- Assessment of the Pediatric Patient in the Emergency Department – A Patient-Client/Family Centred Approach
- Clinical Nursing Expertise in the Care and Treatment of Mental Health Clients with Concurrent Disorders
- Care of the Client with Borderline Personality Disorder in an Acute-Care Setting
- Nurses Advocating for Client/Families who Face Critical Decisions About Treatment and Care in an ICU Setting
- Fostering Best Practice
- Assessment and Device Selection
- Creative Change in Providing Nursing Education
- Supporting Nursing Expertise and Knowledge Transfer
For details on our many best practice guidelines, click HERE.
Assessment of the Pediatric Patient in the Emergency Department – A Patient-Client/Family Centred Approach
Fully 20 per cent or 40,000 of the 200,000 or so patients coming to our Emergency Departments (ED) each year are children. This pediatric population requires a comprehensive approach to care, and communicating with children involves a multi-level process in order to be truly successful. Children have fears, perceptions and altered levels of understanding that must be taken into consideration during their time in an ED.
Vera Girard, Clinical Resource Nurse for the Emergency Department at St. Catharines General Site, understands firsthand the difficulties in assessing and providing care to infants and children. As an ED nurse for 14 years, Vera knows her colleagues want to provide the best they can to this vulnerable population and so chose to do an Advanced Clinical Fellowship through the Registered Nurses Association of Ontario to find a better way to clinically assess our little ones.
“My goal with this fellowship is to give my nursing colleagues a tool to ensure we are assessing infants and children comprehensively and focusing on the unique elements that are so much more sensitive for children, such as levels of hydration, immunization, birth history and weight,” Vera explains.
A member of the Emergency Nurses Association, Vera was able to use information from a pediatric training course and adapt it to suit her colleagues’ need. She developed an education presentation to go along with a small colour-coded chart which nurses carry with them during their busy 12-hour shifts to cover all the bases for a head-to-toe assessment, including airway, breathing and circulation.
“Already, there has been a change within my department,” Vera says. “Nurses are telling me they now feel more equipped to assess children and they are thanking me for the tool, which offers a step-by-step approach.”
“First and foremost, this fellowship is benefiting the children and families we care for through improved nursing care,” Vera says. Next steps are to train ED nurses throughout the NHS’s five Emergency Departments and Prompt Care Centre using the comprehensive assessment framework developed.
Clinical Nursing Expertise in the Care and Treatment of Mental Health Clients with Concurrent Disorders
Debbie Mutch, RPN, Inpatient Mental Health, Greater Niagara General Site
The focus of this Fellowship is to develop clinical expertise in the care and treatment of mental health clients with concurrent disorders. Debbie currently works in a 29-bed acute care Mental Health unit at Greater Niagara General Site in Niagara Falls. It is estimated that of all the admissions to the mental health unit, over 60% of the patients have a mental health disorder as well as a substance abuse/addiction disorder. When mental illness and substance abuse co-exist, both disorders require specific and appropriate primary treatment.
There is no one basic approach for all, but each case needs to be individually assessed for the most appropriate recovery interventions. In order to provide this care, nursing needs advanced competencies in planning appropriate interventions for clients with mental health problems as well as addiction. New knowledge will help to support changes in programs offered to clients suffering with concurrent disorders. It is also hoped that emerging knowledge will help to transform attitudes to positive, empathic, hopeful responses towards clients suffering from concurrent disorders.
Care of the Client with Borderline Personality Disorder in an Acute-Care Setting
The overall learning goal of this fellowship is to improve clinical knowledge and skill in the area of in patient treatment modalities for the patients diagnosed with borderline personality disorder at the 29-bed acute care Mental Health unit at Greater Niagara General Site. The fellowship includes the opportunity to research and develop skills in the area of cognitive therapy, skills that are necessary across the personality disorders spectrum. The focus area includes enhanced knowledge and practical skill development in regards to the borderline personality disordered (BPD) patient in an acute care setting. This includes learning how to conduct behavioural analysis and solution analysis of problematic behaviours such as self harm and substance abuse. Other skills include dialectical behaviour therapy and managing stress for nursing staff as they deal with BPD patients on a day-to-day basis.
