Inadequate Hand-offs: A Healthcare Problem

Shift Report

Inadequate Hand-offs: A Healthcare Problem

Instructions:

A.  Write a brief summary (suggested length of 2–3 pages) of the significance and background of a healthcare problem by doing the following:

1.  Describe a healthcare problem.

2.  Explain the significance of the problem.

3.  Describe the current practice related to the problem.

4.  Discuss how the problem impacts the organization and/or patient’s cultural background.
 

B.  Complete the attached “PICO Table Template” by identifying all the elements of the PICO.

1.  Develop the PICO question.
 

C.  Describe the search strategy (suggested length of 1–2 pages) you used to conduct the literature review by doing the following:

1.  Identify the keywords used for the search.

2.  Describe the number and types of articles that were available for consideration.

a.  Discuss two research evidence and two non-research evidence sources that were considered (levels I–V).
 

D.  Complete the attached “Evidence Matrix” to list five research evidence sources (levels I–III) from scholarly journal sources you locate in major medical databases.
 

Note: Four different authors should be used for research evidence. Research evidence must not be more than five years old.
 

Note: You may submit your completed matrix as a separate attachment to the task or you may include the matrix within your paper, aligned to APA standards.
 

E.  Explain a recommended practice change (suggested length of 1–3 pages) that addresses the PICO question within the framework of the evidence collected and used in the attached “Evidence Matrix.”
 

F.  Describe a process for implementing the recommendation from part E (suggested length of 2–3 pages) in which you do the following:

1.  Explain how you would involve three key stakeholders in the decision to implement the recommendation.

2.  Describe the specific barriers you may encounter in applying evidence to practice changes in the nursing practice setting.

3.  Identify two strategies that could be used to overcome the barriers discussed in F2.

4.  Identify one indicator to measure the outcome related to the recommendation.
 

G.  Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

Solution.

Inadequate Hand-offs: A Healthcare Problem

Healthcare problem

Change-of-shift report has been a norm ever since the nursing practice has existed in healthcare. The patient hand-off is the transfer of knowledge, information, and responsibility for the patient care from one health care professional to another. If the patient hand-off is executed efficiently, it provides continuity of care for the patient. Nurses use it to pass on or share the resource information about the patients including the necessary information and all the relevant critical information as well. Change of shift report is key to providing quality and safe care to the patients. The purpose of the report not only covers all information documented in the Medication Administration Record (MAR), but it summarizes information to the oncoming nurse to practice nursing and keep the patients safe. Change-of-shift report is to be provided in a safe, private area where patient privacy can be protected from any misuse, therefore making it a very private affair. (Papastavrou, Andreou, & Efstathiou, 2013). The patient and families at many times perceive it as something that the patient is not aware of about their health, due the report being conducted in a private area.

Significance of problem

Chassin, 2013 suggests that inadequate hand-off processes can lead to poor patient care. It has been supported and proved by documented theories that during the change-of-shift report, vital patient information is either missed or communicated wrong. When the patients see nurses during the report, they assume that there is something about their health that the nurses are hiding from them. Therefore, it is being communicated in a secret fashion. Many times some of the vital information is miscommunicated, leading to follow-up phone calls after the shift. Patients also express frustration in regards to not being introduced to the new nurse as 87% of the patients get a new nurse every day. Staff nurse being the sound participants of this process were asked to presents their thoughts and comments about this version of change of shift report. After all the staff nurses reviewed the practice and provided their comments, the managing committee of the hospital including charge nurses, nursing supervisors, CNO, CEO, the unit manager came together to study the previous report pattern, nurses comments, and study of the criteria used by neighboring hospitals and other health care facilities for change of shift report (Papastavrou, Andreou, Tsangaris, & Mercuries, 2014).The purpose of this project was to change the ongoing practice and mindset of the staff that following the process in not mandated and we all should be open to change. After all the research and discussions, the new pattern of the report stated as Bedside report came up and is the current practice.

Current practice

The current practice is to exchange a nursing report at the nurses’ station. The two nurses get together with all their documents and sit down away from patients and chaos. They exchange all the information by the room number, names of the patient, and the off-going nurse leaves the facility without any notice to the patients. If the oncoming nurse is late for some reason, a recorded report, where the off-going records the report and leaves for the day is also used. The on-coming nurse then goes to patent’s room and introduce herself, if time permits.

