The RNAO Advanced Clinical Practice Fellowship took place over 20 weeks at Holland Bloorview Kids Rehab under the capable leadership of my mentorship team. The learning objective was to increase my knowledge in implementing evidence based guidelines into practice, through the implementation of recommendations related to Strengths-Based care. The specific Best Practice Guideline I worked with was “Supporting and Strengthening Families through Expected and Unexpected Life Events”.

I had the privilege of attending the RNAO Best Practice Spotlight Organization Summer Institute in June 2013. The knowledge gained at the Institute assisted me in completing the deliverables for my fellowship. It was particularly interesting to hear the experience of others as they were implementing best practice guidelines in their organizations. The tool kit given at the Institute was very useful during my fellowship. My learning plan incorporated the Best Practice Guideline Knowledge to Action process and I was able to work through the various tasks within the six phases.

The literature search provided me an opportunity to work with our librarian. I learned how to do a formal literature search using the various search engines. Dr. L. Gottlieb’s book, “Strengths-Based Nursing Care: Health and Healing for Person and Family “was an amazing resource with a very comprehensive material on what Strengths-Based nursing is. The articles showed that Strengths-Based nursing is just emerging as a framework for nurses to empower clients and families to take a more active role in their health and healing. A literature review paper was completed and a visual summary of recommendations was developed to link findings with the context of our environment at Holland Bloorview. One of the most powerful statements that resonated with me was found in Dr. Gottlieb’s book. She says, “The role of the nurse is to create the conditions that encourage and support the person’s health and natural healing processes”. Dr. Gottlieb took the time to go through each article analysis with me and I so appreciated her insights.

I had the privilege to attend the McGill Exploration Day in Montreal on Strengths-Based nursing care. Dr. Gottlieb was one of the keynote speakers. Two other members of my mentorship team accompanied me along with one of our inpatient social workers who would later by a facilitator at our workshop.

This conference not only increased my learning on Strengths-Based nursing care but also gave us some ideas for what we wanted our day to look like at Holland Bloorview. It also gave us a wonderful opportunity to meet Dr. Laurie Gottlieb, my external mentor. A concept that resonated with me was that in order to fully practice Strengths-Based nursing care, leadership, education, practice and research needed to work in synergy. This gave us much to think about when moving forward in our organization.

My mentorship team very prudently asked me to do an environmental scan to study the current state of family assessments completed at Holland Bloorview. A gap analysis revealed there is no one area in our computerized system that would give nurses a comprehensive picture of the family. When Holland Bloorview documentation went computerized, the genogram and ecomap were no longer a component of the electronic health record (HER). Nurses do not have an area in the electronic health record to document many of the components of family assessment as outlined in the BPG “Supporting and Strengthening Families through Expected and Unexpected Life Events”. It was also noted that nurses had a knowledge deficit in how to navigate through the EHR to read other clinicians (ex. Social workers) documentation on family assessment.

This was a very enlightening exercise for me to complete. The literature, particularly Gottlieb and Wright and Leahey, they emphasize the importance of documentation. A quote from Wright and Leahey’s book “Nurses and Families” sums it up when they state, “It is very important for the nurse to devise a workable, efficient system for integrating, recording, and documenting the large amounts of complex data gathered in family interviews. Such a system provides the nurse with an organized and clear overview of work with the family to address their goals. With an organized recording system the nurse is able to move back and forth from macroscopic to microscopic data, and the family receives more holistic health care”. In the few published studies I read regarding the implementation of a Strengths-Based approach it was interesting to note that they identified a need to change their documentation system to support this approach. Another aspect to consider is the 24/7 nature of nursing. Useful family Information to assist the nurse when interacting with families has a potential to be lost during the handover report. I presented this data along with analysis and recommendations to my mentorship team.

Going on to the second phase of the action plan and my third learning goal, I completed a stakeholder analysis and an external scan. Developing the stakeholder influence and support grid was a new activity for me. Identifying who the stakeholders were, meeting with the stakeholders and generating the stakeholder analysis was a valuable exercise. I was able to gauge the support in the organization and who I would be able to approach for support in moving forward the value driven approach of Strengths-Based care to support our families. My mentorship team was instrumental in assisting me with identifying the stakeholders. This organization has high support in this initiative even with limited resources and competing priorities. The external scan took longer than anticipated as I had to wait for people to return emails and calls. I mainly targeted institutions with pediatric populations and most had a rehab focus. It was interesting to note that our major referring hospital, Sick Kids, was also partnering with Dr. Gottlieb on how to implement a Strengths-Based approach in their hospital. This led to further discussions and participation of nurses from Sick Kids at our workshop day. A number of the hospitals had not heard about this approach to care to support our families and expressed an interest to learn more. The few hospitals that were formally working on implementing this approach had started by running a book club. This may also be a strategy we use moving forward.

To build my skills in developing an evaluation strategy, I embarked on some self-directed learning, and in addition I met with Shauna Kingsnorth from Evidence to Care at Holland Bloorview. She shared with me that when developing an evaluation tool, I need to understand what I want to know, how will the questions align with the objectives, how will I analyze it and what am I going to do with it. This gave me a lot to think about.