The objectives of the learning plan are to establish therapeutic relationships with clients, employ new communication skills in tumultuous periods with the client and to conduct interviews with the client that will help them learn how to construct a new self. Plans have been made for a two-week placement with the Regional Health Department Mental Health Team, who provide psycho-educational group education sessions for personality disorders.
The ACP fellow will be in a unique position to positively influence nursing practice and patient outcomes by promoting best practice and evidence-based treatment modalities. Secondary gains will be realized in a lower length of stay, less self harm activities and less intrusive, disruptive behaviour by the patients, and a higher sense of professional satisfaction with nursing care provided. A safer work environment will benefit both clients and staff. The skills learned will be in keeping with the least restraint policy at the Niagara Health System.
The Fellow works closely with staff, management, educators and the mentorship team to develop knowledge and skills as evidenced by the development of nursing care plans that reflect new knowledge.
Nurses Advocating for Client/Families who Face Critical Decisions About Treatment and Care in an ICU Setting
When Maryke Durrant, Charge Nurse at St. Catharines General Site’s Telemetry Unit, started her Advanced Clinical Fellowship through the Registered Nurses Association of Ontario, she knew it would be of benefit, not only to her colleagues, but to the patients and families who have to make very difficult decisions when their loved one is facing death.
Maryke’s fellowship focused on two areas – exploring patient/ family needs for accurate information, comprehension and personal preferences for involvement in decision-making in an Intensive Care Unit setting, and developing a patient support aid to assist patients to participate in their care in ways that they prefer.
She conducted interviews with patients/families, researched best practices around the world and carried out focus group sessions with hospital staff. Interestingly, Maryke found that patients and families feel they are well-informed about care options, while nursing staff feel more can be done to communicate the patient’s true condition to loved ones.
What came up along the way of Maryke’s six-month fellowship was the realization that determining who is the correct power-of-attorney and next-of-kin to make life and death decisions is an increasing challenge. “As health-care professionals in ICU, we need one member of the family to make those decisions for the patient, because our patients on a ventilator have a critical illness and are usually not able to make their own decisions about continuing life-support or receiving palliative care,” Maryke explains.
“One example is a couple who have recently decided to separate, but there is no formal separation agreement. If the spouse becomes critically ill, his/her partner is not considered next-of-kin, even though the couple is still legally married. We have to determine the separation status and then determine which family member has the legal right to speak for that patient.”
To help Maryke and her colleagues, a speaker from the Public Guardian and Trustee office of Ontario conducted a half-day workshop where staff learned the rules for determining who speaks for the patient, and also focused on the impact cultural views and health care professionals’ personal views can have in helping family members make those difficult decisions.
Education sessions for all NHS ICU staff are now in the works, to ensure our patients/families are getting the care they wish, “and are fully informed about whether their loved one’s care is appropriate or possibly futile”, Maryke says. “I believe this fellowship is having a real impact on our patients, in that they are better informed and more fully engaged in care decisions. Nurses play a unique role in advocating for patients and support tools now in place are a step in the right direction.”
Fostering Best Practice in Medication Reconciliation in the Surgical Setting
The Niagara Health System as a retirement destination serves the oldest age structure within Ontario with a projected growth of 4%, in the 65 and over age group and is anticipated to grow to 18% of total population between now and 2013. The proportion of seniors living alone in Niagara is on average 3% to 7% above the Ontario average of 26.7%. This population presents challenges to the hospital sector to treat elderly clients according to best practice for this age group. The surgical nurses at St. Catharines General site have identified that the patients represented on their unit are elderly and present with a combination of co-morbid conditions often requiring multiple medications and consultations with specialists in addition to the surgeon.
Of particular interest is the movement to a patient-safe culture, and in keeping with the new advancements in patient safety, there is an opportunity for a nursing fellow to take the lead role in advancing nursing practice in this area. Barb Bologna, RN, led the development of a program to protect the patient and improve admission through to discharge care by considering reconciling the patient’s medication. Improvement literature is rich in the area of medication reconciliation and a nurse-led project can prove to benefit patients, staff and healthcare in general.
