Registed Nurses' Association of Ontario

Using Promoting Recovery through Person- and Family- Centred Care

Shawn Nichola Smith, BScN, RN
St. Joseph's Healthcare Hamilton

Please give a brief description of the project and organizational context.
St. Joseph’s Healthcare Hamilton is a large, 1000 bed academic and research facility in Hamilton, Ontario. My target population was the inpatient adult psychiatric units which comprise 62 beds out of 100 acute psychiatric beds at the Charlton Campus. My mentoring team consisted of my primary mentor Mary-Lou Martin, RN, BScN, MScN, MEd, Ruth Sahr, RN, BScN, CPMH (c) and unit manager Holly Raymond MSW, RSW, Helen Kirkpatrick, RN, MScN, MEd, PhD, participated as a consulting mentor to me and my project. She had led the development of a nursing research program at SJHH in which hope was the overarching clinical and research focus. Her contributions were numerous and extremely valuable.

A pre-project chart audit revealed practice gaps of inconsistent documentation of the engagement, consultation, collaboration and care planning with the families of the persons we serve. Information gathered from the Patient and Family Council identified that families reported: poor communication with staff; lack of, or low appreciation of their level of distress; low level of understanding of their current situation; they did not feel included in care; they cited feeling unsure of how to cope or how to help a loved one cope after discharge.
A major goal of my ACPF project was to increase the level of engagement between staff, clients and their families. A secondary goal of the project was to promote the increased uptake if recovery oriented practices by nurses. The attainment of these goals would then culminate to support nurses to improve their engagement and ability to partner with clients and families thus improving patients’ and families’ health outcomes. The third goal was to introduce a strengths based nursing approach to nursing staff. This approach to nursing care offers nurses knowledge and skills to engage more collaboratively and holistically with patients and their families.

An outcome of the ACPF was to develop a tool that would be used by nurses which would address the gaps identified in the audit. These gaps included: lack of collaboration and partnering in care planning. The tool developed was a personal recovery workbook. The workbook focused on hope, strengths, goals, overall well-being, family and holistic strategies of the person and family to enable staff to better partner and collaborate in their care. The workbook will be given to patients shortly after admission. The nurses will engage and partner
with the patient and/or family to complete the workbook. As the nurses collaboratively work with the patient and/or their family, it will enable the staff to develop a therapeutic relationship and better understand the patients’ and families’ experiences. The workbook is the property of the patients so upon discharge or transfer from the unit the workbook will stay them.

Provide a brief description of the overall learning goal (objectives) and share the description of the skills, knowledge, and expertise that you have gained through the fellowship.
The overall learning goal of my fellowship was to increase my competence in the implementation of the BPG, Person and Family Centered Care and promote nursing practice that supports hope and empowerment of patients and families
My objectives were to increase my knowledge of the Best Practice Guideline (BPG), Person-and Family-Centred Care (P&FCC)and to gain expertise in BPG implementation with the focus of fostering increased recovery oriented nursing practice and improving engagement with families.

I attended a virtual (online) Registered Nurses Association of Ontario (RNAO)Best Practice Champion workshop. I also attended the RNAO Best Practice Summer Institute. These workshops helped me gain knowledge and skills in project management and of change management. Specifically, I gained knowledge about how to develop a project and of the steps required to implement change on my unit. I acquired skills in stakeholder analysis and included all those who would be involved in the practice change. My gap analysis was assisted by the tools provided in the Toolkit: Implementation of Best Practice Guidelines, Second Edition. Using this information allowed me to be mindful of the implementation strategies I chose and helped me to target my stakeholders 'needs. I was not able to meet with the mental health program’s business manager to learn about the metrics of P&FCC or recovery that would be used at SJHH. This objective was deferred to my post-fellowship work.

I have acquired in-depth knowledge of person and family centered practices. The fellowship enabled me to strengthen my practice skills in establishing and sustaining therapeutic relationships and partnerships with my patients and families. I increased my knowledge about hope through a literature search and review, and discussions with my mentoring team. I increased my knowledge about recovery oriented practices.This was accomplished through my visits to Ontario Shores Mental Health Centre, the Niagara Health Systems (NHS) (St. Catherine's site) and Holland Bloorview Children’s Rehabilitation facilities. I accomplished my goal of increasing my knowledge about how recovery concepts could be implemented on my unit from the observations at these three sites. One concrete example which I brought back to my manager was the implementation of the “My space board” from NHS. This is a white board that is placed at the bedside of each patient and it is used as a communication tool between the patient, family and staff. (See attached photograph). My nurse manger is following up with hospital printing services to have a decal made so that we can adapt this on my fellowship units.

