By Wilson, Mary Jane
“When information is missed in patient handovers, people die,” Dr. Gail Wolf tells graduate nursing students at the University of Pittsburgh. As the nursing vice-president for the University of Pittsburgh Medical Center (UPMC), a 15-hospital system in western Pennsylvania, Dr. Wolf speaks from experience. She tells graduate students about a patient in his 30s who suffered a vessel nick in the operating room. It was repaired and not reported to the unit nurse after recovery. The patient later became slightly hypertensive and drowsy, tell-tale symptoms but not abnormal after general anesthesia and surgery. He bled internally; unfortunately, by the time his clinical condition presented as acute distress, it was too late to intervene and the patient died (Wolf, 2003). Nurses know their handover reports are important. Most develop a system and even forms for taking report. It’s vital to pass on all important but not superfluous information because timeliness is a vital aspect of their jobs. This is a fine balancing act. The associate risks frequently are unappreciated until there is an adverse event. These events are often determined to be due to miscommunication between providers during a transition in patient care (Simpson, 2005).
Changes
Over the past 20 years, changes in health care have affected reports in various ways. Nursing has become more complex and time- pressed. At the same time, patient acuity has increased dramatically. Communicating nursing care during the patient’s total hospital stay is a difficult task given the context of high patient turnover and time constraints (O’ Connell & Penney, 2001). Simply put, there is more information to give in a shorter time period.
Primary nursing allows a comprehensive view of the patient, which also increases the volume of information that can be reported. Nursing practice has increased skills and attention devoted to physical assessment; nurses focus on a patient in terms of systems. This has evolved to the practice of thoroughly reporting all findings, including the normal data such as “bowel sounds in all four quadrants.” Reporting normal values in every organ system is time intensive and can become rote. Technology has led to more lab results and procedures to report, and acutely ill patients may remain on a medical-surgical unit rather than in ICU. These factors all influence the amount of information which can be provided in shift report.
Changes in the health care environment have encouraged nurses to become more efficient. The time involved in shift handover has been no exception. Reports have evolved from a room full of staff listening to a report on every patient, to oneon- one verbal or taped reports on individual shift assignments. Reports need to include all pertinent information, but reporting every physical assessment finding, every activity, every meal, and every visitor makes reports too lengthy. However, if reporting by exception deteriorates to, “Ms. X is fine, she had a headache, gave her Tylenol(R) at 8 pm and that’s it,” nursing has a problem.
Review of the Literature
Relevant literature related to patient handover was identified using electronic databases (CINAHL, Ovid MEDLINE, AMED, and Psyc- INFO). Key words included handover, shift report, and nursing. The search yielded 17 articles.
Purpose and importance of the shift report. Nursing shift reports enhance the continuity and quality of nursing care by providing information on nursing assessments, and drawing attention to specific nursing interventions and goals for the next shift (Priest & Holmberg, 2000). They are important for ensuring and maintaining continuity and quality of patient care as well as complying with professional standards and legal requirements (Miller, 1998; Thurgood, 1995).
Numerous authors agree that a poor report can jeopardize a patient’s safety (Dowding, 2001; Lally, 1999; Malestic, 2003; Sherlock, 1995). Occurring multiple times each day with each patient in the health care setting, handoffs are prone to errors and omissions that can contribute to negative patient outcomes (Simpson, 2005; Wolf, 2003). High levels of responsibility, accountability, autonomy, and authority accompanied the transition from team to primary nursing reports. Patient reporting is a task that repeatedly tests a nurse’s knowledge skills and communication (O’Connell & Penney, 2001; Thurgood 1995).
Handovers achieve goals beyond communicating patient care. These include debriefing, clarifying information, updating knowledge, and building a sense of team (Lally, 1999; Lamond, 2000; Miller 1998; O’Connell & Penney, 2001). The report process merits further study to maximize its role in information sharing and resource management (Dowding, 2001; Lamond, 2000; Miller, 1998).
Content and mode of the shift report. Reports should support the development of consistent, collaborative nursing interventions across shifts; they should summarize and communicate current info about the patient’s status, needs, treatment plan, and responses or outcomes to treatment (Malestic, 2003; McLaughlin & Bryant, 2004; Simpson, 2005). Reports can follow various models such as “body systems,””head-totoe,” or “reporting by exception.” All report modes should allow face-to-face time to answer questions (McLaughlin & Bryant, 2004).
Nursing reports are given in a variety of ways: verbal, written, taped, or bedside (McLaughlin & Bryant, 2004; Miller, 1998; O’Connell & Penney, 2001). Each one has advantages and disadvantages (Dowding, 2001; Lamond, 2000). Wallum (1995) suggested that nurses use care plans to replace the handoff report; his research indicated that over 60% of nurses studied had not referred to the relevant care plans during their shift.
