In January 2003, the Quebec government adopted Bill 90, which redefined, among other things, the clinical evaluations performed by nurses. Amendments to the Nurses Act introduced the concept of the Therapeutic Nursing Plan (TNP), a document that makes it easy to access nurses' evaluation-based clinical decisions, which are essential in patient follow-up.

"Before, nurses' decisions were not always documented in patient records, or they were difficult to find. Care plans were sometimes written in pencil and were therefore 'erasable.' However, nurses are accountable for their evaluations, and these decisions affect their professional liability," stated Jennifer Hague, a Clinical Nurse in specialized care and the coordinator of the TNP project for the Nursing Directorate (ND). "Thanks to the TNP, all decisions are now documented in patient records. The safety and quality of nursing care are therefore greatly improved."

Quebec health institutions had until April 1, 2009 to implement the TNP. At the Douglas, training on the TNP started in November 2008, and 251 nurses were trained in 5 months.

Learning a new work method is seldom easy; however, despite some initial resistance, the nurses quickly understood the benefits of changing their work habits in order to integrate the TNP into their daily practice.

"A two-pronged training approach (on-line and in-class) helped nurses take charge of their own learning process," explained Suzie Grégoire, a continuing education consultant for the Teaching and Training Coordination Bureau (TTCB). "After the training, each nurse attended at least one practical workshop of approximately 90 minutes. Sandra Clergé, Jennifer Hague, Johanne Roy and Régis Villeneuve from the ND, assisted by unit nurses Caroline Drolet and Guy Limoges, shared the task of leading workshops for day, evening and night staff to ensure that all shifts were covered." Staff who were less familiar with on-line training could always call on the support of Claudette Carpentier, a TTCB communications technician.

What is measured gets done

The ND's target in terms of the number of nurses trained was met (99% of nurses). The only remaining tasks are an analysis of the quality of the TNPs and an evaluation of whether nurses:

• Systematically complete a TNP for each patient who requires clinical follow-up.
• Have integrated the TNP training into their practice.
• Are satisfied with the two types of training they received.

Since June 1, the Nursing Directorate, in collaboration with Steve Castonguay, an emergency measures and quality consultant with the Quality Directorate, has been conducting an audit to evaluate the quality of the TNPs and the TNP training process. "Our aim is not to evaluate each nurse individually but rather to ensure that the quality of nursing in the inpatient and outpatient units is at the desired level and to compare our activities with recognized best practices," said Jennifer Hague.

"The contribution of nurses is essential in improving patient health and the quality of care they receive. The goal of this audit is to ensure that the work of nurses is based on best practices and reflects the Douglas Institute's vision of excellence in terms of care, teaching and research," concluded Hélène Racine, Head of Nursing.