Using continuous process improvement methodology to standardize nursing handoff communication

Systematic Review of Quality Improvement Projects Related to Intershift Nursing Handover

BACKGROUND

Nursing handover is a real-time process in which patient-specific information is passed between nurses to ensure the continuity and safety of patient care.

PURPOSE

The purpose of this study was to determine the effects of quality improvement (QI) projects in improving the intershift nursing handover process.

METHODS

A computerized search was performed of electronic databases for articles published during 2009-2019 in English or Korean for which the full texts were available. The included studies involved QI projects, handover between nurses, and intershift handover. The QI-MQCS (Quality Improvement Minimum Quality Criteria Set) was used to appraise the quality of QI strategies.

RESULTS

The handover methods used in the 22 QI projects could be broadly divided into 2 types: (1) using a standardized communication tool; and (2) involving patient-participation bedside handover.

CONCLUSIONS

The published research on intershift handover-related QI projects employed standardized communication tools and the patient-participation bedside handover method to reduce adverse events and handover times and increase the satisfaction of patients and nurses. Future studies should measure the changes in patient safety-related outcomes.

Improving Throughput for Patients Admitted From the Emergency Department: Implementation of a Standardized Report Process

BACKGROUND

Inefficient emergency department to inpatient handoff processes can contribute to delayed care.

LOCAL PROBLEM

The average emergency department length of stay for admitted patients and admission wait times at this institution were well above national averages, and a standard handoff process was lacking.

METHODS

Lean methodology was used to evaluate flow and identify opportunities for improvement.

INTERVENTIONS

Two tools were developed to standardize handoff.

RESULTS

Emergency department length of stay and admission wait times were not significantly improved following intervention implementation. However, patient transfer time decreased significantly (P < .01, F = 29.02) from 30.5 minutes (SD = 18.2) to 21.7 minutes (SD = 7.4). The length of time to give/receive report also decreased significantly (P = .04, F = 2.2) from 3.8 (SD = 1.6) minutes to 2.8 (SD = 1.2) minutes.

CONCLUSIONS

Although length of stay and admission wait times did not decline significantly, implementation of standard work and tools can potentially improve patient flow.

Developing an Evidence-Based Nursing Handover Standard for a Multi-Site Public Hospital in Switzerland: Protocol for a Web-Based, Modified Delphi Study

BACKGROUND

Poor communication processes create opportunities for errors when caregivers fail to transfer complete and consistent information. Inadequate or nonexistent clinical handovers or failures to transfer information, responsibility, and accountability can have dire consequences for hospitalized patients. Clinical handover is practiced every day, in a multitude of ways, in all health care settings.

OBJECTIVE

The goal of this study is to build a consensus, evidence-based nursing handover standard for inpatients during shift changes or internal transfers between hospital wards. The study will be based on papers published by Slade et al.

METHODS

This protocol describes a modified Delphi data-collection survey involving a targeted panel sample of 300 nurse experts. A multi-round survey will select an anonymous panel from a multi-site public hospital in Switzerland. Each survey stage will be described and will build on the previous one. The study will end with a focus group discussion involving a randomly selected panel to explain why items for the evidence-based clinical nursing handover standard were accepted or not accepted. An item must achieve a consensus of ≥70% for inclusion.

RESULTS

The present study's expected outcome is a consensus-built, evidence-based nursing handover standard for inpatients during shift changes or internal transfers between the wards of a multi-site public hospital in Switzerland.

CONCLUSIONS

This survey will enable us to develop an evidence-based nursing handover standard for use during shift changes and internal inpatient transfers in a multi-site public hospital in Switzerland.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15910.

An Evidence-Based, Nursing Handover Standard for a Multisite Public Hospital in Switzerland: Web-Based, Modified Delphi Study

BACKGROUND

Ineffective communication procedures create openings for errors when health care professionals fail to transfer complete, consistent information. Deficient or absent clinical handovers, or failures to transfer information, responsibility, and accountability, can have severe consequences for hospitalized patients. Clinical handovers are practiced every day, in many ways, in all institutional health care settings.

OBJECTIVE

This study aimed to design an evidence-based, nursing handover standard for inpatients for use at shift changes or internal transfers between hospital wards.

METHODS

We carried out a modified, multiround, web-based, Delphi data collection survey of an anonymized panel sample of 264 nurse experts working at a multisite public hospital in Switzerland. Each survey round was built on responses from the previous one. The surveys ended with a focus group discussion consisting of a randomly selected panel of participants to explain why items for the evidence-based clinical nursing handover standard were selected or not selected. Items had to achieve a consensus of ≥70% for selection and inclusion.

RESULTS

The study presents the items selected by consensus for an evidence-based nursing handover standard for inpatients for use at shift changes or internal transfers. It also presents the reasons why survey items were or were not included.

CONCLUSIONS

This modified Delphi survey method enabled us to develop a consensus- and evidence-based nursing handover standard now being trialed at shift changes and the internal transfers of inpatients at our multisite public hospital in Switzerland.