Using a Report Template
Very few articles addressed the contents of a report, and only one offered a template (Brown- Lazzara, 2004). Concise reporting that minimizes duplication yet avoids missing information is a complex job; tools that simplify and standardize the process help. See Figure 1 for a full-page template for use and replication. A table of usage guidelines for the template is found in Table 1. The critical elements that should be addressed in every report will vary by unit and type of patient, but it is important to agree within professional groups on report format as a time-saving device. Uniform order of information is achieved by following a template in a consistent manner; it simplifies communication for both giver and receiver.
Reporting that follows the trend of charting by exception will be most time effective. Stating every normal assessment finding and listing every lab value is time consuming. It also may prompt the listener to miss important information. Normal findings are pertinent and should be stated when they indicate change, recovery, or response to treatment. If information is missed, it is each nurse’s responsibility to look it up. “I don’t know. The other nurse didn’t tell me,” is not an acceptable answer to a physician or colleague. Technological advances are not a substitute for effective communication in the delivery of safe care (Malestic, 2003).
Research
The report template (see Figure 1) was utilized in a nursing project study at UPMC Shadyside Hospital (Pittsburgh, PA). At Shadyside, reports are taped on a phone system called VoiceCare. It was noted that nurses give report in a variety of ways with varying degrees of completeness. The authors reviewed the issue and learned there was an established set of guidelines for UPMC nurses to use in giving report. The use of a template could incorporate the guidelines to make report an easier process.
Step 1. “Knowledge” of existing guidelines assessed. An informal survey of 63 nurses found that only one knew of and had seen the written guidelines.
Step 2. Assistance enlisted. Four registered nurses from the resource pool at Shadyside volunteered to assist in evaluating the taped nursing reports. Four medical- surgical telemetry units were selected to assess. Each of these units had an average bed capacity of 38.
Step 3. Data collection. Volunteer nurses randomly selected and listened to 262 shift reports from all five shift times (7:00 a.m. – 3:00 p.m., 3:00 – 11:00 p.m., 11:00 p.m. – 7:00 a.m., 7:00 a.m. – 7:00 p.m., and 7:00 p.m. – 7:00 a.m.). These shift reports were compared to established guidelines over a 3-month period.
Step 4. Results. Figure 2 details the recommended information omitted from shift reports to oncoming nurses. The four nurses who collected information made suggestions and revisions to the established guidelines to provide a better process for Shadyside, where each nurse receives a printed Kardex for care on each patient. All agreed that most information on the Kardex, such as the physician’s name, did not need to be stated in the verbal report.
Step 5. Providing a report template. A report template was created and dispersed to nurses on the four medical-surgical units that were evaluated. Each nurse received a letter encouraging him or her to use the template as a guideline for giving shift reports. The unit directors on each unit were provided with copies of the templates to post near the telephones used for taping the VoiceCare reports. They also were given copies of the nursing letter and asked to promote use of the template.
Project Goals:
1. Nurses will utilize the shift report template.
2. Shift reports will include the significant data.
3. Superfluous information will be minimized. 4. Nurses will provide information in a uniform manner.
5. Nurses will find giving and receiving report simpler and streamlined.
6. Patient care and safety will be maximized.
Step 6. Evaluating use of the template. Three of the units in the initial study (named units 2, 4, and 5) were evaluated for a 5- month period beginning 1 month after forms were distributed, with no further intervention other than to answer questions. The other two units (named units 1 and 3) received ongoing encouragement from the unit director, the nursing educators, and the researchers. Fifty random samples were taken from each unit to evaluate the use of the template. See Figure 3 for results; these data differ from the initial information because nurses chose to eliminate the information that came printed on their working Kardex.
Because these reports are taped in a VoiceCare system, the reporter’s name, shift, and date were added to verify that the correct report was heard; mistakes are rare but can occur. In the initial study, 2 of the 262 reports were on a different patient. In the follow up, there also were two taped reports for which the patient data were entered in VoiceCare under the incorrect patient code number.
Discussion
Figure 3 shows a wide variation in results. Recognizing that units 2, 4, and 5 received no intervention beyond the distribution of the template and letter, it may be logical to expect their scores to be lower.
Unit 3 was involved in the initial study and the nurses there had shown a sincere interest in the project. The researchers attended a unit staff meeting then gave ongoing encouragement to utilize the template. The nurses also made recommendations and suggestions specific for their unit. Individual nurses who omitted items or gave superfluous information in report were encouraged to make changes consistent with the template. While this improved the scoring of unit 3, a factor that was likely to lower the scores involved a high use of agency nurses over the 6-month study period. While these agency nurses had access to the templates, visible near every telephone, they all did not receive specific encouragement to use the forms.
Unit 1 was added to the study because a number of nurses saw the template and asked the researcher to provide them with it. They encouraged each other in its use and evaluated each other.
