tree, (2) PowerPoint for staff education, (3) staff pamphlet summarizing policy, and required nursing care and documentation

RNAO Best Practice Guideline: Promoting Safety: Alternative Approaches to the Use of Restraints Recommendation # 9

:

Education on working with clients at risk for the use of restraints should be included in all entry to practice nursing curricula as well as ongoing professional development opportunities…

(RNAO, 2012).

Seclusion – What is it?

“A space wherein a patient is free to walk but is prevented from leaving that space by way of a locked door” (St. Michael’s Hospital, 2014)

Phase 3

Number of seclusion events in the Acute Care Unit (ACU)

• The need for a formal guideline on the use of seclusion is important in ensuring that nursing practice follows best practices, legislation and standards.

• When staff did receive education sessions and tools to aid their practice, the use of seclusion in 17CC ACU notably decreased by 46%.

• Staff in 17CC are fully engaged and there is the opportunity to implement more initiatives, strategies and resources.

• Pre-training data (November 1-30, 2017) and post-training data.

(February 8– March 9, 2018) collected 2 weeks after the start of staff training • Pre: 30 seclusion events, 6 patients.

• Post: 14 seclusion events, 7 patients  A 46% decrease in the number of seclusion events.

TOOLS DEVELOPED

• Roll out of staff education sessions • Data collection  Training Evaluation Tool • Environmental scan  Data collection on the use of seclusion posttraining

RESULTS RN confidence and competence in applying seclusion PRE: Seclusion Use Questionnaire Documentation Nursing Care Assessments

RECOMMENDATIONS/NEXT STEPS PowerPoint presentation for staff education

With no formal policy or procedure to guide staff around the specific use of seclusion, a review of seclusion was undertaken.

CONCLUSION

Locked Seclusion Decision Making Tree

BACKGROUND

RESULTS (Continued)

Pamphlet: Nursing Care & Documentation

Criteria for Use

• Continue staff training and involve CNS and Nurse Educator.

• Start training for MHESA staff (NB: MHESA will also have the ability to seclude).

• Collaborating with 17CC Team Leader to revise current ACU High Risk Observation procedure .

• Current corporate restraint policy, Alternatives to the Use of Physical Restraints is up for review April 2018 • Advocate for the inclusion of seclusion in the corporate policy. It is important to note, that a review of other GTA hospital policies covers both physical restraints and seclusion Future BPG initiatives can focus on different aspects of restraints.

REFERENCES •

Confidence

0

PURPOSE & OBJECTIVES Overall • To create a unit based procedure for nursing practice Aim that follows best practices, legislation, CNO standards and guidelines and supports patients’ rights within the use of seclusion.

Goals

• To decrease the number of seclusion events in the Acute Care Unit (ACU) by 25%.

• All RNs to be trained on the prevention, assessment, and use of seclusion.

• Increase RN confidence and competence in applying seclusion by 50%  evidence by post training evaluation surveys.

Agree

5

10

Somewhat Agree

15

Somewhat Disagree

20

Pamphlet: Policy Summary

• •

Disagree

POST: Training Evaluation Tool

•

College of Nurses of Ontario. (2017). Practice Standard: Restraints. Toronto: College of Nurses of Ontario. Retrieved from: https://www.cno.org/globalassets/docs/prac/41043_restraints.pdf.

Mental Health Act, 1990. R.S.O. 1990, Chapter M.7 Registered Nurses’ Association of Ontario. (2012). Promoting Safety: Alternative approaches to the use of restraints. Toronto: Registered Nurses’ Association of Ontario.

St. Michael’s. (2015). Alternatives to the Use of Physical Restraints Policy.

Documentation

ACKNOWLEDGEMENTS

Nursing Care Assessments Criteria for Use Confidence

0 Agree

5 Somewhat Agree

10

15 Somewhat Disagree

20

25

Disagree

* Competence was measured as having the understanding of: documentation, nursing care, assessments and criteria for use

17CC & MHESA, especially the Nursing Staff Heather Rawnsley, RN Rachel Lodge, RN Jennifer Little, CNS Donna Romano, Professional Practice Mentor

Education & Decision Support Strategies for Transplant Recipients and Kidney Donors Maureen Connelly, Kevin Bradley, Michelle Gabriel, Kathryn Salvatore, Lucy Chen & Dana Whithman

Kidney Transplant Program BACKGROUND

RESULTS

• Not all donor recipient pairs are compatible due to either blood type or immune system incompatibility. There are treatment options in these situations, including paired exchange or blood type incompatible direct donation.

RECOMMENDATIONS/NEXT STEPS • Develop an standard operating policy (SOP) to articulate how patients are educated on the two options for incompatible pairs.

• Donors and/or recipients often experience decisional conflict, especially if their opinions differ about which treatment option fits each of their needs.

• Develop paired exchange SOP. • Update ABOi SOP.

• RNAO BPG Decision Support for Adults Living with Chronic Kidney Disease informed this initiative. Specifically, Patient Decision Making Needs 1.0-3.0 & Decision Support Interventions 4.0 and 5.0.

• Database tools to capture data – e.g. tracking number of transplant recipients who have ABOi vs KPD transplants for long term data on outcomes.

ABOi Glycosorb filter

• Training on decision coaching for our team members.

Historic reasons for donor exclusions (Karpinski et al. 2006)

• Ongoing assessment of the utility for the decision support tool

Kidney Paired Exchange

REFERENCES Karpinski et al. Am J Kidney Dis. 2006 Feb;47(2):317-23 • Donor inquires Oct. – Feb. 20 = 121 • 13 were eligible for KPD or ABOi • Decision Tool administered to donor/recipient pairs • Positive feedback from staff and pairs:

INTERVENTION/PROCESS •

PURPOSE & OBJECTIVES •

•

To define and develop a shared decision in making process using the Ottawa Decision Support Tool an effort to increase tool to ensure the needs of the incompatible donor recipient pair are met.

To establish a streamlined process for ensuring all incompatible kidney donor transplant recipient pairs receive decision coaching on treatment options available to them.

Development process involved literature review, patient interviews, and comparison scoring of donor/recipient responses on the decision support tool.

1. Change in practice for immunology testing to virtual cross match immune compatibility – cost saving and timely results.

2. Regular donor and recipient coordinators meetings to review incompatible donor recipient pairs and ongoing care plans utilizing the decision support tool.

3. Review of metrics for example # of pairs entered into Canadian Blood Services computerized Kidney Paired Donation Registry.

4. Regular patient review to nephrologists and referring center's for transplant candidates and treatment options being considered for them, i.e. blood type incompatible direction donation (ABOi) or Kidney Paired Donation (KPD).

 “This really helped me clarify my decision” – kidney donor.  "Decision coaching helped me appreciate and respect values that are important to our patients” RN coordinator.

CONCLUSION  Ottawa Decision Support Tool aid assists with identifying patient knowledge, values and clarifying treatment decisions with more certainty.  Learned the importance of decision coaching skills.  Key success factor was the change to virtual cross match – allows for earlier identification of incompatible pairs and what options are available.

Kidney Disease: Improving Global Outcomes (KDIGO). (2017).

Living Kidney Donor Work Group. KDIGO Clinical Practice Guideline on the Evaluation and Care of Living Kidney Donors.

Transplantation, 101(S108), S1-S109.

St. Michael’s Hospital. (2017). LDP 5.2 ABO Incompatible Living Kidney Transplantation. Toronto, ON: Transplant Coordinator.

Registered Nurses’ Association of Ontario. (2009). Decision Support for Adults Living with Chronic Kidney Disease. Toronto, Canada. Registered Nurses’ Association of Ontario.

O’Connor, A.M. & Jacobsen, M.J. (2003). Workbook on developing and evaluating patient decision aids. Ottawa, ON: The Ottawa Hospital.

ACKNOWLEDGEMENTS St. Michael’s Hospital Nursing Practice and Education

Stop Harm and Violence Education for 9CC Staff Miranda Priestman, Judy Pararajasingham, Mary Copeland, Heather Charlesworth St. Michael’s Hospital, Registered Nurses Association of Ontario

FOCUS

Stop Harm & Violence Education

INTERVENTION/PROCESS Stop Harm and Violence Education is awareness, de-escalation, disengagement and code white responses

RESULTS

CONCLUSION

• 100% of full time staff participated.

• 98% of staff agreed or strongly agreed with “I learned new ideas and skills today that I will be able to apply directly to my practice” • 94% agreed or strongly agreed with “I will be more effective within my role as a result of this learning”

Stop Harm and Violence Education for 9CC Staff: Engaged and met their learning needs

Managing Workplace Violence

Increased their confidence in preventing, managing and responding to violence

Focus Groups

RNAO BPG: Workplace Health, Safety and Well-Being of the Nurse Train the Trainer

BACKGROUND 2015 Staff Engagement Survey: 73.2% of Trauma/Neurosurgery Staff felt safe at work vs. the hospital average of 80.3%

Safety and Learning System: December 2016 to September 2017: 38 documented incidents of workplace violence on 9CC Previous Managing Responsive Behavior education: staff wanted education on managing violence

Staff Stop Harm and Violence Education

Focus groups were held with 9CC staff to discuss code whites and incidents of aggression.

• 62 staff members participated (55% of full time staff).

• Focus group general themes informed education Stop Harm and Violence Education was mandatory for all full time staff.

PURPOSE & OBJECTIVES Overall Goal: provide education for 9CC staff on techniques to prevent, manage and respond to violence 1) 75% of full-time staff complete the Stop Harm and Violence workshop

3) 50% increase in participant confidence levels on 8 out of 10 indicators in comparing the pre to post assessments.

• • • • • • •

Stop Harm and Violence Education for 9CC new hires Code White simulations on floor Annual course refreshers for staff Debriefing tools Process for staff communication post adverse event Hard restraints; a set location & clear expectations Stop Harm and Violence education for all St. Michael’s staff including security • Hospital-wide violence flagging system with electronic indicators • Individual employee electronic alert system

REFERENCES • Flores, K., Rinne A. (2017). Development and implementation of “High Observation Rounds” to promote interdisciplinary collaboration in responsive behavior management on the Trauma and Neurosurgery Inpatient Unit. St. Michaels Hospital. Toronto, Ontario, Canada.

