Poor Communication between Doctors and Nurses during Patient Hand-Over - Case Study Example

Poor Communication between Doctors and Nurses during Patient Hand-Over Student: Institution: Poor Communication between Doctors and Nurses during Patient Hand-Over Effective communication between doctors, nurses and other healthcare workers is critical during hand-over or change in shifts to protect the safety of patients. In fact, clinical practice guidelines across various jurisdictions have underscored the significance of formal handover as part of professional practice. The majority of patients suffer adverse effects when handovers fail to follow proper procedures (Stevens, 2008). According to Borowitz et al. (2008), the failure of appropriate handover or poor processes places patients at a significant risk of adverse events. The effects may include unplanned admission to the intensive care unit, cardiac arrest or death. Therefore, health care professionals should share information during handover in order to maintain patient safety and quality care. The optimum care of patients is a shared responsibility between doctors and nurses. Accordingly, the quality and safety of patient care depends on the information exchange and collaboration between clinicians. Handovers are essential in clinical settings because they facilitate the exchange of information regarding the patient and the care they require (Matic, Davidson, & Salamonson, 2011). Conversely, handovers are complex procedures that are influenced by a myriad of factors. Such issues include workloads and the nature of the work environment. Nonetheless, clinicians should ensure that they share fundamental information about the patient’s condition during handover to ensure continuity of care (Stevens, 2008). Continuity of care is a very crucial component in the delivery of health care services. As such, the principal objective of handovers is to ensure the transfer of high quality and critical clinical information during transition (Stevens, 2008). At the core of continuity of care is the effective transfer of information. In essence, discontinuity of information translates to endangering patient safety, as well as the continuity of care. Therefore, lapses in information during handover can, and do result in mistakes, which increase mortality and morbidity (Nagpal et al., 2010). The aim of this paper is to examine how communication during handover can be enhanced through the process of clinical reasoning. The discussions will include a clinical scenario that will exemplify a case of poor handover and how it affected the safety of the involved patient. Background Julia (pseudonym), a 67-year-old woman was admitted to the surgical unit the previous night for Open Reduction Internal Fixation (ORIF). The patient had sustained left olecranon fracture after falling a day before admission. During her preoperative assessment in the physician’s office, Julia reported a 4-5 day intermittent shortness of breath and a phlegm-producing cough. Her husband reported that Julia has been snoring at night a lot lately. The doctor realized that she had obstructive sleep apnoea and was being treated nightly with continuous positive airway pressure (CPAP). Nevertheless, the patient had a history of a rise in cholesterol and hypothyroidism, and she was on Tiptonin and Statin medication. The anaesthesiologist noted Julia’s OSA but did not document respiratory assessment. Since the patient’s surgery was scheduled in the afternoon, the physician did not order post-operative CPAP. The surgery took place late in the afternoon with no complications. Julia’s husband requested overnight admission for observation because of her sleep apnoea history. The lead surgeon handed Julia over to the critical care nurse (Jones) at 6:30 pm with no mention or report of her sleep apnoea. Since my shift was to begin at 7:00, Jones left the unit, and I took over from her. The instruction given by Jones during handover was that the surgeon had ordered Fentanyl 50-100mcg IV for alleviating pain. About one hour after handover, Julia complained of pain, and I administered the recommended analgesia. However, the patient vomited and complained of pain. Another dose of Fentanyl was administered together with an antiemetic. The patient complained of inadequate pain control, and I contacted the physician. The physician ordered morphine for pain control and another antiemetic. Julia fell asleep after taking both medications and I assumed that she was comfortable. I checked on Julia after 30 minutes and found her lethargic although she could be aroused. I felt that the morphine had taken effect and that the patient was sleeping peacefully; hence, I did not contact the physician. I checked on her again after 30 minutes and realized that she had neither a pulse nor respirations. I called the blue code, and the patient was transferred to the ICU when resuscitation attempts failed to revive her. Pathophysiology and Psychosocial Aspects of Sleep Apnoea Partial or complete closure of upper airway characterises obstructive sleep apnoea (OSA). Consequently, the affected patient experiences sleep fragmentation and oxyhaemoglobin desaturation (Joo & Herdegen, 2007). According to Mwenge et al. (2013), the primary clinical manifestation of sleep apnoea is stoppages of breathing in the middle of sleep. Global statistics has indicated that approximately 3-4 percent of people suffer from sleep apnoea (Mwenge et al., 2013). However, the pandemic of obesity may witness an increase in this proportion. Although OSA may be prevalent in non-obese populations, obesity is the prominent epidemiological risk factor of this condition (Mwenge et al., 2013). Nevertheless, OSA can cause serious neurocognitive clinical symptoms, which include impaired cognition, excessive sleep or fatigue during the day, as well as reduced quality of life. Patients with OSA have a sevenfold increase in road accidents (Joo & Herdegen, 2007). Evolving evidence (Abrishami, Khajehdehi, & Chung, 2010) has identified OSA as an independent predisposing factor for cardiovascular sequelae. Furthermore, recent findings have shown that OSA is an underlying risk for hypertension (Mwenge et al., 2013). The underlying cause of this condition