Improving Nurses’ Hand-off Process on Oncology Setting Using Lean Management Principles

Background: Patients in oncology setting are struggling with the complexed disease, and long and intensive treatment options. This increase the need of patients for more coordination and effective hand-off between health providers including nurses. Aims: The main aim of this project is to improve the effectiveness of hand-off between nurses in the oncology setting using lean management principles. Methods: One group pretest-posttest quasi-experimental design was conducted at King Hussain Cancer Center during quarter two to quarter four in 2017. The project was conducted using the lean tools including root cause analysis, redesigning the hand-off process; using structured tools, and standardization of the hand-off process. Results: The finding of this project showed a significant decreasing in the hand-off duration and the incidence of events related to nursing practice deviation in post-intervention. Moreover, the results showed that the nurse satisfaction score was improved. However, there is a little difference in patient satisfaction results between two quarters for overall satisfaction and per each domain. Conclusion: The project approved that the use of structured tools, safety briefing, and standardized hand-off process play important role in improving the effectiveness of the hand-off process.

Strategies to Improve Information Transfer for Multitrauma Patients

The aim of this multiphase mixed-method study was to improve access, flow, and consistency of information transfer for multitrauma patients leaving the Emergency Department. Methods included literature review, focus group interviews, chart audits, staff surveys, and a review of international trauma forms to inform an intervention developed with a researcher-led, clinician stakeholder group. Analysis included descriptive and inferential statistics. Baseline data revealed variability existed in patient-care documentation, showing little standardization. Improvement strategies implemented included a gold standard for information embedded in handover tools, raising staff awareness of complexities for information transfer. Improvement was seen in communication between wards coordinating transfer, improved documentation, decreased information duplication, improved legibility, and increased ease and efficiency in navigating to key information. Improvement in communication at patient transition is essential to continuity of safe, effective care, and is impacted by complex interactions between multiple factors. Difficulty increases for patients with high acuity.

Embracing the wild profusion: A Foucauldian analysis of the impact of healthcare standardization on nursing knowledge and practice

Standardization has emerged as the dominant principle guiding the organization and provision of healthcare, with standards resultantly shaping how nurses conceptualize and deliver patient care. Standardization has been critiqued as homogenizing diverse patient experiences and diminishing nurses' skills and critical thinking; however, there has been limited examination of the philosophical implications of standardization for nursing knowledge and practice. In this manuscript, I draw on Foucault's philosophy of order and categorization to inform an analysis of the consequences of healthcare standardization for the profession of nursing. I utilize three exemplars to illustrate the impact of the primacy of standardized thinking and practices on nurses, patients and families: pain assessments using the 0-10 pain scale; patient triage emergency departments through the Canadian Triage and Acuity Scale; and determination of cause of death within the context of the current opioid crisis. Through each exemplar, I demonstrate that standardization reductively constrains nursing knowledge and the health and healthcare experiences of patients and populations. I argue that the centrality of standardization must be re-envisioned to embrace the complexity of health and more effectively and meaningfully frame nursing knowledge and practice within healthcare systems.

An observational study of patient handover communications among nurses on an oncology critical care unit

BACKGROUND

Breakdown in communication is a common cause of errors in hospitals. Aim/Objectives: To evaluate the feasibility and utilization of evidence-based recommendations for nurse-to-nurse shift handover on an oncology critical care unit.

DESIGN

Observational study.

METHODS

Nurses were provided education that integrated evidence-based recommendations for handover of care. Nursing shift report was observed for one month in 2015 and for one month in 2016. Results were evaluated for inclusion of 24 evidence-based essential elements for handover communication.

RESULTS

Total completeness of handover increased with 86.64% (N = 38) in 2015 and 88.68% (N = 35) in 2016. Interruptions during handover were positively correlated with length of handover (r = 0.587, n = 18, p = .010), thus confirming the need for structured, more effective handover methods.

CONCLUSIONS

Providing education, mentoring, and real-time feedback to motivated staff may lead to improvements in handover communication methods, yielding positive patient outcomes.

The Hidden Lives of Nurses' Cognitive Artifacts

BACKGROUND

Standardizing nursing handoffs at shift change is recommended to improve communication, with electronic tools as the primary approach. However, nurses continue to rely on personally created paper-based cognitive artifacts - their "paper brains" - to support handoffs, indicating a deficiency in available electronic versions.

OBJECTIVE

The purpose of this qualitative study was to develop a deep understanding of nurses' paper-based cognitive artifacts in the context of a cancer specialty hospital.

METHODS

After completing 73 hours of hospital unit field observations, 13 medical oncology nurses were purposively sampled, shadowed for a single shift and interviewed using a semi-structured technique. An interpretive descriptive study design guided analysis of the data corpus of field notes, transcribed interviews, images of nurses' paper-based cognitive artifacts, and analytic memos.

