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Nurse Handoffs: Vital Communication for Patient SafetyJessica L. McCluskyFerris State UniversityAbstractNurse-to-nurse handoffs occur whenever care of a patient is transferred from one nurse to another. Standardizing the format of this communication helps reduce errors and improve patient safety. A deficiency in the reporting process is noted on a pediatric progressive care unit in a large children’s hospital. To improve this, implementing a bedside report structure is proposed. Keys to the success of this implementation are leadership support and encouragement, as well as nursing staff participation and ownership. Nurse Handoffs: Vital Communication for Patient SafetyNurse-to-nurse handoffs, handovers, or shift-to-shift report occur whenever care of a patient is transferred from one nurse to another (Sherwood & Barnsteiner, 2012). Keenan, Yakel, Lopez, Tschannen, and Ford (2013) determined this exchange of information is a crucial and vulnerable time in patient care. Standardizing the format of this nurse communication helps reduce errors and improve patient safety (Sherwood & Barnsteiner, 2012). The purpose of this paper is to describe the importance of nurse-to-nurse handoff and its effect on improving patient safety, as well as outlining a general project plan for the enhancement of shift report on a progressive unit in a pediatric acute care hospital. High reliability standards and quality improvement models will be examined.Needs AssessmentIn a recent study, James (2013) estimates the annual death count associated with an adverse event in the hospital setting to be between 210,000 and 400,000. Further, the Joint Commission has evaluated communication as one of the top contributors to these events, with deficiencies occurring in approximately 80% of cases (Popovich, 2011). Communication between healthcare professionals occurs most frequently as handoffs between nurses, and with patient care in the hospital setting being a 24-hour service, multiple nurses will provide care each day (Evans, Grunawalt, McClish, Wood, & Friese, 2012). The average hospital stay in the United States is 4.8 days; assuming an average of three nurses per day is approximately 15 handoff communications that will occur within an average stay, with additional report added if the patient is transferred between units or to another facility (Centers for Disease Control and Prevention [CDC], 2014; Keenan et al., 2013). Sherwood and Barnsteiner (2012) discuss the need for effective and thorough handoffs between nurses, as a decrease in quality of these communications is correlated with patient adverse events. With the changing healthcare environment, the need for effective communication between nurses will only increase. Because of improved technology and medicine, the patient population in the United States is living longer, giving rise to a larger number of chronic diseases and comorbidities (Hegarty, Walsh, Condon, & Sweeney, 2009). These not only lead to more acutely ill patients, but also increase the number of potential issues and complications a nurse needs to manage. Providing patient-centered care is heavily reliant on the caregiver having the appropriate and accurate information regarding patient condition and needs.Nursing staff also reports high levels of job dissatisfaction in relation to traditional handoff times between shifts. Dissatisfiers include communication difficulties in noisy conference rooms, waiting times while other staff is providing report, and no patient or family involvement (Evans et al., 2012). Nurses are additionally left waiting beyond their scheduled shift length, which not only results in an increase in expense for the organization, but also in hurried and abbreviated reports with less attention to detail (Evans et al., 2012). Research identified many barriers to effective and accurate handoffs between nurses. Evans et al. (2012) describes report as requiring suspended time, or time with limited or no interruptions. Interruptions lead to unfinished thoughts and discontinuity of information, a perfect environment for breeding errors. Additional identified barriers included a lack of standardized report tools or expectations, and a use of outdated communication technology such as a tape recorder to pass information between shifts (Evans et al., 2012). The Joint Commission identified communication issues as one of the top contributors to preventable healthcare errors and was frequently identified as a root cause in sentinel events (Popovich, 2011). In response to overall sentinel events in the country, the Joint Commission established National Patient Safety Goals. Goal number 2 calls for improved communication between caregivers that timely, accurate, and completely understood (Popovich, 2011). With this issue gaining national attention, it is vital organizations actively work to improve their own processes. In the identified area for this quality improvement project, the pediatric progressive care unit, personal experience indicates no standard structure for reporting, nurses staying beyond