Effective Nursing Handoffs in Nursing Practice

Nursing Handoff Communication Research

Nursing handoffs are important components in the modern health care setting given their role in transfer of the responsibility and authority of care from one practitioner to another during shifts. Generally, nurses work in different shifts when providing patient care in order to reduce their work burdens and potential stressful moments. Therefore, nursing handoffs help ensure continuity of care during a patient's stay in the health care facility. Despite the significance of nursing handoff in continuity of care, this process has been characterized by numerous communication problems. In most cases, nursing handoffs are substandard and contribute to several challenges in enhancing patient outcomes and satisfaction. This study seeks to examine communication problems in nursing handoffs with a view of identifying effective strategies towards enhancing this process. This issue is important in current nursing practice with regards to enhancing patient outcomes and satisfaction. Effective nursing handoffs are achieved through proper communication strategies and processes that promote continuity of care.

Background and Significance of the Problem

Handoffs are essentially crucial elements that serve various functions including social bonding, team building, and coaching and teaching. In the health care setting, nursing handoffs play an important role with regards to information processing i.e. ensuring that essential information is transferred for patient safety. This implies that nursing handoffs are important in maintaining continuity of care during a patient's stay in a health care facility. Handoffs act as communication links between the various medical personnel or professionals providing patient care. Despite their significance in continuity of care and ensuring patient safety, nursing handoffs have recently been characterized by errors, care omissions, inefficiencies, increased costs, increased hospital stay, preventable re-hospitalizations, and unsuitable treatment (Halm, 2013, p.158). This is primarily because they are carried out in a substandard manner or are variable handoffs. This is major issue that requires examination in order to identify suitable measures for improving nursing handoffs with the aim of improving patient safety and promoting continuity of care.

Statement of the Problem and Purpose of Study

Variable or substandard nursing handoffs have contributed to several issues that affect patient safety and the quality of treatment. These kinds of nursing handoffs are brought by several inefficiencies and communication problems during the process. Therefore, the critical issue or problem is why inadequate nursing handoffs continue to take place regardless of its devastating impacts on patient care. The purpose of this study is to develop effective measures for improving nursing handoffs in order to enhance patient care and outcomes. This study will entail examining the major issues that contribute to substandard or variable handoffs, impact of inadequate nursing handoffs, and suitable measures for improving these handoffs.

Literature Review

The main reason for nursing handoff is to communicate patient information to ensure safe, continuous care. Given its significance in patient care, nursing handoff has received considerable attention in the nursing field and practice. This significant attention to this practice in the recent past has been fueled by the fact that it's renowned as a trouble spot in ensuring continuity of care and patient safety. Researchers in this field have examined numerous issues, particularly communication associated with nursing handoffs.

Nursing Handoff and Patient Safety

The significance of nursing handoff in ensuring continuity of care and patient safety has been long established. According to Popovich (2011), the main function of handoffs in nursing practice is to communicate patient information, which is used as the premise of ensuring safe, continuous care (p.55). This researcher argues that patient safety is the most important component of nursing handoff in relation to promoting continuity of care when essential information and responsibility of care of a patient is transferred from one healthcare provider to another. This view is supported by Abraham et al. (2011) who argue that nursing handoff plays a vital role in ensuring the continuity of activities relating to patient care (p.28). These researchers attribute the significance of nursing handoff in patient safety on the premise that it's a crucial clinical and organizational process that takes place in every level of the hospital. They further contend that the significance of nursing handoff in patient safety is evident in its three major aspects i.e. transfer of information, responsibility, and authority.

In support of these claims Farhan et al. (2011) postulates that ensuring safe transition of shift responsibility from the outgoing to incoming healthcare provider is one of the basic functions of nursing handoffs (p.1). However, these researchers state that this can be achieved through precise communication of information during the end of the shift. Unlike Popovich (2011) and Abraham et al. (2011), Farhan et al. (2011) examine the significance of nursing handoff in patient safety on the basis of transfer of information and responsibility. To this extent, they consider nursing handoff as the transfer of information and responsibility but not authority. Based on these researchers, nursing handoff involves transfer of patient information and/or responsibility of a department to help promote continuity of care and patient safety (Farhan et al., 2011, p.1).

Communication Challenges in Nursing Handoff

Abraham et al. (2011), state that nursing handoffs remain a major threat to patient safety and continuity of care despite their vital role in promoting the continuity of activities relating to patient care (p.28). As a result, nursing handoffs have been considered as remarkable haphazard since they sometimes contribute to patient harm instead of safety and continuity of care. Farhan et al. (2011) concurs with Abraham et al. (2011) by arguing that studies have shown that poor nursing handoffs were the most widespread causes of medical errors because of teamwork problems. While standardization of handoff structure and formal training have been adopted to enhance this nursing practice, nursing handoffs are still characterized by poor quality as evidenced in medical errors, which negatively affect patient safety and continuity of care. Blouin (2011) concurs with these researchers by stating that each nursing handoff presents a unique opportunity for medical errors even though its primary function and objective is to help promote safe, continuous care through providing accurate patient information (p.97).

