Review of the literature

Review of the literature Order Description Write a paper (1200 words) in which you analyze and appraise each of the (15) articles identified in Topic 1. Pay particular attention to evidence that supports the problem, issue, or deficit, and your proposed solution. Hint: The Topic 2 readings provide appraisal questions that will assist you to efficiently and effectively analyze each article. 1.Why was the study done? Was there a clear explanation of the purpose of the study and, if so, what was it? 2.What is the sample size? Were there enough people in the study to establish that the findings did not occur by chance? 3. Are the instruments of the major variables valid and reliable? How were variables defined? Were the instruments designed to measure a concept valid (did they measure what the researchers said they measured)? Were they reliable (did they measure a concept the same way every time they were used)? 4.How were the data analyzed? What statistics were used to determine if the purpose of the study was achieved? 5.Were there any untoward events during the study? Did people leave the study and, if so, was there something special about them? 6.How do the results fit with previous research in the area? Did the researchers base their work on a thorough literature review? 7.What does this research mean for clinical practice? Is the study purpose an important clinical issue? Refer to "Sample Format for Review of Literature," "RefWorks," and "Topic 2: Checklist." Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. Topic 2: Checklist Review of Literature and Incorporating Theory Instructions: This checklist is designed to help students organize the weekly exercises/assignments to be completed as preparation for the final capstone project proposal. This checklist will also serve as a communication tool between students and faculty. Comments, feedback, and grading for modules 1-4 will be documented using this checklist. Topic Task Completed Comments / Feedback Points Review of Literature • Analyze and appraise each of the 15 articles identified in module 1. (15 articles). _____ / 90 • Analysis organized using the sample provided in “Sample Format for Review of Literature.” _____ / 10 Total _____/100 Incorporating Theory • Identified a theory that can be used to support proposed solution. _____ / 10 • Main components of theory described. _____ / 10 • Rationale for selecting theory provided. _____ / 10 • Discussed how theory works to support proposed solution. _____ / 5 • Explained how theory will be incorporated into project. _____ / 5 Total _____/40 Original Article Translating an Evidence-Based Protocol for Nurse-to-Nurse Shift Handoffs Marlene Dufault, RN, PhD, Cathy E. Duquette, RN, PhD, CPHQ, NEA-BC, Jeanne Ehmann, RN, MS, CPHQ, Rose Hehl, RN, BS, Mary Lavin, RNP, MS, Valerie Martin, RN, MS, NE-BC, CHE, Mary Ann Moore, RN, BS, Shirley Sargent, RN, MS, Patricia Stout, RNP, MS, Cynthia Willey, PhD ABSTRACT Purpose: Ineffective communication is the most frequently reported cause of sentinel events in U.S. hospitals. Examining hospital processes and systems of communication, and standardizing communication practices can reduce the risks to patients in the acute care environment. The purpose of this paper is to describe the use of an innovative, translating-research-into-practice model to generate and test a cost-effective, easy to use, best-practice protocol for nurse-to-nurse shift handoffs in a medium-sized magnet-designated community hospital in the United States. Theoretical Framework: Roger’s Diffusion of Innovations Theory was used as the overall framework for the translational model with Orlando’s theory providing theoretical evidence for the best practice protocol. Approach: Using the first three steps of the model, methods included: (1) identifying clinical problems related to shift handoffs; (2) appraising and systematically evaluating the strength of theoretical, empirical, and clinical evidence; and (3) translating this evidence into a best-practice patient-centered, standardized protocol for nurse-to-nurse shift handoffs. Conclusions/Implications: Meaningful clinician participation in the development of a standardized, evidence-based, patient-centered approach to nurses’ change-of-shift handoffs was achieved. Using the Collaborative Research Utilization Model can facilitate the integration of new knowledge both in the clinical and academic community. KEYWORDS translational research, evidence-based clinical policy, collaborative research utilization model, nurse-to-nurse shift handoffs, shift report, handoffs, end-of-shift report, nurse-to-nurse report, bedside shift report, computerized report Worldviews on Evidence-Based Nursing 2010; 7(2):59–75. Copyright ©2010 Sigma Theta Tau International Marlene Dufault, Professor, College of Nursing, University of Rhode Island, and Research Consultant, Newport Hospital, Kingston, RI; Cathy E. Duquette, Vice President, Nursing and Patient Care Services Newport Hospital, Newport, RI; Jeanne Ehmann, Director, Performance Improvement & Evaluation, Newport Hospital, Newport, RI; Rose Hehl, Staff Nurse, Newport Hospital, Newport, RI; Mary Lavin, Associate Clinical Professor, College of Nursing, University of Rhode Island, Kingston, RI; Valerie Martin, Director of Surgical Services, Newport Hospital, Newport, RI; Mary Ann Moore, Staff Nurse, Newport Hospital, Newport, RI; Shirley Sargent, Doctoral Student & Research Assistant, College of Nursing, University of Rhode Island, Kingston, RI; Patricia Stout, Associate Clinical Professor, College of Nursing, University of Rhode Island, Kingston, RI; Cynthia Willey, Professor, College of Pharmacy, University of Rhode Island, Kingston, RI. This project was funded by the Delta Upsilon Chapter-at-Large, Sigma Theta Tau International, and by The Nursing Foundation of Rhode Island. We wish to acknowledge the contributions of the University of Rhode Island College of Nursing Class of 2008; Barbara Davis, Newport Hospital librarian; Jean Taft, RN, and the Newport Hospital nursing staff who opened their practice to the eyes of research. Address correspondence to Marlene Dufault, PhD, RN, College of Nursing, White Hall, University of Rhode Island, Kingston, RI 02881; [email protected] Accepted 23 January 2010 Copyright©2010 Sigma Theta Tau International 1545-102X1/10 Worldviews on Evidence-Based Nursing Second Quarter 2010 59 Protocol for Nurse-to-Nurse Handoffs BACKGROUND AND SIGNIFICANCE Adverse events resulting from faulty communications are a leading cause of death and injury in hospitals in the United