Scholarly Project Synthesis: Improving Nursing Handoff



Scholarly Project Synthesis: Improving Nursing Handoff

Cheryl Miller

Ferris State University

Abstract

This scholarly project paper outlines the development, implementation, and completion of a proposed plan to support effective communication in the nursing handoff process for patients admitted from the emergency department (ED) to an in-patient setting at Munson Medical Center. It includes a description of the project proposal plan, the project outcomes achieved, a discussion of my personal and professional accountability, a review of issues and concerns, an evaluation of the implementation process, recommendations toward future implementation of similar project plans, demonstration of knowledge related to nursing practice, theory and research, and a detailed summary of key points.

Scholarly Project Synthesis: Improving Nursing Handoff

This paper is a synthesis of my scholarly project focused on supporting communication in the nursing handoff process at Munson Medical Center for patients being admitted from the ED to an in-patient setting. An environmental assessment of the nursing handoff process was completed in collaboration with nursing staff. An extensive literature search confirmed the importance of this investigation. My project deliverables have been revised to include a PowerPoint slide presentation which can be used in part or whole to educate staff, a gap analysis of potential barriers in the handoff communication process, evidenced based recommendations targeted toward those potential barriers, and a nursing satisfaction survey tool for consideration and review. These deliverables may serve as a working tool for nursing leadership when considering future recommendations toward improving communication in the nursing handoff process. Scholarly project activities focused on understanding the established process for nursing handoff, observation and investigation of the handoff communication process, interviewing and collaborating with nursing staff, application of evidence based research findings, discovery of potential barriers, and formulating possible solutions in collaboration with nursing staff from the ED and A7 nursing units. These activities are consistent with the standards of professional practice for nursing administrative leaders as outlined in the Nursing Administration Scope and Standards of Practice (ANA, 2009). These practice guidelines serve as a decision-making model for nursing leadership who are responsible to advocate for nurses and patients in the delivery of health care services.

Effective communication in nursing handoff has been identified as a national safety concern by The Joint Commission (TJC) in 2006 (Friesen, White & Byers, 2008). Improving exchange of information during the patient admission process may positively impact patient safety and advocate for nursing staff in the exchange of patient information during the nursing handoff communication process. Research by The Joint Commission (2012) suggests that communication errors may result in 80 percent of serious medical errors. Effective nursing handoff communication is a complex and important issue in health care. Furthermore, Cohen and Hilligoss (2012) suggest that sharing patient admission information between the ED and the in-patient setting requires nurses to use greater expertise due to differences in work practices and in communication styles.

The nursing handoff process, established at Munson Medical Center in 2011, is as follows: when orders are written and the patient is ready to move, the ED nurse calls the receiving unit and asks for the nurse who will be handling care for the patient. The ED nurse states that the ED admission handoff form is complete, ready for review, and the patient will be coming up in fifteen minutes. The ED nurse tells the receiving nurse to call if there are any questions and the in-patient nurse reviews the charting in FirstNet and prepares to receive the patient. This handoff process follows guidelines outlined by The Joint Commission (2011), which includes the following five key characteristics: interactive communication with an opportunity for questions and answers, up to date information regarding patient care activities, a process for verification including read back and repeat back, an opportunity to review historical data, and minimizing interruptions so that information is retained. Patterson and Wears (2010) suggest that that 20-30% of patient information exchanged verbally is not documented in the electronic medical record and the baseline conditions for handoff are highly variable. This is important and relevant as most of the information exchanged during nursing handoff is gathered from the electronic medical record. Verbal interactions are limited and may be variable. Variability in communication can lead to omission of information during the nursing handoff process (Patterson & Wears, 2010). Omission of information during handoff may negatively impact nurses’ ability to provide safe and effective patient care. Klee, Latta, Davis-Kirsch and Pecchia (2011) imply that when critical patient information is not shared during the handoff process, patients’ safety is at risk.

