DESIGNING A NURSE TO NURSE HANDOVER FORM, Lecture notes of Nursing

Download DESIGNING A NURSE TO NURSE HANDOVER FORM and more Lecture notes Nursing in PDF only on Docsity! IDENTIFYING CRITICAL INFORMATION FOR NURSING HANDOVER: DESIGNING A NURSE TO NURSE HANDOVER FORM by Nicola Jane Chalke B.Sc., University of British Columbia, 2006 B.A., University of Victoria, 1999 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMNTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) January, 2014 © Nicola Jane Chalke, 2014   ii   Abstract Patient handover represents a significant safety risk. At each handover information could be lost, misinterpreted or not well communicated. Patient handover refers to any time responsibility for a patient’s care is transferred from one care provider to another. This process requires succinct communication between the care providers, in this case nurses, to ensure continuity and safety of patient care. A significant handover that occurs daily on any nursing unit is the handover that occurs between nursing shifts: the departing nurse reports to the arriving nurse. The purpose of this research was to use an appreciative inquiry process to answer the question: what is the critical information that should be included in a nurse-to-nurse inter-shift report on an acute medical unit at a tertiary, urban teaching hospital? A purposive sample of nurses from the study unit worked together over three separate project group meetings to develop, pilot and refine a new handover form. The 4 D process of the appreciative inquiry method was used including: discover, dream, design and deliver. Thematic analysis was used for each cycle of the apprecitive inquiry process and the main themes found are presented. The central findings from this project included developing a handover form that presents succinct, organized, objective and written information that focuses on the critical events or information from the previous twelve hours and what needs to happen in the next twelve hours. To ensure appropriate use of the form the purpose of the form should be emphasized to all staff and connected to patient safety and continuity of care. In addition, the team discussed implementing a formal and informal feedback process to further encourage appropriate use of the form. Finally, developing trust among team members to ensure completion of the handover form and accompanying documentation, such as the kardex and careplans.   v   Design ................................................................................................................................. 106 Delivery............................................................................................................................... 107 Key Findings........................................................................................................................... 108 Limitations .............................................................................................................................. 126 Conclusions............................................................................................................................. 127 References................................................................................................................................... 130 Appendices.................................................................................................................................. 136 Appendix A: Literature review table ...................................................................................... 136 Appendix B: Script for project team recruitment (in-person)................................................. 139 Appendix C: Study description and consent Form ................................................................. 140 Appendix D: Survey participation flyer.................................................................................. 143 Appendix E: Survey cover letter (email) ................................................................................ 144 Appendix F: Email content for survey link............................................................................. 146 Appendix G: Previous AMU inter-shift report ....................................................................... 147 Appendix H: Questions for project group.............................................................................. 148 Appendix I: Photos of group designed inter-shift report ....................................................... 149 Appendix J: Inter-shift handover form draft #1..................................................................... 151 Appendix K: Inter-shift handover report final version .......................................................... 152 Appendix L: Survey questions final version.......................................................................... 153     vi   List of Tables Table 4.1 Summary of meetings and themes………………………………………….. 103   vii   Acknowledgments I would like to take this opportunity to offer my sincere gratitude for all of the support and encouragement from the faculty, my fellow students and nursing colleagues, who provided me with inspiration and motivation to maintain momentum and complete my project. I would like to offer special appreciation for the members of my thesis committee, Dr. Bernie Garrett and Lorraine Blackburn and especially to Dr. Maura MacPhee, my thesis advisor and mentor. I would like to thank Dr. MacPhee for her commitment to my project and for pushing, challenging and believing in me when I needed it the most. Thank you to my project team members who worked as hard as I did to make this project a reality. Each and every team member came to the project team meetings with an open mind and with a willingness to share their thoughts, ideas, experiences and dreams. Without them this project would not have been a success. Finally, I would like to express my gratitude to my family for their unending support in my education.   2   Background   The patient handover process represents a potential for a patient safety and quality incident. The terms handover and handoff are used interchangeably in the literature. For the purposes of this project the term handover will be used to ensure consistency. Patient handover refers to any time when the responsibility for patient care is transferred from one provider to another (Clarke, et al., 2012; Shandell-Falik, Feinson, & Mohr, 2007). As patients move between providers, nurse to nurse in this case, accurate, timely and critical information about the patient’s condition, care and treatment plan must also be transferred (Clarke, et al., 2012). Leonard, Graham and Bonacum (2004) indicate that “communication failures are the leading causes of inadvertent patient harm” (pg. 85). Missing information can result in significant patient harm, unanticipated delays in care and nursing time to track down this information (Clarke, et al., 2012; Shandell-Falik, Feinson, & Mohr, 2007). Functioning in an acute care hospital environment requires clear, accurate and timely team communications (Miller, Riley, & Davis, 2009). Significant patient injury due to poor communications can occur when care providers do not have the same understanding of what clinical information is vital to the care of the patient (Miller, Riley, & Davis, 2009). The creation of a standardized inter-shift handover report is supported in the literature to ensure consistency in communicating information that is considered vital to the patient’s care (Leonard, Graham, & Bonacum, 2004; Miller, Riley, & Davis, 2009; El-Jardali & Legace, 2005; Clarke, et al., 2012). Many regulatory bodies, such as Accreditation Canada, Qmentum Medicine Standards, and the College of Registered Nurses of British Columbia, Professional Standards of Practice, recognize the importance of patient handovers and both communication and documentation of these transfers of care (Accreditation Canada, 2011; College of Registered Nurses of British   3   Columbia, 2011). According to the Accreditation Canada Qmentum Medicine Standards, it is a required organizational practice to ensure effective communication of patient information between transition points (Accreditation Canada, 2011). More specifically, Accreditation Canada indicates that this transfer of information has been shown as a vital piece to improving patient safety between transition points, such as shift change, and that the healthcare team utilizes established means to transfer information timely and accurately (Accreditation Canada, 2011). In addition, the Institute for Healthcare Improvement (IHI) and the Canadian Patient Safety Institute (CPSI) have produced documents that further support the need for standardized communication tools between points of transfer, including shift change, to ensure patient safety and quality of care (Institute for Healthcare Improvement, 2009; The Safety Competencies Steering Committee, 2008). Current context   The Vancouver Coastal Health (VCH) Authority has also recognized the importance of standardized communication tools as a means to address patient quality and safety. Previous work includes the standardizing and implementation of the Surgical Safety Checklist. In addition, the health authority is moving towards standardizing practice and the information or technology systems regionally to improve communications. At Vancouver General Hospital (VGH) there has been a previous project in conjunction with the Emily Carr School of Art and Design communications students that has looked at methods or modes of communicating nurse to nurse inter-shift report. This included written report, but also use of technologies such as iPhones or Blackberries. In addition, VGH has standardized other reporting and communications, including the operations bed utilization   4   meetings that occur twice daily. These meetings aid in the planning and assessment of patient flow through the system and the different teams are expected to report on their expected discharges, surgical slates, anticipated staffing challenges and other important planning information in a standardized format. This has been helpful in decreasing variance during the report out and also to ensure all parties are in effect speaking the same language. Currently at VGH each nursing unit has their own system for nurses to pass along information between shifts. In speaking with the nurses on one acute medical unit, these “shift report forms” are “hit or miss” in terms of being filled out adequately or at all (Personal Communication, November 4, 2012). The nurse to nurse handover forms are often left blank or with information that is not crucial to the patient’s care plan and often times critical information is not being shared. In speaking with the nursing educators on this particular unit, they indicated anectdotally that often times the nurses are not sure what information is critical to the patient’s care (personal communication, November 4, 2012), which can be an indicator of nurses’ not having a shared understanding of what is considered critical information in the handover process. Problem statement   Currently VGH does not have a standardized handover process for shift change between nurses. The individual nursing units within VGH presumably have a handover process or form to communicate patient care needs and information between nursing shifts. This process or form is not standardized and is potentially missing vital information required for increased quality of care and patient safety. This is not congruent with requirements from Accreditation Canada or recommendations from safety institutions such as IHI or CPSI.   7   layout and format that worked on their unit and ensured a shared understanding among all of the frontline nursing staff. Both the data collection phase and the data analysis phase occurred concurrently (Polit & Beck, 2011). The project group were audio recorded, transcribed verbatim and analyzed by the researcher (Polity & Beck, 2011). Thematic analysis was used to identify critical information required in the nurse to nurse handover process. As a result of this process, a nurse to nurse handover form was created that incorporated the critical information identified by the end-users in the focus groups. Once the handover form was developed the form was shared with the group for validation and feedback. After validation the form was piloted on the study unit for a period of two weeks. During this implementation period an anonymous, online survey was available to all front line users of the form to give feedback and make recommendations. After the trial implementation period the project group came back together to analyze the feedback given by the staff nurses, make any necessary changes to the form and discuss strategies to support the change process. This represented the fourth phase of the AI process, the delivery phase, where there was a final creation of a new handover form, designed by the end-users (Shandell-Falik, Feinson, & Mohr, 