varies among patients considerably. However, people with a smaller pharyngeal airway often have sleep apnoea. Obesity and a fat/thick neck have been identified as possible causes of OSA (Abrishami, Khajehdehi, & Chung, 2010). Continuous positive airway pressure (CPAP) therapy is a potent and efficacious therapy for treating OSA. CPAP minimises the daytime effects of OSA because it eliminates airway closures during sleep (Joo & Herdegen, 2007). Nonetheless, study findings (Mwenge et al., 2013) have indicated that the majority of patients with OSA do not use CPAP optimally. A number of factors influence adherence to CPAP, which include patient characteristics, disease characteristics, technological factors, initial CPAP exposure factors and psychosocial factors (Aloia et al., 2007). Postoperative Management of Sleep Apnoea The balance between adequate respiration and pain control presents a primary challenge during postoperative management of OSA. Opioids and other anaesthetic agents depress respiration even in patients without sleep apnoea. The postoperative complications of OSA include myocardial infarction, airway obstruction, cardiac arrhythmia, stroke and sudden death (Nugent, Phy, & Raj, 2012). Therefore, clinicians must take precautions prior and after surgery in order to avert or minimise the severity of these risks (Chung, Yuan, & Chung, 2008). Aloia et al. have recommended screening for sleep apnoea for all surgical patients given that the majority of these patients may not have been diagnosed. Nevertheless, perioperative management of sleep apnoea is critical to enhancing patient safety, as well as quality of life. The safe management of sleep apnoea perioperatively mandates the cautious use of sedating and narcotic medications. For example, opiate drugs (morphine, fentanyl, meperidine and others) often cause dose-dependent decrease in respiratory drive, tidal volume and respiratory rate. Consequently, these agents cause hypoventilation, hypercarbia and hypoxemia. Therefore, it is crucial to use opiates cautiously in patients with sleep apnoea because they exacerbate the severity and frequency of respiratory events after their administration (Nugent, Phy, & Raj, 2012). Furthermore, it is imperative to reduce upper airway oedema, controlling blood pressure and prevention of DVT and aspiration. Most importantly, postoperative monitoring facilitates the identification of complications in a timely manner (Chung, Yuan, & Chung, 2008). Clinical Decisions The clinical scenario presented beforehand has highlighted the apparent consequences that arise in clinical settings due to poor communication between doctors and nurses during handover. Both the lead surgeon and the anaesthetist were aware that Julia had obstructive sleep apnoea and was on nightly CPAP. However, this critical information was not communicated to the critical care nurse during handover. Furthermore, I was not aware of this situation when I took over the care of Julia from Jones. The mistake I made in this case scenario was to continue administering the recommended Fentanyl and morphine subsequently. Schmalenberg and Kramer (2009) has asserted that the persisting poor relationship between doctors and nurses has hampered effective communication between them. Thus, Borowitz et al. (2008) has found out that withholding critical information during handover (deliberately or inadvertently) places the patient at increased risk. Secondly, the anaesthesiologist overlooked a very vital component of the pre-operative physical examination, which was failing to complete and document Julia’s respiratory and cardiac assessment. The proper documentation of the patient’s status would have supported clinical reasoning in order to inform sound decisions. Nevertheless, uncontrolled pain was a significant manifestation post-operative. However, the written orders were too narrow considering that Julia had multiple health problems. The patient ended up receiving excessive narcotics due to the failure to document the underlying condition appropriately. Excessive administration of opiates constituted a medication error and Sirota (2007) has identified poor communication as one of the primary causes of these errors, which cause adverse events. Clinical Reasoning Nurses who possess effective skills in clinical reasoning influence patients’ outcomes positively whereas those who lack these skills fail to identify impending patient deterioration. Nurses and other clinicians essentially engage in numerous clinical reasoning events for each patient under their care. For example, a nurse may enter a patient’s room and immediately make valid observations, draw conclusions and initiate appropriate care (Alfaro-LeFevre, 2009). Poor clinical reasoning skills impede the rescue of patients in cases of adverse events. Clinical reasoning has increasingly become a critical component of nursing against the backdrop of escalating adverse events and healthcare complaints (Banning, 2008). This section aims to use the clinical reasoning cycle to evaluate the clinical decisions I made in the provided scenario. The first step in the clinical reasoning cycle that I undertook was to consider Julia’s situation. During handover, Nurse Jones informed me that Julia had come to the hospital for Open Reduction Internal Fixation (ORIF). The first thing that I thought of was that Julia required continuous assessment and monitoring of her vital signs because she had just left the operating room. Surgery and anaesthesia potentially affect patients’ vital signs. Thim et al. (2010) have indicated that the assessment, monitoring, and measurement of a patient’s vital signs represent crucial components of postoperative care. Thus, postoperative patients require constant monitoring to detect any deterioration in their physiological parameters. The second-step entailed collecting cues and crucial information about the patient. Accordingly, I reviewed Julia’s handover report and the prescription chart. The information I gathered from these documents was that Julia had a history of a rise in cholesterol and hypothyroidism and she was on Tiptonin and Statin medication. I then gathered new information by recording the patient’s blood pressure, heartbeat, pulse and