• Redmond, R. & Curtis, E. (2009). Focus Groups: Principles and Process.

Nurse Researcher, 16 (3), 57-69.

• Registered Nurses’ Association of Ontario. (2008). Workplace Health, Safety and Well-being of the Nurse. Toronto, Canada: Registered Nurses’ Association of Ontario.

• Thibault, M. (Jan 2018). Stop Harm and Violence: Verbal de-escalation and physical skills training. Strategic Risk Protection Inc. & Rescue 7 Inc.

A group of staff met with vendors, and paired with Strategic Risk Protection Inc. to develop this program

2) 75% of all staff agree or strongly agree on the evaluation form “I will be more effective within my role as a result of this learning” and “I learned new ideas and skills that I will be able to apply directly to my practice”

RECOMMENDATIONS/NEXT STEPS

ACKNOWLEDGEMENTS Education sessions taught by 7 interprofessional team members They learned to teach the program in a week of train the trainer with Strategic Risk Protection Inc. and Corporate Health and Safety Services

Recognizing the hard work and contributions by the Train the Trainers; Samantha White, Tatiana Calle, Anh-Tu Nguyen, Allison Rinne, Rebecca Blidner & John Matile.

BPG & Program Leadership: Mike Thibault, Heather Charlesworth, Judy Pararajasingham, Mary Copeland and Colleen McNamee.

Promoting Patient Safety Through Improved Communication in Transfer of Accountability Marie Oanes-Prystay RN, Jennifer Trieu RN St. Michael’s Hospital, Cardiology Unit

FOCUS Improving communication in transfer of accountability (ToA) between nurses with patient-centered care at the bedside. This includes safety checks, falls prevention, and updating white communication boards with the estimated date of discharge (EDD), and providing patient oriented discharge summary (PODS) teaching.

The following recommendations from RNAO Best Practice Guidelines on Care Transitions, Falls, and Person-and-Family Centered Care were used:

INTERVENTION/PROCESS To improve bedside ToA with safety checks, with a target goal of 80% compliance over the next four months April – July 2018.

• Re-educate staff on the “4 Essential Elements of the ToA Process” • Display the “4 Essential Elements of the ToA process” at work stations • Re-supply markers, erasers and cleaning sprays for all bedside White Communications Boards in each room

To improve standardized documentation and communication tools, by following the fourth essential elements of the ToA process, with a target goal of 80% compliance over the next four months April – July 2018.

Qualitative Narratives: Staff (Grey) and Patient (Blue) Responses It is a reasonable idea.

I think it will improve communication

• Conduct bi-weekly audits for Bedside ToA during intershift • Conduct bi-weekly audits on updating Kardexes, White Communication Boards, Preventing Falls Safe Transfer Posters, and completing PODS teaching.

It allows patients to be engaged in their care and patients get a sense of satisfaction

Use effective communication to share patient information, their risk for falls and standardized documentation tools to the next responsible health-care provider to ensure continuity of care and to prevent falls and falls injuries.

It’s good. It ensures patient safety and continuity of care

Engage with the patient in a participatory model of decision making and communicating by collaborating on elements of care and communication strategies. Obtain ongoing feedback to determine patient satisfaction, and to utilize this feedback for improvement.

BACKGROUND

To improve clinical handover practices with the focus on patient safety and to increase patient engagement. Outcome measures were identified to monitor change and evaluate improvement. % Bedside ToA with safety checks % Fall incidences % Standardized documentation and communication tools % Patient satisfaction and engagement in Bedside ToA

It is useful, I know the Activity plan of the day

Staff awareness about the importance of effective communication in Bedside ToA for patient safety and engagement has increased.

1. Conducting Bedside ToA with patient engagement. Marie Prystay RN and Masuda Zaman Nursing Student (Permission Given).

RECOMMENDATIONS/NEXT STEPS

Nighttime SIMPLE Intentional Rounding was implemented in February 2016, and has been sustained on the unit. However the number of falls incidences in 2017 remains relatively unchanged due to increased number of falls during the day (Night 11 Falls, Day 17 Falls).

PURPOSE & OBJECTIVES

I feel less anxious because I know who will be my Nurse, when you leave

CONCLUSION

ToA , particularly when conducted at the bedside, encourages patient’s active involvement in their own care, and ensures opportunity for asking and responding to their questions (Griffin, 2010).

The compliance for past BPG initiatives that affect patient safety and communication has not been successfully sustained. A recent update by the RNAO (2017) identified that effective communication is central to falls prevention and patient safety.

I know who will be looking after me, and who my Doctor is

3. Using the Preventing Falls Safe Transfer Poster between interprofessional team members to communicate safe transfers and ambulation Marie Prystay RN and Amber Freethy PT (Permission Given).

• • • • •

Conduct ToA huddles with reminders to update communication tools Encourage more staff to champion Bedside ToA in practice Medical Media to finalize Preventing Falls Safe Transfer Poster Ongoing feedback from patients and staff for improvement Audits for compliance for promoting patient safety through ToA

REFERENCES 2. Reviewing and updating White Communication Board during intershift handover.

To decrease fall incidences, with a target goal of reducing 25% of fall occurrences during the daytime over the next four months April – July 2018.

• PDSA Cycle 1: Developed Preventing Falls Safe Transfer Poster in collaboration with nurses and allied health professionals.

• PDSA Cycle 2: Identified preferred location of poster among interprofessional team members, Above head of bed vs. Beside White Communication Board.

• Education on Preventing Falls Safe Transfer Poster • Education on new falls signage with bed-exit alarm is implemented • Monitor bed-exit alarm is on at all times for patient identified as fall risks

To improve patient satisfaction and engagement, with a target goal of 20 patients will be randomly surveyed over the next four months April – July 2018.

• Obtain ongoing feedback to determine whether Bedside ToA follows the core concepts of patient centered care: respect and dignity, information sharing, participation, and collaboration.

• Review Care Utilizing Evidence Cardiology Metrics: Patient Experiences

RESULTS • 94 % of staff (N= 34) including RNs and CAs were educated on the interventions.

• Patient randomly surveyed for input regarding their satisfaction, knowledge about plan of care and safe transfers • Staff randomly surveyed for input regarding their satisfaction of improving communication in patient safety with Bedside ToA and interventions

Registered Nurses’ Association of Ontario (2017). Preventing Falls and Reducing Injury from Falls.

Registered Nurse s’ Association of Ontario (2014). Nursing Best Practice Guidelines Program Care Transitions.

Registered Nurses’ Association of Ontario (2015). Person- and FamilyCentered Care St Michael’s Hospital Policy (2014). Intershift Nursing Transfer of Accountability

ACKNOWLEDGEMENTS 7CCS Cardiology Staff - Nurses, Clinical Assistants and Allied Health, Ada Andrade (Nurse Practitioner), Kimberly Tan (Nurse Educator), Norine Meleca (Clinical Lead Manager), Cecilia Santiago (Nursing Practice Manager), and Marcelo Siles (Medical Media).

Contact Information: prystaym@smh.ca trieuje@smh.ca

Preventing and Mitigating Nurse Fatigue on General Internal Medicine (14 CC) Magetta Vincent RN, BScN, QIC, Shirley Bell RN, Educator, Kim Grootveld CLM, MSc QI St. Michael’s Hospital, Toronto, Ontario, Canada FOCUS

INTERVENTION/PROCESS

To implement a standardized TOA tool between RNs and CAs. This initiative was informed by RNAO BPG Preventing and Mitigating Nurse Fatigue in Health Care, (2011) recommendations 6.2, 6.3 7.1.

Interviews:

BACKGROUND • Researchers have identified that Nurse Fatigue is a subjective feeling of tiredness that is physically and mentally penetrative” (Registered Nurses Association of Ontario [RNAO], 2011).

• “Nurse Fatigue may significantly interfere with functioning and may persist despite periods of rest” (RNAO, 2011).

• “Working as a collaborative team can serve to mitigate nurse fatigue” (Dickerson & Latina, 2017).

• Gaps in the transfer of accountability have been highlighted by nurses and clinical assistants (CAs) as a barrier to collaborative teamwork. Furthermore, there is no standardized process for clinical assistants to get information regarding their assigned patients.

RESULTS Figure 3. Staff perceptions of impact of TOA tool on teamwork, self care, and staff wellness

• Face to face interviews (n =40) with 14CC RNs & CAs & Pre survey (n = 60) • After qualitative survey: Pre survey distributed and received (n = 143) RNs & CAs • Meeting with 14CC RNs and CAs

Figure 5:Compliance rate of GIM created TOA tool between RNs and CAs, CAs to CAs for break, and CAs to RNs during and at the end of shift.

Interventions: • • • •

Continuous stakeholder engagement TOA revised over six PDSA Cycles Ongoing booster sessions and huddles Awareness campaign: group emails staff meetings, signage

PURPOSE & OBJECTIVES: • • • • •

To engage Stakeholders (14CC RNs and CAs) in creating the TOA process To gather feedback if the tool can be improved or revised through a PDSA cycle To improve the TOA process between 14CC RNs and CAs To improve14CC RNs and CAs perception and experiences related to the TOA tool To improve team work on 14CC by 90% by Jan 2018

CONCLUSION

Figure 2: GIM RN & CA High quality patient outcome and staff wellness

• First weekly audit revealed 100% of RNs & CAs TOA completion.

Weekly audit #1 RNs/CAs TOA Template tool Evaluation of compliance and satisfaction of RNs/CAs in using tool

• CAs are an important part of our care team on 14CC. Without a TOA process between RNs & CAs information they learn in a shift can be at risk for not passed being on.

• TOA between RNs & CAs will help to better identify patient care needs, generate collaborative decisions and associated workload.