their scheduled shift length waiting to give handoff, and new nurses feeling inadequate and frustrated after the handoff process.High Reliability, Just Culture, and Quality Improvement ModelsThe unit being examined in this paper is a pediatric progressive care unit at a large children’s hospital. This unit consists of 24 inpatient beds and specializes in patients with nephrology and cardiology diagnoses, but also sees patients with a multitude of other diagnoses who require close monitoring. According to hospital records, 6,163 patient days were recorded here in 2013 (M. Davis, personal communication, April 14, 2014).High Reliability StandardsA high reliability organization (HRO) builds and runs daily operations with a culture focused on safety (Sherwood & Barnsteiner, 2012). The goal of an HRO is complete safety, defined as zero serious safety events and hospital-acquired conditions, as well as scores of zero on the patient safety indicators (Stokes, 2013). This requires work and dedication from all members of the staff in an organization. According to Sherwood and Barnsteiner (2012), an HRO can only be successful if all members are aware of the effect their daily processes and tasks have on other areas. For example, a change should not be made in one department or unit without discussing and tracking where else this change would also effect. Additionally, leadership involvement is crucial to an HRO (Stokes, 2013). Both middle and executive level leadership teams are needed to create accountability and weave safety into the everyday workings of the institution (Sherwood & Barnsteiner, 2012). Safety becomes hardwired, not just a priority (Stokes, 2013).On the identified pediatric progressive care unit, there are some high reliability ideals demonstrated. Leadership at the supervisor and manager level take a great interest in the safety of the unit by participating in unit-based root cause analysis meetings. Additionally, checklists are used for room set-up for admitting a patient, and pictures are posted to guide stockers and nurses to the appropriate places to locate supplies. Both of these strive to ensure nurses have the necessary supplies at all times so patient care is not compromised. Finally, a safety story or good-catch is shared at the beginning of each department meeting. This causes every meeting to begin with a focus on safety on the unit, hardwiring that culture into each staff member.Just CultureThe American Nurses Association (ANA) (2010) describes the Just Culture model as the focus an organization has on creating an environment that is not punitive with mistakes, but rather encourages staff to report any errors that occur. This type of culture believes that the staff member should not be punished for an error that the system failed to help recognize and eliminate. However, mistakes are recognized in three categories of behavior from accidental to reckless, and managers are encouraged to appropriately provide corrective action with the individual as the behavior demands (ANA, 2010). This notion of reporting all errors, though, is difficult to weave into an organization’s culture. A study by Niedner, Muething, and Sutcliffe (2013) found that pediatric physicians and nurses filed incident reports on their own errors less than 50% of the time. More concerning to this type of culture, one-third of the group surveyed reported their own errors only 20% of the time or less. In addition to creating a culture open and accepting to errors, Just Culture also seeks to develop a staff that is risk-orientated and able to identify shortcomings in protocols or processes (ANA, 2010). The identified pediatric progressive care unit would benefit from the establishment of Just Culture principles. Personal experience with this staff shows fear of punitive action for any misstep in patient care. Incident reports are available, but a staff member states they are rarely used due to anxiety of punishment (E. Jirous, personal communication, April 17, 2014). In order to slowly begin the change in staff beliefs to more risk-identifying, safe system designing culture, the leadership team should focus on open and honest communication at all times. Nurses need to be reminded to look for these process failures, and consistently encouraged to not only share them but also participate in corrective actions.Quality Improvement Models An example of a quality improvement model is the plan-do-study-act, or PDSA, cycle. This cycle represents the idea that every change is a hypothesis that needs to be tested to determine possible outcomes (Graban, 2012). Instead of a trial-and-error method, this model helps guide the user through the process of testing changes to see if the expected improvement occurs (World Health Organization [WHO], 2011). The PDSA model makes it easy to adjust the initial hypothesis and retest if the expected outcomes do not occur, and continue this process with every alteration in process. Graban (2012) stresses the importance of using this model to build new knowledge, not simply to implement immediate change. A change does not guarantee a success; therefore, it