Nursing In Critical Care - Case Study Example

Nursing In Critical Care I am a staff nurse in the Emergency Department in one of largest university teaching hospitals in the South West of England. For confidentiality purposes, the name of the trust will be withheld in accordance with the code of professional conduct (NMC 2006). In the last few months, I have read research documents on the application of the handover process of critically ill patients from nursing staff of the emergency department to the staff in the intensive care unit. The appropriate transfer of information between the nurses of the emergency department and critical care units is essential in order to achieve continuity of effective, individualized, and safe patient care. Much has been written in terms of nursing literature on the function and process of patient handover in the general nursing practice; however no studies were found pertaining to the handover process between nurses in the emergency department and those in the critical care environment. Introduction In the nursing practice, there are different processes and procedures which form a significant part of quality patient care. These processes often impact on the outcome of patient care with the nurses being prompted to deliver the best type and the best quality in their services. For the most part, patients benefit from such practices and procedures; however, there are instances when these processes and procedures are not adequately carried out during the practice. In the emergency department, critically ill patients are often encountered and they often end up being referred to the intensive care unit. Assessments in the emergency unit are carried out on these patients. Such processes yield essential information pertinent to the patient’s care. After such data is gathered and the patient is referred to the ICU staff, information is then handed over to the ICU staff. In some instances however, the information handed over is incomplete or is not adequately explained to the nurses in the ICU. Such situation represents a failure of communication between the two nursing teams. In some instances, essential information is not turned over to the critical care nurses because the focus seems to be on the critical condition of the patient. Aside from incomplete information relayed, there also seems to be a lack of clarity on the data transmitted during the handover process. Handover has been highlighted in the emergency unit I am currently working with as an important process. I have been taught that it can influence the quality and continuity of patient care. Even with these instructions however, there are still many instances when there are issues and incomplete data transmitted during the handover process. Based on these considerations, it is safe to assume that there are gaps in our current knowledge and practice, especially in terms of patient handover to the intensive care nurses. This paper shall now explore a detailed progress report between nurses in the emergency department and the critical care unit in their transfer and handover of critically ill patients. It shall seek to establish the possible factors affecting an effective handover process and the different gaps and issues seen in the practice and the application of this procedure. Databases I began my search for appropriate literature by accessing the electronic data bases available in my work place. These databases included the CINAHL and the Cochrane Library. I was also able to get tips from the librarian on how to find appropriate materials for my research. The subject matter was very wide and in order to narrow down my search, I generated keywords like communication, critical care, documentation, patient handover and emergency department. A combination of these keywords was also conceptualized. I recorded all the information I gathered in order to ensure that I would not miss vital data during my search. Even after applying this database search, I still came up with a wide range of information. I then had to compile a list of electronic databases which were able to assist me with my report. I also widened my database search to cover other databases and other relevant subject areas. By using more specific keywords in combination with each other, I was able to narrow down the relevant materials for my research. I set aside the relevant materials for possible consideration and review. Aim This paper shall seek to establish the possible factors affecting an effective handover process between emergency and critical care unit nurses and the different gaps and issues seen in the practice and the application of this procedure. It aims to present the different issues encountered by emergency nurses in their handover of critically ill patients to the critical care unit nurses. It shall also evaluate how well nurses apply this practice in the actual hospital setting. Discussion Many patient transfers occur within the hospital between the emergency department and the critical or coronary care unit, especially when the patient is acute and unstable. The exchange of information between the nurses from the emergency department and the critical care unit plays an important role in the continuity of effective, individualized and safe patient