Scholarly Project Synthesis: Improving Nursing Handoff

SCHOLARLY PROJECT SYNTHESIS: IMPROVING NURSING1

Scholarly Project Synthesis: Improving Nursing Handoff

Cheryl Miller

Ferris State University

SCHOLARLY PROJECT SYNTHESIS: IMPROVING NURSING1

Abstract

This scholarly project paperoutlines the development, implementation, and completion of a proposed plan tosupport effective communication in the nursing handoff process for patients admitted from the emergency department (ED) to an in-patient setting at Munson Medical Center. It includes a description of the project proposal plan, the project outcomes achieved, a discussion of my personal and professional accountability, a review of issues and concerns,an evaluation of the implementation process, recommendations toward future implementation of similar project plans, demonstration of knowledge related to nursing practice, theory and research, and a detailed summary of key points.

SCHOLARLY PROJECT SYNTHESIS: IMPROVING NURSING1

Scholarly Project Synthesis: Improving Nursing Handoff

This paper is a synthesis of my scholarly project focused onsupporting communication in the nursing handoff process at Munson Medical Center for patients being admitted from the ED to an in-patient setting.An environmental assessment of the nursing handoff process was completedin collaboration with nursing staff.An extensive literature search confirmed the importance of this investigation. My project deliverables have been revised to include a PowerPoint slide presentation which can be used in part or whole to educate staff, a gap analysis of potential barriers in the handoff communication process, evidenced based recommendations targeted toward those potential barriers, and a nursing satisfaction survey tool for consideration and review. These deliverables may serve as a working tool for nursing leadership when considering future recommendations toward improving communication in the nursing handoff process. Scholarly project activities focusedon understanding the established process for nursing handoff, observation and investigation of the handoff communication process, interviewing and collaborating with nursing staff, application of evidence based research findings, discovery of potential barriers, and formulating possible solutions in collaboration with nursing staff from the ED and A7 nursing units.These activities are consistent with the standards of professional practice for nursing administrative leaders as outlined in the Nursing AdministrationScope and Standards of Practice (ANA, 2009). These practice guidelines serve as a decision-making model for nursing leadership who are responsible to advocate for nurses and patients in the delivery of health care services.

Effective communication in nursing handoff has been identified as a national safety concern by The Joint Commission (TJC) in 2006 (Friesen,White & Byers, 2008).Improving exchange of information during the patient admission process may positively impact patient safety and advocate for nursing staff in the exchange of patient information during the nursing handoff communication process. Research by The Joint Commission (2012) suggests that communication errors may result in 80 percent of serious medical errors. Effective nursing handoff communication is a complex and important issue in health care. Furthermore, Cohen and Hilligoss (2012) suggest that sharing patient admission information between the ED and the in-patient setting requires nurses to use greater expertise due to differences in work practices and in communication styles.

The nursing handoff process, established at Munson Medical Center in 2011, is as follows: when orders are written and the patient is ready to move, the ED nurse calls the receiving unit and asks for the nurse who will be handling care for the patient. The ED nurse states that the ED admission handoff form is complete, ready for review, and the patient will be coming up in fifteen minutes. The ED nurse tells the receiving nurse to call if there are any questions and the in-patient nurse reviews the charting in FirstNet and prepares to receive the patient. This handoff process follows guidelines outlined by The Joint Commission (2011), which includes the following five key characteristics:interactive communication with an opportunity for questions and answers, up to date information regarding patient care activities, a process for verification including read back and repeat back, an opportunity to review historical data, and minimizing interruptions so that information is retained.Patterson and Wears (2010) suggest that that 20-30% of patient information exchanged verbally is not documented in the electronic medical record and the baseline conditions for handoff are highly variable. This is important and relevant as most of the information exchanged during nursing handoff is gathered from the electronic medical record. Verbal interactions are limited and may be variable. Variability in communication can lead to omission of information during the nursing handoff process (Patterson & Wears, 2010).Omission of information during handoff may negatively impact nurses’ ability to provide safe and effective patient care. Klee, Latta, Davis-Kirsch and Pecchia (2011) imply that when critical patient information is not shared during the handoff process, patients’ safety is at risk.

