Aug 26, 2019
By Betty Jean Hendricken RN, BScN

Enhancing and sustaining evidence-based practice in long-term care

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Takeaway messages:

  • Long-term care in many provinces is significantly under-resourced.
  • Building innovative community partnerships is vital to support the health and dignity of residents living in long-term care homes.
  • Resident care and outcomes are positively impacted when front-line staff are empowered with the knowledge and tools to make a difference in the lives of their residents.

The Region of Halton is a vibrant and growing community with more than 500,000 residents and four distinct communities—Burlington, Halton Hills, Milton, and Oakville—and is one of the fastest-growing regions in Ontario. Halton Region owns and operates three not-for-profit long-term care homes within its community:

  • Allendale is a 200-bed home located in Milton. It has built a reputation for high-quality care and service for more than 50 years.
  • Post Inn Village is a 228-bed home in the heart of the Oak Park community in Oakville. It opened on January 17, 2005.
  • Creek Way Village is a 144-bed home located in the Orchard Park community of Burlington. It opened on September 12, 2005.

Halton Regional Long-Term Care Homes are committed to service excellence through continuous quality improvement and supportive community partnerships in the pursuit of promoting a culture of evidence-based practice to enhance the quality of care provided to our residents.

There has been profound change in Ontario’s long-term care sector since the province introduced its aging-at-home strategy in August 2007. This strategy increased funding for seniors to receive care at home and thus created stringent criteria for long-term care home admission eligibility. Once the strategy was in place, only seniors with a high level of need were eligible for admission into the province’s long-term care homes, meaning their condition was clinically complex and they required extensive care.

The following statistics are taken from “This Is Long-Term Care 2018” by the Ontario Long Term Care Association:

  • 85% of residents need extensive help with daily activities such as getting out of bed, eating, or toileting
  • 1 in 3 residents are highly or entirely dependent on staff 
  • 90% have some form of cognitive impairment
  • 2 out of 3 residents are severely impaired
  • 46% of residents exhibit some level of aggressive behaviour related to their cognitive impairment or mental health condition
  • 40% of residents have a mood disorder such as anxiety, depression, bipolar disorder, or schizophrenia
  • 40% of residents need monitoring for an acute medical condition

These statistics speak directly to resident acuity, that is, the complexity of the care needs of residents living in long-term care. Resident acuity has soared in the past few years and sadly, care levels and resources have not increased in tandem.

Partnership and goals

The complexity of residents in our long-term care homes, coupled with the significant funding and resource challenges in long-term care, underscores the importance of building relationships with community partners. In an effort to establish a dynamic, long-term partnership that seeks to improve resident care through supporting informed, knowledge-based nursing practice, Halton Regional Long-Term Care Homes partnered with the Registered Nurses Association of Ontario (RNAO) in the spring of 2016 and started a three-year journey to become an RNAO-designated Best Practice Spotlight Organization (BPSO).

The long-term goals of our partnership with the RNAO over our three-year BPSO pre-designation period were to

  • build capacity among front-line staff in our selected Best Practice Guidelines (BPGs) to support excellence in service and outcomes;
  • enhance and sustain our existing evidence-based culture;
  • sustain the spread of BPG implementation and become a resource to support other homes in the province;
  • develop rigorous and systematic structures and processes to evaluate BPG implementation, nursing practice, and resident outcomes accurately; and
  • develop sustainable knowledge translation structures and processes to support the implementation of multiple clinical nursing BPGs beyond our three-year pre-designation candidacy period.

Under the guidance of the RNAO, our homes implemented the following Best Practice Guidelines during the pre-designation period:

  • Preventing Falls and Reducing Injury from Falls, Fourth Edition
  • Person -and Family-Centred Care
  • Preventing and Addressing Abuse and Neglect of Older Adults

The foundation of RNAO Best Practice Guideline implementation is the creation of a champion mindset in front-line staff. Champions attend an initial training course and are encouraged to take on leadership roles within the home. The RNAO provides opportunities for champions to participate in knowledge exchange sessions to share experiences and strategies. When staff are empowered with the knowledge and tools to make a difference in the lives of their residents, the impact on resident care and outcomes is significant. The champions of Halton Region have responsibilities related to knowledge transfer at the front line, including leading practice change in their resident home areas, acting as the conduit for information sharing between the resident home areas and the best practice working group, and acting as a resource in the resident home area to support best practice implementation.

