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Problem Identification and Rationale for Improvement

Discuss about the Leading and Managing in Nursing-E-Book.

Healthcare settings are responsible for delivering best possible services to the healthcare consumers to achieve better outcomes within a stipulated time. Professionals working in collaboration with each other in different settings are to demonstrate suitable professional skills and competencies to engage in safe practice. It is to be remembered that the care setting is accountable for putting in place the varied policies for clinical practice as per the best interests of the patient population. In this regard it is crucial that changes are implemented in practice to augment the policies or procedures adhered to. Action plans are to be articulated based on research evidence that can guide positive changes in different areas of practice within the different wards. These are to be then implemented in consultation with all stakeholders and a thorough evaluation is also warranted for understanding the effectiveness of the same. The present paper reports on handovers of shift duty as the chosen area of practice in the current ward of ICU at a reputed healthcare setting at Riyadh, Saudi Arabia and critically reviews its procedure. Based on evidence based approach, an action plan is drawn up on how the practice can be better improved. The report identifies the problem in the clinical area and gives a rationale for improvement on the basis of relevant literature. A standard setting statement is drafted in this regard. Details for the implementation of the plan are discussed including how the standard would be communicated to others and the method of evaluation of the standard set. A conclusion is provided at the end of the paper to summarize key points.

Delivery of appropriate and safe health care is at the core of the services provided at the present ICU at the Riyadh hospital. The ICU is the specialized department that focuses on providing intensive treatment to the patient population. The professionals working at the unit are accountable for catering to the needs of individuals suffering from life threatening diseases and illness. Patients require close monitoring and constant support provided in a professional manner by skilled workers (Haniffa et al., 2017). The ward is distinguished from other wards in that the staff-to-patient ratio is higher and access to advanced equipment and resources is enabled.

Shift handover is a common tradition among nursing professionals at the ward that has drawn the attention at present in relation to need of betterment. Clinical handovers refer to the transfer of accountability and professional responsibility of patient care aspects from one professional or professional group to another on a temporary and permanent basis. The purpose of the handover is to make sure that professionals about to take in charge of care have the required level of understanding of clinical priorities (Blais et al., 2015). At the present ward, a number of concerns have been identified in relation to the procedure of shift handover. Though it Is acknowledged that shift handover is essential and inevitable for shift working pattern, not much have been done to ensure that the procedure for the same is robust. Clinical handovers between shifts has remained a high risk activity at the setting for patient safety. Critical information is not transferred in a correct and effect manner that maintains continuity of care.

Evidence-Based Action Plan for Improvement

Observations at the ICU indicated that shift handovers did not take place at a designated area and at a particular time without interruptions. While some professionals considered completing the handovers at the bedside, others did not consider so. At one instance it was noticed that a nurse had used the office room for the handover. Handovers at places other than the bedside are not effective as the professionals are not able to observe the patient and collect updated patient information at the time of the handover (Malekzadeh et al., 2013). The staff taking part in the handover has a crucial role in the process. The desired process model encompasses staffs from all grades to be present (Graan et al., 2016). At the current ward the handovers included only the incoming and outgoing nursing professional. The duration of the handovers were also found to be differing to a considerable extent. While some handovers lasted for 45 minutes, some were completed within 15-20 minutes. It is the best practice that shift handovers are carried out without interruption so that optimal information is passed on within a short time frame in an accurate manner. At the present ICU it was observed that handovers were often disturbed and interrupted. Moreover, the proportion of urgent and non-urgent distractions was nearly equal. Despite a guideline put in place for handover, there has been non-adherence to the same. It is therefore significant to bring improvement in the standard of shift handovers at the unit.

The importance of shift handovers has been gaining recognition in the recent times against the evolving healthcare needs of patient population. In the past, ICUs were only covered by senior medical officers and experienced nursing professionals. In the more recent time, with the advent of modern technologies and knowledge of medical science, ICUs have increasingly become populated with junior physicians and nurses with lesser working experiences. It is therefore crucial that appropriate guidelines are put in place so that the process of care delivery is not impaired at any stage (Spooner et al., 2018).

Shift handovers are the transfer of clinical issues pertaining to a patient that needs to be known and the changes required in the treatment plan outlined after the responsibility of care has been transferred from one professional to another. The intensive care unit handover is perceived to be a core skill of the professionals working in it. For many professionals it has been highlighted to be a stressful event of their regular practice (Zegers et al., 2016). Skills for effective handovers are to be taught to professionals as a part of their formal education. Nevertheless, the actual scope for developing the skills for handovers is gained during the daily practice. As pointed out by Thomson et al., (2018) the main aim of shift handover is provision of a high quality care. Nevertheless, communication of poor information at the time of handover endangers safety of the patient. A rich pool of evidence points out that ineffective shift handovers are responsible for medication errors together with increase of risks of sentinel events. Further, the risks of delays in the course of treatment are witnessed that leads to prolonged length of stay at hospital and decreased patient satisfaction. Effective communication is an integral part of clinical handovers and has been referred as one of the most important goals for patient safety. This entails that credible and up-to-date information is passed on that is minimally disrupted.