The setting for this scholarly project is Munson Medical Center, a Magnet designated and acute care hospital in Northern Michigan employing over 4,000 employees (Munson Medical Center, 2013). Annual patient visits are more than 300,000 (Munson Medical Center, 2013). The annual patient volume in the EDis 52,000with an admission rate per day of 35% (A. Holmes, personal communication, November 1, 2013). The inpatient unit selected for participation in this project was A7, a stroke telemetry unit, with a predicted annual patient stay volume of 8,905 for 2014 (M. Ramseyer personal communication, November 1, 2013). The impetus for this project began after I attended a meeting with nursing staff from the ED and in-patientsettings to discuss the nursing handoff process. There were reports of frustration and increasing tension between the nursing staff in the ED and in-patient setting concerning nursing handoff practices. The nursing handoff report process was reviewed and discussed. The following barriers were mentioned:the need for the ED to make multiple calls in order to give notification of the patient’s arrival on the in-patient unit, staff not following the established fifteen minute rule, insufficient information in the ED handoff report, and no notification to the receiving bedside registered nurse (RN) of the patient’s impending arrival.

As a result of this discussion and my academic requirements to complete a scholarly project, a proposed plan was developed and presented to my preceptors. The initial premise was to review, revise, and standardize the nursing handoff report process for patients being admitted from the ED to an in-patient unit. The scholarly project goal is to support nursing in their role to provide safe and effective careby ensuring that a standardized, agreed upon format is in place for nursing handoff. Tomajan (2012) suggests that professional nursing leaders have a duty to advocate for the safety and welfare of nursing staff and patients. In addition, Marshall (2011) notes that professional nursing leaders are administratively mandated to create a vision and manage processes in order to seek successful change strategies to promote patient care and safety. Application of evidenced based research, nursing theory, and leadership principles are included throughout this scholarly project plan, and in this discussion.

Description of Scholarly Project

The initial goal of this project was to review, revise, and standardize the nursing handoff process while advocating for nursing staff in the provision of patient care. Thesescholarly project goalsare consistent with the mission and vision statement of Munson Medical Center (2013) to provide comprehensive quality care, to protect patients, and advocate for their safety. The initial goals, activities and objectives included retrievingresearch evidencetargeted toward patient safety and effective handoff communication,identifying barriers in the nursing handoff process, formalizing an agreed upon process through collaboration of nursing staff and key nursing leadership, formulating an education plan to implement the proposed changes with assistance from the staff development team, evaluating the nurse to nurse report process through a nursing satisfaction survey, seeking verbal feedback from both of my preceptors throughout each phase of project implementation, and receiving written feedback at completion of this project.These actions are supported by the Nursing AdministrationScope and Standards of Practice (ANA, 2009) which, guide professional nursing leaders tasked with developing practice standards to support safe and effective health care delivery.

Initial project activities includedsearching for and obtaining relevant research by September 5, 2013, meeting with key leadership from the emergency department to perform an accelerated gap analysis by September 15, 2013, meeting with shift coordinators from the emergency departmentevery two weeks to share ideas and brain storm solutions by September 30, 2013, formulating and developing strategies to improve and standardize the report process by October 30, 2013, obtaining approval from all stakeholders, seeking assistancefrom staff development to educate staff by November 15, 2013, and implementing and evaluating the revised nurse to nurse process by December 15, 2013 via distribution of a nursing satisfaction survey. The original scope of this scholarly project was narrowed down after consultation with the A7 and ED unit managers as it was felt to be too monumental in nature. Thenew scope was effectively narrowed down to include:review of the original charter and nursing handoff goals, direct observation of the nursing handoff process in collaboration with staff from A7 and the ED nursing unit, collaborate and uncover communication barriers, and utilize evidence based research to offer potential solutions for consideration and review.Seeking to understand current nursing practices and collaborating with nursing colleagues to foster improvementis consistent with guidelines by the Nursing AdministrationScope and Standards of Practice (ANA, 2009)aimed toward the promotion of best care practices. The ED andA7 manager eachoffered support for this scholarly project by providing contactwith shift coordinators, and a physical space from which to work. The A7 unit manager suggested that this graduate nursing student follow patient admissions from the ED setting to the A7 nursing unitin order to evaluate and compare handoff guidelines to nursing handoff practices.Patient admissions from the ED to A7 nursing unit were observed via collaboration with nursing staff. Electronic documentation was reviewed via FirstNet. Jean Watson's Philosophy and Science of Caring (2008) theory and principles were utilized to communicate and collaborate with nursing staff. Open communication was encouraged with a mutual respect for both positive and negative feelings in order to promote nursing engagement in discussion of the nursing handoff process.

