Mar 03, 2015, By: Christine Johnson, RN, MN, GNC(C) , Tricia Carta, RN, MN , Karen Throndson, RN, MN
Patient safety and continuity of quality care are dependent on effective communication. Clinical nurse specialists at the Health Sciences Centre in Winnipeg were finding that when they sought out essential patient information from front-line nurses, they sometimes encountered gaps in knowledge about the patient. Having to acquire this information elsewhere was causing unnecessary delays in care.
The authors, members of an advanced practice nurses group at the Health Sciences Centre in Winnipeg, undertook a quality improvement project to gain an understanding of the problems in information exchanges between nurses. Through interviews with front-line nurses on four units, they found that many factors contributed to the lack of knowledge nurses had about patients, such as inconsistent documentation, poorly defined plans of care and variable communication patterns. This project highlighted the need to develop a standardized handoff template to aid in information exchanges.
Patient safety and continuity of quality care are dependent on effective communication. The handoff process is integral to the exchange of pertinent patient information between nurses at transitions of care. Barriers to an effective handoff include too little information, inconsistent quality of information, limited opportunity to ask questions and frequent interruptions (Welsh, Flanagan, & Ebright, 2010).
We are members of the Advanced Practice Nurses Group at the Health Sciences Centre in Winnipeg. In our role as clinical nurse specialists, we have seen that front-line nurses often seem to lack essential patient information when we are asking for it. A common response we get is “this is the first time I’ve had this patient.” We are left to seek out information from other sources. Lack of information can have an impact on patient safety, create confusion, delay discharge and hinder continuity of care.
Four members of our group launched a quality improvement project in 2012 to examine the ways patient information was gathered and exchanged between nurses, providing an opportunity to look further into documentation, handoffs and other information exchange processes.
Poor communication practices in health care are a root cause of poor outcomes for patients. Effective communication is essential to the role of nurses in influencing and improving patient outcomes (Adams & Osborne-McKenzie, 2012). Further, effective communication practised by the entire care team increases shared knowledge and goals concerning patients and their plan of care (Radtke, 2013).
The importance of consistent nursing documentation, to record pertinent details such as assessments, findings, health histories, tests, treatments and outcomes, has been reported in the literature (Adams & Osborne-McKenzie, 2012; Braaf, Manias, & Riley, 2011). A study by De Marinis et al. (2010) outlined the challenges of documenting consistently, noting that nurses carry out more activities than they document. Documentation of care decreased significantly when a greater number of activities were completed during shifts.
We asked the managers of patient care on a surgical unit, a women’s health unit and two medical units in our centre for permission to conduct short semi-structured interviews on information exchange with front-line nurses. Different handoff processes were employed on these units. Nurses on the women’s health unit used bedside reports conducted in the presence of patients. One of the medical units used verbal reports, presented in a group setting; the other used tape-recorded reports. Verbal reports were used on the surgical unit.
We sent an e-mail, an information letter and a consent form to approximately 200 front-line nurses in all. We placed a copy of the letter and consent form in the units’ communication books and put up posters to promote the project. Our interview questions were informed by a literature review on handoff processes. We wanted to know if the front-line nurses felt they had all the information they needed when caring for patients and ask what kind of information is lacking or hardest to get. We reviewed the questions with a few front-line nurses and made adjustments based on their feedback. Thirty-nine nurses agreed to be interviewed and signed consent forms.
Each of us took responsibility for interviewing nine or 10 nurses. Interviews, scheduled for times that were convenient for participants, lasted 10-20 minutes on average and were conducted over a period of three months.
We used field notes for gathering the responses. No individual identifiers were tracked; personal identifiers could not be attached to specific responses.
Our group then met to review the interview data. The level of nursing experience of the participants ranged from less than a year to more than 20 years. We identified similarities and differences in the responses across the four units and looked for common themes.
Four key themes emerged, highlighting documentation, care plans, patient assignments and handoffs as factors that influenced the level of knowledge nurses have of patients and their care plans.
Inconsistent documentation. Documentation is designed to convey a patient’s status to other health-care providers, assist in developing a plan of care, evaluate the plan and provide continuity of care. Inconsistent documentation was identified as a problem in these four units. The participants indicated that the reasons for inconsistent documentation were lack of time for this activity along with high patient acuity and high patient turnover.
- “Care is often delayed because we are relying on second-hand information from the patient.” (Participant 12)
- “Charting is often poor; information is missing that I then have to track down during my busy day.” (Participant 37)
No plan of care. Participants expressed frustration over the lack of clear care plans, contributing to delays in treatment and discharge.
- “The plan of care or plan for discharge is the hardest information to get. Therefore, I must go to the chart to find it.” (Participant 34)
- “Nurses are not consistently kept in the loop. The doctor communicates with the patient but not with the nurse. This creates extra work for the nurse to confirm the plan and explain it to others.” (Participant 4)
Variable communication patterns. Participants reported that the type of handoff process contributed to problems with information exchange. It was suggested that the quality of the report depended on the experience and style of the particular nurse. Most participants appeared to prefer verbal reporting because it gives them an opportunity to ask questions and get immediate feedback. The bedside report received mixed reviews.
