I recently completed 36 years of nursing at St. Joseph’s Healthcare Hamilton. My commitment to patient care has always driven me to seek out possibilities to improve the care that I provide. As a nurse who loves nursing, I am frequently looking for opportunities to gain new knowledge and skills that can be translated into better care for patients. I feel that this keeps me vested in my profession. I contemplated applying for an Advanced Clinical Practice Fellowship (ACPF) for some time and when I discussed this with one of our Nephrology Nurse Practitioners she encouraged me to pursue it. The management team in the Kidney Urinary Program at St. Joseph’s Healthcare Hamilton, (SJHH), was in full support of my fellowship from the initial meeting.
I knew I was up to this challenge, even though it was overwhelming at times. The proposal was extensive and very detailed but in hindsight I realized that this process ensured a strong commitment from the candidate. I was fortunate to have strong leadership from my mentoring team, Gail Burns, Nurse Manager, Transplant Clinics and kidney Urinary Program Clinics, and Paula Eyles, Clinical Nurse Specialist (CNS), Patient Education. I also had assistance from Mary-Lou Martin, CNS/Associate Clinical Professor, who supported my proposal submission in many ways. I am truly grateful to the Registered Nurses Association of Ontario (RNAO) and SJHH, for supporting me in this incredible experience. I repeatedly exclaimed to my colleagues, “When do you get the opportunity in your career to focus solely on your own learning needs, for your own professional development and know you can impact and improve the care we provide to our home patients?”

Home dialysis patients are in constant states of learning new and/or reviewing health information in order to manage their care at home. At SJHH, the Home Dialysis Program, which includes both Hemodialysis and Peritoneal Dialysis, focuses on self-management. Since, the education and health information nurses provide is ongoing, it seemed most appropriate that I concentrate my learning on the Best Practice Guideline (BPG) entitled, ‘Facilitating Client Centred Learning’. I was especially interested in integrating teach-back into our nurses’ daily practice to assess patient understanding.

RNAO Fellowship Goal

My fellowship goal was to acquire the knowledge and skills required to become an expert on Best Practice Guideline, Facilitating Client Centred Learning. As a nursing expert I would share this new knowledge through education to my colleagues with the outcome goal being to enhance their practice and improve patient care. The teach-back skill was introduced to the staff in the Independent home dialysis program through education sessions, which also provided the opportunity for practice of this new skill. Patient education materials were also created along with a tool to support documentation of teach-back. Using the L.E.A.R.N.S model of care delivery in each session, we reviewed and discussed how to maintain the excellent care we provide and to ensure all staff were practicing with the same focus….the patient is the centre of care.

Preparation and Background Work

The first several weeks were intense with new learning and gaining new knowledge to move forward with my goals. I did extensive reading and found it refreshing to see what the rest of the renal community was doing. One “ah-ha moment” I had early on was how easy it was to get distracted by some of the fascinating research studies being done! Realizing this, I met with my mentors regularly to talk about what I was doing and how it was going and this helped me to keep on task! I summarized the BPG and made notes on the topics I would be sharing with the home dialysis group. This review helped to cement the concepts embedded in the BPG and provided a strong foundation for my work. I completed my tutorial with the librarian to learn how to do a literature search and how to use various search engines. I completed an annotated bibliography on several articles I reviewed that were published after 2011 to see if there was any new evidence based research. These skills were new to me but I can see how linking the existing literature to my project was valuable to its success. The few articles that I found supported teach-back as a simple, effective way to assess comprehension and determine what needs to be retaught.

I was able to attend two RNAO Best Practice Champion workshops. These workshops helped me organize and prepare my stakeholder analysis and ensure I included all those who would be involved in the practice change. My gap analysis was assisted by the tools provided by the “Toolkit: Implementation of Best Practice Guidelines, Second Edition. These activities helped provide me a picture of the community and environment I was working within. I based my gap analysis on review of present documentation practices, observation of nurses in the home program in teaching sessions and patient and nurse surveys. Even though I work in this area the gap analysis provided me with information and insights and a different lens to see challenges and opportunities from.
Baseline Surveys

I interviewed 19 home dialysis patients: ten home hemodialysis and nine peritoneal home dialysis patients. My original plan was to interview patients in the dialysis unit and in their home but as I began to test my questions on a few patients who had dropped into the home hemodialysis unit, I soon realized the time required to do this would certainly be longer than I had expected. I did not want to burden patients with more home visits and occupy their limited time. Instead, I chose to randomly select patients who were coming into clinic whether it was home hemodialysis or peritoneal dialysis. The interviews, which I originally felt would take 30 minutes actually ranged from 30 minutes to 120 minutes. I found patients wanted to share their experiences, positive and negative and the time allowed patients the opportunity to tell their story and validate their experiences.

The survey was time-consuming but so rewarding and informative that the time became insignificant. I was able to thank the patient for sharing their experience and on a few occasions apologize for those undesirable experiences. I took the opportunity to listen to each patient. My favourite question to ask was what were the qualities or words that described a home dialysis nurse. So many words came from that question. To my surprise the word said most often was knowledgeable. Patients told me that it was very important that their nurse needed to know what she was doing. The expected words were also said such as kind, caring, sense of humor, and so many more. What I created with this was a wordle. A wordle is a cluster of words. It places the frequency of each word into prominence in the cluster based on how often it appears. With the support of the printing department I created wordle art to describe what a home nurse is. Posters were made and placed in the home training units for patients and staff to remind everyone what was important to patients.