The setting for this scholarly project is Munson Medical Center, a Magnet designated and acute care hospital in Northern Michigan employing over 4,000 employees (Munson Medical Center, 2013). Annual patient visits are more than 300,000 (Munson Medical Center, 2013). The annual patient volume in the ED is 52,000 with an admission rate per day of 35% (A. Holmes, personal communication, November 1, 2013). The inpatient unit selected for participation in this project was A7, a stroke telemetry unit, with a predicted annual patient stay volume of 8,905 for 2014 (M. Ramseyer personal communication, November 1, 2013). The impetus for this project began after I attended a meeting with nursing staff from the ED and in-patient settings to discuss the nursing handoff process. There were reports of frustration and increasing tension between the nursing staff in the ED and in-patient setting concerning nursing handoff practices. The nursing handoff report process was reviewed and discussed. The following barriers were mentioned: the need for the ED to make multiple calls in order to give notification of the patient’s arrival on the in-patient unit, staff not following the established fifteen minute rule, insufficient information in the ED handoff report, and no notification to the receiving bedside registered nurse (RN) of the patient’s impending arrival.

As a result of this discussion and my academic requirements to complete a scholarly project, a proposed plan was developed and presented to my preceptors. The initial premise was to review, revise, and standardize the nursing handoff report process for patients being admitted from the ED to an in-patient unit. The scholarly project goal is to support nursing in their role to provide safe and effective care by ensuring that a standardized, agreed upon format is in place for nursing handoff. Tomajan (2012) suggests that professional nursing leaders have a duty to advocate for the safety and welfare of nursing staff and patients. In addition, Marshall (2011) notes that professional nursing leaders are administratively mandated to create a vision and manage processes in order to seek successful change strategies to promote patient care and safety. Application of evidenced based research, nursing theory, and leadership principles are included throughout this scholarly project plan, and in this discussion.

Description of Scholarly Project

The initial goal of this project was to review, revise, and standardize the nursing handoff process while advocating for nursing staff in the provision of patient care. These scholarly project goals are consistent with the mission and vision statement of Munson Medical Center (2013) to provide comprehensive quality care, to protect patients, and advocate for their safety. The initial goals, activities and objectives included retrieving research evidence targeted toward patient safety and effective handoff communication, identifying barriers in the nursing handoff process, formalizing an agreed upon process through collaboration of nursing staff and key nursing leadership, formulating an education plan to implement the proposed changes with assistance from the staff development team, evaluating the nurse to nurse report process through a nursing satisfaction survey, seeking verbal feedback from both of my preceptors throughout each phase of project implementation, and receiving written feedback at completion of this project. These actions are supported by the Nursing Administration Scope and Standards of Practice (ANA, 2009) which, guide professional nursing leaders tasked with developing practice standards to support safe and effective health care delivery.

Initial project activities included searching for and obtaining relevant research by September 5, 2013, meeting with key leadership from the emergency department to perform an accelerated gap analysis by September 15, 2013, meeting with shift coordinators from the emergency department every two weeks to share ideas and brain storm solutions by September 30, 2013, formulating and developing strategies to improve and standardize the report process by October 30, 2013, obtaining approval from all stakeholders, seeking assistance from staff development to educate staff by November 15, 2013, and implementing and evaluating the revised nurse to nurse process by December 15, 2013 via distribution of a nursing satisfaction survey. The original scope of this scholarly project was narrowed down after consultation with the A7 and ED unit managers as it was felt to be too monumental in nature. The new scope was effectively narrowed down to include: review of the original charter and nursing handoff goals, direct observation of the nursing handoff process in collaboration with staff from A7 and the ED nursing unit, collaborate and uncover communication barriers, and utilize evidence based research to offer potential solutions for consideration and review. Seeking to understand current nursing practices and collaborating with nursing colleagues to foster improvement is consistent with guidelines by the Nursing Administration Scope and Standards of Practice (ANA, 2009) aimed toward the promotion of best care practices. The ED andA7 manager each offered support for this scholarly project by providing contact with shift coordinators, and a physical space from which to work. The A7 unit manager suggested that this graduate nursing student follow patient admissions from the ED setting to the A7 nursing unit in order to evaluate and compare handoff guidelines to nursing handoff practices. Patient admissions from the ED to A7 nursing unit were observed via collaboration with nursing staff. Electronic documentation was reviewed via FirstNet. Jean Watson's Philosophy and Science of Caring (2008) theory and principles were utilized to communicate and collaborate with nursing staff. Open communication was encouraged with a mutual respect for both positive and negative feelings in order to promote nursing engagement in discussion of the nursing handoff process.