2007). The hope is that this newly created handover form will be utilized for every handover and will contain the information required to achieve a “perfect handover”. This form can then be utilized by the unit and potentially adapted and utilized on other units in an attempt to standardize nursing shift handover on a more global scale at Vancouver General Hospital. Using the AI process focused the questioning of the group in a positive way and engaged the key stakeholders and end users in creating a new handover form, which increased the chances of   8   a successful project (Clarke, et al., 2012; Knibbs, et al., 2012; Shandell-Falik, Feinson, & Mohr, 2007; Sullivan Havens, Wood, & Leeman, 2006   9   Literature Review   In this chapter I will discuss my process for searching the literature for relevant articles on nursing handover. My definition of nursing handover is described, as well as the themes that have been found while searching the literature. These themes will be described and each of the primary articles will be summarized within the themes. A final summary of the literature will be included and will highlight areas that are missing from the current published literature. Search process   For this literature review, I searched Google Scholar, CINAHL and PubMed for articles related to nursing handover and any articles that combined the appreciative inquiry with nursing handover. My key words included appreciative inquiry, nursing handover, patient hand off and patient transfers. My exclusion criteria included any articles that were in print for greater than ten years, those published in a language other than English and articles that were not focused on nursing patient handover. From this search I retrieved 38 articles, and after utilizing the exclusion criteria, 14 articles remained that most closely related to my study. I will selectively describe the 14 research studies and findings of those articles that resemble my study setting, an acute care hospital in a large, North American city The articles included in this review and the purpose of each article are summarized in a table found in Appendix A and described in more detail in the literature review. Definition   Patient handover refers to any time when the responsibility for patient care is transferred from one provider to another (Clarke, et al., 2012; Shandell-Falik, Feinson, & Mohr, 2007).   12   open-ended questions about the current handover process and nurses’ preferred handover structure and method and part three was a Likert scale asking agreement questions about the handover process. For the direct observation component the research assistant observed information regarding “the style and structure of handover for each participating ward including duration, location and delivery” (Kerr, et. al., 2011, pg 344). Researchers’ observations discovered that all handovers were completed verbally and all units utilized a written handover sheet, which included basic information for all the patients on the unit. This sheet was handed out prior to the verbal handover commencing and allowed nurses to write notes and augment the sheet (Kerr, et. al., 2011). Kerr, et. al. found that there was vast variation across the same organization with regards to the structure and process of nursing handover, with variation in styles from unit to unit. For example, some units conducted morning to afternoon handover as a group, while other units gave nurse-to nurse handover reports or a charge nurse gave report for all the nurses. In addition, report occurred in a variety of locations with significant variation across units. Handover occurred for instance, at the nurses’ station, the charge nurse’s office, in the hallway, the supply room, break room and on only one unit at the patient bedside. The survey Likert scale findings indicated that nurses who completed the survey preferred both a verbal and written handover (68%); and their preferred location for handover was the staff room (67.3%). Over 80% felt that no change was necessary to their unit’s current handover process. Although a majority felt that no change was necessary, some comments to open-ended questions, indicated concern with interruptions (32%), relevancy of information provided (27.5%) and the length of time handover took to complete (25.5%). The findings of this study illustrate how there are large variations in handover process and structure, even within one organization. The authors discussed how handover could result in   13   patient safety incidents from a lack of continuity of care. Standardization, or implementation of guidelines or checklists, of the process and structure of this high-risk activity could be of benefit. Finally, this study highlights other critical aspects of handover such as interruptions, subjective information, missing information, relevancy and time constraints as major weaknesses of the current handover process (Kerr, et. al., 2011). Although 80% of the nurses surveyed did not feel that changes were needed to the handover process, the results of this study might serve to convince the nursing staff otherwise. The second article focusing on handover and patient safety that I will review is by Patterson & Wears (2010) and is a literature review from the Joint Commission on Quality and Patient Safety. The purpose of this literature review was to focus on the importance of standardizing handover for patient safety. The authors focused on the “primary functions” of the patient handover process. They focused on identifying themes, which they refer to as framings and each framing has a primary function (Patterson & Wears, 2010, pg. 52). The literature review examined articles that included nurse and physician handovers, and the review, conducted between 2008 to 2009, yielded 400 relevant articles (Patterson & Wears, 2010, pg. 53). The researchers synthesized the available literature and identified seven “primary framings” for patient handovers including information processing, stereotypical narratives, resilience, accountability, social interaction, distributed cognition and cultural norms (Patterson & Wears, 2010, pg. 55). I will discuss briefly each conceptual framing and the primary purpose of the framing. Information processing is the first framing and is the one most commonly found within the literature (Patterson & Wears, 2010). The main purpose of this framing is information transfer. This transfer of information is generally done within a busy environment with   14   interruptions, non-standardized language and background noise which open this process up to risk that information may not be correct or complete. The second framing is referred to as stereotypical narratives, which refers to reporting by exception. Highlighting what goes against the norm or the “deviations from the typical narratives”, discussing the abnormal results or situations such as allergies, is the primary function of handover in this framing (Patterson & Wears, 2010, pg. 56). Thirdly is resilience, which is taking a fresh set of eyes and looking at the information provided to make sure that it makes sense and that any assumptions have data to support them clinically. Accountability is the forth framing patient handover, and refers to the primary function of transfer of responsibility from one provider to another. The fifth framing is social interaction referring to how a handover is a construction of both caregivers, the departing and arriving caregiver and how they interpret the information together. Distributed cognition is the six framing. In this framing the primary function of handover is the transfer of care from one provider to another and how this affects the entire interdisciplinary team. For example, a change of attending physician can affect the interdisciplinary team caring for a patient who are not changing over. The entire team needs to be informed of this change of provider and also of any changes in the care plan or strategy. Finally, the last framing is cultural norms and how the group of care providers’ values are defined and how the unit or team culture is created and maintained. The authors of the review identified several primary functions for the handover process. For each framing, they indicated how standardization could improve handover process outcomes. They also discussed how standardization can be influenced by factors, such as culture. Each unit, therefore, should develop aa unique standardized process based on its practice environment, team dynamics, unit culture and patient population.   17   werer commentaries, letters or editorials The remaining 20 articles were independently reviewed in depth by two researchers to ensure overall agreement of the scoring. Content analysis was utilized to discover the barriers and strategies for handovers in nursing independently by both reviewers. The barriers included: communication elements (errors, omissions, role confusion and language barriers), problems specifically associated with standardization (non global understanding of the information required), equipment issues, environmental issues (interruptions or lack of dedicated space), lack of or misuse of time, difficulty with the complexity of cases, lack of training around the how to handover and finally human factors (non- engagment in the process) (Riesenberg, et. al., 2010). The facilitators focused on training and communication skills that addressed the barriers. For example, training around how to be clear and concise and manage time to include time for preparation manage; and communication skills to ensue the receiving RN understands the content being handed over (Riesenberg, et. al., 2010). Other strategies include standardization goals, including processes with guidelines and tools to ensure that essential information is included consistently, technologic solutions, environment solutions, training and education. In addition, the authors recommended that staff be involved in the development of these processes to increase buy in and that leadership be involved to ensure consistency. This finding supports my study utilizing an Appreciative Inquiry methodology which relies heavily on frontline staff involvement in the process. The barriers and strategies to effective handover described in this literature review illustrate the importance of communication and the use of tools to ensure that critical information is transferred consistently between health care providers (Riesenberg, et. al., 2010). In addition,   18   the environmental factors, method of handover and form taken, written, verbal, electronic are highlighted as important considerations for the handover process. To summarize key findings from the four articles that focused on patient safety and handover, the author’s describe how every patient handover represents a significant opportunity for communication failure that could easily result in adverse patient events. Increasing the safety of these handovers is the focus of many researchers, regulatory bodies and patient safety organizations. The primary challenge in improving the safety of patient handovers is a lack of a concise definition of handover and the activities that it does and does not include (Patterson & Wears, 2010; Cohen & Hilligoss, 2010). Although there are many functions of handover, without a concise definition implementing strategies for improvement are difficult. In addition without a concise definition it is difficult to determine in what way and how to standardize the process (Patterson & Wears, 2010; Cohen & Hilligoss, 2010). This could be a contributing factor to the lack of research evidence to suggest that standardization improves patient outcomes (Patterson & Wears, 2010; Cohen & Hilligoss, 2010). Nursing and handover   The following articles referred specifically to nurse-to-nurse handovers. Several times throughout a patient stay nursing staff hand over patient information to each other. This occurs at shift change, when going for a break, at times when assignments are rearranged mid-shift, when transferring a patient from one unit to another, or even when discharging a patient home to community nursing care. The focus of my project is on nursing inter-shift handover. This occurs when the departing nurse hands over patient care to the arriving nurse. Not only is information transmitted, but the responsibility of care for this patient is also transferred.   