States, even though there is empirical evidence to support interventions aimed at preventing their occurrence. In recent years, experts in health care communications research have speculated that many omissions of relevant patient care and missing or incorrect communication of patient information problems are related to a lack of research-based standards in administrative protocols and policies (National Quality Forum [NQF] 2005). The NQF report recommends a standardized approach to handoff communications as 1 of 30 high-priority practices that have strong evidence base, can be generalized, and are likely to benefit patient safety if implemented. Such practices were derived from the Agency for Healthcare Research and Quality’s (AHRQ), University of California San Francisco-Stanford University Evidence-Based Practice Center (AHRQ 2001), and the NQF project Steering Committee. “The transmission of care information in a timely and clearly understandable form to patient’s current healthcare providers who need that information to provide care” ranks in the top-10 of this NQF-endorsed set of safe practices (NQF, p. vii). As accreditation and regulatory groups began targeting communication as a quality-of-care indicator, inadequate information transfer has expanded from an individual administrative problem to a public health policy issue (Joint Commission 2005). The Joint Commission has published guidelines that specifically address recommendations for nursing shift handoffs (Joint Commission 2005). In its 2006 National Patient Safety Goals, the commission requires hospitals in the U.S. to “Implement a standardized approach to hand-off communications, including an opportunity to ask and respond to questions.” (Joint Commission 2005). However, integrating these guidelines along with the findings of empirical, theoretical, and clinical evidence into standards of care, and then translating these into the day-to-day caregiving activities of frontline clinicians has posed a significant challenge. For nursing, patient safety and quality is directly linked to correct and complete information received at the change-of-shift interchange. Nurses’ use shift report information in assessing patient needs, planning patient care, establishing goals, and prioritizing and managing their care. Hospitals in the U.S. recognize and benchmark, (through participation in performance improvement surveys provided by such organizations as Press-Ganey) the toll of missing or incorrect communication of patient information resulting in omission of patient care and dissatisfaction from patients, families, and clinicians (Press-Ganey 2002). For example, Press-Ganey Survey data revealed an opportunity for improvement in scores on variables related to patient confidence in care, their feeling safe and secure, being kept informed, being included in the decision-making process of patient goals, and perceiving how well the staff work together to care for them. In addition, nurse satisfaction related to nurse-to-nurse interaction, teamwork among nurses, and having adequate time for patient care was also benchmarked against the National Database of Nursing Quality Indicators (2006). The literature suggesting that clinicians do not apply what is known about best handoff practices is copious (Lamond 2000; Payne et al. 2000; Sexton et al. 2004). A major barrier to using the evidence of current research for attaining best handoff practice is clinician and patient attitudes and lack of knowledge (Manias & Street 2000; Sexton et al. 2004). Numerous studies indicate that handoffs are often lacking in depth (Lamond 2000; Sexton et al. 2004). Nursing school curricula on handoffs is only fairly adequate, and varies widely based on current practices in clinical agencies in which students receive their clinical experience. Other barriers include system problems (Hardy et al. 2000), and lack of standards, policies, and protocols that integrate research innovations into practice (Sherlock 1995; Joint Commission 2005). Although significant advances in information technology and millions of research dollars have given nurses the tools to obtain significant data at the start of their shift to be able to prioritize patient care and manage their patient load effectively, the transfer of information in a clear, timely manner that puts the patient central to all information surrounding caregiving activities remains inadequate. Traditional methods of shift report such as verbal, taped, and “silent report” tend to be long, inconsistent, and are fraught with missing or incorrect patient information (Manias & Street 2000; Anderson & Mangino 2006). Frequently the content reverts to irrelevant statements or judgmental comments, leading to negative attitudes by the oncoming nurse (Elm 2004). Poor communication between clinicians may prolong recovery, impede rehabilitation, or precipitate complications especially dangerous to vulnerable hospitalized patients who have predisposing comorbidities. Missing or incorrect communication of patient information can result in omissions of relevant patient care, and dissatisfaction from patients, families, and nursing colleagues (Manias&Street 2000). PURPOSE The gap between what we know (research) and what we do (practice) is at the heart of the research translation 60 Second Quarter 2010 Worldviews on Evidence-Based Nursing Protocol for Nurse-to-Nurse Handoffs problem in implementing a standardized approach to handoff communications. Unfortunately, it can take 10 years for research-based approaches to become integrated into standards for care (Coyle & Sokop 1990; Barta 1996; Estabrook et al. 2003; French 2005). This requires an innovative method to remove the barriers to effectively translating these discoveries in a cost-effective manner in order to change clinician practice in an entire organization, improve patient outcomes, and integrate these innovations into the education of future (student) clinicians. Studies in research utilization and translation suggest that organizations in which nurses practice and students learn can either foster or inhibit the application and translation of new knowledge into practice (Horsley et al. 1983; Titler et al. 1994; Dufault et al. 1995; Rogers 1995; Stetler et al. 1998a; Dufault 2001). It was believed that student involvement in the project would facilitate future incorporation of best practices on nurse-to-nurse handoffs into patient care and provides students, as well as clinicians, with an experiential opportunity to learn the process of translating research findings to solve day-to-day clinical