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Loud and clear: Teach-Back enriches nurse-patient communicationBy James Wysotski

Vimy Barnard-Roberts, a nurse practitioner in the Heart and Vascular Program, uses the Teach-Back Method to instruct David Martin Watson about managing heart failure. (Photo by Katie Cooper, Medical Media Centre)

When research shows patients immediately forget 40 to 80 per cent of medical information they hear, and nearly half of what they do retain is inaccurate, better methods of communicating are required. Three nurse practitioners at St. Michael’s think the Teach-Back Method is the solution.

Teach-Back is a health literacy tool some nurses use to teach a skill or present potentially complex medical information to patients by breaking it down into simple pieces and then having patients repeat back in their own words what they just learned. It can be individualized and research has shown Teach-Back to

increase knowledge level and retention.

“The purpose of it is to validate patients’ understanding,” said Vimy Barnard-Roberts, a nurse practitioner in the Heart and Vascular Program of St. Michael’s Hospital. It confirms “they truly understand what the content or the education point is.”

When dealing with information about medications or when patients should seek medical attention, confirming comprehension has the potential to improve patient safety.

Barnard-Roberts and two other nurse practitioners in her program, Ada Andrade

Maria Laylo, a nurse in Hematology/Oncology, was in her first year of nursing when her manager mentioned a research opportunity through St. Michael’s nursing research program.

“I had never done research or quality improvement before, so I volunteered,” said Laylo. “It looked like a good opportunity for a new nurse like me to learn and make a change in our unit.”

The Knowledge Translation of Performance Data for Frontline Nurses and Leaders Project (known as PERFORM KT) connects front-line nurses with research mentors

By Emily Holton

Continued on page 2 Continued on page 4

INTOUCHMAY 2015

Nurses connect the dots between data and better patient care

CELEBRATING NURSING WEEK

MAY 11 TO 17

MAY 2015 | IN TOUCH | 2

Happy National Nursing Week!

The Nursing Week theme this year is, Nurses: with you every step of the way.

This theme certainly rings true for me; nurses are with patients every step of the way. The landscape of health care is constantly changing, and yet nursing practice continues to lead and excel in the delivery of cutting-edge, evidence-based care. Beyond the bedside, we are contributing to these changes through education, research, quality improvement and policy work behind the scenes.

Nurses work with the interprofessional team every step of the way. Guided by our Interprofessional Strategic Plan, “Living Interprofessional Excellence,” interprofessional practice is now the hallmark of St. Michael’s care. Nursing practice is only enhanced by this team approach, and our patients reap the benefits through better coordination,

Ella Ferris Executive Vice-President, Programs, Chief Nursing Executive, Chief Health Disciplines Executive

communication and collaboration across professions.

Finally, nurses are with St. Michael’s every step of the way. 2015-16 marks the beginning of a new Strategic Plan as well as Quality Improvement Plan. The action items related to these plans are exciting and ambitious, and the successful execution of many of them hinge on excellence and innovation in nursing practice. The important role that nurses can play in advancing the hospital’s strategy is a great privilege and responsibility, and I have no doubt that we are well positioned for success. Our remarkable achievements with transfer of accountability and improving transitions in care are a testament to what we can achieve together. As an RNAO Best Practice Spotlight Organization, nurses continue to implement evidence-based, best practice guidelines.

Looking ahead, nurses’ role in problem-solving to minimize disruptions related to 3.0 construction should not be underestimated. The next few years will undoubtedly be challenging, but as we

OPEN MIKE with

go through the challenges related to construction I hope we can all remember that the end results will be well worth it.

I also wanted to say, and I hope this is already clear: Nurses, St. Michael’s is with you every step of the way. Your knowledge, skills and judgment are unique and indispensable to our patients, the interprofessional team and the hospital. St. Michael’s is here to support you with health and safety resources, continuing education and professional development opportunities. This year, we’re evaluating our health and wellness programs to make sure that they’re meeting your needs. When you see the Nursing Health and Wellness Survey in your email inbox, I hope that you’ll fill it out. Your opinions and insights will help inform future health and wellness programs.

Thank you nurses for your care, compassion and enduring commitment to excellence in quality and evidence-based care. Happy National Nursing Week to all of you!

