Nursing Shift Handover - Research Paper Example

Introduction It is critical that nurses understand and practice efficient shift handover procedures. Shift handover ensures a continuity of care services across nursing shifts that reduces the likelihood of human error and increases patient and staff satisfaction due to the standardization of procedures. A key issue in the theoretical approach to shift handover is effective communication. Studies show that failure to cultivate effective communication during handover can contribute to accidents and/or injury. Traditionally, shift handover has been a one-way communication process, where the nurse in charge provided relevant information and instructions to the incoming nurses. The key feature not present in this approach is the individual care planning and the gathering of all the information about patients was written into ward diaries using nurses notes (Kasseau). In post-modern nursing, shift handover includes communication between the change of shift, communication between care providers about patient needs, handoff, records and information tolls to assist communication between care providers about the care provision for patients (Clinical handover). Shift handover procedures are essential when considering that nurses take breaks from tasks of which they have joint responsibility, and that under these conditions communication fosters coordination of activities and accountability. Nursing provides continuous care services to patients and a shift handover is generally a time of; preparation by outgoing personnel; shift handover wherein incoming and outgoing nurses exchange information; and cross-checking of information by the incoming nurses as they take on the responsibility for tasks. The ideal outcome of shift handover is precise and reliable communication of task-relevant information across shifts to guarantee continuity of safe and efficient working environments. The following paper will demonstrate the importance of nurse shift handover using a recent nursing handover event at ………….. Hospital in the UK, and a relevant literature review. Firstly, an example of a shift handover will be presented. Secondly a literature review will outline communication theory in regards to nursing handover, as well as review the most up-to-date studies into efficient shift handover in a nursing setting. Thirdly, the key principles involved in developing efficient shift handover will be listed. Finally, a conclusion shall synthesise the main points of the document and provide evidence that nurses shift handover is a critical area of concern and attention. It is anticipated that this paper will contribute to furthering the understanding of the psycho-social processes involved in shift handover in the nursing environment, to enhance safety in the workplace, and to increase the satisfaction of patients and nursing staff. Theory & Practice Placement Communication Theory The shift handover forms an important part of the communication process that occurs twice a day for most nurses. Communication theory suggests that an ideal shift handover requires that communication processes at this time be valued highly; that the handover be particularly focused at times when nurses have been absent for long periods from the work tasks, during routine maintenance, when there is a deviation from the normal working day, and when the handover occurs between inexperienced and experienced staffs; when critical information is needed by incoming staff to maintain patient care; when logs and displays are utilized to aid information needs across a diverse staff composition (e.g., across ethnicities, age, experience); and when staffs are committed to ongoing communication skills. The handover itself between two individuals should be done face-to-face, with two-way participation, as both personas are expected to be responsible and accountable for accurate information being transmitted. It is essential that both verbal and text-based forms of communication occur, and that as much time as needed be taken to guarantee precision in transference of information. Practice Placement Example of Shift Handover The emergency department (ED) of a hospital is a busy and dynamic setting. Its operating equilibrium is entirely dependant on continuous feedback loops of information and activities. As a system, the ED needs to function optimally in order to develop and to meet the needs of those dependent upon it (e.g., patients and staffs). To do this, the ED as a holistic unit of people must have confidence that the specific decisions made and actions taken within the system will be consistent, reliable and expeditious. Due to the unique pressurized environment of an ED, a variety of constraints and protocols have been established to ensure the accurate communication of information. From personal experience working within the ED it is evident that there are critical elements that can hinder the transmission of correct information at shift handover. There have been incidents of inexperienced nurses lacking awareness of the importance of an issue; time and excessive work pressures have affected interpersonal behaviors (e.g., impatience or misunderstandings); infrequent exposure to particular patient needs; inefficient reporting of “near-miss” incidences, or simply recording or communication error; personal biases that influence case review processes; the time that shift handover takes place; and the fact that a nurses working day involves shift work itself (i.e., circadian rhythm disturbances). As such, it appears that nursing staffs within the ED are experiencing suboptimal conditions, and that effective communication is vital to ensure patient safety, employee satisfaction and a well-calibrated ED. It appears that there is insufficient empirical investigation of the outcomes of shift handover methods used presently within EDs. This is an ironic situation considering the Blair Government’s attitude of patient-centred care provision by the health industry, and the growing discourse in the professional and academic community about ways to reduce medical error, and how to support patient-centred practices. At present, an average ED shift handover consists of steps: 1. The designated nurse in charge for the next shift walks around the unit before the handover. 