DNP Capstone Projects Examples
Examining The Impact of A Standardized Nursing Handoff Tool On Patient Falls and Nursing Communication
Examining The Impact of A Standardized Nursing Handoff Tool On Patient Falls and Nursing Communication
Abstract
Ineffective communication between healthcare practitioners, such as registered nurses, increases the risk for adverse patient events. Nursing handoff reports help to ensure vital patient information is discussed between incoming and outgoing nurses to promote continuity of care, and therefore, patient safety. The purpose of this project was to determine to what degree does the use of a standardized handoff tool, I PASS the BATON, impact the rate of patient falls on medical/surgical and direct observation units. The project also aimed to identify the degree to which the use of this standardized handoff tool impacted the level of nurse satisfaction with the handoff report process. The implementation of the standardized handoff tool was assisted by using Lewin’s Change Model and Roger’s Innovation Diffusion Theory. This quasi-experimental quantitative project measured patient safety by obtaining patient fall data pre- and post-tool implementation. Nurse satisfaction with the handoff report process was determined by nurse satisfaction surveys pre- and post-tool implementation. The data found an improvement in the level of nurse satisfaction after the implementation of the I PASS the BATON tool. However, there was no significant change in the patient fall rates after the implementation of the handoff tool. Nurse satisfaction improved, which may indicate that the continued use of a standardized tool may positively impact nursing handoff reports. Due to the small sample size measuring patient fall data, it is recommended that the tool be utilized for a longer period of time in an effort to collect more sufficient data in order to determine more significant outcomes.
Table of Contents
Chapter 1: Introduction to the Project 1
Advancing Scientific Knowledge. 6
Nature of the Project Design. 10
Assumptions, Limitations, Delimitations. 12
Summary and Organization of the Remainder of the Project 12
Chapter 2: Literature Review.. 15
Population and Sample Selection. 43
Instrumentation or Sources of Data. 43
Chapter 4: Data Analysis and Results. 49
Chapter 5: Summary, Conclusions, and Recommendations 57
Summary of Findings and Conclusion. 57
Recommendations for future projects. 62
Recommendations for practice. 62
List of Tables
Table 1. Pre-Implementation Medical/Surgical Unit Surveys
Table 2. Pre-Implementation Direct Observation Unit Surveys
Table 3. Post-Implementation Medical/Surgical Unit Surveys…………………….……
Table 4. Post-Implementation Direct Observation Unit Surveys …………………… . .65
Chapter 1: Introduction to the Project
Communication is an important tool in any human interaction, which goes beyond what is said verbally as it also includes nonverbal behaviors such as eye contact, posture, and body language. Performing effective handoffs requires proper communication methods and the use of tools, such as electronic handoff tools, may help to ensure that important patient information is discussed during verbal communication methods. Key characteristics of communication during handoff include responsibility, authority, and transfer of information (Santos, Campos, & Silva, 2018).
Handoff, also referred to as handover, reports are essential in providing safe care for patients. During the handoff report process, patient status and other information is communicated between healthcare practitioners, such as between two nurses during a “change of shift” report. During this time, it is critical to communicate important information regarding patient care to ensure continuity of care as well as patient safety. As stated by The Joint Commission (2017, p. 1) “a hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication.” Some causes for poor communication may include “inaccurate, incomplete, not timely, misinterpreted, or otherwise not was is needed” (The Joint Commission, 2017), leading to adverse events resulting in sentinel events. The Joint Commission defines a sentinel events as “patient safety” events, such as death, permanent harm, or short term but severe harm (2017, p. 1).
There are many factors that may lead to ineffective handoff reports including
“sharing too little information, inconsistent procedures, limited opportunities to ask questions and verify content, unfamiliarity with documentation systems, and interruptions and noise” (Kear, 2016). Studies have shown that the implementation of a standardized nursing handoff tool can increase effective communication during handoff reports. However, there has not been a significant amount of research regarding the implementation of a standardized handoff tool among medical/surgical and direct observation unit nurses in the Southern California acute care setting. The purpose of this topic is to further examine the effect of a standardized tool among medical/surgical and direct observation unit nurses in a small Southern California hospital.
Background of the Project
Ineffective communication between healthcare practitioners significantly increases the risk for adverse events. According to Johnson, Carta, & Throndson (2015), effective handoff communication can be negatively impacted by having too little information, poor quality of information, frequent interruptions, and minimal opportunity for follow up questions, all of which may impact patient safety. Streeter & Harrington (2017) state that communication failures during handoff reports account for approximately 65% of sentinel events in the acute care setting. A literature review found that a number of studies have found a significant amount of information is not discussed during handoffs, thus putting patients at higher risk for injury. The literature review findings indicate that the use of a standardized handoff tool help to ensure patient safety by communicating vital information to the oncoming shift or during a transfer of care (i.e. unit or facility transfers).
Over the last several years, there has been increasing recognition for the need of handover improvement in the clinical setting. Handoff reports are one of the most important tools in communication patient status to ensure patient safety (Hada, Coyer, & Jack, 2018, p.10). This increased recognition has lead to further research on the implementation of a standardized tool for handoff reports. While the needs may vary between settings, the implementation of a an appropriate handoff tool has shown to decrease the rates of adverse patient events (Santos, Campos, & Silva, 2018; Patton et al., 2017; Fryman, Hamo, Raghaven, & Goolsarran, 2017). While no single standardized tool has been identified as the most effective, Bakon & Millichamp (2017) note that the implementation of any standardized structure may help to improve handoff communication. Utilizing a standardized tool, such as I PASS the BATON, may help to guide nurses on how to provide effective handoffs and the implementation of an evaluation tool can help to ensure the report-receiver is receiving the vital information regarding patient care on medical/surgical and direct observation units in a small acute care setting.
Problem Statement
While the literature indicates that the use of a standardized handoff tool increases effective communication among nurses, it is not known if and to what degree using a standardized handoff tool among medical/surgical and direct observation unit nurses will reduce the number of falls. The risk for adverse events increases significantly when there are poor handoff reports given, which could result in death or serious harm to the patients Santos, Campos, & Silva, 2018; Campbell & Dontje 2019). Literature recognizes that the use of tools in nursing practice help to foster and improve communication skills.
Handoff, also referred to as handover, reports are essential in providing safe care for patients. During the handoff report process, patient status and information is communicated between healthcare practitioners, such as between two nurses during a “change of shift” report. During this time, it is critical to communicate important information regarding patient care to ensure continuity of care as well as patient safety. As stated by The Joint Commission (2017) “a hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication.” Some causes for poor communication may include “inaccurate, incomplete, not timely, misinterpreted, or otherwise not was is needed” (The Joint Commission, 2017), leading to adverse events resulting in sentinel events.
The hospital in which the project will be conducted does not use a standardized method of handoff delivery, resulting in handoff reports being performed at the discretion of the nurse giving report. However, it is standard practice in the hospital to perform handoff reports at the bedside. The problem was identified by observing shift-change handoff reports and through discussion of the current practices with the unit managers and the hospital educator. Moreover, patient safety, fall rates in particular, are of high concern on both units. By the implementation of a standardized tool, fall rates may decline related to a more thorough handoff report and more time effective handoff reports. Through the use of a standardized handoff tool on medical/surgical and direct observation units in a small Southern California hospital, patient safety will be monitored by gather patient fall data in an effort to determine if the use of the standardized tool in this setting is beneficial.
Purpose of the Project
The purpose of this quantitative project is to determine to what degree a relationship exists between the use of a standardized I PASS the BATON tool in reducing the number of patient falls by improving communication during handoff reports among registered nurses on medical/surgical and direct observation units in a Southern California acute care setting. The I PASS the BATON tool will be utilized to determine if nurse handoff communication methods are more effective and to determine if the rate of falls on both units are affected by the handoff tool. A minimum of 25 nurses will be needed to identify the effects of a standardized handoff tool, I PASS the BATON. The unit of analysis will involve quantitative methods and will be analyzed using descriptive statistics by using the SPSS program to compare efficacy of reports before and after the implementation of a report tool.
Quantitative methods will involve operational and measurement levels for the variable. These levels will involve evaluation of nurse performance in giving a handoff report before and after the implementation of a handoff tool. This will involve surveys to be completed by the nurse receiving report. The report-receiver will answer a survey with questions regarding the handoff report that was received. The standardized handoff tool will be defined by an existing standardized tool, I PASS the BATON tool. The efficacy of handoff communication will be measured by the report-receiver via numeric grading system.
This project may contribute to the field of nursing by promoting more effective communication during handoff reports. Patient safety remains to be a priority in the acute care setting and may be better maintained with more effective handoff reports. The use of I PASS the BATON, a standardized handoff tool, may help nurses to discuss all vital information while decreasing the time spent performing handoff reports, thus allowing more time spent with patients.
Clinical Question(s)
This project focused on the effect of the implementation of the I PASS the BATON tool among nurses on medical/surgical and direct observation units. The aim was to determine if the I PASS the BATON tool would help improve nurses’ ability to communicate critical patient information. Lewin’s Change Model and Roger’s Diffusion Theory were both critical components in implementing the tool. Providing positive feedback as well as clear definitions of the purpose of the standardized tool may have assisted nurses in adopting this tool.
The following clinical questions guided this quantitative project:
Q1: To what degree does using the I PASS the BATON tool as a standardized handoff tool impact on the fall rates on medical/surgical and direct observation units?
Q2: To what degree does using the I PASS the BATON tool as a standardized handoff tool increase nurse satisfaction with the handoff process as demonstrated by survey questions regarding satisfaction with handoff reports pre- and post-tool implementation?
In an effort to determine the outcome of the use of a standardized tool, nurses receiving report (i.e. report-receiver) were asked to rate the quality of the report-giver’s communication of patient information in the handoff report. Several components were involved in this evaluation, including the quality of communication, inclusion of critical information, decrease in errors, and improving patient safety. Patient safety was monitored by identifying patient fall rates on both units during the project. Data was collected pre- and post-tool to determine if the rate of falls decreased with the use of the I PASS the BATON tool.