Follow St. Michael’s on Twitter: @StMikesHospital

and Haytham Sharar, learned about the method during an Institute for Healthcare Improvement webinar in 2010, and gained funding to research it through St. Michael’s Advanced Practice Nursing Research Advancing Practice Program. Their study followed six nurses and 32 patients, and while their results showed no significant impact on patient outcomes, such as less hospitalization, they observed an improvement in self-care scores and found that nurses liked how the method provided a framework for teaching patients and confirming comprehension.

Since then, the trio presented their findings at several international conferences, including the American Heart Failure Association where they hosted a workshop on how to do Teach-Back. The University of Ottawa Heart Institute also reached out with the intent to adopt the practice.

Awareness and adoption of the method is steadily on the rise at St. Michael’s thanks to an interprofessional practice forum

on the topic and word of mouth.

“It has great potential,” said Andrade, who is working with Patient Education to explore opportunities to expand usage of Teach-Back. “It can be used by anyone for any piece of information at any time.”

“It can be used in an office, at bedside or in a clinic,” said Barnard-Roberts in agreement.

Full understanding might not happen on the first attempt, according to Andrade. Patients will repeat information right away, but are sometimes unable to do so again later. A second attempt at Teach-Back usually proves successful.

It might take a little more time than simply relaying detailed information and hoping it’s retained properly, but Barnard-Roberts said it’s worth it in the end. Not only has it helped staff improve communications by identifying standard explanations patients frequently have trouble grasping, but “it’s less didactic and more interactive.”

Teach-Back story continued from page 1

MAY 2015 | IN TOUCH | 3St. Michael’s is an RNAO Best Practice Spotlight Organization

Chris Macleod, a Toronto lawyer who lives with a rare form of cystic fibrosis, experienced a flare-up in the summer of 2012 that sent him to 6 Bond for the better part of four months.

When in hospital, Macleod remembers choking and gasping for air. He had been forced to carry an oxygen tank and considered a lung transplant.

That all changed in the fall of 2012 when Macleod began taking Kalydeco, a groundbreaking medication that helps a small number of CF patients breathe easier. Kalydeco is the only drug that treats the underlying cause of CF: a faulty gene and its protein product.

Since starting on Kalydeco, Macleod has married Gloria, an elementary-school teacher, travelled to Albania, the Philippines and Mexico, and is back to work as a commercial litigator.

Macleod hasn’t been hospitalized since. His lung capacity has doubled and he no longer needs an oxygen tank.

“And we’re still progressing,” Macleod said. “That’s the difference Kalydeco has made.”

Health Canada approved the drug in 2012 for

use in people who carry the G551D mutation. Ontario agreed to fund the drug last fall. It carries a staggering price tag ($300,000), and is licensed only for use in those three per cent of CF patients with specific CF mutations.

Dr. Elizabeth Tullis, director of the hospital’s Adult Cystic Fibrosis Clinic, the largest in North America, helped to ensure Kalydeco was available to Canadians.

“I’ve never seen anything like this,” Dr. Tullis said. “People with CF on Kalydeco don’t need hospital admission, are able to work or attend school, and they feel better than they have in years. It’s very overwhelming as a CF physician to see how this has changed people’s lives.”

St. Michael’s was the only site in Canada to participate in the early Phase 2 clinical trials for the drug and had the largest number of patients enrolled in the Phase 3 trial.

Dr. Tullis said the next challenge for researchers to tackle is the common mutation seen in 90 per cent of Canadians with CF.

Fixing this mutation may require more

From constantly coughing to clearer lungs: a CF patient’s journey on a new treatment

Chris Macleod lives with CF and can breathe easier thanks to novel treatment changes largely introduced by Dr. Elizabeth Tullis, director of St. Michael’s Adult Cystic Fibrosis Clinic. (Photo by Katie Cooper, Medical Media Centre)

By Melissa Di Costanzo

than one medication. Based on results of Phase 2 and 3 studies, a combination of two drugs has already been submitted to Health Canada. If approved, this combination would likely carry a price tag similar to that of Kalydeco.

There may be other options. Some drugs that have been approved for use in different diseases could also correct the CF protein defect and one such medication is being studied at St. Michael’s – the only site in Canada.

