Enhancing Nursing Leadership Skills at the Point-of-Care
Summary
Ontario’s Aging at Home initiative describes the aging population and associated complexity of illnesses as a major challenge for health care systems (2017). As one of the largest and most progressive long-term care homes in the province, the Perley and Rideau Veterans’ Health Centre (PRVHC) addresses these challenges by providing a broad spectrum of care. This 450 bed long-term care home includes the Sub-Acute Unit for the Frail Elderly (SAFE), a unique unit that offers restorative care for older people recovering from illness or injury. The home also offers a 40 bed convalescent unit for people 18 years and older. Residents admitted to these units often require medical-surgical nursing care, including intravenous infusions. There is an increasing demand for complex medical care on our long-term care units as well, since more residents are receiving treatment at home rather than in an acute care setting.
As a BPSO, Perley Rideau’s strategic plan aims to align new approaches to care with relevant best practices. Accordingly, building capacity in the nursing workforce is a priority to ensure quality, evidence-based and person-centred care. This Advanced Clinical Practice Fellowship aligns with PRVHC’s strategic plan, as the focus was to develop my point-of care leadership knowledge and skills, to increase my ability to collaborate with my nursing colleagues, and to build capacity in evidence-based practice at the point-of-care. We identified a need for nursing education and training on Peripherally Inserted Central Catheters (PICC) based on nurses’requests for support with care of PICC’s and the results of a past learning needs assessment. Therefore, I selected PICC care as my focus for this project.
The early stages of this fellowship involved reflective practice activities and discussions with mentors and a direct manager to develop my nursing leadership knowledge and skills. Following, I conducted a learning needs assessment, a thorough literature review, and liaised with community partners, including a Vascular Access Nurse and the Vascular Access Team at a hospital to identify practice gaps in PICC care. Through ongoing support from my mentors and collaboration with the nursing team, I implemented evidence based-practices by planning, creating and developing point-of-care resources, planning, developing and delivering education and training sessions and providing one-to-one mentoring opportunities for novice nurses.
My learning plan included three objectives: to increase my leadership capacity, to collaborate with the nursing team and to strengthen my coaching and mentoring skills. My learning outcomes are as follows:
Professional Development:
Increased my leadership capacity through self-assessments, reflective practice and meaningful discussions with my mentors.
Expanded my personal resources by utilizing strategies and tools to improve my self-management skills.
Increased my collaborative behaviours by engaging key stakeholders through all stages of the project.
Enhanced my role as a Champion; utilized the knowledge-to-action framework to implement, evaluate and sustain best practices.
Developed my role as an informal leader at the point-of-care by acquiring expertise in PICC care.
Built upon my coaching and mentoring skills; helped novice nurses translate knowledge to practice.
Project Management:
Developed strong skills in identifying practice gaps through a literature review and by liaising with community stakeholders.
Learned to create, develop, and disseminate a learning-needs survey to identify knowledge gaps; utilized adult learning principles to assess learning styles.
Learned how to conduct a performance-needs assessment to identify solutions for knowledge gaps.
Enhanced my leadership skills by collaborating with the nursing team to plan, create and develop point-of-care resources for evidence-based practice.
Gained knowledge and skills in planning, creating and developing educational materials and presentations based on best practice; applied adult learning principles to tailor education and training to nurses’ preferred ways of learning.
Acquired a better understanding of the processes involved in evaluating outcomes of a project to determine areas for improvement and to sustain practice changes.
Program planning and development:
Acquired knowledge and skills in planning, creating, implementing and evaluating an educational program for front-line nurses to provide methods for the application of knowledge to practice.
Learned to apply the techniques of the train-the-trainer approach for knowledge transfer of the educational program.
Facilitation and Simulation:
Built upon my facilitator skills through the delivery of nursing education and training.
Enhanced my ability to collaborate with my nursing colleagues by engaging them to fully participate in education and training.
Learned to develop clear objectives to initiate practice changes.
Acquired knowledge and skills in simulation through creating, planning, developing and delivering simulation opportunities.
Outcomes
A chart audit was conducted to determine resident outcomes experienced as a result of this fellowship. The sample size was five residents, which included all residents with PICC’s in the facility 30 days pre and post training. The focus of the audit was documentation on PICCs in PCC; documentation on PICCs under other headings, such as “Nursing Progress Notes” was not audited. The following criteria were measured: the number of progress notes on PICCs per shift, and documentation on the following; resident assessment, skin and PICC site assessment, external length, assessing patency, flush (solution, technique, and amount), documentation on troubleshooting, and documentation of the PICC insertion record. The outcomes are as follows:
Areas that Improved:
There was no documentation of the PICC insertion record pre training; the insertion record was documented for two residents post training.