is important to test outcomes regularly. The pediatric progressive care unit utilized this model with the reorganization of their in-room supply cupboards. Changes were proposed, discussed, and trialed. Overall, three different arrangements were utilized before a decision was made. This shows the use of the PDSA model, as each change was followed by a trail. Since this was done six months ago, a suggestion to the unit would be to retrial their cupboards to make sure the setup is still meeting their needs and does not need additional updates.Proposed Plan for ChangeProposed PlanThe barriers to accurate, effective nurse-to-nurse handoff are well documented. In the identified unit for this quality improvement project, pediatric progressive care, personal experience indicates no standard structure for reporting, nurses staying beyond their scheduled shift length waiting to give handoff, and new nurses feeling inadequate and frustrated after the handoff process. To improve the effectiveness and accuracy of handoffs on this unit, the implementation of patient bedside report is proposed. Bedside report is when the off-going and on-coming nurses convene at the patient’s bedside to give a full handoff. Along with a verbal assessment of the patient, events, tests, medications, plans, and goals, the nurses can conduct checks of intravenous fluids or medications and do an environmental safety check. Evans et al. (2012) found that bedside report resulted in many improvements, including increased nurse satisfaction, improved assessment with the patient in the immediate vicinity, and increased patient satisfaction related to caregiver identification and knowledge of care. Additionally, parents report feeling more informed and involved in their child’s care, and adult patients enjoyed having their goals and plan set with both nurses present, resulting in continuity of care (Riesenberg, Leisch, & Cunningham, 2010) This process will be initiated with leadership education and support. As the high-reliability model suggests, leadership support will be vital in establishing this large change on the unit (Sherwood & Barnsteiner, 2012). Next, a group of champions from the unit will be identified and brought together to discuss the most fluid process to introduce this to staff, and to also voice any questions or concerns. In addition to reviewing the electronic medical record at the bedside computer, a script will be developed to lead nurses in a head to toe manner of report, followed by test results, medications, plan of care, and discharge goals. The purpose of this systematic report is to increase the standardization for all nurses. Riesenberg et al. (2010) found that standardization is the most effective strategy for improving the success of nurse-to-nurse report. Education on scripting, benefits of bedside report, and handling unique situations will be discussed in depth with questions answered. Following education, bedside report will roll out first utilizing the selected group of champions. These champions will begin giving report to the on-coming shift at the bedside. Once familiarity has been established, bedside reporting will extend to all nurses on all shifts. To evaluate this process, pre- and post-surveys will be given to nurses and willing patients to determine satisfaction, length, ease, and level of knowledge. Throughout this process, unit leadership including manager, supervisors, educator, and charge nurse will be available to answer questions and help encourage the process. It will also be leadership’s responsibility to hold the staff accountable for completing report in this new method. Feedback from staff and leadership will be considered throughout the implementation for modifications.Connection to Nursing Sensitive IndicatorNursing sensitive indicators (NSIs) were identified as a list of elements directly related to nursing that influence care outcomes (ANA, 2007). By recording these measurements, the ANA is able to continuously demonstrate the effect nurses have on patient care (ANA, 2007). Numerous research studies have shown a significant correlation between utilizing bedside report and an increase in nursing job satisfaction (Anderson, 2006; Evans, 2012). Stemming from this, an increase in that job satisfaction is directly related to a decrease in voluntary nurse turnover (Ramoo, Abdullah, & Piaw, 2013). This decrease in voluntary nurse turnover is identified as an NSI by the ANA (ANA, 2007).Ethical ImplicationsNursing professionals are faced with many ethical responsibilities on a daily basis, from providing appropriate and quality care to striving for excellence with all they do (Izumi, 2012). Izumi (2012) discusses how recent changes in healthcare regulation forces quality improvement projects to be determined in the executive levels of an organization. Bedside nurses are then used only as collectors of data, instead of being the voices on which the projects should be built. This leads the nurse to view quality improvement as an obligation, rather than an opportunity, and may lead to a decrease in the interest of providing care (Izumi, 