In addition to direct observation and personal interviews of nursing staff, electronic documentation was reviewed via FirstNet. As a result, variability in documentation within the EMR was noted on the nursing handoff forms. Verbal communication was also observed to be variable and was confirmed through communication with nursing staff. It was felt that these were likely due to interruptions from phone calls, telemetry monitoring needs, and direct patient care needs. Nursing experience was thought to play a role in the way that information is exchanged in the handoff process. Nursing staff shared that a full verbal report is given by nurses who work in the ED setting and in the nursing pool, as they recognize that the handoff process may not include all of the information desired. These findings are supported by evidenced based literature focused on nursing handoff practices. Patterson and Wears (2010) suggest that patient handoffs are complex and variable in nature leading to a risk in patient safety. Conducting an environmental assessment through collaboration with nursing staff and promoting process improvement initiatives is supported by the Nursing Administration Scope and Standards of Practice (ANA, 2009). These activities have the potential to improve communication, promote excellent care, and foster patient safety. Four evidenced based research recommendations were found and offered to ED and A7 nursing leadership teams for consideration and review. These were meant to serve as a working tool for the stakeholders of this scholarly project so that future decisions could include these recommendations. A time investment of over 120 hours was completed with collaboration from my project preceptors, key nursing leadership, and nursing staff from the ED and A7 nursing units. My personal and professional performance in the completion of this scholarly project is included in this discussion. Feedback has been gathered from my preceptors, as well as, the stakeholders of this project. A self-analysis through critical reflection is also included. Evidenced based research, nursing theory, and nursing leadership principles were utilized throughout completion of this project.

Demonstration of Personal & Professional Accountability

Demonstration of my personal accountability toward completion of this scholarly project plan is evidenced by completion of the following: more than fifteen literature based articles were reviewed, compiled and utilized throughout this project analysis; the original charter and goals for nursing handoff, as established in 2011, was collaboratively reviewed and compared to current practices; an initial gap analysis was completed in collaboration with nursing staff from the ED and in-patient units; an environmental assessment of the nursing handoff process was completed with collaboration of ED and A7 nursing staff; review of electronic documentation was completed via FirstNet; and data was gathered from the Performance Improvement department at Munson Medical Center related to the number of negative patient outcomes which resulted from communication breakdown during the nursing handoff process. This graduate nursing student attempted to balance personal needs and academic work in order to avoid burnout, stress and stay attentive toward the needs of this scholarly project. Finding balance is important and necessary to stay energized and foster creative thinking. This creative balance contributed to being able to offer four evidence based recommendations to the stakeholders of this project for their consideration and review. Evaluation of personal needs, academic requirements, stakeholder needs and organizational needs were a constant consideration during the planning, implementation, and completion of the scholarly project.

Demonstration of professional accountability is evident by adherence toward the ethical, legal, and nursing practice standards defined by the Nursing Administration Scope and Standards of Practice (ANA, 2009) throughout the planning, implementation, and completion of this scholarly project to improve communication in the nursing handoff process. The goals, activities, and objectives outlined are consistent with these guidelines and support appraisal, research, collaboration and identification of evidenced based recommendations. Research literature was used to validate the nursing handoff observations and formulate recommendations. Nursing theory by Watson (2008) was used to guide communication practices to foster engagement and advocate for nurses in this discussion by showing a respect for positive and negative feedback. Use of transformational and relational leadership principles as described by Marshall (2011) allowed this graduate nurse to engage and collaborate with nursing leadership and nursing staff in the discussion of nursing handoff in order to discover barriers and seek solutions. All of these scholarly project activities provide proof of my accountability toward professionalism. They are consistent with guidelines for practice found in the Nursing Administration Scope and Standards of Practice (ANA, 2009) for nursing leadership practice. Evidence based research supports the finding that nursing handoff communication is a critical issue facing health care practice that it is complex in nature, and that poor handoff can adversely impact patient safety (Cohen & Hilligoss, 2012). Attention to nursing handoff practices and patient safety measures can help leadership develop policies and nursing practices that support organizational goals to provide effective patient care. Professional accountability is also demonstrated by this graduate nurses’ actions to receive permission from both preceptors and from the A7 and ED unit managers during implementation of this scholarly project. The planned activities to retrieve research evidence targeted toward patient safety and effective handoff communication, to identify potential barriers, to collaborate with nursing staff and key nursing leadership, to provide evidence based recommendations for stakeholder consideration, and to seek verbal and written feedback demonstrate my professional accountability. These activities are supported by the Nursing Administration Scope and Standards of Practice (ANA, 2009) which guide professional nursing leaders tasked with the promotion of safe and effective health care practices.