There was no documentation on troubleshooting steps for PICC issues pre training; troubleshooting steps were documented on two occasions post training and the steps were carried out as per best practice.
More nurses are aware of and identifying PICC issues, such as dislodgement evidenced by an increase in the number of requests for further support with troubleshooting PICCs.
Areas for Continued Improvement:
There was a decrease in the documentation on the following criteria post training; external length, flush, and patency; however it was also noted that new nurses are now providing PICC Care. Strategies to increase the application of knowledge include: continued protected time to provide ongoing education and training, creating a structured progress note for documentation criteria in PCC, and providing visual reminders of PICC care best practices in the 24 hr report binder, which is accessed by all registered staff every shift.
My nursing colleagues were the key stakeholders for this fellowship, as their participation in education and training was essential for increasing awareness of their practice and for ensuring take up of evidence-based practice recommendations. Through a collaborative approach, we obtained great buy-in from nursing staff, resulting in excellent outcomes for the nursing team and the organization:
Areas of Improvement:
PICC Education and Training Session: The quality indicator for nursing outcomes was improved comfort with PICC care among nursing staff. All nurses completed pre and post education surveys for self-evaluation of knowledge, skills and confidence with PICC care; 89% of participating nurses reported an increase in knowledge, skills, and confidence in PICC care.
PICC skills station at The Perley Rideau Skills fair: 75% of nurses participating in the skills fair attended the PICC care station. A post-education survey using a likert scale asked nurses to rate whether they strongly agree (highest number) or strongly disagree with the statement The following education supported my learning and development; 72% rated the PICC Care training 5/5 and the remaining rated it 4/5; (the majority of nurses commented that they wanted more opportunities for hands-on practice).
PICC Point-of- resource; Collaboration with the nursing team in the planning, development and evaluation of a point-of-care resource for PICC Care; nurses were surveyed informally to evaluate the usability of the resource; 96% of nurses surveyed stated the resource will be helpful to support their practice at the POC.
Champions of PICC Care: Expanded Best Practice Champion role by selecting ten registered staff as Champions of PICC care; all Champions were signed-off for competency in PICC care best practices (PICC dressing change, PICC Cap change and flush, PICC assessment).
Behavioural Changes: Many nurses gave positive verbal feedback about the training and their intentions to change and/or continue to improve their current practice.
Organizational outcomes: Increased capacity in our nursing workforce through education and training to ensure our nurses are equipped to provide quality, evidence-based care of PICCs.
Areas for Continued Improvement:
Protected time to continue leading PICC education and training for all nursing staff; continue to conduct competency assessments to identify practice gaps, support application of knowledge and to ensure all nurses achieve competency in PICC care.
Increase the number of Champions by 20 to support knowledge dissemination on all shifts.
Overall experience
This fellowship was an extraordinary experience for me; it provided me with opportunities for self-directed learning through concrete and intuitive approaches that led to increased self-development and self-awareness. The first weeks, I focused on enhancing my leadership skills through the implementation of the practice recommendation, Building Relationships and Trust from RNAO’s BPG Developing and Sustaining Nursing Leadership (2013). I selected this recommendation, as it addresses the emotional impact that our work relationships have on us and on our behaviour. I found this recommendation to be a relevant approach for developing my leadership knowledge and skills, since I sometimes wear my emotions and at times this interfered with my ability to collaborate effectively.
Early on in this fellowship, I recognized the conversations I shared with my mentors were not only my most enjoyable moments; they were my roadmaps for improving my leadership knowledge and skills. Through meaningful discussions, they helped me to identify my strengths and areas for improvement, they shared strategies and pointed me to practice tools, and they encouraged me to seek opportunities to apply what I learned.
When I shared challenges, such as a conflict I had with an “unyielding colleague” or my reluctance to make practice recommendations to avoid insulting a nursing colleague, they saw opportunities to grow. They supported me in navigating difficult situations and provided the guidance I needed to practice new leadership behaviours. I am grateful that I had the opportunity to benefit from their expertise by expanding my leadership capacity and contributing to building a culture of best practice.