General Internal Medicine (14CC)Audit

Figure 3. Implemented TOA tool to include A) TOA from RN to CA, B) TOA from CA to CA, C) TOA from CA to RN during and at end of shift

MEASURES Target: 14 CC RNs will begin performing TOA with CAs at the beginning, during, and end of shift by Jan 9th 2018

# of RNs # of CAs not # of CAs using not using TOA using TOA tool TOA tool tool 8 0 0

DATE

# of RNs using TOA tool

9-Jan

20

10-JAN

20

8

0

0

11-JAN

20

8

0

0

12-JAN

20

8

0

0

8

0

0

8

0

0

8

0

0

13-JAN 14-JAN 15-Jan

20 20 20

Figure 4. Evaluation of compliance and satisfaction of RNs/CAs in using tool.

“CAs are better

Figure 1: Teamwork and collaboration

informed and more accountable

113 Registered Nurses

38 Clinical Assistants

“What took us so long to think of a TOA tool between RNs & CAs?” “Team work makes hard work easy and effective”

“Better Communication”

• TOA tool has helped to ensure accurate and relevant information is communicated.

• RNs have reported satisfaction with the creation of this TOA tool.

• CAs indicate it has taken more time for report . However, helpful to have a template where they can remember their plan of care with RNs.

RECOMMENDATIONS & NEXT STEPS • Conduct sustainability focus groups with RNs and CAs. • Continue to conduct audits to measure compliance and share the results with staff at each team meeting.

• Focus on the process to make it more efficient for the CAs. • Next PDSA cycle begins September 2018.

ACKNOWLEDGEMENTS 14CC RNs & CAs Donna Romano, Professional Practice Mentor

Transfer Of Accountability In The Inpatient Mobility Unit Maria Fernanda Becerra Gomez RN St. Michael’s Hospital, Toronto, Ontario.

FOCUS

INTERVENTION/PROCESS

RESULTS

• • • • •

Audits

Survey

Identify barriers to effective Transfer of Accountability (TOA) Implement bedside TOA Facilitate communication between nurses Increase patient safety Creating and implementing a standardized tool for bedside TOA during shift report.

RNAO BPG recommendations: • Recommendation 2.2 Use effective communication to share client information among members of the inter-professional team during care transition planning.

• Recommendation 3.2 Use standardized documentation tools and communication strategies for clear and timely exchange of client information.

• Recommendation 3.3 Obtain accurate and complete client medical information

BACKGROUND Inadequate “handoffs” between clinicians remain among the most common factors contributing to the occurrence of adverse events (Bates & Gawande, 2003) TOA is not only a transfer of information, but responsibility and accountability for patients care.

Currently in the Inpatient mobility: • There is no standardized tool for bedside TOA • TOA is performed at the nursing station, subsequently repeated in the room when nurses introduce themselves to the patient • Staff were staying longer past their shift to complete TOA

•Performed audits to better understand and find gaps within our TOA practice.

•Audit components: • Hand Hygiene entering and exiting the room • Face to face TOA • Patient engagement • Use of standardized tool • Safety checks

CONCLUSION

Do you perform TOA at the bedside?

Have you completed a TOA course?

Survey • Aid for the understanding of current TOA practice and to address nursing concerns • Survey consisted of 4 questions 1. Do you perform TOA at the bedside?

2. Why do you think TOA is not performed at the bedside?

3. Have you completed a TOA course?

4. If so , when did you last complete the course?

RECOMMENDATIONS/NEXT STEPS Why do you think TOA is not performed at the bedside?

• Finalize the last draft and review with staff.

• Provide on site education and address nursing concerns during TOA. • Aid staff with strategies to manage barriers (e.g. privacy, dealing with family members).

• Continue to implement care plan as a standardized tool for TOA. • After implementation, continue to perform audits on a regular basis.

• Find champions within the nursing staff to help with sustainability.

Care Plan • • • •

• All nursing staff agreed with the use of the new care plan to standardize TOA. • Staff qualitative narratives show positive feedback regarding the new care plan.

• Staff identified the need for further education and ways to manage barriers.

• Comparing the pre- and post- implementation results, audits show increased compliance to bedside TOA and use of worksheet. It is expected that as nurses get used to the new tool, compliance rate will improve over time.

Revamped care plan with nurses provide concise and structured TOA Organized head–to-toe, with added safety checks.

Provided teaching to staff on the use of the new Care Plan.

Reached 75% of staff before implementation.

Nursing Staff Feedback “Condensed, but much easier to use”

“TOA is faster when following the Kardex”

“I love that it is one page”

REFERENCES • Bates, D. W., Gawande, A. A., & Bates D.W., G. et al. (2003). Improving safety with information technology. New England Journal of Medicine, 348(25), 2526–2534. https://doi.org/10.1056/NEJMsa020847 • Registered Nurses’ Association of Ontario, (2014). Clinical Best Practice Guidelines: Care Transitions. Retrieved from: http://rnao.ca/sites/rnaoca/files/Care_Transitions_BPG.pdf

ACKNOWLEDGEMENTS

OBJECTIVES Audit • Conduct current state analysis to identify gaps and understand staff perception towards bedside TOA • Develop a care plan to be used as a standardized tool in communicating relevant and organized information at shift change • Raise awareness for the importance of bedside TOA, with a focus on streamlining the process and timely information exchange

Audit Elements

Pre-implementation

Post-implementation

TOA at bedside

67%

88%

Use of worksheet

13%

36%

Thank you to all nursing staff in the Inpatient Mobility Unit, Vasuki Paramalingam (Clinical Leader Manager), Wen-Ya (Lory) Lee (Clinical Nurse Educator), and Cecilia Santiago (Professional Practice Mentor) for all their support and hard work.

Transfer of Accountability for Breast Cancer Patients Aryam Kidane RN, BScN, Michaela McCrady RN, BScN, Anna Kacikanis RN, MN, Cecilia Santiago RN, MN, CNCC(C) St. Michael’s Hospital, Toronto, Ontario, Canada PROCESS MAP: POST/DESIRED STATE

FOCUS Creation, implementation and evaluation of a transfer of accountability (ToA) tool for breast cancer patients RNAO BPG: Care Transitions •

Recommendation 2.1: Collaborate with client, family, caregivers and interprofessional team to develop transition plan.

Recommendation 2.2: Use effective communication to share client information among interprofessional team.

Recommendation 3.2: Use standardized documentation tools and communication strategies for information exchange.

• •

BACKGROUND • A breast cancer diagnosis can be overwhelming, anxiety inducing as patient’s journey involves multiple transition points.

• Information about a Breast Centre patient’s care trajectory is found in multiple forms and communication can be fragmented.

• The ToA tool provides a cohesive mechanism where breast cancer patient information is shared amongst multidisciplinary team and the patient at various transition points.

PURPOSE & OBJECTIVES

Breast cancer patient referred by surgical oncologist to MDC, to transition care, to medical and radiation oncologist.

RN meets with patient in Breast Centre clinic.

RN gathers data for paper ToA form.

RESULTS CONTINUED

PROCESS: PDSA CYCLE

Patient Survey (n = 5)

RN inputs data into computer system app (includes biopsy, surgery, medical history, health information)

• 80% (n=4/5) patients stated the tool helped to decrease their anxiety.

• Patient suggestions: (1) consider changing the title Transfer of Accountability; (2) include plastic surgeon’s name and number on contact list, and (3) ensure that ToA form is reviewed with patient.

Patient Qualitative Narratives

ToA form accessible for team and patients

“Nice surprise – great to have a snapshot summarizing all the information on just 2 pages.”

Patient seen in MDC. Treatment plan made.

Med Onc/RN give ToA form and go over information with patient. Patient receives package folder which contains community supports. MDs discuss in tumor board.

“A tool that people can take with them to share with other medical professionals.”

“Very informative. It had all the names of the people I spoke with. Contact list with role stated helps clarify ‘who does what’.”

“I was quite impressed with it. It filled in the gaps that I couldn’t quite remember.”

CONCLUSION

RESULTS

• To alleviate anxiety among breast cancer patients • To promote communication among multidisciplinary team for effective and safe care transitions

100% of staff agreed that this tool is helpful in patient’s care transition.

Objectives:

92% would like to have this tool available in Soarian.

• ToA tool facilitates effective information exchange amongst teams and alleviates patient’s anxiety during their cancer care trajectory.

• Our objective to reduce anxiety of 4 out of 5 patients was achieved.

• Staff perceived that this tool would be useful in information exchange at transition points.

• Although the ToA tool is helpful, there is room for improvement in both areas of effective communication and patient satisfaction.

•

62% strongly agreed, 23% agreed, and 15% disagreed it is easy to navigate.

NEXT STEPS

Goal:

•

INTERVENTION: TOA FORM

Staff Survey (n = 13) Staff Responses (Strongly Agreed to Strongly Disagreed)

80% of patients will find that the ToA tool has decreased their anxiety during their various appointments 75% of staff will perceive the ToA as feasible and useful

“Fantastic to have all the diagnosis and treatment details in one place and accessible for the patient.”

PROCESS MAP: PRE-STATE Breast cancer patient referred by surgical oncologist to: Multidisciplinary Clinic, to transition care, to medical and radiation oncologist.

Assessments and discussions by multidisciplinary team members are documented in various forms.

Patient do not receive a unified tool containing information from various appointments

RN meets with patient in Breast Centre Clinic

Patient seen in Multidisciplinary Clinic (MDC).

Treatment plan made.

Discussed in tumor board among all MDs.

• • • •

“Great tool” Figure: ToA tool used for sample patient Jane Smith.

Information consists of: patient demographics (entered prior to patient’s first visit to MDC); medical and psychosocial components (staging, pending tests, follow-up plans); care team (role, contact numbers).

Information is easily accessible through the software program called Care Plan.

Consider changing title ToA to a more patient-oriented language.

Disseminate ToA tool to external GPs and radiation oncologists.

Merge program with Soarian to auto-populate information.