Jean Watson's Philosophy and Science of Caring (2008) principles served as a guideline for communication and collaboration with nursing staff. These principles promoted open communication and a respect for positive and negative feedback which were an important part of this project. A relational leadership style approach was used when communicating with nursing staff in order to foster communication and gather ideas for further discussion, research analysis, and strategizing of solutions. Marshall (2011) suggests that by being present, actively listening, and showing empathy professional relationships are built and team work develops. This teamwork can promote process improvement. In addition, feedback was sought following my PowerPoint presentation at Munson Medical Center on November 13, 2013. A nursing satisfaction survey was given to project stakeholders to gage the effectiveness of my presentation based upon the following: whether or not the purpose was clear, the content was organized, the topic was supported by research evidence, the goals and objectives were clearly defined, the information was relevant useful, the research literature tool was relevant and useful, and the research recommendations were relevant and useful using a six point Likert scale. Nursing leadership and staff found my PowerPoint presentation to be informative, professional, and useful. High ratings were given. Professional accountability was demonstrated throughout all phases of this scholarly project including staying within the timeline for this project, and exceeding the 120 hour time investment necessary to complete this scholarly project.

Description and Analysis of Outcomes

The scholarly project outcomes include validation that the nursing handoff process meets the guidelines set forth by The Joint Commission (2012) for nursing handoff practice. These criteria include having an interactive process, an opportunity for questions, that information is up to date, a process for verification, and that historical data related to previous care, treatment and services are included. The final criterion to limit interruptions during handoff was not observed. This information was offered to stakeholders as a possible area for improvement. The nursing handoff process, as established, meets the mission, vision, and values of Munson Medical Center to provide superior quality patient care. Several barriers were identified through direct observation and interview of ED and A7 nursing staff. They are as follows: a lack of understanding of the differences in nursing culture between the ED and A7 nursing units as evidenced by expressions of verbal frustration and incongruent information exchange, a lack of understanding of the real time constraints in the ED and A7 nursing units due to staff deficiencies, bed capacity, and unexpected changes in patient acuity evidenced by personal communication with these nursing staff. This lack of understanding was reported to result in delay of patient transport leading to frustration and the need to make multiple follow up phone calls. In addition, variability in electronic documentation was evidenced by online review of charting. Verbal nursing handoff practices varied by observation and according to personal interview with ED nursing staff. Lastly, it was noted that there was no identified process from which to evaluate the perceived effectiveness of the nursing handoff process or global reporting mechanism to keep staff informed regarding adverse patient outcomes. Literature findings support these observed barriers and will be discussed next. Cultural differences between nursing units in the hospital setting can have a negative impact upon the perceived quality of nursing handoff communication, as reported. The nursing focus of the ED is centered on the acute medical needs of the patient, while the in-patient nursing staff focuses upon immediate and long-term patient care needs. This difference in focus impacts the information exchanged in handoff and may negatively impact the perception of quality related to the handoff communication process. Ong, Biomed, & Coiera (2011) support this concept by the findings that communication during nursing handoff is complicated by divergent approaches to patient care resulting in an increase likelihood of omission of information.