In addition to direct observation and personal interviews of nursing staff, electronic documentation was reviewed via FirstNet. As a result, variability in documentation within the EMR was noted on the nursing handoff forms. Verbal communication was also observed to be variable and wasconfirmed through communication with nursing staff. It was felt that these were likely due to interruptions from phone calls, telemetry monitoring needs, and direct patient care needs. Nursing experience was thought to play a role in the way that information is exchanged in the handoff process. Nursing staff shared that a full verbal report is given by nurses who work in the ED setting and in the nursing pool, as they recognize that the handoff process may not include all of the information desired. These findings are supported by evidenced based literature focused on nursing handoff practices. Patterson and Wears (2010) suggest that patient handoffs are complex and variable in nature leading to a risk in patient safety. Conducting an environmental assessment through collaboration with nursing staff and promoting process improvement initiatives is supported by the Nursing AdministrationScope and Standards of Practice (ANA, 2009). These activities have the potential to improve communication, promote excellent care, and foster patient safety. Four evidenced based research recommendations were found and offered to ED and A7 nursing leadership teams for consideration and review. These were meant to serve as a working tool for the stakeholders of this scholarly project so that future decisions could include these recommendations.A time investment ofover 120 hours was completed with collaboration from my project preceptors, key nursing leadership, and nursing staff from the ED and A7 nursing units. My personal and professional performance in the completion of this scholarly project is included in this discussion. Feedback has been gathered from my preceptors, as well as, the stakeholders of this project. A self-analysis throughcritical reflectionis also included.Evidenced based research, nursing theory, and nursing leadership principles wereutilized throughout completion of this project.

Demonstration of Personal & Professional Accountability

Demonstration of my personal accountability toward completion of this scholarly project plan is evidenced by completion of the following:more than fifteen literature based articles were reviewed, compiled and utilized throughout this project analysis; the original charter and goals for nursing handoff,as established in 2011, was collaboratively reviewed and compared to current practices; an initial gap analysis was completed in collaboration withnursing staff from the ED and in-patient units; an environmental assessment of the nursing handoff process was completed withcollaboration of ED and A7 nursing staff;review of electronic documentation was completed via FirstNet;anddata was gathered from the Performance Improvement department at Munson Medical Center related to the number of negative patient outcomes which resulted from communication breakdown during the nursing handoff process. This graduate nursing student attempted to balance personal needs and academic work in order to avoid burnout, stress and stay attentive toward the needs of this scholarly project. Finding balance is important and necessary to stay energized and foster creative thinking. This creative balance contributed to being able to offer four evidence based recommendations to the stakeholders of this project for their consideration and review. Evaluationof personal needs, academic requirements, stakeholder needs and organizational needs were a constant consideration during the planning, implementation, and completion of the scholarly project.

