Evidence based practice
Background InformationTraditionally nurses delivered clinical information about the patient, the clinical events on their shift and the plan of care to the oncoming shift to ensure continuity of care and to make sure that their colleagues were informed about tasks or instructions that needed to be completed by the next shift. This process had a variety of names; report, handover or handoff. The format was often different from unit to unit.
It usually took place in an off stage room or office or at a charting station from away from the patients. This project aimed to assess if moving nurse to nurse handover to the patient’s bedside could promote safety and decease the length of time that it took to complete the process. The study was designed to evaluate if moving shift handover to the patient’s bedside could lead to more cost effective care and if by reducing the amount of time that nurse were away from the bedside during handover could result in improved patient safety.
Review of LiteratureWhen reviewing the literature, the researchers found that while bedside handover was credited to improve communication and patient and staff satisfaction that very little empirical data was available about the economic, cost effective benefits of the process. They discussed the findings of 7 articles that were reviewed and they cited 17 sources that were dated from 1947 to 2009.
The oldest citations were related to the change management process and not directly related to bedside handover. Literature review found that the delay in nurses connecting with patients during traditional handover could result in reduced patient safety and in increase in adverse events (Caruso, 2007). Trossman, in an article in The American Nurse in 2009, reported anecdotally that bedside handover was more economical than traditional process but data was not provided.
The author did not find empirical data that measured adverse safety events specifically during handover but retrospective case studies and anecdotal accounts had inferred that reduction in events was an outcome of moving away from traditional methods of shift handover. “Nursing Handover at the bedside allows the nurse to visualize the patients at the start of shift and perform safety checks. (Caruso, 2007) Discussion of MethodologyThis study used a mixed? method, evaluative approach involving quantitative (quasi? experimental) and qualitative (ethnographic) designs.
Researchers The study was conducted in three small rural Australian hospitals, on acute care units. The three sites while similar in fundamentals had some variances in size, patient populations and types of staffing matrixes. The study sampling size was 48 nurses who agreed to transition to the new process. Implementation of the process was replicated in the three sites to more accurately assess and measure results. The only criterion for staff was that they had to be currently working in the unit in a patient care role.
Data was collected in 3 stages using quantitative and qualitative components. Quantitative elements comprised of digital time recordings of the duration or length of handover and collecting data related to adverse patient events during handover, pre and post the process change. Researchers also used the ethnographic approach by observing nurse handovers to note the types of information discussed and the terminology used. In addition, nurses were interviewed about their perceptions and satisfaction with handover and asked to estimate how long the process takes to complete.
This was also done before and after implementation of the change. Researchers used Lewin’s model of change management to put the process change in place. Specific Data AnalysisResearchers collected demographic data only related to the age and gender of the sample group. Years of nursing experience was not recorded. This information was organized by age groups and recorded in table form. Quantitative data was collected as handovers at three sites were timed pre and post the practice change and this information was analyzed and presented in graphs demonstrating the any differences.
Results were tabulated by numbers of patients and staff and average times computed by unit. The mean length of handover with traditional handover was 0. 44 hours which deceased to 0. 22 hours after the move to bedside handover. Data on the number of adverse patient safety outcomes during handover were gather pre and post implementation and tabulated. Qualitative data collected from nurse interviews, pre implementation of bedside handover indicted that they found the traditional handover to be “difficult and time consuming.
” This data was presented in graphs, demonstrating the any differences with in the three sites. Nurses were also asked to estimate the time taken to complete shift handover pre and post implementation. Researchers used a mixed model, descriptive statistics to correlate results and draw conclusions. Researcher’s Conclusion:The authors concluded that there was a clear trend that indicated that shift handover conducted at the patient’s bedside was considerably shorter in duration.
Exact figures or estimates, on how this would translate into cost savings in economic terms were not addressed. Researcher’s data found that adverse patient events decreased, which would correlate to previous research that this form of handover leads to improved patient safety outcomes. Researchers were not convinced that this study could adequately validate that the process leads to improved accuracy and better communication and that further research was needed to fully explore those areas of the process. A3. Assessment of Evidence:
In reviewing all the information related to this study in the five areas contained in the graphic, the study was designed to test the hypothesis that a process change from a traditional method of shift handover to nurse handover at bedside would shorten the duration of time it took to conduct the process, which it turn could lead to economic benefits to the organizations that adopted the process modification. The researchers also wished to gather data that would establish that the new process lead to improved patient safety which also while enhancing patient care can also led to cost savings for organizations.
In addition, they sought to examine the nurses’ perceptions of both types of handover and if the views changed with the new process introduction. Digital recordings of the times it took the nurses to conduct handover using both methods showed a clear reduction in the length of time it took to complete handover at the bedside against using the traditional method. Unfortunately the study did not directly equate the time savings to cost deduction benefit in real terms or figures. The numbers of adverse patient events deceased from 18 prior to implementation of bedside handover, which was reduced to 7 events after the new process was in place.
