Nursing process improvement and shift reporting methods in critical care units

Nursing Process Improvement and Change

Change management or process improvement in healthcare guarantees that the vital systems in the healthcare organizations are functioning at their optimal. The objectives of healthcare procedure enhancement are to promote the effectiveness of the systems across units while capitalizing on profits and in due course improving quality of patient's care and experience. Clinical procedure improvement does not only concentrate on patient care, but also evaluates the whole procedure from planning through patient's discharge. Process improvement entails underlining the systems selected for enhancement effort, categorizing problems in the system, starting a redesign procedure that eradicates the problems and radically enhances the system's performance (Strople & Ottani, 2006). The Critical Care Unit charge nurse reporting is crucial and determines the efficiency and quality of care provision.

The charge nurse in Critical Care Unit is a need to employ clinical expertise and managerial skills to enhance efficiency in the delicate unit. Charge nurses must be available always, control all the actions happening in the patient care department and act as role models to others in the same unit. The charge nurse must be proficient in keeping nursing records, demonstrate clinical skills and coordinate all the activities taking place in the Unit. The charge nurse assesses patients, plans patient care and eases nursing interventions founded on protocols, procedures and evidence. The nurse must be able to prioritize the workload in the Unit, be an active member of the emergency team, help staff with difficult or heavy assignment, solve dilemmas and promote team building. This role calls for efficient communication systems to enhance the charge nurse reporting system.

Currently, the end of shift Critical Care Unit charge nurse reporting is handwritten and every shift's report update is hand written. This form of reporting is time consuming and inefficient hence the need to create a shared drive/folder in the Windows Excel Spreadsheet formula so that unit report can be entered electronically and accessed by password.

Identification of Problem or Process to be Changed

Shift report is a comprehensive procedure that serves to offer nurses with crucial patient information to enhance patient care planning and clinical decisions. A shift report also offers nurses with a forum for operations such as collaboration and patient problem solving. Nurses start their day through taking part in nursing shift reports. The shift report also referred to as inter-shift report is a communication procedure between two shifts of nurses to deliver pertinent patient information, and to allow the continuity of patient care. Nurses rely on the accuracy and content of shift reports to make proper clinical decisions and to prioritize and arrange patient care. The present methodologies employed in the Critical Care Unit to collect and deliver patient information are ineffective and may lead to negative patient upshots. The nursing shift report affects patient's outcomes.

Handwritten shift communications are sometimes inaccurate, misinterpreted, incomplete, biased or omitted and may misdirect nursing surveillance causing failures in acknowledging and avoiding critical patient complications. The Joint Commission on Accreditation (JCAHO) has recognized communications failures as the major cause of sentinel events in most hospitals and list shift report as the main factor behind major sentinel events. For instance, the major cause of over 50% of fatal falls is communication breakdown, which include failure to provide information during nursing reports. Breakdown in written and verbal communication among health care providers are a leading concern in care delivery.

Most hospitals particularly in Critical Care Unit experiences 65% of sentinel events with 90% of the root cause being communication breakdown. Moreover, medical errors are prevalent in the Critical Care Unit. The most predominant medical errors are errors of drug administration, dispensing and prescription errors, which are because of illegible handwritten communication. These problems are prevalent hence requiring a change in the system of communication to include SBAR, (Situation, Background, Assessment, and Recommendation) took at Critical Care Unit. SBAR communication tool supports honest and open communication for sharing information, question asking and provision of suggestions (Strople & Ottani, 2006).

To improve shift reporting and minimize errors and communication breakdown with the aim of improving patient care, computer technology is paramount as it ensures positive health outcomes and patient safety. The intervention measures through computerized systems will help in lowering medication errors and sentinel events. A serious approach for healthcare providers to reduce communication breakdown that instigates sentinel events calls for means of enhancing care delivery systems. Healthcare providers should assess the available options and combine data systems as a machinery to eradicate avoidable communication breakdown. As a result, the problem in the Critical Care Unit inter-shift reporting can be solved through pioneering innovative and new methods of inter-shift reporting.