19   There are many references to nursing handover in the published literature and many of the articles and researchers describe the handover process and attempt to illustrate areas for improvement. In doing so, I have identified three main ingredients to nursing handover, including format or type of handover (verbal, written or taped), location of handover and finally content of handover, which is the focus of my study. Format. Format of nursing handover refers to the way in which information is passed between nurses, either verbally, face-to-face, written on a handover form, or audiotaped and listened to by the arriving nurse. Recently there have been indications of electronic handovers that utilize the electronic health record and nurse’s handover notes (Staggers & Blaz, 2012). Although the two studies described below included discussion on all of the main ingredients for handover, their findings, discussion and recommendations related directly to the format of nursing handover, which is why they are located within this sub heading. The first article I will review that focuses on the format of nursing handover is by Welsh, Flanagan and Ebright (2010). The purpose of their study was to look at nursing end of shift report and describe the factors that facilitate handover and those that act as barriers. This study used a grounded theory approach and was conducted at a United States veteran’s administration medical center where the staff utilized two different formats of shift report, taped and written. A convenience sample of twenty nurses were recruited and consisted of a cross section of three shifts of both Registered Nurses and Licensed Practical Nurses from three different inpatient units (Welsh, et. al., 2010). The authors used short, semi-structured interviews with nurses where they asked them to describe the handover process and any ideas for improvement. The participating nurses were interviewed in a semi-private room and other nurses came in and out of the room during the interview process. The two researchers coded the data using a 3-   22   Secondly, the authors suggest that there are several other purposes for handover other than information transfer, which is in agreement with other articles discussed previously. The functions of handover included patient information transfer, teambuilding, social elements, education with teaching moments, group cohesion and emotional support (Staggers & Blaz, 2012). The final category discussed the content of shift handover report. The authors found that although this was researched there was no clear indication or guidance of what the content should encompass and indicated that more work in this area was needed, especially in terms of key information for nurses receiving handovers (Staggers & Blaz, 2012). The findings in these studies indicate that the format of inter-shift handover varies widely; however, the preference was for a combination of both written and verbal handover (Welsh, et. al., 2010). Inconsistent and inaccurate information was noted to be an issue in both formats of handover and the combination could help to decrease this impact. Interruptions and lack of time were also listed as reasons for inaccurate information and common barriers, with all types of formats (Welsh, et. al., 2010). A written handover form with a handover checklist to ensure consistency increased the planning ability of the arriving nurse and allowed the nurse to write notes during the verbal component of handover (Welsh, et. al., 2010; Staggers & Blaz, 2012). The verbal component of handover is important to allow questions and clarification of the departing nurse to ensure that the arriving nurse has interpreted the information in the same way and continuity of care is maintained (Welsh, et. al., 2010; Staggers & Blaz, 2012). In addition, teaching and learning and teambuilding can occur during the face to face interactions which was noted as an additional function of handover in other articles (Cohen & Hilligoss, 2010; Patterson & Wears, 2010; Staggers & Blaz, 2012).   23   Location. The specific location of the nursing inter-shift handover is another of the main ingrediants impacting the handover process. The location component refers to where the handover takes place, for example, in a report designated room, at the nurses’ station, in the back hallway or even at the patient bedside. As one of the major identified barriers to effective and efficient handover is interruptions, the location of the report has a large impact on the accuracy of the information (Welsh, et. al., 2010). Three articles discovered in my search process discussed the location of the shift handover report and the implications of each location. The first article I will review was written by Athwal, Fields and Wagnell (2009). This article describes a nurse-led initiative to design a standardized shift report thereby creating a more time efficient process that also increased the quality of the report. The study describes the nurse-led project which occurred at a large, non-profit, magnet hospital in a United States suburban tertiary hosiptal (Athwal, et. al., 2009). Nurses voiced their concerns regarding inter-shift report and the lack of formal guidelines or structure at a unit staff meeting and were encouraged to present these concerns to the unit practice council from which a working group was created to address the concerns. The current shift handover report was studied for two months to identify the length of time handover consumed, as well as, staff thoughts regarding the process and ideas for improvements. The current process involved all nurses at change of shift meeting in the conference room for up to an hour for handover. The working group decided on a new shift report incorporating a written report with a one on one verbal handover occurring at the patient’s bedside (Athwal, et. al., 2009). The new process had the arriving nurse reviewing the written update, meeting with the departing nurse to ask questions and then the two nurses going to the patient’s bedside to finish report and introduce the new arriving nurse to the patient. The working group had challenges with implementing this   24   new process and changing the previous practice of report in the conference room; however, because this change came from the staff themselves there was more buy in and support. The process was trialed for one month and after this minor modifications were made. The new process was evaluated based on the amount of time that shift report took, overtime related to report and patient satisfaction (Athwal, et. al., 2009). The major result was related to the amount of time report took, this was reduced from 30-60 minutes in the conference room, to no time in the conference room and 10-15 minutes at the patients’ bedsides. Although this project also looked at creating a standardized handover form attempting to capture specific content, the process of report was the more significantly impacted element (Athwal, et. al., 2009). The amount of time and the location of the report were drastically changed for this particular unit, resulting in less time, less interruptions and less unanswered call bells as the nurses were on the unit and not in the conference room. Very little was mentioned in the article regarding the changes to the written shift report and the impact of standardizing this form, instead the time savings based on the location of the report were highlighted. The second article I will review discussing the location of handover report was written by Street, et. al. (2011) and focuses on handover occurring at the patient’s bedside. The purpose of this study was to identify the strengths and limitations in current handover practices and implement a new process of handover at the patient’s bedside. The study was conducted in multiple phases in a public Australian hospital (Street, et. al., 2011). The first phase involved a cross-sectional survey of nurses on 18 units at change of three shifts on a particular day. The Staff Clinical Handover Survey was utilized, this survey was previously utilized and validated by O’Connell, Macdonald and Kelly (2008) and was expanded and modified for this study. The modifications occurred in consultation with nurses considered   27   (Thomas & Donahue-Porter, 2012). Initially the staff feedback was unfavorable with nurses voicing unease at discussing patient issues at the bedside, the increased time it took to perform handover and logistical issues when multiple patients were on isolation requirements. However, as the project progressed the nursing satisfaction increased with strengths identified as an increase in knowledge regarding patient priorities, an opportunity for nurses to ask each other questions and the standardized “I PASS the BATON” tool guided nurses toward the information considered critical to the handover. Patient satisfaction was also noted to increase, with no invitation to participate in handover being refused (Thomas & Donahue-Porter, 2012). Although the deliberate inclusion of the patient and the family in the handover process was found to need constant and consistent reinforcement. The authors in this study found that the involvement, participation and support of the unit leadership was instrumental in implementating such process changes. In addition, buy in from the unit staff affected by the change is also integral to the project success. In summary, location of patient handover is also variable. However, many units wanting to implement patient-centered care emphasize the importance of the bedside handover and involving the patient and family (Street, et. al., 2011; Thomas & Donahue-Porter, 2012). This format requires an element of verbal, face-to-face handover, which is not always available in all areas. The barriers to this location for handover include hesitancy from nurses to discuss sensitive patient information at the bedside and how to actively involve the patient rather than just discuss over them (Street, et. al., 2011; Thomas & Donahue-Porter, 2012). As interruptions are a major barrier to safe handover, having an identified location for handover is important, however, many reports occurred where ever there was space (Athwal, et. al., 2009; Street, et. al., 2011).   28   Content. Standardization of inter-shift handover report also includes the specific information that is passed along from the offgoing RN to the oncoming RN. Standardizing the content of the report refers to ensuring that critical information is captured and passed along from shift to shift. This would ensure continuity of care and prevent important information being forgotten and non-essential information being passed along. My project seeks to understand what is considered critical content for inter-shift handover and how to ensure that it is captured with each handover. In my literature search three articles explored standardizing the content of inter-shift handover. The first article I will review was written by Lamond (2000) and had two goals. First of all, the author explored the nature of the content of shift handover and how this handover report assisted nurses in processing the information and planning care. Secondly, the information contained in the handover report was compared to information available from other sources to identify the information that is unique to handover reports (Lamond, 2000). This study occurred in England in both acute medical and surgical units within two district hospitals. This was conducted as a comparative study with a two-by-two design comparing the two National Health Service hospitals and the type of ward, medical or surgical (Lamond, 2000). Five handover reports on each unit were audio recorded in succession, as well as, all medical and nursing documentation were examined for a total of 15 patients from each unit being included in the study. The units practiced team nursing and report was given away from the bedside. Patients were divided into groups and each group was assigned to a team of nurses, therefore during report one nurse in each team gave report on all the patients in that group to the next team of nurses. In the end, the author captured 20 shift reports, 5 on each of two medical units and the same on the surgical units.   