Impact on background

The current practice of change-of-shift had a very detrimental effect on the patient and nurse satisfaction. The nurses were tired from long day of hard work and miscommunicated the patient information often (Foster-Hunt, Parush, Ellis, Thomas, & Rashotte, 2015).The oncoming nurses reporting to work did not have a good start due to miscommunication and were left behind to figure things out for themselves. At night, shortage of staff works as an icing on the cake. The patient and families always reported satisfaction due to chaos at change-of-shift. The patient felt left out and worried about the private meeting between the nurses. The patients indicated that they were not introduced to the new nurse until they needed something from them. The families expressed concerns about leaving their family member to the unknown in the evening.

Changes in the shift are necessary for patient care. In ensuring maximum care for patients, it is critical for patients to be informed fully and promptly. The interruptions experienced hand-offs may largely threaten the veracity of communication between nurses, hence, critical to patient-centered care and attention. (Uhl, Fisher, Docherty, & Brandon, 2013). Also, at the end of a shift, nurses tend to hurry with their remaining tasks, such practices can significantly affect their efficiency and service delivery to patients at stake. Inadequate hand-offs thereof can lead to poor care that in turn cause poor ratings for the organizations that offer health services.

According to a study (Horwitz, Moin, Krumholz, Wang, & Bradley, 2008) suggests that omission or error of key information and details during sign out can impact negatively on patients and healthcare providers. The study suggests that the connection between inadequate communication among staff at the time of transfer of responsibility and adversative consequences are experienced hours later by the patient or the healthcare provider. These errors include deletion of content which require judgment and synthesis. Such errors result in delays, duplication of effort and inefficiencies in handling the client.   

PICO table

P-Population Staff nurses and patient group.

I-Intervention Bedside change of shift report.

C-Comparison Change of shift reports at nurse’s station

O-Outcome Reduction of miscommunication by the nurses.

PICO question

“In a change of shift report between off-going and on-coming nurse, does bedside report reduce that chances of miscommunication?”

Keywords

The keywords used for research were:

Nursing Ethics, Change of Shift Report, Bedside Report, Patient satisfaction, Culture of nursing report, SBAR (Situation, Background, Assessment, Recommendation)

Numbers and types of articles

Research articles used for research totaled to four research-based and two non-research based. Listed below are the reference to the articles:

1. Foster-Hunt, T., Parush, A., Ellis, J., Thomas, M., & Rashotte, J. (2015). Information structure and organization in a change of shift reports An observational study of nursing hand-offs in a Pediatric intensive care unit. Intensive and Critical Care Nursing, 31(3), 155–164. doi:10.1016/j.iccn.2014.09.004
2. Howard, K. P., & Becker, C. A. (2016). Moving change-of-shift report to the bedside for UAP. Nursing, 46(4), 14–16. doi:10.1097/01.nurse.0000481434.79307.73
3. Cornell, P., Gervais, M. T., Yates, L., & Hardeman, J. M. (2013). Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol. JONA: The Journal of Nursing Administration, 43(7/8), 422–428. doi:10.1097/nna.0b013e31829d6303
4. Kittson, A. L., Mantling Athlon, Å, Elliott, J., & Cant, M. L. (2013). What’s my line? A narrative review and synthesis of the literature on registered nurses’ communication behaviors between shifts. Journal of Advanced Nursing, 70(6), 1228–1242. doi:10.1111/jan.12321

• Papastavrou, E., Andreou, P., Tsangaris, H., & Mercuries, A. (2014). Linking patient satisfaction with nursing care: The case of care rationing – a correlational study. BMC Nursing, 13(1), 26. Doi: 10.1186/1472-6955-13-26

• Frieze, C. R., Grunewald, J. C., Bhullar, S., Bihlmeyer, K., Chang, R., & Wood, W. (2014). Pod nursing on a medical/surgical unit. JONA: The Journal of Nursing Administration, 44(4), 207–211. doi:10.1097/nna.0000000000000051.