Benefits of Appropriate ICU Handovers

Marshall et al., (2018) have brought into focus the benefits of appropriate ICU handover. The most significant benefit is that safety of the patients is protected. Lapses when present in handover lead to mistakes that are fatal for patients. The subsequent result is mortality and morbidity. Poor handover also leads to inconsistency and fragmentation of care. If one is to achieve greater continuity of care robust handover is to be undertaken. Increases service satisfaction in the next benefit of proper handover. Patient’s perception and outlook of competency and professionalism is improved and reaffirmed as a result of proper handover communication. The researchers mentioned that timely diagnosis and investigations of health problem presented by patients is possible when handover is accurate. This is a sign of increased efficiency and improvement in service delivery of the care setting.

Kowitlawakul et al., (2015) mentioned that good handover not only is beneficial for the patients but is also beneficial for the physicians and other health care professionals apart from nurses. With the recent shift of the focus care to a more debatable culture within care systems, accountability of the professionals has been prominent and drawn attention of all. Accountable and clear communication protects against inconvenient attribution of charge for errors occurring in due course of care. Under condition when updated and clear information is present as a result of hand over, it is easier for physicians to take control of the care activities in a more confident manner.  Handovers give the opportunity to get involved in early stage specialty care. Well-led sessions for handover can set the foundation for clinical education whereby novice professionals can engage in professional development. When best quality of care is provided it is highly rewarding for professionals who experience an increased sense of job satisfaction.

Shift handovers must consider achieving a striking balance between efficiency and comprehensiveness. The risk to healthcare service user and the care setting is to be reduced through optimization of quality of care. The below mentioned overarching standards are articulated to ensure that the transfer of service user information is smooth and effective. The standards have been put in place considering the implications for clinical handover practices among nurses.

Standard 1- The shift handover is to be undertaken in a professional manner. The involved stakeholders are to demonstrate personal accountability by being positive and respectful about the other professionals involved in the same process. Further, handovers are to be carried out at a particular place within the setting and for adequate period.

Standard 2- The shift handover is to be undertaken as a well planned task. The handovers are to be reflective of the written record and the information to be delivered is to be linked with the care plan of the consumer. In addition, the needs of the oncoming officer are to be met through cross checking the knowledge level of the professionals.

The shift leader at the ICU is to handover the details to the next team on duty prior to the commencement of the shift. This would allow the members from the previous shift to be present at that time for maintaining safety and delivering best quality care. All members of the team are to be allowed for attending and a grade is to be present for attendance. The leader should make sure that the team is informed about the details of the shift handover. Involvement of the shift leader ensures that proper management decisions are taken, and the handover conveys the seriousness of the clinical scenario. The Lead nurse is to make sure that each clinical handover sheet has an electronic version that is stored in a secured and safe storage method. All members of the next shift are to be available for attending and participating in an active manner in the handover process.

The length of handovers would depend on the severity of the situation and the local procedures. Depending on the local systems in place for working practice of staffs, there would be two or three handovers each day. The staffs are to be present on time and have the necessary preparations for attending the handover at the commencement of the shift. Further, the staff is to access the comprehensive clinical notes during the process of handover, in addition to ward dairy and communication book. The time of the handover would be known by all staff.

Handover is to take place in a designated place that can accommodate the entire team taking part in the process. It is crucial that confidentiality is maintained while discussion is being done about sensitive information. Arrangements are to be done so that the handover is carried out in an environment not permitting disturbances and interruptions. It is advisable that a sign reading ‘Do not disturb’ is put up for preventing interruptions. The shift leader of the previous shift would be responsible for ensuring that there are arrangements made for observing and supporting the service users while the handover is going on.

All handovers would be carried out in a pre-determined format along with a robust structure that paves the way for suitable exchange of information. The nurse lead is to oversee the decision making process regarding handover template. The template is to be signed off before use by the unit’s nurse lead. No deviation would be allowed from the decided template that has been approved by the nurse lead. All staffs are to be given the updated version of the copy. All issues pertaining to clinical rinks that are encountered during the handover are to have the support of current care plans or risk management plans. The shift leader would have the added responsibility of recording the designation and names of the attendant for every handover. Electronic handovers are to be updated when a shift handover is over. The information to be included in the handovers must be accurate and updated. Information related to service users with specific problems is to be mentioned separately. Emphasis would be given to continuing management plans requiring urgent investigations. Short term and long term changes are to be articulated clearly to foster resource allocation (Sonntag et al., 2016).