In keeping with the opportunity to support nursing expertise and knowledge transfer, a fellowship focused on Fostering Best Practice in Medication Reconciliation in the Surgical Setting is a perfect fit to encourage leadership development, advance nursing practice and improve patient care in the Niagara Region. Barb’s leadership focus was on education and policy in the area of patient safety related to medication reconciliation. Medication reconciliation is the process of identifying the most accurate list of medications the patient is taking by comparing the patient’s current list against physician’s admission, transfer and discharge orders. Patient safety literature reveals that poor communication of medical information is responsible for a large number of medication errors and adverse drug events.
Barb’s overall learning goal for this fellowship was to improve knowledge and skill in the area of medication reconciliation and to lead a change in nursing practice in collaboration and consultation with Marilyn Kalmats, RN, M.Ed as her primary mentor, along with a wider mentoring team inclusive of Heather Rodgers, Regional Surgical Educator, and Erin Barkel, Patient Safety Specialist.
Barb worked across multiple sites in order to access Library Resources, attend meetings and to conduct research and consultations. Time was spent on the clinical unit, accessing staff input to assess needs and modify the approaches to introduce, implement, educate and sustain identified changes in practice regarding medication reconciliation for the surgical patient. Barb gained leadership experience and knowledge and skills through literature resources, working in conjunction with ISMP, information from conferences, and in-house resources.
Assessment and Device Selection for Vascular Access
The Niagara Health System has identified five success factors to support the NHS vision of Together in Excellence – Leaders in Healthcare. These include; focusing on those we serve, bringing out the best in each other, building strong and successful relationships, creating a better way, and using our resources wisely. In keeping with the NHS vision and core values of compassion, professionalism and respect, the focus of Cindy’s RNAO fellowship will be to provide nursing leadership in the creation of a program for the implementation of RNAO’s Best Practice Guideline for Assessment and Device Selection for Vascular Access (May 2004).
The defined goal for the fellow is to design and implement a plan in order to facilitate knowledge transfer from the fellow regarding BPG to the nursing staff, thereby facilitating the implementation of best practice in patient care. As part of this fellowship, the Emergency Department practice at St. Catharines General Site will benefit by moving to best practice via the implementation of the guideline. The patient care goal is to improve nursing practice and patient care in the Emergency Department through admission to discharge by implementing the recommendations and practices outlined in the Best Practice Guideline.
Cindy Burtnik, RN, will be working closely with staff, management, educators and the mentorship team to develop knowledge and skills and to plan for the implementation of the guideline. The primary mentor has a clinical background in Emergency Nursing and superior skills in leadership and change management. Debbie Smith, RN, MScN has practiced in both large and small community hospitals and will provide the primary mentorship to the fellow. The mentorship team will also include Kelly Sylvester, who has extensive emergency nursing experience and will provide guidance and leadership from her experience as an educator.
The ACP fellow will be fulfilling the leader position to influence nursing practice and positively impact patient outcomes by promoting best practice and evidence based research. As with past successful fellowships, the success of implementation at the St. Catharines General Site ER will be fostered, supported and spread to the Emergency Departments and in-patient units across all 7 NHS Sites (including the Prompt Care centre at Ontario Street Site). Ultimately, the specific goals of the fellowship and secondary goals to enhance the knowledge and clinical practice of the nurses and educators will result in positive patient outcomes such as; improved patient satisfaction, reduced length of stay and minimization of patient risk associated with invasive therapies in keeping with the national agenda toward patient safety.
Creative Change in Providing Nursing Education by the Development of a Clinical Resource Nurse Model
The Niagara Health System is the last and largest provincial hospital amalgamation under the Health Services Restructuring Commission. Size and geography creates challenges for providing education across the 7 sites to more than 1,600 nursing staff. The NHS has 992 beds including acute, complex continuing care, extended care, rehabilitation, and palliative care.
The Education department has 6 regional educators providing service to Medicine, Complex Continuing Care/Long Term Care, Surgery, Critical Care, Emergency and Maternal Child program areas. The vision of the Education Department is to lead in educational excellence through self-directed learning and knowledge management principles. Our goals are to focus on the client, develop teams, utilize adult education principles, incorporate best practice in all we teach, inspire creativity, innovation and to foster the development of leadership skills at all levels of practice.
Mentors from the nursing faculty at Brock University will provide rich learning experiences and guidance in both clinical and educational objectives for the fellow. One of the mentors has completed extensive work in developing a Clinical Resource Nurse Model. Experience will be gained by a variety of methods including clinical areas of the NHS, attendance on campus at Brock University, via site visits to identified hospitals and attendance at RNAO-sponsored educational events.