All the articles used are Academic journals. The literature research found abundant sources to complete research on “why bedside hand-off is beneficial.” The research journals used are a quality improvement, quality assurance, qualitative, and observational journals. The non-research articles are scholarly articles written by nursing leaders.

Research and Non-Research based evidence

For research of the implementation of the change of shift report at the bedside, five research and three non-research articles were used. All the articles are well cited in above section as well the references section. The research articles used are from certain hospital units located all over the world. The research articles concluded the ease and benefits of bedside report by nurses and UAP’s. By routinely communicating shift report at the bedside, nurses and other healthcare providers can consistently reinforce patients’ plan of care, promote patient-centered care, and improve the overall quality of attention and care. Several positive outcomes were documented about the implementation of a blended bedside shift report, with few drawbacks. Nurse attitudes about the report at the final data collection were more positive than at the initial post-implementation data collection.

The following two research and three non-research sources can illegibly portray the statement.

1. Howard, K. P., & Becker, C. A. (2016). Moving change-of-shift report to the bedside for UAP. Nursing, 46(4), 14–16. doi:10.1097/01.nurse.0000481434.79307.73

The research abounds with the benefits of bedside shift report on the safety, communication, accountability and involvement of the patient in his care. The sources show how bedside reports are essential to unlicensed assistive personnel(UAP).

• Cornell, P., Gervais, M. T., Yates, L., & Hardeman, J. M. (2013). Improving shift report focus and consistency with the situation, background, assessment, recommendation protocol. JONA: The Journal of Nursing Administration, 43(7/8), 422–428. doi:10.1097/nna.0b013e31829d6303

This research literature used SBAR to protocol to improve the shift reports in four medical-surgical units. SABR-made reports were focused and ample time was spent on discussion of the patient.Also, less time was spent on transcription of information. The results showed that average duration of a shift to take place did not decrease using the SBAR. The caregivers spent a significant time on tasks to report. Also, there was more dialogue and less writing.

• 6.   Frieze, C. R., Grunewald, J. C., Bhullar, S., Bihlmeyer, K., Chang, R., & Wood, W. (2014). Pod nursing on a medical/surgical unit. JONA: The Journal of Nursing Administration, 44(4), 207–211. doi:10.1097/nna.0000000000000051

In this research, results suggested that reorganization of a medical unit to using the pod model was found to be more efficient at improving the selected patient and nurse outcomes. Also, Attention to patients and nurses will result in a meaningful improvement in patient care that supports care delivery that is patient-centered, efficient and safe. Also, improvement is seen in those care units that support evidence-based practice.

• Kittson, A. L., Mantling Athlon, Å, Elliott, J., & Cant, M. L. (2013). What’s my line? A narrative review and synthesis of the literature on registered nurses’ communication behaviors between shifts. Journal of Advanced Nursing, 70(6), 1228–1242. doi:10.1111/jan.12321

This research study stipulates that areas that lack consistency in the nursing field be communicated. In order to improve communication in the nursing team, there must be a more integrated approach to understanding the complex processes involved. The research concludes by stating that the neglected area of study is that requirements or role of determining the communication standards of the nursing team.

•  Sand‐Jecklin, K., & Sherman, J. (2014). A Quantitative Assessment of Patient and Nurse Outcomes of Bedside Nursing Report Implementation. Journal of Clinical Nursing, 23(19-20), 2854-2863.

The above research focusses on the measureable outcomes of unified form of bedside nursing report. It identifies benefits associated with bedside report. The assessment was taken on seven medical-surgical units in a large university hospital which implemented the blended nursing report. The assessment indicated several positive outcomes such as nurse satisfaction as nurse’s satisfaction about the final data collection were to a greater extent positive than the initial post implementation data collection.   

