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ABC Case Study Series: Hawke’s Bay Hospital Education Fuels ABC Success in Perioperative Departments Vivace Group Ltd PO BOX 1799, CAMP ST, QUEENSTOWN 9348 P: 03 442 7122 M: 021 782 266 E: [email protected] Hawke’s Bay Hospital: Education Fuels ABC Success in Perioperative Departments Executive Summary A recent focus on improving smokefree practice within Hawke’s Bay Hospital Perioperative Unit has driven an increase in the number of patients being offered brief advice, from 0% to 83% in just two months. Factors that have played a role in contributing to this outcome are listed below: A hospital-wide training target is fueling a sense of urgency for staff to complete training: 80% of all doctors and nurses are to have completed ‘Ask about the Elephant’ and ABC training by May 2010. A flexible, innovative approach to training delivery is promoting greater staff attendance and engagement, e.g. in the Emergency Department funding was provided to back-fill staff attendance at the training session, and in Day Surgery, the training was divided into three sections and staff were allowed to complete the training in any order, allowing for staff to ‘drop in and out’ of the session as was typical, without needing to repeat again. A comprehensive train the trainer model was introduced, and to date 25 link nurse champions have been trained to deliver in-ward ABC training and provide on the ground support for staff. They also provide valuable input into the design and modification of systems and training to suit each ward’s specific needs. Trainers are given a full days training, receive a welcome pack and are supported during the year with four follow up sessions and regular communication. Funding is provided for staff to cover time spent on smokefree duties and their efforts are recognised in terms of contribution to professional development. Nurse managers are encouraged to play a supportive role for link nurse champions and expectations about their role are formally agreed with the smokefree team early on. The ABC training places an emphasis on ‘shifting thinking’ around smokefree practice, focusing on the role of the health professional and the impact that they can make - ensuring each staff member understands the role they play in supporting the patient to be smokefree on their wider hospital journey. An incentive was introduced to encourage staff to take up the e-learning tool – a $10 coffee card for use in the hospital café for staff who could not be released for education sessions and who undertook completion of the e-learning tool in their own time. The introduction of a new patient smokefree form, prompting the ABC approach is supporting health professionals to have ‘the conversation’ with new patients, and its bright clear design is being well received by staff. Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 2 Resources are being revised to include changes to the Anaesthetic Record, so that nicotine replacement therapy is included under post op medications and the development of periop specific smokefree posters is underway for patient areas that promote key messages around smokefree practice pre and post surgery. Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 3 Background Hawke’s Bay Hospital is the largest hospital in the Hawke’s Bay region, and provides medical, surgical, specialist, assessment and rehabilitation services for the local population. Based in Hastings, the hospital discharges approximately 125,000 patients per year, and employs a staff of over 1,500 nurses to deliver its health services. Smoking is a major issue for the local population, with the region reporting a higher than average percentage of smokers: 24.8%, compared to 20% nationally (2006 census). The hospital has been implementing a ‘Totally Smokefree’ project across the community since 2007; a strategic framework of complementary strategies and workstreams delivered through the hospital and across the community to build smokefree practice and behaviours. The introduction of the national health target ‘Better help for smokers to quit’ in July 2009 has seen additional focus being placed on the hospital setting, and has supported an increased investment in training, systems innovation, and resource development for hospital staff and patients, to promote better implementation of smokefree practice by health professionals across the hospital . Smokefree practice involves the screening of smoking status of all patients and the provision of brief advice and practical support to be smokefree, (known as the ABC approach – Ask Smoking status, provide Brief advice, provide Cessation advice or referral.) A recent drive to boost smokefree practice across the perioperative departments has had successful results, with one of the busiest departments in the hospital - the Hastings Day Surgery - reporting an increase in the percentage of smokers being offered brief advice, from 0% in December 09, to 83% by February 2010. Interviews were conducted with staff across the DHB from within the smokefree department and in perioperative to identify the contributing factors that have supported the increased implementation of the ABC approach in these departments. The findings are summarised below. ‘Shifting the Thinking’ about Smokefree Practice The recent focus on improving smokefree practice across the perioperative departments is part of an ongoing comprehensive approach to ‘shifting thinking’ amongst the wider workforce at the Hawkes Bay DHB that has been taking place for the last few years. The ‘shift’ was kick-started with the introduction of the DHB’s smokefree policy in 2007. As well as addressing environmental issues, the policy committed staff to screening patients on smoking behaviour and delivering brief advice, even before the ABC approach was formally introduced. “It meant the organisation had to shift its thinking from seeing smokefree as just being about the car park and grounds, to clinical practice and how we can best encourage and support patients to be smokefree. It’s about making a difference. This difference can be achieved through health care staff routinely asking patients about tobacco use and providing advice and support to those patients that are not smokefree,” (Smokefree Project Manager). Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 4 Staff Education Drives a Shift in Staff Thinking The smokefree team recognised early on that without a shift in thinking, efforts to increase smokefree practice within the hospital would not be well supported by staff. Education was identified as the key to delivering this ‘mind shift’ and this lead to the development of the ABC training programme for staff. Today the training is delivered in two parts; the first part is a 20 minute presentation about the importance of smokefree practice, the systems that support it and the provision of NRT. The training places particular emphasis on the role of the staff as health professionals, encouraging staff to understand the important role they play and building confidence in practicing the ABC approach. “It’s re-positioning the focus to be positive… most people who smoke don’t actually want to smoke. It’s about understanding that the ABC approach is about providing patient care rather than judging patients,” (Smokefree Liaison Nurse). The training is designed to support the staff to have a wide knowledge-base to draw from when conducting the brief conversation with patients about the importance of being smokefree. However if a patient is wanting more information and support, and time is pressured, staff are encouraged to provide a referral to the internal smokefree service to be followed up. “Staff were nervous at first because they thought they had to become cessation experts. It’s about a brief and effective intervention and then referring on to the smokefree service” (Smoking Liaison Nurse). Once staff have completed the first part of the training they are directed to complete the Ministry of Health’s online e-learning tool ‘Ask about the Elephant’ (www.smokingcessationabc.org.nz). On completion of the e-learning tool they qualify as quit card providers. An incentive was introduced to encourage staff to take up the elearning tool – a $10 coffee card for use in the hospital café for staff who could not be released for education sessions and who undertook completion of the e-learning tool in their own time. “That was a nice touch….things like that all help,” (Anaesthetic Technician Manager.) ‘Train the Trainer Model – Smokefree Link Champions With over 1,500 nurses based at the hospital alone and only one dedicated trainer, a train the trainer approach was identified as the most efficient and sustainable way of delivering the ABC training quickly across the workforce and providing ongoing in-ward support for staff. . A comprehensive train the trainer model was developed by the smokefree team and the ‘Smokefree Link Champion’ project was launched early in 2009. To date 25 nurses have been recruited to deliver in-ward ABC training and support the consistent approach of the ABC approach through the hospital wards. Potential champions were rallied via a hospital-wide advertising campaign and a face to face in-ward recruitment drive, which was successful in encouraging additional participation. At least one link nurse was recruited from each department, ensuring that there is a ‘go to person’ in each ward to manage any day-to-day matters that arise. Link champions received a full day’s in-depth training on the importance of Smokefree practice and the ABC approach, evidence of tobacco harm, nicotine addiction, provision Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 5 of NRT and quit cards, internal processes and resources – including NRT Standing Order and mandatory assessment of nicotine dependence (appendix 1). They were also provided a ‘welcome pack’ which included a free month’s gym membership, as a thankyou for their efforts. In addition to training staff, the champions can also provide valuable input into the design of systems and resources for each department. “The nurses can see what is and isn’t working in their area, and their input means that each department is able to fully participate.” (Smokefree Liaison Nurse). Whilst their role is voluntary, funding is provided by the smokefree programme to pay for extra staff to back-fill time spent away from the ward on smokefree-related duties. This has been identified as an important step in securing staff participation and support from management: “This has really helped as it means we can free them (link champions) up without putting extra burden on other staff members,” (Clinical Nurse Manager.) This has also helped in gaining the active support of the nurse managers, who play an important role in aiding the link champions to deliver training and reinforce smokefree practice across the department. To assist this outcome the smokefree team has developed an agreement for each link nurse’s manager that sets out the expectations of their role in relation to smokefree practice. The link nurses continue to meet four times per year to have ongoing training, remotivation and provide the opportunity to discuss any issues that arise. Additional support is provided during the year via letters, emails and relevant research sent to share with their staff from the Smokefree Liaison Nurse. Comments from the staff identified that the link champion system appears to be working well for the hospital, and nurses are becoming increasingly excited about their roles, feeding back stories of staff and patient successes: “It’s working really well – its been amazing the pockets of passion that have come out of these champions,” (Smokefree Liaison Nurse). Steps are now underway to ensure that the link champion’s roles are being recognised in the nurse portofolios, as a demonstration of leadership and other key skills, forming part of their ongoing professional development. Internal Target Fuels Training Drive While the link champions provided a boost to capacity for training delivery, prior to the health target training attendance was not being achieved at the desired levels. In response, the smokefree team secured the support of senior management