Please give a brief description of outcomes for patient/client population that were experienced as a result of fellowship
The major outcome of my ACPF was the development of the workbook. This Person and Family-Centred Recovery Workbook was developed for patients and their families to foster their recovery efforts while in hospital. The workbook focuses on hope, strengths, goals, overall well-being, family and holistic strategies of health. The concept of recovery was integrated into the workbook. I met with patients on the two acute care mental health units to gain a better understanding of their experiences with their current and past admissions to hospital. These patients communicated they felt inundated with repeatedly asked questions. Patients also expressed that they didn’t feel staff supported or understood them at the beginning of their stay. They wished “that staff would be different” by “wanting to know more about them” and not treat them like a “check-list”.

The workbook was trialed with3patients and their feedback confirmed its utility and relevance in this setting. Patients expressed enthusiasm and they looked forward to using this workbook and were hopeful that the staff would continue to support use of the workbook. Patients identified that the workbook should be introduced to patients within the first few days of their admission depending on the readiness of the patient.

I increased my knowledge about hope through readings and discussions with my mentoring team. Two of the patients in my trial expressed concern that the workbook may not be fully adopted by the staff and thus the intent of the workbook would be lost. They stated that they had been involved in previous new initiatives during previous hospital admissions in which they experienced this fallout of staff. All of the clients in the trial did not consent at this time to involve their families. One patient indicated that she had limited involvement with her family. The second patient declined without a reason. The third patient was happy to have family participation however due to their work schedules family involvement was not possible.

The Personal Recovery Workbook developed through this fellowship continues to be evaluated and revised. My manager is supporting my commitment to the continued development of the
workbook after my fellowship. My goal is to enhance the utility and relevance of the workbook for patients and/or their families and the staff of 9 AMH and 10 AMH.

Provide a description of the outcomes experienced among colleagues/staff, organization, and stakeholders as a result of the fellowship.
This APCF positively impacted nurses 'practice on two acute mental health units because it supported implementation of best practices, promoted a recovery oriented approach and enhanced engagement between patients/families and nurses.
My nursing colleagues and members of the inter-professional team have provided feedback about the workbook's utility and relevance. They reported that the workbook addresses gaps that have been previously identified. They indicated the workbook would enhance knowledge about patients and families, and promote partnering with patients and families about care and recovery. The manager of the Patient and Family Advisory Council is currently reviewing the workbook and she will provide feedback. I developed and presented a poster at the Knowledge Café at SJHH during Nursing Week which was sponsored by the Psychiatric Mental Health Nursing Promotion Group. The poster communicated my ACPF work about the implementation of the Best Practice Guideline, Client and Family Centered Care. Over 200 multi-disciplinary staff, students, patients, families and visitors attended the event.

During my fellowship, I led multiple staff discussions on the BPG, P&FCC and a strengths based nursing approach and how it could positively change nursing practice and patients’ and families’ care experience. Staff evaluations identified that the fellow was knowledgeable in the BPG and SBNC.A power point presentation was developed and delivered to nursing and allied health staff at staff in-services. The power point presentation was also posted on the SJHH intra-net. I developed a poster and an educational bulletin board for both acute care mental health units. I created an info graphic and developed a reflective practice tool to aid in the uptake of this new knowledge and support the implementation of this BPG. I had meetings with the manager of the Patient and Family Advisory Council and with Peer Support Services at SJHH to discuss and seek input about the workbook.

The Administrative Director for Acute Care Mental Health Services and the Director of Nursing for the Mental Health and Addiction Program have been informed about my ACPF work. My mentoring team, manager and I will be meeting with them post-fellowship to discuss the outcomes of my work and future recommendations.

Overall Experience:

Please provide your overall feedback on the fellowship experience as a whole. Feel free to include your favourite moment(s).
This ACPF experience has been outstanding and it exceeded my expectations! I am a nurse with 15 years’ experience at SJHH and 22+ years of nursing experience and yet I learned so much. I value the learning experience the ACPF has provided because it has enhanced my knowledge and skills so that my colleagues and I can enhance person and family centered care on two acute care mental health care units. This ACPF has provided me with a unique opportunity to implement a best practice guideline.

Through this ACPF I have gained a deeper understanding and appreciation of my professional work and its impact of patient and family care; and the practice of my peers. This learning has occurred through the support, feedback and role modeling of my mentoring team. My learning was also enhanced by the development of new relationships with nurse experts at other sites. One of my best learning experiences was travelling to Montreal with one of my mentor to meet Dr. Laurie Gottlieb, the author of Strengths Based Nursing Care. I incorporated strengths based nursing care into the Recovery Workbook and my education session with staff. I was inspired by her passion for nursing and her pioneering work in advancing the professionalization of nursing. My knowledge of recovery and SBNC was increased through my observations and discussions with nurses, patients and their families. The RNAO Best Practice Summer Institute promoted knowledge acquisition of best practice guideline implementation and sustainability, and development of new professional relationships with nurses interested in best practices.

This ACPF experience has reinvigorated my passion for nursing and my commitment to ongoing professional development.