Plan to disseminate: CIBC Breast Centre Symposium; CANO Conference

ACKNOWLEDGEMENTS “When staff become more aware/familiar with tool, I believe it will make care flow more seamless.”

Breast Centre Staff Nursing Practice and Education

REFERENCES Haq, R., Kong, A., Leung, Y. M., Richter, S., Vu, K., Jovicic, A., Soren, B., Li, B., Gulasingam, P., Jainudeen, S. (2016). Personalized multifaceted care plans for breast cancer survivors: Results of a randomized study.

Oncology Exchange, 15 (3). Retrieved from http://www.oncologyex.com/pdf/vol15_no3/research_haq-pmcp.pdf Registered Nurses’ Association of Ontario (2014). Care Transitions. Toronto, ON: Registered Nurses’ Association of Ontario. Retrieved from http://rnao.ca/sites/rnao-ca/files/Care_Transitions_BPG.pdf

The First Step to Illness Management Recovery (IMR) Implementation Natalie Gdyczynski, BScN, RN St. Michael’s Hospital FOCUS

INTERVENTION/PROCESS

RECOMMENDATIONS

 Engaged a group of clients in adapting IMR program group materials to increase relevance and significances to individuals.

The Registered Nursing Association of Ontario (RNAO) Best Practice Guidelines that were the inspiration of this fellowship were:

 Organize IMR training for clinicians of the STEPS for Youth Program  Implement first IMR module Recovery Strategies  Obtain client feedback via anonymous form at the end of each session  Assess program and incorporate clients’ feedback to encourage a continuous co-design process.  Utilize Abbreviated Quality of Life Enjoyments and Satisfaction Questionnaire pre and post intervention to collect process measures and evaluate outcomes

 Harnessed staff expertise to choose first topic for the adapted IMR manual

 Client-Centred Care (2002)  1.0 Nurses embrace as foundational to client-centered care the following values and beliefs: respect, human dignity, clients are experts in their own lives, clients as leaders, clients goals coordinate the care team 

RESULTS

 Produced modified IMR Group Program Practitioner Guide and Handouts to reflect co-design process  Incorporated Kahoot! application into program to increase interest of youth in the material

Strategies to Support Self-Management in Chronic Conditions (2010)

“ There is a definite need for our clients to have access to non-biased information on substances, especially as cannabis is becoming more popular. They are making choices without knowing the impact it might have on their mental health – IMR is a way for them to access that information in a non-judgmental setting.”

 1.2a Nurses combine effective behavioral, psychosocial strategies and self-management education process as part of delivering self-management support  1.3 Nurses collaborate with clients to: establish goals; develop action plans that enable achievement of goals; and monitor progress towards goals  2.0 Nurses use a variety of innovative, creative, and flexible modalities with clients when providing self-management support

BACKGROUND The Starting Treatment Early for Psychosis Service (STEPS) for Youth Program is an early intervention team that supports individuals ages 14-34 who are experiencing psychosis for the first time.

According to the Early Psychosis Intervention Network (EPION), the first few years of psychosis carry the highest risks of serious physical, social, and legal harm.

- Nicole Etherington, MSW

REFERENCES 1. Completed process map to determine service gap.

Illness Management and Recovery Evidence-based Practices (ebp) Kit https://store.samhsa.gov/product/IllnessManagement-and-Recovery-Evidence-BasedPractices-EBP-KIT/SMA09-4463

2. Conducted comprehensive literature review on the effectiveness of IMR as an evidence-based practice in community mental health programs.

Ministry of Health and Longterm Care. (2011, March 31). Early Psychosis Intervention Program Standards. Retrieved February 22, 2018.

3. Conducted internal/ external review.

Mueser, K. T., Corrigan, P. W., Hilton, D. W., Tanzman, B., Schaub, A., Gingerich, S., et al. (2002). Illness management and recovery: A review of the research.

Psychiatric Services, 53, 1272-1284.

Currently the outpatient mental health and addiction service does not offer Illness Management and Recovery (IMR). This group aims to teach individuals who experience severe mental illness (SMI) strategies to effectively manage their psychiatric disorders, giving them the opportunity to advance towards their personal recovery goals.

4. Reviewed the Knowledge Informing Transformation documents prepared by the Substance Abuse and Mental Health Services to support implementation of IMR evidence based groups in the community mental health programs

PURPOSE & OBJECTIVES

5. Conducted clinician survey to determine which module is most relevant to client population.

 The purpose of this fellowship is to introduce IMR evidence-based groups in the Community Mental Health Service at St. Michael’s Hospital, specifically in the Starting Treatment Early for Psychosis Service (STEPS) for Youth program.  My primary objective was to develop an adapted IMR manual for STEPS clinicians to utilize when facilitating the IMR group.

6. Conducted focus group with STEPS clients to obtain feedback on IMR curriculum and delivery options 7. Incorporate feedback into adapted IMR Practitioner Manual.

CONCLUSION  The need for an evidence-based illness self-management group was recognized by all staff members.  Throughout the co-design process clients expressed they felt empowered by being treated as leaders in their care.  The finished adapted IMR Practitioner Guide is ready for clinician use.

“It is nice to be asked what we want to see…it makes me feel important and like a leader in my care”.

Anonymous

Registered Nurses’ Association of Ontario. (2010). Strategies to Support Self-Management in Chronic Conditions: Collaboration with Clients. Toronto, Canada. Registered Nurses’ Association of Ontario.

ACKNOWLEDGEMENTS I want to thank Donna Romano and Nicole Kirwan for their support and guidance throughout this project.

Understanding Nurses’ Knowledge of Peripheral Intravenous (PIV) Care and Maintenance to Reduce Vascular Access Complications on the Trauma and Neurosurgery Inpatient Unit Olivia Roman, RN, Lisa Cluett, RN, Katrina Flores, RN, Judy Pararajasingham, RN, Clinical Nurse Educator Place the names of the institutions

FOCUS • Collect information to determine baseline data regarding the assessment, care and documentation of peripheral intravenous sites (PIVs) on the Trauma and Neurosurgery Inpatient Unit • Use information collected in conjunction with the RNAO’s Best Practice Guidelines in order to develop education and resources to improve the care of PIVs

PURPOSE

RESULTS

• To determine staff knowledge of PIV care and obtain baseline data on current practices that will inform educational resource needs in order to ensure adequate understanding of care, maintenance and documentation of PIVs on 9CC

QUANTITATIVE • Audits were performed on existing patient PIVs and on RN documentation

PROCESS/INTERVENTIONS Interviews - Held with RNs over one month - Determined staff perception of PIV site care, maintenance and documentation

BACKGROUND • Up to 80% of hospitalized patients receive at least one PIV during their stay (Zhang, et al., 2016) • Mismanagement of PIVs sites can result in increased vascular access complications such as mild to severe infections that may lead to significant morbidity and/or mortality (Zhang, et al., 2016).

Significant complications can occur such as blood stream infections, extravasation, hemorrhage, infiltration and phlebitis •

•

Lack of PIV access can lead to delayed or missed: o Procedures and tests o Administration of fluids, medications and blood products (McCallum & Higgins, 2012)

Audits - On PIV dressing s (ie. soiled, clean and dry) - On documentation in Kardex and Soarian

Qualitative data on nurses’ perception of barriers to PIV site care and maintenance

Baseline quantitative data  PIVs that were uncomplicated* Amount of completed documentation in Kardex and Soarian

*Uncomplicated PIV dressing = not secured with tape, not soiled or loose

Percentage of Uncomplicated PIV Dressings

Percentage of Completed Documentation

100

100

80

80

60

%

22%

20

20

0

0 Uncomplicated PIV dressings

Poor documentation (i.e. unclear and/or incomplete) leads to a decrease in quality of care (McCallum & Higgins, 2012)

Uncomfortable with skills

Soarian

Kardex

CONCLUSION • Based on results, a knowledge gap was identified in regards to the assessment, care, maintenance and documentation of PIVs

Interviews with RN’s revealed common themes: • Regarding proper documentation (how and where to document, how to proceed when documentation is incomplete) • Regarding care and maintenance, including flushing procedures and how to perform PIV dressing changes

• Changing PIV dressings with certain patient populations (elderly, confused, “hard poke”, patients with responsive behaviours)

• Step-by-step dressing change guide was created to assist staff with PIV dressing changes • Guide was reviewed with staff during 1:1 educational sessions

• Presented in 1:1 education sessions

9%

• Resources were presented to a targeted 85% of RN’s on the Trauma and Neurosurgery Inpatient Unit

QUALITATIVE

Lack of Knowledge

%

40

• Two resources were created using the RNAO’s Best Practice Guidelines and the St. Michael’s PIV care and maintenance policy

RESULTS

• Created with the assistance of the St. Michael’s Hospital Vascular Access Team

60

46%

40

• Quick reference guide to assist RN’s in the care, maintenance and documentation of PIV

NEXT STEPS •

Follow-up interviews after formal education, dressing guide and quick reference guide implementation to assess effectiveness of education and guides

•

Goal of 5% increase of uncomplicated PIV dressings, 3% increase in Soarian documentation and 6% increase in Kardex documentation

by July 2018

•

Engage venipuncture and phlebotomy trained registered nurses to encourage, educate and assist colleagues in PIV site care and maintenance

REFERENCES • • • •

McCallum L, Higgins D. (2012)Care of peripheral venous cannula sites. Nursing Times; 108: 34/35, 12-15.

Registered Nurses’ Association of Ontario. (2005). Care and Maintenance to Reduce Vascular Access Complications. Toronto, Canada: Registered Nurses’ Association of Ontario.

St. Michael’s Hospital. IV therapy initiation/saline lock and care and maintenance. (2007).

Zhang, L., Cao, S., Marsh, N., Ray-Barruel, G., Flynn, J., Larsen, E., & Rickard, C.M. (2016). Infection risks associated with peripheral vascular catheters.

Journal of Infection Prevention. 17, 207-213.