Evidence Based Matrix (Attached on Excel File)

Recommended practice change

After all the research and review of the literature, the committee decided to implement a new fashion of report known as bedside nurse report. The nurses were to exchange all the information in the specific patient’s room in the presence of the patient rather than at the nurse’s station in whispers. The patient is a part of the exchange of the information and is welcome to update any health information being exchanged. It also included the introduction of the oncoming nurse to the patient and family rather them leaving the patient in dark to find for themselves. “Since 2013, giving a report at the patient bedside has been recommended by the Agency for Healthcare Research and Quality (AHRQ) to progress on patient safety. (Cornell, Gervais, Yates, & Hardeman, 2013). However, it was not until recently that it was known how Nursing Bedside Shift Report works to keep patients safe. (Kittson, Athlon, Elliott, & Cant, 2013)

The implication of the new process had a great impact on the organization as well as the pt. population. The hospital management conducted an audit to see how the change has affected the staff as well as the patients. The results of the audits were as following:

• Increased staff nurse satisfaction as they were able to get all the information about the patient with looking like a detective and were able to be open with the patient about the health concerns, complications, needs, attitudes, caregiver expectations. The nurses also rejoiced the benefit of leaving on time.

• The patients were 87% more satisfied that before because they were introduced to the nurse and were not left to figure things out. They often preferred to be a part of the team rather than being a stranger in their care decisions.

• The call lights ratio reduced by 64% during bedside report as the nurses were physically present in the room to address concerns rather than waiting for half an hour report to finish and address the issues.

• The organization was at a financial benefit and also reaped the benefit of higher satisfaction of the staff member. In one month $8470 were saved from nurse overtime.

Key stakeholders

All the stakeholders mentioned below were very involved in the whole project. It consumed about 40% of their work time for an entire working month. The CNO personally interviewed nurses and participated in the Retention survey. The nurses took the time to share their concerns with all the stakeholders. An open door policy was adopted by the CEO to communicate better. Since this whole process, the relation between the staff has improved much and become less restrictive. The management compared the policies and procedures from other hospitals and researched the process of bedside report. They measured the outcomes from research and data collected by other hospitals who had already adopted the change.

After the management had approved the evidence-based practice recommended change, nursing supervisors must be educated about the modification. After they adapt to change, it can be further implemented in the staff nurses. The nurse manager should adapt the change by taking the report from staff nurses at the bedside. Rather than nurses going to the manager, they will meet at pt.’s bedside to discuss change or new results. The education department is required educational in-services to explain the switch to the nurses. They are obliged to all the evidence to generate the essential education to the staff. Nurses must accept and understand the change. The management at the facility is the one responsible for educating and helping patients understand the facility’s policies and care. The chief nursing officer will be a resource for answering all the questions as well as obtaining input about adapting process from the nurses. The nursing staff is required to take into consideration of the change in the organization and be able to pass this information to their patients.

Barriers

The two main types of barriers that were encountered during the change process were physical barriers and obstacles to research that is the attitude of staff towards change. The physical barrier was the cost that was projected towards keeping the nursing assistants for half an hour longer to have the nurse focus towards the report and individual patient rather than running back and forth to different pt. rooms. The other barrier was the staff nurses accepting the change because it is human nature to be afraid of the change what so ever. The nurses were hesitant of the research and theories being biased and incomplete. Change is always resistive.

Strategies for barriers

A well-documented and in-depth research, confidence, communication, teamwork, education, and understanding are critical for the institution of any change. The nurses were presented with an open door policy to come in with any questions, concerns, ideas and thoughts about the modification. The change was not made permanent and was adopted on a trial basis, very open to further change. The cost containment was adjusted from the saving that was budgeted from the overtime reduction by the nurse due to accurate and timely bedside report.

Indicator to measure outcome

The best indicator to gauge the results of the change was staff nurse retention survey. Based on the number of staff nurses who went along with the change and expressed positivity in adjustment to change rather than chaos. After the management team had compiled the survey results, 87% percent staff nurses accepted the change as positive with only few distraction. The change was implemented as a final step towards bedside shift report. Patient satisfaction scores came back with much higher numbers. The nurses reported an improved accuracy of the information that was passed to them. They also appreciated the patient participation which directed the nurses towards reaching patient’s expectations. The nurses reported that they were able to provide patient-centered care after meeting and knowing what the patient needs before starting the shift. The off-going shift appreciated the fact that they left the facility in peace and not getting phone calls after leaving. The nurses enjoyed the fact that they can each out the patients for any information that as missed.