“Our responsibility is to participate in as many of these studies on new drugs as possible,” said Dr. Tullis. “We don’t know what the right medication is going to be for these patients but the more quickly these studies are done, the faster we will find the best solution.”

Dr. Tullis is also celebrating $500,000 in new annual funding from the province, which has allowed her to hire another nurse, a social worker, a physiotherapist, a pharmacist and a clerical position.

May is Cystic Fibrosis Awareness Month

#CFAwarenessMonth

New nurses Maria Laylo and Zeinab Yusuf lead a five-minute Soarian education session with nurse Anna Solala. (Photo by Yuri Markarov, Medical Media Centre)

and provides monthly education sessions. With this support and some dedicated backfill time, nurses analyze and use their unit’s performance data to identify and plan improvements to care.

Laylo, Zeinab Yusuf (also a new nurse) and their mentor found an important gap in the unit’s documentation: although their own patient surveys showed that nurses were performing pain assessments appropriately, that work wasn’t showing up in Soarian. Laylo and Yusuf designed five-minute Soarian education sessions to take place whenever colleagues had a spare moment at the nursing station. They’ve seen a big jump in documentation of pain since then.

In Gastro/General Surgery, nurses Stephanie MacDonald and Beharta Bregasi joined the program to look at their unit’s data on falls. They discovered that 65 per cent happened between midnight and 7 a.m. MacDonald and Bregasi introduced “intentional rounding” on the night shift, using a standard script. This means that every night on their unit, a team of one nurse and one clinical assistant visit patients hourly to offer assistance with activities such as toileting and remind patients to ask for help.

Joanne Bennett, a clinical leader/manager on the unit, said the strength of MacDonald and Bregasi’s approach was in their consultation and collaboration with their peers.

“It took many, many iterations of the rounding sheet and process to get it right,” said Bennett. “But it meant they had front-line buy in from the beginning; everyone agrees that their process is doable and equitable. Stephanie and Beharta led the initiative themselves, and engaged champions to help them.”

Through the program, Respirology nurses Jessie Kar Yan Chiu and Michelle Ng discovered that their unit’s patient satisfaction scores for pain management were low. They developed an in-service education session for their peers.

Better patient care story continued from page 1

MAY 2015 | IN TOUCH | 4

PERFORM KT is a research study funded by the Ontario Ministry of Health and Long-Term Care and led by Dr. Lianne Jeffs, St. Michael’s Volunteer Association chair in nursing research and director of nursing/clinical research. Several Ontario hospitals are participating in the program.

“It makes sense for a bedside nurse to be doing this kind of research,” said Ng. “We have the perspective on patient care, and we are tuned into issues facing our unit’s nurses.”

MAY 2015 | IN TOUCH | 5

Clinical consultants build on nursing experience for St. Michael’s 3.0

When Jessica Cunnington worked as a registered nurse in the Medical-Surgical Intensive Care Unit in the 1970s, patient beds were pushed up against one wall and surrounded by monitors and other equipment. That made it difficult to move around the bed and, in particular, to reach a patient’s head.

Cunnington now works for the hospital’s Planning and Development Department, helping to co-ordinate the design of inpatient units in the Peter Gilgan Patient Care Tower.

All rooms in the tower’s new MSICU will have 360-degree access to patient beds for caregivers. Monitors and lights will be on ceiling-mounted articulating arms. From her own health-care experience, she knows this will be crucial to help nurses do their jobs.

Cunnington and Cathy Bidwell are registered nurses who now work as clinical consultants with Planning and Development. Both have spent most of their careers at St. Michael’s in nursing and clinical leader/manager roles in operating rooms, obstetrics, intensive care units, therapeutic endoscopy and the Medical Device Reprocessing Department. They have built strong relationships with physicians, health disciplines staff and other nurses.

As clinical consultants, Cunnington and Bidwell wear various hats. First, they are project managers, overseeing the timeline, budget and scope of building projects. Second, they are advisers, using their clinical expertise to help inform design decisions such as the layout of an operating room or flow of a unit. Third, they are communicators, translating the requests of the hospital’s stakeholders

to the architectural and building teams who draw and execute the plans.