2012). Therefore, it is extremely important that the professional nurse fights to be heard and participates actively in improvement projects. This drive and commitment to continuously improving care should be cultivated at an early level. Nursing schools and new nurse hospital orientation programs must openly support nursing opinions and ideas, and provide multiple opportunities for participation. When there is buy-in and cooperation from the nursing staff, projects are much more likely to succeed and benefit the patient (Izumi, 2012). With the implementation of a bedside report process, research indicates that nurses initially voice concerns over patient confidentiality, especially in semi-private rooms (Sherman, Sand-Jecklin, & Johnson, 2013). However, Radtke (2013) argues that information sharing in a patient room is more confidential than in at the nursing station where the hallways are frequented by guests and other staff. Additionally, this format gives power to the patient, and allows him or her to determine whether to participate with the bedside report process, and whether visitors are allowed to be present (Radtke, 2013). One hospital reported having the risk management staff review this confidentiality concern. The final decision was that general patient information, test results, and plans of care could be shared at the bedside in semi-private rooms with the cooperation of the patient. Information deemed sensitive, such as family situations or any infections disease discussion, would be shared between the nurses in the privacy of a conference room following bedside report (Evans et al., 2012). This puts the nurse in charge of advocating for the patient and making decisions to keep the patient’s best interests in the forefront. ConclusionIt has been well established that accurate nurse-to-nurse handoffs increase the safety and quality of care patients receive. In order to improve this process on a pediatric progressive care unit, the implementation of bedside report is proposed. Keys to the success of this implementation are leadership support and encouragement, as well as nursing staff participation and ownership. ReferencesAmerican Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Retrieved from EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdfAmerican Nurses Association. (2007). The national database of nursing quality indicators. The Online Journal of Issues in Nursing, 12(3).American Nurses Association. (2010). Position statement on Just Culture. Retrieved from , C., & Mangino, R. (2006). Nurse shift report: Who says you can't talk in front of the patient? Nursing Administration Quarterly, 30(2), 112-122.Centers for Disease Control and Prevention. (2014). Hospital utilization. Retrieved from , D., Grunawait, J., McClish, D., Wood, W., & Friese, C. R. (2012). Bedside shift-to-shift nursing report: Implementation and outcomes. MEDSURG Nursing, 21(5), 281-292. Graban, M. (2012). Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement. Boca Raton, FL: CRC Press.Hegarty, J., Walsh, E., Condon, C., & Sweeney, J. (2009). The undergraduate education of nurses: Looking to the future. International Journal of Nursing Education Scholarship, 6(1), 1-11. doi:10.2202/1548-923X.1684Izumi, S. (2012). Quality Improvement in Nursing: Administrative Mandate or Professional Responsibility? Nursing Forum, 47(4), 260-267. doi:10.1111/j.1744-6198.2012.00283.xJames, J.T. (2013). A new, evidence-based estimate of patient harm associated with hospital care. Journal of Patient Safety, 9(3), 122-128. doi: 10.1097/PTZ.0b013e3182948a69Keenan, G., Yakel, E., Dunn Lopez, K., Tschannen, D., & Ford, Y. (2013). Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. Journal of the American Medical Informatics Association, 20(2), 245-251. doi:10.1136/amiajnl-2012-000894Niedner, M., Muething, S., & Sutcliffe, K. (2013). The high-reliability pediatric intensive care unit. Pediatric Clinics of North America, 60(3), 563-580. doi:10.1016/j.pcl.2013.02.005Popovich, D. (2011). Cultivating safety in handoff communication. Pediatric Nurse, 37(2), 55-60.Radtke, K. (2013). Improving patient satisfaction with nursing communication using bedside shift report. Clinical Nurse Specialist, 27(1), 19-25. doi:10.1097/NUR.0b013e3182777011Ramoo, V., Abdullah, K., & Piaw, C. (2013). The relationship between job satisfaction and intention to leave current employment among registered nurses in a teaching hospital. Journal of Clinical Nursing, 22(21), 3141-3152. doi:10.1111/jocn.12260Riesenberg, L., Leitzsch, J., & Cunningham, J. (2010). Nursing handoffs: A systematic review of the literature. American Journal of Nursing, 110(4), 24-36. doi:10.1097/01.NAJ.0000370154.79857.09Sherwood, G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes. West Sussex: Wiley-Blackwell.Stokes, C. D. (2013). Healthcare reform and the journey to high reliability. Nurse Leader, 11(6), 28-30. doi:10.1016/j.mnl.2013.09.012World Health Organization. (2011). Multi-professional patient safety curriculum guide. Retrieved from who_mc_topic-7.pdf ................
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