Demonstration of professional accountability is evident by adherence toward the ethical, legal, and nursing practice standards defined by the Nursing AdministrationScope and Standards of Practice (ANA, 2009) throughout the planning, implementation, and completion of this scholarly project to improve communication in the nursing handoff process. The goals, activities, and objectives outlined are consistent with these guidelines and support appraisal, research, collaboration and identification of evidenced based recommendations.Research literature was used to validate the nursing handoff observations and formulate recommendations. Nursing theory by Watson (2008) was used to guide communication practices to foster engagement and advocate for nurses in this discussion by showing a respect for positive and negative feedback. Use of transformational and relational leadership principlesas described by Marshall (2011) allowed this graduate nurse to engage and collaborate with nursing leadership and nursing staff in the discussion of nursing handoff in order to discover barriers and seek solutions. All of these scholarly project activities provide proof of my accountability toward professionalism. They are consistent with guidelines for practice found in the Nursing AdministrationScope and Standards of Practice (ANA, 2009)for nursing leadership practice.Evidence based research supports the finding thatnursing handoff communication is a critical issue facing health carepractice that it is complex in nature, and that poor handoff can adversely impact patient safety (Cohen & Hilligoss, 2012). Attention to nursing handoff practices and patient safety measures can help leadership develop policies and nursing practices that support organizational goals to provide effective patient care. Professional accountability is also demonstrated by this graduate nurses’ actions to receive permission from both preceptorsand from the A7 and ED unit managers during implementation of this scholarly project. The planned activities to retrieveresearch evidencetargeted toward patient safety and effective handoff communication, toidentify potential barriers,to collaboratewith nursing staff and key nursing leadership, to provideevidence based recommendations for stakeholder consideration, and to seek verbal and written feedback demonstrate my professional accountability. These activities are supported by theNursing AdministrationScope and Standards of Practice (ANA, 2009) which guide professional nursing leaders tasked with the promotion of safe and effective health care practices.

Jean Watson's Philosophy and Science of Caring (2008) principles served as a guideline forcommunication and collaboration with nursing staff. These principles promoted open communication and a respect for positive and negative feedback which were an important part of this project. A relational leadership style approach was used when communicating with nursing staff in order to foster communication and gather ideas for further discussion, research analysis, and strategizing of solutions. Marshall (2011) suggests that by being present, actively listening, and showing empathy professional relationships are built and team work develops. This teamwork can promote process improvement. In addition, feedback was sought following my PowerPoint presentation at Munson Medical Center on November 13, 2013. A nursing satisfaction survey was given to project stakeholders to gage the effectiveness of my presentation based upon the following: whether or not the purpose was clear, the content was organized, the topic was supported by research evidence, the goals and objectives were clearly defined, the information was relevant useful,the research literature tool was relevant and useful, and the research recommendations were relevant and useful using a six point Likert scale. Nursing leadership and staff found my PowerPoint presentation to be informative, professional, and useful. High ratings were given. Professional accountability was demonstrated throughout all phases of this scholarly project including staying within the timeline for this project, and exceeding the 120 hour time investmentnecessary to completethis scholarly project.

Description and Analysis of Outcomes

The scholarly project outcomes include validation that the nursing handoff process meets the guidelines set forth by The Joint Commission (2012) for nursing handoff practice. These criteria include having an interactive process, an opportunity for questions, that information is up to date, a process for verification, and that historical data related to previous care, treatment and services are included. The final criterion to limit interruptions during handoff was not observed. This information was offered to stakeholders as a possible area for improvement. The nursing handoff process, as established, meets the mission, vision, and values of Munson Medical Center to provide superior quality patient care. Several barriers were identified through direct observation and interview of ED and A7 nursing staff. They are as follows: a lack of understanding of the differences in nursing culture between the ED and A7 nursing units as evidenced by expressions of verbal frustration and incongruent information exchange, a lack of understanding of the real time constraints in the ED and A7 nursing units due to staff deficiencies, bed capacity, and unexpected changes in patient acuity evidenced by personal communication with these nursing staff. This lack of understanding was reported to result in delay of patient transport leading to frustration and the need to make multiple follow up phone calls. In addition, variability in electronic documentation was evidenced by online review of charting. Verbal nursing handoff practices varied by observation and according to personal interview with ED nursing staff. Lastly, it was noted that there was no identified process from which to evaluate the perceived effectiveness of the nursing handoff process or global reporting mechanism to keep staff informed regarding adverse patient outcomes. Literature findings support these observed barriers and will be discussed next. Cultural differences between nursing units in the hospital setting can have a negative impact upon the perceived quality of nursing handoff communication, as reported. The nursing focus of the ED is centered on the acute medical needs of the patient, while the in-patient nursing staff focusesupon immediate and long-term patient care needs. This difference in focus impacts the information exchanged in handoff and may negatively impact the perception of quality related to the handoff communication process. Ong, Biomed, & Coiera (2011) support this concept by the findings that communication during nursing handoff is complicated by divergent approaches to patient care resulting in an increase likelihood of omission of information.