In the plans for 3.0, Cunnington and Bidwell have shortened distances between patient rooms and support rooms – where clean linens are stored,

for example – where possible. Based on feedback from nurses and their own experiences, they know that this easily overlooked part of planning can help to decrease nurses’ fatigue and increase time at the bedside.

“Trust is a crucial part of our work,” said Cunnington. “The hospital’s end users of a building project know we understand what they need to do their jobs and trust that they will see this in the final design plans.”

Bidwell, who is overseeing the renovations to the Emergency Department, said she was eager to see how transforming patient flow through

the ED would improve patient care.

“In the Slaight Family Emergency Department, patients will be triaged and directed to the appropriate area for care depending on whether they are mobile and can walk on

their own, or if they need to be transported by a stretcher,” she said. “By streamlining care in this way, we’ll make sure we have the right space for the right patient at the right time.”

Cunnington said she looked forward to seeing all single rooms in the Peter Gilgan Patient Care Tower, with dedicated space in each room for the patient, his or her family and for staff.

“Privacy, natural light, better infection control and family-centred care are all part of the designs,” she said. “There is a lot to look forward to.”

A rendering of a patient room in the Peter Gilgan Patient Care Tower’s MSICU. All rooms will be private and equipped with monitors and lights on ceiling-mounted articulating arms, providing 360-degree access to patient beds. (Rendering by NORR)

By Kate Manicom

“Privacy, natural light, better infection control and family-centred care are all part of the designs”

MAY 2015 | IN TOUCH | 6

A patient’s relative passes the time by watching TV and reading a magazine in the Sullivan Family Lounge. (Photo by Yuri Markarov, Medical Media Centre)

Sullivan Lounge gets a makeover

A man waiting in the Sullivan Family Lounge while a relative was having day surgery was so frustrated by the fact the TV wasn’t working that he donated $10,000 to buy a new one and make some other renovations.

As a result, the hospital was able to buy a new flat-screen TV for the lounge as well as new furniture that meets senior friendly design standards.

“Friends and relatives may be waiting here in the lounge for several hours, so it’s important to provide a comfortable place for them,” said Meredith Muscat, the clinical leader manager for day surgery. “We try to make it very serene and quiet and anti-anxiety.”

The lounge, located in the Terrence Donnelly Day Surgery Centre on the fifth floor of Cardinal Carter North, consists of a main seating area, library and quiet room.

In addition to the TV, the anonymous donation was used to buy four guest chairs, three single-seat lounge chairs,

three two-seater lounge chairs and two three-seater lounge chairs. All the chairs have seats that are 18 inches off the ground and 20 inches wide - making it easier for seniors to get in and out of them. They have firm cushions and armrests for lumbar support and are upholstered in simple contrasting colours to make them easier for seniors to see. The walls were also painted in contrasting colours for the same reason.

The money was also used to purchase two meeting tables, as well as two coffee tables and four end tables, which are both oval-shaped to prevent seniors from hurting themselves on sharp or hard edges.

By Iram Partap

A photo of the lounge prior to renovations.

The improvements align with St. Michael’s senior friendly hospital strategy and used the Code Plus Senior Friendly Design Standards, evidence-based guidelines that take into consideration how well the physical environment is equipped to address the developmental needs of older adults.

MAY 2015 | IN TOUCH | 7

The Home Dialysis Program always said that when it had 100 patients who were receiving dialysis at home, it would have a big celebration. But before the party could be held in April, the number had risen to 115 patients and is still climbing.

“It’s more than just a number, since of course there is a patient and a personal story behind each one,” said Liz Anderson, the clinical leader manager for the Kidney Care Centre, Home and Satellite Dialysis Units. “But it is an important milestone for us 25 years after the home dialysis program began at St. Michael’s.”

Anderson attributed the accelerated growth in the Home Dialysis Program over the last two or three years to four things:

• A urologist dedicated to the program, Dr. Jason Y. Lee, for peritoneal dialysis catheter insertions. Dr. Lee surgically

implants the catheter in advance, and when the patient is ready to begin dialysis, Dr. Jeffrey Perl, a nephrologist performs a minor surgery to bring the buried portion to the surface. By burying catheters in advance, the patient has their access already in place when it’s time to begin dialysis and dialysis can be started in a more timely fashion.

