PICOT Statement

The Problem

Inadequate patient information transfer from outgoing and incoming nurses during change of shifts. The quality of communication that is passed over from the outgoing nurse to the incoming nurse is a key requirement for effective interdependent professional processes in hospitals. Breakdowns in effective communication was reported to cause 80% of change of guard events in 2010 by hospitals who voluntarily gave their reports (Carroll et al., (2011). Inadequate handoffs have been blamed for these undesirable events. It is thus in order to assert that inadequate hand offs create unsafe climates in hospitals, something that contradicts the primary doctrine of having hospitals in the first place.

Intervention

Bedside rounding. Having a system that allows incoming nurses to get information from outgoing nurses on the basis of each patient is somewhat hard unless there is a ‘bedside’ meeting. This kind of a meeting during handover, ensures that there is sufficient “communication between nurses and other healthcare professionals about the patient’s health, care plan and progress (King’s College London, 2012).” Patients and nurses alike, get the opportunity to listen to each other and to inform each other of the progress and new developments. New staff and students get the chance to be oriented into the system too.

Current Practice

Taped or handwritten or typed report. The current practice involves the use of taped or handwritten, or typed reports. These forms of handover are often not desirable since they might omit some specific and important information that incoming doctors need. As such, there is a widespread misinformation on the part of those who are assuming responsibility.

Outcome

Important and critical clinical information is handed over to incoming nurses during shift changeover. Such information is necessary in preventing and avoiding critical errors which arise due to action or inaction on those with the responsibility. As a consequence, the hospital environment will be made more safe and it will be an effort towards achieving the basic role, goals, and objectives of the hospital.

Time

This study will be complete before the end of this unit.

Literature Search

Abraham, J., Kannampallil, T. G., & Patel, V. L. (2012). Bridging gaps in handoffs: a continuity of care based approach. Journal of biomedical informatics, 45(2), 240-254.

Handoff among healthcare providers has been recognized as a major source of medical errors. Most prior research has often focused on the communication aspects of handoff, with limited emphasis on the overall handoff process, especially from a clinician workflow perspective. Such a workflow perspective that is based on the continuity of care model provides a framework required to identify and support an interconnected trajectory of care events affecting handoff communication. To this end, we propose a new methodology, referred to as the clinician-centered approach that allows us to investigate and represent the entire clinician workflow prior to, during and, after handoff communication. This representation of clinician activities supports a comprehensive analysis of the interdependencies in the handoff process across the care continuum, as opposed to a single discrete, information sharing activity. The clinician-centered approach is supported by multifaceted methods for data collection such as observations, shadowing of clinicians, audio recording of handoff communication, semi-structured interviews and artifact identification and collection. The analysis followed a two-stage mixed inductive–deductive method. The iterative development of clinician-centered approach was realized using a multi-faceted study conducted in the Medical Intensive Care Unit (MICU) of an academic hospital. Using the clinician-centered approach, we (a) identify the nature, inherent characteristics and the interdependencies between three phases of the handoff process and (b) develop a descriptive framework of handoff communication in critical care that captures the non-linear, recursive and interactive nature of collaboration and decision-making. The results reported in this paper serve as a “proof of concept” of our approach, emphasizing the importance of capturing a coordinated and uninterrupted succession of clinician information management and transfer activities in relation to patient care events.

Abraham, J., Kannampallil, T. G., Almoosa, K. F., Patel, B., & Patel, V. L. (2014). Comparative evaluation of the content and structure of communication using two handoff tools: implications for patient safety. Journal of critical care, 29(2), 311-e1.

Purpose

Handoffs vary in their structure and content, raising concerns regarding standardization. We conducted a comparative evaluation of the nature and patterns of communication on 2 functionally similar but conceptually different handoff tools: Subjective, Objective, Assessment and Plan, based on a patient problem-based format, and Handoff Intervention Tool (HAND-IT), based on a body system-based format.

Method

A nonrandomized pre-post prospective intervention study supported by audio recordings and observations of 82 resident handoffs was conducted in a medical intensive care unit. Qualitative analysis was complemented with exploratory sequential pattern analysis techniques to capture the characteristics and types of communication events (CEs) and breakdowns.

Results

Use of HAND-IT led to fewer communication breakdowns (F_1,80 = 45.66: P < .0001), greater number of CEs (t₄₀ = 4.56; P < .001), with more ideal CEs than Subjective, Objective, Assessment and Plan (t₄₀ = 9.27; P < .001). In addition, the use of HAND-IT was characterized by more request-response CE transitions.

Conclusion

The HAND-IT’s body system-based structure afforded physicians the ability to better organize and comprehend patient information and led to an interactive and streamlined communication, with limited external input. Our results also emphasize the importance of information organization using a medical knowledge hierarchical format for fostering effective communication.

Chaboyer, W., McMurray, A., & Wallis, M. (2010). Bedside nursing handover: a case study. International journal of nursing practice, 16(1), 27-34.