This fellowship will focus on Leadership in the Education domain. The overall goal of the fellowship is to design and implement a Clinical Resource Nurse Model in order to facilitate knowledge transfer for NHS nursing staff.
As part of this fellowship, the NHS plans to support the development of a new way of doing business by utilizing the unit nurse as a knowledge resource. The fellow will gain the necessary skills and expertise to transfer her teaching skills and knowledge to other nurses. These nurses in turn will be supported to share nursing knowledge to all nurses on the clinical units by enhancing their teaching and leadership skills. The increased knowledge and expertise of the nurse will improve patient care. The organization will have expert Clinical Resource Nurses providing support at the bedside to champion best practice initiatives and to support ongoing learning.
The assessment phase will include a review of nursing education models within multi-site organizations, change management and leadership skills. Focus groups will be used to identify needs and gather nursing input from all stakeholders in nursing. In collaboration with the education team, the ACP fellow will introduce the concept to Managers, recruit Clinical Resource Nurses, provide educational workshops for Clinical Resource Nurses and develop outcome-based tools.
The ACP fellow would gain knowledge and skills through literature resources, site visits, consultation with Brock University nursing faculty, information from conferences, and in-house resources. Support will be received from the Mentor, Managers, staff nurses, and the Education team. The outcome of the fellowship for the fellow will be enhanced personal skills in knowledge transfer of teaching, clinical and leadership expertise. The outcome of the fellowship for the NHS is to have Clinical Resource Nurses available at each site for staff nurses, which will enhance and improve patient care.
The ACP fellow will be in the position to influence nursing practice and positively impact patient outcomes in the elderly by promoting best practice and evidence-based research.
Supporting Nursing Expertise and Knowledge Transfer through Mentor Relationships
The Niagara Health System as a retirement destination serves the oldest age structure within Ontario with a projected growth of 4%, in the 65 and over age group and is anticipated to grow to 18% of total population between now and 2013. The proportion of seniors living alone in Niagara is on average 3 – 7% above the Ontario average of 26.7 %. The demographic of this population presents challenges to the hospital sector to treat elderly clients according to best practice for this age group. The medical-surgical unit at the Welland Hospital site of the Niagara Health System has made significant progress toward advancing the role of the RPN toward more autonomous practice within a Total Patient Care Model.
In keeping with the opportunity to support nursing expertise and knowledge transfer through mentorship relationships, RPN Darlene Levinski’s fellowship focused on “Developing the Role of the Registered Practical Nurse in Caring for the Elderly on a Medical/Surgical Unit”. Following a recent concentrated education effort on the medical-surgical unit, with a need been identified in education related to care of the elderly client it was the perfect fit to advancing nursing practice and patient care in the Niagara Region. The fellowship included an opportunity for Darlene to research, plan and deliver education and to develop a sustainability plan to ensure knowledge transferred is put into practice.
Following a concentrated education effort on the medical-surgical unit, a gap has been identified in education related to care of the elderly client. The advancement of the RPN role from the previous task orientated model was replaced by a new RPN role in a Total Patient Care Model. RPNs now have primary responsibility for the patients and work in collaboration with the RN.
The overall goal of Darlene’s fellowship was to improve RPN knowledge and skill in nursing care of the elderly thereby enhancing the role and profile of the RPN. The fellowship involved collaboration and consultation with Debbie Roberts, Clinical Educator for Transitional Care as a mentor, the team of Clinical Educators, Kim McNaughton, the Clinical Manager, the staff and nursing leaders who had articulated the need for advancement of the RPN role.
Darlene worked across multiple sites in order to access Library Resources, attend meetings and to conduct research and consultations. She also spent time on the clinical unit, accessing staff input to assess needs and modify the approaches to enhance the RPN role.
Outcomes included benefits to increased nursing skill and knowledge, reduced lengths of stay, improved patient; education, safety and satisfaction for the elderly population. In addition, the fellowship has provided an opportunity to improve practice in leadership, organizational, and facilitation skills.
The work of this fellowship will also significantly contribute to the ‘new look’ of the Nursing Professional Practice Council as it truly actions RNs and RPNs Working Together.