Furthermore, it was observed that real time variability due to constraints of staffing shortages, bed availability, and unexpected changes in patient acuity are not readily known to nursing staff between these units which may also impact expectations and communication practices. Patterson and Wears (2010) suggest that patient handoffs are complex and variable in nature leading to a risk for patient safety. A nursing engagement tool may add insight into the perceived effectiveness of nursing handoff and promote organizational accountability between nurses engaged in the handoff process. The Joint Commission (2012) found that the focus of the ED nursing unit is typically to stabilize and dispose of the patient, rather than to diagnose and manage their condition. As a result, the expectations related to the exchange of information also differs and may create a level of tension between nursing staff communicating across these settings. A7 nursing staff verbalized frustration in regards to incongruent information exchange during handoff citing the need for information relating to patient orientation, ability to ambulate, whether family was present with the patient, and where the patient came from. These differences in expectations negatively impacted the perceived effectiveness of the nursing handoff process as reported. Therefore, having a process in place to reduce variability and evaluate nursing staff satisfaction related to the handoff process is recommended.

The Joint Commission (2012) implies that nursing handoff practices be considered an organizational priority, and that real time performance feedback promotes professional accountability. Therefore, a nursing handoff evaluation tool is recommended and was presented to stakeholders of this scholarly project. The Joint Commission (2012) suggests that the consequences of poor nursing handoff include omission of care, increased length of stay, increased costs, and patient harm. Sharing these adverse outcomes with nursing staff during my PowerPoint presentation fostered awareness, engaged staff, and promoted further discussion toward improving the nursing handoff process between the ED and A7 nursing units. A second recommendation for consideration and review was an educational program to recognize, celebrate, and promote understanding of the environmental and cultural differences between the ED and in-patient settings. This could be accomplished through a cross training experience for nursing staff during general orientation or by providing online education via HealthStream. Nursing education targeted toward cultural differences between nursing environments creates understanding through awareness and increases sensitivity toward the needs of others. Marshall (2011) also supports these actions to develop targeted education plans as they are consistent with a transformational leadership approach to engage and empower nursing staff. A third recommendation presented to stakeholders of this project was implementation of a quiet zone for retrieving nursing handoff report in order to limit interruptions and distractions. Implementation of a quiet zone for nursing to retrieve patient handoff information contributes to patient safety by allowing nurses to focus on the task at hand. Mistry et al. (2008) suggests that limiting interruptions and distractions can reduce omission of information, improve retention of details, and improve communication. McKinney (2010), similarly finds that out-of-sync timing in the communication process contributes to omission of information during the nursing handoff process. Lastly, a nursing survey tool was created and presented to stakeholders during my Powerpoint presentation aimed toward evaluating nursing perceptions of communication during the handoff process using a five point Likert scale. The Joint Commission (2012) note that having a sound measurement tool in place to measure quality handoff practice helps to monitor compliance, identify specific barriers, and increase compliance toward effective communication practices. Reporting of adverse patient outcomes related to nursing handoff is another consideration which was recommended and reviewed in order to create staff awareness of and professional accountability for effective nursing handoff practices. Project deliverables included a gap analysis reporting of potential barriers in the handoff process, four evidenced based recommendations targeted toward these barriers, an ED and in-patient nursing survey tool, and evidenced based literature findings. These deliverables may serve as a working tool for nursing leadership at Munson Medical Center tasked with improving nursing handoff communication.

Analysis of Issues, Concerns & Challenges

The initial challenges that I encountered in the implementation of this scholarly project were related to the scope; it was far too large to reasonably fit within the time constraint of 120 hours, it exceeded my skill level, and the leadership support. It was effectively narrowed after a collaborative meeting with managers of the ED and A7 nursing units. An agreement was made for me to observe patient admissions from the ED to the A7 nursing unit, to collaborate with nursing staff, and to follow online documentation through FirstNet in order to apply research evidence, assess barriers, and seek potential solutions. The next challenge I encountered was not being able to obtain the data that I would have liked in relation to the number of adverse patient outcomes related to the handoff process at Munson Medical Center. The specifics were felt to be confidential in nature. It did not negatively impact the outcome of the project, and stakeholders seemed satisfied with the level of detail that I reported. Lastly, I struggled to keep a balanced perspective during the investigation and writing of the handoff topic. My initial efforts to analyze the nursing handoff process were only focused upon the gaps in the handoff process and I did not realize this until later. Fortunately, it became apparent while I was reading my draft paper, and I was able to go back and acknowledge the strengths in the nursing handoff process to give a more rounded presentation to nursing leadership and nursing staff. Not doing so, would have been short sighted on my part and may not have been received well. I felt that it was important to have a fair and balanced reporting to advocate for and acknowledge ED and A7 nursing staff and leadership in their efforts to promote safe and effective care during the handoff process. I did meet that goal during my PowerPoint presentation to the stakeholders of this scholarly project.