2. The actual handover occurs away form the patient areas to maintain patient confidentiality. 3. The appropriate number of staffs to observe patients during the handover period are established, and they do not have any other tasks to complete. 4. A delegated nurse leads the handover, although they do not often attempt to actively encourage others to participate in the process. 5. In general, an appropriate length of time is set aside for the handover, although this is variable as it depends on patient needs at that point in time. Hence, it tends to be structured around; identified risk factors as per patient; observational levels of patients; the Mental Health Act status; where patients are located, how many there are on and out of the unit, and when patients are due back; planned admissions, discharges, transfers, leaves and absent without leave patients; planned meetings; changes in patient medication; unusual occurrences occurring during the shift; and staff issues. 6. In general, any outstanding tasks from the previous shift are carried over the next. 7. At the beginning of the shift, a designated nurse prints out a list of all the patients in the ward with key information about bed numbers, diagnoses, age, etc as an overview sheet. The aim of this is to provide a history of the status of the ED for oncoming staffs. 8. A “Nurses Work Sheet” is also passed on at handover that is a matrix of patients and tasks that is the responsibility of nurses for each shift. This produces a working record that in combination with the buff chart provides the oncoming nurses with an update of each patient at a glance. A Review of the Literature Traditionally, a nursing shift handover was a one-way communication process, wherein the delegated nurse of being in charge would transmit perceived important information to the oncoming nurses. A distinctive feature of this early model was the lack of individual patient care planning, and all the information about patients was recorded into ward diaries or in patient files or in nursing notes. The predominantly verbal handover tended to use white boards to communicate patient data in only a limited way, and reflected the focus at the time within health care of a biomedical model that ignored the psych-social features of shift handover (Sherlock). It was not unusual for the information to be recorded erroneously or to eventually become a meaningless and out-of-date progression of odd notes about the state of patients, heavily biased by unempirical judgments and so a high level of valuable and critical information would not be included in reports (Sherlock). Discrepancies would likely draw the attention of questioning supervisors and doctors which fostered a “blaming culture” among nurses within and across shifts. Consequently, patient satisfaction was low as they felt disenfranchised and uncared for by the process. Due to the discontinuity of shift work that accompanies nursing studies show there is a relationship with increased accident and injury rates. Particularly, some studies have shown that incidences of accidents and injury tend to increase at or near shift handover. However, the factors underlying the increased incidents are not fully understood. With regard to communication theory these incidents indicate; a failure of policy-makers to account for ambiguity that is inherent in language; a high potential for misunderstanding exists when nurses have different mental models of their unit’s status; an inability to take into consideration the information needs of others and to give them access to ways to take in information accurately; and an over-reliance on one channel of communication, such as verbal only. A study that has investigated interventions to enhance communication between nurses, and nurses and doctors, was the Cochrane systematic review. Two randomized trials were used with structured team rounds and the results showed that collaborative decision making reduced the average length of hospital stay for patients. It was also concluded that accidents and injury may be more likely for the patient during shift handover when; there is a covering doctor instead of the patient’s allocated doctor or patient team; communication between external specialist services and the inpatient system is hindered; there is not a process for documenting patient care plan and medication management; when handover occurs in the presence of the patient (i.e., can cause anxiety and confusion for the patient if they do not understand the technical terms during the handover). With regard to shift handover being conducted away form patients, Cahill and colleagues (1998) used a qualitative study to tape-record patient in-depth interviews that were analysed using grounded theory. It was found that active participation of patients in the handover process only occurred when the patient perceived themselves as being “well”. Participation was a function of how informed the patient felt themselves to be about their condition, those patients who believed they were fully informed had a higher level of participation. However, for those that did not feel they had complete knowledge about their illness were less likely to participate, and more likely to experience anxiety and confusion. The introduction of assessment and treatment programs that include written plans and education of patient needs has been found to assist in the precision of handover and to increase the safety and care of patients. A programme developed for respiratory care in an orthopedic surgical ward to investigate viable methods for reducing morbidity rates (Sharke, 1994). Comparisons were made between the pilot phase (3 months) and