Need For Change or Enhancement

The definition of change comprises of exploring, assessing and understanding the call for change in the context of the organization accordingly, evaluating, and specifying possible solutions. Having developed a well-functioning nursing staff via streamlined systems and concrete resources and operations, many challenges remain in the Critical Care Unit particularly in inter-shift reporting. While the conventional medical principle that requires medical practitioners to do no harm to patients and underlines the balance of benefits and risks, the principle is also suitable to the general practice in the medical fraternity. The integration of the intricacy and the possible harm makes the medicine practice, particularly; intensive care unit more burdened with dangers than any other complex areas. While safety is considerably recognized as an important element in Critical Care Unit, the intricacy of procedures makes this unit prone and vulnerable to errors.

The transition of crucial information concerning patients from one nurse to another is a crucial element of communication in any healthcare organization. An efficient handoff fosters the transfer of crucial information, treatment and care continuity. Ineffective handoffs put at risk the patient's safety and come with adverse events (Strople & Ottani, 2006). As the health care industry has continued to grow and become more specific, with increased numbers of nurses in patient care, patients encounter more handoffs. Inefficient inter-shift reporting leads to gaps and failures in patient care, which include death, wrong surgical sites and medication errors. Clinical settings are complex and dynamic presenting difficulties for effective communication among nurses.

Technological advances and the expanding knowledge in health care has lead to further categories of specialized units created for specific procedures and specific illnesses, "The informational content of the shift report can be individualized to present data sets that best represent the needs of a specific nursing area"( (Strople & Ottani, 2006). The dynamic specialization while it improves patients' upshots and promote healthcare delivery can lead to serious dangers and instigate issues with handoffs .The critical care unit in the hospital uses handwritten handoffs that due to errors and illegibility instigates a host of problems. As a result, development of policies to lower these rubs are necessary, hence the need for change.

Handoffs are considerably dependent on the interpersonal communication of the charge nurse besides the experience level and knowledge of the nurse. The handoff problem has become so prevalent that the JCAHO, a body that inspects and accredits hospitals, established a national client safety goal on inter-shift reporting (Simpson, 2005). The goals call for implementation of standardized perspective to handoff communication entailing the prospect to ask and give answers to questions. Given the failures instigated through communication breakdown, adoption of advanced technology in health care and the requirements of JCAHO objectives, the Critical Care Unit should adopt a change and implement electronic data entry system in the form of a shared drive/folder in the Windows Excel Spreadsheet formula.

Literature Review

According to Strople & Ottani (2006), nurses have been on the forefront of technology for years, and a logical process would take complete benefits of computer technology to enhance shift reports, "To support time-sensitive data collection and retrieval, real-time documentation of defined patient observations should be performed using point-of-care technologies such as PDAs or other wireless devices." Developments in information technology are constantly transforming work performance in most organizations (Georgieva & Stoykova 2011). The explosion of IT and its application in health care has changed the culture of workplace; it has increased efficiency, patient satisfaction and reduced risks to patients. According to Aspden (2007), medication errors can be solved through EMRs (Electronic Medical Records). Hospitals should change from using paper work to using electronic medical records given that EMRs allow practitioners to access patient's medical information. EMRs also allow practitioners to check out any undesirable drug effects or allergies and multiple users can read and analyze electronic document at the same time.

According to Strople & Ottani (2006), point-of care documentation hold benefits of remitting communication omissions and errors. However, consideration is given to the method of data collection and to wireless device utilized. Strople & Ottani (2006), asserts that utilization of electronic systems as an adjunct to the handoff report enhances patient care and should be used to its complete capacity."An automated shift report designed to integrate all pertinent patient information, including past medical history and specific precautionary measures, will assure that information is carried from shift to shift, bridging serious informational gaps" (Strople & Ottani, 2006) .Most organization are facing challenges when trying to build up productive work atmosphere. However, when technical and social systems are jointly optimized, health care organizations considerably benefit from IT.

The ever-rising abundance of information requires that health care nurses synthesize and make decisions through inter-shift updates. Decisions are founded on the data trends and present information provided through handoffs (Simpson, 2005). To compress information besides making it controllable among the nurses involved, handoff s lead to progressive information loss given that data is not conveyed, misinterpreted or missed. The misinterpretation and omission of crucial information, particularly in handwritten handoffs causes discontinuity of care provision besides impending patients' therapeutic course. These failures come with major safety threats to patients and affects delivery of quality.