problems. The goal of this project was to use a six-step translatingresearch- into-practice approach, the Collaborative Research Utilization (CRU) model, to develop and test an evidence-based, patient-centered, best practice protocol for nurse-to-nurse shift handoffs in a 129-bed, magnetdesignated urban community hospital. The hospital serves a high population of tourists, the military and older adults from the surrounding community that is similar in the percent minorities, gender, and socioeconomic status to other community hospitals in the state. With its full range of services, including inpatient and ambulatory surgery, acute inpatient care, emergency services, obstetrical, pediatric, inpatient behavioral health services, intensive care, inpatient and outpatient rehabilitation services, it also has a wide range of community health education and prevention programs. The hospital has had a highly integrated computerized patient information and nursing documentation system for several years. Patient acuity is typical for a community hospital with nursing care hours per patient day on the medical-surgical units that compares favorably with that of other similar size and type hospitals, at 7.4 hours per patient day. In 2004, the hospital was awarded magnet designation by the American Nurses Credentialing Center. Contractual agreements with the state university’s College of Nursing as a clinical site for graduate and undergraduate students are in place. In the first three steps of implementing this model, a team of nurses and undergraduate and graduate nursing students generated the evidence-based, patient-centered, “best practice” protocol. THEORETICAL FRAMEWORK The overall project’s framework comes from theory in research utilization as well as Roger’s “adoption of innovations” theory. In addition, Orlando’s (1990) middle-range theory provided the theoretical evidence for the specific patient-centered, best practice protocol, and is discussed further under Step 2 of the approach. Adoption of Innovations Theory The adoption of innovations theory focuses on understanding how behavioral change is brought about in an organizational system. According to the theory, three factors improve research translation into practice: the availability of a body of validated, predictable knowledge, a cadre of clinicians competent in translating and using this knowledge with favorable attitudes toward research, and a supportive policy-generating structure that promotes innovation (Titler et al. 1994; Dufault et al. 1995; Rogers 1995; Janken & Dufault 2002). Use of the CRU model, based on Roger’s theory, addresses each of these factors. First, the model provides for resources to review the body of validated literature on nursing shift handoffs. Second, faculty-led, experiential, problem-focused learning exercises called research roundtables guide clinicians and students to evaluate and translate this empirical knowledge. Third, themodel provides for the organizational structures within the hospital to create, test, and sustain the evidencebased policies, standards, and processes needed to cue clinician action. In the CRU model, a six-step approach is used as adapted from the Conduct and Utilization of Research in Nursing Project (Horsley et al. 1978). The steps also correspond to Roger’s five-stage process of agenda setting, matching, redefining/restructuring, clarifying, and routinizing in the process of describing the adoption of new practices within organizations. The sequentially designed activities progress from step 1 to step 6 and are described in detail in the context of Roger’s theory in Janken and Dufault (2002). In the model, nurse researchers are paired in teams with clinicians, clinical specialists, and undergraduate and graduate nursing students to address the specific clinical issue, in this case, the development of a patient-centered, best practice protocol for nurses’ shift handoffs based on empirical, theoretical, and contextual evidence to support its use. APPROACH Over 20 years of experience with using the CRU model has provided insight into this strategy that helps translate successful research-based interventions into clinician Worldviews on Evidence-Based Nursing Second Quarter 2010 61 Protocol for Nurse-to-Nurse Handoffs practice. Using this model to change clinician practice and sustain organizational change had previously been applied to other clinical problems and empirically tested in seven other studies in which the evidence-base is strong, but underused in practice (Tracy et al. 1995; Dufault & Lessne- Willey 1999; Dufault & Sullivan 1999; Dufault 2004; Dufault et al. 2006). Between 1985 and 2005, as the first step in themodel, over 70 research roundtableswere conducted to change nursing practice in 26 target clinical content areas where practice lagged behind a large body of empirical knowledge (Tracy et al. 2006). Since 2005, an additional 25 roundtables have been conducted in areas related to systems, processes, and the environment of care. It had never been used to design and test a standardized, evidencebased, patient-centered approach to handoff communications for present and future clinicians. An advantage of using the CRU model to formulate best practice standards, policies, and protocols is that it may improve the clinical environment by translating research-driven change in practice, as well as to develop present and future clinicians who are competent in these skills. The six steps of the approach are: 1. Identification of the clinical problem and assessment of the empirical, clinical, and theoretical evidence for potential translation. 2. Evaluation of the relevance of the empirical evidence as it relates to the selected problem, agency values, standards and policies, and potential cost and benefits. 3. Designing a policy, standard of care, or protocol that meets the needs of problem. 4. Actual or construct replication and evaluation of the policy, standard of care, or protocol. 5. Decision to adopt, alter, or reject the policy, standard of care, or protocol. 