In a study that examined the root cause of poor nursing handoffs, Popovich (2011) state that communication problems are the major factors that hinder the effectiveness of nursing handoffs (p.56). This is the same view provided by Abraham et al. (2011) who argue that communication failures have been identified as the leading causes of a series of clinical errors and unfavorable events during patient care (p.28). They stated that approximately 50% of communication failures or problems during nursing handoffs occur between care providers. Blouin (2011) also states that communication challenges are the root causes of unprecedented outcomes in nursing handoffs (p.97). This researcher supports his claim through the findings of a study that concluded that approximately 80% of serious clinical errors usually involve miscommunication between caregivers during transitions in the care delivery process. Actually, sentinel events reported to the Joint Commission between 1995 and 2006 were attributable to communication failures during transitions of care or nursing handoffs.

Even though they recognize the importance of accurate communication in nursing handoffs, Farhan et al. (2011) attribute poor transitions of care to other factors than communication. They argue that poor nursing handoffs are brought by lack of standardized structure and practice. This is primarily because research has shown that a gap exists between evidence and practice during nursing handoffs, which seemingly hinders the ability to standardize this important component of clinical practice. Moreover, the current healthcare system lacks a robust system through which safe nursing handoff of responsibility can take place and contributes to medical errors.

Improving Nursing Handoff Communication

While these researchers concurs that communication failures and breakdowns are the major causes of poor transitions of care, they provide different recommendations of potential solutions to help improve nursing handoff communication. Farhan et al. (2011) propose the establishment of a simple tool to provide the framework for nursing handoff (p.1). The simple tool incorporates medical and operational information that is vital for efficiency and organization of the subsequent shift. The authors further propose the use of ABC tool as part of a robust system and standardized structure and practice towards enhancing nursing handoff. Abraham et al. (2011) agree with Farhan et al. (2011) that standardization through the use of a handoff communication tool would help deal with problems associated with such transitions in care. However, Abraham et al. (2011) suggest that such a tool should be based on a body system format, which enables classification of patient care information based on varying body systems in order to eliminate variability in content and form of current process of nursing handoff (p.34). The handoff communication tool should be accompanied with strategies for streamlining pre-turnover activities through an information-push model in which information is sent to users without having them explicitly ask for the required information.

Popovich (2011) provides several recommendations to help improve nursing handoff communication including assuming responsibility for a patient, verifying his/her surrounding, and determining his/her condition and existing or pending treatments. The other measures include determining specific times when nursing handoffs are needed or occur and examining their procedures to identify effective ways in diverse situations.

Blouin (2011) recommend the SHARE model as a probable solution towards improving nursing handoff communication. This model involves standardizing critical content, identifying and utilizing existing and new technologies within the care delivery system, allowing for questions, reinforcing quality and measurement, and educating and coaching. This can be achieved through assuming a leadership role and participating in organization-wide efforts.

Research Question, Hypothesis and Variables

The research question for the study is, "What are the major causes of substandard nursing handoffs and how can they be prevented?" This question will be examined on the premise that the modern healthcare setting has been characterized by problems in handoffs despite the evolution and increased specialization of health care processes (Friesen, White & Byers, 2008). Moreover, the evolution and increased specialization of modern healthcare has generated significant challenges for effective communication, which affect nursing handoffs.

The research question will be examined by testing two research hypotheses and null hypothesis. The two research hypotheses that will be tested in the study are

Hypothesis 1: Inadequate nursing handoffs are brought by factors in the health system.

Hypothesis 2: Nursing handoffs challenges can be dealt with to enhance patient care.

During the study, the researcher will address this null hypothesis: there is no variation in patient outcomes following the implementation of effective or standard nursing handoffs. This will be addressed by examining patient outcomes with regards to improved health after addressing the issues in nursing handoffs.

The independent variable in this study is the healthcare system because it is not affected by any factors but contribute significant aspects to the other variables in the study. The healthcare system remains constant in the study by acting as a source of factors influencing nursing handoffs and patient outcomes. The dependent variables are nursing handoffs and the health outcomes of patients. Nursing handoffs is influenced by factors in the health care system whereas patient outcomes are influenced by the nature and process of nursing handoffs.

Theoretical Framework

Overview and Guiding Propositions

The theoretical framework for conducting this study on nursing handoffs is communication competence and medical communication behaviors. To this extent, the researcher assumes that nurses possess medical communication competence that is essential during the delivery of care. Moreover, the researcher assumes that these professionals have capability to use communication competence to govern their communication behaviors when transferring the responsibility and authority of care to another nurse (Streeter, 2010). Based on these assumptions, the researcher believes that competent medical communication between nurses during handoff or at change of shift occurs when it helps in ensuring continuity of care. Therefore, if the communication hinders continuity of care, it cannot be considered competent medical communication.