Advancing Scientific Knowledge
The need for further examination of the efficacy of handoff communication among acute care nurses in Southern California has not been determined. The implementation of a handoff communication tool may aid nurses in more effective communication methods during handoff reports. Effective handoff reports help to ensure continuity of care and, therefore, patient safety as well as nursing satisfaction with the handoff communication process (Hada, Coyer, & Jack, 2018). It was proposed that should the project provide evidence that the use of a standardized tool among medical/surgical and direct observation unit nurses was effective with improving communication, this could potentially be an additional component to incorporate hospital-wide at the project site.
With the use of a standardized tool, nurses may more effectively demonstrate effective handoff communication skills, which will in turn promote patient safety, thus improving patient outcomes. Moreover, this could help to improve morale and working relationships among nurses on the unit by allowing them to more effectively communicate in a timely fashion, which may allow more time for vital nursing duties to be completed. The long term results of this could demonstrate improved patient safety and decreased adverse events related to poor communication.
Significance of the Project
Effective communication is key to providing effective handoff reports. Approximately 80% of serious medical errors are related to poor communication during handoff reports (Kear, Bhattacharya, & Walsh, 2016, p. 379). Kear (2016) recognizes the need for complete and accurate patient information during the handoff report in order to prevent preventable adverse events from occurring (p. 379). Such preventable events may include patient falls, medication errors, and delays in patient treatment (The Joint Commission, 2017). Kear, Bhattacharya, & Walsh (2016) found that information is frequently “falling through the cracks” due to involvement of multiple healthcare providers, varying methods of handoffs, unfavorable work culture, and poor time management. Insufficient data may not be communicated during the handoff reports for a variety of reasons such as poor communication methods, which may be related to “fast-paced, loud, and chaotic environments, unplanned timing in handoffs,…and the need to exchange a large amount of information in a compressed timeframe” (Kear, Bhattacharya, & Walsh, 2016).
According to Hada, Coyer, & Jack (2018), “The Garling Report” released by The Commission of Inquiry into Acute Care Services in New South Wales Public Hospitals acknowledges that handover reports are one of the most important tools in communicating patient status to ensure patient safety. The Garling Report strongly recommends the use of a “structured tool” that is enforced by hospital policy. However, in order to appropriately use the handover tool, proper training should be implemented to ensure it is being used to its full potential. Research suggests that there is a significant increase in the compliance of a handover tool between groups that received training versus those who do not. Hada et al. (2018) found there was an improvement in patient safety with a 9.37% decrease in falls, 75% decrease in pressure injuries, and 11.1% decrease in medication errors (Hada et al. (2018).
Communication is not just limited to verbal forms but also includes written form as well as body language. Carroll, Williams, and Gallivan (2012) states that while handoff reports are a part of everyday work duties for nurses, there is little information on what constitutes a “good handover.” Carroll et al (2012) found that many handoff sessions last between two to thirteen minutes and only 26% of the active medical issues were included in the reports. Nurse opinions of handoff interactions vary, which could be a factor in the amount of information that is discussed during the handoff process as well as varying opinions regarding communication methods (i.e. body language, eye contact).
Recognition of professional responsibilities and liabilities is necessary in practicing effective change of shift reports (Lee, Phan, Dorman, Weaver, & Pronovost, 2016). By identifying factors among medical/surgical nurses for this project, more insight may be provided on factors directly related to this unit within the small Southern California hospital. Identification of common barriers within the hospital may help to modify a standardized tool to suit the needs of the units within the hospital. If the use of a standardized tool proves to be helpful with improving handoff reports, adopting the use of the tool long-term may help to improve patient outcomes by improving safety measures.
Rationale for Methodology
The purpose of the doctoral project was to introduce a standardized handoff tool in an effort to improve nursing handoff reports on a medical/surgical and direct observation units in a Southern California hospital. Using a quasi-experimental design, data collection allowed for statistical analysis. In order to obtain more concrete evidence regarding the efficacy of standardized handoff tools, quantitative design was the most appropriate. Quantitative data increased the probability of more validity and reliability in the findings. Quantitative data provides statistical data to demonstrate the relationship between variables (Center for Innovation in Research and Teaching, 2019). Quantitative data is often viewed as more “scientific” as the findings may “not be seen as a mere coincidence” (Daniel, 2016, p. 94). It is not unknown that handoff reports are an area in which improvement is needed. However, it was not known how nurses on Southern California medical/surgical and direct observation units perceived the handoff process.
Kear, Bhattacharya, & Walsh (2016) performed a study on nephrology units across the United States with a similar design utilizing assessment tools from the Agency for Healthcare Research and Quality (AHRQ) and handoff tools created by the Joint Commission in an effort to collect objective data regarding the handoff process. The objectivity of the data allowed for more concrete data findings. Obtaining the quantitative data by requesting participating nurses to complete a set of questions pre- and post- tool implementation helped to determine if handoff communication improved with the use of the tool. Because handoff communication occurs between a minimum of two nurses, a set of questions were to be completed by the report-receiver after receiving report. The report-receiver rated the report-giver’s ability to provide clear, concise, and pertinent patient information. Lastly, patient fall rate data were collected in order to determine if the rate of falls decline after implementing I PASS the BATON tool.
Nature of the Project Design
This quasi-experimental pre and post design project involved a brief set of questions to be completed by the participating nurses on the medical/surgical and direct observation units. Brief training handouts were provided to day and night shift nurses that discussed the pre- and post-tool implementation process as well as the proper use of the I PASS the BATON tool. A 1 to 5 scale was utilized for the set of questions with 1 meaning strongly disagree, 2 disagree, 3 neutral, 4 agree, and 5 strongly agree. With the permission of the authors, surveys for the project were used from a research article by Anderson & Mangino (2006). The pre-and post-tool set of questions asked questions regarding the staff accountability for completing nursing care prior to the change-of-shift, whether or not questions were answered during report, satisfaction of interpersonal relationships, patient condition, provision of pertinent information, and satisfaction with report time.
Data collection performed prior to the implementation of the I PASS the BATON tool. After implementation of the tool, data collection continued for the remaining one week of the project to determine if fall rates changed during the implementation of the tool. Upon completion of the project, data was analyzed using SPSS to identifying any changes in the fall rates. Lastly, the data from set of questions was analyzed to determine if the nurses’ perception of handoff communication improved with the use of the tool.
Definition of Terms
“The following terms were used operationally in this project.”
Adverse event. An unintentional physical injury that occurs due to medical management that needs more monitoring, such as treatment or longer hospitalization, and may, in some cases, lead to death (Agency for Healthcare Research and Quality, 2019).
Patient falls. “An unplanned descent to the floor with or without injury to the patient” (Agency for Healthcare Research and Quality, 2019b).
Handoff report. A handoff report, also known as handover, shift report, shift change report, nursing report, is the communication of patient care information between healthcare professionals, such as nurses. This involves communication may be performed during a change of shift, during which time responsibility of patient care is transferred from one nurse to another. The handoff report allows the nurse assuming care to “ask questions, clarify and confirm” (Friesen, White, & Byers, 2008).
I PASS the BATON tool. The I PASS the BATON tool is a standardized handoff mnemonic that guides handoff communication. This tool identifies the following: illness/severity; patient summary; action list; situation awareness and contingency planning; synthesis by receiver.
Sentinel event. An event, or risk for, that results in death or a serious psychological or physical injury, such as loss of limb or function (The Joint Commission, 2012).
Assumptions, Limitations, Delimitations
It is assumed that participants in this project were not deceptive with their answers, and that the participants answered questions honestly and to the best of their ability. There is a risk that nurses may be overly gracious with their ratings for nurses with whom they have a friendly relationship. On the other hand, they may be more critical towards those whom they do not know or do not have a good cohesive working relationship.
It is assumed that this project is an accurate representation of the current situation in small hospitals in Southern California acute care settings. Many of the larger for-profit hospitals in the region have stricter policies and procedures regarding nursing handoff. However, the smaller for-profit and community based hospitals do not always have the funding or manpower to implement tools such as standardized handoff tools. Moreover, the management within each hospital, and each unit, may vary regarding the support of implementing a standardized tool into everyday practice.
Potential limitations of the project included participant bias, resistance to adopting a handoff tool, and the small number of participants. Delimitations of the project include the location of the project, the units on which the project was performed, and the tool used for the project. This project was focused solely on the medical-surgical and direct observation units, which could have lead to a smaller sample size.
Summary and Organization of the Remainder of the Project
Patient safety remains to be of highest importance in healthcare. Certain measures must be taken in an effort to maintain patient safety, and thus improving patient outcomes. Due to the increasing recognition regarding the need for effective communication in handoff reports, more research is being conducted to find effective tools in order to promote effective handoffs. Some causes for poor communication may include “inaccurate, incomplete, not timely, misinterpreted, or otherwise not was is needed” (The Joint Commission, 2017), leading to adverse events resulting in sentinel events. In an effort to prevent adverse events, the implementation of a standardized handoff tool may prove to be beneficial in improving the efficacy of nursing handoff reports.
In an effort to evaluate the impact of the use of a standardized handoff tool, this project will be performed in a small Southern California hospital on the medical/surgical and direct observation units with the participation of a minimum of 25 nurses. The standardized tool, I PASS the BATON, will be utilized to help guide nursing handoff communication during shift change. A survey created by Tidwell et al. (2011) will be completed by the nurses to identify perception of the handoff efficacy and patient safety. Patient fall rates will also be analyzed to determine if the implementation of a standardized handoff tool is helpful in decreasing the rate of falls on these units.
Chapter 2: Literature Review
Over the last several years, there has been increasing recognition for the need of handover improvement in the clinical setting. Halm (2013) notes that The Institute of Medicine reported that the majority of adverse outcomes in the acute care setting are linked to failures in communication. Handoff reports are one of the most important tools in communicating patient status and ensuring patient safety by providing accurate patient information about the patient’s care and treatment (Hada, Coyer, & Jack, 2018, p. 9). The increased recognition has lead to further research on the implementation of a standardized tool for handoff reports. While the needs of this tool may vary depending on setting, the implementation of a setting-appropriate tool has shown to increase communication efficacy and decrease adverse patient events. Research studies recommend further research on the development of more effective handoff tools and standards but there has been minimal evaluation of the use of this tool among nurses on medical surgical and direct observation units in a small Southern California hospital. Utilizing a standardized tool may help to guide nurses in performed effective handoffs reports.