the programme itself (6 months). The results showed that the use of patient assessors and a written treatment plan improved patient morbidity rates, improved patient outcomes, reduced patient length of stay and reduced treatemtn volumes that in turn reduced costs. Turning now to the impact of shift handover on the interpersonal needs of nursing staff the very nature of shift work as a risk factor in poor health and social well being must be considered. Particularly on evening shifts, night work can cause a mismatch between circadian rhythms and environmental synchronizers, resulting in the “sleep-wake” cycle to be disrupted. Otherwise known as “shift lag” syndrome, nurses may feel fatigued, sleepy, experience insomia or disorientation, digestive problems, feel irritable or demonstrate poor mental agility, and have an overall reduce care and communication performance. However, age, gender, and personality characteristics can buffer or exacerbate the affects of shift work. Recently, there has been growing research interest into the underlying interpersonal processes involved in shift handover, and a greater consideration of the factors within the ward that affect communication among nurses, doctors and other health care providers. It is recognised that interpersonal relationships have a direct affect on communication abilities and outcomes. Consistently, it has been shown that poor communication has an adverse effect on the provision of health care services, as critical details are not acknowledged or recorded, and there is an absence of feedback when there is no written care plan for each patient. A study into the communication that occurs between nurses during shift handover was undertaken by exploring the perception of what was considered to be important information. A survey method was used to identify the prioritization of patient safety information as a feature of handover content among 197 nurses across a variety of health care settings. The results showed that 68% of the nurses rated information from the sending nurse as satisfactory, whereas 56% responded that a computer-based system was of more use to provide continuity of care information. Overall, the areas which nurses agreed were a high priority for interpersonal skills were communicating; the history of the illness and procedures; the medical diagnosis and problems on sending units; the physician’s orders; reasons for transfer; and safety considerations. Interpersonal skills have become not only valued, but also essential to the practice of nursing. Nursing is a social activity and so there is a critical need for the nurse to be able to communicate competently as the social relationships they form with other health care staffs and patients has a direct impact on healing processes (Klagsbrun, 2001; Queensland Health, 2004). A nurse can show strong interpersonal skills during shift handover through active listening, empathy and use of silence (Stein-Parbury, 2005). Active listening is a vital interpersonal skill for the nurse (Klagsbrun, 2001). It is a skill that allows the nurse to reflect on the deeper meaning of what the is being said. For example, active listening is when the incoming nurse hears what the outgoing nurse is saying, reflects back what is said, the intent behind what is said, using different words, and then allows the outgoing nurse to acknowledge or discount the interpretation (Stein-Parbury, 2005). Empathy has also been stated to be a key interpersonal skill in the helping relationship. It appears that a comprehensive definition of empathy needs to include morals, emotions, thoughts and behaviours (Reynolds & Scott, 2001). As empathy encompasses an understanding of others, and their present situation, it is evident that empathy is essential to nursing (Stein-Parbury, 2005). There is also the interpersonal skill of silence. Silence is powerful, in its contribution to effective communication (Perry, 2005). Compassion, acceptance and support have been indicated as behaviours that are often best communicated through the use of silence (Perry, 2005). Particularly, during times of intense emotion, the use of silence is often necessary. Also the use of silence provides the nurse with an opportunity to observe and reflect on the speaker’s non-verbal communications, and so aid the further understanding of the intent behind the other nurse’s words. It is necessary that that nurses cultivate their team-engagement skills as inter-disciplinary partnerships will become the norm. As such the nurse must be flexible to accepting the variety of discipline approaches that exist, and that they may find themselves working with. A key feature of nursing practices is to work within a team environment. The nurse may find themselves working in a team environment comprised of other nurses, doctors, volunteers, chaplains, social workers and other health and human service workers (Martin, 2000). Team-work has been a traditional practice that is supported by nursing philosophy and is demonstrated in a variety of its practices. It is well recognized within the nursing literature of the interdependence of the physical, functional, psychosocial and spiritual dimensions of the workplace account for team member well being, as well as facilitating a multidisciplinary and so comprehensive approach to patient care Cronenwett & Redman, 2003). Importantly, the nurse must cultivate their critical analysis skills to reflect on their own practices, to enable a continuous improvement in interpersonal skills, team-focus and patient-centred practices. Further, leadership and management issues are of critical importance to the discipline of nursing (Baker, 2000a; Kelly-Hayes, 2003). Nurses are in key position to influence hospital care policies, such as those pertaining to shift handover, as well as state and national legislation (Sullivan, 2001). It is contended that student nurses need to be encouraged to develop their leadership and managerial skills, as well as their clinical skills (Baker, 2000b). Quality management important to nursing as it allows for an evaluation of the outcomes of practices. In turn, this style of management provides for a preventative approach to nursing that identifies potential problems quickly, and facilitates research into viable alternative solutions (Belcher, 2000; Hendel & Steinmann, 2002). It has been shown that cross-functional teams are much more flexible, and that when team members are able to ‘cover’ each other in general patient care duties, the patient is afforded more comprehensive and careful care (Baileff & Suite, 2000). Critical Examination of Practice Placement and the Literature It is evident that effective shift handover in nursing requires accurate communication in both verbal and written forms. At present, the ………………….. ED relies heavily on verbal feedback and instruction. However, this practice ignores literature that shows the increased likelihood of accident or injury when only one channel of communication is relied upon. Also, present shift handover practices at the hospital fail to include factors which could aid more effective communication such as; empirical investigation into the information needs of incoming nurses, ways to improve face-to-face communication, awareness of the importance of active two-way communication, and the critical need to standardise forms of written and verbal communication; standardising communication procedures to ensure that deviations from a normal working day will not affect patient care during shift changeover; an inclusive policy that encourages nurses to contribute toward identifying current practices which negate effective shift handover, and solutions to providing guidelines. It is of benefit to the ED that handover occurs face-to-face as this is generally agreed upon in the literature to be the best practice, as errors tend to occur because of the differences in mental models of outgoing and incoming nurses. Two-way communication encourages the incoming nurse to ask questions and to rephrase information, which can help in revealing inconsistencies or misunderstandings. The face-to-face process also allows gestures, eye contact, tone of voice and other interpersonal information to be used to transfer information and to clarify details. With written support, face-to-face handovers are less likely to result in an accident or injury or other incident. The current ED face-to-face practices could be enhanced by education of nurses into disclosing problems, hypotheses and intent during handover, rather than simply listing events that have occurred throughout the previous shift. In future, the ED could make a formal review of its best practices to formulate a specific “Checklist for Effective Handover.” This could include; 1) a sufficient schedule of over-lap time; 2) ensure that all shift handovers are face-to-face; 3) provide more opportunities for questions to be asked and cultivate a nursing culture that encourages disclosure, inclusion and hypothesizing; 3) ensure standardised resources are available to outgoing staff so that they can prepare handover information (e.g., assessment and treatment plans, patient schedules); 4) determine if all the necessary information is available and accessible to incoming nurses; 5) provide structured handover worksheets with specific questions or material to be covered; 6) ensure that nurses collaborated as to what information will be used to develop the handover worksheet; 7) provide an opporutinity in both written and verbal information transfer for hypotheses and intent to be stated; 8) ensure that there is a checklist for multiple tasks that must be carried out before coming onto a shift; 9) ensure all shift procedures are written up for reference; 10) ensure that all nurses are sufficiently trained in handover procedures; 11) continuously monitor and evaluate handover procedures; 12) ensure that both outgoing and incoming nurses are aware of the equal responsibility and accountability of handover; and 13) promote a culture that encourages communication among staffs. Conclusion In conclusion, it shift handover is critical to the nursing environment, and effective shift handover is essential to patent care and safety, as well as for nursing staff job satisfaction. Clear conclusions can be drawn about the responsibilities of nurses, both outgoing and incoming, with regard to shift handover. Optimum shift handovers require that; nurses make effective shift handover communication a top priority; hospitals seek to continuously improve the interpersonal and communication skills of nursing staffs; clear procedures are provided that indicate specifically how to carry out an effective shift handover; that there is a greater reliance placed on face-to-face, two-way communication; that there is a greater reliance on combining both verbal hand written forms of communication during handover; try to plan maintenance and other disruptions to be completed during one shift to minimize the risk of miscommunication during handover; and to make an effort to brief personnel that have been absent for long periods of time. A critique of the practice placement example for this paper indicated that the ED needs to; revise its current shift handover practices in a more formal manner by way of an empirical investigation; modify practices to incorporate more standardised procedures, especially with regard to written information; and to encourage a nursing culture that is collaborative, inquisitive, cooperative and communicative. It is anticipated that this paper will extend on understandings of current practices of nursing shift handovers in the UK. _ Further research which compares best practice described in this report with current practice offshore would help to identify areas for improvement. A second area meriting further research is how to ensure accurate and reliable and unambiguous carry-forward of written information from shift to shift. Information technology offers a possible solution. Read More