In informal discussions, nurses made the following general paraphrased statements:
* It is hard to change my routine.
* I’m really trying, but I fall back into old patterns when rushed.
* I am already giving good reports and don’t see the need to change.
* This seems like one more burden to already overwhelmed nurses.
* This is a really good idea and will save time.
* Reports are improving in focus and completeness on our floor.
* There is less superfluous information.
* Graduate nurses and nursing students grasp the tool most eagerly.
* The biggest benefit is to the newer nurses.
* Some nurses follow it perfectly.
Conclusions
The critical elements that should be addressed in every report will vary by institution, unit, and type of patient. What is important is that each appropriate subgroup agrees upon a report format to ensure content quality and timeliness, and simplify a complex report communication process.
Recommendations for the Future
The case for a written handover. Historically, handovers in hospital settings involved a nurse from the off-going shift reporting to the entire oncoming team of nurses, students, and nursing assistants. Over the last 20 years, reports have changed based on practice and time constraints. The handover process is meant to promote continuity and efficiency, but there are inherent vulnerabilities due to human factors (Simpson, 2005).
The report tool could be the nurse’s documentation record, which would be handed to the nurse coming on. This document should contain the assessment, plan of care, relevant test findings, and nurse’s notes, including occurrences, treatments, as-needed medications, and patient responses. The nurse taking report would no longer need to write, but would review the document with or without a taped or verbal report. Then he or she would utilize a blank document for shift care documentation. This would in turn be handed to the next shift.
Sharing comprehensive nursing documentation each shift would minimize duplication, streamline reporting, and save significant time. Even as hospitals change to electronic health records, nurses may need a worksheet of some form. The transition to electronic records offers an additional challenge to nursing practice, including the way handovers are accomplished. The Handover Report Template Tool (see Figure 1) is intended to help nurses during these times of rapid change to remain rooted in their solid foundation of patient-centered care.
Summary
Nurses have responded professionally to the challenges of health care. They require specialized knowledge and skills, and open attitudes to give and receive handover reports safely and effectively (Malestic, 2003; Thurgood, 1995). More creative ways of conducting the handover of patient care should be explored so an important aspect of nursing practice becomes more than a ritual. In the highly stressful workplace, this tool may will help nurses and simplify one vital task.
References
Brown-Lazzara, P. (2004). Make your better best with a reporting system. Nursing Management, 35(8), 48A-48D.
Dowding, D. (2001). Examining the effects that manipulating information given in the change of shift report has on nurse’s care planning ability. Journal of Advanced Nursing, 33(6), 836-846.
Lally, S. (1999). An investigation into the functions of nurses’ communication at the inter-shift handover. Journal of Nursing Management, 7(1), 26-36.
Lamond, D. (2000). The information content of the nurse change of shift report. Journal of Advanced Nursing, 31(4), 794-804.
Malestic, S.L. (2003). A quick guide to verbal reports. RN, 66(2), 47-49.
McLaughlin, E.L., & Bryant, A. (2004). Get an A+ on end-of-shift report. Nursing2005, 34(6), 32-33.
Miller, C. (1998). Ensuring continuing care: Styles and efficiency of the handover process. Australian Journal of Advanced Nursing, 16(1), 23-27.
O’Connell, B., & Penney, W. (2001). Challenging the handover ritual. Recommendations for research and practice. Collegian: Journal of the Royal College of Nursing, Australia, 8(3), 14-18.
Priest, C.S., & Holmberg, S.K. (2000). A new model for the mental health nursing change of shift report. Journal of Psychosocial Nursing & Mental Health Service, 38(8), 36-43.
Sherlock, C. (1995). The patient handover. Nursing Standard, 9(25), 33-36.
Simpson, K. (2005). Handling handoffs safely. American Journal of Maternal Child Nursing, 30(2), 152.
Thurgood, G. (1995). Verbal handover reports: What skills are needed? British Journal of Nursing, 4(12), 720-722.
Wallum, R. (1995). Using care plans to replace the handover. Nursing Standard, 9(32), 24-26.
Wolf, G. (2003). Nursing 2061: Organizational and management theory. Lecture presented at the University of Pittsburgh, School of Nursing, Pittsburgh, PA.
Mary Jane Wilson, MS, RN, is Senior Professional Nurse, Cardiology Step- Down Unit, Shadyside Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA.
Acknowledgments: The author would like to thank Lauren Saul who valued the template, encouraged research, and proofread the many drafts of this article. Special thanks to all of the nurses at Shadyside Hospital, Pittsburgh, PA, who assisted as well.
Copyright Anthony J. Jannetti, Inc. Jun 2007
(c) 2007 Medsurg Nursing. Provided by ProQuest Information and Learning. All rights Reserved.
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