Registed Nurses' Association of Ontario

Multi-Organ Transplant

Kerry Katz
University Health Network

As a Registered Nurse (RN) on a 62 bed complex Multi-Organ Transplant (MOT) unit at University Health Network (UHN), I frequently care for patients with diabetes. A significant number of our patients are newly diagnosed post-transplant; however, prior to the fellowship there were limited resources to support learning related to diabetes management and teaching at the bedside. In addition, my clinical experience was that patients would have persistent hyperglycemia and significant time to action, which increases the risk of rejection, graft loss and infection. This inspired my RNAO Fellowship, Leadership – Education stream, with the objective to develop my knowledge and skills required for the development of an education program for staff nurses related to diabetes education.

Throughout the fellowship I achieved my learning objectives to objectives to build on current diabetes knowledge, enhance my skills related to education delivery, and to develop leadership skills. Learning was achieved through shadowing and consultation of experts in fields related to the learning objectives, attending in-person and online workshops, modules, webinars and courses, reading best practice guidelines, clinical guidelines, peer-reviewed literature and coursework material, interacting with vendors and attending vendor in-services related to diabetes management technology, attending the International Diabetes Federation (IDF) World Diabetes Congress, and engaging with the UHN Diabetes Special Interest Group (DSIG) and the RNAO Diabetes Nursing Interest Group (DNIG) and attending webinars hosted by these groups. The learning that was achieved was demonstrated by the provision of a comprehensive education initiative on the MOT unit at UHN, including three in-services for staff RNs (related to insulin administration, blood glucose management and treatment, patient education, and use of patient glucometers), the creation of an insulin reference poster and placement in medication administration areas on the unit, and the creation of a diabetes education “toolkit” for teaching at the bedside, also placed in key areas on the unit and provided to discharge coordinators. The resources created by this fellowship are currently being reviewed by stakeholders at each site and will be shared across UHN. The feedback from staff regarding this initiative was incredibly positive and results from evaluation showed improvement in knowledge and confidence related to diabetes management, as well as improvement in glycemic control upon review of patient data.

Facilitating education has improved the critical thinking skills of MOT RNs required for diabetes management and insulin administration. Specifically, it has expand nurses’ capacity to begin to think critically about blood glucose patterns and insulin adjustment. This has helped nurses advocate for the appropriate and timely treatment, by providing clear and concrete suggestions to the MD or NP. This assists the MD and NP to make decisions about care in a timely manner. For example, patient charts reviewed at the beginning of the fellowship revealed an average of 5 days of persistent hyperglycemia without changes to insulin regimen. After the education initiative, the change in practice was exemplified by the improved time to action in insulin changes seen in chart reviews; in one example, a patient had high blood glucose and each primary RN prompted the MD to make changes to insulin so that by the 3rd day there was improvement, and by the 5th day the blood glucose range had returned to target. Furthermore, in-services provided related to the use of patient glucometers (glucometers that are given to patients by the discharge coordinators during patient education and differ from the hospital glucometers used by RNs) and the step-by-step how to guide in the Diabetes Education Toolkit on the unit has helped the RNs to feel safer in their support of patients practicing blood glucose monitoring prior to discharge. Informal feedback through surveys has also demonstrated that the RNs feel more confident that they can support the patients learning related to the use of these glucometers.

Throughout the fellowship I was able to achieve my short-term objectives, for MOT nurses to receive education sessions and resources, increase knowledge and confidence related to diabetes care, insulin therapy, patient education and advocacy, and to be able to safely support the use of patient glucometers, and to have ongoing and sustainable education and resources for staff nurses on MOT and throughout UHN, and have in place a formal education pathway for new MOT RNs to have diabetes education as part of the 3 month follow-up practice review. In addition, I was able to achieve my objective to increase the use of the PERK package through its RN-friendly format in the Diabetes Education Toolkit for the target population of newly-diagnosed post-transplant patients, and to improve glycemic control of MOT patients with diabetes. While it is too early to determine the long-term effects, it is anticipated that an increase in patient teaching provided to patients diagnosed with diabetes post-transplant by MOT nurses will increase in knowledge and skill related to self-management of diabetes as demonstrated by patients during initial visits to the Transitional Diabetes Clinic (TDC) post-transplant. This long-term evaluation will be assessed at year-end with the support of mentor Andrea Miller, NP, at the TDC.

Achievement of the learning objectives was also demonstrated by the provision of diabetes education to in-patients and ambulatory patients under mentorship of Mary Ann Rosales (Discharge Coordinator, MOT), Elaine Wylie (CNS, Sun Life Banting & Best Diabetes Education Centre), and Andrea Miller (NP, Sun Life Banting & Best Diabetes Education Centre). My professional goals include becoming certified as a diabetes educator and becoming an advanced practice RN. This opportunity has allowed me to qualify and prepare to write the Certified Diabetes Educator (CDE) Exam in May 2016. The learning opportunities have given me exposure to many different patient scenarios and I feel well prepared to take on a CDE role in the future. In addition, the connections created with those in leadership roles at UHN have put me in an excellent position to apply for two interim Advanced Practice Nurse Educator (APNE) openings at UHN. Furthermore, I have been able to further establish a leadership role on MOT, and have the opportunity to work as a Special Project RN, alongside the Patient Care Coordinator (PCC) and APNE, on quality improvement and education projects on the unit.

In summary, the ACPF has been an incredible learning experience that has helped me to advance in my professional nursing career. I have felt very rewarded by the impact on patients and staff, and look forward to sharing the resources created throughout UHN. The experience has solidified my passion for education and diabetes management, and helped me to fully explore the role of the CDE and APNE as well as other nursing roles, as well as make lasting connections with colleagues in these fields. The ACPF helped me to achieve my learning objectives and bring me closer to achieving my professional goals, and I have many exciting career opportunities ahead as a result.