A case study of six wards in two hospitals was undertaken to describe the structures, processes and perceptions of outcomes of bedside handover in nursing. A total of 532 bedside handovers were observed and 34 interviews with nurses were conducted. Important structural elements related to the staff, patients, the handover sheet and the bedside chart. A number of processes before, during and after the handover were implemented. They included processes for managing patients and their visitors, sensitive information, and the flow of communication for variable shift starting times. Other key processes identified were the implementation of a safety scan and medication check. The situation, background, assessment and recommendations approach was used only in specific circumstances. Perceived outcomes were categorized as improving accuracy and service delivery, and promoting patient‐centred care. Although the move to bedside handover is not the norm, it reflects a patient‐centred approach.

Manias, E., & Watson, B. (2014). Moving from rhetoric to reality: patient and family involvement in bedside handover. International journal of nursing studies, 51(12), 1539-1541.

Patient and family involvement in bedside handover enables patients and families to interact with health professionals. Active participation only occurs through reciprocal relationships of dialogue and shared decision-making (Bolster and Manias, 2010). Rather than being an information-giving exercise or just a chance to exchange greetings, patient and family involvement is an opportunity to make an important contribution to patient care (Thompson, 2007). While much has been written about the need to include patients and families in bedside handover, it is not clear whether in actual practice their views are considered at all, or indeed, whether health professionals really want them to be involved in the first place.

Riesenberg, L. A., Leisch, J., & Cunningham, J. M. (2010). Nursing handoffs: a systematic review of the literature. AJN The American Journal of Nursing, 110(4), 24-34.

Objective: Handoffs of patient care from one nurse to another are an integral part of nursing practice; but there is abundant evidence that poor communication and variable procedures result in inadequate handoffs. We sought to conduct a systematic review of articles that focused on nursing handoffs, conduct a qualitative review of barriers to and strategies for effective handoffs, and identify features of structured handoffs that have been effective.

Methods: We conducted a systematic review of English-language articles, published between January 1, 1987, and August 4, 2008, that focused on nursing handoffs in the United States. The search strategy yielded 2,649 articles. After title review, 460 of these were obtained for further review by trained abstractors.

Results: Ninety-five articles met the inclusion criteria; of these, 55 (58%) were published between January 1, 2006 and August 4, 2008. Content analysis yielded identification of barriers to effective handoffs in eight major categories and strategies for effective handoffs in seven major categories. Twenty articles involved research on nursing handoffs. Quality assessment scores for the research studies ranged from 2 to 12 (possible range, 1 to 16). The majority of the research studies on nursing handoffs (17 studies; 85%) received quality scores at or below 8 and only three achieved scores above 10. Ten (50%) of the studies included measures of handoff effectiveness.

Conclusion: Despite the well-known negative consequences of inadequate nursing handoffs, very little research has been done to identify best practices. There is remarkable consistency in the anecdotally suggested strategies; but there is a paucity of evidence to support them. We call for high-quality studies of handoff outcomes that focus on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Pothier, D., Monteiro, P., Mooktiar, M., & Shaw, A. (2005). Pilot study to show the loss of important data in nursing handover. British Journal of Nursing, 14(20), 1090-1093.

A good nursing handover process is a crucial part of providing quality nursing care in a modern healthcare environment. The conservation of patient data during the handover process is vital to ensure good continuity of care and safe practice. Any errors or omissions made during the handover process may have dangerous consequences. The authors observed the handover of 12 simulated patients over five consecutive handover cycles between nurses. Three handover styles were used and the amount of data loss was recorded for each style. A purely verbal handover style resulted in the loss of all data after three cycles. A note-taking style (the traditional style used in most hospital wards) resulted in only 31% of data being transferred correctly after five cycles. When a typed sheet was included with the verbal handover, data loss was minimal. Current handover methods may result in significant loss of important data that may impact on patient care. The authors recommend that prior to handover, a formal handover sheet be constructed that can be transferred as part of the handover process.

References

Abraham, J., Kannampallil, T. G., & Patel, V. L. (2012). Bridging gaps in handoffs: a continuity of care based approach. Journal of biomedical informatics, 45(2), 240-254.

Abraham, J., Kannampallil, T. G., Almoosa, K. F., Patel, B., & Patel, V. L. (2014). Comparative evaluation of the content and structure of communication using two handoff tools: implications for patient safety. Journal of critical care, 29(2), 311-e1.

Carroll, J. S., Williams, M., & Gallivan, T. M. (2012). The ins and outs of change of shift handoffs between nurses: a communication challenge. BMJ Qual Saf, bmjqs-2011.

Chaboyer, W., McMurray, A., & Wallis, M. (2010). Bedside nursing handover: a case study. International journal of nursing practice, 16(1), 27-34.

King’s College London. (2012). What are the benefits and challenges of ‘bedside’ nursing handovers?  Policy plus evidence, issues and opinions in healthcare. (36)

Manias, E., & Watson, B. (2014). Moving from rhetoric to reality: patient and family involvement in bedside handover. International journal of nursing studies, 51(12), 1539-1541.

Riesenberg, L. A., Leisch, J., & Cunningham, J. M. (2010). Nursing handoffs: a systematic review of the literature. AJN The American Journal of Nursing, 110(4), 24-34.

Pothier, D., Monteiro, P., Mooktiar, M., & Shaw, A. (2005). Pilot study to show the loss of important data in nursing handover. British Journal of Nursing, 14(20), 1090-1093.