care (Mcfetridge, 2007). The continuity of care is a relevant part of the nursing practice and nurses have to undertake appropriate evaluations in order to ensure that this part of their practice is adequate and is compliant with the standards of nursing care. According to Mcfetridge, (2007), poor communication can have a negative impact on the patient’s psychological experience, symptom management, treatment decisions and quality of life. The rapid stabilization and transfer of critically ill patients to the intensive care unit is important in the management and support of the patient and their families. In providing care to patients and their relatives, it is crucial for nursing staff to apply the person-centred communication. In a study by Stewart, et.al. (2000), the authors established that patient centred communication impacts on patient’s health through perceptions that their visits were patient-centred and with perceptions that mutual benefits were gained with the physician. Patient centred care also successfully improved the patient’s status and improved the efficacy of care in minimizing diagnostic tests and referrals (Stewart, et.al. 2000). It is therefore important to apply patient centred care in the nursing practice, irrespective of age and other patient characteristics. In the handover process, the person-centred approach would include the process of ensuring that all pertinent details of the patient’s care are relayed to the critical care nurses. This is part of the continuity of care which is incumbent upon every patient care delivered. In order to secure continuity of care, Chaboyer, et.al., (2000) discussed that there is a need for the effective transfer of patient information in relation to patient’s condition and management between both units. In so doing, there is less fragmentation in patient care which can sometimes lead to critical incidents or omissions in the nursing practice. In order to improve continuation of patient care from the emergency unit to the critical care unit, there is a need for all effective forms of communication – verbal and written. These methods of communication help ensure that the nurses understand each other and have no miscommunication with each other (Mcfetridge, 2007). Good continuity of care is essential for all members of the health team and nursing handover helps ensure that accurate and adequate patient data is transferred from one unit to another despite erratic shift work in the emergency and critical care units (Mcfetridge, 2007). Moreover, nursing handover practices seem to play a major role in ensuring good team morale, solidarity, and cohesion (Parker and Wiltshire 1995). Mcfetridge (2007) also explained that handover practices vary from each other and the communication processes also vary with each nurse and with each unit involved. Failures in the application of these processes often result to serious consequences for patients. In a report by Chaboyer, et.al., (1998) the authors described how one hospital successfully implemented bedside handover as a strategy for patient-centred care. They were able to establish that patients perceived handover positively and they often end up as active participants in the handover process when bedside handover was used (Chaboyer, et.al., 1998). It also gave patients an opportunity to understand the plan involved in their care. By gaining such knowledge, their plan of care was more appropriate and safe. In a study by Timonen, et.al., (2000) the authors established that the person-centred nature of care was ensured when patients were encouraged to ask questions during the handover process. However, if the patient handover was focused more on documents, on the application of medical terms, and if there were too many nurses at the bedside during handover, barriers to patient participation became apparent. Chaboyer, et.al., (1998) emphasized that the nurses tried to limit their use of medical terms and they asked patients to make comments during the handover process. The authors set forth that “while issues such as patient confidentiality and sharing sensitive information are commonly identified as barriers to implementing bedside handover, this project demonstrated that they can be overcome by the use of written information, lowering voices and sharing sensitive information away from the bedside” (Chaboyer, et.al., 1998). In effect, although patient handover can have certain issues in the application, with appropriate interventions, these issues can be avoided and resolved. In a paper by Zaccaro, et.al., (2001) a model for team performance which can help explain patient handover may be effective when used by the nursing team was presented. They set forth that effective teams are those which are able to integrate their individual efforts into the team. Since bedside handovers often take place with different nurses from outgoing and incoming staff, they can help support this integration. With many teams existing within a complex and dynamic environment, coordination between the members of the nursing team is important in the handover process (Zaccaro, et.al., 2001). In gathering groups of nurses together, bedside handovers help make the coordination more efficient. Team leadership is also an important factor in the handover