After the handover is completed the shift leader would make sure that the duties and tasks are prioritized in a clear manner to every staff member. The leader would also be accountable for making sure that the staffs are competent enough for undertaking the delegated duties. All nurses are to delegate the assigned duties retaining accountability. The physician is to be informed on an immediate basis in case there is any deterioration in the health condition of a patient. Additional handovers might be required for supporting the workforce and prioritizing the workload. In case in any action is not completed the same would be documented so that there is no loss of information.

The deadline for implementation of the set standard would depend on the availability of resources and consensus of all stakeholders. This might require minimum of two months but might vary accordingly. It is to be remembered that the implementation needs to be smooth and free of hindrances. Thus the setline would be set after ensuring that no major challenges would be faced at later stages.

The newly set standard would be communicated to the stakeholders through a meeting conducted at the workplace. The session has to be attended by all the professionals who play a role in the handover process together with the physicians. The management body is to conduct the meeting and the need of changing the present handover process is to be clearly communicated. The benefits of the change proposed are to be defined and explained that can set the foundation for change through preparedness of the professionals. The emotional impacts of the proposed change are to be considered. The personal concerns are to be considered while crafting the message to be forwarded. The requirements from the professional’s end are to be clearly explained to them. The roles and task delegations are to be clearly articulated so that there is no injustice done with any professional (Yoder-Wise, 2014).

Any emerging queries and doubts are to be resolved appropriately without any conflicts of interests. An open two-way communication channel would be crucial for understanding the concerns of the professionals. If they are to be provided with answers to their questions, it would be crucial to communicate in an honest manner.  Speaking clearly has been noted as the key to communication that fosters change in the workplace setting (Huber, 2017).


Monitoring process of the standard set would be crucial for understanding the effectiveness of the same. The ICU’s nurse lead would be responsible for reviewing the present arrangements of handover and planning the way in which the standards are to be adhered to. When completed, the local arrangements are to be overseen. The lead would further coordinate for monitoring the compliance with the set standards with the help of a regular audit. Auditing has been denoted as a valuable tool for improving quality of care through adherence to set standards (Esposito & Dal Canton, 2014). The audit would measure the clinical process of shift handovers against the well defined standards outlined above. The focus of the audit would be to bring into focus the discrepancies arising between the set standard and actual practice for identification of areas of clinical practice needing improvement. The initiative would be professional a expressed through clinical competence of the staffs, confidentiality of the result, and objective connection between theory and practice. The achievement of carrying out a successful audit might be reached through varied actions such as solving problems, increasing the workforce’s culture of learning, and reducing t gap existing between real life scenarios and theoretical standards.

Awareness of the set procedure and the utility would be an essential part of the discussions with staff on ward induction. This would be a part of reflective practice and on-going supervision adopted in the ICU environment with the clinical practitioners. The nurse leads are to consult with the staff in context of further needs of support and training required by them with the aid of processes for policy reviews. Training is to be provided to staff lacking the required skills (De Silva et al., 2015).

Conclusion

Identification of high-risk situations for safety of patient is critical for ensuring betterment of health services within a service setting. One of the most crucial areas for patient safety is shift handovers which refers to the process of transfer of clinical data from one professional group to another as a result of changes in working shifts. It has been identified in the ICU currently the workplace that breakdown of communication is linked with poor shift handovers that increase the risks of sentinel events. Challenges faced while undertaking the process of shift handover promote chances of human errors. For ensuring that patients safety is promoted, the nature of the handover and the barriers faced have been identified appropriately for enhancing quality of the handover process. An action plan has been put in place in the present paper that when implemented would guide a better handover process within the ICU setting. With successful engagement of all the stakeholders into the process, and suitable allocation of resources, it is hopeful that significant improvements would be made in near future.