6. Development of means to sustain, disseminate, and extend the innovation to other settings. Step 1. Identification of a clinical problem and assessment of the clinical, theoretical, and empirical evidence for potential translation. Improving the clinical environment by translating research on nurse-nurse handoffs into practice at the bedside was recognized as a need in the hospital. Assessment of Clinical Evidence Prior to this project, nurses identified that the method of shift-to-shift handoffs at the study site was inconsistent with no hospital-wide standard format for nurse-nurse handoffs. This posed a particular problem for those nurses who float from unit to unit and were expected to use whatever format was operational on each unit of the hospital. With nurses questioning the feasibility and usefulness of various methods, there was also no data on the timeliness or cost related to overtime for the multiple methods of shift report at the study site. The types of formats used at the hospital included verbal reporting, audio-taped in combination with verbal, and in others, a rounding format. On one unit, a new hybrid method had been initiated which was a semi-silent report format based upon computer-generated documentation. A nurse-satisfaction survey was conducted by a staff nurse on this unit before and 6 months after the change to semisilent report. Survey findings suggested that the silent, computer-generated report format resulted in a negative impact on team functioning with 74% of the nurses reporting worsened overall team functioning. Also, 47% of nurses reported a negative impact on the student or graduate nurse experience when the silent computer-generated report was used on that unit (Taft 2006). In addition to Taft’s survey hospital scores on related NDNQI measures were examined. Two nurse-satisfaction outcomes including satisfaction with nurse-to-nurse interactions, and satisfaction with teamwork among nursing staff were at a high level. However participation in decision-making and time for patient care were in the moderate levels with T-scores at 51.54 and 51.18 levels as compared with other magnet hospitals of similar bed-size. It was also noted that at the study site, Press-Ganey scores on patient satisfaction with variables believed to be associated with nurses’, shift handoffs had all declined slightly over the past year. Patient satisfaction outcome results for items related to how well the nurses kept patients informed, how well staff worked together to care for patients, with staff efforts to include patients in decisions, staff concerns for privacy, and patient’s perceptions of safety and security while in the hospital were 87.6; 91.1; 88.0; 89.7; and 91.8, respectively. Each of these scores represented a slight decline from the previous 3 month reporting cycle, although they still remained above the national mean. Assessment of Theoretical Evidence In addition to the CRU model with its underpinnings of Roger’s Adoption of Innovations Theory to frame the overall translational research project, Orlando’s Nursing Theory was used as theoretical evidence to support change to a standardized format that recognizes the immediate needs of patients, and is patient-centered. Orlando’s theory is congruent with the philosophy of Nursing at the hospital, which draws from the works of Henderson (1991), Orlando (1990), and Watson (1988). Effective communication has been embraced by Newport Hospital in a “back to basics” approach to professional nursing practice and is in alignment with 62 Second Quarter 2010 Worldviews on Evidence-Based Nursing Protocol for Nurse-to-Nurse Handoffs Orlando’s theory of meeting the immediate needs of patients and supporting the concept of nursing’s role as a patient/family advocate. Orlando’s theory focuses on the deliberative nursing process (Orlando 1990). As described by Schmieding (2006), Orlando views the role of the nurse as finding out and meeting the patient’s immediate need for help. Nurses use their perception, thoughts about their perception, or the emotions elicited to explore with patients the meaning of their behavior. Using this process assists the nurse in eliciting the nature of the problem and identifying what help is needed for the patient. According to Schmieding, “the use of her theory keeps the nurse’s focus on the patient” (Schmieding 1986, p. 1), thus making it especially suitable for application to the process of nursing handoffs.When applying Orlando’s theory, the nurse identifies her own perceptions, thoughts, and feelings about the patient’s behaviors as she obtains them from the computerized rounds report and the nurse reporting off in the situation, background, assessment, and response (SBAR) portion of the process. She then validates them with the patient during the bedside component of the shift handoff. Deliberative nursing actions to meet immediate patient needs for the next 8 hours are the next step. Last, she verifies with the patient whether or not she met his needs, and determines if further action is needed when she prepares her summary as the off-going nurse at the end of her shift. Specific examples of the application of Orlando’s theory to the specific components of the protocol are listed in Table 1. Assessment of Empirical Evidence To assess the body of empirical evidence, literature searches were conducted from 1992 to 2009 in the Medline (via Pub-Med), CINAHL, and Cochrane Database of Systematic Reviews using the search terms of shift report, handoffs, handovers, end-of-shift report, nurse-tonurse report, bedside shift report, computerized report, and silent report. ERIC was also searched in the understanding that teaching students the technique of shift handoffs is an important role of nurses, and may have been reported in the literature. In addition, resources gathered from a teleconference sponsored by Healthcare Pro (2006) and Holly (2006) at the 2006 Eastern Nursing Research Conference helped to identify other potential sources of evidence. References from previous literature reviews on this subject were manually searched and it was found that this search was inclusive. Using specific inclusion criteria for appraisal, 40 abstracts were screened. Articles were included that were qualitative and quantitative studies as well as the gray literature that specifically described processes and interventions for shift-to-shift report by nurses that could be replicated. Full text articles of all 40 abstracts were retrieved for closer screening by a doctoral nursing student at the university. Only one randomized study had been published on this topic, and most studies were descriptive and qualitative in design. Consequently, no meta-analyses were available on the subject. In addition to the studies found in the search, one unpublished meta-synthesis was also found (Holly 2006) as reported at the 2006 Eastern Nursing Research Society Conference, in addition to the study conducted by Taft (2006) at the hospital. The 42 studies were critiqued in depth for methodological strengths and weaknesses. An evidence summary table detailing each study’s reference