This would seem to indicate that patient safety was enhanced by the new process. Site 3 data revealed that post implementation that nurses interviewed registered a slight increase in dissatisfaction with the process. The other two sites showed an increase in the satisfaction and all three sites estimated the time they took to complete handover showed significant improvements in all three units. The study concluded that handover was shorter after the process change and that the reduction in adverse incidents within the time frame indicated that bedside handover increased patient safety.
The authors did acknowledge that the study was limited by sample size and that using a mixed method approach, was time consuming when the time for the study was limited. It is difficult to see how gathering data on the nurses’ preferences and perceptions about handover contributed to the aim of the study, which was to see if altering the method of delivery would impact duration of report and improve safety. The literature review the authors listed, did not state how many articles that were sourced but cited 7 articles that they had reviewed which were relevant to validate the need to answer their specific questions.
They did not find any empirical research data that demonstrated the cost effectiveness of the process. They could have made a larger more significant review of literature prior to implementation or better record their literature search and review results. The study lists the authors as the researcher, a doctoral nurse and a statistician research partner to analyze the results. As this was conducted over three rural sites, the article makes no mention of who assisted with data gathering and interviews or how the change was effected. Multiple people doing ethological observations and interviews can affect results.
It also does not speak to the time frame in which the study was conducted. In discussing methodology, the study makes note that 14 sessions in the 3 sites, where morning to afternoon handovers were observed and so there appears to be no data collection related to night shift which makes up one third of nursing hours daily. Given some of the night shift challenges such as less staffing, fewer doctors’ in house and often higher volume of sedated or confused patients, collecting no data from this group may have substantially altered the data.
While the study makes reference to observing styles and terminology used as baseline data prior to the process change, it does not address if the nurses’ used a standardized format, process or tool to ensure uniformity of the information being passed to the next shift during handover. It does not address if there was conformity in the structure of the handover across the 3 units, which could skew results for both duration and accuracy and therefore impact safety results. The reduction in adverse events like falls could be related to the fact that after the change in handover method that the nurses were out rounding on patients with the off going shift rather than having reduced staffing levels on the floor while staff give lengthy handoffs away from the patients behind closed doors. The study recommended that further research is needed to address some of these questions and to study if the type, format, quality and accuracy of information during bedside handoff impacts the length and the safety data collected. A4. Ethical Issues:
During any research that involves humans, there are always ethical concerns that must be considered. The Nuremberg Code and the Declaration of Helsinki laid out ethical guidelines and rules for researchers to follow after some of the atrocities conducted by Nazi researchers during the Second World War were revealed. (Houser, 2007) Protection of privacy and informed consent are always one of the first issues that must be addressed. The participants should be made aware of any risks or hazards that they have the right to withdraw at any time from the study should they so choose.
Researcher must “do no harm’ and demonstrate that there is benefit to the knowledge obtained. In the United States, access to patients’ health information is protected and illegal without clinical necessity or patients consent. As this study was conducted in Australia, there may be different laws about access to health records and patient’s privacy but researchers would still be required to get consent from any patients where the handover was being observed by the researchers at the patient’s bedside. In this study, the researchers make no reference to how or if consent was obtained.
They identify the nurses “self-selected” to partake in the study (Bradley & Mott, 2010), which one presumes means that they volunteered. The authors did make note that two of the nurses refused to give their age when asked for demographic data so they may have been aware of their rights. Privacy of the patients health information being discussed during handover and consent for the presence of observers at the patient’s bedside is also not discussed in this study so none of the ethical data is discussed or available.
The study does not address in the methodology if the study was approved by an Institutional Review Board and if consent was obtained from participants. A5. Type of Research: There are numerous methodologies for conducting research and often the choice is related the hypothesis that is to be examined. This study utilized a mixed method approach and gathered both quantitative and qualitative data. ” Quantitative research is used measurement to determine the effectiveness of interventions”. (Houser, 2007) This method utilizes designs where collected data and results can be statistically and mathematically computed compared and analyzed. Variables are accounted for and numbers pre and post implementation or interventions are measured and conclusions are drawn dependent on the numbers. The quantitative data included collecting demographic data from the sample group participants, the timing and logging the duration or length of the handovers and collecting data on the number of adverse patient safety incidents during the study period.
Qualitative research is more humanistic in approach rather than numerical. It is concerned with the perceptions and acceptability of a process to patients and staff rather than determining effectiveness. It is harder to measure but equally important in nursing research as no matter how successful and efficient a new procedure or process is unless it is well received by the patients and staff and the benefits apparent, it is unlikely to be effective and sustained.