References

Blais, K., Hayes, J. S., Kozier, B., & Erb, G. L. (2015). Professional nursing practice: Concepts and perspectives (p. 530). NJ: Prentice Hall. Retrieved from https://books.google.co.in/books?id=V4AgtSSbRdUC&printsec=frontcover&dq=Blais,+K.,+Hayes,+J.+S.,+Kozier,+B.,+%26+Erb,+G.+L.+(2015).+Professional+nursing+practice:+Concepts+and+perspectives+(p.+530).+NJ:+Prentice+Hall.&hl=en&sa=X&ved=0ahUKEwiEmIDDmoDcAhUJbysKHXpqD6IQ6AEIMjAC#v=onepage&q&f=false

Boucheix, J. M., & Coiron, M. (2008). Analysis of the written handover process during shift changes within the hospital. An ergonomic evaluation of the use of a new writing format. Activités, 5(5-1). DOI: 10.4000/activites.1963

De Silva, A. P., Stephens, T., Welch, J., Sigera, C., De Alwis, S., Athapattu, P., ... & Siriwardana, S. (2015). Nursing intensive care skills training: a nurse led, short, structured, and practical training program, developed and tested in a resource-limited setting. Journal of critical care, 30(2), 438-e7. DOI: 10.1016/j.jcrc.2014.10.024

Esposito, P., & Dal Canton, A. (2014). Clinical audit, a valuable tool to improve quality of care: General methodology and applications in nephrology. World Journal of Nephrology, 3(4), 249–255. DOI: 10.5527/wjn.v3.i4.249

Graan, S. M., Botti, M., Wood, B., & Redley, B. (2016). Nursing handover from ICU to cardiac ward: Standardised tools to reduce safety risks. Australian Critical Care, 29(3), 165-171. DOI: 10.1016/j.aucc.2015.09.002

Haniffa, R., Lubell, Y., Cooper, B. S., Mohanty, S., Alam, S., Karki, A., ... & Schultz, M. J. (2017). Impact of a structured ICU training programme in resource-limited settings in Asia. PloS one, 12(3), e0173483. DOI: https://doi.org/10.1371/journal.pone.0173483

Huber, D. (2017). Leadership and Nursing Care Management-E-Book. Elsevier Health Sciences. Retrieved from https://books.google.co.in/books?id=CZx5AAAAQBAJ&printsec=frontcover&dq=Huber,+D.+(2017).+Leadership+and+Nursing+Care+Management-E-Book.+Elsevier+Health+Sciences.&hl=en&sa=X&ved=0ahUKEwi-rMHVmoDcAhUIfH0KHW_gBDsQ6AEIJjAA#v=onepage&q&f=false

Kowitlawakul, Y., Leong, B. S., Lua, A., Aroos, R., Wong, J. J., Koh, N., ... & Mukhopadhyay, A. (2015). Observation of handover process in an intensive care unit (ICU): barriers and quality improvement strategy. International journal for quality in health care, 27(2), 99-104. DOI: 10.1093/intqhc/mzv002

Malekzadeh, J., Mazluom, S. R., Etezadi, T., & Tasseri, A. (2013). A standardized shift handover protocol: Improving nurses’ safe practice in intensive care units. Journal of caring sciences, 2(3), 177. DOI: 10.5681/jcs.2013.022

Marshall, A. P., Tobiano, G., Murphy, N., Comadira, G., Willis, N., Gardiner, T., ... & Gillespie, B. M. (2018). Handover from operating theatre to the intensive care unit: A quality improvement study. Australian Critical Care. DOI: https://doi.org/10.1016/j.aucc.2018.03.009

Sonntag, O., Plebani, M., Della, P., Jones, D., Steward-Wynne, E., Walsh, J., ... & Lee, M. (2016). Effective communication in clinical handover: from research to practice (Vol. 15). Walter de Gruyter GmbH & Co KG. Retrieved from https://books.google.co.in/books?id=JJrUCwAAQBAJ&printsec=frontcover&dq=effective+communication+in+clinical+handover&hl=en&sa=X&ved=0ahUKEwiRn8Hbm4DcAhVMfisKHesdDIQQ6AEIKTAA#v=onepage&q=effective%20communication%20in%20clinical%20handover&f=false

Spooner, A. J., Aitken, L. M., & Chaboyer, W. (2018). Implementation of an Evidence?Based Practice Nursing Handover Tool in Intensive Care Using the Knowledge?to?Action Framework. Worldviews on Evidence?Based Nursing, 15(2), 88-96. DOI: 10.1111/wvn.12276

Thomson, H., Tourangeau, A., Jeffs, L., & Puts, M. (2018). Factors affecting quality of nurse shift handover in the emergency department. Journal of advanced nursing, 74(4), 876-886. DOI:  10.1111/jan.13499

Yoder-Wise, P. S. (2014). Leading and Managing in Nursing-E-Book. Elsevier Health Sciences.

Zegers, M., van Sluisveld, N., & Wollersheim, H. (2016). Optimal handover of ICU patients. Quality Management in Intensive Care: A Practical Guide, 43. DOI: https://doi.org/10.1017/CBO9781316218563.007

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