Story – A Conversation with Dr. Joye St. Onge (Planning for Safe Patient Care)

Dr. Joye St. Onge, Head of Service for Geriatric Medicine, sat down with us to share about her work, and how her team helps clinical groups throughout the hospital plan for safe patient care.

What is your role at St. Joe’s?

I oversee the clinical services in geriatric medicine, and provide clinical care and consults on units and some clinics. We see about 60 inpatients a month.

We work all over the place, on medical, surgical and rehab units. We would be called to make a new cognitive diagnosis if one hasn’t been made and to optimize care, which involves reviewing medications and looking for ones that might be causing side effects.

Can you describe the patient population you work with?

We work with older patients with complex problems. They can have pneumonia but their memory has been declining and they haven’t been remembering to take medications, for example, or they’re not managing at home, have been falling a lot in the last few months and we don’t know why. Often with older patients their illness or condition is more complex than the original problem they came in for. When this is the case, the team will ask Geriatric Medicine to provide a consult. Our approach is to take a holistic look at all the problems that are contributing to that patient being in the hospital.

Some people might look at a complex geriatric patient with ten different problems and say there’s nothing to be done. But we don’t see it that way; it just takes time, detail work and exploration. There’s always something you can do.

What drew you to a career in medicine and working with this patient population specifically?

The honest reason is that I really liked school, and I really like natural sciences. I had good marks and thought I would see if I could get into medical school. I didn’t fully know what I was getting into but it turned out to be everything that I loved.

Working with geriatrics patients is very gratifying.  They have multiple diseases, and multiple medications interacting, as well as social and functional factors. I like carefully going through all those different layers in detail, which helps me to feel that I understand my patients’ problems in their entirety. I also like the aspect of inter-disciplinary teams, which is very important in geriatrics.

Could you describe the types of responsive behaviours you encounter on the job?

The types of behaviours we see are verbal and physical aggression, calling out, restlessness, and wandering. These are called responsive behaviours because these behaviours always have meaning. Dementia impairs verbal communication and individuals can’t clearly express what they’re feeling inside.

How do you create a care plan for a patient that has responsive behaviours?

The behaviour care team is made up of staff from geriatric medicine, geriatric psychiatry and behavioural supports, working together with unit-based staff to provide the best possible care for this population. Our goal is to also to reduce incidents of workplace violence.

A family caregiver will have the best perspective because they have been providing care for a long time and can read cues and understand what the behaviour means better than any of us. Another strategy is close observation. For example, you can tell from facial expression that a patient is in pain. Getting used to what those things look like and recognizing triggers is key, and then the second part is actually testing the ideas in your care plan to see if they work. Sometimes it’s just trial and error to find a solution; nurses are very good at this. Care planning is very important because non-pharmacological strategies are often more effective than medication.

It’s a complex problem and the treatment needs to be very individualized. There are no real blanket strategies.

A big facilitator is the way St. Joe’s has made this a corporate priority. The leaderships’ support of various initiatives we’re trying has helped us make progress. The engagement and expertise of front line staff in care planning has noticeably changed over recent years, and that is really great to see.

How can staff find the balance between providing compassionate and non-judgemental care but at the same time keeping themselves and other staff safe?

That is the big question. It’s very hard. When I see care providers struggling with that, there’s fear, frustration, and emotional burnout. Having care plans that meet patients’ unique needs and evolve as those needs change is essential. We have to go beyond providing care, though, and also find ways to set up environments and staffing models that support that balance.

What keeps you passionate? 

I think I’ve always been a problem-solver or a puzzle solver – that’s what attracted me to medicine and geriatrics. I think that’s what drives me really. I really love my job! I work with great people. There are a lot of colleagues that are interested in geriatric care so I think we boost each other and are constantly talking about how we can make things better. That’s inspiring and keeps you moving.

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