Evaluation of Scholarly Project

Feedback and suggestions were obtained throughout the implementation of my scholarly project by my project preceptors. Suggestions were made regarding the research recommendations, the writing of my draft paper, and review of my PowerPoint presentation. Final evaluation of this scholarly project included verbal and written feedback from my project preceptors, as well as, from the nursing staff and leaders attending my project presentation. Those in attendance gave high scores for all areas. Project preceptors completed an evaluation tool using a four point Likert scale based upon the following: whether or not the project goals addressed identified barriers, if evidenced based solutions were offered, whether current literature considerations were met; what my greatest strengths and weaknesses were; and suggestions for improvement. Both project preceptors felt that I exceeded the expectations of this project and that I grew professionally through this experience. These surveys are included in the appendices of this paper. A self-evaluation was completed through reflection and self-analysis of my leadership actions, my application of research evidence, and nursing theory throughout the implementation of this project. My identified strengths are my abilities to establish a vision and plan for this scholarly project, to communicate those goals to others, to collaborate with nursing leadership and staff, to actively seek and listen to others perspectives, and to be flexible and responsive when changes are needed. My initial weaknesses are related to over estimating what I could accomplish through this scholarly project as evidenced by my need to revise the project scope to a more manageable size and my limited focus during my initial gap analysis. I would attribute those weaknesses to a lack of experience. Overall, I am quite happy with my personal and professional performance in the planning, development, implementation, and final results of this scholarly project plan.

Recommendations

Recommendations for a future scholarly project focused on nursing handoff communication and patient safety should be strongly considered as it allows the graduate nursing student many opportunities to investigate and apply literature based evidence, to collaborate with nursing staff and nursing leadership, to gain understanding of the communication processes, to apply nursing theory, and leadership principles. These actions are consistent with the guidelines in the Nursing Administration Scope and Standards of Practice (ANA, 2009) which guide professional nursing leaders in the development of organizational policies and procedures which advocate for nursing staff and patient care services. This opportunity allows student nurses the ability to step outside of their comfort zone, to explore ideas, seek creative solutions, and gain first-hand knowledge of project implementation. Personal skills required include motivation and drive to work through challenges, stay on task, and a bit of courage to overcome fear of the unknown. It is a challenging and rewarding experience.

Application of Nursing Practice, Theory & Research Principles

Research literature was applied throughout the development, implementation, and completion of this project. Fifteen literature based articles dedicated toward nursing handoff practices and patient safety were gathered, reviewed, utilized, and cited in the initial scholarly project proposal plan, in the planning of project activities, in the observation and analysis of the nursing handoff process, in personal communication with nursing staff, preceptors, and nursing leadership, in my journal writings and analysis, and in synthesis of this paper. Application of current literature is supported by the Nursing Administration Scope and Standards of Practice (ANA, 2009) which guide professional nursing leaders in their quest to improve patient care practices and promote patient safety. A transformational leadership approach was applied in order to engage nursing staff and to collaborate with the stakeholders of this scholarly project. Marshall (2011) suggests that a transformational leader is visionary, utilizes research evidence to guide their practice, uses power effectively through collaboration with others, and is willing to take risks in order to seek new strategies to promote safe and effective health care delivery. A spirit of open communication and mutual respect was utilized to foster communication between nursing staff consistent with Jean Watson's Philosophy and Science of Caring (2008) in order to encourage a free exchange of information related to nursing handoff, patient safety, and effective communication strategies.

