Improve geriatric knowledge for staff in caring for patients with responsive behaviour at the Reactivation Care Center- Humber River Hospital-Church site
Summary
Humber River Hospital (HRH) is a large community teaching hospital located in the Northwest region of Toronto. HRH, a multiple site organization consists of the Wilson site, Church site and Finch site. HRH- Church site is the Reactivation Care Center (RCC) which is a collaborative and innovative approach with multiple hospitals designed to help patients who no longer need acute care services to wait for another alternate care facility such as convalescent and long-term care or rehabilitate to go home. HRH has one unit at Church site with 34 alternate level of care beds. HRH shares the physical spaces with other organizations such as Sunnybrook Hospital, Trillium Health Partner, William Osler, South Lake Hospital, and St. Joseph’s hospital.
The scope of this fellowship was to design the framework and build capacity among registered staff to care for patients with responsive behaviours due to neurodegenerative diseases such as dementia at HRH RCC unit- Church site with the potential to disseminate this framework and share knowledge expertise to the acute medical units at Wilson site as a part of implementation of the RNAO clinical Best Practice Guideline- Delirium, Dementia and Depression and other organizations’ units at the RCC.
My learning goals were (1) to enhance my knowledge with regards to the assessment and management of responsive behaviours in older adults with dementia and other neurodegenerative diseases and (2) to develop a clear understanding of leadership competencies that require in implementation science. Throughout the fellowship, I have learned extensive amount of knowledge and resources in caring for the older adults with responsive behaviours, and I have used that knowledge to prepare educational materials to build capacity among the staff at the Reactivation Care Center. I have also gained leadership skills, knowledge and expertise in knowledge implementation and project management. In particular, I have utilized the LEADS leadership in a caring environment framework (Dickson& Tholl,2014) to build my leadership skills (earning leadership as a lifelong journey, lead self and engage others) and applied RNAO- Transformational Leadership Practices Conceptual Model (Registered Nurses’ Association of Ontario, 2013) throughout the fellowship. I have learned that the value of the organizational supports from all levels, professional identity, mentors, and lifelong learning attributes has influenced the abilities to build relationships and trust among staff and management, create the safe space for learning, support the culture of knowledge integration and sustain positive changes, which can lead to healthy outcomes for patients and staff in the organization.
In addition, I assessed the staff’s knowledge gap and needs in dementia care using the assessment tool “sense of competence in dementia care staff scale” and interviewing the key stakeholders (director, manager, Clinical Practice Leader and staffs). From the result of the knowledge gap that the majority of the staffs have the basic dementia care knowledge; however, they have some challenge in translating that knowledge into practice, I have gained the skills in assessing the needs and how to develop the educational plan and educational materials that tailor to that need. Furthermore, I have sharpened my skills about multiple ways of teaching and mentoring staffs to improve their practical skills that can use in daily practice. Also, I have gained invaluable skills to collaborate and engage with the key stakeholders at the different levels in the organization.
Outcomes
The outcomes for the patient population are multiple levels. First and foremost, the staffs built the knowledge in identifying the triggers and preventing the responsive behaviours among the patients. In addition, the staffs engaged with patients and family on admission by using the tool “About me” to get to know the patients, their preferences and routine. I have also developed the routine care plan review for the patients with responsive behaviours in the weekly interdisciplinary team which included the unit manager, nurse practitioner, physician, occupational therapist, physio therapist, social worker, team lead and staff nurse, so the team can discuss what has worked and what hasn’t worked and created the opportunity to share what they know and what needed to focus on in the revised care plan for the following week. The individualized care plan was continued to be revised weekly until the patient didn’t have the responsive behaviours. The care plan and strategies were shared with the family members to engage family members in their love one’s care.
The frontline staff have attended weekly in-services over the course of two months with the various topics related to how to care for the patients with responsive behaviours including aggression, agitation, teamwork and communication and wandering (8 in-services in total and 30-45 minutes each session). The staffs were very engaged in the case studies during the in-services and shared their experience in working with persons with responsive behaviours. They were comfortable to share their knowledge and we have learned from each other as a learning collective in identifying the triggers and managing the care for the patients with responsive behaviours. The staffs are well-attended on each in-service. On average, between 70-90% of all staffs attended at the in-services. At the end of each in-services, the staff identified some strategies they would try or change in the way to approach to care I have developed the routine care plan review for the patients with responsive behaviours in the weekly interdisciplinary team. with their patients who they have some challenges in working with in terms of the responsive behaviours. To reach those staffs that couldn’t attend the in-services, I also sent out the presentation for their reviews. Some staffs actively asked me if they could have the presentation slides.
In addition, I presented the condense version presentation in caring for patients with responsive behaviours in the Geriatric Round, which was accessible to all staff at the hospital include acute care Wilson site, and Reactivation Center both Church and Finch sites in November 2020. There were close to 50 participants attended the round and received a lot of positive feedbacks. I also posted the material in our hospital BPSO website for all staff to access. Furthermore, I participated in the dementia working group that focuses on planning and implementing the dementia care in all the medical units at the Wilson site as a part of the commitment to implement RNAO BPG Delirium, Dementia and Depression.
Overall experience
Overall, this fellowship has been an invaluable opportunity for me in many levels to develop as an experienced clinician and as a leader in knowledge implementation and quality improvement. I have grown personal and professionally with the support of my mentor and director. I appreciated the guidance of my mentor during my biweekly check-in to keep me stay on track with the project and someone who was willing to listen and provided emotional support during my difficult and uncertain time. In returns, I was able to create a safe and cohesive space for the staffs to have the conversations and share their knowledge, concerns and challenges to learn from each other as a learning collective, a space where they can feel they were listened and promoted teamwork and improved work culture. Through the work in this fellowship, I had a great opportunity to see understand both perspectives from the upper management and the frontline staff who deliver the care and was the bridge to connect to work together for the common goal to improve the quality of care for our older adult patients who experienced dementia related behaviours.
Doing the fellowship during the COVID 19 pandemic has proposed a number of uncertainty and moving components such as lock down, limited gathering, staffing shortage and staffs’ fatigue. I have learned to be flexible, adapt with the current situation and, be mindful of staff wellbeing and burn-out. Earlier in my project, I have learned that virtual educational delivery would not work with the staffs at the RCC as the acuity and the process of admitting patients have changed, and readjustment with the changes came with the learning curve. I have cancelled the scheduled in-services due to multiple admissions or the shortage of staffs at those days. I have also learned how to create the inviting and engaged environment that staff still can learn and engage in learning during the uncertain and constant changing time. I have learned to explore the feasible strategic alternatives such as providing in-services on Saturday and Sunday (usually the least hectic time of the week usually). I engaged the staffs early in my project to provide input and feedbacks for my educational plan and proposed process. I sent the emails with learning material, reminder posted material in the hospital BPSO site for everyone who are interested. I had a great opportunity to exercise my leadership skills in the organizational wide platform at the Geriatric Round and share my learning and experience with the Dementia Working Group, which mandates to plan and implement dementia care at the acute care site of Humber River Hospital. Last but not least, I have the privilege to be the mentor for the North West Toronto BPSO Ontario Health Team ACPF fellowship in RNAO BPG Client-Centered Care implementation evaluation.
Dickson, G., & Tholl, B. (2014). Bringing Leadership to Life in Health: LEADS in a Caring Environment: A New Perspective (2014th ed.). Springer London. https://doi.org/10.1007/978-1-4471-4875-3
Registered Nurses’ Association of Ontario (2013). Developing and Sustaining Nursing Leadership, (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario. This work is funded by the Ontario Ministry of Health and Long-Term Care.