and agreement was reached to set an internal training target for the DHB; 80% of all doctors and nurses are to have completed the e-learning tool and attended the ABC training by the end of May 2010. This target has helped fuel a major effort to get clinical staff up-skilled: “We’ve delivered a huge education drive across the hospital,” (Smokefree Liaison Nurse). It has also helped communicate the message that everyone has a role to play in achieving the target: “It’s about lots of small conversations taking place along the patient journey. “ (Smokefree Liaison Nurse.) Training Tailored to Meet Department Needs Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 6 In order to get the maximum attendance and ‘buy-in’ for the ABC training, the smokefree team has tailored their training approach to meet the needs of different departments. In terms of the emergency department (ED) this has meant extending the training to be one and a half hours in length, delivered in small groups of just one to three staff. Funding was also provided to back-fill staff attending training, so that they could commit to the time off without distractions. This approach promoted better engagement by staff, who had time to ask questions and become familiar with the material. “We didn’t have drop in and outs – it was amazing!” (Smokefree Liaison Nurse). This approach has been recognized as successful in building support for the ABC approach across ED. “Staff there are telling me stories about patients giving up….we have seen a massive shift in where people are at.” (Smokefree Liaison Nurse). New Smokefree Screening and Intervention Form Part of the training delivered to staff includes a focus on using the new smokefree screening and intervention form - a patient administration form that is now included in all patient administrative packs (appendix 2). The form supports hospital staff to have a conversation with patients about smoking behaviour and cessation options. It is completed by the pre-administration nurse, house officer or anaesthetic technician: “who ever opens up the pack owns it and has to do it,” (Smokefree Liaison Nurse). The focus in training is to ensure that this initial conversation with the patient addresses smoking status and cessation options effectively. ”They are encouraged to focus on how being smokefree is the best thing they can do for their health, and to prepare for surgery.” (Smokefree Liaison Nurse). The form has been designed to stand out in the pack, using a bright green design. Feedback from nurses has shown this approach is working, with one nurse reported to comment - “It sticks me in the eye.” Driving Smokefree Practice across Perioperative January 22 this year marked the ‘go live’ date for rolling out the new form across perioperative. The day was supported by posters and communications and a large morning tea provided by smokefree staff to help raise staff awareness of the new form’s introduction. This important day followed months of staff training activity, tailored to meet the needs of this particular department. To accommodate staff needs, training was bought into the department and was broken down into three sections – covering key themes relating to smokefree practice, the ABC approach and NRT provision. Staff were able to drop in and out of training sessions and this made training in this busy environment manageable. “This was really important…. It meant attendees were able to drop in and out of a session as their schedules required, and if they came into training late they could just stay on after to complete the part which was missed” (Smokefree Liaison Nurse). Due to the large number of patient handovers typically taking place in perioperative, the presentation was extended to 45 minutes to ensure that each stage of the patient journey was addressed and a smooth ‘handover’ for patients was achieved. The training Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 7 was delivered by the trainer wearing scrubs – to ‘fit in’ with the department, an approach which was reported to be well received by staff. Whilst only approximately half of all perioperative staff had received training by March 2010, results indicate that the training has had a major impact. In Hastings Day Surgery there were 88 events recorded during February 2010, in which 14% of patients were identified as smokers, and brief advice was given to 83%. This compares with 0% of patients being offered brief advice in December 2009. Team Approach Supports Practice in Perioperative The appointment of a passionate and effective link champion for the perioperative department, and the active support of her manager are both seen as key factors supporting the successful implementation of smokefree practice across this area: “It’s a ‘team’ approach – otherwise it’s too big for one person.” (Clinical Nurse Manager). Expectations about the role of the nurse manager and link champion were established early on: “Right from the first instance – we had a contract with the project manager, like a terms of reference, making it really clear what the expectations were, which was really good.” (Clinical Nurse Manager). The “team approach” involved a joint planning process, with the smokefree team, to identify the priorities in terms of education, and patient focus. “We began by prioritising patients who were staying over night, because they would be more vulnerable to nicotine withdrawal.”