and country of origin, study objectives, sampling and type, design, and major findings. In addition, criteria developed by Melnyk and Fineout-Overhold (2005) to rank the strength of the empirical evidence were applied to each study. Of the 40 published studies, nine were chosen for presentation and further discussion at a research roundtable in Step 2 because they specifically addressed the process issues identified by staff nurses in Taft’s (2006) study and in focus groups, and tested specific methods for shift handoffs. These process issues included lack of depth, clarity, timeliness, and organization of reports; inconsistency and missing or incorrect patient information; interruptions and social conversation; and inadequate opportunity for nurse-to-nurse discussion to facilitate teamwork between shifts. Table 2 presents an evidence summary of the studies chosen for the roundtable. This concluded Step 1 of the CRU model. Step 2. Evaluating the relevance of the research as it relates to the selected problem, agency values, standards and potential cost and benefits. Critiques of the research evidence were used in a hospital-wide research roundtable discussions sponsored and led by staff nurses on two units (surgical unit and the rehabilitative care unit). Stetler et al.’s (1998a) tools for utilization-focused reviews were used to guide the roundtable discussions. During the roundtables, nine of the studies critiqued in Step 1 were evaluated further for their clinical applicability, usefulness, congruency of the study with the theoretical basis for current practice at the hospital, and substantiating evidence from other studies, systematic reviews, and potential for translation into a patient-centered, “best practice” protocol. An earlier version of these tools has been demonstrated to be effective in getting clinicians to examine and change their practice in the seven previous studies (Janken et al. 1988; Dufault et al. 1995; Dufault & Lessne-Willey 1999; Dufault & Sullivan 1999; Dufault 2004; Tracy et al. 2006). Recommendations were generated and are discussed below. Worldviews on Evidence-Based Nursing Second Quarter 2010 63 Protocol for Nurse-to-Nurse Handoffs TABLE 1 SBARP best practice protocol for nursing shift handoffs, with supporting empirical and theoretical evidence PROCEDURE EMPIRICAL EVIDENCE THEORETICAL EVIDENCE (ORLANDO’S THEORY) 1. A standardized SBARP format is to be used as follows: Situation Background Assessment Recommendation Patient Experienced nurses have a clear idea of a “good” handover—it is rapid, goal-directed, effective, brief (Payne et al. 2000; Dowding 2001), and patient-centered (Malestic 2003; Anderson & Mangino 2006). A systematic structure of the report organizes large amounts of data in a meaningful way to convey complex patient care issues. There are essentially four practices that are basic to nursing: (1) observation, (2) reporting, (3) recording, and (4) actions carried out with or for the patient (Orlando 1990, p. 31). The oncoming nurse will: Review assignment sheet. Obtain required online documentation on all assigned patients. Read the information on the computerized rounds report. Meet with the off-going nurse and review information adding info not on the rounds report. Each off-going nurse will provide a verbal report on each patient using the SBARP format emphasizing “forceful feature” to highlight critical areas in the following sequence: There is need for clarification in each health care institution of the purpose of change of shift report as well as the roles of the reporter and the receiver (Clair & Trussell 1969; Parker 1996). Computer-generated shift reports reduce noise and chaos (Miller 1998; Baldwin & McGinnis 1994), and are inclusive of information needed. Handovers function to produce group cohesiveness (Payne et al. 2000). Preprinted handover sheet more effective (Reilley & Stengrevics 1989; Miller 1998). Handovers are more effective when they are thorough, concise, and patient centered (Hardy et al. 2000; Malestic 2003; Simpson 2005). Face-to-face interaction in the handoff is salient (Mason 2004; Patterson 2005), and promotes the professionalism of nursing and team cohesion (Lally 1998; Kerr 2002). A nurse’s observations are the raw material with which she makes and implements her plans for the patient’s care. Observations that are indirect include hearing comments about the patient at reports. . .or through perusal of the doctor’s order sheet, progress notes, nurse’s notes, etc. (Orlando 1990, p. 7). An unencumbered working relationship between nurses is vital for the provision of professional nursing (Schmieding 1986, p. 28). Situation: Review patient’s admitting information, diagnosis and problem list. Background Using computerized rounds report, review in this order: past medical history resuscitation status, patient social information, current orders, scan med/IV list. Specific order of shift report was noted that aids an individual’s search for patterns (Lamond 2000). Communication problems are the no. 1 cause of sentinel events. Five recommendations: 1. Use clear language. 2. Incorporate effective communication techniques. 3. Standardize shift to shift and unit to unit reporting. 4. Smooth handoffs between settings. 5. Use technology to your advantage. (Joint Commission 2005). Indirect knowledge of the patient consists of any information that is derived from a source other than the patient (Orlando 1990, p. 32). (continued) 64 Second Quarter 2010 Worldviews on Evidence-Based Nursing Protocol for Nurse-to-Nurse Handoffs TABLE 1 (Continued) PROCEDURE EMPIRICAL EVIDENCE THEORETICAL EVIDENCE (ORLANDO’S THEORY) Assessment: Oncoming nurse will: Verify the most recent patient assessment with off-going nurse. View lab results. View most recent vital signs and note trend. Read progress notes online. Choose one technique of report and stay with it (Joint Commission 2005). The nursing process begins with a patient behavior. This behavior results in a reaction from the nurse. The nurse then confirms her perception, thought, or feeling with the patient. (Orlando 1972). The natural consequence of observation is a decision to act or not to act in relation to what is observed (Orlando 1990, p. 7). Recommendation: Off-going nurse and oncoming nurse will discuss: What needs to be done for the next shift? What is the plan for this patient to move to next level of care? 1. Purpose—why is the patient here? 2. Picture—what results are we looking for both long term and short term? 3. Plan—what did or did not work? 4. Part—what part can you play during the