One of the theoretical propositions for this study on nursing handoff is that competent medical communication results in continuity of care and improved patient safety. Secondly, ineffective nursing handoffs are usually brought by poor communication behaviors since such behaviors hinder effective and seamless information exchange. The third theoretical proposition is that an effective handoff is determined largely by the nurse's use of specific communication skills and behaviors during the transfer of responsibility of patient care to another nurse.

Application of Theory to Study Focus

The focus of this study is to examine the major factors that contribute to ineffective nursing handoffs and how this process can be improved to enhance patient safety through ensuring continuity of care. Consequently, the researcher will examine communication skills and behaviors that contribute to effective or quality nursing handoffs. This will be followed by an exploration of whether these communication skills and behaviors are applied by nurses in various healthcare settings during transfer of care. Once this is determined, the researcher will proceed to identify individual and/or institutional changes that should be adopted to ensure these communication skills and behaviors are applied in nursing handoffs across all settings. By carrying out these processes, the researcher will effective apply the theoretical propositions and assumptions to the focus of the study.

In essence, the application of theory to the project's focus involves examining the various variables in the propositions and their impact on the phenomenon of interest. During this process, the researcher will highlight and examine how these variables differ and under what circumstances. Moreover, the variables identified in the theoretical propositions will be utilized to develop research hypotheses and questions, which will in turn govern the study. In this case, the research hypotheses will be created on the basis of the impact of one variable (independent variable) on another variable (dependent variable). Through this process, the researcher will demonstrate how lack of collaboration during handoffs creates adverse effects (Delrue, 2013). The lack of collaboration is brought by poor communication skills and behaviors among nurses.

Methodology

Sample/Setting

This study will be carried out on a convenient sample of nurses in an intensive care unit of a local health care facility. In essence, the study participants will be all ICU nurses in a large-scale hospital located in Hoboken, New Jersey. The intensive care unit provides an appropriate setting because of the significance of information communication among the care team. Moreover, nurses in this unit will provide an appropriate sample for the research since their work entails gathering, integrating, and utilizing patient data for the purpose of caring. Therefore, this sample and setting will help in gaining vital insights regarding current nursing handoff practices, their effectiveness in relation to patient safety and outcomes, and areas of improvement.

Sampling Strategy

The researcher seeks to utilize convenience sampling strategy to identify an appropriate sample for the study. Since the study will be carried out in the ICU setting, convenience sampling strategy will be utilized since the sample will be easy to reach. Through this strategy, the researcher will select study participants based on their convenient accessibility and closeness to the researcher. Moreover, convenient sampling will be utilized since testing the entire target population is impossible because all nurses are involved in handoff processes and it would impossible to include all of them in the research. The other factors contributing to the use of this strategy include the availability of subjects, inexpensiveness, and ease of use. Therefore, the researcher will easily access the subjects for the study.

Research Design

The researcher will utilize a mixed method approach to examine the current nursing handoffs process in relation to their ineffectiveness as well as important aspects for enhancing the process relative to improved patient safety. Mixed method approach is a suitable research design for this study since it will help generate rich and numerical data regarding the phenomenon under investigation.

Extraneous Variables

When conducting the mixed method study on nursing handoffs, extraneous variables i.e. undesirable variables that affect the link between the variables being examines are likely to occur (Hall, 1998). Some of the potential extraneous variables that are likely to influence relationships between variables being examined in this study include the conditions of the hospital or inpatient unit, relationship between nurses and their supervisors, and the practitioner level of competence. The conditions of the hospital and relationship between nurses and their supervisors influence variables through affecting the nurses' job satisfaction, which influence their communication and behaviors. In contrast, the level of competence affects the relationship between variables in the study by affecting nurses' understanding of the significance and process of nursing handoffs. The researcher will control these variables through selecting a hospital or inpatient unit with an effective work environment as well as selecting study participants based on their knowledge of nursing handoff and its related practices.

Instruments

The researcher will utilize the Clinical Handover Staff Survey developed by O'Connell, Macdonald & Kelly (2008). However, this instrument will be modified depending on the specific aspects and conditions of the hospital in order to reflect the nursing unit. This implies that information that is specific to the hospital or nursing unit will be included in order to effectively gauge current nursing handoff practices. The use of this instrument is influenced by its validity and reliability since it has been utilized in many studies that focus on nursing practices, particularly in relation to handoff practices. Moreover, the validity and reliability of this instrument will be tested based on its relevance to the specific hospital or nursing unit and nurses' understanding of the specific questions in the survey. The researcher will also conduct non-participant observation, interviews, and focus groups.

Description of the Intervention

The Clinical Handover Staff Survey will be administered to the facility for a period of 30 days when all participants will be required to place the surveys in a designated mailbox at the facility. This will be preceded by providing nurses with information regarding the survey and other methodologies used in the study. The non-participant observation will be carried out through examining existing practices during end-of-shift hours through which the researcher will document communication practices and behaviors of nurses when handing over responsibility of care to other nurses. The researcher will also perform interviews and focus groups that focus on understanding nurses' perceptions of current handover practices and what could be done to improve them with regards to patient safety.