I developed a family questionnaire to survey families on their nursing care experience. It was so invigorating to hear what families had to say and how we were currently supporting them and how we could improve the patient care experience. I had the opportunity to present the findings to senior and middle management. An audit was also conducted to learn nursing documentation practices in the few questions that are part of the client and family database. The audit results are captured in the environmental scan. A pre and post workshop evaluation was developed to get baseline knowledge about Strengths-Based nursing care. I also included a question regarding what they most wanted to learn and what resources they felt were needed to build on this learning. This assisted us in tailoring the learning experience (workshop) to their needs. The data provided great insight into how to move forward in building on workshop learnings. An evaluation based on the Kirkpatrick model of evaluation was also created to capture the participant’s experience of the day. The data indicated that the workshop was very well received. Nurses felt invigorated and excited about looking at their practice from a Strengths-Based lens to support their families. The early data from the post workshop fluid survey indicated that more support in continued learning would be necessary to build on what they learned at the workshop. I had an opportunity to share these findings at the workshop debrief the following week.

With the foundational work completed, I felt prepared to organize our learning event: a Strengths-Based Nursing Care workshop. This was a large undertaking but well worth the effort. The senior management team was incredibly supportive by providing the resources necessary to bring this workshop to Holland Bloorview.

I used the RNAO “Planning the Learning Event” document framework to assist in executing all the items required in organizing such a day. To assist me in building knowledge translation activities I met with the teaching and learning center, the nurse practice council and worked closely with my mentorship team. Ana DiMambro and Dr. Gottlieb were particularly helpful as both have a background in education. I shared the pre-workshop questionnaires with my mentorship team to guide us in the curriculum development for the day. We also took into consideration the BPG’s and Dr. Gottlieb’s book and what would be most beneficial for our participants. Objectives were developed and Dr. Gottlieb prepared her presentations. To support the learning following the three presentations, activities were developed. I collaborated with the 3 inpatient units, ambulatory care nurses and Sick Kids to develop realistic case scenarios for them to work through. Participant folders were developed and included information, a scenario, and worksheets for each activity, a resource sheet and an evaluation form. This was somewhat challenging as I had to take into consideration the knowledge base of our participants. I approached 4 other staff members to assist in the facilitation of our 3 activities. I developed facilitation manuals to prepare the facilitators for their role. WE had a total of 60 participants including 10 nurses from Sick Kids. As a sustainability strategy, we had asked all participants to develop a personal goal and a unit goal. Throughout the month of January I took photos of nurses and families and with the help of our multimedia specialist put a video together to show case our nursing staff. The foundation of SBNC is the collaborative partnership between the nurse and the family. This video was to showcase that collaborative partnership and give a tribute to our nurses. The evaluation data would suggest that the participants had a good learning experience and could incorporate what they have learned into their practice.

The full experience of putting this workshop together went much smoother than anticipated due to the support of my mentorship team and senior management support. I believe that I have grown in my organizational, leadership and workshop facilitation skills through this experience.

Sustainability:
I felt the workshop was the culmination of my work and yet, the work has just begun. In the debrief meeting with my mentorship team, senior director, operations managers, clinical educators and clinical resource leaders, I had an opportunity to share the evaluation data from the participants and share next steps in sustaining the learning that occurred. We reviewed the initial visual summary of recommendations for implementing SBNC to support and strengthen our families at Holland Bloorview. It became apparent that this work needed to continue under the guidance of a dedicated person. The organization is willing to support me until the end of March to develop a yearlong plan moving forward. This plan will be shared at Nurse Practice Council. The Plan will sit under the BPSO plan under Nurse Practice Council in order to ensure its sustainability. The managers and clinical resource leaders will be contacting the participants at the workshop to put the personal goal they developed at the workshop on their performance appraisals. This would also facilitate the sustainability and increased learning of Strengths-Based approach to care in supporting and strengthening our families.

Strategies to sustain the learning that occurred at the workshop and to continue the learning can include lunch and learns, start a book club, reflective practice activities and put together a toolkit for each unit. I will be working alongside participants from the workshop who will be the champions for their unit in organizing and developing these strategies. Additionally, Dr. Laurie Gottlieb has expressed an interest in continuing our relationship. She would like to be involved in the monitoring of how we are further implementing this approach at Holland Bloorview.

Furthermore, I believe nurses need the right tools to support Strengths-Based nursing care. I have met with the senior director responsible for overseeing our documentation, the nurse practice council and an Information Systems specialist to move forward in developing a client/family profile. We will be meeting in March to begin the planning and creation of such a document that would allow nursing to have a place to document family information as well as easily access this information.

Our clinical educators will be incorporating Strengths-Based principles into the core competency days and the nursing Preceptorship day. Ana and I will be presenting at our Teaching and Learning day on Strengths-Based Education. Additionally, I will be presenting at two conferences in May to share what I have learned in this fellowship.

My learning will be sustained through the ongoing activities listed above. I will also be going back to my unit and am very excited about formally incorporating a Strengths-Based approach to my care. I would like to further explore how to intentionally use the spiraling model for uncovering and discovering strengths.

Also, I would also like to integrate the Strengths-Based language into my discussions and conversations with patients, families, students and staff members.

Conclusion:
The experience of this Advanced Practice Clinical Fellowship has been challenging and invigorating. I have grown personally and professionally with the support of my very capable mentorship team. I have developed relationships both within and outside of Holland Bloorview that will continue to assist me in my professional growth. I can appreciate how the support from your senior management team is pivotal in the success of quality improvement initiatives. By setting learning objectives with clear deliverables, I was able to accomplish more than I thought possible. With the continued implementation of the BPG “Supporting and Strengthening Families through Expected and Unexpected Life Events by incorporating a Strengths-Based approach to our nursing care we will truly impact the lives of our clients and families.

I would like to thank RNAO for granting me this learning experience.

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