While the literature indicates that the use of a standardized handoff tool increases effective communication among nurses, little is known on the use of a standardized tool among nurses and the effect of effective communication. The real issue affecting nurses and patients is the ability to communicate effectively during handoff reports. The risk for adverse events increases significantly when there are poor handoff reports given, which could result in death or serious harm to the patients. The importance of effective communication is becoming more recognized but there has not been significant research indicating the impact of more in-depth education regarding handoff reports among nurses. Literature recognizes that the implementation of a standardized tool may not only help to improve efficacy of handoff reports but will also help to increase patient safety and nurse satisfaction.
Using CINAHL, Science Direct, Academic OneFile, InfoTrac and Health Reference Center Academic, a literature review was conducted in an effort to further investigate the topic. Two major themes were identified, including communication and nursing care. Communication contains three subthemes: handoff failures, standardized handoff tool, and bedside report. Three subthemes associated with nursing care include: patient safety, nurse satisfaction, and behavioral change.
Theoretical Foundations
Kurt Lewin’s Change Theory is comprised of three stages: unfreezing, change, and refreezing. This model may help to identify issues that require change and how to implement the necessary changes. Lewin’s theory is applicable to implementing a new handoff tool as it has been recognized that patient safety may be at risk directly related to poor handoff reports. This may help with the change process by providing a framework during the unfreezing and change process as well as the final freeze process in which they continue to practice the changes implemented.
For the implementation of a standardized handoff tool, the unfreezing stage would include information on the importance of effective handoffs as well as the expected outcomes of the change (Vines, Dupler, Van Son, & Guido, 2014). The change stage is the actual process of learning and implementing the standardized tool and the freezing stage would involve the nurses’ ability to continue to utilize the tool. Refreezing would involve the adoption of the tool and continuing to utilize the standardized tool beyond the project period.
Malekzadeh, Mazluom, Etezadi & Tasseri (2013) implemented a standardized handoff protocol in the intensive care unit and performed the unfreezing stage by discussing the tool with charge nurses, initiating formal announcements, and involved various employees to participate in this stage (p. 180). This project will have a similar implementation of the unfreezing stage in that the primary investigator will be informally speaking with staff nurses prior to the start of the project and will be obtaining the assistance from unit charge nurses, the medical/surgical and direct observation unit managers, and the hospital educator.
Using Lewin’s change stage, the I PASS the BATON standardized handoff tool will be implemented. Malekzadeh, Mazluom, Etezadi & Tasseri (2013) performed this stage by providing a total of 90-minute education sessions on the new handoff protocol (p. 180). The investigators observed and evaluated the nursing handoffs to determine if the new practices were performed appropriately. Those who did not perform the handoff reports effectively had follow-up education sessions (Malekzadeh et al., 2013, p. 180). For the purpose of this project, the primary investigator will be discussing the I PASS the BATON briefly during change-of-shift and by providing written information and guidelines for the nurses. The investigator will also be on-site for several of the days the new tool is implemented in order to provide clarification on any questions the nurses may have with the new tool or how to answer the survey questions after receiving report.
Lewin’s last stage, refreezing, is the stage in which the “new practice has altered the organization setting, forcing it to accommodate” (Manchester et al., 2014, p. 85). During this stage, reinforcement maybe necessary to ensure nurses continue to practice the use of the standardized tool (Manchester et al., 2014, p. 85). In an effort to maintain the refreeze stage, Malekzadeh et al. (2013) performed strict supervision to ensure nurse adherence to the use of the new standardized tool (p. 180). For this project, the refreeze stage may be the most challenging as the primary investigator will not be present to do so. In this case, the unit managers will determine if they would like to supervise and ensure there is continued use of the I PASS the BATON standardized tool.
Another change model that is applicable to the implementation of a standardized handoff tool is E.M. Roger’s Innovation Diffusion Theory. This theory, which is an expansion of Lewin’s original theory, contains five steps that identify how an individual, or organization, acknowledges an issue and adopts the measures for change. In this theory, it is recognized that leaders play a crucial role when implementing change. Moreover, this theory recognizes factors that may prevent adoption to change, which may include strengths or weaknesses of the group and managing factors (Wagner, 2018). Wagner notes this theory identifies the “how, why, and at what rate new ideas are taken up by individuals” (2018). The five levels of adopting change include: innovators, who thrive on change; early adopters, who are cautious of change but are willing; early majority, who take longer to adopt change but are not necessarily resistant; late majority, who are highly skeptical of the new practices; and the laggards, who are the last to adopt change practices (Wagner, 2018). Identifying the level of acceptance of new practices may assist leaders in recognizing individuals that are more resistant to change versus those who may be more accepting to the new practices, such as the implementation of a standardized tool. Identification of those who are more open to the use of a standardized handoff tool may provide more encouragement for the individuals who may be more resistant to the new handoff practices.
Lewin and Roger’s theories may be applied to implementing the use of a standardized handoff tool. Both theories provide an understanding of the change process, which provides conceptual framework to the project design. Moreover, the understanding that individuals adopt new practices at different rates allows for planning for measures to overcome this barrier. Some may be resistant to change for various reasons, however, if there is not a solid understanding regarding the need for change, resistance levels may be higher. The primary investigator will provide information on the potential safety risks directly related to current handoff practices in an effort to encourage nurses to be more receptive to adopting a standardized handoff tool. By utilizing Lewin and Roger’s theories, the change process will be more appropriately planned, which may help to increase compliance rates as well as decrease the risks for patient safety related to poor handoff reports.
Review of the Literature
Communication. Communication is an important tool in any human interaction. This goes beyond what is said verbally as it also includes nonverbal behaviors such as eye contact, posture, and body language. Some of the discussed research indicates that verbal ad nonverbal behaviors play an important role in nurse satisfaction but other factors, such as duration of report, may also be influential on satisfaction levels. The discussed studies found that incomplete or incorrect information lead to poor team communication, ultimately resulting in putting patients at risk for adverse events.
Human factors influences one’s ability to properly communicate patient information are apparent in each study. Barriers to effective handoff reports include the “sharing too little information, inconsistent procedures, limited opportunities to ask questions and verify content, unfamiliarity with documentation systems, and interruptions and noise” (Kear, 2016). Because needs of units vary, Kear (2016) recommends that nurses and coordinators work together to identify the needs of that unit in order to effectively implement tools for more effective handoff reports. Subthemes within this category include: handoff failures, standardized handoff tool, and bedside report.
Handoff Failures.
Project 1. Abraham et al. (2016) note that of the events involving transfer of patient information in the acute care setting, nursing handoff reports are the most frequently occurring and account for approximately 35% of sentinel events. In a mix-methods design, the researchers identified common contributors to poor handoff reports. The researchers argue that sentinel events occur due to communication failures during the handoff reports. These failures may include, but are not limited to: varying communication methods, time permitted for reports, interruptions, distractions, “lack of training, and communication bottlenecks” (Abraham et al., 2016, p. 76). While The Joint Commission has proposed standardized handoff reports to avoid sentinel events, an understanding of the content required for effective communication needs further evaluation.
In a mixed-methods design utilizing an exploratory sequential conversational analysis, Abraham et al. (2016) evaluated the communication properties, interaction, and the relationships with communication characteristics. The study was performed in a medical intensive care unit at an academic hospital in Texas involving 16 participating nurses during change-of-shift reports, which occurred twice a day. The findings recognize that an interactive handoff report leads to more effective communication, which is not a concept that was frequently observed. Interactive communication methods include practices such as read-backs (i.e. reading back information received to confirm accuracy) and equal participation between the incoming and outgoing nurses. The investigators found that nurses who practice self-reflection and metacognition have an easier transition into adopting new communication processes (Abraham et al., 2016).
Project 2. Poot, de Bruijne, Wouters, de Groot, and Wagner (2014) performed an observational study aimed at identifying current practice and opinions of the handover process in a perinatal setting. The researchers were evaluating several different aspects of the handover process, including “situational awareness” which consisted of the common SBAR (situation, background, assessment, and recommendation) tool and the handover process, which included duration, amount of interruptions, eye contact, questions, and reading information back to the outgoing nurse. On average, nurses spend 2 minutes or more per patient, 52% experienced distractions, 43% did not involve active questioning, 32% had no eye contact, and 97% did not read back information obtained during the handover report. While the researchers found the handoff reports to be insufficient through their observations, they found that receiving nurses rated the handover process highly. Due to the high ratings by the nurses, the researchers indicate there is a lack of awareness of patient safety during the handover process. The researchers recommend simulation training or video reflection in order to encourage more awareness and engagement during the handover process. Subthemes include situational awareness, distractions during handover reports, and eye contact between participants.
Project 3. Goncalves, Rocha, Anders, Kusahara, & Tomazoni (2016) note several handoff communication failures in a descriptive-exploratory design on neonatal intensive care units (NICU) at three hospitals in Brazil. There were 70 nurses participating in the data collection process between the three hospitals. The researchers note “the excessive or reduced amount of information; limited opportunity to ask questions; inconsistent information; omission or transfer of mistaken information; nonuse of standardized processes; unreadable records; lack of teamwork; interruptions and distractions” (Goncalves, Rocha, Anders, Kusahara, & Tomazoni, 2016). The researchers do note that NICUs tend to be high stress environments that involve highly technical equipment that may contribute to the barriers to communication methods. The findings indicated that handoff failures include items such as: delays and early departures, side talk, and noise. While some of these barriers are dependent on the setting, the researchers recommend implementing more training on handoff communication among current nurses as well as during nursing school in an effort to develop appropriate communication habits early in practice.
Standardized Handoff Tool.
Project 1. According to Fryman, Hamo, Raghaven, & Goolsarran (2017), approximately two-thirds of adverse events in hospitals are related to inefficient handoff reports. The researchers stress the importance of a standardized handoff tool, which have been shown to decrease adverse events when comparing to a non-standardized approach. In this study, the researchers utilized the IPASS method integrated into electronic health records to test the practicality and effectiveness. The findings showed a significant decrease in adverse events.