Mentorship and Networking

I met regularly with my mentors. They were supportive but left the development and creativity to me and we would review and revise as a team. We planned meetings through email invites, phone calls and some ad hoc discussions. I resourced many additional health care professionals in person or by phone. I collaborated with my nurse manager every few weeks to keep her informed of my fellowship and what I was accomplishing. She was very encouraging and supported all my initiatives. I met with SJHH’s BPSO lead Helen Kirkpatrick, who gave me the idea for a wordle. I had a very informative experience with Theresa Harper, Patient Education Specialist at Hamilton Health Sciences (HHS), who was a co-team leader on the development panel for this BPG. She has also been involved in the implementation of teach-back in the Rehab unit at HHS, McMaster site. I shadowed diabetes educators to observe them using the teach-back skill in everyday practice. I had several phone conversations with the charge nurse in the Rehab unit at HHS, McMaster campus regarding their sustainability with teach-back implementation through another ACPF. I met with another ACPF candidate at SJHH Ruth Sahr from Mental Health. We discussed our fellowships and felt that it would be a great opportunity for all of SJHH’s fellows to meet and share experiences and support for other candidates. This is a great opportunity for us to sustain this project within the organization and also help disseminate information to other areas.

Learning Plan and Change

Review of the learning plan was important to keep the focus on my goals and strategies. But interestingly as I became immersed in the fellowship I found that some of my plans needed to change based on survey results. It was glaringly obvious that we needed an easy to administer tool to assess how patients learn best. I realized that my plans would need to change to include new learning objectives: to gain knowledge of how learning styles affect learning and then to analyze several tools to find one that meets the needs of our patients. I reviewed many learning style tools and narrowed it down to two. With the input from the home nurses we agreed on one tool we felt met our needs. I worked with my mentor Paula Eyles, CNS, Patient Education, who then assisted in simplifying it to the required literacy level for patient readability. I trialed it with a few patients to assess ease of use and all four patients agreed it was a simple tool to use. This finding was exciting and proved that the surveys I conducted had a useful impact on shaping patient care. This tool will now be used for every patient entering the home program.

I found there were many occurrences where the personal learning I was experiencing changed the path of my fellowship, and my learning plan needed revising to reflect this. I also revised my learning plan when I realized my expectations might have been too ambitious for the timeline that I had to complete this fellowship. Through my journaling, I reflected often on what had transpired through my fellowship and I realized that I enjoyed the challenges presented and that I actually thrived on change. I discussed the changes with my mentoring team and we agreed. I knew that I had to be mindful of the fact that not all of my colleagues embraced change as I did.

Closing

As I conclude my fellowship it is bitter sweet. I thoroughly enjoyed this experience for so many reasons. I was able to work closely with my mentors and to get to know them. I tapped into their many skills as leaders, educators and as a mentor. I had opportunities to meet or speak with several people working on the same mission of using best practice to drive patient care. I observed the diabetes educators using teach-back skills in their everyday practice. I was an enthusiastic educator for the staff, I provided as many education sessions as required to transfer knowledge I acquired during my fellowship. Attendance was close to 100% at the education sessions. At the final interactive education session, each staff was given a USB with all presentations, supporting articles, the BPG and other patient education material for future reference.

My role as charge nurse will allow me the opportunity to continue to develop the documentation for more teach-back scenarios. Interestingly I had plans to develop 5-10 teach-back tools for the Independent Home Dialysis program, which I now realize, was not realistic. The process is time consuming. All stakeholders need to be considered and have input and this takes time. I learned that setting time lines for responses from vested parties was critical to feedback.

I now feel prepared to continue this process of developing patient education material and supporting documentation reflecting teach-back use, in collaboration with my colleagues and our patient education specialist. I look forward to coaching and encouraging the use of teach-back into their everyday practice. I am the face of teach-back! When the nurses see me they think of teach-back and how to use this skill in their everyday practice. I am excited to continue the sustainability of this learning experience.

With the success of this within the nursing group of this program, I will be spreading and sharing this knowledge to our multi-disciplinary team starting with our home dialysis technologists. They play an important role in our partnering model by educating patients on the technical pieces of home dialysis. The completed new patient education material has been finalized and the teach-back documentation is in draft for approval at the next nursing advisory committee meeting. I have had discussions with my primary mentor regarding sharing this within the other areas of the Kidney Urinary Program. We have identified the value of assessing patient understanding in other critical patient care areas such as kidney transplantation, where medication compliance is critical. I hope to provide this education to the pre and post-transplant nurses in an effort to continue the valuable work from this fellowship.

This fellowship journey was very valuable as a seasoned nurse. It energized me personally and it showed others that one is never too old to learn new things. As a charge nurse I have the capacity to sustain teach-back by mentoring, coaching and assisting with the development and/or revision of patient education materials and supportive documentation tools. I have established new relationships within SJHH’s organization that can benefit future collaboration with other programs, such as our mental health program, working with them to address depression in dialysis patients. I enjoyed the education sessions and sharing my knowledge with my colleagues. This is evidence based care at work. Finally, I feel confident in my skills to support staff with coaching and educating them to be their best as patient educators.

Sharing my Experience

This fellowship has given me the opportunity to share this experience with many front line staff nurses. I will be presenting at Nursing Advisory Committee, the Board of Directors, and I will have a poster for presentation at the BPSO day at SJHH. I submitted an abstract to ‘The Canadian Nephrology Nurses and Technologists’ national conference, this fall, on teach-back skills and documentation.

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