- “Sometimes taped report is difficult. Face to face is easier to clarify and to make sure you understood the information correctly.” (Participant 32)
- “The bedside report needs to go. The patient is not always interested in giving input. This process is time consuming, and both nurses have to be available.” (Participant 2)
Some participants spoke of ongoing challenges in communicating with other members of the health-care team. Many said they preferred receiving information in a face-to-face verbal report and through updated patient chart entries.
- “Communication between so many residents, attendings and nurses can result in different information being relayed.” (Participant 15)
- “Sometimes the unit clerk knows more about the patient than the receiving nurse.” (Participant 8)
Consistency of patient assignments. A therapeutic nurse-patient relationship promotes patient satisfaction, enhancing the patient’s trust and confidence in the caregiver. We found there was overwhelming support for patient assignments that are consistent because they foster therapeutic relationships and a better understanding of patients and care plans, particularly when complex functional and social issues are present.
- “You are much more familiar with the patient and how to care for them.” (Participant 25)
- “It helps to get the same patient. I am comfortable with the patient and they are comfortable with me. It builds trust. I can follow up with the care plan, and I have more suggestions for the health-care team.” (Participant 34)
Participants identified several barriers to obtaining patient information, such as lack of time, high patient acuity and large volumes of paperwork. Having dedicated time to document and review patients’ charts means nurses have relevant and consistent information at hand when approached with questions from other health-care providers, as well as patients and their families.
Not all patient care areas were sampled. We had selected the women’s health, surgical and medical units for participation in the project because of the variety of handoff processes in use by their nursing staff. Consequently, our sample size was relatively small. Another limitation was that all information was self-reported by participants.
Comments made in the interviews indicated that a newly introduced handoff process in the women’s health unit was not fully supported by participants working there, but the reasons were not made clear to us. Further investigation into the nurses’ challenges with bedside reporting is warranted to glean a deeper understanding of their specific issues.
Among the tests for compliance related to information transfer at care transitions in Required Organizational Practices (Accreditation Canada, 2015) are that information that is required to be shared is defined and standardized and that patients and families receive information that they need to make decisions and support their own care. After reviewing the results of our project, our next step was to promote the need for a handoff template, with an SBAR (Situation, Background, Assessment, Recommendation) format, that would allow standardized information to be relayed in a concise, timely fashion. Such a template was then developed by nurses in the surgery program. Use of this tool allows them to capture the big picture and ensures that a detailed plan of care is created and is being followed. Feedback from nurses has been positive; they have commented that patient status is more efficiently reported and that quality of the information has been enhanced. Our chief nursing officer has endorsed the use of a standardized, SBAR-format handoff template across the entire centre.
We presented our project and the findings at nursing grand rounds and to our Nursing Practice Council. The work has also been featured in a poster presentation for the Manitoba Centre for Nursing and Health Research at its research day event in May 2014.
In another offshoot of our project, nurses working in the surgery program formed a committee to audit charts and give feedback to colleagues on improving documentation practices. As well, this group has addressed the problem of lack of time to document by implementing a “buddy system,” providing coverage for uninterrupted documentation and chart review time during the shift.
The authors recognize the contributions of Jocelyn Preston, a former clinical nurse specialist in the HIV program, to the project and to developing this manuscript.
Accreditation Canada. (2015). Required organizational practices: Handbook 2016.
Adams, J. M., & Osborne-McKenzie, T. (2012). Advancing the evidence base for a standardized provider handover structure: Using staff nurse descriptions of information needed to deliver competent care. Journal of Continuing Education in Nursing, 43(6), 261-266.
Braaf, S., Manias, E., & Riley, R. (2011). The role of documents and documentation in communication failure across the perioperative pathway. A literature review. International Journal of Nursing Studies, 48(8), 1024-1038.
De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D.,…Matarese, M. (2010). ‘If it is not recorded, it has not been done!’? Consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19(11-12), 1544-1552.
Radtke, K. (2013). Improving patient satisfaction with nursing communication using bedside shift report. Clinical Nurse Specialist, 27(1), 19-25.
Welsh, C. A., Flanagan, M. E., & Ebright, P. (2010.) Barriers and facilitators to nursing handoffs: Recommendations for redesign. Nursing Outlook, 58(3), 148-154.
Christine Johnson, RN, MN, GNC(C), is a Clinical Nurse Specialist in the Rehab and Geriatric Program, Health Sciences Centre, Winnipeg.
Tricia Carta, RN, MN, is a Clinical Nurse Specialist in the Burn Program, Health Sciences Centre.
Karen Throndson, RN, MN, is a Clinical Nurse Specialist in the Cardiac Program, Health Sciences Centre.