temperature. Afterwards, I recalled knowledge about the physiopathology of Julia’s problem (rise in cholesterol and hypothyroidism). Both hypothyroidism and high cholesterol level impair the circulation of oxygen in the body system (Plekker et al., 2008). Therefore, it was crucial to monitor Julia’s blood pressure continuously. Thirdly, I processed the information that I had gathered. First, Julia had problems with her cholesterol levels, in addition to suffering from hypothyroidism. Thus, I had to keep monitoring her blood pressure to distinguish between normal and abnormal values. Second, I discriminate collected data to identify relevant and irrelevant facts. I was more concerned with her BP and pulse than temperature. I then made deductions from the relevant information to identify relationships. For instance, I had to determine if an increase in blood pressure was an effect of anaesthesia, opiates, or rise in cholesterol. Third, I predicted outcomes based on established facts. For example, the failure to maintain sufficient oxygen saturation would have had an increased risk to hypoxaemia. Kennedy (2007) has argued that oxygen therapy is a crucial component of postoperative care during recovery and after discharge from the recovery room. From the findings in the preceding section, I identified Julia’s problem. I deduced that the patient was experiencing a lot of pain and had problems with breathing. The subsequent goal was to alleviate the pain and maintain normal breathing within the hour. In relation to breathing, I ventilated the patient considering the effect of anaesthetic on lung function (Kennedy, 2007). Julia came in the recovery room with laryngeal air mask after general anaesthesia and Oxygen 61 was in progress. Since the morphine was prescribed as a patient-controlled analgesia for Julia, it was necessary to maintain a steady flow of oxygen in the body system to avert reduced oxygen supply (Thim et al., 2012). Steady flow of oxygen prevents the risk of hypoxaemia and hypoxia (Parkes, 2011). After implementing the action plan, the next step in the clinical reasoning process was to monitor the effectiveness of the administered oxygen therapy and analgesia. In the case of Julia, I paid particular attention to her vital signs to discern if there were improvements or deteriorations. The initial assessment of vital signs followed a ten-minute interval initially before transitioning to the thirty-minute interval. Odell, Victor, and Oliver (2009) have underscored the role of the nurse in monitoring a patient’s vital signs in order to detect deterioration and trigger rapid response timely. Furthermore, I evaluated the patient’s pain level based on her self-report. Since pain is subjective in nature (Bucknall, Manias & Botti, 2007), I allowed Julia to actively participate in pain assessment. Julia was asked to indicate the severity of her pain and the places she felt the pain. Reflective Practice and Recommendations The final step of the clinical reasoning cycle is reflecting on the entire process and new learning. First, I have learned that decision-making is very crucial in nursing practice. This model is particularly helpful when providing care in intricate clinical scenarios like the one involving Julia. However, I found this process to be complex and challenging. Nonetheless, approaching the scenario with an open-mind, in addition to engaging with members of the multidisciplinary team was helpful. The most interesting fact I learnt is that cues shape clinical decisions in profound ways. Hence, it is profound to pay attention to the intuitive knowledge gained from caring for patients with similar conditions. The Australian Nursing and Midwifery Council (ANMC) has formulated national competency standards for the registered nurse. According to ANMC, the registered nurse should demonstrate competencies in the provision of nursing care. One of the four domains that define competencies for the registered nurse is professional practice. At the core of this domain is the demonstration of satisfactory knowledge base, protection of a group and individual rights, providing care in accordance with legislation affecting nursing and taking accountability for practice (ANMC, 2006). Within the context of these competency standards, nurses are responsible for the safety of patients. A competent nurse will strive to provide quality care to patients while ensuring that they cause no harm. When taken together with clinical reasoning, the competency standards lay the foundation for guiding nurses to make informed decisions regarding patient’s care. On the other hand, health facilities should reform working practices (especially workloads, workforce planning and interruptions) to facilitate efficient handovers. Conclusion Effective communication between nurses and doctors during handover influences patient safety and the quality of health care services. Appropriate handovers are especially important when handling surgery patients with obstructive sleep apnoea. Post-surgical complications are more prevalent in patients with OSA than those without the condition. Therefore, the identification of these patients before surgery enhances clinical outcomes. Julia did not receive adequate care because the physician failed to provide critical information regarding her sleep apnoea. Therefore, nurses and doctors should form collaborative working relationships that will place patients’ needs at the forefront. Decision-making process through the clinical reasoning model is an elemental step towards patient safety and quality care. References Abrishami, A., Khajehdehi, A., & Chung, F. A. (2010). A systematic review of screening questionnaire for obstructive sleep apnoea. Canadian Journal of Anaesthesia, 57(5), 849-865. Alfaro-LeFevre, R. (2009). Critical thinking and clinical judgment: A practical approach to outcome-focused thinking (4th ed.). St Louise: Elsevier. Aloia, M. S., Arnedt, JT, Stanchina, M., & Millman, R. P. (2007). How early in treatment is PAP adherence established? Revisiting night-tonight variability. Behavioural Sleep Medicine 5, 229-240. Banning, M. (2008). A review of clinical decision-making: Models and current research. 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