next shift? (Dowding 2001) Using a framework that contains words that are easily understood would facilitate communication among the different professionals caring for the patient (Schmieding 1993, p. 465). The purpose of nursing is to supply help a patient requires in order for his needs to be met. The nurse achieves her purpose by initiating a process that ascertains the patient’s immediate need and helps to meet the need directly or indirectly (Orlando 1990, p. 9). Patient: Off-going and oncoming nurses will meet with the patient and signal change of shift. Introduction of oncoming nurse. Assess patient concerns? Discuss plan for the next shift to move patient toward discharge or to the next level of care. Off-going nurse turns over patient to oncoming nurse. Staff and student education considerations Patients want to be heard. They should be given opportunity to be involved in the handover. Interpersonal competence during handovers was low (Cahill 1998; Kelly 2005). Reporting in front of the patient reassures the patient that everyone knows what is going on and that the patient is the priority, provides reassurance, security (Anderson & Mangino 2006). By involving the patients in their plan of care and keeping all caregivers updated on that plan, patients feel more secure, and are more likely to participate in their own care and follow recommended health care options. (Kassean & Jagoo 2005; Anderson & Mangino 2006). In order to change handover practices, nurses from the units must be actively enlisted for trial and training (Kihlgren et al. 1992; Baldwin & McGinnis 1994; Parker 1996; McKenna & Walsh 1997; Simpson 2005). The phenomenon of the nurse-patient encounter represents a major source of nursing knowledge (Schmieding 1993 p. 16). Both the patient and the nurse must participate in a communication process to identify the nature of the problem as well as its solution (Schmieding 1986, p. 5). When using Orlando’s theory, the nurse identifies her own perceptions thoughts and feelings about the patient’s behaviors, then validates them with the patient (Potter & Tinker 2000, p. 41). The nurse does not assume that any aspect of her reaction to the patient is correct, helpful or appropriate until she checks the validity of it in exploration with the patient (Orlando 1990, p. 57). Any observation shared and explored with the patient is immediately useful in ascertaining and meeting his need or finding out that he is not in need at that time (Orlando 1990 p. 36). Training in the nursing process discipline is viewed as a prerequisite for teaching the process discipline. (Orlando 1972, p. 37). Worldviews on Evidence-Based Nursing Second Quarter 2010 65 Protocol for Nurse-to-Nurse Handoffs TABLE 2 Evidence summary table of studies selected for research roundtable on nurses’ shift handoffs REFERENCE AND COUNTRY STUDY OBJECTIVE SAMPLE NO. AND TYPE DESIGN FINDINGS STRENGTH OF EVIDENCE ACCORDING TO MELNYK AND FINEOUT-OVERHOLT (2005) CRITERIA Anderson, C., & Mangino, R. (2006). USA To evaluate implementation of a bedside shift report format on patient staff nurse, and physician satisfaction Thirty-two bed general surgical unit of a 600 bed tertiary care hospital in a large metropolitan area in the southwestern United States. Nonrandomized time-series pretestposttest- posttest design A defined methodological process for implementation was utilized including staff education, feedback and ongoing evaluation. Outcomes included: 1. Financial savings. 2. Increased patient satisfaction. 3. Increased staff satisfaction. 4. Increased physician satisfaction. 5. Nurse reports of ease in prioritizing shift work. Lev. III Cahill, J. (1998). UK To examine patient perceptions on a bedside handoff method Tape recorded interviews with 10 hospitalized patients were conducted one day prior to discharge. Grounded theory qualitative Three themes emerged: 1. Maintaining a professional distance. 2. Establishing professional sharing. 3. Maintaining patient safety. Most, not all patients want to be heard. They should be given the option to be involved in the handover. Lev. VI (continued) 66 Second Quarter 2010 Worldviews on Evidence-Based Nursing Protocol for Nurse-to-Nurse Handoffs TABLE 2 (Continued) REFERENCE AND COUNTRY STUDY OBJECTIVE SAMPLE NO. AND TYPE DESIGN FINDINGS STRENGTH OF EVIDENCE ACCORDING TO MELNYK AND FINEOUT-OVERHOLT (2005) CRITERIA Dowding, D. (2001). Scotland To examine the effects that (1) type of change-of-shift report (retrospective vs. prospective) and (2) schema-type (consistent vs. inconsistent) information has on the amount of information documented, recalled, and used in care planning Forty-eight RNs from acute medical and acute surgical hospital wards randomly allocated to 1 of 4 experimental conditions Experimental study/Factorial design Type of report had a significant effect on care planning ability. Type of schema had an effect on accuracy of documentation and recall, but not on care planning ability. Note: study conditions were as of an audiotape without interaction and opportunity for questions. Level II Lally, S. (1998). UK To investigate the functions of nurses’ communications at the intershift handover Six handovers on a general surgical/vascular unit in a UK hospital. Ethnography The intershift report involves messages and strategies that enhanced social cohesion of the team as well as the medium for transfer of patient information. Level VI (continued) Worldviews on Evidence-Based Nursing Second Quarter 2010 67 Protocol for Nurse-to-Nurse Handoffs TABLE 2 (Continued) REFERENCE AND COUNTRY STUDY OBJECTIVE SAMPLE NO. AND TYPE DESIGN FINDINGS STRENGTH OF EVIDENCE ACCORDING TO MELNYK AND FINEOUT-OVERHOLT (2005) CRITERIA Lamond, D. (2000). UK To compare the information content of the nurse change-of-shift report with documented notes Study also explores information in the shift report forceful feature (a situation that allows an individual to access appropriate knowledge within their long-term memory store). Medical notes, nursing documentation, and shift reports for 60 patients in two acute medical and two acute surgical wards in southeast UK. Two-by-two comparison design. Patient notes/charts contained more information than given at change of shift—with the exception of global judgments of the patient’s psychological information. This information is often communicated orally instead of written. Correlation between information in documentation and report was r = 0.47 (p < 0.0001). Forceful features were identified in the report as being: 1. Specific order of shift report was noted that aids an individual’s search for patterns. 