29   The author found that the patients’ notes, charts and specific written documentation contained much more information than what was given in shift report (Lamond, 2000). The charts and notes are official legal documents and therefore are required to contain this information. The author also found that global judgements about the patients’ condition, personality and psychological status were reported verbally in handover more than they were written down or officially documented. However, judgements made about the patients’ care needs were more often officially documented and contained in the charts rather than reported in handover. The content that was standardized and consistent among reports included name, age, physician, date of admission and admission diagnosis or operation, after this the content varied and was more specific to each patient and his/her situation. Finally, the author found that the nurse giving report was effectively saving the arriving nurse from collecting this information his/herself and therefore decreasing time needed to process and understand the information. The second article I will review was written by Staggers and Jennings (2009) and is a qualitative study that sought to describe the content and context of inter-shift handover report on medical and surgical units and assess whether the nurses utilize electronic health records during their handovers. This study took place across seven medical and surgical units in three separate acute care hospitals in the United States. The researchers collected data by observing and audio taping inter-shift handover report (Staggers & Jennings, 2009). The units used different handover formats including audio tape, written and verbal. Data was collected on 13 separate occasions with a total of 53 patient handovers and 38 different nurses being observed and audiotaped. Both verbatim transcripts and fieldnotes were used in the study to capture the content and the context of handover, such as the   32   an electroic tool (pg. 463). To achieve this purpose the authors’ sought to understand the existing content and organization of nursing handover by examining the structure, content and organization of nursing clinical handovers. A qualitative approach was used to look at 126 nursing handovers in seven different clinical settings in a large Australian city (Johnson, et. al., 2012). The majority of handovers were on medical/surgical units. To gain access to the nursing handover process, the reasearchers approached the managers on each unit and written consent was obtained from the nursing staff to observe and digitally record the clinical handovers. Thematic and content analysis was utilized after the transcripts were transcribed verbatim. Five major themes were identified that described the structure of inter-shift nursing handover (Johnson, et. al., 2012). The first theme was described as the identification of the patient, including patient identifying information, room, name, gender, age and risks such as infection control risks, falls risk or at risk for pressure sores. The second theme was the clinical history/presentation and in all handovers except for one followed immediately after the identification of the patient. The information included here was related to the patient’s previous medical history and what brought the patient into the hospital. The third theme identified was the clinical status. This information was noted as assessment data such as vital signs and stable or deteriorating medical status. Clinical status was handed over to the arriving nurse in the form of signs and symptoms that described the current medical status and also the functional status of the patient, such as high blood pressure and able to mobilize to the bathroom independently. Although the researchers found this theme followed the clinical history category often, the information contained within this theme did not follow any logical order. The fourth theme was found to be the care plan. Contained in this category was information related to the care given to   33   the patient or upcoming plans of care, including tests, diagnostics or procedures that were scheduled. As well, dressing changes and other tasks carried out were described in this theme. The fifth and final theme found was that of goals of care or outcomes. This information was not frequently included in the inter-shift handover report and pertained to discharge plans or goals for that shift. The authors note that there was minimal evidence that the nurses actively prepared the patients for discharge although this is a key component of any hospitalization and should be discussed immediately upon admission (pg. 466). The authors’ also found that there was minimal nurse-patient interaction during the inter- shift handover (Johnson, et. al., 2012). In addition, they found that there was variation in the structure of inter-shift handover report and the information was not presented in any logical order. The authors supported the use of a developed tool for structuring inter-shift handover report, such as SBAR, but also attempted to develop a tool based on the five themes described to give a structured order to handover. The order of the key themes described above is how the author’s recommend structuring report, but with some flexibility. They also recommend that critical information should be given after the first and second themes or categories, patient identification and clinical history, to ensure that this information is not lost in the handover. This study described the current content of inter-shift handover and made recommendations for structure and content, but did not explore what the nurses’ wanted to hear in report and what information they considered to be critical to the continuity of care. In summary, the researchers who described the content of inter-shift handover found that wide variation as with the other elements of inter-shift handover, location and format (Lamond, 2000; Staggers & Mowinski Jennings, 2009; Johnson, et. al., 2012). The content of inter-shift handover was found to be comprised of factual data and nursing judgements, with the nursing   34   judgements being more often found in handover than documented in the chart (Lamond, 2000; Staggers & Mowinski Jennings, 2009). There was also no consistent structure to the content of the handover and the nurses were found to jump from topic to topic with no logically planned sequence (Staggers & Mowinski Jennings, 2009; Johnson, et. al., 2012). All of these researchers found that nurses utilized a consistent approach to the beginning of inter-shift handover identifying the patient’s name, age, room number, admission date, physician and admitting diagnosis, but then was inconsistent after this point (Lamond, 2000; Staggers & Mowinski Jennings, 2009; Johnson, et. al., 2012). Appreciative inquiry and nursing handover Appreciative Inquiry (AI) is an approach or methodogoly that uses a positive or strength based approach to change by looking at what processes or structures are currently working well within on a unit and trying to replicate this over and over again with each handover (Knibbs, et al., 2012; Sullivan Havens, Wood, & Leeman, 2006; Richer, Ritchie, & Marchionni, 2010). AI has been described as both a methodology and a philosophy that emphasizes positive elements of systems already in place, drawing on the strengths of what is currently being done and engaging those who are actively involved or effected by the organizational change proposed (Cooperrider, Whitney & Stavros, 2008; Sullivan Havens, et. al., 2006; Knibbs, et al., 2012; Richer, et. al., 2010). Two studies found in my literature review looked at nursing handovers utilizing the AI approach. The AI approach is the process that I will be using to conduct my project and therefore these two articles are very relevant to my study. Although both articles focused on standardizing and improving nursing handover between two units within one hospital rather than on inter-shift handover the findings from these studies are still applicable to my research project.   37   the new way of performing the patient handover process. They described the key elements and activities that needed to take place at each stage of the process. The fifth and final step is “destiny”. In this phase participants discuss how to implement the change and how to move their dream into the reality of everyday practice with all of their colleagues (Shendell-Falik, et. al., 2007). The group in this project discussed what initiatives would assist in making their dream become daily practice, which would have priority, how the various initiatives would impact implementation (which have the highest payoff) and who would work on each initiative, based on varying passions and skill sets. After this session and discussion the group agreed on the specific roll out plan and timeline of activities and created a chart to illustrate the various initiatives. They also created a list of the stakeholders that would be most impacted by the change and a plan around engagement and adopting the change. The group also created an overall communication strategy and a list of impacts to patient safety, care and teambuilding that would be useful in explaining to the stakeholders to increase buy in. The outcomes of this project were described as short-term and intermediate. The short- term outcomes included five iniatives to improve the patient handover process between the two units (Shendell-Falik, et. al., 2007). These five iniatives included: a welcome script, a script to communicate specific information when a patient handover occurs; safety assessments, the ED implemented a way to start key elements of the patient database to improve safety through access to timely care; standardized transfer report, a standard report was created that communicated patient status, diagnostic testing, treatment, interventions and follow up plan; low-risk cardiac transport protocol, a protocol was developed to transfer specific low-risk patients from the ED to the telemetry unit without a cardiac monitor promoting more efficient resource utilization and   38   finally interpersonal relationships, a program was developed to allow for shadowing colleagues in the other department to see the challenges faced during their daily practice. Intermediate outcomes included collecting data and identifying metrics to measure the success of the initiatives and projects, including: “patient satisfaction, nurse satisfaction and team work, nutritional and skin assessment, compliance with cardiac enzyme regimen and medication administration records” (Shendell-Falik, et. al., 2007, pg. 101). Focusing on a specific process to improve in this project was a successful way to meet several of the project goals. Safety was improved for patients in the handover process, staff were engaged and built relationships with each other and employee satisfaction was improved by having a voice and the ability to participate in the project that had the greatest effect on them (Shendell-Falik, et. al., 2007). The second article I will review is by Clarke, et. al., (2012) and also focuses on standardizing patient handover between an acute medicine and sub-acute medicine units within a tertiary teaching hospital in Canada. The aim of this project was to utilize appreciative inquiry (AI) in the study of unit to unit transfer handovers to establish which processes were working well and should be incorporated into a standard practice. The idea for this project arose from several incident reports discussing issues with the unit to unit handover of patients and was brought forward to the Nursing Practice Council of a large tertiary teaching hospital in Canada (Clarke, et. al. 2012). The principal investigator was a faculty member from the affiliated university, other team members included two managers from participating units, one clinical resource nurse, two direct care nurses who were interested in learning more about this type of research, a manager from the Safety and Quality department and an undergraduate nursing student who was a research assistant.   39   The study utilized four phases of the AI approach: discovery, dream, design and destiny. The discovery phase involved interviews with all of the stakeholders asking them to describe what works really well within the current system of unit to unit handover (Clarke, et. al. 2012). The stakeholders identified for this phase included direct care nurses, patient care managers, clinical nurse educators and clinicians, patients and family members from the participating units. The interviews were semi-structured, lasted between 15 to 20 minutes and were conducted by the direct care nurses involved in the project team. Themes that emerged from the interviews included trust, information needed for the handover and communication – related variables. Overarching all of these themes and emerging again and again was patient safety being the most important aspect. The information the nurses needed to prepare and ensure a thorough safe patient handover included knowledge of the patient, reason for admission, the events that occurred while admitted and plans for discharge (Clarke, et. al. 2012). Relevant tests, therapies, treatments and any pending tests, diagnostics or rehabilitation plans were also deemed relevant to the handover process. The biggest challenge identified was finding the time and quiet space to collect and organize the relevant information. Nurses identified that a face to face handover as the ideal way to transfer patients, but acknowledged that this was likely not practical (Clarke, et. al. 2012). Instead the nurses agreed to providing handover on the phone where there is an opportunity to ask questions and clarify information. This was preferable to the present process of faxed report. In addition, the nurses agreed that there should be some form of standardized report form so that the nurses were all on the same page. Finally it was brought up that communication with the patient and family as to the reason for the transfer needed to occur to prevent confusion and anxiety.   