In this study qualitative data was collected by interviewing the nurse participants’ pre and post hand over process change to assess their perception of the traditional handover style and asked them to estimate how long the process usual took to complete. The interviews were then repeated after the implementation of bedside handover and the researchers concluded that the nurses found value in the new process. The article also noted that ethnography, a form of qualitative research was utilized.
Ethnography is observation and study of the culture and interactions of a target population or group. In this case the researchers observed the nurse to nurse handover to observe habits and terminologies that were part of the unit culture and habits. A5a. Other Types of Research: There are different kinds of research design and the method chosen is often dependent on the hypothesis to be tested or contingent on the question to be answered. Research methods fall in to two main groupings, quantitative and qualitative.
This article used both methods in a mixed method approach. This article could have done a better systematic review search of current literature to summarize the findings of other studies on the desired topic and make recommendations for a practice change bases on the findings. Other subtypes of qualitative research include Phenomenological, which seeks to gather insight into a human experience, in the case of nursing research this would be a health related experience for example an awareness of how a patient copes with a chronic ailment like diabetes.
Ethnology used in this study seeks to examine the interactions, terminology and subculture with a group like a group of patients in a bariatric support group in the article the authors looked at how the group of nurse participants usually delivered handover. A grounded theory method seeks to gain knowledge or understanding related to a social process connected to a health matter or decision like the choice to make advanced directives. (Brown, 2009) Quantitative subtypes include; experimental research which is difficult to do in a nursing context and would have difficult to do in this study.
It is based on scientific protocols that require control groups and random assignment of participants to the study or the control. Variables and other influences need to be negated or controlled and interventions must be consistent in each instance. Descriptive studies where individual variables like pain or anxiety, that may differ from patient to patient, are quantified using scales to provide a more uniform measurement for result assembly and rationalization. Correlational studies seek to examine the relationship between variables like lack of exercise and poor diets association to heart disease.
These subtypes may not have worked well within the researchers framework but the descriptive method could be used to rate patient satisfaction with the process. Problem: Beside handover has been credited with many benefits over traditional approaches to shift report. Claims include improved nurse communication and accountability, increased staff and patient satisfaction, reduction of everything from falls and medication errors to a decrease in staff overtime and call bell usage. Recent research links bedside handover to improved patient safety outcomes.
More comprehensive studies are needed to test the validities of these assertions and ascertain if bedside handover is a patient safety initiative. There are numerous driving forces that are making this method of shift to shift communication an increasingly popular strategy. “One of The Joint Commissions on Accreditation of Healthcare Organizations (JCAHO) 2010 National patient Safety Goals (NPSG) was to improve shift handover communication,” (Nodznaia, 2012) “including an opportunity to ask and respond to questions”. (Riesenberg, Leitzsch, & Cunningham, 2010) In 2009, the NPSG was to “improve the effectiveness of communication among caregivers” (JCAHO, 2009). Communication lapses and failure to relay relevant information have been correlated to 70% of all sentinel events in hospitals. (Alvarado et al. , 2006) Inadequate communication has been acknowledged as an element related to the current issues of medical malpractice claims and sentinel patient safety adverse incidents. “Errors in communication give rise to substantial clinical morbidity and mortality. (Riesenberg, 2010) The change of shift and nurse to nurse hand over has been marked as an especially vulnerable time for patients, with less staff on the floor and distracted giving handover to colleagues, the potential for missed information and a poor patient outcome is higher than at any other time during the shift. “Shift change updates are widely believed to be a point of vulnerability in complex systems with high consequences for failure” (Patterson, 2008).
It has become of increasing importance to healthcare organizations that patient satisfaction scores are consistently in the high percentiles nationally. With the introduction of the Affordable Care Act in 2009 reimbursement is tied to improved outcomes and increase patient satisfaction with entries and providers. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are Centers for Medicare & Medicaid Services’ (CMS) (Nodznaia, 2012) collects patient satisfaction data and have cut increasingly higher percentages from organizations funding who post low scores.
Bedside handover according to the literature can have a positive impact on patient satisfaction by improving nurse patient communication, allaying patient anxiety and assisting patient to be more involved with their plan of care and better informed consumers. Catholic Healthcare West recorded improvement in patient satisfaction scores after the implementation of the bedside handover model.
(Rush, 2012) Most articles on the topic agree that additional effort should be expended to collect empirical evidence to support the largely anecdotal evidence and retrospective case studies that point to improvements in patient safety. While government and financial initiatives encourage intuitions to move to this method of handover in an effort to meet ever increasing quality and safety goals, the profession must ensure that the evidence supports the validity of the change as best practice. B2. See Attached Matrix