Limitations of the study included a lack of measurement regarding length of time it took to use I-PASS. Another limitation was the results were based off surveys completed by residents instead of a data analysis regarding the effect of patient care. The researchers also found that there was difficulty in maintaining compliance with the use of the tool. Upon a six month follow up of the compliance in utilizing the tool, the researchers found that only 60% of residents were using it. The researchers then created a sustainability model which increased the compliance to 100%. The findings of this study show that the implementation of a standardized tool is greatly beneficial to patient safety. However, monitoring in compliance as well as follow up training may be necessary to maintain compliance.
Project 2. In a pre-post intervention study on a pediatric intensive care unit (PICU) utilizing the I-PASS Nursing Handoff tool, Starmer, Schnock, Lyons, Hehn, Graham, Keohane, & Landrigan (2017) evaluated the quality of the verbal handoff process and the duration of time required for the handoff. The results showed significant improvement in the quality of handoff, which increased communication regarding important patient information. Examples of these aspects pre-intervention versus post-intervention include illness severity (37% versus 67%), patient summary (81% versus 95%), and opportunity for oncoming nurse to ask questions (34% versus 73%). The findings indicate that the use of a standardized tool, such as I-PASS significantly increase the handoff communication process. Information exchange was more efficient and timely, thus allowing time for more follow up questions.
Project 3. A mixed methods quantitative-qualitative study performed by Abraham, Kannampallil, Almoosa, Patel, & Patel (2013) recognize that handoff reports vary “in their structure and content,” which increases the probability of inappropriate or ineffective handoff reports. This study involved a nonrandomized pre-post intervention study that was conducted in an ICU setting. The goal was to identify patterns in handoff characteristics and types of communication by utilizing two different handoff tools, HANDoff Intervention Tool (HAND-IT) and Subjective-Objective-Assessment-Plan (SOAP). The study found that the HAND-IT tool was more effective in promoting more interactive and proper communication techniques. This tool prompted follow up questions from the receiver while the tool itself guided the interaction to provide a more seamless interaction. With improved communication, critical patient information was discussed which lead to promotion of continuity of care.
Project 4. Approximately 80% of serious medical errors are related to poor communication during handoff reports (Kear, Bhattacharya, & Walsh, 2016). Using a mixed-methods research approach, Kear et al. (2016) examined the handoff report process in the nephrology setting. The researchers found that nephrology unit nurses reported information frequently “falling through the cracks” due to involvement of multiple healthcare providers, varying methods of handoffs, and varying hours of operation within the nephrology setting. The researchers developed a survey with the use of three sections: socio-economic data and employment information, 50 closed-ended questions regarding a handoff tool that combined items from the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission, and lastly, several open-ended questions inquiring about the handoff process. The survey including findings such as “insufficient staffing, lack of time for patient care, and low level of importance related to safety and handoff procedures.” The researchers also found that insufficient data was being communicated during the handoff reports. Several factors may play a role in poor communication during handoffs, including “fast paced, loud, and chaotic environments, unplanned timing in handoffs,…and the need to exchange a large amount of information in a compressed timeframe.” The researchers argue that recognition of professional responsibilities and liabilities is necessary in practicing effective change of shift reports.
Conclusion. Communication is an important tool in any human interaction, which goes beyond what is said verbally as it also includes nonverbal behaviors such as eye contact, posture, and body language. Performing effective handoffs requires proper communication methods but other tools, such as electronic handoff tools, may help to ensure that important patient information is discussed during verbal communication methods. Key characteristics of communication during handoff include responsibility, authority, and transfer of information (Santos, Campos, & Silva, 2018). Moreover, Chapman, Scheickert, Swango-Wilson, Aboul-Enein, & Heyman (2016) recommend the involvement of leadership, which in the case of nursing students refers to nursing faculty. Standardized handoff tools have shown to increase the efficacy of handoff reports. Standardized tools not only help to ensure all necessary information is discussed, but can also help to decrease the amount of time spent during report, which then allows for more time spent providing patient care. Nursing leadership should remain involved in the development of a standardized tool to ensure that items included in the tool are pertinent to the unit in which it will be utilized.
Bedside Report.
Project 1. Over the last decade, that has been increasing recognition for the need of handover improvement in the clinical setting Hada, Coyer, & Jack, 2018, p.10). According to Hada, Coyer, & Jack (2018), “The Garling Report” released by The Commission of Inquiry into Acute Care Services in New South Wales Public Hospitals acknowledges that handover reports are one of the most important tools in communicating patient status to ensure patient safety. Based off the findings, The Garling Report strongly recommends the use of a “structured tool” that is enforced by hospital policy and is performed at the bedside. In order to appropriately use the handover tool, proper training should be implemented to ensure it is being used to its full potential. The use of a handover tool at the bedside has also been found to improve overall patient satisfaction. Based off the findings of the Garling Report, Hada et al. (2018) designed a pilot study aimed at determining the efficacy of handover training with a standardized tool. The study was performed in two geriatric and rehabilitation unites of a teaching hospital in Australia, which totaled 78 beds between the two units. A total of 58 registered nurses, both full time and part time, were participants in this study. The findings of this study found that there was a significant increase in the compliance of a handover tool between the groups that received training and those that did not. Moreover, patient safety improved with a 9.37% decrease in falls, 75% decrease in pressure injuries, and 11.1% decrease in medication errors. Overall, the pilot study had positive findings in patient safety as well as satisfaction with the use of a handover tool. Two subthemes found in this article include bedside report and the use of a standardized tool.
Project 2. Bigani & Correia (2018) performed an exploratory-descriptive qualitative study to determine what experiences were among nurses, family, and patients after implementing bedside handoff reports. The study involved 25 nurses and 15 patients and families who answered multiple choice and open-ended questions. The findings indicated that many nurses did not prefer bedside reports due to increased length of time to perform reports and a sense that patients and families do not want to be bothered during shift-change. Patients and families, however, did not recognize any barriers to bedside report. Some of the patients and families stated they had difficulty understanding their role in the report and a small number noted they were too fatigued to understand or fully participate.
While nurses reported a small amount of barriers, there were a significant amount of safety concerns that were identified while performing report at the bedside. These included: “missing safety equipment, missing orders, and issues relating to pain, dressings, medications, intravenous access, and diagnosis” as well as corrections or updates regarding patient history (Bigani & Correia, 2018). The patients and families reported several benefits to bedside reporting including a sense of comfort and caring. The researchers argue that bedside reporting ultimately enhances the relationship between nurses and patients/families and allows active participation in care.
Project 3. Campbell & Dontje (2019) performed a qualitative pre- and post-implementation project in the emergency department at a small trauma center. The questionnaire was scored with 7 questions and another part of the questionnaire included 2 of the Hospital Survey on Patient Safety Culture questions. In addition, handoff observations were performed by leadership. The findings of this project showed there was an increase in nurses feeling they received complete and accurate handoff reports post-implementation. In regards to handoff style, 62% of the nurses noted a preference of the bedside handoff reports. The authors asked two questions from the Hospital Survey on Patient Safety Culture questionnaire, which included the loss of patient information during handoff reports and shift changes being problematic. After the implementation of bedside reports, both of these items had a significant decrease in the amount of nurses who agreed with these statements, which the authors note have had poor ratings since 2012. More importantly, nurses reported more situation awareness during their handoff, which ultimately better maintained patient safety. While this project was limited to one department, it provides support that bedside reports not only promote better communication between the nurses but also allows for an increase in patient safety.
Conclusion. The literature review regarding implementation of bedside report provides insight on the opinions, barriers, and benefits of this handoff method. While the handoff reports may take longer, it allows the incoming and outgoing nurse to more actively participate in the report. Moreover, it allows family and patients to participate by asking questions or providing updated information. Most importantly, bedside reports increase patient safety as this promotes more situational awareness.
Nursing Care. In the acute care setting, nurses spend the largest amount of time with patients. Efficient handoff reports is one of the main methods of maintaining patient safety. The transfer of critical patient information ensures the transition of care goes smoothly and all pertinent patient information is discussed. This section includes subthemes: patient safety, such as patient falls, nurse satisfaction, and behavioral change.
Patient Safety.
Project 1. Patient safety is dependent any many different factors but the primary factor is communication and situational awareness. According to Johnson, Carta, & Throndson (2015), effective handoff communication can be negatively impacted by having too little information, poor quality of information, frequent interruptions, and minimal opportunity for follow up questions. In a qualitative study, the researchers aimed to examine the exchange of information during handoffs and documentation. Upon gaining a deeper understanding, methods to increase patient safety can be better identified and addressed.
Four themes emerged during the study, which included: inconsistent documentation, inconsistency of patient assignments, lack of care plans, and various methods of communication during handoffs. The participants in the study revealed that reasons for inconsistent documentation was largely due to time constraints related to high patient acuities and turnover. Inconsistent patient assignments prevented nurses from developing better rapport, and therefore more effective therapeutic communication, with their patients leading to gaps in care and decreased patient satisfaction. Lack of care plans lead to delays in patient treatment as well as discharge planning. Lastly, various methods of communication lead to a decrease in the quality of information exchanged during the handoff process.
Most of the participants expressed a preference of verbal handoff methods as this allowed them time to ask follow up questions on information. The nurses had mixed opinions on the efficacy of bedside handoff reports but research has shown that bedside reports can increase patient satisfaction. The researchers suggest implementing a standard SBAR tool to aid in the information exchange, however, the other themes would need to be addressed in order to increase patient safety.
Project 2. In a validation study performed by Ferrara, Terzoni, Davi, Bisesti, & Destrebecq (2017), the researchers validated the quality of the handoff process by utilizing the Handoff CEX-Italian scale in an Italian hospital on medical surgical units. The findings discovered that the lowest scoring areas with the use of the scale included communication skills, context, and organization. While personality can affect communication methods, the researchers acknowledge that this is not the sole cause for ineffective handoff reports. Poor scores for organization was related to lack of a structured method, poor organization by the nurse, and too little time to discuss necessary patient information. The organization and communication may be potential factors in the context of information that is shared. Addressing these areas of concern can help to improve patient handoff reports, and therefore increase patient safety.