practice. In the Chaboyer, et.al., (1998) study the Nursing Director and the NUMs carried out different processes to secure a smooth transition to bedside handover. The nurses also established that bedside handover gave opportunities for them to garner support from shift coordinators and team leaders (Chaboyer, et.al., 1998). Moreover, carrying out bedside handover ensured that senior nurses were able to model behaviour and interventions which manifested patient safety and facilitated the exhibition of critical decision making skills among nurses (Cahill, 1998). Chaboyer, et.al., (1998) also exhibited that about 60% of nurses believed that bedside handover ensured support from their nursing supervisors and other clinical leaders. Such leadership has been important in implementing change and in improving team performance (Chaboyer, et.al., 1998). Staff feedback also emerged as a useful tool in securing safe and efficient patient care. Comments integrated into handover guidelines manifested how staff nurses at bedsides are given much value. These guidelines also served as tools for nurses to express what they have been doing informally in their practice (Chaboyer, et.al., 1998). This helps provide more levels of safety in communication; it assists members in securing consistency, accountability in communication, and competence in practice (Chaboyer, et.al., 1998). Furthermore, these guidelines provides tools for clinical staff to use in teaching students and new staff members in terms of immediate and safe processes in delivering patient care. In a paper by Pothier, et.al., (2005) the authors established that the handover process is an important part of providing quality care in a modern healthcare setting. The preservation and gathering of patient data in the handover process is important in ensuring quality and continuing care and patient safety. Errors and omissions in the handover process can have dire consequences for patients. Authors were able to observe the handover of 12 simulated patients between nurses and in the process, they detected three handover styles used (Pothier, et.al., 2005). A purely verbal handover style caused loss of all data after three cycles. The note-taking style resulted to a 31% retention of data transferred correctly after 5 cycles. Applying both the verbal and written methods caused minimal data loss. In effect, this study revealed that the current handover practices can cause significant amount of data loss; this may impact on patient care (Pothier, et.al., 2005). The authors recommended that formal handover sheets be used as part of the handover process in order to preserve data gathered from the patients. Manias and Street (2000) set out to consider the different ways by which the nursing handover includes a network of communication which affects nursing interactions. This critical study considered a research group of six nurses who were involved in a critical care unit. The handover was seen in many forms and served a variety of roles. At the beginning of the shift, the nurse coordinator from the previous shift presented a general handover of all patients to incoming nurses (Manias and Street, 2000). The nurses then proceeded to the bedside handover where the intent was changed to cover different perspectives on patients and to cover patient’s individual needs. Data analysis presented five practices for consideration: global handover fulfilling the needs of nurse coordinators; the examination; the tyranny of tidiness; the tyranny of busyness; and the demand to create a sense of finality (Manias and Street, 2000). By challenging the understanding of nurses of these practices, they become more sensitive to nurses needs and are able to promote the handover process as a means of collaboration of communication (Manias and Street, 2000). In considering the above literature, I was able to understand the need for evidence-based practice in the handover practice. The above studies send forth the message about the importance of research in terms of providing information on the different types of handover, its benefits, and the barriers often encountered by nurses in their implementation. In the emergency department where I work, whenever we transfer patients to the ICU, handovers are carried out on the bedside. Mcfetridge (2007) pointed out that bedside handovers can sometimes be ineffective because of numerous distractions which they can encounter in the handover process. In effect, such distractions can impact negatively on the attention span of the listener and the receiver of information. Handover processes do not necessarily refer to bedside handovers with such handovers carried out in the nursing stations away from patients. Some of these handovers have been moved to the patient bedsides where the latter are able to access their care information, are able to ask questions, and are able to comment about their care process. Suggestions have been made about moving the handovers away from the patients because of the noise and distractions which are often seen at the bedside of ICU patients (Chaboyer, et.al., 1998). It is important however for the nurses to be temporarily substituted before a handover can be carried out away from the bedside. In considering the previous literature on bedside