42   (Accreditation Canada, 2011; Institute for Healthcare Improvement, 2009; The Safety Competencies Steering Committee, 2008). In reviewing the literature and the studies performed regarding safety and the patient handover process, issues have been raised that interfere with the standardization process. The lack of agreed upon definition of patient handover is an idenitified need within this area of research (Cohen & Hilligoss, 2010; Patterson & Wears, 2010; Staggers & Blaz, 2012). An agreement of what processes and functions handover includes or does not include is lacking (Cohen & Hilligoss, 2010; Patterson & Wears, 2010). Without a widely agreed upon definition of handover and the functions it includes it is difficult to standardize the process or content (Patterson & Wears, 2010). It is also difficult to implement interventions to improve the process (Patterson & Wears, 2010) There is no widely agreed upon definiton of handover and the functions it includes, but there is agreement that transfer of information from one health care provider to another is a primary function of the process (Cohen & Hilligoss, 2010; Patterson & Wears, 2010; Staggers & Blaz, 2012). The researchers in this area also indicate that this is not the only function of patient handover, but also teaching, learning and socialization are additional functions of the handover process (Cohen & Hilligoss, 2010; Patterson & Wears, 2010; Staggers & Blaz, 2012). Nursing inter-shift handover is composed of three main ingredients or components, namely format, location and content. There are three main formats for inter-shift handover, verbal, written or audiotaped. Format for inter-shift handover varies widely across the studies conducted with inconsistent and inaccurate information being a noted issue in all types of formats (Welsh, et. al., 2010; Staggers & Blaz, 2012). The overwhelming preference from nurses in all studies was for a combination of both written and verbal handover (Welsh, et. al.,   43   2010; Staggers & Blaz, 2012; Athwal, et. al., 2009). The preference was for a checklist to ensure all components of handover are accomplished, a written form for the arriving nurse to write notes on and a verbal component (Welsh, et. al., 2010; Staggers & Blaz, 2012). This verbal component allows questions and clarification, but also meets the needs of the other functions of inter-shift handover including teaching, learning and teambuilding (Cohen & Hilligoss, 2010; Patterson & Wears, 2010; Staggers & Blaz, 2012). As with format, the location of inter-shift handover is also variable across sites where research was conducted. There is an emphasis on the importance of bedside handover that would involve the patient and the family (Street, et. al., 2011; Thomas & Donahue-Porter, 2012). However, researchers found that there were barriers to this location such as nurses feeling uncomfortable discussing sensitive patient information at the bedside, especially in multi-patient rooms and that often the patient was not actively involved but rather being talked over (Street, et. al., 2011; Thomas & Donahue-Porter, 2012). The main finding in this section was that it is important to have an identified location for inter-shift handover and that the location assists in decreasing interruptions and distractions. (Athwal, et. al., 2009; Street, et. al., 2011; Thomas & Donahue-Porter, 2012). Again when exploring the content of nursing inter-shift handover, wide variation was found in the sequence patient information was presented and there was no standardized approach to what the necessary content should include (Lamond, 2000; Staggers & Mowinski Jennings, 2009; Johnson, et. al., 2012). In general, the patient’s name, age, room number admission date, admitting physician or team, admitting diagnosis or surgery were presented consistently at the beginning of handover, but after this the content and sequencing was inconsistent (Lamond, 2000; Staggers & Mowinski Jennings, 2009; Johnson, et. al., 2012). The nurses jumped from   44   topic to topic with no structure or logical process (Staggers & Mowinski Jennings, 2009). The major components of the inter-shift handover content includes factual patient data and nursing judgements (Lamond, 2000; Staggers & Mowinski Jennings, 2009). Although the concrete data could be found readily in the written documentation including the patient chart and flowsheets, the nursing judgements were only identified in inter-shift report (Lamond, 2000). Johnson, et. al., (2012), identified the major components observed in nursing inter-shift report and recommended a sequence to standardize content. This recommended sequence included: identification of the patient, patient’s relevant history and reason for admission, current clinical status, current plan and upcoming treatments, therapies or diagnostics and finally goals of care, optimal outcomes or discharge goals (Johnson, et. al., 2012). The authors also recommended that critical information be presented after the patient’s relevant history so as to not be lost in the report and instead be highlighted (Johnson, et. al., 2012). Discussion around the barriers and facilitators to nursing inter-shift report was consistent among researchers and similar findings were presented. Commonly mentioned barriers included information characteristics such as the sharing of too much, too little or irrelevant information, no ability to ask questions or seek clarification and the most emphasised was that of interruptions and distractions, which had the biggest impact on the ability to give a comprehensive and safe inter-shift handover (Lamond, 2000; Staggers & Mowinski Jennings, 2009; Johnson, et. al., 2012; Riesenberg, et. al., 2010; Sullivan Havens, et. al., 2006; Athwal, et. al., 2009; Street, et. al., 2011; Thomas & Donahue-Porter, 2012; Kerr, et. al., 2011). The major facilitators included a focus on relevant content, ability to seek clarification and ask questions, but at the same time utilize a checklist and written report for the purposes of jotting down notes (Athwal, et. al., 2009; Staggers & Blaz, 2012; Welsh, et. al., 2010). In addition, a major facilitator was the inclusion of   47   active and engaged inquiry or questioning (Watkins & Mohr, 2010). AI has been described as both a methodology and a philosophy that emphasizes positive elements of systems already in place, drawing on the strengths of existing processes and engaging those who are actively involved or effected by the organizational change proposed (Cooperrider, Whitney & Stavros, 2008; Sullivan Havens, Wood, & Leeman, 2006; Knibbs, et al., 2012; Richer, Ritchie, & Marchionni, 2010). Appreciative inquiry is grounded in social constructivist theory. Social constructivist theory is based on the idea that we construct the world around us through our interactions and conversations, that reality cannot be known, but is rather constructed through our interpretations (Mills, Bonner, & Francis, 2006; Watkins & Mohr, 2001). Social constructivism as it relates to the AI method and process is seen in the inquiry of the past and present processes and imagining the ideal future and to create that future (Watkins & Mohr, 2001). In addition, the social constructivist paradigm recognizes the influence that the researchers and the participants have on the interpretation of the subject of inquiry and that the ideal future state is constructed from shared experience (Polit & Beck, 2011; Annells, 1997). As the AI approach is based on positive psychology and active involvement of the participants, involving the unit staff in the project process is integral to this approach and influences the interpretation of the subject in a way that is reflective of the work being done in their setting, thereby increasing engagement and enthusiasm for the project. This study was conducted using the AI “4 D” process of discovery, dream, design and destiny or delivery. For the purposes of this project, delivery will be used to describe the final phase. The first phase, discovery, seeks to uncover what is already working well with the current process or in this case, the current inter-shift handover form and what could be done   48   differently to improve on the process. Typical questions asked in this phase included, describe a time when you received a perfect handover, what did it look like? What is working well with your current handover form? What could be improved upon with your current handover form? The second phase is dream where the project team was asked to consider the perfect handover and what would need to be in place to have that perfect handover occur every single time and what benefits that would have. Questions asked in this phase are what would it look like to have the “perfect” handover every time? If you received the perfect handover every time what impact would this have on you? Your day? Your specific work? The third phase is the design phase, where the team created a handover form incorporating the elements discussed in the first two phases. The goal of this phase was to create a handover form that ensures the dream described becomes a reality. The main question asked in this phase was what are the critical elements needed in every handover to achieve the perfect handover? Finally, the fourth phase is delivery, where a new standardized inter-shift handover form is created, refined and implemented and on the study unit. In this phase, the previously created form was rolled out to the unit and feedback was sought using an anonymous online survey tool, questions were asked related to the functionality of the new form, ease of use and recommendations to further improve the form (Clarke, et al., 2012; Knibbs, et al., 2012; Shandell-Falik, Feinson, & Mohr, 2007; Sullivan Havens, Wood, & Leeman, 2006; Richer, Ritchie, & Marchionni, 2010). Ethics Ethics approval was sought and granted by both the University of British Columbia Behavioural Ethics Review Board and Vancouver Coastal Ethics Review Board. My office contains a locked space where I kept the project consent forms and my notes will be kept for at least 5 years after the conclusion of the study. At that time, I will shred hard   49   copies of documents related to the study. I also conducted digital recordings and after I had transcribed these recordings, Dr. MacPhee offered to store the recordings on her password- protected research computer, and these recordings will be deleted 5 years after the end of the study. The original recordings were deleted from the recorder after transfer of data to the computer. Sample and setting   Overall setting. The setting of this study was an acute medical unit within an acute, urban, tertiary teaching hospital in the Lower Mainland. The unit is a fifty-two bed acute, tertiary general medical unit employing a mix of Patient Care Aides, Licensed Practical Nurses, Registered Nurses and Employed Student Nurses. In addition, there are multiple preceptor students and nursing student groups active on the unit at any given time. Project team sample and setting. A non-probability, purposive sample of unit nursing staff and leadership were asked to participate in action research as members of a project team that designed, implemented and refined a standardized handover form (Polit & Beck, 2011). The sample consisted of representatives from key stakeholder groups or those groups with the most knowledge and interest in the development of a standardized handover form. The frontline leaders included one Patient Care Coordinator (PCC) and one Clinical Nurse Educator (CNE), as well as, two frontline direct care nurses that work on the unit involved in the study and trial. There were also two unique members on the project team. A current direct care nurse from the study unit, who had previously held positions in the leadership team as both a PCC and a CNE, and a human factors engineer working for the Patient Quality and Safety department at Hospital X. Both of these individuals agreed to participate and lend their unique perspectives of the content and layout of the nurse-to-nurse handover form.   52   received a handover that was the perfect handover and what made it the perfect handover? (Clarke, et al., 2012). As well, they were asked to describe what works well or not well with their current handover form, to discover the current process and what they saw as the strengths and weaknesses. Dream. The next phase is the dream phase and the questions focused on replicating the “perfect handover” described in the discovery phase. Questions included: “What would it look like to receive a perfect handover at the beginning of every shift? What would need to be in place for that to happen?” (Clarke, et al., 2012). These questions attempted to find ways to increase the value of the current handover form, and to appreciate the current process. Design. During the design phase, the group focused on the essential elements needed to create a handover form that will capture the critical information consistently. The question asked for this phase was “what are the core or critical elements needed for a perfect handover?” The project group discussed the information needed on the handover form, design, layout and format that will work on their unit and ensure a shared understanding among all of the frontline nursing staff. The project group drew out