Nursing Leadership and Management
Introduction

Nurse handoff communication during shift change is one of the most frequent, though key, nursing duties which provides the basis for delivering safe, reliable care (Eggins & Slade, 2015). Study results reveal that ineffective nurse communication at the time of patient handoff is the main reason for sentinel events (Drach-Zahavy & Hadid, 2015; Eggins & Slade, 2015). Together with National Patient Safety Goals (NPSG) for improving efficacy of communication among caregivers, the WHO (World Health Organization), AHRQ (Agency for Healthcare Research and Quality) and other such health organizations recognize the significance of prioritizing the task of dealing with risks to patient safety linked to ineffective handoff communication; consequently, they have put forward recommendations for improving upon the above problem (Drach-Zahavy & Hadid, 2015).

Yolo County's North Caroky Hospital is a small 35-bed community hospital employing a score of 12-hour night shift nursing personnel. The hospital nurses' failure to provide quality BSR (Bedside Shift Reporting) can, to a great extent, adversely influence patient outcomes. Moreover, ineffective communication can cause treatment delays or the administration of incorrect treatment, needless preventable expenses, unplanned extension of hospitalization duration, lower personnel and patient satisfaction rates, and eventually, harm to the patient (Drach-Zahavy & Hadid, 2015). In this paper, a focused, evidence-based project will be discussed, which attempts to improve BSR quality of twenty 12-hour night shift nursing staff in the given hospital's medical-surgical division, by implementing a standardized instrument for BSR, targeted at improving quality of communication among nursing personnel and avoiding clinical errors at the hospital. 

Clinical Leadership Theme 

Some of the themes for improving clinical leadership identified in the course of the project are patient safety, employee and patient satisfaction, and employee communication. A broad theme/topic statement for the project may be: We endeavor to enhance quality of handoff communication during shift changes on North Caroky Hospital's medical-surgical division (Organizational Approval Letter Template Appendix 2) by implementing a standardized instrument for BSR, dealing with 5 major nursing behaviors, namely, introduction, preparation exchange of information, safety examination, and patient participation. This process commences with appropriate preparation of succeeding nurses, and culminates in steady, proper, superior-quality BSR delivery without miscommunication which may harm patients. It is anticipated to: 1) enhance safety of patients; 2) increase employee and patient satisfaction; 3) improve nurse-patient communication; and 4) prevent needless hospital expenses. Efforts in this regard are imperative, owing to identification of the following needs: 1) safety of patients by way of improved communication; 2) employee as well as patient satisfaction; and 3) averting communication errors during shift change.

This BSR project covers the CNL (Clinical Nursing Leader) curricular component of managing the care environment. It attempts at bringing about improvements in patient safety and satisfaction, and reinforcing collaboration through bringing about improvements in the communication process at the time of shift change in the orthopedic division. CNL roles responding to the project are as follows: Team Manager, Information Manager and System Analyst.

Clinical/Organizational Problem

The issue detected at the hospital under study is: inadequate communication among nursing care workers whilst verbally reporting to peers at the time of shift change. For improving nurse-nurse and nurse-patient communication, there is a need for thorough bedside reporting during shift change. Such a move will improve patient satisfaction and outcomes, and communication among nursing staff, besides promoting patient participation in their respective care plans.

Description of Problem

The process of patient handoff may be defined as: patient care transfer between two care providers. In the course of this shift, patients are at maximum risk of suffering from communication-linked errors. Observations of the targeted clinical microsystem process revealed that night shift nursing staff didn’t provide quality BSR; in fact, some nurses didn’t even perform BSR. Rather, shift reporting was undertaken away from the patient bedside, in hospital hallways or at nursing stations. This project recognizes the likely obstacles revealed via a nursing survey administered prior to implementation, including nurse mindsets, views, and beliefs pertaining to elements of performing BSR. Nursing workers believe quality BSR performance is contingent on time availability, linguistic obstacles, patient conformity, employee outlooks or opposition, and concerns of HIPAA (Health Insurance Portability and Accountability Act) violation (Boshart, 2016; Ford and Heyman, 2017). The issue identified is: inadequate communication among nursing care workers whilst verbally reporting to peers at the time of shift change. For improving nurse-nurse and nurse-patient communication, there is a need for thorough bedside reporting during shift change. Such a move will improve patient satisfaction and outcomes, and communication among nursing staff, besides promoting patient participation in their respective care plans.

Between-shift nurse reporting involves off-going nurses handing over charge of the patient to the incoming nurse. Here, it is vital to effectively convey crucial details on patient care plan and current health status. BSR performance facilitates patient and patient family participation in care. Further, it facilitates engagement in information sharing, which guarantees identification and alignment of patient, healthcare team, and patient family objectives. BSR enhances patient satisfaction, lowers patient fall rates, reinforces the patient-nurse relationship, reduces hospitalization duration, reinforces collaboration, and improves nursing staff prioritization and accountability during shift commencement.