Conclusion

In summary, the nursing handoff process for patients being admitted from the emergency department to an in-patient setting at Munson Medical Center consistently meets the guidelines established by The Joint Commission (2012) for nursing handoff with one exception. A clear process to eliminate interruptions during handoff could not be established. Therefore, recommendations were made to consider implementation of a quiet zone for charting and retrieving handoff report. That is being considered. The nursing handoff process, as established in 2011, meets the mission, vision and values of Munson Medical Center to promote quality patient care. Through observation, collaboration, and interviews of A7 and ED nursing staff several potential barriers became evident in the nursing handoff practice, which should be investigated further. The lack of understanding or recognition of cultural differences between the ED and A7 nursing units was apparent, along with variability in electronic documentation and verbal reporting. Contributing factors were felt to be interruptions or distractions from real time work demands such as telemetry monitoring, telephone calls, and patient care needs. The lack of a nursing survey tool to evaluate nursing handoff and the lack of a reporting mechanism for adverse patient outcomes related to nursing handoff were identified as areas for improvement. Targeted education including online education or cross cultural nursing experiences may help to promote increased understanding of the divergent nursing focus between the ED and in-patient settings. This is being considered. A nursing survey tool may help to engage nursing staff and promote nursing accountability toward effective handoff practices. Establishing a global reporting mechanism may help to create a sense of urgency and foster nursing engagement of this crucial topic. Together, these recommendations have the potential to improve the nursing handoff process at Munson Medical Center by reducing variability, promoting awareness and understanding of cultural differences, engaging nursing staff, and creating nursing staff accountability. I am hopeful that the insights gained through this scholarly project and plan for ongoing application provide a working tool and stepping stone toward future improvement in the nursing handoff process for nursing staff in the ED and in-patient settings. Ultimately, patient safety and improved outcomes may result.

Appendix A

Project Deliverable

Nursing Student Gap Analysis through Research and Observation

Potential Barrier of Communication Literature Recommendations

|1. Lack of knowledge R/T cultural differences between the ED and |1. Education of nursing staff to promote understanding of the |

|in-patient setting. |differences in nursing focus between these units. (Cohen & Hilligoss,|

| |2010). Possible options include online education through HealthStream |

| |or providing a cross cultural nursing experience during orientation |

|2. Variability in electronic documentation and verbal reporting. |2. Establishment of a quiet zone for receiving report in order to |

|Contributing factors may include nursing experience, work time |limit distractions and improve retention and retrieval of information |

|demands, interruptions or distractions. |from the electronic record (Cohen & Hilligoss, 2010) |

|3. No identified process (outside of PEERS) to evaluate the nursing |3.Development of a nursing survey tool for ED and in-patient settings |

|handoff process. |to evaluate effectiveness of nursing handoff process (The Joint |

| |Commission, 2012) |

|4. No global reporting process identified for reporting of adverse |4. Establish global reporting mechanism for adverse patient outcomes |

|patient outcomes related to nursing handoff. |related to nursing handoff to create a sense of urgency, foster |

| |nursing engagement, and nursing accountability (The Joint Commission,|

| |2012) |

Appendix B

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In-Patient Nursing Satisfaction Survey of Handoff Process

Please answer the following questions using the number scale provided below.

1. Strongly Agree 2. Agree 3. Neutral 4. Disagree 5. Strongly Disagree

1. Electronic documentation is complete ____________

2. I have sufficient time to gather the information needed from the electronic medical record to

plan and prioritize patient care ____________

3. I have the opportunity to ask questions and clarify information when needed

____________

4. Handoff is interrupted _________

5. Pertinent information not found in electronic documentation is shared __________

6. Handoff process promotes patient safety __________

5. Suggestions for improvement

Thank you for taking time to complete this survey.

Effective patient handoff is a priority at Munson Medical Center

Appendix C

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ED Nursing Satisfaction Survey of Handoff Process

Please answer the following questions using the number scale provided below.

1. Strongly Agree 2. Agree 3. Neutral 4. Disagree 5. Strongly Disagree

1. Staff is readily available to accept patient admissions within the fifteen minute time frame

once a bed is available/clean? ____________

2. Contact is made with the receiving RN or charge RN the first time that I call ____________

3. Handoff is interrupted __________

4. Too much information is requested __________

5. This handoff process promotes patient safety ___________

6. Suggestions for improvement

Thank you for taking time to complete this survey.

