TOPIC handover is the transfer of information,

TOPIC – IMPROVING NURSING HANDOVERPURPOSEThe primary aim of the project is to reduce the adversepatient outcome without disturbing the continuity of care with higher qualityof care.

INTRODUCTIONA clinical handover is the transfer of information, accountabilityand responsibility for a patient or group of patients. A standardisation of keyprinciples for clinical handover will aid effective, concise and completecommunication in all clinical situations and facilitate care delivery.Traditionallyhandovers have occurred in different ways and can vary depending upon thecaregivers roles, hierarchies, circumstances and traditions (Athwal, Fields& Wagnell. 2009). Inadequate communication handovers have been identifiedas the basic cause in sentinel events (Adamski, 2007; Patterson & Wears,2010).  The different unit culture andcontexts and resulting lack of collaboration and cohesion between nurses tocreate increased risk for adverse events (Behara et al., 2005).

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A typical handover involves the exchange of importantinformation such as patients engagement, medications and discharge plans fromone nurse to another. Handover is a common tradition among nurses howeverstandard and effective handover and information communication skills are nottaught formally taught during nursing academic education; rather nurses learnsuch skills during their daily practice and form more experienced nurses. BACKGROUNDDifferent countries have started to implement strategiesto reduce the working hours of healthcare professionals (Australian MedicalAssociation, 2006b, Australian Medical Association, 2006a, British MedicalAssociation. 2004). In 2004, Sexton, Chan, Elliot, Stuart & Crookesunderstook a study to investigate the value and content of nurse to nurse shiftreport because of criticisms related to time expenditure, content, accuracy,and usefulness of shift report within the role of modern nursing. There were 23handovers were audio taped in a medical ward in Sydney, Australia hospital.Then the audio was analyzed and classified according to the location in medicalrecord. The results demonstrated that 84.

6% of the information discussed in thereport could be found in existing documentation structures. 9.5% of time theinformation was not relevant to patients care were discussed. Actualinformation exchanged was not in current documentation was only 5.9%. In 2002 Kerr, reports that there is a structured handovermethod the quality of care is promoted and nurses will have a full understandingand knowledge about the patients.The importance of having a structured handover processstating that it will lead to an improvement in the quality of care deliveredwere discussed by Glen in 1998.OVERVIEW OF CURRENT EVIDENCEA study was conducted in 2011 at a hospital located inMashad, Iran.

The population consisted of ICU nurses having bsc degree with 6months of work experience. The study sample size was of 55 nurses. The main aimfor this study was to improve the nursing handover styles     METHODOLOGYDiscourse analysis does not seem to be the choice ofmethod of many texts in the literature search. One discourse analysis onnursing handover looked at anxiety in nursing practice (Evans et al., 2008).However there are many research articles that integrate components of discourseas language in use. Language in use can stand alone or be made significant bythe related social interaction.

Many researches had shown mixed views of nursestowards beside clinical handover. Handover is a predominant practice in healthcareand problems such as medication errors and delays in treatment can arise frompoor communication during handover. Perceptions and experiences of bedsideclinical handover and to lay a foundation to improve future bedside clinicalhandover processes. In this study i would like to explore nurses perceptions ofbedside clinical handover.INTERVIEW METHODAccording to McNamara 1999; Interviews are particularlyuseful for getting the story behind a participants experience. The interviewer canpursue in depth information around the topic. Group interview is a semistructured interview which involves a moderator leading a discussion betweensmall groups of respondents in a specific topic. An interpretive, descriptive,qualitative research approach was used to gain an insight into nursesunderstanding and their perception.

Group interview with semi structuredquestions were conducted with nurses. The inclusion criteria for this studywere registered nurse with one year of clinical experience in hospital, nurseswho are involed in bedside handover and nurses who had participated earlier inbedside handover. There were mainly 7 question in the interview been conducted.The questions were mainly based on the existing perception and knowledge ofnurses regarding their view about bedside clinical handover.INTERVIEW PROCESSNurses from different background were chosen for thisstudy. The demographic data of the nurses were also included such as theirgender, age, grade and work experience.

 Fourgroups with five nurses in each group. The interview was held in a private roomto ensure privacy. Each group were interviewed for 30 minutes to an hour. Non verbalclues such as body language and expressions were also taken intoconsiderations. A member from the research team sat in all the interview toprovide guidelines. In this study nurses described that some patientsverbalized not to be involved in the clinical handovers conducted at bedside asthey would prefer to do other thing such as rest or attend to visitors andfamily members. ETHICSThis research has mainly focused on bedside clinicalhandover importance.