Conclusion

Change of shift has been a problem in the nursing career and has significantly affected care given to the patients at large. Research suggest that a change to bedside shift reports are convenient and flexible. Also, with recent programs in place to educate both patients and caregivers on adherence to the new bedside reports are important and soon will reduce the cases of patient’s dissatisfaction and mistrust. With reports from nursing staff, it is evident the change is achievable and efficient. Nurses will have not to worry after the give a hand-off to the fellow colleague. To add on the stakeholders are required to follow the policies to the latter. Also, it is their responsibility to make it clear for patients to understand the changes in policies and procedures involved in the delivery of healthcare. Therefore, as nurses we must embrace change and fight off the effects associated with inadequate hand-offs.

References

Chassin, M. R. (2013). Improving The Quality of Health Care: What’s Taking So Long? Health Affairs, 32(10), 1761-1765.

Cornell, P., Gervais, M. T., Yates, L., & Hardeman, J. M. (2013). Improving Shift Report Focus and Consistency with the Situation, Background, Assessment, Recommendation Protocol. Journal of Nursing Administration, 43(7/8), 422–428. doi:10.1097/nna.0b013e31829d6303

Foster-Hunt, T., Parush, A., Ellis, J., Thomas, M., & Rashotte, J. (2015). Information Structure and Organisation in Change of Shift Reports: An Observational Study of Nursing Hand-Offs in a Pediatric Intensive Care Unit. Intensive and Critical Care Nursing, 31(3), 155–164. doi:10.1016/j.iccn.2014.09.004

Frieze, C. R., Grunewald, J. C., Bhullar, S., Bihlmeyer, K., Chang, R., & Wood, W. (2014). Pod Nursing on a Medical/Surgical Unit. The Journal of Nursing Administration, 44(4), 207–211. doi:10.1097/nna.0000000000000051

Horwitz, L. I., Moin, T., Krumholz, H. M., Wang, L., & Bradley, E. H. (2008). Consequences of Inadequate Sign-Out for Patient Care. Archives of Internal Medicine, 168(16), 1755-1760.

Howard, K. P., & Becker, C. A. (2016). Moving Change-Of-Shift Report to The Bedside for UAP. Nursing, 46(4), 14-16. doi:10.1097/01.nurse.0000481434.79307.73

Kassean, H. K., & Jagoo, Z. B. (2005). Managing Change In The Nursing Handover from Traditional to Bedside Handover- A Case from Mauritius. BMC Nursing, 4(1), 1.

Kittson, A. L., Athlon, M., Elliott, J., & Cant, M. L. (2013). What’s My Line? A Narrative Review and Synthesis of The Literature on Registered Nurses’ Communication Behavior’s Between Shifts. Journal of Advanced Nursing, 70(6), 1228–1242. doi:10.1111/jan.12321

McLaughlin, E., Antonio, L., & Bryant, A. (2004). Get an A+ on End‐Of‐Shift Report. Nursing2015, 34(6), 32hn8.

Papastavrou, E., Andreou, P., Tsangaris, H., & Mercuries, A. (2014). Linking Patient Patisfaction with Nursing Care: The Case of Care Rationing – A Correlational Study. BMC Nursing, 13(1), 26. doi:10.1186/1472-6955-13-26

Sand‐Jecklin, K., & Sherman, J. (2014). A Quantitative Assessment of Patient and Nurse Outcomes of Bedside Nursing Report Implementation. Journal of Clinical Nursing, 23(19-20), 2854-2863.

Today, M. (2006). Improving Clinical Information Through Structured Conversation. Retrieved from Medscape Today: http://www.medscape.com/viewarticle/550701_3

Uhl, T., Fisher, K., Docherty, S. L., & Brandon, D. H. (2013). Insights into Patient and Family‐Centered Care Through the Hospital Experiences of Parents. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 42(1), 121-131.