Methodology

Initiating change begins with understanding the nature of the change and its causes (Walburg, 2006). The causes of the proposed change are increased failures and medical errors caused through handwritten inter-shift reports. To evaluate the effects of handwritten inter-shift reports, the high-risk process is subjected to FMECA (Failure, Mode, Effect, and Criticality Analysis) (Kavaler, 2012). The FMECA procedure assesses the steps in the system that fails and causes adverse upshots. Flow charts are employed and errors at each step are rated according to criticality on the final event. Solutions and redesign are planned and implemented. The quality improvement team is then engaged to effect the change.

The charge nurses are the change agent given that they require adopting the use of EMRs in the Critical Care Unit to enhance quality care delivery. The change agent requires energy, effort, time to facilitate change that will help in improving care delivery in the unit. The charge nurse is the manager whose role is vital in change implementation. The delays and misinterpreted or omitted information in handoffs is the driving forces of the proposed change. The proposed change commences with assessment, which entails identification of the opportunity or problem. With the problem caused by handwritten inter-shift reports and updates, it is obvious that there is a need to adopt change and implement electronic data systems that will help in inter-shift reporting. The change agent identifies the compelling factors and restraining factors to the proposed change. The agent also identifies the processes, benefits and costs, and resources needed for the proposed project. This follows planning of change and its implementation. Figure 1 below shows the outline for the change process.

Figure 2: Project Management Outline

Note: From Pinheiro, A.B. (20l0). How do managers control technology-intensive work? Journal of Technology Management & Innovation, 5(2), 3.

The development of Windows Excel Spreadsheet formula will allow charge nurses to manage their time effectively and provide effective patient care delivery. This strategy will handle multiple data entry and sharing. The data in the Excel spreadsheet is more secure and accurate compared to handwritten data. Spreadsheets enhance file managements systems. The nurse managers must learn to organize, control and access data more effectively besides overcoming IT challenges. As a result, leadership skills are paramount for charge nurse and must embrace transformational leadership to foresee the implementation of Windows Excel Spreadsheet formula in Critical Care Unit.

Transformational leadership goes beyond transactional leadership. This type of leadership focuses on interpersonal relationships and supports revolutionary change in human services. Transformational leaders are effective in change implementation as they merge values, desires, goals and motives of leaders and subordinates into a shared cause. The proposed change also calls for shared leaderships that ascertain the significance and responsibility of all nurses in unit's performance and fate. The charge nurse organizes the nurses at the unit to make crucial decisions regarding quality assurance and practice standards.

Implementation Strategies

To underline the need for change in the health care organization, quality management strategies are paramount. Quality management helps health care organizations in recognizing failed standards and problems and suggests ways to enhance care and care quality. The quality management program is founded on a combined mechanism of accountability and information. The clinical information systems provide the information required to allow the organization to track outcomes and activities. Total Quality Management is also applicable in underlining the devotion to excellence and they enhance quality besides improving client satisfaction in health care organizations.

Total Quality Management focuses on addressing the needs of external and internal customers. Under Total Quality Management, the nurses must understand their clients and try to achieve their needs (Kavaler, 2012). The TQM investigates the means to enhance patient care while Continuous Quality Improvement constantly enhances performance and quality. This research involved a comprehensive quality management plan that designed, measured, assessed and developed strategies to improve performance and care delivery in Critical Care Unit. This approach identified systems and process that represented the mission and goals of the organization, and specified prospects for improvement. The critical paths were used to identify expected upshots. The critical path method is a plan based on mathematics that helps in scheduling all the activities of a project. The critical path method allows managers to identify all the activities needed to complete a project, the links between these activities and the order through which projects needs to be completed (Kavaler, 2012).Through the critical path method, the project manager builds up a diagram that utilizes arrows to illustrate how tasks are dependent to each other. The critical path is the longest path that connects project activities. If activities on the critical path are not finished on time, the whole project falls behind schedule.