ACKNOWLEDGEMENTS Adam Wires, RN CVAA (C) VA-BC Mary Copeland, CLM Colleen McNamee, Corporate Nursing Education Manager Registered nurses on TN Inpatient unit who participated in interviews

Standardizing Substance Use Screening & Assessment in the Community Mental Health Service Ryan Hoekstra, BPHE, BScN, RN St. Michael’s Hospital

NEXT STEPS

RESULTS

BACKGROUND Prior to this best practice guideline (BPG) initiative :  No standardized protocols existed for substance use screening or assessment in St. Michael’s Community Mental Health Service.  Few community clinicians had formal addictions training.  No data was available to identify prevalence of client substance use.  Screening, assessments & subsequent interventions were left primarily to the discretion of each client’s assigned clinician.

OBJECTIVES

80% Clients unwilling to participate

Inadequate staff training 60%

Screening tool takes too long to complete

Inaccurate 60% reporting from clients

Screening & assessment tool consists of two stages: (1) Screening Question*: Does client have a problem with alcohol or substance use?

If yes, follow up with (2) substance use severity index If no, no additional action it taken

60% Figure 1. Barriers Identified by ACT teams in Utilizing a Standardized Substance Use Screening Tool

*Screening Question directed towards client’s assigned clinician during monthly client review without client involvement.

 1.2

Identify barriers of implementing substance use screening & assessment tools in the community.

Create a reliable, valid, & sustainable screening tool to identify substance use among clients registered to the Flexible Outreach Community Urban Support (FOCUS) team.

Part 2

Implement the substance use screening & assessment tool to:

 2.1:

Obtain objective data on the prevalence of substance abuse disorder.

 2:2:

Identify clients who may benefit from addictions interventions.

 2.3:

Provide clinicians with concrete interventions to implement with their clients.

Part 1

 For the clients identified as having substance use challenges; provide their clinician with concrete, client-centered intervention options in both harmreduction & abstinence models of care. Continue to consult with local experts in harm reduction & abstinence interventions.

Results of survey & feedback:  100% of respondents identified significant barriers to screening clients for substance use in the community (see Figure 1 for barriers).

n=192

 Traditional screening & assessment tools widely accepted in hospital settings were not found to be practical options in the community.

Response Rate 53% (n=102)

“Too often addictions & psychiatry are viewed as different models of care. Screening for substance use needs to be a top priority in community psychiatry.”

- Dr. Samuel Law, FOCUS Psychiatrist

REFERENCES Figure 3. First Stage Screening Results

METHODS CONCLUSION & DISCUSSION

 Literature review of current screening, assessment & intervention strategies in practice. 

 Create & distribute an online survey to multiple Assertive Community Treatment (ACT) teams in Greater Toronto.

As of April 2018, 102 out of 192 (53%) of FOCUS clients were discussed during the monthly client review. 100% of those clients were successfully screened using the First Stage Screening Question.

 Interview FOCUS psychiatrists to determine baseline screening practices & explore suggestions for sustainable approaches to screening clients.



 Use survey & interview feedback to create standardized protocol for screening & assessing for substance use.

Substance use data from this project is now integrated into the monthly client review, allowing for sustainability (easy access for clinicians to update status)



Current findings align with literature that suggests approximately 50% of people with severe mental illness experience challenges with alcohol or substance use (Health Canada, 2009).

Part 2  Initiate process map; first stage screening question to assess for potential substance use.  When necessary, use Substance Use Severity Index (2-10 Minute validated) to identify: Substance(s) used, severity of substance use, readiness for change.

 Initiate Second Stage Screening & Assessment tool for clients who screened positive in the first stage.

 Clinician judgment is recognized as a validated tool in longterm community treatment (Canada Health, 2009).

Part 1  1.1

 Continue the First Stage Screening Question during monthly client review until 100% of clients have been successfully screened.

Figure 2. Standardized Process Map for Substance Use Screening & Assessment

Health Canada. (2002). Best Practices: Concurrent Mental Health & Substance Use Disorders. Retrieved from https://www.canada.ca/en/healthcanada/services/health-concerns/reports-publications/alcohol-drugprevention/best-practices-concurrent-mental-health-substance-abusedisorders.html Registered Nurses’ Association of Ontario. (2006). Nursing best practice guideline: Client Centered Care (Rev. ed.). Retrieved from http://rnao.ca/sites/rnaoca/files/Client_Centred_Care.pdf Registered Nurses’ Association of Ontario. (2015). Engaging Clients Who Use Substances. Retrieved from http://rnao.ca/sites/rnao-ca/files/Engaging_ Clients_Who_Use_Substances_13_WEB.pdf

ACKNOWLEDGEMENTS Murray Krock, Director, Nursing Practice & Education, Professional Practice Nicole Kirwan, Clinical Leader Manager, Community Mental Health Keith Hansen, Nurse Practitioner, Mental Health Program

Self-Care for the Critical Care Nurse Sinead Gordon RN Cardiovascular Intensive Care Unit, St. Michael’s Hospital

BACKGROUND • To support an initiative on Self-Care for the Critical Care Nurse in the Cardiovascular Intensive Care Unit (CVICU), the following recommendations were adopted from the “Workplace Health, Safety, and Wellbeing of the Nurse” Best Practice Guideline (BPG) from the Registered Nurses Association of Ontario (RNAO): • Recommendation 3.3 Organizations/nursing employers promote and support initiatives related to the physical and mental health and well-being of the nurse. This includes, but it not limited to, fitness programs, health promotion and wellness activities, and fitness-to-work initiatives.

• 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/nursing employers engage in knowledge transfer activities that promote best practice regarding the health, safety and well being of Nurses.

INITIAL ASSESSMENT • A series of open-ended interviews with nurses in the CVICU (n=10) were used to assess perceptions of self-care, knowledge of corporately-available health and wellness resources, and identify opportunities to support the health and wellness of nurses.

• From these initial interviews, it was clear that: • Nurses’ possessed adequate knowledge of the concept of selfcare, referring to “good work-life balance”; “eating right, good hygiene, exercise and sleep” and “looking after both mental and physical health”.

• However, most were completely unaware of resources St. Michael’s Hospital provides for health and wellness.

• Many also felt that available resources were not designed to support the unique needs of shift workers.

• In general, respondents did not feel that bedside nurses at St. Michael’s were adequately supported to engage in self-care activities.

• These initial interviews suggested the need to focus on Recommendation 4.1, and increase knowledge transfer about available resources for nurses in the CVICU.

AIM & METHODS • Aim: • To raise awareness of health and wellness resources provided

by St. Michael’s Hospital and ensure nurses in the CVICU know how to access them

RECOMMENDATIONS/NEXT STEPS

RESULTS Use of Wellness Resources

by CVICU RNs

• Methods: • Review of available health and wellness resources through Corporate Health and Safety Services (CHSS) and discussion with manager and educator • Pre- and post-survey for CVICU nurses • Creation of Workplace Wellness Champion role • Education sessions for nurses based upon survey results

How much do you agree with this statement: “Using the available resources at St. Michael’s would benefit my well-being.”

INTERVENTION/PROCESS

REFERENCES

• The month of February was designated Workplace Wellness Month.

• Every week, for 3 weeks, a different topic was discussed in the unit based on areas of interest disclosed in the survey: • Physical and Mental Wellness • Perks and Discounts • EFAP (Employee and Family Assistance Program)

Harris, David F. The Complete Guide to Writing Questionnaires; How to Get Better Information for Better Decisions. Durham, North Carolina: I & M Press, 2014.

How much do you agree with this statement: “I have a healthy work/life balance”

• Each presentation was 5 minutes in length and presented on weekdays to nurses on both day and night shifts.

• A handout summarizing the presentation was given to everyone in attendance.

RESULTS • The following graphs depict the results of the pre- and postintervention surveys completed by CVICU nurses. An 80% response rate was received.

How much do you agree with this statement: “I am aware of the Wellness Resources available to me at St. Michael’s Hospital.”

• The following strategies are recommended in order to sustain this initial introduction to health and wellness promotion for critical care nurses working in the CVICU: • Institution of a Workplace Wellness bulletin board in the CVICU where self-care ideas can continue to be spotlighted; • Posting and circulation of articles about health and wellness and information about St. Michael’s health and wellness offerings to promote awareness and enable easy access for CVICU nurses; • Continue with the concept of a Workplace Wellness Champion who can carry on the promotion of self care of the Critical Care Nurse.

CONCLUSION • Nurses in the CVICU are very interested in self-care and in learning about available health and wellness resources.

• Prior to this initiative, there was a deficiency in awareness of corporately available resources for nurses and how these could be accessed to maintain a healthy work/life balance.

• Through short burst education sessions, awareness of corporately available health and wellness resources was increased and nurses in the CVICU learned how to access them.

• This initiative has ensured that nurses in the CVICU have access to additional tools to support them to maintain a healthy work life balance.

• Key success factors were the support of management and the interest shown by fellow CVICU nurses.

Registered Nurses’ Association of Ontario. Workplace Health, Safety and Well Being of the Nurse. Toronto, Canada: Registered Nurses’ Association of Ontario, 2008.

Smith, O., Skiffington, A., Krock, M. et al. Understanding nurse’s health and wellness at St.Michael’s Hospital: A descriptive study. Toronto, Ontario, 2015.

Strange, Carol Anne. How to make the most of your evenings. Breathe Magazine; Issue 10, 2018.

ACKNOWLEDGEMENTS • Donna Romano (BPG Mentor) and the Professional Practice Department at St. Michael’s • Orla Smith (Unit Mentor) CLM of CVICU • Michelle Williams (Unit Mentor) Nurse Educator of CVICU • Abe Manabat (Unit Mentor) Fellow nurse in CVICU • Nurses of the CVICU

Transition from Doing To and Doing For To Doing With our Patients FOCUS

PDSA Cycles

Sarah Kreher RN, Katherine Mansfield RN, BScN, MN, CGN St. Michael’s Hospital RESULTS-Post Implementation

•

RNAO Best Practice Guideline: Person and Family Centered Care

PDSA #1 Staff Education: Project Introduction & Feedback Place

•

Engage the patient in a participatory model of decision making

PDSA #2 Essential Whiteboard Tools at every whiteboard

•

Participatory Model of Care: When the care provided is based on what patients want and need

PDSA #3 Staff Feedback & Whiteboard Introductions

the names of the institutions

95% Felt concerns are being addressed

Utilization of Whiteboard Labels “Knowing the white board 80% Stated they know their plan of care Was up to date meant a lot to me. I loved when they tailored the facts 20% Had “Plan of Care” noted on the whiteboard to me, such as the number of laps I “I love the whiteboard for messages to and from the team” was now walking. I even noticed when the RN took the effort to find a “It means a lot when I can be involved in the care plan” marker when one was not there.