2. Global information given in report, along with organized information facilitates information processing by the recipient of report. Level VI (continued) 68 Second Quarter 2010 Worldviews on Evidence-Based Nursing Protocol for Nurse-to-Nurse Handoffs TABLE 2 (Continued) REFERENCE AND COUNTRY STUDY OBJECTIVE SAMPLE NO. AND TYPE DESIGN FINDINGS STRENGTH OF EVIDENCE ACCORDING TO MELNYK AND FINEOUT-OVERHOLT (2005) CRITERIA Parker, J. (1996). Australia To observe the content process, and methods of handovers Twelve handovers in critical care, burn, step down, medical, and surgical units of two major teaching hospitals Ethnography A variety of processes were used, use of notes, computer printouts, no notes. Emerging patterns included: 1. Clinical transmission of information 2. Management of unit resources. 3. Peer review of professionalism 4. Debriefing of anxiety provoking events Lev. VI Patterson, et al. (2004). USA To describe the strategies used during handoffs in four settings with high consequence for failure. Observational hours: NASA-67 Nuclear Power-177 Railroad dispatch-60 Ambulance Dispatch-118 Ethnographic Qualitative Analysis of observational data All handoffs were interactive and face-to-face with 19 strategies identified. Lev. VI Payne, S., et al. (2000). UK To explore how nursing records are used in the process of exchanging information about geriatric patient care 146 observation hours of 23 handovers and 34 interviews of nurses in addition to written records, care plans, and “scraps” in 5 geriatric hospital units. Ethnographic qualitative Experienced nurses have a clear idea of a “good” handover—it is rapid, goal-directed and brief (this presents problems for new staff or SNs). Handovers function to produce group cohesiveness. Frequent use of jargon and abbreviations. Production of Kardexes and care plans appears to be motivated by concerns of litigation. “Scraps” important. Level VI (continued) Worldviews on Evidence-Based Nursing Second Quarter 2010 69 Protocol for Nurse-to-Nurse Handoffs TABLE 2 (Continued) REFERENCE AND COUNTRY STUDY OBJECTIVE SAMPLE NO. AND TYPE DESIGN FINDINGS STRENGTH OF EVIDENCE ACCORDING TO MELNYK AND FINEOUT-OVERHOLT (2005) CRITERIA Sexton, A., et al. (2004). Australia Comparison study of the content of nursing handovers to formal documentation sources Thirty bed general surgical ward in suburbs of Sydney, Australia. Twenty-three nursing handovers covering all shifts were audio-taped and observed by two researchers. Mixed method 93.5% of information passed at handover was already available in the medical record or other written sources. Some handovers promoted confusion Level IV 70 Second Quarter 2010 Worldviews on Evidence-Based Nursing Protocol for Nurse-to-Nurse Handoffs Research Roundtable Findings There are few studies that examine the efficiency, costeffectiveness, and clinical outcomes of specific approaches to nursing shift handoffs. Dowding (2001) found that the type of report had a significant effect on an individual’s ability to plan patient care and the type of information content on their ability to accurately record and recall the information they heard. Subjects can recall more information accurately when they hear prospective reports and schema-consistent patient information. Patterson et al. (2004) found that effectiveness and efficiency improved when handoffs were provided in the same order every time, were verbal, face-to-face, where there were limited distractions and interruptions, and provided a summary, plan and goals. The findings of Dowding and Patterson were substantiated by staff nurses in their discussion of the studies. They noted that they too were able to recall and use the information given in report when there was a predictable pattern to the delivery of information. Nurses further indicated interest in a new format they learned in a Healthcare Pro (2006) conference as developed by Kaiser Permanente of Colorado (2006), called the SBAR (situation, background, assessment, and response) method to enhance communication during handoffs, although it had not been empirically tested at the time of this review. Considerable discussion during the roundtable focused on the “silent report” method having received more attention recently as a cost-saving method where minimal communication between nurses eliminates “time-over shift” or excess overlapping of oncoming and leaving shifts of nurses. As early as 1994, using a computer-generated nursing written shift report, Baldwin & McGinnis (1994) reported outcomes of this type including reduced overtime, increased direct patient care at the shift change, and improved communication of pertinent patient data. Reduced legal risk of breech of patient confidentiality due to overheard conversations, decreased admission wait time, and reduced noise and chaos also resulted. Roundtable participants challenged Sexton et al. (2004) study that questions whether nurses need the handoff verbal report. Sexton found that 93.5% of information passed at the handoff was already available in the medical record or other written sources. However, participants were in agreement with Lamond’s (2000) study suggesting that there is evidence that the verbal handoff contains “forceful feature” information that may facilitate the processing of patient information that leads to more efficient care planning. A study by Taft (2006) at this study site found that the silent computergenerated report format resulted in a negative impact on team functioning with 74% of the nurses reporting a worsened overall team functioning. This is also consistent with Lally’s (1998) finding that the verbal intershift handoff enhances a shared value system amongst nurses. In Taft’s study at the hospital, 47% of nurses reported a negative impact on the student or graduate nurse experience when the silent computer-generated report was used (Taft 2006). Most recently, bedside nurse shift reporting in which patients are included in the handoff process has been attempted to have patients more involved in their care. Kassean and Jagoo (2005) found this method facilitated nurses obtaining salient data and their ability to prioritize and manage patient care effectively. Anderson and Mangino (2006) also found that bedside reporting resulted in a decrease in time-over shift (incidental time), took less time, and assisted nurses in prioritizing their work because they were able to visualize all patients within the first half hour of their shift. Staff nurses reported increased satisfaction related to accountability, interpersonal