Project 3. According to Streeter & Harrington (2017), communication failures during handoff reports account for approximately 65% of sentinel events in the acute care setting. In a cross-sectional online survey, the Streeter & Harrington evaluated the information exchange process as well as the communication behaviors associated with efficient patient handoff reports. The findings of the study revealed a preference for organized, detailed, and comprehensive report from the outgoing nurse with quality follow up questions from the incoming nurse. Factors related to poor handoff reports consisted of poor outgoing nurse organization and knowledge of patient information as well as side “chit chat” or discussion about information that is not pertinent to patient safety and care. The ability to provide concise and relevant information from the outgoing nurse while the clarification of information from the incoming nurse are important behaviors that are necessary in an effective handoff report.
Conclusion. Patient safety, such as prevention of patient falls, is reliant on several aspects of care but is especially reliant on effective handoff reports. Some of these aspects include well organized reports with relevant information provided by the outgoing nurse and follow up questions from the incoming nurse. Participation by both nurses can help increase rapport and encourage information giving, therefore a sharing of critical patient information. With the implementation of a structured handoff tool, such as SBAR, this can allow nurses to have a more organized report, which will ultimately increase report efficiency and patient safety.
Nurse Satisfaction.
Project 1. Performing effective handoffs requires proper communication methods and tools to ensure that important patient information is discussed during verbal communication in an effort to prevent the occurrence of adverse events. Chapman, Scheickert, Swango-Wilson, Aboul-Enein, & Heyman (2016) performed a descriptive qualitative study to determine nurse satisfaction levels with communication of care and report received, comfort levels with the use of electronic tools, and satisfaction with the use of electronic tools. The researchers implemented the use of an electronic Situation-Background-Assessment-Recommendation (SBAR) tool and followed up with a survey on nurse perceptions of the handoff process. Evaluation of the nurses’ surveys found there was a high level of satisfaction with an electronic SBAR report that was performed at the bedside, which indicates that the use of an electronic tool may help to ensure communication of important patient information.
The researchers recommend the involvement of information technology (IT) and leadership to ensure handoffs are being performed appropriately and to ensure nurses do not revert back to relying on “verbal handoffs at the nurses’ desk” but are instead performed at the bedside. Chapman et al. (2016) note there have been several positive benefits to bedside handoffs, which included communication benefits, improvement of collaboration among the nurses, increased handoff efficiency, and decreased amount of time spent on handoff reports.
Project 2. In a prospective pre-post intervention study, Nagpal et al. (2013) aimed to determine if the quality of the handover improved with a standardized tool in a post anesthesia care unit (PACU). A trained researcher observed 50 pre-intervention and 40 post-intervention, with twenty percent of the reports being observed by second observer to assess for interrater reliability. Quality of handoffs included five categories: information omissions, tasks errors, teamwork, nurse satisfaction, and duration. Limitations of the study included smaller sample size, potential for compromised authenticity due to the nature of the study.
The finding of the study indicated that the use of a standardized handoff tool significantly increased the quality of handoff reports. While the aim of the study was not meant to evaluate the new handoff tool, but more to determine if the use of a standardized tool improved handoff efficacy. This study provides evidence that a standardized tool improves patient safety measures by reducing errors, improving teamwork, and nurse satisfaction.
Project 3. A mixed methods study performed by Bakon & Millichamp (2017) aimed to evaluate the handover process and identify best practices when transferring patients from the emergency department to other units in an Australian hospital. The study involved 28 nurses between the emergency department other units within the hospital. The study found that nursing handoff reports were the most efficient when implementing a standardized tool to ensure critical information is discussed during the report process. The researchers developed and implemented a standardized tool utilizing an ISBAR (identity, situation, background, assessment, plan) format that was easy to use but still addressed important patient information.
There were several versions made in an effort to meet the needs and priorities of different units. Bakon & Millichamp found that other units had priorities, such as resuscitation status whereas the emergency department nurses prioritized monitoring of vitals. The final version was utilized by an emergency department nurse completing this form prior to patient transfer to another unit. Once it was completed, it was faxed to the received unit and followed up by a phone call from the emergency department nurse. The phone call allow and opportunity for the receiving nurse to ask questions and gather any further information regarding the patient.
Over a four-week period, surveys were sent to the participating units and nurses to gather data. Limitations of the study included a smaller number of participating emergency department nurses, possibly due to the nature of staffing in this department. In addition, this study was limited to one hospital and therefore did not include patients who were transferred to units that were not on-site. There was positive feedback regarding the use of the tool, which indicates nurses may be amenable to the implementation of standardized tools. The researchers argue that standardized tools should be structured and easy to use.
Project 4. A study performed by Carroll, Williams, and Gallivan (2012) states that while handoff reports are a part of everyday work duties for nurses, there is little information on what constitutes a “good handover.” This multi-method study was conducted on two medical-surgical units and included survey questionnaires, direct observation, audio taping, and a post-handoff questionnaires. The researchers found that most of the handoff sessions lasted between two to thirteen minutes and only 26% of the active medical issues were included in the reports. The subtheme of the study was nurse perceptions of the handoff report. Nurses’ opinions on the handover interaction found that oncoming nurses were more satisfied with increased eye contact whereas the outgoing nurses rated the interaction higher when the interaction was shorter with fewer questions and less eye contact.
The study was limited to two medical-surgical nursing units, which may have affected the outcomes of the study. Further research is recommended on what a “good handover” is and should include other types of acute care units to determine if the findings are similar. Carroll acknowledges the importance of handoff reports, there appears to be crucial information on the patient status that is not discussed during the process. Nurse opinions of the handoff interaction varies as well, which could be a factor in the amount of information that is discussed during the handoff process. The development of handoff guidelines may be an appropriate intervention in helping to improve the handoff process while ensuring all pertinent patient information is discussed.
Conclusion. Nursing satisfaction has shown to increase with effective handoff reports. Oncoming nurses who receive and short and concise handoff report may then begin their day in a timely fashion, which will in turn allow for increased patient safety. Moreover, this will help to ensure continuity of care and prevent the occurrence adverse events. Nonverbal and verbal forms of communication may be factors in the level of satisfaction for nurses but other factors, such as the culture of the unit, can also be influential.
Behavioral Change.
Project 1. A mixed methods study by Leijen-Zeelenberg, van Raak, Duimel-Peeters, Kroese, Brink, Ruwaard, & Vrijhoef (2014) aimed to identify barriers to implementing change in the implementation of handoff tools in the acute care setting. The study implemented a standardized electronic communication tool with an emphasis on information transfer and feedback. The study involved six acute care units in the Netherlands, with five of the units serving as control groups. Interviews via focus groups were performed in addition to questionnaires that were completed by nurses, general practitioners, psychiatrists, and medical specialists from a variety of acute care units, which totaled 40 participants. Three main barriers were identified, which included a change to providers’ existing handoff routines, implementation methods, and lack of urgency in the need for improved handoff tools. Organizational change is necessary to implement new practice methods, such as the use of a new handoff tool. Each practitioner must also be willing to participate and accept new methods of communication, which involves learning new methods but also requires unlearning old habits. In order to unlearn old habits, the researchers “suggests that openness to vulnerability, willingness to listen, reflection of feeling and a high tolerance for raised feelings are important qualities for unlearning” (Leijen-Zeelenberg et al., 2014).
Project 2. A survey study performed by Lee, Phan, Dorman, Weaver, & Pronovost (2016) utilized the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture (HSOPSC) to examine the relationship between perceptions of handoff reports, patient safety culture, and patient safety. The study was performed in a large pediatric medical center containing two campuses. The study found that staff perceptions of the hospital’s safety culture had an impact on safety practices, such as handoff reports. While the researchers note the “psychological links between perception, attitude, and behavior,” patient safety can be increased by effective handoff communication (Lee, Phan, Dorman, Weaver, & Pronovost, 2016). In regards to behavior, the results found that transfer of care (whether during shift change or transfer of units) was influenced by handoff reports. The researchers note that individual behavior and organization need to be addressed “before shared beliefs and values on perceptions of patient safety cane be formed” (Lee, Phan, Dorman, Weaver, & Pronovost, 2016). While communication methods are key in providing effective handoff reports, behavior also plays a large role in the ability to perform this duty. The overall safety culture of the facility may also play a role in staff behavioral approach to patient safety.
Project 3. Patton, Tidwell, Falder-Saeed, Young, Lewis, & Binder (2017) performed a quality improvement project to identify safest practices during unit transfers among pediatric patients. The study created and implemented a facility wide handoff tool to promote patient safety and to ensure patient information was addressed. While there was an increase in patient safety, there was also an increase in nurse satisfaction. Prior to the implementation of the tool, nurses expressed concern regarding receiving patients from other units due to limited patient information communication. While the use of a standard tool was implemented, the researchers involved the nurses to identify areas in which the transfer process may be improved. In terms of behavioral change, this study represents the importance involving staff to increase compliance when implementing change. If staff are involved, they may gain more of a sense of ownership and become more accepting to adopting new practices.
Conclusion. Behavioral change is an important factor when implementing new practice methods. Having an understanding of the need for unlearning old practices while implementing new methods needs to be recognized. Staff behaviors are affected by overall culture of the unit and hospital or facility, therefore leadership plays a significant role in promoting patient safety. Leadership involvement and promoting a sense of urgency may help to decrease resistance among staff and therefor increase the willingness to adopt new handoff methods. Moreover, leadership involvement may help to ensure staff are continuing to utilize the standardized handoff protocols.
Summary
The need for efficient nursing handoff reports is becoming more recognized. Handoff reports are crucial in communication patient status during the transition of care. This helps to maintain patient safety and prevent, or decrease, the occurrence of sentinel events. The Joint Commission has identified standardized nursing handoff tools as a viable measure to increase the efficacy of handoff reports. While Medical Surgical units tend to have patients that are considered to be more stable, many of them have comorbities, thus increasing their risk for adverse events related to poor handoff reports. Research has shown that the implementation of a standardized tool has been effective in improving handoff reports, however, little research has been done on medical surgical units, particularly in Southern California.