Highlights of implementation

Once the initial group of champions was in place, our RNAO Best Practice Coordinator/Coach led guideline implementation using the RNAO Knowledge to Action Framework, a systematic, well-planned approach to bring best practice to life. We used this tool to

  • enhance existing roles and develop clear BPSO roles and responsibilities and strong communication processes for our three long-term care homes, individually and jointly;
  • develop a clear implementation strategy and buy-in of both regional and home-level senior leaders, which is integral to building a sustainable culture of best practice;
  • complete a gap analysis to identify gaps in existing practice;
  • determine who will influence guideline implementation, both positively and negatively, and how best to engage the stakeholders;
  • enhance our existing infrastructure to support guideline implementation; and
  • build staff capacity through the development of implementation tools and evidence-driven education to support sustained practice change.

Accomplishments

Our partnership with the RNAO as a BPSO pre-designate provided the foundation for staff to take part in driving practice change. The following is a list of our accomplishments for each Best Practice Guideline.

Preventing falls and reducing injury from falls:

  • development of a post-admission falls checklist
    • used by PSWs on admission to review the resident’s environment, mobility aids, footwear, sensory aids
  • development of a High-Risk Falls Review Tool
    • identifies residents who have had 2 or more falls in the previous 7 days
    • used by the manager and nurse in charge to complete an in-depth analysis
  • weekly falls huddles
    • provide the opportunity to review all residents who have fallen in the past week and look at their medication, and review the care plan and environment
  • development of a brochure for residents/families
    • given to residents/families on admission and includes information on our Falls Prevention and Management Program highlights, tips to prevent slips and falls, and interventions to prevent falls

Person– and family-centred care:

  • bath/shower preference sheet
    • posted in the resident’s room and includes information about bath or shower preference, scheduled day, and any other specific preferences
  • inviting PSWs to admission and annual care conferences
    • develops leadership in the PSW role and highlights the importance of their role with the resident/family and interdisciplinary team
    • PSWs give and receive information at care conferences and pass that information on through PSW-to-PSW report
  • All About Me/My Life Story
    • given to resident/family on admission for completion and is posted in the resident’s room with their picture
    • valuable resource that informs the care team about the resident’s preferences, values, and life story
    • promotes a resident-centred approach to care as it acts as a conversation starter, allowing staff to build relationships and support personalized resident care

Preventing and addressing abuse and neglect of older adults:

  • development of a brochure for residents/families
    • given to residents/families on admission and includes information on types and signs of elder abuse, misuse of power, causes of elder abuse, and our duty to report
  • staff, resident, and family education
    • “Be One” event at which staff spoke about their reasons for working in long-term care, and residents spoke about their experiences living in long-term care

Sustainability

The RNAO’s Knowledge to Action Framework set the stage and provided the tools for us to achieve our BPSO designation. Ongoing monitoring and evaluation is required to maintain adopted initiatives and process changes to preserve a culture of evidence-based practice in an effort to improve resident outcomes. Sustainability is not static. It is a fluid process based on ongoing research, gap analysis, environmental assessment, and policy and process development. As an organization, our commitment to sustainability is evidenced by embedding best practice changes in our policies and procedures, staff orientation, and ongoing education, as well as maintaining our pool of champions by planning for staff turnover and committing to ongoing engagement with and education for our champions.

Conclusion

The RNAO is committed to widespread deployment and implementation of Best Practice Guidelines, promoting consistency in evidence-based practice. As such, we are proud to be an RNAO BPSO Designate. Halton Regional Long-Term Care Homes are committed to clinical excellence and continue to seek new and innovative ways to strengthen nursing practice.


References

Health Analytics Branch, Health System Information Management and Investment Division, Ministry of Health and Long Term Care. (2015). Long-term care in Ontario: Sector overview.

Ontario Health Coalition. (2019). Situation critical: Planning, access, levels of care and violence in Ontario’s long-term care.

Ontario Long Term Care Association. (2018). This is long-term care 2018.

Registered Nurses Association of Ontario. (2012). Toolkit: Implementation of best practice guidelines (2nd ed.).

Betty Jean Hendricken RN, BScN is a Clinical Nurse Specialist in the Region of Halton, Services for Seniors Division, based in Burlington, Ontario.
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