relationships, and receiving pertinent information. Physician satisfaction improved with their reporting more informed nurses. Key patient satisfaction improvementswere achieved in the areas of nurses keeping patients informed, how well the staff worked together to care for patients, and the patient perception of inclusion in the decisionmaking process, including decisions about their treatment (Anderson & Mangino 2006). However, adding the element of a bedside component that includes the patient and ancillary staff has only been empirically evaluated in these two studies, and nurses who reviewed Anderson and Mangino’s study pointed out that it was a nonrandomized time-series pretest-posttest-posttest designed study, rather than a randomized, controlled trial. Despite this, nurses from the intensive care unit who include a bedside component strongly advocated including the patient in the report. They further pointed out that there is strong theoretical evidence from Orlando’s work, on which the theoretical framework for the nursing department is based, to support including a bedside component in the protocol to be developed. A consistent approach to information transfer with guaranteed patient-nurse contact was becoming an important aspect of the patient-centered, best practice protocol to be developed. A staff nurse conducting a related study on the impact of nurse’s intentional presence pointed out that studies suggested that increasing contact with nurses has been identified as an important variable in improving patient outcomes (Fordham & Dunn 1994). They found that a powerful function of a nurse is the ability to promote trust with patients. The nurse also pointed out that consistent behavior and freedom from uncertainty and doubt were found to be influential trust factors in a study by Meize-Gochowski (1984). Roundtable participants also identified Joint Commission recommendations that need to be consulted specify Worldviews on Evidence-Based Nursing Second Quarter 2010 71 Protocol for Nurse-to-Nurse Handoffs TABLE 3 Recommendations and supporting empirical evidence generated in research roundtable discussions 1. Need goal-focused, thorough, rapid and brief report (Payne et al 2000) 2. Active verbal communication—person to person needed to allow mentoring and team building (Payne et al. 2000; Dowding 2001; Patterson 2005, Taft 2006) 3. Consistent, organized format needed (Lamond 2000, Dowding 2001) 4. SBAR (situation, background, assessment, and response) (Kaiser Permanente of Colorado 2006) format with integration of patient (add “P”) 5. Need to have status of all patients on unit (Taft 2006) 6. Patients need to be included with walking rounds at bedside (Cahill 1998; Anderson & Mangino 2006) 7. Joint Commission Recommendations: clear language, standardized shift to shift and unit to unit report, effective communication techniques, use technology as adjunct (Joint Commission 2005). 8. Need training on handovers (Parker 1996) that clear language, a standardized approach, and use of effective communication techniques with technology as adjunct seemed in concert with all of the empirical evidence presented during the roundtable. Finally, it was noted that there needs to be time protected to train all staff, as well as students, in the protocol to be developed. In summary, eight recommendations specific to the patientcentered, best-practice protocol were generated (listed in Table 3). Step 3. Designing evidence-based best practice standards, policies, or protocols for translating recommendations generated in the research roundtables to conform to the organization’s specific needs. A subgroup of the hospital’s Nursing Research Committee representing staff nurses from each of the hospital units worked with the research consultant and a doctoral student to discuss the eight roundtable recommendations for congruence with findings of the 34 studies not presented in the research roundtable. In addition, they conducted further interviews with staff nurses on each of the units to establish the exact process currently in use for handoffs and for use of the computergenerated rounds report evaluated in Taft’s (2006) survey. A best practice for nursing shift handoffs was generated, using the evidence of the 42 empirical studies, Orlando’s theory, contextual factors such as existing policies and values, nursing staff competency and patient preferences as described in the Press Ganey Patient Satisfaction Survey data. Table 1 describes the patient-centered, evidence-based, best practice protocol developed for the hospital. CONCLUSIONS, SUMMARY, AND IMPLICATIONS Standardization and stabilization of clinical practice related to the transfer of information is an essential aspect of patient safety and improves clinical outcomes. In this article, the first 3 steps of the CRU model as used to develop the patient-centered, best practice protocol were described. Incorporating directions established by AHRQ, the Joint Commission and the NQF this project created meaningful clinician change in the hospital setting to a standardized, evidence-based, patient-centered approach to nurses’ change-of-shift handoffs. Using the CRU model, an innovative empirically tested method of translating research into practice, may ensure that results are disseminated both in the clinical and academic community. This is consistent with Dopson & Fitzgerald (2005) integrating framework to understand how clinicians and organizations use empirical knowledge for decision-making. It is clear that in the CRU model, a critical role is played by key individuals or “research champions” at the staff nurse and management levels in partnership with academic affiliates to promote an evidencebased health care culture. This also supports the findings of Gabbay and Le May (2004) whose ethnographic study of knowledge management through the collectively constructed “mindlines” identified the role of providing networking opportunities and the significant implications this has for translating research findings into communities of practice. Participation in activities of the CRU model, such as research roundtables and focus groups, provide such networks for students, clinicians, administrators, and scientists to ensure that research is practice-based and practice is research-based. The potential for future nurses to use this method through their involvement in the project can have a positive and sustained long-term impact not only on amore effective approach to handoffs, but to other clinical problem-solving in their future. 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