In this study the group of nurses were given privacy andthe information was not disclosed in front of patients and their familymembers. This survey had deliberately not included patients so that the privacyand dignity of patient shall be maintained. Apart from this the study do nothave any ethical issues as we have not particularly discussed about the medicalcondition or any other topic which would effect the confidentiality of thepatient.LIMITATIONSThe participants were all from one ward of an acutetertiary hospital and it only reflected on the perception of that clinicalarea. The ward mainly received patients with higher socio economic backgroundand therefore the expectations regarding to participation in clinical handoveris different from other wards. Findings from quantitative study would be notgeneralized to other settings.

EVALUATION OF RESULTSA total 20 nurses participated in this interview. Majorityof the participation were 95% of female nurses with an average of 10 years ofwork experience. Some nurse felt that there were frequent interruptions anddistractions from the patient and surrounding because of which the importantinformation was missed out during handovers. They felt that with no interruptionsand distractions the handover would be holistic. Whereas some other nurses perception was they were viewedas unprofessional by the patients and family members while conducting nursinghandover. Nurses even felt that instead of giving handover they had to do smalltask in between said by the patients and relatives.

Some nurses also mentionedthat they tend to giggle and laugh during handover but they felt as if theywere exposing themselves to patients and family members and they weresusceptible to negative impressions from patients and their family members.This provided insight into nurses perceptions of bedsidehandover and the challenges faced by the nurses during bedside handover. Nursesidentified both the advantages and disadvantages of bedside clinical handoverfrom nurses point of view. This was illustrated by lack of consistency in thenurses perception of bedside clinical handover.    SERVICE IMPROVEMENT PROJECT6.1 CURRENT FINDINGSPatient confidentiality can be compromised. Insemi private rooms there would be other patients and relatives who would alsobe listening to all the confidential information of the patient in the cubicle.Request of secrecy.

Some of the patients orfamily members request nurses not to reveal certain information due to theirpersonal reasons where in this would be the most important information thatneeds to be passed on to incoming nurse on shift. Misinterpretation of information. During bedsidehandover the other patients and relatives would hear the diagnosis of thispatient and they would start fearing unnecessarily and would create amisunderstanding among other patients.Disturbance during bedside handover.

Nurses feltthat in between the handover there would be interruptions and distraction bypatient relative regarding updating the status of patient condition and theirtreatment plans because they could see nurse in the room. Time consuming. While bedside clinicalhandover there would be patient involvement their doubts and questions wereinevitable thus delay the process of handover which leads to delayed patientcare and their treatment.SERVICE IMPROVEMENTSIn order to bring the change initiated requires adirection and power of leadership. By the work of Swansburg and Swansburg whoargued that “Transformational leaders are seen in healthcare organizations as acommitment to excellence.” To bring about a change in a hospital setting is ahuge task as it is about the change in the attitude and behaviour of the staffin a difficult environment in order to gain their co-operation. The first step would be to create awareness among thepeople who were going to be affected by this new improvements that would includethe staff nurses, ward managers, patients and their family members. This wouldhelp in improving the handover system.

Discussion among nurses in the wardwhich will lead to more information about the new handover system. Problems facedduring handover should be brought up in the meeting by the nurses should betaken into consideration and solved at managerial level with betterimprovements and put in practice. Different communication channels to be usedsuch as personal contact with nurses to understand their point of view.

Initiallythe ward managers would act as mentor for other nurses who are been experiencedin this particular areas to encourage the nurses and support them in their difficultsituation. Time to time revising and practicing would become an ease to putinto daily habit of practice. Initially they would be supervised by theirseniors and later on once they are confident enough they can carry out theirwork through self confidence.Planning and implementation should be done very carefullyto minimize the adverse effects on the change. To deal with the conflict aflexible and humanistic approach has to be taken in consideration. The suggestionsbeen put forward by the team members should be treated with respect and dignity. Feedbacks should beconstructive according to the level of performance. If the nurses were doingreally well appraisal to be given to them so that they would strive more harderto put in their efforts as the famous proverb says “No pain No gain.

“LEADERSHIP PROCESS FOR SERVICE IMPROVEMENT  MANAGING CHANGE OF SERVICE IMPROVEMENTFor any strategy to workout it needs to be evolved. For thatparticular evolution we need to make changes and upgradation. Inspite ofinnovation and upgradation it could be uncertain to expect good luck into thesurvival and expansion of business. Incremental change is a type of changewhere change is implemented slowly over a specified period of time (De Wit andMeyer, 2010).