They made me feel good-clearly “Great care by the RNs” it was important”

RESULTS- Pre-Implementation Staff Pre-Survey

“Nothing about me without me”

PATIENT INTERVIEWS

Marker, holder & cleaner at every whiteboard

CONCLUSION & DISCUSSION

BACKGROUND •

We have had positive results from patients that their concerns are being addressed

• Multiple tasks often overtake nurses’ ability to engage meaningfully with patients

•

The whiteboard is a strategy for how interprofessional teams can better partner with patients for improved continuity and transition

• Our question – “How can WE better enable patients to be an active participant in their care?”

•

• Partnership is key to patient recovery and progress Patient Whiteboard; Plan of Care

Staff Pre-Survey •

PURPOSE & OBJECTIVES • To understand barriers in establishing a partnership with patients

• To enhance/sustain patient centered strategies previously introduced with other BPG initiatives

Audits over 8 weeks 4 pre & 4 post N=160

INTERVENTION/PROCESS •

Audits of kardexes and whiteboards (n= 160)

•

Focus groups with 95% of RNs over 1 month: Provided education on BPG & examined suggested strategies for communicating 'Plan of Care’

•

Patient & Family Interviews n=20

Patients & staff actually like the whiteboard as a modality of communication

RECOMMENDATIONS & NEXT STEPS

• To explore and incorporate possible solutions to facilitate this partnership

Data gathering through:

Audits & sharing results are key to sustaining change

•

Monitor patient whiteboards (Goals/Plan of Care)

•

Ensure whiteboards are utilized as a consistent tool to share goals/plan of care

•

Audit TOA (To listen for discussion with patient on plan of care

•

Continue to acquire feedback through patient interviews

Patient Pre-Survey What patients shared……

“Frustrating when staff clearly are not listening – they have their own agenda of what they want to do/talk about” “Having a white board with nothing on it, or the wrong date day after day – is not helpful. We feel better not to have one if it’s not updated”

ACKNOWLEDGEMENTS Murray Krock, Nursing Professional Practice Joanne Bennett, Clinical Leader Manager, 16CCN 16CCN Nursing Staff

INCREASING AWARENESS OF COMPASSION FATIGUE AND RESILIENCE IN MEDICAL SURGICAL ICU Samantha Roberts RN Unit Mentor: Shannon Swift RN, MN, CNCC(C)

FOCUS • Increasing awareness of compassion fatigue and promoting resiliency through self care strategies amongst MSICU staff.

• RNAO BPG: Preventing and Mitigating Nurse Fatigue in Health Care, recommendations that informed this initiative included:  4.1 Occupational health and safety educational programs include formal and informal education sessions  7.3. All employees, physicians, volunteers and students should take responsibility for maintaining optimal personal health and well-being.

Professional Practice Mentor: Donna Romano RN, MSc, PhD, CPMHN(c)

PURPOSE & OBJECTIVES

RESULTS

RECOMMENDATIONS/NEXT STEPS • Continue to promote SMH Wellness Programs at unit level.

• Create an awareness of compassion fatigue and enhance resiliency in MSICU through education and promoting self-care strategies.

• Provide yoga sessions specifically for MSICU by Wellness Consultant Shivalee Paliwal.

• Conduct post survey after interventions developed and distributed.

• Post Survey was sent out April 4, 2018. Utilized as a measurement tool to see if awareness has increased with compassion fatigue and resilience education.

BACKGROUND • Compassion fatigue also called “vicarious traumatization” or secondary traumatization is the emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events (Figley, 1995).

• Literature findings highlight that:  “Compassion fatigue develops over time – taking weeks, sometimes years to surface. It is a low level, chronic clouding of caring and concern for others in your life.” (Oshberg, 2017).  Compassion fatigue occurred in trauma nurses who reported fewer hobbies, weaker co-worker relationships, and working longer than 8-hour shifts (Hinderer et al., 2014).  Clinicians working with trauma survivors, having lower emotional self-awareness, predicted higher compassion fatigue (Killian, 2008).  Resilience should not be seen as an individual accountability which can lead to a culture of self-blame (Scammel, 2017). To build resilient healthcare communities, interventions need to be enacted at individual and organizational levels (Scammell, 2017).  Policies and practices can significantly enable resilience or indeed contribute to worker stress (Scammell, 2017).

• 25% of staff participated in-services education on resiliency and compassion fatigue.

INTERVENTION/PROCESS 1. Survey: ten questions  Targeted awareness of resiliency and compassion fatigue, current state of self-care activities, awareness of St. Michael’s Hospital (SMH) resources for wellness.

• 7% of staff attended the reflection on resiliency presentations.

• 25% of attendees in the resiliency workshop were from MSICU. • 2 education sessions of SMH Wellness resources by performance and wellness consultant, Shivalee Paliwal.

CONCLUSION 2. Provided huddle in-services on resiliency and compassion fatigue education.

• MSICU staff were involved in self-care activities.

REFERENCES Hinderer, K.A., VonRueden, K.T., Friedmann, E., McQuillan, K.A., Gilmore, G., Kramer, B., and Murray M. (2014). Burnout, Compassion Fatigue, Compassion Satisfaction, and Secondary Traumatic Stress in Trauma Nurses. Journal of Trauma Nursing 21 (4): 160169. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25023839. dio: 10.1097/JTN.0000000000000055.

Killian, K.D. (2008). Helping Till It Hurt? A Multimethod Study of Compassion Fatigue, Burnout, and Self Care in Clinicians Working with Trauma Survivors. Traumatology 14(2): 32-44. Retrieved from http://www.washburn.edu/academics/college-schools/appliedstudies/departments/social-work/sw-files/sc-traumatology-2008-killian-32-44.pdf

• 100% of staff who completed survey could define resilience.

Oshberg. F. MD. (2017). When Helping Hurts. The American Institute of Stress – AIS. Retrieved from https://www.stress.org/military/for practitioners leaders/compassionfatigue/

4. Promoted 8 hour resiliency workshop for staff.

• 75% of survey respondents were aware of compassion fatigue, however may not have conscious strategies to mitigate the effects on wellness.

Scammell. J. (2017). Resilience in the workplace: personal and organizational factors.

British Journal of Nursing, 26 (16): 939. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28880612 dio:10.12968/bjon.2017.26.16.939

5. Promotion of SMH wellness resources including: Employee Assistance Program, comp Psych, and chair yoga.

• 34 staff members participated in resilience and compassion Fatigue education.

3. Provided two 1 hour presentations on resiliency facilitated

by Donna Romano, RN, MSc, PhD, CPMHN(c).

ACKNOWLEDGEMENTS Karen Wanamaker RN, MN, CLM MSICU

6. Resilience Challenge with staff.

• Most reported the education was helpful and provided further open discussions on the effects of stress in the workplace leading to depression and physically not being well.

MSICU Staff Team

Quality Improvement Project– Home Dialysis Training Videos Sukhjeet Samra BScN, RN and Rachel Tong BScN, RN St. Michael’s Hospital – Home Dialysis Unit

INTRODUCTION

• Procedures were broken down into sections to allow patients to review the steps, pause the video, and then perform the steps.

The purpose of this project is to provide educational videos to supplement peritoneal dialysis training at the Home Dialysis Unit.

 One of our peritoneal dialysis patients consented to be the patient actor in the videos.

 Our program serves patients from diverse cultural backgrounds, socioeconomic statuses, information retention abilities and different literacy levels.

 The Home Dialysis team reviewed our videos to provide feedback before patients and their caregivers were given access to these videos. Videos were uploaded to the St. Michael’s Hospital Home Dialysis website. Videos were also accessible in DVD or USB format.

 Current teaching methods are patient specific and include the use of a written manual, hands-on-practice, and demonstrations.  In a study conducted by Neville et al. (2005), use of visual tools and symbols led to reduced peritonitis rates, compared to groups who were trained using traditional methods.

Figure 2; Data collected from DCCP Database from St. Michael’s Hospital

OBJECTIVE We aim to improve patient satisfaction and confidence while performing dialysis and dialysis related care at home. We also aim to ensure patients adhere to the correct technique while carrying out their peritoneal dialysis routine at home.

A study from Baker, et al. (2000) showed that health literacy was lower among older age groups. Studies have suggested that the act of reading requires adequate vision, concentration, good memory, the ability to process information, and to recognize words, all of which generally declines with increasing age.

PATIENT DEMOGRAPHICS

 We developed story boards for our videos; these included the dialogue, the audio voice over, and the visual images for each frame of the video.  Dialogue was reviewed by our patient education specialist to ensure it was written at a grade five literacy level. Storyboards were also reviewed by our program nephrologists.  The hospital’s medical media team assisted planning the process and filming the training videos. Videos were created to improve ease of understanding of the procedures. The length of each video was set to a maximum of ten minutes to ensure patients remained focused.

Figure 1; Data collected from DCCP Database from St. Michael’s Hospital

A survey was developed to obtain feedback from patients and families. Surveys were used to evaluate their comfort level in performing these procedures independently at home, compared to performing the procedures without the videos.

ACKNOWLEDGMENTS A special thank you to the home dialysis team for your continuous support, our patient education specialist, and the medical media team.

DISCUSSION

REFERENCES

Additionally, creating these videos was helpful in unifying the teaching of procedures among the staff in our unit. For example, different terminology was being used to describe the various parts of the equipment. Terminology and teaching methods are now standardized, which allow ease of communication between all patients and staff members.