Explanation of causes

In the hospital under study, senior-level medical consultants who delivered bedside handovers conversed quietly, and only with their peers, i.e., other senior practitioners. Conveying of greatly sensitive information was done using curtains to divide cubicles. Further, handovers were typically protracted, hurried, and unsystematic, within a typically noisy setting. Clinicians pushed around for position whilst briskly walking between patients for properly hearing what their peer was saying. Senior physicians could interact better and move closer to patients, but junior practitioners felt afraid and uncomfortable to venture closer and voice their views, moving around the fringes of cubicles. Additionally, the latter reported being overwhelmed by their workplace atmosphere which was characterized by regular staff interruptions, disorder, and time pressures. They, thus, preferred submissiveness during the clinical handover process. Furthermore, the fact that their position during handover was less than ideal increased chaos, owing to the inability to accurately communicate crucial information (Mardis et al., 2016). Hence, key results weren’t verified at the time of handover. According to prior studies on the subject, though the BSR approach is valued by patients and practitioners alike (Mardis et al., 2016), it gives rise to the challenges of noise, confidentiality concerns, and interruptions (Mardis et al., 2016). 

Power-related problems can impact junior physicians attempting at asserting themselves. Owing to them being situated far away from handover-delivering consultant, the hospital's junior providers couldn’t hear clearly, hesitated when it came to speaking their mind, and were worried that the task would be impeded and delayed should they pose any questions. A nationwide handover practice survey's findings indicated that clinical handover was typically performed by only senior providers, and not junior physicians, within 96 percent of healthcare institutions (McMurray et al., 2015). Clinical handover is, apparently, greatly dominated by clinical consultants, which may cause junior physicians' confidence to suffer a blow, and may cause them to refrain from voicing their views. It also potentially contributes to absence of opportunities to participate actively, and to the notion that communication at the time of clinical handover strictly lies within medical consultants' domain.

Another stakeholder group experiencing communication issues during handover are medical specialists, whose role involves managing distinct clinical care elements. They can be victims of cognitive bias, in which unique educational and experience-related patterns deeply impact an individual's processing lens (Ofori-Atta, Binienda and Chalupka, 2015). Medical specialists' determination to stick to particular care guidelines might bring about communication disruptions (e.g., a patient lacking an official ultrasound was admitted by the plastics registrar). Hence, overreliance on a single characteristic or detail can result in communication breakdowns and potential negative consequences. Patients being situated in different wards is a second possible communication issue for medical specialists. Consequently, medical specialists have to go from one ward to the next, and this has the potential to result in disorderly, fractured handover.

Proposed solution

At present, no preset policy exists on the way the hospital under study is to carry out reporting during shift change. Observations revealed that BSR wasn’t performed at all...…inability to express the change with regards to its timeframe, rationale, and change process steps. Kotter is hailed as one among the leading leadership advocates, and his 8-step change theory includes (Kotter, 1996):

1. Creating a feeling of urgency 

2. Building a strong coalition 

3. Vision creation 

4. Vision communication 

5. Elimination of barriers 

6. Creating short-term victories 

7. Building on the change 

8. Anchoring change within the organizational culture (Kotter, 1996).

Kotter and Lewin's efforts can inform the formulation of change models relevant to BSR adoption.

Barriers to implementation

Nursing personnel continue to struggle when it comes to thorough BSR implementation, despite fresh evidence indicating the significance of active patient participation in the BSR process (Boshart, 2016). Literature commonly cites confidentiality violations as one of the major obstacles. Nursing staff are more concerned about patient privacy and HIPAA (Health Insurance Portability and Accountability Act) breaches if their patient family members or other patients are present within the room at the time of reporting (Salani, 2015). Besides confidentiality, they are also apprehensive about discussing sensitive topics like test outcomes that doctors are yet to explain to patients, complex familial dynamics, and discussing treatment non-adherence with patients.

Handling sensitive information. At times, patients or their family members might still remain uninformed of a particular diagnosis or other disease-related information. BSR is the absolute wrong place to discuss bad news. The physician could, for instance, not have explained a lab test outcome as yet to the patient, or a man might not have been informed that his child is suffering from hepatitis C. Typically, such sensitive details don’t have to be addressed during shift change. If it does have to be addressed, the information may be imparted prior to entering the patient's room, or be quietly indicated on the patient's chart at the time of BSR. For clarifying such scenarios for nursing personnel, the hospital can establish procedures to discuss sensitive information (e.g., hepatitis C or AIDS/HIV status) at the time of BSR.

Negotiation of interactions with patient families. As a family can be quite complicated, nursing staff may struggle with ascertaining which members ought to be present during BSR and how one must interact with them. Part of BSR involves asking patients which friends or family members can participate. For instance, nursing staff may request those who visit the patient to leave for a while at the time of BSR; should the patient request that one or more visitors stay behind, the process can proceed.

Trying to refrain from disturbing the patient. Nursing staff might dislike disturbing patients, particularly those who couldn’t sleep throughout the night and have only just fallen asleep. They may apply their own professional judgment and decide whether or not to involve the patient in BSR. If such concerns arise often and nurses can't adequately perform BSR, a patient door hanger may be used saying “don't disturb" or "kindly wake me up during BSR.” Letting patients choose is better than allowing nurses to assume (Eggins & Slade, 2015). Even where patients desire not to participate, nursing staff must enter their rooms and perform a visual safety check.

Fear of change. Certain nursing personnel fear a loss of control over BSR or lack confidence in BSR performance. Generally, failure to constantly supervise BSR causes nursing staff to revert to old and familiar processes and habits. It is imperative to recognize that acceptance of change is challenging and simultaneously underscore the significance of abiding by novel processes. Once nursing staff get adjusted, they start seeing benefits in the form of safety catches, time saving, and patient care prioritization.