• A dialysis co-ordinator/nurse navigator, Mina Kashani, dedicated to the program, guiding patients through dialysis options and their journey if they choose home dialysis

• The program now treats patients from Toronto East General Hospital, which does not have its own home dialysis program

• A case manager in charge of daily clinical operations, Fatima Benjamin-Wong

The program currently has 20 patients on home hemodialysis, where their blood is filtered through a machine that eliminates impurities and fluids. Eighteen of them do “conventional” dialysis three times a week,

Home Dialysis Program celebrates 100th patient at home

Mina Kashani, a dialysis co-ordinator/nurse navigator for the Home Dialysis Program, meets with patient Bryan Cleveland. (Photo by Yuri Markarov, Medical Media Centre)

By Leslie Shepherd

while two do nocturnal home dialysis, which is performed for six or eight hours while the patient sleeps at night.

Ninety-five patients have chosen peritoneal dialysis, in which their abdominal lining, or peritoneum, acts as a membrane across which fluids and impurities pass. Wastes are taken out by means of a cleansing fluid called dialysate, which is washed in and out through a catheter inserted in the abdomen. This can be done manually, during the day, while patients go about their normal activities. But most use a machine to fill and empty their abdomen three to five times during the night while they sleep.

The Home Dialysis Program is also celebrating a physical expansion. It recently received approval to hire two additional nurses and it’s acquiring additional space on 2 Shuter for a satellite clinic to conduct peritoneal dialysis training. It has also started seeing some patients in Huntsville and Parry Sound via telemedicine, reducing their travel and financial costs. Nurses in the program made home visits totaling 700 hours last year.

Q & AJean Wilson was the first nurse practitioner hired at the St. Michael’s Hospital Academic Family Health Team almost four years ago. Five more have been hired since. Wilson was drawn to St. Michael’s because of its mission and values and her passion for caring for vulnerable patients. Here is what she had to say about being a nurse practitioner.

Q. Tell us about your role.

As a primary care nurse practitioner I provide health assessments, diagnose illnesses or other ailments a patient may have, order blood work, x-rays and ultrasounds and prescribe medication (except for controlled substances). I also conduct home visits with some of my patients, run health and wellness programs, such as our Chronic Obstructive Pulmonary Disease and prenatal programs, and provide support to the health centre team by seeing patients usually seen by a different clinician who is being fit in for a same day or next day appointment because of an unexpected illness or issue.

Q. What do nurse practitioners and nurses have in common?

We are both nurses. Although I identify as a nurse practitioner I started my career as a registered nurse and the care that I provide

JEAN WILSON,LEAD NURSE PRACTITIONER FOR THE ST. MICHAEL’S HOSPITAL ACADEMIC FAMILY HEALTH TEAM, ST. LAWRENCE HEALTH CENTRE SITE

to my patients is done through a nursing lens. All nurses, whether they are a registered nurse or a nurse practitioner, are educated to provide care in a holistic way. This means we look at the whole person instead of zeroing in on one particular ailment. We work with our patients to get to the root of their problem and try to determine what other social or emotional factors in their life might be contributing to their illness or conditions.

Q. What is the difference between a nurse practitioner and a physician?

The biggest difference is that physicians have a broader scope of practice and can order certain tests that nurse practitioners can’t such as magnetic resonance imaging and CAT scans. They can also prescribe narcotics. We work collaboratively with the physicians and other clinicians at the St. Michael’s Hospital Academic Family Health Team. When a patient requires more care than I can provide I consult with the physicians for their guidance and recommended treatment approach.

Q. What do you do in your spare time?

Now that spring is here I am looking forward to getting back into my garden. My husband and I have also started a sommelier course at George Brown. We’ve learned a lot about wine making and tasting and we look forward to putting our knowledge to practice.

By Heather Brown

(Photo by Yuri Markarov, Medical Media Centre)

INTOUCH MAY 2015

In Touch is an employee newsletter published by Communications and Public Affairs. Please send story ideas to In Touch editor Leslie Shepherd at shepherdl@smh.ca.

Design by Dermot Covel, Medical Media Centre