Effective patient handoff is a priority at Munson Medical Center

Appendix D

Literature Review and Findings

|Bally, J. M. (2007). The role of nursing leadership in creating a mentoring culture in acute care environments. Nurs Econ, |Nurses must recognize and |

|25(3), 143-148. |understand the |

| |interrelationships of |

| |organizational culture |

|Cheung, D. S., Kelly, J. J., Beach, C., Berkeley, R. P., Bitterman, R. A., Broida, R. I.,…White,M. L. (2009). Improving |Concept map of ED handoff |

|handoffs in the emergency department. Annals of Emergency Medicine XX(X), 2-10 |process helps to understand|

| |vulnerability, improve |

| |function and measure |

| |progress |

|Clancy, T. R., Effken & J. A., Pesut, D. (2008). Applications of complex systems theory in nursing education, research, and |Computational modeling and |

|practice. Nurs Outlook 56(5), 248-256. doi: 10.1016/j.outlook.2008.06.010. |simulation are emerging |

| |tools for complex system |

| |research |

|Cohen, M. & Hilligoss, B. (2012). Handoffs in hospitals: A review of the literature on information exchange while transferring |Handoff can significantly |

|patient responsibility or control. Retrieved from |impact patient safety, it |

| |is highly sensitive to |

| |variations in context and |

| |setting |

|Delrue, K. S. (2013). An evidence based evaluation of the nursing handover process for emergency department admissions |Doctoral dissertation |

|(Doctoral dissertation). Retrieved from |focused on nursing handover|

|Friesen, M., White, S. & Byers, J. (2008). Handoffs: Implications for nurses. In R. G. Hughes(eds.), Patient Safety and |Strategies to improve |

|Quality: An Evidence Based Handbook For Nurses (pp. 1-48).Rockville, MD: Agency for Healthcare and Quality. |handoff communication |

|Klim, S., Kelly, A. Kerr, D., Wood, S. & McCann, T. (2013). Journal of Clinical Nursing, 22, 2233-2243, doi:10.1111/jocn.12274 |Framework and standardized |

| |process contributes to |

| |patient safety |

| |Magnet decision |

|Kempnich, J. (2011). Utilizing decision acceleration for Magnet gap analysis. Nursing Management 42(2), 43-45. |acceleration is best |

| |practice for conducting gap|

| |analysis, fast paced and |

| |outcome oriented |

|Kennan, G. M., Tschannen, D., & Wesley, M. L. (2008). Standardized nursing terminologies can transform practice. JONA, 38(3), |Building competency |

|103-106. |requires consistent use of |

| |communication |

|Klee, K., Latta, L., Davis-Kirsch, S. & Pecchia, M. (2012). Using continuous improvement methodology to standardize nursing |CPI technology enabled |

|handoff communication. Journal of Pediatric Nursing, 27, 168-173. |significant results, |

| |clinical interruptions were|

| |a limitation |

|Mascosoli, S., Laskowski-Jones, L., Urban, S. & Moran, S. (2009). Improving handoff communication. Nursing, 39(2), 268-271. |Improving process enhanced |

| |patient care and |

| |communication |

|McKinney, M. (2010). Smoothing transition: Joint Commission targets patient handoffs. Retrieved from |Common handoff failures are|

| |cultural, out-of-sync |

| |timing between sender and |

| |receiver |

|Ong, M., Biomed, E., & Enrico Coiera, M. B. (2011). A systematic review of failures in handoff communication during |Uniqu Unique needs of |

|intrahospital transfers. The Joint Commission Journal on Quality and Patient Safety 37(6), 274-283. |clinical setting must be |

| |considered, consistent |

| |evidence of risk to patient|

| |safety |

|Patterson, E. S. & Wears, R. L. (2010). Patient handoffs: Standardized and reliable measurement tools remain elusive. The Joint|Handoff software improved |

|Commission Journal on Quality and Patient Safety, 36(2), 51-71. |both consistency of |

| |information transfer and |

| |perceptions of patient |

| |handoff |

| |Fact Sheet R/T Consequences|

|The Joint Commission Center for Transforming Healthcare. (2012). Facts about the hand-off communications project. Retrieved |of substandard handoff and |

|from |fact sheet |

Appendix E

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Appendix F

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References

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