Anouk T.N. van Diepen, George A. Tomlinson, Sarbjit V. Jassal; The Association between Exit Site Infection and Subsequent Peritonitis among Peritoneal Dialysis Patients, Clinical Journal of the American Society of Nephrology, Volume 7, Number 8, June 2012, Pages 1266-1271, http://cjasn.asnjournals.org/content/7/8/1266.long

This was a valuable learning opportunity to remind our staff of the diverse learning needs our patients have and how best we can teach in a patient-centered approach.

METHOD  We created two instructional videos on (1) exit site care and (2) how to do a Continuous Ambulatory Peritoneal Dialysis (CAPD) exchange.

RESULTS

CLINICAL RELEVANCE • Infections remain a frequent cause of peritoneal dialysis failure.

• Exit site infections (ESI) have a strong association with increased peritonitis rates (Anouk, et al, 2012).

• Multiple peritonitis episodes may lead to scarring of the peritoneal membrane (Peritoneal Dialysis, 2006). This can lead to ineffective dialysis.

• According to the International Society of Peritoneal Dialysis (ISPD) guidelines on PD training, there are multiple factors that affect patient outcomes. These include trainer’s experience level, training time, flexible and individual training methods. (Lei Z. et al, 2016).

Baker, D. W., Gazmararian, J. A., Sudano, J., Patterson, M. The association between age and health literacy among elderly persons. The Journals of Gerontology: Series B, Volume 55, Issue 6, 1 November 2000, Pages S368–S374, https://doi.org/10.1093/geronb/55.6.S368 Lei Zhang, Carmel M. Hawley, David W. Johnson; Focus on peritoneal dialysis training: working to decrease peritonitis rates, Nephrology Dialysis Transplantation, Volume 31, Issue 2, 1 February 2016, Pages 214–222, https://doi.org/10.1093/ndt/gfu403 National District Attorneys Advocacy Center, Train the Trainers Workshop, Columbia, SC, 1999 Neville A., Jenkins J., Williams J. et al. Peritoneal dialysis training: a multisensory approach. Perit Dial Int 2005; 25 (Suppl. 3): S149–S151 Peritoneal Dialysis: What You Need to Know, National Kidney Foundation,2006, Page 13, https://www.kidney.org/sites/default/files/docs/peritonealdialysis.pdf

Home Dialysis Unit 8 Cardinal Carter North St. Michael’s Hospital T. 416.864-5794 tongr@smh.ca (Rachel Tong) samrasuk@smh.ca (Sukhjeet Samra)

Supporting Women & Families with Early Pregnancy Loss in the Emergency Department Sarah Martin, Lee Barratt, Kate MacWilliams St. Michael’s Hospital, Toronto, Ontario, Canada

AIM

PURPOSE & OBJECTIVES

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

•

To assess ED staff comfort with providing supportive and bereavement care

•

To provide education related to early pregnancy loss and supporting families

•

To create tools for ED staff, such as patient-centred discharge education materials

RNAO BPG: Supporting and Strengthening Families Through Expected and Unexpected Life Events #1 Develop a genuine partnership with families #3 Identify resources and supports to assist families address the life event, whether this is expected or unexpected #4 Educate and provide information to nurses, families, policy-makers and the public to assist families to manage expected or unexpected life events #5 Sustain a caring workplace environment conducive to family-centered practice

•

INTERVENTION / PROCESS • Created a partnership with 15CC

CONCLUSION / RECOMMENDATIONS •

DSS and staff survey defined the magnitude of the issue and knowledge gap

•

Tools have been (and will be) adapted and implemented to support staff best practices and staff comfort

• Stocked discharge sheet and booklet in the ED

Upcoming Tools

To create a checklist for improving care for early pregnancy loss (based on BPG recommendations)

• Discharge toolkit for the Emergency Department Checklist Process information for nurses Discharge information for patients Mementos • Butterfly sign • Discharge information for medications

INTERVENTION / PROCESS •

Defined the issue through a survey of 100 ED staff members including RNs, MDs, Clericals, Social Work, and Pharmacy

BACKGROUND

•

PAIL’s Compassionate Care Workshop will help us in knowing what to say and what can be done to provide compassionate, sensitive and skilled cared for those experiencing loss

•

Huddles will support education and uptake with the tools

•

Women access the ED for a variety of reasons when experiencing a miscarriage

•

We plan to re-survey staff comfort in caring for this patient population

•

In 2016, ED had 2,803 visits of women experiencing a miscarriage, or bleeding in early pregnancy (source: Decision Support Services [DSS])

•

Operational stakeholders are engaged and this is the beginning of a much larger project. Overall, ED staff are very supportive and partnerships are being built across the hospital network

•

•

Journal of Emergency Nursing: Understanding the Experience of Miscarriage in the Emergency Department Themes • Loss not acknowledged, but dismissed • Perceived lack of discharge education • Lack of clarity regarding follow up • Experiences of marginalization Currently, we have no standard practice regarding how to care for this patient population as per surveyed staff

“No current practice”

“I have no idea”

“No different from other discharges”

• Ordered printed resources from the Pregnancy And Infant Loss (PAIL) network in seven different languages • Organized a PAIL Compassionate Care workshop for early May

REFERENCES • Macwilliams K. et al. (2016). Understanding the Experience of Miscarriage in the Emergency Department. Journal of Emergency Nursing, 42(6), 504-512.

• Provincial Council for Maternal and Child Health. (2017, March 31). Early Pregnancy Loss in the Emergency Department. http://www.pcmch.on.ca/health-careproviders/maternitycare/pcmch-strategies-and-initiatives/early-pregnancy-loss-emergencydepartment/

ACKNOWLEDGMENTS We wish to graciously acknowledge and thank the following for their support throughout this work : Donna Romano, Evidence Based Practice Nursing Manager Leighanne MacKenzie , Program Director, Inner City Health Melissa McGowan, ED Research Education Coordinator SMH ED staff

Improving the Care Transition of General Internal Medicine Congestive Heart Failure Patients Tamara A. Lewis RN; Shirley Bell RN St Michael’s Hospital, Toronto, Ontario, Canada

RNAO Best Practice Guideline Recommendation 5.1 • Health-care professionals engage in continuing education to enhance the specific knowledge and skills required for effective coordination of care transitions.

BACKGROUND • Congestive heart failure (CHF) is a chronic condition that is associated with acute exacerbations, and frequent 30-day readmissions on average 21.0% (HQO, 2016).

• Heart Failure (without angiogram) is the third leading most expensive type of hospitalization in Canada in 2012-2013 at $276 Million (CIHI, 2014).

• Compared with their index hospitalization, medical patients cost on average 42% (or $3,117) more per hospitalization at readmission, for an average cost of $10,404 per hospitalization (CIHI, 2012).

• General Internal Medicine (GIM) Aim: To reduce the number of CHF patients readmission rate through CHF education.

• SMH QIP: 80% of patients will have evidence of CHF education prior to discharge.

• Nurses are uniquely positioned to impact the reduction of readmissions, and improve care transition of CHF patients by equipping patients with education, information and community resources to self-manage their condition.

3 Category Survey • RN’s commitment to delivering/ensuring client receives CHF education package.

• RN’s commitment to daily education of CHF clients on GIM • RN’s ability to recall CHF education material on: Medications Daily Weights Fluid Restrictions Dietary (Salt) Restrictions • Symptoms of worsening CHF • Activity • Coping/Community Resources/Followup

• To re-educate GIM RNs on material found in CHF education package and on teach back

N/A 9%

RN Re-education One-on-one informal education given by BPG Champion to RN using SMH CHF Education Package as teaching tool.

Conducted FebruaryMarch 2018

Never 34%

Always 19%

Sometimes 38%

% RN engages patient in CHF education daily Never 4%

N/A 6%

Sometimes 36%

Always 54%

• • •

Provide continuous RN education/re-education on CHF Liaise with stakeholders Improve Teach-Back Checklist to involve Patient Validation of CHF Education while admitted on GIM • Conduct Soarian retrospective chart audits to capture: o % of CHF clients/family/caregivers receiving CHF education package o % of CHF clients/family/caregivers receiving CHF teaching o % of CHF clients with CHF order set on admission o % of CHF clients with follow-up clinic appointment within 1 month of discharge • Conduct post implementation evaluation: o Post RN education surveys o Post patient discharge follow-up call/questionnaire • Evaluate impact of the program on 30-day readmission over time.

REFERENCES •

RN demonstrate ability to teach-back integral topics in CHF education package prior to receiving reeducation:

• Conducted FebruaryMarch 2018

Medication

RESULTS

Proportion of ‘Yes’ Respondents (n = 53)

Canadian Institute of Health Information. (2014). Leading Hospitalization Costs in Acute Inpatient Facilities in 2012–2013 : Information Sheet.

Retrieved from https://www.cihi.ca/sites/default/files/document/cad_costingdata_infosheet1 4_en.pdf Canadian Institute for Health Information. (2012). All-Cause Readmission to Acute Care and Return to the Emergency Department. https://secure.cihi.ca/free_products/Readmission_to_acutecare_en.pdf Health Quality Ontario [HQO]. (2016). Transition between Hospital and Home. Retrieved from http://www.hqontario.ca/Portals/0/documents/qi/health-links/use-teachback-when-building-caregiver-and-patient-capacity-en.pdf Naylor, M., & Keating, S. A. (2008). Transitional Care: Moving patients from one care setting to another. The American Journal of Nursing, 108(9 Suppl), 58–63. http://doi.org/10.1097/01.NAJ.0000336420.34946.3a Registered Nurses 'Association of Ontario. (2014). Clinical Best Practice Guidelines: Care Transitions. Retrieved from http://rnao.ca/bpg/guidelines/care-transitions

•

64% •

Phase 1: RN Survey (n = 53) RN demonstrate ability to teach-back integral topics in CHF education package prior to receiving re-education 42 40

Daily Weight

62%

Fluid Restrictions

75%

Dietary (salt) restrictions

79%

Symptoms of worsening CHF

64%

Activity

30%

Follow-up/Community supports/Coping

26%

•

•

40 35

• To provide enhanced learning for patients admitted with a diagnosis of CHF to General Internal Medicine

% RN gives patient package/ensures patient received package

• • • •

45

OBJECTIVES

RECOMMENDATIONS/NEXTSTEPS

RESULTS (CONTINUED) Pre-education Survey Results (n=53)

Phase 2

Best Practice Guideline Topic • Care Transitions

INTERVENTION/PROCESS Phase 1

FOCUS

34

33

34

30 25 20 16 15 10 5 0

14

Yes No

CONCLUSION • While majority of RN survey respondents stated their commitment to distributing the CHF education package and educating clients, they identified areas for improvement, such as availability of resource; accessibility (with respect to literacy and language) and need for a broader multidisciplinary approach to education of CHF clients.