their ideas on the white board in the meeting room and I photographed this to use in the form design (Appendix I). By the conclusion of our first meeting, the team had decided on the information needed on the handover form. Both the data collection phase and the data analysis phase occurred concurrently (Polit & Beck, 2011). The project group was audio recorded, transcribed verbatim and analyzed by the researcher (Polity & Beck, 2011). Thematic analysis was used to identify critical information required in the nurse to nurse handover process. As a result of this process, a nurse to nurse handover form was created by the researcher that incorporates the critical information identified   53   by the end-users in the focus groups (Appendix J). The analysis phase will be described in more detail in the analysis section. Once the handover form was developed the form was shared electronically with the project group for validation and feedback. Project group members were asked to consider whether or not the form captured the project discussion accurately and included the core elements that we had discussed. A second meeting with the project team was requested to provide feedback and validation of the newly created form, this meeting occurred within a confidential space at Hospital X that I reserved. Unfortunately one team member was unable to attend the meeting, and she provided feedback electronically for me to take to the meeting. Another team member could only attend during her break time to give her feedback and ideas. During this session, I once again took notes and audio taped the session. The purpose of this session was to come to a team agreement on the final form to be piloted on the unit and to validate the form. Prior to agreeing to the form, the team wanted to try it out with a sample patient. A scenario was presented by one of the team members as an example of a patient for the other team members to trial filling out the form. Some slight wording was changed from the initial iteration, and one of the team members offered to re- create the form in Visio instead of Excel to make the form look more finished. Agreements were made on the final version of the form and timelines were agreed to for the pilot period. Survey procedures. After team validation, the form (see Appendix K) was piloted on the study unit for a period of two weeks. I obtained the permission of the unit’s nursing manager to pilot the form. The development of the form and project team work is congruent with quality and safety initiatives underway within Hospital X (personal communication, Blackburn, 2012). The form is self-explanatory and no training was required among nurses on   54   the unit. I did, however, post the form on educational boards within the unit and sent out a broadcast e-mail with an e-attachment of the form explaining the purpose of the form and the two-week pilot process. The project team felt it was important to highlight the fact that the handover form was meant to complement the nursing Kardex and not serve as a stand-alone document, which was done every morning in group report. The nursing manager for the unit and the educators assisted me with informing the nursing staff of the handover trial. An email was sent to all nursing staff three days before the start of the trial and also the day the trial started to ensure all staff were aware (Appendix E and F). In addition, the Patient Care Coordinators and Clinical Nurse Educators on the unit discussed the new form, the pilot and the online survey during each morning huddle for the duration of the pilot period. During this pilot period an anonymous, confidential online survey was available to all front line users of the form to give feedback and make recommendations. The survey (See Appendix L) was a brief, 10 minute on-line survey rating the form with respect to comprehensiveness, utility and critical nature of content. A reminder e-mail and survey link was sent out with the pilot information three days prior to the start of the trial, the day the trial began and again one week after the original e-mail to generate more feedback and survey responses (Appendix F). The survey was closed after two weeks. I utilized the internal hospital survey system that is confidential and password-protected. Access to the survey is only available from internal hospital computer systems and therefore staff were uanble to complete the survey from home. The study unit has a total of 103 nursing staff, comprised of full time, part time and casual Registered Nurses and Licensed Practical   57   Reflexivity. I incorporated reflexive journaling and regular check-ins with my researcher advisor to maintain reflexivity. Journaling was used to note my own preconceived notions from personal and professional experience, surrounding the research question and phenomenon. I found that the decisions made by the project team in terms of their preferred structure for handover report was not what I was expecting or had anticipated. Utilizing the reflexive journaling assisted me with separating my assumptions from what the project team was concluding and prevented me from leading the group in the direction that I had previously anticipated. Checking in with my research advisor also assisted with reflexivity by discussing personal assumptions, thoughts and feelings in an attempt to distinguish these from the emerging findings. Triangulation. A variety of triangulation techniques were used to enhance the quality of the data gathered, generated and analyzed for this research project (Polit & Beck, 2011). Data triangulation. The data was triangulated utilizing person triangulation and having a variety of members on the project team with varying levels of experiences and in a variety of roles, both leadership and clinical (Polit & Beck, 2011). The six-member project team consisted of five Registered Nurses, including three staff nurses, one Patient Care Coordinator and one educator, as well as a Human Factors Engineer. The rich variety of experience and knowledge within the project team ensured that the data was generated and validated by multiple perspectives, therefore, enhancing the quality and trustworthiness of the data (Polit & Beck, 2011). Method triangulation. Multiple methods were utilized to gather the data for this research project. Utilizing the appreciative inquiry method, questions were sent to the project team prior to the first working session. These questions were then addressed in the first working session,   58   and as both a participant and observer I wrote observation notes and audio recorded the session. In addition, previous handover forms were utilized by the project team to assist in the creation of a new handover form. Finally, an electronic feedback survey was utilized to survey the entire unit of nurses for their viewpoints and feedback regarding the newly developed handover form. All of these methods of data collection were utilized in the analysis and subsequent generation of themes (Polit & Beck, 2011). Comprehensive and vivid recording of information. Both participant field notes and observations were recorded at each project team meeting to enhance the comprehensiveness of the information recorded. All of the project team working sessions were audio taped and transcribed verbatim, including pauses, slang and “umms” of the participants. The combination of participant observations and transcribed working sessions were analyzed to develop the themes discussed in this paper. Quotations from the participants were utilized to demonstrate the comprehensive recording and capturing of the data utilized and to enhance the trustworthiness of the analysis and results described in the next chapter. Member checking. Member checking refers to the technique of validating findings and researcher interpretations with the participants of the study to increase the credibility of the data (Polit & Beck, 2011). In this study, after the first project team working session I interpreted the data that was gathered regarding the critical elements for a nursing inter-shift handover report and created a draft of this report. This draft report was then sent to all of the participants of the project team via email to validate that the report accurately reflected the thoughts and intentions of the group. In a subsequent meeting this draft form was again validated with the members of the project team, feedback was solicited and changes were made prior to piloting the form.   59   Utilizing the member checking technique enhances the credibility of the data gathered and ensured that the document created was an accurate reflection of the project team’s intentions.           62   Trust. A sub-theme that emerged during the team discussion was that of trust. The team emphasized the need to trust the departing nurse to provide an accurate and succinct handover, because the handover sheet is considered one of the most important sources of patient information. Other sources of patient information, such as the kardex and patient flowsheets also contain relevant patient information, but the handover sheet is viewed as critical for succinctly gathering and reporting information from shift to shift. Unfortunately the kardex, which contains general information for the patient, such as upcoming tests, procedures, diagnostics, as well as, dates for tube, line, drain and dressing changes, is not trusted by the staff to be consistently updated by the departing nurse. Something that’s challenging about the kardexes is that I often will repeat information in my written report because even though I’ve updated the kardex nobody trusts what’s written on the kardex anymore so if you really want something to be relied on you have to write it every shift to make it clear to people (RN B). The frustration around needing to repeat information on the inter-shift report that should only be located in the kardex was expressed by all team members. They felt that if they could trust that all staff members were consistently updating the kardex then the inter-shift report could focus on more critical patient information. …So I think if the kardexes were accurately updated then the inter-shift report could be very brief, but the problem is that the kardexes don’t get updated so a lot of the kardex information ends up in the shift report (PCC). The consensus of the group was that updating the various communication tools was not seen as a priority compared to direct patient care tasks and when time was tight the communication   63   updates were what was left out of the shift. “I think part of it is making it…having nursing see it as more of a priority and more of a responsibility of their shift…” (RN B) Duplication of information. Another sub-theme that emerged from this discussion was the concept of duplication of information or double charting. The team expressed that often they were repeating information that should be found in other sources of patient information, such as the kardex or patient care plan, in the inter-shift report to ensure the arriving nurse received this information. Part of this was due to the lack of trust in these other documents being accurate or up-to-date and also not trusting the arriving nurse would actually read these documents. This lack of trust led the team to feel frustrated in the amount of time they took to repeat information in various locations. We repeat information that should be in the kardex. Same as kind of like a care plan too or certain patients want certain things like if someone is in a pain crisis this, this and this works. I find that if we have a like a really good working care plan and the time to do it in a dream world like you can save yourself from writing it down over and over again in shift report (RN A). Or it’s not duplication but it’s written in the inter-shift report, which is lost every shift and therefore is written down again and again (PCC). Continuity of care. The final sub-theme found in the overview discussion was that of the importance of continuity of care for patient safety. The group agreed that there are issues related to the other communications tools, such as regular updates of important kardex information (e.g., tests, line changes etc.), but a priority for the project team was to revise the current inter-shift handover report form to best reflect an overview for each patient based on critical events within   64   the past 12 hours and critical patient goals for the following 12 hours. The group felt that this time frame would provide an accurate portrayal of the patient’s overview and best assist nurses for the arriving shift to plan patient care delivery for their shift. I think that is definitely something that gets missed a lot is communicating the actions that need to get done. Cuz [sic] often I come on and I’ll read through my reports and I’ll take a look at the orders that have been written and the information there is completely different from what I’m seeing. So it’s either that the person hasn’t fully grasped what needs to be done or they haven’t like seen it’s not on the kardex or whatever else (RN B). I think knowing your patient is information in the kardex, care plan whatever [sic], I think the inter-shift report is to try and allow you to pick up where the last person left off and plan your day (PCC). Efficiency. Another theme that emerged from the discussion was efficiency. Although it is necessary to gain an overview of the patient’s recent past and current healthcare trajectory, it is also necessary to present information in the most succinct and structured way as possible. The project team agreed that the best way to efficiently structure critical information would be in a written format. The kardex represents one source of written information, although not well trusted, which increases the importance of a well-structured and thought out handover report. A well-structured handover report should serve as an additional source of critical information. Currently, handover information is often done verbally in a rushed, jumbled, non-systematic manner. Important information is often left out and irrelevant information is sometimes included.   