RESULTS

Findings suggest nurses' paper brains are personal, dynamic, living objects that undergo a life cycle during each shift and evolve over the course of a nurse's career. The life cycle has four phases: Creation, Application, Reproduction, and Destruction. Evolution in a nurse's individually styled, paper brain is triggered by a change in the nurse's environment that reshapes cognitive needs. If a paper brain no longer provides cognitive support in the new environment, it is modified into (adapted) or abandoned (made extinct) for a different format that will provide the necessary support.

CONCLUSIONS

The "hidden lives" - the life cycle and evolution - of paper brains have implications for the design of successful electronic tools to support nursing practice, including handoff. Nurses' paper brains provide cognitive support beyond the context of handoff. Information retrieval during handoff is undoubtedly an important function of nurses' paper brains, but tools designed to standardize handoff communication without accounting for cognitive needs during all phases of the paper brain life cycle or the ability to evolve with changes to those cognitive needs will be underutilized.

Handover and transport of critically ill children: An integrative review

BACKGROUND

The handover and transport of critically ill pediatric patients requires communication amongst multiple disciplines. Poor communication is a leading cause of sentinel events and human factors affect handover and transport.

OBJECTIVES

To synthesize published data on pediatric handover and transport and identify gaps to provide direction for future investigation.

METHODS

Integrative literature review.

RESULTS

Forty research studies were reviewed and revealed the following themes: risk for patient complications, standardized communication, and specialized teams and teamwork were associated with improved outcomes. No articles were identified regarding transportation of critically ill pediatric patients from the emergency room to the intensive care unit. There was a knowledge gap in best practices in handover and transport within the unique subsets of the pediatric population including neonate, toddler, school-aged, and adolescents.

CONCLUSIONS

Research supported a combined approach of specialized teams using standardized communication in the handover and transport of the pediatric patient to improve outcomes. Further study is warranted on interprofessional (team to team) handover practices, select subsets of the pediatric population, and the handover and transport of critically ill patients from the emergency room to the intensive care unit.

The Symbolic Functions of Nurses' Cognitive Artifacts on a Medical Oncology Unit

Acute care nurses continue to rely on personally created paper-based tools-their "paper brains"-to support work during a shift, although standardized handoff tools are recommended. This interpretive descriptive study examines the functions these paper brains serve beyond handoff in the medical oncology unit at a cancer specialty hospital. Thirteen medical oncology nurses were each shadowed for a single shift and interviewed afterward using a semistructured technique. Field notes, transcribed interviews, images of nurses' paper brains, and analytic memos were inductively coded, and analysis revealed paper brains are symbols of patient and nurse identity. Caution is necessary when attempting to standardize nurses' paper brains as nurses may be resistant to such changes due to their pride in constructing personal artifacts to support themselves and their patients.

Interventions employed to improve intrahospital handover: a systematic review

BACKGROUND

Modern medical care requires numerous patient handovers/handoffs. Handover error is recognised as a potential hazard in patient care, and the information error rate has been estimated at 13%. While accurate, reliable handover is essential to high quality care, uncertainty exists as to how intrahospital handover can be improved. This systematic review aims to evaluate the effectiveness of interventions aimed at improving the quality and/or safety of the intrahospital handover process.

METHODS

We searched for articles on handover improvement interventions in EMBASE, MEDLINE, HMIC and CINAHL between January 2002 and July 2012. We considered studies of: staff knowledge and skills, staff behavioural change, process change or patient outcomes.

RESULTS

631 potentially relevant papers were identified from which 29 papers were selected for inclusion (two randomised controlled trials and 27 uncontrolled studies). Most studies addressed shift-change handover and used a median of three outcome measures, but there was no outcome measure common to all. Poor study design and inconsistent reporting methods made it difficult to reach definite conclusions. Information transfer was improved in most relevant studies, while clinical outcome improvement was reported in only two of 10 studies. No difference was noted in the likelihood of success across four types of intervention.

CONCLUSIONS

The current literature does not confirm that any methodology reliably improves the outcomes of clinical handover, although information transfer may be increased. Better study designs and consistency of the terminology used to describe handover and its improvement are urgently required.

Nurses as knowledge workers: is there evidence of knowledge in patient handoffs?

Patient care handoffs are critical to ensuring continuity of care and patient safety. Current definitions of handoffs focus on information, but preventing errors and improving quality require knowledge. The objective of this study was to determine whether knowledge and wisdom were exchanged during medical and surgical patient care handoffs and to discover how these were expressed. The study was a directed content analysis of 93 handoffs using the data/information/knowledge/wisdom framework. Results indicated knowledge was present in all handoffs, comprising 41% of the phrases across the two types of units. No wisdom was coded. The percentage and types of knowledge phrases differed between medical and surgical units. Handoffs could be more knowledge based by linking handoff content to patient problems and goals. Future handoffs could be computationally derived, context-specific, and linked to problem-focused care plans and patient summaries. Improved data visualization and cognitive support are needed.