EVIDENCE BASED PRACTICE MATRIX

Evidence-Based Practice Matrix of Ten Pieces of Primary Research on One Topic Related to Nursing
Authors	Resource &	Year of Pub	Research Type	Population/	Outcome Variables Measured	Measured Level (I-III)Pertinent Data from Results	B3b: Author’s Suggested Conclusions
Database	Sample Size
Kari Sand-Jeklin and Jy Sherman	Journal of Clinical Nursing	2014	Qualitative Experimental	Seven medical-surgical in a large  university hospital	To quantify the outcomes of a practice change to a blendeded form of bedside report	there were significant improvements in surveys carried out on fourpatients that greatly impacted by the change of bedside report.  Nurses’ perception on the of the report importantly improved. However there	there were various positive outcomes that were recorded in relation to implementation of a the new bedshift report, with a few drawbacks.Nurse attitudes towards the report at the end-process data collection were more positive than at the initial one.
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Cornell, Gervis MT, Yates L, Vardaman JM.	Journal of Nursing Administration	2013	Meta-Analysis	healthcare providers were coached on SBAR in 4 medical-surgical units.	to improving shift report focus and consistency with the SBAR(situation, background, assessment, recommendation) protocol	The average time for shift reports show no decrease using the SBAR tool. Nurses spent significantly more time on tasks specific to report. There were indication of more dialogue and less writing with the SBAR tool.	The SBAR provides a fundamental structure that enables comprehensive, consistent and patient-centric reports
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Margaret A. Avallone and Yvonne L. Weideman	Journal of Nursing Education and Practice	2015	Qualitative Experimental	Sample of 28 ABS nursing students. 14 students who received the NHEB were equated to a similar group (n = 14) who were not exposed.	to assess the effect of a NHEB in the development of handoff communication skill	The provider handoff scores in the intervention group improved significantly (M = 4.64, SD = 1.3) over the comparison groupchangescores(M=1.5,SD1.34)whenmeasuredbyindependentsamplest-test(t =7.33,p=.000). Thehandoffrecipients’ scores in the intervention group also improved significantly (m = 5.5, SD = 1.01) compared to no improvement in the recipient control group (M = -0.36, SD = 1.39), (t = 12.7, p = .000).	Without structured handoff education, nursing students are passive recipients during handoffs and do not engage in safety communication practices. Exposure to a NHEB improves student handoff communication skills and provides an opportunity to practice evidence-based handoff skills with structured support during clinical experiences. The NHEB could be considered for incorporation into prelicensure programs. Further study using a larger sample size is recommended based on these preliminary findings. Additionally, this intervention should be evaluated in novice nurse cohorts.
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Tara Foster-Hunt, Avi Parush, Jacqueline Ellis, Margot Thomas, and Judy Rashotte	Intensive and Critical Care Nursing	2014	Observational Study	All the 14 perticipants were female nurses having three or less experience and 24 female nurses more than four years of experience	to understand the information tranfer in hand-offs to improve care quality and safety	Level III results. All hand-off reports exposed two levels of information abstraction. The patient analysis did not reveal any indicators that the patient’s familiarity was associated with the level of the organization of the type of hand-off provided.	The study revealed a common structure among health care providers in conveying shift hand-off information. There was correlation between organization of the information structure and the PICU
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Tammy Uhl, Kimberley Fisher, Sharron L. Docherty, and Debra H. Brandon	Journal of Obstetric, Gynecologic, and Neonatal Nursing	2013	Descriptive Study	9 parents participated in one of three semistructured focus groups during Phase 1. During Phase 2, 134 parents completed the inpatient hospital experience survey.	Parental care experience during hospitalization of their patients. Identifying the strategies to improve better patient-centered care	The themes identified focused on reality, engaging adversity of patients (issues with shift reports communication) and advancing to better patient-centered care	This study supports the ongoing evaluation of PFCC program and also suggests some improvements in the patient and family-centered care delivered. (Includes improvement of shift reports communications)
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Margaret A. Avallone; Yvonne L. Weideman	Journal of Nursing Education and Practice	2015	Qualitative Study	All second-semester students enrolled in an ABS in Nursing program at a large University in the Northeastern United States  participated in the NHEB pilot study	to assess the impact of a NHEB (Nursing hand-off Education Bundle) in the development of handoff communication skills	The provider handoff scores in the intervention group improved significantly (M = 4.64, SD = 1.3) over the comparison group change scores(M=1.5,SD1.34)when measured by independent samples t-test(t =7.33,p=.000). The handoff recipients’ scores in the intervention group also improved significantly (m = 5.5, SD = 1.01) compared to no improvement in the recipient control group (M = -0.36, SD = 1.39), (t = 12.7, p = .000).	NHEB improved handoff communication skills in a bracket of ABS nursing students
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