So as to improve the nursing handover we need to implement thethings over a period of time which would give enough time for the individual tounderstand and get into the process in a systematic manner. In the same waythere are many different theoretical and models of change. One of the best andpopular cornerstone models for bringing up an organisational change wasdeveloped by Kurt Lewin in 1940 and it is still considered and holds it to bevery true till today. His model is known as Unfreeze- Change- Refreeze which isreferred to be the important three stages of change process.

Being a socialscientist he explained beautifully using changing shape of a block of ice. But asthe main aim of this project is to improve the nursing clinical handover whichgoes hand in hand with leadership and management of change related to bedsidehandover, this project also implies with the ADKAR theory of change.THE ADKAR CHANGE MODELThis modelis created by Prosci founder Jeff Hiatt, it is a goal oriented changemanagement model which guides an individual and to make changes changes in anorganization. ADKAR is an acronym that brings out an achievement for a changeto be successfull that is :A: Awareness;D: Desire; K: Knowledge; A: Ability; R: ReinforcementChange is acomplex process and moreover it is inevitable. Change is a difficult process inany organization. It is required to start from a basic level starting from thenew thinking, new models and new frameworks for smooth functioning of thedesired change without hampering the surrounding. This model can be used in awide range to bring out the change process in an organization.

When this typeof model is been used for a change it allows the leaders and the changemanagement teams to aim on their change that will make an individual change asto achieve the results of the organization. ADKAR can give us a clear goal andoutcome for change in the management. It gives a systematic framework so thateveryone in the organization can use and it would be easy to understand anddescribe the matter. As the problems included from both the nurses and thepatients side which would likely to be changed as patients have trust on nursesand the management would be implementing change without compromising patientstreatment and care and as well as the integrity and financial status of thehospital is maintained. Therefore ADKAR model would be a key for a change inimproving nursing handover.Phase 1:  Awareness In thisscenario, firstly the leader should identify the problems faced by theorganization depending upon the nature and depth of the problem and how badlythe organization is been affected should be calculated. The leader will thenfind out the root cause of this problem and take into considerations and try toimprove that particular area.

From this study the awareness for the need ofchange would be explained by taking presentations in the meeting and theimportance of change would be explained in the managerial level. So that eachand every individual will discuss the topics held in the meeting with theirward colleagues. Based on this the reaction could be vague but at the same timethey would ask for how would it be implemented? How soon we can put inpractice?Phase 2:DesireIn thisthere should be a set desired goal. There should be willingness and approval fromthe other members of the hospital, its not only a leaders job to change.

Each andevery individual of the organization is equally responsible in their ownpossible ways. There should be equal participation and motivation to reach tothat particular goal which has to be achieved in such a period of time. All theparticipants engagement is very essential throughout the process. A good teamwork would boost the energy of the participant to reach the desired aim. In thispatient should be focused about the adverse effects and risking a patient lifeas well as to put nurses profession at risk.Phase 3:KnowledgeFirstly thepersisting knowledge would be assessed so that we are aware the nurses point ofview and how they look into it and how things are been carried out on a dailybasis. Then we would identify which are the lacking sources and then improvethem on that basis.

Implementing new skills and behaviour would not be easilyaccepted by everyone. So starting from the improvement and then graduallyintroducing new skills would make sense to them and they would put intopractice. Adequate training should be provided to get the best out from them. Onduty training should be given in a practical manner while handing over. In thisa leader would lead the group and train the other colleagues.Phase 4:Ability In this onlytheoretical knowledge is not required. The ability to perform towards change isalso necessary.

To bridge the gap between the knowledge and the ability theemployees should be trained in such a area by giving a scenario so that theycan make mistakes and questions would arise. By this they will understand theirmistakes and would not repeat this in future. To realize the change, staffsalso need time. When the ability is achieved, changes take place and we can seethe demonstrated new behaviours in practice. Phase 5: ReinforcementHuman brainsare weired for thse same habit and psychologically we are programmed to revertback to old habits been used for a longer period of time. Hence monitoring thechange is sustained or not.

And if not, where it has stopped so that we canreinforce and push into a start again. If there is positive attitude and resultrewarding the employees for making the change and demonstrating is important. Ifmost of the employees are reverting back to same method after a particularperiod of time, check whether they require more training and reinforce them tocontinue working in the new manner.


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