ACKNOWLEDGEMENTS • • • •

Nursing Practice and Education All GIM RNs; Sophia Wong RN BPG Champion Shirley Bell RN, BScN Clinical Nurse Educator, Unit Mentor Cecilia Santiago, RN, MN, CNCC(C) Contact Information

Contact Information Tamara A. Lewis, RN, BScN T: 416-864-5335 Email: lewist@smh.ca

Improving Complex Symptom Management at End-of-Life, in the Palliative Care Unit: An Educational Approach Victoria McLean RN BScN and Emma Rhodes RN BScN St. Michael’s Hospital RECOMMENDATIONS/NEXT STEPS

FOCUS

PURPOSE & OBJECTIVES

Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline (BPG): End-of-Life Care During the Last Days and Hours

RNs in PCU will improve their knowledge and skill of complex symptom management at End-of-Life

RNAO BPG Practice Recommendations:

• To disseminate educational package prior to education day

o Chest tubes

o Classroom

• To have achieved 100% attendance at education day

o GI tubes/drains

o Skills day

• To identify improved competency levels in post-education survey

o PleurX catheters

o Small group learning

3.1 Nurses are knowledgeable about pain and symptom management interventions to enable individualized care planning

RESULTS/FINDINGS

4.2 Successful education in end-of-life care includes specific attention to the structure and process of learning activities

BACKGROUND

• Survey identified areas of focus:

• Preferred education methods identified:

o Emergencies at end-of-life

3.2 Pharmacologic and non-pharmacologic care strategies RNAO BPG Education Recommendations:

• 11/24 RNs responded

METHODS No unit specific RN education

Complete Education Day in April 2018

Evaluate Education Day Disseminate Self-Reflection and Learning Needs Survey Post-education Nursing Week BPG Sustainability Poster Gallery Walk Event

Meeting with stakeholders

Submit poster abstract for 2018 International Congress on Palliative Care

Logic Model (framework)

Sustainability

Change in Palliative Care Unit (PCU) Philosophy of Care

Increasing Complexity of Symptoms

Identify knowledge gaps (survey)

ReQuIST Application (approved)

• Bi-annual dissemination of RN Self-assessment and Learning Needs Survey to guide future education

Action Plan (to do list)

• CLM interest in aligning education outcomes with Performance Appraisal process

DISCUSSION/CONCLUSIONS Disseminate survey and analyze results

Plan Education Day

There is a need for specialized education to manage complex symptoms in the PCU What we learned:

Currently No Existing RN Education

Comprehensive RN Self-Assessment and Learning Needs Survey • Via Survey Monkey over a three week period • Focus was to determine knowledge and competency levels pertaining to

Current literature shows: • Teaching methods must be diverse to target learning styles (Martin, 2011) • Educators are not teachers but rather facilitators and mentors (Martin, 2011) • Nurses require more education to effectively manage complex symptom at end-of-life (White & Coyne, 2011)

management of complex symptoms in the PCU

• The buy-in from multiple stakeholders kept us focused • Our initial framework evolved as we progressed through the planning process Key success factors: • CLM, Professional Practice Mentor and Unit Mentor support

• 26 questions: Likert Scale, Yes/No, Ranking, Comment Box, Checkboxes

• Financial support

PCU Education Day 2018

• Content expert support • Organizational resources (survey tool, workspace, AV equipment)

• Use survey results to identify areas of focus for education • Recruit content experts to deliver education

• RN engagement • Access to existing specialized content from other organizations

• Continue to update content in educational package semiannually

REFERENCES Broglio, K., & Bookbinder, M. (2014). Pilot of an Online Introduction to Palliative Care for Nurses.

Journal Of Hospice & Palliative Nursing, 16(7), 420-429. doi:10.1097/NJH.0000000000000089 Registered Nurses Association of Ontario. (2011). End-of-Life Care During the Last Days and Hours.

Retrieved December 5, 2017, from http://rnao.ca/sites/rnao-ca/files/End-ofLife_Care_During_the_Last_Days_and_Hours_0.pdf Martin, C. (2011). Implementing a Blended-Learning Hospice Staff Orientation Program. Journal Of Hospice & Palliative Nursing, 13(5), 326-333. doi:10.1097/NJH.0b013e318223d093 Wen, A., Gatchell, G., Tachibana, Y., Tin, M. M., Bell, C., Koijane, J., & ... Masaki, K. (2012). A Palliative Care Educational Intervention for Frontline Nursing Home Staff: The IMPRESS Project. Journal Of Gerontological Nursing, 38(10), 20-25. doi:10.3928/00989134-20120906-96 White, K. R., & Coyne, P. J. (2011). Nurses' Perceptions of Educational Gaps in Delivering End-of-Life Care. Oncology Nursing Forum, 38(6), 711-717. doi:10.1188/11.ONF.711-717

ACKNOWLEDGEMENTS Katherine Mansfield Lorraine Ciccarelli Kieran McIntyre Jonathan Ailon

Sheila Deans-Buchan Anna Kacikanis Donna Romano Charmaine Clayton

DESTRESS---Debriefing post Events for STress REduction and Supported Self-care Dong Wei (Wendy) Xu, RN, BScN, CNN (C), CNCC(C), Michelle Williams RN, MEd, Norine Meleca RN, BScN, MN, MScHQ St. Michael’s Hospital

FOCUS

PURPOSE & OBJECTIVES

Workplace Health, Safety and Well-being of the Nurses

Purpose:

• Recommendation 3.0 Organizations/nursing employers implement and maintain education and training programs aimed at increasing awareness of health and safety issues for nurses.

• Recommendation 3.3 Organizations/nursing employers promote and support initiatives related to the physical and mental health and wellbeing of the nurse.

BACKGROUND • “[Critical events] can trigger the cognitive, affective, physical, and/or behavior changes in the worker” (Caine R. M., 2003).

1. To improve staff satisfaction on post critical event debriefings,

The DESTRESS Tool • Based on a Critical Incident Stress Debriefing (CISD) model • A debriefing session is composed of four phases

DESTRESS Road Map

2. To improve the coping skills of staff post exposure to such critical events.

Objectives:

Notify CLM, Charge Nurse, Clinical Nurse Educator, and/or BPG champion of need for DESTRESS

1. To develop, implement and evaluate a tool for post critical event stress debriefing in CICU.

Identify Facilitator(s) of DESTRESS session

2. To initiate and sustain a standardized post critical event debriefing process in the CICU.

INTERVENTION/PROCESS  Focus group interview n=8

• “[Debriefing] can help reduce potential stress responses among staff while ensuring that employers are not exposed to litigation by staff who think they have been neglected” (Healy S., 2013).

 13 questions on staff experience and satisfaction on post critical event debriefing

Time and place for the DESTRESS session set by the facilitator(s) upon review of staff schedule Invite staff involved to the DESTRESS session DESTRESS session info sent to staff invited to the debriefing via email

 Structured survey n=29

Initiate modified Critical Incident Stress Debriefing Tool (mCISDT)

• Data collection, analyses and result presentation  Survey result presented back to staff via PowerPoint  Promoted staff engagement • Literature review and development of the DESTRESS tool and process.

• Stakeholder engagement • Staff teaching on utilization of the process and tool (n=25) • PDSA cycle 1, feedback: • Debriefing should be offered within 5 days of the critical event

• Debriefing allows for validation of feelings and normalization of responses to critical events. It allows discussions among staff and helps them exploring strategies to improve coping.

• DESTRESS provides a standardized framework and road map to post critical event debriefing in CICU. It allows for easy utilization of post critical event debriefing into nursing practice.

• A policy on post critical event debriefing should be formalized and practice integrated to promote wellbeing of critical care nurses.

Facilitator(s) reviews the critical event

• Needs Assessment:

• “[Their effects] can accumulate and contribute to staff burnout” (Hanna D., 2007).

CONCLUSION

RESULTS

RECOMMENDATIONS/NEXT STEPS • Provide staff training on facilitation of post critical event debriefings.

• Continue to modify the DESTRESS tool and process to facilitate its utilization into routine practice.

• Study the implication of a debriefing policy on the wellbeing of critical care nurses.

REFERENCES Caine R. M., T.-B. L. (2003). Early identification and management of critical incident stress. Critical Care Nurses, 23 (1), 59-65.

Hanna D., R. M. (2007). Debriefing after a crisis: what’s the best way to resolve moral distress? Don’t suffer in silence. Nursing Management, 39-47.

Healy S., T. M. (2013). Importance of debriefing following critical incidents. Emergency Nurse, 20 (10), 32-37.

ACKNOWLEDGEMENTS

• Each session should be kept within 30 minutes • Private location is preferred • PDSA cycle 2, feedback: • Timing for debriefing sessions should be flexible • Proper break coverage on the unit should be arranged to facilitate attendance

We would like to thank all CICU nursing staff for their continuous support on BPG initiatives.

Great appreciation to CICU Unit Based Council members.

Special thanks to: Donna Romano, Evidence Based Practice Nursing Manager Norine Meleca, CLM, CICU Beverly Hearty, Chaplain Spiritual Care