handover, studies discuss bedside handovers to be better practices in patient care; however, this may not apply to the critically ill patient. For the most part, the critically ill patient may be unconscious and might not be able to make comments or might not understand the handover process being carried out on his bedside. Therefore, for the critically ill patient, carrying out the handover process at his bedside may not be the better choice or plan of care. A study by McKenna (1997) set forth that allocating time for handover manifests respect and value for one’s colleagues. The authors also pointed out that carrying out the handover process in a more private setting would be less intimidating because the emergency nurses would be able to present without a full staff or without the team surrounding their space. However, applying this practice to our emergency unit does not seem to be the best and most prudent move because there may not always be staff available to cover our work while we attend to patient handovers. In this case, even as bedside handovers may not work well for critically ill patients, it is also difficult to implement in the current nursing shortage setting. Data Collection This paper used a multi-method design which combined documentation review, semi-structured individual, and focus group interviews. It was both descriptive and exploratory. By listening to the respondents, I was able to gain understanding of how people interpreted their personal and professional life. The paradigms approach was utilized because it allowed the professionals to agree on beliefs, values and techniques. These methods of research assisted me in establishing the results of the study and in answering the questions raised at the beginning of the research process. Methodology All the research papers utilized the qualitative method of research. This is the best method to apply because it potentially extracts individual information from life experiences and feelings of respondents and uses these to support the research question raised. This method of research can also have its limitations with a small population of respondents and with no statistical analysis carried out on the data results. Nevertheless, the method applied in this research fits the purpose of the study and the questions it seeks to answer. Qualitative focuses more on the process of answering queries according to themes of worded answers, not on statistical figures. It is appropriate for smaller populations and a smaller number of respondents. In this case, it fits this research as a small population of emergency nurses are being included in this study. Conclusion This paper has established that patient handover is an essential element of the continuity of quality care from the emergency department to the critical care unit. Gaps and issues in the application of this process often involves inadequate coordination and faulty communication between staff members of the emergency department and critical care unit; bedside distractions during the handover process; and issues of patient confidentiality are problems which affect the effective application of the handover process. The application of bedside handovers can be carried out in the emergency department; however, there may be too many distractions in the bedside for this process to effectively take place. In our unit, bedside handovers seem to work well when carried out away from the patients; however, the issue of nursing shortage affects the effective application of this handover practice. Works Cited Cahill J. (1998). Patient's perceptions of bedside handovers. J Clin Nurs, volume 7, pp. 351-359. Chaboyer, W., McMurray, A., Johnson, L., Wallis, M., & Chu, S. (1998). Bedside Handover; One Quality Improvement Strategy to “Transform Care at the Bedside”. Griffith University. Retrieved 13 April 2011 from http://www98.griffith.edu.au/dspace/bitstream/10072/29476/1/59352_1.pdf Manias, E. & Street, A. (2000). The handover: uncovering the hidden practices of nurses. Intensive and Critical Care Nursing, volume 16, pp. 373–383 Mcfertridge B (2007). Exploration of handover process. Nursing in Critical Care, volume 12-16 McKenna L (1997) Improving the nursing handover report. Prof Nurse, volume 12(9): pp. 637–9 Nursing and Midwifery Council (2006). Code of Professional Conduct. Nursing and Midwifery. NMC, London. Parker J, Wiltshire J. (1995). The handover: three modes of nursing practice knowledge. In: Gray G & Pratt R (eds) Scholarship in the Discipline of Nursing. Churchill Livingstone, South Melbourne, pp 151–168 Pothier, D., Monteiro, P., Mooktiar, M., & Shaw, A. (2005). Pilot study to show the loss of important data in nursing handover. British journal of nursing, volume 14(20), pp. 1090-1093 Stewart, M., Brown, J., Donner, A., McWhitney, I., Oates, J., Weston, W., & Jordan, J. (2000). The Impact of Patient-Centered Care on Outcomes. The Journal of Family Practice. Retrieved 13 April 2011 from http://www.jfponline.com/Pages.asp?AID=2601&issue=September_2000&UID Timonen L, & Sihvonen M. (2000). Patient participation in bedside reporting on surgical wards. J Clin Nurs, volume 9: pp. 542-548 Zaccaro SJ, Rittmana AL, Marksb MA. (2001). Team leadership. The Leadership Quarterly, volume 12: pp. 451-483. Read More