(Link Champion) The link champion’s roll was to also provide feedback into what was and wasn’t working for her area. “For example we found that when we initially rolled it out, people wanted NRT but this was often being missed by the recovery nurse,” (Link Nurse). The documentation was not supporting a smooth transition and patients typically weren’t getting a patch administered before they went to the ward. This issue has subsequently been addressed, and a permanent change to the anesthetic record is now underway (see below). Having experience across all the department areas has been invaluable to supporting the link nurse to deliver her role. “It has been really important for getting the buy-in internally, using someone within the team. She is a familiar face for staff…part of our family, and has a good relationship and rapport with people.” (Clinical Nurse Manager). The clinical nurse manager’s role is described as one of “raising awareness to staff of the need to value smokefree education and the benefits for the patients if they do that … and the benefits for the organistion.”” (Clinical Nurse Manager). Her role is also about providing opportunities on the roster for staff to have time to do the training and meet with the link nurse, get feedback and work together to remove any departmental barriers. The approach has helped build internal support and behaviour change, according to the Link Champion: “Initially when we started this, there was a bit of negativity, it was seen as ‘yet another thing we have to do,’ but with education and the way it has been rolled out, everyone has taken it on board and sees the importance. Now we’ve got nurses that can write quit cards, passion is filling. “Having confidence in an effective in-hospital referral system is also seen as a factor contributing to the likelihood of referrals taking Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 8 place. “The support is great. They usually will show up within 5 or 10 minutes of being called,” (Link Champion). ABC Training Drives Positive Change Among Anaesthetic Technicians The anaesthetic technicians within the Hawkes Bay hospital are one of the most recent staff groups to have received the ABC training, and according to the technician manager its impact is already showing results. Initially the technician manager did not see Smokefree Practice as being particularly relevant to his department: “Our area was a bit ‘grey’ because we don’t have much time with patients, and then after 10 minutes they are asleep! Also surgery is a big deal for patients and we don’t want to put patients on edge. “ However, attending the internal training has changed this perception across the ward. “The training was great. It helped me realise that actually is important to have the conversation (about smoking status) with patients and often you actually do have time.” The changes to the pre-administration form have helped support this conversation: “It gives us an opening to discuss their smoking behavior, and discuss options for cessation support moving forward.” The training has supported staff to get behind the smokefree message and make changes in their personal lives too. “The talk around the departments is quite positive … and we’ve had positive feedback from staff who smoke too.” Approx. 50% of those who staff who smoke have started on NRT as a direct response to the training. The availability of NRT has been identified as a critical factor in supporting staff to promote this to patients: “People have the opportunity if they want to, to give up smoking for a minimal amount of money. So if people ask we can really help them.” The elearning tool has been completed by most staff, and the $10 coffee card was seen as a positive incentive to getting staff to do the training. The perception is that the anaesthetic technicians are there to reinforce the messages patients have already received (in the hospital): “People tend to listen to you more when you’re in scrubs, they really pay attention to what you say.” One barrier in place however is that whilst technicians are increasingly offering brief advice to patients, they are currently unable to provide quit cards through the quit care provider scheme, a matter which is being looked into further. Looking Ahead The comprehensive approach to shifting thinking and supporting behavior change at Hawkes Bay hospital appear to be having an increased impact on staff behaviour, with hospital data and feedback from staff suggesting that change is very much taking place in those departments that are being targeted. In the immediate future the smokefree team, working with the Link Champion, will continue to prioritise driving staff education across the perioperative department, and the focus will be placed on rolling out training to outpatient departments later in the year. A number of changes are taking place currently in terms of systems and resources: Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 9 Changes to the Anaesthetic Record The link champion for perioperative identified a ‘gap’ existed in terms of the administering of NRT to post-operative patients. “Once a patient has come out of surgery the recovery nurse wasn’t looking on the medication charts to identify NRT requirement, which meant that patients could be waiting hours before any nicotine replacement was offered,” (Link Champion). Changes are now underway to the Anaesthetic Record, to have NRT included under post-operative medications. “This change will be fantastic – It means that patients will be able to benefit from the effects of NRT more quickly and that NRT is routinely on anaesthetists and recovery nurses minds. There has been huge support for this right through the department” (Smokefree Liaison Nurse). New Visual Aids Promote Pre-surgery Smokefree Practice to Patients Two large new posters are being designed for display in patient areas that promote going smokefree as “the best thing you can do to prepare for surgery.” The posters highlight the risks and potential complications related to smoking and surgery, and the negative impact on wound healing time. This approach is designed to both support patients to be prepared for any discussions taking place in the ward, and encourage patients to initiate action. “It encourages patients to talk to their nurse, doctor or any health professional about the issue – who ever is close at hand,” (Link Champion). A similar message is also going to be promoted on the hospitals public story boards and perioperative will be leading this approach, putting information on there about smokefree practice for patients, and celebrating the staff involved. Appendices Appendix 1: Training Day schedule for Link Nurse Champion Training Day Appendix 2: Smokefree Screening and Intervention Form. Hawkes Bay DHB Case Study, April 2010 Vivace Group Ltd 10