The theoretical foundations related to this project are Kurt Lewin’s change theory and E.M. Roger’s Innovation Diffusion Theory. These theories help to identify a framework to address the need for change while taking the individuals’ (i.e. nurse’s) involvement and acceptance of the change. Moreover, shared values and beliefs related to safety culture between individuals and the organization are also a factor in maintaining patient safety.
A literature review was performed using CINAHL, Science Direct, Academic OneFile, InfoTrac and Health Reference Center Academic to further investigate current practices and studies regarding handoff reports. Two major themes, communication and nursing care, were identified and six subthemes were further investigated: handoff failures, standardized handoff tool, bedside report, patient safety, nurse satisfaction, and behavioral change. The literature review indicates that patient safety is at high risk directly related to poor handoff reports. Several factors can be related to poor handoff reports, including lack of training, frequent interruptions, poor verbal and nonverbal communication, and a lack of situational awareness.
The literature review supports the need for improvement of handoff reports. Utilizing standardized tools, such as I-PASS or HAND-IT, may help to ensure nurses are discussing all important aspects of patient care. A mixed-methods design will be used for this project utilizing surveys. The quantitative portion will involve a points-based system and the qualitative portion will ask an open-ended question to the report-giver and the report-receiver. The aim of the project is to determine if a standardized handoff tool improves handoff reports among nurses on a Medical Surgical unit in a Southern California hospital.
Chapter 3: Methodology
Handoff reports are critical discussions regarding patients during transition of care. Poor communication during handoff reports can result in sentinel or near-miss events in the acute care setting (The Joint Commission, 2017). Increasing recognition regarding the need for effective communication has led to the belief that the use of a standardized handoff tool may help to improve communication during handoff reports (Hada, Coyer, & Jack, 2018, p.10). The purpose of this project was to determine how the use of standardized handoff reports influence the efficacy of handoff reports among medical/surgical and direct observation unit nurses in a Southern California hospital. This chapter will discuss the project methodology, findings, and recommendations.
Statement of the Problem
While the literature indicates that the use of a standardized handoff tool increases effective communication among nurses, it was not known if and to what degree using a standardized handoff tool among medical/surgical and direct observation unit nurses will reduce the number of falls. The real issue affecting nurses and patients is the ability to communicate effectively during handoff reports. The risk for adverse events increases significantly when there are poor handoff reports given, which could result in death or serious harm to the patients (Kear, Bhattacharya, & Walsh, 2016, p. 379). The importance of effective communication is becoming more recognized but there has not been significant research indicating the impact of more in-depth education regarding handoff reports among nurses. Literature recognizes that the use of tools in nursing practice help to foster and improve communication skills.
Handoff, also referred to as handover, reports are essential in providing safe care for patients. During the handoff report process, patient status and information is communicated between healthcare practitioners, such as between two nurses during a “change of shift” report (Kear, Bhattacharya, & Walsh, 2016, p. 384). During this time, it is critical to communicate important information regarding patient care to ensure continuity of care as well as patient safety. As stated by The Joint Commission (2017) “a hand-off is a transfer and acceptance of patient care responsibility achieved through effective communication.” Some causes for poor communication may include “inaccurate, incomplete, not timely, misinterpreted, or otherwise not was is needed” (The Joint Commission, 2017), leading to adverse events resulting in sentinel events. With the use of the standardized I PASS the BATON tool on the medical/surgical and direct observation units in a Southern California hospital, patient safety may be improved and maintained.
Clinical Question
Several clinical questions will help guide this quantitative project.
Q1: To what degree does using the I PASS the BATON tool as a standardized handoff tool impact on the fall rates on medical/surgical and direct observation units? Fall rates will be obtained on both the medical/surgical and direct observation units before and after the implementation of the I PASS the BATON standardized handoff tool. The aim of this clinical question was to determine if fall rates decline with the use of a standardized tool.
Q2: To what degree does using the I PASS the BATON tool as a standardized handoff tool increase nurse satisfaction with the handoff process as demonstrated by survey responses regarding satisfaction with handoff reports pre- and post-tool implementation? The degree to which nurse satisfaction is impacted by the use of the I PASS the BATON standardized handoff tool was measured. A survey created by Anderson & Mangino (2006) was to be completed by the nurses in an effort to collect quantitative data regarding nurse satisfaction with the handoff reports pre- and post-tool implementation. This was determined by requesting nurses receiving report to complete a brief set of questions regarding the quality of communication pre- and post-tool implementation. There will be a total of 6 questions and will be based off a 1 to 5 scale, 1 meaning very dissatisfied, 2 dissatisfied, 3 neutral, 4 satisfied, and 5 meaning very satisfied. The nurse receiving report were requested to complete two surveys per shift.
The use of the survey pre- and post-tool implementation aimed to determine if there was a change in the level of satisfaction with the handoff process. In an effort to measure patient safety, fall rates were obtained from both participating units to determine if there was a decrease in the amount of patient falls pre- and post-implementation of the standardized handoff tool. The use of questions and fall data collection aimed to provide quantitative data that could be measured to determine if there were variations in the variables pre- and post-tool implementation.
Project Methodology
The purpose of the doctoral project was to introduce a standardized handoff tool in an effort to improve nursing handoff reports on medical/surgical and direct observation units in a Southern California hospital. Using a quantitative quasi-experimental pre- and post-survey design, data was obtained by identifying patient fall rates pre- and post-tool implementation and by determining nurse satisfaction with the handoff process by asking nurses to complete a brief survey. It was not unknown that handoff reports are an area in which improvement is needed. However, it was not known how nurses on Southern California medical/surgical and direct observations units perceived the handoff process.
Obtaining the quantitative data by requesting nurses receiving report to respond to a set of 6 questions pre- and post- tool implementation helped to determine if nurse satisfaction with handoff reports improved with the use of the tool. On a scale of 1 to 5, the report-receiver rated the report-giver’s ability to provide clear, concise, and pertinent patient information as well as the level of satisfaction with the handoff communication.
Project Design
Quasi-experimental quantitative design was chosen due to the ability to measure the variables, which include the fall rates and nurse satisfaction with handoff reports in this project. This design was selected over descriptive or correlational research due to the ability to measure and manipulate the variables instead of simply observing (Ingham-Broomfield, 2014, p. 33). Surveys provide a standardized procedure for obtaining answers to questions and maintains objectivity (Morgan, 2014, p. 52). The use of quantitative methods via survey allowed for generality, however, in this project the range of survey participants was limited to registered nurses on the medical/surgical and direct observation units (Morgan, 2014, p. 52).
Data collection was performed by asking set of questions pre- and post-tool implementation. The falls data will be provided by the hospital educator for the medical/surgical and direct observation units. The data sets included the first week of the project prior to implementing the I PASS the BATON tool and the second set included patient fall data post-tool implementation. The rates of falls were compared to determine if there is a variation in the fall rates before and after the tool was implemented.
Prior to the start of the project, the night and day shift nurses were educated on the purpose of the project during shift change report. There was a very short discussion on the I PASS the BATON tool, the appropriate use of the tool, and the set of questions that will be required after each handoff report pre- and post-tool implementation. There was written material for the nurses to review throughout their shift so they had an understanding on the purpose of the tool as well as the requirements. The author was also be on-site during the beginning stages of implementing the pre-tool series of questions as well as during the implementation period. The author was also be available via phone when not on-site in case the nurses had any questions or concerns regarding the handoff process.
Population and Sample Selection
The project was completed on medical/surgical and direct observation units and involved a combined total of 16 nurses pre-implementation and 10 post-implementation. The sample size was determined by using a 95% confidence level with a 5% margin of error based off of the number of nurses who work on the medical/surgical and direct observation units. The project population included both day and night shift registered .
The project site was at a hospital in Placentia, California on the medical/surgical and direct observation units. The medical/surgical units have a high number of minor post-surgical and orthopedic patients. The direct observation unit has more unstable patients, particularly those who require constant cardiac monitoring and are at high risk for decline in status. The nurses who participated were limited to registered nurses who work on these units. Data will be stored for 3 years (until approximately November 17, 2022) and will personally be destroyed by the primary investigator by shredding all documents.
Instrumentation or Sources of Data
The sources of data included the pre- and post-tool implementation surveys, which will provide quantitative data. Utilizing SPSS, the variables were analyzed to determine if there was a variation between the pre- and post-tool implementation regarding nurse satisfaction with the handoff process. The nurses used the I PASS the BATON mnemonic for handoff reports during the second half of the duration of the project. Data regarding patient falls were obtained by the hospital educator pre- and post-tool implementation to determine if there was an impact in patient safety during the two week period of the project.
Validity
Validity refers to the accuracy of data results in a quantitative study (Heale & Twycross, 2015). “Validity determines whether the research truly measures what it was intended to measure or how truthful the research results are” (Golafshani, 2003, p. 599). In an effort to maintain validity of the project, a score system will be utilized for the surveys previously utilized by Anderson & Mangino (2006) study related to bedside handoff reports. The surveys were completed pre- and post-tool implementation by the nurses receiving report. The use of a scored system allowed for construct and criterion-related validity to ensure data is valid (Heale & Twycross, 2015). Internal validity may have posed a concern as some nurses may be more generous with scoring instead of giving accurate scores. In an effort to avoid a breech in internal validity, it was reinforced that that information on the questionnaires provided will not be shared with individuals other that the primary investigator and project chairs. The validity of the I PASS the BATON tool was determined by the use of the set of questions to be completed by the nurses to determine the level of satisfaction with handoff report as well as the number of patient falls before and after the implementation of the tool.
Reliability
Reliability refers to how consistent measurements are in a study (Heale & Twycross, 2015). Reliable research would allow for other researchers to replicate the study in the future utilizing similar methodology (Golafshani, 2003, p. 598). Golafshani (2003) recognizes that a “high degree of stability,” which refers to the ability to reproduce similar results in a test-retest method, leads to a higher level of reliability )p. 599). In an effort to ensure reliability, descriptive statistics was utilized in order to provide quantitative data analysis from the series of questions regarding nursing satisfaction with handoff reports and for patient falls pre-and post-tool implementation. The project design and methods will be clearly described as well as the data analysis process and findings.