67   having to rely on yourself that you’ve written everything down that that nurse may want to know (RN B). With further exploration, it was discussed that many novice nurses were not comfortable with written handover and were fearful they were missing something that was important for the arriving nurse. The team also hypothesized from their experiences as novice nurses that providing an appropriate written handover was not something that was taught to them. The only exposure was during preceptorship and the quality of the written handover was therefore dependent on how well the preceptor wrote report. Two team members explained that the assumption of senior nurses being more adept at written report was not completely accurate: The idea that senior nurses’ reports are sort of a gold standard on some level is not really true, as sometimes they are worse than a new grad because you come on and 17 things have happened and all you can see is like O2 sats 99%, A&O check…and like what does that even mean? (RN B) I think senior is the wrong term to be using, but a good nurse, some nurses have only been nursing for a year, but senior is not mandatory to giving a good report (PCC). Process. The final sub-theme identified was that of process. The process around inter- shift handover appears to be a major issue on the study unit. With both written and informal verbal handover, combined with what was described as a non-structured current handover form, the process of how, when and what information to handover to the arriving nurse is convoluted and confusing. As described by a team member:   68   …everything is jumbled and I like being systematic with things otherwise medicine itself is all over the place so if you add an all over the place report it doesn’t give you a focus for how or what you need to keep an eye on (RN A). The project team agreed that the best way to increase the efficiency and effectiveness of the inter-shift handover report and to improve the process was to have the report follow a systems - based format to organize the information. One project member endorsed a body or physiological systems approach to the handover report; “I like that it’s structured and gives you the full picture as opposed to being all over the place” (CNE). Other team members agreed and shared their thoughts and experiences: Like the best handover reports that I ever get are when we’re getting an ICU transfer I love getting report from those nurses. Because it’s always like this is what they came in with, this is the code status, this is what happened and now their like neuro blah blah blah cardio, go always through systems, every single system and when they come up I feel like I know the patient (RN A). I think if it’s given as a systems report you can deal with the system and put a check box beside it and file it away and go to the next one and when it’s a report that doesn’t have any type of systematic process to it at no point do you feel like you’ve closed a piece of it up (RN C). Objectivity. Another theme that emerged from the discovery phase was the need for objective data versus subjective data on the inter-shift handover form, presented through professional communication. The danger of simply following the previous nurse’s opinion or assessment was echoed throughout the project group as a real hazard to the patient’s well being.   69   This contributed to the need for the inter-shift report form to contain objective patient data rather than opinion or conjecture. It’s challenging when you have to sift out what’s judgments or criticisms or nurse um personal challenges versus sort of system challenges and um issues that you’re going to face as an individual coming from your perspective. If it stays really objective then there’s less sort of trying to root out what information you actually need from the report (RN B) Professional communication. Professional communication emerged as a sub-theme described below by the team. The team felt that personal judgments, criticisms or impressions of the patient and/or family are not relevant to patient care delivery: I think if it’s a systems report it would be very succinct and would just be the medical issues and what you need to know and not like…everybody reacts to different people differently. Sometimes people can be like ‘oh that patient’s awful’ and then they’re totally fine with you, like I think it depends on your approach and if you go in already thinking they are going to be awful they are going to pick up on that (RN B). A big thing for me is when they come in and say ‘oh this patient is such a…such a whatever, pain in the butt’ or like with a really negative connotation to the day, ‘oh you’re going to have such a horrible day’. Is that really necessary? Tell me what I need to know, but the attitude going into it is important because it sets up my day (RN A).   72   what the plan is then the inter-shift report would give you a summary of what the day nurse has been tackling all day and what you need to proceed with (PCC). The project team felt that the inter-shift handover report is currently not emphasized as a priority. For a succinct, standardized report to occur consistently, the critical purpose of this document needs to be reinforced. More education and reinforcement is necessary to define the purpose of the inter-shift report and how the reporting process is essential to continuity of care and patient safety. Emphasis on the purpose of the report and its link to continuity of care and patient safety will hopefully enhance nurses’ effective use of the form. I think part of it is making it…having nursing see it as more of a priority and more of a responsibility of their shift to give an accurate and thorough report at the end because I think we tend to prioritize shift reports down further and further as things get busy then all of a sudden it’s six pm and we are trying to quickly jot down reports for four patients or whatever…(RN B) Systematic relevance. The project team agreed that the best handover is one that is presented systematically, based on physiologic systems and with only relevant information. This was based on the best-case scenario that the kardex is completely up to date, trustworthy and reliable. I think I would like it laid out in systems and have like neuro and do it like a check… everything’s good… like CVS, GI, I don’t know if that would be like an easier thing and just check if it’s all good and if there are abnormalities just do a brief blurb…(CNE).   73   The other piece that I think that would help to avoid is that kind of verbal panic that I might get in trouble because I might have forgotten to tell you something so instead I tell you everything to overcompensate (RN C). Physiological Systems approach. The group felt that a physiologic or body systems approach would ensure the handover report is organized, succinct and would have a secondary effect of triggering nurses’ critical thinking. That would be really great if we had system indicators, it sounds really terrible, but people…but it triggers you to think where does that information fit best cuz [sic] sometimes too I’ll be trying to do a systems report, but some things fall into a number of categories so you’re like where do I put this piece of information (RN B). As is mentioned in the above quote, some of the discussion with the project team focused on how to actually do an effective physiological systems report. Although this content is taught in nursing school, many novice nurses struggle with identifying critical information to include in a physiological systems report. The project team felt that this approach to inter-shift handover report would be a benefit for novice nurses and for all the nursing staff. This was something that was lacking too in nursing…like we talked about systems but we never really… we weren’t asked enough to break things down but that’s a struggle even three years later… some people are really good at that and some people really struggle so this would help to outline it in your mind (RN C). From some nurses it would facilitate the thinking from some nurses assuming they actually took this and incorporated it into how they… I mean I know our   74   flow sheets already have it in systems and that hasn’t necessarily had the same type of influence but I mean if everything was systems based then maybe they would, just because of that consistency, be able to integrate it more into their thinking… (PCC). One member of the project team noted that a physiological systems based handover not only assists the arriving nurse to get organized and start putting together the bigger picture of the patient in the most efficient way, but it also aids the nurse writing the report. The physiologic systems method would encourage the nurse to reflect on how all of the body systems work together and if there was anything missed during the shift. I feel like this report thing goes both ways in that it helps the nurse that’s coming on to have this information, but it also short hand helps the nurse that is on to organize their thinking and to summarize the patient to think if there’s anything they’ve missed or whatever… sometimes this stuff can be really good for like new grads even if they aren’t necessarily utilizing it perfectly to just help them to start thinking in that way (RN B). And I think it can be overwhelming in medicine because we very rarely have a patient that only has issues in one system or issues have effects in several systems, so where do you place that information and not repeat it several times? (CNE). Determining relevance. Throughout the project meeting in both the discover and dream phases, the idea of information relevance was continually mentioned. The team agreed that the core or critical elements of the inter-shift handover report are the data relevant to patient   77   I think something that needs to be teased out is that this is meant to be just as valuable for a senior nurse to a senior nurse and right now on our unit there’s a lot of new staff so there’s a lot of things being done to accommodate the needs of the new staff which hopefully won’t always be the case… (PCC). Developing trust. Various strategies to build trust among staff were discussed by the project team in the dream phase of the AI process. The team discussed strategies to develop trust in the inter-shift handover communication through feedback and role modeling. They also discussed developing trust by reiterating the importance of up-to-date kardexes and care plans. Finally, the team discussed the inter-shift handover form as serving as a teaching tool and improving the critical thinking of nurses in a more general sense. Feedback. The project team agreed that some system of feedback and continuing education is necessary to ensure that only the relevant or critical pieces of information are included on the inter-shift handover report. I don’t know what it would look like, but it would be very nice to have some form of feedback process so we could be like ‘that inter-shift report you provided was awesome and my day totally started well’ or ‘essentially you failed to mention their hemoglobin was 52 and I needed to follow up with the stat blood work that was done at 0600’… it would be great to have a feedback process for a lot of things but in order for this to actually be successful and successful in a shorter period of time, that would be very valuable (PCC) . Although there was agreement from the project team around the value and necessity of giving feedback to improve the inter-shift handover reports, there was discussion around how to best provide constructive feedback to staff. Some project team members thought that it should   78   be a formal system, while others thought that this should be an expectation between colleagues to provide this feedback. Like a very formal review process almost like an audit system in terms of like contacting certain people to give feedback on what was missing or not missing on the reports and what they…or even a check sheet that you could implement for a week or something and people could just document shift report was accurate or like provided unnecessary information or failed to provide necessary information such as…(RN B). And in a perfect world we would have communication between staff so you could just say it would have been really helpful for me this morning if I had known this in the inter-shift report, but we more and more tend not to provide that feedback (PCC). The team agreed that constructive feedback is feedback that is presented in a positive way. Positive feedback should focus on improvement and be presented as an educational tool. I think it would be important to keep it in a positive and motivating light and be careful it’s not going to cause more conflicts between staff. It’s human nature to almost not take it as well, some people take it better than others so I don’t know if there is a way to be subjective and evaluate a form without making it impact the team piece (human factors engineer). After considerable discussion about a constructive feedback process, the team decided that input should be sought from staff, educators and management. There was consensus that feedback is a necessary part of all nurses’ professional development.   