Data Collection Procedures
The primary investigator attended shift change report at 7am and 7pm on several different days prior to the start of the project. The primary investigator verbally described what was expected of the nurses, such as completing a series of questions pre- and post-tool implementation, performing handoff report as the usually do for one week, and then performing handoff report for one week utilizing the I PASS the BATON mnemonic. Flyers regarding the project were posted in the unit breakrooms and nurses station in order to gain recognition for the need of participants. Nurses had the freedom to choose if they would like to participate in the project after receiving education on the purpose and procedure of the project.
Data collection began with obtaining fall rates on the medical/surgical and direct observation units, which were provided by the hospital educator. For the first week of the project, nurses were asked to complete the pre-tool implementation series of questions after they performed their usual method of handoff reports. After the pre-tool implementation stage, a brief orientation the standardized tool provided to the participants via verbal discussion during change of shift and handwritten tools. At the end of the tool implementation period, a second set of patient fall data was obtained from the hospital educator.
The patient fall data was obtained over the two week period of the project. Patient fall data was collected during the first week of the project, during which time the I PASS the BATON tool will not be utilized. This time frame of the patient fall data was over the course of 7 days, ending on the evening prior to the implementation of the I PASS the BATON tool during handoff reports. Patient fall data post-tool implementation was collected for the same duration of time, which was 7 days after the tool was being used by the nurses. Once all patient fall data had been collected, data was analyzed to determine if there was a change in patient fall rates.
Data Analysis Procedures
Using descriptive statistics, data was analyzed in SPSS. The quantitative data included the scored surveys that were answered by the nurses to determine if there wass a significant change in scores between pre-and post-tool implementation. The variables that were measured will included: accountability for completing nursing, ability to seek clarification during report, satisfaction of interpersonal relationships, patient condition, pertinent information included in report, and satisfaction with report time. Another variable that was analyzed was the patient fall rates pre- and post-tool implementation.
Ethical Considerations
The basic ethical principles identified in the Belmont Report shall be upheld in this project. Such basic principles include respect for persons, beneficence, and justice (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979). The respect for nurse autonomy will be maintained by allowing nurses to choose whether or not they wish to participate in the project. Beneficence was maintained as no individuals (i.e. nurses or patients) will be harmed in this project. The project consisted of data collection related to patient fall rates and involved nurse participation in utilizing the I PASS the BATON handoff tool, neither of which will involve a risk for harm. All nurses will be treated justly and will not be discriminated based off age, gender, or experience (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979). However, for the purpose of this project, it will be required that participating nurses have an active registered nursing license in the state of California. During the data collection, nurses’ information will be kept anonymous and stored in a sealed envelope at the charge nurses’ desks. Patient privacy concerns related to falls data were addressed by omitting patient identifiers from the data collected during the pre- and post-tool implementation periods.
Limitations
Limitations of the project included a smaller sample size related to the size of the hospital and the limitation to two units within the site. Another possible limitation was the length of time for the training of the standardized tool as well as a smaller sample size. Some nurses may not have been willing to score their peers honestly for fear of breech of privacy or directly related to interpersonal relationships with peers.
Summary
Handoff reports are critical components in ensuring patient safety. The literature indicated that the use of a standardized handoff tool increases effective communication among nurses during handoff reports. However, little is known how the use of a standardized tool in a small Southern California hospital would be affected by the permeation of a standardized tool. The purpose of this doctoral project was to introduce a standardized tool to a Medical Surgical Unit and Direct Observation Unit in an effort to determine if communication methods improved. Quantitative and qualitative data were obtained via surveys and data collection regarding patient falls and medication errors. Limitations of the project include a smaller sample size and potential for internal validity concerns related to peer relationships among nurses.
Chapter 4: Data Analysis and Results
Upon performing a literature review, it was found that the use of a standardized handoff tool helps to improve the communication between nurses during handoff reports. However, it was not known if the rate of patient falls is affected by the use of a standardized handoff tool on a medical/surgical and a direct observation unit in a Southern California hospital. Streeter & Harrington (2017) note that a large number of adverse events in the acute care setting are directly linked to poor communication among healthcare practitioners. Adverse events, such as falls, may lead to serious patient harm or even death.
The purpose of the project was to determine if the use of a standardized handoff tool affected the frequency of patient falls pre- and post-implementation of the I PASS the BATON tool. Another clinical question investigated during the project was to determine if nursing satisfaction was impacted with the use of a standardized handoff tool. Using a quasi-experimental quantitative design, statistical data was obtained and analyzed to identify the relationship between the two variables: patient falls and nursing satisfaction. This chapter will discuss the descriptive data, data analysis procedures, and the findings of data analysis.
Descriptive Data
The population involved in this project consisted of registered nurses working on medical/surgical and direct observation units at a small hospital in Southern California. Surveys were anonymous and only requested years of experience as a registered nurse. The years of experience ranged from 1 year to 16 years between the two units. There was otherwise no personal or identifiable data collected during the project. As noted in Tables 1 through 4, nurses completed 10 surveys pre-implementation and 6 surveys post-implementation while the nurses on the direct observation unit completed 22 pre-implementation and 14 surveys post-implementation.
Table 1
Pre-Implementation Medical/Surgical Unit Surveys
Table 2
Pre-Implementation Direct Observation Unit Surveys
Table 3
Post-Implementation Medical/Surgical Unit Surveys
Table 4
Post-Implementation Direct Observation Unit Surveys
Data Analysis Procedures
To examine the clinical questions, quantitative research design was most appropriate to measure the affect of the I PASS the BATON tool on nursing satisfaction and patient fall rates. During week one of the project, nurses continued to perform handoff report as they normally did and the oncoming nurses were asked to complete satisfaction surveys after receiving report. During the second week of the project, the I PASS the BATON tool was implemented. Nurses were asked to use the tool when giving report to the oncoming nurses. The oncoming nurses were again asked to complete satisfaction surveys after receiving report from the outgoing nurse using the handoff tool. Data was analyzed with the assistance of a data analyst using Fisher’s exact tests to determine if the results were statistically significant.
Potential sources of error in the project regarding patient falls could include unreported patient falls on the units. There is potential for errors regarding nursing satisfaction with the use of a standardized tool. First, if nurses did not fully understand how to use the I PASS the BATON tool, it may not have been used appropriately. Second, there is no guarantee that all of the nurses were using the I PASS the BATON tool during the post-implementation stage. This could have affected nursing satisfaction among the oncoming nurses during this stage. Lastly, despite the surveys remaining anonymous, some nurses may not have truthfully answered surveys, perhaps because of feeling overly generous with answers (i.e. agree or disagree). This could have affected internal validity but it is unknown if nurses were completely honest on the surveys.
Despite the potential for breech of internal validity, validity was maintained with the analysis of the data. The validity of the data was maintained by using a score system for the nursing satisfaction surveys, which allows for criterion-related validity (Heale & Twycross, 2015). Reliability was maintained in the project due to the ability to reproduce similar results. However, factors may influence the level of nurse satisfaction in other acute care settings, such as interpersonal relationships, years of experience, and nurse workload. The fall rates were not as reliable due to the low rates of falls on the units. Because fall rates were overall low, the fall rate analysis was not statistically significant with the Fisher test.
Results
The first clinical question aimed to examine was to what degree does using the I PASS the BATON tool as a standardized handoff tool impact on the fall rates on medical/surgical and direct observation units. On the medical/surgical unit, there was one fall during pre-implementation period and one fall during post-implementation period. The direct observation unit had one fall during pre-implementation period and two falls during the post-implementation period. Thus, the total number of falls slightly increased overall from two to three overall, a 50% relative increase. Table 5 demonstrates the fall rates pre- and post-tool implementation with the medical/surgical unit described as “Med/Surg” and the direct observation unit listed as “DOU.”
Table 5
Patient Fall Rates Pre- and Post-Implementation of a Standardized Handoff Tool
The second clinical question aimed to examine to what degree does the use of the I PASS the BATON tool as a standardized handoff tool increase nurse satisfaction with the handoff process. This question was demonstrated by survey questions regarding satisfaction with handoff reports pre- and post-tool implementation. The results are presented by unit and for the total sample. As shown in Table 6, there was a statistically significant improvement in perceptions for the medical/surgical unit on four out of the six survey items. The direct observation unit had improvements on all but one item with no statistically significant changes on any of the six items.
Table 6
Handoff Survey Responses by Unit
|
Item |
Unit |
n (%) responses of “Strongly Agree” or “Agree” |
Fisher’s exact p-value |
|
| Pre | Post | |||
| Staff is accountable for completing nursing care (IVs have 300+ left, dressing changes completed, etc.) | Med/Surg | 3 (30%) | 6 (100%) | .011 |
| DOU | 14 (63.6%) | 12 (85.7%) | .255 | |
| Before I assume care of patients, my questions about the patients are answered. | Med/Surg | 4 (40%) | 6 (100%) | .034 |
| DOU | 18 (81.8%) | 13 (92.9%) | .628 | |
| Interpersonal relationships between shifts are good. | Med/Surg | 3 (30%) | 6 (100%) | .011 |
| DOU | 18 (81.8%) | 13 (92.9%) | .628 | |
| Patient condition matches what I get in report. | Med/Surg | 4 (40%) | 6 (100%) | .034 |
| DOU | 12 (52.2%) | 12 (85.7%) | .074 | |
| Shift-to-shift report gives me pertinent information related to patient condition. | Med/Surg | 4 (40%) | 5 (83.3%) | .145 |
| DOU | 14 (63.6%) | 11 (78.6%) | .467 | |
| Report time is adequate. | Med/Surg | 5 (50%) | 4 (66.7%) | .633 |
| DOU | 17 (77.3%) | 10 (71.4%) | .712 | |
Note. Sample sizes for Med/Surg Unit were n=10 at pre and n=6 at post; sample sizes for DOU unit were n=22 at pre and n=14 at post.
When evaluating the responses for the total sample (Table 7), there were statistically significant improvements on four of the six items, although all items showed improvement in responses. The data suggests that the use of a standardized handoff tool improved nurse satisfaction with the handoff report for the oncoming nurses on both units.