79   You should be able to take some degree of feedback. That’s part of the profession, you should be able to take feedback and put into your practice and make your practice better (RN C). Role modeling. The project team also felt that role modeling is an important method for improving effective communications during the inter-shift handover report. I think one of the major things that works on our ward is role modeling and people like setting those expectations and I know because we have the staff mix we do when the junior staff see senior staff doing something they tend to quickly pick up on those skills faster than when you introduce something that they don’t necessarily see other people doing…(RN B). I think if you have some buy in from some key people who are sort of role models on the ward you’ll start to see that actually start happening throughout the staff and with all of the staff members (RN A). The project team agreed that role modeling is an aspect of professional accountability that should be reinforced as an expectation of professional nursing practice on their unit. If they see what the night nurse wrote down it might prompt them in their own practice to look for this stuff, like I didn’t even think of this. It might set up an as expectation. It really helps my day when you walk into a room and you kind of know what you are going to get (RN C). Trust in written communication. The team discussion also focused on other sources of information that need to be accurately updated to support content included on the inter-shift handover form. The team noted that disparities between information on the form and content in   82   inter-shift handover use through role modeling and positive feedback. As well as, proper completion of the accompanying documentation such as kardexes and care plans. Design   The central focus of the design phase of the AI process was what the different system categories should consist of and what was the core or critical elements needed to consistently provide a ‘perfect’ handover. The design phase of the AI process was started during the first project team meeting, was the focus of the second team meeting and was concluded in the third team meeting. The discussion in the dream phase centered on the best-case scenario and a ‘perfect world’ example of what inter-shift handover report would look like. From here the project team proceeded to the design phase of creating an ideal inter-shift handover form. In the first meeting, the team discussed physiological systems categories to include and critical information pertaining to each systems category. The structure or layout of content was also determined in this project team meeting. The team passionately debated the content for the form, emphasizing the need to include all relevant information and maintain succinctness. The team encountered difficulties with structuring a handover form to capture all the possibilities of a medicine patient. The project team felt that if this was attempted the form would be cluttered and confusing and would lead to less important information being noted and also less critical thinking. This is discussed in more detail in the ‘categories’ section. The team felt that ongoing education and professional accountability (e.g., feedback, role modeling) could serve as means to focus and refine content included during handover (versus trying to include everything in one form).   83   Different examples were drawn on the meeting room’s white board. Photos were taken of the different versions and can be found in Appendix I. The team modified and discussed the various components. The following subsections presented below highlight the process the project team went through in designing the form. The following themes emerged during the first project team meeting discussion of the design phase of the Appreciative Inquiry process: 1. Categories, 2. Process, and 3. Content. Categories. To begin designing the inter-shift handover form, the team began by considering the way the form should be structured. Throughout the first team meeting, the participants were consistent with the need to have the handover form organized by physiologic systems. This is where the team began coming up with the structure and categories that should be represented on the handover form. From the beginning the team agreed that because diagnosis, falls risk, aggression alert, restraints and infection control concerns are listed in the kardex these should not be included on the inter-shift handover report. Ensuring this information is captured in the kardex will be emphasized with education around the purpose of the inter-shift report. Physiologic systems. The team agreed easily upon the following physiologic systems categories: neurologic, cardiovascular, respiratory, gastrointestinal, genitourinary and skin. These physiologic systems formed the bulk of the inter-shift handover form. Pain. There was more discussion related to pain and psychosocial categories and how or if these should be represented on the inter-shift handover form. On the current handover form   84   utilized on the study unit, pain is addressed only by indicating when the last analgesia was administered. The team felt this was inadequate, as it did not address the pain concerns of the patient or what strategies might work for them. I think pain might be a stand-alone thing, we have a lot of patients that have generalized pain and that can take up a large part of your shift dealing with PRN pain just trying to make them comfortable (RN A). I think pain issues as a general statement is good to have but having last analgesia is not helpful, you can check the MAR (medication administration record) for that information. And that doesn’t always capture the information you really need (CNE). Psychosocial. The team agreed that it was important to have a category for psychosocial information that pertains to the patient or the family. I think psychosocial on the inter-shift report would capture any relevant family issues and also any kind of quirks of the patient you might need to consider, for example a very involved family (RN B). Earlier in the team meeting discussion, the team emphasized the need to only include objective data and information. However, the team did agree that objective psychosocial data was important to the arriving nurse and is important to making a daily plan. The family is very involved and you need to set boundaries, I don’t think that’s a subjective thing, you can be polite and nice but you still need to set boundaries…(RN C).   87   each system should have a “check-off” if normal with a space for writing in any notes about abnormal systems function. There was some discussion about using terms such as “normal” and “abnormal” and a decision was made to refer to “normal” as “No Concerns.” I do think there’s value in having something to check off to say I did think about this and I don’t have any concerns rather than I may or may not have thought about it (RN A). Or if you had a check box if everything was fine you just check it off then at least you know, or the people coming in, and you don’t have that verbal handover, you know that they went through all of it, they haven’t just gone half way through and then um got into another event (RN C). Information sources. Another concern was the multiple sources of patient information. The team agreed that the handover form had to stay true to its purpose without repeating information (and creating redundancy and additional work). I feel like there is so many different areas to write this information, the report sheet, the kardex, the tick sheets, the census, nurses notes, I feel we should have something on the report sheet specifically saying this is where you will find more information (RN A). The team decided this information should not be re-charted, but should be acknowledged. The “check-off” system to alert nurses to other sources of information was agreed upon in lieu of re-charting. For instance, the handover form includes check-offs that the kardex was in fact updated and to indicate the need to read the nurses’ notes for more information on a specific   88   event. The team agreed that the nursing notes often contain relevant information that is overlooked or lost, adding to nurses’ workload issues. I would almost want to have that as a separate piece rather than related to the systems. For example if I’ve been looking for a patient’s wallet for 12 hours and I want to pass that along, I’d like to write missing wallet next to the see nurses’ notes so the nurse can go and look in the chart for the information (PCC). The team agreed that the inter-shift handover form should indicate other sources of detailed information (e.g., kardex, patient chart) to reduce the tendency to re-chart on specific systems or patient events (e.g., procedures, treatments). The team also wanted to include a follow-up section on the handover form. This section would be a priority “to do” list, acting as a guide of what has happened with the patient and what needs to happen, improving continuity. I think that if the system part of it was filled out properly it would capture the last 12 hours and your follow-up section would capture what you need to prioritize with the day (PCC). Content. When the project team started to discuss the form design, they knew they wanted it to be physiological systems-based but exact content details needed to be determined. The team continually referred back to the purpose of the handover report: ensuring safe, continuity of patient care delivery. Forcing functions. One consideration found in this theme was the idea of forcing functions, such as check boxes, or trigger words. The project team felt that by listing the separate systems this would act in itself as trigger words. They felt that more words or boxes on the report would cause confusion for nurses.   89   This report is already much better organized, especially for those who have very structured minds, but if you don’t have that type of mind and don’t intuitively think that way this will guide you to think a certain way (RN B). I think even for the people that struggle with it though it’s probably the most consistent concise way to facilitate their thinking even if it’s not a natural thing it still walks them through it, might take them a little longer (PCC). I think for the systems just having the systems listed would be enough for me to think ‘ok neuro what does that look like, what do I need to say about that’ I think separate from that there should be sort of trigger areas the way there is on this [old, previous version] form, abnormal vitals or whatever else…I think like having actual sections for different systems and having things like follow up section like abnormal labs section, abnormal vitals or whatever else (RN A). The unique input from the human factors engineer supported the nurses within the project team. She stated, “I think by having words it prompts people to think about certain things”. In addition, she thought that utilizing forcing functions, such as checklists, would actually decrease the utility of the form as a teaching tool and source of critical thinking and professional accountability: “If you put more on there you start limiting what people will actually report”. Other group members agreed and added that there was such a wide variety of patient conditions on the unit that providing forcing functions for everything would be challenging. There’s such a wide variety of issues that we would want to report on, yeah, it’s hard to kind of have all of that covered on the form with forcing functions (CNE).