Table 7
Handoff Survey Responses for Total Sample
|
Item |
n (%) responses of “Strongly Agree” or “Agree” |
Fisher’s exact p-value |
|
| Pre
(N=32) |
Post
(N=20) |
||
| Staff is accountable for completing nursing care (IVs have 300+ left, dressing changes completed, etc.) | 17 (53.1%) | 18 (90%) | .007 |
| Before I assume care of patients, my questions about the patients are answered. | 22 (68.8%) | 19 (95%) | .035 |
| Interpersonal relationships between shifts are good. | 21(65.6%) | 19 (95%) | .018 |
| Patient condition matches what I get in report. | 16 (48.5%) | 18 (90%) | .003 |
| Shift-to-shift report gives me pertinent information related to patient condition. | 18 (56.3%) | 16 (80%) | .133 |
| Report time is adequate. | 22 (68.8%) | 14 (70%) | .999 |
Summary
This section provides a concise summary of what was found in the project. It briefly restates essential data and data analysis presented in this chapter, and it helps the reader see and understand the relevance of the data and analysis to the clinical question(s). Finally, it provides a lead or transition into Chapter 5, where the implications of the data and data analysis relative to the clinical question(s) will be discussed. The summary of the data must be logically and clearly presented, with the factual information separated from interpretation. For qualitative studies, summarize the data and data analysis results in relation to the clinical question(s). For quantitative studies, summarize the statistical data and results of statistical tests in relation to the clinical question(s). Finally, provide a concluding section and transition to Chapter 5.
Chapter 5: Summary, Conclusions, and Recommendations
Efficient communication during nursing handoff reports is essential in maintaining patient safety. During change of shift reports, critical patient information is passed on from one practitioner (i.e. the outgoing nurse) to the practitioner assuming care (i.e. the oncoming nurse). Ineffective handoff reports may be related to incorrect or too little information, untimely, or is left to inaccurate interpretation (The Joint Commission, 2017). Streeter & Harrington (2017) note that about 65% of sentinel evens in the acute care setting are directly related to poor communication during handoff reports. Due to the high risk for patient harm, it is essential that proper handoff reports be performed.
Summary of the Project
The purpose of this project was to determine if the standardized I PASS the BATON tool affected patient safety by measuring the rate of patient falls. The level of nurse satisfaction with the use of a standardized handoff tool was also investigated. Research indicates that the use of standardized handoff tools can help to promote more effective communication and may, therefore, positively impact patient safety.
Summary of Findings and Conclusion
Effective communication plays a significant role maintaining patient safety and may promote nursing satisfaction with handoff reports. The Joint Commission (2017) states that poor communication during handoff reports may lead to adverse patient events, causing harm, or in some cases, death, to patients. The I PASS the BATON tool is a standardized handoff tool that may be utilized during nursing handoff reports to ensure that all pertinent patient information is discussed before the oncoming nurse assumes care of patients.
A literature review was performed to determine if a standardized handoff tool has been shown to affect the efficacy of nursing handoff reports. The major themes identified upon literature review were communication and nursing care, both of which directly affect patient safety. The findings of the literature review indicate that handoff failures have a significant impact on the safety of patients in the acute care setting Abraham et al. (2016). While there has been research indicating a positive impact on patient safety and nursing communication with the use of a standardized handoff tool, there has been minimal research performed in smaller acute care settings in Southern California.
Using a quantitative quasi-experimental research design, this project aimed to determine if the fall rates on medical/surgical and direct observation units were affected by the use of the I PASS the BATON handoff tool. Another aspect that was investigated was the impact of the I PASS the BATON tool on nurse satisfaction with the handoff reports. Nursing satisfaction surveys were completed by registered nurses on medical/surgical and direct observation units to determine if nursing satisfaction improved with the use of the standardized handoff tool. Patient safety was measured by obtaining patient fall data pre- and post-implementation of the handoff tool. This chapter will summarize the findings of the project and will discuss the conclusions of the project findings.
Implications
The project aimed to examine the effect of the use of the I PASS the BATON tool as a standardized handoff tool in the acute care setting. This section will discuss the theoretical implications, particularly regarding the influence of Lewin’s Change Theory and Roger’s Innovation Diffusion Theory. Secondly, the practical implications of the project findings will be discussed. Lastly, future implications will be identified.
Theoretical implications.
Kurt Lewin’s Change Theory is comprised of three stages: unfreezing, change, and refreezing. Roger’s Innovation Diffusion Theory, which is an expansion of the Lewin’s Change Theory, identifies how change may be influenced by individuals or organizations. When implementing change among nurses, such as the use of a standardized handoff tool, these tools may prove to be helpful in carrying out the planning and implementation stages. While thy may have been helpful in this project, such as the unfreezing (i.e. recognizing the need for more efficient reports) and the change stages, a longer period of time to perform the project may have allowed for more reinforcement with the change process. Moreover, this may have allowed a better utilization of Roger’s theory by identifying the leaders and those willing to adopt change may have lead to more participation among the nurses, particularly on the medical/surgical unit.
The first clinical question examined in this project was to determine to what degree using the I PASS the BATON tool as a standardized handoff tool would impact the fall rates on medical/surgical and direct observation units. The overall fall rates were fairly low at the hospital in which the project took place. The rate of falls between the medical/surgical and direct observation units during the pre-implementation period was 2 while the number of falls during the post-implementation period was 3. The reason for increase in falls is unclear but it may be related to factors such as increased general patient acuity, years of experience of staff, or poor handoff reports.
The purpose of the second clinical question was to examine to what degree does the use of the I PASS the BATON tool as a standardized handoff tool affect nurse satisfaction with the handoff report process. The nurses on the medical/surgical and direct observation units completed surveys after receiving handoff report from the outgoing nurse during the pre- and post-implementation periods. Overall, nurse satisfaction with the handoff reports appeared to improve during the post-implementation period in which the I PASS the BATON tool was used.
The findings of the project indicate there was an improvement with nurse satisfaction with reports, there was no significant improvement in the patient fall rates. While the literature review found that patient safety improved, many of these literature reviews were performed in larger hospitals in the United States and performed for a longer duration. Therefore, a limitation to this project was that it was in a smaller hospital in Southern California. Another limitation is the duration of the project, which was two weeks, may not have allowed enough time for sufficient data collection.
Practical implications.
Literature review had found that nurse satisfaction with handoff reports varied among settings but many of the findings indicated that nurses felt there was room for improvement. This project did find an increase in nurse satisfaction with the report process after the use of a standardized tool was implemented. If nurses are more satisfied with handoff reports, this may encourage a more positive interaction between outgoing and oncoming nurses and therefore improve communication regarding vital patient information.
Future implications.
Upon the initial literature review, it had been identified there is evidence that supports the need for more efficient nursing handoff reports. While there were a variety of settings discussed in the literature review, there was little information on the effect of a standardized handoff tool in a small acute care setting. While the findings of the project found there to be an increase in nursing satisfaction with the nursing handoff reports, there was no significant improvement in the patient fall rates. It is possible that as nurses become more familiarized with the I PASS the BATON tool, handoff reports will continue to improve and therefor positively impact the rate of patient falls. Future projects may benefit from a longer data collection period in an effort to collect more fall data and to determine if a longer period of time continues to improve the handoff report process.
Recommendations
Several recommendations were identified for future projects. The first recommendation is to implement a standardized handoff tool to help nurses ensure all pertinent information is discussed in report. Several recommendations for future projects include a longer duration for data collection, more nurse education regarding the use of the tool and data analysis tools, and performing a project at a site with a larger patient population.
Recommendations for future projects.
It is recommended that future projects examining the use of the I PASS the BATON tool perform the data collection period over a longer time frame. This may allow more ample time to obtain data, such as nursing satisfaction surveys and monitoring the rates of patient falls. Due to the increase in overall nurse satisfaction with the handoff report process, patient safety may be positively impacted over a longer timeframe. The longer duration of project implementation may also allow for more time to educate the nurses on the appropriate use of the handoff tool as well as the data collection tools. Lastly, a larger patient population may provide more sufficient data regarding patient safety, such as falls.
Recommendations for practice.
The use of a standardized handoff tool may be helpful in increasing the level of nurse satisfaction with handoff report. Handoff report is an essential tool in ensuring the oncoming nurse has vital information regarding patient status and upcoming activities scheduled during the shift. While there is no clear identification of a change in nurse satisfaction with interpersonal relationships between shifts, the use of a standardized handoff tool and the improvement of handoff reports may positively impact these relationships. Patient safety remains to be a priority in the acute care settings. The use of a standardized handoff tool may aid in effective handoff reports, thus improving patient safety measures and outcomes.
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Appendix A
Ten Strategic Points
Appendix B
I PASS the BATON Handoff Tool
“I PASS the BATON” is a TeamSTEPPS tool that provides one option for conducting a structured handoff.
| I PASS the BATON | ||
| I | Introduction | Introduce yourself and your role/job (include patient). |
| P | Patient | Name, identifiers, age, sex, location. |
| A | Assessment | Presenting chief complaint, vital signs, symptoms, and diagnosis. |
| S | Situation | Current status/circumstances, including code status, level of uncertainty, recent changes, response to treatment. |
| S | Safety Concerns | Critical lab values/reports, socio-economic factors, allergies, alerts (falls, isolation, etc.) |
| the | ||
| B | Background | Co-morbidities, previous episodes, current medications, family history. |
| A | Actions | What actions were taken or are required? Provide brief rationale. |
| T | Timing | Level of urgency and explicit timing and prioritization of actions. |
| O | Ownership | Who is responsible (nurse/doctor/team)? Include patient/family responsibilities. |
| N | Next | What will happen next? Anticipated changes? What is the plan? Are there contingency plans?
|
TeamSTEPPS. Content last reviewed January 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html
Appendix C
Nursing Satisfaction Survey
| Anderson, C.D. & Mangino, R.R. (2006). Nurse shift report; who says you can’t talk in front of the patient? Nurs Admin Q, 30(2), pp 11-122. |
Appendix D
I PASS the BATON Permission
Appendix E
Nursing Satisfaction Survey Permission
Appendix F
Site Approval Letter
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